Cal MRSA law raises decolonization issue
Cal MRSA law raises decolonization issue
Patients test positive; now what?
State laws passed in the name of patient safety may straddle infection prevention programs with mandates that ultimately are counterproductive, an infection preventionist warned recently in Fort Lauderdale, FL, at the annual conference of the Association for Prevention of Infection Control and Epidemiology (APIC).
One of the things I am concerned about is that we are getting overlegislated and we are spending precious resource dollars," said Nancy Parris, RN, RHIA, MPH, CIC, CPHQ, an IP at Providence St. Joseph Medical Center in Burbank, CA.
The law in question is California Senate Bill 1058, which became effective Jan. 1 in the state. It requires active surveillance testing (AST) of certain patients for methicillin resistant Staphylococcus aureus (MRSA).
"We're one of the states that recently passed a law — sadly — to do ASTs," Parris told APIC attendees. "It tells us we have to test within 24 hours of admission. It targets certain patients, so it is considered targeted, active surveillance testing."
The California AST law applies to patients:
- discharged from acute care hospitals within 30 days;
- admitted to an intensive care or burn unit;
- receiving inpatient dialysis treatment;
- transferred from a skilled nursing facility;
- those slated for inpatient surgery who have a documented medical condition, making them susceptible to infection.
The law mandates notification of patients who test positive upon admission testing. "The law says the patient shall be notified by the attending physician immediately or as soon as practically possible," Parris explained. Those who test positive for MRSA infection must be provided with oral and written discharge instructions regarding aftercare and precautions to prevent the spread of infection.
"That's effectively all they are telling us to do with these results," she said. "If they are positive for infection that we have to give them written and oral discharge instructions. That fine; that's appropriate. But it is confusing because it is thrown under the same bill in the same area of this surveillance testing, and really they are two different things."
For their part, some physicians understandably want to do more than inform patients they are colonized. "We have educated the physicians," Parris told APIC attendees. "They know they have to talk to the patient and one of the things they say is, "What else do to we need to do?' We tell them nothing else. We are not endorsing [MRSA] decolonization for a number of reasons. This is an unclear law and we are simply testing because we have to. We have comments from some of the physicians that we need to do something else — we need to decolonize."
That raises a costly and potentially ineffective issue, as decolonization can be both expensive and short lasting, she said. "It certainly is not long term; there is not any clear decolonization protocol, and there is [the issue] of emerging resistance of mupirocin to MRSA," she noted. In complying with the law, Parris and colleagues decided to go beyond the patient groups and test a wider variety of patients. "We have had about 215 patients overall that were positive with MRSA on admission," she said. "Half of them fell into one of those defined risk groups and the other half did not. So, if we target our patients and we screen them — and if we were to isolate those and act upon that — we [are still] missing half of the patients that come into the hospitals and are positive for MRSA. It really causes me [to question] why are we screening? What are really gaining from this? If you are going to do this — if you are going to act upon it and isolate or decolonize — you really need to do universal screening."
As a result, the law may require excess expenditures that could go toward environmental services positions or IP staffing, a presumably more effective use of limited funds than testing with some assumption that it will reduce transmission. "It can be useful information and I love it for epidemiology, but it does not interrupt transmission in any way," Parris said. "We need to look at this the way we did with HIV and AIDS — any patient can have MRSA and they also can have a resistant Acinetobacter or carbapenem-resistant Klebsiella. They can have these other organisms. While we are focusing on MRSA, what are we missing?"State laws passed in the name of patient safety may straddle infection prevention programs with mandates that ultimately are counterproductive, an infection preventionist warned recently in Fort Lauderdale, FL, at the annual conference of the Association for Prevention of Infection Control and Epidemiology (APIC).
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