Shannon Oriola, RN, CIC, COHN, the department lead for infection prevention and clinical epidemiology at the Sharp Metropolitan Medical Campus in San Diego, discusses her experience with active surveillance testing (AST) in the wake of the September 2008 passage of SB 1058, California’s infection reporting and MRSA screening legislation.
Q: What is mandated in California?
A: We’re mandated to conduct AST on patients admitted to the ICU, the burn unit, receiving dialysis, discharged from a hospital within the last 30 days prior to admission, or patients coming from a nursing home. In 2011, we will be required, if the patient is negative on admission, to screen them on discharge. It is also mandated that physicians provide patients with their test results. And of course there are national patient safety goals focused on MDROs and you need a program to address these pathogens, plus we must educate staff, licensed independent practitioners and patients. So we have to test, we must have a program and we have to educate — not only for CMS and the Joint Commission, but state legislation requires this as well.
Q: What do you screen for specifically?
A: Some facilities in California don’t have the resources to figure out who needs to be screened so they are screening every patient on admission. We have been guided by the literature and our hospital epidemiologist, and we know to look at our risk and the pathogens we are seeing in addition to state legislation. In our CABG population we had seen S. aureus sensitive, not resistant, so we started screening patients undergoing CABG or any open heart surgery for S. aureus. For our elective open heart surgeries, we will take a nares specimen to test for MSSA or MRSA; if it’s MSSA or MRSA, the patient will receive Bactroban to decolonize them prior to surgery, and we encourage them to use Hibiclens to shower twice a day for five days prior to their surgery. If it’s MRSA, they will also receive vancomycin as a prophylactic antibiotic before surgery. Last year we had no infections in our cardiac surgery population attributed to S. aureus, whether sensitive or resistant. So we look at our high-risk, high-volume procedures, and those that require implants, as those patients, of course, have a greater risk of morbidity and mortality if they develop an infection. Another challenge when screening patients as mandated by SB 1058 is screening patients that have had a prior hospitalization within the last 30 days prior to admission. That can be challenging for the admitting nurse to figure out, so we are in the process of trying to automate this process within our three hospitals.
Q: AST can be costly to conduct; what has been your experience in terms of resources needed?
A: I believe that one of the University of California system hospitals calculated the cost of active surveillance to be about $1 million, so it can be quite expensive. I have a part-time infection preventionist whose primary function is to focus on MDROs. We also have an electronic health record system that helps streamline the process. I realize I am very fortunate because I have these resources and I have a very supportive administration. Not only do I have resources to support the mandates, but our campus is one of the most wired for healthcare information technology in the country. We are very lucky to be in this situation, as I realize it can be very difficult for smaller facilities that don’t have the technology or the support. The easiest thing for them to do might be to make AST part of the standing orders on admission; depending on their demographics, which may be their at-risk population anyway.
