Reducing Harm: MRSA

1. Reducing Harm:MRSA Fran GriffinInstitute for Healthcare Improvement

2. The Next Campaign WE’RE GOING AFTER HARM…

3. 100,000 Lives Campaign • Deploy Rapid Response Teams • Deliver Reliable Care for Acute Myocardial Infarction • Prevent ADE by implementing Medication Reconciliation • Prevent Central Line Infections • Prevent Surgical Site Infections • Prevent Ventilator-Associated Pneumonia

4. 5 Million Lives Campaign The Platform • Reduce Surgical Complications – Adopt “SCIP” • Prevent Harm from High Alert Medications • Reduce MRSA Infections • Reduce Congestive Heart Failure Readmissions • Prevent Pressure Ulcers • Get Boards on Board

5. Prevent MRSA Infection The Goal: Reduce methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection by December 2008

6. A Vision For The Future? 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

7. Or This? MRSA in the UK

8. What Does the Evidence Tell Us? • Target Modes of MRSA Transmission • Person-person via hands of health care providers • Personal equipment (e.g., stethoscopes, PDAs) and clothing • Environmental contamination • Airborne transmission • Carriers on the hospital staff • Rare common-source outbreaks

9. Prevent Infection and Colonization • Colonized patients • Reservoir for transmission • Nearly 1/3 develop infection, often after discharge • Long-lasting and can transmit MRSA to patients in other health care settings (e.g., nursing homes) and family members • High rates of MRSA colonization complicate empiric antibiotic therapy (e.g., vancomycin)

10. Human & Financial Impact • Over 126,000 hospitalized persons infected annually • 3.95 MRSA infections occur per 1,000 hospital discharges • Over 5,000 patients die as a result of these infections • Over $2.5 billion excess health care costs attributable to MRSA infections On average, each patient with MRSA infection has: • 9.1 days excess length of stay (LOS) • Over $20,000 in excess cost per case (range $7,000 – $32,000) • 4% in excess in-hospital mortality

11. Expert Input • Association for Professionals in Infection Control and Epidemiology (APIC) • Centers for Disease Control and Prevention (CDC) • Society for Healthcare Epidemiology of America (SHEA) • Experts published in literature • Other Campaign partners

12. 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

13. Hand Hygiene • Single most important intervention before and after patient contact • Compliance rates of 40-50% no longer are acceptable • Hold staff accountable • Encourage patients and families to remind caregivers • Alcohol hand rubs make hand hygiene easier • Rapidly kill bacteria (except Clostridium difficile spores) • Surprisingly gentle on hands • Not a substitute for soap and water when hands are grossly soiled

14. Tips: Hand Hygiene • Count the steps! • Check placement • Provide the supplies • Provide real-time feedback • Send and post department-level data

15. Decontamination of Environment and Equipment • Use dedicated equipment for colonized/infected patients • Clean patient care and personal equipment when leaving the bedside – “just a dab’ll do ya!” • Put environmental services personnel on the team • Clean and disinfect the environment carefully • Focus on “high touch” areas

16. TIPS: Decontamination • Use a checklist for cleaning • Educate staff • Verify competence • Schedule cleaning times for rooms of patients in isolation or on contact precautions. • Use immediate feedback mechanisms to assess cleaning and reinforce proper technique.

17. Active Surveillance • Cultures (ASCs) to detect colonized patients • Necessity of ASCs per se in controlling MRSA is controversial • “Knowledge is power” – clinical cultures miss many colonized patients • Successful programs combine ASCs with reliable implementation of other interventions • Flag colonized patients when discharged

18. TIPS: Active Surveillance • Begin with admission cultures only • Measure compliance; add the second culture when high (> 90%) • Provide real-time notification of positive admission culture • Schedule consistent day of week for second culture, • Include culture in routine discharge order sets. • Measure transmission • number or rate of patients who convert from negative to positive. • Flag colonized patients when discharged

19. Contact Precautions • Use for infected and colonized patients per CDC/HICPAC guidelines • Gloves, gowns and hand hygiene • Single rooms preferred • Reinforces need for reliable barrier practices • Facilitates cleaning during stay and post-discharge • If necessary, cohort patients with MRSA

20. TIPS: Contact Precautions • Train staff on importance • Ensure adequate supplies • Check and replenish supplies regularly • Consider scheduled times for checking supplies • Educate patients and families/visitors • Encourage them to question personnel • Use “visual cue” especially if single rooms or cohorting not possible • Ensure patients on precautions have same standard of care as others • frequency of entering the room • monitoring vital signs • Plan & notify for patient leaving room

21. Device Bundles • Critically ill patients at high risk • May be colonized or acquire in hospital • Bundles • Central Line: prevent BSLI • Ventilator: prevent VAP • Minimize device days!

22. Culture Change • Implement Leadership WalkroundsTM • Senior leaders talk directly with front-line staff about safety • Train staff in SBAR • Situation-Background-Assessment-Recommendation • Establishes clear layout of information • Non-threatening manner allows for appropriate assertion • Conduct briefings on units to increase staff awareness • Involve patients and families in processes, such as rounds.

23. What Leadership Should Do • Acknowledge the magnitude and consequences of the problem • Emphasize the “business case” for MRSA reduction • Encourage intolerance of the status quo • Empower front-line multi-disciplinary teams to get the job done • Provide necessary supplies, resources, and personnel • Hold staff accountable for reliable performance of basic infection control practices once appropriate systems and supplies are in place • Review data regularly • Remove barriers to success

24. Other Tips for Getting Started • Begin in a high-risk area (ICU or group of ICUs) • Learn to work as a multi-disciplinary team • Feed back compliance data in real time • Monitor impact of change on MRSA transmission • Demonstrate that the additional investment in resources pays off • When reliable compliance with ALL 5 MRSA interventions is achieved AND the rate of MRSA colonization begins to fall… …celebrate success and SPREAD!

25. Winning Execution Strategies • Pick a patient segment upon which to test • Work with those who want to work with you • Small tests of change, small tests of change, small tests of change • Learn as you go: develop process for review and improvement • Encourage customization

26. This can be done! University of Virginia Hospital Thompson RL, Cabezudo I, Wenzel RP. Epidemiology of nosocomial infections caused by methicillin-resistant Staphylococcus aureus. Ann Intern Med. 1982;97(3):309-317.

27. VAPHS 4-West Hospital-Acquired MRSA Infection Rate(per 1,000 days of care) Source: “Eliminating Hospital-Acquired Infections” presentation slides from Jon Lloyd, MD, FACS, from VHA’s Best Practice Symposium, September 18, 2006

28. “If prevention is primary, action is imperative.” – William Jarvis Infect Control Hosp Epidemiol. 2004;25(5):369-372.