An Analysis of the VA’s Anti-MRSA Efforts

Methicillin-resistant Staphylococcus aureus (MRSA) infections are one of the most common causes of disease in the healthcare setting. The most common problems include ventilator-associated pneumonia, bloodstream infection associated with central venous catheters, and surgical-site infections. In 2001, the Veterans Affairs (VA) Pittsburgh Healthcare System began working with the Pittsburgh Regional Healthcare Initiative and the Centers for Disease Control and Prevention to reduce and eliminate healthcare-associated MRSA infections with the use of an “MRSA bundle.” The bundle, based on published guidelines, comprised universal nasal surveillance for MRSA colonization, contact precautions for patients who were carriers of MRSA, hand hygiene, and an institutional culture change whereby infection control became the responsibility of everyone who had contact with patients. After implementation of this approach in a pilot project, the rates of healthcare-associated MRSA infections were reduced by 60% on a surgical ward and by 75% in a surgical intensive care unit (ICU) within 4 years. Because of the success of the pilot project, the Veterans Health Administration implemented a national initiative to decrease healthcare-associated MRSA infections in acute care facilities. In their report [N Engl J Med. 2011;364(15):1419-1430], the investigators analyzed the effect of the MRSA Prevention Initiative during the period from October 2007, when the program was fully implemented in ICUs and non-ICUs nationwide, through June 2010. As part of the initiative, beginning in March 2007, medical centers were directed to implement the MRSA bundle in 1 patient care unit and in all remaining acute care units, with the exception of mental health units, by October 1, 2007. The bundle consisted of surveillance for nasal colonization with MRSA for all patients admitted to the hospital, all patients transferred from one unit to another within the hospital, and all patients discharged from the hospital. All patients admitted to the hospital were included in the initiative. Each month, personnel at each facility entered into a central database aggregate data on adherence to surveillance practice, the prevalence of MRSA colonization or infection, and healthcare-associated transmissions of and infections with MRSA. During the period included in the analysis, 196 medical, coronary care, and surgical ICUs and 428 medical, surgical, rehabilitation medicine, and spinal cord injury units provided data. These units represented all but 3 of the 153 VA medical centers nationwide. There were 1,934,598 admissions to, transfers within, or discharges from these units (ICUs, 365,139; non-ICUs, 1,569,459) and 8,318,675 patient-days (ICUs, 1,312,840; non-ICUs, 7,005,835). The mean (±SD) age of patients admitted to VA acute care facilities during the period included in the analysis was 62.6±14.4 years; 95% of the patients were men. The median length of stay was 3.0 days (interquartile range, 2.0-7.0). A total of 1,712,537 surveillance screening tests were obtained during the analysis period from patients who were admitted to or transferred or discharged from acute care facilities nationwide (329,903 obtained in ICUs and 1,382,634 in non-ICUs). During this period, the percentage of patients who were screened at admission increased from 82% to 96%, and the percentage screened at transfer or discharge increased from 72% to 93%. During the analysis period, the rate of transmission of MRSA in the ICUs was reduced from 3.02 per 1000 patient-days in October 2007 to 2.50 per 1000 patient-days in June 2010, a decrease of 17% (P<.001 for trend). During the same period, the rate of transmission in the non-ICUs was reduced from 2.54 per 1000 patient-days to 2.00 per 1000 patient-days, a decrease of 21% (P<.001 for trend). Between April 2006 and March 2007, the rates of healthcare-associated MRSA infections in ICUs had not changed, but they declined from 1.64 infections per 1000 patient-days in October 2007, when the bundle was first implemented, to 0.62 per 1000 patient-days in June 2010, a decrease of 62% (P<.001 for trend). During this same period, the rates of healthcare-associated MRSA infections in non-ICUs fell from 0.47 per 1000 patient-days to 0.26 per 1000 patient-days, a decrease of 45% (P<.001 for trend). After implementation of the bundle, there were declines in the rates of MRSA infection not related to a device, in bloodstream MRSA related to a device, in pneumonia related to a device, in skin and soft-tissue infections, and in urinary tract infections.