1. An Operational Citywide Electronic Infection
Control Network:
Results from the First Year
Abel Kho MD, MS; Paul Dexter, MD
Brad 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

2. Outline
• The problem with MRSA
• The INPC and Informatics infrastructure
• Citywide electronic alerts and results to
date
• Converting alerts into action
• Questions

3. MRSA Background
Purpose
• 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.

4. 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

5. Prevalence of Methicillin-Resistance
Among S. aure us Infections, Denmark
and US, 1960-2004
0
10
20
30
40
50
60
70
1960 1966 1972 1978 1984 1990 1996 2002
%Resistant
USA (ICUs) Denmark (BSIs)

7. Methods to reduce transmission in
hospitals:
–Hand Hygiene
–Barrier Isolation
–Active Surveillance

8. 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

9. The Indiana Network for
Patient Care (INPC)
An operational community wide
electronic medical record

10. 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

11. RegionalRegional
CentralCentral
IndianaIndiana
HospitalsHospitals
(INPC)(INPC)

12. Consolidating the Silos
Global PatientGlobal Patient
IndexIndex
ConceptConcept
DictionaryDictionary
Global ProviderGlobal Provider
IndexIndex
St FrancisClarian Health
Partners
Wishard Health
Services
Community
Public Health
IUMG PC
MMG
St Vincent
IUMG SC

13. Preliminary Studies

14. 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 contactisolation.
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.

15. Electronic Regional Infection
Control Network
ERICNet

16. ERICNet
–2004
–Create a shared electronic platform for
infection control
–Built upon the existing INPC
–Would require organizational and
individual change

17. Getting There
• Build consensus (bottom up)
• Meetings!
– Build teams
– Designate champions
– Listen to feedback from the users (surveys,
weekly teleconferences)

18. Getting There - Informatics
• Standardize the MRSA (and VRE) lists
from all hospitals in Indianapolis
• Create standardized reports and data
entry forms
• Integrate with workflow

19. St Francis MRF
Concept
Dictionary
Clarian MRF Community
MRF
St Vincent MRF
Global Patient
Index
Wishard MRF
Wishard
Hospital
University
Hospital
Admit

20. Sample E-mail Alert
• From: larry@kite.wishard.edu
Date: 08-14-2007 16:32
Subject: %%% 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

26. Results to Date

27. 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

28. Careweb Alerts
0
50
100
150
200
250
300
350
400
450
May-07
June
July
August
September
October
November
December
Jan-08
February
March
April
May
June
July
August
September
Alerts

29. Number of Admissions Number of Unique Patients
1 2560
2 669
3 229
4 96
5 43
6 18
7 15
8 4
9 9
10 5
11 5
12 2
16 1
21 1
29 1
Total 3658

30. % MRSA admissions originating from an outside hospital
0
5
10
15
20
25
30
Retrospective
Estimate
Six Months of Alerts 18 Months of Alerts
Months
%

34. 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

35. 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

36. What do we do with this
information?

37. AHRQ ACTION Contract
Implementation
 “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

38. 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

39. 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

40. 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)

41. 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.

42. 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)

43. Admission Culture Compliance for Study Units
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jan-07
Feb-07
Mar-07
Apr-07
May-07
Jun-07
Jul-07
aug-07
Sep-07
Oct-07
Nov-07
Dec-2007
%complianceagainstprotocol
A-1
A-2
B-1
C-1
C-2
W-1
Average of % of patients receiving admission cx
Hosp-unit

44. 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.

45. 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).

46. 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.

47. 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)

48. 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

49. 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

50. 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