The Utility and Cost of MRSA Surveillance and Contact Precautions

Transcription

1 The Utility and Cost of MRSA Surveillance and Contact Precautions Eliza Lewine 1, Nikil Moodabagil MD 2, Purav Brahmbhatt 1, Erin Boswell MD 3, Brandon Mauldin MD 1,2 Logan Davies MD 2,3 1. Tulane University, School of Medicine 2. Tulane Medical Center 3. Southeast Louisiana Veterans Health Care System

2 AGENDA MRSA Surveillance and Contact Precautions Driver s of Current Practice 3 Key Questions 1. Evidence for Practice 2. Patient and Provider Impacts 3. Financial Impacts Q+A

3 Current Practice Current Practice: Multi Drug Resistant Organisms (MDRO) Includes MRSA and VRE Precautions include standard, contact, airborne and droplet precautions Contact Precautions: Standard precautions + Private Room Dedicated Room Equipment Minimize patient movement to cafeteria Gown and Gloves

4 CDC recommendations to prevent transmission of MDRO:...implement contact precautions routinely for all patients infected with MDROs and for patients...previously identified as being colonized with target MDROs. Grade IB evidence Current Tulane Policy Patients are placed on Contact Precautions if they have an active MRSA Infection or if they have been colonized with MRSA within the past 12 months

5 Drivers of CP? Industry Factors Clinical Factors CDC Guidelines Hospital Policy Custom OVERUSE HARM Risk aversion LOS/complicati ons Immunocompromised Patients Clinician factors Economic factors Patient factors

6 Key Question #1: Are contact precautions (CP) likely effective?

7 Active Detection and Isolation CDC isolation guideline First Randomized Trial Hawkins, et al. VA MRSA Study Jain et al

8 Active Detection and Isolation VA MRSA Study Jain et al 3-year observational study ( ) Decreased MRSA and C Diff and VRE 150 hospitals 2 million patients MRSA Bundle Gurieva et al. (2012) Universal surveillance for MRSA CP for MRSA + patients Improved hand hygiene Culture change 3 year study No control group

9 Active Detection and Isolation Contact Precautions or something else? Universal Decolinization Targeted Decolinization Universal Decolinization ADI Huang et al. (2013)

10 Active Detection and Isolation Contact Precautions or something else? Hand washing and Chlorexhidine Baths Hand washing and Chlorhexidine Baths ADI Derde et al. (2013)

11 Active Detection and Isolation Contact Precautions or something else? ADI ADI with Hand Washing ADI with Hand Washing Robicsek 2018 Huang 2013 Harbarth 2008 Huskins 2011 Jain 2011 Lee 2013 Derde 2014

12 Active Detection and Isolation

13 Active Detection and Isolation Systemic Reviews Morgan DJ et al No high quality data support or reject use of CP for endemic MRSA or VRE. Our survey found more than 90% of responding hospitals currently use CP for MRSA and VRE but approximately 60% are interested in using CP in a different manner. More than 30 hospitals do not use CP for control of endemic MRSA or VRE Kullar R et al CPs reduced MRSA transmission in epidemic settings and in instances with high compliance but a decrease in infection rates was not shown. In endemic settings, there are few data to support routine use of CP s to control the spread of MRSA.

14 Key Question #2: Do adverse consequences due to contact precautions occur?

15 I haven t gotten my pain medication for four hours. I wonder if it s because of my infection. -Patient Perspective

16 Provider Perspective I try and see them last because then you re not taking any organisms into any other rooms. -Nurse

17 I still see him once or twice a day (on) prerounds and rounding with the attending otherwise, I don t go back to see him. -Resident Provider Perspective

18 CP: Patient-Provider Contact Impacts Frequency of visits Evans et al. (2001) Surgical ICU setting Number of encounters and contact time per encounter 22% less contact time with HCWs (p<0.001) Morgan et al. (2013) ICU and wards 36.4% fewer hourly HCW visit 17.7% less direct patient contact time with HCWs

19 CP: Patient-Provider Contact Impacts Interns visited for fewer minutes (p<0.001) (1) Interns visited less often (p<0.001) (1) Attendings visited fewer rooms (p<0.001) (2) Visits with Non CP patients Visits with CP patient Hourly patient contacts by HCW (p=0.03) (3) Darshiel-Earp (2014) 2. Saint et al (2003) 3. Kirkland and Weinstein (1999)

20 CP: Patient-Provider Contact Impacts Time to CT Scan for inpatients 1 Time from ER to inpatient room 2 Time for transfer to nursing home hrs +10 hrs +7days Days with no vital signs recorded 4 Days with no nursing notes 4 Days with no MD progress note Karki S et al. (2013) 2. Gilliigan et al. (2010) 3. Goldszer et al. (2002) 4. Stelfox et al. (2003)

21 Do your healthcare providers always follow the Contact Precautions? I guess it all depends on the rules of the hospital Pretty much like 75% that wear them and 25% maybe don t doing the same job. -Patient Perspective

22 Do you always follow the Contact Precautions? First time certainly because I have no idea what s going on. And then afterwards once I realize there s no need I really don t. -Resident Provider Perspective

23 CP: Provider Hand Hygiene Compliance HAND HYGEINE CP gown use requirement does not lead to an increased compliance with hand hygiene in an ICU setting (Golan et al. 9 ) CP did not increase compliance with hand hygiene practices in ICU setting (Gilbert et al. 10 )

24 CP: Patient Safety Impacts Table from Michael Edmond MD, MPH, MPA

25 When my family comes they don t wear them I guess they don t think the infection in my heart is going to get to them. Patient -Patient Perspective

26 I notice that a lot (of the managers) will say they were on precautions so I didn t go in the room. Provider Perspective - Dietary

27 CP: Patient Satisfaction Impacts Kennedy and Hamilton 1997 Rehab Unit Patients on CP more angry about their care (p=0.037) 85% patients believed they had limited rehabilitation Gammon 1998 Tarzi et al Catalano et al Mehrotra et al Inpatient Rehab. Unit Inpatient Inpatient More anxiety 12.8 vs 8.2 (p<0.001) and depression 12.5 vs 7.3 (p<0.001) Depression: 77% CP vs 33% non-cp patients Higher depression and anxiety scores after 1 week (p<0.001) Increasing HAM-D scores in proportion to LOS for CP patients and decreasing HAM-D scores in non-cp patients Greater number of perceived concerns with care (p<0.01); poor coordination of care (p=0.02) and a lack of respect (p=0.001) for CP patients Patients were twice as likely to report issues with their care than non-isolated patients

28 Key Question #3: What is the financial impact?

29 Cost Impact Harris et al. University of Maryland Medical Center $187,992 Verlee et al. Spectrum Health Hospitals Grand Rapids, MI Non-ICU: $35/ patient day ICU: $42/ patient day Edmond et al. VCU Medical Center Annual cost of $497,924 Graman et al. Strong Memorial Hospital Annual cost savings of $255,000 Martin et al. UCLA Annual cost savings of $2.7 million

30 CP can result in Less time with providers More dissatisfied patients Significant costs for the hospital With any benefit? Is it time to re-evaluate Contact Precautions at our institutions?

31 Acknowledgments Michael Edmond, MD MPH MPA Rethinking Contact Precautions Christen Mayer MD, Infection Control Dept. Tulane Medical Center Maura Reynolds RN, Infection Control Dept. Tulane Medical Center

32 Thank you!