Cultural transformation key to success of MRSA Initiative in health care systems

Principles of positive deviance, staff ownership have driven MRSA rates down.

Rates of infection from methicillin-resistant Staphylococcus aureus may have been reduced by up to 60% in the Pittsburgh Veterans Administration health care system because of the Veterans Healthcare Administration MRSA Prevention Initiative, according to Rajiv Jain, MD, chief of staff for VA Pittsburgh and director of the Initiative.

Jain said that in Veterans Administration hospitals nationwide, the initiative may have led to a decrease in MRSA infections of up to 50% in the ICU and 30% overall.

In spite of these numbers, many experts think that the most remarkable aspects of the program have nothing to do with statistics.

“There are two main things which I believe separate this program from others: active surveillance and cultural transformation,” Jain told Infectious Disease News. “With regard to active surveillance, we screen everybody who comes into the system, not just high-risk patients. As for the cultural transformation, this program is driven by staff and supported by leadership — not the other way around.”

However, despite the promising preliminary results, some skepticism about the program remains among infectious disease specialists.

Ernest Robillard, RN, is the MRSA Program Coordinator at the Boston VA Healthcare System. He discussed how far MRSA infection control has come in the context of the initiative. “In the 1970s and 1980s, we virtually accepted that patients in the ICU would get MRSA and vancomycin-resistant enterococci,” he said. “In the 1990s, we started to think of infections as adverse events that we wanted to eliminate. Now we have an initiative that can prevent the transmission of and infection by MRSA.”

The program was piloted in the VA Pittsburgh Healthcare System on the surgical ward in 2001. In 2004, the program was expanded to include the ICU, and then it became facility wide, including acute care and the community living center, in 2005.

In August of 2006, a decision was made to take the initiative national. Seventeen VA hospitals were chosen as beta sites to test the program. They promulgated the directive in January 2007 and then began implementing the program in the ICUs at each site. By December 2007, the program was fully implemented in acute care at the beta sites.

From February through December 2008, the program was introduced into community living centers at the 17 beta sites and as of May 2009, the program is being tested in the mental health units at the 17 locations.

Jain said that since the program has gone national, all of the programs have displayed varying strengths. Of course, with Pittsburgh as the alpha program, most of the attention has been focused there; but all of the programs are showing strong preliminary data similar to the data seen in Pittsburgh.

Program components

There are four main tenets of the VA MRSA Initiative. The first, as Jain discussed, is active surveillance. Not only does the directive call for nasal screening all patients who enter the system, but it also stipulates that patients be screened upon transfer from one unit to another, then again at discharge. The aim is to identify MRSA and to break the chain of transmission.

The second component focuses on contact precautions. Patients who test positive for MRSA will be placed in contact precaution as defined by CDC standards. They will remain there until they test negatively for the infection. If a patient is still positive for MRSA at discharge, they will remain flagged for contact precaution if they are readmitted to the hospital.

Hand hygiene is the third component of the program. The directive stresses that health care workers wash their hands before and after contact with patients.

The final component of the initiative is a culture change. The directive states that “infection prevention and control is everyone’s job.” To encourage full compliance, the initiative is designed to allow healthcare workers at the unit level of each facility to determine how the program will be implemented. Employees are given a voice in determining strategies that will work best in that particular hospital.

Martin Evans, MD, is the associate project director and former hospital epidemiologist at the Lexington VAMC in Lexington, Ky. “Every institution is allowed to adopt its own practices that work best for their specific place,” he said. “These programs are not carbon copies of each other. There is room for flexibility and adaptability.”

Jain explained the nature of and reasons for the cultural transformation component of the directive. “Though everyone understands that hand hygiene is key, compliance varies greatly from health system to health system,” he said. “When hospital staff become engaged and involved, we have found that compliance goes way up. If there is any magic to what we have done, it comes down to the levels of compliance we are seeing in our preliminary data.”

Jain said that the cultural ownership of the program among hospital staff has created an environment in which MRSA prevention is a top priority. When compliance increases and infection rates decrease, front-line staff feel as though they have reaped the rewards. “This program belongs to the people who implement it,” he said. “Beyond that, the program has been integrated into day-to-day operations of each hospital. The culture change piece makes it more than just an add-on program.”

Each hospital has a MRSA program coordinator. It is not absolutely necessary that the program coordinator be a physician. The position requires organizational skills, the ability to account for survey data and the ability to bring housekeeping and nursing staff members together with infection control personnel and hospital administrators to best work out strategies for MRSA reduction. “Having a person like this on staff helps to keep from interrupting other people’s work,” Jain said.

However, no data on the success of the programs have been published in peer-reviewed journals. Many clinicians in the field have taken a wait-and-see attitude and others have voiced serious concerns with the basic tenets of the initiative.

Controversial strategies

There has been significant backlash to the initiative since its inception. Officials within the program have recognized and addressed it both publicly and privately.

Jain said that, at the beginning, the main issue was that there were no data to support the resources required for active surveillance. “It was a lot to ask to begin universal screening,” he said. “We had to have faith that it was going to pay dividends in terms of reducing the number of infections and the length of stay. When we went national, even though there were some preliminary signs that the program was working, people still resisted.”

“The pushback at the national level was partially due to the lack of data,” Evans told Infectious Disease News. “But beyond that, people simply do not like being told what to do.”

Gio Baracco, MD, the hospital epidemiologist at the Miami VAMC, also discussed early challenges to the program. “Available science is not conclusive enough, which leads to skepticism,” he said. “Unfortunately, the VA MRSA program was not set up to answer many of these questions.”

Baracco said that one of the most important criticisms is that, “other important infection control priorities are being neglected.”

There has been significant public debate about this issue. Near the center of that discussion is Richard Wenzel, MD, MSc, professor and chairman of the department of internal medicine at Virginia Commonwealth University in Richmond, who wrote an editorial, “Screening for MRSA: a flawed hospital infection control intervention,” published last year in Infection Control and Hospital Epidemiology. Wenzel and his colleagues wrote that “an approach to control of MRSA without a broader infection control program would fail with many other resistant pathogens.” They created a model for a horizontal infection control program that aimed to reduce all organisms at all sites by 50%. In so doing, they demonstrated that it is possible to reduce MRSA infections by 50%, as well.

“I have serious concerns about a vertical infection control program that focuses on a single organism,” Wenzel told Infectious Disease News. “We have to take a serious look at the impact of a vertical vs. a horizontal program on morbidity, mortality and cost.”

Wenzel said that the resources the VA MRSA Initiative are receiving are diverting attention away from pathogens that are equally infectious and prevalent. He argued that the time and money would be more effectively spent in reducing all infections, rather than just one. “There is simply more bang for your buck with a horizontal program than with a vertical program,” he said.

Though many in the infectious disease field share the concerns expressed by Wenzel, most clinicians will not make a decision about the program unless randomized trials are conducted and results are published.

Evans addressed some of the other concerns expressed by Wenzel. “Our hand hygiene compliance rates have shot way up as a result of this program,” he said. “While we understand that MRSA is just one organism, no matter which way you cut it, increased hand hygiene compliance is going to result in fewer infections.”

Cultural transformation, community outreach

Though there has been opposition to some of the aspects of active surveillance, most are impressed with the enthusiasms with which the VA MRSA Initiative has been carried out. Apart from a facility-wide focus on MRSA control, many of the programs have reached beyond the walls of the hospital and into the community.

Theresa Haley is the MRSA Prevention Coordinator at the Lebanon VAMC in Lebanon, Penn. “Through the principle of positive deviance, we have seen people on our staff go far beyond the call of duty in spreading the message of MRSA control,” she told Infectious Disease News. “We have gone into daycare centers to educate staff there. We have developed a strong message in schools, with principals, athletic directors and coaches. All of this leads back to better outcomes for our patients.”

Haley said that in-house programs have been strengthened as a result of the community outreach. “These efforts come back to us in the forms of increased enthusiasm and a reduction in the number of infections,” she said.

Suzanne Fritz, RN, is the infection preventionist at the Lebanon VAMC. She addressed another component to the ideas discussed by Haley. “Patients are becoming more savvy,” she told Infectious Disease News. “With so many sources of information, they have a sharper understanding of what needs to be done with regard to infection control. They understand the infection process.” She said that providers occasionally need to clear up misconceptions but that, overall, better-informed patients help fuel the program.

Baracco discussed another benefit of patient education. “We need to get away from the mindset that ‘a hospital is a dangerous place and there is an expected risk of infection’ and into one that says ‘no patient should leave with a problem they did not bring in,’” he said. According to Baracco, the more that people know about the processes of infection and infection control, the less likely they are to fear hospital facilities.

An ancillary benefit to the community outreach has been the development of off-shoot MRSA control programs. Haley discussed the South Central Pennsylvania MRSA Prevention Partnership, which is an association of rural hospitals in that region that have come together to fight the infection.

“Before the initiative, these hospitals were isolated, battling infection control on their own,” Haley said. “Now they are coming together to share information. That could not have happened without the kind of cultural ownership written into the VA MRSA Initiative directive.” Similar programs have begun to appear around the country.

Continuing challenges

Despite overwhelming enthusiasm within the system, challenges remain and questions linger.

“The dream is to get to a 0% infection rate,” Jain said. “But that journey may take us a while for a few reasons. The first is that the VA is such a large health care system that the mere size and scope of it makes 0% a difficult goal. The second is that many of our patients are connected to the community. Even if we have an aggressive program, if local community hospitals are not complying with our standards, infections are going to occur and it will be difficult to get to 0%. People enter the health care system through many avenues.”

Haley said that maintaining momentum and a positive atmosphere will be an ongoing challenge. She said that keeping staff informed and getting new patients up to speed with the program will require constant attention.

Wenzel said that, “there is nothing inherently wrong with a vertical program such as this one, as long as it is supported by basic horizontal infection control strategies committed to cutting in half all organisms at all sites,” he said. “The biggest criticism we have is that although some of these facilities have shown an effect in reducing MRSA, none of them have shown a reduction in total infection rates. We think that this is really important from a clinical perspective and from a patient perspective.”

Despite these criticisms, the VA MRSA Initiative has received worldwide attention, largely because of the shift in the approach to infection control.

“The VA launched forward in the war against MRSA when others were taking a wait-and-see approach,” Robillard said. “This program is costly, and many hospital systems are already strained financially. The lack of good data has caused skepticism. However, the program challenges some pre-conceived ideas regarding how infection control should be done, and this is important.”

Baracco summed up the key points of the initiative. “Health care-associated transmission and infection with MRSA and other multidrug-resistant bacteria are largely preventable,” he said. “If we all work together to raise the standards of patient safety, improve our systems and our own accountability, and empower front-level staff to identify barriers and implement solutions, we can be very successful at it. The initiative has taken the bull by the horns, and we have refused to believe that the status quo in infection control is acceptable.” – by Rob Volansky

What is your opinion of active surveillance as an infection control strategy?

For more information:

• VHA MRSA Initiative Directive: www.pittsburgh.va.gov/MRSA/MRSA_Prevention_Initiative.asp
• Wenzel RP et al. Infect Control Hosp Epidemol. 2008;29:1012-1018.