Questions & Answers:
Recommendations for Prevention and Control of Methicillin-resistant Staphylococcus aureus in Acute Care Facilities
The following are the questions that have been asked about the Recommendations for Prevention and Control of Methicillin-resistant Staphylococcus aureus in Acute Care Facilities. Updated 2/15/2008.
Q: How was the procedure for collection of nasal swabs developed--what references were used?
An excellent reference for this procedure is the APIC Guideline to the Elimination of MRSA Transmission in Hospitals (www.apic.org).
Q: Can you suggest a threshold for MRSA transmission rate where Tier 2 recommendations would kick in? Baseline rates in a hospital may be low, but not "decreased" by tier 1 recs.
There is no specific threshold. The Recommendations state that Tier Two Recommendations are indicated when hospital-acquired MRSA infection rates are not decreasing, despite implementation of and adherence to the baseline infection prevention and control measures and Tier One Recommendations. (see Executive Summary)
Q: Over what time frame must the 3 consecutive negative cultures be taken?
Three negative nares tests for MRSA, regardless of the MRSA detection method used (culture or molecular testing), are recommended to discontinue Contact Precautions. These three consecutive tests should be performed 7 days apart, and should be obtained no less than 1 week after completion of decolonization or clinical treatment.
(See: Tier One, Discontinuing Contact Precautions / removing patient flags for MRSA – 8.B.ii and 8.B.iii)
Q: Are the guidelines for culture the same for molecular testing in reference to the 3 consecutive negative swabs?
Three negative nares tests for MRSA, regardless whether the MRSA detection method used is culture or molecular testing, are recommended (7 days apart) to discontinue Contact Precautions.
Q: Question on Tier 1 Recommendations, Management of healthcare workers with MRSA. Are you screening HCW?
No, routine screening of healthcare workers is not recommended. (Tier One, 10.b)
Q: For facilities not experiencing MRSA HAI's, do annual risk assessments need to include ASC's or can MRSA surveillance data, including risk factors suffice for decision-making re: MRSA prevention/control activities?
Basing a risk assessment on monitoring results of clinical cultures alone does not meet the requirement of an annual risk assessment. If colonized patients go undetected – or if infection control practices are sub-optimal, colonized patients can serve as a reservoir from which MRSA transmission can occur.
Q: There is a physician who always uses his personal stethoscope on patients in contact precaution and then cleans it with an alcohol swab, is this sufficient?
Patient-dedicated or single-use disposable non-critical equipment is recommended for use with MRSA-positive patients on Contact Precautions. (See Tier One, 1.f.iii)
Q: With respect to the initial risk assessment with active surveillance cultures, must we do this. Last year we identified a high risk setting and plan on implementing active surveillance cultures on patients from this healthcare setting and monitor rates.
The Recommendations state that an annual risk assessment must be conducted and MRSA rates monitored because identified high-risk groups or patient care units may change over time.
Q; Is patient consent needed for collection of cultures?
This is a facility decision. MDH posed this question to the Minnesota Hospital Association Patient Safety Committee. Their response was: “Our legal counsel confirmed that informed consent is not required for MRSA screening. As it would be treated the same as a lab test, which is typically covered under the general admit consent.”
Q: What is an antibiogram?
An antibiogram is a compilation of antimicrobial susceptibilities of selected pathogens and can provide facility-specific antibiotic resistance trends for identified pathogens. The Minnesota Department of Health develops an annual antibiogram for several pathogens based on data reported to our lab. The MDH 2006 antibiogram is available at: http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/antibio2006.pdf
Q: When considering MRSA rates increasing before implementing Tier 2 precautions are we only to consider the hospital acquired or do we have to factor in the community acquired MRSA as well?
The Recommendations require acute care facilities to monitor MRSA rates within their facility – regardless of where the MRSA (infection or colonization) was acquired.
Q: Do you foresee funding opportunities becoming available to assist in implementing the programs?
In the last session, the legislature required MDH to publish the MDH MRSA Recommendations, however there was no funding associated with this.
Q: Will the MDH be funding these surveillance programs?
No.
Q: When you say "no funding" is provided, does that also mean we can't charge the patient for the cultures?
MDH is not providing any funding. MDH posed this question to the Minnesota Hospital Association (MHA) Patient Safety Committee and their response was: “Some facilities are charging for the screening, similar to other screens. Though in a DRG payment system, it does not change the payment received. There was discussion at the MHA infection control expert group that Medicare may be looking into some reimbursement mechanism”.
Q: How will the statute be enforced, will there be minimum standards for such programs?
MN Statute 144.585 does not include any enforcement language.
Q: Is there any recommendations for environmental cultures done within the facility for surveillance of MRSA?
See Environmental Measures 5.g. “Consider obtaining environmental cultures when there is epidemiologic evidence that an environmental source is associated with ongoing MRSA transmission. Consult facility microbiology laboratory supervisors and MDH for assistance in developing and environmental screening protocol as needed. (See: HICPAC, 2006 and Weese, J, Environmental surveillance for MRSA. In: Ji Y, ed. Methods for Molecular Biology: MRSA Protocols. Totowa: Humana Press, 2007).
Q: On the initial risk assessment, what is the recommended process? Should one do ASC on all patients (outpatients as well as inpatients) admitted for a select time, say one week, to determine the high risk areas.
An excellent reference for methods to conduct the risk assessment is the APIC Guideline to the Elimination of MRSA Transmission in Hospitals (www.apic.org). There is no recommended time frame in which to conduct the risk assessment but it is important to attempt to obtain a representative sample of your facility’s population.
The MDH MRSA Recommendations pertain to acute care facilities; for specialty care areas within acute care facilities, please see General Infection Prevention and Control Recommendations, A.8.
Q: When cleaning rooms after patients with MRSA have stayed in them, do we need separate cleaning equipment such as mops and the cleaning solution for the mops?
No separate equipment is required for cleaning in rooms of MRSA patients. See the APIC Text, 2005, Chapter 102 – Environmental Services, for more information or consult with your Environmental Services Director.
Q: Any suggestions on how or tools to start on the antimicrobial stewardship portion of the guidelines?
Recommended references for developing an antimicrobial stewardship program include:
- The Centers for Disease Control and Prevention’s Campaign to Prevent Antimicrobial Resistance in Healthcare Settings: www.cdc.gov/drugresistance/
- Delit T, Owens R, McGowan JE, Jr., etal. Infectious Diseases Society of America Guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159-177.
- Fishman N. Antimicrobial stewardship. Amer J of Med 2006;119(6A):S53-S61.
Q: Currently we conduct a "MRSA Risk Assessment" on all admissions (acute care facility); please clarify the facility MRSA Risk Assessment I should conduct - Point Prevalence?
If you are performing facility-wide active surveillance cultures, the MRSA Recommendations state that facilities collecting ASCs on all patients should monitor MRSA infection and colonization rates (see Tier One, 4.a.i). An excellent reference for methods to conduct the risk assessment is the APIC Guideline to the Elimination of MRSA Transmission in Hospitals (www.apic.org).
Q: What I think I heard is that facilities must do ASC, is this correct?
MN Statute 144.585 requires that hospitals in Minnesota perform a risk assessment using ASCs at least annually, unless they are conducting ASCs on all patients (see Tier One, 4.a).