1. MRSA SCREENING: THEORETICAL VS. PRACTICAL Nancy Alfieri, March 5, 2008

3. Why Screen? PROs: MRSA has increased (in CHR) from 2.2 to 9.4/10,000 patient days since 2003 CMRSA (new cases) is rising as quickly as health-care associated MRSA in the CHR U.S. data indicates an MRSA infection costs an additional $35,000 (while other nosocomial infections add $14,000 to $15,000) Patients with unidentified MRSA act as reservoirs for transmission

4. CONs: Screening programs are expensive… $100,000 allows 5,000 persons to be screened (average of 2.5 screens/person) 3 averted infections = $105,000 Isolation precautions challenge systems already stretched to capacity

5. CHR Universal Screening Pilot Project 3 months, 3 units (orthopedic surgery, palliative/medicine, medical teaching) Methods: All patients admitted to these units were screened Prevalence screens conducted prior to beginning screening and on termination of the pilot Anatomical sites screened were: –Nasal culture –Z body swab (axilla and torso) –Up to three wounds Suppression: CHG bath/shower

6. Results 89.2% of eligible patients were screened PREVALENCE SCREEN RESULTS FMC (%)PLC (%)RGH (%)Total Previously unknown MRSA positive patients detected during Prevalence Screen #11/37 (2.7)4/26 (15.3)0/335/96(5.2) Previously unknown MRSA positive patients detected during Prevalence Screen #21/33 (3.0)2/29 (6.7)0/273/89(3.3)

7. New Cases Admitted During Pilot FMC (%)PLC (%)RGH (%) Positive screening at admission to study unit8/445 (1.8)20/238(8.4)11/246 (4.5) Positive clinical isolate* at admission01/238(0.4)0 Positive clinical isolate >72 hrs in hospital01/238(0.4)0 Total8/445 (1.8)22/238 (9.2)11/246 (4.5)

8. Acquisition of Newly Detected MRSA Positive Cases FMCPLCRGHTotal (%) Nosocomial*312217 (41.5) LTC1045 (12.2) Community410418 (43.9) Unknown0011 (2.4) Total8221141 (100.0)

9. The Last Table is Important! Why? An equal number of cases are hospital- acquired and community-acquired This means up to 44% of the positive patients would have been “missed” using an admission screening protocol based on previous hospitalization or living in “institutional” settings

10. What Did We Learn… For the CHR, traditional admission screening would not capture a large proportion of the MRSA-colonized clients Medically complex patients with multiple co- morbidities and frequent health care encounters are to be considered “high risk” for MRSA Some surgical patient populations may be low risk

11. What did we learn…(cont’d) “Universal” screening is challenging to units facing significant staffing shortages Housekeeping workload increases as the burden of patients on isolation increases Suppression regimes may be an effective way to decrease transmission risk Streamlining screening processes is key to sustainability

12. Next Steps… In the CHR we are proposing expansion of the “universal” screening process and staging implementation Screening programs require regular analysis for efficiency and effectiveness Screening combined with interventions to reduce transmission requires further study

13. GO OUT ON A LIMB…

14. Recommendations 1.Go ‘out on a limb’, test your population appropriately 2.Engage the front-line care providers and measure workload, transmission/ acquisition rates in screening programs 3.Question, Question, Question…. if the screening protocols don’t impact nosocomial acquisition…then what? 4.Test interventions: Effective screening specimens Decolonization Suppression Isolation Environmental controls Hand hygiene