MRSA program reaps rewards at VA

Prototype expanded throughout the system

Mention the U.S. Department of Veterans Affairs (VA) hospital system to QI professionals and you'll likely hear about any of the dozens of projects and programs developed at the VA that have percolated throughout the country — and beyond — with great positive impact on patients.

A month ago, one of the VAs biggest successes — combating methicillin-resistant Staphylococcus aureus (MRSA) — was trumpeted in the New England Journal of Medicine1. It started out as a project at one VA facility in Pittsburgh in 2002, says Rajiv Jain, MD, chief consultant of specialty care services in the VA Office of Patient Care Services. "The objective then was to see if a bundled approach of strategies was put into the surgical, and then intensive care units, if we would decrease MRSA infections."

The bundle consisted of checking every patient's nasal cavity for the presence of MRSA, using universal precautions for patients who tested positive, hand-washing protocols, and changing the culture of the facility to ensure that infection control was not just the responsibility of doctors and nurses, but of every single person who had contact with the patient.

The result was a "significant" decrease in MRSA infections, Jain says. They expanded it to all units in Pittsburgh with enough success that in 2007, the protocol was expanded to all VA facilities.

The national project, which measured rates between 2007 and 2010, resulted in a decline from 1.64 infections per 1,000 patient days to .62 per 1,000 patient days in the ICU. In non-intensive care settings, the MRSA infection rate fell by nearly half, from .47 per 1,000 patient days to .26 per 1,000 patient days.

Going from a local effort to a national one isn't easy. Jain says they were concerned about making it work in 150 facilities when each one had its own particular issues. To that end, they brought people from each facility to Pittsburgh first to see how it worked there, how each component of the bundle was implemented, and get feedback from those who used it daily.

After launch, the team was available to provide guidance to any facility that needed it.

Martin Evans, MD, program director for multidrug-resistant organisms at the VA Office of Infectious Diseases, says Jain's insight was to find a single person at each facility as a key person to provide support — the MRSA Prevention Coordinator — whose role it was to ensure that the protocol stayed up and running smoothly, to monitor success, deal with problems, and trouble-shoot any issues that arose.

"You can say we are one system, but things are local," says Gary Roselle, MD, program director at the VA Office of Infectious Diseases. "The mission was to have central guidance, but local implementation. It's not that we ever changed the bundle itself, but implementation strategies were local. I'd bet there were 150 different ways this was implemented."

Jain notes that local modifications included deciding what intensive care unit to select — some chose coronary care, some chose the medical ICU. "All we cared was that it was an ICU first." When they were told to expand the program, they decided where to go next — a surgical ward or some other unit.

The choice of where to put the hand sanitizing dispensers — most chose by the door, but location didn't impact outcomes — and whether to use a rapid or standard MRSA test were also left to each VA facility.

No part of the bundle is off-the-charts strange — although there are some hospitals that weren't used to and weren't happy about testing every patient for MRSA. But Roselle says having a checklist makes a difference in outcomes. "You may think each item itself is straightforward, but you have to make sure each item is checked off, all the time and every time."

Jain says that bundles are useful and are often used — but usually just in the ICU. What makes this different is that MRSA impacts more than the ICU, and this bundle can be applied across all acute care units.

The positive impact of the program was not a surprise. The degree of change? Roselle notes that it was "a nice reward." Another positive that came out was a reduction in some other difficult organisms that plague hospitals. Evans says that some of the VA hospitals looked at vancomycin-resistant enterococci (VRE) and C. difficile.

"Much of the way they are spread is like MRSA," says Evans. "We thought that the components of the MRSA efforts, and the culture change resulting, would probably impact other organisms." In ICU and non-ICU settings, facilities that looked, indeed, found a reduction in VRE rates, and in non-ICU settings, C. difficile rates decreased. "They weren't the targets, but they were impacted."

One other note the physicians made related to another study in the same issue of NEJM. Huskins et al found that looking for MRSA and VRE in ICU patients — and then implementing a barrier precaution protocol for those who test positive — didn't affect infection rates. The lack of benefit of active surveillance, which was the only thing that any of the other VA facilities had issue with in the bundle, probably relates to the way they surveilled, says Evans. "When a patient was admitted, they did the culture, but the results came five days later 60% of the time. That won't have an impact on what you did with that patient until then."

The VA is using much more rapid testing — in some facilities such as the one in Lexington, they require test results before a patient is sent to a unit. "That's very different than what Huskins and his group did," Evans says. "It didn't work because they didn't use the surveillance the same way we did. They were using precautions in people who had a history of MRSA. But only 10% of our patients fit that characterization. If only 10% of patients are getting precautions, and only half the time they should have been, the last line of their paper, which says that active surveillance as achieved during their trial isn't effective, is not surprising."

For more information on this story contact:

• Rajiv Jain, MD, Chief Consultant of Specialty Care Services, VA Office of Patient Care Services. Email: rajiv.jain@va.gov.

• Gary Roselle, MD, Program Director VA Office of Infectious Diseases. Email: gary.roselle@va.gov.

• Martin Evans, MD, Program Director, Multi Drug Resistant Organisms, VA Office of Infectious Diseases. Email: Martin.evans@va.gov.

Reference

  1. Jain R, Kralovic SM, Evans ME et al. Veterans Affairs initiative to prevent methicillin-resistant staphylococcus aureus infections. N Engl J Med 2011; 364:1419-1430.