Questions and Answers

• What is Methicillin-resistant Staphylococcus aureus?
• What is bacteraemia?
• What is a case of MRSA bacteraemia?
• How does MRSA spread?
• What are the risk factors for MRSA?
• What is being publicly reported?
• What determines the rate?
• What will the health care system do with the rate information?
• What will happen if hospitals identify high rates of MRSA (bacteraemia)?
• Why are MRSA bacteraemia not reportable to local Medical Officers of Health in the same way that C. difficile is?
• Can the MRSA rates be used as a guide to choosing hospitals?
• What has the Ministry of Health and Long-Term Care done to ensure that hospitals have the tools necessary to fight hospital acquired infections like MRSA?
• What is the ministry doing to improve hand hygiene practices in hospitals
• What is the ministry doing to ensure the proper use of antibiotics in hospitals?

Staphylococcus aureus is a type of bacterium that lives on the skin and mucous membranes of healthy people. Occasionally, S. aureus can cause an infection. When S. aureus develops resistance to certain antibiotics, it is called methicillin-resistant Staphylococcus aureus, or MRSA.

Bacteraemia is the presence of bacteria in the bloodstream and is referred to as a bloodstream infection.

A case is a patient identified with laboratory confirmed bloodstream infection with methicillin-resistant Staphylococccus aureus (MRSA). A bloodstream infection is a single positive blood culture for MRSA.

MRSA can live on surfaces for months and spreads through contact. Good hand hygiene is the single most effective way to prevent the spread of infectious diseases like MRSA. Mild cases may not require treatment and severe cases may require other antibiotics.

Risk factors for MRSA acquisition include invasive procedures, prior treatment with antibiotics, prolonged hospital stay, stay in an intensive care or burn unit, surgical wound infection and close proximity to a colonized person with MRSA. MRSA can also be transmitted from mother to child through breast milk.

Beginning December 30, 2008, each hospital will post its quarterly rate and new case count of MRSA bacteraemia acquired in their facility on their website.

The first reporting period will cover the months of September, October and November.

At the end of each quarter, the ministry will report the previous quarter's data on its website by hospital site including:

• The number of new hospital acquired MRSA bacteraemia cases that is zero (0) or totalling five (5) or more associated with that hospital site, or if this is fewer than 5 cases (i.e. 1 to 4 cases), text reading "< 5 cases", and
• the hospital acquired MRSA bacteraemia rate

The total number of new cases of MRSA bacteraemia acquired in the hospital in a quarter is divided by the total number of patient days for that quarter. Patient days are the number of days spent in a hospital for all patients. The results are multiplied by 1000. This represents the rate of hospital acquired associated MRSA bacteraemia associated with the reporting facility per 1000 patient days for that quarter. (e.g. 2 cases for that quarter ÷ 30,000 patient days for that quarter = 0.00006 x 1000 = 0.06 per 1000 patient days). The rates of infection will be calculated by quarter.

Hospital acquired infection rates provide one measure of patient safety and quality of care. The rate of hospital acquired MRSA bacteraemia can be used to analyze any trends of infection, sources of infection and general surveillance of MRSA bacteraemia. It can also assist hospitals to evaluate the effectiveness of infection prevention and control interventions and make further improvements based on this information.

Hospitals that identify high rates of MRSA/VRE bacteraemia should review their infection prevention and control practices to ensure that these align with best practices, including those recommended in the PIDAC documents. They should review their hospital surveillance practices, environmental cleaning practices and consult their local Public Health Unit (PHU) and Regional Infection Control Network (RICN) to identify if there are any further actions that they should consider taking.

MRSA and VRE bacteraemia are not reportable to the local Medical Officer of Health under the Health Protection and Promotion Act because outbreaks of MRSA/VRE bacteraemia are rare. Public reporting of MRSA/VRE bacteraemia as a patient safety indicator is important because they are an important source of surveillance information as they represent the severe end of the spectrum of infection.

No. MRSA rates should not be used as a guide to choosing which hospital to seek care at. These rates are indicators and represent only a snapshot of an isolated area of a hospital's performance. Like other indicators, it is important to look at MRSA rates in a broader context.

Hospital care is complicated and depends on many factors. That is why many indicators must be examined in order to get a sense of how hospitals are performing - where they excel and where improvements could be made. It is important to look at all of these indicators in combination. To judge performance based on only one indicator would be misleading.

Since 2004, the ministry has been building capacity in the health system to respond to and address infectious diseases in health care settings.

The government's approach to combating infectious diseases in our hospitals entails:

1. Turning expert advice into action;
2. Supporting our frontline health care workers; and
3. Establishing strong leadership and clear lines of accountability.

First, the government is using expert knowledge to understand the science of infectious diseases and combat its spread.

In 2004, the government established the Provincial Infectious Diseases Advisory Committee - known as PIDAC - that pulls together experts in public health and infectious diseases to give government the best and most current advice on infectious diseases.

The government established the Ontario Agency for Health Protection and Promotion in 2007 to position Ontario as a world leader in public health.

Second, the government is supporting frontline health care workers in their various roles to help prevent the spread of infectious diseases by:

• launching a provincial hand hygiene program in March 2008;
• funding 166 additional hospital infection prevention and control practitioner positions in hospitals since 2004;
• creating 14 Regional Infection Control Networks since 2004 to share best practices and pool limited resources;
• launching Infection Control Resource Teams in 2008 to provide rapid, on-site assistance with outbreak investigation and management in hospitals
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• providing ongoing education to hospital staff in collaboration with PIDAC, the Ontario Hospital Association, and the Regional Infection Control Networks (RICNs);
• making available web-based learning modules for health care workers; and
• developing leading edge [Generic Output Specification] guidelines in Fall 2008 to ensure that new hospital construction in Ontario is designed to improve infectious disease control and hand washing; and

• announcing a plan in May 2008 to mandate public reporting of eight patient safety indicators
• making C. difficile outbreaks reportable to our public health units beginning in September 2008; and
• establishing clear expectations for hospitals and medical officers of health in the response and management of infectious disease.

Improving hand hygiene, through the use of soap and water or alcohol-based hand rub, is the single most effective way of reducing the spread of infections.

A multi-faceted hand hygiene program for all Ontario hospitals - called Just Clean Your Hands - was launched in March 2008. The government has provided hospitals with train-the-trainer sessions, tools and materials (including educational CD-ROMs, posters and other visual reminders), an audit process to evaluate the program's impact, and a website for easy access to information and a place for hospitals to share lessons learned. It is designed to highlight the need for all hospital staff to be engaged in rigorous hand washing practices.

Public reporting of hand hygiene compliance among hospital staff will begin on April 30, 2009.

The Institute for Safe Medication Practices (ISMP) Canada is completing a review of antibiotic use in Ontario hospitals for the ministry. A full report is anticipated in the near future. This report will provide a basis on which to provide guidance for the health care system in establishing best practices for the judicious use of antibiotics. Currently there are a number of best practice documents and guidelines available from professional organizations throughout Canada related to judicious antibiotic use. The ministry will ensure that these best practices are made available to providers. This will include working with the regulatory colleges for the various health care professions