IMPLEMENTING A NOVEL APPROACH TO REDUCING MRSA IN A HOSPITAL COLLABORATIVE Brad Doebbeling, MD, MSc, Paul Dexter, MD, Heather Hagg, MS, Shawn Hoke, Abel Kho, MD VA HSR&D Center of Excellence, Indiana University Center for Health Services and Outcomes Research, Regenstrief Institute, IU School of Medicine, Indianapolis, IN; Purdue University Schools of Engineering & Technology, Indiana University School of Informatics, Indianapolis & West Lafayette, Northwestern University, Chicago Academy-Health Annual Research Meeting, June 10 th , 2008 Acknowledgements: AHRQ ACTION funding
Transcript
IMPLEMENTING A NOVEL APPROACH TO REDUCING MRSA IN A HOSPITAL COLLABORATIVE
Brad Doebbeling, MD, MSc, Paul Dexter, MD, Heather Hagg, MS, Shawn Hoke, Abel Kho, MD
VA HSR&D Center of Excellence, Indiana University Center for Health Services and Outcomes Research, Regenstrief Institute, IU School of Medicine, Indianapolis, IN; Purdue University Schools of Engineering & Technology, Indiana University School of Informatics, Indianapolis & West Lafayette, Northwestern University, Chicago
Academy-Health Annual Research Meeting, June 10th, 2008
Acknowledgements: AHRQ ACTION funding
Implementing a Novel Approach to Reducing MRSA in a Hospital Collaborative
Purpose Scope Implementation Evaluation and Preliminary Results Lessons Learned Next Steps
MRSA Background
Purpose MRSA Burden
Over 126,000 persons are infected by MRSA in hospitals annually
~ 4 MRSA infections per 1,000 hospital discharges Over 5,000 die as a result of these infections Over $2.5 billion excess healthcare costs
On average, for each MRSA patient this means: 9.1 days excess LOS Over $30,000 in excess cost per case (range $30,000-
60,000) 4% in excess in-hospital mortality
1/3 patients acquiring MRSA will become infected.
Reservoir for the Spread of Antibiotic Resistant Pathogens
Colonized patients, NOT just infected patients, can transmit
AR pathogens to healthcare workers and other patients.
Unidentified Colonized Patients
• Clinical Cultures +• History of MRSA
Prevalence of Methicillin-Resistance Among S. aureus Infections, Denmark and US, 1960-2004
Computer Alerts of MRSA Help Improve Isolation Adherence RN awareness of MRB status increased from 24% at
baseline to 59% at 1 year. -93% at 1 year after notifying nurses.
Implementation of isolation precautions increased from 15% at baseline to 51% after 1st intervention and then to 90%.
RI electronic tool notifies staff of MRSA positive history at Wishard, based on micro data from all Indy hospitals (except VA).
286 unique patients generated 587 admissions (4,335 inpatient days) where receiving hospital unaware of the prior history of MRSA.
An additional 10% of MRSA admissions received by project hospitals over one year and over 3,600 inpatient days without contact isolation. Cac et al Arch Intern Med. 2007;167(19):2086-0
Kho et al J Am Med Inform Assoc 2008; 15:212-216
AHRQ ACTION Contract
Implementation “Testing Techniques to Radically Reduce Antibiotic
Resistant Bacteria (MRSA)”
AHRQ funded Indiana ACTION Team effort over 18 months through the ACTION collaborative funding mechanism
Our interventions are based on the Pittsburgh model as specified by AHRQ: conduct active surveillance of all incoming pts. in
ICUs improve rates of contact isolation Improve hand hygiene rates
Electronic Data Sharing in Indy
• Indianapolis has unique health information exchange – Indiana Network for Patient Care (INPC) – includes nearly all of the healthcare systems in
Indianapolis – spans >95% of all of the inpatient care in the
city.
• The five competing health care systems (VA excluded) have agreed to share information on their patients, to ensure safe and quality health care.
Conceptual Framework and Strategy
Interdisciplinary Research & Ops Teams• Clinicians, Health Services Researchers,
Engineering/Technology Faculty, Purdue Communication faculty/students, Organizational Psychologists, Informaticists
• Identification of solutions from within, bottom up• Leadership support and buy-in• Standardization where evidence exists or to
simplify• Customization to meet local redesign needs
Technique used engage front line staff in improving processes and sustaining change
Based on identification of practices of used by ‘positively deviant’ staff/departments
Critical for staff involvement/buy-in
What is Positive Deviance?
Integrated Lean/PD approach
DevelopFuture State Process
Process ControlStrategy
Baseline Current Processes
Identify Operational Barriers
Define the Problem
Discovery
Action
Health Systems Involved
Two ICU units in 3 original hospital systems St. Francis (two ICUs in South Hospital) Clarian (Methodist and University Hospital) Community (Community East and Heart
Hospital) Early success encouraged 3 remaining
systems to join the project Wishard (two ICUs) VA Medical Center (housewide) St. Vincent's (two ICUs in north facility)
System Redesign
• Our health care engineers partner with and train front-line workers to use lean-six sigma and positive deviance approaches
• Focus on coaching front-line staff teams to lead instituting systems changes to systematize processes and sustain practices.
• Emphasize regular measurement and feedback of adherence to enhance adoption.
• Weekly Meeting of all hospital teams to identify barriers & facilitators, review and reinforce progress, share best practices, strategize about spread and solutions.
Evaluation and Results Range of 3-22% (monthly average) incoming
patients colonized with MRSA on study units
The number of conversions varied across
study units (4 23 during study period)
Variability in pre-intervention Nosocomial
infection rates across participating hospitals
(.015 .025)
Greater variability in pre-intervention study
unit MRSA infection data (.008 .074)
Preliminary Results
Preliminary pre and post intervention results for first three hospitals suggest average of 60% reduction on study units
~ 20% reduction hospital wide Currently investigating optimal
biostatistical approach such as time series analysis to confirm
Lessons Learned--Implementation
System redesign approach of training, consultation and coaching front-line staff seems to be strong, sustained approach
Importance of buy-in from highest institutional levels crucial
Enthusiasm builds from within because redesign teams own it!
Informatics tool helpful in identifying great cross-over of MRSA patients in hospitals
Lessons Learned--Research
Our proposed data collection too intensive for most community hospitals
Need to adequately staff data collection and observation of intervention bundle compliance
Need a better electronic data collection infrastructure relating to compliance and outcome data
Little time for paper writing and dissemination projects (Hazard of short time lines for funding)
Next Steps
MRSA Initial project officially concluded June 2008
Data continues to be compiled, verified…nosocomial infection data results being validated against MRSA clinical isolates
Working on further proposal development to investigate effective implementation mechanisms, spread of intervention, role of active surveillance in infection control, and spread and sustainability of interventions over time
AHRQ MRSA Team Brad Doebbeling, MD, MSc – Co-PI Paul Dexter, MD – PI Abel Kho, MD Shawn Hoke Jamie Workman-Germann, MS Doub Webb, MD Laurie Fish, RN Claire Rumpke, RN Loretta Marsh, RN Sandra Benson, RN Marie Comminsky, RN Diana Greathouse, RN Kim McCoy, MS Amy Kressel, MD Mahesh Merchant, PhD Mindy Flanagan, PhD George Allen
Additional Information
VA HSR&D Center for Implementing Evidence-based PracticeRegenstrief Institute, Inc., Indianapolis
