National Ethics Teleconference

**National MRSA (Methicillin-Resistant *Staphylococcus Aureus*)
Initiative:**

**Ethical Considerations in Implementation**

**October 31, 2007, 1:00 -- 2:00 pm ET**

# 

# INTRODUCTION

**Dr. Berkowitz:**

Good day everyone. This is Ken Berkowitz. I am the Chief of the Ethics
Consultation Service at the National Center for Ethics in Health Care
and a physician at the VA NY Harbor Healthcare System. I am very pleased
to welcome you all to today\'s National Ethics Teleconference. By
sponsoring this series of calls, the Center provides an opportunity for
regular education and open discussion of ethical concerns relevant to
VHA. Each call features an educational presentation on an interesting
ethics topic followed by an open, moderated discussion of that topic.
After the discussion, we reserve the last few minutes of each call for
our \'from the field section\'. This will be your opportunity to speak
up and let us know what is on your mind regarding ethics related topics
other than the focus of today\'s call.

# ANNOUNCEMENTS

[CME credits]{.underline} are available for [listeners]{.underline} of
this call only. To receive CME credit for this course, you must complete
the registration and evaluation process at the Librix Website,
<https://vaww.ees.aac.va.gov/>, dial into the VANTS phone line and
attend 100% of the call.

 

For this call, a CME credit hour will [NOT]{.underline} be offered by
EES for participating in the conference call if the registration and
evaluation process has not been completed by December 1, 2007.

If you have any questions about this process or about the Librix
Website, please contact the Project Manager, John Whatley, PhD, at (205)
731-1812 x312 or by e-mail at <John.Whatley@va.gov> .

**PRESENTATION**

**Dr. Berkowitz**:

Today's presentation will focus on ethical considerations in the
implementation of the MRSA Initiative. Our discussion will educate
participants about the ethical justification and informed consent
requirements for MRSA screening.

The objectives of the call are to:

-   describe ethical reasons for MRSA screening;

-   describe how informed consent policy, as described in VHA Handbook
    1004.1, applies to MRSA screening;

-   describe the comparative risks and benefits of MRSA screening; and

-   integrate consistent informed consent processes with MRSA screening
    practices in the field.

Joining me on today's call are:

Timothy Cuerdon, PhD, Health Systems Specialist, Quality and Performance
Management Office;

Mary Beth Foglia, RN, PhD, MA, a member of the Ethics Center staff who
specializes in preventive ethics and ethics consultation and evaluation;

Rajiv Jain, MD, the Chief of Staff at the VA Pittsburgh Healthcare
System and the Veterans Health Administration National MRSA Program
Director;

Susan Owen, PhD, a medical ethicist at the Ethics Center; and

Gary Roselle, MD, National Program Director for Infectious Diseases,
Chief of Medicine and Acting Chief of Staff at the Cincinnati VA
Hospital.

**Dr Berkowitz:**

Dr. Jain, could you begin today's discussion by telling us about MRSA
and the extent of the problem that we face?

**Dr. Jain:**

MRSA is a gram-positive coccus that is resistant to multiple
antibiotics, causes serious disease, and is often difficult to treat. It
is the cause of healthcare-associated infections (HCAI's) in a variety
of settings and can be cultured from nares and other sites in patients
who are colonized or infected with this organism. It is transmitted, in
general, by contact, such as with the hands of patients or health care
workers or inanimate objects contaminated with MRSA. Such transmission
amplifies the number of patients who may become colonized and who are
then at risk for clinical infection (VHA Directive 2007-002).

A recent epidemiological study published in JAMA estimated that 94,360
invasive MRSA infections occurred in the United States in 1995 and that
these infections were associated with death in 18,500 cases. The
incidence rate in 1995 was 31.8 per 100,000 persons but was
disproportionately higher among those 65 years of age or over (127.7),
blacks (66.5) and men (37.5). Deaths associated with MRSA were also
disproportionately higher among these groups than the population at
large. (Klevens et al., Invasive Methicillin-Resistant Staphylococcus
aureus Infections in the United States. Jama (2007) 298:15:1763-1771).

**Dr. Berkowitz:**

What has VA done to address this problem?

**Dr. Jain:**

At the VA Pittsburgh Health System we developed a bundled approach to
try to reduce the MRSA problem. Our bundle has four components: 1)
active surveillance; 2) hand hygiene; 3) contact precautions; and

4\) cultural transformation. Based upon the sustained positive outcomes
at Pittsburgh, 17 VA facilities were selected as Beta Sites in the
summer of 2006. The Beta Sites are the remaining hospitals in VISN 4 as
well as eight additional VA medical facilities (Baltimore, Buffalo,
Houston, Lexington, Los Angeles, Miami, North Florida/South Georgia and
Tucson). The Beta Sites used the same bundle approach used at
Pittsburgh; test results are still pending. VA Pittsburgh hosted a
two-day kickoff in August 2006 and the Beta Sites began the program
October 1, 2006. By January 2007, recognizing the threat to veterans and
the enormous public health implications of MRSA, VHA launched a
nationwide prevention initiative.
(<http://vaww.va.gov/pittsburgh/mrsa/mrsa_overview.htm>.).

**Dr. Berkowitz:**

Could you describe the MRSA Initiative?

**Dr. Jain:**

Veterans Health Administration (VHA) Directive 2007-002 establishes
policy for the implementation of a standardized initiative to reduce
Methicillin-Resistant *Staphylococcus aureus* (MRSA) infections in the
population served by VHA. The National Initiative seeks to capitalize on
the success at VA Pittsburgh Health Care System and duplicate and
further improve their efforts throughout the VA health system. The
initiative focuses on the implementation of active MRSA surveillance,
appropriate contact isolation precautions as well as data reporting and
evaluation in acute care facilities for now with subsequent expansion to
nursing home care units. Another integral component is an emphasis on
leadership support of staff-owned and operated implementation of these
transmission-based precautions. Through the National Initiative the VA
has chosen to be proactive and establish a nationwide prevention program
that will ensure that veterans are cared for in the safest possible
setting. (<http://vaww.va.gov/pittsburgh/mrsa/mrsa_overview.htm>.).

**Dr. Berkowitz:**

To whom does the MRSA Initiative apply?

**Dr. Jain:**

VHA released Directive 2007-002, Methicillin Resistant Staphylococcus
aureus, in January 2007.  The Directive mandated all VA facilities to
implement the MRSA Prevention Initiative in one high-risk population by
March 15, 2007.  By June 30, 2007, all critical care units were to
implement the MRSA Bundle, with deployment across all acute care units
by Dec 31, 2007. In January 2008, the Initiative will be phased into at
least one Nursing Home Care Unit (NHCU), and then deployed to all NHCUs.
Mental Health, Ambulatory Care, Outpatient Centers, and other VA
facilities are expected to implement the program later in FY2008.

All VAs will enter their data through the Inpatient Evaluation Center
(IPEC) beginning no later than October 15, 2007. IPEC is a VHA program
office based in Cincinnati under the leadership of Drs. Almenoff and
Render that is currently collecting data for ventilator-associated
pneumonias and central-line associated infections.

**Dr. Berkowitz:**

Thank you, Dr. Jain, for describing MRSA and the extent of the problem
we face, and also for outlining the MRSA Initiative and how it is
currently being rolled-out in VHA facilities throughout the country.
With this background in mind, we can begin to turn to ethical
considerations related to implementation. Dr. Owen, what ethical issues
or questions have been raised by those in the field who are implementing
this initiative, particularly in relation to informed consent?

**Dr. Owen:**

Some local facilities have expressed confusion about what consent
procedures MRSA screening requires. For example, in some places, no
explicit informed consent discussion seems to be taking place, while in
other places, practitioners are advocating for signature consent.
Variations in procedure have been reported not only across but also
within facilities and individual practitioners may differ in what risks
and benefits they disclose and emphasize to patients.

**Dr. Berkowitz:**

What ethics question will we focus on during today's discussion?

**Dr. Owen:**

Given that the national MRSA Initiative requires VA facilities to screen
patients for MRSA by inserting a cotton swab into the nose, and VA
policies require that patients be given a chance to participate in an
informed consent process for all proposed procedures and treatments,
what informed consent processes are ethically justifiable when
initiating the MRSA screen?

**Dr. Berkowitz:**

In order to answer this question, let's begin by looking at VHA policies
and ethics principles. Dr. Foglia, what policies and principles govern
informed consent?

**Dr. Foglia:**

VHA Handbook 1004.1, "Informed Consent for Treatments and Procedures" is
based on the fundamental ethical tenets of shared decision making and
respect for patient autonomy. According to VHA Handbook 1004.1, "In VHA
patients have the right to accept or refuse any medical treatment or
procedure recommended to them. Except as otherwise provided in this
Handbook, all treatments and procedures require the prior, voluntary
informed consent of the patient, or if the patient lacks decision-making
capacity, the patient's authorized surrogate (para. 4a)." As part of the
informed consent process, the practitioner must disclose information to
the patient about risks and benefits of the proposed treatment or
procedure, including no intervention at all, and the patient must have
the opportunity to refuse as well as to consent. This general informed
consent process (informing the patient of the risks and benefits,
alternatives - including no intervention at all; promoting voluntary
decision making; and documenting the process) must be followed for MRSA
screening as for all other treatments and procedures.

**Dr. Berkowitz:**

In order to meet this informed consent standard, the patient must have a
genuine choice about whether or not to consent to a treatment or
procedure. In the case of MRSA screening, each facility needs to make
sure that there is a process in place to discuss the risks and benefits
of this procedure. It is important to keep in mind that it is not only
the risks and benefits associated with the procedure of nasal swabbing
itself, but also with how the patient information gathered from the
procedure will be used, and the effects the results may have on the
patient's care.

For example, even though screening programs are a well recognized means
of secondary prevention (e.g., early detection of disease), earlier
experiences with sickle cell screening and more recent experiences with
AIDs/HIV are instructive. Stigmatization of individuals or groups is a
serious concern and can result in social isolation, and other unintended
harms. On the other hand, impediments to screening may have led to
spread of disease and increased morbidity and mortality.

Dr. Roselle, what are the risks and benefits of MRSA screening and what
ethical issues have been raised regarding the determination of risks and
benefits?

**Dr. Roselle:**

I should begin by emphasizing that we are for the most part discussing
potential rather than actual risks and benefits. For the individual
patient, the word "potential" is used because the risks are difficult to
quantify and may or may not occur. This is in contradiction to certain
other procedures. For instance, dye injection used for radiologic
procedures will induce allergic reaction in a minority of patients, but
will, for sure, occur. This is not the case for MRSA screening. The
primary benefit to the patient seems to be that the patient would know
that he or she is colonized with the bacteria. The screening program,
therefore, does have benefit to the individual patient in that a patient
who is screened as negative should be at less risk of acquiring MRSA
based on those results and the program efficacy. Prevention of
colonization is a benefit to the patient since such prevention is one
critical step in preventing true infection in that patient. Although
MRSA screening may benefit individual veterans as just noted, it is also
a benefit to the population and health care system as a whole in
decreasing overall risk of MRSA transmission.

A brief review of the medical and public health literature, however,
suggests that there is uncertainty about the comparative risks and
benefits of MRSA screening. Several issues, including possible
downsides, have been raised:

First, although MRSA screening may benefit individual veterans by
providing information about whether or not they are colonized with the
bacteria, antibiotic treatment for colonization may not be given to
asymptomatic carriers (*MRSA: Join the Battle to Prevent Infection* --
March, 2007). Although this may not be a risk to an individual patient,
whether or not treatment for colonization will be provided should be
discussed in order for the patient to make an informed choice about MRSA
screening.

Second, contact isolation imposes rules for patients and staff not
generally in place for other patients.

Third, it is uncertain whether placement options in sub-acute facilities
will be jeopardized when the patient's record contains information that
he or she is a carrier of MRSA (*Infection Control and Hospital
Epidemiology*: 2005).

Although he MRSA Initiative brochure, "Testing for MRSA," provides a
starting point for this informed consent discussion, the considerations
discussed above should be communicated clearly to patients, in addition
to possible known benefits for the patient and the population,
consequences of certain test results, etc. It should also be clarified
what happens when a patient refuses to agree to MRSA screening.

**Dr. Berkowitz:**

Could you elaborate on what contact isolation involves for patients?

**Dr. Roselle:**

Contact Precautions are intended to prevent transmission of infectious
agents, including epidemiologically important microorganisms, which are
spread by direct or indirect contact with the patient or the patient's
environment as described. A single patient room is preferred for
patients who require Contact Precautions. When a single-patient room is
not available, consultation with infection control personnel is
recommended to assess the various risks associated with other patient
placement options. Healthcare personnel caring for patients on Contact
Precautions wear a gown and gloves for all interactions that may involve
contact with the patient or potentially contaminated areas in the
patient's environment.

**Dr. Berkowitz:**

I'd like to elaborate a little about possible risks associated with
contact isolation. Although a private room may sound appealing to many
patients, there is evidence to suggest that patients who are isolated
for infection control may experience more adverse events. According to a
May 8, 2007, study in Jama, "Safety of Patient Isolated for Infection
Control," "isolated patients were 8 times more likely than control
patients to experience supportive care failures such as falls, pressure
ulcers, and fluid or electrolyte disorders; in contrast, no significant
differences in diagnostic, operative, anesthesia, medical procedure, or
adverse drug events were noted " This study calls attention to what it
describes as "difficult trade-offs . . . such as the tension between
preventing injury to other patients (such as reducing nosocomial
transmission of pathogens) and maximizing the well-being of an
individual patient (by avoiding barrier restrictions)."

Turning back to risks in general, we have been told informally that
there may be local variations in risks. Dr. Roselle, could you elaborate
and explain the effect such variations might have on the informed
consent discussion?

**Dr. Roselle:**

A possible risk of MRSA screening is that placement options in sub-acute
or chronic care facilities might be jeopardized if a patient's record
contains information that he or she is colonized with MRSA. We know
through experience that in some locations this effect on placement has
not occurred or that discrimination about placement based on MRSA
colonization may be illegal in their jurisdiction. In such locations, it
would be in keeping with informed consent requirements to indicate that
this is a theoretical risk cited in the literature, but that this effect
has not been observed in this particular geographical location. This
would preserve the general uniformity of disclosure about risks and
benefits, while at the same time providing additional specific
information that might be useful to the patient as he or she makes a
decision about whether or not to undergo screening. In other
geographical areas, the risk to placement may be more likely and the
informed consent discussion should indicate this as well.

**Dr. Berkowitz**:

The informed consent processes we have been discussing concerns risks
and benefits to patients of consenting to or declining MRSA screening.
Several people have focused on the public health benefits of MRSA
screening. Dr. Cuerdon, could you elaborate on these benefits, and their
pertinence?

**Dr. Cuerdon:**

Individuals can unknowingly carry this bacterium on their skin or in
their nasal passages without experiencing any symptoms. These MRSA
colonized individuals, while not experiencing symptoms of infection
themselves, can transmit the bacterium to others. Hospitalized patients
who have open wounds or are immuno-compromised are at increased risk of
a more serious infection resulting from MRSA. In these at-risk
individuals, MRSA infections may be quite serious and are sometimes
life-threatening. MRSA colonizers then unknowingly place their fellow
patients at greater risk of infection. In theory, MRSA transmission can
be minimized if the new patient agrees to be screened at admission to
the hospital for the presence of MRSA on their skin or in their nasal
passages and is isolated if positive.

It is my belief that many patients would find this information about the
risks and benefits of MRSA screening to their fellow patients to be
relevant to their decision whether or not to agree to be screened. I
believe that many patients would weigh the potential risks to themselves
due to the screening against the potential benefits to their fellow
patients, and would welcome the opportunity to express their sense of
altruism and concern for others by agreeing to be screened. It is my
view that many patients would not consider themselves to be fully
informed if they did not receive this information about the risks and
benefits that the MRSA screening creates for their fellow patients.

**Dr. Berkowitz:**

Thank you, Dr. Cuerdon. Dr. Owen, what role does the discussion of
public health benefits play in the informed consent discussion?

**Dr. Owen:**

Although we agree that the patient should be educated about the public
health benefits of MRSA screening, we believe that the informed consent
discussion of risks and benefits for a particular patient should focus
primarily on risks and benefits to that patient.

**Dr. Berkowitz:**

Are there additional elements of the informed consent process especially
relevant to MRSA screening?

**Dr. Owen**:

According to VHA Handbook 1004.1, the patient's decision must be
voluntary: i.e., "the practitioner must promote the patient's voluntary
decision-making during the informed consent process. The practitioner
must convey that the patient is free to choose among any recommended
treatments and procedures, including no treatment, or to revoke a prior
consent, without prejudice to the patient's access to future health care
or other benefits" (para. 7b). In order to ensure that a patient is and
feels free to voluntarily accept or refuse MRSA screening, the
practitioner must clarify what kind of care and accommodations will be
provided if the patient accepts or refuses.

**Dr. Berkowitz:**

Thus far we have described the uncertainties that surround the risks and
benefits of MRSA screening and emphasized what a fully informed consent
process and discussion would include. Despite the fact that VHA Handbook
1004.1 requires that such a process and discussion take place for all
treatments and procedures, we have a sense that some local facilities
may view MRSA screening as an exception -- perhaps because of the public
health concerns and recent press about the MRSA problem?. Dr. Foglia,
are there exceptions to the informed consent requirement as identified
in policy that would apply to the MRSA initiative?

**Dr. Foglia:**

MRSA screening is not an exception to informed consent requirements. VHA
Handbook 1004.1 allows informed consent requirements to be waived in
only the most extreme circumstances, such as medical emergencies,
declared public health emergencies or clear and imminent public health
risks (e.g., acute infectious tuberculosis). So although extreme
circumstances may sometimes justify curtailment of individual rights
with respect to health care choices, at this time none of these
exceptions apply to general MRSA screening. There is no clear and
imminent public health threat posed by not screening every patient, and
only preliminary evidence that accomplishing the screening will have
substantial public health benefit.

Even if there were more evidence that accomplishing MRSA screening would
have substantial public health benefit, it still may be that the
reduction in public health risk would not be of sufficient magnitude to
warrant overriding the patient's right to accept or refuse screening,
similar to the current way that we think about flu shots. Thus, patients
should retain the fundamental right to shared decision making through
implementation of our standard informed consent process. Health care
practitioners should conduct MRSA surveillance by following sound
informed consent practices that comply with VA policy and prevailing
ethics norms in health care.

Therefore health care practitioners that are conducting MRSA
surveillance should follow our usual and customary informed consent
practices as detailed in the handbook.

**Dr. Berkowitz:**

To summarize thus far, according to policy and ethical principles and
practice, MRSA screening requires informed consent. Some of the
confusion that has been reported by the field concerns an additional
question: does MRSA screening require signature consent? Dr. Foglia,
could you answer that question?

**Dr. Foglia:**

According to VHA Handbook 1004.1, "The patient's signature consent must
be obtained for treatments and procedures that:

1\. Involve the use of sedation;

2\. Involve the use of anesthesia or narcotic analgesia;

3\. Can be reasonably expected to produce significant discomfort to the
patient;

4\. Can be reasonably considered to have a significant risk of
complication or morbidity;

5\. Require injections of any substance into a joint space or body
cavity, including any nonvascular space;

6\. Involve testing for human immunodeficiency virus (HIV); or

7\. Are listed in Appendix A.\"

From what we understand about MRSA screening, objective evidence that is
currently known about the risks *does not* seem to rise to the level
that would require signature consent. A verbal consent process is,
however, required and we should make clear that this verbal process is
entirely the same as that used for signature consent, with the only
difference being that no signature is required.

**Dr. Berkowitz:**

Our primary objective in today's call is to make clear that VHA Handbook
1004.1 and ethics principles and practices require that the patient know
enough about potential risks and benefits to have a genuine choice about
whether or not to undergo any treatment or procedure, including MRSA
screening. This does not mean that signature consent is required, but it
does mean that local facilities should ensure that processes are in
place to have an informed consent discussion with each patient. And of
course if evidence were to arise in the future, written informed consent
for MRSA screening could be added to our requirements.

I would like to raise one additional ethical issue related to MRSA
screening. VA has often served as an example of innovation in quality
care and the MRSA Initiative itself has received quite a bit of interest
and positive attention throughout the health care community nationally.
We are grateful to everyone in VA for their hard work in beginning to
address the MRSA problem. To the extent that state legislators and
others are looking to the VA MRSA Initiative as a model, it is very
important that confusion about how the program is implemented be
minimized. Some reports in the media suggest that there may be confusion
about whether individual patients have a choice about whether to
participate in the MRSA screening process which itself is often referred
to as a mandate. The main objective of today's call has been to clarify
this confusion by focusing on the ethical commitments to informed
consent and patient autonomy that have long characterized the practices
of VA. To be clear, the MRSA Initiative is mandated, but each individual
patient's participation is not.

Before we turn to the moderated discussion with questions from the
field, I would like to ask Dr. David Ross, Director of VA's Clinical
Public Health Program, who is listening on today's call, if he has any
comments on ethical considerations in the implementation of the MRSA
Initiative.

**Dr. Ross:**

I agree that MRSA, as well as other resistant pathogens, is a serious
public health concern.  For epidemiologic purposes, it is important to
distinguish between hospital-acquired methicillin-resistant *S. aureus*
(HA-MRSA) and community-acquired methicillin-resistant *S. aureus*
(CA-MRSA).  The prevalence of the former appears to be falling, and the
latter rising, among inpatients.  Colonization patterns may be different
between the two.

With regard to benefits to individual patients from screening, the
direct benefit from being screened is unclear:

-   If the patient is found to have nasal colonization with MRSA, it is
    not clear what the direct benefit is from that knowledge alone.   It
    is not clear what the direct benefit to the patient would be from
    isolation.  There are of course, direct benefits from hand hygiene,
    but these are not unique to methicillin-resistant *S. aureus*, and
    should be used universally before and after patient
    encounters regardless of the patient\'s colonization status*.* If
    decolonization were to be attempted, decolonization maneuvers such
    as topical antibiotics have generally not been shown to be effective
    against endemic colonization, except in high-risk populations.
    Clearly, use of systemic antimicrobials for decolonization carries
    the risk of adverse events.

-   If the patient is found not to have MRSA colonization, the knowledge
    itself may be reassuring to the patient that they are at decreased
    risk from infection.  However, because nasal swabs may have low
    sensitivity for detecting colonization, especially for CA-MRSA, such
    reassurance may be misleading.

-   With regard to harms from individual patients who are found to be
    colonized, the potential adverse effects of isolation have been
    discussed in the script, and are a real concern.  There are
    obviously few or no data on stigmatization from MRSA colonization,
    but based on previous experience with cancer and HIV patients, this
    is another real concern, as is difficulty in placing patients in
    sub-acute or chronic care facilities following a finding of MRSA
    colonization.

With regard to benefits to the general in-patient population, this is
obviously a matter of considerable debate; although there are strong
viewpoints on both sides, I do not believe that the case has been made
that active surveillance cultures and isolation have been shown to be of
benefit in the general in-patient population.  It is not clear to me
what the benefit is to the general in-patient population at VAMCs
that have few or no bloodstream infections due to MRSA.

With regard to harms, the major issue, which is an actual harm, is the
diversion of infection control resources and lack of control of other
nosocomial pathogens, especially, in the setting of lack of evidence of
benefit for active surveillance cultures plus isolation.  The cost of
avoiding a single episode of MRSA bacteremia has been estimated in the
literature at \$100,000 - \$355,000; costs are likely to be
significantly higher in settings in which the background rate is low to
begin with.

The issue of consenting to isolation should also be considered, since
this may have consequences to individual patients independent of active
surveillance cultures alone.

 

**MODERATED DISCUSSION**

**Dr. Berkowitz:**

Well thank you, Dr. Ross, for those thought-provoking comments to start
our discussion. We do have about fifteen minutes left for continued
discussion. Does anyone from the faculty have any thoughts about what
Dr. Ross said, or does anyone else on the call have any questions or
thoughts based on what's been presented and talked about so far?

**Ms. Abrams, NYC, NY:**

We were given instructions that if a patient refuses to be swabbed, they
are to be put in isolation with the presumption that they are colonized
with MRSA.

**Dr. Berkowitz:**

Dr. Jain, is there clear guidance about what to do with patients that
refuse?

**Dr. Jain, Pittsburgh, PA:**

Yes, the guidance that we have posted on our MRSA website clearly
acknowledges the fact that there are going to be some patients who are
going to refuse to have the screening done. Our approach then is to ask
the Infection Control staff to review their past record to make sure
that the patient was not a known MRSA carrier within the last 24 months,
definitely within the last 12 months. If the answer is no and there is
no such information, we are to respect that refusal, and no, there is no
official guidance to say that they still have to be isolated. Actually,
on the contrary, we then give you permission to not count that against
you in terms of your data for swabbing on that unit.

**Dr. Berkowitz:**

In general, I know that it is very common to have local interpretation
and local practices. However, to reiterate, as far as the official
guidance goes, there is no requirement to isolate patients who refuse.
It does sound like there is a requirement to take a good look at the
individual case and then treat the patient as you think makes the most
sense. Is that fair to say, Dr. Jain?

**Dr. Jain:**

Yes, that's correct.

**Dr. Foglia, Ethics Center:**

There is one case study out that talks about how isolating patients,
especially in particular units, really has to be looked at carefully
where group interactions are actually important therapeutically. The
units that have been discussed in this case study are rehabilitation
units and mental health services.

**Dr. Berkowitz:**

So that the paper is speculating that the effect of isolation might be
magnified since the treatment plans depend on interaction?

**Dr. Foglia:**

Correct.

**Ms. Williams, Bronx, NY:**

I don't think we've made a decision locally or even at the national
level to actually isolate people in those rehab settings, like spinal
cord and long-term care. There will be a discussion about that at the
November forum next week. In fact, we put patients on contact
precautions, but in fact at this facility we do not tell them that they
have to stay in their rooms. We work with nurses to educate them to wash
their hands when they leave the room. We're trying to deal with the
concern about the negative effects of isolation. I am surprised at the
discussion of informed consent. Since the very beginning of the
initiative in March, there was a discussion of educating the patient
about what we were doing, but the concept of informed consent is a
little bit different than providing education to the effect "I'm going
to swab your nose, find out if you have this bug, are you willing to let
me do this?" And I might be wrong, but I would expect that this is how
the majority of these interactions with the patients are happening.
Nurses are not educated or taught to do risk/benefit discussions of
procedures before they're done. It's interesting to hear about the
information consent concept at this point in time.

**Dr. Berkowitz:**

One of the reasons that we chose this topic to have a NET Call on is
because we at the Ethics Center use our Consultation Service to keep a
finger on the pulse of what is concerning people in the field, and we
did have several ethics consultations come to us with confusion about
this. Some people recognized our general requirements for informed
consent discussion about all proposed treatments and procedures and were
wondering if MRSA screening rose to an exception, or if not, were
looking for guidance on what should happen. And that's why we had, what
I have found to be, very excellent discussions with Dr. Jain and his
group and Dr. Roselle and Dr. Cuerdon and Dr. Ross. We came up with this
conference to make sure that people understand that the intent in our
system is to follow those informed consent tenets and to make sure that
this is actually what's happening when the initiative is implemented.

**Ms. Williams:**

I certainly can see that we may need to change our education with nurses
who are doing this to give the patient a little more information. We
certainly give them information about what we're doing and why we're
doing it and if they are positive and we isolate them, we give them
information about that. But within the context of an actual informed
consent, risk/benefit discussion, the timeframe for that makes getting
the swabs done kind of difficult for nursing and I guess I'm just very
surprised at this point. We have four units doing this and I doubt that
the content that the patients are getting prior to swabbing contains any
of that discussion.

**Dr. Berkowitz:**

For those people who are familiar with the Ethics Center's
IntegratedEthics Initiative, one thing that we realize is that in health
care, concerns come up all the time. Once we have identified gaps in the
quality of ethics practices, such as we think may be happening in some
places around informed consent for MRSA screening, we should always
strive to close those gaps to align actual practices with standards --
in this case with standards for informed consent.

**Ms. Williams:**

Now remember, most of these places started with the ICU. Now I would say
in our ICU, the number of people that actually can give consent, which
was the first unit we brought up and has 20 patients, the number of
people that can actually give consent is probably 50%.

**Dr. Berkowitz:**

I'm an ICU physician and I know that the principles of informed consent
for all treatments and procedures hold in the ICU also. Many patients
are capable of providing consent, if not we have authorized surrogates
and if there is no available surrogate, then VA policy has a mechanism
whereby we can proceed. But again, the fundamental point here is that
with all other treatments and procedures, the same as for the MRSA
screening, patients have a right to know what they're getting into,
understand it, and then can make a decision whether to accept or reject
it. That is the ethics principle that drives what should be our
practices.

**Ms. Williams:**

I understand and I totally agree with that. I'm just saying that this
was rolled out in a fashion in which that discussion never happened
prior to this. And to hear it now as an acting MRSA coordinator is
really disturbing.

**Dr. Berkowitz:**

I'm sorry you find it disturbing, but hopefully we'll find a way to make
it improve our practices. Anyone else have a comment?

**Caller:**

I have a question. What is the difference between getting an informed
consent for the MRSA screening just drawing blood? We don't really get
informed consent on that \-- you go in, you tell the patient that you're
drawing some blood and there's an implied consent with that if they
don't say anything or they don't say no.

**Dr. Berkowitz:**

The same ethical principles apply. I think patients understand more,
that the 'routine' blood-drawing may be part of their everyday
treatment. I think they're more used to thinking about that and perhaps
they need fewer details. But for blood tests that have different
implications, such as an HIV test or other more serious blood tests, we
at the Ethics Center would expect a much more robust discussion of the
implications of the testing, the implications of the results, and I
think as things get more complicated, the discussion has to get more
complicated also. And that I think is reflected in this discussion.

**Ms. Williams:**

I'm going to jump in one more time. I thought about this active
surveillance being very much like blood drawing, something that was
going to become a routine procedure.

**Dr. Berkowitz:**

I'm glad we had this call then to clarify this issue. Together with what
was previously said, this should be in people's consciousness for even
the most routine procedures. Put yourself in the patient's place, think
what you would or wouldn't want to know about things that are being done
that are going to affect your care. And again we feel very strongly in
VA that patients should participate in that kind of decision-making.

**Caller from Dallas:**

Every veteran that comes into our VA sees that we are implementing the
MRSA Directive. It is on our interactive TV, we play it all the time.
And so that's an expectation, they know that that's going to be done.
Our patients are saying, "don't you need to swab me?" And my concern is
that we have a hard enough time getting nurses to be compliant, most of
the time I have to do quick orders for them. But if we start making this
verbal informed consent process mandatory, there's going to be a lot
less compliance. They're not going to have time and it's not going to
get done.

**Dr. Berkowitz:**

Informed consent is required in VA for all treatments and procedures. So
we're not suggesting anything new. Again, one of the things that's made
us want to have this call is that we're concerned that people may be
implementing this initiative without giving consideration to the
requirements for informed consent that do exist. Now, as Dr. Cuerdon
mentioned, you could speculate on this in all different ways. It may be
that when this is explained to patients, the patients will want to
participate and they'll understand the importance of the initiative. But
it also may be that patients will opt out. And I think similar arguments
can be made when we ask patients if they would like to have a flu shot
or not and why we require signature consent for HIV testing. So there
are a lot of different things that you can make a strong argument should
be done medically or should be done from a public health standpoint.
Again, the data on the MRSA screening is preliminary and is very
positive, but the jury is still out, and until we have more data, we
feel very strongly, as do all the faculty on this call, that patients
should understand what is being proposed and should have a choice about
whether or not to participate. I don't think that's a question at this
point.

**Dr. Roselle, Cincinnati, OH:**

I just want to try and clarify this a little bit. I think one of the
confusions is always with the words "informed consent." Because when we
think of informed consent, you think of signature consent and iMed and
all of that. The MRSA Initiative and this screening is no different than
the 50 other things you do all day to the patients. So the hospital has
some drill already in place I hope for doing that. For instance, playing
the television show is one way to get information to the patients and
that can serve as the education. So I think that we have to be clear
that this is not special for MRSA or nasal swabs. It's just like
everything else. All day long patients tell us to go away. You give them
their pills, they say go away. So I think we don't want to get crazy and
make this into a *cause celebre*, but we have to be cognizant that the
patient has to be a participant.

**Ms. Williams:**

They're definitely participating because they're letting us swab their
noses.

**Dr. Berkowitz:**

But if they're letting you swab their noses without understanding the
potential or real risks and benefits and really understanding what
they're agreeing to, then that's not informed consent.

**Ms. Williams:**

Again, that's not a nurse's job to get that informed consent either.

**Caller:**

I was wondering who would do the informed consent because according to
our hospital policy here, the doctors do it or the practitioner who is
ordering the test does it.

**Dr. Berkowitz:**

Well, I think that's probably a local decision. Certainly the person who
is obtaining the informed consent should be somebody who is familiar
enough with it to really be able to participate in a good discussion. As
we've heard, there may be some films or TV shows or pamphlets that could
serve as the basis for the beginning of education. Everything doesn't
have to be discussed verbally, but at some point someone needs to make
sure that the information that's being given out is balanced and is
complete and that the patient has a chance to ask questions and that
they make a decision that is voluntary.

**Caller from New Jersey:**

Is there any possibility at any point that a patient who refuses consent
who is highly suspected to be colonized or to have an infection might be
isolated?

**Dr. Berkowitz:**

Again, as I think Dr. Jain already said, every case should be reviewed,
and I think a common sense approach based on the facts of the case is
what's really going to drive the care that the patient gets.

**Dr. Jain:**

I would like to echo what you just said. I think that it is hard to
imagine all of the possible scenarios, but my appeal to the infection
control professionals would be that we look on a case by case basis.
There are always going to be cases, but I think that the point that is
being made is that we want to make sure that the patients understand the
pros and the cons and have an opportunity to refuse and if they have an
opportunity to refuse, then that not be considered punitive in any way
at all. Beyond that, I think there needs to be some clinical discussion
to see what may be the best course of action and frankly, I have also
heard that there are some cases where the patient is indeed
MRSA-positive, but they don't follow directions, they're all they are
going in all different places in the hospital and touching different
things and doing other things. I think one has to, even in those
scenarios, try to do the best job we can with education, working with
the patient, working with the family members, working with the pastor,
chaplain, working with any kind of forces we have to try to work with
that patient.

**Dr. Berkowitz:**

And that's similar, Dr. Jain, to an approach that we would take with any
other patient who is requiring isolation or restriction, whether it's
for MRSA or not. I notice that we're getting late on time. I'm sorry
that we didn't get to the "From the Field" section of the call, but I
would like to take a minute to thank Dr. Cuerdon, Dr. Jain, Dr. Roselle,
and Dr. Ross, and from our Ethics Center Dr. Foglia and Dr. Owen, for
helping put this call together. I think it's been very
thought-provoking. We never really expect the discussion to be concluded
during the call time and I think that this discussion will continue. I
would just like to make a few closing remarks and then we might have
time for one or two more comments.

**CONCLUSION**

I would like to remind people that we'll post on our web site a detailed
summary of this call as we do for every National Ethics Teleconference
and we'll be sending a follow-up e-mail for this call that will include
the call summary information, the information on the CME credits, and
all the information on the references and the web links that we've
mentioned in the call. Again, please look to our website in your Outlook
e-mail for details and announcements about upcoming national ethics
teleconferences. Please let us know if you or someone you know should be
receiving the announcements or follow-ups to these calls and didn't. If
you want to get on our mailing list or if you have suggestions for
topics for future calls, our email address is vha ethics \@va.gov or VHA
Ethics on the Outlook system. I think that we do have one or two more
minutes for comments.

**Caller:**

I wanted to speak briefly back to the isolation issue with patients. It
is not our policy to restrict our patients on their movement. The only
restrictions on their movement are their own internal restrictions they
may have while they're hospitalized. When we put patients in contact
precautions, they are allowed to leave their rooms; they do so on a
regular basis. We do patient education with them as far as hand hygiene
and the reasons that we're using contact precautions with them, to make
sure that they are informed about the risks that they're being a carrier
can pose to their fellow patients.

**Dr. Berkowitz:**

Certainly education is important in all aspects of this and I'm not
enough of an expert to comment on the difference between contact
precautions and isolation. I don't know whether Dr. Jain or Roselle
would want to add anything to that?

**Caller:**

The patients are in isolation when they're in their rooms, but we don't
restrict them to their rooms as is often done in private hospitals.

**Dr. Jain:**

Right. And I think that is the practice in many hospitals, so I think
that the approach you are taking would be consistent with the practices
that many of the places take. They are very careful that the patients
are educated and that as much as possible are restricted, but if they do
need to go out, obviously for different tests, appointments, and some
important activities, then that's taken into consideration with
education and all the appropriate precautions.

**Dr. Roselle:**

For nursing homes where this initiative has not been instituted yet,
these issues have been discussed at great length and at the November
5^th^ meeting I'm actually going to be going over a draft of issues
related to long-term care, because that is a much more complicated area
with much less data.

**Dr. Rasmussen, Ethics Center:**

One of things that occurred to me as we were listening to this
conversation was that if people can be colonized with MRSA and be
asymptomatic with it, much of this initiative has to do with patient
screening. However, the same principles could be applied to employees in
health care facilities or visitors coming to health care facilities that
have colonization of MRSA and could well be transmitting that to the
patients who are in the hospital. So has there been any discussion or
consideration of mandatory health care provider screening for MRSA?

**Dr. Jain:**

Yes, that topic has come up to the national task force as a topic of
discussion and we have formed a small work group to begin to take a look
at this issue. I think it is a very pertinent question and I think it's
a question we get asked quite often and again there's not a lot of data
to support this. The only guidance that I will offer, based on some of
the European experience, is that one has to look at this as a
low-hanging fruit approach. I think once we tackle the issue of patients
that are infected, patients that are colonized, and hand hygiene
compliance and all of those issues, that's where 80-90% of your benefit
lies in achieving reductions. At some point when we have done quite a
bit to try to squeeze out the last 10-15% of the infection rate, we do
need to look at some of the other issues, but in the meantime, we have
begun to tackle it in a pro-active manner.

**Dr. Ross, Washington, DC:**

I'd like to ask if there have been any discussions about archiving of
MRSA isolates and molecular analysis and tracking geographical areas.

**Dr. Berkowitz:**

So you could try tracing the path of the spread of an infection?

**Dr. Ross:**

Right. Particularly if we have vets who are transferred from one
facility to another, or who are moving between facilities for care.

**Dr. Roselle:**

We should talk about it off-line a little bit, because that's a really
complicated issue.

**Dr. Berkowitz:**

Again, I want to thank everyone again who participated in developing the
call and in the interesting discussion. I'm sure that this is a
discussion that will continue, as it should, and again, thank you and
have a great day.

**REFERENCES**

Klevens, et al. Invasive Methicillin-Resistant Staphylococcus Auereus
Infections in the United States. *JAMA:* 2007; 298 (15):1763-71.

Kreman T, Hu J, Pottinger J, Herwaldt LA. Survey of Long-Term Care
Facilities in Iowa for Policies and Practices Regarding Residents with
Methicillin-Resistant Staphylococcus Aureus or Vancomycin-Resistant
Enterococci. *Infection Control and Hospital* *Epidemiology.* 2005;
26(10): 811-5.

Stelfox HT, Bates DW, Redelmeier DA. Safety of Patients Isolated for
Infection Control. *JAMA* 2003; 290(14): 1899-1905.VHA Handbook 1004.1,
Informed Consent for Treatment and Procedures.

<http://vaww.ethics.va.gov/docs/policy/VHA_Handbook_1004-1_Informed_Consent_Policy_20030129.pdf>

VHA Directive 2007-002, Methicillin-Resistant *Staphylococcus Aureus*
(MRSA) Initiative.
<http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1525>

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