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Implementing a Novel Approach to Reducing MRSA in a Hospital Collaborative

Doebbeling BN, Hagg HK, Kho A, Hoke SC, Dexter PA. Implementing a Novel Approach to Reducing MRSA in a Hospital Collaborative. Paper presented at: AcademyHealth Annual Research Meeting; 2008 Jun 10; Washington, DC.




Abstract:

Research Objectives: Methicillin Resistant Staphylococcus aureus (MRSA) is a major nosocomial (hospital-acquired) pathogen, responsible for many serious infections. MRSA prevalence in hospitals and the community has increased dramatically, resulting in prolonged hospital stays and many deaths. Increasing evidence suggests careful implementation of evidence-based practices and system changes that may dramatically reduce MRSA. We have implemented a systems redesign program to reduce MRSA in multiple hospitals. Study design: Multihospital, quasi-experimental study. Methods: Using principles of lean, systems engineering, implementation science and positive deviance, we redesigned care processes and implemented a MRSA bundle consisting of: Active Culture Surveillance, Contact Isolation, and Hand Hygiene across all six of the major hospital systems within the Indianapolis metro area. We partnered with hospital leaders and formed learning collaboratives of front-line workers in 2 critical care units per hospital system (12 units total). We trained, coached and facilitated application of these approaches by front-line staff to benchmark, identify, adapt and implement solutions, developing methodologies for continuous feedback of performance data. We also developed an informatics data mining tool to share culture results across hospital systems, supporting more rapid isolation procedures in units. Cultural assessment surveys and implementation tracking were used to evaluate the sustainability and spread adoption. We assessed rates of MRSA infection and colonization over time on participating units and facilities. Principal Findings: Weekly team calls and ongoing data collection show active engagement of the hospitals teams. The most common process failure modes identified across sites were lack of visibility of isolation signs, availability of contact isolation equipment, and lack of robust processes to insure admission and discharge active culture surveillance were performed. Major redesign of patient transportation and environmental services’ terminal and daily clean processes were also required in most units. Staff and patient adherence with the MRSA bundle across participating study units show a major increase in adherence to the clinical practice guidelines associated with the MRSA bundle. Preliminary results show MRSA rates on study units declined by approximately 60% and overall rates declined approximately 20% hospital wide in the initial three hospital systems at 9-12 months followup. Conclusions: Lean, positive deviance, and systems engineering techniques have been used to implement the MRSA bundle across 12 units (6 hospital systems). This program has led to an increase in adherence with EBPs to reduce MRSA colonization and infection. Efforts focused on staff engagement, training, coaching and ongoing measurement and feedback of adherence contributed to sustained organizational change. Hospitals remain engaged and are prepared to spread the MRSA bundle to other units and other hospitals. Implications for Policy, Delivery or Practice: These findings demonstrate that effective partnering with front-line staff in redesigning care practices in ICUs to foster regular use of evidence-based practices can dramatically reduce MRSA infections. Using the conceptual framework of positive deviance and lean, staff engagement, coaching, and sustaining organizational change are important approaches for redesigning effective work practices in other healthcare settings.





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