Divided, Can We Conquer?

Maureen Larkin, for HealthLeaders Media, March 20, 2008

The healthcare industry has long been divided about the best ways to prevent the spread of MRSA--or methicillin-resistant Staphylococcus aureus. Should we test all patients who come to the hospital for treatment, or should we focus our money and resources, testing only those who are at high risk? The results of two studies released last week may have left us even more divided about how we can combat this serious--and sometimes fatal--infection.

The first, released in the March 12 edition of The Journal of the American Medical Association, was done at a clinic in Geneva, Switzerland. The study tested 10,193 patients admitted for surgery between October 2004 and May 2006. Another 10,000 were admitted without the test. Patients who tested positive for MRSA were isolated from other patients, given antibiotics, and scrubbed with disinfectants. Despite these efforts, the number of MRSA infections for each group was similar. Researchers concluded that a universal screening of surgical patients was not worth the time and resources it would take.

The other study, released earlier this week in the Annals of Internal Medicine, shows that universal hospital surveillance for MRSA reduced infection rates by 70 percent at Evanston Northwestern Healthcare--a three-hospital system outside Chicago. During the study, researchers tested different groups of patients for MRSA to determine the best testing methods to combat infection. For the first 12 months, researchers tested no patients, followed by 12 months of testing only patients admitted to the ICU. For the next 21 months, the health system tested all patients who came into the hospital for care. Only universal surveillance was successful in significantly reducing healthcare-associated MRSA infections, the study says.

How can two similar studies bring back two very different conclusions?

"The biggest difference between the two studies was the scope of surveillance," says Ari Robicsek, MD, one of the researchers who worked on the Evanston Northwestern Healthcare study. "Theirs was unit based--it screened only 50 percent of surgical patients at a very large general hospital."

Certainly, the two reports--which appear to be conflicting--haven't done much for settling the debate about the best way to control MRSA. But if you look closely at the two studies, they do, in fact, point to the idea of widespread testing as a way to combat the spread of MRSA. The results gathered by Swiss researchers, who studied only a portion of patients admitted to the hospital in one particular department, are similar to those gathered by physicians at Evanston Northwestern Healthcare when only screening patients admitted to its ICU. It wasn't until Evanston Northwestern started universally testing that the real difference was apparent.

Robicsek says when a hospital only screens specific units, it runs the risk of missing a large number of patients in other departments that are infected by or carry the disease, allowing the bug to metastasize further. Screening all incoming patients makes sure that all cases of MRSA are identified immediately, reducing the time that a patient suffers with the infection and the cost of treating it.

But while universal screening has worked for Evanston Northwestern Healthcare, Robicsek is hesitant to say that every hospital should start universal screening immediately. He recognizes that the Evanston Northwestern study is the first to report on whole-house surveillance.

"When a hospital needs to make a risk assessment, they need to look at how much MRSA disease they are actually seeing," he says. "If a large portion of patients who develop MRSA were those that were not known to have MRSA, then that center would benefit from widespread screening."

More hospitals are moving toward universal testing, but the conflicting appearance of these two studies is sure to create further division in the industry. Unfortunately, it's not a topic on which we can all agree to disagree. MRSA is running rampant in our hospitals and at some point, we'll have to find a solution that works for our budgets, our staff levels, and most important, our patients.

Maureen Larkin is quality editor with HealthLeaders magazine. She can be reached at mlarkin@healthleadersmedia.com.
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