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Methicillin-resistant Staphylococcus aureus (MRSA) is a major pathogen in hospital-acquired infections. MRSA-colonized inpatients who may benefit from undergoing decolonization have not been identified.
To identify risk factors for MRSA infection among patients who are colonized with MRSA at hospital admission.
A case-control study.
A 146-bed Veterans Affairs hospital.
Case patients were those patients admitted from January 2003 to August 2011 who were found to be colonized with MRSA on admission and then developed MRSA infection. Control subjects were those patients admitted during the same period who were found to be colonized with MRSA on admission but who did not develop MRSA infection.
A retrospective review.
A total of 75 case patients and 150 control subjects were identified. A stay in the intensive care unit (ICU) was the significant risk factor in univariate analysis (P<.001). Prior history of MRSA (P = .03), transfer from a nursing home (P = .002), experiencing respiratory failure (P<.001), and receipt of transfusion (P = .001) remained significant variables in multivariate analysis. Prior history of MRSA colonization or infection (P = .02), difficulty swallowing (P = .04), presence of an open wound (P = .002), and placement of a central line (P = .02) were identified as risk factors for developing MRSA infection for patients in the ICU. Duration of hospitalization, readmission rate, and mortality rate were significantly higher in case patients than in control subjects (P< .001, .001, and <.001, respectively).
MRSA-colonized patients admitted to the ICU or admitted from nursing homes have a high risk of developing MRSA infection. These patients may benefit from undergoing decolonization.
To assess the impact and sustainability of a multifaceted intervention to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission implemented in 3 chronologically overlapping phases at 1 hospital.
Interrupted time-series analyses.
A Veterans Affairs hospital in the northeastern United States.
Patients and Participants.
Individuals admitted to acute care units from October 1, 1999, through September 30, 2008. To calculate the monthly clinical incidence of MRSA colonization or infection, the number of MRSA-positive cultures obtained from a clinical site more than 48 hours after admission among patients with no MRSA-positive clinical cultures during the previous year was divided by patient-days at risk. Secondary outcomes included clinical incidence of methicillin-sensitive S. aureus colonization or infection and incidence of MRSA bloodstream infections.
The intervention—implemented in a surgical ward beginning October 2001, in a surgical intensive care unit beginning October 2003, and in all acute care units beginning July 2005—included systems and behavior change strategies to increase adherence to infection control precautions (eg, hand hygiene and active surveillance culturing for MRSA).
Hospital-wide, the clinical incidence of MRSA colonization or infection decreased after initiation of the intervention in 2001, compared with the period before intervention (P = .002), and decreased by 61% (P < .001) in the 7-year postintervention period. In the postintervention period, the hospital-wide incidence of MRSA bloodstream infection decreased by 50% (P = .02), and the proportion of S. aureus isolates that were methicillin resistant decreased by 30% (P < .001).
Sustained decreases in hospital-wide clinical incidence of MRSA colonization or infection, incidence of MRSA bloodstream infection, and proportion of S. aureus isolates resistant to methicillin followed implementation of a multifaceted prevention program at one Veterans Affairs hospital. Findings suggest that interventions designed to prevent transmission can impact endemic antimicrobial resistance problems.
To measure the effectiveness of an industrial systems-engineering approach to a methicillin-resistant Staphylococcus aureus (MRSA) prevention program.
Before-after intervention study
An intensive care unit (ICU) and a surgical unit that was not an ICU in the Pittsburgh Veterans Administration hospital
Allpatientsadmittedtothe study units
We implemented an MRSA infection control program that consisted of the following 4 elements: (1) the use of standard precautions for all patient contact, with emphasis on hand hygiene; (2) the use of contact precautions for interactions with patients known to be infected or colonized with MRSA; (3) the use of active surveillance cultures to identify patients who were asymptomatically colonized with MRSA; and (4) use of an industrial systems-engineering approach, the Toyota Production System, to facilitate consistent and reliable adherence to the infection control program.
The rate of healthcare-associated MRSA infection in the surgical unit decreased from 1.56 infections per 1,000 patient-days in the 2 years before the intervention to 0.63 infections per 1,000 patient-days in the 4 years after the intervention (a 60% reduction; P = .003). The rate of healthcare-associated MRSA infection in the ICU decreased from 5.45 infections per 1,000 patient-days in the 2 years before to the intervention to 1.35 infections per 1,000 patient-days in the 3 years after the intervention (a 75% reduction; P = .001). The combined estimate for reduction in the incidence of infection after the intervention in the 2 units was 68% (95% confidence interval, 50%-79%; P < .001).
Sustained reduction in the incidence of MRSA infection is possible in a setting where this pathogen is endemic. An industrial systems-engineering approach can be adapted to facilitate consistent and reliable adherence to MRSA infection prevention practices in healthcare facilities.
To identify characteristics of encounters between healthcare workers (HCWs) and patients that correlated with hand hygiene adherence among HCWs.
Intensive care unit in a Veterans Affairs hospital.
There were 767 patient encounters observed (48.6% involved nurses, 20.6% involved physicians, and 30.8% involved other HCWs); 39.8% of encounters involved patients placed under contact precautions. HCW contact with either the patient or surfaces in the patient's environment occurred during all encounters; direct patient contact occurred during 439 encounters (57.4%), and contact with environmental surfaces occurred during 710 encounters (92.6%). The median duration of encounters was 2 minutes (range, <1 to 51 minutes); 33.6% of encounters lasted 1 minute or less, with no significant occupation-associated differences in the median duration of encounters. Adherence with hand hygiene practices was correlated with the duration of the encounter, with overall adherences of 30.0% after encounters of ≤1 minute, 43.4% after encounters of >1 to ≤2 minutes, 51.1% after encounters of >3 to ≤5 minutes, and 64.9% after encounters of >5 minutes (P < .001 by the x2 for trend). In multivariate analyses, longer encounter duration, contact precautions status, patient contact, and nursing occupation were independently associated with adherence to hand hygiene recommendations.
In this study, adherence to hand hygiene practices was lowest after brief patient encounters (ie, <2 minutes). Brief encounters accounted for a substantial proportion of all observed encounters, and opportunities for hand contamination occurred during all brief encounters. Therefore, improving adherence after brief encounters may have an important overall impact on the transmission of healthcare-associated pathogens and may deserve special emphasis in the design of programs to promote adherence to hand hygiene practices.
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