1. Provincial MRSA Infection Prevention and Control (IPC) Guidelines and Standards (2008) Bernice Heinrichs, MN, CIC Project Manager, IPC

2. Presentation outline MRSA Guidelines and Standards overview Specific Recommendations MRSA Guidelines and Standards across the care continuum MRSA surveillance and reporting in Alberta

3. MRSA Skin Infections Photograph courtesy of Dr. Mark Joffe, CHICA Conference 2007

4. MRSA Skin Infections Photographs courtesy of Dr. Mark Joffe, CHICA Conference 2007

5. MRSA Skin Infections Photographs courtesy of Dr. Mark Joffe, CHICA Conference 2007

6. MRSA Skin Infections Photographs courtesy of Dr. Mark Joffe, CHICA Conference 2007

7. Background MRSA infections can cause worse clinical outcomes than MSSA infections CNISP reported increased rate of MRSA in Canadian hospitals from 0.46 to 5.90 per 1000 admissions 1995-2004 Health care costs of MRSA in Canada estimated at $82 million in 2004 Patients with MRSA require prolonged hospitalization (average 26 days) Goetghebeur M, Landry PA, Han D, Vicente C. (2007). Methicillin-resistant Staphylococcus aureus: A public health issue with economic consequences. Can J Infect Dis Med Microbiol. Vol. 18. No 1. January/February

8. Provincial MRSA IPC Guidelines The purpose of the guidelines is to define IPC best practices to reduce the transmission of MRSA and to outline the management of patients infected or colonized with MRSA across healthcare and community settings Patients should not be denied access to service because of colonization or infection with MRSA

9. Development of Provincial MRSA IPC Guidelines Identified as a priority for managing antimicrobial resistance An MRSA Working Group was appointed by the Deputy Provincial Health Officer in April 2005 The Working Group included representatives from urban and rural facilities, long term care, public health, acute care, community and emergency care

10. MRSA IPC Guidelines Provide guidance to reduce the transmission of MRSA Available on AHW website http://www.health.gov.ab.ca/resources/publicatio ns/IPC_MRSA-Guidelines-Aug07.pdf Appendices include one page information sheets for transport personnel, specimen collection, outbreak checklist and education pamphlets for client/visitor/family, patient information, hospital facility staff, and community

11. MRSA Standards One of four provincial standards released in January 2008 Based directly on the Provincial MRSA IPC Guidelines Specify requirements for preventing the spread of MRSA in all health care facilities and settings and managing outbreaks when they occur Clarify the role of the regional MOH in managing outbreaks of MRSA

12. MRSA Standards Minister Dave Hancock directed Regional Health Authorities (RHAs) to implement the standards February 1, 2008 Monitoring for compliance will occur

13. MRSA Standards – what do they mean in practice? Health Canada’s Routine Practices are the foundation for the MRSA guidelines and standards In acute care, contact precautions should be used in addition to Routine Practices for MRSA positive patients For all other settings, the utilization of personal protective equipment should be based on risk assessment for transmission

14. Brief Review of Provincial MRSA IPC Guideline Sections Definitions Assessment of Risk Decreasing MRSA Transmission Medical Transport Surveillance Screening Outbreaks Decolonization Education Occupational Health and Safety

15. (Adapted from Health Canada, Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care, 1999) Higher Risk of TransmissionLower Risk of Transmission PATIENT  Draining skin lesions or wounds not covered by dressings  Respiratory secretions (uncontrolled)  Patient requiring extensive hands-on care  Patient has invasive devices  Poor compliance with hygienic practices and infection control precautions, e.g., confused patient  Incontinence of stool or urine (not contained)  Exfoliating skin conditions  Skin lesions or wounds covered by dressing  Able to control respiratory secretions  Capable of self care  Good hygiene  Able to comply with infection control precautions  Continent Risk of Transmission

16. Higher Risk of TransmissionLower Risk of Transmission MICROORGANISMS MRSA characteristics that promote transmission:  Spread by contact  Able to survive in the environment  Able to colonize invasive devices  Propensity for asymptomatic/carrier state Risk of Transmission continued

17. Higher Risk of TransmissionLower Risk of Transmission ENVIRONMENT  Inadequate housekeeping  Shared patient care equipment without cleaning between patients (e.g., thermometer bases, commodes)  Crowded facilities  Shared facilities (e.g., rooms, toilets, bath, sinks)  High patient-nurse ratio  Appropriate housekeeping  Dedicated equipment  Adequate spacing between beds  Dedicated bathroom facilities  Low patient-nurse ratio Risk of Transmission continued

18. Higher Risk of TransmissionLower Risk of Transmission HOST PATIENT  Requiring extensive hands-on care.  Have invasive procedures or devices  Non-intact skin  Exfoliating skin conditions  Debilitated, severe underlying disease  Extremes of age  Recent antibiotic therapy  Immunosuppression  Able to do self-care  No indwelling devices  Intact skin and mucous membranes Risk of Transmission continued

19. MRSA Standards Patients with a history of hospitalization or of being institutionalized (e.g. mental health, LTC, corrections) for 24-48 hours or more, within the past 6 months should routinely be screened on admission to an acute care facility Purpose is to identify patients who are colonized or infected with MRSA, place MRSA positive patients into contact precautions and reduce risk of MRSA transmission

20. MRSA surveillance in Alberta Outbreak investigation of community associated MRSA (CA MRSA) June 2005-Feb 2006 Lab surveillance ongoing - the 1 st clinical MRSA isolate for each patient is submitted to the Provincial Laboratory of Public Health for Pulse Field Gel Electrophoresis (PFGE) testing

21. MRSA Outbreak reporting Any person who knows or has reason to suspect the existence of MRSA: In epidemic form; Occurring at an unusually high rate; or That is caused by a nuisance or other threat to public health, Shall immediately notify the regional MOH by the fastest means possible

22. AHW reporting of MRSA MRSA data is reported to regions electronically from the Provincial Laboratory of Public Health Monthly MRSA data is included in a AHW Notifiable Disease Summary and distributed to provincial IPC contacts throughout the province A more comprehensive provincial MRSA surveillance plan is being developed

23. Strain specific rates (per 100,000), by Health Region for MRSA in Alberta (Jan 1, 2006 -Dec 31, 2007) Health Region CMRSA Strain Type 2467810 Chinook53.00.00.314.40.625.2 Palliser45.40.0 1.50.534.7 Calgary32.00.10.45.81.559.9 DTHR62.80.33.3 0.330.0 East Central12.10.45.84.50.415.7 Capital7.10.09.44.60.345.5 Aspen7.00.68.59.01.132.1 Peace Country5.40.02.91.80.059.0 Northern Lights3.30.72.011.31.392.0 ALBERTA24.70.14.25.50.848.0

24. Strain specific rates (per 100,000), by Month for MRSA in Alberta (Jan 1, 2006 -Dec 31, 2007)

25. Summary Provincial MRSA guidelines and standards outline requirements for preventing the spread of MRSA in all health care settings and clarify the role of the regional MOH in managing outbreaks MRSA is a growing problem in health care settings Specific protocols are required to stop the spread of infection from patient to patient