The Kentucky MRSA Collaborative: Reviewing Progress Made During 2009 Ruth Carrico PhD RN CIC Assistant Professor School of Public Health and Information Sciences University of Louisville

Objectives Review elements of the MRSA Collaborative including the program goals and toolkit Review elements of the MRSA Collaborative including the program goals and toolkit Review data from the Collaborative Review data from the Collaborative Utilize data to identify improvements for the 2010 journey to infection elimination Utilize data to identify improvements for the 2010 journey to infection elimination

Collaboration Brings groups together to work on shared problems Brings groups together to work on shared problems Encourages and enables the sharing of experiences and discovery of new ways to do old things Encourages and enables the sharing of experiences and discovery of new ways to do old things Steeped in the experiences of social networking Steeped in the experiences of social networking Collective intelligence allows greater opportunities than individual ideas and activities Collective intelligence allows greater opportunities than individual ideas and activities Success of the collaboration is hinged upon involvement, recognition of its value, and devotion to continuous improvement Success of the collaboration is hinged upon involvement, recognition of its value, and devotion to continuous improvement Each participating hospital is responsible for their own improvement activities Each participating hospital is responsible for their own improvement activities

Toolkit and Benchmarking Developed through Advisory Board and infection preventionist from across the state Developed through Advisory Board and infection preventionist from across the state Contains evidence basis, sample documents, tools and evaluation resources Contains evidence basis, sample documents, tools and evaluation resources Benchmarking through secured Web site to collect data on hand hygiene, room cleaning and MRSA rates Benchmarking through secured Web site to collect data on hand hygiene, room cleaning and MRSA rates

Toolkit Format Evidence basis Evidence basis Compendium, Infection prevention competencies, CDC guidelines, IHI Compendium, Infection prevention competencies, CDC guidelines, IHI Sample documents Sample documents Policies, checklists, isolation signs Policies, checklists, isolation signs Tools and resources Tools and resources APIC Elimination Guide, videos, grids APIC Elimination Guide, videos, grids Evaluation metrics Evaluation metrics Observation methods, description of outcome measures with definitions Observation methods, description of outcome measures with definitions

Toolkit Components How to implement and use the toolkit How to implement and use the toolkit Risk assessment Risk assessment Tools and resources Tools and resources Cleaning (environment and equipment) Cleaning (environment and equipment) Isolation Isolation Hand hygiene Hand hygiene Fact sheets Fact sheets Antimicrobial stewardship Antimicrobial stewardship Outcomes measures Outcomes measures

Sample Risk Assessment Encourages multidisciplinary approach Encourages multidisciplinary approach Builds accountability and collaboration Builds accountability and collaboration Identifies risks across the organization and prioritizes so there is alignment with the goals/resources of the organization Identifies risks across the organization and prioritizes so there is alignment with the goals/resources of the organization Begins dialogue regarding priorities Begins dialogue regarding priorities

Practice Observations Environmental cleanliness Environmental cleanliness Hand hygiene Hand hygiene

Impact of the Environment Patients colonized or infected with healthcare- associated pathogens frequently contaminate items in their immediate vicinity Patients colonized or infected with healthcare- associated pathogens frequently contaminate items in their immediate vicinity These pathogens may remain viable on surfaces for days to weeks These pathogens may remain viable on surfaces for days to weeks Healthcare workers can contaminate their hands by touching contaminated surfaces Healthcare workers can contaminate their hands by touching contaminated surfaces These pathogens on HCW hands can be transmitted to other patients, surfaces, and themselves if hands are not cleansed properly These pathogens on HCW hands can be transmitted to other patients, surfaces, and themselves if hands are not cleansed properly

Impact of the Environment Routine cleaning of patient rooms is often suboptimal Routine cleaning of patient rooms is often suboptimal Inadequate cleaning of rooms after discharging a patient with MRSA or VRE puts subsequent patients admitted to that room at risk of acquisition of the organism Inadequate cleaning of rooms after discharging a patient with MRSA or VRE puts subsequent patients admitted to that room at risk of acquisition of the organism Improved cleaning and disinfection of the environment can reduce the risk of patients acquiring multidrug- resistant pathogens Improved cleaning and disinfection of the environment can reduce the risk of patients acquiring multidrug- resistant pathogens Monitoring the effectiveness of environmental cleaning is necessary Monitoring the effectiveness of environmental cleaning is necessary

The Inanimate Environment Can Facilitate Transmission ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL. X represents Multidrug resistant organism culture positive sites

Environments Contaminated with MRSA Percent of surfaces contaminated with MRSA varied among pts colonized or infected Percent of surfaces contaminated with MRSA varied among pts colonized or infected 6% of surfaces when patient colonized in nares 6% of surfaces when patient colonized in nares 36% if MRSA in wound or urine 36% if MRSA in wound or urine 59% if heavy GI colonization 59% if heavy GI colonization 19% in outpatient clinic contaminated with MRSA 19% in outpatient clinic contaminated with MRSA Boyce JM et al ICHE :622 Johnson et al ICHE :1133

Common Items Contaminated in Healthcare Patient Rooms Common Common Bedrails Bedrails Bedside tables Bedside tables Blood pressure cuffs Blood pressure cuffs Floors Floors Light swtches, faucets handles Light swtches, faucets handles Less common Less common IV pumps IV pumps Bed control buttons Bed control buttons Pulse oximetry units Pulse oximetry units Urine containers Urine containers Computer keyboards Computer keyboards

Viability in the Environment MRSA 2-9 weeks MRSA 2-9 weeks VRE 1-12 weeks VRE 1-12 weeks C difficile spores days to 5 months C difficile spores days to 5 months Acinetobacter 3-33 days Acinetobacter 3-33 days Norovirus hours to 12 days Norovirus hours to 12 days Hota B et al CID 2004; 39:1182 Kramer A et al BMC Infect Dis 2006; 2:130

Improving Practice Housekeepers and nursing staff often do not agree on who should clean what Housekeepers and nursing staff often do not agree on who should clean what Housekeepers do not always understand Housekeepers do not always understand Which disinfectant to use Which disinfectant to use What concentration What concentration How often to change cleaning cloths/mop heads How often to change cleaning cloths/mop heads Principles of clean v. dirty Principles of clean v. dirty Determine competencies, then monitor and provide feedback Determine competencies, then monitor and provide feedback Develop policies regarding who should clean what Develop policies regarding who should clean what American Society for Healthcare Environmental Services ( American Society for Healthcare Environmental Services (

Methods for Assessing Cleaning practices Visual inspection Visual inspection Checklists to assure surfaces have been wiped Checklists to assure surfaces have been wiped Marking with fluorescent dye and checking to see if marker was moved (P Carling CID 2006;42:385) Marking with fluorescent dye and checking to see if marker was moved (P Carling CID 2006;42:385) Culturing surfaces (NOT a good idea) Culturing surfaces (NOT a good idea) ATP bioluminescence assays to measure cleanliness ATP bioluminescence assays to measure cleanliness

Outcomes Measure Positive blood cultures identifying MRSA Numerator Definition: Number of patients with MRSA bloodstream infection during the calendar month Numerator Definition: Number of patients with MRSA bloodstream infection during the calendar month Numerator Exclusions: Numerator Exclusions: Patients with a length of stay of 2 days or less 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 patient’s stay Patients with MRSA bloodstream infection identified from blood cultures collected in the first 2 days of the patient’s stay Denominator Definition: Total number of admissions or patient days in calendar month Denominator Definition: Total number of admissions or patient days in calendar month Denominator Exclusions: Denominator Exclusions: Patients with a length of stay of 2 days or less 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 patient’s stay Patients with MRSA bloodstream infection identified from blood cultures collected in the first 2 days of the patient’s stay

Outcomes Measure Positive blood cultures identifying MRSA Denominator Definition: Total number of admissions or patient days in calendar month Denominator Definition: Total number of admissions or patient days in calendar month Denominator Exclusions: Denominator Exclusions: Patients with a length of stay of 2 days or less 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 patient’s stay Patients with MRSA bloodstream infection identified from blood cultures collected in the first 2 days of the patient’s stay If using patient days, need to subtract the number of days from each patient stay after they are identified as having a positive blood culture for MRSA from the total If using patient days, need to subtract the number of days from each patient stay after they are identified as having a positive blood culture for MRSA from the total

Key Practices Optimal skin preparation before invasive techniques (e.g., central line insertion, surgical incisions) Optimal skin preparation before invasive techniques (e.g., central line insertion, surgical incisions) Disinfection of IV access sites (scrub the hub with alcohol 15 seconds) Disinfection of IV access sites (scrub the hub with alcohol 15 seconds) Proper technique when drawing blood cultures Proper technique when drawing blood cultures Hand hygiene Hand hygiene Environmental cleaning and disinfection Environmental cleaning and disinfection

Participating Hospitals 126 licensed hospitals in KY 126 licensed hospitals in KY Commitment from 95% Commitment from 95% Critical Access Hospitals (≤ 25 beds)29 Critical Access Hospitals (≤ 25 beds)29 Hospitals less than 100 beds27 Hospitals less than 100 beds27 Hospitals beds20 Hospitals beds20 Hospitals >250 beds24 Hospitals >250 beds24 Specialty Hospitals14 Specialty Hospitals14

2009 Results: MRSA BSIs JFMAMJJASOND # Hospitals Most # BSIs # Hospitals without BSI % of Hospitals w/out BSI Total BSIs

2009 Results: Hand Hygiene JFMAMJJASOND # Hospitals # reporting 100% Average

2009 Results: Room Cleaning JFMAMJJASOND # Hospitals # reporting 100% # reporting 0%

Continuous Improvement Check to make sure the data you enter into the system is correct Check to make sure the data you enter into the system is correct If reporting period closes, you can still provide data. Contact KHA for assistance If reporting period closes, you can still provide data. Contact KHA for assistance The goal is still elimination so continue improvement efforts The goal is still elimination so continue improvement efforts Increase participation across more KY hospitals Increase participation across more KY hospitals Provide feedback and discuss results with other departments Provide feedback and discuss results with other departments Provide feedback regarding how the Collaborative can assist with improvement activities Provide feedback regarding how the Collaborative can assist with improvement activities

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