McCleary MRSA Prevention

On November 17 and 18, I attended an event sponsored by the Consumers Union, Safe Patient Project, titled “To Err is Human, To Delay is Deadly”.  Other activists and advocates very similar to me, attended and participated in panels.  Victims and organizers also attended.  The CU has the momentum to make  difference for patients and their safety.

I was inspired by the work and the level of dedication of these activists.  Most of us work alone with no funding and our goal is simple, to protect vulnerable patients from harm when they are being treated in our nation’ or State’s hospitals or by our doctors. It is little to ask or expect.  We pay a huge premium for care and we deserve the best.

The work of the Maine Quality Forum MDRO metrics group regarding MRSA  has culminated in a plan for a “Point Prevalence Test” .  This is the approach they have chosen rather than just going ahead with a good solid MRSA screening program.  During this ”test” we will screen known high risk populations for MRSA only on admission  for 6 months.  Then each and every hospital will report their results.  If at those hospitals, any population tests less than 7% positive screenings, they will eliminate that high risk population from the populations to be screened from that point on.  This sounded reasonable until I figured out that only 5% MRSA positives of the over 4000  transfer patients to EMMC has each year would be 200 patients colonized that would be admitted with  undetected MRSA colonization. (Only 1% would be 40 patients).   200 or more patients would go into EMMC each year colonized with MRSA colonization facing a myriad of procedures, or surgery, or other risky events that could leave them infected and disabled or dead.  Colonized patients are 7 times as likely to suffer an active MRSA infection.   200 patients would not be isolated and so could spread MRSA to other patients who are roomed with them.  This is not acceptable.   The goal should not be to do a test and eliminate high risk populations for screening purposes. The screening program should have the goal of finding all colonized patients.  Any percent of patients testing positive should validate a high risk population for screening purposes. On top of that,one single MRSA active hospital acquired infection in any population should trigger the beginning testing in that new high risk population.

If however there are no positive MRSA screenings in any particular high risk population after a full year, it would be reasonable then to eliminate them from screening.  If  in that facility, any patient in that High Risk population or any other population has an active hospital acquired infection at any time beyond that, that population should be added back into the high risk screening program.

So, after all these months of debating and negotiating in the MQF, we now have a plan that has potential to self destruct within the next 6 to 9 months. We also have a plan that has no method of determining efficiency.  Screening on discharge is the only way we would know if a pateint has become colonized or infected while hospitalized.  Our law says that  “hospitals will do surveillance on high risk patients”.  It does not specify that the surveillance would be only on admission.  Most patients are at increased risk for colonization or infection because they going into the hospital or a particular hospital department.  We should re screen these patients one week into a hospital stay or on admission into the ICU, and on discharge.  THIS ADDITIONAL SCREENING IS THE GUAGE ON HOW EFFECTIVE INFECTION CONTROL FOR MRSA IS IN A FACILITY.  It is exactly what the VA hospitals all across the country are doing.

6 months isn’t  enough time to evaluate if the screening and the other preventative recommendations are stopping MRSA or even decreasing it.  It will take a year or two to know if a program is working.  Of course, most of my proposal for Active Detection and Isolation was tossed in HHS committee hearings.  In it’s place the ESO (Epidemiologically Significant Organism) draft was accepted.  It is a generic prevention program that may help, but it really does not clearly address specifics of MRSA prevention.  The specifics are in there, but  they are obscure and subject to interpretation.  ADI specifially outlines the steps necessary to stop MRSA.  All of ADI was included in my original proposal but it was considered “too cumbersome” for our hospitals.  That’s too bad, because it works when enacted.  It will take at least 2 years to see if this ESO draft and this limited MRSA testing will work.  I am not confident that it will.  One can hope it will……

This work is frustrating.  Advocates and Activists don’t have access to accurate numbers of MRSA and infections or deaths because of it.   Most of us have a family member that has either died or become disabled because of it, or have had MRSA ourselves. Because of our loss and troubles we have come in contact with many MRSA victims or their survivors, but we never have the actual numbers of patients effected by this horrible scourge.   Keeping the number of infections a secret by not reporting them (and making the numbers public )allows hospitals the advantage of knowing the “data” and the rest of us are kept in the dark. This puts anyone like me, who is  trying to improve patient safety with work toward prevention, at a disadvantage.   This secret keeping about data doesn’t have anything to do with prevention or saving lives…it has to do with power and control and elitism.  It also has to do with lack of transparency and disclosure. And it has to do with outright fear.  Hospitals are more afraid of liability than they are of almost anything else.   I did not know the rate of patients who test positive in current MRSA screening programs in Maine hospitals when I agreed to the 7% rule.  Since the day of that meeting, I have written to both of the biggest medical centers in Maine.  One responded but did not answer my question and the other did not respond.  So much for transparency or collaboration.

I have all kinds of time.  I am retired.  I don’t require a paycheck.  I have a home office…my laptop, my printer, my phone  and my lazyboy.  So, I am prepared to keep working at MRSA prevention until I believe Maine hospitals have it right. I do not believe they have it right yet.  When rates drop and our hospitals are safe and infection free, we will all know we have it right.

I my previous post, I mentioned that humans carry MRSA two ways, colonization and actual infection with the accompanying symptoms, according to what part of the body it affects.

So, why is it important to screen hospital  incoming patients for MRSA?

When we are admitted to the hospital, we have no control over who we are roomed with, how well the housekeepers clean, if the staff washes their hands, or many other safety factors.  We can stay alert or ask a friend to and keep on top of those things, but if somebody is roomed with us who has MRSA in their nose or somewhere else on their body, we can’t control that.  We are forced into living with and sharing facilities with a stranger, not knowing what they are in the hospital for unless we ask them ourselves.  I know of two people who found out their roommates had MRSA and it was only a short time later that they had it too.  This is just plain unacceptable.

I live with the suspicion that my father was roomed with a patient with MRSA.  3 of his roommates had respiratory infections, all of them with chronic lung problems and at least one of them came from a nursing home. They all predeceased Dad.   ALL of them were at high risk for MRSA, but NO SCREENING was done at his hospital and so they do not detect MRSA except when they do what is called “CLINICAL” cultures.  Patients are often 4 or  6 or 10 days into their infections before the difinitive diagnosis of MRSA is made and that diagnosis is made with a CLINICAL culture.   Then it may be several days (or never) before anybody discloses to the patient that they have it.  During that time, no special precautions are taken and the germ is spread with wild abandon.  It gets onto the doctors clothing and hands, onto the nurses scrubs, ….it gets carried to the nurses station and onto the computers, off it goes to the Physical Therapy room and into Xray, to the MRI machine and onto the lab techs box she carries, and around and around it goes.  No wonder there is inadequate control over MRSA in Maine hospitals.

Screening on admission, of high risk patients, will alert the hospital, the caregivers and the patient that they are carrying MRSA.  This may be just colonization, but that is significant in and of itself.  It means they have no signs of infection, but the germ is growing in thier nose, or a body crease, or open sore or on their skin.   And they can spread it around.

Large numbers of colonized patients are admitted to hospitals every day that are not detected.  This is both a risk to those patients and to the other patients they are  roomed with. We can’t continue to keep our heads in the sad about colonized patients.  Both CDC and SHEA, the so called experts of disease control, state that colonized patients as well as infected patients need to be isolated and contact precautions used.  That means a separate room and handwashing, gloves, gowns and masks (as needed)  on or between every patient contact.  Yet, it is impossible to abide by that recommendation.  Why?  Because without screening, we will not know if they are colonized. 

Patients who are colonized with MRSA are at a significant increased risk of getting a full fledged infection.  They are also reservoirs of MRSA for spread to other patients, Healthcare workers and the environment.  Without knowing who is colonized and enacting the proper contact precautions, MRSA gets spread all over the place and there is no way to control it.

We screen, we isolate and we protect…both the colonized patient and the other patients.  No MRSA prevention program will work without high risk screening /Active Detection and Isolation.