1. BEST PRACTICES: MRSA PRECAUTIONS Dr. Elizabeth Bryce

2. Topics to Be Covered  Devising Risk Strategies  Risk Assessment for Level of Precautions  Determining the Need for Additional Precautions

3. Devising Risk Strategies: Waxing Philosophical To develop effective prevention strategies must understand the components responsible for the current state in your facility:  Rates of Community acquired MRSA  Rates of Healthcare Acquired MRSA  Rates in your Facility The same situation? Very high rates of CMRSA+ high incidence of HCMRSA + endemic in facility VS Little CMRSA + little HCMRSA + low facility rates

4. Risk management strategies… BUT also consider:  Your Patient Population  Your Environment  Impact of implementation plan/procedures  Feasibility  Probability of Effectiveness of measures What is the goal of your strategy? MRSA EradicationMRSA Control?

5. But Wait …..There’s More! Who will you target?  The Facility Population?  Just Inpatients? Or Residents?  Pre-Admit Population (prior to admission)  The Community?

6. Risk Assessment Transmission and persistence determined by:  Vulnerable patients  Selective antimicrobial pressure  Colonization pressure  Impact of implementation strategies  Continued adherence to prevention (long- term investment)

7. Risk Assessment Two components to remember  Organizational risk assessment which sets policy and procedure  Individual risk assessment with each patient interaction

8. General Control Interventions  Administrative Support  Antimicrobial Stewardship  Surveillance  Environmental Cleanliness  Routine/Contact Precautions  Education  Additional Precautions  Critical Review of implementation strategies

9. Administrative Support  Fiscal Resources  Human Resources  Implementing System Changes  Physical Plant Changes  Promoting Adherence/Role Modeling  Fostering a Safety Climate

10. Antimicrobial Stewardship  Shortest duration possible  Narrowest spectrum possible  Treat the patient, not the report!  Formulary Reviews  Built-in Compliance features in Pharmacy  Practice Guidelines

11. Environmental Cleanliness  Correct Agent/Dilution  Correct method  Avoid Clutter  Focus on frequently touched surfaces  Isolation Cleaning Protocols  Don’t forget shared equipment

12. Education Many different strategies  Facility-wide versus focused  Informational, interactive, training, campaigns  Ideally behaviour change oriented And trying to effect a culture change

13. Routine Precautions  Have an essential role in preventing transmission – always  Particularly important vis a vis undetected cases  Hand Hygiene particularly important here as is Risk Assessment

14. Additional Precautions Very important to consider the context and the situation Contact Precautions : Evidence: Consensus versus evidence based recommendation. Elements: single/isolation rooms or cohorting, use of gown and gloves for potential patient contact or contact with contaminated areas Unresolved: Duration of CP Impact of CP on patient well-being and care Use of CP preemptively

15. Other Barriers  For the most part; as per Routine Precautions  Mask – anticipated exposure to droplets/secretions  Respirator – generally not specifically for MRSA  Facial Protection – anticipated exposure to droplets/secretions

16. Other Measures  Notifying others of patient transfers or diagnostic procedures  Ensuring patients clean hands and cover open wounds when outside room  Visitors informed of appropriate precautions  Education of patient

17. Finally…… Control of MRSA should be  Dynamic  Systematic  Tailored to reflect the epidemiology/environment  Flexible – can be scaled up or down  Measured Strive to: Assess the problem, evaluate the effectiveness of the measures implemented.

18. References  Taconnelli E: MRSA: risk assessment and infection control policies. Clin Microbiol Infect 2008  Humphreys H National guidelines for the control and prevention of MRSA – what do they tell us? Clin Microbiol Infect 2007:13:846- 853  PICNet revised ARO guidelines Dec 2007  Sigel J Management of multidrug-resistant organisms in healthcare settings, 2006 Am J Infect control 2007;35:S165-193  Coia JE Guidelines for the ontrol and prevention of MRSA in healthcare facilities. J Hosp Infect 2007;63S:S1-S44