The importance of nursing homes in the spread of methicillin-resistant Staphylococcus aureus (MRSA) among hospitals

Abstract

Background: Hospital infection control strategies and programs may not consider control of methicillin-resistant Staphylococcus aureus (MRSA) in nursing homes in a county.

Methods: Using our Regional Healthcare Ecosystem Analyst, we augmented our existing agent-based model of all hospitals in Orange County (OC), California, by adding all nursing homes and then simulated MRSA outbreaks in various health care facilities.

Results: The addition of nursing homes substantially changed MRSA transmission dynamics throughout the county. The presence of nursing homes substantially potentiated the effects of hospital outbreaks on other hospitals, leading to an average 46.2% (range, 3.3%-156.1%) relative increase above and beyond the impact when only hospitals are included for an outbreak in OC's largest hospital. An outbreak in the largest hospital affected all other hospitals (average 2.1% relative prevalence increase) and the majority (~90%) of nursing homes (average 3.2% relative increase) after 6 months. An outbreak in the largest nursing home had effects on multiple OC hospitals, increasing MRSA prevalence in directly connected hospitals by an average 0.3% and in hospitals not directly connected through patient transfers by an average 0.1% after 6 months. A nursing home outbreak also had some effect on MRSA prevalence in other nursing homes.

Conclusions: Nursing homes, even those not connected by direct patient transfers, may be a vital component of a hospital's infection control strategy. To achieve effective control, a hospital may want to better understand how regional nursing homes and hospitals are connected through both direct and indirect (with intervening stays at home) patient sharing.

Figure 1

Average increase in daily number of MRSA carriers in Orange County after sustained MRSA outbreaks A) across all hospitals countywide, B) across all nursing homes countywide

Figure 2

Relative increases in MRSA prevalence and number of facilities experiencing this increase at six months and three years post-outbreak in various OC healthcare facility sustained outbreaks

Figure 3

Effects of MRSA prevalence increases in the largest hospital on nursing homes experiencing large, moderate, and small prevalence increases over time

Appendix 1