Becker's Clinical Quality & Infection Control

11 be largely, or even completely, prevented — but that's not to say doing so is an easy task. Nevertheless, the country as a whole has made progress in recent years in combating the staph infection. The CDC's most recent National and State Healthcare-Associated Infections Progress Re- port found an 8 percent decrease in hospital-onset MRSA bacteremia between 2011 and 2013. An 8 percent decrease is a step in the right direc- tion, but Veterans Affairs medical centers and the Nashville, Tenn.-based Hospital Corporation of America are two organizations that have made more than just steps, but leaps, in the right direc- tion by tackling the infection problem with gusto. Both the VA and HCA have implemented infec- tion prevention initiatives in the last decade that have dramatically reduced MRSA rates in their respective facilities. The VA takes a stab at MRSA with a four-part bundle In 2007, The VA launched a four-part MRSA re- duction program in all acute-care VA hospitals across the nation. The program included active surveillance mea- sures to identify MRSA carriers, the use of contact precautions to prevent infection transmission, hand hygiene measures and the development of a system-wide cultural transformation that under- lined staff responsibility in defining and imple- menting MRSA prevention practices. By June 2010, the initiative had prompted an ini- tial MRSA infection reduction of 62 percent in the VA's ICUs and 45 percent in non-ICU acute-care settings. Additionally, the program continues to have a sustained effect on MRSA infections with an overall reduction of 72 percent in ICUs and 66 percent in non-ICU acute-care settings in 2012. Because the whole four-part bundle was imple- mented together, it's impossible to scientifically attribute the success of the program to any one single part, according to Martin E. Evans, MD, di- rector of the MRSA Prevention Initiative for the VA. That's not to say one can't speculate, however. "We do know that there had been a hand hygiene directive in place before implementation of the MRSA program and there has also been informa- tion about the use of contact precautions from the CDC ever since 2006 in place and yet, even with those things in place, we were not [seeing] any diminution in HAIs in the ICUs," says Dr. Evans. The two elements that were added when the bun- dle was rolled out were active surveillance and culture transformation. "With active surveillance, there's this constant need on the behalf of the healthcare workers to be aware of this program and be educating the pa- tients," notes Dr. Evans. "This is just my personal opinion but I think the universal surveillance has really driven a culture transformation." The MRSA Prevention Initiative was so successful that it was expanded to become the Multidrug-Re- sistant Organism — or MDRO — Prevention Ini- tiative when the VA added prevention guidelines for other pathogens as well, such as Clostridium difficile and carbapenem-resistant Enterobacteriaceae. HCA launches three-arm MRSA study with shocking results Around the same time the VA was launching its four-part MRSA-reducing program, HCA was throwing its own hat into the drug-resistant staph infection-fighting ring. Perhaps not coincidentally, Jonathan B. Perlin, MD, PhD — former under secretary for health in the U.S. Department of Veterans Affairs — joined HCA as president of clinical services and CMO in 2006. He is also the current American Hospital Association board of trustees chairman. "I had the pleasure being a leader of the VA for six years and my background is in quality and safety, so I was really pleased to see one of the trends that worked was in infection prevention and control," says Dr. Perlin. "This has been an area of lifelong interest and passion so, when I arrived at HCA, it was only natural that those interests would con- tinue as we tried to reduce one of the scourges of multidrug-resistant infections." With that purpose in mind, HCA launched a landmark study. The three-arm comparative ef- fectiveness trial involved: 1. Screening patients for MRSA and, if posi- tive, isolating them 2. Screening patients and, if positive, not only isolating them but decolonizing them, using a sponge bath with chlorhexidine gluconate, and some nose drops for five days; and 3. Skipping the universal screening altogether and, upon admission to the ICU, giving ev- eryone the sponge bath and nose drops for five days. The study included 43 HCA-affiliated hospitals, 74 ICUs and nearly 75,000 patients. "The answer was stunning," says Dr. Perlin. "Compared to either screen-isolate or screen-iso- late-decolonize, the winning arm was decoloniz- ing everybody upon admission to the ICU." Universal decolonization reduced MRSA cultures by 37 percent and all bloodstream infections by 44 percent, and that was on top of every known best practice to date, according to Dr. Perlin. "Universal decolonization – a practice still used in all HCA hospitals — is now part of the CDC's compendium of recommended practice, so it is an endorsed approach to really establishing the lowest possible levels of avoidable bloodstream infections and MRSA." Where other hospitals and health systems stand with MRSA prevention As previously noted, hospitals and health systems nationwide are making an effort to reduce MRSA infections. In fact, several states mandate univer- sal MRSA screenings in healthcare facilities. That said, fighting MRSA is still not a high prior- ity for some organizations. "I hate to say so but I think a lot of the reason more hospitals aren't more proactive is because of the money, because it is expensive and it's easy to just look the other way," says Dr. Evans. "Infection pre- vention is not like seeing a patient who needs dialysis and will die without it; it's much less direct than that." Because the decision to roll out the four-part MRSA-reducing program came from the secre- tary of the VA, funding was provided for every VA facility to have the necessary personnel — includ- ing a MRSA prevention coordinator to make sure the initiative was implemented and a half-full- time equivalent lab technician to deal with the tests coming into the laboratory. Funds were also provided for the actual swabbing and for education materials which, according to Dr. Evans, "really sweetened the deal." Full funding for a MRSA reduction program is not a luxury every facility can boast, but Dr. Per- lin urges healthcare providers to not be deterred. "While certainly there are some expenses in- volved, it's far more important that the patient not pay the ultimate price by acquiring an in- creasingly avoidable infection," says Dr. Perlin. He explains that for every 99 patients who are de- colonized for MRSA, potentially one life-threaten- ing bloodstream infection is avoided. HCA took that information to health economists to deter- mine the costs saved by avoiding infection, the re- sults of which were published in Infection Control and Hospital Epidemiology. "The data demonstrates that for every thousand patients, there's net savings of $170,000 associ- ated with not paying for HAI-related complica- tions so, while there may seem to be some upfront expenses, the truth of the matter is that avoiding avoidable infections not only saves the patient potentially his or her life, it's net efficient for the hospital or health system," says Dr. Perlin. For healthcare providers looking to up the ante with their MRSA and multidrug-resistant organ- ism initiatives, Dr. Evans suggests adopting the VA's four-part bundle, rolling it out first in areas that have especially high-risk and vulnerable pa- tients — like the ICU — before expanding into universal surveillance. Dr. Perlin suggests a different approach. "The first place to start is with a discussion across clin- ical and administrative staff — including physicians, nurses, pharmacists, infection prevention personnel and administrators — to commit to approaching healthcare in a way that is governed by science, not opinion. Everyone has to make a collective commit- ment to using the best research evidence available." The process of translating contemporary science into practice is traditionally one that is fairly slow but Dr. Perlin remains optimistic, saying, "Compared to how long it used to take, I'm actually favorably im- pressed that the uptake has been quite remarkably swift both in the U.S. and internationally." n How the VA, HCA Dramatically Reduced MRSA Infections (continued from cover)

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