One IP's Take on Active Surveillance Testing

Shannon Oriola, RN, CIC, COHN, the department lead for infection prevention and clinical epidemiology at the Sharp Metropolitan Medical Campus in San Diego, discusses her experience with active surveillance testing (AST) in the wake of the September 2008 passage of SB 1058, California’s infection reporting and MRSA screening legislation.

Q: What is mandated in California?

A: We’re mandated to conduct AST on patients admitted to the ICU, the burn unit, receiving dialysis, discharged from a hospital within the last 30 days prior to admission, or patients coming from a nursing home. In 2011, we will be required, if the patient is negative on admission, to screen them on discharge. It is also mandated that physicians provide patients with their test results. And of course there are national patient safety goals focused on MDROs and you need a program to address these pathogens, plus we must educate staff, licensed independent practitioners and patients. So we have to test, we must have a program and we have to educate — not only for CMS and the Joint Commission, but state legislation requires this as well.

Q: What do you screen for specifically?

A: Some facilities in California don’t have the resources to figure out who needs to be screened so they are screening every patient on admission. We have been guided by the literature and our hospital epidemiologist, and we know to look at our risk and the pathogens we are seeing in addition to state legislation. In our CABG population we had seen S. aureus sensitive, not resistant, so we started screening patients undergoing CABG or any open heart surgery for S. aureus. For our elective open heart surgeries, we will take a nares specimen to test for MSSA or MRSA; if it’s MSSA or MRSA, the patient will receive Bactroban to decolonize them prior to surgery, and we encourage them to use Hibiclens to shower twice a day for five days prior to their surgery. If it’s MRSA, they will also receive vancomycin as a prophylactic antibiotic before surgery. Last year we had no infections in our cardiac surgery population attributed to S. aureus, whether sensitive or resistant. So we look at our high-risk, high-volume procedures, and those that require implants, as those patients, of course, have a greater risk of morbidity and mortality if they develop an infection. Another challenge when screening patients as mandated by SB 1058 is screening patients that have had a prior hospitalization within the last 30 days prior to admission. That can be challenging for the admitting nurse to figure out, so we are in the process of trying to automate this process within our three hospitals.

Q: AST can be costly to conduct; what has been your experience in terms of resources needed?

A: I believe that one of the University of California system hospitals calculated the cost of active surveillance to be about $1 million, so it can be quite expensive. I have a part-time infection preventionist whose primary function is to focus on MDROs. We also have an electronic health record system that helps streamline the process. I realize I am very fortunate because I have these resources and I have a very supportive administration. Not only do I have resources to support the mandates, but our campus is one of the most wired for healthcare information technology in the country. We are very lucky to be in this situation, as I realize it can be very difficult for smaller facilities that don’t have the technology or the support. The easiest thing for them to do might be to make AST part of the standing orders on admission; depending on their demographics, which may be their at-risk population anyway.

Q: How do you clear patients out of contact precautions?

A: We are fortunate in that we can clear patients out of precautions because some hospitals take the “once positive, always positive” approach, and they never try looking again. We actually introduced molecular testing to help us with our throughput. If a patient was historically positive for MRSA, and we didn’t have any private rooms available, they would have to go into a semi-private room and we would have to block the other bed until we got the test result because we didn’t know if the patient was negative or positive. Then we were having a back-up in our ED — patients couldn’t flow through and be admitted, so we brought in molecular testing to speed things along. We obtain two specimens from the patient — one from the nares and another from the axilla and perineum, and if they are negative, we will clear them out of precautions. Now we have all private rooms in our new hospital so throughput is not an issue; however, we are still able to get patients out of precautions quickly if the test results are negative. And if we can screen patients before they are admitted for elective surgery, it helps with patient satisfaction when they are not placed into precautions, it also saves on nursing’s time.

Q: Do you monitor acquisition rates?

A: We do. The MDRO guideline states that you must be decreasing your rates, but it isn’t very specific. That’s why SHEA and HICPAC published in 2007 a paper that proposed simple metrics that can be used. At my hospital we look at patients positive for an MDRO on readmission which may be considered an advanced measure. We look to see if they are positive on readmission but were negative during their prior hospitalization (within the last 30 days). If they weren’t transferred to a nursing home, etc. we would determine that the patient may have acquired the MDRO on the prior hospital visit It’s sometimes difficult to tell where a patient might have acquired MRSA. We just submitted a report looking at our MDRO data and how many patients ended up developing an infection; we think that’s the more important issue. We had no MRSA bloodstream infections last year, which is one of the basic measures that have been a requirement of California legislation. We perform MDRO surveillance on MRSA and VRE bacteremia and rates of transmission. We also report the number of MDRO infections related to our targeted device and procedure associated infections such as VAP, infections related to central lines, etc. Before passage of state legislation we were screening patients for MRSA in the medical ICU, which we considered a high-risk population. We also target-screened our surgical population, not only for MRSA but MSSA as well. Now our high-risk patients fall under the legislation’s provisions. We had also performed AST for VRE in our transplant program; this was precipitated by three urine cultures positive for VRE and we wanted to see if the “iceberg effect” was present on the unit and performed a point prevalence survey which yielded several patients colonized for VRE. We then initiated an AST program for VRE on the transplant unit for a few years. After two years we observed minor transmission of VRE; however we did not observe that the patients went on to develop an infection caused by VRE. We also trend ESBLs as well as Acinetobacter baumanii; we have other emerging MDROs that we are keeping a close eye on.

Q: Some experts believe that AST is unnecessary if evidence-based practices that uphold infection prevention are followed. What’s your opinion?

A: I can see their point. I am not as fortunate as other facilities that claim to have as high as a 90 percent hand hygiene compliance rate, but we have done a lot of work in this arena to try to improve. We are in the accountability stage right now – people know what the correct practice is but don’t apply it consistently, so we are working on improving hand hygiene and adherence to contact precautions. As the guidance states, if you have your basics hard-wired, and you still have transmission, that’s when you implement tier 2 measures which include go to active surveillance testing.

Q: Are you worried about AST creating a bug-of-the-month mentality?

A: If you have your infection prevention basics down, it doesn’t matter what the bug is. We need healthcare workers to comply with infection prevention practices regardless of the pathogen isolated. If you don’t have really good compliance with basics such as hand hygiene and contact precautions, you have to go back to the mangers and ask for their help with healthcare worker accountability. The managers can assist with compliance by having them adhere to hospital policy. If you perform good infection prevention and control practices, then if a new bug emerges, then it shouldn’t matter because you’re not going to spread it.

Q: How do you feel about screening being legislated?

A: If we had done what Denmark did more than 20 years ago we may not be where we are today, but the genie is already out of the bottle. When hospitals don’t always do the right thing, that’s when rules are put into place. In hindsight it would have been better to tackle this years ago, but we are a much bigger country than Denmark with many having different models of healthcare. Denmark is a smaller country with a different system of healthcare delivery and has more control over their clinicians.