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VA targets MRSA with national hospital effort
Not just ASC cultures, VA seeks a culture change
The Veterans Health Administration is rolling out one of the most ambitious efforts to date to control the rampant rise of methicillin-resistant Staphylococcus aureus (MRSA). A directive has gone out to all 165 hospitals in the federal system to adopt aggressive infection control measures that include active surveillance efforts and a "culture change" within the institution.
Veterans Affairs (VA) hospitals nationwide are gradually adopting the measures, which are based on a multifaceted "bundle" approach developed at the Pittsburgh VA Hospital. "Pittsburgh implemented this and they really showed the proof of the concept," says Gary Roselle, MD, infectious disease program director at the VA Central Office and a health care epidemiologist at the Cincinnati VA Medical Center. "They did it and had success, so with that proof of concept and the alignment with [current] guidelines, it was reasonable for the VA to extend this to a nationwide program."
While active surveillance cultures (ASC) have been the subject of ongoing debate, perhaps the most intriguing aspect of the initiative is the call for culture change. This somewhat nebulous concept is expressed in part at the Pittsburgh VA through MRSA meetings that include everyone from top administrative officials to housekeepers, Robert Muder, MD, recently said at a grand rounds presentation held by the Association for Professionals in Infection Control and Epidemiology (APIC). "That was very important to identify what the problems were and to make sure that people on the units understood what their role in infection prevention was," he said. "It also enables them to link their behavior with health care outcomes. We shared with them the MRSA infection and transmission data. I think that is very powerful."
The bundle also includes ASC via nares swabs to detect patients colonized with MRSA, a controversial measure that the VA has decided to embrace based on the success in Pittsburgh.
"The bundle is active surveillance [cultures] hand hygiene, contact precautions, and cultural transformation," Roselle says. "The directive basically indicates that the MRSA bundle will be initiated at VAs across the country, starting with a single unit, usually an intensive care unit. Following that, it will be expanded to the rest of the intensive care units and then throughout the facility."
MRSA share of staph hits 67%
Roselle recently presented findings showing the need for such aggressive measures in VA hospitals. A review of patient treatment records, coded diagnoses and laboratory data revealed that the proportion of staph infections caused by MRSA in the VA health care system rose from 46.9% in 2001 to 58.3% in 2006.1 The increase was even more pronounced when researchers looked at inpatients only, where the proportion of MRSA causing staph infections rose from 59.1% to 67% over the same period. "This was designed to look at the VA as a system and answer the question, do we have an issue that needs to be addressed?" says Roselle, who presented the findings recently in Baltimore at annual conference of the Society for Healthcare Epidemiology of America.
The answer was an unequivocal "yes." The national directive — which is not optional — should provide a fascinating look at whether one hospital's success can be translated over a health care system. "The advantage of having a directive is that it is something signed by top management in the VA," he said. "It is [revisable] on new information as opposed to legislation, which is more difficult to change."
This is not the first time VHA has issued systemwide infection control policies, as previous efforts have targeted Legionella and tuberculosis prevention. "I am fairly confident that this will be successful," Roselle says. "It requires a major effort at each facility in order to sustain the effort over time. I think that will be the critical issue."
Indeed, the Pittsburgh program on which the national effort is based was not an overnight success. However, it has yielded steady reductions of MRSA, including an overall 39% drop hospitalwide since the program began in a single ICU in 2002. The incidence of MRSA decreased from 2.31 infections per 1,000 pt-days during the two-year pre-intervention period to 1.40 during the final two years of the intervention.2 "It is possible in a hospital with a 20-plus-year history of highly endemic infections and a very complex case mix [to] dramatically reduce the incidence of MRSA infection, " Muder said.
Can MRSA be stopped?
The project was undertaken with consultation and encouragement by the Centers for Disease Control and Prevention. "In our hospital, MRSA was the leading cause of surgical-site infections and bacteremia, and this was in spite of the fact that we had a pretty good infection control program," Muder said. "For example, all surgical-site infection rates for clean surgery were generally well below 2%. So we were doing reasonably well with infection control, but the CDC actually posed a question to us: Can you actually control MRSA in the hospital?"
To do that, culture change would be necessary. A key aspect of the culture change component was adaptation of some philosophical principles from the production model used by Toyota automakers, he explained.
"The take-home message of that is that one actually needs to change the entire system," Muder said. "Because if you look at everybody's infection control policies, I bet they all read really well and they all say all the things we need to do. The fact of the matter is when you come down to the unit level, nobody is doing them. People don't know what they are; there are an incredible number of barriers to actually getting those things done, and hospital management really doesn't support it in terms of either material or a commitment. Infection control practitioners go from floor to floor like voices in the wilderness asking people to please behave, and the response is predictably suboptimal."
But the aforementioned meetings and the clear commitment of administration began to change the hospital culture, he noted. For example, MRSA screening cultures were not only done on admission to the original unit, but on discharge. "The reason we did them on discharge is that we wanted to know what our transmission rate was," he said. "[Then at the meeting], we could say, 'Mr. Smith in the corner room came in without MRSA. He got MRSA here and had to go back to the OR. Now he is going to be on vancomycin for another three weeks.' That is very powerful. Then you ask, 'Why do you think that happened?'"
The tone is not accusatory, Muder emphasized, but framed more as an obstacle for a broad-based, fully committed team to overcome. "Those meetings typically include the hospital chief of staff, the chief of nursing, infection control people, an MRSA coordinator, unit staff," he said. "And not just the professional nurses. It also included aides, escorts, housekeeping people. We shared with them the admission and discharge swabbing rates so they knew how well they were performing."
The writing on the wall
That is a long way from presenting some graphs at an infection control committee meeting and concluding all is well because infections rates are one standard deviation below the baseline, he adds. "It's important to note that the people who are spearheading this in our institution are actually the senior leadership of the VA," Muder said. "They are very visible, they are well connected in Washington and they make a very compelling case to the senior leadership of the VA that this is worthwhile. People now in very prominent places are understanding that this is worthwhile from a morbidity, mortality, patient safety standpoint — which I think is undeniable. And the fact is that it is highly cost-effective."
The team found that 9% of patients coming into the unit were colonized on admission. "Only 40% could have been identified through a history, so 60% of our burden of MRSA carriage would have been unknown," Muder said. To facilitate placing colonized patients in contact isolation, the interventions included computer enhancements that allowed unit-specific data reports of culture positive patients. "So it does not require the infection control nurse to daily scan the list and call the floors," he noted, "because obviously, if that person is home sick or distracted by other problems, then that is not going to get done."
With administrative support, other systems were improved, including streamlining supplies so that all isolation equipment was available at bedside for patients under contact precautions. "One of the problems we identified was that shared equipment was not being disinfected," Muder added. "[The] equipment was just returned to a room and left there until the next person used it. One needs a system so that it is always ready, clean, and available for the next patient."
Alcohol hand hygiene dispensers were installed to improve compliance with that cardinal infection control practice. With administration involved and lines of communication open, the program is well past the model of the infection control "police" trying to improve compliance with all the responsibility and none of the power. "This has really taken off," Muder said. "The writing is on the wall for this."