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.

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%

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

New England Baptist Hospital Orthopedic Surgery Inpatient Surgery - 2005 Massachusetts Market

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.

The Implementation of an MRSA and MSSA Eradication Program at NEBH

Reason #1: Increase in MRSA in Community

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

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

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

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

? 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

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.

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

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.

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

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

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

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

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

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)

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.

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.

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.

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

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.

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.

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

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

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!

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.