794 infection control & hospital epidemiology july 2018, vol. 39, no. 7
routine CP for MRSA and VRE can be performed without increasing healthcare-associated infections with these organ- isms, but whether removing CP reduces overall patient harms remains unclear.3,6–8 This study demonstrated that removing routine CP forMRSA and VRE was associatedwith a decline in noninfectious adverse events, including falls and trauma, postoperative hemorrhage and/or hematoma, wound dehis- cence, pressure ulcers, and PE/DVTs. None of the secondary end points were statistically significant, which is likely due to the low overall rates of the individual events. These data sup- port prior research indicating that the use of CP can be a barrier to access to healthcare providers and that this can impact adverse event rates. Importantly, the populations with the largest decline in
noninfectious adverse events were the patients with MRSA and VRE, who they were no longer isolated during the post- intervention period. While this population was isolated, the average rate of noninfectious adverse events was 21.4 per 1,000 MRSA/VRE admissions, and after the policy change, the adverse event rate decreased to 6.08 per 1,000 MRSA/VRE admissions. While an argument could be made that the decline in adverse events was multifactorial and may have been due to other quality-improvement interventions, the large decline in noninfectious adverse events was observed only in the MRSA/ VRE population and not in the “no isolation” group. In addi- tion, Figure 2b shows that the decline began shortly after the policy change and that the lower rate remained months after the intervention. Also, no change in the rate was observed in the other isolation statuses, who remained in isolation in the postintervention period, but events in these populations were rare, making this aspect difficult to fully assess. In our prior study, we showed that MRSA and VRE clinical
cultures, as a marker of healthcare-associated infections, did not increase after CP discontinuation and CHG bathing was expan- ded to all units.6 This study further demonstrates that other reportable infectious adverse events did not increase after CP were discontinued, including infectionswith other organisms and device-associated infections. Prior to the collection of these data, there was a theoretical concern that having fewer patients on CP could lead to increases in hospital-acquired infections, but our study results did not show an increase after the policy change. This finding may be due to the other horizontal infection prevention strategies, including near-universal CHG bathing and our high hand hygiene rate (>90%). This study also showed a significant decline in the SSI rate after the policy was changed. Thereasonfor theimprovement is unclear, anditmay be related to improved access to healthcare providers, decreased microbial burden from expandedCHGbathing, or both. Further research is needed in this area. While these initial data are encouraging, our study has some
limitations. First, this study was performed at a single acute- care hospital with single-patient rooms and a high hand hygiene compliance rate (>90%).6 Whether these data on infectious adverse events are generalizable to other hospitals with shared patient rooms or a lower hand hygiene rate is
unclear. Further research in other hospitals is necessary to determine the additional factors necessary for this new policy to be successful. Our institution also has a robust quality-control department
that is focused on reducing adverse events. Although no spe- cific hospital-wide interventions occurred during this study, it is unclear whether the results are generalizable to other insti- tutions that do not have established programs focused on reducing falls, DVTs, postsurgical adverse events, etc. To see a significant decline in noninfectious adverse events among MRSA/VRE patients, a combination of quality-improvement strategies and removal of CP may be necessary to improve outcomes. Further research in this area should be conducted. This study was quasi-experimental; therefore, it was not
possible to demonstrate causality. Although the data suggest that removing CP and expanding CHG bathing contributed to a decline in noninfectious adverse events, further research is necessary with a more robust study design, such as a pro- spective, randomized control trial or a cross-over study. To determine the composite end points, our teamreviewed the
list of all reportable events and selected the eventswith a plausible link to healthcare worker contact time. Although our team con- sidered this list thoughtfully, it is unclear how many of these events were truly due to lack of healthcare contact, given that the amount of time each spentwith their providerswas not evaluated in this study. These events, in general, are all likely multifactorial, and contact with providers is likely just 1 factor. The data used were also collected for public reporting and
not specifically for research or patient care. While these find- ings may be generalizable to other hospitals that report based on the same definitions, the data were collected based on reporting criteria and may not have captured all actual events. However, this limitation likely impacted both the pre- intervention and postintervention periods equally because the definitions were relatively constant, except for CAUTI, which was not statistically significant. To determinewhich patients would have qualified forMRSA/
VRE in the postintervention period, we used specific criteria that would have triggered an isolation alert in the preinterven- tion period. This approach has some limitations. First, it is possible that a patient had history of MRSA/VRE from another hospital that would have been missed in the postintervention period, but this group likely represents only a small portion of the MRSA/VRE population. It is also possible that some VRE patients may have beenmissed, given that routine screeningwas no longer performed in the postintervention period (1.3% of patients were VRE screen positive in the preintervention per- iod). However, given the California mandate, MRSA screening was continued in the postintervention period, so our data are likely reasonably accurate. Although incorrect isolation status is a concern, only a small portion of cases would have been affected. Even if patients were missed, the overall rate of non- infectious adverse events did decline. This study showed that 1 year after discontinuing routine CP for endemic MRSA and VRE and expanding CHG bathing,
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