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Eradicating MRSA and MSSA Prior to Inpatient Orthopedic
SurgeryMaureen Spencer, RN,M.Ed., CICInfection Control ManagerDiane
Gulczynski, RN, MS, CNORSenior Vice President, Patient Care
ServicesSusan Cohen, MT, ASCPManager, Microbiology LaboratoryNew
England Baptist Hospital, Boston, Ma.
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Who We AreNew England Baptist HospitalOrthopedic Center of
ExcellenceAcute 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
lifestylesThe 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
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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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Increase in Admissions with CA-MRSA and Decrease in HA-MRSA
infections
VRECHART
396
232
223
235
271
271
290
130
# New VRE Patients
# Nosocomial VRE Infections
TOTAL
VRE PATIENTS
MRSAChart
524
783
896
947
9816
10213
11410
1719
2864
# New MRSA Patients
# Nosocomial MRSA Infections
Note: MRSA Eradication Program Began 7/06 (FY06=29;
FY07=199)
TOTALS
MRSA PATIENTS
MRSAADMRATE
1
1.5
1.8
1.7
1.5
1.5
1.6
2.1
6.7
Rate of New MRSA Cases
Rate of New MRSA Cases/Admissions
2ndBact
3
1
8
5
1
# Secondary Bacteremia (MRSA/StAureus)
Sheet1
FY 95FY 96FY 97FY 98FY 99FY 00FY 01FY 02FY 03FY 04FY 05FY 06FY
07 (Oct-Apr)
# New MRSA Patients384041495278899498102114171286
# Nosocomial MRSA Infections2234436716131094
FY 95FY 96FY 97FY 98FY 99FY 00FY 01FY 02FY 03FY 04FY 05FY 06FY
07
# New VRE Patients857353639232223272729257
# Nosocomial VRE Infections1823623511002
POOR M=34; V=2POOR M=24; V=4POOR M=19; V=4POOR M-12; V=3POOR
M=14; V=8POOR M=34 V=14
(M/V=3)(M/V=8)
FY 99FY 00FY 01FY 02FY 03FY 04FY 05FY06FY 07
# Patient Admissions515951574819541666926694700581814257
Rate of New MRSA Cases1.01.51.81.71.51.51.62.16.7
FY 03FY 04FY 05FY06FY07
# Secondary Bacteremia (MRSA/StAureus)31851
# Surgical Site Infections6560494627
# Operations88379669921689865347
&LYTD=AS OF 2/04&R&F
Authorized User:21 M-Screen+
Authorized User:Leary; Cantelli
Authorized User:Hynes, Tam, Peacock, Cantelli
Authorized User:199 M-Screen+
Sheet2
Sheet3
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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 BacteremiaFiscal Year#SSIs # Secondary
Bacteremias % Bacteremic#operations 2003653 5%8837 2004601 2%9669
200549816%9216 200646511%89862007331 3%6900
SSI with Secondary Bacteremia
1
0
0
0
0
0
1
0
2
2
1
1
1
1
0
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
SSI with Secondary Bacteremia
# cases
SSI with Bacteremia due to MRSA
1
0
0
0
0
0
1
0
1
1
1
0
0
1
0
2
0
0
0
0
0
0
0
0
0
0
DEC
SSI with Bacteremia due to MRSA
Sheet1
NEW ENGLAND BAPTIST HOSPITAL
SURGICAL SITE INFECTIONS WITH SECONDAR BACTEREMIA
FY05-FY06
BY DATE OF SURGERY
Oct-041MRSAOct-041MRSA
NOV0NOV0
DEC0DEC0
JAN0JAN0
FEB0FEB0
MAR0MAR0
APR1MRSAAPR1MRSA
MAY0MAY0
JUN2MRSAS AURJUN1MRSAS AUR
JUL2MRSAS AURJUL1MRSAS AUR
AUG1MRSAAUG1MRSA
SEP1S AURSEP0S AUR
Oct-051S AUROct-050S AUR
NOV1MRSANOV1MRSA
DEC0DEC0
JAN2MRSAJAN2MRSA
FEB0FEB0
MAR0MAR0
APR0APR0
MAY0MAY0
JUN0JUN0
JUL0JUL0
AUG0AUG0
SEP0SEP0
Oct-060Oct-060
NOV0NOV0
DEC0DEC0
JAN0JAN0
FEB0FEB0
MAR0MAR0
APR1APR1
Sheet2
Sheet3
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? Point Source OutbreakIn October 200527 Staph aureus isolates
(17 MSSA and 10 MRSA) were sent to the Mayo Clinic for pulsed field
gel electrophoresisThese 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 bands3
were community-acquired strains and 3 nosocomialThe 3 nosocomial
cases were unrelated in terms of time, person and place
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Program ImplementationThe 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 ServicesResearched MRSA problem and
developed a White PaperJanuary 2006 - prepared a letter to the
Infection Control Committee regarding eradicating MRSA in all
surgeriesFebruary 2006 conducted an anonymous active surveillance
culture study in the operating roomFebruary 2006 prepared three
testing proposals with budgetary cost for Board of
Trusteestraditional 3 day process for results rapid test purchasing
equipmentrapid test leasing equipment
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February 2006 Anonymous Surveillance Cultures
Purpose: to determine pre-opMRSA and MSSA colonization rates
133 patients were cultured in the OR once anesthetized
Results:38 Staph aureus (29%) *5 - MRSA ( 4%)
*all undiagnosed cases*no contact precautions used in OR or
postop *received Cefazolin for surgical prophylaxis
We conducted another anonymous surveillance culture study in Feb
2006 133 spine patients noses were cultured in the OR 29% grew out
Staph aureus and 4% were positive for MRSA which was undiagnosed
and therefore surgical prophylaxis withVancomycin was not
administered and no precautions were used in the OR, PACU or
nursing units. These patients may alsoHave been discharged to a
rehab facility with no flagging for precautions.
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Board Approval to ImplementTask Force Established March
2006Purpose:Reduce post-operative wound infectionsEradicate
methicillin-resistant S aureus (MRSA) and methicillin-sensitive S
aureus (MSSA) nasal colonizationGoal - For Inpatient surgeryNasal
screens in prescreening processAppropriate decolonization treatment
Adjusted perioperative antibiotics
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March 2006 October 2006 weekly meetings with surgical services,
infection control, micro, administration, and medical staff
membersJuly 2006 letter to surgeons July 17, 2006 initiated pilot
on Spine ServiceAugust 2006 - presentation to the Patient Care
Assessment CommitteeAugust 2006 letter to all medical staffAugust
2006 letter to OR SchedulingSeptember 2006 initiated program for
all inpatient surgeries
Implementation Steps
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Policy and ProcedureDeveloped procedural steps for departments
and units affected by the implementationPatient AccessOperating
Room SchedulingPrescreening Unit Pre-surgical unit (Bond
Center)Operating RoomPost Anesthesia Care UnitNursing
UnitsMicrobiology LabAncillary Departments: Housekeeping, Central
Transport
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Implementation StepsMay 2006 - Microbiology LabPurchased rapid
polymerase chain reaction equipmentHired a full-time
technologist
June 2006 - The prescreening unit (PASU) Hired a full-time MRSA
CoordinatingMedical Technician
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MRSA/MSSA Eradication Program
Pilot conducted from July August, 2006
Full implementation for all inpatient surgeries occurred on
September 1, 2006
Micro Lab initiated PCR rapid testing
Estimated cost: ~$400,000/first year
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Cost of the MRSA/MSSA Program
~$400,000 implementation cost: ~$100,000 for 2 full-time
positions: Microbiologist and PASU Medical Technician~$60,000 PCR
rapid test equipment~$40.00/test x ~ 6,000 inpatient surgeries~
$240,000(compared to an MRSA culture ~ $20.00)
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PASU Testing ProcessPre-admission Screening Unit (PASU) obtains
screen. A double swab is used to collect a nares sample.Patient
receives education:brochure on MRSA and MSSAinstruction sheet on
what to do if positivehand hygiene brochurea 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 ProcessA 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 dayMSSA - cultures read the next morningMSSA 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 specimenHow 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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EquipmentWe began using the Cepheids SmartCycler in May 2006 and
conducted validity testing and training of staff.In July 2006 we
started the pilot programIn September 2006 we went live for all
inpatient surgeriesIn 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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TeamworkMicrobiology, 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 fashionMicrobiology
results to PASU as soon as they are available.Information Systems -
setting up systems for automatic broadcastingNursing - make sure
the correct swabs are used.
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Results From July 17, 2006 through June 30, 20075588 patients
screened1243 (22%) positive for MSSA 256 ( 5%) positive for
MRSARepeat nasal screens on MRSA patients revealed 82%
eradicationSSI 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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ConclusionA 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
PatientsWhat 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
NEBH is an orthopedic center of excellence located in downtown
Boston, Ma. We have 150 beds and our inpatients services are approx
75% orthopedic surgery.And this will continue to increase due to
the older population and more active lifestyles, the emergence of
new less invasive procedures and newer technology.However, in 2005
while orthopedic surgical site infections were decreasing, we
noticed an increase in secondary bacteremias due to SSI. This
prompted Diane Gulczynski to research the literature, and develop a
set of recommendations for the Executive Team and the Board of
Trustrees in January 2006 which included initiating active
surveillance cultures, patient bathing with chlorhexiine and
appropriate surgical prophylaxis with Vancomycin for MRSA
patients.
17 MSSA isolates and 10 MRSA isolates were sent to the Mayo
Clinic for pulsed field gel electrophoresis to determine if we were
experiencing a point source outlbreak. None of the strains had the
same number and size of bands to indicate a point source outbreak
or carrier among staff.