Sustained Reduction in Healthcare Associated (HA) MRSA Infections Using A Multi-Pronged Approach in a Large Community Hospital System

Background: Proven strategies have reduced HA-MRSA in US hospitals.  In 2007, HCA implemented an enterprise wide MRSA ABC campaign for inpatients in 154 hospitals.  Campaign tools were developed for: Active MRSA surveillance (ASC) of high risk patients, enhanced Barrier precautions, Compulsive hand hygiene, Disinfection and cleaning and Executive champions and education.   High risk patients were defined as ICU, prior history of MRSA colonization or infection, resident of a long term care facility, nursing home or other group living, transfer from another healthcare facility or selected surgical procedures [open heart, open spine, total hip, and total knee joint replacement] and excluded psychiatric inpatients.   Initial outcomes showed mean HA-MRSA rates decreased for VAP, CLABSI and SSI, 52%, 35% and 24% respectively from 2006 baseline compared to 2007-2008 post implementation.

Objective: To sustain reduction in HA-MRSA infections in 2009 compared to 2007-2008.

Methods: Admission or pre-surgical screening identified patients with high risk criteria for a nares swab to detect MRSA colonization.    Swabs were obtained either at the presurgical visit or within 48h of admission to test by BD CHROMAgar or GeneOhm PCR methods.   MRSA positive surgical patients received pre-operative nasal mupirocin and vancomycin prophylaxis at the surgeon’s discretion.  Using NHSN criteria, infection preventionists reviewed patient records and self reported HA-MRSA VAP and CLABSI infections per 1000 device days from adult ICUs and HA-MRSA SSI per 100 procedures.  Hand hygiene was measured by alcohol based hand rub product purchased per adjusted patient days.

Results: In 2009, 29% of 1.5 million adult patients qualified for ASC screening and facilities swabbed >85% high risk patients.    MRSA colonization was an average 10.5% [15.8 % in group living, 8.8% ICU, 8.5% transfers] compared to 10% in 2007-2008 and for surgeries 3.9% compared to 4.6%.  Geographic regions showed differences in colonization rates ranging from 5% in Utah to 12.6% in Florida.  High risk patients were also analyzed for patient level risk factors for colonization.    Over 90% of HCA hospitals across 20 states reported sustained mean HA-MRSA decreases for VAP, CLABSI and SSI, 58%, 62% and 15% respectively in 2009 from 2007-2008 post implementation reductions.   Targeted SSI procedures showed decreases with the exception of open spine procedures which had no decrease.   Hand hygiene purchases increased from a mean of 50 to 83 ounces per adjusted patient day, while gown usage was unchanged.

Conclusions: A standardized systems approach including ASC compliance and hand hygiene, in combination with evidence based practices, results in sustained reduction of HA-MRSA infections in community hospitals.