Implementing a Novel Approach to Reducing MRSA in a Hospital Collaborative

1. Brad Doebbeling, MD, MSc, Paul Dexter, MD, Heather Hagg, MS, Shawn Hoke, Abel Kho, MD VA HSR&D Center of Excellence, Indiana University Center for Health Services and Outcomes Research, Regenstrief Institute, IU School of Medicine, Indianapolis, IN; Purdue University Schools of Engineering & Technology, Indiana University School of Informatics, Indianapolis & West Lafayette, Northwestern University, Chicago Academy-Health Annual Research Meeting, June 10th, 2008 Acknowledgements: AHRQ ACTION funding Implementing a Novel Approach to Reducing MRSA in a Hospital Collaborative

2. Implementing a Novel Approach to Reducing MRSA in a Hospital Collaborative • Purpose • Scope • Implementation • Evaluation and Preliminary Results • Lessons Learned • Next Steps

3. MRSA Background Purpose • MRSA Burden • Over 126,000 persons are infected by MRSA in hospitals annually • ~ 4 MRSA infections per 1,000 hospital discharges • Over 5,000 die as a result of these infections • Over $2.5 billion excess healthcare costs • On average, for each MRSA patient this means: • 9.1 days excess LOS • Over $30,000 in excess cost per case (range $30,000-60,000) • 4% in excess in-hospital mortality • 1/3 patients acquiring MRSA will become infected.

4. Reservoir for the Spread of Antibiotic Resistant Pathogens • Colonized patients, NOT just infected patients, can transmit AR pathogens to healthcare workers and other patients. • Clinical Cultures + • History of MRSA Unidentified Colonized Patients

5. Prevalence of Methicillin-Resistance Among S. aureus Infections, Denmark and US, 1960-2004

6. Post-intervention: ICU MRSA bacteremia rate declined 80%, p<.001 Non-ICU bacteremia rate declined 67%, p=.002 No decline in MSSA bacteremia Huang, S. Clin Infect Dis 2006;43:971-8

7. What Does the Evidence Tell Us? Consistent Use of Known Practices Work • Target Modes of MRSA Transmission • Person-person via hands of health care providers • Personal equipment (e.g., stethoscopes, PDAs) and clothing • Environmental contamination • Healthcare environment • Home/Community environment

8. Computer Alerts of MRSA Help Improve Isolation Adherence • RN awareness of MRB status increased from 24% at baseline to 59% at 1 year. -93% at 1 year after notifying nurses. • Implementation of isolation precautions increased from 15% at baseline to 51% after 1st intervention and then to 90%. • RI electronic tool notifies staff of MRSA positive history at Wishard, based on micro data from all Indy hospitals (except VA). • 286 unique patients generated 587 admissions (4,335 inpatient days) where receiving hospital unaware of the prior history of MRSA. • An additional 10% of MRSA admissions received by project hospitalsover one year and over 3,600 inpatient days without contactisolation. Cac et al Arch Intern Med. 2007;167(19):2086-0 Kho et al J Am Med Inform Assoc2008; 15:212-216

9. AHRQ ACTION Contract Implementation • “Testing Techniques to Radically Reduce Antibiotic Resistant Bacteria (MRSA)” • AHRQ funded Indiana ACTION Team effort over 18 months through the ACTION collaborative funding mechanism • Our interventions are based on the Pittsburgh model as specified by AHRQ: • conduct active surveillance of all incoming pts. in ICUs • improve rates of contact isolation • Improve hand hygiene rates

10. Electronic Data Sharing in Indy • Indianapolis has unique health information exchange • Indiana Network for Patient Care (INPC) • includes nearly all of the healthcare systems in Indianapolis • spans >95% of all of the inpatient care in the city.   • The five competing health care systems (VA excluded) have agreed to share information on their patients, to ensure safe and quality health care. 

11. Conceptual Framework and Strategy • Interdisciplinary Research & Ops Teams • Clinicians, Health Services Researchers, Engineering/Technology Faculty, Purdue Communication faculty/students, Organizational Psychologists, Informaticists • Partnership with selected Hospital Clinical Staff • Integrated Lean/Positive Deviance Approach: • Identification of solutions from within, bottom up • Leadership support and buy-in • Standardization where evidence exists or to simplify • Customization to meet local redesign needs

12. What is Positive Deviance? • Technique used engage front line staff in improving processes and sustaining change • Based on identification of practices of used by ‘positively deviant’ staff/departments • Critical for staff involvement/buy-in

13. Integrated Lean/PD approach Define the Problem Baseline Current Processes Discovery Identify Operational Barriers Develop Future State Process Action Process Control Strategy

14. Health Systems Involved • Two ICU units in 3 original hospital systems • St. Francis (two ICUs in South Hospital) • Clarian (Methodist and University Hospital) • Community (Community East and Heart Hospital) • Early success encouraged 3 remaining systems to join the project • Wishard (two ICUs) • VA Medical Center (housewide) • St. Vincent's (two ICUs in north facility)

15. System Redesign • Our health care engineers partner with and train front-line workers to use lean-six sigma and positive deviance approaches • Focus on coaching front-line staff teams to lead instituting systems changes to systematize processes and sustain practices. • Emphasize regular measurement and feedback of adherence to enhance adoption. • Weekly Meeting of all hospital teams to identify barriers & facilitators, review and reinforce progress, share best practices, strategize about spread and solutions.

16. Evaluation and Results • Range of 3-22% (monthly average) incoming patients colonized with MRSA on study units • The number of conversions varied across study units (4 23 during study period) • Variability in pre-intervention Nosocomial infection rates across participating hospitals (.015  .025) • Greater variability in pre-intervention study unit MRSA infection data (.008  .074)

17. Preliminary Results • Preliminary pre and post intervention results for first three hospitals suggest average of 60% reduction on study units • ~ 20% reduction hospital wide • Currently investigating optimal biostatistical approach such as time series analysis to confirm

18. Lessons Learned--Implementation • System redesign approach of training, consultation and coaching front-line staff seems to be strong, sustained approach • Importance of buy-in from highest institutional levels crucial • Enthusiasm builds from within because redesign teams own it! • Informatics tool helpful in identifying great cross-over of MRSA patients in hospitals

19. Lessons Learned--Research • Our proposed data collection too intensive for most community hospitals • Need to adequately staff data collection and observation of intervention bundle compliance • Need a better electronic data collection infrastructure relating to compliance and outcome data • Little time for paper writing and dissemination projects (Hazard of short time lines for funding)

20. Next Steps • MRSA Initial project officially concluded June 2008 • Data continues to be compiled, verified…nosocomial infection data results being validated against MRSA clinical isolates • Working on further proposal development to investigate effective implementation mechanisms, spread of intervention, role of active surveillance in infection control, and spread and sustainability of interventions over time

21. AHRQ MRSA Team • Brad Doebbeling, MD, MSc – Co-PI • Paul Dexter, MD – PI • Abel Kho, MD • Shawn Hoke • Jamie Workman-Germann, MS • Doub Webb, MD • Laurie Fish, RN • Claire Rumpke, RN • Loretta Marsh, RN • Sandra Benson, RN • Marie Comminsky, RN • Diana Greathouse, RN • Kim McCoy, MS • Amy Kressel, MD • Mahesh Merchant, PhD • Mindy Flanagan, PhD • George Allen

22. Additional Information VA HSR&D Center for Implementing Evidence-based Practice Regenstrief Institute, Inc., Indianapolis Phone: 317-988-4493 Fax: 317-554-0114 http://www.ciebp.research.va.gov http://www.indyhsr.org Contact Us Shawn Hoke, Program Manager Heather Woodward, Implementation Director Brad Doebbeling, EBP Co-PI Paul Dexter, Informatics Co-PI

23. Additional Slides

24. Lean Tools Define the Problem Project Charter Baseline Current Processes Process Map Check sheet Process Observation Worksheet Identify Operational Barriers Spaghetti Diagram Develop Future State Process Lean Tools Process Control Strategy Process Control Plan

25. Discovery and Action • Informal meetings held with front line staff to discuss the current status of the process • Incorporate as much front line staff as possible • The goal is to ‘discover’ the issues and potential solutions and then take ‘action’ as rapidly as possible. • It is easier to “act your way into a new way of thinking” then to “think your way into a new way to acting”