MRSA, VRE indicators prove troublesome
National benchmarks not yet available
Before you figure on using antibiotic resistance as one of your ORYX indicators, consider the example of Miriam Hospital in Providence, RI. The facility is working on a quality improvement project on vancomycin (Eli Lilly’s Vancocin) resistance. "Here in the quality department, we identify and track patients at high risk for antibiotic resistance and flag them if they should be readmitted," says Diana Wantoch, Miriam Hospital’s quality manager. "We’ve been tracking rates of MRSA [methicillin-resistant Staphylococcus aureus] and VRE [vancomycin-resistant enterococci] as quality indicators for a few years, and our infection control committee has a team working on a QI project on vancomycin."Nancy Vallande, director of infection control at Miriam, says VRE poses a complex problem. To use resistance as an indicator, you have to know what to measure.
"At first we counted all nosocomial cases," says Vallande, "whether they were colonized or infected." The Hospital Infection Control Practices Advisory Committee guidelines from the Centers for Disease Control and Prevention (CDC) in Atlanta recommend prevalence surveys, so when the team saw a nosocomial case develop, they would survey that unit. "We would culture everyone’s perirectals," she says, "and when we found one or two cases of colonized VRE, we’d add those cases to their numbers." In addition, they would screen all the stools done in the hospital.
"But we found that we were tampering with the system," explains Vallande. "Our rates were increasing because we went looking for cases. If we’d just looked at cases that popped up on general microbiology testing of urines, wounds, and blood, our stats would have been more accurate."
There are no national data on acceptable rates of resistance for hospitals. The CDC’s National Nosocomial Infections Surveillance system tracks infections such as bacteremias, and contains data on hospitals nationwide and thresholds against which to benchmark.
"Our problem is that we can’t just measure every nosocomial case," concludes Vallande. "Perhaps we should look only at the infected cases — they are the important ones — or we may just report our blood cultures. We’re undecided on this point, but we probably won’t use resistance indicators for our ORYX requirement."
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