The VHA has been a leader in infection control with the MRSA Prevention Initiative to prevent infections in both acute-care and long-term care. A cornerstone of the MRSA Prevention Initiative is testing all patients for MRSA on admission, discharge and semi-annually. No other healthcare system in the US obtains this amount of MRSA data. Those acute-care patients found to have MRSA are isolated in a private room and healthcare workers (HCW) are required to use of gown and gloves for contact. In acute-care isolation has been associated with fewer HCW visits and greater depression, anxiety, delirium, worse process measure and more adverse events (primarily falls and pressure ulcers). 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 n 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). Direct observation methods will be employed to quantify HCW-resident interactions at these 10 CLCs. Survey results will inform recruitment for one-on-one interviews with CLC HCWs at 10 geographically dispersed CLCs to understand HCW beliefs, knowledge and perceptions of barriers to adherence with infection prevention practices. These interviews will identify educational needs for infection prevention education. 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. 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.
The VHA is committed to providing long-term care in a home-like environment. This has to be balanced with patient safety and protecting residents from MRSA infections. Infections in CLCs are a primary cause for transfer to acute-care and have led to outbreaks in acute-care facilities. The most common cause of infections is MRSA. In acute-care, patients with MRSA are isolated in their room and healthcare workers are required to use gowns and gloves for entry. Isolation is highly debated in long-term care. These measures lessen the home-like environment and, small studies suggest, may lead to depression, delirium and adverse events. The goals of this project are to establish a scientific foundation for MRSA infection prevention policy in long-term care settings both quantitatively and qualitatively balancing infection prevention, patient safety and the ideals of patient-centered care.
