Thursday, November 11, 2010

Special Invited Veterans Day Post on MRSA

For the Veterans Day post, it is worthwhile mentioning the role of the VA in advancing research on infection prevention. Despite some bureaucratic hurdles, the VA has supported some of the more creative work over the years and having one of the few fully electronic medical record systems, has the potential to implement a more sophisticated approach to infection prevention.

A recent, high profile intervention in the VA is the MRSA Prevention Initiative. Mobilizing millions of dollars with a top down mandate, the VA has focused efforts on infection control, especially as it relates to MRSA. The majority of the intervention relates to improved hand hygiene and compliance with Standard and Contact Precautions and encourages involvement of local healthcare workers through positive deviance. More controversial was the mandate to perform active surveillance for MRSA, swabbing patients admitted to acute-care facilities almost ceaselessly (admission, transfer and discharge, obtaining > 90% compliance in many facilities). While no verdict has been reached on the effectiveness of active surveillance for MRSA, the VA, to its credit, has supported research into alternative approaches.

One of these alternative approaches was hatched by a mentor of mine known to this blog simply as Eli. Focusing on the known risk factors for MRSA as a means of identifying patients at high risk for carriage, he and I looked at simple rules that could predict patients who should be targeted for MRSA (and VRE) screening. In a closed system like the VA with a fully electronic medical record, these prediction rules could be automated. In the Baltimore VA, we examined possible prediction rules and found that documentation of antibiotic use within the past year identified 84% of the risk of MRSA transmission and 98% of the risk of VRE transmission. In other words, if the electronic medical record had documentation of antibiotic use, an order could have been automatically generated at time of admission for MRSA or VRE culturing. This testing would identify virtually all patients with VRE and most with MRSA while culturing half the patients currently subjected to swabbing. The full effect of such an approach needs investigation in other VA populations but is promising.

At a time when attention is turning towards generating solid data on sometimes intrusive infection control interventions, I’d like to salute the VA for taking the lead on supporting research that may help transform hospital epidemiology from expert opinion to a scientifically outcomes based field.

Note: Special thanks to our guest blogger and author of the discussed ICHE paper, Dan Morgan. Dan is an assistant professor at the University of Maryland and currently supported by an AHRQ K-award to study the non-infectious consequences of contact isolation.

1 comment:

  1. May be of interest for geeks who want to know where the VA MRSA prevention control program cam e from and what it looked like on the way. See slides 11-24 on this set: This slide set was made when the program was being transitioned from Pittsburgh-only to a VA-wide implementation.