MDRO screening policies and practices vary in ICUs
MDRO prevention continues to be on the forefront of infection prevention, but screening practices are not always uniform, according to a new study.
The study, published in the October issue of the American Journal of Infection Control, shows that screening practices for multidrug-resistant organisms (MDRO) in the ICU vary from facility to facility. Researchers from the Columbia University School of Nursing in New York City analyzed survey data from infection preventionists (IP) at 250 hospitals that participated in the CDC's National Healthcare Safety Network in 2008.
The majority of ICUs (59%) across the country routinely screened for MRSA, although fewer hospital ICUs screened for deadlier organisms such as vancomycin-resistant Enterococcus (22%), gram-negative rods (12%), and Clostridium difficile (11%).
Additionally, 40% of ICUs had a written policy to screen for any MDRO, but only 27% had a policy for periodic screening following admission. One-third of ICUs had a policy on isolation or contact precautions, and nearly every respondent (98%) required contact precautions for patients with a positive culture.
Although the numbers were slightly surprising, there is also some indication that hospitals are placing more emphasis on infection control in relation to patient safety, says Monika Pogorzelska, PhD, MPH, associate research scientist at the Columbia University School of Nursing, and lead author of the study.
"There really needs to be a recognition on the hospital's part that infection control is an important priority for the hospital and has a huge impact on patient safety," Pogorzelska says. "Now that impacts reimbursement through CMS with some things like bloodstream infections. So I think infection control is becoming much more recognized by hospital administrators as an important focus in the hospital in terms of quality patient care."
Support for an individual policy
Even though there was wide variation of how hospital ICUs addressed MDRO screening, some argued that the numbers support the fact that hospital policies should be driven by the unique risks to individual facilities.
"Rather than being driven by legislative mandates that are not evidence-based, MDRO screening should be based on a facility's risk assessment, as the epidemiology of these organisms can vary from region to region," Michelle Farber, RN, CIC, APIC 2012 president, said in a press release. "APIC recommends that each institution design an HAI prevention program that is effective for their facility and needs."
Pogorzelska agrees that there shouldn't be one blanket approach to MDRO screening, as supported by some of the data collected in the study. The study identified the following factors that indicated a facility is more likely to screen all admissions for any MDRO:
- State-mandated reporting
- Teaching hospitals
- Hospitals with 201-500 beds
- Hospitals located in the western United States
More and more organizations and regulatory bodies are developing recommendations for controlling MDROs, but Pogorzelska says that hospitals should be freed up to conduct their own assessment based on the individual risks in their region and their facility.
"Even though we see this wide variation, it doesn't necessarily mean that there should be a call to standardize how things are done in hospitals, because there is the recognition that what works for one hospital doesn't necessarily work for another hospital because there is such variation just by geography alone," she says.
Hospitals should also evaluate their own internal processes in terms of how much time they are devoting to things like reporting mandates and how that affects other areas of infection prevention such as surveillance. According to another study conducted by the Columbia University School of Nursing, infection control departments spend an average of 16 hours per month on mandatory reporting.
"It's not clear to us with this increased focus on reporting whether the hospital is providing them with more resources or whether it's taking away from the time they would be spending on other activities," says Pogorzelska. "It's something hospitals should really be aware of and really do a time assessment on how infection control departments use their time."
Focusing your screening efforts
One of the reasons hospitals don't screen every patient for MDROs is because it can be a significant burden on staff time and often requires additional resources. Instead, many hospitals compromise by focusing their screening efforts on high-risk patients.
For example, more facilities screen for MRSA because it's typically more common than some of the other more dangerous MDROs. On the other hand, infection surveillance may indicate that more patients from a certain patient population are coming in with a specific MDRO.
"You might want to focus infection prevention efforts towards screening groups that you know are at higher risk," Pogorzelska says. "For example, you typically see more C. diff from admissions from nursing homes, so hospitals might actually limit their screening of C. diff to those patients that are admitted from nursing homes instead of everyone."
Screening efforts will also depend largely on the resources that are available. Mid-sized teaching hospitals typically have more staff members and a substantive infection control department that can handle this burden, whereas a small rural hospital that only has one IP and doesn't encounter many serious MDROs may be forced to take a different approach.
"Hospitals really need to make a decision based on the local epidemiology of the hospital and the types of infections that they see most often that really impact patient care and then focus on those," Pogorzelska says. "I think that's why we see this [study] variation."
States with MDRO screening and reporting requirements
There are currently 12 states that have legislation requiring the screening and/or reporting of hospital-acquired MRSA rates:
- New Jersey
- South Carolina
Taking a vertical and horizontal approach to MDRO prevention
Editor's note: The following is an excerpt from a story in the December 2011 issue of Briefings on Infection Control.
Every healthcare facility has patients who are colonized with a multidrug-resistant organism (MDRO), whether it's from the community, another hospital, or another patient in the facility. Subsequently, preventing these patients from entering your facility is relatively impossible-unless you're willing to bolt the doors shut.
Instead, a more realistic approach involves preventing the spread of MDROs the moment those colonized patients enter your facility.
Depending on the type of facility you work in and the risk factors in that environment, the backbone of your prevention efforts may follow either a vertical path or horizontal path. These expressions are used to delineate two different approaches to MDRO prevention, says Peggy Prinz-Luebbert, MS, MT(ASCP), CIC, CHSP, owner and consultant for Healthcare Interventions, Inc., in Omaha, Neb.
A horizontal approach is what Luebbert calls an "all for one" approach that focuses on tried-and-true prevention efforts on all patient populations. Essentially, you treat everyone the same, so you won't need to do anything special for a unique bug. A horizontal approach involves the following:
- Standard precautions
- Hand hygiene
- Respiratory etiquette
- Environmental cleaning
- Aseptic technique
A vertical approach takes those same basic infection control principles while adding a one-size-does-not-fit-all tactic. Each bug is treated differently and each patient has a unique infection prevention procedure.
The vertical approach focuses on the following efforts:
- Active surveillance
- Level of transmissibility
- Mode of transmission
- Consequences of infection
First, do a risk assessment
Which approach you decide to take really depends on what unit you are working on, the specific needs of your patients, and the type of medical procedures that are being performed in that unit. This is where the risk assessment comes in, which will help determine where the risks are specifically, and what kind of approach will optimize your prevention efforts.
"You need to do a risk assessment for your environment, your patients, and your bugs," Luebbert says. "Look at which one of these works best for you. There isn't one approach that works for everyone. In some environments the horizontal approach is enough, but in others you might need to use the vertical."
For example, if you are in an outpatient setting, you may want to consider the following as you perform your risk assessment:
- Type of patients
- Type of procedures
- Bodily fluids that staff members may come in contact with
- Pathogens that may enter the facility
An outpatient surgery center may find that standard precautions for every patient is sufficient to prevent infection and control the cross-contamination of potential MDROs. However, an ICU that cares for patients who have more critical conditions may require many more considerations in order to prevent potentially deadly outcomes if an MDRO like MRSA were to take root and spread from patient to patient.
"If you're in an ICU setting where you've got lots of tubes and IVs, the patients are on a lot of antibiotics, and there is going to be a lot of people touching and treating that patient, then you might need more than just a horizontal approach," Luebbert says.