An Operational Citywide Electronic Infection Control Network:

Results from the First Year

Abel Kho MD, MS; Paul Dexter, MDBrad Doebbeling, MD, MSc,

Northwestern University, VA HSR&D Center of Excellence, Indiana University Center for Health Services and Outcomes Research, Regenstrief

Institute, IU School of Medicine, Indianapolis, IN

Outline

• The problem with MRSA• The INPC and Informatics infrastructure • Citywide electronic alerts and results to

date • Converting alerts into action• Questions

MRSA BackgroundPurpose

• 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 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.

Reservoir for the Spread of Antibiotic Resistant Pathogens• Colonized patients, NOT just infected

patients, can transmit AR pathogens to healthcare workers and other

patients.

Unidentified Colonized Patients

• Clinical Cultures +• History of MRSA

Prevalence of Methicillin-Resistance Among S. aureus Infections, Denmark and US, 1960-2004

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Methods to reduce transmission in hospitals:

– Hand Hygiene

– Barrier Isolation

– Active Surveillance

Models of Success

• Netherlands, Denmark• Prompt isolation of MRSA positive patients• “Search and Destroy” approach• Surveillance cultures on patients recently

hospitalized in other countries• Prevalence of MRSA <1% in the

community and hospitalized patients

The Indiana Network for Patient Care (INPC)

An operational community wide electronic medical record

INPC – Participants • 11 hospitals from the 5 major Indianapolis

hospital systems (95% of inpatient care)• Includes county and state public health

departments• Standards based (LOINC, HL7)• More than a billion clinical observations• 13 year old information exchange

Regional Regional Central Central Indiana Indiana

HospitalsHospitals(INPC)(INPC)

Consolidating the Silos

Global Global Patient Patient IndexIndex

Concept Concept DictionaryDictionary

Global Provider Global Provider IndexIndex

St FrancisClarian Health Partners

Wishard Health Services

Community

Public HealthIUMG PC

MMG

St Vincent

IUMG SC

Preliminary Studies

The Regional Nature of MRSA Admissions

• 2006

• 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.

Kho AN, Lemmon L, Commiskey M, Wilson SJ, McDonald CJ. Use of a Regional Health Information Exchange to Detect Crossover of Patients with MRSA between Urban Hospitals. Journal of the American Medical Informatics Association 2008 15(2):212-216.

Electronic Regional Infection Control Network

ERICNet

ERICNet

– 2004– Create a shared electronic platform for

infection control– Built upon the existing INPC– Would require organizational and

individual change

Getting There

• Build consensus (bottom up)• Meetings!

– Build teams– Designate champions– Listen to feedback from the users (surveys,

weekly teleconferences)

Getting There - Informatics

• Standardize the MRSA (and VRE) lists from all hospitals in Indianapolis

• Create standardized reports and data entry forms

• Integrate with workflow

St Francis MRF

Concept Dictionary

Clarian MRF

Community MRF

St Vincent MRF

Global Patient Index

Wishard MRF

Wishard Hospital

University Hospital

Admit

Sample E-mail Alert• From: larry@kite.wishard.edu

Date: 08-14-2007 16:32Subject: %%% INFECTION CONTROL ALERT %%%

WISHARD INFECTION CONTROL ALERT:

Patient 0000005-2 was admitted on 14-Aug-07 01:22 PM to

Hospital:  Location: ERSR on Unit: ERSR

Alert based on data from your institution.

Please login to INPC CareWeb for further details.url: http://kite.wishard.edu:7100

Results to Date

Tracking MRSA

• > 17,000 MRSA cases • As of 2007, 3558 cases of skin and soft

tissue infections – CA-MRSA?– 37% AA– Increasing year on year

• 5705 Alerts to date

Careweb Alerts

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Number of Admissions Number of Unique Patients1 25602 6693 2294 965 436 187 158 49 9

10 511 512 216 121 129 1

Total 3658

% MRSA admissions originating from an outside hospital

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RetrospectiveEstimate

Six Months of Alerts 18 Months of Alerts

Months

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Usability Survey

• 12/20 ICPs responded• Useful? 100%• Average alerts per day: 5• Average new cases: 2.2 • Average 4.4 cases entered per day• 2.3 minutes to enter a new case• Spend 1-2 hours per week entering or

editing cases

Things we should improve

• Automate capture of new cases from laboratory

• Avoid double entry of MRSA cases into into their own system

• Improve Reporting Tools• Increase amount of information in alerts• Deliver alerts to Admissions office as well

What do we do with this information?

AHRQ ACTION ContractImplementation

“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 ICUs improve rates of contact isolation Improve hand hygiene rates

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

Improvement Cycle

Take Action /Develop

Future State

Process Control

Strategy

Baseline Current

Processes

Identify Operational

Barriers

Define/ Discovery

Process Observation Worksheet

Spaghetti Diagram

Lean Tools

Process Map

Check sheet

Process Control Plan

Voice of the Customer

PD Discovery Session

PDSA Cycles

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)

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.

Evaluation and Results• Range of 3-22% (monthly average) incoming

patients colonized with MRSA on study units

• The number of conversions varied across study units (4 23 during study period)

• Variability in pre-intervention Nosocomial infection rates across participating hospitals (.015 .025)

• Greater variability in pre-intervention study unit MRSA infection data (.008 .074)

Admission Culture Compliance for Study Units

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Statistical Analysis• Infection data from 5 hospitals were collected at monthly time intervals 12

months before and after implementation

• A Poisson generalized estimating equation (GEE) model to evaluate the

impact of the intervention bundle.

• Expected mean number of MRSA cases per 30 day time period and

corresponding 95% Cis for pre-, intervention intervals.

• GEE estimation procedures to adjust for the covariance structure of the

repeated observations.

• Interaction terms to account for hospital, health system and unit

differences in the effect of the intervention bundle.

MRSA Infection Results

• An overall decrease in the number of MRSA cases following the intervention bundle.

• For each of the models, initial parameter estimates suggest a statistically significant effect of the intervention (p=0.06).

• After adjusting for the covariance structure of the repeated observations, the significance is even greater (p<0.01).

Lessons Learned--Implementation

• Importance of buy-in from highest institutional levels crucial.

• Value of engaging frontline staff in the process of planning and implementation.

• Enthusiasm builds from within because redesign teams own it!

• Use of Lean Six Sigma tools, especially process mapping.

• Data collection tool, and resources to manage and analyze the data crucial.

Lessons Learned--Research Our proposed data collection too

intensive for most community hospitals Need to adequately staff data

collection and observation of intervention bundle compliance

Need a better electronic data collection infrastructure relating to compliance and outcome data

Little time for paper writing and dissemination projects (Hazard of short time lines for funding)

Conclusions

• Hospitals do not operate in a vacuum

• Infections do not care what health care system you receive most of your care

• Regional / Coordinated efforts

• Standardized approach to data collection and intervention

Future Work• Ongoing funding from AHRQ / CDC

1. Study ambulatory care factors which determine what patients are admitted with invasive CA-MRSA infections

2. Disseminate best practices to control HA-MRSA

• Automate capture and reporting of culture results and intervention compliance

Acknowledgement s• Agency for Healthcare

Research and Quality (HHSA290200600013 Task order #1)

• Larry Lemmon• Shahid Khokhar• Shawn Hoke• Jamie Workman-

Germann, MS • Doub Webb, MD

• Laurie Fish, RN• Claire Rumpke, RN• Loretta Marsh, RN• Sandra Benson, RN• Marie Comminsky, RN• Diana Greathouse, RN• Kim McCoy, MS• Mahesh Merchant, PhD• Mindy Flanagan, PhD