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CRE 12-307 – HSR&D Study

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CRE 12-307
Comparative safety and effectiveness of isolation in VHA community living centers
Daniel Josiah Morgan MD MS
Baltimore VA Medical Center VA Maryland Health Care System, Baltimore, MD
Baltimore, MD
Funding Period: April 2015 - September 2019

BACKGROUND/RATIONALE:
The VHA has been a leader in infection control with the Methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative (PI) to prevent infections in both acute-care and long-term care. Current infection prevention practices in long-term care facilities (LTCFs) are adopted from those designed for acute-care settings and may not be appropriate for a LTCF population. In Community Living Centers (CLCs), the VHA is committed to providing Veterans with long-term, residential care that embodies the attributes of a home-like environment. The use of isolation in CLCs varies by facility from very aggressive (long-term isolation of those unable to perform personal hygiene or with active infections-facilities adhering to the VA MRSA PI) to conservative (using standard precautions for all patients-primarily hand hygiene-facilities adhering to CDC guidelines). These policies are based on low quality data and the effect of this practice variation between CLCs is unknown; however these issues are of critical significance to the nearly 45,000 Veterans residing in CLCs (according to a recent VHA/CDC publication up to 58% of CLC residents have MRSA). CLC residents often require transfer to acute-care facilities for infections and have led to outbreaks in acute-care.

Because CLCs constitute both a home-like residence and a medical facility, understanding MRSA isolation practices in CLCs requires a multi-method approach that accounts for both national comparative effectiveness data and front-line perspectives on the barriers to adhering to infection prevention policies. To pursue a nationwide comparative effectiveness study we will first develop and administer a survey to all CLCs to assess MRSA isolation practice (as an exposure) and use unique VHA secondary databases for outcomes MRSA acquisition and infection (IPEC) and unintended consequences (MDS 3.0). Through these integrated projects that use unique VHA data we expect to determine which aspects of isolation are associated with 1) MRSA prevention and 2) unintended consequences and how future infection prevention efforts can best improve overall patient safety.

OBJECTIVE(S):
Aim 1: Determine associations between aggressiveness of MRSA isolation policies in 133 VHA CLCs with MRSA acquisition rates and potential side effects associated with isolation.

Aim 2: In 10 representative CLCs, observe how infection prevention practices influence healthcare workers (HCW) behavior and assess barriers/means to improve infection prevention through interviews

METHODS:
Aim 1 will employ survey methods to quantify the national VHA variation in MRSA prevention among CLCs. Analyses will examine associations between the exposure aggressiveness of MRSA isolation policy and outcomes of MRSA acquisition and unintended consequences of isolation including adverse events.

Aim 2 will use direct observation of HCWs in 10 CLCs to measure frequency and duration of resident contact and compliance with hand hygiene with CLC residents as a factor of isolation status. We will then use qualitative interviews with HCWs to identify barriers in infection control practices in order to better understand the relationship between type of MRSA isolation practice on MRSA acquisition rates and potential side effects associated with isolation. A qualitative approach will inform how HCW beliefs, HCW knowledge, discipline, and site-level policies interact to modify care. From this assessment, we will determine target approaches to improve education.

FINDINGS/RESULTS:
Aim 1: No results to date.
Aim 2: A total of 999 hours of observation were conducted across eight VA CLCs during which 4,325 visits were observed. Residents in isolation received an average of 4.73 visits per hour of observation compared with 4.21 for non-isolation residents (p < 0.01). Residents in isolation received an average of 3.53 resident care activities per hour of observation, compared with 2.46 for residents not in isolation (p < 0.01). For residents in isolation, compliance was 34% for gowns and 58% for gloves. Healthcare worker hand hygiene compliance was 45% vs. 44% on entry (p = 0.79) and 66% vs. 55% (p < 0.01) on exit for isolation and non-isolation rooms respectively.

IMPACT:
This information will advance the science of patient safety in long-term care and inform more rational policy and education for infection prevention in VHA CLCs.

PUBLICATIONS:

Journal Articles

  1. Pineles L, Perencevich EN, Roghmann MC, Gupta K, Cadena J, Baracco G, Pfeiffer CD, Forrest G, Bradley SF, Crnich C, Reisinger HS, Morgan DJ. Frequency of nursing home resident contact with staff, other residents, and the environment outside resident rooms. Infection control and hospital epidemiology. 2019 Jul 1; 40(7):815-816.
  2. Jindai K, Goto M, MacKay K, Forrest GN, Musuuza J, Safdar N, Pfeiffer CD. Improving fluoroquinolone use in the outpatient setting using a patient safety initiative. Infection control and hospital epidemiology. 2018 Sep 1; 39(9):1108-1111.
  3. Pineles L, Petruccelli C, Perencevich EN, Roghmann MC, Gupta K, Cadena J, Baracco G, Pfeiffer CD, Forrest G, Bradley SF, Crnich C, Reisinger H, Morgan DJ. The Impact of Isolation on Healthcare Worker Contact and Compliance With Infection Control Practices in Nursing Homes. Infection control and hospital epidemiology. 2018 Jun 1; 39(6):683-687.
  4. Perencevich EN, Harris AD, Pfeiffer CD, Rubin MA, Hill JN, Baracco GJ, Evans ME, Klutts JS, Streit JA, Nelson RE, Khader K, Reisinger HS. Establishing a Research Agenda for Preventing Transmission of Multidrug-Resistant Organisms in Acute-Care Settings in the Veterans Health Administration. Infection control and hospital epidemiology. 2018 Feb 1; 39(2):189-195.
  5. Hujer AM, Higgins PG, Rudin SD, Buser GL, Marshall SH, Xanthopoulou K, Seifert H, Rojas LJ, Domitrovic TN, Cassidy PM, Cunningham MC, Vega R, Furuno JP, Pfeiffer CD, Beldavs ZG, Wright MS, Jacobs MR, Adams MD, Bonomo RA. Nosocomial Outbreak of Extensively Drug-Resistant Acinetobacter baumannii Isolates Containing Carried on a Plasmid. Antimicrobial agents and chemotherapy. 2017 Nov 1; 61(11).


DRA: Aging, Older Veterans' Health and Care, Infectious Diseases
DRE: Epidemiology, Prevention
Keywords: Best Practices, Guideline Development and Implementation, Management and Human Factors, Outcomes - Patient, Practice Patterns/Trends, Quality Improvement, Quality of Life
MeSH Terms: none