Preventing MRSA in Hospital Settings: System Redesign and Informatics Strategies in a Community Collaborative

Slide Presentation from the AHRQ 2008 Annual Conference

On September 9, 2008, Brad Doebbeling, Abel Kho, Heather Hagg, Jamie Workman, Mindy Flanagan, Kim McCoy, Shawn Hoke, Paul Dexter, made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (1.7 MB).

Slide 1

Preventing Methicillin Resistant Staphyloccus Aureus (MRSA) in Hospital Settings: System Redesign and Informatics Strategies in a Community Collaborative Brad Doebbeling, Abel Kho, Heather Hagg, Jamie Workman, Mindy Flanagan, Kim McCoy, Shawn Hoke, Paul Dexter

Indiana University (IU) Center for Health Services & Outcomes Research, Regenstrief Institute.
Department of Veterans Affairs (VA) Center of Excellence in Implementing Evidence-based Practice.
IU School of Medicine, Indiana University-Purdue University-Indianapolis (IUPUI) & Northwestern University.

Supported by a contract from Agency for Healthcare Research and Quality (AHRQ) through Accelerating Change and Transformation in Organizations and Networks (ACTION).

Slide 2

MRSA Background

Purpose

• MRSA Burden.
• Over 126,000 persons are infected by MRSA in hospitals annually.
• ~4 MRSA infections per 1,000 hospital discharges.
• Over 5,000 die as a result of these infections.
• Over $2.5 billion excess healthcare costs.
• On average, for each MRSA patient this means:
• 9.1 days excess length of stay (LOS).
• Over $30,000 in excess cost per case (range $30,000-60,000).
• 4% in excess in-hospital mortality.
• 1/3 patients acquiring MRSA will become infected.

Slide 3

What Does the Evidence Tell Us?

Consistent Use of Known Practices Work

• Target Modes of MRSA Transmission:
  • Person-person via hands of health care providers.
  • Personal equipment (e.g., stethoscopes, PDAs) and clothing.
  • Environmental contamination.
    • Healthcare environment.
    • Home/Community environment.

Slide 4

Computer Alerts of MRSA Help Improve Isolation Adherence

• RN awareness of Medical Review Board (MRB) status increased from 24% at baseline to 59% at 1 year. -93% at 1 year after notifying nurses.
• Implementation of isolation precautions increased from 15% at baseline to 51% after 1st intervention and then to 90%.
• RI electronic tool notifies staff of MRSA positive history at Wishard, based on micro data from all Indy hospitals (except VA).
• 286 unique patients generated 587 admissions (4,335 inpatient days) where receiving hospital unaware of the prior history of MRSA.
• An additional 10% of MRSA admissions received by project hospitals over one year and over 3,600 inpatient days without contact isolation.

• Note: Cac et al. Arch Intern Med 2007;167(19):2086-90
            Kho et al. J Am Med Inform Assoc 2008; 15:212-16.

Slide 5

AHRQ ACTION Contract

Implementation

• "Testing Techniques to Radically Reduce Antibiotic Resistant Bacteria (MRSA)."
• AHRQ funded Indiana ACTION Team effort over 18 months through the ACTION collaborative funding mechanism.
• Our interventions are based on the Pittsburgh model as specified by AHRQ:
  • Conduct active surveillance of all incoming pts. in intensive care units (ICUs).
  • Improve rates of contact isolation.
  • Improve hand hygiene rates.

Slide 6

Conceptual Framework and Strategy

• Interdisciplinary Research & Ops Teams
  • Clinicians, Health Services Researchers, Engineering/Technology Faculty, Purdue Communication faculty/students, Organizational Psychologists, Informaticists.
  • Partnership with selected Hospital Clinical Staff.
• Integrated Lean/Positive Deviance Approach:
  • Identification of solutions from within, bottom up.
  • Leadership support and buy-in.
  • Standardization where evidence exists or to simplify.
  • Customization to meet local redesign needs.

Slide 7

What is Positive Deviance (PD)?

• Technique to engage front line staff in owning & improving processes and sustaining change.
• Based on identification of practices of used by 'positively deviant' staff/departments.
• Critical for staff involvement/buy-in.

Slide 8

Integrated Lean/PD approach

• Discovery
  • Define the Problem.
  • Baseline Current Processes.
  • Identify Operational Barriers.
• Action
  • Develop Future State Process.
  • Process Control Strategy.

Slide 9

Health Systems Involved

• Two ICU units in 3 original hospital systems
  • St. Francis (two ICUs in South Hospital.)
  • Clarian (Methodist and University Hospital.)
  • Community (Community East and Heart Hospital.)
• Early success encouraged 3 remaining systems to join the project
  • Wishard (two ICUs.)
  • VA Medical Center (housewide.)
  • St. Vincent's (two ICUs in north facility.)

Slide 10

System Redesign

• Our health care engineers partner with and train front-line workers to use lean-six sigma and positive deviance approaches.
• Focus on coaching front-line staff teams to lead instituting systems changes to systematize processes and sustain practices.
• Emphasize regular measurement and feedback of adherence to enhance adoption.
• Weekly Meeting of all hospital teams to identify barriers & facilitators, review and reinforce progress, share best practices, strategize about spread and solutions.

Slide 11

Preliminary Results

• Preliminary pre and post intervention results for first three hospitals suggest average of 60% reduction on study units.
• ~20% reduction hospital wide.
• Currently investigating optimal biostatistical approach such as time series analysis to confirm.

Slide 12

An Operational Citywide Electronic Infection Control Network: Results from 1st Year

• Infection control is a regional problem, requiring a coordinated effort.
• Created a citywide electronic notification system to prospectively track all known patients with MRSA.
• Currently track 17,000 patients with a history of MRSA infection or colonization across Indianapolis.
• Since May 2007, delivered 2698 admission alerts on patients with a history of MRSA, 19 percent based on data from another institution.
• 20 infection control providers (ICPs) spanning 16 hospital.

• Note: The bar graph measures the number of "Alerts" from May to Jan.
            Kho, Lemmon, Dexter, Doebbeling. AMIA2008.

Slide 13

Lessons Learned—Implementation

• System redesign approach of training, consultation and coaching front-line staff seems to be strong, sustained approach.
• Importance of buy-in from highest institutional levels crucial.
• Enthusiasm builds from within because redesign teams own it!
• Informatics tool helpful in identifying great cross-over of MRSA patients in hospitals.

Slide 14

Lessons Learned—Research

• Our proposed data collection too intensive for most community hospitals.
• Need a better electronic data collection infrastructure relating to outcome data.
• Hospitals desire regular feedback on impact of interventions.
• Little time for paper writing (Hazard of short time lines for funding.)

Slide 15

Refined Intervention Bundle Components

• Engagement Process: The engagement process involves multiple social change processes centered on PD.
• Outcome Data Feedback: Transmission and infection rates are shared with staff.
• Process Data Feedback: Nursing unit staff track performance on infection control practices.

Slide 16

Refined Intervention Bundle Components (continued)

• Learning Collaborative: Teams from hospitals connect with teams from other hospitals employing the MRSA Intervention Bundle to foster learning and innovation.
• More extensive activities to train interdisciplinary teams within each of the participating health systems (compared with first study).

Slide 17

AHRQ Grant—Hospital Acquired Infections (HAI) Assessment Center

• Acting as assessment, technical, and resource center for AHRQ and 5 other AHRQ ACTION Partners:
  • Denver Health and Parkland Health, Texas.
  • Health Research and Educational Trust (HRET) (Michigan Hospital Association Keystone Center.)
  • Iowa.
  • American Institutes for Research (AIR).
  • Yale.

• Note: Indy Investigators—IU Center for Health Services & Outcomes
  Research, Regenstrief Institute: Jamie Workman-German; Mindy
  Flanagan; Amber Welsh; Shawn Hoke; Brad Doebbeling.

Slide 18

AHRQ HAI Assessment Center

• Goal of overall initiative to identify factors associated with implementation of training that can assist hospitals in successfully reducing and sustaining the reduction of infections associated with the process of care.
• Training tools aimed at Ventilator-associated pneumonia (VAP), Bloodstream infection (BSI), and surgical site infection (SSI).

Slide 19

Indiana ACTION Team HAI Goals

• Facilitate and coordinate consistent collection of information across the HAI Initiative.
• Provide technical assistance to the 34 hospitals.
• Analyze and synthesize the information from the common information collection instruments.
• Share lessons learned about the barriers, solutions and PD practices in implementing and sustaining infection safety.

Slide 20

Consortium for Healthcare Informatics Research (CHIR)

• Interdisciplinary group of collaborating investigators affiliated with VA sites distributed across the U.S.
• Improve the health of veterans through foundational and applied informatics research.
• Advance the effective use of unstructured text and other types of clinical data in the electronic health record.
• Indy Team—Merchant, French, Saleem, Burton, Friedlin, Flanagan, Allen, Doebbeling.

• Note: Salt Lake City VA, Indy VAMC, West Haven VA, Boston VA, Portland VA, Philadelphia VA, Nashville VA, Tampa VA, Regenstrief Inst., National Library of Medicine (NLM), National Institutes of Health (NIH), Mayo Clinic, Carnegie Mellon U., Vanderbilt U., U. of Pittsburgh, Oregon HS U., U. of Utah.

Slide 21

Consortium for Health Informatics Research: Text Processing Project

• Concept extraction from clinical notes.
  • Retrieve clinical concepts and their modifiers.
    • Diagnoses, negation, temporality, ambiguity, etc.
• Develop knowledge from concepts.
  • Develop new or more knowledge about a patient.
    • Timelines, symptomology, patient models.
• Apply knowledge.
  • Use new knowledge to enhance patient care.
    • Posttraumatic stress disorder (PTSD).
    • Predict suicidailty.
    • Find undiagnosed patients.
    • MRSA.
    • Automate warnings to infection control practitioner (ICP) & wards.
    • Determine treatment efficacy.

Slide 22

CHIR Methods Development Projects

• De-identification of sensitive data.
• Concept Extraction.
• Clinically-relevant inference and modeling.
• Document quality assessment.
• Evaluation and annotation methods.

Slide 23

The diagram presents the "Systems Architecture."

Slide 24

CHIR Applied Projects

Two major applied projects to demonstrate the value of its research activities—high priority for veteran's health.

• Methicillin-resistant Staphylococcus aureus (MRSA) infection (Indianapolis VAMC).
• Post-traumatic stress disorder (PTSD).

New Pilot projects

Slide 25

Architecture for MRSA tracking and reporting system

The diagram presents the "Architecture for MRSA Tracking and Reporting System," which is comprised of data access and formatting and user interface and reports.

Slide 26

Ontology Development and Text Processing for MRSA Surveillance

• Develop, review and refine an ontology for clinically and epidemiologically relevant concepts to enable detection of MRSA.
• Index MRSA-related Concepts in Clinical Narrative.

Slide 27

Aims of the CHIR MRSA Project

• Clinical Inference and Analysis of MRSA-Related Information Contained in the Medical Record.
• Develop and evaluate a prototype surveillance application that uses automatically processed VA electronic health record data.

Slide 28

Translational Aim

• Evaluate algorithms for making multi-type predictions based on heterogeneous data, using MRSA as a clinical domain.

Slide 29

Acknowledgements

• Funding AHRQ ACTION Network, Hospital Acquired Infections Collaborative.
• VA HSR&D and Consortium for Healthcare Informatics Research.
• Indianapolis Collaborators.
• AHRQ and VA Collaborators.