An effective computerized reminder for contact isolation of patients colonized or infected with resistant organisms

Perceptions of infection control professionals toward electronic surveillance software supporting inpatient infections: A mixed methods study

BACKGROUND

Electronic surveillance software (ESS) collects multiple patient data from hospital software to assist infection control professionals in the prevention and control of hospital-associated infections. This study aimed to understand the perceptions of end users (i.e., infection control professionals) and the facilitators and barriers related to a commercial ESS named ZINC and to assess its usability.

METHODS

A mixed-method research approach was adopted among infection control professionals 10 months after the implementation of commercial ESS in the university hospital of Nancy, France. A qualitative analysis based on individual semistructured interviews was conducted to collect professionals' perceptions of ESS and to understand barriers and facilitators. Qualitative data were systematically coded and thematically analyzed. A quantitative analysis was performed using the System Usability Scale (SUS).

RESULTS

Thirteen infection control professionals were included. Qualitative analysis revealed technical, organizational and human barriers to the installation and use stages and five significant facilitators: the relevant design of the ESS, the improvement of infection prevention and control practices, the designation of a champion/superuser among professionals, training, and collaboration with the developer team. Quantitative analysis indicated that the evaluated ESS was a "good" system in terms of perceived ease of use, with an overall median SUS score of 85/100.

CONCLUSIONS

This study shows the value of ESS to support inpatient infections as perceived by infection control professionals. It reveals barriers and facilitators to the implementation and adoption of ESS. These barriers and facilitators should be considered to facilitate the installation of the software in other hospitals.

Unpacking nudge sensu lato: insights from a scoping review

Nudges may play an important role in improving infection prevention and control (IPC) in hospitals. However, despite the novelty of the framework, their objectives, strategies and implementation approaches are not new. This review aims to provide an overview of the methods typically used by nudge interventions in IPC in hospitals targeting healthcare workers (HCWs). The initial search in PubMed yielded nine hits. Consequently, the search criteria were broadened and a second search was conducted, introducing 'nudge sensu lato' which incorporates insights from sources beyond the traditional nudge framework while maintaining the same objectives, strategies and approaches. During the second search, PubMed, Epistemonikos, Web of Science and PsycInfo were searched in accordance with the PRISMA guidelines. Abstracts were screened, and reviewers from an interdisciplinary team read the full text of selected papers. In total, 5706 unique primary studies were identified. Of these, 67 were included in the review, and only four were listed as nudge sensu stricto, focusing on changing HCWs' hand hygiene. All articles reported positive intervention outcomes. Of the 56 articles focused on improving hand hygiene compliance, 71.4% had positive outcomes. For healthcare equipment disinfection, 50% of studies showed significant results. Guideline adherence interventions had a 66.7% significant outcome rate. The concept of nudge sensu lato was introduced, encompassing interventions that employ strategies, methods and implementation approaches found in the nudge framework. The findings demonstrate that this concept can enhance the scientific development of more impactful nudges. This may help clinicians, researchers and policy makers to develop and implement effective nudging interventions.

Computer Informatics for Infection Control

Computer informatics have the potential to improve infection control outcomes in surveillance, prevention, and public health. Surveillance activities include surveillance of infections, device use, and facility/ward outbreak detection and investigation. Prevention activities include awareness of multidrug-resistant organism carriage on admission, identification of high-risk individuals or populations, reducing device use, and antimicrobial stewardship. Enhanced communication with public health and other health care facilities across networks includes automated electronic communicable disease reporting, syndromic surveillance, and regional outbreak detection. Computerized public health networks may represent the next major evolution in infection control. This article reviews the use of informatics for infection control.

Development and evaluation of the automated risk assessment system for multidrug-resistant organisms (autoRAS-MDRO)

BACKGROUND

A high proportion of infections acquired in hospitals are caused by multidrug-resistant organisms (MDROs). The priority in MDRO prevention is to detect high-risk patients and implement preventive intervention as soon as possible.

AIM

To develop an automated risk assessment system for MDROs (autoRAS-MDRO) to screen for patients at MDRO infection risk and evaluate the predictive validity of the autoRAS-MDRO.

METHODS

Data for 4200 variables were extracted from the electronic health records (EHRs) for constructing the MDRO risk-scoring algorithm, which was based on a logistic regression model. The autoRAS-MDRO was designed such that the MDRO risk classification (high, moderate, low risk) could be automatically displayed on the nursing Kardex screen in the EHRs system. For the development of the MDRO risk-scoring algorithm, 1000 patients with MDROs and 4000 patients without MDROs were selected; similarly, for the evaluation, 2173 and 8692 patients with and without MDROs, respectively, were selected.

FINDINGS

The predictive validity of the autoRAS-MDRO was as follows: (i) at the 6-month evaluation: sensitivity, 81%; specificity, 79%; positive predictive value (PPV), 49%; negative predictive value (NPV), 94%; and Youden index, 0.60; (ii) at the 12-month evaluation: sensitivity 79%, specificity 78%, PPV 47%, NPV 94%, and Youden index, 0.57.

CONCLUSION

The autoRAS-MDRO had moderate predictive validity. It could be useful in redirecting nurses' time and efforts required for MDRO risk assessment and implementation of infection control measures, and in reducing the incidence of MDRO infection in hospitals, thereby contributing to patient safety.

MiBAlert-a new information tool to fight multidrug-resistant bacteria in the hospital setting

BACKGROUND

Although the timely isolation of patients is an essential intervention to limit spread of drug-resistant bacteria, information about the colonization status is often unavailable or lost when patients are readmitted or transferred between hospitals. Therefore, carriers of drug resistant bacteria are not recognized sufficiently early, and proper and timely isolation precautions are not taken. Consequently, resistant bacteria of public health concerns including vancomycin resistant enterococci (VRE) and methicillin resistant Staphylococcus aureus (MRSA) can spread epidemically. To ensure timely identification and proper isolation of such patients we developed an automatic real-time alert of carriers of drug resistant bacteria.

OBJECTIVES

The aim of this paper is to describe the system, called MiBAlert, and share the initial experiences in connection with an outbreak of VRE in the greater Copenhagen area (the Capital region), Denmark.

METHODS

We obtained data on cases of VRE from hospitals in Copenhagen during the period when the first version of MiBAlert was implemented and log-data on the use of MiBAlert. Furthermore, a survey was conducted among 88 staff members to investigate their experiences of MiBAlert.

RESULTS

The alert is a tool directed toward healthcare personnel accessing the electronic health record (EHR) and those further involved in the care and treatment of the patient. It is based on a web service using data from the national microbiological database, MiBa. MiBAlert is a real-time electronic non-intrusive alert generated automatically in the header of the EHR each time record is accessed. On February 15, 2015 a pilot version of MiBAlert was launched. All positive tests for VRE throughout 1year were shown with alert status by MiBAlert visible to all medical staff with access to EHR. The alert system was automatically updated directly in the EHR across the five hospitals in the Capital region. We found that the system performed satisfactorily, being operational 24/7 all 135 trial days, apart from 72min, for all the hospitals. Of the staff who responded to the survey, 82% considered that MiBAlert overall improved compliance with isolation precautions regarding VRE-positive patients. We found a marked decline of new patients infected or colonized with VRE concomitant with the implementation of MiBAlert and the survey results.

CONCLUSION

We found that MiBAlert was a valuable tool in a bundle approach to counter a multiple hospital outbreak of VRE, and that it has a great potential to improve the control of other drug-resistant bacteria.

Utilizing an integrated infrastructure for outcomes research: a systematic review

OBJECTIVE

To explore the ability of an integrated health information infrastructure to support outcomes research.

METHODS

A systematic review of articles published from 1983 to 2012 by Regenstrief Institute investigators using data from an integrated electronic health record infrastructure involving multiple provider organisations was performed. Articles were independently assessed and classified by study design, disease and other metadata including bibliometrics.

RESULTS

A total of 190 articles were identified. Diseases included cognitive, (16) cardiovascular, (16) infectious, (15) chronic illness (14) and cancer (12). Publications grew steadily (26 in the first decade vs. 100 in the last) as did the number of investigators (from 15 in 1983 to 62 in 2012). The proportion of articles involving non-Regenstrief authors also expanded from 54% in the first decade to 72% in the last decade. During this period, the infrastructure grew from a single health system into a health information exchange network covering more than 6 million patients. Analysis of journal and article metrics reveals high impact for clinical trials and comparative effectiveness research studies that utilised data available in the integrated infrastructure.

DISCUSSION

Integrated information infrastructures support growth in high quality observational studies and diverse collaboration consistent with the goals for the learning health system. More recent publications demonstrate growing external collaborations facilitated by greater access to the infrastructure and improved opportunities to study broader disease and health outcomes.

CONCLUSIONS

Integrated information infrastructures can stimulate learning from electronic data captured during routine clinical care but require time and collaboration to reach full potential.

Automated tracking and ordering of precautions for multidrug-resistant organisms

BACKGROUND

The transmission and infection risk associated with multidrug-resistant organism (MDRO) carriers necessitates surveillance and tracking to provide proper contact precautions. As MDROs increase in scope, automated electronic health record (EHR) systems may help with surveillance demands.

METHODS

We created a system for MDROs and Clostridium difficile tracking that automated the following 3 main surveillance and tracking activities: monitoring of microbiology results and initiation of chart-based flags, ordering of contact precautions on admission, and ensuring appropriate removal of precautions.

RESULTS

Automation saved 43 infection preventionist hours per 1,000 admissions, in addition to previously unquantified hours spent reviewing MDRO history for every admission. Automatic retiring of certain MDRO flags ensured removal of contact precautions after a specified time. A point-prevalence assessment for eligibility for discontinuation found that all precautions were appropriate, with none eligible for removal. By integrating microbiology data, EHR tracking flags, and automated orders, this system assured rapid and comprehensive placement of patients into contact precautions without requiring oversight by infection prevention personnel.

CONCLUSION

We show that automated systems embedded within EHRs can ensure tracking and application of appropriate contact precautions while simultaneously producing tremendous time savings for infection prevention programs.

Impact of Electronic Surveillance on Isolation Practices

Objective.

To assess the impact of an electronic surveillance system on isolation practices and rates of methicillin-resistant Staphylococcus aureus (MRSA).

Design.

A pre-post test intervention.

Setting.

Inpatient units (except psychiatry and labor and delivery) in 4 New York City hospitals.

Patients.

All patients for whom isolation precautions were indicated, May 2009–December 2011.

Methods.

Trained observers assessed isolation sign postings, availability of isolation carts, and staff use of personal protective equipment (PPE). Infection rates were obtained from the infection control department. Regression analyses were used to examine the association between the surveillance system, infection prevention practices, and MRSA infection rates.

Results.

A total of 54,159 isolation days and 7,628 staff opportunities for donning PPE were observed over a 31-month period. Odds of having an appropriate sign posted were significantly higher after intervention than before intervention (odds ratio [OR], 1.10 [95% confidence interval {CI}, 1.01–1.20]). Relative to baseline, postintervention sign posting improved significantly for airborne and droplet precautions but not for contact precautions. Sign posting improved for vancomycin-resistant enterococci (OR, 1.51 [95% CI, 1.23–1.86]; P = .0001), Clostridium difficile (OR, 1.59 [95% CI, 1.27–2.02]; P = .00005), and Acinetobacter baumannii (OR, 1.41 [95% CI, 1.21–1.64]; P = .00001) precautions but not for MRSA precautions (OR, 1.11 [95% CI, 0.89–1.39]; P = .36). Staff and visitor adherence to PPE remained low throughout the study but improved from 29.1% to 37.0% after the intervention (OR, 1.14 [95% CI, 1.01–1.29]). MRSA infection rates were not significantly different after the intervention.

Conclusions.

An electronic surveillance system resulted in small but statistically significant improvements in isolation practices but no reductions in infection rates over the short term. Such innovations likely require considerable uptake time.

Infection prevention in the emergency department

Infection prevention remains a major challenge in emergency care. Acutely ill and injured patients seeking evaluation and treatment in the emergency department (ED) not only have the potential to spread communicable infectious diseases to health care personnel and other patients, but are vulnerable to acquiring new infections associated with the care they receive. This article will evaluate these risks and review the existing literature for infection prevention practices in the ED, ranging from hand hygiene, standard and transmission-based precautions, health care personnel vaccination, and environmental controls to strategies for preventing health care-associated infections. We will conclude by examining what can be done to optimize infection prevention in the ED and identify gaps in knowledge where further research is needed. Successful implementation of evidence-based practices coupled with innovation of novel approaches and technologies tailored specifically to the complex and dynamic environment of the ED are the keys to raising the standard for infection prevention and patient safety in emergency care.

Regenstrief Institute's Medical Gopher: a next-generation homegrown electronic medical record system

OBJECTIVE

Regenstrief Institute developed one of the seminal computerized order entry systems, the Medical Gopher, for implementation at Wishard Hospital nearly three decades ago. Wishard Hospital and Regenstrief remain committed to homegrown software development, and over the past 4 years we have fully rebuilt Gopher with an emphasis on usability, safety, leveraging open source technologies, and the advancement of biomedical informatics research. Our objective in this paper is to summarize the functionality of this new system and highlight its novel features.

MATERIALS AND METHODS

Applying a user-centered design process, the new Gopher was built upon a rich-internet application framework using an agile development process. The system incorporates order entry, clinical documentation, result viewing, decision support, and clinical workflow. We have customized its use for the outpatient, inpatient, and emergency department settings.

RESULTS

The new Gopher is now in use by over 1100 users a day, including an average of 433 physicians caring for over 3600 patients daily. The system includes a wizard-like clinical workflow, dynamic multimedia alerts, and a familiar 'e-commerce'-based interface for order entry. Clinical documentation is enhanced by real-time natural language processing and data review is supported by a rapid chart search feature.

DISCUSSION

As one of the few remaining academically developed order entry systems, the Gopher has been designed both to improve patient care and to support next-generation informatics research. It has achieved rapid adoption within our health system and suggests continued viability for homegrown systems in settings of close collaboration between developers and providers.

A retrospective analysis of interruptive versus non-interruptive clinical decision support for identification of patients needing contact isolation

BACKGROUND

In determining whether clinical decision support (CDS) should be interruptive or non-interruptive, CDS designers need more guidance to balance the potential for interruptive CDS to overburden clinicians and the potential for non-interruptive CDS to be overlooked by clinicians.

OBJECTIVE

(1)To compare performance achieved by clinicians using interruptive CDS versus using similar, non-interruptive CDS. (2)To compare performance achieved using non-interruptive CDS among clinicians exposed to interruptive CDS versus clinicians not exposed to interruptive CDS.

METHODS

We studied 42 emergency medicine physicians working in a large hospital where an interruptive CDS to help identify patients requiring contact isolation was replaced by a similar, but non-interruptive CDS. The first primary outcome was the change in sensitivity in identifying these patients associated with the conversion from an interruptive to a non-interruptive CDS. The second primary outcome was the difference in sensitivities yielded by the non-interruptive CDS when used by providers who had and who had not been exposed to the interruptive CDS. The reference standard was an epidemiologist-designed, structured, objective assessment.

RESULTS

In identifying patients needing contact isolation, the interruptive CDS-physician dyad had sensitivity of 24% (95% CI: 17%-32%), versus sensitivity of 14% (95% CI: 9%-21%) for the non-interruptive CDS-physician dyad (p = 0.04). Users of the non-interruptive CDS with prior exposure to the interruptive CDS were more sensitive than those without exposure (14% [95% CI: 9%-21%] versus 7% [95% CI: 3%-13%], p = 0.05).

LIMITATIONS

As with all observational studies, we cannot confirm that our analysis controlled for every important difference between time periods and physician groups.

CONCLUSIONS

Interruptive CDS affected clinicians more than non-interruptive CDS. Designers of CDS might explicitly weigh the benefits of interruptive CDS versus its associated increased clinician burden. Further research should study longer term effects of clinician exposure to interruptive CDS, including whether it may improve clinician performance when using a similar, subsequent non-interruptive CDS.

A simulation-based assessment of strategies to control Clostridium difficile transmission and infection

Background

Clostridium difficile is one of the most common and important nosocomial pathogens, causing severe gastrointestinal disease in hospitalized patients. Although "bundled" interventions have been proposed and promoted, optimal control strategies remain unknown.

Methods

We designed an agent-based computer simulation of nosocomial C. difficile transmission and infection, which included components such as: patients and health care workers, and their interactions; room contamination via C. difficile shedding; C. difficile hand carriage and removal via hand hygiene; patient acquisition of C. difficile via contact with contaminated rooms or health care workers; and patient antimicrobial use. We then introduced six interventions, alone and "bundled" together: aggressive C. difficile testing; empiric isolation and treatment of symptomatic patients; improved adherence to hand hygiene and contact precautions; improved use of soap and water for hand hygiene; and improved environmental cleaning. All interventions were tested using values representing base-case, typical intervention, and optimal intervention scenarios.

Findings

In the base-case scenario, C. difficile infection rates ranged from 8–21 cases/10,000 patient-days, with a case detection fraction between 32%–50%. Implementing the "bundle" at typical intervention levels had a large impact on C. difficile acquisition and infection rates, although intensifying the intervention to optimal levels had much less additional impact. Most of the impact came from improved hand hygiene and empiric isolation and treatment of suspected C. difficile cases.

Conclusion

A "bundled" intervention is likely to reduce nosocomial C. difficile infection rates, even under typical implementation conditions. Real-world implementation of the "bundle" should focus on those components of the intervention that are likely to produce the greatest impact on C. difficile infection rates, such as hand hygiene and empiric isolation and treatment of suspected cases.

Infection preventionists' awareness of and engagement in health information exchange to improve public health surveillance

BACKGROUND

Advances in electronic health record (EHR) systems and health information exchange (HIE) are shifting efforts in public health toward greater use of information systems to automate notifiable disease surveillance. Little is known about infection preventionists' (IPs) awareness, adoption, and use of these technologies to report information to public health.

METHODS

To measure awareness and engagement in EHR and HIE activities, an online survey of IPs was conducted in states with HIE networks. A total of 63 IPs was invited to participate; 44 IPs (69%) responded. The survey asked about the adoption and use of EHR systems, participation in regional HIE initiatives, and IP needs with respect to EHR systems and public health reporting.

RESULTS

Over 70% of responding IPs reported access to an EHR system, but less than 20% of IPs with access to an EHR reported being involved in the design, selection, or implementation of the system. Just 10% of IPs reported that their organizations were formally engaged in HIE activities, and 49% were unaware of organizational involvement in HIE. IPs expressed a desire for better decision support, paperless reporting methods, and situational awareness of community outbreaks.

CONCLUSION

Many IPs lack awareness and engagement in EHR and HIE activities, which may limit IPs ability to influence or utilize key information technologies as they are implemented in health care organizations.

A regional informatics platform for coordinated antibiotic-resistant infection tracking, alerting, and prevention

BACKGROUND

We developed and assessed the impact of a patient registry and electronic admission notification system relating to regional antimicrobial resistance (AMR) on regional AMR infection rates over time. We conducted an observational cohort study of all patients identified as infected or colonized with methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin-resistant enterococci (VRE) on at least 1 occasion by any of 5 healthcare systems between 2003 and 2010. The 5 healthcare systems included 17 hospitals and associated clinics in the Indianapolis, Indiana, region.

METHODS

We developed and standardized a registry of MRSA and VRE patients and created Web forms that infection preventionists (IPs) used to maintain the lists. We sent e-mail alerts to IPs whenever a patient previously infected or colonized with MRSA or VRE registered for admission to a study hospital from June 2007 through June 2010.

RESULTS

Over a 3-year period, we delivered 12 748 e-mail alerts on 6270 unique patients to 24 IPs covering 17 hospitals. One in 5 (22%-23%) of all admission alerts was based on data from a healthcare system that was different from the admitting hospital; a few hospitals accounted for most of this crossover among facilities and systems.

CONCLUSIONS

Regional patient registries identify an important patient cohort with relevant prior antibiotic-resistant infection data from different healthcare institutions. Regional registries can identify trends and interinstitutional movement not otherwise apparent from single institution data. Importantly, electronic alerts can notify of the need to isolate early and to institute other measures to prevent transmission.

A Web-based multidrug-resistant organisms surveillance and outbreak detection system with rule-based classification and clustering

BACKGROUND

The emergence and spread of multidrug-resistant organisms (MDROs) are causing a global crisis. Combating antimicrobial resistance requires prevention of transmission of resistant organisms and improved use of antimicrobials.

OBJECTIVES

To develop a Web-based information system for automatic integration, analysis, and interpretation of the antimicrobial susceptibility of all clinical isolates that incorporates rule-based classification and cluster analysis of MDROs and implements control chart analysis to facilitate outbreak detection.

METHODS

Electronic microbiological data from a 2200-bed teaching hospital in Taiwan were classified according to predefined criteria of MDROs. The numbers of organisms, patients, and incident patients in each MDRO pattern were presented graphically to describe spatial and time information in a Web-based user interface. Hierarchical clustering with 7 upper control limits (UCL) was used to detect suspicious outbreaks. The system's performance in outbreak detection was evaluated based on vancomycin-resistant enterococcal outbreaks determined by a hospital-wide prospective active surveillance database compiled by infection control personnel.

RESULTS

The optimal UCL for MDRO outbreak detection was the upper 90% confidence interval (CI) using germ criterion with clustering (area under ROC curve (AUC) 0.93, 95% CI 0.91 to 0.95), upper 85% CI using patient criterion (AUC 0.87, 95% CI 0.80 to 0.93), and one standard deviation using incident patient criterion (AUC 0.84, 95% CI 0.75 to 0.92). The performance indicators of each UCL were statistically significantly higher with clustering than those without clustering in germ criterion (P < .001), patient criterion (P = .04), and incident patient criterion (P < .001).

CONCLUSION

This system automatically identifies MDROs and accurately detects suspicious outbreaks of MDROs based on the antimicrobial susceptibility of all clinical isolates.

A framework for assessing patient crossover and health information exchange value

OBJECTIVE

To evaluate the benefit of a health information exchange (HIE) between hospitals, we examine the rate of crossover among neurosurgical inpatients treated at Emory University Hospital (EUH) and Grady Memorial Hospital (GMH) in Atlanta, Georgia. To inform decisions regarding investment in HIE, we develop a methodology analyzing crossover behavior for application to larger more general patient populations.

DESIGN

Using neurosurgery inpatient visit data from EUH and GMH, unique patients who visited both hospitals were identified through classification by name and age at time of visit. The frequency of flow patterns, including time between visits, and the statistical significance of crossover rates for patients with particular diagnoses were determined.

MEASUREMENTS

The time between visits, flow patterns, and proportion of patients exhibiting crossover behavior were calculated for the total population studied as well as subpopulations.

RESULTS

5.25% of patients having multiple visits over the study period visited the neurosurgical departments at both hospitals. 77% of crossover patients visited the level 1 trauma center (GMH) before visiting EUH.

LIMITATIONS

The true patient crossover may be under-estimated because the study population only consists of neurosurgical inpatients at EUH and GMH.

CONCLUSION

We demonstrate that detailed analysis of crossover behavior provides a deeper understanding of the potential value of HIE.

A comparison of automated methicillin-resistant Staphylococcus aureus identification with current infection control practice

Infections with Methicillin-Resistant Staphylococcus aureus (MRSA) account for almost 20,000 deaths per year. Early identification of patients with MRSA infection or colonization aids in stopping spread. We compared automated identification of MRSA using HL7 lab result messages to current manual infection control practices at a local hospital during July-September 2008. We used data from infection control providers (ICPs), the microbiology lab, and a Regional Healthcare Information Exchange to assess the accuracy of manual and automated methods. Three hundred seventy MRSA cases were identified from July-September 2008. Manual identification recognized 314 (sensitivity 84.9%, positive predictive value 99.4%) MRSA cases and automated detection from HL7 messages identified 341 (sensitivity 92.2%, positive predictive value 98.8%). Automated processing of HL7 lab report messages is a more sensitive method of capturing MRSA cases than current standard infection control practice, with minimal loss of specificity.

Reminder systems to reduce the duration of indwelling urinary catheters: a narrative review

Catheter-associated urinary tract infection (CAUTI) is a common and costly problem for hospitalized patients. Policymakers have taken notice of the importance of these infections, and changes to the prospective payment rules of Medicare, Medicaid, and many additional third-party payers have been implemented to hold hospitals accountable for the delivery of poor quality health care services. As key members of the health care team, nurses must be prepared to utilize evidence-based practices to prevent CAUTI in hospitalized patients. This article describes several variable-technology interventions to remind clinicians to remove unnecessary urinary catheters and proposes potential roles for nursing informatics in the prevention of CAUTI in hospitalized adults.

Implementing the MRSA recommendations made by the Commission for Hospital Hygiene and Infection Prevention (KRINKO) of 1999 - current considerations by the DGKH Management Board

In Germany, recommendations on dealing with patients who are colonised with methicillin-resistant S. aureus (MRSA) for the inpatient sector have been published in 1999 by the Commission for Hospital Hygiene and Infection Prevention (KRINKO). Some challenges arise with regard to the practical implementation of the KRINKO recommendations. These challenges do not principally question the benefit of the recommendations but have come into criticism from users. In this commentary the German Society for Hospital Hygiene (DGKH) discusses some controversial issues and adds suggestions for unresolved problems regarding the infection control management of MRSA in healthcare settings.

Rapid identification of hospitalized patients at high risk for MRSA carriage

Patients who are asymptomatic carriers of methicillin-resistant Staphylococcus aureus (MRSA) are major reservoirs for transmission of MRSA to other patients. Medical personnel are usually not aware when these high-risk patients are hospitalized. We developed and tested an enterprise-wide electronic surveillance system to identify patients at high risk for MRSA carriage at hospital admission and during hospitalization. During a two-month study, nasal swabs from 153 high-risk patients were tested for MRSA carriage using polymerase chain reaction (PCR) of which 31 (20.3%) were positive compared to 12 of 293 (4.1%, p < 0.001) low-risk patients. The mean interval from admission to availability of PCR test results was 19.2 hours. Computer alerts for patients at high-risk of MRSA carriage were found to be reliable, timely and offer the potential to replace testing all patients. Previous MRSA colonization was the best predictor but other risk factors were needed to increase the sensitivity of the algorithm.

Utility of commonly captured data from an EHR to identify hospitalized patients at risk for clinical deterioration

Rapid Response Teams (RRTs) respond to critically ill patients in the hospital. Activation of RRTs is highly subjective and misses a proportion of at-risk patients. We created an automated scoring system for non-ICU inpatients based on readily available electronic vital signs data, age, and body mass index. Over two weeks, we recorded scores on 1,878 patient with a range of scores from 0 to 10. Fifty patients reached the primary outcome of code call, cardiopulmonary arrest, or transfer to an ICU. Using a cutoff score of 4 or greater would result in identification of an additional 20 patients over the 7 patients identified by the current method of RRT activation. The area under the Receiver Operating Curve for the prediction model was 0.72 which compared favorably to other scoring systems. An electronic scoring system using readily captured EMR data may improve identification of patients at risk for clinical deterioration.