Anti-MRSA program succeeds across institutions: 'a coordinated hand-hygiene program [can] bring significant reductions in MRSA infection rates.'.

CHICAGO -- Multisite implementation of a generic hand-hygiene culture-change program can significantly reduce infections caused by methicillin-resistant Staphylococcus aureus, according to Dr. M. Lindsay Grayson.

In a landmark study involving six urban and rural Australian hospitals, a centrally organized program encouraging the widespread use of alcohol-based hand rubs halved MRSA bacteremia rates, Dr. Grayson said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

It is the first large multisite study to demonstrate the benefits of a hand-hygiene culture change, said Dr. Grayson, director of infectious diseases at Austin Health, a provider of tertiary health services in Melbourne, and professorial fellow at the University of Melbourne. In fact, it was a single-institution study at Austin Hospital that set the stage for this expanded study (Med. J. Aust. 2005; 183:509-14).

"[In the current study, we] introduced alcohol-based hand rubs and alcohol wipes for [those sharing] equipment, as well as an educational program for health care workers, patients, and patients' relatives," he reported.

The researchers encouraged the culture change with a promotional drive that included coffee-break seminars, quizzes with prizes, a newsletter on hand hygiene, and the attachment of notices to staffers' pay advice slips. They devised slogans to remind people about hand hygiene, and even hired an advertising consultant to maximize the effect of the message.

They also held feedback sessions with senior nurses on sentinel wards to provide them with information on recent outcome data, and they conducted medical, surgical, and nursing grand rounds on MRSA.

A key component of the program was the development of a computer-based educational package that could be accessed online.

These and other culture change procedures were maintained and used in the 2-year multicenter study of four hospitals in metropolitan Melbourne and two regional hospitals. The program was coordinated by staff at Austin Health and the Victorian Quality Council in Melbourne, and funding was provided by the Department of Human Services for the state of Victoria, which backs efforts to control the MRSA "superbug."

The primary outcome measures were rates of hand-hygiene compliance measured at 3- and 6-month intervals, and of MRSA disease--including bacteremia and clinical isolates--per 100 patient discharges measured at 1-month intervals, Dr. Grayson said.

"For all six sites, hand-hygiene compliance rose from 21% at baseline to 47% at 2 years. We identified the same significant improvements in MRSA disease rates that we identified in the single-center Austin study," he said, noting that MRSA bacteremia fell from 0.03 to 0.01 per 100 patient discharges, and clinical isolates fell from 1.12 to 0.8 per 100 discharges.

"We were able to show that during the 2-year program, there were 719 fewer isolates than would have been expected had we not intervened. More importantly, MRSA bacteremia rates were roughly halved, with 60 fewer patients developing bacteremia than we would have otherwise expected," Dr. Grayson said at the meeting, which was sponsored by the American Society for Microbiology.

The results of a cost analysis suggest that the culture change produced a potential savings over the 2-year period of at least $1.5 million. "The program cost roughly $750,000, so this was a 2-to-l multiplier effect in terms of savings," Dr. Grayson said.

This study shows that "a coordinated hand-hygiene program that does not involve direct observation can improve compliance in both rural and urban health care settings and bring significant reductions in MRSA infection rates," he concluded.

A Swiss researcher, Dr. Hugo Sax, said that although such studies show that progress is being made in hand hygiene, optimal rates of compliance will be achieved only if more physicians lead by example.

"We have to address and educate different health care populations with tailored approaches instead of a one-size-fits-all approach," said Dr. Sax, a consulting physician at the University Hospital in Geneva.

But first, physicians must align their own thinking toward patient safety, he said in an interview. "Physician training doesn't have the same patient-care focus that nurses and others experience, so hygiene is not a high-level issue for physicians, and it should be."

Dr. John M. Boyce, chief of infectious diseases at the Hospital of Saint Raphael in New Haven, Conn., agreed. "The evidence that hand hygiene reduces the spread of MRSA and other organisms is compelling, and we have to convince our physician colleagues that using alcohol hand rubs both before and after each patient visit doesn't slow down their daily routines," he said in an interview.

BY BRUCE K. DIXON

Chicago Bureau