A shock to the system

Back in April of 2011, in a blog post about the VA MRSA Initiative, I wrote:

“It seems that HAIs are falling across the VA system, probably as a result of an important culture change, and improved application of so-called "horizontal" approaches to infection prevention. Bravo to the VA!”

Of course, in addition to praising the VA, I called into question the one “vertical” component of the MRSA initiative (MRSA screening/isolation) based upon the dramatic reductions in VRE and C. difficile that accompanied the intervention, and the evidence that very little of the reported MRSA reduction could have been due to reduced MRSA transmission.

Thanks to Michi Goto and colleagues, we now have even more evidence that the MRSA Initiative coincided with a fundamental shift in infection prevention in the VA healthcare system. Their recently published CID paper adds hospital-onset Gram-negative bacteremia to the list of HAIs that saw significant reductions after the MRSA Initiative was implemented (see graph above). I will outsource most of the rest of this blog post to Maryn McKenna and Marc Bonten, please read their excellent analyses.

Marc ends his blog post by observing that “we still don’t know how” the VA achieved these HAI reductions—in particular, we don’t know the relative importance of the most expensive, resource-intensive aspect of the program (MRSA screening). As someone who served as a VA hospital epidemiologist during the implementation of the initiative, I’ll give my completely unsupported, data-free opinion: the MRSA screening was both unnecessary and essential to the VA’s success. 

Unnecessary because the HAI reductions, as Marc’s group demonstrated, were not achieved via the prevention of bacterial transmission that MRSA screening/isolation seeks to achieve. 

Essential because it served as a “shock to the system” within the VA. The complexity of implementing any universal screening and isolation program requires multidisciplinary buy-in, major investments in laboratory and infection prevention resources (in the VA system, funding for molecular detection and funding of a new “MRSA coordinator” position, essentially an extra infection preventionist). It’s this kind of system-wide investment that can change the culture, moving basic infection control practice higher on everyone’s priority list. 

We should be very surprised if any complicated, resource-intensive, universal screening intervention (including, now, universal C. difficile screening) doesn't move the needle in a quasi-experimental (before-after) study design.  We also shouldn't be surprised when that same intervention fails to impress in cluster-randomized trials, as we've seen with MRSA screening in STAR*ICU, REDUCE MRSA, MOSAR, etc.

High stakes metrics and human nature

Eli didn't want to wade into the VA waiting-time crisis, so I'll just do it instead.  Because we’ve covered this ground before. Whenever a metric is tied to a high-stakes incentive or disincentive (monetary bonus or penalty, job security, etc.), gaming of that metric is inevitable. College test scores, crime rates, HAI rates, the dynamic is the same. 

So forgive me if I’m not shocked, shocked, that VA administrators used various ways to game their waiting-time metrics in response to what this NY Times report describes as “pressures to excel in the annual performance reviews used to determine raises, bonuses, promotions and other benefits.” Fudging dates, creating “ghost clinics”, keeping two sets of appointment books—all are being reported to have occurred in some facilities. If you think this is the scandal, you are missing the point. The scandal is that the VA has too few physicians to see an expanding number of veterans needing care (see Eli’s post for more on the trends contributing to primary care shortages).

So I hope lawmakers begin working to fix that problem, once they finish expressing their outrage for the cameras. The VA is an excellent healthcare system, one that matches or outperforms the private/non-VA sector in many measures of care quality and safety. I’m sad that this is getting lost in the current media frenzy—read this piece for a nice counterpoint.

Did the CMS no-payment rule impact hospital HAI prevention practice?

Beginning in October 2008 CMS stopped reimbursing hospitals for excess costs attributable to CLABSI or CAUTI.  While numerous studies and surveys have linked high compliance with HAI prevention bundles for CLABSI and VAP to reduced infection rates, few studies have looked at whether CMS no payment rules improved HAI prevention process measures.

To answer that question, Sarah Krein at the VA Ann Arbor Healthcare System completed surveys of VA and non-VA hospital HAI prevention practices in 2005 and again in 2009.  Their hypothesis was that if adoption of HAI bundles differed between non-VA and VA facilities, some of this difference could be do to the CMS no payment rules since VA facilities aren't directly affected by CMS rules.

The results are pretty interesting and don't really support any impact from the CMS no payment rules.  For CLABSI, both VA and non-VA hospitals reported significant increases in bundle component use with VA having higher use in both 2005 and 2009 (see graph below).

Similar results were reported for VAP and CAUTI.  The authors conclude by saying that "the CMS payment rule is likely not the primary driver of the increased use of infection prevention practices among US hospitals over the past several years."

Source: Krein et al. JGIM July 2012

Revisiting the VA MRSA Initiative

Most of our readers know about the VA MRSA Initiative, the results of which were published in the NEJM at the same time as the STAR*ICU study results. These two studies were widely and mistakenly viewed as having contradictory results.

The tremendous success of the VA initiative (see here for my earlier summary of the results) was also mistakenly assumed to be primarily related to the most expensive aspect of the “bundled” initiative, universal active detection and isolation (ADI). This was despite the fact that transmission fell only by 17-21% while infection rates fell by over 60% in ICUs, and infection rates due to non-targeted bugs (VRE and C. difficile) were reduced even more dramatically than was MRSA. In other words, there was plenty in the original paper to suggest that ADI accounted for very little of the observed MRSA infection reduction, and that the bulk of that reduction was due instead to prevention of MRSA infection among those already colonized.

Well, we now have a mathematical model, by Gurieva, Bootsma and Bonten, that demonstrates this point quite clearly. I refer you to their paper and to my colleague Eli’s excellent commentary for details, but the bottom line: transmission prevention was likely responsible for no more than 6% of the reduction in MRSA infection rate. As you’d expect, the proportion of infection reduction due to transmission prevention is strongly correlated to the relative risk for MRSA infection among the newly colonized (via transmission) versus existing MRSA carriers. But as the figure below (from Gurieva paper) shows, even if one assumes a 10-fold higher daily risk for MRSA infection among newly colonized versus existing colonized, transmission prevention would still account for less than a quarter of the observed infection reduction

Why all the letters? STAR*ICU and VA studies agree!

Remember that April 2011 New England Journal of Medicine issue with results from two seemingly contradictory studies on MRSA control? Here was our take on both the VA and STAR*ICU studies, written the same week the studies were released. Apparently, some people chose to dust off their typewriters and comment the old-fashioned way. Those letters, and the authors’ responses, are now published. Aside from the last two letters, which make a good point about a flaw in the denominator of the VA study (the failure to remove patients not at risk for acquisition by virtue of already being colonized), all the letters start from the premise that these two studies have contradictory results.

As Charlie Huskins and his colleagues point out in their letter, this is a flawed premise. They point to Figure 3 of their paper to make this point—allow me to expand, since they were obviously working within some crazy word limit that bloggers are not bound by.

Below you’ll find Figure 3 from the STAR*ICU study, which graphs the number of MRSA and VRE “events” (new colonization or infection) during an extended baseline period and the intervention period, in both control and intervention units:

No differences between control and intervention units, and no significant difference from the baseline rates, right? Hold on a minute!! It really isn’t fair to compare these data to the VA data, since the VA study doesn’t include a concurrent control group and doesn’t include sufficient baseline data with which to perform a proper segmented regression analysis. So now let’s take all of that extraneous stuff out (you know, all that tedious extended baseline data and the control arm data—get rid of it!!!). Now the graph looks like this:

The trend line is mine, and demonstrates that MRSA and VRE events dropped by about a third in the intervention units. Since this measure incorporates both transmission and infection metrics, you’d predict it would land smack in the middle of the VA estimates for reduction in MRSA transmission (17-21% reduction) and infection (62% reduction). And it does!

So please stop claiming that the VA study and the STAR*ICU study don’t agree—they do agree, if you just ignore the baseline and control arm data. And as we’ve already learned, control groups are for losers.

I need your vote!

Last week I posted an idea on the 2011 VHA Employee Innovation Website.  Now VA employees are being asked to vote.  The instructions say that I should share my idea with my colleagues - that would be you. If you work for the VA and like my idea, please vote! Hvala lijepa.

Idea Title: Driving Patient Safety with Point-of-Use Signs for Hand Washing

Idea Description: One of the biggest threats to patient safety is hospital-acquired infections. Hand hygiene is the #1 method for preventing the spread of infections. VA has done a great job placing alcohol hand rub dispensers in patient care areas, but hand washing isn't 100%. Placing point-of-use reminder signs directly next to hand-rub/soap dispensers to encourage providers to wash their hands has potential to significantly improve hand washing compliance. Signs that offer encouragement and information and not just say employees must wash hands would be simple to design, test, implement and be very cost-effective.

Vote: Here

Those deviants!

Photo: OpenIDEO

I have a bookshelf that is filled with many books on leadership and management that I read while working on my Master of Public Administration degree. While each of them might have a kernel or two of unique insights, most of these books contain a great deal of fluff. The basic formula for these books is to take concepts that are often common sense, give them a new name, and create the illusion of a totally new discovery about human behavior.These books often focus on a magic number--7 principles, 10 milestones, 12 steps (wait, that's something else!), and they continue to be steadily churned out (just take a look at any airport bookstore). Of all of these books that I've read, one did stand out as different and important, and that was Robert Greenleaf's Servant Leadership.

One recent book in this genre caught my eye given it's potential application to HAI prevention: The Power of Positive Deviance: How Unlikely Innovators Solve the World's Toughest Problems. Positive deviance was a part of the interventions implemented in the Veteran Affairs initiative to reduce MRSA that was recently reported in the New England Journal of Medicine (see Dan's comments here and here). My colleague in Sao Paulo, Alex Marra, has published on his use of positive deviance to improve compliance with hand hygiene. You can read an interview with Alex focusing on the use of positive deviance here.

In a nutshell, the concept of positive deviance is to simply involve not just experts but everyone in identifying solutions to problems. And it recognizes that a few individuals (the positive deviants) devise solutions to problems that the vast majority of people never realize. The deviants then share their successes with others and in doing so previously intractable problems are solved. Importantly, change is driven bottom-up, not top-down. The book uses several case studies, including the Pittsburgh VA hospital MRSA initiative.

Like the overwhelming majority of leadership/management books, this is another one that essentially follows the same formula as many others--a relatively simple, commonsense concept is given a new name, and presto, problems appear to be solved. I have no doubt that positive deviance can be used successfully in infection prevention, but it's simply another way to achieve the outcomes we want. It's not magic and it's not the be-all, end-all. But it's another tool, and if it works for your organization, well, you go girl!

VA reduces HAIs! In other news, VA spends millions on MRSA screening

Jain and colleagues just published data from the VA healthcare system implementation of the "MRSA directive". For those who are still unaware, in 2007 the VA began mandating the IHI MRSA bundle system-wide, with MRSA screening (active detection and isolation, or "ADI") applied to all VA admissions. The results? From October 2007 until June 2010, the MRSA transmission rate decreased by 17% in ICUs and 21% in non-ICUs, and the incidence of healthcare associated MRSA infections in ICUs fell by 62%. Very impressive indeed.

But that's not the whole story. During the same time period, a subset of these VA hospitals also reported their rates of healthcare-associated VRE and C. difficile infections, and guess what? VRE HAIs fell by 100% in ICUs and 70% in non-ICUs, and C. difficile HAIs fell by 57% in non-ICUs. It seems that HAIs are falling across the VA system, probably as a result of an important culture change, and improved application of so-called "horizontal" approaches to infection prevention. Bravo to the VA!

Here's the problem: because the VA jumped right into universal ADI, utilizing the most expensive screening technology available, they've poured millions of dollars into one specific intervention (ADI), and we still have no idea if ADI had anything to do with their MRSA reductions. After all, MRSA HAI rates have been falling across the country, both inside and outside of ICUs, including in hospitals that do no ADI, or that do targeted ADI. And of course Mike's hospital, where no ADI is done, would scoff at a mere 60% rate of decrease, having reduced MRSA HAIs by almost 90% using horizontal approaches.

My conclusions? First, the VA is to be congratulated for demonstrating real and sustained progress in HAI prevention (disclaimer: I was a VA hospital epidemiologist for 10 years, including during the first 2 years of implementation of the MRSA directive). Second, VA policy makers should consider the possibility that universal MRSA screening is now doing more harm than good, if only because it costs millions of dollars annually that could be used to improve other infection prevention programs. By all means, continue the MRSA initiative. But consider relaxing the "universal" ADI directive to allow individual hospitals the latitude to tailor ADI practices to best address their current risk assessment.