VA’s Resistant Infection ‘Bundle’ Drives Down MRSA in Community Living Centers

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By Annette M. Boyle

Martin E. Evans, MD

Martin E. Evans, MD

LEXINGTON, KY — A bundle of preventive measures that drove down the number of methicillin-resistant staphylococcus aureus (MRSA) infections acquired in acute care hospitals and spinal injury units in the VA healthcare system has proven effective in reducing MRSA rates in long-term care facilities, as well.

MRSA infections are more common in long-term care facilities than in acute care settings, according to Martin E. Evans, MD, of the MRSA/multi-drug resistant organism program office in the VA’s national infectious diseases service at the Lexington, KY, VAMC and professor of infectious diseases at the University of Kentucky School of Medicine.

Nationwide, 26% to 62% of long-term care residents may be colonized with MRSA. Residents with indwelling devices, such as catheters and central lines, have the highest rates of infections. The VA operates 133 long-term care facilities, called community living centers (CLCs), which provide care for 12,000 veterans.

The VA rolled out the MRSA Prevention Initiative to CLCs in January 2009. Evans led a group of researchers that assessed the success of the program by tracking MRSA prevalence at admission and the prevalence of healthcare associated infections (HAIs) from July 2009 until December 2012. Over the 42 months studied, the rate of MRSA HAIs declined 36%, according to results published in a recent issue of the American Journal of Infection Control. The prevalence rate of MRSA at admission increased from 23.35 to 28.7% during the study period.1

The initiative had four components:

  1. All patients had nasal swabs to check for MRSA on admission, transfer and discharge.
  2. Staff used Centers for Disease Control and Prevention (CDC) recommended precautions for contact with patients confirmed to have MRSA.
  3. Hand hygiene received increased emphasis.
  4. Institutional culture change made infection control and prevention part of everyone’s job.

The initiative did not recommend specific programs for driving cultural change, with some centers adopting Positive Deviance, some choosing Six Sigma and others developing their own systems.

Primarily, the frequent checks for MRSA in patients led to new behaviors and understanding of the infection by staff members, according to Evans. “There’s no way to get away from increased awareness of MRSA with staff constantly rehearsing infection control and approaching patients with nasal swabs. Staff internally absorb the messages that they are delivering to patients.”

The MRSA Prevention Initiative categorized colonized or infected residents as high- or low-risk based on how likely they were to transmit MRSA to others. Low-risk residents showed willingness and ability to follow directions regarding personal hygiene, did not have active MRSA infections and could cover or contain all wounds, drainage and body fluids. These residents could be given private rooms or shared accommodations with other low-risk residents and were permitted to mingle with other residents if they observed proper precautions. Staff managed high-risk residents using the CDC’s contact precautions, however, which include housing in single-patient rooms, restricting patient transport and movement to medically necessary purposes, frequent cleaning and disinfection of rooms, gowning, gloving and use of disposable or patient-dedicated noncritical patient-care equipment whenever possible.

MRSA UTIs drop significantly

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The most common MRSA hospital-acquired infections (HAIs) were skin and soft tissue infections (45%), urinary tract infections (25%), pneumonias 9%, bloodstream infections (8%) and ear nose and throat infections (7%). Non-pneumonia lower respiratory tract infections, bone infections and gastrointestinal infections each accounted for less than 3% of MRSA HAIs.

Rates for MRSA infections associated with indwelling devices declined substantially also. Slightly more than half (51%) of the MRSA bloodstream infections during the study period were central line associated. Over the three-and-a-half years, the rate of central line associated MRSA blood stream infections fell from 0.07 to 0.02 per 1,000 device-days. At the same time, the MRSA catheter-associated rate of urinary tract infections (58% of all UTIs) dropped from 0.34 to 0.28 per 1,000 device-days.

“Catheters are frequently used in CLCs, so we had a lot of data, which made it easier to see the impact of the program, even though there was no specific MRSA-related initiative for catheters,” Evans told U.S. Medicine.

Skin and soft tissue infection rates remained the same, as did non-device related blood stream infections and pneumonias. Healthcare acquired MRSA lower respiratory tract infections and non-catheter-associated urinary tract infections saw significant declines.

The authors noted that declines of the magnitude seen in this study have not been reported in other long-term care settings.

Evans attributed some of the improvement to systemwide efforts to address MRSA infections. “In the VA, the MRSA program is now in all the different venues a patient might use. If a patients stays within the VA system, they might go from an acute care hospital to a CLC or mental health facility and, in each place, they’ll encounter the same approach to infection control,” he pointed out.

Evans’ observation is supported by previous simulations that have shown that when hospitals in a region all adopt MRSA screening and contact isolation practices, MRSA prevalence declines. 2

Within the VA, the MRSA Prevention Initiative rolled out to all acute care ICUs and non-ICUs in October 2007, expanded to all spinal cord injury units in July 2008 and to all mental health units in July 2009. Ambulatory care venues implemented the program starting in April 2010. Evans and his colleagues have previously published results showing significant improvements in infection rates in acute care settings and spinal cord injury units.

1 Evans ME, Kralovic SM, Simbartl LA, Freyberg RW, Obrosky DS, Roselle GA, Jain R. Nationwide reduction of health care-associated methicillin-resistant Staphylococcus aureus infections in Veterans Affairs long-term care facilities. Am J Infect Control. 2014 Jan;42(1):60-2.

2 Lee BY, Bartsch SM, Wong KF, Yilmaz SL, Avery TR, Singh A, et al. Simulation shows hospitals that cooperate on infection control obtain better results than hospitals acting alone. Health Aff (Millwood). 2012;31:2295–2303.

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