CDC: Hospitals "need to do more" to control MRSA

AHRQ report disheartening

Five percent of patients treated in U.S. hospitals for methicillin-resistant Staphylococcus aureus (MRSA) die from the infection, says a new report from the Agency for Healthcare Research & Quality.1 Nearly 19,000 Americans died in 2005 of MRSA infections, according to a study from the Centers for Disease Control and Prevention (CDC). Researchers project that 94,360 patients developed an invasive infection from the pathogen in 2005, and 85% appear to be traceable back to hospitals, nursing homes or medical clinics.2

What are the implications of these statistics?

"The study suggests that MRSA is an important cause of infection in health care facilities in this country, and that health care facilities need to do more to control it," says John A. Jernigan, MD, MS, acting deputy chief of the CDC's Prevention and Response Branch.

Appropriate strategies must be fully implemented, regularly evaluated for effectiveness, and adjusted so there is a consistent decrease in the incidence of targeted multidrug-resistant organisms (MDROs) such as MRSA, says Jernigan. Successful prevention and control of MDROs requires administrative and scientific leadership, and a financial and human resource commitment, he says.

"We've got to martial all of the forces, otherwise this bacteria will remain in our environment. Everybody's got to do their job," says William F. Minogue, MD, FACP, executive director of the Maryland Patient Safety Center in Elkridge.

Over the years, staph has "reared its ugly head" several times, says Minogue, but each time the pharmaceutical industry came up with an antibiotic that worked. "Methicillin was supposed to be the magic one that was going to continue to work, but that is not so anymore," he says. "Unfortunately, there is a lot of hysteria in the community that I don't think is really warranted if we all change some of our hygiene behaviors."

Here are three interventions hospitals should be doing:

• Hygiene practices.

This includes hand washing or use of an alcohol-based sanitizer before and after every patient contact and before and after putting on gloves, wearing gowns when visiting or caring for people who are sick or carry bacteria such as MRSA, and meticulous cleaning of the environment and equipment.

"There is a tremendous amount of pressure on this," says Minogue. "We are seeing enforcement at a level we have never known before."

• Isolating infected patients and having staff use contact precautions.

While some hospitals have reduced infection rates with this practice, there is some concern that it could result in poor care for isolated patients. CDC guidelines recommend that hospitals attempt to reduce their infection rates by first improving hygiene procedures, and that they resort to screening high-risk patients only if other methods fail.

• Active surveillance.

"This is somewhat new to us, to find out when people come in the door whether they are carrying the bacteria or not," says Minogue.

Most hospitals are doing active screening for intensive care unit patients because they are the most vulnerable. "Some have added the neonatal ICU to that. And some are beginning to screen patients coming from other community venues, such as dialysis centers," says Minogue.

Previously, active surveillance wasn't really practical because it took 48 to 72 hours to get results, until recently. "Meanwhile, colonized patients moved through the system of care undetected," says Minogue. "Now with quick turnaround tests it's a different game — on average you have an answer in about 12 hours — and that is very good news."

At Henry Ford Health System in Detroit, surveillance cultures for MRSA are taken upon a patient's admission to an ICU and weekly thereafter. "Once positive cultures are received, patients are placed in contact precautions for the remainder of their ICU admission," says Sue A. Lloyd, MT(ASCP), CHSP, CIC, manager of infection prevention. Patients undergoing high-risk surgery have nasal swabs preoperatively. If positive for MRSA, vancomycin will be used for prophylactic antibiotics.

Collaboration is key

Ten Maryland hospitals have joined forces with the Maryland Patient Safety Center. The hospitals are using a different approach than the typical educational campaigns targeting health care workers. The "Positive Deviance" method asks hospitals to look for unique practices that already exist in units, that make it possible for everyone to always follow infection control practices. Some examples:

  • Hooks were placed outside patient rooms so doctors had a place to hang their white coats while wearing protective gowns in isolation.
  • Clergy covered their bibles with surgical caps to avoid carrying infections from patient to patient.
  • Housekeeping staff developed checklists for cleaning rooms, then tested the effectiveness of their process with a glow-in-the-dark chemical that showed the spots they missed.
  • One nurse mentioned that she stocked her ICU patient rooms with full bottles of hand sanitizer each morning, so health care workers, therapists, family, and other visitors could easily remember to always wash their hands. Now all the nurses on her unit are doing the same thing.

"Patients acquire MRSA infections in every American hospital today. Those who deny that are either lying or not looking," says Richard Boehler, MD, vice president for medical affairs and chief medical officer at St. Joseph Medical Center in Towson, MD, one of the participating hospitals.

At Baltimore Washington Medical Center in Glen Burnie, MD, another participating hospital, programs and policies have been instituted to control the spread of MRSA. "Ongoing education of staff, patients, and family is also a goal," says Donna Lemmert, RN, CIC, infection control coordinator.

The emphasis is on hand hygiene and wearing a gown and gloves for contact with all patients who have been identified as having a drug-resistant organism.

The hospital has identified critical care unit patients as a high risk of being carriers of MRSA. "All patients who are admitted to our ICU and CCU are screened at the time of admission for MRSA," says Lemmert.

The hospital uses technology that identifies positive patients within three hours. If cultures are positive, the patient is placed on contact precautions, which requires people who enter the room to not only clean their hands before and after contact with the patient, but also to wear a gown and gloves while in the room.

In addition, all patients are screened who are undergoing orthopedic surgical procedures that require implanted joints, and if positive, are treated before they undergo surgery.

St. Joseph's began doing active surveillance nasal cultures on all patients admitted to the ICU in 2000. High-risk patients are routinely prophylactically isolated while awaiting culture results, and about 20-25% of this group are culture positive.

"It is important to differentiate between colonization and infection with MRSA. A lot of the statistics surrounding MRSA and hospitals batch the carriers with those infected," says Boehler. "We isolate both groups, of course, but there is a profound difference in the two groups."

The carriers, mostly nasal and some skin fold, are by far the biggest group, and are at risk going forward of becoming infected with surgery, major illness or wound.

"For me, community means acquired prior to hospitalization at my facility," says Boehler. "This includes patients from institutional settings such as nursing homes, other hospitals in transfer or recently discharged, as well as the 'at large' citizen. Clearly, the former groups are the most prone to being colonized or infected."

The hospital has seen a 5 to 10% increase per year for the last several years in the numbers of patients presenting from the community with MRSA, both colonized and infected. "In the same time frame, we have been successful in reducing the incidence of hospital-acquired MRSA by 45%," says Boehler.

As part of its active surveillance, patients are routinely re-cultured upon discharge from the ICU, or every seven days for long-stay patients.

This has been accomplished by rigid attention to contact isolation precautions and hand washing. "We do 'phantom shopper' surveillance by units and by discipline and routinely feedback performance," says Boehler. "We have remained at over 90% compliance with CDC guidelines for quite a long time, but this takes continuous attention."

References

  1. Elixhauser A, Steiner C. Infections with methicillin-resistant Staphylococcus aureus (MRSA) in U.S. Hospitals, 1993-2005, HCUP Statistical Brief No. 35, July 2000. Agency for Healthcare Research and Quality, Rockville, MD.
  2. Klevens RM, Morrison MA, Nadle J, et al. Invasive Methicillin-Resistant Staphylococcus aureus Infections in the United States JAMA. 2007;298:1763-1771.

[For more information, contact:

Richard Boehler, MD, Vice President for Medical Affairs/Chief Medical Officer, St. Joseph Medical Center, 7601 Osler Dr., Towson, MD 21204-7582. E-mail: RichardBoehler@catholichealth.net

Donna Lemmert, RN, CIC, Infection Control Coordinator, Baltimore Washington Medical Center, 301 Hospital Dr., Glen Burnie, MD 21061.

Sue A. Lloyd, MT(ASCP), CHSP, CIC, Manager, Infection Prevention, Henry Ford Health System, One Ford Place, Detroit, MI 48202. Phone: (313) 874-4329. Fax: (313) 874-9515. E-mail: slloyd3@hfhs.org.

William F. Minogue, MD, FACP, Executive Director, Maryland Patient Safety Center, 6820 Deerpath Rd., Elkridge, MD 21075-6234. Phone: (410) 540-9210. Fax: (410) 540-9139. E-mail: wminogue@marylandpatientsafety.org.

Guidance on management of MDROs is available from the CDC's Healthcare Infection Control Practice Advisory Committee. Visit www.cdc.gov.]