By Brenda L. Mooney
LEXINGTON, KY — The VA requirement to obtain nasal surveillance swabs on all patients at hospital admission, unit-to-unit transfer and discharge appears to be a key component of the continued decline in methicillin-resistant Staphylococcus aureus (MRSA) rates at VAMCs.
A new report points out that, five years after implementing a national initiative to reduce MRSA, cases at the VA have continued to drop. That is significant, according to the authors, because it shows that efforts to reduce resistant infections can be successfully sustained over 57 months in a large national healthcare system
Report authors observe that the universal screening “served to constantly remind staff of MRSA and the need to prevent transmissions and MRSA HAIs through good compliance with hand hygiene and contact precautions,” adding, “The continued high compliance with nasal surveillance at admission (96%) and at transfer and discharge (94%) in VA facilities nationwide suggests that health care workers continue to be fully engaged with the Initiative.”
The VA’s MRSA Prevention Initiative was implemented in 2007, and initial results two years ago showed significant decreases in the transmission of MRSA — a 17% decline within intensive care units and a 21% decline for non-ICUs — as well as reductions in healthcare-associated infection (HAI) rates within the hospitals, 62% for ICUs and 45 for non-ICUs.
Since then, from July 2010 through June 2012, according to the latest report, both MRSA transmissions and HAIs continued to drop in non-ICU settings — decreasing an additional 13.7% and 44.8%, respectively — although rates were unchanged in ICUs from the previous results.
The latest report, put together by Martin E. Evans, MD, of the Lexington, KY, VAMC, and the VHA MRSA/MDRO Program Office, and colleagues from the National Infectious Diseases Service was published in the November issue of the American Journal of Infection Control.1
The continuing decrease is the result of the dissemination within VA of a “MRSA bundle” — a group of infection-control strategies that include active surveillance of MRSA incidents in the hospital, MRSA testing of patients as they enter and leave the hospital, contact precautions by staff and improved hygiene. In addition to fostering cultural change by focusing on individual responsibility for infection control among healthcare workers, it also created the position of MRSA Prevention Coordinator at each medical center.
“The analysis … shows that over the ensuing 24 months, MRSA transmission and MRSA HAI rates continued to decrease nationwide,” the authors stated. “Detailed analysis showed that there were statistically significant declines in MRSA transmissions and MRSA HAIs in non-ICUs but not in the ICUs. The absence of statistically significant trends in the ICUs may be because MRSA transmission and MRSA HAI rates were low.”
The article noted that, during that time period, there were 2,382,952 admissions to or transfers or discharges from VA hospitals, of which 372,290 involved intensive care units. That represented more than 6 million patient days nationwide.
With the mean monthly percentage of patients screened for MRSA upon facility admission at 96.2%, the prevalence of patients carrying MRSA at admission decreased from 16.0% to 15.2%.
At the same time, monthly transmission rates in ICUs and non-ICUs combined declined 12.1%, with the 13.7% decrease in non-ICU rates accounting for most of that. Monthly MRSA HAI rates in ICUs and non-ICUs combined declined 36.4%; again the decrease in non-ICUs (44.8%) made up most of that change. The authors suggested that the absence of statistically significant trends in ICUs may be because MRSA transmission and MRSA HAI rates were low and becoming asymptotic in those settings.
Quarterly rates of combined device- and nondevice-associated MRSA bloodstream HAIs in ICUs and non-ICUs also fell 36.4%, but no significant changes in pneumonia or urinary tract infection rates were documented. Furthermore, there were no differences in bloodstream MRSA HAI rates when the infections were separated into device- and nondevice-associated infections.
Looking at the entire 57 months of the VHA MRSA Prevention Initiative from its inception in October 2007, the authors report that:
- Overall MRSA transmissions declined 24.2%;
- ICU MRSA transmissions declined 21.8%;
- Overall MRSA HAIs declined 68.6%;
- ICU MRSA HAIs declined 71.9%; and
- Non-ICU MRSA HAIs declined 65.5%.
- MRSA admission prevalence from April 2008 (with a definition change) through June 2012 increased 15.2%.
“Of note, recent declines in MRSA HAI rates in the United States have been reported by others, but differences in methods, populations evaluated, and absence of information about infection control activities make it difficult to determine the relevance of these data to the VA experience,” according to the report authors. “Declines in the prevalence of specific MRSA clones over time have also been reported, raising the possibility that declining MRSA HAI rates among veterans may merely reflect broader trends in bacterial populations. Although we do not have data on clonal trends from MRSA HAI isolates, the prevalence of patients carrying MRSA on admission to VA facilities increased by approximately 15% over the 57 months of the Initiative, suggesting that the declining MRSA HAI rates observed were not solely due to a decreasing prevalence of MRSA in the VA patient population served.”
Discussion in the article noted that bloodstream infections accounted for most of the decline in MRSA HAIs observed in VA facilities from July 2010 through June 2012, suggesting that the lack of a difference in the rates of device- and nondevice-associated bloodstream infections suggests that the decline observed was not due solely to implementation of a formalized approach to placing and maintaining central line intravascular catheters.
“This is consistent with the VA experience from 2005 to 2007 before implementation of the MRSA Prevention Initiative when MRSA bloodstream HAIs did not decrease despite the use of bundles for central-line associated bloodstream infections,” according to the report. “In this case, MRSA HAI rates only began to decline significantly when the VA MRSA bundle, which included universal nasal surveillance for a single pathogen — MRSA — was added to Contact Precautions and hand hygiene, which had been in place for years as general strategies to control infection by multiple pathogens.”
The authors again cautioned that the VA MRSA Prevention Initiative is a quality-improvement program, not a prospectively designed trial. Therefore, data are not available to determine how much the decrease in observed MRSA transmissions and MRSA HAIs was due to the MRSA bundle, changes in MRSA in the community, or other HAI prevention efforts.
- Evans ME, Kralovic SM, Simbarti LA, Freyberg RW, Orosky DS, Roselle GA, Jain R. Veterans Affairs methicillin-resistant Staphylococcus aureus prevention initiative associated with a sustained reduction in transmissions and health care-associated infectionsAJIC: American Journal of Infection Control – November 2013 (Vol. 41, Issue 11, Pages 1093-1095, DOI: 10.1016/j.ajic.2013.04.015)