Mrsa | A Multi-Dimensional Team Approach Solves MRSA Challenge

By Wanda Lamm, RN, BSN, CIC

Persistence is the cornerstone of the methicillin-resistant Staphylococcus aureus (MRSA) prevention program at Nash Health Care. Through our multidisciplinary approach, we focused intensely on hand hygiene, contact precautions and environmental cleaning. We also felt that if we focused on MRSA, which causes high-profile healthcare-associated infections (HAIs), these control measures would also have an impact on other multi-drug resistant organisms as well. Mirror clings, signs and screen savers highlighting hand hygiene were used as reminders to staff and physicians. As a result of our efforts, Nash Health Care has been recognized for an Excellence in MRSA Reduction Award by VHA Inc., the national healthcare network, for progress in addressing this serious patient safety issue and in recognition of an 84 percent reduction in MRSA infections. In fact, Nash Health Care achieved nine consecutive months without a nosocomial MRSA infection.

In 2008, Nash Health Care chartered a multidisciplinary Performance Improvement Team, including representatives from nursing, radiology, environmental services, respiratory therapy, emergency, pharmacy, laboratory, operating room and administration. This patient safety initiative focused on engaging bedside staff and leadership, as well as the patient who was empowered to speak up if staff failed to wash their hands. In 2010, more emphasis was placed on compliance, with hand hygiene and wearing personal protective equipment (PPE) in contact precautions. Presentations were also made at town hall meetings that were held by senior leadership. In addition, data on hand hygiene, personal protective equipment compliance, and MRSA infections rates were reported regularly by Infection Prevention to the hospital Quality Leadership Council (this council consists of senior leadership and board members).

In 2010, our facility set a corporate goal for hand hygiene and personal protective equipment compliance. Data was collected and entered into an electronic system, analyzed and shared with each department and medical discipline through email, department meetings, committee reports, and bulletin boards. If a department’s rate fell below the goal, an action plan was developed. Infection Prevention worked closely with management and staff to improve rates by talking with them concerning work flow, sharing what worked for departments that were successful , and helping to determine actions to implement to effect improvement. One plan included adding additional waterless hand sanitizers in areas the staff identified as high-workflow centers; making it easier and more convenient to perform hand hygiene.

Our contact precautions policy was revised to require an isolation gown and gloves for entry into a contact isolation room. The same process is used for colonized and infected patients. We surveyed our staff regarding their preference for using isolation carts or PPE boxes placed on the door to the isolation room; the staff chose PPE boxes. The rationale was that the boxes were more visible, even when the room door was open; therefore making it less likely to accidentally walk in and not see the isolation sign.

Our facility began an active surveillance program in 2001 consisting of screening high-risk patients for MRSA and vancomycin-resistant Enteroccocus (VRE) on inpatient admission to the acute-care hospital. MRSA screens were obtained from nares, tube sites and wounds. VRE screens were obtained from the peri-rectal site. High-risk patients are identified as any patient who has been hospitalized within the previous 90 days, on dialysis (either hemodialysis or peritoneal), or who entered from a long-term care facility, group home or prison. All critical-care patients were screened for MRSA in nares on admission to the Critical Care Unit. Later, we added the active surveillance program for MRSA and VRE on admission to our rehabilitation hospital and included screening elective surgery patients for MRSA on their preoperative visit. When a positive MRSA or VRE culture is complete, Infection Prevention enters an electronic flag. The flags can be discontinued only by Infection Prevention when strict criteria are met. When a patient flagged for MRSA or VRE is readmitted, a contact precautions order is automatically generated. The patient remains on isolation until strict criteria are met.

In 2007, we computerized admission assessment questions so that if one of the screening questions is answered “yes,” an automatic order for MRSA and VRE screenings appears. Prior to this, we used a written protocol with order sheet that had to be pulled and placed on the chart. Compliance was not always good and computerization enhanced compliance.

Through the VHA MRSA Collaborative, we participated in several webinars featuring experts across the country and learned about initiatives that other facilities had successfully implemented. We learned about CHROMagar through one of these VHA programs. We determined that culture results could be obtained earlier through switching from standard culture technique to CHROMagar. Our laboratory representative, who is the microbiology supervisor, investigated and made the change to the CHROMagar

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