A Targeted Infection Prevention Intervention
extension to cluster randomised trials. BMJ. 2012; 345:e5661. doi:10.1136/bmj.e5661. 48. Safdar N, Marx J, Meyer NA, Maki DG. Effectiveness of preemptive barrier precautions in controlling nosocomial colonization and infection by methicillin-resistant Staphylococcus aureus in a burn unit. Am J Infect Control. 2006;34(8):476-483.
Original Investigation Research
49. Cools HJ, van der Meer JW. Infection control in a skilled nursing facility: a 6-year survey. J Hosp Infect. 1988;12(2):117-124. 50. Meddings J, Mody L, Gaies E, Hickner A, Saint S. What interventions are effective in preventing catheter-associated urinary tract infections in long-term care settings? PROSPERO. 2013:CRD42013005787. http://www.crd.york.ac.uk
/PROSPERO/display_record.asp?ID =CRD42013005787. Accessed January 24, 2015. 51. Kohli E, Ptak J, Smith R, Taylor E, Talbot EA, Kirkland KB. Variability in the Hawthorne effect with regard to hand hygiene performance in high- and low-performing inpatient care units. Infect Control Hosp Epidemiol. 2009;30(3):222-225.
Invited Commentary
Revisiting Standard Precautions to Reduce Antimicrobial Resistance in Nursing Homes Nimalie D. Stone, MD, MS
The need to address transmission of multidrug-resistant organisms (MDROs) has never been more critical for nursing homes. Nursing home care is increasing in complexity as growing proportions of residents are entering homes directly from acute care hospitals. The post–acute care population experiences health care expoRelated article page 714 sures such as invasive medical devices, wounds, and antibiotic use that are wellestablished risk factors for MDRO acquisition, colonization, and infection. In this issue of JAMA Internal Medicine, Mody and colleagues1 describe a new approach to reduce MDRO prevalence and incidence of infections in nursing homes through a multifaceted, targeted infection prevention (TIP) intervention. The TIP intervention incorporates an extensive educational curriculum for nursing staff, active surveillance for MDRO colonization and infections, and the preemptive use of gown and gloves during daily care of all residents with indwelling medical devices (eg, urinary catheters, feeding tubes). Using cluster randomization at the facility level, implementation of the TIP intervention resulted in a 23% reduction in MDRO prevalence among residents with indwelling devices in 6 intervention homes compared with 6 usual care homes. In addition, residents in the intervention homes had a significantly lower risk of methicillin-resistant Staphylococcus aureus acquisition (hazard ratio, 0.78; P = .01) and fewer clinically diagnosed catheter-associated urinary tract infections (hazard ratio, 0.54; P = .04). While the comprehensive nature of the TIP intervention makes it difficult to determine the contribution of any individual component on the clinical outcomes seen in the study, the preemptive use of barrier precautions reflects an important shift in the use of gown and gloves away from a pathogen-driven model to a resident-centered model. The burden of MDRO colonization in nursing homes is high, and new acquisition of resistant organisms occurs frequently.2 Given the absence of active surveillance programs, limited use of laboratory diagnostics, and poor communication about MDRO history at care transitions, identification of MDRO colonization in nursing homes is difficult. However, the presence of indwelling devices has clearly been shown to increase risk of MDRO colonization and risk of infection in jamainternalmedicine.com
nursing home residents.3 The approach taken by Mody and colleagues 1 to focus on certain resident risk factors for implementation of gown and gloves may help nursing homes ensure that appropriate practices are in place during care of the highest-risk individuals in the facility. In some ways, this strategy aligns more closely with the fundamental principle of standard precautions to consider risk of transmission during care activities for every person, regardless of known infection or colonization status.4 Although adherence to standard precautions entails the use of gown and gloves based on risk of exposure during any patient care task, health care facilities (including nursing homes) often emphasize the importance of gown and gloves use during care for individuals known to be colonized or infected with MDROs (ie, contact precautions). Infection control programs often focus more on monitoring health care personnel adherence to gown and gloves use when interacting with MDRO-colonized individuals, even low-risk individuals with limited risk of organism shedding. This is despite evidence that health care personnel are inconsistent in adherence to standard precautions even during patient care activities with high potential for exposure to body fluid or mucous membranes.5 The training and feedback to health care personnel on a pathogen-directed use of gown and gloves may inadvertently undermine the importance of risk-based use of gown and gloves during patient care. In the nursing home setting, several implementation issues influence appropriate use of gown and gloves. Some facilities have frontline nursing staff wear gloves for all resident contacts, regardless of the patient care activity. However, when gloves are used inappropriately, hand hygiene adherence is reduced.6 Other facilities may be reluctant to use gown and gloves for fear that this equipment will undermine efforts to create a homelike environment for residents. Gown and gloves are perceived as a barrier between the resident and the caregiver, which could adversely affect the psychosocial wellbeing of the resident.7 However, if gown and gloves were no longer only associated with MDRO colonization or infection, perhaps the use of this equipment during care would not be considered as stigmatizing to residents. Mody and colleagues1 have provided a strong argument for reconsidering the approach to MDRO management in nurs(Reprinted) JAMA Internal Medicine May 2015 Volume 175, Number 5
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a The University of Melbourne Libraries User on 03/28/2016
723
Research Original Investigation
A Targeted Infection Prevention Intervention
ing homes given the challenges to identifying colonized individuals and transmission events. However, more work needs to be done to fully understand the ramifications of this change in practice. The definition of “high risk” in this study was limited to the presence of devices, but other groups of residents (eg, those with wounds) may also benefit from this risk factor– based implementation of precautions. The effect of this intervention at the facility level, including MDRO prevalence among residents without devices, should be explored. In addition, the cost-effectiveness of the TIP intervention and the feasibility of sustaining the intervention without the external support provided by the study team must be examined given the signifiARTICLE INFORMATION
REFERENCES
Author Affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
1. Mody L, Krein SL, Saint SK, et al. A targeted infection prevention intervention in nursing home residents with indwelling devices: a randomized clinical trial [published online March 16, 2015]. JAMA Intern Med. doi:10.1001/jamainternmed.2015 .132.
Corresponding Author: Nimalie D. Stone, MD, MS, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Bldg 16, Mail Stop A-31, Atlanta, GA 30333 ([email protected]). Published Online: March 16, 2015. doi:10.1001/jamainternmed.2015.137. Conflict of Interest Disclosures: None reported. Disclaimer: The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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cant investment in infection prevention education and infrastructure required for successful implementation. Despite these unanswered questions, this article demonstrates the feasibility of performing a well-designed, prospective multicenter, interventional study in a community nursing home setting. It addresses an important safety issue for a high-risk population and shows the efficacy of several practical infection prevention interventions. We need more highquality, outcomes-driven infection prevention research studies in nursing homes to expand the evidence base for strategies to reduce MDROs and infections in this rapidly growing health care setting.
2. Fisch J, Lansing B, Wang L, et al. New acquisition of antibiotic-resistant organisms in skilled nursing facilities. J Clin Microbiol. 2012;50(5):1698-1703. 3. Wang L, Lansing B, Symons K, et al. Infection rate and colonization with antibiotic-resistant organisms in skilled nursing facility residents with indwelling devices. Eur J Clin Microbiol Infect Dis. 2012;31(8):1797-1804. 4. Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation
precautions: preventing transmission of infectious agents in healthcare settings. http://www.cdc.gov /hicpac/2007IP/2007isolationPrecautions.html. Accessed December 19, 2014. 5. Gammon J, Morgan-Samuel H, Gould D. A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions. J Clin Nurs. 2008;17 (2):157-167. 6. Eveillard M, Joly-Guillou ML, Brunel P. Correlation between glove use practices and compliance with hand hygiene in a multicenter study with elderly patients. Am J Infect Control. 2012;40(4):387-388. 7. Furuno JP, Krein S, Lansing B, Mody L. Health care worker opinions on use of isolation precautions in long-term care facilities. Am J Infect Control. 2012;40(3):263-266.
JAMA Internal Medicine May 2015 Volume 175, Number 5 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a The University of Melbourne Libraries User on 03/28/2016
jamainternalmedicine.com
extension to cluster randomised trials. BMJ. 2012; 345:e5661. doi:10.1136/bmj.e5661. 48. Safdar N, Marx J, Meyer NA, Maki DG. Effectiveness of preemptive barrier precautions in controlling nosocomial colonization and infection by methicillin-resistant Staphylococcus aureus in a burn unit. Am J Infect Control. 2006;34(8):476-483.
Original Investigation Research
49. Cools HJ, van der Meer JW. Infection control in a skilled nursing facility: a 6-year survey. J Hosp Infect. 1988;12(2):117-124. 50. Meddings J, Mody L, Gaies E, Hickner A, Saint S. What interventions are effective in preventing catheter-associated urinary tract infections in long-term care settings? PROSPERO. 2013:CRD42013005787. http://www.crd.york.ac.uk
/PROSPERO/display_record.asp?ID =CRD42013005787. Accessed January 24, 2015. 51. Kohli E, Ptak J, Smith R, Taylor E, Talbot EA, Kirkland KB. Variability in the Hawthorne effect with regard to hand hygiene performance in high- and low-performing inpatient care units. Infect Control Hosp Epidemiol. 2009;30(3):222-225.
Invited Commentary
Revisiting Standard Precautions to Reduce Antimicrobial Resistance in Nursing Homes Nimalie D. Stone, MD, MS
The need to address transmission of multidrug-resistant organisms (MDROs) has never been more critical for nursing homes. Nursing home care is increasing in complexity as growing proportions of residents are entering homes directly from acute care hospitals. The post–acute care population experiences health care expoRelated article page 714 sures such as invasive medical devices, wounds, and antibiotic use that are wellestablished risk factors for MDRO acquisition, colonization, and infection. In this issue of JAMA Internal Medicine, Mody and colleagues1 describe a new approach to reduce MDRO prevalence and incidence of infections in nursing homes through a multifaceted, targeted infection prevention (TIP) intervention. The TIP intervention incorporates an extensive educational curriculum for nursing staff, active surveillance for MDRO colonization and infections, and the preemptive use of gown and gloves during daily care of all residents with indwelling medical devices (eg, urinary catheters, feeding tubes). Using cluster randomization at the facility level, implementation of the TIP intervention resulted in a 23% reduction in MDRO prevalence among residents with indwelling devices in 6 intervention homes compared with 6 usual care homes. In addition, residents in the intervention homes had a significantly lower risk of methicillin-resistant Staphylococcus aureus acquisition (hazard ratio, 0.78; P = .01) and fewer clinically diagnosed catheter-associated urinary tract infections (hazard ratio, 0.54; P = .04). While the comprehensive nature of the TIP intervention makes it difficult to determine the contribution of any individual component on the clinical outcomes seen in the study, the preemptive use of barrier precautions reflects an important shift in the use of gown and gloves away from a pathogen-driven model to a resident-centered model. The burden of MDRO colonization in nursing homes is high, and new acquisition of resistant organisms occurs frequently.2 Given the absence of active surveillance programs, limited use of laboratory diagnostics, and poor communication about MDRO history at care transitions, identification of MDRO colonization in nursing homes is difficult. However, the presence of indwelling devices has clearly been shown to increase risk of MDRO colonization and risk of infection in jamainternalmedicine.com
nursing home residents.3 The approach taken by Mody and colleagues 1 to focus on certain resident risk factors for implementation of gown and gloves may help nursing homes ensure that appropriate practices are in place during care of the highest-risk individuals in the facility. In some ways, this strategy aligns more closely with the fundamental principle of standard precautions to consider risk of transmission during care activities for every person, regardless of known infection or colonization status.4 Although adherence to standard precautions entails the use of gown and gloves based on risk of exposure during any patient care task, health care facilities (including nursing homes) often emphasize the importance of gown and gloves use during care for individuals known to be colonized or infected with MDROs (ie, contact precautions). Infection control programs often focus more on monitoring health care personnel adherence to gown and gloves use when interacting with MDRO-colonized individuals, even low-risk individuals with limited risk of organism shedding. This is despite evidence that health care personnel are inconsistent in adherence to standard precautions even during patient care activities with high potential for exposure to body fluid or mucous membranes.5 The training and feedback to health care personnel on a pathogen-directed use of gown and gloves may inadvertently undermine the importance of risk-based use of gown and gloves during patient care. In the nursing home setting, several implementation issues influence appropriate use of gown and gloves. Some facilities have frontline nursing staff wear gloves for all resident contacts, regardless of the patient care activity. However, when gloves are used inappropriately, hand hygiene adherence is reduced.6 Other facilities may be reluctant to use gown and gloves for fear that this equipment will undermine efforts to create a homelike environment for residents. Gown and gloves are perceived as a barrier between the resident and the caregiver, which could adversely affect the psychosocial wellbeing of the resident.7 However, if gown and gloves were no longer only associated with MDRO colonization or infection, perhaps the use of this equipment during care would not be considered as stigmatizing to residents. Mody and colleagues1 have provided a strong argument for reconsidering the approach to MDRO management in nurs(Reprinted) JAMA Internal Medicine May 2015 Volume 175, Number 5
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a The University of Melbourne Libraries User on 03/28/2016
723
Research Original Investigation
A Targeted Infection Prevention Intervention
ing homes given the challenges to identifying colonized individuals and transmission events. However, more work needs to be done to fully understand the ramifications of this change in practice. The definition of “high risk” in this study was limited to the presence of devices, but other groups of residents (eg, those with wounds) may also benefit from this risk factor– based implementation of precautions. The effect of this intervention at the facility level, including MDRO prevalence among residents without devices, should be explored. In addition, the cost-effectiveness of the TIP intervention and the feasibility of sustaining the intervention without the external support provided by the study team must be examined given the signifiARTICLE INFORMATION
REFERENCES
Author Affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
1. Mody L, Krein SL, Saint SK, et al. A targeted infection prevention intervention in nursing home residents with indwelling devices: a randomized clinical trial [published online March 16, 2015]. JAMA Intern Med. doi:10.1001/jamainternmed.2015 .132.
Corresponding Author: Nimalie D. Stone, MD, MS, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Bldg 16, Mail Stop A-31, Atlanta, GA 30333 ([email protected]). Published Online: March 16, 2015. doi:10.1001/jamainternmed.2015.137. Conflict of Interest Disclosures: None reported. Disclaimer: The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
724
cant investment in infection prevention education and infrastructure required for successful implementation. Despite these unanswered questions, this article demonstrates the feasibility of performing a well-designed, prospective multicenter, interventional study in a community nursing home setting. It addresses an important safety issue for a high-risk population and shows the efficacy of several practical infection prevention interventions. We need more highquality, outcomes-driven infection prevention research studies in nursing homes to expand the evidence base for strategies to reduce MDROs and infections in this rapidly growing health care setting.
2. Fisch J, Lansing B, Wang L, et al. New acquisition of antibiotic-resistant organisms in skilled nursing facilities. J Clin Microbiol. 2012;50(5):1698-1703. 3. Wang L, Lansing B, Symons K, et al. Infection rate and colonization with antibiotic-resistant organisms in skilled nursing facility residents with indwelling devices. Eur J Clin Microbiol Infect Dis. 2012;31(8):1797-1804. 4. Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation
precautions: preventing transmission of infectious agents in healthcare settings. http://www.cdc.gov /hicpac/2007IP/2007isolationPrecautions.html. Accessed December 19, 2014. 5. Gammon J, Morgan-Samuel H, Gould D. A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions. J Clin Nurs. 2008;17 (2):157-167. 6. Eveillard M, Joly-Guillou ML, Brunel P. Correlation between glove use practices and compliance with hand hygiene in a multicenter study with elderly patients. Am J Infect Control. 2012;40(4):387-388. 7. Furuno JP, Krein S, Lansing B, Mody L. Health care worker opinions on use of isolation precautions in long-term care facilities. Am J Infect Control. 2012;40(3):263-266.
JAMA Internal Medicine May 2015 Volume 175, Number 5 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a The University of Melbourne Libraries User on 03/28/2016
jamainternalmedicine.com
