Bed Utilization of Patients With Methicillin-Resistant Staphylococcus aureus in a Canadian Tertiary-Care Center

Patient-days used for isolation in a community hospital

BACKGROUND

Isolation of patients with known or suspected infection strains the resources of hospitals, but little information exists on the actual utilization of isolation beds.

METHODS

The infection control team of a community hospital keeps a log of hospital days used for isolation. We obtained information from this log for August 2009 through August 2010 on hospital days for isolation due to methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, Clostridium difficile, other multidrug-resistant organisms, and disorders necessitating droplet or airborne isolation, such as tuberculosis, meningococcal meningitis, varicella, and influenza. We also included days of isolation used to rule out the presence of these infections. All data from the medical-surgical and intensive care units were included unless the start date or end date of isolation was missing. Utilization percentages (isolation days divided by total hospital days) were calculated for the total period, for each month, and for each category of isolation.

RESULTS

During the study period, 18.1% of hospital days were devoted to isolation (13.7% for definite infection and 4.4% to rule out infection). Monthly utilization ranged from 13.4% to 22%. Patients with confirmed methicillin-resistant S aureus or C difficile infections and patients with possible C difficile infection accounted for 75% of the isolation days.

CONCLUSIONS

Isolation beds were required for a substantial portion of total patient-days in our study. Our data may help hospitals use hospital beds efficiently and predict nursing needs, hospital supply needs, and workload for environmental services.

The role of patient isolation and compliance with isolation practices in the control of nosocomial MRSA in acute care

Background  Nosocomial infection remains the most common complication of hospitalisation. Despite infection control efforts, nosocomial methicillin resistant Staphylococcus aureus (MRSA) transmission continues to rise. Various isolation practices are used to minimise MRSA transmission in acute care. However, the effectiveness of these practices has seldom been evaluated. Objectives  This review sought to evaluate the efficacy of isolation practices in minimising MRSA transmission in the acute hospital setting and explore staff, visitor and patient compliance with isolation practices. This review updates a review published in 2002. Search strategy  A systematic search for relevant published or unpublished English language literature was undertaken using electronic databases, the reference lists of retrieved papers and the Internet. This extended the search published in the original review. Databases searched included: Medline, CINAHL, EMBASE, Cochrane Library and Joanna Briggs Institute Evidence Library. Selection criteria  All English language research reports published between 1990 and August 2005 that focused on the role of isolation practices on the nosocomial transmission of MRSA in adult, paediatric or neonatal acute care settings were eligible for inclusion in the review. Studies that evaluated multiple infection control strategies or control of MRSA outbreaks were excluded. The main outcome of interest was the incidence of new cases of MRSA. The secondary outcome was staff, visitor and patient compliance with the isolation practices. Data collection and analysis  Two reviewers assessed each paper against the inclusion criteria and a validated quality scale. Data extraction was undertaken using a tool designed specifically for this review. Statistical comparisons of findings were not possible, so findings are presented in a narrative form. Results  Seven studies met the inclusion criteria. Given the small number of included studies and variable methodological quality, care must be taken when interpreting the review findings. There is some evidence that cessation of single room isolation and cohorting of MRSA patients does not increase nosocomial MRSA transmission when hand-washing compliance and standard precautions are maintained. Indeed, there is some evidence that reduced MRSA transmission can be achieved by improving compliance with contact precautions alone. The low level of hand hygiene compliance reported in the literature suggests that staff compliance with isolation practices is a significant factor in evaluating any infection-controlled intervention in the clinical setting. While staff compliance data are conflicting, regular audit and feedback of performance may improve compliance. Implications for clinical practice  The heterogeneous nature of the topic and methodological weaknesses of included studies impairs the ability to aggregate data and develop specific practice recommendations. While this review presents evidence to suggest that ceasing single room or cohort isolation does not lead to increased MRSA transmission, these studies maintained high levels of hand hygiene or standard precautions. Additionally, the role of extraneous factors, such as environmental reservoirs, specific MRSA strains and patient mix, is unclear. None of the included studies measured financial, social or psychological factors associated with isolation practices. There is an urgent need for well-designed research with significant sample sizes to develop an evidence base upon which to underpin future clinical practice.

Methicillin-resistant Staphylococcus aureus in Canada: a historical perspective and lessons learned

The history of methicillin-resistant Staphylococcus aureus (MRSA) in Canada has many similarities to MRSA evolution worldwide, but especially to that in the United States and United Kingdom. Reports of MRSA occurred as early as 1964, and community isolates were cited in the 1970s. Nosocomial outbreaks were becoming common by 1978 and flourished gradually thereafter. Endemic institutional MRSA became predominant in the 1990s, threatening large teaching hospitals in particular. In the last decade, both hospital-acquired and community-acquired MRSA have created major medical problems in Canada. More recently, an epidemic of Canadian community-acquired MRSA-10, has led to heightened public health concerns. Canadian contributions to MRSA science are numerous, with organized surveillance continuing to mature across the nation. A typing system for epidemic clones is now available and is being judiciously applied. Estimated costs for MRSA surveillance, treatment, and control are extraordinary, paralleling the dramatic rise in the number of MRSA isolations. Whereas surveillance continues to form an essential aspect of MRSA management, control, eradication, and overall diminution, MRSA reservoirs deserve much greater attention. Such efforts, however, must be as widely publicized in the community and in patient homes as they are in medical institutions responsible for both acute and long-term care.

Overcrowding and understaffing in modern health-care systems: key determinants in meticillin-resistant Staphylococcus aureus transmission

Recent decades have seen the global emergence of meticillin-resistant Staphylococcus aureus (MRSA), causing substantial health and economic burdens on patients and health-care systems. This epidemic has occurred at the same time that policies promoting higher patient throughput in hospitals have led to many services operating at, or near, full capacity. A result has been limited ability to scale services according to fluctuations in patient admissions and available staff, and hospital overcrowding and understaffing. Overcrowding and understaffing lead to failure of MRSA control programmes via decreased health-care worker hand-hygiene compliance, increased movement of patients and staff between hospital wards, decreased levels of cohorting, and overburdening of screening and isolation facilities. In turn, a high MRSA incidence leads to increased inpatient length of stay and bed blocking, exacerbating overcrowding and leading to a vicious cycle characterised by further infection control failure. Future decision making should use epidemiological and economic evidence to evaluate the effect of systems changes on the incidence of MRSA infection and other adverse events.

The role of patient isolation and compliance with isolation practices in the control of nosocomial MRSA in acute care

BACKGROUND

Nosocomial infection remains the most common complication of hospitalisation. Despite infection control efforts, nosocomial methicillin resistant Staphylococcus aureus (MRSA) transmission continues to rise. Various isolation practices are used to minimise MRSA transmission in acute care. However, the effectiveness of these practices has seldom been evaluated.

OBJECTIVES

This review sought to evaluate the efficacy of isolation practices in minimising MRSA transmission in the acute hospital setting and explore staff, visitor and patient compliance with isolation practices. This review updates a review published in 2002.

SEARCH STRATEGY

A systematic search for relevant published or unpublished English language literature was undertaken using electronic databases, the reference lists of retrieved papers and the Internet. This extended the search published in the original review. Databases searched included: Medline, CINAHL, EMBASE, Cochrane Library and Joanna Briggs Institute Evidence Library.

SELECTION CRITERIA

All English language research reports published between 1990 and August 2005 that focused on the role of isolation practices on the nosocomial transmission of MRSA in adult, paediatric or neonatal acute care settings were eligible for inclusion in the review. Studies that evaluated multiple infection control strategies or control of MRSA outbreaks were excluded. The main outcome of interest was the incidence of new cases of MRSA. The secondary outcome was staff, visitor and patient compliance with the isolation practices.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed each paper against the inclusion criteria and a validated quality scale. Data extraction was undertaken using a tool designed specifically for this review. Statistical comparisons of findings were not possible, so findings are presented in a narrative form.

RESULTS

Seven studies met the inclusion criteria. Given the small number of included studies and variable methodological quality, care must be taken when interpreting the review findings. There is some evidence that cessation of single room isolation and cohorting of MRSA patients does not increase nosocomial MRSA transmission when hand-washing compliance and standard precautions are maintained. Indeed, there is some evidence that reduced MRSA transmission can be achieved by improving compliance with contact precautions alone.The low level of hand hygiene compliance reported in the literature suggests that staff compliance with isolation practices is a significant factor in evaluating any infection-controlled intervention in the clinical setting. While staff compliance data are conflicting, regular audit and feedback of performance may improve compliance.

IMPLICATIONS FOR CLINICAL PRACTICE

The heterogeneous nature of the topic and methodological weaknesses of included studies impairs the ability to aggregate data and develop specific practice recommendations.While this review presents evidence to suggest that ceasing single room or cohort isolation does not lead to increased MRSA transmission, these studies maintained high levels of hand hygiene or standard precautions. Additionally, the role of extraneous factors, such as environmental reservoirs, specific MRSA strains and patient mix, is unclear. None of the included studies measured financial, social or psychological factors associated with isolation practices. There is an urgent need for well-designed research with significant sample sizes to develop an evidence base upon which to underpin future clinical practice.

Community-associated methicillin-resistant Staphylococcus aureus, Canada

A total of 184 methicillin-resistant Staphylococcus aureus (MRSA) strains were collected from patients who sought treatment primarily for skin and soft tissue infections from January 1, 1999, to March 31, 2002, in east-central Saskatchewan, Canada. Molecular subtyping analysis using pulsed-field gel electrophoresis showed 2 major clusters. Cluster A (n = 55) was composed of a multidrug-resistant MRSA strain associated with a long-term care facility and was similar to the previously reported nosocomial Canadian epidemic strain labeled CMRSA-2. Cluster B (n = 125) was associated with cases identified at community health centers and was indistinguishable from a community-associated (CA)-MRSA strain identified previously in the United States (USA400). Cluster B remained susceptible to a number of classes of antimicrobial agents and harbored the lukF-PV and lukS-PV toxin genes. Over 50% of both clonal groups displayed high-level resistance to mupirocin. This is the first report of the USA400 strain harboring the lukF-PV and lukS-PV toxin genes in Canada.