By Kelly M. Pyrek
Currently, there are at least 15 states that require some kind of reporting or screening for methicillin-resistant Staphylococcus aureus (MRSA), according to the latest statistics from the Association for Professionals in Infection Control and Epidemiology (APIC). While they acknowledge that healthcare-associated infections (HAIs) must be stopped, many infection preventionists say they feel as though knee-jerk legislation is leading this issue, and not the actual scientific evidence for active surveillance. No one can dispute that any means to eliminate HAIs is an imperative; however, as the push for implementation science increases, some are wondering if screening has been studied enough to warrant a legislative mandate. It's one of those issues with which infection preventionists and healthcare epidemiologists grapple as they continue to push for doing what's right for improved patient outcomes.
"Despite ongoing research examining the issue, a simple answer has remained elusive," says Matthew Wise, MPH, PhD, a lieutenant commander in the United States Public Health Service and epidemiologist in the Office of Prevention Research and Evaluation at the Division of Healthcare Quality Promotion for the CDC. "There is continuing legitimate scientific debate regarding this practice and how hospitals and other healthcare facilities should best focus their MRSA prevention efforts. One of the recommendations we make to states considering this type of legislation is to ensure that all stakeholders are involved in the legislative process. We believe that ensuring open communication between legislators, infection preventionists, hospital staff, and healthcare epidemiologists is the best way to assure that policy decisions are based on the best scientific evidence available and appropriately reflect the local epidemiology of MRSA as well as the availability of resources for implementation."
Wise and his colleagues at University of Chicago Medical Center, the New York City Department of Health and Mental Hygiene, and Rush University Medical Center, wanted to assess healthcare workers (HCWs)' perceptions of a mandatory screening law passed in Illinois in 2007. The legislation, the MRSA Screening and Reporting Act (SRA), requires that patients admitted to intensive care units as well as other high-risk patients, as determined by each hospital, be screened for MRSA colonization at admission. They conducted their study in eight Chicago-area hospitals, using structured focus groups and disseminating questionnaires among three groups of hospital staff members -- leadership, midlevel and frontline -- at each hospital.
The researchers then compared 126 HCWs' statements about MRSA and the legislation across staff types and discovered that 56 percent of the participants said they thought the legislation had a positive effect at their healthcare institution. The impact of potential MRSA colonization among patients hit home for many of the participants. As Wise and colleagues write, "One participant noted, 'I think it’s been surprising in terms of the epidemiology of who we expect would be colonized with MRSA and who actually is … Eighty percent of our positive nasal MRSA screens are coming from the community and not from an extended-care facility.'" They report that another participant said, "When you actually have legislation that means you’re actually forced to do it because it’s going to be documented. So now you’re getting better outcomes for your patient, better outcomes for the people that walk [into] the facilities."
Interestingly enough, frontline HCWs -- personnel who provided direct patient care, which primarily included intensive care unit nurses and physicians -- were more likely to agree than midlevel and leadership staff. These healthcare professionals counted among the benefits of the legislation greater awareness of MRSA among staff and better knowledge of the epidemiology of MRSA colonization. Conversely, the perceived negative consequences included the psychosocial effect of screening and contact precautions on patients and increased use of resources.
Wise says he was surprised at the acceptance levels of mandatory reporting by frontline staff, despite the added workload. "On a day-to-day basis it was the critical care nurses and other frontline staff who were collecting nasal swabs and donning and doffing personal protective equipment to care for patients that had been placed on contact precautions," Wise says. "Almost 60 percent of frontline staff reported that their work responsibilities had changed because of the legislation, yet over 70 percent of this group would choose to voluntarily continue the activities required by the legislation."
According to Wise and colleagues, just under17 percent of all participants agreed that the SRA had made it harder to complete their other job responsibilities, and only 13 percent said they thought that the SRA had taken away from other important patient safety activities. A little more than 20 percent of all participants thought that too much time and resources were being devoted to MRSA at their institution. The most commonly reported barriers encountered in implementing the SRA were the financial cost associated with implementation, lack of sufficient laboratory capacity and staffing, and general resistance to change on the part of healthcare personnel. Other barriers included lack of access to supplies, difficulties managing bed flow, lack of healthcare personnel compliance with contact precautions, and the activities not being part of the normal process or daily routine.
As Wise and colleagues write, "Themes of increased resource use resulting from the SRA emerged across a variety of questions in focus groups. This included themes surrounding increased use of supplies, such as gowns and gloves, as well as increased financial expenditures by hospitals to implement and sustain the required activities. However, other themes related to resource use painted a more nuanced picture, including a perception that increases in the number of MRSA screening tests performed could overwhelm existing laboratory capacity and increase the difficulty of managing bed flow. Given the wide array of resource issues confronting hospitals when implementing the SRA, one common piece of advice given to hospitals in other states considering similar legislation was for each facility to evaluate the resources they have before implementation, ensuring that hospitals can tailor implementation plans and goals to available resources and seek additional resources where necessary."
Less convinced of the benefits of the legislation were the leadership group members (chief executive officer, chief operations officer, chief medical officer, chief nursing officer, leaders of quality departments, etc.) and midlevel staff groups (infection preventionists and department or unit managers). Wise and colleagues report that frontline staff members were more likely to agree that the SRA improved the quality of care at their facility (63.9 percent) than midlevel and leadership staff (41.9 percent and 38.7 percent, respectively).
The project also revealed concern over patients' welfare; according to Wise, the most common perceived negative consequence of the SRA was the psycho-social effect of screening and contact precautions on patients. As Wise and colleagues write, "Hospital staff reported patients feeling 'contaminated' and 'bewildered and puzzled about what it means' when they were told that they were colonized with MRSA. Some research has shown that patients under contact precautions have less contact with healthcare personnel, higher frequency of noninfectious adverse events, and greater depression and anxiety, although this has not been consistently found in all studies. The increased application of contact precautions because of the SRA highlights the importance of the most common piece of advice focus group participants gave other hospitals in states considering similar legislation: to educate both patients and staff about MRSA screening. Some evidence suggests that certain negative outcomes associated with contact precautions can be prevented through enhanced patient education. States or hospitals considering programs that could result in substantial increases in the use of contact precautions should develop educational messaging targeted to both patients and staff to mitigate the psycho-social effect of isolation on patients. Staff education efforts should emphasize understanding the reasons why the screening program is being implemented."
Wise's project helped reveal some general perceptions of the MRSA burden at participants' institutions as well as the mandatory reporting law. According to Wise and colleagues, more than 80 percent of frontline staff agreed that MRSA was common, whereas half of midlevel staff and just more than one-third of leadership staff agreed. However, only approximately one-third of participants agreed that MRSA was currently a problem at their facility, with no significant differences across groups in percent agreement. Almost 85 percent of the participants were aware of the legislation itself and just over 80 percent were familiar with the specific activities required by the SRA. More than three-quarters of all staff types agreed that both senior leadership and patient care staff supported the requirements of the SRA.
"Having buy-in from hospital staff was one of the most commonly cited facilitators to implementing the activities required by the MRSA screening legislation in Illinois," Wise says. "We did see that across all professional categories only about a third of hospital staff perceived MRSA to be a problem at their facility, but only 20 percent of staff perceived that too much time and resources are being devoted to MRSA. Although some facilities did cite lack of compliance with certain requirements of the legislation as a barrier to implementation, we did not collect any information on whether these compliance issues were related to perceptions of MRSA as a problem."
One point to consider is that acceptance levels of MRSA-screening legislation could be different at a smaller facility or a different geographic area, or with a different patient population and clinical challenges. "One of the limitations in this evaluation was that the participating hospitals, as well as the staff choosing to participate at those hospitals, represented a convenience sample of voluntary participants limited to the Chicago metropolitan area," Wise says. "We recognize that the epidemiology of MRSA as well as the availability of resources may vary not only from state to state, but from hospital to hospital, and that this could influence staff perceptions of mandatory MRSA screening. Nevertheless, we believe our paper can help other states considering similar legislation to think about some of the potential benefits and consequences, as well as barriers and facilitators, to implementing such a program."
Wise and colleagues note that 59 percent of participants would choose to continue the activities associated with the legislation. "We saw important differences across staff types in terms of the perceived sustainability of the legislation in Illinois: while over 80 percent of frontline healthcare providers perceived the activities to be sustainable for the next five years, only about half of hospital leadership thought the legislation was sustainable over that time," Wise says. "Despite the changing context resulting from healthcare quality and reporting mandates, we still saw substantial concern expressed over the value of mandatory MRSA screening on the part of some hospital administrators at the time of our evaluation (Fall 2009)."
As we have seen, participants in this project advised facilities in states considering similar legislation to educate staff and patients about MRSA screening and to draft clear implementation plans. And as Wise and colleagues explain, "Regardless of whether the SRA is ultimately shown to benefit patients by reducing the incidence and prevalence of MRSA infection and colonization, implementation of this legislation makes clear that public policy does not occur in a vacuum and that the resulting consequences must be considered during the planning, implementation, and evaluation of such policies."
It's clear then that infection preventionists and clinicians owe it to themselves to better inform policymakers so that mandatory screening legislation is improved with an eye toward advancing the infection prevention agenda.
"One piece of advice hospital staff gave to other states considering similar legislation was to develop program evaluation strategies to ensure that policies are achieving the intended results," Wise says. "Conducting consistent, ongoing surveillance for MRSA and other healthcare-associated infections can provide infection preventionists and clinicians with local data on whether policies appear effective at reducing infections."
Studies assessing the use of active MRSA screening to reduce MRSA infections have shown conflicting results, and for now, practitioners must comply with their states' legislation, but more evidence of the impact screening has on infection rates might be on the horizon, according to Wise. "Our evaluation focused on the experiences and perceptions of hospital staff in implementing the requirements of MRSA screening legislation. Although hospital staff reported several perceived benefits resulting from the legislation (increased awareness of MRSA, better understanding of the local epidemiology of MRSA, better patient outcomes, increased patient education on MRSA, greater implementation of contact precautions, and increased hand hygiene compliance), these were only their perceptions," he says. "Other studies are currently being conducted to quantify the impact of the legislation in Illinois on MRSA infection and colonization."
Reference: Wise ME, Weber SG, Schneider A, Stojcevski M, France AM, Schaefer MK, Lin MY, Kallen AJ and Cochran RL. Hospital Staff Perceptions of a Legislative Mandate for Methicillin-Resistant Staphylococcus aureus Screening. Infect Control Hosp Epidem. Vol. 32, No. 6. Pp. 573-578. June 2011.