Where: Crouse Hospital in Syracuse, N.Y., a 431-bed facility.
The issue: Controlling the spread of methicillin-resistant Staphylococcus aureus (MRSA) infections in hospitalized patients.
In 1999, Crouse Hospital experienced an outbreak of MRSA in an adult critical care unit. To keep the outbreak from spreading, MRSA patients were cohorted to one side of the critical care unit and a dedicated nursing staff was assigned to the group. Cohorting worked well to control the outbreak, so the hospital implemented a plan to permanently designate a MRSA unit, complete with a dedicated nursing staff. Establishing the MRSA unit took about a year, said manager Barbara Miller Stahl, RN.
How it works
Crouse routinely screens all high-risk patients for MRSA, including those being transferred from nursing homes and other hospitals and those with open wounds. The 17-bed MRSA unit houses an average of 11 patients daily who are either infected with or colonized with MRSA. Staff assigned to the MRSA unit are not required to wear gowns but wash their hands before and after changing their gloves between patients. Unassigned personnel gown upon entering the unit and wash their hands before and after changing gloves between patients. Gowns are removed on leaving the unit and are changed only in between caring for patients who have infections with other resistant organisms. These patients are cohorted to another area of the unit.
The unit cares for older patients with chronic illnesses as well as younger patients with sickle-cell anemia and athletes with community-acquired infection, according to Ms. Miller Stahl. MRSA patients who are receiving peritoneal dialysis or who need to be on telemetry cannot be admitted to the dedicated unit, because of their need for specialized care.
Staff had several concerns about the new unit at first, according to Ms. Miller Stahl and Shelley Gilroy, FACP, medical director of infection control. “Physicians were afraid that they would become colonized or infected by treating patients in the MRSA unit or that their patients who were colonized but not infected would become infected if admitted to the MRSA unit,” said Dr. Gilroy.
In response to these concerns, the infection control team and nursing supervisors explained that it was actually safer in the MRSA unit because staff are required to wear gloves and follow precautionary hand-washing protocols, whereas in other areas of the hospital these precautions are not routinely used before patients are diagnosed, said Ms. Miller Stahl. “Convincing the other sections of the hospital that this was the best place, the safest place and the greatest place to send the MRSA patients was a real challenge,” she said.
The hospital has saved more than $1 million and reduced the average length of stay for MRSA patients from 30 days to 12 days;
- Nosocomial MRSA rates decreased because of the “once positive, always positive” policy, which calls for former MRSA patients to be readmitted into the MRSA unit rather than the general hospital population; and
- MRSA rates went from 0.66 per 1,000 patient care days in September 2000 to 0.43 per 1,000 patient care days in July 2002. Rates had decreased further to 0.25 per 1,000 patient care days as of November 2007.
- Accumulate data to show administrators and staff the positive effects of cohorting MRSA patients in one unit. “The data showed that this was having a dramatic impact on the MRSA rate in the hospital, as well as on length of stay and on hospital spending. The hospital saved substantially just on buying fewer gowns,” said Ms. Miller Stahl.
- Isolate all MRSA patients and consider them “once positive, always positive,” the policy at Crouse. “This is not a popular policy, but it has helped us prevent spread of MRSA,” explained Dr. Gilroy. “It has been reported in the literature that the majority of readmitted carriers harbor MRSA for greater than three years.”
How patients benefit
Cristina A. Topor, MD, head of Crouse's hospitalist program, said MRSA patients get equal—if not better—care in the dedicated unit than elsewhere in the hospital. “These are often patients who are hospitalized several times a year, so there is an air of familiarity among the patients and the nursing staff,” said Dr. Topor, adding that this dynamic tends to engender more personal, attentive care. The ability of patients to move freely about the MRSA unit is another important and easily overlooked benefit. “If these patients were isolated in private rooms, obviously that would not be an option,” she said.
Dr. Topor said plans are in motion to admit patients who need telemetry. “Sometimes heart problems develop after the patient has been admitted to the MRSA unit, and it is very hard on the patient when they have to be moved to an isolation room elsewhere,” she said.
Words of wisdom
While Crouse was in an ideal position to start up the MRSA unit, it makes economical sense to separate MRSA patients even if it requires a capital investment, according to Dr. Gilroy. “We are taking a pro-active approach, because the cost of treating a hospital-acquired MRSA infection is much higher than the cost of the intervention to prevent it.”