Infection Control Certification May Lower MRSA Rates

Larry Hand

April 10, 2012

April 10, 2012 — California hospitals appear to have significantly lower rates of methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection if their infection control directors are board-certified, according to a study published in the March issue of the American Journal of Infection Control.

Monika Pogorzelska, PhD, MD, from the Columbia University School of Nursing in New York City, and colleagues surveyed California hospitals between April and June 2010, which was more than a year after California mandatory reporting of infection rates went into effect and after California required targeted MRSA screening.

Of 331 nonspecialty acute care hospitals invited to participate by the researchers and the Association for Professionals in Infection Control (APIC) and Epidemiology, 203 (61%) completed some part of the survey. The objective of the study, funded by the Blue Shield of California Foundation, was to investigate the effect of mandatory reporting on the role of infection preventionists and healthcare-acquired infections.

The researchers asked about structure of care characteristics such as bed size and teaching status, processes of care such as screening of patients on admission and presumptive isolation, and outcomes, including the MRSA and vancomycin-resistant Enterococcus (VRE) bloodstream infection (BSI) rates and Clostridium difficile infection rates for the first quarter of 2010. They also asked whether the infection control directors were certified by the Certification Board of Infection Control and Epidemiology (CBIC) and were members of either the Society for Healthcare Epidemiology of America or APIC.

Of the 203 respondents, 180 (54%) answered questions in the multidrug-resistant organisms (MDRO) section, and 91 hospitals provided rates for MRSA BSI (mean, 0.43 MRSA BSI/1000 central line-days) and VRE BSI (mean, 0.21 VRE BSI/1000 central line-days). For C difficile, 105 hospitals provided infection rates (median, 0.41 infections/1000 inpatient days).

Slightly more than half of the hospitals (51.2%) reported that the infection control director was board-certified, and most hospitals (89.7%) reported that the director was a member of 1 of the associations.

Hospitals that had a board-certified infection control director had significantly lower MRSA BSI rates compared with hospitals that did not have a board-certified infection control director (incidence rate ratios [IRR], 0.32; P = .02). Similarly, hospitals that participated in an Institute for Healthcare Improvement campaign had significantly lower MRSA BSI rates than those that did not participate (IRR, 0.30; P = .01).

In multivariate analyses that controlled for structure of care characteristics, hospitals that screened all patients at admission for MRSA had an IRR 10.2 times higher than hospitals that did not have this policy. Conversely, hospitals with policies to target MRSA screening for new admissions had significantly lower MRSA BSI rates compared with hospitals without the policy (IRR, 0.03; P = .01).

"In our study, having an infection control director who was certified in infection control was a significant independent predictor of lower MRSA BSI rates," the researchers write. The authors suggest the difference may be a result of the adoption of evidence-based practices or of better organizational quality or support.

Almost all hospitals (97.2%) reported that they collected some type of surveillance culture at admission for MDRO, mostly from transfers from nursing homes (77.8%), intensive care units (72.8%), dialysis (63.3%), or readmissions within 30 days (75.6%). In addition, 36 hospitals (20%) reported collecting surveillance cultures from all admissions except labor and delivery.

About 29% of hospitals reported screening all patients for MRSA on admission, but many more (87.3%) reported targeted screening such as for nursing home (96.0%), intensive care (86.8%), dialysis (76.8%), and readmitted (89.4%) patients. Few hospitals reported targeted screening on admission for VRE (6.7%) or C difficile (3.9%), possibly because the California regulations focus only on MRSA.

Most hospitals reported having policies to limit contact with patients positive for MRSA (93.3%), VRE (65%), or C difficile (83.9%). However, the method used most often to detect MRSA was standard culture, with results available only after 1 to 3 days.

"[B]ecause few hospitals report the use of presumptive isolation or contact precautions for patients with pending results and institute isolation only when culture results are positive, the usefulness of screening at admission is greatly diminished," the researchers write.

The study confirmed that 87% of the California hospitals had policies in place to screen for MRSA, which is a higher rate than shown in previous research. However, a lag exists between reporting and screening requirements and institution and hospital policy implementation.

The authors write that results may have a selection bias because "hospitals with high intensity of infection control processes and low [healthcare-associated infection] rates may have been more likely to participate in this study." In addition, lack of data from all hospitals may be a limitation.

Nevertheless, the researchers conclude, "This study highlights the importance of infection control certification as an important predictor of [healthcare-associated infection] rates. It also demonstrates the continued focus placed on MRSA as evidenced by policies instituted by infection control departments, potentially in response to state mandates."

More than 4900 people hold certification in infection control worldwide, according to CBIC.

The authors have disclosed no relevant financial relationships.

Am J Infect Control. 2012;40:96-101. Abstract