Reduce MethicillinResistant Staphylococcus aureus MRSA Infection

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Reduce Methicillin-Resistant Staphylococcus
aureus (MRSA) Infection

• Institute for Healthcare Improvement

This document is in the public domain and may be
used and reprinted without permission provided
appropriate reference is made to the Institute
for Healthcare Improvement.
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100,000 Lives Campaign

• 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

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5 Million Lives Campaign

• Reduce Surgical Complications Adopt SCIP
• Prevent Harm from High-Alert Medications
• Reduce MRSA Infection
• Improve Care for Patients with Congestive Heart
  Failure
• Prevent Pressure Ulcers
• Get Boards on Board

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Reduce MRSA Infection

• The Goal
• Reduce methicillin-resistant Staphylococcus
  aureus (MRSA) transmission and infection

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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

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Target Principal Modes of Transmission

• MODE
• Person-person via hands of health care providers
• Patient and personal equipment and clothing
• Environmental contamination

• STRATEGY
• Hand hygiene
• Dedicated equipment and disinfection
• Cleaning and disinfection

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Prevent Infection and Colonization

• Colonized and infected patients
• Reservoir for transmission
• Nearly 1/3 develop infection, often after
  discharge
• Long-lasting
• Can transmit MRSA to others

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MRSA Risk Factors

• Hospital admission
• Admission to a nursing home
• History of antibiotics
• HIV infection
• IVDU
• MRSA colonization
• Hemodialysis

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Healthcare Workers and MRSA

• Prevalence of MRSA colonization by employee
  profession
• Category Employees Prevalence of MRSA
  Carriers
• Clinical ward 577
  52 (9.0 CL)
• Medical staff 96
  6 (6.3 CL)
• Nursing 481
  46 (9.6 CL)
• Lab/ Radiology 220
  6 (2.7 CL)
• Engineering 50
  1 (2.0 CL)
• Administrative 118
  1 (0.8 CL)
• Total 965
  60 (6.2 CL)
• CL95 95 confidence interval
• Source Eveillard et al. ICHE 200425114-120

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Human and Financial Impact

• Hospital stays from MRSA Infection
• 368,600 in 2005 were from MRSA infection
• 30 increase from 2004
• 10-fold increase since 1995
• 4.7 hospital mortality for patients with MRSA
  in 2004 vs. 2.1 for patients without MRSA
• Hospitalized patients with MRSA infection in
  2004
• 10 day length of stay vs. 4.6 days for all other
  stays
• 14,000 cost of hospital stay on average vs.
  average of 7,600 for all other stays

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New Data

• Estimates based on calendar year 2005 US data
• 94,000 invasive MRSA infections in population
• 19,000 (approx) died (18) during initial
  hospitalization
• 86 of invasive MRSA disease - exposures to
  hospitals or health care settings
• 14 - no recent hospitalization or other risk
  factors
• Majority of cases overall had infection manifest
  or discovered when the person was out of the
  hospital
• 58 were community-onset HA-MRSA infections
  (e.g., persons recently discharged from a
  hospital or recently had surgery)
• 27 were hospital-onset HA-MRSA infections (i.e.,
  the typical nosocomial MRSA infections)
• 14 were community associated CA-MRSA infections

Klevens RM, Morrison MA, Nadle J, et al. Invasive
methicillin-resistant Staphylococcus aureus
infections in the United States. JAMA.
20072981763-1771.
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Continuing Trend
Elixhauser, A. (AHRQ) and Steiner, C. (AHRQ).
Infections with Methicillin-Resistant
Staphylococcus Aureus (MRSA) in U.S. Hospitals,
19932005. HCUP Statistical Brief 35. July 2007.
Agency for Healthcare Research and Quality,
Rockville, MD. http//www.hcup-us.ahrq.gov/reports
/statbriefs/sb35.pdf
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Five Key Interventions

• Hand hygiene
• Contact precautions for infected and colonized
  patients
• Decontamination of the environment and equipment
• Active surveillance testing
• Central Line and Ventilator Bundles

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Hand Hygiene

• Single most important intervention
• before and after patient contact
• Compliance rates of 40-50 no longer are
  acceptable
• Design process for reliability.then hold staff
  accountable
• Alcohol hand rubs make it easier
• Rapidly kill bacteria (except Clostridium
  difficile spores)
• Surprisingly gentle on hands
• Not a substitute for soap and water when hands
  are grossly soiled

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Hand Hygiene

• CDC Guidelines for Hand Hygiene in Healthcare
  Settings, 2002
• Implement a Hand Hygiene program
• Availability of supplies
• Healthcare workers to evaluate products
• Healthcare worker dermatitis
• Monitoring compliance
• Feedback to staff, including physician
• Accountability
• Include patients and visitors

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Tips Hand Hygiene

• Check placement
• Provide supplies
• Count the steps !
• Provide real time feedback
• Provide post unit level data

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Decontamination of Environment and Equipment

• Use dedicated equipment for colonized/infected
  patients.
• Clean patient care and personal equipment when
  leaving the bedside.
• Put environmental services personnel on the team
• Clean and disinfect the environment carefully.
• Focus on high-touch areas.

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TIPS Decontamination

• Use a checklist for cleaning.
• Specify the order for cleaning to avoid
  recontamination during the process
• 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.

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Active Surveillance

• Screen to detect colonized patients.
• Necessity of screening per se in controlling MRSA
  is controversial.
• Knowledge is power.
• Clinical cultures miss many colonized patients.
• Successful programs combine screening with
  reliable implementation of other interventions.
• Flag colonized patients when discharged.

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TIPS Active Surveillance

• Begin with admission screening only.
• Measure compliance add follow-up tests when
  performance is high (gt 90).
• Provide real-time notification of positive
  results.
• Schedule consistent day of week for follow-up
  tests.
• Include follow-up test in routine discharge order
  sets.
• Measure transmission.
• Number or rate of patients who convert from
  negative to positive

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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

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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
• 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

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Device Bundles

• Critically ill patients at high risk
• May be colonized or infected in hospital
• Bundles
• Central Line prevent CRBSI
• Ventilator prevent VAP
• Minimize device days!

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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.

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What Leadership Should Do

• Acknowledge the magnitude and consequences of the
  problem.
• Emphasize the business case for MRSA reduction.
  
• Remove barriers.
• Empower front-line multidisciplinary teams to get
  the job done.
• Provide necessary supplies, resources, and
  personnel.
• Encourage intolerance of the status quo.
• Hold staff accountable for basic infection
  control practices once appropriate systems and
  supplies are in place.
• Review data regularly.

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Tips for Getting Started

• Begin in a high-risk area (ICU or group of ICUs).
• Learn to work as a multidisciplinary 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!

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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.

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This Can Be Done!
University of Virginia Hospital
Thompson RL, Cabezudo I, Wenzel RP. Epidemiology
of nosocomial infections caused by
methicillin-resistant Staphylococcus aureus. Ann
Intern Med. 198297(3)309-317.
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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 VHAs Best Practice Symposium,
September 18, 2006
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Number of HA-MRSA and CA-MRSA
Infections CT Hospital, 2000 - 2006
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If prevention is primary, action is
imperative. William Jarvis

• Infect Control Hosp Epidemiol. 200425(5)369-372.

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