Is MRSA on the run? CEOs getting on board,

IPs now have friends in high places

A scourge of hospitals for decades, methicillin-resistant Staphylococcus aureus (MRSA) may finally be on the run, and it's moving in the right direction: from the bedside to the "C-suite." In initiatives that speak to both quality and cost-savings, hospital CEOs are putting their considerable clout behind infection prevention efforts against the most highly publicized health care-associated infection (HAI).

What better target than an HAI that has gained national notoriety by infecting people in the hospital and community, spurring consumer demands for change in a litigious, money-crunched health care climate that is increasingly being told by payers to prevent infections or pay for them. Indeed, preventing infections speaks directly to the bottom line by reducing length of stay and extended care that may be targeted for nonreimbursement by the Centers for Medicare & Medicaid Services (CMS).

"Certainly, some of the discussion that has taken place with regard to 'pay for performance' has gotten folks interested; but more important, there is a real movement by hospitals throughout the country to really do a better job at focusing on delivering care and service," says Steve Lawler, CEO of Pitt County Memorial Hospital in Greenville, NC. "I think people understand that it creates a difference in the marketplace."

Lawler and CEO colleagues at the VHA, a national health care alliance based in Irving, TX, have MRSA firmly in their sights. The VHA brought together hospital CEOs from throughout its Central Atlantic region, launching a "board-directed" quality initiative to reduce MRSA infections. Forty-nine participating hospitals have been collecting data since October 2007, and the results are promising. Overall, the hospitals have reduced MRSA by 20%, which equates to nearly $4 million saved by preventing 151 infections.

So much for infection prevention being a nonrevenue-generating department. Infection preventionists who labored in relative obscurity in a protracted battle with this bug now have friends in high places, as CEOs react to the surge of political, regulatory, and financial issues suddenly swirling around MRSA prevention.

"I think people realize that there has to be an investment in [infection prevention]," says Lawler, chairman of the VHA board that created the initiative. "It's not something that happens by magic. It happens by focus, by accountability, and by making sure you have the right resources."

Those resources may be used for interventions to stop MRSA transmission by using active screening cultures to detect and isolate colonized or infected patients.

"Our hospital has been involved in that kind of program for about two years," Lawler says. "We were the second hospital in the country that actually started doing 100% screening of our patients."

Money talks — louder than ever — but the high road in this discussion is improving quality, reducing suffering, and saving lives.

"At VHA, when we sit around the table as a board, we talk about how are we are doing in quality — not only in MRSA, but several other areas," Lawler says. "Eradicating MRSA, reducing device-related infections, or reducing mortality by following bundle compliance are probably things everyone is talking about and paying attention to in the C-suite."

While the cost-saving aspect is certainly being emphasized in the current recession, the CEOs were focused more on quality improvement when the project began in 2007, says Terri Bowersox, FACHE, director of clinical performance improvement at VHA's Central Atlantic office in Charlotte, NC.

"But in 2008 — especially toward the end of 2008 — we could definitely see our board of directors at VHA Central Atlantic really shifting to more of a financial focus and being interested in how they can reduce their costs," Bowersox says. "We started putting the economic issues out there, like the CDC estimate of an average cost of $26,000 per MRSA infection. That has really gotten their interest, because now it is not only a quality-of-care issue — it is a financial issue."

That initiative is translating to lower rates, even as an unrelated wave of clinical prevention efforts in intensive care units are being credited for dramatic MRSA reductions in Centers for Disease Control and Prevention sentinel hospitals.

"Our MRSA infection reduction initiative is clearly working," Bowersox says. "Sixteen participating hospitals have already reduced their MRSA infection rates by 30% or more. We are on track to reduce MRSA infections in the region by 80% in three years."

In addition to CEO involvement, the hospitals are working with nursing units to implement a culture of safety, using monthly data collection and monitoring, best-practice sharing, and customized coaching by VHA clinical improvement consultants, she says.

Another aspect of the program is a web site, the Leading Practices Portal, which enables VHA hospitals to access information about their performance in specific clinical areas and to compare other hospitals regionally and nationally. The site helps hospitals identify gaps in their performance and points the hospitals to resources for improvement, Bowersox says.

IPs say zero is the target

The infection preventionists at the individual hospitals in the project welcome the high-profile support, saying they want to move beyond any benchmark goals and flat-line MRSA infections.

"I don't think ethically or morally you can say, 'We're OK if 10% of our patient population gets MRSA infections,'" says Robin Carver, RN, BSN, CIC, director of infection prevention and control at WakeMed Health & Hospitals in Raleigh, NC. "We are excited and we celebrate anytime we prevent one infection. Is zero realistic? I don't know — it might be. In the world of infection prevention, this is our passion. I don't think we are OK with a 5% or 10% infection rate."

Carver and other IPs in the participating hospitals are finding that with CEO support, many — if not all — things are possible. "Hospital infection control has never been as resourced and supported as it is in our hospital," she says. "As long as I can really provide the background and explain to the administrators why I really need it, I have not been denied anything lately."

And Carver is putting those resources to good use. Through the VHA initiative, WakeMed has reduced its hospital-acquired MRSA rates by 51% in one year. "We are continually coming up with new ways to engage, excite, and remind staff to incorporate MRSA infection control efforts into their daily processes, such as hand washing, barrier protection, and active surveillance," Carver says. "Weekly screening of patients, combined with comprehensive and sustained educational activities, have really helped us to improve our rates."

Education doesn't stop at health care workers, but actually starts with admitted patients. They are shown something akin to a "pre-flight" video, which warns of the risk of infection and advises patients to remind caregivers to wash their hands. In addition, she has deputized "infection control resource nurses" to make hand-washing observations and collect data that will be reported back to staff.

"We also just created what we call the 'hand hygiene ambassador team,'" Carver explains. "We asked managers about any employees that they have on their unit who really want to be change agents. If the employee on that unit can engage their colleagues in fun, nonthreatening ways to remind each other to do hand hygiene, [then it may become] the social norm in that unit."

Such things are possible when a program comes as a directive from the CEO, as workers can hardly blame the infection prevention "police" for being overzealous when they are enforcing an institutional priority.

"Our CEO's endorsement and support of this program has made it clear that this is an important initiative," says Wanda Lamm, RN, BSN, CIC, infection prevention coordinator at Nash Health Care Systems, Rocky Mount, NC. "Hand hygiene continues to be a key to our success."

Nash Health Care Systems has been participating in various VHA infection control initiatives and saw this effort as another opportunity to tackle MRSA and other multidrug-resistant organisms. To date, the VHA initiative has helped the hospital to reduce its MRSA infection rates by 77%.

Lamm calls her hand hygiene observers "secret shoppers," but the main point is that health care workers are well aware that their patient encounters may be monitored and are on board with the program.

"It's actually been very positive," Lamm says. "I think the tone has been set that we expect this to be done as part of our patient safety initiative. I really don't hear about any 'push-back' from staff. One of the things that has helped me the most is that our patient safety officer is a physician who has been a huge supporter and works with the medical staff to get help from their side as well."

Every month, Lamm compiles the data on hand hygiene compliance by departments and disciplines. She doesn't exactly put the report on a shelf for later perusal.

"I send it out as a global e-mail so everybody can see how everybody is doing," she says. "Nobody wants to be the low man on the totem pole. We decided we were not going to hold back. We are just going to let everybody know how everybody is doing."

Lamm also has a patient education component in her program, but the VHA initiative does not require every hospital to adopt the same strategies.

"By Joint Commission standards, we are required to do a risk assessment," Carver notes. "We look at where the issues in our hospital are: Where are the potential risks for transmission? Through that risk assessment, every hospital decides what works best for them."

For example, while Lamm has been using active surveillance for years, Carver's program is relatively new to the practice.

Ultimately, as IPs are well aware, improving hand hygiene rates and other interventions will yield benefits beyond MRSA prevention. "An initiative like this is going to impact any organisms that are spread through this route," Lamm says.

Carver concurs, noting, "in conjunction with our decrease in MRSA, we have also seen a decrease in our overall VRE rate. If you combine the interventions with environmental decontamination — we know a lot of gram negatives are environmental organisms — you are going to see a decrease in those gram negatives, too."