Identification And Prevention Of MRSA Transmission
Identification and Preventionof MRSA Transmission1
PresenterKyle Popovich, MD, MSAssociate ProfessorRush University Medical CenterContributions byDavid Calfee, MD, MSWeill Cornell MedicineVineet Chopra, MD, MScUniversity of MichiganRuss Olmsted, MPH, CIC, FAPICTrinity Health, Livonia, MI2
Learning ObjectivesIdentify strategies that can be used in acute caresettings to reduce the transmission of methicillinresistant Staphylococcus aureus (MRSA)Recognize the advantages of horizontal infectioncontrol strategiesExplain the importance of adherence to recommendedinfection control interventions3
OutlineIdentification of MRSAHand hygienePersonal protective equipmentEnvironmental cleaning and disinfectionHow to educate our patients4
Patient IdentificationFacilities need a system in place to alert health carepersonnel about patients with MRSALab alert systems can notify staff of newly positiveMRSA resultsEarly identification of patients with MRSA allows forearly placement of patients on Contact Precautions5
Staff CommunicationIntra- and inter-facility communicationis important for alerting health carepersonnel of a patient’s MRSA status– e.g., when transferring patients toother health care facilitiesFacilities can develop electronicsystems to identify or “flag” patientswith MRSA at readmission to quicklyinstitute Contact Precautions(Image Source. Slayton RB, CDC MMW, 2015)6
Actionable FeedbackInclude hospital-onset MRSA bloodstream infections as well as otherMRSA ratesEngage hospital leadership and health care personnel with feedbackregarding their facility’s or unit’s MRSA rates and trendsIdentify areas of improvement and motivate health care personnel andleadership to reduce rates of MRSA at their institution or in their omizable?(Image adapted from Hysong S, Implementation Science, 2006)7ActionableChange
Hand Hygiene Soap and water or alcoholbased hand-rub Before and after patientcontact or contact with thepatient care environmentIncreased hand hygiene adherence has been associated with:– Decrease in MRSA transmission– Decrease in healthcare-associated infections(Pittet D, Lancet, 2000)8
5 Moments for Hand Hygiene1. Before touching a patient2. Before providing aclean/aseptic procedure3. After direct contact with abody fluid4. After touching a patient5. After touching surfacesaround a patient(Image Source. Your 5 Moments for Hand Hygiene, WHO, 2006. Boyce JM, Am J Infect Control2002; WHO, 2009)9
Hand HygieneAdherence to hand hygiene can be poorMinor lapses in hand hygiene can lead to crosstransmission of MRSA, especially in settings with highcarriage rates of MRSAHospitals need programs to promote hand hygiene aswell as mechanisms to monitor staff adherence– Trained personnel to monitor– Electronic methods(Boyce JM, Am J Infect Control, 2002)10
Hand Hygiene Adherence (%)Impact of Feedback on Hand HygieneAdherenceDays(Armellino D, Hussain E, Schilling ME, et al. Using high-technology to enforce low-technology safetymeasures: the use of third-party remote video auditing and real-time feedback in healthcare. Clin InfectDis. 2012; 54:1-7.)11
Personal Protective Equipment (PPE)Patients colonized or infected with MRSA may beplaced in private rooms or cohorted with similarpatients to reduce the spread of MRSAContact Precautions (gloves and gowns) are usedduring clinical encounters with patients who arecolonized or infected with MRSAContact Precautions may help reduce the spread ofMRSA in the hospital(Calfee D, Infect Control Hosp Epidemiol, 2014)12
PPE: Current ControversiesUniversal glove and gown use?Universal glove use instead of Contact Precautions?Are there adverse effects to patients who are placed onContact Isolation?Adherence to the intervention is critical(Morgan DJ, Infect Control Hosp Epidemiol, 2015)13
Environmental Cleaning and Disinfection MRSA can survive onhospital surfaces Contaminates patient’senvironment e.g., over-bed tables,bedrailsContaminates patient care equipment e.g., stethoscope, blood pressure cuffThere should be dedicated medical equipment for a singlepatient with MRSAShared equipment should be cleaned and disinfected beforeusing it with another patient14
Environmental CleaningEnvironmental cleaning reduces opportunities forcontamination of health care worker handsEnvironmental services is an important component ofthe infection control teamProcess for monitoring environmental cleaning anddisinfecting adherence and thoroughness(Calfee D, Infect Control Hosp Epidemiol, 2014)15
Horizontal Infection Control StrategiesStrategies that are NOT pathogen specificThese interventions can reduce transmission of MRSA to otherpatientsThese interventions have the additional benefit of reducingtransmission of other potential pathogens including othermultidrug-resistant organisms (MDROs)16
How to Educate Our PatientsExplain what colonization with MRSA meansExplain how people can get MRSA infectionsDiscuss with patients what hospitals aredoing to prevent MRSA infections– Hand hygiene, environmental cleaning,Contact Precautions– Empower the patient to ensure that theirhealth care providers are performing handhygiene17
Infection Control After Hospital DischargeIf you are prescribed an antibiotic for a MRSA infection, complete the fullcourse of antibioticsPerform frequent hand washing, particularly before and after changing awound dressing or bandageHand hygiene for people who live with the patientKeep wounds clean and change bandages as instructedAvoid sharing personal items such as towels or razorsWash clothes and bed linens according to the recommendation on thelabelsAfter hospital discharge, for future care inform health care providers aboutMRSA status(MRSA Information for Patients, CDC, 2016)18
Take-Home PointsAdherence to the recommended infection controlstrategies is essentialHorizontal infection control strategies can impact MRSAand other multidrug-resistant organismsPrograms are needed to educate health care personneland patients, promote the importance of variousinterventions and to improve adherence with therecommended strategies19
ReferencesArmellino D, Hussain E, Schilling ME, et al. Using high-technology to enforce low-technology safety measures: the use of third-party remote videoauditing and real-time feedback in healthcare. Clin Infect Dis. 2012; 54:1-7.Boyce J M, Pittet D, HICPAC et al. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection ControlPractices Advisory Committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. Am J Infect Control. 2002; 30(8): S1-S46.Calfee DP, Salgado CD, Milstone AM, et al. Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acutecare hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014; 35:772-96.Hysong SJ, Best RG, Pugh JA. Audit and feedback and clinical practice guideline adherence: Making feedback actionable. Implementation Science.2006; (1):9–18.Methicillin-resistant Staphylococcus aureus (MRSA). Information for patients. Centers for Disease Control and Prevention, CDC. Updated on April15, 2016. Available at http://www.cdc.gov/mrsa/healthcare/patient/Morgan DJ, Murthy R, Munoz-Price LS, et al. Reconsidering contact precautions for endemic methicillin-resistant Staphylococcus aureus andvancomycin-resistant Enterococcus. Infect Control Hosp Epidemiol. 2015; 36:1163-72.Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection ControlProgramme. Lancet. 2000; 356(9238):1307-12.Slayton RB, Toth D, Lee BY, et al. Vital Signs: Estimated Effects of a Coordinated Approach for Action to Reduce Antibiotic-Resistant Infections inHealth Care Facilities –United States. Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report. 2015; 64(30): 826-31.WHO Guidelines on Hand Hygiene in Health Care. World Health Organization, WHO. 2009. Available 6/en/Your 5 Moments for Hand Hygiene. World Health Organization, WHO. 2006. Available ne A3.pdf?ua 120
Speaker Notes21
Speaker Notes: Slide 1Welcome to the third module of the methicillin-resistantStaphylococcus aureus, or MRSA, Tier 1 course, titled“Identification and Prevention of MRSA transmission”. Thismodule will discuss the importance of identifying andimplementing strategies to prevent MRSA transmission.22
Speaker Notes: Slide 2This module was developed by national infection preventionexperts devoted to improving patient safety and infectionprevention efforts.23
Speaker Notes: Slide 3By the end of this module, you will be able to: Identify strategies that can be used in health care settings toreduce the transmission of methicillin-resistant Staphylococcusaureus, also called MRSA; Recognize the advantages of horizontal infection controlstrategy, which are infection control interventions that are NOTpathogen specific; and Explain the importance of adherence to recommendedinfection control interventions.24
Speaker Notes: Slide 4The following infection control interventions can be used toreduce the transmission of MRSA: hand hygiene, personalprotective equipment and environmental cleaning anddisinfection. This presentation will build on the content andinterventions discussed in the Foundational Infection PreventionStrategies courses.25
Speaker Notes: Slide 5First, an important component of preventing MRSA transmissionis early identification of patients with MRSA. Facilities need toestablish a prospective MRSA monitoring program, which alertshealth care personnel about patients with MRSA. Some facilitiesmay choose to enhance their MRSA monitoring program byinstituting a lab alert system to notify staff of newly positiveMRSA results. This early identification of patients with MRSA iscrucial, because it allows for placement of these patients onContact Precautions early in their hospitalization.26
Speaker Notes: Slide 6Once patients with MRSA are identified, this information needsto be effectively communicated. There needs to be both intraand inter-facility communication about a patient’s MRSA status.An example of a time when inter-facility communication wouldbe highly valuable is when a patient is being transferred to along-term care facility. Effective intra-facility communication canhelp hospitals identify MRSA in readmitted patients. Electronicsystems can be used to identify or “flag” patients with MRSA atreadmission so Contact Precautions can be quickly instituted.27
Speaker Notes: Slide 7Implementing a MRSA monitoring program will also helphospitals and units identify trends and changes in their MRSAinfections over time. Feedback on infection rates can includehospital-onset MRSA bloodstream infections as well as otherMRSA rates. Hospital- and unit-level MRSA rates can be used tobetter engage hospital leadership and health care personnel.This feedback can be used to identify areas of improvement aswell as to motivate health care personnel and leadership tomake changes to further reduce the rates of MRSA. It isimportant that feedback about MRSA be actionable.28
Speaker Notes: Slide 7 ContinuedRefer to the Foundational Infection Prevention Strategies that inorder for feedback to lead to actionable change, it should betimely, individualized, non-punitive and customizable. For moreinformation about data that may be useful to assess or include inyour MRSA monitoring program, review module 102 of thiscourse.29
Speaker Notes: Slide 8Effective hand hygiene is important for preventing thetransmission of all healthcare-associated infections (HAIs),including MRSA. Refer to the Foundational Infection PreventionStrategies course, hand hygiene involves health care personnelusing either soap and water or an alcohol-based hand gel ontheir hands before and after patient contact or after contact withthe patient care environment. Studies have demonstrated thatincreased hand hygiene adherence in hospitals is associated witha decrease in MRSA transmission as well as a decrease in otherHAIs.30
Speaker Notes: Slide 9As a reminder, the World Health Organization cites five momentsof hand hygiene for all health care personnel. These includebefore touching a patient, before clean and aseptic procedures,after body fluid exposure or risk, after touching a patient andafter touching patient surroundings.31
Speaker Notes: Slide 10The major problem with hand hygiene is health care personneladherence to hand hygiene can be poor. This is problematicbecause even minor lapses in hand hygiene can lead to thespread of MRSA, particularly in health care settings with highcarriage rates of MRSA. Therefore, hospitals need programs inplace which can promote hand hygiene as well as monitor theadherence of health care personnel to hand hygiene before andafter patient contact. Some institutions use trained personnel tomonitor adherence to hand hygiene.32
Speaker Notes: Slide 10 ContinuedOther hospitals have used novel methods such as electronicalerts, video recording and performance feedback to improvehand hygiene adherence rates of health care staff. For moreinformation about hand hygiene monitoring strategies, pleasereview the second module for the Hand Hygiene course titled,Hand Hygiene 102: Education, Monitoring and Feedback.33
Speaker Notes: Slide 11In this study by Armellino and colleagues, cameras were placedin a 17-bed medical intensive care unit to record hand hygiene ofhealth care personnel. During the study, performance feedbackwas provided on electronic boards in the hallway and via email.As shown in this figure, following the introduction ofperformance feedback, there was a significant increase in theadherence of health care personnel to hand hygiene.34
Speaker Notes: Slide 12Personal protective equipment, or PPE, is another importanthorizontal strategy to reduce transmission of MRSA. As mentioned,Contact Precautions recommend the use of gloves and gowns byhealthcare personnel during clinical encounters with patients whoare colonized or infected with MRSA. Contact Precautions are widelyused in acute care settings for patients with various multidrugresistant organisms (MDROs) and may help reduce the spread ofMRSA in the hospital. Additionally, patients colonized or infectedwith MRSA may be cohorted with similar patients or placed inprivate rooms to reduce the spread of MRSA. For more informationabout Contact Precautions and cohorting, please review thefoundational course on Personal Protective Equipment (PPE 101).35
Speaker Notes: Slide 13However, PPE use for patients with MRSA is not without a fewcontroversies. Current guidelines from the CDC Society forHealthcare Epidemiology of America and the Infectious DiseasesSociety of America recommend the use of Contact Precautionsfor patients who are colonized or infected with MRSA. However,several studies have suggested alternative approaches forcontrolling the spread of multidrug-resistant organisms(MDROs)in the hospital.36
Speaker Notes: Slide 13 ContinuedUniversal glove and gown use for all patients who are in theintensive care unit, irrespective of MRSA status, has beenproposed. Others have suggested that universal glove use couldbe effective in reducing the transmission of MRSA. Conversely,other experts have suggested that there may be adverse effectsto placing patients on Contact Precautions, although there is stillconflicting data on this issue. As you can see more research inthis area is still needed. Regardless of any PPE strategy that yourhospital chooses to use to prevent MRSA transmission, it isessential that adherence is monitored and reinforced. PPE usefor preventing MRSA transmission will be further addressed inthe MRSA Tier 2 modules.37
Speaker Notes: Slide 14A final strategy presented in this module for reducing the spreadof MRSA in hospitals is environmental cleaning and disinfection.MRSA can survive on hospital surfaces and can contaminate thepatients’ environment such as the over bed tables and bed rails.In addition, MRSA can contaminate patient care equipment suchas stethoscopes and blood pressure cuffs. Because of this, thereshould be dedicated medical equipment for a single patient withMRSA or alternatively, equipment should be cleaned anddisinfected before using it on another patient.38
Speaker Notes: Slide 15Thorough environmental cleaning reduces the opportunity forhealth care personnel to contaminate their hands with MRSAand other potential pathogens. Therefore, environmentalservices personnel should be viewed as important members ofthe infection control team. This includes having a mechanism inplace for monitoring quality and thoroughness of environmentalcleaning. Additional information about environmental cleaningcan be found in the Environmental Cleaning course.39
Speaker Notes: Slide 16Each strategy discussed so far is considered a “horizontal,” or“foundational” infection control intervention, in that it is NOTpathogen or infection-type specific. For example, we just talkedabout environmental cleaning, which helps to decrease all typesof pathogens in the environment and thereby contributes toprevention of many types of infections in addition to onescaused by MRSA. It is considered a horizontal infectionprevention strategy.40
Speaker Notes: Slide 16 ContinuedIn contrast, “vertical” infection control strategies are those thattarget a specific pathogen or type of infection. For example,ensuring a urinary catheter is placed using aseptic technique is avertical strategy designed specifically to prevent catheterassociated urinary tract infections. It’s ability to prevent othertypes of infections is very limited.So, horizontal strategies can reduce the transmission of MRSA toother patients, but in addition, have the added benefit ofreducing transmission of other multidrug-resistant and nonresistant pathogens as well.41
Speaker Notes: Slide 17One last measure to help prevent MRSA transmission is theeducation of patients and their families. It is important toeducate our patients and their family members about MRSA.Providers can explain what colonization with MRSA means andhow people can get MRSA infections. In addition, providers candiscuss with patients the specific strategies hospitals are using toprevent MRSA infections. These include the strategies discussedin this module: hand hygiene, environmental cleaning andContact Precautions.42
Speaker Notes: Slide 17 ContinuedProviders can also empower the patient and family members toensure that their health care providers are performing handhygiene before and after they are caring for them. It is importantfor a hospital to have a process in place for identifying who willcommunicate with the patient and their family members.43
Speaker Notes: Slide 18A common question patients and their family members have iswhat infection control strategies should they use after hospitaldischarge and the patient is at home. The CDC has an excellentwebsite that reviews these recommendations.Recommendations for patients include: If you are prescribed an antibiotic for a MRSA infection, complete thefull course of antibiotics Perform frequent hand washing, particularly before and afterchanging a wound dressing or bandage Hand hygiene for people who live with the patient44
Speaker Notes: Slide 18 Continued Keep wounds clean and change bandages as instructed Avoid sharing personal items such as towels or razors Wash clothes and bed linens according to the recommendationon the labels After hospital discharge, for future care inform health careproviders about MRSA status45
Speaker Notes: Slide 19There are several take-home points to keep in mind: First, adherence to the recommended infection controlstrategie
Patient Identification. Facilities need a system in place to alert health care personnel about patients with MRSA. Lab alert systems can notify staff of newly positive MRSA results. Early identification of patients with MRSA allows for early placement of patients on Contact Precautions. 5
Anyone can get MRSA. Infections range from mild to very serious, even life-threatening. MRSA is contagious and can be spread to other people through skin-to-skin contact. If one person in a family is infected with MRSA, the rest of the family may get it. MRSA was first identified in the 1960’s and was mainly found in hospitals and nursing homes.
The resident with MRSA can room with a resident who also has MRSA if a private room is not available. Unusual circumstances, such as the behavior of a particular infected resident, would need to be evaluated on an individual basis. Without disclosing the medical condition of the resident with MRSA, the roommate
MRSA risk assessment may include: – Assessment of adherence with existing infection prevention policies and protocols – Estimates of a facility’s MRSA burden e.g., rates of transmiss
– Isolation of MRSA from a blood specimen collected in 2016 on hospital day 4 or later from inpatient units – No MRSA positive blood specimen in the 14 days prior – Only a patient’s first HO MRSA BSI in 2016 was reviewed Consensus review for likely clinical source(s)
Lab coats are contaminated 69% of the time during care of patients colonized with MRSA The pathogen is transferred from the lab coat to the healthcare workers’ hands 27% of the time1 Gloves become contaminated with MRSA 42% of the time in the room of a patient wit
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