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.

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College Answer

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

2.

Review  current  infection  control  policy-  when  it  was  written,  people  involved  in writing it, MRO rate at the time of writing policy.

3.

Get expert help- infectious disease specialists, infection control specialist either from your hospital or from elsewhere.

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.

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.

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.

7.

Discuss report with staff in your ICU for comments or any suggestions.

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

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.