Wednesday, January 20, 2010

Speaking of mandates.....

....Eli alerted me to a new screening law in Maine that went into effect last week. According to this news account, the law requires MRSA screening of all new admissions with recent hospital or long term care facility exposure, those on dialysis, and prisoners. Interestingly, it appears the law only mandates screening for six months, and then allows hospitals to decide themselves how to proceed with MRSA prevention….if true, it is a curious wrinkle. I was especially interested in this law, given that I practiced infectious diseases in Maine for 3 years before returning to Iowa to get further training in microbiology.

Take note of this quote from Dr. John Jernigan at CDC:
"There are some studies that suggest that programs that have employed active screening have been very effective at reducing MRSA infection rates. On the other hand there are those that have used the strategy and not been so effective. Also there are studies that suggest that MRSA infection rates can be reduced effectively without the use of active screening. It may have to be tailored to local situations and circumstances."
I’m scheduled to present a “pro-con” debate with John next month….since I agree entirely with this quote, I’m worried that our “debate” will be very boring.

Addendum: I found the legislation on the interwebs. This is what was submitted, and this is what passed (can you detect the subtle changes?). So the details above must be what the Maine Quality Forum cooked up.

10 comments:

  1. Dan,
    I wrote the original proposal for the Maine legislation. I did it after months of research and after my own father's death with nosocomial hospital acquired MRSA. I am not proud of the 6 month "study" that the Maine Quality Form put out.
    My proposal was for the entire process of ADI as outlined in the 2003 SHEA. The Maine Hospital association watered my bill down. I was not in favor this even further watered down and probably self limiting "study", although it is a start.
    My goal is MRSA prevention in all hospitals in Maine, not just the big ones. Many if not most of our hospitals did no screening at all and they had MRSA outbreaks. Essentially, MRSA was considered was "part of doing business". Many don't isolate known colonized patients. It is my opinion they don't want to know who is colonized.
    I am proud of my original proposal and if it had passed, we would now be using the known approach of ADI for MRSA. Instead we have ongoing "hand washing campaigns" and the soft directives of the CDC and this "study".
    There are over 150 (already in existance..we don't need more) studies that prove ADI works. Is there any other standard MRSA prevention approach that can show such results for our hospitals? No. Everybody across Maine and the US is doing something different and at all levels of efficiency. More importantly, they are not stopping MRSA.
    I had hoped for better in the State of Maine.
    I was part of the MQF meetings. I fought the battle with IC docs and nurses for 9 months and we hatched this inadequate and likely not very valuable "study".
    One thing good about it is that the high risk groups chosen are excellent and we only lack a few we should add. And, the whole process woke up Maine HOspitals to the fact that victims and their survivors will not tolerate HAIs any longer. MRSA is an ongoing failure of our hospitals and it has been in the closet long enough.

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  2. Thanks, Kathy, for sharing this additional background with our readers!

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  3. Maine needs to get some estimate of its baseline MRSA burden over the past 10 years. Although administrative data only provides a snapshot of the occurrence of MRSA it might be worth looking at discharge data submitted to the Maine DOH.

    Both California and Illinois have published such data. In California in 2007 there were ~4.0 million discharges and 52,219 cases of MRSA were observed. This translated into 13 cases/1000 discharges. Medicare and MediCal were the primary payer for 71.4% of those cases. The mean ALOS was 13.6 days and charges (not cost) to the state was 5.4 billion dollars. For non-MRSA patients the mean ALOS was 4.0 days.

    In Illinois after they expanded their search to include 25 secondary discharge diagnoses codes ~ 20,000 cases of MRSA were identified with ~1.7 million discharges.

    Illinous went a step further than California using POA codes. 25.1% of the MRSA present on admission had recent exposure to health care. However 68.3% had no recent (within one year) exposure to health care.

    In California the most common MRSA admission diagnoses were skin and soft tissur infection, sepsis and pneumonia accounting for 16,734 cases. The most common infections that might be consdered HAI were complications of an implanted device and complications of surgery accounting for 5,126 cases.

    We need to stop arguing about which one best practice ( or should I say which one person's view) might reduce the incidence of HAI MRSA. No I do not think we need to test all patients but we do have clues as to which patients might be at higher risk for MRSA. The longer we drag this arguement out the more more patients will suffer I would argue that all of you who have MD or PhD after your name come to a consensus as to what recommedations hosptial should follow such as ADI/decolonization. I would argue for better HICPAC Isolation guidelines.

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  4. When is this "pro-con" debate for those who would like to attend?

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  5. February 25th at the Remington Winter Course, website here: http://www.grantdowning.com/meetings/wcid10_info.html
    I will also be talking about prevention of ventilator associated pneumonia. I will not be skiing, 'cause that's not safe.
    The slides for this course are generally posted free online for anyone to view (click on the "past presentations" link to see what I mean). So if you can't make it you can still get all the material--I will link to it once it is online, after the course.

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  6. "It is an area of controversy amongst scientists who look at this issue," Jernigan says. "There are some studies that suggest that programs that have employed active screening have been very effective at reducing MRSA infection rates. On the other hand there are those that have used the strategy and not been so effective. Also there are studies that suggest that MRSA infection rates can be reduced effectively without the use of active screening. It may have to be tailored to local situations and circumstances."

    This is the quote from Dr Jernigan that you agree with. I guess I could say I agree with some of it too and I disagree with the rest of it and about anybody who read it could say the same. Wishy washy.
    This comment is typical of CDC. You can do a lot or do just a few things or do nothing at all, (as far as MRSA screening goes) and still be in compliance with the CDC guidelines.
    Dr Jernigan sounds like his employer's guidelines. One thing I know is that all of ADI when used in it's entirety works. Screening alone and inadequate screening won't work. It is the combination of all the steps that works. I just will never understand the stand against it.

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  7. I think the real issue is that ADI is only one possible, and I would say suboptimal, strategy to control MRSA. Sure it could work, but it ignores VRE and all of the multidrug resistant Gram-negative bacteria that are resistant to every available antibiotic.

    There are strategies like universal isolation (ADI without the AD) that may be more effective and control the spread of most organisms. There is CHG bathing that can control the spread of many organisms and prevent device infections.

    We have 3-4 good antibiotics to use against MRSA now but none for the acinetobacter we see every day and no one is talking about.

    The microbiology (ADI) approach favored by some that would have us swab everyone for every possible bacteria will eventually be too expensive to pursue. When it was just MRSA, maybe it was be OK, but when you add 3, 4, 5 organisms then it is simply impossible to implement. For acinetobacter, for instance, you need to obtain 2-3 swabs for it to have any sensitivity and that is just for that one organism!

    AND THE BIGGEST THING for me is that many people who have MRSA bring it into the hospital with them and ADI does nothing to prevent any infections in them.

    Finally - when someone who writes for this blog says anything that scientifically questions ADI, it does not mean we are OK with MRSA spreading willy-nilly. To the contrary, we care very deeply and want to do as much as possible to prevent MRSA (and also VRE and MDR-GNR and influenza etc) from causing infections in our hospitals, we just choose to look at the whole picture and not just MRSA.

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  8. How about a strategy that mandated that each acute care hospital had to spend x% of their revenue on infection prevention including staff? Now the money could go to people who would be responsible for preventing all types of infection, could educate staff and could do ADI or MRSA if MRSA was a problem but who could also choose to do mandatory hand-hygiene compliance with RFID badges too!

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  9. "AND THE BIGGEST THING for me is that many people who have MRSA bring it into the hospital with them and ADI does nothing to prevent any infections in them."

    I have heard this one about a thousand times. How do you know that? How can you possibly say that? Screening will detect it, and they can benefit from decolonization if they are going to undergo an invasive procedure. They can have contact isolation to prevent spread of disease, and they have appropriate preoperative antibiotics. But, it 's just a whole lot easier to blame the patient's infection on the patient, than to blame the inadequacies of the infection control program of a hospital. Screen everybody, that is fine. But, at the very least screen high risk pateints and use all of the rest of ADI to prevent active infections.
    Rapidly emerging CA MRSA is a threat to all of us, both in and out of the hospital. Is Acinetobacter a commonly colonized bacteria in the community? I haven't heard or read that it is. We can't ignore MRSA. If we do, it will be totally out of control and so will all the other infections you speak of.
    It has been proven that ADI for MRSA slows and reduces infecions from other microbes too.

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  10. The bottom line is that approx. 20 thousand people die each year from MRSA, countless others die from other HAI's (VRE, C. Diff, etc.). Not to mention the permanent harm, unemployment, piles of medical bills & extra costs that go along with many MRSA infections---if you're lucky enough not to die from it.

    Why is it that we can't get a consensus on a minimum standard that every hospital in this country should employ to prevent these deaths? We go to the hospital to get well and instead thousands of people are being harmed or having their lives cut short from MRSA and other HAI's.

    Shame on the Healthcare industry for not making this a public health priority. If we spent half of the money the CDC & hospitals across the country have spent on H1N1 prevention, marketing, vaccines, etc, we'd be making some progress.

    Every hospital is working in their own vacuum, using their own 'cookbook' recipes to try to control this deadly bug. Hospitals across the country are cutting back on ICP's and IC budgets.

    In the meantime, death certificates mislead public policy makers because MRSA and other HAI deaths are grossly under-reported on death certificates.

    What will it take? How many more deaths?
    We're waiting.......

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