David P. Calfee, MD, MS; Shannon Davila, MSN, RN, CIC, CPHQ; Vineet Chopra, MD, MSc; Payal K. Patel, MD, MPH; Ashley Snyder, MPH; David Ratz, MS; Andrew J. Rolle, MPH; Russell N. Olmsted, MPH, CIC; Kyle J. Popovich, MD, MS
Disclaimer: The findings and conclusions in this report are those of the authors and do not represent the official position of the CDC, the American Hospital Association, or the Department of Veterans Affairs.
Acknowledgment: The authors thank the Health Research & Educational Trust (HRET) Health Care-Associated Infection team, as well as the National Program Team and all members of the CDC STRIVE collaborative. They also thank M. Todd Greene, PhD, MPH, for analytic support, and Jessica Ameling, MPH; Rachel Ehrlinger, BA; Jason Engle, BS; Karen E. Fowler, MPH; and Jason Mann, MSA, for assistance with manuscript preparation.
Disclosures: Dr. Calfee reports a CDC contract with the HRET, which subcontracted with Weill Cornell Medical College, during the conduct of the study. Ms. Davila and Mr. Rolle report a CDC contract with HRET during the conduct of the study. Dr. Chopra, Dr. Patel, Ms. Snyder, and Mr. Ratz report a CDC contract with the HRET, which subcontracted with University of Michigan to support faculty/staff effort, during the conduct of the study. Mr. Olmsted reports personal fees from the HRET during the conduct of the study and personal fees from Ethicon outside the submitted work. Dr. Popovich reports personal fees from the CDC contract with the HRET during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-3535.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement: Study protocol: Not applicable. Statistical code: Available from David Ratz (e-mail, firstname.lastname@example.org). Data set: Not available.
Corresponding Author: David P. Calfee, MD, MS, Weill Cornell Medicine, 525 East 68th Street, Box 265, New York, NY 10065; e-mail, email@example.com.
Current Author Addresses: Dr. Calfee: Weill Cornell Medicine, 525 East 68th Street, Box 265, New York, NY 10065.
Ms. Davila: New Jersey Hospital Association, 760 Alexander Road, Princeton, NJ 08543.
Dr. Chopra: University of Michigan Department of Internal Medicine, 2800 Plymouth Road, Building 16, Room 432W, Ann Arbor, MI 48109-2800.
Dr. Patel: VA Ann Arbor Healthcare System, 111-I, 2215 Fuller Road, Ann Arbor, MI 48105.
Ms. Snyder: University of Michigan Department of Internal Medicine, 2800 Plymouth Road, NCRC Building 16, Room 430W, Ann Arbor, MI 48109-2800.
Mr. Ratz: Veterans Affairs Ann Arbor Healthcare System Center for Clinical Management Research, PO Box 130170. Ann Arbor, MI 48113-0170.
Mr. Rolle: Health Research & Educational Trust, American Hospital Association, 155 North Wacker Drive, Suite 400, Chicago, IL 60606.
Mr. Olmsted: Integrated Clinical Services, Trinity Health, 20555 Victor Parkway, Livonia, MI 48152.
Dr. Popovich: Rush University Medical Center/Stroger Hospital of Cook County, 600 South Paulina, Suite 143, Chicago, IL 60612.
Author Contributions: Conception and design: D.P. Calfee, S. Davila, V. Chopra, P.K. Patel, A.J. Rolle, R.N. Olmsted, K.J. Popovich.
Analysis and interpretation of the data: D.P. Calfee, V. Chopra, P.K. Patel, A. Snyder, D. Ratz, R.N. Olmsted.
Drafting of the article: D.P. Calfee, S. Davila, V. Chopra, D. Ratz.
Critical revision of the article for important intellectual content: D.P. Calfee, V. Chopra, P.K. Patel, A.J. Rolle, R.N. Olmsted, K.J. Popovich, D. Ratz.
Final approval of the article: D.P. Calfee, S. Davila, V. Chopra, P.K. Patel, A. Snyder, D. Ratz, A.J. Rolle, R.N. Olmsted, K.J. Popovich.
Provision of study materials or patients: A.J. Rolle.
Statistical expertise: V. Chopra, A. Snyder, D. Ratz.
Administrative, technical, or logistic support: S. Davila.
Collection and assembly of data: A.J. Rolle, D. Ratz.
Methicillin-resistant Staphylococcus aureus (MRSA) remains one of the most common causes of health care–associated infection (HAI).
To evaluate the effect of education and a tiered, evidence-based infection prevention strategy on rates of hospital-onset MRSA bloodstream infection (BSI).
Prospective, national, nonrandomized, interventional, 12-month, multiple cohort, pre–post observational quality improvement project.
Acute care, long-term acute care, and critical access hospitals with a disproportionate burden of HAI.
All patients admitted to participating facilities during the project period.
A multimodal infection prevention intervention consisting of recommendations and tools for prioritizing and implementing evidence-based infection prevention strategies, on-demand educational videos, Internet-based live educational presentations, and access to content experts.
Rates of hospital-onset MRSA BSI, overall and stratified by hospital type, during 12-month baseline and postintervention periods. Variation in outcomes across hospital types was examined.
Between November 2016 and May 2018, 387 hospitals in 23 states and the District of Columbia participated, 353 (91%) submitted MRSA data, and 172 (49%) indicated that MRSA prevention was a priority. Unadjusted overall rates of hospital-onset MRSA BSI were 0.075 (95% CI, 0.065 to 0.085) and 0.071 (CI, 0.063 to 0.080) per 1000 patient-days in the baseline and postintervention periods, respectively.
The intervention period was short. Participation and adherence to recommended interventions were not fully assessed. Baseline rates of hospital-onset MRSA BSI were relatively low. Prevention of MRSA was a priority in a minority of participating hospitals. Patient characteristics and other MRSA risk factors were not assessed.
In hospitals with a disproportionate burden of HAIs, access to tools to assist with implementation of evidence-based prevention strategies and education resources alone may not be sufficient to prevent MRSA BSI.
Centers for Disease Control and Prevention.
STRIVE project timeline.
Outcome data were methicillin-resistant Staphylococcus aureus bloodstream infections as reported by participating hospitals to the CDC National Healthcare Safety Network. CDC = Centers for Disease Control and Prevention; ICAR = Infection Control Assessment and Response; PCA = Practice Change Assessment; SHA = state hospital association; STRIVE = States Targeting Reduction in Infections via Engagement; TAP = Targeted Assessment for Prevention.
Study flow diagram.
CAD = cumulative attributable difference; CDC = Centers for Disease Control and Prevention; HAI = health care–associated infection; MRSA = methicillin-resistant Staphylococcus aureus; NHSN = National Healthcare Safety Network.
* “States” includes the District of Columbia.
† “Withdrew” defined as hospital and state jointly decided the hospital would stop participating in the program.
‡ 172 of the 353 hospitals included in the data analysis indicated that they focused on MRSA prevention during the project period.
Table 1. Characteristics of Hospitals That Submitted MRSA BSI Data*
Appendix Table 1. Components of Participating Hospitals' Infection Control Programs at Baseline*
Table 2. Hospital-Onset MRSA BSI Data Submitted by Hospitals Participating in the STRIVE Initiative
Hospital-onset MRSA BSIs per 1000 patient-days for the 353 participating hospitals that submitted MRSA data.
Rates are shown by month for the 12-month preintervention (baseline) and 12-month postintervention periods. The solid line represents the monthly MRSA bloodstream infection rate; dashed lines represent the 95% CIs. B = baseline month; BSI = bloodstream infection; M = intervention month; MRSA = methicillin-resistant Staphylococcus aureus.
Hospital-onset MRSA BSIs per 1000 patient-days among participating hospitals that indicated that MRSA BSI prevention was a specific area of focus during the project period.
Rates are shown by month for the 12-month preintervention (baseline) and 12-month postintervention periods. The solid line represents the monthly MRSA BSI rate; dashed lines represent the 95% CIs. B = baseline month; BSI = bloodstream infection; M = intervention month; MRSA = methicillin-resistant Staphylococcus aureus.
Appendix Table 2. Aggregated Monthly MRSA BSI Data From Hospitals That Indicated That MRSA BSI Prevention Was a Specific Area of Focus During the Project Period
Hospital-level rates of hospital-onset MRSA BSI during the pre- and postintervention periods (n = 350).
In this Sankey bar chart, the connecting segments show how hospitals changed from the pre- to the postintervention periods. The slopes of the connecting segments should be interpreted cautiously because some segments connecting to the same rate category are increasing or decreasing visually but indicate no change in rates in these hospitals. Only segments that connect to a different category indicate changes in rates from the pre- to the postintervention period. BSI = bloodstream infection; MRSA = methicillin-resistant Staphylococcus aureus.
Appendix Table 3. Aggregated Monthly MRSA BSI Data From All Participating Hospitals That Submitted MRSA BSI Data
Appendix Table 4. Comparison of Hospital-Onset MRSA BSI Rates Between the Pre- and Postintervention Periods
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Calfee DP, Davila S, Chopra V, et al. Quantitative Results of a National Intervention to Prevent Hospital-Onset Methicillin-Resistant Staphylococcus aureus Bloodstream Infection: A Pre–Post Observational Study. Ann Intern Med. 2019;171:S66–S72. doi: https://doi.org/10.7326/M18-3535
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Published: Ann Intern Med. 2019;171(7_Supplement):S66-S72.
Hospital Medicine, Infectious Disease, MRSA, Multi-Organ Failure and Sepsis, Pulmonary/Critical Care.
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