The Oklahoma Foundation for Medical Quality (OFMQ) is excited to have been awarded a special project by the Centers for Medicare & Medicaid Services (CMS) to reduce Healthcare Associated Infections (HAIs) in Oklahoma hospitals. We are working with select facilities to implement evidence-based practices known to reduce incidence and transmission of HAIs. Information will be reported to the Centers for Disease Control's (CDC) National Health Safety Network (NHSN).

   The hospitals volunteering in the project represent varied demographics and geographic locations. Each of these hospitals has agreed to report HAI data on Catheter-Associated Urinary Tract Infections and Clostridium Difficile Infections in at least 4 units of their facility to the NHSN Patient Safety Reporting System. OFMQ HAI specialists are working intensively with each hospital to assess and offer evidence-based improvement  processes, protocols and practices related to all HAIs. As more emphasis is placed on nationwide HAI data, we think this project will be a precursor to mandated reporting in the future.

 

   Multi Drug Resistant Organisms (MDROs) invade your hospital like termites invaded my walls.  Once they show up, these creatures are hard to get rid of.  Like the termites that ate away at my home, MDRO's can find portals of entry into your healthcare system, and you might not find the nest until extensive damage is done.

The History of MDRO's

   In 1928 Penicillin was first mass produced.  For many years, staph Aureus was the primary type of skin infection. After antibiotic usage had been prevalent for about twenty years, the first Methicillin-Resistant Organism formed in 1961.  Methicillin Resistant Staph Aureus (MRSA) was first identified in the UK and quickly spread across the globe.  In 1972, MRSA accounted for approximately two percent of all Staph Infections. By 1994, it grew to 45 percent; and by 2004, more than 65 percent of all Staph infections were attributed to MRSA.

Reporting MRSA & other MDRO's

   Tracking MRSA and other MDRO's was the first step in limiting the spread of this super bug.  So organizations that promoted quality started tracking their HAI infection rates related to MRSA.  Hospitals found that MRSA was most likely to be transmitted in the ICU.  Thus, the first legislation required hospitals to track HAI's in ICU settings.

   In 2008, the state of Oklahoma required that ICU's everywhere report their HAI related to ventilator associated pneumonia (VAP) and central line blood stream infections (CLABSI), and became one of seven states to use the CDC's National Health Safety Network (NHSN) new database.  Released in early February 2009, the NHSN database allows IC practitioners to enter data for HAI into a national database.  The state obtains this data every month as does the CDC. 

Malpractice & HAI

   Hospitals are not strangers to liability.  In fact hospitals dedicate 24 percent of their annual budget to liability insurance. Hospitals must quickly identify areas where care is sub-standard.   In October 2008, the Centers for Medicare & Medicaid (CMS) began its pay-for-performance exercise reducing payments for conditions that were acquired in the hospital setting which studies have shown to be "preventable" errors.  HAI's are at the top of the list. Research shows that complying with hand hygiene, isolation practices and disinfection procedures leads to reduced incidence of acquired infection.  The concept of bundling, or framework considered the standard of care, was promoted to all hospitals.  In today's legal arena, a hospital that is not compliant with CDC recommended bundles for HAI is a prime target for lawsuit.

A Case Against the Hospital

   The case of Klotz vs. Missouri (2007) was one of the first HAI cases to change the burden of proof from the plaintiff to the hospital.  Mr. Klotz had a heart attack.  On the way to the hospital, the EMS placed a peripheral IV, and within 24 hours he received a permanent pacemaker in the cath lab.  The patient had well-documented signs and symptoms of peripheral IV infection.  However, the surgeon decided to place the pacemaker.  Mr. Klotz in fact had MRSA.  He developed blood stream sepsis, vegetation of MRSA on his valves, and required up to 15 surgeries after this initial hospitalization to deal with the aftermath of his MDRO. 

Becoming an Exterminator for Super Bugs

   ICP's are exterminators for MDRO's.  Like the termite inspector in my home, ICP's must evaluate internal practices and develop a risk assessment.  ICP's must place a critical eye on compliance with best practice for invasive devices, MDROs, antibiotic stewardship and procedure compliance. 

   But identifying the problem is not the only step.  ICP's must search the crevices and actively look for unseen portals of entry. Surveillance data must be on hand to show attorneys or surveyors that you not only practice great hand hygiene, but you also evaluate compliance with your own policies and procedures.  ICP's and their IC committees must make a plan of action and show progress toward meeting goals to reduce the opportunity of MDRO. 

   It seems everyone by now has been told to practice hand hygiene: how, when and why to practice hand hygiene. So why can't we get everyone on board to practice hand hygiene?  With all the education, the in-services, the stories in the news, the abundant supplies of alcohol gel, we still must reiterate past the point of redundancy the simple need to practice hand hygiene.

   After my years of experience in health care, watching simple little bacteria mutate to become more and more resistant, I am concerned that resistant bacteria might be transferred from one patient to another. Studies have shown we do not actually need to touch the source patient to acquire the causative organism of the patient's infection. In one study, 42 percent of nurses' gloves were MRSA positive after touching surfaces in an MRSA patient's room without ever touching the patient ¹. That means that given the right set of circumstances, we would not even need to be in the hospital or in close proximity to the patient to come in contact with that patient's pathogen.  We would only have to come into contact with a contaminated surface - contaminated by someone who had not practiced hand hygiene. Once contact has been made, that organism, with its virulence and antibiotic resistance, can be easily inoculated into a cut or wound and cause infection; or even into normal flora that can become colonized with that organism.

   Once colonized, patients are likely to become infected with the organisms that are a part of their normal flora.Among hospitalized patients who acquire MRSA colonization, 30-60 percent eventually will develop MRSA infections such as a wound infection, bacteremia, urinary tract infection, or pneumonia.²  Even without a wound, the organism can potentially cause infection years later when we are immuno-compromised or neutropenic .

   So what do we do? Practice hand hygiene!  Wash your hands before and after restroom breaks. Wash your hands before eating. Practice hand hygiene after touching a contaminated surface. Practice hand hygiene before entering a patient's room, and practice hand hygiene as you come back out. Practice hand hygiene between tasks in a patient's room. Never, ever think to yourself that it does not matter because it is not a sterile site. The only two places that we desire normal flora are in our mouth and in our colon, and the normal flora is different for each. If you are suctioning a trach, you have gone way past the mouth. Remember that gloves can be just as contaminated as the surface of your hand, minus normal flora, depending on what you have touched.   

   Practice hand hygiene as you leave work.  Just wash your hands of all of it, and do not take it home with you.  Just wash your hands. There, I've said it again!

1. Boyce, J  Hand Hygiene: An Important Element In Controlling MRSA John M. Boyce, MD Chief, Infectious Diseases Section Hospital of Saint Raphael and Clinical Professor of Medicine Yale University School of Medicine New Haven, CT
2. North Carolina Guidelines for Control of Antibiotic Resistant Organisms, Specifically Methicillin-Resistant Staphylococcus aureus (MRSA) and Vancomycin-Resistant Enterococci (VRE) Karen K. Hoffmann, R.N., M.S., C.I.C., Irene Pipines Kittrell, R.N.
   January 1997