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Safe, cost-effective prevention of staph infection.

At the time the article was written, the author was director of laboratory services at Humana Hospital Hoffman Estates in Hoffman Estates, Ill He is now administrative laboratory director at Edgewater medical Center in Chicago,

This hospital instituted contact isolation of patients at high risk for MRSA, pending the outcome of microbiology tests.

Methicillin-resistant Staphylococcus aureus (MRSA) is a nagging problem for hospitals with admissions from convalescent and extended-care facilities. Nosocomial infections always raise a source-identification challenge. MRSA, more so than others, also increases length of stay and poses a risk of colonization among staff members as well as other patients.

This was a big concern at our 200-bed hospital, where MRSA infection typically added two days to a patient's stay. In the summer of 1987, the infection control committee-with assistance from pharmacy, the laboratory, nursing, and administration-implemented a policy to prevent its spread.

Direct patient contact was clearly implicated as the mode of transmission for nosocomial MRSA infections. The incidence of these infections had a cyclical nature, and to break the cycle, we had to take control at the time of admission. Since patients admitted from local extended-care facilities accounted for most of the MRSA-positive cultures, the committee considered such admissions the primary source of our problem.

With this high-risk vector identified, we activated the hospital's new contact isolation policy. The simple and effective plan has virtually eliminated MRSA contagion at this hospital:

Any patient admitted from a site known to have an MRSA problem is automatically placed in contact isolation pending an admission assessment. Nursing collects a nasal screen for MRSA, along with cultures from other potential MRSA sites-decubitus wounds, tubes, and Foley catheters. All personnel coming 'into contact with the patient must wear masks, gowns, and gloves. The patient remains in contact isolation until all screens show he or she is MRSA-free.

Microbiology results are reported within 48 hours. If they are negative for MRSA, the patient is taken out of isolation. If the results are positive, however, the patient is already isolated and we need not worry about who might have been exposed. The MRSApositive patient is held in contact isolation until the laboratory grows a negative culture.

Our straightforward antiMRSA strategy yielded immediate and decisive benefits. During the first six months of 1987, just before the policy was introduced, we admitted an average of 15 nursing home patients each month who would have been candidates for contact isolation. An average of three patients per month tested positive for MRS A-one month, we had six positive results. The associated colonization rate for this nosocomial infection was about 3 per cent among the hospital staff and previously uninfected patients.

The contact isolation policy eliminated associated colonization entirely within three months, and the rate is still zero nearly two years later.

Immediate culturing of high-risk patients upon admission also cuts two days from the length of stay of those who prove to be infected. The clinical signs of MRSA infection are difficult to deten-nine immediately in geriatric patients, who often have several other medical problems. (The most common Medicare DRG among nursing home admissions at our hospital is DRG 89-simple pneumonia and/or pleurisy, age greater than 17, with a complication-involving an average stay of two weeks.) Without the automatic approach, culturing generally takes 48 hours after a clinician begins to suspect MRSA infection.

Our MRSA isolation policy saves both the hospital and the patient time and money. It costs about $75 to isolate a patient for two days. This covers the cost of the MRSA testing screen and masks, gowns, and gloves. (Personnel costs are not affected.) Thus the hospital spends about $1,125 to run the program each month if we isolate the expected 15 patients.

Since 12 of the patients will probably test negative, $900 of that outlay might be considered unnecessary expense. But the $900 is more than made up for by the three positive cases identified each month. Without immediate culturing, those patients would have to stay on at least two extra days to clear up their MRSA infection, which adds $1,000 to the hospital bill for each case.

We knew the program was justified in terms of protecting the staff and uninfected patients. These numbers showed the plan also made fiscal sense. Even if we identify just one MRSA-positive patient per month, the program breaks even. The savings become more significant when you consider that almost 70 per cent of our extended-care admissions come in with MRSA-related problems, and that MRSA infections would multiply without early contact isolation.

A positive result during isolation helps the hospital substantiate MRSA contagion in an extendedcare facility, so the facility can take corrective action. Nursing homes are reluctant to admit that patients contracted MRSA infection at their facility, and they will not reaccept them until negative MRSA cultures have been reported. If the source of infection is not identified and eliminated, these patients are likely to be reinfected because they have become highly susceptible.

Admission contact isolation of patients at high risk for MRSA infection gives the hospital an ideal quality assurance monitor-one that results in cost savings and control of a potentially serious problem.
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Copyright 1989 Gale, Cengage Learning. All rights reserved.

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Title Annotation:methicillin-resistant Staphylococcus aureus
Author:Krempel, George
Publication:Medical Laboratory Observer
Date:May 1, 1989
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