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A Hospital-Based Intervention to Reduce MRSA Hospital-Associated Infections (HAIs) in a Rural Medical Center
www.ajicjournal.org Vol. 39 No. 5
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live’’ data aggregation began on September 1, 2010. Various upgrades and changes were made to the system as a result of input from Facility A personnel. Results: HH observations increased from ,50/month to .5000/month. HH adherence was maintained over 90% for all shifts with no HAIs transmitted in the pilot unit from 9/15/10 through 12/31/10 (chart). Lessons Learned: An EHHMS enabled constant, real-time tracking and aggregation of HH adherence. Significant and sustained increases in HH compliance among all personnel in the unit were maintained. The electronic technology enabled Facility A IPs to address sensitive HH issues in real time, and in a collegial manner. Importantly, a significant decrease in HAIs in the pilot ICU was documented during the time that HH adherence rates were enhanced. In conclusion, IPs and healthcare facilities should consider similar new technologies in the ongoing endeavors to reduce HAI rates in healthcare facilities.
Presentation Number 6-047
A Hospital-Based Intervention to Reduce MRSA Hospital-Associated Infections (HAIs) in a Rural Medical Center Lorna DeGrazia, RN, MSN, CIC, Nurse Epidemiologist, Vassar Brothers Medical Center, Poughkeepsie, NY Issue: MRSA infections are costly and potentially lethal to all age groups especially high risk compromised patients prone to infections. In August 2007, an implementation plan was set up to reduce MRSA in the hospital setting. A committee was formed to investigate, analyze and develop an interventional plan based on a facility-wide MRSA risk assessment. The 3-month ICU pilot study was chosen for baseline testing of rates and MRSA infections followed by CCU and RCU (chronic ventilator unit). Project: Nurses were trained in ICU, CCU and RCU on MRSA active culture testing using the correct technique in obtaining nares samples for Polymerase Chain Reaction (PCR) on admission, day 7, and day of discharge. Unit personnel were trained on hand hygiene, contact precautions and use of personal protective equipment, environmental/equipment decontamination, and nares decolonization. The study period started Jan. 1, 2008 on ICU and CCU; and Jan.1, 2009 on RCU, ending on Dec. 31, 2010.The number of MRSA-positive cases by unit were gathered monthly as were the number of hospital-associated infections. A Fisher’s exact test was used in the data analysis to compare rates and statistical significance. Results: Both the 3-year study of the ICU and CCU, and the 2-year study of the RCU showed improved MRSA PCR testing compliance with decreasing trend in the number of HAIs. In ICU the 2008 HAI rate was 0.18%. The 2010 rate was 0.00% (p50.64.) with no statistically significant differences between 2008 / 2009 or 2009 / 2010. There was a statistically significant decrease between 2010 and the baseline rate (p ,0.001). In CCU, there was a statistically significant decrease in HAIs from 0.36% in 2008 to 0.00% in 2010 (p50.02.) In RCU, there was a statistically significant decrease in the proportion of HAIs during the 2- year study, reducing from 1.71% in 2009 to 0.66% in 2010 (p50.02). Lessons Learned: Implementation of MRSA reduction strategies for high risk patients is an organizational challenge. Staff acceptance of the new program was facilitated by administrative and physician support. Barriers
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American Journal of Infection Control June 2011
included staffing for teaching, off-shift penetration, changes in lab procedures for PCR testing and obtaining the appropriate swabs. A reduction in HAIs in critical care validated the project with good outcomes. Presentation Number 6-048
Quality Assurance Data Collection Provides Opportunity for Organizational Improvement Following a Rise in Sternal Surgical Site Infections (SSI) Post-Coronary Artery Bypass Graft (CABG) Surgery Katherine Matteson, RN, BSN, MS, CIC, Infection Control Practitioner; Russell Hynek, PharmD, Paul Lata, PharmD, Pharmacist; Linda McKinley, RN, MPH, CIC, Infection Control Practitioner; Lynn Michel, RN, MSN, APRN, BC, VA NSQIP/CICSP Coordinator; Athanasia Schreiner, RN, MSN, APNP-BC, Nurse Practitioner; Catherine Stampfli, RN, BSN, MRSA Prevention Coordinator; Sandra Tainter, RN, BSN, Nurse Manager; Christopher Crnich, MD, MS, Staff Physician & Hospital Epidemiologist; William S. Middleton Memorial VA Hospital, Madison, WI Issue: A cluster of 4 cases of sternal SSIs post- CABG procedures were identified during routine quality assurance data collection for the VA National Cardiac Surgery Program between July-November 2009. A focused review of the cases identified multiple areas for improvement despite participation and reported compliance with multiple Surgical Care Improvement Project (SCIP) measures. Project: Infection control conducted a focused review of the cases including pathogen, pre-op MRSA screening results, pre-op antibiotic selection and timing, graft site, glycemic control and obesity. A multidisciplinary team was formed to identify areas for improvement. Risk factors identified were 1. All infections caused by Staphylococcus species (2-MRSA, 1-MSSA, 1-CNS), 2. MRSA colonization (50%), 3. Uncontrolled diabetes (75%) 4. Antibiotic selection and/or timing (75%) 5. Duration of surgery (100% above 300 min/CDC NHSN mean) and 6. Graft site selection in diabetic patients (75%). Interventions targeted pre-and intra-operative risk factors including 1. Earlier MRSA screening, 2. Decolonization of MRSA positives (i.e., mupirocin and chlorhexidine bathing), 3. Assurance of pre-op glycemic control, 4. Use of vancomycin for MRSA positives, 5. 2nd antibiotic dose for longer procedures, and 6. Appropriate graft site selection for diabetic patients. Results: Despite SCIP measures reported at or above target for antibiotic timing (99%) and antibiotic selection (95%) during FY09 this data excludes vancomycin. A review of vancomycin during FY09 for cardiothoracic (CT) surgical procedures found 0 of 12 surgical cases (0%) had properly infused 1-hour prior to incision. The SCIP measure for glucose control in CT surgical patients was also reported at target, 95%, during FY09 but this measure does not assess pre-op A1c. Following interventions there have been no cases of sternal wound infections following CABG surgery since December 2009. Lessons Learned: Process measures for ensuring compliance of evidence based interventions (e.g. antibiotic selection and timing) can provide a false sense of assurance and should not be considered as replacement to outcome monitoring. Quality assurance outcome monitoring along with focused case reviews can always provide opportunities for organizational improvement. Presentation Number 6-049
New Methods for Hand Hygiene Measurement of all HCW ‘‘Before and After’’ Patient Contact and/or Contact with the Patient’s Enviroment can Drive Hospital Acquired Infection Rates to ZERO! Jennifer Kraft Spivey, RN, MSN, CNOR, CIC, Infection Preventionist, St Vincent Heart Center of Indiana, Indianapolis, IN Issue: Infection Preventionists are charged with measurement of hand hygiene practices of HCW by The Joint Commission’s National Patient Safety Goals, however there are many methods of measurement to choose from and many are unreliable in showing the ‘‘true picture’’ of hand hygiene practices of HCW around the clock in our
E141
live’’ data aggregation began on September 1, 2010. Various upgrades and changes were made to the system as a result of input from Facility A personnel. Results: HH observations increased from ,50/month to .5000/month. HH adherence was maintained over 90% for all shifts with no HAIs transmitted in the pilot unit from 9/15/10 through 12/31/10 (chart). Lessons Learned: An EHHMS enabled constant, real-time tracking and aggregation of HH adherence. Significant and sustained increases in HH compliance among all personnel in the unit were maintained. The electronic technology enabled Facility A IPs to address sensitive HH issues in real time, and in a collegial manner. Importantly, a significant decrease in HAIs in the pilot ICU was documented during the time that HH adherence rates were enhanced. In conclusion, IPs and healthcare facilities should consider similar new technologies in the ongoing endeavors to reduce HAI rates in healthcare facilities.
Presentation Number 6-047
A Hospital-Based Intervention to Reduce MRSA Hospital-Associated Infections (HAIs) in a Rural Medical Center Lorna DeGrazia, RN, MSN, CIC, Nurse Epidemiologist, Vassar Brothers Medical Center, Poughkeepsie, NY Issue: MRSA infections are costly and potentially lethal to all age groups especially high risk compromised patients prone to infections. In August 2007, an implementation plan was set up to reduce MRSA in the hospital setting. A committee was formed to investigate, analyze and develop an interventional plan based on a facility-wide MRSA risk assessment. The 3-month ICU pilot study was chosen for baseline testing of rates and MRSA infections followed by CCU and RCU (chronic ventilator unit). Project: Nurses were trained in ICU, CCU and RCU on MRSA active culture testing using the correct technique in obtaining nares samples for Polymerase Chain Reaction (PCR) on admission, day 7, and day of discharge. Unit personnel were trained on hand hygiene, contact precautions and use of personal protective equipment, environmental/equipment decontamination, and nares decolonization. The study period started Jan. 1, 2008 on ICU and CCU; and Jan.1, 2009 on RCU, ending on Dec. 31, 2010.The number of MRSA-positive cases by unit were gathered monthly as were the number of hospital-associated infections. A Fisher’s exact test was used in the data analysis to compare rates and statistical significance. Results: Both the 3-year study of the ICU and CCU, and the 2-year study of the RCU showed improved MRSA PCR testing compliance with decreasing trend in the number of HAIs. In ICU the 2008 HAI rate was 0.18%. The 2010 rate was 0.00% (p50.64.) with no statistically significant differences between 2008 / 2009 or 2009 / 2010. There was a statistically significant decrease between 2010 and the baseline rate (p ,0.001). In CCU, there was a statistically significant decrease in HAIs from 0.36% in 2008 to 0.00% in 2010 (p50.02.) In RCU, there was a statistically significant decrease in the proportion of HAIs during the 2- year study, reducing from 1.71% in 2009 to 0.66% in 2010 (p50.02). Lessons Learned: Implementation of MRSA reduction strategies for high risk patients is an organizational challenge. Staff acceptance of the new program was facilitated by administrative and physician support. Barriers
E142
American Journal of Infection Control June 2011
included staffing for teaching, off-shift penetration, changes in lab procedures for PCR testing and obtaining the appropriate swabs. A reduction in HAIs in critical care validated the project with good outcomes. Presentation Number 6-048
Quality Assurance Data Collection Provides Opportunity for Organizational Improvement Following a Rise in Sternal Surgical Site Infections (SSI) Post-Coronary Artery Bypass Graft (CABG) Surgery Katherine Matteson, RN, BSN, MS, CIC, Infection Control Practitioner; Russell Hynek, PharmD, Paul Lata, PharmD, Pharmacist; Linda McKinley, RN, MPH, CIC, Infection Control Practitioner; Lynn Michel, RN, MSN, APRN, BC, VA NSQIP/CICSP Coordinator; Athanasia Schreiner, RN, MSN, APNP-BC, Nurse Practitioner; Catherine Stampfli, RN, BSN, MRSA Prevention Coordinator; Sandra Tainter, RN, BSN, Nurse Manager; Christopher Crnich, MD, MS, Staff Physician & Hospital Epidemiologist; William S. Middleton Memorial VA Hospital, Madison, WI Issue: A cluster of 4 cases of sternal SSIs post- CABG procedures were identified during routine quality assurance data collection for the VA National Cardiac Surgery Program between July-November 2009. A focused review of the cases identified multiple areas for improvement despite participation and reported compliance with multiple Surgical Care Improvement Project (SCIP) measures. Project: Infection control conducted a focused review of the cases including pathogen, pre-op MRSA screening results, pre-op antibiotic selection and timing, graft site, glycemic control and obesity. A multidisciplinary team was formed to identify areas for improvement. Risk factors identified were 1. All infections caused by Staphylococcus species (2-MRSA, 1-MSSA, 1-CNS), 2. MRSA colonization (50%), 3. Uncontrolled diabetes (75%) 4. Antibiotic selection and/or timing (75%) 5. Duration of surgery (100% above 300 min/CDC NHSN mean) and 6. Graft site selection in diabetic patients (75%). Interventions targeted pre-and intra-operative risk factors including 1. Earlier MRSA screening, 2. Decolonization of MRSA positives (i.e., mupirocin and chlorhexidine bathing), 3. Assurance of pre-op glycemic control, 4. Use of vancomycin for MRSA positives, 5. 2nd antibiotic dose for longer procedures, and 6. Appropriate graft site selection for diabetic patients. Results: Despite SCIP measures reported at or above target for antibiotic timing (99%) and antibiotic selection (95%) during FY09 this data excludes vancomycin. A review of vancomycin during FY09 for cardiothoracic (CT) surgical procedures found 0 of 12 surgical cases (0%) had properly infused 1-hour prior to incision. The SCIP measure for glucose control in CT surgical patients was also reported at target, 95%, during FY09 but this measure does not assess pre-op A1c. Following interventions there have been no cases of sternal wound infections following CABG surgery since December 2009. Lessons Learned: Process measures for ensuring compliance of evidence based interventions (e.g. antibiotic selection and timing) can provide a false sense of assurance and should not be considered as replacement to outcome monitoring. Quality assurance outcome monitoring along with focused case reviews can always provide opportunities for organizational improvement. Presentation Number 6-049
New Methods for Hand Hygiene Measurement of all HCW ‘‘Before and After’’ Patient Contact and/or Contact with the Patient’s Enviroment can Drive Hospital Acquired Infection Rates to ZERO! Jennifer Kraft Spivey, RN, MSN, CNOR, CIC, Infection Preventionist, St Vincent Heart Center of Indiana, Indianapolis, IN Issue: Infection Preventionists are charged with measurement of hand hygiene practices of HCW by The Joint Commission’s National Patient Safety Goals, however there are many methods of measurement to choose from and many are unreliable in showing the ‘‘true picture’’ of hand hygiene practices of HCW around the clock in our