Beyond β: Lessons Learned from Implementation of the Department of Veterans Affairs Methicillin‐Resistant Staphylococcus aureus Prevention Initiative
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.Infection Control and Hospital Epidemiology (Impact Factor: 4.18). 07/2010; 31(7):763-5. DOI: 10.1086/653818
To describe the key strategies and potential pitfalls involved with implementing the Department of Veterans Affairs (VA) Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention Initiative in a qualitative evaluation, we conducted in-depth interviews with MRSA Prevention Coordinators at 17 VA beta sites at 2 time points during program implementation.
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ABSTRACT: The epidemiology of infections caused by methicillin-resistant Staphylococcus aureus (MRSA) is changing. Temporal trends and differences between healthcare settings must be described in order to better predict future risk factors associated with this dangerous bacterial infection. A national MRSA-infected cohort was identified from 2002 to 2009 in the Veterans Affairs Healthcare System of the United States: hospital (HOS), long-term care (LTC), and outpatient (OPT). We analyzed within-setting time trends using generalized linear mixed models and between-setting differences with χ(2) and Wilcoxon rank-sum tests. The incidence of S. aureus, methicillin-susceptible S. aureus (MSSA), and MRSA infections increased significantly over time in all three settings based on modeled annual percentage changes (P < 0.001). MRSA incidence rates rose by 14, 10, and 37% per year in the HOS, LTC, and OPT settings, respectively. Among 56,345 MRSA-infected patients, the comorbidity burden was highest among LTC inpatients (n = 4,427) and lowest among outpatients (n = 7,250), with an average absolute difference in specific comorbidities of +2 and -7%, respectively, compared to HOS inpatients (n = 44,668). Over time, there was a significant (P ≤ 0.02) decrease in previous inpatient admissions and surgeries (all settings); diabetes with complications and surgical site infections (HOS, OPT); and median length of stay and inpatient mortality (HOS, LTC). Alternatively, obesity, chronic renal disease, and depression were more common between 2002 and 2009 (P ≤ 0.02). Over the past 8 years, we observed significant changes in the epidemiology of MRSA infections, including decreases in traditional MRSA risk factors, improvements in clinical outcomes, and increases in other patient characteristics that may affect risk.
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ABSTRACT: To develop and validate a model to predict resistance to community-acquired pneumonia antibiotics (CAP-resistance) among patients with healthcare-associated pneumonia (HCAP), and to compare the model's predictive performance to a model including only guideline-defined criteria for HCAP. Retrospective cohort study. Six Veterans Affairs Medical Centers in the northwestern United States. Culture-positive inpatients with HCAP. Patients were identified based upon guideline-defined criteria for HCAP. Relevant cultures obtained within 48 hours of admission were assessed to determine bacteriology and antibiotic susceptibility. Medical records for the year preceding admission were assessed to develop predictive models of CAP-resistance with logistic regression. The predictive performance of cohort-developed and guideline-defined models was compared. CAP-resistant organisms were identified in 118 of 375 culture-positive patients. Of guideline-defined criteria, CAP-resistance was associated (odds ratio (OR) [95% confidence interval (CI)]) with: admission from nursing home (2.6 [1.6-4.4]); recent antibiotic exposure (1.7 [1.0-2.8]); and prior hospitalization (1.6 [1.0-2.6]). In the cohort-developed model, CAP-resistance was associated with: admission from nursing home or recent nursing home discharge (2.3 [1.4-3.8]); positive methicillin-resistant Staphylococcus aureus (MRSA) history within 90 days of admission (6.4 [2.6-17.8]) or 91-365 days (2.3 [0.9-5.9]); cephalosporin exposure (1.8 [1.1-2.9]); recent infusion therapy (1.9 [1.0-3.5]); diabetes (1.7 [1.0-2.8]); and intensive care unit (ICU) admission (1.6 [1.0-2.6]). Area under the receiver operating characteristic curve (aROC [95% CI]) for the cohort-developed model (0.71 [0.65-0.77]) was significantly higher than for the guideline-defined model (0.63 [0.57-0.69]) (P = 0.01). Select guideline-defined criteria predicted CAP-resistance. A cohort-developed model based primarily on prior MRSA history, nursing home residence, and specific antibiotic exposures provided improved prediction of CAP-resistant organisms in HCAP.
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ABSTRACT: CONTEXT:: Public health has an important and critical role in responding to emerging multidrug-resistant organisms, such as carbapenem-resistant Enterobacteriaceae. The Centers for Disease Control and Prevention developed a survey as a tool for state health departments to determine carbapenem-resistant Enterobacteriaceae prevalence within their region. OBJECTIVE:: This report summarizes an assessment of the health department experience with the survey, their perceived roles and responsibilities in responding to an emerging health care-associated pathogen, and potential barriers to public health engagement of acute care facilities in response activities. DESIGN:: Key informant interviews consisting of open-ended and 5-point Likert scale questions were conducted. PARTICIPANTS:: Interviewees represented state health departments that administered the survey and select states that did not. RESULTS:: Of 11 states interviewed, 7 (64%) had administered the survey to acute care facilities. Despite similar competing priorities and concerns about administering the survey, different perspectives emerged among the 11 states; those that administered the survey regarded it as a learning opportunity, whereas other states emphasized concerns about survey logistics and other public health demands. All 11 states perceived the prevention of an emerging pathogen to be a public health priority, but the degree of their action depended on availability of resources and existing relationships with infection preventionists. Health departments had less interaction with other hospital personnel (eg, facility leadership) and limited knowledge of the roles and associated responsibilities of other health care partners (eg, Quality Improvement Organizations). CONCLUSIONS:: Although considered a public health priority, response efforts to emerging pathogens were reported to vary among state health departments. A better understanding is needed of the factors that motivate and facilitate state health departments to engage in a public health activity despite the challenges of competing priorities and limited resources. Efforts should also focus on improving the relationship between health departments and hospital leadership and other health care partners.