On 9/29/2009 Tom Talbot said:

Thank you everyone for participating today - we look forward to our next interactive blog on October 13th!

On 9/29/2009 Tom Talbot - JCR said:

Ellen -- Sorry, I missed your question initially. Very good question re: MDROs in behavioral health settings. I think in all healthcare settings, the risk of transmission of MDROs and methods to prevent such transmission need to be considered. In behavioral health settings, some aspects of the treatment plans may be impacted by traditional infection control measures, however. For example, the use of group therapy may not be conducive for cohorting and isolation of patients. I think it's important to balance these issues -- hand hygiene and basic infection control practices are key for everyone in that setting. Also would recommend working with your local infection preventionists to help navigate some of the unique nuances of your practices environment.

On 9/29/2009 Tom Talbot - JCR said:

Darcy -- There are several factors that may increase a patient's risk of acquiring an MDRO infection. These include underlying comorbities (like chronic renal disease, cancer, etc), recurrent contact with the healthcare environment, and prolonged antimicrobial exposure. It's also worth noting that several studie shave shown that in hospitalized patients, the risk of acquiring an MDRO is increased if an MDRO-infected patient had been staying in the same room previously, likely refelcting the role of the environment in the spread of MDROs.

On 9/29/2009 Tom Talbot - JCR said:

Tanya -- Good question. I think that it is important for all areas of a facility to understand the burden and impact of MDROs. This helps drive home the importance that all healthcare workers have in preventing MDRO transmission.

On 9/29/2009 Darcy said:

What increases the risk a patient to develop an MDRO infection?

On 9/29/2009 Tanya D. said:

What other departments, in addition to IC, should know the frequency of MDROs, and how often should this data be shared?

On 9/29/2009 Tom Talbot - JCR said:

Gerri -- If you are using a proportional method to assess the burden of MDRO infection, a key aspect you need to account for is making sure duplicate isolates of a pathogen from the same patient are not counted in the totals. We recommend that you count only one isolate per patient in burden assessments.

On 9/29/2009 Ellen Prost said:

I work in our behavioral health department at an ambulatory care setting...do we need to worry about MDROs? If so - what do we need to consider?

On 9/29/2009 Gerri Timms said:

How do I ensure that I'm not overestimating the proportion of resistant isolates in my MDRO calculations?

On 9/29/2009 Tom Talbot - JCR said:

Lars -- That's a tough one. There have been no studies of which I am aware that directly examines mortality risk between two different MDROs. Basically, the risk of death apprears similar in terms of fold-increase in mortality for most every MDRO.

On 9/29/2009 Kent Willow said:

I am having trouble getting in front of senior leaders to talk about the impact of MDROs, do you have any advice for me?

On 9/29/2009 Lars Forsen said:

Which MDRO infection has the highest risk of mortality?

On 9/29/2009 Tom Talbot - JCR said:

Don -- Trying to determine if a patient with an MDRO infection has a higher risk of dying (vs. persons infected with a susceptible strain of the same organism) is challenging. That said, there have been an increasing number of studies with a variety of MDROs that have shown a patient infected with an MDRO has about a two-fold increased risk of death compared to a susceptible-infected counterpart. The two-times increase in risk falls out for almost any MDRO that has been studied.

On 9/29/2009 Don Barlie said:

How do we determine if patients infected with MDROs have an increased risk of dying?

On 9/29/2009 Tom Talbot - JCR said:

Zach -- Excellent question. I think different leaders are swayed by different types of data. For some, showing the burden of MDRO at your facility coupled with information on the morbidity of such infections may be enough. For others, data on the costs of MDRO to the patient and the institution may be important. For others, coupling these data with specific cases of MDRO-infected patients may be a provocative stimulus for prevention. I also think it's most important to have a dialogue with leadership supported by data. Hopefully, the reading and tools in the Toolkit will help facilitate that. Thanks!

On 9/29/2009 Zack Drouse said:

What data do we show our leaders to most effectively demonstrate the clinical impact of MDRO infections?

On 9/29/2009 Tom Talbot - JCR said:

Lisa -- For transporting patients on isolation for MDRO, several steps are important. I recommend using a clean bed or stretcher (rather than wheeling the patient's existing bed), having the healthcare workers don PPE (some institutions have them wear gowns and gloves, others have argued gloves alone are OK if pt is placed on a clean bed -- I favor gloves + gown, personally), strict adherence to hand hygiene, and notification of the receiving department that the patient is on isolation to streamline throughput and minimize time spent in the waiting area. Also, we keep MDRO pts on contact precautions whil ein holding and recovery, and when in the OR, prior to the start of the case (in which the patient is covered and those working directly with the patient are in sterile garb), we have healthcare workers don PPE.

On 9/29/2009 Tom Talbot - JCR said:

Carla -- I think incidence rates are the best tool to assess trends of MDROs over time. This reflects the number of new cases acquired, as opposed to prevalence, that includes all previously identified cases. Good question!

On 9/29/2009 Tom Talbot - JCR said:

Cydell -- Tough question for which there are very limited data to help guide us. Some will say, "yes" -- that the patient should still be isolated (the once-guilty, always guilty approach). Others have used an arbitrary time window (e.g. 3 months, 6 months, 1 year) since last isolation of the MDRO along with absence of current evidence for colonization, absence of draining wounds, etc. The CDC guidance is vague on this, and we really need more studies helping to guide this very commonly-confronted issue.

On 9/29/2009 Tom Talbot said:

Lisa -- Thanks for the question! Any patient who is identified as infected or colonized with an MDRO should be placed in contact precautions. As a part of that, I always stress that caregivers entering the room need to wear gowns and gloves, even if contact with the patient or his or her environment is not anticipated. There are good data that show almost 100% of the time a caregiver enters a patient's room, they will touch the patient or a significant part of the environment. I point out that, in the heat of the moment, an ungowned healthcare worker who is asked to contact the patient or the environment ("Hey, can you look at my wound dressing," the IV alarms, etc), most, if not all, do not go back out in the hallway and don a gown before acting. Keep it simple is my motto! Thanks!

On 9/29/2009 Lisa said:

What precautions need to be taken when transporting patients with hx of MDRO'S from pre-op to OR, OR to PACU, etc?

On 9/29/2009 Carla Sommers said:

Which is more accurate to understand MDRO trends - incidence or prevalence rates?

On 9/29/2009 Cydell said:

If infection and/or colonization with an MDRO occurred 5 years ago, should the patient still be placed in contact isolation?

On 9/29/2009 Tom Talbot - JCR said:

Wesley -- Very important question. There are a couple of ways you can examine your facility's MDRO burden. You could look atthe proportion of all isolated of the organism identified in your lab that are resistant (e.g. % of Staph aureus isolates that are MRSA). You coul dalso look at the number of cases of the MDRO over a defined period of time or denominator of person-risk (e.g. rate of MRSA of xx cases per 1,000 admissions, per 1,000 ICU days, etc). I like the latter measure better, as it is not impacted by efforts that will impact non-resistant organisms as well. Plus, the incident rate method of measurement really allows you to assess the impact of interventions designed to prevent the MDRO infections. Take a look at Chapter 2 in the toolkit. There are some great tools on how to assess the burden of MDROs at your facility.

On 9/29/2009 Lisa said:

Should patients with a hx of MDRO infection/colonization, always be placed in "contact precautions", and if so what is the requirement for wearing gowns. Must they be worn anytime you are caring for the patient or only if you anticipate your clothing may come in contact with the patient?

On 9/29/2009 Wesley McGruin said:

How can we quantify the burden of MDRO infection?

On 9/29/2009 Tom Talbot - JCR said:

Stacey -- Great question. I think the first step in establishing any infection control program, whether an all-encompassing one or one directed against MDROs, is to conduct a thorough institutional risk assessment. This allows you to get a "lay-of-the-land," so to speak. It's also important to assess the priorities and risk areas identified by administration and medical leadership, so that you can get buy-in for your projects. The MDRO Toolkit has some nice information on conducting a risk assessment. Thanks!

On 9/29/2009 Stacey Wollmont said:

What is considered the first step in developing an effective control program?

On 9/29/2009 Tom Talbot - JCR said:

Cathy -- Thanks for starting off the blog with an interesting question! In terms of criteria for discharging pts with C. difficile infection (or any MDRO infection, for that matter), clinicians should use similar clinical judgement for discharge. For example, is the patient hemodynamically stable? Are they able to take po? Do they have a stable home environment? There is no need to keep a patient in the hospital longer just because of their diagnosis of C. diff. In fact, I advocate for getting ANY patient out of the hospital as soon as they are stable to avoid acquisition of any other healthcare-associated infections or complications. Also, note that patients with C diff infection do not need follow-up testing of the stool for C diff toxin to make sure the infection has "cleared." Resolution of symptoms should be the guide. Hope that helps!

On 9/29/2009 Cathy said:

Should a patinet with C-diff that has been on medication for 15+ days be discharged home?