Good Intentions Does not Always Mean Good Policy

[Michael Wishart]

This is an interesting opinion piece. How many of our policies and practices are driven by science, and how many by political pressure?

Cheers
Michael

Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
ph: 07 3326 3068 Email: michael.wishart@svha.org.au

Controversies in Hospital Infection Prevention

Good Intentions Does not Always Mean Good Policy

Posted: 05 May 2018 03:09 PM PDT

How often do negative studies influence our behavior, or better yet our policies? For those of you that are familiar with the work I have published, you know that I published a lot of material focused on MRSA; emerging resistance, community-emergence, burden of disease, attributable cost, risk factors, and on. I was in a position at CDC to access and synthesize a lot of data, with a goal of putting the problem in perspective and ideally affect policy. Well intended as it was, I remember very clearly in mid-2007 when policy got way ahead of the science. Two independent (but related) events occurred on October 16-17, 2007 that led to several years of a watershed of policy developments. Although I give a huge amount of credit to the very passionate and important patient advocates and consumers that built momentum for the policies but with hindsight the policy inertia was really overcome when a senior student at

Staunton River High Schoo

l died on October 16 from MRSA sepsisMRSA he acquired in the community. The press linked that death to Dr. Elizabeth Bancrofts

editorial

that same week stating more people die of

MRSA

in the U.S. than of AIDS published on October 17. Many of us see much of the public reporting and mandatory reporting policies have opened up real pathways for additional hospital resources to invest in HAI prevention. However all of us should recognize some policies of that era are likely in place that really should be re-examined.

One of these is the Illinois

210 ILCS 83/ legislation

requiring all patients admitted to intensive care units be screened for MRSA by nasal active surveillance testing (AST). Lin and colleges just published a negative study with a lot of important findings. To many, the findings will not be a surprise

(CID May 15 2018, pp 1535-1539)

Lin worked with 51 intensive care units at 25 hospitals over 5 years starting within months of enactment of this mandate to evaluate any changes in ICU MRSA prevalence through periodic point prevalence surveys performed by trained study staff during the time of this mandate. The study was a quasi-experimental time series evaluation but without a real before observation group and no control group. However, I believe that any impact would have been additive over time the first year would have been a sort of wash in period for an intervention as broad in participation as this. They sampled 3909 patients having the power to even detect an absolute difference in carriage as small as a 1.9% change in prevalence (eg, 10% vs 8.1%)

but they detected none

. No change in prevalence of MRSA on these patients.

Compliance was high overall (93%), admission prevalence was comparable to other studies (9.7%), and overall, at any given survey of known positive patients and unknown, 11.1% were positive in any given month, in any given year of this study. Sure, time to placement of contact precautions lagged from test turnaround time or from time to test result to actual placement of precautions, but most notably the mandated testing was only 84% sensitive compared to best testing methods employed by the study investigators. This is the real world after all.

While these ICUs have invested time, effort, and money into these admission swabbing and targeted placement of contact precautions, the prevalence of MRSA carriage has not budged in these intensive care unit patients.

There may be many reasons the hospitals in Illinois overall are seeing an estimated

30% decrease

in their hospital-onset MRSA BSI (as most states are) since the 2010 NHSN baseline, but admission screening isnt one of them. Maybe its CLABSI prevention, or that uptake of the percentage of study patients receiving CHG baths. However, this study suggests it was not the mandated AST for all ICU patients admitted to the ICU. These patients are bringing their MRSA in with them, lets free up staff time to prevent the infections.

I know there are many major federal policies we all can be passionate about changing or starting, these are crazy days. But when the scientific evidence is so strong illustrating that a very well-intended policy regarding use of nursing and infection control resources does not have the intended impact change it. Nursing care can better be spent caring for patients, practicing best infection control for all patients in these intensive care units.

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[Donna Schmidt]

Hello this is just a general comment about the topic from a community health perspective

I consider myself lucky because I get to focus my attentions on the community setting in my district. I have found that it has provided a generally less experienced perspective on infection prevention and control.

In my experience, health departments continue to focus their monitoring on the hospital setting, even though many of those infections have been acquired in the community. Health information including journals, education, policies, procedures and conferences continue to predominantly focus on what happens in hospitals. Even the demographics of Infection Control Professionals indicate that the majority are based in hospitals. Sure, many may also be required to manage the community, but this is not their primary focus.

Community nursing services commonly rely on hospital and private-based medical governance, with no more direct access to specialist teams than a GP. So when a patients condition becomes too complex, they have to be referred back to the ED. There are community health speech pathologists, OTs and physios that the community nursing service cant refer to because the system doesnt work that way.

We change at least as many IDCs and SPCs as hospitals and yet the CAUTi project is not community focussed. I cant submit occupational exposure data because I am not from a hospital. I regularly push for community to be included in district policies. Sometimes it works and sometimes it doesnt.

Yes, hospitals are acute care facilities where patients are at a high risk of mortality and mobility. However, in the community we are seeing more and more patients with serious medical, surgical and oncological conditions, many of which have an indwelling device of some sort. We also see patients with MROs in clinics that vulnerable patients also attend. Yet, health departments dont include comparable data for HAIs acquired during community-based health care. Even education resources remain predominantly hospital based e.g. HETI and hand hygiene.

Im not saying managing HAIs in the community setting is easy. In fact WA tried this with MRSA and it was resource intensive. But there are some things that could be done, if we at least took time to investigate options. Any results would then filter into hospitals and make their job a little easier. Yet there is no general support to move in this direction.

So this leads me to agree that although governing bodies may have good intentions, theyre actions arent always be best for all concerned.

Kind Regards,
Donna Schmidt
Clinical Nurse Consultant Infection Control – Primary & Community Health
Rosemeadow Community Health Centre
5 Thomas Rose Drive, Rosemeadow, NSW, 2560
Tel (02) 4633 4113 | Fax (02) 4633 4111 | Mob 0438 925 816
donnamarie.schmidt@health.nsw.gov.au

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From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Michael Wishart
Sent: Monday, 7 May 2018 11:42 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Good Intentions Does not Always Mean Good Policy

This is an interesting opinion piece. How many of our policies and practices are driven by science, and how many by political pressure?
Cheers
Michael
Michael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
ph: 07 3326 3068 Email: michael.wishart@svha.org.au

Controversies in Hospital Infection Prevention

Good Intentions Does not Always Mean Good Policy

Posted: 05 May 2018 03:09 PM PDT

How often do negative studies influence our behavior, or better yet our policies? For those of you that are familiar with the work I have published, you know that I published a lot of material focused on MRSA; emerging resistance, community-emergence, burden of disease, attributable cost, risk factors, and on. I was in a position at CDC to access and synthesize a lot of data, with a goal of putting the problem in perspective and ideally affect policy. Well intended as it was, I remember very clearly in mid-2007 when policy got way ahead of the science. Two independent (but related) events occurred on October 16-17, 2007 that led to several years of a watershed of policy developments. Although I give a huge amount of credit to the very passionate and important patient advocates and consumers that built momentum for the policies but with hindsight the policy inertia was really overcome when a senior student at

Staunton River High Schoo

l died on October 16 from MRSA sepsisMRSA he acquired in the community. The press linked that death to Dr. Elizabeth Bancrofts

editorial

that same week stating more people die of

MRSA

in the U.S. than of AIDS published on October 17. Many of us see much of the public reporting and mandatory reporting policies have opened up real pathways for additional hospital resources to invest in HAI prevention. However all of us should recognize some policies of that era are likely in place that really should be re-examined.

One of these is the Illinois

210 ILCS 83/ legislation

requiring all patients admitted to intensive care units be screened for MRSA by nasal active surveillance testing (AST). Lin and colleges just published a negative study with a lot of important findings. To many, the findings will not be a surprise

(CID May 15 2018, pp 1535-1539)

Lin worked with 51 intensive care units at 25 hospitals over 5 years starting within months of enactment of this mandate to evaluate any changes in ICU MRSA prevalence through periodic point prevalence surveys performed by trained study staff during the time of this mandate. The study was a quasi-experimental time series evaluation but without a real before observation group and no control group. However, I believe that any impact would have been additive over time the first year would have been a sort of wash in period for an intervention as broad in participation as this. They sampled 3909 patients having the power to even detect an absolute difference in carriage as small as a 1.9% change in prevalence (eg, 10% vs 8.1%)

but they detected none

. No change in prevalence of MRSA on these patients.

Compliance was high overall (93%), admission prevalence was comparable to other studies (9.7%), and overall, at any given survey of known positive patients and unknown, 11.1% were positive in any given month, in any given year of this study. Sure, time to placement of contact precautions lagged from test turnaround time or from time to test result to actual placement of precautions, but most notably the mandated testing was only 84% sensitive compared to best testing methods employed by the study investigators. This is the real world after all.

While these ICUs have invested time, effort, and money into these admission swabbing and targeted placement of contact precautions, the prevalence of MRSA carriage has not budged in these intensive care unit patients.

There may be many reasons the hospitals in Illinois overall are seeing an estimated

30% decrease

in their hospital-onset MRSA BSI (as most states are) since the 2010 NHSN baseline, but admission screening isnt one of them. Maybe its CLABSI prevention, or that uptake of the percentage of study patients receiving CHG baths. However, this study suggests it was not the mandated AST for all ICU patients admitted to the ICU. These patients are bringing their MRSA in with them, lets free up staff time to prevent the infections.

I know there are many major federal policies we all can be passionate about changing or starting, these are crazy days. But when the scientific evidence is so strong illustrating that a very well-intended policy regarding use of nursing and infection control resources does not have the intended impact change it. Nursing care can better be spent caring for patients, practicing best infection control for all patients in these intensive care units.

______________________________________________________________________
This email and any attachments to it (the “Email”) is confidential and is for the use only of the intended recipient, and may not be duplicated or used by any other party without the express consent of the sender. If you are not the intended recipient of the Email, please notify the sender immediately by return email, delete the Email, and do not copy, print, retransmit, store or act in reliance on the Email. St Vincent’s Health Australia (“SVHA”) does not guarantee that the Email is free from errors, viruses or interference. Emails to and from SVHA or its related entities may be scanned and filtered in locations outside Australia.
MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.

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