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MRSA Outbreak Management

MRSA Outbreak Management. March 25, 2008. London Health Sciences Centre. and. St. Joseph's Health Care London. Citywide Program. Medical Director, Manager, Educator + 12 FTE Infection Control Practitioners, 1 program secretary 8 hospital sites

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MRSA Outbreak Management

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  1. MRSA Outbreak Management March 25, 2008

  2. London Health Sciences Centre and St. Joseph's Health Care London

  3. Citywide Program • Medical Director, Manager, Educator + 12 FTE Infection Control Practitioners, 1 program secretary • 8 hospital sites • Approx 2,363 beds - 1,118 acute care beds (cardiac, transplant, neuro, ortho surgery, burns, trauma, obstetric, pediatric) - 130 ICU beds - Ambulatory/Short stay - LTC, Complex Care, Palliative, Rehab, Regional Psychiatric, Dialysis, Cancer Care

  4. MRSA: A growing problem • First outbreaks in late 1995 • 2002-2003 increases began again • Increasing rates each year since • CNISP data • QMPLS data

  5. Canadian Nosocomial Infection Surveillance Data – 1995-2006

  6. Ontario QMPLS Report – July 2007

  7. QMPLS Reported Number of Bacteremias – July 2007

  8. Complicating Factors • Restructuring • Nursing shortages • Multiple organizational priorities • SARS • Infrastructure challenges • Changes in the care delivery model • Non adoption of Routine Practices

  9. What’s being done to stem this tide? • Provincial recommendations • CPSI • CCHSA • Organizational Scorecard reporting

  10. Making a Change Happen D x V x F > R D- Discomfort (or dissatisfaction with the status quo) V- Vision (of the preferred future) F- First steps (clarity of the plan for how to move forward) R- Resistance factors “The product of the discomfort, vision, and first steps must be greater than the resistance or the change will fail Dannemiller & Jacobs (1992)

  11. MRSA Reduction, Logic Model 2007-2012 Draft

  12. ARO Reduction Plan, 2007-2012LHSC/SJHC • ↑ training for HCWs • ↑feedback of rates to leaders and front line staff • ↑screening • Develop city-wide hand hygiene committee • Install point of care ABHR • Compliance audits (hand hygiene, infection control precautions, multi-disciplinary clinical walk-abouts, screening practices with feedback) • Establish unit specific workgroups • ARO specific Infection Control team meetings

  13. Step 1 Process Flow Map, MRSA Screening Step 2 Control Plan, MRSA Screening and Containment Step 3 Failure Modes and Effects Analysis (FMEA)

  14. Leader Reports

  15. Be Prepared For an Outbreak! • Well established surveillance program • Relationships, team work • Flagging system • Discuss issues and problem solve scenarios beforehand • Suppression therapy, cohorting, bed closures, staff screening • Policies & procedures • Isolation, indications for patient screening, admission, contact, prevalence

  16. What is an Outbreak? New cases (incidence) in a given population, during a given time period, at a rate that substantially exceeds what is "expected.” How do you know you are having an outbreak? Surveillance!

  17. Verify Existence of Outbreak • Evidence that transmission has occurred • Consistent definition of hospital acquired • Epidemiologic review • Person, place, time • History- access to health care in the previous 12 months • Retrospective analysis of current stay • Previous rooms, units, contacts, staff • Molecular typing may be helpful

  18. Contact precautions Cohort patients Epidemiologic investigation Multi-disciplinary team Case Finding Communicate & educate Feedback Audit Environment Isolation Practice Compliance Cohort staff Suppression therapy? Staff screening? Restrict admissions? Control Measures First Steps Additional Steps

  19. Suppression Therapy • Insufficient evidence to support the use of topical or systemic antimicrobial treatment for eradicating MRSA. Loeb. M., Main, C., Walker-Dilks, C., Eady, A.(2003). Antimicrobial drugs for treating MRSA colonization. Cochrane Database Systematic Review 4 CD003340. • Value in outbreak? (decrease reservoir) • Nasal mupirocin • Mupirocin plus systemic • Mupirocin +/- CHG • CHG alone

  20. Common Challenges, Acute and Non-acute Care • Cohorting patients & staff • Patient mobility • Staff screening • Communication • Patient supplies & cleaning • Non-compliance • Insufficient ABHR

  21. Acute Care Shortage of nurses High acuity Bed closures Students Competing priorities Non-acute Care Physical limitations Insufficient supplies Frequent staff turnover Non-regulated HCW Poor lab access …………Challenges Continued

  22. Non-Acute Care Literature Hughes, C., Smith, M., Tunney, M.(2008). Infection control strategies for preventing the transmission of MRSA in nursing homes for older people. Cochrane Database Systematic Review 1. CD006354. • Lack of studies on measures to prevent transmission • Studies show nursing home is risk factor • Studies show prevalence is increasing • Screening high risk admissions? • Train key staff • Hand hygiene adherence, environmental cleaning

  23. Are Control Measures Generalizable to all Settings? No…………Why? Settings may be very different; • Acute care vs non-acute care • Tertiary teaching facility vs community hospital • Intensive care vs general medical unit • Baseline epidemiology on unit • Is MRSA epidemic or endemic?

  24. Our Conclusions • Observation must be constant • Team work pays off • MRSA management is resource consuming • Nosocomial acquisition can be reduced through intervention • Multiple unit specific interventions are required

  25. Screening patients for MRSA

  26. Screening Issues Turn around time Sensitivity Cost

  27. Screening • Focused screening • Screen only high risk patients • Universal screening • Screen all patients being admitted • Universal + focused • Screen all patients in areas where there is a problem • Screen high risk patients elsewhere

  28. Focused Screening • Choose patients for screening based on risk factors • Previous hospitalization major risk factor • In Ontario based an admission or >12 hour stay in any healthcare facility in previous 12 months

  29. Focused Screening • Advantages: • Cheaper • May be all you need • Disadvantages: • Need to identify patients who need screening • Poor compliance with screening • May miss patients with other risk factors

  30. Universal Screening • Advantages: • No need to “flag” patients • Compliance may be better • More sensitive for identification of carriers • Disadvantages: • More costly

  31. Old Screening algorithm New Screening algorithm MRSA Screen Swabs (nasal + rectal) Innoculate Separate plates Both swabs single plate 4X/day Oxacillin Salt Mannitol Agar (X2) Chromogenic Agar (MRSA Select) 24-48 hrs 24 hours Pick Yellow Colonies Presumptive Reporting to Ward 4X daily Confirm as MRSA by PCR Confirm as MRSA by PCR if no previous isolate identified from patient Report to Ward once daily

  32. Time to reporting MRSA positive patients to the ward *Statistically significant difference, p<0.0001

  33. Number of contacts of index case *Statistically significant difference, p<0.05

  34. Number of contacts who become MRSA positive

  35. Thank you MaryLou Card marylou.card@lhsc.on.ca Kathy McGhie kathy.mcghie@lhsc.on.ca Dr. Michael John michael.john@lhsc.on.ca

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