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Saskia v. Popescu, PhD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in Biodefense from George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in Infection Control and has worked in both pediatric and adult acute care facilities.

A New Approach to Discontinuing MRSA/VRE Isolation Precautions

AUG 27, 2019 | SASKIA V. POPESCU
Imagine you’re a patient with a methicillin-resistant Staphylococcus aureus (MRSA) infection and, during your hospitalization, you’re in contact isolation precautions. For many, this can be a frustrating, lonely experience, even though it is necessary for the safety of health care workers and other patients. For health care workers, treating a patient under isolation precautions can be cumbersome, time-consuming, and resource-intensive. Contact precautions for those with endemic MRSA are often associated with longer admission wait times, longer length of stay, delays in transfers to long-term care facilities, and more. 
   
For those patients though, with endemic MRSA and/or vancomycin-resistant Enterococcus (VRE) colonization, many health care facilities are considering discontinuing contact precautions. As colonization of MRSA or VRE becomes the new norm, it has left many to question whether these infection prevention efforts are truly effective in light of the impact on the health care worker and the implications for the patient.

To assess this, a new study sought to evaluate whether discontinuing contact precautions for those patients with endemic MRSA and/or VRE colonization would increase the number of available beds and help improve access and patient flow. The research also explored whether this tactic would lead to prevention of other infections by facilitating earlier rooming (ie, no longer waiting in the waiting areas where transmission is more likely). This study is particularly unique in that, instead of assessing nosocomial infections, the investigators focused on rates of MRSA and VRE before and after this new protocol was in place. 
    
The study took place at Beth Israel Deaconess Medical Center in Boston, Massachusetts, which has 673 beds, of which 64% are double-occupancy rooms. Since MRSA and/or VRE patients require isolation and can only be paired with patients of like infection, this is a perfect environment for testing. Starting in May 2016, the hospital discontinued contact precautions for patients with endemic MRSA and VRE colonization, coupled with an education initiative. The research period spanned from May 2015 to April 2017 in order to assess both pre- and post-intervention rates. In addition to studying MRSA and VRE rates, the research team also looked at patient satisfaction scores, patient falls, and nosocomial pressure ulcers (frequently associated with contact precautions related to these infections), as well as gown and glove expenditure. 
      
The investigators noted that “prior to DcCP [discontinuation of contact precations], the mean monthly number of beds closed daily for MRSA and/or VRE isolation ranged from 2.7 to 5.3. The estimate of potential lost charges due to these bed closures pre-DcCP was $9383 per 100 bed days (95% CI: 8447 to 10 318).”

During the study period though, the mean occupancy was 88.9%, and there were more than 35,000 new inpatient admissions. Prior to the policy change, the median emergency department wait time was 64 minutes, which didn’t significantly change, but there was a 61% decrease in expenditure of gowns and 16% in gloves, which were both statistically significant figures. The bed closures for MRSA and/or VRE prior to this change were estimated to negatively impact the hospital by more than $9,000 per 100 bed days, meaning that by removing the isolation, the hospital saved money. No changes in patient satisfaction or patient falls were noted. When the study team assessed the monthly incidence of MRSA and VRE, they did see an increase in the rate of nosocomial MRSA clinical isolates, but it was not statistically significant, nor was the rate of nosocomial VRE isolates. 
    
Ultimately, the investigators found that by removing contact precautions for patients with endemic MRSA and/or VRE colonization, they could save money and increase bed availability without a statistically significant increase in nosocomial MRSA/VRE-related infections. This study sheds light on the need for more analysis on the necessity to isolate patients with these endemic infections and colonization. 
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