North Carolina Eliminating Methicillin-Resistant Carolina Eliminating Methicillin-Resistant Staphylococcus aureus 1 ... (Heplock) used by hospital ... North Carolina Eliminating Methicillin-Resistant

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  • 1N o r t h C a r o l i n a E l i m i n a t i n g M e t h i c i l l i n - R e s i s t a n t S t a p h y l o c o c c u s a u r e u s

    Developed by the North Carolina Center for Hospital Quality and Patient Safety, PO Box 4449, Cary, NC 27519-4449

    www.ncha.org/ncchqpsSeptember 2007

    The materials in this tool kit can be reproduced for the purpose of improving infection prevention processes in a hospital or healthcare organization, but cannot be reproduced with intentions of commercial use.

    Nor th Caro l ina E l iminat ing

    Meth ic i l l in -Res is tant Staphylococcus aureus

    (MRSA)

    T O O L K I T

  • 2 N o r t h C a r o l i n a C e n t e r f o r H o s p i t a l Q u a l i t y a n d P a t i e n t S a f e t y

    A c k n o w l e d g e m e n t s

    Thanks to those that have shared their time and expertise to help develop and produce thistool kit. It is through their expertise, creativity and generosity of sharing their knowledgethat we have been able to produce this tool kit.

    Specifically, thank you to:

    Terri Bowersox, BSIE, MBA, FACHE Director, Performance Improvement VHA Central Atlantic 521 E. Morehead Street, Suite 300 Charlotte, NC 28202

    The Statewide Program for Infection Control andEpidemiology (SPICE)CB# 7030, Bioinformatics 2156130 Mason Farm RoadUniversity of North Carolina School of MedicineChapel Hill, N.C. 27599-7030

    The following NC Center for Hospital Quality and Patient Safety staff were involvedin writing the tool kit:

    Carol Koeble, MD, MS, CPEDirectorNC Center for Hospital Quality and Patient SafetyVice PresidentNorth Carolina Hospital AssociationCary, NC

    Barb Edson, RN, MBA, MHAQuality and Patient Safety ConsultantNC Center for Hospital Quality and Patient SafetyCary, NC

    Cover Design and artwork by Dale Design, Cary, NC

  • 3N o r t h C a r o l i n a E l i m i n a t i n g M e t h i c i l l i n - R e s i s t a n t S t a p h y l o c o c c u s a u r e u s

    Chapter 1: Introduction

    Chapter 2: The Project

    Chapter 3: The Team and Communication

    Chapter 4: Performance Improvement

    Chapter 5: Measurement

    Chapter 6: Spreading and Formalize

    Chapter 7: Reference Materials

    T a b l e o f C o n t e n t s

  • 4 N o r t h C a r o l i n a C e n t e r f o r H o s p i t a l Q u a l i t y a n d P a t i e n t S a f e t y

    In 2003, 63-year-old Marion Costa was rushed to the hospital for treatment of a life threatening gastrointestinalbleed. She received two pints of blood before being moved to the ICU and then to a step-down unit when hercondition stabilized. The Heparin IV Lock (Heplock) used by hospital staff was left in her arm as a precautionarymeasure in case she need additional blood transfusions in the ICU and dated for removal in three days.

    Three days later Marion developed severe headache, backache and leg pain. She became disoriented andspiked a fever that went up to 105 degrees. Her doctor had to put her to sleep for pain control and she awoke36 hours later having no idea what happened to her. She had been cultured and diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA) and was put on Vancomycin and other antibiotics to treat the infection.Her primary care physician visited her a few days later and Marion complained of pain and stiffness in her upperarm. Her doctor took one look at the outdated Heplock that was still in her arm after six days and told her thatnow he knew the source of her infection. He ordered tests that morning and found phlebitis in the artery wherethe expired Heplock had been inserted.

    But that was just the beginning of Marion's hospital infection ordeal. A week later severe gastrointestinal bleedingresumed and she was diagnosed with a C-difficile, which caused inflammation of her colon and diarrhea. Again,she required more blood transfusions. Within the week, she was discharged to a nursing home to continue herantibiotics treatments for her MRSA infection. After one week at the nursing home she began running another highfever and a few days later was transferred by ambulance back to the hospital. She was diagnosed with a gramnegative blood infection, which was found lodged in the PICC line used for administering her antibiotics. Marionwas treated with eight different antibiotics to treat the blood infection.

    Marion considers it a miracle that she survived her hospital infection nightmare. She remains angry that her lifewas endangered by the poor infection control practices she observed during her hospitalization.

    I n t r o d u c t i o n1

    Marion Costa, Red Bank, NJ

    Story reprinted with permission from Marion Costa,the author. Story appears on Consumers Unionwebsite, http://www.consumersunion.org

  • 5N o r t h C a r o l i n a E l i m i n a t i n g M e t h i c i l l i n - R e s i s t a n t S t a p h y l o c o c c u s a u r e u s

    T h e P r o b l e mHealthcare-associated infections (HAIs) are a major cause of morbidity, mortality and excessive healthcare costs. Basedon the best available data the Centers for Disease Control and Prevention (CDC) estimates nearly 2 million HAIs occurin U.S. hospitals and 99,000 people die as a result of these infections annually. There are approximately 4.5 HAIsper 100 hospital admissions, 9.3 infections per 1000 patient days in the intensive care unit and 2 surgical siteinfections per 100 operations. HAIs cost between 5-6 billion dollars annually, with an average additional incrementaldirect cost of $8,832 per patient. 1,2

    Staphylococcus aureus is a major cause of infections in both the hospital as well in the community. S.aureus is a gram-positive, opportunistic bacterium that colonizes the skin. It is present in the nares of approximately 25-30% of healthypeople. Depending on its intrinsic virulence or the ability of the host to ward off infections, S.aureus can cause arange of infections in humans including superficial skin lesions such as boils; more serious infections such aspneumonia, mastitis, phlebitis, meningitis, and urinary tract infections; and deep-tissue infections, such as osteomyelitisand endocarditis.3 S. aureus is a major cause of HAIs reported to the National Nosocomial Infections Surveillance(NNIS) System, including surgical site infections (SSI), ventilator-associated pneumonias (VAP) and catheter-associatedblood stream infections.4

    Infections with methicillin resistant Staphylococcus aureus (MRSA) are especially problematic because they are resistantto the usual antibiotics (penicillin, amoxicillin, oxacillin and methicillin) used to treat them. Antibiotic resistance inS.aureus emerged in the 1940s when penicillin use was common. Over the next two decades resistance to penicillinand the newer semi-synthetic pencillinase resistant agents became wide spread. Within six months after the marketingof methicillin in 1960, resistant isolates were reported. Since then methicillin resistant S.aureus has spread worldwide.In 1997 resistance to vancomycin, the last commonly used antimicobial agent for which S.aureus was uniformlysubsceptible to, emerged.5,6

    A recent report by the Agency for Healthcare Research and Quality (AHRQ) reviewed data from the Healthcare Costand Utilization Project (HCUP) to analyze the trends and impact of MRSA. Hospitalizations associated with MRSAincreased tenfold between 1995 and 2005; more than tripled from 2000 to 2005; and increased 30 percent from2004 to 2005. In 2005 approximately 368,600 hospital stays were for infections with MRSA. Hospital dischargeswith a diagnosis of MRSA were 0.7%. The length of stay for MRSA hospitalization was more than doubled whencompared with all other stays, 10 days versus 4.6 days respectively. Hospital costs are increased with MRSAhospitalizations. On the average MRSA hospitalizations cost $14,000 compared to $7,600 for non-MRSA stays. In-hospital mortality was more than double for MRSA patients over non-MRSA patients. The in-hospital death rate was4.7 percent for MRSA stays compared to 2.1 percent for all other hospitalizations. Over 5,000 patients die as aresult of these infections.7

    CDC estimates nearly 2 million healthcare acquired infections occur in US hospitals and 99,000 peopledie annually.

    Healthcare acquired infections cost between 5-6 billion dollars annually, with average incremental cost$8,832.00 per patient.

    S. aureus is a major cause of HAIs reported to the National Nosocomial Infections Surveillance (NNIS) System. Hospitalizations with methicillin resistant Staphylococcus aureus (MRSA) increased 10 fold between 1995 and 2005. The length of stay for patients with methicillin resistant Staphylococcus aureus (MRSA) was 5.4 days longer than

    those patients without MRSA. On the average methicillin resistant Staphylococcus aureus (MRSA) hospitalizations cost $14,000 compared to

    $7,600 for non-MRSA stays. Over 5,000 patients die annually as a result of methicillin resistant Staphylococcus aureus (MRSA) infections.

  • 6 N o r t h C a r o l i n a C e n t e r f o r H o s p i t a l Q u a l i t y a n d P a t i e n t S a f e t y

    Source: AHRQ, Center for Delivery, Organization and Markets, Healthcare Cost and Utilization

    Project, Nationwide Inpatient Sample 1993-2005

    The statewide MRSA infection rate for North Carolina hospitals is unknown. The Centers for Disease Control estimatesMRSA infections in hospitalized patients account for 3.95 per 1,000 discharges (0.4 percent).8 The ARHQ, using2006 discharge data, found a rate of 7.48 per 1000 discharges (0.75 percent) for both hospital MRSA and CA-MRSA. Using discharge data9 for North Carolina non-VA, acute care hospitals an estimated 4,345 - 7,701 MRSAinfections occurred in hospitalized patients during 2006. Based on the direct hospital costs in

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