impact of mrsa guidelines in québec 845
significantly. This finding strongly suggests that the MRSA guidelines had a direct impact on lowering HA-MRSA inci- dence. A survey of the implementation of preventive measures showed that in 2004, only 53% of Quebec hospitals had implemented MRSA screening upon hospital admission and during hospitalization, whereas in 2009, 94% of facilities had implemented these protocols.14 Undoubtedly, MRSA screening was and continues to be an important measure in infection prevention and control. Interval 3, spanning 2010 to 2015, marked a postguideline
period when many of the evidence-based MRSA prevention measures continued. During this time, concurrent significant incidence reductions in bothCLABSI andHA-MRSAoccurred at 1%per 4-week period. Some significant decreases during interval 3 may be explained by the HA-MRSA BSI definition change that occurred April 1, 2013, when follow-up postdischarge was reduced from 4 weeks to 1 week. Sensitivity analysis showed that including April 1, 2013, as a third break point resulted in a significant decrease for HA-MRSA but not for CLABSI (which did not undergo definition changes) as well as removal of significant incidence changes during interval 3 (Online Supple- mental Appendix; Table 3). In another sensitivity analysis only including data up to April 1, 2013, nonsignificant rate changes per 4-week period in interval 3 were also observed. The results of neither sensitivity analysis affected CLABSI IRRs. Interestingly, the resumption of significant decreases in
CLABSI rates during interval 3 may suggest an increased effort to target device-related HAIs such as CLABSI. For instance, new NHSN guidelines on CLABSI practices were published in 2010,29 and guidelines for catheter-associated urinary tract infections were published in 2009.30 These newer recommen- dations may have prompted CLABSI incidence trend decreases. A new web portal for surveillance data entry (April 1, 2013) and related training sessions may have improved the quality of data and may have decreased the number of skin contaminants reported as CLABSIs. For HA-MRSA, the continuing and steady significant incidence reductions from interval 2 likely stemmed from ongoing infection prevention and control efforts introduced during interval 2. As mentioned earlier, the MHSS published the “Action Plan on the Prevention and Control of Nosocomial Infections” for 2006–2009, which included specific steps towards prevention and control of HAI; the plan was later updated for the 2010–2015 period. Meanwhile, during this interval, both HAI and MRSA-specific prevention measures continued. Internationally, the World Health Organization Hand Hygiene Campaign was launched in 2009,31 and the Association of Professionals in Infection Control (APIC) guidelines on elimination of MRSA in hospital settings was published in 2010.32 These continued, and new initiatives may have contributed to a decrease in all HAIs, including HA-MRSA and CLABSI. However, the second break point of January 3, 2010, was not significant for HA-MRSA incidence decreases; the rate of decrease was the same in intervals 2 and 3. This finding may suggest (1) that the effec- tiveness of the MRSA guidelines diminished over time and was
replaced by an effect of new horizontal HAI interventions, (2) that guidelines continued to have an effect over time, as the rate of decrease remained constant between intervals 2 and 3, or (3) that a combination of both occurred. However, given that this study was ecological in nature, it is impossible to infer causality between interventions and decreases in rates. Assuming independence between HA-MRSA rates and CLABSI rates, the abrupt decrease in HA-MRSA rates and not in CLABSI rates after the first break point may allude to a temporal association with compliance to provincial MRSA guidelines. Another interesting finding was that the incidence decreases
in HA-MRSA and CLABSI were seen only in teaching facilities. These results suggest that a swifter response and imple- mentation of MRSA guideline recommendations may have occurred in teaching facilities. Nonteaching facilities did not demonstrate the same significant decreases. One reason may be that teaching facilities have greater lengths of stay and perform more invasive procedures than nonteaching hospitals,33,34 thereby having higher infection rates and thus a greater potential for improvement. While all facilities surveyed provide acute care, nonteaching facilities may have lower acuity and a lower-risk case mix than teaching facilities. Moreover, it is possible that teaching hospitals implemented IPC recommendations more aggressively than nonteaching hospitals. In the survey of practices for the prevention of MRSA in Quebec, teaching hospitals had reached their IPC-to-bed ratio, while nonteaching hospitals had not.14 Consequently, the incidence of any HAI may be lower in nonteaching facilities but may have improved less rapidly.
Limitations
Limitations of the study include its ecologic design and potential selection bias from the ongoing enrollment of facil- ities into the surveillance programs.While horizontal infection control interventions such as hand hygiene promotion might explain observed trends for both HA-MRSA and CLABSIs, the effect of MRSA-specific guidelines should be mostly observed in HA-MRSA, which was seen in this study. Only cases MRSA CLABSIs occurring in the ICU were common to both sur- veillances. This study’s ecological design also limited our ability to infer causality between guideline implementation and incidence rates. The quasi-experimental study design with a comparator group showed immediate significant incidence decrease after break point 1 and MRSA guideline publication and prolonged incidence decreases thereafter. This finding suggests that these recommendations were associated with the decreasing HA-MRSA incidence. Notably, MRSA surveillance became mandatory for all acute-care facilities in January 2007, and CLABSI surveillance became mandatory for ICUs with ≥10 beds in April of the same year. SPINmonitors both HA-MRSA and CLABSI, and having a centralized surveillance system may minimize systematic
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