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Selecting a Strategy to Stop HAI
Cheryl Clark, for HealthLeaders Media , August 15, 2011
This is a tale of three urban hospitals, each grappling with nosocomial infection prevention in three very
different ways. It's hard to tell which one works best, but all are taking on an issue that is at the center of a
national and very charged debate.
The first hospital swabs patients for colonization of methicillin-resistant staphylococcus aureus, the leading
culprit of hospital-acquired infections. And it does so not just as patients are admitted to the intensive care
unit, which is legislatively mandated in that state, but this hospital also screens patients as they leave the
ICU. With this and other infection-reduction measures, rates of MRSA and other HAIs have dropped.
The second hospital aggressively performs MRSA swabs on all patients admitted to all hospital beds, an
expensive undertaking that involves putting some patients in isolation, and coping with the issue of false
positive results. Rates of infections have dramatically declined.
The third hospital has taken an entirely different approach, avoiding testing altogether, except for some
patients undergoing high-risk neuro, cardiac, and joint-replacement procedures. This hospital pays graduate
students to prowl the halls to observe hand-washing practices in an effort to prevent not just MRSA, but
every other destructive bug a hospital might see. ICU patients receive chlorhexidine baths, and staff
members work hard with central line?associated catheter bundles to make sure the devices are used safely.
The hospital saves about $1 million in lab supplies each year. At this hospital, too, rates of infection have
decisively improved.
"We're not looking for any specific organism," says Michael Edmond, MD, hospital epidemiologist at
hospital No. 3, Virginia Commonwealth University Medical Center, an 800-bed hospital in Richmond. "All
the interventions we have implemented are effective against all organisms that are transmitted in the same
way: through contact?MRSA, KPC, vancomycin-resistant enterococcus, C. difficile. You name it.
"The patient's goal when they come to the hospital is not 'I don't want to get a MRSA infection,'" Edmond
says. "It's, 'I don't want to get an infection?period.'"
These three approaches are part of what has become a noisy argument in the field of infection control,
which is becoming all the more volatile as government payers impose financial penalties on hospitals
where these infections occur. Now, an increasing number of states?10 to date?legislate MRSA surveillance
for all ICU patients. No one really knows which strategy is the best, most cost-effective, and resourceefficient for each situation.
One in 20 hospitalized patients develops some kind of infection during the hospital stay, according to the
Centers for Disease Control and Prevention, which estimates the cost of that care at between $28 billion to
$34 billion per year.
The solutions are extremely complex, says John Jernigan, MD, director of the Office of HealthcareAssociated Infection Prevention, Research, and Evaluation at the CDC.
"And how we get there is something that there's still some argument about. The point is, there are more and
more examples of how multidrug-resistant organisms in healthcare organizations can be prevented. People
have been able to move the needle. It's no longer enough to say, 'Well, our rates can't come down because
rates can't come down.'"
But here, in more detail, are these hospitals' stories:
Marcia Patrick, RN, is director of infection prevention and control for MultiCare Health System in Tacoma,
WA. She says she pictures MRSA as "the cloud of debris that surrounds Pigpen, the character in the
cartoon strip, Peanuts.
"We're in an urban area. We have high rates of homelessness and IV drug users. Community-acquired
MRSA showed up about 10 years ago and is very prevalent in the community. Part of the spread came from
people just not cleaning things well or washing their hands, and it allowed these organisms to spread in day
cares, schools, and other public places." Also hospitals.
That's why 3.5 years ago, MultiCare, a four-hospital system with 868 beds, made an about-face on its
infection control policy and launched a program that so far few hospitals have, but more surely will in
coming years: testing ICU patients upon admission to and discharge from the unit. "We look at our trends
and patterns in patients who are negative on admission and positive on discharge to see where there's been
a break in [good infection control] practice. It helps keep us all on our toes," Patrick says. "This quality
measure is a good one to make sure we're providing the safest care we can to our patients." All HAIs at
MultiCare have dropped by about 85% over the past five years, and MRSA infections are less than half
what they were.
Patrick notes that MultiCare may be unusual. "There may be hospitals that don't have this as a problem and
don't have the indication to do the screening that we do."
Two thousand miles east in Chicago, NorthShore University HealthSystem is even more aggressive in
conducting MRSA patient surveillance.
Ari Robicsek, MD, associate chief medical information officer and epidemiologist, says in 2005,
NorthShore was the first hospital system in the country to institute "universal" MRSA testing for all
patients being admitted, not just those entering the ICU.
Today, he says, several hospitals in the United States?although a minority at this point?test all admitted
patients for MRSA. But since NorthShore started screening, despite the high cost of $30 each for 50,000 to
60,000 patients a year, "we've experienced extremely positive results."
From August 2005 to April 2007, "we experienced a 69.6% reduction in infections," Robicsek says. "And
after that, a number of other hospitals followed suit, notably the entire VA healthcare system, adopting a
universal testing on admission policy."
Is that a severe approach?
"We know that if someone is a carrier of MRSA, they have about a 10% risk of going on to develop an
infection," he says. "And that risk is even higher while they're in the hospital. So if we know which patients
are carriers of MRSA, we can isolate them and help prevent them from spreading MRSA to other people,
who themselves have a 10% higher risk of going on to develop an infection."
Separate from its MRSA surveillance program, NorthShore also tests all ICU patients once a month for
gram-negative bacterial strains that are highly resistant to antibiotics, such as E. coli, Klebsiella, and
especially Acinetobacter "so we can take extra special precautions to reduce the spread of these organisms."
"This comes from learning lessons from other places that were not proactive in looking for these bacteria
and were caught unaware with very high rates of infection in ICUs," Robicsek says. The most dramatic
example is in New York state with KPC genes in Carbapenem-resistant Klebsiella. "These are resistant to
virtually all antibiotics we have available, and many ICUs on the East Coast have a high prevalence of
these KPC organisms."
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Robicsek acknowledges that NorthShore is trying to develop a more cost-effective process that minimizes
false positives, which have, in the past, amounted to 1.5% to 2%, or about 1,000 patients a year. "Patients
with false positive results are unnecessarily isolated and treated, a situation that's not ideal for those
patients."
What NorthShore has come up with is an algorithm in the electronic medical record that identifies patients
who are at high risk of developing MRSA infection. It's a clinical decision-support tool programmed to
signal a threshold that would indicate a test is warranted. "With this, we would instead test only 50% of our
patients but would capture nearly all patients with MRSA.
"I suspect that as more hospital systems develop more mature EMR systems, they'll move to something
similar as well."
Virginia Commonwealth is the testing holdout. Edmond says that over the past seven years, since the
hospital instituted aggressive hand hygiene and other changes but avoided taking patients' nasal swabs,
"overall infections in the ICU went down 85%, bloodstream infections dropped 84%, ventilator-associated
pneumonia dropped 95%, MRSA infections dropped 89%, and Clostridium difficile infections are down by
54%."
Meanwhile hand-hygiene compliance went from 45% to 92% over the past few years.
Edmond says the VCU administrator "asks me every year, 'Why don't we test for colonized patients?' And I
say, 'Why?'
"Instead of trying to figure out who's got it, we should assume everybody may have it and do the right thing
every time."
He adds that many state laws, urged on by advocacy groups of patients whose loved ones were harmed or
died because of MRSA, mandate MRSA screening.
"But there are many more organisms out there that do bad things to people, too. And if you think about it,
for MRSA, we have multiple effective antibiotics?but for others, for example Acetobacter strains, we have
no antibiotics that work. I can't make sense of that."
Of course, hand washing isn't the only thing that makes VCU's nosocomial prevention program work,
Edmond says. It also involves basic, commonsense cleanliness, "separating uninfected from infected, clean
things from dirty things."
Also critical is the need to constantly remind hospital staff how they're doing on hand washing with weekly
results of graduate students' surveys. "You can't let up. A lot of the impact you have will extinguish if you
do," Edmond says.
Jernigan advises hospitals to know not only their own transmission rates for HAIs, but also rates in the
region, at other hospitals and long-term care facilities.
"When other patients from these facilities go back to any other hospital in the region, they can help spread
these bugs from facility to facility. So it's pretty convincing that regional awareness, and a regional
approach is likely to have the greatest impact."
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