Performance of methicillin-resistant Staphylococcus aureus protocols in Dutch hospitals

Survey of isolation room equipment and resources in an academic hospital

PURPOSE

The purpose of this paper, a point prevalence study, is to quantify the incidence of isolation and identify the type of communicable diseases in isolation. The paper evaluates isolation precaution communication, availability of personal protective equipment (PPE) as well as other equipment necessary for maintaining isolation precautions.

DESIGN/METHODOLOGY/APPROACH

A standardised audit tool was developed in accordance with the National Standards for the Prevention and Control of Healthcare Associated Infections (May 2009). Data were collected from 14 March 2017 to 16 March 2017, through observation of occupied isolation rooms in an academic hospital in Dublin, Ireland. The data were subsequently used for additional analysis and discussion.

FINDINGS

In total, 14 per cent (125/869) of the total inpatient population was isolated at the time of the study. The most common isolation precaution was contact precautions (96.0 per cent). In all, 88 per cent of known contact precautions were due to multi-drug resistant organisms. Furthermore, 96 per cent of patients requiring isolation were isolated, 92.0 per cent of rooms had signage, 90.8 per cent had appropriate signs and 93.0 per cent of rooms had PPE available. Finally, 31 per cent of rooms had patient-dedicated and single-use equipment and 2.4 per cent had alcohol wipes available.

PRACTICAL IMPLICATIONS

The audit tool can be used to identify key areas of noncompliance associated with isolation and inform continuous improvement and education.

ORIGINALITY/VALUE

Currently, the rate of isolation is unknown in Ireland and standard guidelines are not established for the evaluation of isolation rooms. This audit tool can be used as an assessment for isolation room compliance.

Barriers and enablers to meticillin-resistant Staphylococcus aureus admission screening in hospitals: a mixed-methods study

BACKGROUND

To reduce the risk of transmission of meticillin-resistant Staphylococcus aureus (MRSA), international guidelines recommend admission screening to identify hospital patients at risk of colonization. However, routine monitoring indicates that optimum screening compliance levels are not always achieved. In order to enhance compliance, we must better understand those factors which influence staff screening behaviours.

AIM

To identify factors which influence staff compliance with hospital MRSA screening policies.

METHODS

A sequential two-stage mixed-methods design applied constructs from normalization process theory and the theoretical domains framework to guide data collection and analysis. Initial qualitative findings informed subsequent development of a national cross-sectional survey of nursing staff (N = 450). Multiple regression modelling identified which barriers and enablers best predict staff compliance.

FINDINGS

Three factors were significant in predicting optimum (>90%) compliance with MRSA screening: having MRSA screening routinized within the admission process; category of clinical area; feedback of MRSA screening compliance within the clinical area. Integration of data-sets indicated that organizational systems which 'make doing the right thing easy' influence compliance, as does local ward culture. Embedded values and beliefs regarding the relative (de)prioritization of MRSA screening are important.

CONCLUSION

To our knowledge, this is the first study to provide original evidence of barriers and enablers to MRSA screening, applying both sociological and psychological theory. As antimicrobial resistance is a global health concern, these findings have international relevance for screening programmes. Future policy recommendations or behaviour change interventions, based on the insights presented here, could have significant impact upon improving screening compliance.

Healthcare workers' knowledge and perceptions of the risks associated with emerging extensively drug-resistant bacteria

OBJECTIVE

Guidelines have been issued in 2010 to prevent the spread of emerging extensively resistant bacteria (eXDR), but their implementation is difficult. We aimed to evaluate healthcare workers' (HCW) knowledge and their risk perception to identify barriers to the implementation of guidelines.

METHODS

Semi-structured interviews were conducted at a University Hospital, where case patients are regularly admitted. The interviews focused on HCW's knowledge, risk perception, and challenges met. The evaluation of HCW's knowledge and contagiousness and perception of severity of eXDR carriage were analyzed statistically. Risk perception and opinion about guidelines were analyzed by qualitative description.

RESULTS

One hundred and twenty-one HCWs were interviewed. The category of HCW, having searched for information on resistant bacteria, and having taken care of case patients were associated with better knowledge. The HCW category, age, type of unit, seniority, and having taken care of case patients were associated with risk perceptions. Qualitative analysis identified 61 themes. HCWs were extremely concerned by the spread of bacteria within the hospital. The main challenges identified were organizational and communication issues.

CONCLUSION

HCWs reported a lack of knowledge and a lack of resources to implement guidelines. Strategies to improve guidelines implementation must be based on a better availability of resources, better communication, and new educational methods.

Impact of a Mandatory Infection Control Education Program on Nosocomial Acquisition of Methicillin-ResistantStaphylococcus aureus

Objective.

To assess the impact of an institution-wide infection control education program on the rate of transmission of methicillin-resistantStaphylococcus aureus(MRSA).

Design.

Before-and-after study.

Setting.

A 472-bed, urban, university-affiliated hospital.

Intervention.

During the period March-May 2004, all hospital staff completed a mandatory infection control education program, including the receipt of hospital-specific MRSA data and case-based practice with additional precautions.

Outcome Measure.

The rate of nosocomial MRSA acquisition was calculated as the number of cases of nosocomial MRSA acquisition per 100 days that a person with MRSA colonization or infection detected at admission is present in the hospital (“admission MRSA” exposure-days) for 3 time periods: June 2002-February 2003 (before the Toronto outbreak of severe acute respiratory syndrome [SARS]), June 2003-February 2004 (after the outbreak of SARS), and June 2004-February 2005 (after education). A case of nosocomial acquisition of MRSA colonization or infection represented a patient first identified as colonized or infected more than 72 hours after admission or at admission after a previous hospitalization.

Results.

The rate of nosocomial acquisition of MRSA colonization or infection was 8.8 cases per 100 admission MRSA exposure-days for the period before SARS, 3.8 cases per 100 admission MRSA exposure-days for the period after SARS (P< .001 for before SARS vs after SARS), and 1.9 cases per 100 admission MRSA exposure-days for the period after education (P= .02 for after education vs before education). The volume of alcohol-based handrub purchased was apparently stable, with 4,010 L during fiscal year 2003-2004 (April 2003-March 2004) compared with 3,780 L during fiscal year 2004—2005. The observed rate of compliance with hand washing did not change significantly (40.9% during education vs 44.2% after education;P= .23). The total number of patients screened for MRSA colonization was not different in the 3 periods.

Conclusions.

The rate of nosocomial acquisition of MRSA colonization or infection decreased after SARS and was further reduced in association with a hospital-wide education program.

Knowledge, perceptions, and practices of methicillin-resistant Staphylococcus aureus transmission prevention among health care workers in acute-care settings

BACKGROUND

Health care workers (HCWs) play a critical role in prevention of health care-associated infections such as methicillin-resistant Staphylococcus aureus (MRSA), but glove and gown contact precautions and hand hygiene may not be consistently used with vulnerable patients.

METHODS

A cross-sectional survey of MRSA knowledge, attitudes/perceptions, and practices among 276 medical, nursing, allied health, and support services staff at an acute-care hospital in the eastern United States was completed in 2012. Additionally, blinded observations of hand hygiene behaviors of 104 HCWs were conducted.

RESULTS

HCWs strongly agreed that preventive behaviors reduce the spread of MRSA. The vast majority reported that they almost always engage in preventive practices, but observations of hand hygiene found lower rates of adherence among nearly all HCW groups. HCWs who reported greater comfort with telling others to take action to prevent MRSA transmission were significantly more likely to self-report adherence to recommended practices.

CONCLUSIONS

It is important to reduce barriers to adherence with preventive behaviors and to help all HCWs, including support staff who do not have direct patient care responsibilities, to translate knowledge about MRSA transmission prevention methods into consistent adherence of themselves and their coworkers to prevention guidelines.

Overview of strategies for overcoming the challenge of antimicrobial resistance

The discovery of penicillin undoubtedly transformed the management of life-threatening bacterial infections. However, a less comfortable aspect of the antibiotic revolution was that within 10 years, over 80% of patients with acute bronchitis were receiving antibiotics without any evidence of clinical benefit. Antibiotic use inevitably causes collateral damage to the normal human flora and increases the risk of infection with antibiotic-resistant bacteria and Clostridium difficile. The twin aims of antibiotic stewardship are first to ensure effective treatment for patients with bacterial infection and second to provide convincing evidence and information to educate and support professionals and patients to reduce unnecessary use and minimize collateral damage. We review evidence of progress with these aims in Europe and nationally in Scotland.

Patient experience of source isolation: lessons for clinical practice

Methicillin-resistant Staphylococcus aureus (MRSA) is now the leading antimicrobial-resistant organism of concern to clinicians worldwide. Preventing and controlling the increase and spread of MRSA within the health-care environment is therefore an important function of the infection control team. The prevention and control of MRSA requires strict use of both Standard and Additional Precautions, which include good hand hygiene practices, judicious antimicrobial prescribing, and source isolation. While few would dispute the need for these precautions for preventing the spread of MRSA and other infections, their use may result in adverse physical and psychological effects for the patient. In an age of quality and safety of health care, ensuring infection control practice such as source isolation and contact precautions adhere to fundamental human rights is paramount. This paper presents a review of the literature on the patient experience of source isolation for MRSA or other infectious diseases. The review yielded five major interconnected themes: (1) psychological effects of isolation; (2) coping with isolation; (3) social isolation; (4) communication and information provision; and (5) physical environment and quality of care. It found that the experience of isolation by patients has both negative and positive elements. Isolation may result in detrimental psychological effects including anxiety, stress and depression, but may also result in the patient receiving less or substandard care. However, patients may also benefit from the quietness and privacy of single rooms. Nurses and other healthcare workers must look for ways to improve the experience of isolation and contact precautions of patients in source isolation. Opportunities exist in particular in improving the environment and the patient's self-control of the situation and in providing adequate information.

How nurses seek and evaluate clinical guidelines on the Internet

AIM

This paper is a report of a study conducted to assess nurses' information-seeking strategies and problems encountered when seeking clinical guidelines on the Internet, and to investigate the criteria they apply when evaluating the guidelines and the websites communicating the guidelines.

BACKGROUND

As nurses are increasingly taking on clinical responsibilities, they should be able to use the Internet to access up-to-date clinical guidelines. Currently, nurses' information-seeking skills remain rather limited.

METHOD

In 2008, a convenience sample of 20 nurses solved scenario-based tasks using the Internet to seek clinical guidelines regarding methicillin-resistant Staphylococcus aureus while thinking aloud.

RESULTS

General background information and universal precautions were successfully identified by participants, in contrast to more specific precautions. Nurses' information-seeking skills appeared rather basic, as they employed a limited number of search terms and consulted a limited number of websites. Ineffective searches were mainly caused by a mismatch between the guidelines and nurses' tacit knowledge. Perceived practical relevance and information completeness were the most frequently applied quality criteria. Accuracy and disclosures, which are emphasized in existing e-health literature, were considered less important. As long as information matched nurses' practical and experiential wisdom, they were satisfied.

CONCLUSION

Nurses appeared to rely predominantly on tacit knowledge during the search process and while evaluating the retrieved guidelines. This is dangerous because nurses' reliance on inaccurate information might result in inadequate behaviour. It is therefore essential to expand nurses' current information base by tailoring both navigation structure and the guideline communication to dovetail with nurses' tacit knowledge.

Factors affecting health care workers' adoption of a website with infection control guidelines

GOAL

To identify factors that could affect health care workers' (HCWs) adoption of a website for communicating infection control guidelines.

METHODS

In total, 20 semi-structured interviews were conducted with HCWs in 5 different occupational groups and 4 different hospitals in the Netherlands and Germany. A website communicating guidelines for the prevention and control of Methicillin Resistant Staphylococcus aureus served as a casus. The HCWs, the majority of whom had prior experience with the website, were asked to give their opinions about factors that hinder or facilitate adoption of the website in practice. The interviews were based on the PRECEDE (Predisposing, Reinforcing, and Enabling Causes in Educational Diagnosis and Evaluation) model complemented by quality criteria for health-related websites. This model encompasses different categories of factors relevant to technology adoption in health care.

RESULTS

A total of 361 interview statements were relevant to the four main categories of the PRECEDE model, yielding the following observations: (1) Technological factors (72 statements): The usability, design, and relevance of the website were positively valued. The website enabled HCWs to access contextually relevant information quickly. The website's credibility was evaluated rather negatively, as respondents perceived that the website's guidelines were not in concurrence with the best available evidence and it was not clear to HCWs who created the website. (2) Individual factors (85 statements): Respondents, particular infection control professionals, showed individual resistance to the website because they preferred to use their personal knowledge and experience (and communication with colleagues) over online sources. (3) Work-related factors (53 statements): Respondents perceived high work pressure during working hours as an impediment to consulting the website. In contrast, respondents thought the website might lower work pressure for infection control professionals, as they will receive fewer questions from HCWs. (4) Organizational factors (131 statements): Interpersonal (face-to-face) communication between HCWs from different occupational groups in both a formal (training) and informal (feedback) manner was seen as the most stimulating factor behind website use. The respondents identified infection control nurses as the most important opinion leaders.

CONCLUSION

Factors from multiple categories determine HCWs' adoption of web-based guidelines, but the organization appeared to be a paramount reinforcer of initiation and maintenance of technology adoption among HCWs. In order eliminate resistance and create ownership among HCWs toward the website, leading to a willingness to integrate the website into routine care, it is essential to more actively involve HCWs in the early phases of the design process.

Dissemination of the CDC's Hand Hygiene Guideline and impact on infection rates

BACKGROUND

The diffusion of national evidence-based practice guidelines and their impact on patient outcomes often go unmeasured.

METHODS

Our objectives were to (1) evaluate implementation and compliance with clinical practices recommended in the new Centers for Disease Control and Prevention (CDC) Hand Hygiene Guideline, (2) compare rates of health care-associated infections (HAI) before and after implementation of the Guideline recommendations, and (3) examine the patterns and correlates of changes in rates of HAI. We used pre- and post-Guideline implementation site visits and surveys in the setting of 40 US hospitals--members of the National Nosocomial Infections Surveillance System--and measured HAI rates 1 year before and after publication of the CDC Guideline and used direct observation of hand hygiene compliance and Guideline implementation scores.

RESULTS

All study hospitals had changed their policies and procedures and provided products in compliance with Guideline recommendations; 89.8% of 1359 staff members surveyed anonymously reported that they were familiar with the Guideline. However, in 44.2% of the hospitals (19/40), there was no evidence of a multidisciplinary program to improve compliance. Hand hygiene rates remained low (mean, 56.6%). Rates of central line-associated bloodstream infections were significantly lower in hospitals with higher rates of hand hygiene (P < .001). No impact of Guideline implementation or hand hygiene compliance on other HAI rates was identified. Other factors occurring over time could affect rates of HAI. Observed hand hygiene compliance rates were likely to overestimate rates in actual practice. The study may have been of too short duration to detect the impact of a practice guideline.

CONCLUSION

Wide dissemination of this Guideline was not sufficient to change practice. Only some hospitals had initiated multidisciplinary programs; practice change is unlikely without such multidisciplinary efforts and explicit administrative support.

Success of MRSA eradication in hospital routine: depends on compliance

BACKGROUND

To prevent transmission of MRSA, eradication by antiseptic washings and nasal ointment is recommended. There are few studies, which investigated the success of eradication of MRSA carriage during everyday clinical working conditions and results are controversial. We wanted to assess the effectiveness of MRSA eradication procedures--especially octenidine whole body washings and mupirocin nasal ointment--under conditions of everyday life.

PATIENTS AND METHODS

We retrospectively analyzed the files of all patients who were admitted to the medical department of a tertiary care hospital between 1999 and 2004 and who were infected or colonized by MRSA. According to hospital's standards of care patients should have been washed with octenidine and should have got mupirocin nasal ointment only in case of nasal carriage. Patients were regarded as MRSA-eradicated when swabs taken on three consecutive days, earliest, three days after discontinuation of antiseptic and antiinfective procedures were without proof of MRSA.

RESULTS

Only 6% of patients were eradicated. MRSA could be cultured from swabs taken on dismissal of 60% of patients. Fifteen percent of patients had only one or two negative series of swabs. In 19% of patients success of eradication remained unknown. Besides we found that under every day clinical working conditions compliance with several tasks of the eradication protocol was insufficient.

CONCLUSION

Under every day clinical working conditions MRSA eradication is successful only in few patients. Whole body washings should be tested in detailed studies before they should become a recommendation for eradication of MRSA.

Infection control and management of MRSA: assessing the knowledge of staff in an acute hospital setting

Much of the recent work in tackling meticillin-resistant Staphylococcus aureus (MRSA) has focused on hygiene in hospitals, but it is unclear how much hospital staff know about the treatment and management of patients who are colonized or infected with MRSA. The aim of this study was to assess the knowledge and perceived practice of staff regarding MRSA and its management in an acute hospital setting. A further aim was to determine what staff felt was needed in terms of information or education on the risks, management and treatment of MRSA. A questionnaire survey was carried out through group administration during a study day and by face-to-face interviews. Subjects included in the questionnaire were infection and colonization, treatment, and the availability of local support and advice. There were 174 responses, divided equally between doctors and nurses. Knowledge on many aspects of MRSA and its management was deficient, although the majority of participants who felt that they required additional information about MRSA acknowledged this. The survey confirmed that assumptions should not be made about adequate knowledge and expertise of staff in relation to MRSA. Gaps in awareness of aspects of care and management were highlighted and information and educational needs identified.