William E. Scheckler
August J. Valenti
The methods of epidemiology and infection control are broadly applicable regardless of the size, location, or affiliation of a healthcare facility. The day-to-day practice of healthcare epidemiology in most community hospitals is normally more a matter of developing and implementing policies, educating staff, applying appropriate isolation precautions, and conducting surveillance than engaging in the kind of science common to larger academic centers. Nonetheless, the progressively more visible patient safety movement, which appropriately regards healthcare-associated infections (HAIs) as preventable, adverse events, is forcing small hospitals to pay closer attention to the collection, analysis, and feedback of HAI rates. Over the past several years, regulatory agencies and accrediting bodies have responded to pressures to reduce errors and adverse outcomes in hospitals by introducing more process indicators and outcome measures related to HAIs in their assessment of quality.
Until recently, surprisingly little has been published on infection control practices in the community. Evidence of increasing interest in the state of infection control in community hospitals is reflected by a number of newly published studies examining how these infection control programs are configured and how they are responding to the challenges of resource availability, drug-resistant organisms, and antibiotic stewardship [1].
In 2003, the U.S. not-for-profit community hospitals accounted for 61% of the 4,895 acute care hospitals [2]. As hospitals' bed numbers decrease, the percentage of those hospitals classified as rural markedly increases. Overall, 44% of the 4,895 hospitals were classified as rural. Of these rural hospitals, 74% had ≤99 beds. This chapter has been added to this text to help the hospitals that are not major teaching and academic centers and that are not governmentally owned (e.g., Veteran's Administration hospitals). As has been noted, there is a paucity of data from these hospitals in the area of studies of infectious diseases, HAI prevention, and control [3,4,5,6]. Fortunately, National Nosocomial Infections Surveillance (NNIS) system of the Centers for Disease Control and Prevention's (CDC) has always included a number of such community hospitals. The NNIS was merged into the National Healthcare Safety Network (NHSN) in January 2006. This new Web-based system should make access to data entry and analysis for all community hospitals more accessible and useful. Before 2006, the >2,300 hospitals <100 beds could not participate in NNIS. This chapter has been designed for both these smaller hospitals and the larger community institutions in the hope that HAIs can be better prevented and patient care safety improved.
To help target some key issues, we have made extensive use of a collaborative set of evidence-based recommendations published in February 1998 [7] as the major reference for our chapter. We also will display the thoughts of our colleagues in hospital epidemiology who shared their top issues and key frustrations with us in a survey provided
P.152
at the March 2006 Society for Healthcare Epidemiology of America (SHEA) meeting in Chicago and at the May 2006 statewide Wisconsin Association of Professionals in Infection Control and Epidemiology (APIC) meeting. The results of these “convenience sample” surveys are consistent with our own experiences and what we identified in visits to hospitals around the country in the last 5 years.
|
TABLE 11-1 |
||||
|
The survey results are of interest. They should encourage the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to think further about how to make a culture of safety, which must include a team of experts in HAI prevention and control, an absolute requirement and responsibility of the hospital administration and leadership (Table 11-1). Lack of time, an increasing scope of work, a frequent paucity of administration-provided resources, and sense of value highlight the results. A few quotes from the Wisconsin data are relevant. A common thread in the era of pandemic influenza and bioterrorism preparedness concerns the lack of time (hours, staff, or both): “I have the desire to be proactive rather than always reactive, but there is not enough time. ” The frustration with lack of administration support is articulated best from two quite different hospitals. From a 600 bed hospital: “The Infection Control Department is perceived as a thorn in their [administration's] side instead of an important component of healthcare” and from a 100 bed facility: “Infection control has always been seen as a [cost center] rather than an income-producing department.”
Our informal surveys underscore some of the findings published in a formal survey conducted among Volunteer Hospitals of America (VHA) hospitals in various regions of the country by Christenson et al. [8]. These authors conducted a demographic survey of 31 hospitals ranging in size from <50 beds to >500 beds to assess the staffing, structure, and functions of infection control departments in participating hospitals. Participants were asked to conduct observational studies of compliance with process measures, such as hand-hygiene practices, ventilator-associated pneumonia rates, and catheter-related bloodstream and urinary infections. A third of the participants reported levels of infection control staffing below the level of 1 infection control professional (ICP) per 100 occupied beds. Only one hospital reported data entry and analytic support within the infection control department. The results of the process observations showed variability in compliance with evidence-based strategies for preventing HAIs.
Sustained compliance with best practices frequently requires repeated educational interventions, and one can expect varying degrees of availability of trained ICPs performing these interventions to impact results. As Christenson et al. note, the size of the study imposes limitations on the conclusions one can draw but it is hoped that such studies will encourage broader examinations of infection control practices and contribute to evidence-based practices aimed at better control of HAIs globally. Clearly, more study is needed to examine whether there is a correlation between staffing and compliance with evidence-based practices and, ultimately, outcomes.
Good surveillance and infection control activities reduce multidrug-resistant organism rates in acute care hospitals, yet two recent surveys of Canadian hospitals (where antibiotic-resistant organisms are less a problem than in the United States, but are, nonetheless, on the rise) revealed that effective surveillance and control activities are not in place in many Canadian hospitals [9,10,11]. In 2000, a survey of 72% of Canadian hospitals with >80 acute care beds revealed that there was less than 1 ICP per 250 beds in 42% of hospitals, and only 60% of infection control programs had physicians or doctoral professionals with infection control training. Surgical site infection (SSI) rates were provided to surgeons in only 37% of hospitals. A follow-up study indicated that surveillance and control activities in acute care hospitals in Canada are being performed in roughly two-thirds of the 120 hospitals responding to a survey.
P.153
The reasons that infection control programs in many community hospitals are struggling to implement best practices are complex and certainly worthy of further study. We propose a number of recommendations that we hope will be useful to small hospitals facing these challenges. The authors' extensive background and experience will be used to fill in the gaps where the scientific evidence is sketchy or nonexistent because of a lack of studies.
Most of the top issues in Table 11-1 are discussed in detail in other chapters of this book. Scheckler et al. have articulated the principal goals for infection control and epidemiology [7]:
They also note both the value and necessity of measuring the effectiveness of the procedures, policies, and programs put in place to accomplish the three goals. Most hospital epidemiologists agree that, as with medications, conducting prospective, controlled trials of a current procedure compared with a newer procedure is optimal. The outcome of most interest, of course, is the HAI rate targeted by the procedure. Rarely can studies like the medication studies using a double blind controlled method be done. Complicating HAI studies further is that outbreak situations and endemic situations may not show the same results in separate studies because the underlying issues may be different. At times, these realities lead to a conflict in recommendations [12,13,14].
We recommend a careful review of this article by our epidemiologist and ICP colleagues in community hospitals [7]. Our careful review of the article indicates that the discussion and the 23 recommendations are still useful. Since the publication of this paper in 1998, additional studies have supported and increased the evidence supporting these recommendations.
Key Issues In Community Hospitals
Adequate HAI Prevention and Control Team: Who, How Much Time, and How Many
Anyone who has even the most modest knowledge of healthcare expenditures knows that the crunch is on and has been for a number of years. The 1999 Institute of Medicine report, “To Err Is Human” [15] brought the concept of patient safety, or lack of it, to the forefront of public discourse. Lost in this report, however, was the long-standing paradigm of HAI prevention; it was barely mentioned. A subsequent paper showed the value of infection control in the safety push [16]. As our colleagues indicate, lack of time and support are their principal challenges. The complexity of modern healthcare has made simple calculations of the full-time equivalent (FTE) size of the HAI prevention and control team difficult. Scheckler et al. did not use a number. A recent process by the APIC [17] suggested the number of one ICP per 100 beds based on consensus. The literature has no recommendations correlating bed size or discharges with hours needed for a physician hospital epidemiologist.
Our recommendations, which follow, are based on our own extensive experience, our review of the literature, and the reality of increased needs to review renovation and new building projects and to plan for bioterrorism events and/or new influenza epidemics.
Recommendations
These recommendations are, in the view of the authors, bare-bone essentials. Ample evidence indicates that a proactive HAI prevention team can substantially help reduce adverse events in the patients the hospital serves. The critical issue is making the administrative decision makers aware of the literature/evidence.
Administrative Understanding and Support
JACHO attempted in its 2006 requirements for HAI prevention and control and patient safety to require that the administrative authorities of the hospital—chief executive offices (CEO) and board—support the staff and resources to do the job. The fact that these requirements appear to have made little impact in our surveys and our experience with many hospitals suggests that they are either too new to be effective or that they are low on the JACHO surveyors' priority list.
Recommendations
P.154
Changing Human Behavior
Hand hygiene is essential before and after contact with a patient or his or her immediate environment whether using gloves or not. One hospital used the “Clean In, Clean Out” sign in every patient room. However, multiple studies since the CDC's landmark Healthcare Infection Control Practices Advisory Committee (HICPAC) Hand Hygiene Guidelines was released [18] have shown only modest compliance with this intervention, which has proven effective since the time of Semmelweis. All HCWs seem better at hand hygiene after rather than before seeing a patient. Nurses tend to be much better than doctors. And, most surprisingly, nonsurgical primary care physicians and intensivists are better than their surgical colleagues [19].
Isolation guidelines from the CDC's HICPAC are due to be formally released in late 2006. A recent additional Federal Office of Management and Budget review has substantially encumbered the final review process for HICPAC guidelines, even after HICPAC vetted all public comments and expert review and approved a final guideline. This additional step appears to have doubled the time it takes to update or generate a guideline from two to four years. This, in our opinion, is both regrettable and totally unnecessary given the expertise of HICPAC.
However, a long-standing concern of ICPs and hospital epidemiologists is the almost cavalier attitude of some nurses and physicians toward isolation precautions. The apparent lack of understanding regarding the rationale for careful hand hygiene and the use of personal protective equipment (PPE) by those involved in direct patient care frustrates the infection control community. The recent severe acute respiratory syndrome (SARS) outbreak should have demonstrated to all HCWs the value of appropriate use of PPE.
Recommendations
Control of Resistant Organisms
No matter what the setting or size of a hospital, the problem of multidrug-resistant pathogen infection is a major preoccupation for ICPs and has led to calls for action from many quarters. Data comparing percentages of nosocomial Staphylococcus aureus infections with Methicillin-resistant Staphylococcus aureus in NNIS hospitals with <200 beds to those with >200 beds between 1992 and 2002 demonstrates that smaller hospitals, formerly behind larger hospitals in their percentage of MRSA HAIs, have caught up with larger hospitals [20]. There is a need for more study of resistance rates in the community healthcare setting; however, most studies of the epidemiology and control of resistant organisms have come from large, academic centers. Diekema et al. conducted a survey of >400 U.S. hospitals and found that antimicrobial resistance rates were strongly associated with the size, geographic location, and academic affiliation of hospitals [21].
Hospitals, especially those with intensive care units (ICUs), and long-term care facilities are important epicenters and repositories of resistance. Increasing rates of community onset MRSA (CO-MRSA) also are having an impact on hospitals as CO-MRSA strains are recognized as causes of HAI infections as well [22]. Unfortunately, many centers, discouraged by the increase in MRSA and the cost of control, relaxed previously recommended infection control practices in the recent past. In contrast, some northern European countries adopted national, comprehensive programs resulting in impressive control of resistant organisms.
Cost and safety issues surround these infections: increased morbidity and mortality, more expensive and limited treatment options, longer hospital stays, patient dissatisfaction, the cost and inconvenience of precautions, litigation, and adverse publicity for healthcare facilities (especially where drug resistance is publicly reported and/or considered a measure of quality) and are an increasing reality in today's consumer-driven patient safety movement.
With the identification of vancomycin-resistant S. aureus (VRSA), CO-MRSA, more virulent strains of Clostridium
P.155
difficile (CDAD), increased recognition of extended-spectrum beta-lactamase-resistant organisms, fungal resistance, multidrug-resistant M. tuberculosis, to name some of the most concerning organisms, it is imperative that community hospitals have a complete understanding of the resistance patterns in their institutions, their affiliates, and their region. Similarly, they must keep up with developing recommendations for controlling these infections even if such infections have not yet affected them.
While antibiotic resistance is a daunting problem, a substantial body of literature demonstrates that these organisms can be successfully controlled with multidisciplinary efforts that include active surveillance cultures, contact or barrier precautions, careful environmental cleaning, effective antimicrobial stewardship, and strict compliance with evidence-based hand-hygiene practices. The degree to which control measures should be adopted universally, particularly in regions with low prevalence rates of resistance, is one of the issues surrounding the debate among experts over developing guidelines for managing resistance. This can confuse and deter smaller hospitals that are attempting to determine and implement best practices for identification and control of these organisms.
Recommendations
In 2003, the Society for Healthcare Epidemiology of America published an extensive review of the literature and guidelines for the control of MRSA and Vancomycin-resistant enterococcus (VRE) [9]. It is widely known that the publication of this guideline during the simultaneous development of draft guidelines by HICPAC sparked a vigorous debate among experts as to how to interpret and apply the best science to control these organisms. Most hospitals must decide what they will take from each of the guidelines to develop strategies for preventing the dissemination of resistance. Both guidelines should be studied carefully. The recently released CDC HICPAC Multidrug Resistant Organism (MDRO) Guideline recommends that if a hospital's rate of infection with these pathogens is not decreasing, it should implement more aggressive measures, including active surveillance cultures. We present an approach to managing MRSA and VRE adopted by the MaineHealth® Infection Control Consortium in the Appendix to this chapter.
The most salient difference between the two guidelines is the screen and isolate or “search and destroy” practice [13]. The SHEA guidelines recommend aggressive use of active surveillance cultures to identify patients colonized with these organisms (because routine clinical cultures do not detect the colonized reservoir) and placing those patients on contact precautions. To date, the HICPAC draft guidelines favor a graduated approach with increased intensity of control activities in settings where baseline measures fail to decrease transmission rates. A major argument used by those who find the SHEA document too rigorous is that many studies used multiple interventions and are unable to weigh the strength of any single intervention or combination of interventions (an argument never made with any of the other CDC HICPAC guidelines, although this is also true of them). However, Muto et al. vigorously defend the SHEA approach of active surveillance cultures and contact isolation, citing the success of northern European countries and Western Australia in controlling these infections. They contrast this with the failure of standard precautions and failure to control these organisms in other areas of Europe and Australia where a less aggressive approach is used [23,24]. In European countries, the delivery of medical care differs from that in U.S. healthcare facilities for whom these guidelines are intended. In countries and institutions where an aggressive approach, such as that recommended in the SHEA guidelines, has been adopted, however, impressive control of MRSA and VRE have been achieved.
The implications of these guidelines for community hospitals are significant. As Strausbaugh et al. [13] note, neither guideline addresses in a more comprehensive sense the goal of these control efforts. In addition, neither guideline currently considers how resources should be allocated for control programs—an issue of great importance to community hospitals without research dollars to divert to such endeavors.
Translating the science coming out of larger academic centers into practice at the level of smaller, nonteaching hospitals is complicated by a lack of understanding of which interventions are most effective and an imprecise understanding of the epidemiology of these organisms outside of large hospitals. Some experts argue that it is better to direct efforts and resources at reducing SSIs and device-related HAIs as a means to control resistance rather than to implement the type of “search and destroy” strategies that have been successful in Europe. Indeed, the former approach is gaining momentum as a result of national quality efforts toward implementing proven methods of reducing such infections by encouraging the utilization of “bundles” of evidence-based best practices for prevention [13]. However, it is far from clear that this will be an adequate national strategy for decreasing rates of MRSA and VRE in the United States and in community hospitals.
West et al. recently published a paper on the effect of targeted surveillance cultures of high-risk populations for control of MRSA in a community hospital system [25]. They acknowledged the workload and expense associated with universal surveillance cultures and the reluctance of administrations to accept such efforts. They used the SHEA guidelines for isolation of patients colonized or infected with MRSA and achieved reductions in MRSA in a cost-effective manner. Patients infected with MRSA had been placed in isolation since 1988, but infection rates remained stable despite the additional measure of screening nares specimens from patients in the ICU, a practice initiated in 2001. Only after active surveillance cultures targeted high-risk patients throughout the hospital
P.156
was a significant reduction in MRSA infection rates realized. However, Huang et al. have documented the impact of routine screening cultures and isolating colonized patients in ICUs on hospitalwide MRSA bacteremia. They achieved a 40% reduction in MRSA-BSIs in non-ICU patients and a 67% reduction hospitalwide. Using interrupted time-series design for their analysis of 9 years of data, they determined that the statistically significant factor in bringing about these reductions was active surveillance cultures with subsequent placement of patients on contact precautions in the ICU. Typical multiple interventions, such as the introduction of alcohol gels, a handwashing campaign, and maximal sterile barrier precautions for insertion of central lines, did not have significant impact on the rates [26].
Resistant Gram-Negative Organisms
The size, location, and services of a hospital also can conceivably impact the risk for acquisition of these organisms. Extended-spectrum and AmpC beta-lactamase-producing bacteria are important HAIs, and Pseudomonas aeurignosa resistance to quinolones, imipenem, and third-generation cephalosporins; Enterobacter resistance to third-generation cephalosporins; and multidrug-resistant Acinetobacter are on the rise worldwide [27].
The National Committee for Clinical Laboratory Standards (NCCLS) issued its guideline in 1999 to help laboratories identify extended-spectrum beta-lactamase-producing Klebsiellaspecies and Escherichia coli[28]. Despite current recommendations, not all clinical microbiology laboratories routinely identify extended-spectrum beta-lactamase (ESBL)-producing organisms (ESBL-producing organisms). Surveys looking at the ability of clinical laboratories to detect ESBLs identified a serious gap in this regard [29,30]. Community hospital outbreaks are well described [31,32].
Risk factors for acquiring these organisms are similar to those for the acquisition of other HAI gram-negative organisms: indwelling catheters, increased severity of illness, urgent abdominal surgery, ventilator use, and prolonged hospital stay. Lautenbach et al. found patients infected with pathogens with ESBLs had a greater cumulative antibiotic exposure than did controls; total antibiotic exposure was the only independent predictor of infections with these organisms [33]. Their study suggested that curbing the use of all classes of antibiotics used against gram-negative organisms may be important. Control measures should focus on limiting contact transmission of resistant isolates and controlling antibiotic use. Although more study is needed, some have suggested implementing infection control measures for pathogens with ESBLs similar to those used to control MRSA and VRE [9].
Recommendations for the control of ESBL-producing and other multidrug-resistant gram-negative organisms of epidemiologic importance follow. We prefer an aggressive approach to control these organisms until scientific evidence suggests that less aggressive measures are adequate. Harris et al. have published an excellent summary and analysis of the data on active surveillance cultures to identify colonized patients and whether they should be placed on contact precautions [27]. They provide a framework for decision making and recommendations for future investigations. Hospital epidemiologists must determine what is best in their institutions. The following recommendations have been adapted from Paterson and Yu for pathogens producing ESBLs; however, some of these recommendations also could be applied to control other highly resistant gram-negative organisms of epidemiologic importance [34].
Although competent antibiotic stewardship and infection control programs are of demonstrable efficacy in reducing the spread of resistance, overall use of antibiotics, and cost, such expertise may not be available to the smaller community hospital due to lack of monetary or human resources [35,36]. In many hospitals, antimicrobial stewardship is a coresponsibility of infection control, the pharmacy and therapeutics committee, and clinicians. The proportional influence of infection control compared with optimization of antibiotic use on the reduction of HAIs due to resistant organisms seems to depend, to some extent, on the organism and mode of transmission [37,38]. Horizontally transmitted organisms, such as MRSA, VRE, or C. difficile, seem more amenable to infection control measures whereas resistance arising from the endogenous flora
P.157
of patients receiving antibiotics, such as ESBL-producing organisms, requires more emphasis on antibiotic controls. Choosing the most appropriate antibiotic, dose, and duration of therapy based on the proper collection and interpretation of cultures; using an up-to-date clinical microbiology laboratory; treating infection rather than colonization; and limiting the use of certain agents should be part of an overall strategy to reduce resistance in all hospitals [39]. A concurrent review of antibiotic use by specialists along with computer-assisted antibiotic decision support can be extremely helpful in controlling the spread of resistance [40]. Such programs require a substantial commitment of resources by a hospital but can result in cultural changes, reduced costs, and lower rates of bacterial resistance [41]. Promoting infection control and antimicrobial stewardship in all hospitals should be priorities in a national strategy to combat resistance.
|
Figure 11-1 Relationships among diverse healthcare facilities in the community setting—routes for the spread of antibiotic resistance. |
The community hospital must be considered in the context of its “trade routes,” which provide opportunities for the dissemination of resistance (Figure 11-1). Antimicrobial resistance is commonly a regional problem, involving >1 facility in a geographic area. A recent study of the epidemiology of MRSA and VRE among hospitals in Iowa (ranging from ~86 to >858 beds in diverse geographic regions of the state) uncovered differences in the epidemiology of these two organisms; these findings have important implications for their control [42]. For instance, they found that VRE and MRSA shared some risk factors for acquisition as well as some significant differences in that MRSA was endemic in rural hospitals (rural location and hospital size of <200 beds were significant risk factors for MRSA infection) while hospitalization at a smaller hospital had a negative correlation with VRE infection. The authors present compelling evidence of the importance of understanding the regional epidemiology of resistance and identifying reservoirs of these organisms.
Thinking regionally also has been of benefit in controlling VRE and MRSA within a geographic area. A landmark investigation in 32 healthcare facilities in the Siouxland region of South Dakota, Iowa, and Nebraska reported by Ostrowsky et al. demonstrated that control of VRE could be accomplished in a regional healthcare system by performing active surveillance cultures to detect colonization in high-risk patients and using contact precautions for colonized and infected patients [43]. This study demonstrates the efficacy of using evidence-based guidelines in all healthcare facilities in a region.
Cooperative partnerships among centers can improve efforts at controlling multidrug-resistant pathogens and other important HAIs. Kaye et al. recently reported on the work of the Duke Infection Control Outreach Network [44]. They used a standardized approach to surveillance, provided frequent feedback, and followed uniform policies using CDC guidelines at 12 hospitals in their network. They achieved a reduction in bloodstream infections, nosocomial MRSA infections, ventilator-associated pneumonia, and blood borne pathogen exposures among employees. Kaye et al. estimated remarkable economic benefits. As of this writing, their 32 hospital consortium continues to report reductions in these areas and in catheter-associated urinary tract infections on their Web site (www.dicon.mc.duke.edu/). There are other examples of successful regional approaches to multidrug-resistant organisms [45].
Our own experience is with a 13-facility infection control consortium sponsored by MaineHealth® that is modeled on the successful outcomes of the Barnes-Jewish Hospital Infection Control and Hospital Epidemiology Consortium in the St. Louis area, from which we received valuable support in developing our group [46]. The increased cooperation among the MaineHealth® Infection Control Consortium participants, which include very small rural hospitals and larger hospitals (200 to 600 beds), home care agencies, long-term care facilities, a rehabilitation hospital, and so on has been a positive and productive experience to date. The group is sharing expertise, data, and policies on the control of multidrug-resistant organisms and providing member institutions with evidence-based algorithms and standard approaches to regional problems such as CDAD, VRE, MRSA and vaccination strategies. Clinicians and others can link to a single Web site for updated guidelines, policies, and patient educational resources. Regional standardization of policies and shared educational documents contribute to the confidence of clinicians, administrators, and patients.
Burdens of Expanded Work
Planning for a bioterrorism event, dealing with the possibility of the admission of a SARS patient returning
P.158
from Asia, and finally having to plan for “the next” pandemic of influenza have sequentially added new work to an already stressed infection control program. It is not the function of this chapter to replicate what is well covered in other parts of this text. Suffice it to say that these issues are an important part of the field of healthcare epidemiology in community hospitals. They also require close collaboration with local and state public health authorities. The need for an expanded review of the infection control issues and risks in hospital renovation and building projects has also taken on a new urgency in recent years. More work means more time needed. These issues illustrate in a profound way the reality of interdependence as new challenges unfold even as this book is published.
|
TABLE 11-2 |
||||||
|
Requirements for Infrastructure and Essential Activities of Infection Control and Epidemiology in Hospitals [6]
The recommendations of the “essentials” are so relevant to this chapter that we repeat them here with permission. When possible, the panel used an evidence-based approach. Recommendations therefore are categorized in Table 11-2, using a modification of the scheme developed by the Clinical Affairs Committee of the Infectious Diseases Society of America and the CDC HICPAC classification scheme.
Functions
Managing Critical Data and Information
Specifically, these indicators and their analyses must address the following parameters:
Setting and Recommending Policies and Procedures
P.159
Compliance with Regulations, Guidelines, and Accreditation Requirements
Employee Health
The evaluation should include the following:
Intervening Directly to Prevent Transmission of Infectious Diseases
Education and Training of Healthcare Workers
P.160
Resources
Personnel
Nonpersonnel
Conclusions
Despite the historical primacy of infection control among hospital quality and safety initiatives—and its documented efficacy—today's infection control programs that are still trying to manage the traditional duties of surveillance, outbreak management, and education are now asked to include an increasing number of responsibilities. Moreover, they are or soon will be under increased pressure generated by the consumer-driven movement toward public reporting of HAIs—a movement that is not always grounded in good science. The modern infection control program must maintain its standards in an environment of cost-cutting and competition for resources with diverse quality initiatives. Some ICPs are leading these efforts, but others are struggling to find a place at the table.
Community hospitals, particularly rural facilities, are not always able to attract professionals with infection control expertise or interest, and even when these professionals are available, hospital administrators may be unable or reluctant to provide appropriate support for them so they can accomplish their traditional responsibilities in addition to investigating process breakdowns or working on the cultural changes necessary for the adoption of evidence-based practices. It could be argued that cultural and policy changes are more easily brought about in smaller institutions, but a number of factors other than size influence these processes in our experience. The wise epidemiologist weighs systems problems against ignorance or more culpable explanations for resistance to adopting practices of proven efficacy such as hand hygiene.
How, then, is the institution to find creative solutions to the challenges of infection control in the community? Partnering with other institutions to form regional infection control and quality consortia gives small hospitals an opportunity to share resources and expertise with larger hospitals in addition to providing academicians with new opportunities for scientific study. In return, academic hospital epidemiologists should consider how they can support their community-based colleagues in developing scientific studies that will lead to the development of evidence-based practices suitable to the populations they serve.
Working with public health authorities in identifying and managing outbreaks or controlling regional infectious problems can benefit both the private and the public sectors. Infection control working groups, which bring public health and private professionals together for regular discussion of common concerns, afford another opportunity to share expertise and resources. A number of states have found such cooperation gratifying and effective.
Community-based infection control professionals must take a greater role in educating their colleagues, administrators, government, and the public about the importance, causes, and metrics of HAIs. ICPs must convey the validity and utility of sound epidemiologic methodology to those involved in developing the public reporting of HAIs. It is increasingly important to the well-being of patients that those who manage community hospitals appreciate the efficacy of infection control programs. If community-based ICPs and hospital epidemiologists wish to continue their leading role as patient safety advocates, they must be willing to educate a wider audience on the evolution, methodology, and value of healthcare epidemiology. They also must be ready to discuss the impact of their recommendations on the resources of their facilities and the community at large.
There is hope that the recent surge of interest in reducing the number of HAIs—part of the overall focus on patient safety—will lead to increased resources to control HAIs, implementation of evidence-based practices, improved monitoring of outcomes, and a better understanding of how to address the global issue of antibiotic resistance. It is our hope that these efforts will benefit the large number of patients in U.S. community hospitals and elsewhere.
P.161
Appendix
MaineHealth® Infection Control Consortium Guidelines for the Management of MRSA and VRE
Consistent use of standard precautions remains the basis for preventing the spread of infection in all facilities. In addition to standard precautions, transmission-based precautions for “organisms of epidemiological significance” remain important once an organism has been identified. This document seeks to lay the foundation for the basics of care. In certain circumstances, it may be necessary to exceed the basic guidelines, and that decision is the prerogative of any individual institution. In addition, as new guidelines and information are published, it will be necessary to alter or update this document after review and approval by the Consortium DRO Committee.
Prevention is the first principle in the management of drug-resistant organisms (DROs). A DRO prevention and control strategy incorporates evidence-based infection control practices, antibiotic stewardship, laboratory support, and active surveillance. Active surveillance cultures are believed to be essential to the identification of the pool of colonized patients that may be missed by only monitoring results of clinical cultures. Early identification of colonized patients and prompt institution of precautions is necessary to decrease transmission [9,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79].
The description of what constitutes “contact precautions” remains gray in the literature as draft recommendations from the CDC appear to recommend mandatory gloving and gowning for entry into the room. The previously published CDC guidelines call for anticipation of the likelihood of contact with the patient or his or her environment and the decision of whether personal protective equipment (PPE) is needed [9,53,66,80,81,82,83,84,85,86,87,88]. We have chosen to include both at this time, as some institutions are following the older guidelines and others are following the recently released CDC MDRO guidelines (which are similar to the SHEA guidelines with regard to mandatory gowns and gloves).
There is a lack of information in the literature regarding the discontinuation of precautions and “clearance” of multidrug-resistant organisms. A number of studies examined the duration of colonization and found it could persist for months to years. Several articles reported varying degrees of success with decolonization protocols. Some Maine institutions have adopted a “once a MDRO, always a MDRO” policy. Others require several screening cultures from various sites for clearance. The subgroup felt that in consideration of the risk factors for MDRO, acquisition was the place to start deciding which patients were likely to remain positive and decrease unnecessary expense and the emotional impact of active surveillance cultures. After an extensive review, we have proposed a set of exclusion criteria and then standardized the sites and number of cultures required to “prove” culture-negative status. Standardizing the criteria for clearance culturing and the sites/method of culturing will benefit all patients but especially those patients that move between institutions [49,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107].
We also researched the utilization of precaution gowns and gloves for visitors. We found varying requirements in the literature. After careful review, we believe that the chain of transmission falls primarily on the actions of HCWs as they move from patient to patient, not on the actions of visitors, who are there only to see their loved one. We currently do not support the requirement of the routine use of gowns and gloves for visitors; rather, we would emphasize the need for family education regarding hand hygiene with the caveat that if the family members are likely to soil their clothing because of participation in nursing type care of the patient, gowning and/or gloving may be appropriate [13,108,109].
After review and discussion, the following guidelines are presented as current “best practice.”
Recommendations for Acute Care Management of MRSA and VRE
P.162
iii. Open wounds—culture any open area such as a pressure ulcer, diabetic foot ulcer, etc.
P.163
References
P.164
P.165