Collaborative model shows early success in battling MRSA
Collaborative model shows early success in battling MRSA
Early participants cut number of infections by about 85%
A unique collaborative model in the region surrounding Pittsburgh, PA, has shown significant success battling methicillin-resistant Staphylococcus aureus, (MRSA), with early participants in the program showing infection rate reductions of 85%.
Staphylococcus aureus is commonly found on skin. Methicillin is the commonly used and highly effective antibiotic to treat infections caused by Methicillin Sensitive Staph. Aureus (MSSA). Infections caused by MRSA are associated with significantly higher morbidity and mortality than those due to MSSA.
Why target MRSA? "This bacterium stalks every patient that enters an American hospital," asserts Jon C. Lloyd, MD, regional project coordinator for Building Regional Coalitions to Prevent MRSA Infections in Healthcare Facilities, a position that grew out of an interagency agreement between the Centers for Disease Control and Prevention (CDC) and the Veterans Administration Pittsburgh Healthcare System (VAPHS). (Several other organizations the Allegheny County Health Department, the Hospital Council of Western Pennsylvania, VHA Highmark Blue Cross, Blue Shield and the 60+ hospitals participating, also are included in the Southwestern Pennsylvania MRSA Prevention Collaborative).
Learning from Europe
"About two million hospital-acquired infections (HAIs) occur every year in this country — most often transmitted by hands and equipment," Lloyd continues. "Of the two million, 70% of those are due to pathogens that are resistant to commonly used antibiotics, and a growing percentage of those are caused by MRSA. It is the most rapidly growing and among the most virulent antimicrobial resistant bacteria."
Lloyd, who has more than 35 years’ experience as a surgeon, became aware several years ago, in his former role as medical advisor to the Pittsburgh Regional Health Initiative (PRHI), of the success northern European countries had in eliminating MRSA. "Twenty-five years ago in Denmark, Finland, and the Netherlands, they noted rapidly growing resistance of hospital Staphylococcus aureus to Methicillin and other commonly used antibiotics," he observes. "When resistance reached 30%, they embarked on an aggressive search and destroy’ approach to the problem which virtually eliminated MRSA from hospitals in those countries. Today, less that 1% of Staph. Aureus are resistant to Methicillin, and hospital acquired MRSA infections are a rarity in Northern Europe. In U.S. hospitals, 60% of Staph aureus are resistant to Methicillin and MRSA causes 50% of all hospital-acquired surgical site infections, blood stream infections, and pneumonias.
"What the Northern Europeans did to eradicate MRSA from their hospitals is quite simple in concept," Lloyd goes on to say. "They cultured every patient admitted to their hospitals and isolated those who were MRSA-positive from those who were not. Health care workers wore gowns, gloves, and masks and used designated equipment when caring for MRSA-positive patients, and they were maniacal about washing their hands before and after every patient contact."
Protocols that were similar to the Northern European approach were adopted in two units each at the first two hospitals to participate in the Pittsburgh collaborative — VAPHS, and UPMC-Presbyterian/Montefiore in 2002. Infection rates in all four units have dropped by 85% for the last three years. These successes inspired other hospitals to follow suit.
It became obvious that the traditional model of each hospital dabbling independently in MRSA control wasn’t working. Hospitals share patients and health care workers. They also can share success, and that’s exactly what Pittsburgh’s health care community decided to do in a collaborative effort to eliminate hospital-acquired MRSA.
Most hospitals participating in the collaborative have elected to use a model based on a guideline recommended by the Society for Healthcare Epidemiology of America (SHEA), in part because of the documented success at the aforementioned facilities. This evidence-based guideline calls for active surveillance (culturing patients), contact isolation for patients who culture positive for MRSA, and strict hand hygiene.
The two facilities took slightly different approaches, says Lloyd. "The Pittsburgh VA Hospital used an industrial model introduced by PRHI — applying the principles of the Toyota Production System to health care. This enabled the staff on a surgical unit and a surgical ICU to change the system and implement the SHEA guideline." At UPMC, Carlene Muto, MD, MPH, hospital epidemiologist and principal author on the SHEA guideline, worked with colleagues to create the necessary system changes in a medical and a cardiothoracic ICU to enable the staff to culture all patients in those units, apply contact isolation precautions to the MRSA-positive patients, and perform hand hygiene before and after every patient contact. "Dr. Muto’s scholarship and example have been driving forces in our regional MRSA prevention collaborative," says Lloyd.
The important lesson learned from these early successes is that certain system changes must accompany any attempt to apply evidence-based precautions to prevent MRSA infections.
Site visits and workshops convened by the health department and sponsored by the region’s hospital associations and dominant health plan have served to enable health care professionals from the region’s hospitals to self-discover those practices and strategies that are responsible for dramatic reductions in hospital-acquired MRSA infections.
With guidance from the CDC, a core group of 23 Pittsburgh-area hospitals have created a standardized methodology for measuring the impact of the SHEA guideline on hospital-acquired MRSA transmission and associated infection rates.
The Allegheny County Health Department is home to a regional MRSA surveillance system that will receive surveillance data from targeted units in each of the 23 participating hospitals and report their results back to them, along with how they compare with the aggregated results of the other hospitals. This will enable the health care community to learn from its variations, a rare opportunity in the health care industry, according to Lloyd.
"Like the water flowing through the broken levees around New Orleans, MRSA, if left unchecked in our hospitals, has the potential to become a catastrophic public health disaster," comments Lloyd.
He goes on to say that "our health care community, as a result of this collaborative effort, now has resources and a model in place to help prevent such a disaster from occurring."
Positive deviance
At the VAPHS, hospital leaders have committed to systemwide implementation of the SHEA guideline with a goal of achieving a 50% reduction in MRSA infections in one year and elimination of endemic MRSA systemwide in five years.
Starting in July of this year, all patients in both hospitals in the system are being cultured for MRSA on admission, discharge and transfer, barrier precautions are applied to those whose cultures are positive, and strict hand hygiene is mandated for all patients. Building on the success in the two units that dramatically reduced their MRSA infection rates, the VA staff are taking a unique approach to identifying and amplifying specific practices that produce optimal results. "The approach is based on what works; the staff’s assets and strengths," Lloyd says.
The approach, called Positive Deviance (PD), was developed at Tufts University by Professor Marian Zeitland as a research tool. In 1990, it was adapted by Jerry and Monique Sternin as a tool for bringing about behavioral and cultural change. The Sternins have become international experts in applying PD in a variety of cultures and industries. Their only other foray into health care is at Waterbury Hospital in Connecticut, where they are working with the staff on the issue of medication reconciliation.
"The whole idea of PD is that in every organization there are groups of people whose uncommon behaviors enable them to solve intractable problems that their neighbors, who have access to the same resources, haven’t been able to solve," Lloyd says.
He goes on to explain that PD is an approach that is based on fierce self-discovery by the staff of successful practices and then deciding which ones are immediately accessible and useful on a specific nursing unit, and then designing opportunities to implement those practices. The role of leadership is to support the staff in this process.
The Sternins came to Pittsburgh in July and ran an all-day workshop for health care professionals at VAPHS representing their long-term care and acute care facilities. "We subsequently created a living document to serve as a road map for systemwide MRSA prevention, says Lloyd. "Rajiv Jain, MD, VAPHS chief of staff and professor of medicine at University off Pittsburgh School of Medicine, told us that he didn’t know what this model was going to look like, but that he was certain that an empowered staff would know."
The health care community in Southwestern Pennsylvania looks to UPMC and VAPHS for leadership and guidance in MRSA prevention efforts because of the dramatic reductions in MRSA infections they were able to achieve in targeted units. Lloyd observes that "within the past year, the number of hospitals doing targeted active surveillance cultures for MRSA in our community has increased from two to 23. Having instituted housewide surveillance in its two hospitals, VAPHS has the opportunity to set a new gold standard for the community. Southwestern Pennsylvania could easily become a mini-Denmark when it comes to MRSA prevention."
Need More Information?
For more information, contact:
- Jon C. Lloyd, MD, MRSA Prevention Project Coordinator, VAPHS, Pittsburgh Regional MRSA Prevention Coordinator, Centers for Disease Control and Prevention. Phone: (412) 512-3974.
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