'Get to zero': Pittsburgh VA vows to stamp out MRSA

Culture change boosts hand hygiene

Multidrug-resistant Staphylococcus aureus (MRSA) is reaching alarming levels around the country, but at the VA Medical Center in Pittsburgh, MRSA rates have dropped by 60% in the past five years. The key: Health care workers are team players in a comprehensive approach to halting MRSA.

Patients are tested on admission and discharge in a system of active surveillance, but the success story goes far beyond that. The hospital was committed to making a "cultural transformation" that gives health care workers a voice in decision making and problem-solving.

Meanwhile, at every entrance, in every room, in the lobby and outside the elevators, the medical center installed alcohol gel dispensers. It's impossible to avoid hand hygiene. Patients, visitors, and employees alike are urged to pay attention to it.

This multipronged approach to reducing infections has spread to VA hospitals across the country and serves as a model for other hospitals as well.

"It is a significant change in the way we've operated [in the past]," says Rajiv Jain, MD, FACP, chief of staff at the VA Pittsburgh Health Care System and project director for the national VA initiative. "But if we involve more and more people than just the infection control and employee health staff, it becomes easier and the success comes more quickly."

A recent survey of hospitals by the Association for Professionals in Infection Control and Epidemiology in Washington, DC, underscored the importance of combating MRSA. Hospital inpatients are infected at a rate of 46.3 per 1,000, which is eight to 10 times higher than previous estimates, the survey found. (See related article at the end.)

"That's a landmark study," says Jain. "I think it should be a wake-up call to all of us that the problem of drug-resistant organisms is a significant one. We all need to be vigilant and do our part to prevent the spread of infections as much as we can."

A slogan and surveillance

The MRSA eradication program began in 2001 with the slogan, "Getting to Zero." The goal: No more MRSA.

"We probably won't ever get to zero because of the community-acquired MRSA that exists," concedes LaToya Miller, MPH, MRSA program manager, "but we definitely want to strive for that and get as close as possible."

Patients receive a nares swab on admission, discharge, and transfer between units. "The transfer swabs are important because they allow us to track which units the infections are occurring on, if they are occurring," she says.

Employees are not routinely swabbed, says Jain. "Even if [someone] were to become colonized, it's hard to know what that information means," he says. "The majority of the time, the employees are transient carriers. They just carry the organism for a very short time and then they lose it, so they're not carriers anymore."

Treating carriers also might backfire by creating greater antibiotic resistance, he says. However, employees should be educated about MRSA so they can be tested if they are going to have a high-risk procedure, such as heart surgery or a joint procedure, he says.

Education of employees is an important component of the MRSA eradication program, Miller notes.

Making a cultural change

Eradicating MRSA and other multidrug-resistant organisms requires more than traditional infection control tools. It calls for nothing less than a cultural transformation, say Jain and Miller.

"It's basically changing the paradigm of how we view infection control," says Miller. "It needs to be every employee's responsibility. We have found that from infection control down to environmental management, we all have a role in making sure our hospitals are safe and that veterans are not getting hospital-acquired infections."

The culture change begins at the top, as "leadership" takes on a new meaning. No longer do missives come from administration such as orders to an army of employees. Instead, leadership seeks solutions from those on the front lines, says Jain.

"The leadership provides the policy guidance, but the staff [members] are the experts," he says. "They're the ones involved in the day-to-day patient management."

To facilitate that dramatic change, VA Pittsburgh held "discovery action dialogues," or action-oriented focus groups, with staff. Administrators attended unit briefings once a week to share data and get feedback from the employees.

The health system also launched a "positive deviance initiative," which focuses on finding the solutions to problems within a community rather than turning to outside experts. (More information on positive deviance and the VA Pittsburgh Health System is available at www.positivedeviance.org/projects/pittmrsa/VAPHS_Singhal_Greiner.pdf.)

An example: Nurses complained that there were not enough beds for patients with community-acquired MRSA who needed to be in isolation. Environmental services responded to the problem by deciding to do a "terminal clean," or more intense cleaning, on all rooms rather than just a select few. The health system now has more flexibility when placing a patient with MRSA.

The initiative makes the VA "a place where everyone feels comfortable in bringing forth their ideas," says Miller.

Enlist the help of patients

Employees aren't the only ones who have been involved in Getting to Zero campaign. Patients have a role in making sure that health care workers comply with hand hygiene.

In one VA hospital, patients receive cards when they're admitted. When a clinician comes into their room to provide care, they hold up a green card to acknowledge that they've seen the clinician perform hand hygiene. They hold up a pink card to say, "Please stop and wash your hands."

"It's hard for veterans to say, 'Dr. So and So, please stop and wash your hands.' So this is a nonverbal way to tell the provider they need to do hand hygiene," says Miller.

The MRSA program leaves it up to individual hospitals to determine how to boost hand hygiene. Some use an interdisciplinary team to conduct observations — sort of a "secret shopper" in health care. One hospital gives stickers to patients and providers. Patients can give stickers if they observe hand hygiene or take them away if they don't.

The providers and veterans with the most sticker receive rewards.

To sustain a program, you need to be creative and continue to motivate people, says Jain. It needs buy-in beyond infection control and employee health, he says.

"Make it fun," he says. "Celebrate your successes. Reward people when you see good behavior. Make sure you listen to staff and remove barriers. The staff will see this is a real change and they will get excited and help you move forward."

APIC: MRSA widespread throughout U.S. hospitals

Prevalence higher than previous estimates

About 46 out of every 1,000 inpatients are infected or colonized with multidrug-resistant Staphylococcus aureus (MRSA), a rate that is eight to 10 times higher than previous estimates, according to findings from the Association for Professionals in Infection Control and Epidemiology.

In the most comprehensive study of its kind, the Washington, DC-based organization surveyed 1,237 health care facilities, which encompassed 21% of the nation's hospitals. Infection control professionals were asked to report infection rates on specific dates to gather a "snapshot." The responses included hospitals of all sizes from all 50 states.

The prevalence of MRSA has been troubling. In 1972, only 2% of health care-associated S. aureus infections were MRSA. Today, MRSA is the most common pathogen-causing health care-associated infection in the United States.

According to APIC, the survey found that:

  • 81% of patients were detected by clinical cultures;
  • 19% were detected by active surveillance cultures;
  • 77% were detected less than 48 hours within admission, which indicates that they either acquired it in the community or during a previous hospital admission;
  • 37% had skin and soft-tissue infections only (which are generally a sign of community-acquired MRSA);
  • 63% had infections at sites other than skin or soft tissue, such as blood or urinary tract infections or pneumonia.

About 28% of hospitals conduct active surveillance to determine if patients are colonized. The active surveillance typically targeted patients transferred from long-term care facilities or other health care facilities or patients in high-risk areas, such as the intensive care unit or dialysis unit.