Geditz, Alexandra F. MD*; Potter, Jane F. MD†; Vandenberg, Edward V. MD†; Smith, Lynette M. MS‡; Smith, Philip W. MD§
The emergence and spread of multidrug-resistant organisms (MDROs) is one of the major issues faced by the health care community. Many factors are implicated in this problem, including overuse of antimicrobial agents and improper isolation techniques in hospitals and long-term-care facilities (LTCFs). Much of the concern with resistant organisms is focused on methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). These organisms have become endemic in many hospitals and LTCFs, and may be transferred between institutions by patients who are infected or colonized with the resistant bacteria. Although it is generally agreed that MRSA and VRE require additional isolation precautions,1 the proper level of precautions is debated and the current status of isolation practices in the LTCF is not well known. To address this problem, we undertook a survey of Nebraska LTCFs.
MATERIALS AND METHODS
All nursing homes in Nebraska were identified using the health department guide to facilities in Nebraska. A telephone call was placed to each of these facilities to verify that they had skilled nursing facility capabilities. Excluded from the study were facilities that offered exclusively independent living facilities without a skilled nursing unit. Facilities that had both independent living and skilled nursing beds were included. Through this process, we identified 231 nursing homes in the state of Nebraska. For each of these facilities, a questionnaire was sent to the director of nursing in 2001. Facilities varied from metropolitan settings with rapid access to tertiary care hospitals to small towns and rural locations. The facilities were asked to return the completed questionnaire within a 3-week period. At the end of this time, a reminder letter accompanied by a new copy of the questionnaire was sent to those facilities that did not respond. Facilities that did not respond to the second mailing were contacted by telephone and encouraged to participate in the study.
The questionnaire asked for the following information: (1) facility demographics, including number of beds and number of occupied beds; (2) number of isolation rooms; (3) number of private rooms and number of occupants in each nonprivate room; (4) whether there was a designated infection control practitioner (ICP); (5) number on the infection control (IC) team; (6) whether the ICP serves in other capacities; (7) whether new staff were screened for tuberculosis (TB), MRSA, or VRE; (8) whether new staff were formally instructed in isolation procedures and universal precautions; (9) resident bathing, handwashing, and toileting facilities; (10) type of room isolation of residents for MRSA and VRE; (11) duration of isolation of residents for MRSA and VRE; (12) facility policy for screening residents for MRSA and VRE, including whether they were screened before or at admission; (13) whether records of colonized/infected residents were kept; (14) MRSA and VRE case burden, including total cases, cases known at admission, and cases diagnosed more than 2 months after admission; (15) isolation policies, including cohorting. Questionnaires that failed to answer key questions or were returned blank were excluded from the analysis. The information provided was entered into a computerized database and subjected to statistical analysis.
Questionnaires were returned by 120 of 230 surveyed facilities (52%). Of these, 1 was returned blank, and 3 were eliminated from the study because multiple questions were left blank. Thus, 116 questionnaires (50%) were considered complete and subject to analysis.
The median number of licensed beds was 65 (range 21-410) with a median of 59 beds in use (range 12-375). Facilities were asked for the number of private rooms; the median number was 7 per facility (range 0-180). There were 2 occupants in 84% of nonprivate rooms. Of the remaining nonprivate rooms, 14% had 3 or 4 occupants and 2% had 5 or more occupants. They were then asked for the number of designated "isolation rooms" beyond the above-noted private rooms; 103 (90%) of facilities had no designated isolation rooms, 11 (9%) had 1, and 1 (1%) had 5. One response omitted answering this question.
In 103 (89%) of the facilities, all of the rooms had sinks. In 10 (9%), between 50% and 99% had sinks. In 2 (2%) of the facilities, 25% or fewer rooms had sinks. The availability of bathrooms and toilets is shown in Table 1. Each room had its own toilet in 71% of facilities reporting. For another 19% of facilities, bathrooms and toilet facilities were shared between 2 rooms.
Fifteen facilities did not answer questions about ICPs. Of the remainder, 99% had a designated ICP, and 43 (43%) had one person handling IC duties. The other 58 (57%) had an IC team of more than 1 person. In 113 facilities (97%), IC team members also served in other capacities.
Ninety-eight percent of facilities screened new patient care staff for TB, but only 5% were screened for MRSA and 5% for VRE.
Nearly all of the facilities provided formal instruction to new staff members about isolation procedures (97% for RN/LPNs, 97% for CNAs, and 96% for housekeeping), but a somewhat smaller percentage tested on basic isolation procedures at orientation (64% for RN/LPNs, 64% for CNAs, and 59% for housekeeping).
Approach to Infectious Diseases
Table 2 lists the screening rates for TB, MRSA, and VRE. Screening for TB was most commonly done at admission, but screening for MRSA and VRE was most commonly done before admission. A large majority of facilities maintained records of residents with these conditions.
Table 3 shows the prevalence of MRSA cases and the temporal relationship of diagnosis to nursing home admission. Forty-four (38%) of facilities reported no MRSA cases at all in the 24 months prior to the survey, and 58 (50%) had no newly diagnosed cases during that period. Fifty-three (46%) had 1 to 5 newly diagnosed cases in the preceding 24 months. Seventy-three (68%) had no newly diagnosed cases more than 2 months after admission, whereas 33 (30%) had 1 to 5 new MRSA diagnoses in that period.
Ninety (80%) facilities reported no cases of VRE in the last 24 months, and 94 (84%) had no newly diagnosed cases of VRE in that period. Only 2 (2%) reported more than 6 total cases and 6 new cases of VRE in the preceding 24 months.
Isolation policies for MRSA and VRE are outlined in Tables 4 and 5. At least 70% of the facilities responding to this question had some form of isolation or cohorting for colonization with these organisms, and at least 80% isolated residents with active infection in some way. About 50% continued isolation for actively infected residents until the facilities received 3 consecutive negative cultures of the infected site.
Antibiotic-resistant bacteria, especially MRSA and VRE, are an increasing problem in US hospitals and nursing homes.2 Isolation is complicated by the fact that both MRSA and VRE can cause a carrier state that poses an IC hazard, and requires prolonged isolation precautions. Current isolation guidelines recommend contact isolation for MRSA and VRE in hospitals,1 and a form of modified contact isolation for LTCFs. The modifications are due to the more limited resources of LTCFs, and the desire to respect the comfort of residents, who often stay in LTCFs for years.
A 1996 Society for Healthcare Epidemiology of America (SHEA) position paper reviewed several studies of MRSA outbreaks in LTCFs, including measures such as surveillance cultures, barrier precautions, and decolonization attempts.3 More aggressive measures, such as surveillance for MDROs, may be employed in the face of an outbreak, but are not routinely necessary in the LTCF. The guideline discouraged decolonization, but recommended that the LTCF should obtain information on colonization or infection of the prospective resident with MDROs prior to admission. This was done by nearly half of the facilities in our survey. Antimicrobial review is also recommended as measure to decrease resistance4; this was not included in our survey, but an earlier study revealed that about 50% of a sample of 25 Nebraska LTCFs had antimicrobial review programs.5
A 1998 SHEA position paper on VRE in the LTCF recommended a private room for isolation, if available, or cohorting, or placement of a VRE patient with a low-risk resident.6 Single rooms for isolation are not as available in the LTCF, and extrapolations of hospital recommendations to that setting are problematic. In an effort to better understand the resources and current practices on isolation in the LTCF setting, we undertook a survey of all Nebraska LTCFs. All 230 LTCFs in the state of Nebraska were surveyed, and over 50% responded. The median number of beds in responding facilities was 65, with a range from 21 to 410, and the median number of occupied beds was 59.
In an effort to assess isolation capacity, we inquired about private rooms. Although most facilities had private rooms (median 7 per facility), most (90%) had no other designated isolation rooms, and only one LTCF had more than one isolation room available. The most frequently reported number of occupants in nonprivate rooms was 2 (93%). Because most facilities had to place MRSA and VRE patients in shared rooms, we asked about the shared facilities. There was a spectrum of arrangements (see Table 1), with the most common being a toilet in each room but shared bathing facilities. Only about one-fourth had a bathroom and toilet in each room. The median number of users per shared bathroom was 3, and the median number of users per shared toilet was 2. This underscores the potential for spread of resistant organisms, especially VRE, which is carried in the stool and rectal area. Sinks are a key element in IC,3 and nearly 90% of the facilities reported that all of their rooms had sinks.
A variety of arrangements for MRSA and VRE isolation were seen (see Table 4), which reflects the various recommendations in the literature.1,7 In acute care hospitals, contact precautions is recommended for patients with MDROs, which means that health care personnel wear gowns and gloves for all interactions that may involve contact with the patient or the patient's environment. Overall, most of the facilities made some accommodation for the MRSA and VRE cases (single room, contact isolation, cohorting), with less than 10% of LTCFs placing these patients with general roommates. Interestingly, less stringent isolation was employed for residents colonized with one of these organisms than for those with active infection. For instance, a private room with contact isolation was used by 10% and 15 % of LTCFs for isolation of colonized residents with MRSA and VRE, respectively, but by 39% and 52% of facilities for residents with active MRSA and VRE infection. Colonized and infected residents have not been shown to pose different IC risk.
The literature is unclear on when to discontinue isolation for resistant organisms. This was reflected in our survey (see Table 5), although the most common practice was to stop isolation after 3 negative cultures for both MRSA and VRE.
Transfer of patients with resistant organisms between hospitals and LTCFs is a mechanism for the spread of resistant bacteria, and a source of potential dispute.8,9 As a result, some facilities screen transfer patients. In our survey, 10% of LTCFs screened newly arrived residents for MRSA and VRE; 37% and 23% screened prospective residents for MRSA and VRE, respectively, even prior to transfer. Another 3% screened residents for these organisms after an intercurrent hospitalization. Four to 5% reported that they had screened residents for epidemiologic reasons (eg, during a suspected outbreak) beyond any cultures ordered by physicians. MRSA and VRE screening was done more often before admission than after admission, the opposite of the situation for TB screening. Screening allowed admitted residents to be isolated per institutional protocol. Over 75% of facilities kept records on known MRSA, VRE, and tuberculin-positive patients.
MRSA and VRE are increasingly reported, not just in large hospitals, but in small hospitals, LTCFs, and even the community.1 Sixty-one percent of our surveyed LTCFs reported MRSA in their facilities in the last 2 years. Half had newly diagnosed MRSA cases in the last 2 years, usually in small numbers (eg, 1-5), including both residents who had MRSA on admission, and those who turned up with MRSA 2 months or more after admission. VRE was less common, with 20% reporting some VRE in the last 2 years, usually in small numbers, a mixture of newly discovered cases on admission and cases that appeared more than 2 months after admission.
All but one facility had designated IC personnel, but 97% of the ICPs had other roles, which has been shown in other studies.10 Education is essential to an effective IC program. Over 95% of facilities formally educated new staff in isolation practices, and nearly two-thirds tested new staff on isolation procedures at orientation. Over 95% of staff received in-service training in universal precautions at least annually. As consistent with current OSHA regulations,11 98% of new staff were screened for TB; less than 5% of facilities screened staff for MRSA and VRE.
The limitations of this study include the fact that the survey is limited to Nebraska facilities, and may not be generalizable to facilities in other states or regions. The Nebraska Infection Control Network has been training ICPs at a semiannual course for almost 20 years, and as a result, the IC practices in the state may not reflect national practices. It was beyond the purview of the study to validate the questionnaire in the field. In spite of these limitations, the survey provides valuable information on practices and challenges regarding isolation of MRSA and VRE in LTCF settings, information that has bearing on developing realistic isolation standards for long-term care.
In conclusion, multiply resistant bacteria are an increasing problem for LTCFs as well as hospitals. We surveyed Nebraska LTCFs regarding their approach to MRSA and VRE. The survey noted variable approaches to screening, type of isolation, and duration of isolation of MRSA and VRE in long-term care, suggesting a need for further education and guidelines for resistant organisms in this setting.
1. Centers for Disease Control and Prevention. Draft Guidelines for Isolation Precautions; Preventing Transmission of Infectious Agents in Healthcare Settings. 2004.
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9. Strausbaugh LJ, Jacobson C, Yost T. Methicillin-resistant Staphylococcus aureus in a nursing home and affiliated hospital: a four-year perspective. Infect Control Hosp Epidemiol. June 1993;14(6):331-336.
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11. Centers for Disease Control and Prevention. Guidelines for preventing transmission of Mycobacterium tuberculosis in health-care facilities. MMWR. 1994;1994(45):1-132.
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