Cheryl Ann Creen, RN, MSN Candace Cunningham, RN Jane Englebright, PhD, RN

1. MRSA: For the Birds, or Pandemic Potential? Cheryl Ann Creen, RN, MSN Candace Cunningham, RN Jane Englebright, PhD, RN Jason Hickok, MBA, RN Arlene Salamendra Hayley Burgess, PharmD Charles Denham, MD April 8, 2008

2. Review Status NQF Safe Practices for 2008 Update

3. Light Edits: • SP 1: Creating and Sustaining Culture, • Leadership Structures and Systems • Culture Surveys • Teamwork • Risk and Hazard ID and Mitigation • SP 2: Consent • SP 3: End of Life • SP 5: Nursing Workforce • SP 6: Direct Workforce • SP 7: ICU • SP 8: Critical Care Information • SP 9: Order Read-Back • SP 10: Labeling Studies • SP 11: Discharge Systems • SP 12: Safe Adoption of CPOE • SP 13: Abbreviations • SP 15: Pharmacist Role • SP 16: Standardizing Medication Labeling and Packaging • SP 17: High Alert Medications • SP 18: Unit Dose Medications • SP 20: CVC BSI Prevention • SP 22: Hand Hygiene • SP 24: Evidence Based Referrals • SP 25: Wrong Site, Wrong Procedure, Wrong Person Surgery Prevention • SP 26: Perioperative MI/Ischemia Prevention • SP 27: Pressure Ulcer Prevention Moderate Edits:SP 4: DisclosureSP 14: Medication ReconciliationSP 19: Prevention of Aspiration and VAPSP 21: Surgical Site Infection PreventionSP 23: Influenza PreventionSP 28: DVT/VTE Prevention SP 29: Anticoagulation Therapy SP 30: Contrast Media Induced Renal Failure Prevention New Safe Practices for Consideration: Hand-offs – Handovers Second Patient Organ Donor-ship Catheter-associated Urinary Tract Infection MDRO: MRSA/CDAD Pediatric Imaging Crosswalk of SRE: Falls, Restraints Safe surgical care

4. Moderate Edits:SP 4: Disclosure– Evolving practice SP 14: Medication Reconciliation – TJC updatesSP 19: Prevention of Aspiration and VAP –Care of Ventilated PatientSP 21: Surgical Site Prevention – Normothermia potential removalSP 23: Influenza Prevention –Align with CDC 2006 Immun. updateSP 28: DVT/VTE Prevention –Align with ACCP Anti-thrombic 9th guidelines/NQF measures SP 29: Anticoagulation Therapy –Align with TJC NPSG 3ESP 30: Contrast Media-Induced Renal Failure Prevention Update for Gadolinium Adverse Event (NFS)

5. Committee and Subject Matter Expert Work Sessions • Updates to Practice/Additional Specifications of Existing Practices. • Updates to non-Practice narrative elements of the report. • Updates to evidentiary base and citations. • Preparation of new Practice formulations. • Web-Tele-Conference Calls • Scheduling of full committee briefings by subject matter experts. • Audio and multimedia recording and streaming for committee follow-up viewing. • Committee discussions and recommendations. • Final Report • Keep structure the same • Lightly Edited Text • Updated References • Cross-walk Tables • Corrections and Clarification • Care Setting Clarification • Measures To Be Considered • Add Linkages NQF Safe Practice Timeline Q1 2008 Q3 2008 Q2 2008 Q4 2008 Jan Feb Mar April May June July Aug Sept Oct Nov Dec NQF Mtg Appeal Period Public Review SME work March 26-28 Board Approval Fall 2008 NQF Committee March 25 Work Session Completed Work Product (July 15) Call for Nominations Call for Practices Published Report Softcopy Jan 2009 Revisions

6. Update on LFG/ TMIT - 2008 Public Reporting Of 13 SPs LFG Targeted Hospitals Transparency Index Required for “Top Hospitals” Required H LFG 13 Safe Practices H Data Public TMIT High Performer 27 SPs Voluntary TMIT 14 or 27 Safe Practices H H Confidential Practice & Research Feedback H

7. 2008 TMIT • High Performer Program Leapfrog Survey Timeline Q1 2008 Q3 2008 Q2 2008 Q4 2008 Jan Feb Mar April May June July Aug Sept Oct Nov Dec Develop Draft for 2009 SP/LF survey Leapfrog Survey LF Survey deadline June 30 LF Survey release April 1 Streamline of LF questions TMIT HPP survey opens May 15 July 15 Public reporting results Compulsory if organization wants to be considered for Leapfrog “Top Hospitals” • 14 Safe practices • Voluntary report Survey • Focus on Performance Improvement Activities ** Watch for survey submission clinic schedule**

8. MRSA Eradication in a Multi-facility Organization Jane Englebright, PhD, RN CNO and VP Clinical Services Group Jason Hickok, MBA, RN Director, Critical Care and Infection Prevention HCA

9. Objectives • Understand the key role of evidence in understanding clinical strategy for a large organization • Compare barriers and roadblocks encountered in different as changing clinical practices were implemented • Analyze strategies that were successful in overcoming barriers and roadblocks

10. The Epidemic Within Healthcare Invasive MRSA infections occur in approximately 94,000 persons each year • ~ 19,000 deaths each year • 86% are healthcare-associated • 14% are community-associated. • (Klevens et al. Journal of the American Medical Association 2007;298(15):1763-1771

11. The Epidemic Within Healthcare APIC Point Prevelence Survey 2007 • 46 out of every 1000 patients colonized / infected with MRSA • Over $2.5 billion excess health care costs attributable to MRSA infections

12. Professional & Lay Literature Taking Notice

13. We’re Not Alone

14. Consumers Getting Activated

16. Growing Regulatory Interest Source: www.apic.org

17. Federal Legislation MRSA • Bill Number:HR 4451Title:MRSA Research and Study Act of 2007 • Summary:Would establish a competitive grant program for research on preventing, treating, and finding a cure for Methicillin Resistant Staphylococcus Aureus. • Sponsors:Rep. Cliff Stearns (R-FL) • Bill Number:S 2525Title:MRSA Infection Prevention and Patient Protection Act • Summary:Would require hospitals to report no later than 1/1/09 via National Healthcare Safety Network (NHSN) the number of cases of healthcare-associated-MRSA. The bill would require incremental implementation starting with the intensive care unite (ICU) and other high risk departments while establishing a process and timetable for extending the screening to all patients admitted to all hospitals. This would be done in consultation with the Centers for Disease Control and Prevention (CDC). • Sponsors:Sen. Robert Menendez (D-NJ); Sen. Richard Durbin (D-IL)

18. Are you performing ASC of MRSA high risk populations? 27% - Yes 73% - No Do you keep track of the HAI MRSA infection rate separately from colonization?53% - Yes44% - No No consistent baseline No consistent approach HCA Self Exam

19. MRSA in Denmark 100% Rosdahl VT, et al. Infect Control Hosp Epidemiol. 1991;12:83-88. 90% 80% 70% 60% 50% MRSA Bloodstream Infections 40% 30% 20% 10% 0% 1960 1965 1970 1975 1980 1985 1990 1995

20. Effective Control Strategies MRSA Bacteremia Rates Brigham and Women’s Hospital Boston, Massachusetts January, 1996 – January, 2005 • Screening High Risk Patients with Active Surveillance Cultures (ASC's) • Use of Barrier Precautions (BPs)/Clean or dedicated equipment • Hand hygiene and other Standard Precautions Susan Huang, M.D., M.P.H., et al Clinical Infectious Diseases 43:971, 2006

22. Debate: To Screen or Not? • Literature Mixed • Professional Society / Authority Recommendations Mixed • SHEA: Original Guidelines Endorsed • Highly Political, recanted to some degree • SHEA/APIC Statement that “screening should not be legislated” misconstrued as recommendation against . . . • SHEA / APIC Talking Points:

24. Handwashing compliance by health care workers: The impact of introducing an accessible, alcohol-based hand antiseptic.Arch Intern Med. 2000 Apr 10;160(7):1017-21. • Bischoff WE, Reynolds TM, Sessler CN, Edmond MB, Wenzel RP. • Department of Internal Medicine, Medical College of Virginia, Campus of Virginia Commonwealth University, Richmond 23298-0663, USA. • CONTEXT: Under routine hospital conditions handwashing compliance of health care workers including nurses, physicians, and others (eg, physical therapists and radiologic technicians) is unacceptably low.. • RESULTS: Baseline handwashing compliance before and after defined events was 9% and 22% for health care workers in the medical ICU and 3% and 13% for health care workers in the cardiac surgery ICU, respectively. • OBSERVATIONS after introduction of the new, increasingly accessible, alcohol-based, waterless hand antiseptic revealed significantly higher handwashing rates (P<.05), and handwashing compliance improved as accessibility was enhanced-before 19% and after 41% with 1 dispenser per 4 beds; and before 23% and after 48% with 1 dispenser • for each bed. • CONCLUSIONS: Education/feedback intervention and patient awareness programs failed to improve handwashing compliance. However, introduction of easily accessible dispensers with an alcohol-based waterless handwashing antiseptic led to significantly higher handwashing rates among health care workers.

27. HCA Process • Rapid Design Session (9/06) • Two day meeting with a review of current literature and • Multidisciplinary Team representing various specialties and regions • Specific actionable recommendations…

28. HCA’s Solution • The “ABC’s . . .” • Active Surveillance of high risk patients • BarrierPrecautions • Compulsive Hand Hygiene • Disinfection / Environmental Cleaning • Executive Championship

29. Active Surveillance • Starting Requirements • ICU Admits/transfers and • One additional high-risk population – determined by facility • Additional populations to be added within a three month window • Pre-Op Patients: CABG, THR, TKR, Open Spine • Previous History; may choose to isolate w/o screening – if so, private room required • Hemodialysis patients • NICU outborn admissions and/or transfers in • Patients admitted/transferred from a Nursing Home or other Healthcare Facility

30. Barrier Precautions • Isolation of positive patients • Gown, gloves, and mask (follow CDC recommendations) • Standard precautions for all patients • Pictorial instructions for staff and patients • Dedicated equipment for MRSA+ patients • “Ticketing” for non compliance

31. CompulsiveHand Hygiene • Culture change to 100% compliance • Vendor assistance with alcohol gel strategic placement, consider PIYC • Engage Leaders, MDs, Nurses, Clinicians • Executive walk around scripts for leaders • Scripted behavioral expectations of caregivers • “Ticketing” for noncompliance • Positive feedback for compliance through recognition & rewards • Reporting to Infection Control Committee (or equivalent), MEC, Board, and staff • Encourage patient involvement and questioning of hand hygiene practices of their caregivers

32. Disinfection / EnvironmentalCleaning • Pictorial illustrations of proper cleaning techniques • Appropriate use of cleaning agents and adhering to vendor specifications (Timed disinfection that cannot be thwarted.) • Strive for dedicated cleaning staff for a specific area to improve accountability

33. Executive Championship • CEO as Owner for Program • Improved Operations Internally, Positive Communication Externally • Tools: • CEO to appoint an Operational Leader for initiative • Executive walk around observation tool • Senior Leadership Checklist of Action Items • Senior Leadership slide presentation • Billing and Coding Guidelines • Marketing engagement tools for community awareness • Risk reduction by partnership with SNF’s, Home Health • Positive Community Awareness

34. Launch date: 1/17/07

35. Barriers • Denial • Process changes • Resistant physicians

36. “I don’t have a problem… “My program is effective,.. I am at or below benchmarks” “I’ve got bigger problems that need these resources” Review of data and compare to best practice, not benchmark Denial

37. Pre-op patients who need a nasal swab Registration to help identify high risk patients Fine tuning the swabbing process (ICU admissions) Defined ideal processes Data (or lack of data) was shared on need for decolonization after pre-op Process

38. Orthopedic and Neuro Surgeons Liability Process Responsibility Listen Address process issues Peer conversations Surgeon to Surgeon ID Physician to Surgeon Resistant Physicians

39. Most recent information will be provided at time of presentation HCA Hand Sanitizer Use

40. HCA “ABC’s” Program Receives National Recognition Above: Denise Murphy, President of APIC presents HCA’s Dr. Jonathan Perlin, Dr. Jane Englebright, and Mr. Jason Hickok with APIC’s (Association of Professionals In Infection Control and Epidemiology) Award at the National Press Club “International Infection Prevention Week” Commemorative Ceremony. Left: Dr. Perlin presents HCA’s program at the National Press Club and to 11,000 on web-cast

41. IHI: Five Key Interventions • Hand hygiene • Decontamination of the environment and equipment • Active surveillance cultures (ASCs) • Contact precautions for infected and colonized patients • Compliance with Central Venous Catheter and Ventilator Bundles

42. 2008 and Beyond • Expand focus to include other MDROs • Continued focus on hand hygiene • Integrating the concept of Zero Tolerance into our culture

43. Arlene SalamendraPatient Advocate

44. CREATING A CULTURE OF INFECTION PREVENTION Candace Cunningham RN MRSA Prevention Coordinator VA Pittsburgh Healthcare System

45. VA Pittsburgh Healthcare System • 3 campus veteran’s healthcare system • University affiliated • 140 bed acute care campus • Includes 3 critical care units, 1 step-down unit, 3 med-surg/telemetry units • Liver and kidney transplant

46. Phase 1 – Surgical Unit • Collaborative effort of the VAPHS, CDC and Pittsburgh Regional Health Initiative (PRHI). • Goal of project was to eliminate waste thereby providing staff with more time to improve infection prevention efforts. • Toyota Production System principles used as tool to make changes

47. Phase 1 – Surgical Unit • Staff • Identified gaps and barriers related to infection prevention practice. • Used TPS concepts to discover solutions. • Leadership supported staff and assisted in removing barriers.

48. Phase 1 – The beginnings of change • Improvements • Hand hygiene and Contact Precautions compliance • Supply storage including isolation supplies. • Timeliness of patients to physical therapy • Medication delivery times • Implementation of nares swabbing program

49. Phase 1 – The Metrics • Nares swabbing rate compliance. • MRSA hospital-acquired infection • MRSA transmission • REAL TIME feedback of metrics to encourage staff ownership of data

50. Phase 1- Expansion to SICU • September 2004, the MRSA prevention initiative was expanded to the surgical intensive care