MRSA Intervention and Data Collection

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MRSA Intervention and Data Collection
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MRSA Reduction Strategies

• For the Campaign, five components of care are
  recommended
• Hand hygiene
• Decontamination of the environment and equipment
• Active surveillance cultures
• Contact precautions for infected and colonized
  patients
• Device bundles (Central Line Bundle and
  Ventilator Bundle)

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MRSA Process MeasureHand Hygiene Compliance

• Numerator Definition Number of patient
  encounters directly observed in which a health
  care worker performed all components of hand
  hygiene and glove use correctly in the calendar
  month
• Numerator Exclusions None
• Denominator Definition Total number of patient
  encounters observed in the calendar month
• Denominator Exclusions None
• Measurement Period Length Monthly
• Calculate as (numerator / denominator) x 100 as
  a percent.

IHI Measurement Forms, MRSA
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Hand Hygiene Complete Compliance
Gloves should be worn for all types of contact
if the patient is on isolation precautions that
require the use of gloves for contact with the
patient and the environment, or if there is a
unit-based procedure for universal gloving
(wearing gloves for contact with all patients and
their immediate environment).
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Hand Hygiene Collection Strategy

• Compliance is monitored with direct observation
  by a trained observer using a standardized
  procedure and form.
• Observation periods should be 20-30 minutes
  (repeated if necessary) so that approximately
  25-30 patient encounters are observed.
• Observers should be as unobtrusive as possible,
  but do not need to be hidden from health care
  workers on the unit.

IHI Measurement Forms, MRSA
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Hand Hygiene Sampling Strategy

• Schedule set time periods in advance, distributed
  equally across shifts, days, and units (if
  measuring on more than one unit).
• If you are beginning this intervention within a
  pilot unit or units, limit your initial
  measurement to only those units.

IHI Measurement Forms, MRSA
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MRSA Outcomes Measure Bloodstream Infections
per 1000 Patient Days

• Numerator Definition Number of patients with
  MRSA bloodstream infection during the calendar
  month
• Numerator Exclusions Same as denominator
  exclusions
• Denominator Definition Total number of hospital
  patient days for the calendar month after
  subtracting
• Patient hospital days after the onset of an MRSA
  bloodstream infection (e.g., patient is admitted
  and has a 10-day length of stay MRSA bloodstream
  infection identified from culture collected on
  day 4 hospital days 4 through 10 are subtracted
  as this patient is no longer at risk)
• Denominator Exclusions
• Patients with a length of stay of 2 days or less
• Patients with MRSA bloodstream infection
  identified from blood cultures collected in the
  first 2 days of the patients stay
• Measurement Period Length Monthly
• Calculate as (numerator / denominator) x 1000
  as a rate

IHI Measurement Forms, MRSA
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MRSA Definition of Terms

• MRSA bloodstream infection CDC definition for
  laboratory-confirmed bloodstream infection (LCBI)
  with MRSA as the organism identified in blood
  culture (SOURCE The National Healthcare Safety
  Network (NHSN) User Manual, page 6.

IHI Measurement Forms, MRSA
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MRSA Sampling Strategy

• If you are beginning this intervention within a
  pilot unit or units, limit your initial
  measurement to only those units. As you spread
  the implementation, expand your measurement
  accordingly.
• Stay consistent with definitions throughout the
  submission period

IHI Measurement Forms, MRSA