Controlling MRSA Michael Gardam Director, Infection Prevention and Control

1. Controlling MRSA Michael Gardam Director, Infection Prevention and Control University Health Network, Toronto National MRSA Intervention Lead www.saferhealthcarenow.ca

2. Objective To introduce the Safer Healthcare Now! MRSA intervention bundle… …with a focus on MRSA screening

3. The Problem • The MRSA rate in Canadian hospitals increased 17- fold from 1995 to 2006 (CNISP) • It doesn’t have to be this way: • The Netherlands, Denmark and Finland have decreased the percentage of MRSA infections from 30% to 1% of S. aureus infections. • The emergence of Community Acquired MRSA

6. Many of us follow these strategies…but how good a job are we doing?

7. # 1 Hand Hygiene • 30 - 40 % of healthcare providers comply with WHO hand hygiene guidelines • hand hygiene could reduce infections obtained in healthcare settings by up to 50% • Canadian Hand Hygiene Campaign www.handhygiene.ca

8. Staff consistently cleaning their hands is the most important patient safety strategy a hospital can have

9. # 2 Environmental Cleaning • Assessing effectiveness of cleaning by identifying surfaces that were skipped in the cleaning process • Developing observational tools to measure if policies/checklists are being followed correctly; • Verifying competence in cleaning and disinfection procedures using observational tools;

10. # 2 Environmental Cleaning • Scheduling specific cleaning times for rooms of patients in isolation or on contact precautions; • Using immediate feedback mechanisms to assess cleaning and reinforce proper technique

11. # 3 Contact Precautions • …and Routine Practices • Provincial Guidelines available • When to place a patient on precautions

12. # 4 Active Screening

13. Relative impact of admission screening influenced by: Missed cases Hand hygiene compliance Result turnaround time Effectiveness of environmental cleaning Compliance with contact precautions Interval between entry and screening

14. Costs of Active Screening Cultures Active screening avoids additional costs by preventing further colonization and infection It won’t make the facility more money….but will help it lose less money

15. Caveat: American cost studies do not necessarily translate well to the Canadian healthcare system For profit: infections eat up profits Socialized medicine: infections do not affect global budgets…but they worsen efficiency

16. Admission Screening Options No screening Risk-based screening Universal screening Combination of all three

17. Risk based screening • Most common form of admission screening • How well is it working for you? • Do your HCWs ask the questions? • What happens if the patient cannot answer? • Are their MRSA positive patients without traditional institutional risk factors? • Community acquired MRSA

18. Universal Screening • Easier to do operationally….but • Does your epidemiology justify it? • Increased costs up front • Poor substitute for hand hygiene

19. No MRSA admission surveillance at baseline in 3 hospitals • Moved to universal PCR-based screening • ICUs • Whole hospitals • Outcome: MRSA clinical infections • Measured MSSA bacteremias as a control Annals Int Med, March 2008

21. Results • Eventually obtained 90% compliance with admission screening • 70% reduction in invasive MRSA infections • No concurrent reduction in MSSA bacteremias

22. Crossover study of surgical patients • Universal PCR-based admission screening + infection control versus infection control alone • Outcomes • MRSA clinical infections, including MRSA SSIs • New MRSA colonization JAMA March 2008

26. Why no effect? • Low rate of MRSA to begin with • The majority of MRSA infections occurred in patients that were negative on their admission screen (i.e. nosocomial cases) • MRSA results not acted upon in 1/3 of patients i.e. prophylaxis not changed • Good adherence to hand hygiene and contact precautions

27. So what does this mean • Studies must be interpreted in context • Example: • Adding universal screening to a program with no screening will likely make a large difference (especially if hand hygiene is average) • Both studies provide valuable information

28. Why UHN moved to admission universal screening • >90% of our patients have traditional risk factors • Poor compliance with risk based screening • Exposures secondary to “low risk” patients not being screened • Community acquired MRSA • Missed risk factors • Inadequate hand hygiene compliance

30. # 5 Surveillance Healthcare Associated Blood Stream Infections caused by MRSA per 1000 Patient Days • Easy to measure • No confusion with colonization

31. What’s Next? • Secure Senior Leadership • Form a Team • Use the Model of Improvement • Spread Changes • Positive Deviance

32. Parting words • Most healthcare facilities are already doing some/most of these measures • But… • Is senior leadership behind you? • Are you measuring, reporting to stakeholders? • Are your rates improving? • Have you been able to change culture?

33. More Parting words… • Some of the MRSA interventions will help control other organisms too • Clostridium difficile • Vancomycin resistant enterococci • The next scary organism to come along…

34. Change is good……you first! 80% of initiatives fail to realize their intended gains

35. Contact Information Michael Gardam michael.gardam@uhn.on.ca Leah Gitterman leah.gitterman@uhn.on.ca