CDC lauds model VRE plan in Siouxland Health District
Identifying bug rather than assigning blame
In an effort that is being lauded as a model collaboration across the health care continuum, ICPs and colleagues in a tri-state Midwest region called the Siouxland Health District have brought emerging vancomycin-resistant enterococci (VRE) to a grinding halt.
In all, 32 acute-care and long-term care facilities are collaborating with each other and public health officials in a region that includes sections of South Dakota, Nebraska, and Iowa. In addition to sharing information about VRE cases, the program includes selective screening of patients, isolation measures, and a checklist for VRE roommate decisions. (See boxes, pp. 119, 120.)
"When facilities get together, communicate, and really look at how they are going to isolate the bug rather than fix the blame, it really impacts what you are doing," Dee Pedersen, RN, CIC, infection control coordinator at St. Luke’s Medical Center in Sioux City, IA, tells Hospital Infection Control. "Because we could have easily become divided here."
Indeed, interfacility transfers of VRE patients without adequate communication can result in frayed relationships between long-term care facilities and hospitals, making it difficult for either setting to move patients back and forth across the health care continuum. The Centers for Disease Control and Prevention is collaborating on the ongoing project, and has been particularly encouraged by the findings.
"I think the attitude that has occurred in this region as a result of this project has been unbelievable," William Jarvis, MD, chief of the investigations and prevention branch in the CDC hospital infections program, tells HIC. "The long-term care facilities have no problem having their patients go to the acute-care facilities. The acute-care facilities have no barrier getting their patients into long-term care. Many of the barriers that everybody is facing in moving these patients back and forth do not exist in this community."
Jarvis described the program at the annual conference of the Association for Professionals in Infection Control and Epidemiology, held recently in Baltimore. In contrast to Siouxland’s successful program, VRE continues to increase in CDC sentinel hospitals in the National Nosocomial Infec tions Surveillance (NNIS) system, he warned.
"We are seeing a continued increase in VRE in both acute ICU and non-ICU settings, and we now [find] that over 20% of the isolates reported from infections in our NNIS participants are due to vancomycin-resistant strains," Jarvis said at APIC. "Colonization is a major risk for infection [and] control of VRE can be difficult due to inter-facility transmission. There has not been a comprehensive, community-of-health-care-facilities approach to control of VRE."
Incoming cases spark effort
In efforts primarily based out of Sioux City, IA, a VRE task force of public health officials and clinicians was formed when cases began appearing in the Midwest region in late 1996. The CDC was invited in and performed the first of two prevalence surveys in August of 1997. After interventions had been adopted, the CDC repeated the prevalence survey 14 months later in October of 1998. The surveys involved perianal swabbing of some 2,200 patients/residents at four acute-care facilities and 28 long-term care facilities.
Overall, the prevalence of VRE decreased from 2.1% in 1997 to 1.5% in 1998, Jarvis reported. In acute care facilities, VRE prevalence decreased from 6.6 % to 5.4% of patients cultured. In long-term care, prevalence dropped from 1.7% to 1.1%. Moreover, while three of the four acute care facilities had at least one VRE patient in both surveys, the number of long-term care sites with at least one VRE case fell from 12 to eight.
"In other words, we were able to eradicate VRE from a number of these facilities," Jarvis told APIC attendees. While the declines would not be considered dramatic for some pathogens, VRE typically has been so successful after establishing an initial foothold that holding the line — let alone actual reduction — is viewed as a victory.
"This serves as model for how hospital personnel, state health departments, regional departments, and federal agencies can work together," Jarvis said at APIC. "I would challenge you show me a community of health care facilities where VRE has been introduced [and] it remained static or decreased. I don’t know of another one. I think it is a testimony to the interventions at these institutions."
Concerning the interventions, the majority of the VRE patient screening is done in the acute care facilities when clinicians are preparing to discharge patients to long-term care, or when they are receiving patients from long-term care or hospitals outside their region, Jarvis reports. However, the long-term care sites may culture some patients that come from other areas of the country or other hospitals outside the region, he noted. No successful decolonization protocol for VRE has been established, so screening is primarily done to trigger isolation measures or roommate placements in colonized patients.
Jarvis clarified that the acute-care facilities are primarily using CDC guidelines for isolation and prudent use of antibiotics, while the long-term care facilities use what is "manageable" based on their local situation.1 "Some of them wanted to know about the [VRE-] positive patients and immediately place them in acute-care-facility-type isolation. Others did other things," Jarvis tells HIC. In addition, the CDC is studying whether a simple approach like "universal gloving" for contacts with VRE patients in long-term care might be a cost-effective alternative to more extensive isolation of residents, he says.
A no-fault’ approach
Overall, the removal of "blame" factors and the clear charge to notify other facilities about known VRE-colonized cases is probably as big a factor as any other in the success of the program, report ICPs involved in the project. "I think it was the communication between all of the facilities — long-term care and acute," Pedersen says. "We screened long-term care facility admits and dismissals. If we saw something, we shared it with the [other] facility right away. The communication here was one of the big things."
It was Pedersen and colleague Diane Prieksat, RN, CIC, manager of infection control and epidemiology services at Mercy Health Center in Sioux City, who originally alerted state and local health departments to the emergence of VRE in the community and suggested a coordinated response.
"We wanted it to be a no-fault’ type of thing," Prieksat says. "Initially, in some communities when VRE comes about, there may be a lot of speculation about who gave it to whom. So by doing this and involving the health department, we had an objective party that was working with the acute care and long-term care facilities. I think that helped make it a lot more effective."
Another factor in the program’s success is encouraging prudent vancomycin use according to CDC guidelines, Prieksat adds, noting that clinical pharmacologists monitor vancomycin use at her facility. Clinical problem areas identified for additional education efforts have included nephrology, oncology, and orthopedic surgery services. That aspect of the program has resulted in significant improvements in appropriate vancomycin usage, she says.
Reference
1. Centers for Disease Control and Prevention. Recommendations for preventing the spread of vancomycin resistance. Infect Control Hosp Epidemiol 1995; 16:105-113.
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