Dramatic results achieved with MRSA initiative
Gains significant in light of disturbing JAMA article
The bad news: Methicillin-resistant Staphylococcus aureus (MRSA) is a more widespread public health threat than scientists had previously thought. The good news: An award-winning program at Evanston (IL) Northwestern Healthcare demonstrates that hospitals can achieve dramatic results in the reduction of MRSA.
First, the bad news. A paper in the Oct. 17, 2007, issue of JAMA estimates that 94,360 invasive MRSA infections occurred in the Unites States in 2005 and that they were associated with deaths in 18,650 cases.1 In fact, according to an October report from the Centers for Disease Control and Prevention, it seems more people in the United States die from hospital-acquired MRSA than AIDS.
Most of the cases in the JAMA study, said the authors, were health care-associated, with 5,250 (58.4%) being community-onset infections, 2,389 (26.6%) hospital-onset infections, 1,234 (13.7%) community-associated infections, and 114 (1.3%) that could not be classified.
While the majority of invasive MRSA cases occurred outside of the hospital (58%), the JAMA authors wrote, they occurred among people with established risk factors for MRSA, such as a history of hospitalization in the past year.
(As if that wasn't worrisome enough, as this issue went to press, two MRSA-related deaths were reported in public schools, and at least one system closed down to allow time to thoroughly clean its facilities.)
Thankfully, there is much that hospital quality managers and staff leaders can do to limit the spread of MRSA, as demonstrated by Evanston Northwestern, which has been named a recipient of this year's John M. Eisenberg Patient Safety and Quality Award in recognition of the efforts of its MRSA Reduction Program Team.
The three-hospital system was able to reduce MRSA infection rates by 60% within the first year of the program.
A 'long path'
"It's been kind of a long path [to success]," notes Lance Peterson, MD, FIDSA, FASCP, epidemiologist and a founder of the MRSA program at Evanston Northwestern. "We noticed around 2002-2003 that there seemed to be more little pockets of MRSA in the hospital."
Evanston Northwestern had been conducting some pilot programs in its ICUs during 2003, Peterson explains, and that's how the spread was noticed. "In August 2004 we did what's called a point prevalence risk assessment; we swabbed every inpatient's nose in all three hospitals, and 8.5% of all patients had colonization — which was three times higher than what had been published before, so it looked like [the incidence of MRSA was] going up."
So, that month staff started to do admission surveillance in all ICUs. "That was the point at which we started to plan what to do next," Peterson shares. "I talked with the senior vice presidents of quality and nursing, and they agreed that if it looked like the carriage rate was high, we would do something about it."
When he saw just how high it was, Peterson decided to follow the model of the Northern Europeans and the Dutch, who had demonstrated success in this area. That model, he explains, entails universal surveillance and isolation. "Every patient who is admitted gets a swab, and if they test positive, they get isolation," he says, noting that this program began in August 2005.
There was no problem finding enough isolation beds, he continues. "You can actually put two MRSA-positive patients together," he explains. "Overall, our isolation rate only went up 20% because we regularly isolate for other things as well."
Getting staff on board
Getting your staff to buy in to such a program "takes a fair amount of planning," says Peterson. "We had lots of talks with nursing and physician leadership, and sent out newsletters as well."
On the system's Intranet the staff posted information on MRSA that could be downloaded. "We even made a videotape of how to do the nose swab," says Peterson. In addition, he says, the ordering of tests and treatment was made easy with the use of the electronic medical record system. "It just takes a single click," says Peterson. "We made it as simple as possible."
After the program started, continuing presentations on MRSA were held. "After the first three months we started to look at outcomes and there was a very dramatic reduction almost immediately," notes Peterson. After the first year, not only was there a 60% reduction in MRSA infections, but there was also an 80% reduction in bloodstream infections. "Those rates are even lower now," he says.
Compliance monitoring has been an important part of the program, says Peterson, and he is pleased with the participation rates. "It's the earliest thing we monitored," he says. "We started at 80%, and by the end of the first year it was 90% — our goal."
Here again, technology was a big help. "If somebody forgets to do a swab, a bright orange banner shows up on the [electronic] chart every time you log in, which says the MRSA test has not been done," Peterson says. "And it will not go away until it has been done."
In addition, he says, "we did over 1,500 chart audits to make sure that what we were measuring were actual infections." As for staff compliance, "we continue to do snapshots; once every month we look at randomly selected charts, moving around each month, and make sure the actual performance is what they tell us it is." Overall performance, he adds, can be monitored electronically simply by looking at the number of admissions and the number of tests that have been done.
Not surprisingly, Peterson says the biggest challenge has been "keeping hand hygiene [compliance] high enough." What happens when an individual staff member is found to regularly have poor compliance? "We have occasionally sat down with nurses and discussed infection control," he shares. "The focus of the discussion goes like this: 'You have been observed not following [proper procedures], and we wanted to make sure you do not have any questions or concerns.'"
Peterson says the involvement of leadership has been critical to the success of the program. "It really encourages the staff when leadership says this is the right thing to do," he concludes.
(Editor's note: Evanston Northwestern serves as a mentor system for the Institute for Healthcare Improvement, and can be contacted through the IHI for assistance in setting up your own MRSA program. In addition, the December issue of the Joint Commission's Journal on Quality and Safety will include an article by Peterson on how to set up an MRSA program.)
- Klevens MR, Morrison MA, Nadle J, et. al. Invasive Methicillin-resistant Staphylococcus aureus infections in the United States. JAMA 2007; 298:1763-1771.