Loretta A. Simbartl

Nationwide reduction of health care-associated methicillin-resistant Staphylococcus aureus infections in Veterans Affairs long-term care facilities.

The Veterans Affairs methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative was implemented in its 133 long-term care facilities in January 2009. Between July 2009 and December 2012, there were ~12.9 million resident-days in these facilities nationwide. During this period, the mean quarterly MRSA admission prevalence increased from 23.3% to 28.7% (P < .0001, Poisson regression for trend), but the overall rate of MRSA health care-associated infections decreased by 36%, from 0.25 to 0.16/1,000 resident-days (P < .0001, Poisson regression for trend).

Veterans Affairs methicillin-resistant Staphylococcus aureus prevention initiative associated with a sustained reduction in transmissions and health care-associated infections

Implementation of a methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative was associated with significant declines in MRSA transmission and MRSA health care-associated infection rates in Veterans Affairs acute care facilities nationwide in the 33-month period from October 2007 through June 2010. Here, we show continuing declines in MRSA transmissions (P = .004 for trend, Poisson regression) and MRSA health care-associated infections (P < .001) from July 2010 through June 2012. The Veterans Affairs Initiative was associated with these effects, sustained over 57 months, in a large national health care system.

Clostridium difficile Infections in Veterans Health Administration Long-Term Care Facilities.

OBJECTIVE A nationwide initiative was implemented in February 2014 to decrease Clostridium difficile infections (CDI) in Veterans Affairs (VA) long-term care facilities. We report a baseline of national CDI data collected during the 2 years before the Initiative. METHODS Personnel at each of 122 reporting sites entered monthly retrospective CDI case data from February 2012 through January 2014 into a national database using case definitions similar to those used in the National Healthcare Safety Network Multidrug-Resistant Organism/CDI module. The data were evaluated using Poisson regression models to examine infection occurrences over time while accounting for admission prevalence and type of diagnostic test. RESULTS During the 24-month analysis period, there were 100,800 admissions, 6,976,121 resident days, and 1,558 CDI cases. The pooled CDI admission prevalence rate (including recurrent cases) was 0.38 per 100 admissions, and the pooled nonduplicate/nonrecurrent community-onset rate was 0.17 per 100 admissions. The pooled long-term care facility-onset rate and the clinically confirmed (ie, diarrhea or evidence of pseudomembranous colitis) long-term care facility-onset rate were 1.98 and 1.78 per 10,000 resident days, respectively. Accounting for diagnostic test type, the long-term care facility-onset rate declined significantly (P=.05), but the clinically confirmed long-term care facility-onset rate did not. CONCLUSIONS VA long-term care facility CDI rates were comparable to those in recent reports from other long-term care facilities. The significant decline in the long-term care facility-onset rate but not in the clinically confirmed long-term care facility-onset rate may have been due to less testing of asymptomatic patients. Efforts to decrease CDI rates in long-term care facilities are necessary as part of a coordinated approach to decrease healthcare-associated infections.

A Report of the Efforts of the Veterans Health Administration National Antimicrobial Stewardship Initiative

OBJECTIVE To detail the activities of the Veterans Health Administration (VHA) Antimicrobial Stewardship Initiative and evaluate outcomes of the program. DESIGN Observational analysis. SETTING The VHA is a large integrated healthcare system serving approximately 6 million individuals annually at more than 140 medical facilities. METHODS Utilization of nationally developed resources, proportional distribution of antibiotics, changes in stewardship practices and patient safety measures were reported. In addition, inpatient antimicrobial use was evaluated before and after implementation of national stewardship activities. RESULTS Nationally developed stewardship resources were well utilized, and many stewardship practices significantly increased, including development of written stewardship policies at 92% of facilities by 2015 (P<.05). While the proportional distribution of antibiotics did not change, inpatient antibiotic use significantly decreased after VHA Antimicrobial Stewardship Initiative activities began (P<.0001). A 12% decrease in antibiotic use was noted overall. The VHA has also noted significantly declining use of antimicrobials prescribed for resistant Gram-negative organisms, including carbapenems, as well as declining hospital readmission and mortality rates. Concurrently, the VHA reported decreasing rates of Clostridium difficile infection. CONCLUSIONS The VHA National Antimicrobial Stewardship Initiative includes continuing education, disease-specific guidelines, and development of example policies in addition to other highly utilized resources. While no specific ideal level of antimicrobial utilization has been established, the VHA has shown that improving antimicrobial usage in a large healthcare system may be achieved through national guidance and resources with local implementation of antimicrobial stewardship programs. Infect Control Hosp Epidemiol 2017;38:513-520.

Prevention of methicillin-resistant Staphylococcus aureus infections in spinal cord injury units.

BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) health care-associated infections (HAIs) are a concern in the 22 acute care Veterans Affairs (VA) spinal cord injury units where patients with unique rehabilitation and medical needs and a high risk of infection are treated. METHODS A bundle was implemented in VA spinal cord injury units consisting of nasal surveillance for MRSA on admission/in-hospital transfer/discharge, contact precautions for patients colonized or infected with MRSA, an emphasis on hand hygiene, and an institutional culture change where infection control became everyones responsibility. RESULTS From October 2007, through June 2011, there were 51,627 admissions/transfers/discharges and 816,254 patient-days of care in VA spinal cord injury units. The percentage of patients screened increased to >95.0%. The mean admission MRSA prevalence was 38.6% ± 19.1%. Monthly HAI rates declined 81% from 1.217 per 1,000 patient-days to 0.237 per 1,000 patient-days (P < .001). Bloodstream infections declined by 100% (P = .002), skin and soft-tissue infections by 60% (P = .007), and urinary tract infections by 33% (P = .07). CONCLUSION Universal surveillance, contact precautions, hand hygiene, and an institutional culture change was associated with significant declines in MRSA HAIs in a setting with a high prevalence of MRSA colonization and a high risk for infection.

Effect of a Clostridium difficile Infection Prevention Initiative in Veterans Affairs Acute Care Facilities.

Rates of clinically confirmed hospital-onset healthcare facility-associated Clostridium difficile infections from July 1, 2012, through March 31, 2015, in 127 acute care Veterans Affairs facilities were evaluated. Quarterly pooled national standardized infection ratios decreased 15% from baseline by the final quarter of the analysis period (P=.01, linear regression). Infect Control Hosp Epidemiol 2016;37:720-722.

Eight years of decreased methicillin-resistant Staphylococcus aureus health care-associated infections associated with a Veterans Affairs prevention initiative

HighlightsThe Veterans Affairs MRSA Prevention Initiative was implemented in October 2007.MRSA healthcare‐associated infection (HAI) rates were tracked over 8 years.Monthly HAI rates fell 87.0% in intensive care units (ICUs) and 80.1% in non‐ICUsMRSA HAI rates fell 80.9% in spinal cord injury units and 49.4% in long‐term care.All were all statistically significant declines (P < .0001 for trend). Background Declines in methicillin‐resistant Staphylococcus aureus (MRSA) health care associated infections (HAIs) were previously reported in Veterans Affairs acute care (2012), spinal cord injury (SCIU) (2011), and long‐term‐care facilities (LTCFs) (2012). Here we report continuing declines in infection rates in these settings through September 2015. Methods Monthly data entered into a national database from 127 acute care facilities, 22 SCIUs, and 133 LTCFs were evaluated for trends using negative binomial regression. Results There were 23,153,240 intensive care unit (ICU) and non‐ICU, and 1,794,234 SCIU patient‐days from October 2007‐September 2015, and 22,262,605 LTCF resident‐days from July 2009‐September 2015. Admission nasal swabbing remained >92% in all 3 venues. Admission prevalence changed from 13.2%‐13.5% in acute care, from 35.1%‐32.0% in SCIUs, and from 23.1%‐25.0% in LTCFs during the analysis periods. Monthly HAI rates fell 87.0% in ICUs, 80.1% in non‐ICUs, 80.9% in SCIUs, and 49.4% in LTCFs (all P values < .0001 for trend). During September 2015, there were 2 MRSA HAIs reported in ICUs, 20 (with 3 in SCIUs) in non‐ICUs, and 31 in LTCFs nationwide. Conclusions MRSA HAI rates declined significantly in acute care, SCIUs, and LTCFs over 8 years of the Veterans Affairs MRSA Prevention Initiative.

Zeroing in on methicillin-resistant Staphylococcus aureus: US Department of Veterans Affairs' MRSA Prevention Initiative

Implementation of a methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative within US Department of Veterans Affairs medical facilities was associated with a significant reduction in MRSA health care-associated infection (HAI) rates nationwide. The first 36 months of data from the Initiative were analyzed to determine how many facilities reported zero MRSA HAIs each month. From October 2007 through September 2010, there was a 37.6% increase nationwide in the number of facilities achieving zero MRSA HAIs each month.

Legionella in the veterans healthcare system: report of an eight-year survey.

The Veterans Health Administration (VHA) of the Department of Veterans Affairs tracks legionella disease in the system of 172 medical centres and additional outpatient clinics using an annual census for reporting. In fiscal year 1999, 3.62 million persons were served by the VHA. From fiscal year 1989-1999, multiple intense interventions were carried out to decrease the number of cases and case rates for legionella disease. From fiscal year 1992-1999, the number of community-acquired and healthcare-associated cases decreased in the VHA by 77 and 95.5% respectively (P = 0.005 and 0.01). Case rates also decreased significantly for community and healthcare-associated cases (P = 0.02 and 0.001, respectively), with the VHA healthcare-associated case rates decreasing at a greater rate than VHA community-acquired case rates (P = 0.02). Over the time of the review, the VHA case rates demonstrated a greater decrease compared to the case rates for the United States as a whole (P = 0.02). Continued surveillance, centrally defined strategies, and local implementation can have a positive outcome for prevention of disease in a large, decentralized healthcare system.

Legionnaires Disease Surveillance in US Department of Veterans Affairs Medical Facilities and Assessment of Health Care Facility Association

Key Points Question What is the Legionnaires disease burden in the US Department of Veterans Affairs medical facilities, a health care system that has prioritized Legionnaires disease prevention with policy? Findings In this cohort study, the number of Legionnaires disease cases was low (n = 491) and 91% of cases had no VA exposure or only outpatient VA exposure. Total rates of Legionnaires disease significantly increased from 2014 to 2016, but rates in cases with overnight health care system exposure significantly decreased. Meaning Although total Legionnaires disease rates increased, health care system–associated (overnight stay) rates decreased significantly, suggesting that prevention efforts may have contributed to improved patient safety in these settings.