1. Experiences in MRSA Successful Implementation of a Hospital Wide Admission Screening Protocol Cindi Leigh Wigston Infection Prevention and Control Coordinator/Quality Leader Orillia Soldiers’ Memorial Hospital

2. Orillia Soldiers’ Memorial Hospital • Large Community Hospital • 218 in-patient beds • Regional Programs • Dialysis • High Risk Maternal • Paeds/NICU • SADV • CCC/Rehab • Psychiatry (Form 1 Facility)

3. The IP&C Team circa 2001-2006

4. The OSMH Experience • November 2000 • 3 patients identified on transfer to other facility • Review of current policy and procedure • Review of lab reports • Review of staff practice • Point prevalence screen of medical unit (60 beds) • December 2000 • Audit of screening results

5. Initial Findings • December2000 • 147 “high risk” admits • 19.7% Screened within 24 hours • 9.5% Screened within 24-48 hours • 38% Screened after 72 hours • 32.6% Discharged prior to screening

6. Finding the Findings! • Daily review of admission list for previous 24 hours • Utilizing CIS Patient system to determine risk factors (limitation!) • Utilizing laboratory reports (paper copies!) • Writing “Infection Prevention and Control Suggests” orders on patient charts (limitation!)

7. Next Steps January to March 2001 • Met with Senior Management • Met with Nursing Management • Met with IT Staff • Built data set • Developed and implemented staff education • Continued audit of screening compliance

8. Data Set

9. January to March 2001 Findings • 34.1% ‘High Risk’ Admits • 21.4% Screened within 24 hours • 13.8% Screened within 24-48 hours • 30.4% Screened after 72 hours • 34.2% Discharged prior to screening

10. Now What? • Goals • Increase staff knowledge regarding MRSA • Increase staff awareness of risk of MRSA colonization = INFECTION • Increase staff compliance with Additional Precautions • Increase staff compliance with Admission Screening of High Risk Patients • INTEGRATION OF SCREENING INTO PRACTICE - GOAL 80%

11. Meeting Objectives • Identified champions • Nursing management acceptance • Senior management acceptance • MAC acceptance • Education • Unit Challenges • Visibility

12. Why is Screening Important? • Approximately 54% of MRSA cases in hospital were identified through admission screening (CJIC 2005;20(1):36-37) • Active admission screening protocols are integral to control (Lancet Infect Dis. 2005;5(10)653-663) • Early Screening = Early Identification = Less Isolation and Bed Movement!!!

13. Colonization = Infection? • Increased risk of infection in colonized patients • “4 fold increase in infection” (Safdar, AJM 2008;121(4):310-315) • “23% developed infection” (Huang, IDSA 2008, July 3) • “In 16 of the 28 patients with MRSA bacteraemia and MRSA colonization, the MRSA colonization was identified more than seven days before the bacteraemia” (Roghman, Journal Hosp Infect 2007;47(2):98-103

14. Patient Consequences • Patients in isolation received less direct care • Tests are often postponed/cancelled • Unable to transfer to alternative level of care • “STIGMA”

15. Hospital Consequences • Multiple bed moves • Blocked beds • Increased LOS • Increased cost • Isolation supplies • Antibiotic therapy • Dialysis Patients (OSMH) • Patient Cost is Immeasurable

16. And Then Came **Bob** . . . • 52 year old dialysis patient • Admit post BKA • Admission screens negative • Day 14 nasal/rectal MRSA positive • Unable to discharge home as satellite dialysis unit unable to provide dialysis to MRSA patient • Decolonization/abx therapy not effective • Remained positive in weekly follow up • Repeated infections, repeated surgeries • Remained in-patient for 14 months • Blood culture positive MRSA - died

17. Reviewed and Updated Existing Protocol • All patients meeting ‘high risk’ criteria to be screened within 24 hours • Previous hospital admission • Direct hospital transfer • Prior admission to nursing care facility (LTC, group home) • Unit contacts of identified positive patients • Previously identified positive patients • Admission from correctional facility • Dialysis patients • Patients being transferred to CCC/Rehab • Patients being transferred from ICU

18. Simplified Process • Added screening questions to Nursing History • Involved ER in screening activities • Entered unit contacts into CIS system • Unit helpers ensured that “screening kit” was in each room • Daily “ARO Screening Required” email from IP&C team • Ongoing education • Ongoing compliance audits • Changed micro media

20. Screening Compliance Audit

21. Challenges • Staff perception of need • Lack of integrated IT • Cost • Time commitment • ‘Spoon feeding’ vs TAKING OWNERSHIP! • Integrating into practice

22. In Summary • Have patience! • Assess current status and build from there • Set small goals! • Celebrate achievement! • Provide timely feedback • Use “teaching moments” • Shift ownership to staff

23. Questions? Cindi Wigston, IP&C Coordinator/Quality Leader Orillia Soldiers’ Memorial Hospital clwigston@osmh.on.ca 705 325-2201 ext 3390