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Complete Summary

GUIDELINE TITLE

Environmental measures for the prevention and management of multi-drug resistant organisms (MDROs). In: Prevention and control of healthcare-associated infections in Massachusetts.

BIBLIOGRAPHIC SOURCE(S)

  • Environmental measures for the prevention and management of multi-drug resistant organisms (MDROs). In: Betsy Lehman Center for Patient Safety and Medical Error Reduction, JSI Research and Training Institute, Inc. Prevention and control of healthcare-associated infections in Massachusetts. Part 1: final recommendations of the Expert Panel. Boston (MA): Massachusetts Department of Public Health; 2008 Jan 31. p. 54-5.

GUIDELINE STATUS

This is the current release of the guideline.

COMPLETE SUMMARY CONTENT

 
SCOPE
 METHODOLOGY - including Rating Scheme and Cost Analysis
 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS
 IMPLEMENTATION OF THE GUIDELINE
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

SCOPE

DISEASE/CONDITION(S)

Healthcare-associated infections caused by multi-drug resistant organisms (MDROs)

GUIDELINE CATEGORY

Management
Prevention

CLINICAL SPECIALTY

Family Practice
Infectious Diseases
Internal Medicine
Preventive Medicine

INTENDED USERS

Advanced Practice Nurses
Hospitals
Nurses
Physician Assistants
Physicians

GUIDELINE OBJECTIVE(S)

  • To provide evidence-based recommendations for a statewide infection control and prevention program to improve health outcomes by reducing the risk of acquiring and transmitting healthcare-associated infections
  • To provide recommendations for prevention and management of multi-drug resistant organisms (MDROs)

TARGET POPULATION

Hospital patients with or at risk of healthcare-associated infections caused by multi-drug resistant organisms (MDROs)

INTERVENTIONS AND PRACTICES CONSIDERED

Management/Prevention

  1. Routine control and prevention of multi-drug resistant organisms (MDROs) including:
    • Cleaning and disinfecting surfaces and equipment
    • Dedicating non-critical medical items for individual patient use
  1. Intensified MDROs control including:
    • Intensifying and reinforcing training of environmental staff
    • Monitoring cleaning performance
    • Obtaining environmental cultures when indicated
    • Vacating units for environmental assessment when possible

MAJOR OUTCOMES CONSIDERED

Incidence of healthcare-associated infections

METHODOLOGY

METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The Expert Panel was divided into six task groups. In order to generate sound, evidence-based recommendations, a comprehensive reference library was created for each task group comprising articles, publications, and other materials relevant to their work. An expert in library science, aided by a JSI Research and Training Institute, Inc. (JSI) staff member with experience in literature review, conducted literature searches, selected articles for inclusion, and managed and organized the task group libraries. For the purpose of the project, JSI gathered an extensive body of literature (over 2000 published articles). Starting with the reference library of a local healthcare associated infections (HAI) expert, it was supplemented and updated to include the most current articles and expanded on recommendations made by Expert Panel and task group members. Figure 1 in the original guideline document summarizes the literature review process.

Literature searches were conducted in PubMed using applicable Medical Subject Headings (MeSH) and key words. Refer to Figure 2 in the original guideline document for information on literature search methodology.

NUMBER OF SOURCE DOCUMENTS

Not stated

METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Level of Evidence Ranking

Level I: Strong evidence from at least one well-designed randomized controlled trial

Level II: Evidence from well-designed non-randomized trials; cohort or case-controlled analytic studies (preferably from >1 center); multiple time-series studies

Level III: Well-designed descriptive studies from more than one center or research group

Level IV: Opinions of authorities (e.g., guidelines), clinical evidence; reports of expert committees

Level V: No quality studies found and no clear guidance from expert committees, authorities or other sources

METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

To aid the task groups and Expert Panel in their decisions, JSI Research and Training Institute, Inc. (JSI) generated qualitative summaries and reviews of relevant literature, outlining the current "state of the science" on task group-indicated topics of debate. All selected studies were critically assessed for internal validity or methodological rigor and only those with high quality of evidence grades were considered in generating evidence-based recommendations.

METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Consensus Development Conference)
Expert Consensus (Delphi)

DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The 2006 Health Care Reform Law directed the Massachusetts Department of Public Health (MDPH) to establish a comprehensive state wide infection prevention and control program. To direct this new effort, a healthcare-associated infection (HAI) Expert Panel was convened in November 2006 under the auspices of the Betsy Lehman Center for Patient Safety and Medical Error Reduction and MDPH. This multidisciplinary panel of experts included infectious disease specialists, epidemiologists, infection control and hospital quality professionals, consumers, professional organizations, and hospital executives and clinical leaders. Research, coordination and facilitation of the work of the Expert Panel and the associated Task Groups was provided by JSI Research and Training Institute, a public health research and consulting firm located in Boston.

The mission of the Expert Panel was to provide guidance on all aspects of a statewide infection control and prevention program, review the key elements of such a program, and submit their completed recommendations to the Betsy Lehman Center and the Massachusetts Department of Public Health by January 31, 2008.

The Expert Panel held twelve monthly meetings beginning on November 30, 2006. Due to the multi-faceted nature of the Panel's charge, six Task Groups were formed in order to focus the efforts of Panel members on their respective areas of expertise.

  1. Bloodstream and Surgical Site Infections (BSI, SSI)--Prevention, Surveillance, and Reporting
  2. Optimal Infection Control Program Components
  3. Ventilator-Associated Pneumonia (VAP)--Prevention, Surveillance, and Reporting
  4. Methicillin-Resistant Staphylococcus aureus (MRSA) and Other Selected Pathogens--Prevention, Surveillance, and Reporting
  5. Public Reporting and Communication
  6. Pediatric Affinity Group--Prevention, Surveillance, and Reporting

Panel members were asked to join at least one group, aligning with their expertise and interest. Additionally, group membership was supplemented with experts and stakeholders from outside the Expert Panel. Each task group was led by an Expert Panel member (Task Group Leader) who facilitated the calls and assisted in the literature review process. Task groups held one-hour-long conference calls every three weeks. A JSI coordinator supported each task group by reviewing and summarizing the literature and aiding in drafting recommendations. Coordinators were also responsible for all administrative work including minute taking, distribution of materials, and communication between the Expert Panel and task groups.

Due to time and capacity limitations, catheter-associated urinary tract infections (CAUTI) were not a specific task group topic. However, the product of a parallel process of evidence review and guideline updating, by experts representing the Infectious Disease Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA), was graciously made available to our project. An ad hoc committee of Expert Panel members and outside experts studied and endorsed these prevention guidelines and they have been incorporated into this final report.

Expert Panel recommendations, in addition to being scientifically sound, needed to take into account the current practices of infection control programs in Massachusetts. For this purpose, JSI surveyed infection control program directors across the Commonwealth in the areas of prevention, surveillance, reporting, and education relating to HAIs. The comprehensive survey questionnaire was developed using a review of current literature, expert reports, and existing surveys. After receiving input and approval from the Expert Panel and the Harvard Pilgrim Health Care Institutional Review Board, the survey was piloted in six hospitals. Once final revisions were made, the survey was mailed to the infection control program of all 71 acute care (non-Veterans Administration) hospitals in Massachusetts. A follow-up phone interview was also conducted to solicit more qualitative information and clarify any answers on the written survey. The completed survey responses were analyzed and results were distributed to project members to aid in their decision-making.

Taking into consideration both the results of the survey and the evidence, task groups drafted recommendations in the areas of HAI prevention and reporting. When voting, either during meetings or electronically, task group members had the opportunity to make comments and suggest additional changes. JSI then tallied the task group votes, reviewed comments, and brought back any major points of contention to the task group.

RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Strength of Recommendation Ranking

Category A: Strongly recommended

Category B: Recommended for implementation

Category C: Consider for implementation

Category D: Recommended against implementation

Category UI: Unresolved issue

No recommendation: Unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exists.

COST ANALYSIS

The annual economic burden of healthcare-associated infections (HAI) in Massachusetts ranges from approximately $200 million to well over $400 million. While it is difficult to determine a precise estimate, it is clear that these infections are costly. Mandatory reporting of institutional-level HAI is a potential tool for improvement of quality of care and a method to be used by consumers, insurers, or providers to make decisions regarding where to seek or fund healthcare. If HAI are reduced with mandatory reporting, societal cost-savings should be anticipated. However, the effect of mandatory reporting on HAI rates is yet unknown. Additionally, increased costs to the hospitals and the Department of Public Health (DPH) should be anticipated. The methods used in this report should be beneficial to other state DPH. With limited resources and the potential benefits of public reporting yet to be established, there is a need to carefully balance the additional burden of reporting with current prevention efforts in order to obtain the optimum outcome, less infections.

Refer to Prevention and Control of Healthcare-Associated Infections in Massachusetts, Part 2: Findings from Complementary Research Activities (see the "Availability of Companion Documents" field) for more information on cost-analysis.

METHOD OF GUIDELINE VALIDATION

Internal Peer Review

DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Once recommendations were approved by the task group members, they were presented to the Expert Panel for consideration and any necessary final revisions.

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Note from the Massachusetts Department of Public Health (MDPH) and the National Guideline Clearinghouse (NGC): Prevention and Control of Healthcare-Associated Infections in Massachusetts guideline has been divided into individual summaries. In addition to the current summary, the following are available:

Level of evidence ranking (I – V) and strength of recommendation ranking (A – D, Unresolved issue [UI], No recommendation) definitions are presented at the end of "Major Recommendations" field.

Tier 1: General Recommendations for Routine Prevention and Control of Multi-Drug Resistant Organisms (MDROs) in Health Care Settings

  1. Clean and disinfect surfaces and equipment that may be contaminated with pathogens, including those that are in close proximity to the patient (e.g., bed rails, over-bed tables) and frequently touched surfaces in the patient care environment (e.g., door knobs, surfaces in and surrounding toilets in patients' rooms) on a more frequent schedule compared to that for minimal touch surfaces (e.g., horizontal surfaces in waiting rooms). A-IV*
  2. Dedicate non-critical medical items to use on individual patients known to be infected or colonized with MDROs when possible. B-IV*
  3. Focus on cleaning and disinfecting frequently touched surfaces (e.g., bedrails, bedside commodes, bathroom fixtures in the patient's room, doorknobs) and equipment in the immediate vicinity of the patient. A-IV*

Tier 2: Recommendations for Intensified MDRO Control Efforts

Institute one or more of the interventions described below when:

  • Incidence or prevalence of MDROs are not decreasing despite the use of routine control measures
  • The first case or outbreak of an epidemiologically important MDRO is identified within the healthcare facility or unit
  • Continue to monitor the incidence of the target MDRO infection and colonization; if the rates do not decrease, implement additional interventions as needed to reduce MDRO transmission
  1. Implement patient-dedicated use of non-critical equipment. B-IV*
  2. Intensify and reinforce training of environmental staff who work in areas targeted for intensified MDRO control. Some facilities may choose to assign dedicated staff to targeted patient care areas to enhance consistency of proper environmental cleaning and disinfection services. B-IV*
  3. Monitor cleaning performance to ensure consistent cleaning and disinfection of surfaces in close proximity to the patient and those likely to be touched by the patient and healthcare workers (HCWs) (e.g., bedrails, carts, bedside commodes, doorknobs, faucet handles). B-IV*
  4. Obtain environmental cultures (e.g., surfaces, shared equipment) only when epidemiologically implicated in transmission. B-IV*
  5. Vacate units, when possible, for environmental assessment and intensive cleaning when previous efforts to control environmental transmission have failed. B-IV*

*Identifies evidence from the Centers for Disease Control and Prevention (CDC)'s updated guidelines without repeating the detailed literature review process.

Definitions:

Level of Evidence Ranking

Level I: Strong evidence from at least one well-designed randomized controlled trial

Level II: Evidence from well-designed non-randomized trials; cohort or case-controlled analytic studies (preferably from >1 center); multiple time-series studies

Level III: Well-designed descriptive studies from more than one center or research group

Level IV: Opinions of authorities (e.g., guidelines), clinical evidence; reports of expert committees

Level V: No quality studies found and no clear guidance from expert committees, authorities or other sources

Strength of Recommendation Ranking

Category A: Strongly recommended

Category B: Recommended for implementation

Category C: Consider for implementation

Category D: Recommended against implementation

Category UI: Unresolved issue

No recommendation: Unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exists.

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

POTENTIAL BENEFITS

Evidence-based best practice guidelines and interventions for prevention of healthcare-associated infection will promote patient and healthcare worker safety and improve health outcomes by reducing the risk of acquiring and transmitting healthcare associated infections.

POTENTIAL HARMS

Not stated

IMPLEMENTATION OF THE GUIDELINE

DESCRIPTION OF IMPLEMENTATION STRATEGY

The final recommendations contained in Prevention and Control of Healthcare-Associated Infections in Massachusetts were adopted by the Betsy Lehman Center for Patient Safety and Medical Error Reduction (BLC) and the Massachusetts Department of Public Health (MDPH). MDPH incorporated the recommendations into the reporting requirements, and developed an assessment tool for surveyors to use to evaluate the implementation of best practices.

IMPLEMENTATION TOOLS

Staff Training/Competency Material

For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

IOM CARE NEED

Staying Healthy

IOM DOMAIN

Effectiveness
Safety

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • Environmental measures for the prevention and management of multi-drug resistant organisms (MDROs). In: Betsy Lehman Center for Patient Safety and Medical Error Reduction, JSI Research and Training Institute, Inc. Prevention and control of healthcare-associated infections in Massachusetts. Part 1: final recommendations of the Expert Panel. Boston (MA): Massachusetts Department of Public Health; 2008 Jan 31. p. 54-5.

ADAPTATION

DATE RELEASED

2008 Jan 31

GUIDELINE DEVELOPER(S)

Betsy Lehman Center for Patient Safety and Medical Error Reduction - State/Local Government Agency [U.S.]
Massachusetts Department of Public Health - State/Local Government Agency [U.S.]

SOURCE(S) OF FUNDING

Massachusetts Department of Public Health

GUIDELINE COMMITTEE

Massachusetts Healthcare-Associated Infections Expert Panel

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Panel Members: Richard T. Ellison III, MD (Chair) Hospital Epidemiologist, Professor of Medicine, Molecular Genetics and Microbiology, University of Massachusetts Memorial Medical Center; Mary Ellen Scales, RN, MSN, CIC (Vice-Chair) Manager, Infection Control, Baystate Medical Center; Mary Alexander, RN, Chief Executive Officer, Infusion Nurse's Society; Eric Alper, MD, Internal Medicine, University of Massachusetts Memorial Medical Center; Evie Bain, RN, Occupational Health & Safety, Massachusetts Nurses Association; Anne Baras, RN, Surgical Technology Department Chair, North Shore Community College; Karen Boudreau, MD, Medical Director, Healthcare Quality Improvement, Blue Cross Blue Shield of MA; Ann Marie Bourque, NP, President, New England Chapter of the National Conference of Gerontological Nurse Practitioners; Lou Ann Bruno-Murtha, MD, Medical Director, Infection Control Division Chief, Cambridge Health Alliance; Wanda Carey, RN, BSN, CIC, Manager, Infection Control, Caritas Norwood Hospital; Philip Carling, MD, Director, Infectious Diseases and Hospital Epidemiology, Caritas Carney Hospital; Donald Craven, MD, Chair, Infectious Disease, Lahey Clinic; Jane Foley, RN, Director of Operations, Nursing, Beth Israel-Deaconess Medical Center; Denise Graham, Sr. Director Public Policy, Association for Professionals in Infection Control and Epidemiology; Paula Griswold, MS, Executive Director, Massachusetts Coalition for the Prevention of Medical Errors; David Hooper, MD, Internal Medicine/ID, Massachusetts General Hospital; Linda Kenney, President, Executive Director, Medically Induced Trauma Support Services; Jim Liljestrand, MD, Medical Director, Quality Improvement, MassPro; Michael Mitchell, MD, Director, Microbiology Services, University of Massachusetts Memorial Medical Center; Sharon-Lise Normand, PhD, Professor of Biostatistics, Harvard Medical School; Richard Olans, MD, Director, Infectious Disease, Hallmark Health Hospitals; Gail Potter-Bynoe, BS, CIC, Manager, Infection Control, Children's Hospital Boston; Selwyn Rogers, MD, Division Chief, Trauma, Burns, and Surgical Critical Care, Director, Center for Surgery and Public Health, Assistant Professor of Surgery, Brigham and Women's Hospital; Jeannie Sanborn, RN, MS, CIC, Infection Control Professional Heywood Hospital; Thomas Sandora, MD, Pediatric ID, Children's Hospital Boston; Kenneth Sands, MD, Senior Vice President, Health Care Quality, Beth Israel-Deaconess Medical Center; Christine Schuster, RN, CEO and President, Emerson Hospital; David Smith, MHSA, Senior Director, Health Data Analysis & Research, Massachusetts Hospital Association; Carol Sulis, MD, Hospital Epidemiologist, Associate Professor of Medicine, Boston Medical Center; Thomas Sullivan, MD, Cardiologist in Private Practice, Women's Health Center Cardiology (Danvers)

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

GUIDELINE STATUS

This is the current release of the guideline.

GUIDELINE AVAILABILITY

AVAILABILITY OF COMPANION DOCUMENTS

PATIENT RESOURCES

None available

NGC STATUS

This NGC summary was completed by ECRI Institute on October 3, 2008. The information was verified by the guideline developer on December 22, 2009.

COPYRIGHT STATEMENT

No copyright restrictions apply.

DISCLAIMER

NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.


 

 

   
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