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A 2005 survey conducted by the Centers for Disease Control and Prevention (CDC) found that more than 94,000 patients in the United States developed serious infections
from Methicillin-resistant Staphylococcus aureus (MRSA) resulting in an estimated 18,650 deaths. This figure was more than the deaths from HIV/AIDS that year. Nationwide, MRSA is the most common cause of ventilator-associated pneumonias and surgical site infections, the fourth most common cause of central line-associated bloodstream infections, and the eighth most common cause of catheter-associated urinary tract infections. MRSA infections have been a growing problem in private and VA medical facilities. Because there are few antibiotics that are effective against MRSA, effective infection prevention and control strategies to prevent the spread of MRSA within health care systems are essential.1
In 2002, the VA Pittsburgh Healthcare System
(VAPHS) began collaboration with the Pittsburgh Regional Healthcare Initiative and the CDC to adopt the principles of the Toyota Production System (TPS) to reduce transmission of MRSA and MRSA health care-associated infections (HAIs). The approach was piloted on a surgical ward at VAPHS. The key strategies implemented included:
- surveillance cultures for MRSA on all admissions
- prompt isolation (in contact precautions) of patients found to be colonized or infected with MRSA; and
- an aggressive hand hygiene training program.
Using TPS, MRSA infections on the surgical ward decreased 60 percent over four years. The strategy was expanded to the Surgical Intensive Care Unit (ICU), where a 75 percent reduction in MRSA HAIs was realized over three years.2 In 2005, the program was expanded to include all acute care units at VAPHS and reductions of similar magnitude were noted on all acute care units.
The VAPHS experience with TPS showed that health care systems and processes could change with positive outcomes. The model was successful in decreasing MRSA HAI rates; however, application of TPS was resource intensive. In order to expand the program in a cost effective manner, VAPHS explored a process called Positive Deviance (PD), described
at www.positivedeviance.org. With PD, "culture change" where infection control becomes everyone's responsibility, was added to the original three strategies to decrease MRSA infections. Active surveillance, contact precautions, hand hygiene, and culture change became known as the "VA MRSA Bundle." Recognizing the success of VAPHS in controlling
MRSA HAIs and seeking to validate the process, VA Central Office provided VAPHS with funding to support trials of the MRSA Bundle at other VAs. Thirty-nine VA facilities applied to be b-test sites, and 17 were selected. Six elected to undergo formal PD training. All b-sites agreed to collect MRSA process and compliance data and report through the CDC's National Healthcare Safety Network (NHSN) beginning in October 2006.
The VHA MRSA Program Office, in collaboration
with researchers at the Center for Health Equity Research and Promotion (CHERP) based at VAPHS, conducted a qualitative evaluation using in-depth interviews
to describe the key strategies and potential pitfalls involved with implementation
of the Directive. A majority of the participants believed that using a cultural transformation approach was necessary for the program to succeed because it allowed staff to buy-in and get involved.3
The original plan for VHA-wide implementation
was projected to occur in a staged process over two to three years. However, the Secretary of Veterans Affairs visited VAPHS in December 2006, and saw firsthand
the success the institution was having in controlling MRSA. Recognizing the importance
of MRSA prevention in Veterans' lives, the Secretary released Directive 2007-002 in January 2007, authorizing implementation
of the MRSA Prevention Initiative and all components of the "MRSA Bundle" in one ICU or other high-risk area in all VHA acute care facilities by March 2007. It directed all acute care units to implement the Initiative by December 31, 2007.
Implementation of the MRSA Prevention Initiative in Community Living Centers began in December 2008, with guidelines developed specifically for the homelike setting.
Guidelines have also been developed for spinal cord injury units, polytrauma units, inpatient mental health units, and ambulatory care/outpatient settings. By the end of April 2010, the MRSA Prevention Initiative will have been deployed VHA-wide.
Data from the VHA MRSA Prevention Initiative
from inception of the program to the present
are currently being analyzed. Preliminary results suggest significant changes in MRSA HAI rates in the ICU and non-ICU setting as well as significant decreases in MRSA transmission
among patients during their hospital stay.
Baracco GJ, Muder RR, Jain R. Methicillin-resistant Staphylococcus aureus: What's the Big Deal? Federal Practitioner
Muder RR, Cunningham C, McCray E, et al. Implementation
of an Industrial Systems-Engineering Approach
to Reduce the Incidence of Methicillin-resistant Staphylococcus aureus Infection. Infection Control and Hospital Epidemiology 2008; 29:702-8.
Garcia-Williams AG, Miller LJ, Burkitt KH, et al. Beyond
beta: Lessons Learned from Implementation of the Department of Veterans Affairs MRSA Prevention Initiative. Infection Control and Hospital Epidemiology 2010, in press.