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Decreasing multiple drug-resistant organisms
Editorial
Decreasing multiple drug-resistant organisms In a recent issue of The New England Journal of Medicine, 2 different studies with contradictory results were published that both focused on decreasing the spread of multiple drug-resistant organisms, including methicillinresistant Staphylococcus aureus (MRSA) in acute care settings.1,2 Although both of these research teams investigated the efficacy of active surveillance (ie, obtaining nasal cultures patients on all newly admitted patients) and isolation policies, there were distinct differences in the study designs, interventions, and results. In the study conducted by Huskins et al,2 surveillance cultures were obtained from patients in 18 participating intensive care units (ICUs). In this cluster-randomized trial, participating ICUs were assigned to standard care (the control group) or to the intervention, which consisted of placing patients who were colonized or infected on barrier precautions or contact isolation. However, cultures in their study were obtained up to 2 days after admission and sent to a clinical microbiology laboratory at the National Institutes of Health. Isolation was not started until after culture results were obtained. It was not surprising that the intervention was not effective. Although the cluster-randomized trial is technically a sound research design, the intervention itself did not ensure the isolation of MRSApositive patients until days after admission. The other study evaluated the implementation of a Veterans Affairs (VA) system-wide “MRSA bundle.”1 This bundle included active surveillance of all patients within 24 hours of admission, local processing of cultures (which may help ensure more rapid results), contact precautions for those who were colonized or infected, a focus on hand hygiene, and a change in the organizational culture whereby infection prevention becomes the responsibility of all employees who have contact with patients. In this study, rates of healthcareassociated MRSA infections decreased significantly in both ICUs and non-ICUs. The contrast between the 2 study designs is stark. First, in the VA study, although preemptive isolation was not conducted, the time taken to obtain the culture results was likely much less than in the ICU study. Second, the focus on promoting a culture of safety that involves all employees who have contact with patients
creates a “high-reliability organization,”3 that is, one of consistent performance at high levels of safety with a collective mindfulness in which everyone who works in the organization is acutely aware that small failures in protocols can cause bad outcomes.4 Achieving high reliability takes leadership, a culture of safety, and robust process improvement. All of these were present when the VA instituted its MRSA bundle, and all of these are needed to achieve and sustain consistent excellence in quality and safety. Before more institutions “jump on the bandwagon” of active surveillance, it behooves us to consider the important contextual factors that are essential to ensure the success of this practice (or any practice, for that matter). Otherwise, we run the risk of mindlessly adding an expensive procedure without providing the setting characteristics to ensure its success.
References 1. Jain R, Kralovic SM, Evans ME, Ambrose M, Simbartl LA, Obrosky DS, et al. Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections. N Engl J Med 2011;364:1419-30. 2. Huskins WC, Huckabee CM, O’Grady NP, Murray P, Kopetskie H, Zimmer L, et al. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med 2011;364:1407-18. 3. Pronovost PJ, Berenholtz SM, Goeschel CA, Needham DM, Sexton JB, Thompson DA, et al. Creating high reliability in health care organizations. Health Serv Res 2006;41(4 Pt 2):1599-617. 4. Chassin MR, Loeb JM. The ongoing quality improvement journey: next stop, high reliability. Health Aff (Millwood) 2011;30:559-68.
Patricia W. Stone, PhD, RN Elaine Larson, RN, PhD, FAAN, CIC Columbia University, New York, New York 0147-9563/$ - see front matter Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.hrtlng.2011.04.048
Decreasing multiple drug-resistant organisms In a recent issue of The New England Journal of Medicine, 2 different studies with contradictory results were published that both focused on decreasing the spread of multiple drug-resistant organisms, including methicillinresistant Staphylococcus aureus (MRSA) in acute care settings.1,2 Although both of these research teams investigated the efficacy of active surveillance (ie, obtaining nasal cultures patients on all newly admitted patients) and isolation policies, there were distinct differences in the study designs, interventions, and results. In the study conducted by Huskins et al,2 surveillance cultures were obtained from patients in 18 participating intensive care units (ICUs). In this cluster-randomized trial, participating ICUs were assigned to standard care (the control group) or to the intervention, which consisted of placing patients who were colonized or infected on barrier precautions or contact isolation. However, cultures in their study were obtained up to 2 days after admission and sent to a clinical microbiology laboratory at the National Institutes of Health. Isolation was not started until after culture results were obtained. It was not surprising that the intervention was not effective. Although the cluster-randomized trial is technically a sound research design, the intervention itself did not ensure the isolation of MRSApositive patients until days after admission. The other study evaluated the implementation of a Veterans Affairs (VA) system-wide “MRSA bundle.”1 This bundle included active surveillance of all patients within 24 hours of admission, local processing of cultures (which may help ensure more rapid results), contact precautions for those who were colonized or infected, a focus on hand hygiene, and a change in the organizational culture whereby infection prevention becomes the responsibility of all employees who have contact with patients. In this study, rates of healthcareassociated MRSA infections decreased significantly in both ICUs and non-ICUs. The contrast between the 2 study designs is stark. First, in the VA study, although preemptive isolation was not conducted, the time taken to obtain the culture results was likely much less than in the ICU study. Second, the focus on promoting a culture of safety that involves all employees who have contact with patients
creates a “high-reliability organization,”3 that is, one of consistent performance at high levels of safety with a collective mindfulness in which everyone who works in the organization is acutely aware that small failures in protocols can cause bad outcomes.4 Achieving high reliability takes leadership, a culture of safety, and robust process improvement. All of these were present when the VA instituted its MRSA bundle, and all of these are needed to achieve and sustain consistent excellence in quality and safety. Before more institutions “jump on the bandwagon” of active surveillance, it behooves us to consider the important contextual factors that are essential to ensure the success of this practice (or any practice, for that matter). Otherwise, we run the risk of mindlessly adding an expensive procedure without providing the setting characteristics to ensure its success.
References 1. Jain R, Kralovic SM, Evans ME, Ambrose M, Simbartl LA, Obrosky DS, et al. Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections. N Engl J Med 2011;364:1419-30. 2. Huskins WC, Huckabee CM, O’Grady NP, Murray P, Kopetskie H, Zimmer L, et al. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med 2011;364:1407-18. 3. Pronovost PJ, Berenholtz SM, Goeschel CA, Needham DM, Sexton JB, Thompson DA, et al. Creating high reliability in health care organizations. Health Serv Res 2006;41(4 Pt 2):1599-617. 4. Chassin MR, Loeb JM. The ongoing quality improvement journey: next stop, high reliability. Health Aff (Millwood) 2011;30:559-68.
Patricia W. Stone, PhD, RN Elaine Larson, RN, PhD, FAAN, CIC Columbia University, New York, New York 0147-9563/$ - see front matter Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.hrtlng.2011.04.048