Quality efforts can be derailed by superbugs
Early alert key to fighting resistant organisms
No hospital wants to become home to what some infection control professionals call "superbugs," but unless providers take steps now to guard their doors against antibiotic- resistant organisms transmitted from nursing home residents, this is exactly what could happen, infection control experts warn.
Quality improvement professionals can play an important part in stopping the spread of these organisms before they start (not to mention the associated high costs both in dollars and damaged facility reputation) by working with infection control colleagues to develop an early alert system and educational effort, says Charles S. Salemi, MD, MPH, chair of the infection control committee for Kaiser Hospital in Fontana, CA.
This best practice model he shares with Hospital Peer Review is based on Salemi’s involvement in a larger quality initiative consisting of representatives from 10 Kaiser hospitals in southern California. One of the task force’s urgent jobs was to look at quality improvement in infection control as it related to patients who were admitted from nursing homes.
Salemi explains why. "They are often debilitated and/or immunosuppressed and are most likely to carry organisms such as vancomycin resistant enterococci (VRE) and methicillin-resistant staphylococcus aureus (MRSA)," he says.
Peg Van Arsdale agrees. "They are especially at risk because they receive more frequent antibiotic therapy both in and out of the hospital than non-institutionalized persons," says the nurse epidemiologist at St. Mary’s Medical Center in Langhorne, PA. "And, they frequently undergo procedures such as urinary catheters and enteral feedings that increase the risk of infection."
The danger increases when hospitals don’t know they’re admitting a patient who is colonized or infected. For example, nursing homes may not inform the hospital that they are transferring such a resident, yet they will refuse to readmit the patient to their facility even if the infection originated there.
"It’s a frightening thing to think of what would happen if they won’t take them back. What are you going to do with these patients?"
Even though neither facility had a nosocomial infection of VRE or MRSA, the threat of that scenario was enough to force both Van Arsdale and Salemi to embark on a proactive strategy with both the hospital staff and surrounding nursing homes.
For example, Van Arsdale began her educational and alert campaign by reinforcing the Pennsylvania Department of Health’s guidelines for MRSA in long-term care.
"We found they had been distributed to facilities but in many cases were not being used," she says. "So we wrote an introductory letter, restating the problem, and sent out another copy of the bulletin to the directors of nursing at local extended care facilities."
The guide contained information such as colonization vs. infection, risk factors, transmission, identification, treatment goals, admission policies, infection control, and communication with hospitals.
"It clearly sets up parameters for communication between the hospital and long-term care facilities," Van Arsdale pointed out. "Long-term care facilities must inform hospitals [of the transfer of MRSA patients] and hospitals must notify these facilities."
Using this section as a springboard, Van Arsdale now faxes the information to the nursing home whenever the hospital identifies an isolate of MRSA or VRE in an admitted resident.
"We used a standardized form that says the person admitted is noted to have MRSA or VRE," she says.
A copy of that form also is sent to the hospital’s social worker. "Because they will be doing referrals to other long-term care facilities, they need to have the information upfront," Van Arsdale says.
In addition, the hospital developed a policy for handling patients with an active history of MRSA or VRE. "If they come in with signs and symptoms, then we cohort them with another patient with the same history," she explains. "If they come in with an unrelated diagnoses such as a fractured hip, then we place them with another nonsurgical patient."
Kaiser developed a similar early alert system and data base for VRE about six months ago.
"When we get the lab result or a referral from another facility that is transferring a VRE patient, we add this to the significant health indicator’ of the admitting screen," says Linda Becker, RN, BSN, MPH, department administrator for infection control. "Then, when the patient is admitted, the screen flags in admitting so the department knows to place the patient in a private room, then notify nursing and infection control," she adds.
If the patient is admitted through the emergency department, the flag also appears on that department’s screen.
This notification, though, is just one part of the VRE prevention plan. Becker and Teresa Canola, RN, BSN, CIC, infection control practitioner, have developed a comprehensive policy and procedures manual and an extensive educational campaign for staff, VRE patients, and visitors.
For example, after infection control has been notified, a special infection control cart is ordered from central processing. The cart contains supplies such as disposable gowns and gloves and a disposable stethoscope, blood pressure cuff, and thermometer.
"Anyone entering the room, including visitors, must wear gown and gloves and comply with strict hand washing," Canola says.
The cart also contains a detailed instruction sheet to remind nursing personnel of special precautions such as:
• taping a precaution sign to the front of the patient’s chart and room entrance;
• wiping all reusable equipment such as an EKG machine with the hospital’s germicide before removing it from the floor;
• using a disposable stethoscope or wiping a nondisposable one with alcohol;
• notifying other departments such as radiology of special precautions when transferring or transporting the patient;
• providing patients and visitors with the educational flyer.
"If the patient is transferred to another unit in the hospital, this cart, along with its instruction sheet, signs, and dedicated equipment, must also be transferred," Canola says.
To introduce the cart and its contents to the staff, Canola created a "self-learning educational tool" that contains information about VRE what it is, how it’s spread, and how cross-contamination can be prevented.
"Because VRE is fairly new to our facility, we’re teaching during our annual education reviews, as well as during staff meetings and special inservices," Becker says.
The packet also made its debut in October during infection control week. "We had a display where employees could answer a questionnaire that included VRE precautions, and if they answered it, they were eligible to enter a drawing for a prize," Canola says.
The thrust of the display and the entire educational campaign is that all hospital employees and physicians must work together to prevent the spread of VRE, Salemi notes.
"Our physicians have also improved their prescribing habits for vancomycin," he says. Vancomycin usage is one of the major risk factors for developing VRE, so we’ve instituted physician-approved guidelines for its appropriate use."
Although the hospital has had only two community-acquired cases of VRE, the infection control committee isn’t letting up. "The time to put these policies in place is now," he says. "Once an outbreak occurs, it’s too late."
His advice to other hospitals? "The time to clean up your act is now."
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