Elements for Succeeding in Reducing MRSA Infections

1. Elements for Succeeding in Reducing MRSA Infections Susan Abookire, MD MPH Department Chair, Quality & Safety, Mount Auburn Hospital Mary Lark Dupont, MSN, RN, CIC Manager, Infection Prevention

2. Elements for Successful Change • Leadership • Culture • Teamwork • Rapid Cycle Improvement • Spread • Measurement

3. Committed Leadership: Prerequisite to Change Leadership commitment has the following major elements: • Acknowledges that MRSA is serious, causes needless morbidity and mortality, and is associated with real costs that go to the hospital’s bottom line. • A sense that major reductions in the MRSA infection rate are possible.

4. Engaging Leadership • In the United States, healthcare associated infections (HAI): • adversely affect 5-10% of the 40 million patients hospitalized each year develop a HAI (2 million patients) • Associated with 90,000 excess deaths per year • Average hospital stay is 5 days longer • Economic impact – over $4.5 Billion Dollars Annually

5. Leadership • Empowerment of front-line multidisciplinary teams to get the job done • provision of necessary supplies, personnel, and infection control, microbiological, and environmental services resources. • Accountability for reliable performance of basic infection control practices • Engagement of clinical staff. • Regular review of data and prompt removal of barriers to success.

6. Supporting A Culture of Safety • Implement Leadership Walkrounds • Respond to staff concerns about patient safety issues and make necessary improvements • Respond to reported adverse events • Train staff in the use of SBAR. • Conduct briefings on units: bring them together for 5 to 10 minutes as part of the daily routine. • Involve patients and families in processes, such as rounds.

7. Forming a Team Once leadership has publicly given recognition and support to the program, create your improvement team. Successful teams working in an ICU (the recommended location for starting this work) include: • A Physician (Intensivist) • ICU Nurse • Infection Prevention Nurse and/or Hospital Epidemiologist • Quality and Patient Safety Specialist Engage from the beginning: • Microbiology Laboratory • Environmental Services • Physical Therapy • Respiratory Therapy • Patients

8. Teamwork • Everyone on MRSA team is equally important • Team Leadership facilitates community • Empower non-clinical staff and treat as equal members of the team. • Encourage and expect everyone to point out unsafe condition or take actions.

9. Rapid Cycle Improvement The model has two parts: 1) Three fundamental questions that guide improvement - set clear aims, • establish measures that will tell if changes are leading to improvement, and • identify changes that are likely to lead to improvement. 2) The Plan-Do-Study-Act (PDSA) cycle to conduct rapid small-scale tests of change in real work settings — by planning a test, trying it, observing the results, and acting on what is learned. This is the scientific method, used for action-oriented learning. The pace of improvement is related to the pace of testing

10. THE MODEL FOR IMPROVEMENT AIMS MEASURES CHANGES TESTING CHANGES *Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. **The Plan-Do-Study-Act cycle was

11. Rapid Cycle ImprovementStart with Small Tests of Change • Champion: Begin work on an ICU or ward where there is a vigorous clinical champion and opinion leader. • Pilot unit test changes: This strategy allows a multidisciplinary team to focus its efforts in a well-defined geographical area and patient population, perform rapid-cycle tests of change, and act on real-time data. • Hold the gains: Reliable performance of all aspects of the MRSA infection control program demonstrate to institutional leadership that dramatic success is possible and the investment in resources can pay off.

12. Rapid Cycle ImprovementFirst Test of Change • Teams may elect to work on any or all of the care components. • A first test of change: • very small sample size (typically, one patient) • Describe in Plan-Do-Study-Act (PDSA) format so that the team can easily predict what they think will happen, observe the results, learn from them, and continue to the next test. • Teams can conduct multiple small tests of change simultaneously across all interventions. This simultaneous testing usually begins after the first few tests are completed and the team feels comfortable and confident in the process.

13. Rapid Cycle ImprovementImplementation • Implementation: After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team can implement the change on a broader scale — for example, for an entire pilot population or on an entire unit.

14. Spread • After successful implementation of changes for a pilot population or an entire unit, the team can spread the changes to other units and eventually to the entire hospital. • Organizations that successfully spread improvements use an organized, structured method in planning and implementing spread across populations, units, or facilities.

15. Measurement • Measure progress on key processes for MRSA Reduction • hand hygiene • decontamination and cleaning • active surveillance • contact precautions • Device Bundle implementations • Measuring compliance with these processes can be helpful in monitoring improvement. • Teams should collect data for these process measures at the unit level (e.g., an ICU or other designated high-risk area) where improvement work is focused.

16. Measurement at Unit Level • Compliance with hand hygiene • Compliance with MRSA contact precautions • Compliance with room cleaning • Compliance with active surveillance cultures on admission • Compliance with Central Line Bundle • Compliance with VAP Bundle

17. Measurement: Hospital Level • MRSA bloodstream infections • Per 1000 Device Days or per 1000 patient days • MRSA VAPs • per 1000 ventilator days • Some organizations prefer ‘days since last event’ • Transmission of MRSA • If active surveillance program is in place

18. Run Charts • Is there improvement? Look for patterns over time. • Run charts: plot data over time • One of the single most important tools in performance improvement. • Benefits include: • They help improvement teams formulate next steps by depicting how well (or poorly) a process is performing. • They help in determining when changes are truly improvements by displaying a pattern of data that you can observe as you make changes. • As you work on improvement, they provide information about the value of particular changes.

20. MRSA Reduction:Five Components of Care 1. Hand hygiene 2. Decontamination of the environment and equipment 3. Active surveillance cultures 4. Contact precautions for infected and colonized patients 5. Device bundles (Central Line Bundle and Ventilator Bundle)

21. Physician Leadership in Hand Hygiene • Nearly 3000 Observations • Over 78% compliance • Physician Leadership in Hand Hygiene

23. Scrupulous Attention to Environment • Mops • Use of Exchange Mops • Wet Wash Beds • Decontamination of Portable Devices

24. Defining the Role of Active Surveillance • Some hospitals have chosen to culture all patients on admission • Ongoing deliberation about isolation of patients who are colonized, but not infected • Decolonizing patients • Cohorting patients

25. Contact Precautions • Gown and glove only with ‘significant patient contact’ • Is this really adequate? • Is touching the door, curtains, trays, tubings, ekg machines, bed rails – free from contamination?

26. Targeting Specific Infections with ‘Device Bundles’ • Eliminate Harm from Ventilator Associated Pneumonia Infections • Eliminate Harm from Central Blood Stream Infections • Eliminate Harm from Surgical Site Infections

27. Ventilator-Associated PneumoniaBest Practice • Elevating the head of the bed to between 30 and 45 degrees • Daily “sedative interruption” and daily assessment of readiness to extubate • Peptic Ulcer disease (PUD) prophylaxis • Deep venous thrombosis (DVT) prophylaxis (unless contraindicated) • Wear gloves when entering a room • Hand hygiene • TEAM WORK

28. Central Line InfectionsBest Practice • Hand hygiene • Maximal barrier precautions • Chlorhexidine skin antisepsis • Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters • Daily review of line necessity, with prompt removal of unnecessary lines At MAH, Roll out of specific teaching of central lines with requirements to demonstrate competency

29. Team Work • Implementing “Bundles” • Communicating about hand washing • Setting common goals

31. Pictured above: Representatives of the MICU and VAP team after accepting MAH’s “Excellence in Patient Safety” Team Award.

32. Measurable Outcomes • Culturing Patients on Admission to Intensive Care Units • Culturing Patient on Discharge from ICU • Establishing rate of Hospital Acquired in intensive care units • Tracking “Conversions” • Immediate Response to ‘conversions’

34. Infection Control And Quality Team • John Tully, MD • Lark Dupont, RN, MS • Diana Sullivan, RN • Susan Abookire, MD MPH • Tracey Phillips, RN