Good Intentions Does not Always Mean Good Policy

How often do negative studies influence our behavior, or better yet our policies? For those of you that are familiar with the work I have published, you know that I published a lot of material focused on MRSA; emerging resistance, community-emergence, burden of disease, attributable cost, risk factors, and on.  I was in a position at CDC to access and synthesize a lot of data, with a goal of putting the problem in perspective and ideally affect policy. Well intended as it was, I remember very clearly in mid-2007 when policy got way ahead of the science. Two independent (but related) events occurred on October 16-17, 2007 that led to several years of a watershed of policy developments. Although I give a huge amount of credit to the very passionate and important patient advocates and consumers that built momentum for the policies – but with hindsight the policy inertia was really overcome when a senior student at Staunton River High School died on October 16 from MRSA sepsis—MRSA he acquired in the community. The press linked that death to Dr. Elizabeth Bancroft’s editorial that same week stating “…more people die of MRSA in the U.S. than of AIDS” published on October 17. Many of us see much of the public reporting and mandatory reporting policies have opened up real pathways for additional hospital resources to invest in HAI prevention. However all of us should recognize some policies of that era are likely in place that really should be re-examined. 

One of these is the Illinois 210 ILCS 83/ legislation requiring all patients admitted to intensive care units be screened for MRSA by nasal active surveillance testing (AST). Lin and colleges just published a negative study with a lot of important findings. To many, the findings will not be a surprise (CID May 15 2018, pp 1535-1539)

• Lin worked with 51 intensive care units at 25 hospitals over 5 years starting within months of enactment of this mandate to evaluate any changes in ICU MRSA prevalence through periodic point prevalence surveys performed by trained study staff during the time of this mandate. The study was a quasi-experimental time series evaluation but without a real before observation group and no control group. However, I believe that any impact would have been additive over time – the first year would have been a sort of wash in period for an intervention as broad in participation as this.  They sampled 3909 patients having the power to even detect an absolute difference in carriage as small as a 1.9% change in prevalence (eg, 10% vs 8.1%) – but they detected none. No change in prevalence of MRSA on these patients. 
  

• Compliance was high overall (93%), admission prevalence was comparable to other studies (9.7%), and overall, at any given survey of known positive patients and unknown, 11.1% were positive in any given month, in any given year of this study.  Sure, time to placement of contact precautions lagged from test turnaround time or from time to test result to actual placement of precautions, but most notably the mandated testing was only 84% sensitive compared to best testing methods  employed by the study investigators. This is the real world after all.

• While these ICUs have invested time, effort, and money into these admission swabbing and targeted placement of contact precautions, the prevalence of MRSA carriage has not budged in these intensive care unit patients.

There may be many reasons the hospitals in Illinois overall are seeing an estimated 30% decrease in their hospital-onset MRSA BSI (as most states are) since the 2010 NHSN baseline, but admission screening isn’t one of them. Maybe its CLABSI prevention, or that uptake of the percentage of study patients receiving CHG baths. However, this study suggests it was not the mandated AST for all ICU patients admitted to the ICU. These patients are bringing their MRSA in with them, let’s free up staff time to prevent the infections.

I know there are many major federal policies we all can be passionate about changing or starting, these are crazy days. But when the scientific evidence is so strong illustrating that a very well-intended policy regarding use of nursing and infection control resources does not have the intended impact – change it. Nursing care can better be spent caring for patients, practicing best infection control for all patients in these intensive care units.