Transcript Outbreak Management MRSA Webinar

MRSA Outbreak
Management
March 25, 2008
Citywide Program
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Medical Director, Manager, Educator + 12 FTE Infection
Control Practitioners, 1 program secretary
8 hospital sites
Approx 2,363 beds - 1,118 acute care beds (cardiac,
transplant, neuro, ortho surgery, burns, trauma, obstetric,
pediatric)
- 130 ICU beds
- Ambulatory/Short stay
- LTC, Complex Care, Palliative, Rehab,
Regional Psychiatric, Dialysis, Cancer Care
MRSA: A growing problem
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First outbreaks in late 1995
2002-2003 increases began again
Increasing rates each year since
CNISP data
QMPLS data
Canadian Nosocomial Infection
Surveillance Data – 1995-2006
6000
12.0
5000
10.0
4500
4000
8.0
3500
3000
6.0
2500
2000
4.0
1500
1000
2.0
500
0
0.0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Rate per 1,000 admissions
Number of MRSA cases
5500
Ontario QMPLS Report – July
2007
QMPLS Reported Number of
Bacteremias – July 2007
Complicating Factors
Restructuring
 Nursing shortages
 Multiple organizational priorities
 SARS
 Infrastructure challenges
 Changes in the care delivery model
 Non adoption of Routine Practices
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What’s being done to stem this
tide?
Provincial recommendations
 CPSI
 CCHSA
 Organizational Scorecard reporting
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Making a Change Happen
DxVxF>R
D- Discomfort (or dissatisfaction with the status
quo)
V- Vision (of the preferred future)
F- First steps (clarity of the plan for how to move
forward)
R- Resistance factors
“The product of the discomfort, vision, and first steps must be
greater than the resistance or the change will fail
Dannemiller & Jacobs (1992)
MRSA Reduction, Logic Model 2007-2012
MRSA REDUCTION Logic Model 2007- 2012
Core Competencies
Strategies
Activities
Target
Groups
Activity
Objectives
Short Term
Objectives
o Annual Core Competency elearning with emphasis on routine
practices and contact precautions
o Review of hand hygiene practices,
focus on opportunities, healthy hands
o Review of correct glove and gown
use, discuss inappropriate usage
Healthcare Workers
Patients
Visitors
1. To establish factors that support
lasting behaviour change in routine
precautions through a variety of
interventions aimed at patients & staff
2. Where possible demonstrate the link
between MRSA reduction/transmission
and routine practices
Education and
Increased
Awareness of
AROs
o Educational Presentations
o Development of MRSA
educational toolkit for
leaders to share with staff
o Display boards and posters
with unit specific rates
along with facility,
citywide, and provincial
benchmarks
o Q & A’s and Case Studies
o Tools for Clinical Educators
o Dissemination of rates to
leadership q 6 mths
Physicians
Nursing and other professional
staff
Housekeeping & Dietary
Support Staff
Clinical Educators
Patients & Families
1. To provide a variety of
educational opportunities to
raise awareness of MRSA
2. To develop alternative self
directed learning tools for staff
3. Teaching on the importance of
colonized patients as reservoirs
for transmission
Environmental and
Infection Control
Supports
o Audit and monitor
environmental cleaning
practices
o Assess usage of hand cleansing
products
o Reduce room stocking of
supplies to reduce waste and
transmission opportunities
o Implementation of cohorting
o Algorithm for patient
management
o Establishment of MRSA
outbreak management policy
Senior leaders, Unit managers,
Housekeeping, PSAs, TSAs
Nursing, Pharmacy
1. To have IP&C practices in
place that prevent transmission
2. To have a resource and facility
wide plan to prevent and manage
outbreaks
3. Engage Pharmacy and
Therapeutics in monitoring
antibiotic usage
Active
Surveillance
Cultures
o Establish a process that
adequately captures patients at
risk for MRSA
o Ensure responsibility is assigned
to one person on each unit for
screening accountability
o Audit compliance with ARO
screening directive q 6 mths and
report to unit and senior leaders
o EPR support of screening
o Ensure screening is in line with
PIDAC recommendations
Nursing
Senior leadership
Unit managers
Admitting , Preadmit and other
Patient entry assessment areas
1. To improve screening compliance
in order to capture patients that
are at increased risk of
colonization/infection
Planning, Research,
Evaluation &
Monitoring
Antibiotic
Utilization
o Research best practice documents, and
published literature for direction on
practice changes
o Establish a multi level working group
to identify ways to reduce transmission
and support necessary change
o Complete reports on incidence and
nosocomial transmission rates and
share throughout the organization
every? 6 months? every month
o Identify successful interventions and
utilize these to make organization wide
improvements
o Collect data on nosocomial ARO rates
on an ongoing basis to measure HH
impact
Working
group
o Monitor
Patient Satisfaction Survey
Infection
ResultsPrevention & Control Team
Infection
Prevention
and annually
Control Site
o Review program plan
and
andrevise
Citywide
Committees
as needed
LHSC & SJHC health care workers
1. To identify practices that contribute
to reduced transmission.
2. To monitor MRSA rates and
summarize biannually.
3. To engage leaders and HCW across
the organization in committing to
MRSA transmission reduction
o Ensure that a multidisciplinary group
reviews utilization and
susceptibility patterns
o Ensure computer
system capable of
providing clinician
with appropriate
treatment choices
o Perform audits of
antibiotic usage
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o
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P & T committee
Senior Leadership
Pharmacy
MAC
Ensure systems are in
place to promote
optimal treatment of
infections and
appropriate
antimicrobial use
1. To increase education and awareness of the seriousness of MRSA transmission and the infection prevention and control measures necessary to reduce transmission.
2. To determine interventions that are successful in interrupting transmission of MRSA
3. To engage leaders and HCW in shared accountability for reducing transmission of MRSA
4. To improve HCW compliance with routine practices, hand hygiene, MRSA screening as well as contact precautions throughout the organization
5. To reduce nosocomial ARO rates by 25% each year of the project.
Long Term
Objective
To have improved compliance with IP&C practices at London Health Sciences Center and St Josephs Health Care that are reflected in reduced MRSA
rates.
Goal
To reduce MRSA transmission through improved infection prevention and control practices at London Health Sciences Center and St Josephs Health Care.
ARO Reduction Plan, 2007-2012
LHSC/SJHC
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↑ training for HCWs
↑feedback of rates to leaders and front line staff
↑screening
Develop city-wide hand hygiene committee
Install point of care ABHR
Compliance audits (hand hygiene, infection control
precautions, multi-disciplinary clinical walk-abouts,
screening practices with feedback)
Establish unit specific workgroups
ARO specific Infection Control team meetings
Step 1
Process Flow Map, MRSA
Screening
Step 2
Control Plan, MRSA Screening
and Containment
Step 3
Failure Modes and Effects
Analysis (FMEA)
Leader Reports
Quarterly Report
Infection Control Indicators
MRSA HAI
Rate/1,000 pt
days
25% Reduction
Target
Screening
Compliance
6 Mth
Target
Hand Hygiene
Compliance
Service
Unit
Medicine
A5
0.8
0.6
75%
100%
25%
50%
48%
100%
A6
0.5
0.37
68%
100%
42%
50%
39%
100%
4IP
0.62
0.46
85%
100%
30%
50%
45%
100%
D6
0.7
0.52
78%
100%
60%
50%
42%
100%
B8
0.68
0.51
82%
100%
75%
50%
68%
100%
7A
0.58
0.43
98%
100%
58%
50%
52%
100%
Surgery
Neurology
Target
Core
Competency
Completion
Target
Be Prepared For an Outbreak!
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Well established surveillance program
Relationships, team work
Flagging system
Discuss issues and problem solve scenarios
beforehand
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Suppression therapy, cohorting, bed closures, staff
screening
Policies & procedures
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Isolation, indications for patient screening, admission,
contact, prevalence
What is an Outbreak?
New cases (incidence) in a given population, during a
given time period, at a rate that substantially exceeds
what is "expected.”
How do you know you are having an outbreak?
Verify Existence of Outbreak
Evidence that transmission has occurred
 Consistent definition of hospital acquired
 Epidemiologic review
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Person, place, time
History- access to health care in the previous
12 months
Retrospective analysis of current stay
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Previous rooms, units, contacts, staff
Molecular typing may be helpful
Control Measures
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Contact precautions
Cohort patients
Epidemiologic
investigation
Multi-disciplinary team
Case Finding
Communicate &
educate
Feedback
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Audit
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Environment
Isolation Practice
Compliance
Cohort staff
Suppression therapy?
Staff screening?
Restrict admissions?
Suppression Therapy
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Insufficient evidence to support the use of
topical or systemic antimicrobial treatment
for eradicating MRSA.
Loeb. M., Main, C., Walker-Dilks, C., Eady, A.(2003). Antimicrobial drugs for treating MRSA colonization.
Cochrane Database Systematic Review 4 CD003340.
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Value in outbreak? (decrease reservoir)
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Nasal mupirocin
Mupirocin plus systemic
Mupirocin +/- CHG
CHG alone
Common Challenges, Acute and
Non-acute Care
Cohorting patients & staff
 Patient mobility
 Staff screening
 Communication
 Patient supplies & cleaning
 Non-compliance
 Insufficient ABHR
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…………Challenges Continued
Acute Care
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Shortage of nurses
High acuity
Bed closures
Students
Competing priorities
Non-acute Care
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Physical limitations
Insufficient supplies
Frequent staff
turnover
Non-regulated HCW
Poor lab access
Non-Acute Care Literature
Hughes, C., Smith, M., Tunney, M.(2008). Infection control strategies for preventing the transmission
of MRSA in nursing homes for older people. Cochrane Database Systematic Review 1. CD006354.
Lack of studies on measures to prevent
transmission
 Studies show nursing home is risk factor
 Studies show prevalence is increasing
 Screening high risk admissions?
 Train key staff
 Hand hygiene adherence, environmental
cleaning
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Are Control Measures
Generalizable to all Settings?
No…………Why?
Settings may be very different;
 Acute care vs non-acute care
 Tertiary teaching facility vs community
hospital
 Intensive care vs general medical unit
 Baseline epidemiology on unit
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Is MRSA epidemic or endemic?
Our Conclusions
Observation must be constant
 Team work pays off
 MRSA management is resource consuming
 Nosocomial acquisition can be reduced
through intervention
 Multiple unit specific interventions are
required
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Screening patients for
MRSA
Screening Issues
 Turn
around time
 Sensitivity
 Cost
Screening
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Focused screening
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Universal screening
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Screen only high risk patients
Screen all patients being admitted
Universal + focused
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Screen all patients in areas where there is a
problem
Screen high risk patients elsewhere
Focused Screening
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Choose patients for screening based on
risk factors
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Previous hospitalization major risk factor
In Ontario based an admission or >12
hour stay in any healthcare facility in
previous 12 months
Focused Screening
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Advantages:
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Cheaper
May be all you need
Disadvantages:
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Need to identify patients who need screening
Poor compliance with screening
May miss patients with other risk factors
Universal Screening
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Advantages:
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No need to “flag” patients
Compliance may be better
More sensitive for identification of carriers
Disadvantages:
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More costly
Old Screening algorithm
New Screening algorithm
MRSA Screen Swabs (nasal + rectal)
Innoculate
Separate plates
Oxacillin Salt Mannitol Agar (X2)
24-48 hrs
Pick Yellow Colonies
Confirm as MRSA by PCR
Report to Ward once daily
Both swabs single plate
4X/day
Chromogenic Agar (MRSA Select)
24 hours
Presumptive Reporting to Ward 4X daily
Confirm as MRSA by PCR if no
previous isolate identified from patient
Time to reporting MRSA positive
patients to the ward
Time to Reporting*
Mannitol Oxacillin Salt plate
58.0 +/- 17.9 hours
MRSAselect plate
34.0 +/- 12.3 hours
*Statistically significant difference, p<0.0001
Number of contacts of index case
Average number of contacts*
Mannitol Oxacillin Salt plate
2.88 +/- 2.03
MRSA select plate
2.30 +/- 1.43
*Statistically significant difference, p<0.05
Number of contacts who become
MRSA positive
2005
2007
287 MRSA cases
475 cases
37 contacts (12.89%)
28 contacts (5.89%)
Thank you
MaryLou Card
[email protected]
Kathy McGhie
[email protected]
Dr. Michael John
[email protected]