MRSA CHANGE STRATEGIES The following tables include change strategies proven to be effective in healthcare settings. Implementing these changes through current or new processes may result in reducing healthcare associated MRSA infections. Reducing MRSA infection includes five components of care: hand hygiene, decontamination of the environment and equipment, active surveillance, contact precautions for infected and colonized patients and central line and ventilator device bundles. Process Measures Identify patients with Active Surveillance Cultures (ASC) Change Strategies 1. Identify patients who will be cultured. Possible strategies include: Develop a medical staff approved policy that identifies those patients at high risk for MRSA and delineates responsibilities Create a standard risk form to identify patients likely to be colonized (e.g. patients admitted from nursing homes, patients with self-reported previous admissions Use a population-based strategy (e.g. all patients in ICU) Consider culturing all patients; assess impact on lab, cost, etc. 2. Design and test a reliable process to obtain cultures and transmit them to the lab. Possible changes include: Include culture in admission pack Design a protocol for obtaining ASCs Add a check-box for culture on the admission assessment form Add ASC to the ICU admission standing orders Consider using alert in order entry system Use a flag or other signal (at the bedside, in the EMR, in the chart) to make it apparent if the culture has NOT YET been done 3. Design and test reliable and timely processes for processing the cultures and notifying results. Planning activities and changes include: Work with lab personnel to coordinate lab ramp-up for new test load, and create lab protocol for ASC tests Review current ASC tests for sensitivity, specificity, cost, and turnaround time; select alternative test if necessary. Establish accountability for testing process Provide feedback to lab and unit regarding test turnaround time Prepare health care workers to inform and work with patients regarding tests, isolation procedures, etc. Design and test a reliable notification process: e.g. electronic alert, phone call to unit, flag inserted in record
4. Take appropriate action when tests are positive Design and test a protocol for management of colonized patients Assess resource requirements for new patient management protocol, especially bed management process (see Contact Precautions, Dedicated Equipment) Create a process for capturing protocol exceptions; review them for ideas about improvement Create policy and protocol to accommodate patients who refuse testing (e.g. isolation) 5. Monitor and provide feedback Distribute weekly e-mails reporting rates and compliance Monthly report to senior leadership Design and implement a process for period oversight and review of tests and protocols 6. Pre-Change Activities: Understand the current process for implementing contact precautions and identify points of failure Flowchart current processes, including patient identification, availability of supplies Use FMEA or fishbone analyses analysis to identify and prioritize failures in contact precaution protocols Create documented protocol, checklist, and forms for contact precautions, including chart stickers, transport and patient transfer forms Assign responsibility to check supplies of gloves, gowns and other supplies, and assess compliance Design process for trash disposal that prevents over-filling Ensure availability of trash receptacles and linen bags Use contact precautions for colonized or infected patients Pre-Change Activities: Educate staff regarding contact precautions Train staff on protocol, with special attention to support staff. Plan for multiple languages and venues Provide for training of new employees and rotating staff 1. Design and test a procedure to identify colonized or infected patients. Suggested changes include: Place sign on patient room door that lists appropriate contact precautions Insert flags in EMR to identify infected/colonized patients Use colored sticker on outside of chart and colored page inside to identify patients and list appropriate precautions; coordinate color with contact precaution sign on patient room 2. Create a culture that supports use of contact precautions. Suggested changes include: Enlist support of opinion leaders and enlist champions leaders discuss and demonstrate proper
technique Enlist opinion leaders to make mutual monitoring an accepted behavior norm 3. Monitor and provide feedback Use inspection ('isolation rounds') to assess compliance with signage, chart flags, supplies Use observations to measure compliance and feedback on compliance with use of precautions Provide daily feedback about infection prevalence rates and protocol compliance Use appropriate room cleaning and disinfection Design and test a process for cleaning and disinfecting rooms occupied by colonized/infected patients. Suggested components include: Make it easy to distinguish disinfected equipment from contaminated equipment Contaminated equipment is bagged and tagged prior to transport for disinfection Appropriate attire (gown, gloves) worn when cleaning Disinfect reusable equipment Prioritize room cleaning and disinfection by focusing on frequently touched surfaces (e.g. bedrails, doorknobs, bathroom fixtures) Document special procedures that are used to clean up bloody fluid Terminal room cleaning when patients are discharged from hospital Create a checklist for room cleaning Use EPA registered disinfectants; follow manufacturers instructions for use Educate staff on cleaning and disinfection procedures and assess competence 2. Design and test a process for appropriately disposing of contaminated materials Protocol for management of disposable and reusable items (e.g. trash, linen, laundry, medical devices) 3. Monitor and provide feedback Provide feedback to staff on compliance Develop an action plan for compliance failures Use dedicated equipment for colonized and infected patients 1. Design and test a process for ensuring the availability of required supplies. Suggested components include: Use disposable patient care items (e.g. blood pressure cuffs) Determine equipment and supplies needed for patient on contact precautions Determine amount of supplies needed
Monitor availability of equipment and supplies Educate staff on appropriate management of equipment Have a process in place for rapid cleaning and disinfection of equipment at the site of use Disinfection agents readily available (e.g. disinfecting wipes, sprays) 2. Monitor and provide feedback Develop a process for monitoring compliance Provide feedback to staff on compliance Develop an action plan for compliance failures Reliable hand hygiene Pre-change activities: Build knowledge about infection, transmission principles, hand hygiene, and hand washing technique Create a locally-specific hand hygiene curriculum and checklist for use in staff education, based on CDC Guideline for Hand Hygiene in Health-Care Settings Provide education just in time - at or near the point of care - with posters or video displays Provide computer video presentations of proper technique - embed in intranet, e-mail distributions or EMR Use fluorescent dye-based training methods to demonstrate correct hand hygiene techniques to clinical staff Pre-Change Activities: Design and test a process for stocking supplies Assign responsibility to check supplies of soap, rub, and gloves, and assess compliance; set up system to report needed restocking Evaluate soap and alcohol dispensers before purchase to check usability; use front line staff in evaluation 1. Create a culture that supports reliable hand hygiene. Suggested changes: Enlist opinion leaders as role models: leaders discuss and demonstrate proper technique. Coach opinion leaders to make mutual monitoring an accepted behavior norm 2. Use reminders at the point of care. Suggested changes: Enlist patient and caregiver cooperation in providing reminders; inform every patient that hand washing is expected and encourage them to observe and question staff Place alcohol-based hand rub dispensers and gloves near the point of care
3. Monitor and provide feedback about performance. Suggested changes: Provide staff with feedback about HAI infections and handwashing compliance using posters, e-mail, newsletters, etc. Use of a central line bundle Hand hygiene Maximal barrier precautions Chlorhexidine skin antisepsis Optimal catheter site selection with subclavian vein as the preferred site for Daily review of necessity with prompt removal of unnecessary lines Use of a ventilator bundle Elevation of head of the bed to between 30 and 45 degrees Daily sedation vacation and daily assessment of readiness to wean Screening: Carefully assess level of consciousness Titrate to a sedation scale Avoid or minimize use of paralytics Use NPPV when appropriate to avoid intubation Appropriate observation during sedation reduction for weaning Daily assessment of readiness to wean Weaning trial when criteria are met Peptic Ulcer Disease (PUD) Prophylaxis Deep Venous Thrombosis (DVT) Prophylaxis MO-08 08-05 05-MRSA September 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.