Quality improvement project to decrease Methicillin- resistant Staphylococcus aureus acquisition in the setting of active screening Presenters: Jose Cadena, MD Tony Ho, MD. UT Health Science Center at San Antonio South Texas Veterans Healthcare System

Transmission (1) organisms: patient’s skin or fomites in the environment (2) organisms must be transferred to HCW’s hands (3) organisms must be capable of surviving on health-care workers’ hands (4) hand hygiene must be inadequate or omitted entirely (5) the contaminated hand(s) or fomites must come into direct contact with another patient Pittet D et al. Lancet Infect Dis 2006;6:641-52

27% of all surfaces cultured 36% if pt’s wound or urine was positive 65% of nurses doing routine care contaminated front of gown or uniform Boyce JM ICHE 1997

“Someone Else’s Problem” “An SEP is something we can't see, or don't see, or our brain doesn't let us see, because we think that it's somebody else's problem.... The brain just edits it out, it's like a blind spot. If you look at it directly you won't see it unless you know precisely what it is. Your only hope is to catch it by surprise out of the corner of your eye.” Douglas Adams, “Life, the Universe, and Everything”.

MRSA as an SEP Staff perceptions of source/control of MRSA in UK. “No matter how hard you try, sometimes it’s cross infection, the risks will be there.” “Habit is habit – if their habit is that [poor infection control], then it continues.” “I think it’s coming from the community; we are trying our best”.

MRSA in ALMVA The Audie L Murphy (ALMVA) is an acute care hospital with 268 beds. ALMVA performs active surveillance (on admission/ transfer/ discharge) to detect MRSA infection/colonization in patients admitted to the hospital.

The problem Despite previous attempts to decrease acquisition of MRSA during the hospitalization, the number of acquisitions remained significant in selected wards. This was a quality improvement (QI) project to decrease the acquisition of MRSA on selected units of the ALMVA (medicine wards: 5A and 6B; surgery wards: 4 South and Medical Intensive Care Unit, MICU) in the setting of active surveillance. A multidisciplinary QI team was formed to try to decrease the MRSA acquisition rate. Up to 23% of patients colonized by MRSA can develop an active infection within 12 months after acquisition.

Quality Improvement Team The QI team was formed by nursing, infection control, environmental management services (EMS), sterilization processing and disinfection (SPD) representative and was supported by hospital leadership. Some important members: Sarah Meinzen, RN Patti Grota, RN Jean Przykucki Amruta Parekh Many other members from nursing, environmental services, leadership. Mentorship provided by dr .Jan Patterson

Aim Statement To decrease MRSA acquisition rate on selected ALMVA units (Medicine: 5A, 6B, Surgery: 4S and MICU) over a 4 month period (February to May 2010) by improving compliance with hand hygiene (HH), environmental cleanliness and compliance with isolation precautions.

Quality Tools Brainstorming and a cause and effect diagram were used to identify the possible causes for increased MRSA acquisition. Histograms were used for visualization of rates. An SPC chart was used to evaluate the impact of the intervention. The PDSA cycle was used for adaption of interventions to enhance outcome.

Interventions Overall improvement plan: The QI team met for initial brainstorming and then for other QI tools and implementation of the PDSA cycle and analysis of results. This improvement process was implemented over a 4 month period.

Interventions  MRSA Bundle. A bundled approach to decrease MRSA transmission rates was used, based on the guidelines to prevent MRSA infection and scientific infection control literature. Compliance with HH and isolation precautions were isolation compliance were monitored.

Prevention “bundle” Ongoing staff education Hand hygiene Contact Precautions Environmental cleaning Active surveillance Cultural Transformation

Measure of Interventions Monthly rate (%) of hand hygiene (HH) and contact isolation compliance, based on blinded observations. Percentage of spotless rooms during weekly rounds by QI team members.

Measures of Success Outcome measure: Number of MRSA acquisitions per 1000 pt days in each individual unit; MRSA transmission rate per 1000 pt days.

Specific interventions: Audit/Feedback. Hand hygiene (HH) and Contact Isolation: Monitored by blinded reviewer. Education on HH and Isolation. Feedback at monthly meetings with nurse supervisors. Personnel from Voluntary Services were trained as blinded reviewers and patient centered infection prevention education was instituted (TJC NPSG 7.01.01). Units had reported 92% HH compliance. Blinded reviewer performed 46 observations,-HH compliance was 50%. Compliance with contact isolation was 47%

Specific interventions: Multidisciplinary Rounds. Interventions to improve environmental care included weekly unit rounds with a multidisciplinary team including nursing, environmental management (EMS) and infection prevention. Rooms ready to be used (after routine terminal cleaning), were inspected for visible soiling (even if minimal), especially at the high touch areas (i.e. bed rails, table, night stand, telephone). Feedback was given for improved room cleaning.

Additional Interventions Audit/Feedback and Education of Support Services. Audit/Feedback included support services that provide direct patient care, i.e., nutrition and food services (N&FS) physical medicine and rehabilitation (PM&R), Respiratory Therapy, and EMS.  Hospital Leadership Involvement Audit/Feedback results were also reported at a morning meeting with hospital leadership who supported compliance efforts. A presentation of the QI project was performed at the beginning of the project for approval at the Clinical Executive Board (CEB-medical staff leadership) and supported. The results of the project were presented to CEB at the end of the intervention period.

Environmental Cleaning System  Policy Review Infection prevention reviewed HH policy and observation tool in light of deficiencies noted Environmental Cleaning System A new environmental cleaning system (Ecolab Environmental) was introduced by EMS. Communication to stakeholders and personnel involved: The MRSA transmission workgroup was formed by nurse supervisors from the “high risk” units, EMS leadership and infection control. They participated on the education of additional stakeholders, clinical and environmental services personnel.

Compliance and Transmission Rate

Environmental Cleanliness % spotless rooms Dates of observations

Process Control Chart The mean MRSA transmission rate decreased from 2.8/1000 pt days to 0.4/1000 pt days. Statistical analysis between pre and post intervention MRSA transmission rates was significant by T-test (p<0.01).

Revenue Impact Units under surveillance average 3000 patient-days a month, or 36,000 patient-days a year. pre-intervention transmission rate was 2.79 per 1000 patient post intervention rate was 0.41 per 1000 patient days.  absolute reduction of 2.38 per 1000 patient days.

Revenue Impact 2 Mean hospital charge for a nosocomial MRSA infection from the literature is $31,400, with $7481 directly attributable to the infection. Assuming the intervention leads to a long-term reduction in transmission rates, and assuming a 23% incidence of significant MRSA infection within 12 months of acquisition, the net cost avoidance would be $147,423 over the course of the year. The cost of implementation was largely due to investment in audit and training. The cost of the new environmental cleaning system was $4,000. MRSA surveillance is required for VA hospitals nationwide and is not an incremental cost.

Discussion Multiple studies to evaluate the risk of invasive MRSA infection after acquisition 23% at 12 months (Datta et al, CID 2008) 29% at 18 months (Huang et al, CID 2003) Increasing morbidity/mortality from MRSA (Lodise et al, Pharmacotherapy 2007) Delayed administration of anti-MRSA medications Vancomycin not regarded as efficacious as beta-lactams, especially as MICs creep upwards.

Future directions/Challenges Emphasize “bundle approach” to the MRSA problem. Enhance compliance with Hand Hygiene and isolation- 2010-2011 QI project Continue audit and feedback for environmental care.- Working on hiring environmental care service workers to fulfill needs. Implementation of reusable medical equipment cleaning by providers

Conclusion Does not have to be “Someone else’s problem”. MRSA acquisition can be decreased in the setting of active screening by using a multi level approach to the problem, including enhanced surveillance of HH compliance, isolation and environmental cleanliness. Decrease in acquisition not only leads to less morbidity/mortality in patients, but a significant cost reduction.