Eradicating MRSA and MSSA Prior to Inpatient Orthopedic Surgery

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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.

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Who We AreNew England Baptist HospitalOrthopedic
Center of Excellence

• Acute inpatient discharges are divided among 3
  service lines
• Orthopedic 74.8
• Medical 17.4
• (Cardiology, Pulmonary, Gastroenterology,
  Nephrology)
• General Surgery 7.8

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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

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New England Baptist Hospital Orthopedic
Surgery Inpatient Surgery - 2005 Massachusetts
Market
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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 523. 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
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Reason 1 Increase in MRSA in Community

• Continued increase in community-acquired MRSA
  cases being admitted to NEBH

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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

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SSI and Secondary Bacteremia
Fiscal Year SSIs Secondary Bacteremias
Bacteremic operations 2003 65 3 5 8837
2004 60 1 2 9669 2005 49 8 16 9216
2006 46 5 11 8986 2007 33 1 3 6900
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? 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

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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

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Board Approval to ImplementTask 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

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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

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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.

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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.

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Equipment

• We began using the Cepheids 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 Cepheids 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.

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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

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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

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What Is Next For NEBH?

• Screening of 5000 Same Day Surgery Patients
• What are we thinking??
• Testing and Treatment by MDs 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!

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Thank You M.
R. S. A.
Make Resistance Stay Away