Maryn McKenna

Journalist and Author

Hospital MRSA – taking local action

By Leave a Comment

If you follow hospital-acquired infections, you know there’s enormous debate nationally over the best strategies to use: “search and destroy” versus targeted surveillance; guidelines from SHEA, APIC, CDC, or elsewhere. The competing assertions and the lack of clarity can be dizzying.

Here’s news though of one local area that has decided to cut through the fog. A private healthcare organization, state universities and a state hospital association have teamed together to create the South Carolina Healthcare Quality Trust, a partnership that says it will test evidence-based best practices and use IT tools to rapidly distribute them to the 60+ smaller hospitals in the state.

There’s not a lot of detail up yet about what the trust plans, so let’s applaud the effort while reserving judgment until we see what strategies they choose to test and why. Meanwhile, though, here is the announcement from Health Sciences South Carolina, which is a collaborative of several universities, and a FAQ; a story from the national publication Modern Healthcare; and one from the state newspaper, the Columbia State.

MRSA and jails and public reaction

By Leave a Comment

I have a GoogleNews Alert set to crawl for any new posts that mention MRSA. The Google crawler goes pretty deep and often finds things that I would not have known to look for; this week, it has produced a letter to the editor about conditions in a women’s jail in South Florida.

The letter itself is interesting, but the public reaction to it, in the form of comments on the website where it was reproduced, is breathtaking.

Here’s a quick recap: A woman named Susan M. Woods writes in the letters to the editor on TCPalm.com (which appears, after some drilling, to be a joint site for the Stuart, Fla. Treasure Coast News/Press-Tribune, the Vero Beach Press Journal, the Jupiter Courier, and the Sebastian Sun) about conditions at the Indian River County Jail, where she has been an inmate:

The absolute squalor women are forced to live in is similar to a Third World country. Backed-up toilets, black mold, roaches all around, and nothing to clean the common areas except diluted Windex — it’s frightening. It should be no surprise to hear that at least seven women have gotten MRSA — a staph infection — in as many months.

It will not surprise any of you who follow news about MRSA that jails and prisons are particularly vulnerable to outbreaks; the Los Angeles County Jail epidemic (first described in this MMWR article and further described in this one and covered in this book, which was written by, umm, me) has been going on for half a decade at this point and has affected thousands of prisoners. That there is an outbreak in a jail in Florida is exasperating and sad.

But that people in Indian River County think prisoners somehow deserve staph is just astounding. In the comments on Woods’ letter, they say:

In my opinion, someone with Susan’s alleged criminal record deserves far worse conditions in her cell than what she is describing in her letters.

You are supposed to not want to be there you idiot. That’s why its like living in a third world county.

The conditions in jail are horrendous but people keep coming back. What should the taxpayers do then? Take money away from roads, schools, emergency services to make sure the jails are clean, bright and cheery? Or hope that the bad conditions convince just one moron to obey the law.

If I understand the trolls commenters correctly, they believe that prisoners forgo human rights to such an extent that it is an appropriate part of their punishment to subject them to infectious diseases. So, OK: If they are unmoved to care for their fellow humans, we will leave them to their karma.

But really: Don’t they want to take care of themselves? It is well-established by now that MRSA in jails does not stay in jails: It moves out into the community when inmates who acquire it in jail are released and return to the outside. So unless you’re going to argue that people in jail should remain there indefinitely — which seems impractical given the rate at which we put people away — to be concerned about MRSA in jails is self-protection if nothing else.

Much new news on hospital-acquired infections

By Leave a Comment

There’s a ton of new, and conflicting, findings on prevention and detection of hospital-acquired MRSA and other infections.

First: Today, in the journal Infection Control and Hospital Epidemiology, three researchers from Virginia Commonwealth University add to the ferocious debate on “search and destroy,” the colloquial name for active surveillance and testing: that is, checking admitted patients for MRSA, isolating them until you have a result, and and if they are positive, treating them while continuing to isolate them until they are clear. “Search and destroy” has kept in-hospital MRSA rates very low in Europe, and has proven successful in some hospitals in the United States; in addition, four states (Pennsylvania, Illinois, California and New Jersey) have mandated it for some admitted patients at least. Nevertheless, it remains a controversial tactic, with a variety of arguments levelled against it, many of them based on cost-benefit.

Comes now Richard P. Wenzel, M.D., Gonzalo Bearman, M.D., and Michael B. Edmond, M.D., of the VCU School of Medicine, to say that the moment for MRSA search and destroy has already passed, because hospitals are now dealing with so many highly resistant bugs (Acinetobacter, vancomycin-resistant enterococci (VRE), and so on). They contend that hospitals would do better to pour resources into aggressive infection-control programs that broadly target a spectrum of HAIs.

The abstract is here and the cite is: Richard P. Wenzel, MD, MSc; Gonzalo Bearman, MD, MPH; Michael B. Edmond, MD, MPH, MPA. Screening for MRSA: A Flawed Hospital Infection Control Intervention. Infection Control and Hospital Epidemiology 2008 29:11, 1012-1018.

Meanwhile, the US Government Accountability Office recently released a substantive examination of HAI surveillance and response programs, in states and in hospitals, that looks at:

  • the design and implementation of state HAI public reporting systems,
  • the initiatives hospitals have undertaken to reduce MRSA infections, and
  • the experience of certain early-adopting hospitals in overcoming challenges to implement such initiatives. (from the cover letter)

The report is too thick to summarize here, but here are some key points:

  • No two places are doing this the same way — which means that data still does not match state to state
  • Experts are still divided about how much MRSA control is necessary
  • Hospitals that have undertaken MRSA-reduction programs have taken different paths
  • But MRSA control does work: It does reduce in-hospital infections, but at a cost.

This report is an important bookend to an earlier GAO report from last April that explored the poor state of MRSA surveillance nationwide. Read it if you wonder why we don’t really know how much MRSA – in hospitals or in the community – we have.

I am stillworking my way through the new Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, released a week ago by a slew of health agencies (Joint Commission, CDC, et al.) and health organizations (American Hospital Association, ACIP, SHEA, IDSA et al.), to see how much the MRSA strategies have actually changed. If anyone has any comments, please weigh in!

Of course we would never have thought of that.

By Leave a Comment

A new paper in the Annals of Internal Medicine suggests an astounding technique for figuring out whether patients experienced an adverse event while in the hospital:

Asking them.

No, really.

The study by Massachusetts researchers (from University of Massachusetts, Brown, Harvard, Massachusetts Department of Public Health and Massachusetts Hospital Association) looked back at the experience of more than 2,600 patients in 16 Massachusetts hospitals during 6 months in 2003. The researchers started from the assumption that the medical-records review done by many hospitals to spot adverse events was not capturing enough information — and that the interviews that some hospitals do with patients after discharge were asking the wrong questions because they focus only on satisfaction.

So the team did a 20-minute phone interview 6 to 12 months after discharge for 2,600 patients, asking about “negative effects, complications or injuries,” and also reviewed the medical records of 1,000 patients who agreed to their charts’ being released for review. For each arm of the study, two physician-reviewers checked results to be sure what was scored as an adverse event actually qualified as one.

And they found: That twice as many adverse events were uncovered when patients were asked about their experience. Among the interviewees, 23 percent reported an adverse event; when records were reviewed, only 11 percent of patients were judged to have experienced one.

Now, let’s be clear: I’m very glad these researchers had the courage to do this study. Anything that supports better care, more transparency in care and more responsiveness to the patient’s experience is a good thing and I support it.

But when I think of the dozens of hospital patients and family members who have told me about their experiences with poor infection control — lack of hand-washing, lack of housekeeping, bloody gauze on floors — and with being completely unable to get anyone in those hospitals to pay attention, it just makes me want to beat my head against a wall. Coming up with the idea of asking the patients about their experience… this is so hard?

As one of the co-authors, Saul Weingart of Dana-Farber Cancer Institute in Boston, said in an accompanying press release: “It’s pretty clear that they can teach us important things about improving patient safety, if only we ask them.”

The cite is: Weissman, JS et al. Comparing Patient-Reported Hospital Adverse Events with Medical Record Review: Do Patients Know Something That Hospitals Do Not? Ann Intern Med 2008; 100-108.