By Kelly M. Pyrek
Kathy Aureden, MS,MT(ASCP) SI,CIC, epidemiology coordinator at Sherman Hospital in Elgin, Ill., shares her perspectives on the controversial topic of screening and how to make sense of infection data.
Q: Why is the topic of screening such a contentious topic?
A: Nothing about screening is black and white. It's like statistics -- if you believe in active surveillance program, you can go the literature and find numerous articles that will support your view. However, the person in the next hospital who doesn't believe in it, can go to the literature and find research that will support his or her view. It's challenging.
Q: A recent study indicated that 97 percent of surveyed hospitals conducted some kind of screening -- so almost everyone seems to be doing it but can't agree on why they are doing it or how they are doing it... is that a good way to undertake such an important task?
A: Screening is sometimes done because you have to, or even because it is done that way at the hospital next door, and seems to be the expectation locally. There are a variety of reasons for screening, and some are legitimate and compelling while others are not. So what is the right way to approach this? Decisions about screening should be based on the infection prevention risk assessment for your facility. Certainly we have to comply with regulatory mandates, and any given screening process should be consistent with expert consensus documents that can provide some structured guidance. Each program should be built on the same foundation. This helps us be consistent and standardized to some extent in our screening efforts. But even if we all use the same guidance, we may not all have the same screening program. And that is OK the screening program is based on a well developed risk assessment and ongoing surveillance.
Q: Why is there no standard that could help address the great variability that exists currently?
A: Because my facility is different from another facility, we do not, and probably should not, have prescriptive standard protocols that dictates the same to each. There is great innate variability in healthcare institutions. There are always variables and different factors, including patient populations, service lines, procedures done, geographic location, and the resources that are available. Agencies such as the Joint Commission do not prescribe active surveillance but, in line with APIC, the CDC and other expert organizations, focus on the annual risk assessment. It is from the risk assessment that the screening program should be developed, based on expert recommendations and the facility’s surveillance findings. It does sometimes seems to frustrate people that the Joint Commission, the CDC, etc. do not outright tell them what, when, and how to do this type of screening. However, mandated screening would be frustrating when compliance with a mandate does not correlate with identified risks. We are sitting on the fine line between what should be prescriptive and what should be amenable to expert interpretation regarding the effectiveness of screening programs from facility to facility.
Q: What are the challenges related to resource allocation needed for active surveillance?
A: With universal screening, there is significant expense associated with procuring the resources needed for the coordination and management of that kind of program. For instance, to screen all admissions means there is going to be a lot of data -- some of that information is not going to be actionable at all and therefore you have thrown resources at something which may not result in a good return on the investment. Also, there may be false positive or negative results due to test sensitivity and specificity, prevalence of occurrence in any given population. And there may be a lack of consistency with specimen types or with specimen collection -- there's not really one perfect site to obtain the culture for a MRSA or ESBL screen and I do not know if there are any general indications to screen for C. difficile.
There is also the impact on the clinical microbiology laboratory to consider. Even if your lab is in-house, can it handle the added workload with the current number of FTEs it has? Will there need to be a significant workload redistribution. Will the lab have to purchase new the equipment to offer screening by PCR rather than culture? Does the lab have the capacity to financially handle a change from culture screening to PCR? What training will be needed for staff if there is a switch from culture to instrumentation? For those facilities that outsource the lab work, what is the expense to the hospital for the increased costs of the tests? The impact on the lab may be so great that the barrier almost seems insurmountable, although I think there will be fewer barriers as benefits of the technologies and affordability of the changes are enhanced in the future.
In order to reliably identify colonized patients, we must be consistent about how we screen. For MRSA, there are additional considerations when screening for community associated strains. It is unclear if the nose really the favored site of colonization for that strain or if it is more likely to be found in the throat or even another body site. IPs will need to look to their own surveillance results and consult the literature to develop the best MRSA screening protocol for their facility, patient populations, and community. And IPs must be prepared to change when additional information or changes in local epidemiology changes. If the strains mutate, will the nose still be the preferred site or will they have followed an evolutionary path away from that site because it is no longer as effective for them as other sites? These are questions that we hope have to answers for in the future. When considering a screening process for multidrug-resistant Acinetobacter, VRE, or ESBLs, IPs must work with their laboratories to develop a process that effectively recovers the target organisms from the appropriate specimen (e.g. a stool with that has billions of bacteria!) or from multiple specimens if there is no preferred site – is there a break-even point with the expense, time and effort on the part of the lab to detect the colonization? It certainly would be in important in an outbreak situation or when there is ongoing increase in incidence that is actionable for infection prevention. Otherwise, the IP risk assessment results should direct the efforts to screen for important pathogens in any given facility.
Having pointed out some of the issues, I do admit to often wishing that I had more data when evaluating my surveillance results. At many times, I'd love to have “universal screening” -- I want to know that a newly admitted patient doesn't have MRSA in his nose, groin or axilla, doesn't have ESBL in his gut, and is not carrying MDR Acinetobacter anywhere on his body. To find a significant pathogen several days or even weeks after that patient has been at our facility (for instance, when the first clinical culture is done sometime after the first two days of an admission) it is difficult to make the case that the patient was colonized prior to admission, and not a victim of transmission after admission.
Preventing transmission is very important, yet, there's another side to that coin – the side on which we PREVENT an infection. I have confidence that most IPs are very involved with best practices to prevent hospital associated infections. It remains very important to make sure that colonizations, whether transmitted in healthcare settings or the patient “just happens” to be colonized, do not progress to infection.
Conducting a screening program usually leads to actions to prevent transmission, which starts with contact precautions for the positive patient and can involve enhanced cleaning/disinfecting processes. In some situations, there may also be an indication for another intervention – e.g. decolonization (CHG skin and mupirocin nasal protocols) that benefits the patient, or as a valid part of an infection prevention intervention to stop transmission during an ongoing outbreak. Other screening situations include identify patients prior to certain surgeries (e.g., cardiac or orthopedic surgeries) for whom the risk of an staphylococcal SSI may be reduced by decolonization prior to the procedure. There needs to be checks and balances to be sure the order for decolonization using nasal mupirocin is truly going to benefit the patient, since the risk of creating mupirocin resistant may result in losing the effectiveness of that treatment in the future.
In addition, there are certain outbreak situations during which we would even decide that healthcare workers screening would benefit our efforts to control the outbreak. While there is a currently a dearth of guidance to help the IP decide when to go down that path, and the IP in that situation may decide to consult an outside expert and certainly must get all key players, (Occupational Health, Infectious Disease physicians, Senior Leadership, Human Resources) involved with the decision and the process. Otherwise, we run the risk of appearing to have made knee-jerk reaction that is difficult to justify if we are challenged after the fact.
Q: There is ongoing debate between experts who embrace pathogen-specific interventions versus non-pathogen specific interventions -- if we simply follow infection prevention principles, shouldn't we be OK?
A: I do targeted screening, not universal screening, and I do it for particular reasons linked to my risk assessment. I happen to be in a facility that has all private rooms, so my main concern is not the current roommate (there is none!), but the next patient in that room. That's a key consideration for my annual risk assessment. Of course, I conduct ongoing surveillance for all significant pathogens, and I track and trend to identify outbreaks and clusters so that we can act with appropriate interventions. The bottom line is the actionable step you take when you get a positive result, e.g. contact precautions so that the organism does not leave the room. I remember many years ago that Judene Bartley said that yes, it is good to prevent transmission -- but regardless of when and how a patient is colonized with an MDRO, it is paramount to prevent infection! That speaks to the value of the IP focus on CLABSI, VAP and CAUTI best practice bundles and initiatives, along with get-the-device-out programs -- if we can decrease the risk of an infection occurring, it still matters, but it matters less, if they have MRSA in their nose or ESBL in their gut. So what is the long-term outcome of your screening program? I feel it needs to be facility-specific based on your risk assessment.
Q: What about the facilities that have a "bug-of-the-month" mentality?
A: There are pros and cons. For me, the pro is if that if your bug du jour is ESBL, the infection prevention and control of that bug is a reinforcement of what needs to be done to prevent transmission of all MDROs! The same can be said for MRSA, for C. diff or anything else –prevent transmission, prevent infection. If the focus on the “bug of the month” keeps that focus, you are benefiting from this mentality. The potential problem with a narrow focus on one particular organism is the missed opportunity to quickly react to control a problem with another organism that is not the current bug of the month. This may be more of a problem in states where screening is mandated, but only if it distracts from a holistic IP program. Part of my risk assessment and my screening program is always going to be the state mandated MRSA screening of patients admitted to our critical care areas. Over time, this mandate has been incorporated in the whole focus of preventing infections in critical care patients, so in truth, the fact that we are mandated to screen for MRSA hasn't distracted us from those other organisms or the interventions we need to take. Your risk assessment should determine where you should put your additional efforts.
Q: Screening is just one of many complicated tasks that infection preventionists face. What advice can you offer?
A: When I first started in infection prevention I felt as if I knew nothing-- and back then there was a lot less to do and know then than there is now! So I can understand feeling overwhelmed. The good thing is that most facilities have quality improvement programs that interact more and more with infection prevention departments. There is a greater expectation facility-wide on working together to prevent infections. This includes senior leadership attention and support, which trickles down through the organization. With increased societal, governmental, and healthcare leadership attention to HAI prevention, it may be more possible to leverage the resources IPs need. For example, my organization’s clinical excellence program oversees internal and external quality metrics, which now includes HAI data for the monthly executive and nursing scorecards for our target HAIs. Being in the red instead of the green for two months in a row on the scorecard means that senior leadership has a “crucial conversation” with the appropriate quality teams and holds them accountable for an action plan. That's powerful because it pushes infection prevention out of my office and into everyone else's realm of influence and action. Critical care often grills me about VAP and CLABSI case and wants to know their rates because they are working so hard to prevent those infections. They feel ownership, and we (the units and the teams) celebrate when we achieve our goals. That wasn’t happening 10 years ago.
I recommend that infection preventionists get involved in their organization's quality program and partner with key stakeholders. That reduces the stress and of feeling the weight of responsibility for HAI process improvement off our shoulders so we can focus on spreading the story (data evaluation) that surveillance is providing to those who will act on it. IPs need to focus on getting data that is actionable and minimize time spent with data that really doesn't matter. For example, if I have been seeing the same fairly low level of MRSA for a long time, I continue to watch to MRSA trends but will direct more focus on that spike in Acinetobacter that was just identified in a certain patient population or on a certain unit. IPs must be sure of their ability to get useful data in a timely manner with the least amount of grunt work ( not always easy) so that they have confidence that they can quickly recognize when the data is telling them it is business as usual or if it's telling them that something is up. IPs need to be members of their local APIC chapters to benefit from just in time networking with colleagues in their area. It is great to be able to pick up the phone or send an email, and get feedback right when you need it. Critical thinking is often enhanced through discussion with a knowledgeable colleague. Try to isolate and track even the small changes that seem to work – you may need to come back to those changes if results that were good start trending toward bad. Always re-evaluate after implementing process improvements to identify the specific interventions that work as well as make sure they are maintained. Focus on what isn't broken should be at a “maintenance” level, so that those things that really need attention or need to be fixed get full attention.