World Journal of Microbiology and Biotechnology, 8 (Supplement 1), 43-45
A changing face of medical microbiology J.G. Barr
Hospital rhicrobiologists are presently finding that radical changes in the way that they aim to fulfil their roles are being induced by government and local management initiatives. These are identified by the well-known phrases: 'value for money'; 'cost effectiveness'; and 'cost benefit equations'~ The main aim is to obtain the best possible value in patient care from laboratory services which have to be organized within defined laboratory and clinical budgets.
admitted to hospitals in the USA will contract an infection as a direct result of their hospital stay. It was noted that "Hospital acquired, or nosocomial infections affect nearly 2 million patients each year in the United States". Aside from the more than $1 billion dollars a year this figure reflects, nearly 3% of these patients die as a result of hospital acquired infections.
How can microbiologists influence this trend. The control of
A Way Ahead Management of resources in hospitals is increasingly going to have far-reaching implications in two areas which are a major platform for the influence and endeavour of microbiologists. These are the control of infection including hospital acquired infection and the rational use of antibiotics measured on the basis of efficacy and cost.
Hospital Acquired Infection The Magnitude of the Problem. A report by a UK Joint DHSS/PHLS working group on hospital acquired infection (HAI) in I988 stated that "the cost in England in 1986 of Hospital Acquired Infections would be s or 950,000 lost bed days." Some additional key factors record the size of the problem in the UK: incidence in the UK is around 5%; duration of hospitalization increases HAI; and H A I increases with preoperative period. In a National Nosocomial Infection Study (NNIS) in the USA in 1979, 44,785 nosocomial infections occurring in 1,362,342 hospitalized patients were reported. The mean nosocomial infection rate was 3.3% of acute care patients discharged. According to the NNIS for nosocomial infections being conducted by the centres for disease control (CDC), significant HA1 will be diagnosed in 3 to 6% of all hospitalized patients. It can be predicted that between 960,000 and 1,500,000 of the 32 million patients
J.G. Barr is at the Department of Bacteriology, Royal Victoria Hospital, Belfast BT12 6BA, Northern Ireland, UK.
infection within a hospital is central to the best use of available resources. The personnel of infection control have, through the vehicle of the Infection Control Committee, the ability by their expertise and the collation of data to influence the costs debited to infection in many ways. A summary of these areas of activity are shown in Figure 1. It is clear from this figure that information gathered from many different areas of influence can be within the remit of infection control and can thus influence the management of hospital resources. Among the many influences are: epidemiological surveillance; antibiotic policies and prescription; and education, information and communication. Epidemiologica[ surveillance is central to the control of infection. Information is gathered and communicated to the units surveyed. In this way prompt action can be taken to increases in infection rates, the spread of specific pathogens or the selection of antibiotic resistance. Information is used to make appropriate modifications of antibiotic policy on the basis of changing baseline antibiotic sensitivity of pathogens isolated. Antibiotic pol!cies are provided for individual clinical units and are based on the prevailing pathogens and their antibiotic sensitivities. The prescription of antibiotics is monitored through a Pharmacy database which provides information on the cost of antibiotics prescribed; antibiotic treatment period for individual patients; the use of prophylactic/therapeutic antibiotics; and the use of parenteral/oral antibiotics. This provides a mechanism for policing instituted antibiotic policies, but interaction with epidemiological surveillance allows direct communication to be provided to clinical units linking antibiotic
9 1992 Rapid Communications of Oxford Ltd World Journal of Microbiology and Biotechnology, Vol ~ S~4pplement I . 1992
43
J. G. Barr
1• I I
1
Hospital Patient Data
Prescription Data Pharmacy
Laboratory Data
~
t
Infection Control Computer
~
~
Control Team
I
i/
interactions.
The Collection and Management of the Data
prescription with the sensitivity of the endemic pathogens and the outcome of treatment for the patient. This approach may be invaluable in demonstrating that, in cost benefit analysis, the more expensive antibiotics prescribed for a short course may be more cost effective than a cheaper antibiotic for a longer course of. treatment. Education is best achieved indirectly by communicating the information gathered by epidemiological surveillance and monitoring antibiotic policies and prescription. Clinical units will be able to see: antibiotic costs; length of patient stay; incidence of infection; changes in antibiotic sensitivity of pathogens; changes in pathogens; and incidence of infection post-discharge. In discussions with bacteriologists, clinicians will be able to assess the importance of these factors on their budgetary management: discussions between them may lead to changes in antibiotic policies, ward techniques or other aspects of patient management. Changes in management can be assessed within the framework of epidemiological surveillance and antibiotic use.
Computer
,- I 'n'~176 ,-
Intensive Surveillance High Risk Units
Figure 1. Infectioncontrol
l
Policies Antibiotics Disinfectants
The aim now is to provide frameworks of information within which the influence of infection and antibiotic costs can be monitored. The prospect is that increasing awareness of the budgetary implications of preventable infections and the best use of antibiotics in prophylaxis and treatment will be achieved by the availability of a developing database. This database must include contributory data from all the fields interacting with infection and antibiotic prescription. The importance of linking databases on computer is emphasized in Figure 2. This figure shows that a number of feeder computer databases provide the essential data for a working infection control computer which will be able to equate the incidence of infection with endemic bacteria and their sensitivities, and the appropriate use of antibiotics in prophylaxis and treatment. These analyses will be useful to a number of different groups. Bacteriologists will detect changes in infection rates and will seek to give appropriate advice. They may advise
I-..
Ho.t
Computers tee
Pharmacy Computer
I
~
j
~
Surveillance Data
Diagnosis Hospital Stay HAl
Antibiotics Prophylaxis Treatment
Figure2. Infectioncontrol computerization. Computers are networked to freelyexchange data sets and transfer betweendatabases,*** Infectioncontrol computer.
44
world Journal of Microbiology and Biatechnology, !7ol 8 Supplement I 9 1992
A changingface of medical microbiology on changes in antibiotic policy on the basis of the analyses, which will give pointers to research into linked and transferable antibiotic resistance. Clinicians will detect changes in the percentage cost of antibiotics in their budget and will seek to have any increases in their antibiotic costs explained and resolved. Hospital management may provide
impetus and support to initiatives which reduce costs associated with prolonged hospital stay or antibiotic use. Hospitals will advertise short hospital stay and low incidence of hospital acquired infection as an important component of the service that they provide.
World Journal of Microbiology and Biotecknology, Vol 8 Supplement I 9 1992
45
A changing face of medical microbiology J.G. Barr
Hospital rhicrobiologists are presently finding that radical changes in the way that they aim to fulfil their roles are being induced by government and local management initiatives. These are identified by the well-known phrases: 'value for money'; 'cost effectiveness'; and 'cost benefit equations'~ The main aim is to obtain the best possible value in patient care from laboratory services which have to be organized within defined laboratory and clinical budgets.
admitted to hospitals in the USA will contract an infection as a direct result of their hospital stay. It was noted that "Hospital acquired, or nosocomial infections affect nearly 2 million patients each year in the United States". Aside from the more than $1 billion dollars a year this figure reflects, nearly 3% of these patients die as a result of hospital acquired infections.
How can microbiologists influence this trend. The control of
A Way Ahead Management of resources in hospitals is increasingly going to have far-reaching implications in two areas which are a major platform for the influence and endeavour of microbiologists. These are the control of infection including hospital acquired infection and the rational use of antibiotics measured on the basis of efficacy and cost.
Hospital Acquired Infection The Magnitude of the Problem. A report by a UK Joint DHSS/PHLS working group on hospital acquired infection (HAI) in I988 stated that "the cost in England in 1986 of Hospital Acquired Infections would be s or 950,000 lost bed days." Some additional key factors record the size of the problem in the UK: incidence in the UK is around 5%; duration of hospitalization increases HAI; and H A I increases with preoperative period. In a National Nosocomial Infection Study (NNIS) in the USA in 1979, 44,785 nosocomial infections occurring in 1,362,342 hospitalized patients were reported. The mean nosocomial infection rate was 3.3% of acute care patients discharged. According to the NNIS for nosocomial infections being conducted by the centres for disease control (CDC), significant HA1 will be diagnosed in 3 to 6% of all hospitalized patients. It can be predicted that between 960,000 and 1,500,000 of the 32 million patients
J.G. Barr is at the Department of Bacteriology, Royal Victoria Hospital, Belfast BT12 6BA, Northern Ireland, UK.
infection within a hospital is central to the best use of available resources. The personnel of infection control have, through the vehicle of the Infection Control Committee, the ability by their expertise and the collation of data to influence the costs debited to infection in many ways. A summary of these areas of activity are shown in Figure 1. It is clear from this figure that information gathered from many different areas of influence can be within the remit of infection control and can thus influence the management of hospital resources. Among the many influences are: epidemiological surveillance; antibiotic policies and prescription; and education, information and communication. Epidemiologica[ surveillance is central to the control of infection. Information is gathered and communicated to the units surveyed. In this way prompt action can be taken to increases in infection rates, the spread of specific pathogens or the selection of antibiotic resistance. Information is used to make appropriate modifications of antibiotic policy on the basis of changing baseline antibiotic sensitivity of pathogens isolated. Antibiotic pol!cies are provided for individual clinical units and are based on the prevailing pathogens and their antibiotic sensitivities. The prescription of antibiotics is monitored through a Pharmacy database which provides information on the cost of antibiotics prescribed; antibiotic treatment period for individual patients; the use of prophylactic/therapeutic antibiotics; and the use of parenteral/oral antibiotics. This provides a mechanism for policing instituted antibiotic policies, but interaction with epidemiological surveillance allows direct communication to be provided to clinical units linking antibiotic
9 1992 Rapid Communications of Oxford Ltd World Journal of Microbiology and Biotechnology, Vol ~ S~4pplement I . 1992
43
J. G. Barr
1• I I
1
Hospital Patient Data
Prescription Data Pharmacy
Laboratory Data
~
t
Infection Control Computer
~
~
Control Team
I
i/
interactions.
The Collection and Management of the Data
prescription with the sensitivity of the endemic pathogens and the outcome of treatment for the patient. This approach may be invaluable in demonstrating that, in cost benefit analysis, the more expensive antibiotics prescribed for a short course may be more cost effective than a cheaper antibiotic for a longer course of. treatment. Education is best achieved indirectly by communicating the information gathered by epidemiological surveillance and monitoring antibiotic policies and prescription. Clinical units will be able to see: antibiotic costs; length of patient stay; incidence of infection; changes in antibiotic sensitivity of pathogens; changes in pathogens; and incidence of infection post-discharge. In discussions with bacteriologists, clinicians will be able to assess the importance of these factors on their budgetary management: discussions between them may lead to changes in antibiotic policies, ward techniques or other aspects of patient management. Changes in management can be assessed within the framework of epidemiological surveillance and antibiotic use.
Computer
,- I 'n'~176 ,-
Intensive Surveillance High Risk Units
Figure 1. Infectioncontrol
l
Policies Antibiotics Disinfectants
The aim now is to provide frameworks of information within which the influence of infection and antibiotic costs can be monitored. The prospect is that increasing awareness of the budgetary implications of preventable infections and the best use of antibiotics in prophylaxis and treatment will be achieved by the availability of a developing database. This database must include contributory data from all the fields interacting with infection and antibiotic prescription. The importance of linking databases on computer is emphasized in Figure 2. This figure shows that a number of feeder computer databases provide the essential data for a working infection control computer which will be able to equate the incidence of infection with endemic bacteria and their sensitivities, and the appropriate use of antibiotics in prophylaxis and treatment. These analyses will be useful to a number of different groups. Bacteriologists will detect changes in infection rates and will seek to give appropriate advice. They may advise
I-..
Ho.t
Computers tee
Pharmacy Computer
I
~
j
~
Surveillance Data
Diagnosis Hospital Stay HAl
Antibiotics Prophylaxis Treatment
Figure2. Infectioncontrol computerization. Computers are networked to freelyexchange data sets and transfer betweendatabases,*** Infectioncontrol computer.
44
world Journal of Microbiology and Biatechnology, !7ol 8 Supplement I 9 1992
A changingface of medical microbiology on changes in antibiotic policy on the basis of the analyses, which will give pointers to research into linked and transferable antibiotic resistance. Clinicians will detect changes in the percentage cost of antibiotics in their budget and will seek to have any increases in their antibiotic costs explained and resolved. Hospital management may provide
impetus and support to initiatives which reduce costs associated with prolonged hospital stay or antibiotic use. Hospitals will advertise short hospital stay and low incidence of hospital acquired infection as an important component of the service that they provide.
World Journal of Microbiology and Biotecknology, Vol 8 Supplement I 9 1992
45
