impact of mrsa guidelines in québec 841
table 1. Description of Poisson Segmented Regression Models Variables, Time Intervals, and Break Points With Corresponding Guidelines Publication Datesa
Time Intervals Temporal Association Interval 1
Interval 2 Interval 3
Variable ßo ß1 ß2 ß3 ß4 ß5
Major Guideline/Policy
January 1, 2006, to March 31, 2007 Periods 1 to 16
April 1, 2007, to January 2, 2010 Periods 17 to 52
January 3, 2010, to March 31, 2015 Periods 53 to 120
Baseline rate at outset of interval 1 Rate change per period during interval 1 Projected rate per period increase for interval 2 Projected rate per period increase for interval 3 Change in baseline incidence from interval 1 to 2 Change in baseline incidence from interval 2 to 3
NOTE. MRSA, methicillin-resistant Staphylococcus aureus; MHSS, Québec Ministry of Health and Social Services. aThe full equation is denoted by the following (the successive 4-week periods are in subscripts): Y(t)=ßo +ß1(t1-16)+ß2(t17-52)+ß3(t53-120)+ß4(tint1)+ß5(tint2)
and their implementation was evaluated in 2009.14Weaimed to quantify the change in incidence rate for HA-MRSA following the implementation of MRSA prevention guidelines and policy directives by comparing changes in HA-MRSA incidence with incidence variations for anotherHAI, intensive care unit (ICU)– associated CLABSI. Although CLABSI incidence decreased during the study period,8,15 we expect that the timing ofCLABSI decrease should be, for the most part, independent from that of HA-MRSA because ICU CLABSIs are not organism specific, and only a few cases (eg, MRSA CLABSI in the ICU) are com- mon to both surveillances. In this study, we looked at incidence rate fluctuations for the following periods: (1) prior to the release of INSPQ MRSA guidelines (January 1, 2006, to March 31, 2007), (2) immediately after MRSA guideline release (April 1, 2007, to January 2, 2010), and (3) during the postguideline period (January 3, 2010, to March 31, 2015, a timeframe within the updated second MHSS Action Plan for 2010–2015) (Table 1). By examining fluctuation trends for HA-MRSA and CLABSI incidence during these time intervals, we investigated whether combined guideline directives and policy had an impact on reducing the incidence of HA-MRSA in Québec.
methods SPIN Surveillance Network
SPIN is a year-round, prospective, province-wide surveillance program that monitors both HA-MRSA (SPIN-SARM)16 and CLABSI (SPIN-BACC).17 HA-MRSA reporting has been mandatory for all healthcare facilities with more than 1,000 admissions since January 7, 2007. CLABSI reporting has been mandatory for all intensive care units (ICUs)with ≥10 beds in the province of Québec since 2007.15 Retrospective analysis of the SPIN-BACC reporting validity showed excellent results
compared with other regional surveillance networks with a sen- sitivity of 88% and specificity of 92%.18 Overall, 37 of 56 adult facilities (66%), including 21 nonteaching and 16 adult teaching ICUs, participated in the ICU CLABSI surveillance program for the entire study period. Furthermore, 79 of 86 acute-care hospi- tals (92%), including 57 nonteaching and 22 teaching facilities, participated in theHA-MRSA surveillance during all study years.
Definitions and Data Collection
The SPIN definition for CLABSI requires that a bloodstream infection occur in a patient with a central venous catheter (CVC) in place and inserted prior to infection onset in the ICU or within 2 days after ICU discharge. Since April 1, 2010, SPIN has used the most recent National Healthcare Safety Network (NHSN) CLABSI definition.19 Cases from 2007 to 2010 were retrospectively reclassified to reflect the new definition. SPIN surveillance measures and definitions have been described previously and are publicly available.15,20,21 Starting in April 2013, MRSA bloodstream infections were
classified as HA if the infection occurred ≥2 days after admission or within 2 days following discharge (within 7 days for procedure-related bloodstream infections and within longer delays for surgical site infections).21 Prior to that date, a period of 4 weeks following discharge was used to classify MRSA BSI as HA. Data were extracted in June (CLABSI) and July 2015 (HA-MRSA). The present study is a retrospective longitudinal cohort analysis that was approved by the INSPQ and did not require institutional board review because it was a secondary analysis of previously collected data.
Statistical Analyses Incidence rates. Pooled HA-MRSA and CLABSI incidence
rates for adult facilities were computed by facility type
Pre-MRSA guidelines and MHSS Action Plan 2006–2009 in effect12
MRSA guidelines published and MHSS Action Plan 2006–2009 in effect12
MRSA guideline update published and MHSS Action Plan 2010–2015 in effect13,14
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