McCleary MRSA Prevention

People ask me what I would do to help stop Hospital acquired infections. It’s been 10 years today since my father died of HAI. Right after he was infected with MRSA, I started researching the causes, the prognosis, the incubation period, prevention, spread and prevalence of these infections. The subject is complex and broad, but these are a few of my ideas about how we can actually make a huge dent in this problem.

1. Get a more accurate count of infections and the deaths caused by them and make it public. Transparency and accountability will lead to better funding and actions to stop this scourge.

a. Develop a way for patients or their family members to report their own infections, because we know hospitals and other healthcare facilities are not reporting all of their infections

b. Require that all infections that contribute to a death, be listed as a cause of death (COD) on death certificates in every State.

2. Require Hospitals/LTCs/Dialysis centers/Surgical Centers to post any current outbreaks on their websites and in plain view for incoming patients.

a. “Outbreak” must be defined first.  Currently ‘outbreak’ means something different according to what infection is being discussed.

3. Rapid screen patients for MRSA and other common infections on emergency admission, or a week in advance of planned admissions. Practice Universal precautions without exception. Postpone elective surgery until the patient has been decolonized.  Contact precautions must be followed without exception for all MRSA colonized and infected patients. All other precautions according to the offending infection must be followed to a tee, by all staff and visitors and this must be enforced.

4. Put everyone in their own room, preventing spread of infection from one patient to another in the same room.

5. Clean up Hospitals and the equipment in them. Assign each patient their own frequently used equipment, ie. Blood pressure cuffs, wheelchairs, walkers, etc.

6. Handwashing all around every time, before and after touching,  nurses, doctors, xray and lab  techs, visitors, and anyone else who touches patients.

7. Help patients to understand their own role in prevention of infections, examples are  handwashing, general hygiene, covering wounds, good nutrition/hydration, covering coughs, not wearing slippers that have been on dirty floors into their bed.

8. Give the Federal and State CDCs regulatory powers. This way, instead of writing recommendations, they can write requirements. Every hospital that is held accountable for infections that they caused, will say “we met the CDC recommendations” and/or “We met the standards of care”.  And they may have met some of them, but certainly not all of them because they don’t’ have to…none of the recommendations are mandated.

Also, the CDC would not have to wait until crisis to go into places with known problems. An invitation would not be needed. Places with known infection outbreaks and/or ongoing infection issues could be visited and problems remedied without waiting for permission to enter. Not a single patient should become infected because the CDC is waiting for an invitation to help the facility.

9. Stop paying Hospitals and other Healthcare facilities for the costs of these infections.  Nobody should have to pay ONE PENNY for an infection they caught while in a facility. Penalties are not enough.  Stop payment from any source patients, insurances or the Federal Government.

This is my short list of ideas. They were gleaned from all sorts of experts and meetings on the subject of infections.  If these things had been in play when my father was hospitalized for rehab for a simple ankle fracture, I sincerely believe his infection would have been prevented.  Two other community members had already died of hospital acquired MRSA infection the same month he was admitted. No outbreak was declared and nothing was ever reported on a State level about that.  No extra precautions or steps were taken to stop the hospital MRSA outbreak.  There was no consistency with handwashing, gloving or precautions even after his infection was diagnosed.  With some hard work and dedication to patients, we can stop this from happening to others.

I am both a retired RN and a healthcare consumer.  I have attended dozens of meetings about Hospital and Healthcare associated infections, or HAIs. I do this because I think it is essential that healthcare consumers (simpler term is PATIENTS) should have a voice in the decisions surrounding HAI prevention, transparency, reports and policy, and over the past decade, the State and Federal governments came around to believing the same thing.  I am an official member of the State of Maine CDC HAI collaborative and I represent consumers.   A few days ago there was a member of the public in our meeting  I tried to listen to the conversation through her  ears.

This is what happened.   Right off the bat, acronyms were used that she, and possibly others in the group do not understand.  Beyond that, some of those acronyms are used in public reports.

It isn’t intentional when professional infection prevention professionals speak in complicated lingo, it is their everyday language.  But, when consumers are part of the conversation, the very least that could be offered is a printed glossary of terms for newcomers, and for some of the people around the table who do not do this work every day, like me and a few others.  I know for a fact that other regular members of our collaborative don’t understand all of those acronyms or terms that are tossed about during our meetings. .

So, what exactly is an SIR?  It is an acronym for “Standard Infection Ratio“. It is a way that the CDC, both State and national, reports infection rates.  The SIR is a risk adjusted number that is reported that includes the number of expected infections,  by facility or by State, or Nationally.  For example, if a big trauma center that accepts the most complicated patients has a higher number of “expected” infections, that is somehow formulated into their SIR. There is also a risk adjustment for teaching hospitals.   WHAT???!!!!   The actual number of infections is not reported when using an SIR.  The mean is the number 1, and anything under 1 like .48 is on the better side of 1 and anything above 1 , like 1.4,  is on the worse side.  Under 1 means fewer infections, and over 1 means more infections. Contrary to most reports, a higher score does not mean a better score.   So, is that now as clear as mud?   After all my years of these meetings, I’m still not 100% sure this explanation is totally accurate, but it is close enough.

So, what does having an SIR in an infection report mean?.  Well, one thing that it means is that Hospitals (or entire States)  can actually HAVE an expected number of infections and that is figured into their SIR report.  That is how the final reported SIR numbers are risk adjusted.   REALLY??  It seems to me  that expected number of infections should always be ZERO….always.   Zero expected infections is exactly what I and I assume all patients expect from any Hospital, so why can they have anything above that as an expectation, no matter what or who their patient population is.  I know this will stir up some discussion and anger from the larger hospitals that claim they care for all the most complex patients, but they also have the resources, the staff (we hope!), and the experts that smaller facilities do not.  And, it is their job although challenging, to keep all of their patients infection free. Nobody ever said elimination of infections would be easy.

This incomprehensible methodology is routinely used to create public reports on infections.  Then the experts who create these muddy reports have the nerve to say that patients do not understand infection reports.  Of course they don’t. A lot of doctors and nurses don’t understand them either.  They don’t know what an SIR is.  Creating a report that even some professionals don’t understand is a disservice to patients and consumers.  How about this approach for a change?  Report actual numbers, not SIRs.  For example,  report the number of hysterectomies the hospital performs every year, and the number of those patients who get a surgical site infection (SSI) as a result.   Hospital A does 1500 hysterectomies (all varieties) every year, and 3 patients get an SSI.  Or, Hospital B performs 50 such surgeries and 3 patients get an SSI. Even with my limited mathematical skills, I can figure out which hospital generally gets the best results regarding infections.   This type of report is useful in two ways.  It gives the volume of procedures done, and it also gives the number of infections that occur, both very important pieces of information for patients.  As a patient, I don’t particularly appreciate or understand “risk adjustments” that help hospitals have a better infection report, I just want to know exactly what my personal risk is with a particular facility, doctor or surgeon.

If Hospitals and entire States are going to publicly report infections, as they absolutely should, make the report useful to everyone, not just to infection prevention professionals and other savvy experts, who actually understand these wonky reports.  Consumers will use that public information to make choices that could very well affect their lives and pocketbooks.   Preventable infections cause horrible suffering and sometimes death,  and they can tack on a huge amount to an already high hospital bill.  We want clear, accurate and easy to understand information about infections.  Creating a public report that only infection professionals can decipher is not really a public service.  It only serves the experts who can understand it.

This has been my brief but spectacular explanation of and opinion about the SIR!

http://www.maine.gov/dhhs/mecdc/infectious-disease/hai/documents/2016-hai-annual-report-maine.pdf.pdf

http://www.comparemaine.org/

http://www.leapfroggroup.org/hospitals/search/list/states/Maine

https://www.cdc.gov/hai/surveillance/progress-report/faq.html

https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/nhsn-sir-guide.pdf

I recently ran into a doctor, that I knew during my work on MRSA prevention in 2009.  Well, actually I corralled him in a lobby after he did a presentation at a recent conference I attended.  He remembered me, and he didn’t call on me for Q&A, so I decided not to let him get away with that.  I have never been rude to anyone in my work, but I am certainly determined and honest.

His demeanor has changed drastically from when he testified against the bill I wrote in 2009, to prevent MRSA infections in Maine Hospitals.  I don’t know  if he was afraid of me because I am bigger than him, or if he agreed with others who called me crazy 4 years ago, but I sensed his discomfort while talking with me.    Even so, he was incredibly candid.  He actually told me that “they” called me crazy and they thought I would quit and give up on my endeavor for safer healthcare.  He was a more humble and agreeable man than I remember.  I believe that his personal healthcare experiences with his beloved parents  have changed his tune.  It’s amazing how humbling an experience with healthcare harm can change just about anyone’s perspective on the whole issue.

Imagine…calling me crazy.   Perhaps I was a little crazy.  I was crazy with anger and grief, because a downright dangerous healthcare system killed my father. His infection WAS preventable, but his facility failed him.    I believe that my craziness was justifiable.   My craziness  led to passion and an obsession of sorts.  That passion was to make a change in the lax and cavalier system that allowed this to happen to my father, and as I learned later, hundreds of thousands of others.   Passion led me to others, MRSA activists and experts, the internet, other MRSA victims and their families, legislators here in Maine,  media both written and TV, the Consumers Union Safe Patient Project, Maine Quality Counts, Maine Quality Forum, Maine CDC, CDC headquarters, the Federal DHS HAI stakeholder meetings, speaking and presentation opportunities, conferences, blogging….and on and on it goes.   My trip because of my craziness continues to be amazing.  The most amazing part of this work has been the other “crazy” people I have met.  Some of the most amazing patient safety experts and advocates in the world are on my email list.

Call me crazy, but I’m feeling pretty good about what I am doing….and if it helps to eliminate healthcare harm….we can add craziness to the list of necessary ingredients for success.

The  Maine Health and Human Services Committee had the opportunity on Tuesday, March 9, to remove the veil of secrecy from MRSA in the State of Maine.  It did not happen.  The suggestion was made that public, mandatory MRSA specific reporting through the National Heath Safety Network (CDC administered) be started.   They didn’t do it.  They missed the opportunity to make hospitals accountable and transparent.   Secrecy, lack of disclosure and accountability have historically been problems with MRSA.  These problems remain in Maine.   Many other States are reporting to NHSN.  ARRA funds were sent to Maine to encourage us to report to NHSN.  Over 20 hospitals have sent staff to be trained to do this reporting……..

BUT…in Maine the reporting that is proposed by the Maine CDC, for MRSA, is not to begin until 2012, is ONLY a proposal, and is  not mandated and the results will not be public.  What good is that to anyone except hospitals and the Maine CDC?  What will the result of such reporting be?  Not much..it is voluntary, secretive and useless and inaccessable for consumers.

Public reporting forces hospitals to COMPARE, COMPETE AND IMPROVE.   The March 2010 Consumer Report article regarding public reporting of hospital acquired bacteremia  proved that.

In January next year, we will go back, armed with the results of the MRSA prevalence test, experience from this past year dealing  with dishonest, but powerful hospitals and their lobby, and the fact that MRSA is still alive and well in our hospitals ………and we will fight for MRSA prevention in the form of Active Detection and Isolation and patient safety in Maine.   We will also fight to remove the shield of secrecy and deceipt that shields our hospital (from any accountability)  by proposing mandatory, public, MRSA specific reporting in the State of Maine.

http://www.bangordailynews.com/detail/135860.html

Below is a photo of a Hand MRSA.  Many of the infections on Vinalhaven affected the hands.

This is an update on a link I added here a few days back.  It is good to hear that the MRSA outbreak on Vinalhaven Island in Maine has been controlled.  Comments in this article make it sound like they were plagued with flea  bites. 

MRSA is a bit more serious than claimed here.  Some of these victims had to be treated with powerful IV antibiotics.  Some of them will be plagued with repeated infections and all of the victims families have been exposed within their homes to MRSA.  Simple exposure is not in and of itself a problem.  But, many of them may have become colonized.  that means they will carry the MRSA bug.  That is also not a problem UNLESS they become gravely ill and/or need hospitalization for invasive procedure. MRSA can then rear it’s ugly head and cause a myriad of problems.  Patients must make their doctor and hospital aware of their close exposure to the infection.  If the doctor does not order a MRSA screening, the patient should demand one.  If they are colonized, they can have a simple treatment that will decrease their chances of serious active infection a great deal.  And, they can be separated from patient who do not carry MRSA thus avoiding spread of the desease.

I suggested that former MRSA patients and caretakers of MRSA patients to be included in the populations to be screened by our hospitals here in Maine.  They were not included.  My opinion is that was a big mistake.  Nobody wants to incite panic, but a little bit of panic makes people pay attention and absorb important information about their health and risks to it.   MRSA status on admission to the hospitals is a very important status to be aware of.

So, it is good that the Maine CDC got right on this outbreak and worked to control it.  I just hope they added  this  important patient education (about avoiding serious infection in the future) to their investigation  process on the Island.