As director of ICU, the general manager of your hospital asks you to review your current infection control policy following an increase of 200% in the number of newly acquired MRSA infections during an ICU admission in the past 2 months.
Outline your approach to this request.
College Answer
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1. |
Obtain relevant details of the increase in infection rate- is it a real increase i.e. is there an increase in the rate of MRSA per 100 or 1000 admissions or have the no of admission gone up significantly too, clinical relevance of finding i.e. is the 200% related to case mix changes, no of patients, demographics and type of patients, duration of ICU stay, details of ICU stay/ procedures/ antibiotic usage, genetic of MRSA- community acquired/ hospital acquired, is MRSA same or similar to the prevalent strain or is it a new strain |
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2. |
Review current infection control policy- when it was written, people involved in writing it, MRO rate at the time of writing policy. |
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3. |
Get expert help- infectious disease specialists, infection control specialist either from your hospital or from elsewhere. |
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4. |
For a review team with yourself, 1 or 2 other intensivists form your ICU, ICU nursing mangers and 1 0r 2 nurses and infectious diseases/ infection control experts. |
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5. |
Review cases, review previous policy, review experience in peer hospitals in your vicinity and in your state if available, perform a literature review of the evidence base on this topic. |
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6. |
Document all above in the form of a report with key findings and recommendations- key finding should include- clinical relevance of findings, cohort of patients affected, current rate of MRSA in your hospitals compared to peer hospitals, postulated causes for the current increase, possible causes why current infection control policy may not have been effective, antibiotic usage and their impact on the increase in MRSA. Recommendations include- infection control i.e. hand washing, vector control if relevant, rigorous cleaning of bed spaces and areas of clinical use. Antibiotic use review, consider antibiotic stewardship, employing appropriate staff for infection control e.g. cleaners, infection control nurse, regular infectious diseases consultant rounds. May need to prepare business case if any new staff or equipment will be needed. Also regular review of rates and distribution of these to all staff should be considered. |
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7. |
Discuss report with staff in your ICU for comments or any suggestions. |
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8. |
Submit report to general manager |
Discussion
You run a gross ICU. It is encrusted with scank, and you will need to clean it. However, a suggestion to nuke the site from orbit would probably be frowned upon by the humourless examiners.
The college answer is comprehensive in its attention to administrative detail. I will merely make an attempt to summarise it.
- Investigate the validity of the reported colonisation rate
- Investigate the demographics of the colonised patients
- Investigate the origin of the patients (which ward are they coming from?)
- Revisit the current infection control policy: is it time to rewrite it?
- Get expert opinions from infectious diseases and infection control specialists
- Form a multidisciplinary review panel (ICU specilists, ID physicians, NUMS and RNs)
- Review the current literature on infection control
- Rewrite infection control policy
- Educate the staff regarding the new policy
- Implement rigorous standards regarding hand washing and bed space cleaning
- Monitor the effects of the implemented policies
Previously successful coccus pogroms in Europe have reported on the efficacy of certain specific measures, which have included the following:
- Introduction of alcohol-based hand rub
- Single rooms for infected patients
- Explicit signs identifying MRSA-infected rooms
- Wearing gloves and gowns when entering patient rooms
A more detailed review of strategies to prevent the transmission of MROs can be found in the Required Reading section
References
Widmer, A. F. "Infection control and prevention strategies in the ICU." Intensive care medicine 20.4 (1994): S7-S11.
Eggimann, Philippe, and Didier Pittet. "Infection control in the ICU." Chest Journal 120.6 (2001): 2059-2093.
Lucet, Jean-Christophe, et al. "Successful long-term program for controlling methicillin-resistant Staphylococcus aureus in intensive care units." Intensive care medicine 31.8 (2005): 1051-1057.