#5
PROJECT NAME: Improving the Outcomes of Patients with MultidrugResistant Gram Negative Rods Bloodstream Infection
Institution: MDACC
Primary Author: Polly Williams, BS, MT(ASCP), CIC
Secondary Author: Javier Adachi, MD
Project Category: General Quality Improvement
Overview:
-Location: Hospital wide MDACC
-Reason change is needed: Several studies have shown that early and adequate antimicrobial
therapy improves the outcome of patients with multidrug-resistant (MDR) gram negative rod
(GNR) bloodstream infections (BSI). Moreover, currently there are limited antimicrobial options
for treatment, and there are no novel antimicrobial agents under development in the
pharmaceutical industry against GNR infections.
-Groups involved: All healthcare providers
-Alignment to organizational goals: Safety and Effectiveness
-Our CS&E team decided to continue this project, with the objective to show the significant
impact and the sustainability of this new QI process.
Aim Statement:
-To improve the outcome of patients with MDR-GNR BSI by starting adequate, prompt and early
antimicrobial therapy. This will be achieved by:
1. Increasing the number of Infectious Diseases consultations, recommending the best
possible active antimicrobial therapy (based on in-vitro susceptibility data)
2. Reducing the timeframe from the identification of each new episode of MDR-GNR BSI at
MDACC microbiology laboratory to the initiation of active antimicrobial therapy
Measures of Success:
-Increase in active antimicrobial therapy against each specific strain of MDR-GNR causing BSI
-Reduction in the time between the final susceptibility to the start of active antimicrobial therapy
-Reduction in the infection-related ICU admissions
-Reduction in the infection-related mortality (associated to MDR-GNR BSI) and overall mortality
Use of Quality Tools:
-Data collection sheets, fishbone diagrams, control charts, process flow maps and the lean
process concept. Two tools, a control chart and 3 process maps (flowcharts), are shown below.
-Figure 1 (control chart) showed a significant increase in the prevalence of MDR-GNR BSI at
MDACC, comparing 2012 with 2009 data (based on binomial probability distribution). Even
though we do not have complete data for 2013, there is an even greater rise in the frequency of
this type of infection during the first months of this year.
Figure 1: Prevalence of MDR-GNR BSI at MDACC from January 2009 to July 15, 2013
Figure 2: Pre-CS&E Process (Process Flow Map A)
Interventions:
-In an attempt to make the process more “lean”, we developed the following steps to reduce the
timeframe between the identification of each new episode of MDR-GNR BSI in the microbiology
laboratory to the initiation of active antimicrobial therapy (based on in-vitro antimicrobial
susceptibility data).
-Starting on July 16, 2012, after approval from the Quality Improvement Assessment Board, the
following new process was developed:
1. All GNR BSI results reported by the microbiology laboratory were checked daily by an
Infection Preventionist [IP] (Mrs. Polly Williams).
2. The IP notified ID team members by email when a patient with a MDR-GNR BSI was
identified
3. An ID physician/team member notified the primary team of the MDR-GNR BSI by email
(Dr. Adachi or on behalf of Dr. Adachi).
4. The primary team made the decision whether to place an online ID consult request
5. A system was developed to prospectively collect data from all patients with MDR-GNR
BSI
Figure 3: Current CS&E Process (Process Flow Map B)
-This QI process was executed every day by our team, including weekends and holidays.
-This QI process was started as a CS&E project (Session 17). However, our team decided to
continue, taking it as an additional and extra-curricular responsibility for a full year, from July 16,
2012 to July 15, 2013. The objective was to show the significant impact of this intervention and
the sustainability of this new QI process.
Results:
Baseline Data pre-CS&E Process (January 2010 to July 15, 2012)
-Of 193 patients, Infectious Diseases was consulted in 117 cases (60.6%), resulting in prompt
and better active antimicrobial therapy in those patients with multidrug-resistant gram negative
rod bloodstream infections.
-However, when comparing patients with an ID consult to those without an ID consult, there
were no significant differences in infection-related ICU admissions, infection-related mortality or
overall mortality.
Table 1: Impact of the QI (CS&E) Process in the Outcome of Patients with MDR-GNR BSI at
MDACC (July 16, 2012 to July 15, 2013)
*p value, comparing pre-CS&E data with post-CS&E process,
and using Chi-square or Fisher Exact Test, when indicated.
Novel and Sustained CS&E Process (July 16, 2012 to July 15, 2013)
-A total of 135 cases of MDR-GNR BSI have been identified during this period of 1 year,
representing a significant increase compared to the previous baseline data (over 2.5 years)
-The significant rise in patients followed with an ID consult (from 60.6% to 76.3%) was followed
by the concomitant initiation of early (from 11.00h to only 7.53h from the report of in-vitro
susceptibility to the start of active therapy) and adequate active therapy (from 95.7% to 98.3%).
-These improvements in the process have had a significant impact in the outcome of cancer
patients with MDR-GNR BSI, with:
1. Reduction in the infection-related ICU admissions (from 16.2% to 3.9%, p=0.018)
2. Reduction in infection-related mortality (from 15.4% to 4.9%, p=0.041) and in overall
mortality (37.6% to 10.7%, p=0.009)
-Even though this new process had a significant impact, there was no significant reduction in the
length of stay (LOS) of those cancer patients, mainly because of the severity and complexity of
our cancer patients and because of the need for adequate therapy with at least 14 days of IV
antimicrobial therapy.
-The most important outcome of this QI process was the significant reduction in infection-related
mortality, helping to “save” at least 14 cancer patients with MDR-GNR BSI at MDACC.
Revenue Enhancement / Cost Avoidance / Generalizability:
-The reduction in infection-related ICU admissions from 16.2% to only 3.9% represents at least
16 patients who did not require transfer to ICU during our current process, making more ICU
beds available for other patients.
-From this process we also identified that the average LOS of cancer patients with MDR-GNR
BSI was 6.5 days, both inside and outside the ICU.
-There was a significant cost avoidance, considering only the cost of ICU bed per day ($19,295,
average data cost per day for FY11 at MDACC). This represents a total cost avoidance of at
least $2,006,680.00, with average cost avoidance per patient of $125,417.50.
Conclusions and Next Steps:
-The lean process had a significant impact in our cancer patients with MDR-GNR BSI, with more
prompt and adequate active therapy through Infectious Diseases consultation, decreased
number of transfers to ICU, and more importantly, decreased infection-related mortality and
overall mortality among those patients.
-The main barrier to successful implementation of this new process is the lack of an electronic,
automatic notification process.
Next Steps:
Figure 4: Ideal New Process (Process Flow Map C)
Our team is currently in active interaction with our institutional leadership for the development
and implementation of an automatic electronic notification process for the management and
treatment of all cancer patients infected with MDR organisms, including the possibility of an
automatic infectious diseases consultation.