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Healthcare personnel opinions regarding the feasibility of a risk-tailored approach to contact precautions for methicillin-resistant Staphylococcus aureus in the acute care setting

Published online by Cambridge University Press:  22 April 2024

Lyndsay M. O’Hara,
Anthony D. Harris,
David P. CalfeeOpen the ORCID record for David P. Calfee[Opens in a new window],
Graham M. SnyderOpen the ORCID record for Graham M. Snyder[Opens in a new window],
James CottamOpen the ORCID record for James Cottam[Opens in a new window],
Nathan N. O’HaraOpen the ORCID record for Nathan N. O’Hara[Opens in a new window] and
Elise M. MartinOpen the ORCID record for Elise M. Martin[Opens in a new window]
Lyndsay M. O’Hara*
Affiliation:
University of Maryland School of Medicine, Baltimore, MD, USA
Anthony D. Harris
Affiliation:
University of Maryland School of Medicine, Baltimore, MD, USAInstitute for Health Computing, University of Maryland, Baltimore, MD, USA
David P. Calfee
Affiliation:
Department of Medicine, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
Graham M. Snyder
Affiliation:
Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
James Cottam
Affiliation:
University of Maryland School of Medicine, Baltimore, MD, USA
Nathan N. O’Hara
Affiliation:
University of Maryland School of Medicine, Baltimore, MD, USA
Elise M. Martin
Affiliation:
Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
*
Corresponding author: Lyndsay M. O’Hara; Email: lohara@som.umaryland.edu
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Abstract

“All or none” approaches to the use of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) both fail to recognize that transmission risk varies. This qualitative study assessed healthcare personnel perspectives regarding the feasibility of a risk-tailored approach to use contact precautions for MRSA more strategically in the acute care setting.

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Type
Concise Communication
Information
Infection Control & Hospital Epidemiology , Volume 45 , Issue 7 , July 2024, pp. 900 - 902
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Copyright
© The Author(s), 2024. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

Background

Controversy exists surrounding the use of contact precautions to prevent the transmission of methicillin-resistant Staphylococcus aureus (MRSA) in US hospitals. Reference Goto, Harris and Perencevich1–Reference Bearman, Harris and Tacconelli3 Studies suggest that MRSA transmission risk differs by setting, healthcare personnel (HCP) type, and type of activity, Reference O’Hara, Calfee and Miller4 and current implementation of contact precautions also varies. Therefore, evidence-informed risk-tailored implementation of contact precautions may offer advantages over current all-or-none approaches. Implementation would be more complex; thus, it is essential to understand potential barriers to and facilitators of policies that allow more strategic use of gloves and gowns. This study assessed HCP perspectives regarding the feasibility of a risk-tailored approach to contact precautions for MRSA in acute care settings.

Methods

We conducted 3 1–1.5-hour focus groups with HCP at tertiary medical centers in Baltimore, New York, and Pittsburgh in 2022. Two hospitals used contact precautions for MRSA and 1 had discontinued MRSA contact precautions in December 2020. All occupational groups who enter contact precautions rooms were invited to participate. Group discussions focused on contact precautions for MRSA only. Examples of possible risk-tailored policies are shown in Figure 1. We developed a codebook based on a focus group guide and used NVivo 9 for data management and analysis. Two reviewers independently coded the transcripts. Thematic analysis was used to summarize the findings. Emergent themes and patterns were identified by inductive analysis. Through reviewer consensus, themes were condensed into overarching categories.

Figure 1.

Examples of two possible risk-tailored policies for caring with patients colonized or infected with MRSA.

Results

Twenty-four HCP (6 in Maryland, 7 in New York, and 11 in Pittsburgh) participated, including 5 environmental services (EVS) personnel, 4 registered nurses, 3 respiratory therapists (RT), 2 physical therapists (PT), 2 physicians, 2 pharmacists, 2 patient care technicians, 1 nurse practitioner, 1 occupational therapist, 1 registered dietician, and 1 food services employee. Findings by theme are presented below and in Table 1 with illustrative quotations.

Table 1.

Summary of most frequently mentioned themes by healthcare personnel related to contact precautions for patients with MRSA

Note: MRSA, methicillin-resistant Staphylococcus aureus; PPE, personal protective equipment; EVS, environmental services.

Advantages and motivations for contact precaution adherence when caring for patients with MRSA

Personal protective equipment (PPE) gives HCP a feeling of protection. Most participants said they wear PPE to protect themselves and were motivated to protect other patients and their own families (Table 1).

“It’s protecting us, it’s helping us not catch the germ, hopefully.”

—EVS personnel (Baltimore)

“I think you get a psychological boost out of the fact that you feel like you’re protecting yourself and you’re going to protect the next patient. I think from a mental standpoint you kind of think you’ve done your job to make sure you didn’t spread it so, gives you a feeling that you’re doing the right thing.”

—RT (Pittsburgh)

“It’s helping protect me. Helping protect my future patients, my family, and then it also gives me a peace of mind. Like, I’m protected, I’m going to be clean when I exit the room.”

—PT (Baltimore)

Perceived disadvantages of contact precautions when caring for patients with MRSA

Participants mentioned environmental impacts, financial costs, additional time spent donning and doffing, discomfort wearing “hot” plastic gowns, patient stigma, and potential for fewer interactions with patients.

“The environmental impact, costs. I also think …the idea that when patients are in isolation it is always a concern that people are less inclined to interact with them. …. in any infection that it changes how we interact with patients.”

—Physician (New York)

“It’s just the new gowns that we have are plastic, you sweat a lot. It’s just hard to maintain, and each time you put them on, you have to tear it off, change your gloves, sanitize and on to the next and do it all over again. Time consuming.”

—EVS personnel (Pittsburgh)

Self-reported adherence to contact precaution guidelines when caring for patients with MRSA

Most participants reported that they usually wear PPE when required (Table 1). Some stated that they may not wear required PPE if they are doing something quick or with minimal patient contact.

“I don’t always follow it….it depends on what I’m going in to do. If I’m going to just check on my patient, they ring the call bell, just popping my head in, “what do you need?” before I put on the whole gown and gloves, or if I’m just going to silence something. But if I’m not actually touching the patient or giving meds or anything, not usually.”

—Nurse (Maryland)

“I do except under rare exceptions which might be, if I’m really busy, if I just have to drop something off real fast like a paper, just be like, you know you go and then step out, you know? But for the most part, otherwise, yes I do.”

—Food services employee (New York)

Risk-tailored approach to contact precautions when caring for patients with MRSA

Most participants were open to a tailored approach based on risk, but some felt it may be too complicated or confusing and that it is best to keep things simple (Table 1).

“I think hospital staff would like it [the risk-tailored approach] just because it could save some of the time that it takes to just put on a gown and gloves if we are to just go in there and fix someone’s food tray, compared to going into a room with an emergency.”

—EVS personnel (Pittsburgh)

“If we have to do a flow chart road map to figure out if we have to wear gown and gloves, then that might be a little too much of a headache.”

—Dietician (New York)

Suggestions for successful implementation

Participants identified targeted education and training on differentiation of risk for both HCP and patients as critical to successful implementation of a more complex, risk-tailored approach.

“It would be helpful for all of us to really understand the risks and it’s probably hard to get the data on exactly what the risks are, but for instance, if we had a better sense of it….in order to move that needle to say, Hey, yeah, there is maybe risk, but the risk is so small and we are wasting a hundred gowns a minute on just low-risk category, let’s all agree here there is really the low-risk activity.”

—Physician (New York)

“I think the patient education should be key also there because if you see someone coming through with a gown and then two minutes later someone comes in without a gown, from a patient perspective, you’re going to wonder why…”

—Pharmacist (Pittsburgh)

Discussion

HCP identified advantages and disadvantages to current contact precaution policies. Despite frustrations with the existing approach, there is a strong sense of motivation to wear PPE to protect themselves, their families, and their patients. Participants appreciated the concept of a risk-tailored approach to MRSA, especially one that is strategic, data-driven, and associated with less glove and gown use. Notably, that sentiment was consistent between sites that used and the site that did not use contact precautions for MRSA. Compared with current all-or-none approaches to contact precautions for patients with MRSA, a risk-tailored approach may conserve transmission prevention advantages while improving HCP satisfaction and reducing waste and inefficiency. Limitations of this study include that HCP’s stated opinions may not correspond with behavior change and focus groups did not address the patient perspective. Because this approach would be more complicated to communicate and potentially rely on real-time risk assessment and decision-making by individual HCP, the optimal balance between the precision of transmission risk calculation and the complexity of implementation should be further evaluated.

Acknowledgments

We would like to thank Lisa Pineles from the Division of Genomic Epidemiology Clinical Outcomes at the University of Maryland for her support in the planning and implementation of this study. We also thank all frontline healthcare personnel who participated in this work.

Financial support

This work was supported by the US Centers for Disease Control and Prevention Epicenters Program.

Competing interests

All authors report no conflicts of interest relevant to this article.

References

Goto, M, Harris, AD, Perencevich, EN. Contact precautions and methicillin-resistant Staphylococcus aureus—Modeling our way to safety. JAMA Netw Open 2021;4:e211574.10.1001/jamanetworkopen.2021.1574CrossRefGoogle ScholarPubMed
Popovich, KJ, Aureden, K, Ham, DC, et al. SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol 2023;44:1–29. doi: 10.1017/ice.2023.102.CrossRefGoogle ScholarPubMed
Bearman, GM, Harris, AD, Tacconelli, E. Contact precautions for the control of endemic pathogens: Finding the middle path. Antimicrob Steward Healthc Epidemiol 2023;3:e57. doi: 10.1017/ash.2023.145.CrossRefGoogle ScholarPubMed
O’Hara, LM, Calfee, DP, Miller, LG, et al. Optimizing contact precautions to curb the spread of antibiotic-resistant bacteria in hospitals: a multicenter cohort study to identify patient characteristics and healthcare personnel interactions associated with transmission of methicillin-resistant Staphylococcus aureus. Clin Infect Dis 2019;69:S171–7.10.1093/cid/ciz621CrossRefGoogle ScholarPubMed
Figure 0

Figure 1.Examples of two possible risk-tailored policies for caring with patients colonized or infected with MRSA.

Figure 1

Table 1.Summary of most frequently mentioned themes by healthcare personnel related to contact precautions for patients with MRSA