HRET HIIN MDRO Taking MDRO Prevention to the Next Level! October 17, 2017 12:30 p.m. 1:30 p.m. CT 1
Kristin Preihs Senior Program Manager, HRET WELCOME AND INTRODUCTIONS 2
Webinar Platform Quick Reference Mute computer audio Today s presentation Chat with participants Download slides/resources Register for upcoming events 3
Today s Agenda Time Objectives Speakers 12:30 p.m. 12:33 p.m. Welcome and introductions Introduction to today s event and agenda overview. 12:33 p.m. 12: 36 p.m. HIIN MRSA Data Update Review HIIN performance related to lab-identified MRSA rates. 12:36 p.m. 12:42 p.m. Framing the Current Challenges Spotlight key drivers from the MDRO Change Package, and tease out the key challenges for implementation and improvement in your facility. 12:42 p.m. 1:10 p.m. Digging Deep to Tackle MDRO Learn from one of the nation s experts in hospital epidemiology regarding strategies to reduce MRSA and other MDROs. Engage in a dynamic give-and-take, with the opportunity to pose your tough issues and learn new approaches to tackling identification, isolation practices, decolonization, and more. 1:10 p.m. 1:25 p.m. Q&A Participants will engage in active dialogue to discuss challenging issues and ask questions regarding evidencebased approaches to drive down MDROs. 1:25 p.m. 1:30 p.m. Action Items and Next Steps Close today s discussion with key points, action items, and next steps. Kristin Preihs Sr. Program Manager, HRET Rich Rodriguez Data Analyst, HRET Betsy Lee, MSPH, RN Barb DeBaun, RN, MSN, CIC Improvement Advisors, Cynosure Health Tom Talbot, MD, MPH Chief Hospital Epidemiologist, Vanderbilt University Medical Center Subject Matter Expert Presenters and facilitators Kristin Preihs Sr. Program Manager, HRET 4
Barb DeBaun, RN, MSN, CIC Betsy Lee, MSPH, RN Improvement Advisors, Cynosure Health FRAMING: ADDRESSING MDRO PREVENTION DILEMMAS 5
Antibiotic Resistance Impact More than 2 million people in the US every year At least 23,000 deaths
Preventing MDRO Infections Antimicrobial Stewardship Horizontal Practices Decolonization Patient Family Engagement 8
Rich Rodriguez, Data Analyst, HRET MDRO DATA 9
Hospital-onset MRSA Bacteremia Rate Baseline 2016-10 2016-11 2016-12 2017-01 2017-02 2017-03 2017-04 2017-05 2017-06 Relative reduction, baseline to Oct '16 - Jun '17 Rate 0.055 0.060 0.054 0.057 0.053 0.058 0.058 0.049 0.057 0.056 0.5% Submission: % of hospitals w/ baseline (n=1361) 99% 99% 99% 99% 99% 98% 93% 89% 84% 10
Tom Talbot, MD, MPH 11
MRSA Healthcare Facility Onset Bacteremia Marker for: Transmission of resistant pathogen in healthcare facility Breakdown in infection prevention practices leading to HAI not captured among the Big 3 device infections [i.e. CLABSI, CAUTI, VAP]
Development of MRSA HO Infection MRSA Infected (+ Blood Culture) Not MRSA Colonized MRSA Colonized Hospital Admission Hospital Day 4+
Impact of Community Prevalence 14
Lab ID Event
MRSA MRSA
Impact of Antibiotic Stewardship Today s Headline News Single most important factor Most commonly prescribed drugs 50% not needed or inappropriately prescribed
Polling Question Our Antibiotic Stewardship Program is: a) Robust and firing on all cylinders b) Pretty good, but still a work in progress c) Just getting started d) Not on our radar e) No vote 19
Interview with Dr. Talbot 20
Impact of Horizontal Practices 21
Basic Practices: Recommended for All Acute Care Hospitals Conduct MRSA risk assessment (III) Use to develop surveillance, prevention, control plan Implement MRSA monitoring program (III) Hand hygiene (II) Contact Precautions for colonized/infected pts (II) Ensure cleaning/disinfection of equipment & environment (II) Educate HCP about MRSA (III) Lab-alert system to notify of new MRSA colonized/infected pts (III) Alert to note readmitted pts with MRSA colonization/infection (III) Provide MRSA data to key stakeholders/sr leadership (III) Educate patients/families about MRSA (III)
To isolate, or not to isolate.. that is the question. 24
Polling Question At our facility we: Do not isolate patients with MRSA infection Isolate patients with MRSA until symptoms resolve Isolate patients with MRSA forever and ever Isolate patients infected with MRSA but not those who are just colonized 25
Decolonization 27
Polling Question At our facility we: Do not perform daily CHG bathing of inpatients Perform daily CHG bathing for ICU patients only Perform daily CHG bathing for ICU patients and non-icu patients who have central line in place Perform daily CHG bathing for ALL inpatients (ICU and non- ICU) Perform daily CHG bathing in other populations not noted (not including pre-surgical bathing) 28
Special Approaches: Use in Locations/Populations w/ Unacceptably High MRSA Rates Active Surveillance Testing (II) Screen HCP for MRSA infection/colonization if epidemiologically linked to a cluster of MRSA infections (III) Decolonization therapy Targeted to pts colonized with MRSA (II) Universal: All patients (I) CHG bathing +/- mupirocin or other intranasal agent Universal gowns and gloves for all patients (II)
CHG Daily Bathing Goal: Decrease cutaneous bacterial burden Reduced source for nosocomial transmission? Reduced contamination of devices? Various concentrations (2-4%) and formulations used Solution Impregnated washcloths Most data in ICU patients
CHG Daily Bathing Various outcomes assessed in clinical studies: MDRO (MRSA, VRE) acquisition MDRO infection CLABSI Hospital-acquired bloodstream infection (BSI) Catheter-associated UTI (CAUTI) VAP C. difficile Blood culture contamination
Setting Product Studied Study period/design N Outcome(s) Studied 9 ICUs/BMT units at 6 academic centers 2% CHG washcloths 1 year/cluster RCT 7,727 patients; 49,885 pt days Hospital-acquired MDROs and Hospital-acquired BSI Results 23% reduction in HA-MDROs; HA-BSI decreased 28% Industry Support? Sage provided product and technical support
Setting Product Studied Study period/design N Outcome(s) Studied Results Industry Support? 5 ICUs at 1 academic center 2% CHG washcloths 13 months/ Pragmatic Cluster Crossover RCT 9,340 patients; 39,922 pt days Composite of CLABSI, CAUTI, VAP (new VAE definition), and C. difficile; Secondary: HA-BSI, clinical MDRO cultures, blood culture contamination Non-significant: 2.86 vs. 2.90 per 1000 pt days None Noto MJ et al JAMA 2015;313:369+
Differences Between Climo & Noto Studies Outcomes Climo Hospital-acquired MDROs and hospital-acquired BSI Noto Composite (CLABSI, CAUTI, VAP, C. diff) Multicenter Study Yes No Active surveillance for MDRO acquisition Audit of Bathing Compliance Yes Yes (product usage data) Training on Bathing Yes at study start No Analysis Concerns Other Adequate adjustment for clustering? No No Patient-level analysis; Adequate power with crossover design? Oral CHG in place for VAP prevention
Setting Product Studied Study period/design N Outcome(s) Studied Results Industry Support? 74 ICUs at 43 hospitals Mupirocin + CHG washcloths 30 months/cluster RCT 74,256 patients MRSA acquisition; ICU-attributable BSI Signif reduction in both outcomes with universal decolonization Authors with prior Sage support but AHRQ and CDCfunded study
Setting Intervention Study period/design N Outcome(s) Studied Results Industry Support? 20 medical & surgical ICUs @ 20 hospitals Gloves and gowns for all patient contact Cluster randomized trial 26,180 patients MRSA and VRE acquisition (combined) No difference in MRSA or VRE acquisition (Combined), but decreased MRSA acquisition -2.98 per 1000 pt days) No relevant
Patient and Family Engagement 41
Questions and Ideas for Action 42
Kristin Preihs Senior Program Manager, HRET ACTION ITEMS AND NEXT STEPS 43
Resources - LISTSERV Join the LISTSERV Ask questions Share best practices, tools and resources Learn from subject matter experts Receive follow up from this event and notice of future events 44
MDRO Change Package 45 http://www.hret-hiin.org/resources/mdro/17/mdro_change_package.pdf
MDRO Top 10 Checklist 46
Additional Resources HRET HIIN ASP Change Package coming soon! http://www.hret-hiin.org/resources/cdi/17/cdi_change_package.pdf 47
ADDITIONAL STUDIES REGARDING CHG BATHING 48
N Outcome(s) Studied Results Industry Support? 6 RCTs and 12 ITS obs studies; CLABSI: 151,546 CVC days MRSA: 389,936 pt days VRE: 78,723 pt days HAIs: CLABSI, MRSA, VRE RR CLABSI: 0.45 (0.37-0.55) RR MRSA 0.67 (0.59-0.77) RR VRE 0.60 (0.42-0.85) None reported
N Outcome(s) Studied Results Industry Support? 17 studies (7 cluster RCTs, 10 pre-post) BSI, CLABSI, CAUTI, VAP, MRSA, VRE, C diff CLABSI IRR 0.44 (0.26-0.75) MRSA IRR 0.59 (0.36-0.94) Others, n.s. change None reported
N Outcome(s) Studied Results Industry Support? 15 studies (3 RCTs, 12 quasi-exper trials) HAIs: CLABSI, CAUTI, VAP, MRSA, VRE CLABSI RR 0.44 (0.32-0.63) CAUTI RR 0.68 (0.52-0.88) VAP RR 0.73 (0.57-0.93) MRSA RR 0.78 (0.68-0.91) VRE RR 0.56 (0.31-0.99) None reported
Thank You! Find more information on our website: www.hret-hiin.org Questions or Comments: HIIN@aha.org 53