Reducing Harm: MRSA Fran Griffin Institute for Healthcare Improvement

The Next Campaign WE’RE GOING AFTER HARM…

Deploy Rapid Response Teams Deliver Reliable Care for Acute Myocardial Infarction Prevent ADE by implementing Medication Reconciliation Prevent Central Line Infections Prevent Surgical Site Infections Prevent Ventilator-Associated Pneumonia 100,000 Lives Campaign

The Platform Reduce Surgical Complications – Adopt “SCIP” Prevent Harm from High Alert Medications Reduce MRSA Infections Reduce Congestive Heart Failure Readmissions Prevent Pressure Ulcers Get Boards on Board 5 Million Lives Campaign

Prevent MRSA Infection The Goal: Reduce methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection by December 2008

MRSA Bloodstream Infections 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% A Vision For The Future? MRSA in Denmark Rosdahl VT et al. Infect Control Hosp Epidemiol 1991;12:

Or This? MRSA in the UK

What Does the Evidence Tell Us? Target Modes of MRSA Transmission ─Person-person via hands of health care providers ─Personal equipment (e.g., stethoscopes, PDAs) and clothing ─Environmental contamination ─Airborne transmission ─Carriers on the hospital staff  Rare common-source outbreaks

Prevent Infection and Colonization Colonized patients ─Reservoir for transmission ─Nearly 1/3 develop infection, often after discharge ─Long-lasting and can transmit MRSA to patients in other health care settings (e.g., nursing homes) and family members High rates of MRSA colonization complicate empiric antibiotic therapy (e.g., vancomycin)

Human & Financial Impact Over 126,000 hospitalized persons infected annually ─3.95 MRSA infections occur per 1,000 hospital discharges Over 5,000 patients die as a result of these infections Over $2.5 billion excess health care costs attributable to MRSA infections On average, each patient with MRSA infection has: 9.1 days excess length of stay (LOS) Over $20,000 in excess cost per case (range $7,000 – $32,000) 4% in excess in-hospital mortality

Expert Input Association for Professionals in Infection Control and Epidemiology (APIC) Centers for Disease Control and Prevention (CDC) Society for Healthcare Epidemiology of America (SHEA) Experts published in literature Other Campaign partners

Five Key Interventions  Hand hygiene  Decontamination of the environment and equipment  Active surveillance cultures (ASCs)  Contact precautions for infected and colonized patients  Compliance with Central Venous Catheter and Ventilator Bundles

Hand Hygiene Single most important intervention before and after patient contact Compliance rates of 40-50% no longer are acceptable ─Hold staff accountable ─Encourage patients and families to remind caregivers Alcohol hand rubs make hand hygiene easier ─Rapidly kill bacteria (except Clostridium difficile spores) ─Surprisingly gentle on hands ─Not a substitute for soap and water when hands are grossly soiled

Tips: Hand Hygiene Count the steps! Check placement Provide the supplies Provide real-time feedback Send and post department-level data

Decontamination of Environment and Equipment Use dedicated equipment for colonized/infected patients Clean patient care and personal equipment when leaving the bedside – “just a dab’ll do ya!” Put environmental services personnel on the team Clean and disinfect the environment carefully ─Focus on “high touch” areas

TIPS: Decontamination Use a checklist for cleaning Educate staff Verify competence Schedule cleaning times for rooms of patients in isolation or on contact precautions. Use immediate feedback mechanisms to assess cleaning and reinforce proper technique.

Active Surveillance Cultures (ASCs) to detect colonized patients ─Necessity of ASCs per se in controlling MRSA is controversial ─“Knowledge is power” – clinical cultures miss many colonized patients ─Successful programs combine ASCs with reliable implementation of other interventions Flag colonized patients when discharged

TIPS: Active Surveillance Begin with admission cultures only ─Measure compliance; add the second culture when high (> 90%) Provide real-time notification of positive admission culture Schedule consistent day of week for second culture, Include culture in routine discharge order sets. Measure transmission ─number or rate of patients who convert from negative to positive. Flag colonized patients when discharged

Contact Precautions Use for infected and colonized patients per CDC/HICPAC guidelines ─Gloves, gowns and hand hygiene Single rooms preferred ─Reinforces need for reliable barrier practices ─Facilitates cleaning during stay and post- discharge If necessary, cohort patients with MRSA

TIPS: Contact Precautions Train staff on importance Ensure adequate supplies ─Check and replenish supplies regularly ─Consider scheduled times for checking supplies Educate patients and families/visitors ─Encourage them to question personnel Use “visual cue” especially if single rooms or cohorting not possible Ensure patients on precautions have same standard of care as others ─frequency of entering the room ─monitoring vital signs Plan & notify for patient leaving room

Device Bundles Critically ill patients at high risk ─May be colonized or acquire in hospital Bundles ─Central Line: prevent BSLI ─Ventilator: prevent VAP Minimize device days!

Culture Change Implement Leadership Walkrounds TM ─Senior leaders talk directly with front-line staff about safety Train staff in SBAR ─Situation-Background-Assessment-Recommendation ─Establishes clear layout of information ─Non-threatening manner allows for appropriate assertion Conduct briefings on units to increase staff awareness Involve patients and families in processes, such as rounds.

What Leadership Should Do Acknowledge the magnitude and consequences of the problem ─Emphasize the “business case” for MRSA reduction Encourage intolerance of the status quo Empower front-line multi-disciplinary teams to get the job done ─Provide necessary supplies, resources, and personnel Hold staff accountable for reliable performance of basic infection control practices once appropriate systems and supplies are in place Review data regularly Remove barriers to success

Other Tips for Getting Started Begin in a high-risk area (ICU or group of ICUs) ─Learn to work as a multi-disciplinary team ─Feed back compliance data in real time ─Monitor impact of change on MRSA transmission ─Demonstrate that the additional investment in resources pays off When reliable compliance with ALL 5 MRSA interventions is achieved AND the rate of MRSA colonization begins to fall… …celebrate success and SPREAD!

Winning Execution Strategies Pick a patient segment upon which to test Work with those who want to work with you Small tests of change, small tests of change, small tests of change Learn as you go: develop process for review and improvement Encourage customization

This can be done! Thompson RL, Cabezudo I, Wenzel RP. Epidemiology of nosocomial infections caused by methicillin-resistant Staphylococcus aureus. Ann Intern Med. 1982;97(3): University of Virginia Hospital

VAPHS 4-West Hospital-Acquired MRSA Infection Rate (per 1,000 days of care) Source: “Eliminating Hospital-Acquired Infections” presentation slides from Jon Lloyd, MD, FACS, from VHA’s Best Practice Symposium, September 18, 2006

“If prevention is primary, action is imperative.” – William Jarvis Infect Control Hosp Epidemiol. 2004;25(5):