These three approaches are part of what has become a noisy argument in the field of infection control, which is becoming all the more volatile as government payers impose financial penalties on hospitals where these infections occur. Now, an increasing number of states?10 to date?legislate MRSA surveillance for all ICU patients. No one really knows which strategy is the best, most cost-effective, and resource-efficient for each situation.
One in 20 hospitalized patients develops some kind of infection during the hospital stay, according to the Centers for Disease Control and Prevention, which estimates the cost of that care at between $28 billion to $34 billion per year.
The solutions are extremely complex, says John Jernigan, MD, director of the Office of Healthcare-Associated Infection Prevention, Research, and Evaluation at the CDC.
"And how we get there is something that there's still some argument about. The point is, there are more and more examples of how multidrug-resistant organisms in healthcare organizations can be prevented. People have been able to move the needle. It's no longer enough to say, 'Well, our rates can't come down because rates can't come down.'"
But here, in more detail, are these hospitals' stories:
Marcia Patrick, RN, is director of infection prevention and control for MultiCare Health System in Tacoma, WA. She says she pictures MRSA as "the cloud of debris that surrounds Pigpen, the character in the cartoon strip, Peanuts.
"We're in an urban area. We have high rates of homelessness and IV drug users. Community-acquired MRSA showed up about 10 years ago and is very prevalent in the community. Part of the spread came from people just not cleaning things well or washing their hands, and it allowed these organisms to spread in day cares, schools, and other public places." Also hospitals.
That's why 3.5 years ago, MultiCare, a four-hospital system with 868 beds, made an about-face on its infection control policy and launched a program that so far few hospitals have, but more surely will in coming years: testing ICU patients upon admission to and discharge from the unit. "We look at our trends and patterns in patients who are negative on admission and positive on discharge to see where there's been a break in [good infection control] practice. It helps keep us all on our toes," Patrick says. "This quality measure is a good one to make sure we're providing the safest care we can to our patients." All HAIs at MultiCare have dropped by about 85% over the past five years, and MRSA infections are less than half what they were.
Patrick notes that MultiCare may be unusual. "There may be hospitals that don't have this as a problem and don't have the indication to do the screening that we do."
Two thousand miles east in Chicago, NorthShore University HealthSystem is even more aggressive in conducting MRSA patient surveillance.
Ari Robicsek, MD, associate chief medical information officer and epidemiologist, says in 2005, NorthShore was the first hospital system in the country to institute "universal" MRSA testing for all patients being admitted, not just those entering the ICU.
Today, he says, several hospitals in the United States?although a minority at this point?test all admitted patients for MRSA. But since NorthShore started screening, despite the high cost of $30 each for 50,000 to 60,000 patients a year, "we've experienced extremely positive results."
From August 2005 to April 2007, "we experienced a 69.6% reduction in infections," Robicsek says. "And after that, a number of other hospitals followed suit, notably the entire VA healthcare system, adopting a universal testing on admission policy."
Is that a severe approach?
"We know that if someone is a carrier of MRSA, they have about a 10% risk of going on to develop an infection," he says. "And that risk is even higher while they're in the hospital. So if we know which patients are carriers of MRSA, we can isolate them and help prevent them from spreading MRSA to other people, who themselves have a 10% higher risk of going on to develop an infection."