A Multi-Dimensional Team Approach Solves MRSA Challenge

June 27, 2011

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 departments 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 technique for active surveillance.

In addition, criteria for discontinuing contact precautions for MRSA and/or VRE was also tightened as part of this initiative. This included that a patient could not be rescreened to discontinue isolation until at least six months after the last positive MRSA or VRE culture and that the patient had to be off all antibiotics for at least one week prior to rescreening. Additional cultures sites taken at least one week apart and on three separate weeks, instead of two cultures 24 hours apart, were added to the rescreening process for clearing the MRSA or VRE flags and removing the patient from isolation.

In 2009, the team identified several other areas for improvement. For example, mobile equipment was identified as an opportunity to transmit organisms, yet spray bottles of disinfectant were not easily accessible to staff. As a result, an organizational decision was made to add disinfectant wipes to mobile equipment throughout the facility. In 2010, we added room and equipment cleaning to our team goals. Infection Prevention partnered with Environmental Services (ES), and the ES staff was educated on the importance of cleaning rooms through a systematic process, allowing proper contact time for disinfectants, and focusing on frequently touched surfaces. The training emphasized that the actual role of environmental services was patient safety and infection control, not just cleaning a room.

ES supervisors were trained to place ultraviolent markers on pre-defined sites in a sample of rooms after patient discharge but before the room was cleaned. Following cleaning, the ES supervisor checked the marked sites with a black light to see if all the ultraviolent marker was removed, If not, the room had to be re-cleaned. Data on cleanliness was shared with the department staff, Environmental Services, Infection Prevention Committee and other hospital committees.

Infection Prevention also began using a device that monitors Aadenosine triphosphate (ATP), a byproduct of cellular metabolism, on surfaces in random patient rooms after the patient is discharged and the room is cleaned. The device was purchased by the hospital volunteers who were also engaged in our MRSA-reduction efforts. The device was programmed with acceptable limits and frequently touched surfaces in various types of patient rooms. Infection prevention nurses randomly checked seven to 10 surfaces in rooms after discharge cleaning was done but before the next patient was assigned. he monitor is programmed to read in a stoplight format of red, yellow, and green. If the readings are green, the room is considered clean. If yellow or red, additional cleaning is done. The ES staff embraced the cleaning initiative and developed a habit of coming to the infection preventionists who were using the ATP monitor and asking for immediate feedback on their performance.

Through the ultraviolet markers and use of an ATP monitor, we learned that visually determining that a room is clean does not always mean it really is clean. We learned about our weaknesses and through feedback to staff, either ES personnel or departmental staff, whichever was responsible for cleaning the item, our efforts yielded improvements in our cleaning.

What has worked best? Surveys with our staff cite that rated peer coaching and using critical language as key. We feel that some departments are more comfortable with "speaking up" than other departments, and we continue to work on this. We introduced an "I Got Caught" campaign to reward good behavior. Infection preventionists and team members wrote guidelines for the program. Ink pens with the slogan were distributed to staff and physicians who were observed washing hands and wearing appropriate personal protective equipment in contact precautions rooms. We verbally thanked these team members for modeling best practices. At specified intervals, names of staff who received pens were placed in a drawing for an additional prize pack offered by the public relations department. The team drew the winning name. Pictures were taken and placed on our hospital Intranet when the prize pack was awarded. Staff response to getting a reward was very positive and many still ask when the next campaign will start.

We believe that our challenge in 2011 is to "maintain the gain" and continue to improve. Our Performance Improvement Team has generated ideas to continually keep hand hygiene, contact precautions compliance and cleaning in focus and visible to staff. We feel that the collaborative approach across all departments is essential to continuing to improve.

Wanda Lamm, RN, BSN, CIC, infection prevention coordinator at Nash Health Care Systems in Rocky Mount, N.C. Lamm has more than 20 years experience in infection control and has been certified in infection control since 1995.