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.
Room Cleanliness
Hand
Hygiene
Medication
Cart
No documented
supervision
Nonadherence
Unclear process for
after hours cleaning
Blinded vs.
Peer Review
Medication cart
taken into room
No standards of
cleanliness
Inadequate time due
to high census
Loss of vigilance
Inconsistent process
of room turnover
Retained medical
supplies
Food/drink on
cart
No check list/
competencies
Infrequently
cleaned showers
Insufficient
Bathroom facilities
Bathrooms
Inavailability of
Equipment wipes
Unclear rolling stock
cleaning process
Inappropriate storage
location
No identification
contaminated
vs. clean
Poorly defined
responsibilities
for cleaning
Equipment
Cleanliness
Patient Ambulatory,
leaves room
Timeliness of
Isolation order/note
Insufficient plastic
sign holders
Cohabitation in
“Bed crunch”
Isolation
Precautions
MRSA Transmission
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.
• 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
70
60%
% spotless rooms
60
50
50%
40%
40
30
20%
20
17%
10
0
2.10.10
2.16.10
0
4.21.10
4.29.10
0
5.5.10
Dates of observations
0
5.13.10
5.20.10
6.3.10
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 patientdays 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 betalactams, 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.