Wednesday, April 13, 2011

VA reduces HAIs! In other news, VA spends millions on MRSA screening

Jain and colleagues just published data from the VA healthcare system implementation of the "MRSA directive". For those who are still unaware, in 2007 the VA began mandating the IHI MRSA bundle system-wide, with MRSA screening (active detection and isolation, or "ADI") applied to all VA admissions. The results? From October 2007 until June 2010, the MRSA transmission rate decreased by 17% in ICUs and 21% in non-ICUs, and the incidence of healthcare associated MRSA infections in ICUs fell by 62%. Very impressive indeed.

But that's not the whole story. During the same time period, a subset of these VA hospitals also reported their rates of healthcare-associated VRE and C. difficile infections, and guess what? VRE HAIs fell by 100% in ICUs and 70% in non-ICUs, and C. difficile HAIs fell by 57% in non-ICUs. It seems that HAIs are falling across the VA system, probably as a result of an important culture change, and improved application of so-called "horizontal" approaches to infection prevention. Bravo to the VA!

Here's the problem: because the VA jumped right into universal ADI, utilizing the most expensive screening technology available, they've poured millions of dollars into one specific intervention (ADI), and we still have no idea if ADI had anything to do with their MRSA reductions. After all, MRSA HAI rates have been falling across the country, both inside and outside of ICUs, including in hospitals that do no ADI, or that do targeted ADI. And of course Mike's hospital, where no ADI is done, would scoff at a mere 60% rate of decrease, having reduced MRSA HAIs by almost 90% using horizontal approaches.

My conclusions? First, the VA is to be congratulated for demonstrating real and sustained progress in HAI prevention (disclaimer: I was a VA hospital epidemiologist for 10 years, including during the first 2 years of implementation of the MRSA directive). Second, VA policy makers should consider the possibility that universal MRSA screening is now doing more harm than good, if only because it costs millions of dollars annually that could be used to improve other infection prevention programs. By all means, continue the MRSA initiative. But consider relaxing the "universal" ADI directive to allow individual hospitals the latitude to tailor ADI practices to best address their current risk assessment.


  1. I want to know what happened with mortality rates and lenght of hospital stay during the study period?

  2. Inpatient mortality has been going down in VA, at least from 1999 to 2008, when I had access to data at VA Central Office. Even after rough adjustment by age and Charlson score it was going down. And faster that the CDC data on US hospitals in general. But it's a tricky thing to consider. Risk adjustment doesn't really account for people going home to die or dying in Long-term-care or hospice rather than a hospital. Nonetheless, the data sure "looked good" and if the rate had been going down slower than all-US or had been going up, there probably would have been a lot of interest.