1. MRSA Outbreak Management March 25, 2008

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. Whats 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

12. ARO Reduction Plan, 2007-2012 LHSC/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

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

15. Leader Reports Quarterly Report Infection Control Indicators ServiceUnit MRSA HAI Rate/1,000 pt days 25% Reduction Target Screening ComplianceTarget Core Competency Completion 6 Mth Target Hand Hygiene ComplianceTarget MedicineA50.80.675%100%25%50%48%100% A60.50.3768%100%42%50%39%100% 4IP0.620.4685%100%30%50%45%100% SurgeryD60.70.5278%100%60%50%42%100% B80.680.5182%100%75%50%68%100% Neurology7A0.580.4398%100%58%50%52%100%

16. 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

17. 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?

18. 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

19. Control Measures 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?

20. 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

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

22. …………Challenges Continued 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

23. Non-Acute Care Literature 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 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.

24. 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?

25. 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

26. Screening patients for MRSA

27. Screening Issues Turn around time Sensitivity Cost

28. 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

29. 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

30. 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

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

32. Old Screening algorithmNew Screening algorithm MRSA Screen Swabs (nasal + rectal) Oxacillin Salt Mannitol Agar (X2)Chromogenic Agar (MRSA Select) Pick Yellow ColoniesPresumptive Reporting to Ward 4X daily Confirm as MRSA by PCRConfirm as MRSA by PCR if no previous isolate identified from patient 24-48 hrs24 hours Innoculate Separate plates Both swabs single plate 4X/day Report to Ward once daily

33. Time to reporting MRSA positive patients to the ward Time to Reporting* Mannitol Oxacillin Salt plate58.0 +/- 17.9 hours MRSAselect plate34.0 +/- 12.3 hours *Statistically significant difference, p<0.0001

34. Number of contacts of index case Average number of contacts* Mannitol Oxacillin Salt plate2.88 +/- 2.03 MRSA select plate2.30 +/- 1.43 *Statistically significant difference, p<0.05

35. Number of contacts who become MRSA positive 20052007 287 MRSA cases475 cases 37 contacts (12.89%)28 contacts (5.89%)

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