- Email: [email protected]
Consideration to culture health care workers related to increased methicillin-resistant Staphylococcus aureus activity in a neonatal intensive care unit
Consideration to culture health care workers related to increased methicillin-resistant Staphylococcus aureus activity in a neonatal intensive care unit Patti S. Grant, RN, BSN, MS, CIC, L. Gale Charns, RN, BSN, CIC, Bonnie W. Rawot, MD, and Susan G. Benedetti, RN, BA, CIC Dallas, Texas
Background: For 2 consecutive years, a care level III neonatal intensive care unit (NICU) in a 700-bed health care facility experienced an increase in health care-associated methicillin-resistant Staphylococcus aureus (MRSA). To decrease transmission, standard infection prevention techniques, active surveillance cultures, and deoxyribonucleic acid typing were done. After control was achieved, members of the organization outside of infection prevention and control requested health care worker (HCW) screening for MRSA, believing that it would decrease chances of future transmission. Methods: To develop effective tools to communicate with organization members: (1) questions that must be resolved before HCW screening can be done accurately, (2) operational requirements for HCW screening, and (3) a ‘‘trigger point’’ for HCW screening should MRSA activity increase in the future. Results: Developed tools to determine when MRSA screening of HCWs is warranted and for the preparation process when MRSA screening is necessary. Without performing HCW screening in the NICU, there were no health care-associated infections with MRSA for 20 months or colonization for 5 months. Conclusion: Proactive consideration of HCW screening can be achieved by designing and implementing tools to illustrate the complexity of the HCW screening process and by defining a ‘‘trigger point’’ for HCW culturing if needed for MRSA control. Decreasing MRSA transmission in this NICU was accomplished without culturing health care workers. (Am J Infect Control 2008;36:638-43.)
Publications depicting outbreaks with methicillin-resistant Staphylococcus aureus (MRSA) in neonatal intensive care units (NICU) portray varying intensity of infection prevention and control interventions, efficacy of actions taken, and conclusions drawn from those experiences.1-7 These occurrences are not unique to the United States because MRSA in NICUs have been described around the globe.8-12 Although the NICU presented in this article experienced waxing and waning MRSA activity, this is not an extensive account of the various measures employed to decrease that activity. Rather, this is a description of tools developed to address persistent requests to screen HCWs for MRSA, driven From the Infection Prevention and Control Program, Medical City Dallas Hospital, Dallas, Texas. Address correspondence to Patti S. Grant, RN, BSN, MS, CIC, Medical City Dallas Hospital, 7777 Forest Lane, Dallas, TX 75230. E-mail: [email protected].
Conflicts of interest: All authors report no conflicts of interest. 0196-6553/$34.00 Copyright ª 2008 by the Association for Professionals in Infection Control and Epidemiology, Inc. doi:10.1016/j.ajic.2008.03.006
638
by those outside the infection prevention and control program, 3 months after the activity substantially declined. This article focuses on a working definition to help determine exactly when to culture HCWs and how to proceed once an epidemiologic link has been established. As detailed in the final National Nosocomial Infections Surveillance System (NNIS) Report, the proportion of Staphylococcus aureus resistant to nafcillin, oxacillin, or methicillin is just under 60%,13 indicating that, even in the absence of an outbreak, MRSA has established itself as an endemic pathogen. Over time, MRSA became more prominent in this NICU despite extensive periods of inactivity. Except for culturing HCWs for MRSA, many of the interventions outlined in published studies1-12 were employed. Five groups of deoxyribonucleic acid (DNA) banding patterns of MRSA intermittently appeared in this NICU. DNA typing was done using DiversiLab by bioMe´rieux (l’Etoile, France). We ruled out chronic or acute HCW colonization/infection in our investigation as the source of transmission because there was not an epidemiologic pattern related to a potential special cause occurrence(s) by line-stay histogram or retrospective surveillance. The identification of 5 MRSA groups by DNA typing did reveal 1 DNA pattern associated with increased morbidity.
Grant et al
METHODS To detect MRSA in the patient population, every 2week active surveillance by polymerase chain reaction (PCR) nasal swab was established and was partly responsible for reducing MRSA activity to an infrequent incidence of infection and colonization. The PCR testing was done using BD GeneOhm (Franklin Jakes, NJ) via nasal liquid Stuart swab. Three months after the success of the cumulative interventions, there was an unexpected and resolute interest in culturing HCWs to detect MRSA carriers. The rationale provided to the infection prevention and control team (IP&C Team) was that by identifying carriers, and decolonizing them, future MRSA transmission would be curtailed. After providing a 2-year summary of MRSA activity in the NICU, the IP&C Team concluded that health care worker screening was not necessary because there was not a rationale for performing HCW screening for MRSA because there was not an epidemiologic link to an outbreak and the DNA pattern associated with increased morbidity had been absent for 3 months. The evidence-based IP&C Team response was not accepted, and the petition for screening intensified. Preliminary preparations were made to culture HCWs in the NICU for MRSA.
Objective Without an epidemiologic link associated with the directive to culture HCWs for MRSA in the NICU,3,14-16 the IP&C Team was faced with culturing all HCWs and not a subgroup linked to a specific point in time as in an outbreak situation. After several multidisciplinary meetings, it was determined that, without a suspected outbreak to guide an epidemiologic link to HCWs and focus MRSA screening, the entire staff would need to be cultured. Because the MRSA DNA pattern associated with increased morbidity had not been identified for 3 months, it was concluded that all HCWs who worked in the NICU for the previous 4 months would be screened. After searching several internal databases, 480 licensed personnel, licensed independent practitioners, and volunteers were identified for MRSA screening.
Check list of determinations for HCW screening The IP&C Team created a checklist that included predictive aspects of the screening process, which required determinations before meaningful HCW screening for MRSA could occur (Fig 1). This list is based on MRSA NICU infection prevention and control interventions unique to this health care facility and a literature search specific to MRSA HCW screening and decolonization experiences.1-9,12,14-21 The driving force behind the check list was to present comprehensive and
November 2008
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meaningful information for consideration because an epidemiologic link to MRSA did not exist and to develop a tool that could be useful, after minor adjustments, with all multidrug-resistant organisms when an epidemiologic link is established.
Operational roadmap for HCW screening Central to a consequential presentation and discussion at interdisciplinary meetings was item number 7 of the document ‘‘Decision Determinations for Necessity of HCW Screening in an Outbreak’’ concerning the sequencing of HCW screening (see Fig 1). The purpose of the roadmap tool is to cull out all aspects and issues involved with HCW screening for MRSA, not the least of which involved screening HCWs at the same interval as the patient population (Fig 2). The reality that HCW screening would not be a one-time event (in the absence of an epidemiologic link to an outbreak) was emphasized during the decision-making process. To assure standardized screening of all populations for investigative and outcome purposes, the determination was made to have HCW screening for MRSA done by the PCR method because that was the procedure used with the NICU patient population during the 2-week active surveillance culture rotations. Last, this flowchart was presented as a potential generic tool for applicability to all organisms throughout our health care facility if needed in the future.
Use of clinical triggers to initiate NICU HCW screening for MRSA After presentation and discussion of these 2 documents by the IP&C Team, the request to culture HCWs subtly shifted focus to a question of when, in the future, would a HCW need to be cultured in the NICU. More specifically, the IP&C Team was asked for a ‘‘trigger point’’ signaling cause for HCW screening in reference to MRSA activity in the NICU under any circumstance. The IP&C Team could not provide a specific trigger point based on literature review in reference to an MRSA outbreak beyond the identification of an epidemiologic link.3,14-16 The original faction calling for HCW screening stated that the assertion of an epidemiologic link was too vague and not sufficient to guide the decisionmaking process; therefore, HCW screening would occur. Using the examples of language style from the 1988 NNIS definition of nosocomial infections22 through to the current National Healthcare Safety Network Manual: Patient Safety Protocols,23 the IP&C Team developed a definition of when, exactly, MRSA culturing of HCWs would be necessary to investigate and decrease MRSA transmission in our NICU (Fig 3). After presentation of the document ‘‘Use of Clinical Triggers to Initiate NICU HCW Screening for MRSA,’’ the request for HCW
640
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Vol. 36 No. 9
Fig 1. Decision determinations for necessity of HCW screening in an outbreak.
screening was withdrawn, knowing that HCW screening would be initiated if this definition were ever met. Last, a request was made to make this document generic to patient populations outside the NICU with the intent of having application to companion health care system facilities; therefore, we added the 5% recommendation7 of patient population activity to be used in the absence of health care facility-specific historical data.
RESULTS The persistent request to culture HCWs for MRSA in this NICU required development of tools to illustrate
directly the complexities of screening involved in the absence of a suspected outbreak situation. The IP&C Team developed 2 evidence-based tools (Figs 1 and 2) that established the requirements for screening NICU HCWs for MRSA, along with a ‘‘trigger point’’ definition for HCW screening if ever activated (Fig 3). These 3 documents reversed the external appeal for HCW screening for MRSA, while at the same time providing an action plan for any future MRSA activity relative to HCW screening. Although a correlation cannot be made between the establishment of these documents and MRSA activity in the NICU, there were no health care-associated infections with MRSA for 20 months or colonization activity for 5 months.
Grant et al
November 2008
641
Fig 2. Operational roadmap: neonatal intensive care unit health care worker screening for MRSA.
DISCUSSION According to a global database dedicated to outbreak investigations, 48.6% of published studies in NICUs were unable to determine an exact etiology of the accelerated activity,9 reminding HCWs of the reality that sometimes the root cause cannot be identified even after a problem is resolved. The same database shows that only 9.8% of NICU outbreaks listed MRSA as the primary pathogen, yet MRSA can evoke strong and unanticipated reactions, as evidenced during our experience with the demand for MRSA culturing of staff a full 3 months after a major decline in activity. Although 43.8% of the NICU outbreak investigations cultured HCWs and identified staff with the same causative organism, Gastmeier et al9 provide a strong cautionary note that a true correlation cannot be drawn from this information. This caveat is further complicated by reports of community-associated MRSA appearing in the NICU24 without further transmission and from newborn nursery environments with likely cross transmission to other patients.25 It cannot always be determined whether the patient or the HCW is the original source of an outbreak,9 although there can be a direct correlation2 to a HCW when a sudden outbreak appears; however, that was not the type of presentation that occurred in this NICU. Because the literature review helped exemplify the challenges associated with knowing whether the HCW carried MRSA to the patient or
vice versa, it further motivated the IP&C Team to develop a viable alternative with consistent application toward when HCW screening was warranted in an outbreak investigation, especially when endemic MRSA can be difficult to eradicate.4,26 The limitation of this approach is obvious: It has not yet been tested. Although acknowledging that limitation, the 3 tools developed did meet the IP&C Team objective of not culturing HCWs, particularly 3 months after the MRSA banding pattern by DNA associated with increased morbidity had been eradicated and overall activity had decreased. Also, the tools developed can be customized to other settings or pathogens, so the IP&C Team has a starting point with different situations. Future research into the refining of a generic definition of applicability for when to culture HCWs in an outbreak investigation, beyond the statement ‘‘with an epidemiologic link,’’ is needed to help infection prevention and control professionals to communicate with their customers in a less perceived vague fashion. However familiar to infection prevention and control professionals, the term ‘‘epidemiologic link’’ did not instill a sense of reassurance to most of those outside the infection prevention and control discipline. The option of perpetual HCW screening for MRSA18 was not an option in this health care facility because we had not experienced multiple MRSA outbreaks in the overall facility or in our NICU; therefore, it would not be a good use of infection prevention resources.
642
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Vol. 36 No. 9
Fig 3. Use of clinical triggers to initiate neonatal intensive care unit (NICU) health care worker screening for methicillin-resistant Staphylococcus aureus
CONCLUSION Just as Carico and Ramirez27 put forth a process for analysis of sentinel events, which provided previously unpublished considerations for implementation, we too are providing a similar approach for exactly when HCW screening should be discussed and then implemented related to MRSA infection and/or colonization in a NICU environment. These documents were useful during interdisciplinary meetings to communicate the complexities associated with HCW screening, and that thoroughness must be the goal if findings are to be applied during the problem-solving process. The IP&C Team in this facility developed 3 integrated tools that both illustrate and ‘‘trigger’’ the moment HCW screening should occur in their NICU related to MRSA. With minor customization, these tools can be
applied to other environments and organisms during periods of increased microorganism activity. The IP&C Team extends gratitude to the following for their contributions leading to the success of MRSA decline: Healthcare Facility Administration, The NICU Staff; Dr David Welch; and Microbiology Supervisor Lori Stevens and the entire Microbiology Staff.
References 1. Back NA, Linnemann CC Jr, Staneck JL, Kotagal UR. Control of methicillin-resistant Staphylococcus aureus in a neonatal intensive-care unit: use of intensive microbiologic surveillance and mupirocin. Infect Control Hosp Epidemiol 1996;17:227-31. 2. Bertin ML, Vinski J, Schmitt S, Sabella C, Danziger-Isakov L, McHugh M, et al. Outbreak of methicillin-resistant Staphylococcus aureus colonization and infection in a neonatal intensive care unit epidemiologically linked to a healthcare workers with chronic otitis. Infect Control Hosp Epidemiol 2006;27:581-5. 3. Gerber SI, Jones RC, Scot MV, Price JS, Dworkin MS, Filippell MB, et al. Management of outbreaks of methicillin-resistant Staphylococcus
Grant et al
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
aureus infection in the neonatal intensive care unit: a consensus statement. Infect Control Hosp Epidemiol 2006;27:139-45. Haley RW, Cushion NB, Tenover FC, Bannerman TL, Dyer D, Ross J, et al. Eradication of endemic methicillin-resistant Staphylcoccus aureus infections from a neonatal intensive care unit. J Infect Dis 1995;17:614-24. Khoury J, Jones M, Grim A, Dunne WM Jr, Fraser V. Eradication of methicillin-resistant Staphylsoccous aureus from a neonatal intensive care unit by active surveillance and aggressive infection control measures. Infect Control Hosp Epidemiol 2005;26:616-21. Saiman L, Cronquist A, Wu F, Zhou J, Rubenstein D, Eisner W, et al. An outbreak of methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2003;24:317-21. Wenzel RP, Reagan DR, Bertino JS, Maron EJ, Arias K. Methicillin-resistant Staphylococcus aureus outbreak: a concensus panel’s definition and management guidelines. Am J Infect Control 1998;26:102-10. Anderson BM, Lindemann R, Bergh K, Nesheim BI, Syversen G, Solheim N. Spread of methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit associated with understaffing, overcrowding and mixing of patients. J Hosp Infect 2002;50:18-24. Gastmeier P, Loui A, Stamm-Balderjahn S, Hansen S, Zuschneid I, Sohr D, et al. Outbreaks in neonatal intensive care units: they are not like others. Am J Infect Control 2007;35:172-6. Regev-Yochay G, Rubinstein E, Brazilai A, Carmell Y, Kuint J, Etienne J, et al. Methicillin-resistant Staphylococcus aureus in neonatal intensive care unit. Emerg Infect Dis 2005;11:453-6. Shiojima T, Ohki Y, Nako Y, Morikawa A, Okubo T, Iyobe S. Immediate control of a methicillin-resistant Staphylococcus aureus outbreak in a neonatal intensive care unit. J Infect Chemother 2003;9:243-7. Stein M, Navon-Venezia S, Chmelnitsky I, Kohelet D, Schwartz O, et al. An outbreak of new, nonmultidrug-resistant, methicillin-resistant Staphylococcus aureus strain (sccmec type iiia variant-1) in the neonatal intensive care unit transmitted by a staff member. Pediatr Infect Dis J 2006;25:5557-9. CDC NNIS System. National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 2004;32:440-85. Siegel JD, Rhinehart E, Jackson M, Chiarello L, for the Health Care Infection Control Practices Advisory Committee. Management of multidrug-resistant organisms in health care settings, 2006. Am J Infect Control 2007;35:S165-93. Arias KM. Quick reference to outbreak investigation and control in helath care facilities. Investigations and control of outbreaks in the health care setting. Gaithersburg: Aspen; 2000. p. 161-80. Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deitchman SD, and The Hospital Infection Control Practices Advisory
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Committee. Guideline for infection control in health care personnel, 1998. Am J Infect Control 1998;26:289-354. Weber SG, Huant SS, Oriola S, Huskins WC, Noskin GA, Harriman K, et al. Legislative mandates for use of active surveillance cultures to screen for methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococci: position statement from the Joint SHEA and APIC Task Force. Am J Infect Control 2007;35: 73-85. Blok HEM, Troelstra AN, Kamp-Hopmans TEM, Gigengack-Baars ACM, Vanderbroucke-Grauls CMJE, et al. Role of healthcare workers in outbreaks of methicillin-resistant Staphylococcus aureus: a 10-year evaluation from a Dutch university hospital. Infect Control Hosp Epidemiol 2003;24:679-85. Miller MA, Dascal A, Portnoy J, Mendelson J. Development of mupirocin resistance among methicillin-resistant Staphylococcus aureus after widespread use of nasal Mupirocin Ointment. Infect Control Hosp Epidemiol 1996;17:811-3. Netto dos Santos KR, de Souza Fonseca L, Gontifo Filho PP. Emergence of high-level Mupirocin resistance in methicillin-resistant Staphylococcus aureus isolated from Brazilian university hospitals. Infect Control Hosp Epidemiol 1996;17:813-6. Loeb M, Main C, Walker-Dilks C, Eady A. Antimicrobial drugs for treating methicillin-resistant Staphylococcus aureus colonization. Cochrane Database Syst Rev 2003;4: CD003340. Garner JS, Jarvis WR, Grace Emori T, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988;16:128-40. CDC National Healthcare Safety Network. NHSN manual: patient safety protocols January 2008. Available at: http://www.cdc.gov/ncidod/ dhqp/pdf/nhsn/NHSN_Manual_PatientSafetyProtocol_CURRNET.pdf. Accessed January 11, 2008. Eckhardt C, Halvosa JS, Ray SM, Blumbert HM. Transmission of methicillin-resistant Staphylococcus aureus in the neonatal intensive care unit from a patient with community-acquired disease. Infect Control Hosp Epidemiol 2003;24:460-1. CDC. Community-associated methicillin-resistant Staphylococcus aureus infection among healthy newborns—Chicago and Los Angeles County, 2004. MMWR 2006;31:329-32. Huang YC, Chou YH, Su LH, Lien RI, Lin TY. Methicillin-resistant Staphylococcus aureus colonization and its association with infection among infants hospitalized in neonatal intensive care units. Pediatrics 2006;118:469-74. Carrico R, Ramirez J. A process for analysis of sentinel events due to health care-associated infection. Am J Infect Control 2007;35: 501-7.
Background: For 2 consecutive years, a care level III neonatal intensive care unit (NICU) in a 700-bed health care facility experienced an increase in health care-associated methicillin-resistant Staphylococcus aureus (MRSA). To decrease transmission, standard infection prevention techniques, active surveillance cultures, and deoxyribonucleic acid typing were done. After control was achieved, members of the organization outside of infection prevention and control requested health care worker (HCW) screening for MRSA, believing that it would decrease chances of future transmission. Methods: To develop effective tools to communicate with organization members: (1) questions that must be resolved before HCW screening can be done accurately, (2) operational requirements for HCW screening, and (3) a ‘‘trigger point’’ for HCW screening should MRSA activity increase in the future. Results: Developed tools to determine when MRSA screening of HCWs is warranted and for the preparation process when MRSA screening is necessary. Without performing HCW screening in the NICU, there were no health care-associated infections with MRSA for 20 months or colonization for 5 months. Conclusion: Proactive consideration of HCW screening can be achieved by designing and implementing tools to illustrate the complexity of the HCW screening process and by defining a ‘‘trigger point’’ for HCW culturing if needed for MRSA control. Decreasing MRSA transmission in this NICU was accomplished without culturing health care workers. (Am J Infect Control 2008;36:638-43.)
Publications depicting outbreaks with methicillin-resistant Staphylococcus aureus (MRSA) in neonatal intensive care units (NICU) portray varying intensity of infection prevention and control interventions, efficacy of actions taken, and conclusions drawn from those experiences.1-7 These occurrences are not unique to the United States because MRSA in NICUs have been described around the globe.8-12 Although the NICU presented in this article experienced waxing and waning MRSA activity, this is not an extensive account of the various measures employed to decrease that activity. Rather, this is a description of tools developed to address persistent requests to screen HCWs for MRSA, driven From the Infection Prevention and Control Program, Medical City Dallas Hospital, Dallas, Texas. Address correspondence to Patti S. Grant, RN, BSN, MS, CIC, Medical City Dallas Hospital, 7777 Forest Lane, Dallas, TX 75230. E-mail: [email protected].
Conflicts of interest: All authors report no conflicts of interest. 0196-6553/$34.00 Copyright ª 2008 by the Association for Professionals in Infection Control and Epidemiology, Inc. doi:10.1016/j.ajic.2008.03.006
638
by those outside the infection prevention and control program, 3 months after the activity substantially declined. This article focuses on a working definition to help determine exactly when to culture HCWs and how to proceed once an epidemiologic link has been established. As detailed in the final National Nosocomial Infections Surveillance System (NNIS) Report, the proportion of Staphylococcus aureus resistant to nafcillin, oxacillin, or methicillin is just under 60%,13 indicating that, even in the absence of an outbreak, MRSA has established itself as an endemic pathogen. Over time, MRSA became more prominent in this NICU despite extensive periods of inactivity. Except for culturing HCWs for MRSA, many of the interventions outlined in published studies1-12 were employed. Five groups of deoxyribonucleic acid (DNA) banding patterns of MRSA intermittently appeared in this NICU. DNA typing was done using DiversiLab by bioMe´rieux (l’Etoile, France). We ruled out chronic or acute HCW colonization/infection in our investigation as the source of transmission because there was not an epidemiologic pattern related to a potential special cause occurrence(s) by line-stay histogram or retrospective surveillance. The identification of 5 MRSA groups by DNA typing did reveal 1 DNA pattern associated with increased morbidity.
Grant et al
METHODS To detect MRSA in the patient population, every 2week active surveillance by polymerase chain reaction (PCR) nasal swab was established and was partly responsible for reducing MRSA activity to an infrequent incidence of infection and colonization. The PCR testing was done using BD GeneOhm (Franklin Jakes, NJ) via nasal liquid Stuart swab. Three months after the success of the cumulative interventions, there was an unexpected and resolute interest in culturing HCWs to detect MRSA carriers. The rationale provided to the infection prevention and control team (IP&C Team) was that by identifying carriers, and decolonizing them, future MRSA transmission would be curtailed. After providing a 2-year summary of MRSA activity in the NICU, the IP&C Team concluded that health care worker screening was not necessary because there was not a rationale for performing HCW screening for MRSA because there was not an epidemiologic link to an outbreak and the DNA pattern associated with increased morbidity had been absent for 3 months. The evidence-based IP&C Team response was not accepted, and the petition for screening intensified. Preliminary preparations were made to culture HCWs in the NICU for MRSA.
Objective Without an epidemiologic link associated with the directive to culture HCWs for MRSA in the NICU,3,14-16 the IP&C Team was faced with culturing all HCWs and not a subgroup linked to a specific point in time as in an outbreak situation. After several multidisciplinary meetings, it was determined that, without a suspected outbreak to guide an epidemiologic link to HCWs and focus MRSA screening, the entire staff would need to be cultured. Because the MRSA DNA pattern associated with increased morbidity had not been identified for 3 months, it was concluded that all HCWs who worked in the NICU for the previous 4 months would be screened. After searching several internal databases, 480 licensed personnel, licensed independent practitioners, and volunteers were identified for MRSA screening.
Check list of determinations for HCW screening The IP&C Team created a checklist that included predictive aspects of the screening process, which required determinations before meaningful HCW screening for MRSA could occur (Fig 1). This list is based on MRSA NICU infection prevention and control interventions unique to this health care facility and a literature search specific to MRSA HCW screening and decolonization experiences.1-9,12,14-21 The driving force behind the check list was to present comprehensive and
November 2008
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meaningful information for consideration because an epidemiologic link to MRSA did not exist and to develop a tool that could be useful, after minor adjustments, with all multidrug-resistant organisms when an epidemiologic link is established.
Operational roadmap for HCW screening Central to a consequential presentation and discussion at interdisciplinary meetings was item number 7 of the document ‘‘Decision Determinations for Necessity of HCW Screening in an Outbreak’’ concerning the sequencing of HCW screening (see Fig 1). The purpose of the roadmap tool is to cull out all aspects and issues involved with HCW screening for MRSA, not the least of which involved screening HCWs at the same interval as the patient population (Fig 2). The reality that HCW screening would not be a one-time event (in the absence of an epidemiologic link to an outbreak) was emphasized during the decision-making process. To assure standardized screening of all populations for investigative and outcome purposes, the determination was made to have HCW screening for MRSA done by the PCR method because that was the procedure used with the NICU patient population during the 2-week active surveillance culture rotations. Last, this flowchart was presented as a potential generic tool for applicability to all organisms throughout our health care facility if needed in the future.
Use of clinical triggers to initiate NICU HCW screening for MRSA After presentation and discussion of these 2 documents by the IP&C Team, the request to culture HCWs subtly shifted focus to a question of when, in the future, would a HCW need to be cultured in the NICU. More specifically, the IP&C Team was asked for a ‘‘trigger point’’ signaling cause for HCW screening in reference to MRSA activity in the NICU under any circumstance. The IP&C Team could not provide a specific trigger point based on literature review in reference to an MRSA outbreak beyond the identification of an epidemiologic link.3,14-16 The original faction calling for HCW screening stated that the assertion of an epidemiologic link was too vague and not sufficient to guide the decisionmaking process; therefore, HCW screening would occur. Using the examples of language style from the 1988 NNIS definition of nosocomial infections22 through to the current National Healthcare Safety Network Manual: Patient Safety Protocols,23 the IP&C Team developed a definition of when, exactly, MRSA culturing of HCWs would be necessary to investigate and decrease MRSA transmission in our NICU (Fig 3). After presentation of the document ‘‘Use of Clinical Triggers to Initiate NICU HCW Screening for MRSA,’’ the request for HCW
640
Grant et al
Vol. 36 No. 9
Fig 1. Decision determinations for necessity of HCW screening in an outbreak.
screening was withdrawn, knowing that HCW screening would be initiated if this definition were ever met. Last, a request was made to make this document generic to patient populations outside the NICU with the intent of having application to companion health care system facilities; therefore, we added the 5% recommendation7 of patient population activity to be used in the absence of health care facility-specific historical data.
RESULTS The persistent request to culture HCWs for MRSA in this NICU required development of tools to illustrate
directly the complexities of screening involved in the absence of a suspected outbreak situation. The IP&C Team developed 2 evidence-based tools (Figs 1 and 2) that established the requirements for screening NICU HCWs for MRSA, along with a ‘‘trigger point’’ definition for HCW screening if ever activated (Fig 3). These 3 documents reversed the external appeal for HCW screening for MRSA, while at the same time providing an action plan for any future MRSA activity relative to HCW screening. Although a correlation cannot be made between the establishment of these documents and MRSA activity in the NICU, there were no health care-associated infections with MRSA for 20 months or colonization activity for 5 months.
Grant et al
November 2008
641
Fig 2. Operational roadmap: neonatal intensive care unit health care worker screening for MRSA.
DISCUSSION According to a global database dedicated to outbreak investigations, 48.6% of published studies in NICUs were unable to determine an exact etiology of the accelerated activity,9 reminding HCWs of the reality that sometimes the root cause cannot be identified even after a problem is resolved. The same database shows that only 9.8% of NICU outbreaks listed MRSA as the primary pathogen, yet MRSA can evoke strong and unanticipated reactions, as evidenced during our experience with the demand for MRSA culturing of staff a full 3 months after a major decline in activity. Although 43.8% of the NICU outbreak investigations cultured HCWs and identified staff with the same causative organism, Gastmeier et al9 provide a strong cautionary note that a true correlation cannot be drawn from this information. This caveat is further complicated by reports of community-associated MRSA appearing in the NICU24 without further transmission and from newborn nursery environments with likely cross transmission to other patients.25 It cannot always be determined whether the patient or the HCW is the original source of an outbreak,9 although there can be a direct correlation2 to a HCW when a sudden outbreak appears; however, that was not the type of presentation that occurred in this NICU. Because the literature review helped exemplify the challenges associated with knowing whether the HCW carried MRSA to the patient or
vice versa, it further motivated the IP&C Team to develop a viable alternative with consistent application toward when HCW screening was warranted in an outbreak investigation, especially when endemic MRSA can be difficult to eradicate.4,26 The limitation of this approach is obvious: It has not yet been tested. Although acknowledging that limitation, the 3 tools developed did meet the IP&C Team objective of not culturing HCWs, particularly 3 months after the MRSA banding pattern by DNA associated with increased morbidity had been eradicated and overall activity had decreased. Also, the tools developed can be customized to other settings or pathogens, so the IP&C Team has a starting point with different situations. Future research into the refining of a generic definition of applicability for when to culture HCWs in an outbreak investigation, beyond the statement ‘‘with an epidemiologic link,’’ is needed to help infection prevention and control professionals to communicate with their customers in a less perceived vague fashion. However familiar to infection prevention and control professionals, the term ‘‘epidemiologic link’’ did not instill a sense of reassurance to most of those outside the infection prevention and control discipline. The option of perpetual HCW screening for MRSA18 was not an option in this health care facility because we had not experienced multiple MRSA outbreaks in the overall facility or in our NICU; therefore, it would not be a good use of infection prevention resources.
642
Grant et al
Vol. 36 No. 9
Fig 3. Use of clinical triggers to initiate neonatal intensive care unit (NICU) health care worker screening for methicillin-resistant Staphylococcus aureus
CONCLUSION Just as Carico and Ramirez27 put forth a process for analysis of sentinel events, which provided previously unpublished considerations for implementation, we too are providing a similar approach for exactly when HCW screening should be discussed and then implemented related to MRSA infection and/or colonization in a NICU environment. These documents were useful during interdisciplinary meetings to communicate the complexities associated with HCW screening, and that thoroughness must be the goal if findings are to be applied during the problem-solving process. The IP&C Team in this facility developed 3 integrated tools that both illustrate and ‘‘trigger’’ the moment HCW screening should occur in their NICU related to MRSA. With minor customization, these tools can be
applied to other environments and organisms during periods of increased microorganism activity. The IP&C Team extends gratitude to the following for their contributions leading to the success of MRSA decline: Healthcare Facility Administration, The NICU Staff; Dr David Welch; and Microbiology Supervisor Lori Stevens and the entire Microbiology Staff.
References 1. Back NA, Linnemann CC Jr, Staneck JL, Kotagal UR. Control of methicillin-resistant Staphylococcus aureus in a neonatal intensive-care unit: use of intensive microbiologic surveillance and mupirocin. Infect Control Hosp Epidemiol 1996;17:227-31. 2. Bertin ML, Vinski J, Schmitt S, Sabella C, Danziger-Isakov L, McHugh M, et al. Outbreak of methicillin-resistant Staphylococcus aureus colonization and infection in a neonatal intensive care unit epidemiologically linked to a healthcare workers with chronic otitis. Infect Control Hosp Epidemiol 2006;27:581-5. 3. Gerber SI, Jones RC, Scot MV, Price JS, Dworkin MS, Filippell MB, et al. Management of outbreaks of methicillin-resistant Staphylococcus
Grant et al
4.
5.
6.
7.
8.
9.
10.
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13.
14.
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