Transcript Some is Not a Number Soon is not a Time

Reducing Harm:
MRSA
Fran Griffin
Institute for
Healthcare Improvement
The Next Campaign
WE’RE GOING AFTER HARM…
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
5 Million 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
Prevent MRSA Infection
The Goal:
Reduce methicillin-resistant
Staphylococcus aureus (MRSA)
bloodstream infection by December
2008
A Vision For The Future?
MRSA in Denmark
100%
Rosdahl VT et al. Infect Control Hosp Epidemiol 1991;12:83-88.
90%
80%
70%
60%
50%
MRSA Bloodstream Infections
40%
30%
20%
10%
0%
1960
1965
1970
1975
1980
1985
1990
1995
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 postdischarge
• 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 WalkroundsTM
─ 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!
University of Virginia Hospital
Thompson RL, Cabezudo I, Wenzel RP. Epidemiology of nosocomial infections caused by
methicillin-resistant Staphylococcus aureus. Ann Intern Med. 1982;97(3):309-317.
VAPHS 4-West Hospital-Acquired MRSA Infection Rate
(per 1,000 days of care)
1.6 1.48
1.4
1.2
0.94
1
0.8
0.6
0.45
0.39
0.27
0.4
0.2
0
26 mo
pre
2002
2003
2004
2005
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):369-372.