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
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Review elements of the MRSA Collaborative
including the program goals and toolkit
Review data from the Collaborative
Utilize data to identify improvements for the
2010 journey to infection elimination
Collaboration
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Brings groups together to work on shared problems
Encourages and enables the sharing of experiences
and discovery of new ways to do old things
Steeped in the experiences of social networking
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
Each participating hospital is responsible for their own
improvement activities
Toolkit and Benchmarking
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Developed through Advisory Board and infection
preventionist from across the state
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
Toolkit Format
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Evidence basis
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Sample documents
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Policies, checklists, isolation signs
Tools and resources
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Compendium, Infection prevention competencies, CDC
guidelines, IHI
APIC Elimination Guide, videos, grids
Evaluation metrics
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Observation methods, description of outcome measures with
definitions
Toolkit Components
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How to implement and use the toolkit
Risk assessment
Tools and resources
Cleaning (environment and equipment)
Isolation
Hand hygiene
Fact sheets
Antimicrobial stewardship
Outcomes measures
Sample Risk Assessment
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Encourages multidisciplinary approach
Builds accountability and collaboration
Identifies risks across the organization and
prioritizes so there is alignment with the
goals/resources of the organization
Begins dialogue regarding priorities
Practice Observations
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Environmental cleanliness
Hand hygiene
Impact of the Environment
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Patients colonized or infected with healthcareassociated pathogens frequently contaminate items in
their immediate vicinity
These pathogens may remain viable on surfaces for
days to weeks
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
Impact of the Environment
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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
Improved cleaning and disinfection of the environment
can reduce the risk of patients acquiring multidrugresistant pathogens
Monitoring the effectiveness of environmental cleaning
is necessary
The Inanimate Environment Can Facilitate Transmission
X represents Multidrug resistant organism culture positive sites
~ 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.
Environments Contaminated with
MRSA
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Percent of surfaces contaminated with MRSA varied
among pts colonized or infected
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6% of surfaces when patient colonized in nares
36% if MRSA in wound or urine
59% if heavy GI colonization
19% in outpatient clinic contaminated with MRSA
Boyce JM et al ICHE 1997 18:622
Johnson et al ICHE 2006 27:1133
Common Items Contaminated in
Healthcare Patient Rooms
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Common
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Bedrails
Bedside tables
Blood pressure cuffs
Floors
Light swtches, faucets handles
Less common
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IV pumps
Bed control buttons
Pulse oximetry units
Urine containers
Computer keyboards
Viability in the Environment
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MRSA 2-9 weeks
VRE 1-12 weeks
C difficile spores days to 5 months
Acinetobacter 3-33 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
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Housekeepers and nursing staff often do not agree on
who should clean what
Housekeepers do not always understand
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Which disinfectant to use
What concentration
How often to change cleaning cloths/mop heads
Principles of clean v. dirty
Determine competencies, then monitor and provide
feedback
Develop policies regarding who should clean what
American Society for Healthcare Environmental
Services (www.ashes.org)
Methods for Assessing Cleaning
practices
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Visual inspection
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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)
Culturing surfaces (NOT a good idea)
ATP bioluminescence assays to measure
cleanliness
ENVIRONMENTAL CHECKLIST FOR DAILY CLEANING - ROOM OBSERVATIONS: Please review a sample of 5 patients per week (1 patient per day)
Hospital: _____________________________________
Date:________________________________________
Unit:_________________________________________
Room:________________________________________
Time:________________________________________
Instruction
At start, perform hand hygiene.
Put on PPE
Clean and disinfect high touch surfaces.
Component
Door knobs/handles
Door surface
Bed rails
Call button
Phone
Overbed table & Drawer
Countertop
Light switches
Furniture
Arms of patient chair
Seat of patient chair
All other misc. horizontal surfaces
Window sills
Bedside commode (perform last)
Medical equipment (e.g., IV controls)
Spot clean walls with disinfectant cloth
Clean and disinfect
BATHROOM, including:
Bathroom door knob
Toilet horizontal surface/seat
Toilet lever/flush
Faucets (at sink)
Bathroom handrails
Sink
Tub/shower
Mirror
Damp dust:
Overhead light (if the bed is empty)
TV & Stand
Clean:
Lights
Clean Floor:
Dust mop tile
Wet mop tile
Replace as needed:
Hand sanitizer
Paper towels
Soiled curtains
For terminal cleaning, damp dust:
Bed frame
Mattress
Remake bed with clean linen
Replace as needed: Pillows, mattresses,
pillow covers, matress covers
Other:
Empty trash & replace liner
Discard dust cloths.
Change mop heads after each isolation room.
Remove PPE before exit.
Perform hand hygiene.
Any significant areas not mentioned above (please describe):
Yes
No
N/A
Hand Hygiene and Isolation Adherence Monitoring Form
Unit/Dept.: ________________ Day of Week: ______ Date: _____/_____/_____ Time: ____:____AM/PM to ____:____AM/PM Initials _
Hand Hygiene
Problem(s) Identified (c): ________________________________________________
Patient
Contact
Environmenal Hand Hygiene
Contactb
Before/After
(MD-AT R F ST)( RN LPN CA NST) NP PA(PT OT RT SP)LAB ES EGR FN IV TR RX CC
MGT CHAP SEC XR TECH-other / ________________
1
Y
N
Y
N
Alc HW N
Y
N
Y
N
Alc HW N
Y
N
Y
N
Alc HW N
Y
N
Y
N
Alc HW N
Y
N
Y
N
Alc HW N
Y
N
Y
N
Alc HW N
Y
N
Y
N
Alc HW N
Y
N
Y
N
Alc HW N
Y
N
Y
N
Alc HW N
Y
N
Y
N
Alc HW N
(MD-AT R F ST)( RN LPN CA NST) NP PA(PT OT RT SP)LAB ES EGR FN IV TR RX CC
MGT CHAP SEC XR TECH-other / ________________
2
(MD-AT R F ST)( RN LPN CA NST) NP PA(PT OT RT SP)LAB ES EGR FN IV TR RX CC
MGT CHAP SEC XR TECH-other / ________________
3
(MD-AT R F ST)( RN LPN CA NST) NP PA(PT OT RT SP)LAB ES EGR FN IV TR RX CC
MGT CHAP SEC XR TECH-other / ________________
4
(MD-AT R F ST)( RN LPN CA NST) NP PA(PT OT RT SP)LAB ES EGR FN IV TR RX CC
MGT CHAP SEC XR TECH-other / ________________
5
(MD-AT R F ST)( RN LPN CA NST) NP PA(PT OT RT SP)LAB ES EGR FN IV TR RX CC
MGT CHAP SEC XR TECH-other / ________________
6
(MD-AT R F ST)( RN LPN CA NST) NP PA(PT OT RT SP)LAB ES EGR FN IV TR RX CC
MGT CHAP SEC XR TECH-other / ________________
7
(MD-AT R F ST)( RN LPN CA NST) NP PA(PT OT RT SP)LAB ES EGR FN IV TR RX CC
MGT CHAP SEC XR TECH-other / ________________
8
(MD-AT R F ST)( RN LPN CA NST) NP PA(PT OT RT SP)LAB ES EGR FN IV TR RX CC
MGT CHAP SEC XR TECH-other / ________________
9
(MD-AT R F ST)( RN LPN CA NST) NP PA(PT OT RT SP)LAB ES EGR FN IV TR RX CC
MGT CHAP SEC XR TECH-other / ________________
10
Outcomes Measure
Positive blood cultures identifying MRSA
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Numerator Definition: Number of patients with
MRSA bloodstream infection during the calendar
month
Numerator Exclusions:
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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
Denominator Definition: Total number of
admissions or patient days in calendar month
Denominator Exclusions:
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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
Outcomes Measure
Positive blood cultures identifying MRSA
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Denominator Definition: Total number of
admissions or patient days in calendar month
Denominator Exclusions:
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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
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
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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)
Proper technique when drawing blood cultures
Hand hygiene
Environmental cleaning and disinfection
Participating Hospitals
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126 licensed hospitals in KY
Commitment from 95%
Critical Access Hospitals (≤ 25 beds)
 Hospitals less than 100 beds
 Hospitals 100-250 beds
 Hospitals >250 beds
 Specialty Hospitals
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29
27
20
24
14
2009 Results: MRSA BSIs
J
# Hospitals
F
M
J
J
A S
O N D
71 75 86 86 84 78 83 80 83 73 82 80
Most # BSIs 13 7
# Hospitals
without BSI
M A
3
4
5
4
3
5
4
3
10 3
59 57 60 74 71 69 65 68 70 61 70 68
% of
83 76 70 86 85 89 78 85 84 84 85 85
Hospitals
w/out BSI
Total BSIs 30 23 15 17 16 15 24 21 16 14 24 16
2009 Results: Hand Hygiene
J
F
M A
M
J
J
A S
O N D
# Hospitals
68 67 83 82 78 75 79 77 80 71 77 76
# reporting
100%
Average
13 12 16 17 15 13 19 18 21 18 18 21
85 80 82 82 82 86 85 86 86 87 86 86
2009 Results: Room Cleaning
J
F
M A
M
J
J
A S
O N D
# Hospitals
46 52 77 78 71 70 71 69 75 67 72 70
# reporting
100%
# reporting
0%
15 28 28 33 35 40 40 39 47 38 52 47
3
1
4
2
0
1
0
1
0
0
0
0
Continuous Improvement
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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
The goal is still elimination so continue improvement
efforts
Increase participation across more KY hospitals
Provide feedback and discuss results with other
departments
Provide feedback regarding how the Collaborative can
assist with improvement activities
Shared Knowledge Websites
http://info.kyha.com/MRSA/default.htm
http://www.infectionpreventiontools.com