The Kentucky MRSA Collaborative: Reviewing Progress Made During 2009

1. The Kentucky MRSA Collaborative: Reviewing Progress Made During 2009 Ruth Carrico PhD RN CIC Assistant Professor School of Public Health and Information Sciences University of Louisville

2. Objectives • Review elements of the MRSA Collaborative including the program goals and toolkit • Review data from the Collaborative • Utilize data to identify improvements for the 2010 journey to infection elimination

3. Collaboration • Brings groups together to work on shared problems • Encourages and enables the sharing of experiences and discovery of new ways to do old things • Steeped in the experiences of social networking • Collective intelligence allows greater opportunities than individual ideas and activities • Success of the collaboration is hinged upon involvement, recognition of its value, and devotion to continuous improvement • Each participating hospital is responsible for their own improvement activities

4. Toolkit and Benchmarking • Developed through Advisory Board and infection preventionist from across the state • Contains evidence basis, sample documents, tools and evaluation resources • Benchmarking through secured Web site to collect data on hand hygiene, room cleaning and MRSA rates

5. Toolkit Format • Evidence basis • Compendium, Infection prevention competencies, CDC guidelines, IHI • Sample documents • Policies, checklists, isolation signs • Tools and resources • APIC Elimination Guide, videos, grids • Evaluation metrics • Observation methods, description of outcome measures with definitions

6. Toolkit Components • How to implement and use the toolkit • Risk assessment • Tools and resources • Cleaning (environment and equipment) • Isolation • Hand hygiene • Fact sheets • Antimicrobial stewardship • Outcomes measures

8. Sample Risk Assessment • Encourages multidisciplinary approach • Builds accountability and collaboration • Identifies risks across the organization and prioritizes so there is alignment with the goals/resources of the organization • Begins dialogue regarding priorities

9. Practice Observations • Environmental cleanliness • Hand hygiene

10. Impact of the Environment • Patients colonized or infected with healthcare-associated pathogens frequently contaminate items in their immediate vicinity • These pathogens may remain viable on surfaces for days to weeks • Healthcare workers can contaminate their hands by touching contaminated surfaces • These pathogens on HCW hands can be transmitted to other patients, surfaces, and themselves if hands are not cleansed properly

11. Impact of the Environment • Routine cleaning of patient rooms is often suboptimal • Inadequate cleaning of rooms after discharging a patient with MRSA or VRE puts subsequent patients admitted to that room at risk of acquisition of the organism • Improved cleaning and disinfection of the environment can reduce the risk of patients acquiring multidrug-resistant pathogens • Monitoring the effectiveness of environmental cleaning is necessary

12. The Inanimate Environment Can Facilitate Transmission Xrepresents Multidrug resistant organism culture positive sites ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

13. Environments Contaminated with MRSA • Percent of surfaces contaminated with MRSA varied among pts colonized or infected • 6% of surfaces when patient colonized in nares • 36% if MRSA in wound or urine • 59% if heavy GI colonization • 19% in outpatient clinic contaminated with MRSA Boyce JM et al ICHE 1997 18:622 Johnson et al ICHE 2006 27:1133

14. Common Items Contaminated in Healthcare Patient Rooms • Common • Bedrails • Bedside tables • Blood pressure cuffs • Floors • Light swtches, faucets handles • Less common • IV pumps • Bed control buttons • Pulse oximetry units • Urine containers • Computer keyboards

15. Viability in the Environment • MRSA 2-9 weeks • VRE 1-12 weeks • C difficile spores days to 5 months • Acinetobacter 3-33 days • Norovirus hours to 12 days Hota B et al CID 2004; 39:1182 Kramer A et al BMC Infect Dis 2006; 2:130

16. Improving Practice • Housekeepers and nursing staff often do not agree on who should clean what • Housekeepers do not always understand • Which disinfectant to use • What concentration • How often to change cleaning cloths/mop heads • Principles of clean v. dirty • Determine competencies, then monitor and provide feedback • Develop policies regarding who should clean what • American Society for Healthcare Environmental Services (www.ashes.org)

17. Methods for Assessing Cleaning practices • Visual inspection • Checklists to assure surfaces have been wiped • Marking with fluorescent dye and checking to see if marker was moved (P Carling CID 2006;42:385) • Culturing surfaces (NOT a good idea) • ATP bioluminescence assays to measure cleanliness

20. Outcomes Measure Positive blood cultures identifying MRSA • Numerator Definition: Number of patients with MRSA bloodstream infection during the calendar month • Numerator Exclusions: • Patients with a length of stay of 2 days or less • Patients with MRSA bloodstream infection identified from blood cultures collected in the first 2 days of the patient’s stay • Denominator Definition: Total number of admissions or patient days in calendar month • Denominator Exclusions: • Patients with a length of stay of 2 days or less • Patients with MRSA bloodstream infection identified from blood cultures collected in the first 2 days of the patient’s stay

21. Outcomes Measure Positive blood cultures identifying MRSA • Denominator Definition: Total number of admissions or patient days in calendar month • Denominator Exclusions: • Patients with a length of stay of 2 days or less • Patients with MRSA bloodstream infection identified from blood cultures collected in the first 2 days of the patient’s stay • If using patient days, need to subtract the number of days from each patient stay after they are identified as having a positive blood culture for MRSA from the total

22. Key Practices • Optimal skin preparation before invasive techniques (e.g., central line insertion, surgical incisions) • Disinfection of IV access sites (scrub the hub with alcohol 15 seconds) • Proper technique when drawing blood cultures • Hand hygiene • Environmental cleaning and disinfection

23. Participating Hospitals • 126 licensed hospitals in KY • Commitment from 95% • Critical Access Hospitals (≤ 25 beds) 29 • Hospitals less than 100 beds 27 • Hospitals 100-250 beds 20 • Hospitals >250 beds 24 • Specialty Hospitals 14

24. 2009 Results: MRSA BSIs

27. 2009 Results: Hand Hygiene

29. 2009 Results: Room Cleaning

31. Continuous Improvement • Check to make sure the data you enter into the system is correct • If reporting period closes, you can still provide data. Contact KHA for assistance • The goal is still elimination so continue improvement efforts • Increase participation across more KY hospitals • Provide feedback and discuss results with other departments • Provide feedback regarding how the Collaborative can assist with improvement activities

32. Shared Knowledge Websites http://info.kyha.com/MRSA/default.htm http://www.infectionpreventiontools.com