MRSA Level Reduced in a Spinal Care Injury Unit

1st October, 2006

Summary

Having adopted a proactive approach to the management of patients colonised with meticillin-resistant Staphylococcus aureus and implemented the Infection Control Nurses Audit Tool in 2005 we have been able to demonstrate that we found a reduction in the level of MRSA colonisation in our patient population within our Spinal Cord Injury Unit while simultaneously achieving high scores in several aspects of care and the level of environmental cleanliness subjected to audit. We believe that having a proactive management approach for patients with MRSA colonisation, achieving a high standard on audit of care practices such as hand hygiene, the correct wearing of PPE, clean medical equipment on the ward and a clean ward environment, that despite the lack of a proven association between low infection levels and high cleanliness standards these combined reflect the desired high standard of patient care.

Introduction

Meticillin-resistant Staphylococcus aureus (MRSA) remains endemic in many UK hospitals (Coia et al, 2006). The primary mechanism of its spread is believed to be due to direct contact between source patients and healthcare workers (Pittet et al, 2000; Mc Bryde et al, 2004). While contaminated equipment and the general hospital environment can be a potential source of this organism (French et al, 2004; Sykes et al, 2006). Other contributing factors to the level of MRSA in any ward is a heavy nursing work load (Vicca, 1999; Bignardi and Askew, 2000), high turnover and high bed occupancy rates (Cunningham et al, 2005).

To reduce the risk of acquisition of this organism effective hand hygiene using antimicrobial soaps and alcohol gels at the bed side for the decontamination of healthcare workers, patients and visitors hands is well recognised as is the wearing of PPE for all interactions with known colonised or infected patients (Damani, 1997). Also the coordination of cleaning within the ward between nurses, domestic services

and estates services is essential so that the health and safety of the patients are not compromised (Wiseman, 2004). The development of an appropriately educated infection prevention and control link nurse within the ward setting is also considered an essential element of any initiative to reduce ward infection rates (Cooper, 2004). To date however there is no evidence that demonstrates a consistent relationship between MRSA bacteraemia levels and hospital cleanliness (Green et al, 2006).

Decolonisation GraphOur Ward and Patients

The Spinal Cord Injury Unit (SCIU) at Musgrave Park Hospital is a 15 bedded unit dedicated to the care of patients requiring rehabilitation from spinal cord injuries. From 2000 - 2005 we had 380 patients admitted to the unit. Seventy-five patients were treated for MRSA infection and or colonisation in that period.

We successfully reduced our MRSA rates during 2005. There were several contributing factors we believe to this reduction.

Bed SpaceMRSA patient management

We undertook a proactive approach between medical staff, nursing staff and infection prevention and control staff to the management of MRSA patients. All patients are screened on admission for MRSA from the carrier sites of the nose and perineum and any other potential sites of infection e.g. urinary catheter (CSU), PEG tube site, or any open lesion. Where possible patients were placed in a single room until the results of screening was available – usually within four days of admission. Treatment was instigated immediately on identification of positive results. All treatments were well documented in both nursing and medical notes. Medical and nursing staff adhered strictly to treatment / decolonising regimes. Rescreening was undertaken and results followed up and acted upon. Rescreening was discontinued following three negative screens or following three failed attempts to decolonise. Single room care of patients with persistent carriage is undertaken where possible.

Our Ward Hygiene, Standard of Equipment Cleanliness and Care Practices

Using the Infection Control Nurses Association Audit Tool on a hand held device the standard of hygiene in all wards, the cleanliness of equipment and care practices such as hand hygiene and the wearing of personal protective equipment was conducted throughout the hospital and in our ward by the Infection Prevention and Control Nursing team and link staff on wards.

The scores we obtained for Environmental Cleanliness, Equipment Cleanliness, Hand Hygiene and the use of PPE exceeded all other wards scores when our results were
compared. They are displayed and compared to the average scores attained by combining the scores of 10 other wards. Table 2. This audit system has allowed us to adopt an intra-Trust benchmarking system where trends can be identified year on year.

Contributing Factors

The SCIU has a low patient turn over rate, and there is also a low staff turn over rate. The ward had daily input from an attending physician who is actively involved in the treatment of patients with MRSA. There are clearly defined responsibilities for cleaning between domestic services, nursing staff and estate service.

Infection Prevention and Control Nursing Team and Link Nurse

The SCIU has a dedicated Infection Prevention and Control Link nurse who is well supported by the ward manager in her role. Having a proactive infection prevention and control link nurse has made communication between the IP&C team and the ward teams more effective and the engagement of link staff in audit is considered essential in developing their awareness. The Infection Prevention and Control Nursing Team have a dedicated member of staff to follow up MRSA patients in the SCIU on a weekly basis, this involves discussing MRSA screen results and decolonisation regimes with staff.

Table 2
Audit Results

Summary

We believe that the successful reduction of the rates of MRSA in our SCIU is the result of a multifactor approach as outlined. No single subject area can be identified as having a specific effect however in combination we have achieved a desired outcome of reducing the level of MRSA in our unit.

References

Bignardi G.E., Askew C. (2000) Workload may be related to the spread of MRSA and other infections. Journal of Hospital Infection, 45, 78-80.

Coia J.E., Duckworth G.J., Edwards D.I., Farrington M., Fry C., Humphreys H., et al (2006) Guidelines for the control and prevention of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities. Journal of Hospital Infection, 63: (Suppl 1) May, 1-44.

Cooper T. (2004) Delivering an infection control link nurse programme: implementation and evaluation of a flexible teaching approach. British Journal of Infection Control, 5 (5) 24-26.

Cunningham J.B., Kernohan W.G., Sowney R. (2005) Bed occupancy and turnover interval as determinant factors in MRSA infection sin acute setting in Northern Ireland: 1 April 2001 to 31 March 2003. Journal of Hospital Infection, 61; 189-193.

Damani N.N. (1997) Manual of Infection Control Procedures. London; Greenwich Medical Media.

Green D., Wigglesworth N., Keegan T., Wilcox MH. (2006) Dose hospital cleanliness correlate with methicillin-resistant Staphylococcus aureus bacteraemia rates? Journal of Hospital Infection, 64, 184-186.

French G., Otter J.A., Shannon K.P., Adams N.M.T., Watling D., Parks M.J. (2004) Tackling contamination of the hospital environment by methicillin-resistant Staphylococcus aureus (MRSA): a comparison between conventional terminal cleaning and hydrogen peroxide vapour decontamination. Journal of Hospital Infection, 57, 31-37.

McBryde E.S., Bradley L.C., Whitby M., McElwain. (2004) An investigation of contact transmission of methicillin-resistant Staphylococcus aureus. Journal of Hospital Infection. 58, 104-108.

Pittet D., Hugonnet S., Harbarth S., et al. (2000) Effectiveness of a hospital-wide programme to improve compliance with hand hygiene, Infection Control Programme. Lancet, 9238; 1307-131.

Skykes A., Appleby M., Perry J., Gould K (2006) An investigation of the microbiological contamination of ultrasound equipment. British Journal of Infection Control, 7; (4) 16-20.

Vicca A.F. (1999) Nursing staff workload as a determinant of methicillin-resistant Staphylococcus aureus spread in an adult intensive therapy unit. Journal of Hospital Infection, 43, 109-113.

Wiseman S (2004) Implementing effective infection control in the hospital environment. Nursing Times Infection Control Supplement, Sept, 100 (36)


Mary Hanrahan, Senior Infection Prevention and Control Nurse Dawn Porter, Infection Prevention & Control Link S/N SCIU Roisin Gillen, Infection Prevention and Control Nurse

Address for Correspondence: Mary Hanrahan, Infection Prevention and Control Dept Musgrave Park Hospital,Stockman’s Lane,Belfast BT9 7JB

Telephone: (028) 90903046 or from Republic of Ireland 048 90903046

email: mary.hanrahan@greenpark.n-i.nhs.uk