PA PSRS Patient Saf Advis 2007 Dec;4(4):124-9.
Prompt Identification and Effective Communication of Status May Reduce MRSA Infections
Infectious Diseases; Nursing
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Introduction

More than 1,700 reports related to methicillin-resistant Staphylococcus aureus (MRSA), including 14 deaths, have been submitted to PA-PSRS since its inception through October 2007. Less than 10% of MRSA reports indicated the facility performed a MRSA screening upon a patient’s admission. Approximately 13% of reports submitted to PA-PSRS indicated that a patient’s MRSA status, either an infection or colonization, was not communicated to healthcare workers. Failure to adequately identify and/or communicate patients’ MRSA statuses can perpetuate infection and transmission to other patients and healthcare workers.

The sometimes devastating effect of an invasive MRSA infection is demonstrated in the following PA-PSRS report.

Patient readmitted mid-July with recurrent MRSA bacteremia from an infected [intravenous (IV)] site during previous admission. When patient was discharged, [after this previous admission] blood cultures had been negative, and patient was discharged on IV antibiotics. Patient was readmitted with recurrent MRSA bacteremia and developed paralysis of lower extremities related to septic thrombophlebitis of the spinal cord with compression.

Staphylococcus aureus is a common bacteria residing on the skin and nasal passages, and it can cause infection when it gains access to the body through an open cut in the skin.1,2 MRSA is a type of Staphylococcus aureus that is resistant to certain antibiotics, including methicillin, oxacillin, penicillin, and amoxicillin.3 MRSA bacterial strains include healthcare-associated MRSA (i.e., MRSA acquired in healthcare facilities) and community-associated MRSA (i.e., MRSA acquired in the community, usually associated with skin infections such as abscesses).1,3

Among multidrug-resistant organisms (MDROs), MRSA is identified as a target organism because methods implemented to reduce MRSA may be applicable to limiting transmission of other MDROs.4 Despite the efforts of healthcare facilities aimed at reducing infection, MRSA infections continue to cause harm to patients. Although elimination of MRSA from healthcare facilities is a complex process, a comprehensive infection control program may decrease its prevalence and incidence. A comprehensive program includes the following: screening patients for colonization and infection (i.e., active surveillance), strict adherence to isolation precautions for colonized and or infected patients, development and implementation of hand hygiene protocols, and improvement in the decontamination of medical equipment and the healthcare environment.

This article will discuss the components of a comprehensive program aimed at reducing MRSA infections in hospitalized patients. Obtaining leadership buy-in and gaining their support is essential for the success of programs aimed at reducing MRSA infections. An administration committed to reducing MRSA provides the needed resources to implement a comprehensive program and the motivation for changing to a culture of patient safety.5

Problem

Healthcare-associated infections (HAIs) including MDROs such as MRSA remain a major cause of morbidity, mortality, increased hospital length of stay, and increased healthcare costs.1 Although there is variation in the reporting of MRSA incidence and prevalence, a recent study by the Centers for Disease Control and Prevention (CDC) conducted at 9 U.S. sites from July 2004 through December 2005 indicated there were 8,987 observed cases of invasive MRSA.1 HAIs numbered 7,639 (85%) and community-associated infections numbered 1,234 (13.7%). There were 114 (1.3%) infections that could not be classified.1 From the number of observed cases, CDC estimated the prevalence of invasive MRSA infections nationwide in 2005 at 94,000 cases;1 these infections were associated with death in nearly 19,000 cases.1

Based on 2004 data, the Pennsylvania Health Care Cost Containment Council reported 13,722 hospitalized patients had a MRSA-related infection. A comparison of patients without a MRSA infection revealed that patients with a MRSA infection were four times more likely to die, and on average, patients with MRSA had an increased length of hospital stay (i.e., up to eight days longer). The average charge for a patient’s hospital stay with a MRSA infection was $87,990, compared to an average charge of $28,711 for a patient without a MRSA infection.6 While not all of these differences are necessarily attributable to the infections alone, they do suggest the magnitude of the problem.

Several factors have contributed to the increase and spread of MRSA, including the unnecessary use of antibiotics over the last two decades for conditions not requiring or responding to antibiotics and the transmission of infections by means of the contaminated hands of healthcare workers from patient to patient due to poor compliance with hand hygiene.1,7 MRSA can also be spread from one person to another through contaminated objects or person to person contact in the community.1

PA-PSRS Data

PA-PSRS reports that discuss screening for MRSA indicate problems in the following areas: delay in order entry, mislabeling of specimens, and specimens not being collected according to protocol. The following reports demonstrate these problems with MRSA screening.

Patient transferred to unit. MRSA screen of the nares was ordered. Upon reviewing chart (five days later), screen was never sent. Patient also had a history of MRSA of the nares and had roomed with other patients.

A nasal MRSA surveillance was ordered, but the specimen was mislabeled. The unit was notified.

A nasal specimen for MRSA screening was collected incorrectly in the wrong vial instead of the required vial for culture. Floor was notified to recollect.

Analysis of PA-PSRS reports indicates problems with identification and communication of MRSA status, resulting in either delayed implementation of isolation precautions or failed recognition of MRSA status by others due to a lack of chart documentation and/or lack of visible isolation signs. Examples of these problems follow in the reports below.

Patient with history of being treated for MRSA was not documented on chart. [Patient’s status was] discovered by anesthesia staff, who notified the nursing floor. The patient went to angiography for a procedure. Report called to floor post procedure, and staff on floor did not notify radiology of MRSA history.

Patient with MRSA, [but there was] no isolation cart or contact isolation sign outside the door.A patient who was in isolation for history of MRSA was in a private room but not placed on isolation precautions for six days. Isolation [precautions were] placed when the error was noted.

Patient was on contact isolation for [vancomycin-resistant enterococci] and MRSA. Staff were not following protocol of wearing gown/gloves.

Effective Components of a Program to Reduce MRSA

Active “Surveillance System”

A surveillance system is an ongoing and comprehensive method of measuring health statuses, outcomes, and related processes of care, and analyzing data and providing information from data sources within a healthcare facility to assist in reducing HAIs.8

The success of active surveillance has been demonstrated at the VA Pittsburgh Healthcare System (VAPHS). VAPHS was the leader in researching and implementing initiatives to reduce MRSA infections, providing direction at the national level. The MRSA Prevention Initiative began as a pilot program at VAPHS in 2001.The VAPHS “Getting to Zero” initiative focuses on active surveillance and contact isolation precautions.9 Evanston Northwestern Healthcare, Illinois, is another healthcare system that demonstrated success in reducing MRSA with a universal MRSA surveillance program. Upon patient admission to any of its three hospitals, staff conduct a nasal swab of all patients to culture for MRSA. In the first year of the program, Evanston reduced MRSA infection rates by 60%.10

Beginning in 2008, Pennsylvania hospitals will be required to screen and culture all nursing home patients on admission for MRSA and implement procedures to identify other high-risk patients who require screening.8 (For more information, see the sidebar about Pennsylvania legislation.)

Facilities must develop procedures to identify other high-risk patients admitted to the hospital. A comprehensive review of patients infected with MRSA can identify populations at risk within a healthcare facility.5 For example, 26% of reports submitted to PA-PSRS identified the intensive care unit (ICU) as the patient care area for patients with a MRSA infection. The National Nosocomial Infections Surveillance System has reported increased rates of MRSA among ICU patients from 38% in 1995 to reducing MRSA infections for ICU patients who have a higher rate of infection than other hospitalized patients.12 Screening and culturing ICU patients may help reduce the spread of MRSA. Other high-risk patients to consider for screening include those with following history or characteristics: current or recent hospitalization (i.e., within the last 12 months), long-term care facility residence, recent invasive procedure, HIV infection, intravenous drug use, hemodialysis, age over 65 years, recent or long-term antibiotic use, and previous MRSA infection or colonization.1,13

Computerized surveillance systems that identify patients previously screened for MRSA are valuable assets. Identification in this fashion may facilitate communication throughout the facility of patient’s MRSA status. For example, facilities with computerized systems may set up databases that prepopulate MRSA status of previously admitted patients and new admissions. Automation may help alert practitioners to this critical clinical information. Additionally, an outreach process for notifying a receiving healthcare facility of a colonized patient prior to transfer is an important component of an active surveillance system.

The following points summarize screening strategies facilities may implement to reduce the spread of MRSA (an asterisk indicates a strategy required for implementation by Act 528):

  • Developing standing orders for MRSA screening to increase compliance
  • Screening for MRSA all nursing home patients and other high-risk populations identified at the facility*
  • Screening high-risk patients on admission, transfer, and discharge from the facility14
  • Obtaining cultures within two hours of admission14
  • Providing mandatory educational programs for facility personnel*
  • Educating staff on proper specimen technique and requiring annual competency14
  • Providing patient care areas with adequate supplies to perform nasal and/or wound cultures14
  • Developing a method to identify patients on admission who previously screened MRSA-positive5
  • Developing a process to notify receiving healthcare facilities about patients who are known to be colonized or infected with MRSA5*

Isolation Precautions

Since 1983, CDC has recommended that facilities place patients with known or suspected infections or colonization with MDROs such as MRSA in contact isolation.7 Contact isolation includes adherence to hand hygiene and the use of gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient’s environment. Contact isolation is intended to prevent the transmission of infectious agents, which are spread by direct or indirect contact with the patient or the patient’s environment.15 A single patient room is preferred for isolation. When single room isolation is not possible, cohorting care may be implemented to prevent transmission of MRSA. Cohorting refers to the practice of grouping patients infected or colonized with the same infectious agent together to confine their care to one area and prevent spread of the organism to susceptible patients (cohorting patients). During infectious outbreaks, healthcare workers may be assigned to a cohort of patients to further limit opportunities for transmission (cohorting staff).16 Although there have been limited studies demonstrating the effectiveness of cohorting patient care, when properly executed, cohorting may limit the opportunities for transmission of MRSA from patient to patient by means of healthcare workers’ contaminated hands or clothing.7

Facilities may consider the following strategies aimed at the processes for implementation of isolation precautions:

  • Providing adequate supplies for isolation that are readily available in all patient care areas
  • Including consistent documentation in the medical record of isolation precautions for MRSA patients
  • Assigning designated staff to post appropriate signage for contact isolation outside the patient rooms
  • Discussing isolation status for MRSA during hand-off communication within the facility5
  • Educating and training healthcare workers to ensure policies and procedures for contact isolation are understood and practiced7,16
  • Educating patients, family members, and visitors (e.g., using informational handouts) about proper hand hygiene, use of gown and gloves, and care of equipment7,16
  • Conducting ongoing audits to determine effectiveness of methods implemented7,16

Hand Hygiene

Hand hygiene may be the single most important measure for controlling the transmission of MDROs. Since 1987, CDC has recommended that staff participate in hand washing after patient contact.7 In October 2002, CDC suggested that alcohol-based hand rubs be the primary choice for hand decontamination and named antimicrobial soaps as an acceptable alternative for when hands are visibly contaminated. Hand rubs can be used in a variety of clinical situations, including before and after patient contact and after touching objects in the patient environment that could be associated with colonized pathogens.17 Despite the evidence supporting hand washing as a key element in reducing transmission of HAIs, healthcare workers’ adherence to recommended hand hygiene practices is unacceptably low, with average compliance estimated as less than 50% in acute care facilities.5 Handwashing frequency varies by type of healthcare worker and by clinical service.18 Several barriers have been identified that prevent healthcare workers from performing hand hygiene. These include inadequate staffing, inaccessible sinks or lack of hand gel products, and reluctance due to skin irritation from frequent hand washing.5,19,20

Implementing a comprehensive hand hygiene program may improve hand washing compliance among healthcare workers. Elements of a successful, sustainable hand hygiene program include the following:

  • Ensuring easy access to alcohol-based hand rubs17
  • Promoting skin care by providing hand lotions17
  • Providing ongoing education to healthcare workers about hand hygiene techniques and clinical situations that warrant hand washing17
  • Conducting routine observation of hand hygiene practices and providing consistent feedback17
  • Using reminders in the workplace (e.g., posters) to motivate compliance with hand hygiene17
  • Educating patients about hand washing and transmission of infectious diseases in its absence, and encouraging patients to ask healthcare workers if they have washed their hands17
  • Using motivational activities (e.g., contests among patient care areas for the highest compliance rates) to achieve long-lasting compliance17

Environmental Issues

Equipment. Multiple studies have demonstrated that equipment carried by healthcare workers (e.g., stethoscopes, tourniquets, sphygmomanometer cuffs, otoscopes, pagers, scissors) and other items transported from patient to patient can become contaminated. These items may serve as a vector for MRSA and other MDROs, either through direct contact with patients or through contact with healthcare workers’ contaminated hands.7

Strategies to target equipment that has potential to serve as a vector for transmission of MRSA may include the following:

  • When a patient is in isolation, dedicating equipment solely to his or her care, whenever possible7
  • Setting a schedule to regulate cleaning of patient’s room and equipment in use for his or her care7
  • Implementing processes to ensure equipment is adequately cleaned and disinfected for use between patients7

Patient care area. Another area of concern is the patient’s bed and surrounding surfaces. MRSA has been isolated from a variety of patient care items and environmental surfaces. Muto et al. cited a study that found that MRSA could survive on the external surface of sterile goods packages for more than 38 weeks.7 The cleaning and disinfecting of all patient care items is important, especially those closest to the patient that are likely to be touched (e.g., bedrails, bedside tables, commodes, doorknobs, telephones, nurse call buttons).

Strategies aimed at disinfecting patient rooms may include the following:

  • Conducting in-service education for housekeeping personnel that addresses:
    • Transmission modes of MRSA and other MDROs
    • Assigned daily cleaning time
    • Additional cleaning throughout the shift
    • Use of a checklist to track cleaning7,16
  • Frequently cleaning and disinfecting commonly touched surfaces7,16
  • Thoroughly applying disinfectant by “active damp scrubbing” or “wet bucket” (These methods involve saturating the surface with disinfectant, leaving surfaces wet for 10 minutes and then wiping dry with clean towels, as opposed to the traditional method of quickly wiping surfaces with a cloth lightly sprayed with disinfectant.)7
  • Assigning cleaning personnel to specific patient care areas7,16
  • Strictly adhering to facility procedures for cleaning and disinfecting7,16
  • Using disinfectants effective against MRSA, such as quaternary ammonium compounds, phenolics, and iodophors for housekeeping7

Summary

The incidence of MRSA infection continues to increase among hospitalized, at-risk patients. Analysis of PA-PSRS reports identified that screening procedures are not consistently performed, and that even when facilities identify MRSA-positive patients, failure to communicate patients’ MRSA statuses is common. Limiting the risk of MRSA transmission involves the development of a comprehensive program that includes the following essential elements: conducting active surveillance, adherence to contact isolation precautions, improvement in healthcare workers adherence to hand hygiene protocols, improvement in the decontamination of medical equipment and the healthcare environment, and ongoing evaluation of processes implemented to reduce MRSA transmission.9

As hospitals and other healthcare facilities begin to implement the essential components of a comprehensive program to prevent the transmission of MRSA, it is theorized that the same results seen at VAPHS and Evanston Northwestern will be replicated nationwide.

Notes

  1. Klevens RM, Morrison MA, Nadle J, et al. Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA 2007 Oct 17;298(15):1763-71.
  2. Elixhauser A, Steiner C. Infections with methicillin-resistant Staphylococcus aureus (MRSA) in U.S. hospitals, 1993-2005 [statistical brief #35 online]. 2007 Jul [cited 2007 Nov 15]. Available from Internet: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb35.pdf.
  3. Centers for Disease Control and Prevention. Healthcare-associated Methicillin resistant Staphylococcus aureus (HA-MRSA). 2007 Oct 24 [cited 2007 Nov 15]. Available from Internet: http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html.
  4. Richet HM, Benbachir M, Brown DE, et al. Are there regional variations in the diagnosis, surveillance, and control of methicillin-resistant Staphylococcus aureus? Infect Control Hosp Epidemiol 2003 May;24(5):334-41.
  5. Pittet D. Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerg Infect Dis 2001 Mar-Apr;7(2):234-40.
  6. Pennsylvania Health Care Containment Council. MRSA linked to nearly 14,000 PA hospitalizations in 2004 [press release online]. 2006 Aug 25 [cited 2007 Oct 29]. Available from Internet: http://www.phc4.org/reports/researchbriefs/082506/nr082506.htm.
  7. Muto CA, Jernigan JA, Ostrowsky BE, et al. SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and enterococcus. Infect Control Hosp Epidemiol 2003 May;24(5):362-86.
  8. Medical Care Availability and Reduction of Error (MCARE) Act. 40 P.S. § 1303.401, et. seq. (2007).
  9. VA Pittsburgh Healthcare System. National MRSA-prevention initiative being led by VA Pittsburgh Healthcare System [press release online]. 2006 Aug 1 [cited 2007 Dec 4]. Available from Internet: http://www.va.gov/pittsburgh/vaphs_press_releases.htm.
  10. Evanston Northwestern Healthcare. MRSA screening program at ENH significantly reduces chance of infection. 2007 Sep 21 [cited 2007 Dec 5]. Available from Internet: http://www.enh.org/aboutus/press/article.aspx?id=5329&lid=141.
  11. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 2004 Dec;32(8):470-85.
  12. Huang SS, Yokoe DS, Hinrichsen VL, et al. Impact of routine intensive care unit surveillance cultures and resultant barrier precautions on hospital-wide methicillin-resistant Staphylococcus aureus bacteremia. Clin Infect Dis 2006 Oct 15;43(8):971-8.
  13. Centers for Disease Control and Prevention. MRSA in healthcare settings [online]. 2007 Oct 3 [cited 2007 Oct 17]. Available from Internet: http://www.cdc.gov/ncidod/dhqp/ar_MRSA_spotlight_2006.html.
  14. MRSA reduction: a national, state, regional, and community effort. Pennsylvania IHI Node Partners: IHI Campaign Update 2007 Apr 6:1-2.
  15. Centers for Disease Control and Prevention. Information about MRSA for healthcare personnel [online]. 2007 Oct 10 [cited 2007 Oct 26]. Available from Internet: http://www.cdc.gov/ncidod/dhqp/ar_mrsa_healthcareFS.html.
  16. Siegel JD, Rhinehart E, Jackson M, et al. 2007 guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings [online]. 2007 Jun [cited 2007 Nov 15]. Available from Internet: http://cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf.
  17. Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee. Society for Healthcare Epidemiology of America. Association for Professionals in Infection Control. Infectious Diseases Society of America. Hand Hygiene Task Force Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 2002 Dec;23(12 Suppl):S3-40.
  18. Pittet D, Mouroouga P, Pereger TV. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999 Jan;130(2):126-130.
  19. Pittet D, Simon A, Hugonnet S, et al. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004 Jul 6;141(1):1-8.
  20. Henderson DK. Managing methicillin-resistant staphylococci: a paradigm for preventing nosocomial transmission of resistant organisms. Am J Infect Control 2006 Jun;34(5 Suppl 1):S46-54.

Supplemental Material

Pennsylvania Legislation Aimed at Reduction and Prevention of HAIs

Pennsylvania is one of the first states to pass legislation concerning healthcare-associated infections (HAIs), in-cluding the following in reverse chronological order.

Act 52 of 2007 Senate Bill No. 968

Act 52 amends the Medical Care Availability and Reduction of Error (Mcare) Act of March 2002 and establishes requirements for internal infection control plans in ambulatory surgical facilities, hospitals, and nursing homes. Act 52 requires facilities to have effective measures for the detection, control, and prevention of HAIs; culture surveillance processes and policies; and a system to identify and designate patients known to be colonized or infected with MRSA or other MDROs.1

Act 52 establishes requirements for hospitals and nursing homes to report HAI information. Hospitals are required to report HAI data to the Centers for Disease Control and Prevention through its National Healthcare Safety Net-work. Nursing homes are required to electronically report patient-specific HAI data to the Department of Health and the Patient Safety Authority.1 For more information, refer to the December 22, 2007, Pennsylvania Bulletin (http://www.pabulletin.com).

Act 52 states the cost of routine cultures and screenings performed on patients in compliance with a healthcare facility’s infection control plan shall be considered a reimbursable cost to be paid by health payers and medical assistance upon federal approval.1

Act 14 of 2003

In July 2005, Pennsylvania became the first state to publicly report HAI data, which was collected by the Pennsylvania Health Care Cost Containment Council (PHC4). The reports have focused on four types of healthcare associated infections including: central line-associated bloodstream infections, ventilator-associated pneumonia, surgical site infections, and indwelling catheter-associated urinary tract infections.2 PHC4, according to Act 14 of 2003, is charged with collecting, analyzing, and reporting information related to improving quality and restraining the cost of healthcare in Pennsylvania.3

Notes
  1. Medical Care Availability and Reduction of Error (MCARE) Act.  40 P.S. § 1303.401, et. seq. (2007). 
  2. Pennsylvania Health Care Containment Council. MRSA linked to nearly 14,000 PA hospitalizations in 2004 [press release online]. 2006 Aug 25 [cited 2007 Oct 29]. Available from Internet: http://www.phc4.org/reports/researchbriefs/082506/nr082506.htm.
  3. Health Care Cost Containment Act 35. P.S. § 449.5 (2007).

Self-Assessment Questions

The following questions about this article may be useful for internal education and assessment. You may use the following examples or come up with your own.

  1. Which one of the following is the most common  mode of methicillin-resistant Staphylococcus aureus (MRSA) transmission?
    1. Equipment in the patient’s room
    2. Airborne particles
    3. Blood and body fluids
    4. Contaminated hands of healthcare workers
  2. An active surveillance program includes which one of the following?
    1. Obtaining cultures for MRSA two days after admission
    2. Culturing all patients
    3. Using a hand hygiene program
    4. Increasing housekeeping staff
  3. All of the following risk reduction strategies may reduce MRSA infections EXCEPT?
    1. Developing standing orders to screen high-risk patients for MRSA
    2. Placing patients screened for MRSA on contact isolation until results are known
    3. Ensuring easy access to hand gels for use after patient contact
    4. Educating patients and families about healthcare-associated infections
    5. Treating non-affected patients with prophylactic methicillin
  4. All of the following characteristics may identify patients at high risk for developing MRSA infections EXCEPT?
    1. HIV infection 
    2. Age under 65 years 
    3. Hospitalization within the last 12 months 
    4. Long-term care residence
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