Eradicating MRSA and MSSA
Prior to Inpatient Orthopedic
Surgery
Maureen Spencer, RN,M.Ed., CIC
Infection Control Manager
Diane Gulczynski, RN, MS, CNOR
Senior Vice President, Patient Care Services
Susan Cohen, MT, ASCP
Manager, Microbiology Laboratory
New England Baptist Hospital, Boston, Ma.
1
Who We Are
New England Baptist Hospital
Orthopedic Center of Excellence
Acute inpatient discharges are
divided among 3 service lines:
Orthopedic =
Medical
=
74.8%
17.4%
(Cardiology, Pulmonary,
Gastroenterology, Nephrology)
General Surgery = 7.8%
2
Massachusetts Health Data Consortium
There were 36 inpatient orthopedic surgical DRGs in FY2005.
NEBH is the market leader in 4 of the top 5 most complex
DRGs.
NEBH dominates the market in joint replacement and spinal
surgery
3
New England Baptist Hospital
Orthopedic Surgery – Inpatient Surgery - 2005 Massachusetts Market
12%
10.24%
10%
8.25%
8%
5.90%
6%
5.42%
4.20%
4%
2%
0%
NEBH
MGH
2001
BWH
2002
2003
UMASS
2004
2005
Baystate
4
The inpatient orthopedic surgical market
is growing and will continue – due to1:
Demographics – older population
and more active lifestyles
The emergence of new procedures
(including minimally invasive
surgery and artificial discs)
Greater penetration of existing
technologies
Increase in the most complex
DRGs
1.Herndon JH. The future of orthopaedics. AAOS Bulletin (online). June 2004; 52:3. Available at
http://www.aaos.org/wordhtml/bulletin/jun04/fline3.htm. Accessed May 16, 2006.
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The Implementation of an
MRSA and MSSA
Eradication Program at
NEBH
6
Reason #1:
Increase in MRSA in Community
Continued increase in community-acquired
MRSA cases being admitted to NEBH
7
MRSA PATIENTS
320
300
280
260
240
220
TOTALS
200
180
160
140
120
100
80
60
40
20
0
FY 99
FY 00
FY 01
FY 02
FY 03
FY 04
FY 05
FY 06
FY 07 (Oct-Apr)
# New MRSA Patients
52
78
89
94
98
102
114
171
286
# Nosocomial MRSA Infections
4
3
6
7
16
13
10
9
4
Note: MRSA Eradication Program Began 7/06 (FY06=29; FY07=199)
8
Reason #2 – Why We Implemented An
Eradication Program
FY05 - 49 surgical site infections (SSI) in 9216 orthopedic
surgeries (0.5%) and in FY06 – 46 SSI in 8986 (0.5%)
Very low rates since the NNIS national overall rate for orthopedic surgery is
1.5%
However, 8 patients in end of FY05 and 5 in beginning of FY06 developed a
surgical site infection with secondary bacteremia post discharge.
• Bacteremia is associated with an increase in morbidity and
mortality
9
SSI and Secondary Bacteremia
Fiscal Year
2003
2004
2005
2006
2007
#SSIs
65
60
49
46
33
# Secondary Bacteremias
3
1
8
5
1
2
1
Oct04
2
1
0
0
0
0
0
NOV
DEC
JAN
FEB
MAR
1
1
1
1
AUG
SEP
Oct05
NOV
SSI with Secondary Bacterem ia
1
0
JUN
JUL
#operations
8837
9669
9216
8986
6900
2
0
APR MAY
% Bacteremic
5%
2%
16%
11%
3%
DEC
JAN
0
0
FEB
MAR
0
0
APR MAY
0
0
0
0
0
0
0
0
0
0
JUN
JUL
AUG
SEP
Oct06
NOV
DEC
JAN
FEB
MAR
APR
# cases
10
? Point Source Outbreak
In October 2005
27 Staph aureus isolates (17 MSSA and 10 MRSA) were sent to the Mayo
Clinic for pulsed field gel electrophoresis
These included 15 nosocomial strains and 12 community-acquired strains
Purpose: To determine if we were experiencing a point source outbreak related
to SSI with bacteremia
Results: 6 of 27 strains had similar number and size of bands
3 were community-acquired strains and 3 nosocomial
The 3 nosocomial cases were unrelated in terms of time, person and place
11
Program Implementation
The Infection Control Committee recommended implementation of an
MSSA/MRSA eradication program
to reduce nasal colonization in patients scheduled for inpatient surgery
and treat MRSA positive screens with vancomycin for surgical
prophylaxis
Administrative support was elicited from the Senior Vice President of
Patient Care Services to fund a program
included nasal screens with rapid polymerase chain reaction (PCR)
technology, which enabled 2-hour results for MRSA and one day for
MSSA.
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Senior VP Patient Care Services
Researched MRSA problem and developed a “White Paper”
January 2006 - prepared a letter to the Infection Control
Committee regarding eradicating MRSA in all surgeries
February 2006 – conducted an anonymous active surveillance
culture study in the operating room
February 2006 – prepared three testing proposals with budgetary
cost for Board of Trustees
traditional 3 day process for results
rapid test – purchasing equipment
rapid test – leasing equipment
13
14
Board Approval to Implement
Task Force Established March 2006
Purpose:
Reduce post-operative wound infections
Eradicate methicillin-resistant S aureus (MRSA)
and methicillin-sensitive S aureus (MSSA) nasal
colonization
Goal - For Inpatient surgery
Nasal screens in prescreening process
Appropriate decolonization treatment
Adjusted perioperative antibiotics
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Implementation Steps
March 2006 – October 2006 – weekly
meetings with surgical services, infection
control, micro, administration, and medical staff members
July 2006 – letter to surgeons
July 17, 2006 – initiated pilot on Spine Service
August 2006 - presentation to the Patient Care Assessment
Committee
August 2006 – letter to all medical staff
August 2006 – letter to OR Scheduling
September 2006 – initiated program for all
inpatient surgeries
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Policy and Procedure
Developed procedural steps for departments and units
affected by the implementation
•
•
•
•
•
•
•
•
•
Patient Access
Operating Room Scheduling
Prescreening Unit
Pre-surgical unit (Bond Center)
Operating Room
Post Anesthesia Care Unit
Nursing Units
Microbiology Lab
Ancillary Departments: Housekeeping, Central
Transport
17
Implementation Steps
May 2006 - Microbiology Lab
Purchased rapid polymerase chain
reaction equipment
Hired a full-time technologist
June 2006 - The prescreening unit (PASU)
Hired a full-time MRSA Coordinating
Medical Technician
18
19
20
PASU Testing Process
Pre-admission Screening Unit (PASU)
obtains screen. A double swab is used
to collect a nares sample.
Patient receives education:
brochure on MRSA and MSSA
instruction sheet on what to do if positive
hand hygiene brochure
a prescription for Bactroban. (They are
instructed only to fill the prescription if
called by PASU)
The swab is then delivered to the
Microbiology Lab.
Samples are entered into the Laboratory
information system.
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Laboratory Testing Process
A Sheep Blood Agar and a CNA plate
are inoculated with one of the swabs.
The second swab is used for the
MRSA PCR testing on the Cepheid
GeneXpert.
PCR results are entered into the
computer.
MRSA positives - automatically
broadcast to PASU – usually same day
MSSA - cultures read the next morning
MSSA positives - automatically
broadcast to PASU.
22
23
Laboratory Challenges
Instructing staff on the
proper swabs to use and how
to obtain a nares specimen
How to differentiate patients
colonized from patients
infected in the lab.
Getting a Molecular Lab up
and running in a short time
frame.
How to notify PASU and
Infection Control of positive
results.
24
Equipment
We began using the Cepheid’s
SmartCycler in May 2006 and
conducted validity testing and
training of staff.
In July 2006 we started the
pilot program
In September 2006 we went
live for all inpatient surgeries
In June of 2007 we began
using Cepheid’s GeneXpert
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Validation
Smart Cycler: The first 100
samples run were screened by
conventional culture for MRSA.
GeneXpert: 75 samples were run
on both the Smart Cycler and the
GeneXpert.
This required PASU to collect
swabs from patients using the
Smart Cycler swabs and the
GeneXpert swabs.
26
Teamwork
Microbiology, PASU, Infection
Control, Surgical Services, Nursing,
Pharmacy and Information Systems are
all involved with the MRSA eradication
process.
PASU – obtaining screens and
delivering to Microbiology Lab in a
timely fashion
Microbiology – results to PASU as
soon as they are available.
Information Systems - setting up
systems for automatic broadcasting
Nursing - make sure the correct swabs
are used.
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Results
From July 17, 2006 through June 30, 2007
5588 patients screened
• 1243 (22%) positive for MSSA
• 256 ( 5%) positive for MRSA
• Repeat nasal screens on MRSA patients revealed 82%
eradication
SSI in Nasal Screen Positive MRSA and MSSA who received
eradication treatment:
• Two (2) MRSA infections in the 256 positives
• Two (2) MSSA infections in 1243 positives
28
Conclusion
A multidisciplinary approach
strong administrative and financial support
consistent communication and teamwork
Outcome:
Prescreening for MSSA and MRSA with
decolonization treatment reduces post surgical
site infections
29
What Is Next For NEBH?
Screening of ~5000 Same Day Surgery Patients
What are we thinking??
Testing and Treatment by MD’s office prior to surgery?
Testing on the day of surgery in order to provide
appropriate surgical prophylaxis?
Who is responsible for patient follow-up post same day
surgery discharge? The nares is still positive!
30
Thank You
M. R. S. A.
Make Resistance Stay Away
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