In contrast to the widely publicized reports of the spread of methicillin-resistant Staphylococcus aureus in hospital settings in recent years, a new study finds a striking bit of success in fighting the bacteria.
Researchers from the Centers for Disease Control and Prevention found that from 1997 through 2007, MRSA central line-associated bloodstream infections declined by 50% among all ICU types except pediatric units, where incidence rates remained stable. The decline among the more than 1,600 facilities that participated in the study, reported in the Feb. 18 edition of the Journal of the American Medical Association, runs counter to the widespread perception that the disease is infiltrating hospital ICUs unable to control the superbug. Such perceptions have prompted legislatures in several states to call for mandatory screening, which is controversial in whether that precaution is effective or necessary.
Though the outcome was clear in the CDC study, the reasons for the decline in infections are uncertain.Fernando Rivera, RN, MS, a staff nurse, practices cleaning the central line of mock patient and fellow nurse Sandra Buckle, RN, BSN, clinical specialist coordinator, at The Mount Sinai Medical Center in New York City.
We werent able to examine the specific causes of the declines in bloodstream infection risk that we observed, says Deron Burton, MD, JD, MPH, an author of the study. But we know that many efforts have been under way in recent years to improve the safety of central-line insertion and care practices in the hospital and to prevent the transmission of MRSA among hospital patients. Improved adherence to evidence-based prevention guidelines also may be playing a role. Although we cannot say specifically which interventions led to the declines we observed in MRSA bloodstream infections, its important to see that the efforts, taken together, appear to be demonstrating remarkable success.
David P. Calfee, MD, MS, hospital epidemiologist and infection control officer for Mount Sinai School of Medicine, suspects the CDC results reflect an overall focus on reducing all central-line infections.
Mount Sinais program to fight such infections has been up and running for about four years, Calfee says. It joined forces with other hospitals in the citywide initiative by the Greater New York Hospital Association and United Hospital Fund. Each hospital picked one or two ICUs to be part of the pilot project to implement a comprehensive program for central-line infections.Rivera, right, stands with David P. Calfee, MD, MS, hospital epidemiologist and infection control officer for Mount Sinai School of Medicine.
Because the collaborative came from a hospital association, we had lots of administrative support, Calfee says. It allowed us to develop a multidisciplinary team, which is sometimes hard to do on your own. The team consisted of medical directors of the ICUs, the nurse managers of the ICUs, infection control, housekeeping, materials management anyone involved with someone getting a central line.
Among the improvements from the collaborative were specific protocols for catheter insertion, use, maintenance, and access, and dressing changes, Calfee says.
Recently our nursing department developed a written protocol and a photo book so that every step of the process has a photo and a description below it. Thats available on our intranet so people can review it at any time, he says.
Fernando Rivera, RN, MS, a staff nurse on Mount Sinais pilot MICU, who was away when the book was created, says he finds the protocols helpful. The protocols were easy to follow and perform from the beginning because the staff participated in their modification and implementation, he says.
Early in the campaign to eliminate infections, Mount Sinai developed prepackaged kits. Nurses go to the shelves, and instead of pulling multiple items from different places for a dressing change, theres one kit that has everything from sterile gloves to skin preps to new dressings.
The prepackaged kits are practical because they encase all the supplies needed for a central line dressing change in one single place, Rivera says. Therefore, they save time and resources.
A little healthy competition never hurts, either, Calfee says, so his department sends out a monthly report on infections for each of the ICUs so they can compare among themselves and with other hospitals in the U.S.Nurses can grab prepackaged kits for dressing changes that include everything from sterile gloves to skin preps to new dressings.
Overall, Mount Sinais reduction in all central-line infections was similar to the drop in central-line MRSA infections the CDC researchers found. Calfee says the hospital had seen declines of more than 50% from the second half of 2005 to the present as compared to infections in the pre-intervention period.
He says education is key and by emphasizing that these infections are preventable and the incidence goal is zero, medical teams are inspired to take every precaution.
Those goals, along with reports in recent years that MRSA caused an estimated 19,000 deaths a year and that 85% of the infections are contracted in healthcare settings, helped spur a new commitment nationwide to fighting the infection.
Audrey Adams, RN, MPH, CIC, administrative nurse manager for the infection control unit at Montefiore Medical Center in the Bronx, was not surprised by the CDC findings and said she had seen similar results at Montefiore shortly after the hospital joined the New York collaborative. She said Montefiores medical ICU was among those taking part in the CDC study.
We had been working with the CLABs (central line-associated bacteremias) since 2005 when we started working with the collaborative to eliminate them. Our medical ICU saw a 66% reduction after the first year of the collaborative project as compared to the previous year, she says.
In addition to using the prepackaged kits, she said, all hospitals in the collaborative switched to the chlorhexidine antiseptic skin prep recommended by the CDC. The agent was widely used in Europe before the 2% solution became available in the U.S. and is more effective in cleaning the skin.
Member hospitals also implemented a checklist covering everything from hygiene to skin prep to choice of catheter site. A subclavian insertion should be the first choice over a femoral site, where risk of infection is greater, Adams says. Daily review of whether the central line is still needed is part of the effort to reduce infections, she said.
At New York-Presbyterian Hospital, infection control champions help police healthcare workers adherence to aseptic technique. The champions are representatives from a variety of units who take classes in the epidemiology department, says Jennie Drexler, RN, MSN, BC, patient care director for the cardiac and chest surgery step-down at the Columbia campus of New York-Presbyterian.
These volunteer staff members, who still have patient assignments, take classes that reinforce techniques such as proper hygiene, full barrier precautions, and using sterile gloves and gowns. The champions then monitor their own units and report any violations.
Say a doctor didnt wash his hands. The infection prevention coach of the unit would write up a ticket for the patient care director who would then approach the doctor, Drexler says.
It gets everyone involved. We also give the RNs the autonomy of stopping the procedure while a central line is being inserted if aseptic technique is not followed, she says.
The hospital also has a secret-shopper-like system of using a person unknown to the staff who watches in the hallways and takes pictures of any signs of practices that violate aseptic procedures. They report back to epidemiology, who then follows up, Drexler says.
The nurses on Mount Sinais unit are given autonomy, as well, Rivera says. The nursing staff participates in the insertion and maintenance of the central lines, with the medical staff supervising, he says. If the protocol is broken at any point, the nursing staff would stop the process to reinforce it or start it from scratch. This autonomy helps to diminish considerably central line-associated infections.
All these precautions taken together may be behind the dramatic drop in all central-line MRSA infections. However, CDC researchers say more needs to be studied on whether similar results are occurring with MRSA infections contracted outside ICUs and hospitals and among other patient populations.