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.
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 8 representative CLCs, observe how infection prevention practices influence healthcare workers (HCW) behavior and assess barriers/means to improve infection prevention through interviews.
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 8 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.
Aim 1: We looked at MRSA acquisitions over five years of admissions to VA long-term care facilities (226,124 admissions). We also collected infection prevention policies from 74 facilities to determine if the facility used isolation for residents with MRSA. The overall rate of MRSA transmission was 2.6/1000 patient days. Overall, rates of MRSA infections declined by 30% during this time period. We found no difference in MRSA acquisition during different isolation periods. Acquisition was associated with higher colonization pressure (e.g. more residents with MRSA per week).
Aim 2: A total of 999 hours of observation were conducted across 8 VA long-term care facilities during which 4,325 visits were observed. Healthcare workers visited residents in isolation more frequently, likely because they required greater assistance. Compliance with gowns and gloves for isolation was limited in the nursing home setting. Adherence to hand hygiene also was less than optimal, regardless of isolation status of residents.
In 40 semi-structured interviews with VA long-term care staff in different roles across medicine, we found that nursing staff take up the mandate to make the facility feel more "home-like." Infection control leaders sometimes view such efforts as disrupting the need to minimize infection transmission. Environmental service workers contribute a unique perspective, as direct care workers who are also trained to think about facility level perspectives on infection control.
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.
External Links for this Project
Grant Number: I01HX001128-01
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Infectious Diseases, Aging, Older Veterans' Health and Care
Best Practices, Guideline Development and Implementation, Management and Human Factors, Outcomes - Patient, Practice Patterns/Trends, Quality Improvement, Quality of Life