Hospitals should continue to conduct routine risk assessments to determine how well their infection control strategies are working before rushing to adopt a highly touted and possibly costly new protocol, says a member of the board of the Association for Professionals in Infection Control and Epidemiology.
The report that an antibiotic ointment and special soap kill more MRSA (methicillin resistant staphylococcus aureus) bacteria in intensive care units than screening and isolating patients found positive may come as a shock to hospital infection control chiefs, says a representative of a national association of infection preventionists.
"This was a great study, very large and robust, with lots of hospitals," says Marc-Oliver Wright, MT, corporate director of infection control for the four-hospital NorthShore University HealthSystem in Evanston, IL, and a member of the board of the Association for Professionals in Infection Control and Epidemiology. "I'm sure this is landing like a small bomb in my state as well.
I'd be surprised if there's any responsible organization in this country that isn't looking at this article and asking themselves the question, 'should we change our practice,'" he says.
"But to be honest, the last thing I would want is for people to rush out and modify their practices, or create new legislative mandates based on one paper," Wright says.
The research published in Thursday's New England Journal of Medicine compared three types of ICU infection prevention strategies at 43 hospitals owned by the Hospital Corporation of America. The protocol with the greatest success—universal decolonization with chlorhexidine baths and nasal mupirocin—showed 44% reduction of bloodstream infections. But that strategy is practiced in very few hospitals around the country.
The strategy with the poorest results, screening and isolating those patients infected, is actually commonplace at most hospitals around the country, including those in the VA Healthcare system, and is required by laws in California, Illinois, Nevada, Washington, Minnesota, South Carolina, Pennsylvania, Maine and New Jersey.
Now, however, infection prevention officials for hospitals in those states must consider their own practices and determine whether, in addition to state-mandated ICU screening, isolation and contact precautions—and its considerable costs—they should also start treating all ICU patients with chlorhexidine baths and mupirocin as well to maximize infection reduction.
That's going to be a terrible expense for hospitals in states that mandate screening, Wright says. But he cautions, "don't stop screening, because you'd be really setting yourself up for nothing more than trouble when the state comes to visit."
What hospitals should do wherever they are is what has long been recommended policy and practice, Wright suggests. And that means they should continue to conduct routine risk assessments to determine how well their infection control strategies are working.
"Ask yourselves how do your rates compare to the rates found in each of the three (research) groups," Wright says. "How do your processes compare, say, if you screen, isolate, and decolonize, or screen and decolonize, or screen and isolate and don't decolonize. How do you fit into the three groups published, and make a decision from there whether to change practice."
"If you're doing better than what was published, or you're doing better than you had been doing and are continuing to go down, or if your rates are lower than anything that's been published in your state or published in some of the national benchmarks," perhaps no change is necessary, he says.
The Centers for Disease Control and Prevention intends to have its Healthcare Infection Control Practices Advisory Committee review the research with an eye to changing federal guidance on MRSA screening in treatment for ICUs, but that probably won't happen right away, CDC officials say.
Gina Pugliese, RN, Vice President of the Premier healthcare alliance's Safety Institute, gave similar advice to hospitals wondering how this research should affect them.
"Each hospital must do a risk assessment of its patient population and units and evaluate the study carefully and decide what works best in that hospital…There will be no cookie cutter approach to these changes for sure," she says. "This study does not require any hospital to change its protocol."
The study may prompt changes eventually. "It has broad implications and benefits for hospitals to move toward universal decolonization," Pugliese says. And because the research protocols used existing improvement infrastructures and personnel within those 43 hospitals to test these interventions, they "can be achieved by most hospitals."
Treating patients with mupirocin ointment rather than testing them first also avoids delays in waiting for test results, which can take several days. It also avoids isolating patients in contact precaution settings, which can adversely impact patient safety, Pugliese says.
Extremely important is the fact that how well hospitals reduce MRSA colonization and infection rates will impact their future federal payment, Pugliese says.
For example, she explains, the Centers for Medicare & Medicaid Services Inpatient Quality Reporting program required hospitals to start collecting data on lab-identified MRSA as of Jan. 1, 2013. And CMS is scheduled to post first quarter 2013 results on its Hospital Compare website in December.
Starting Oct. 1, 2016, CMS intends to include MRSA rates in its algorithm to determine value-based purchasing incentives.
Surely time will tell whether states will rush to change their laws in light of this new study. But Wright worries that might not be such good thing. Universal decolonization has some downsides, one of which is development of MRSA strains that resist mupirocin.
That's why his hospital no longer uses that strategy. Instead, it screens patients based on an electronic health record assessment of those at highest risk, which turns out to be 50% of all of its admissions, as well as all patients admitted to the ICU to comply with state law.
Rates at NorthShore's four hospitals are even better than what was published in the NEJM paper, he says. "We haven't done a formal analysis, but when I, our infectious disease physician and hospital epidemiologist looked at this study results, we said, we're not going to do this because we're doing better than they are."
Wright is concerned, however, that state legislatures will overreact. "The thing I'm going to go to bed worrying about tonight is the well-intentioned, well-meaning legislator who is sitting in front of a computer right now with a Word document open."