Project Scope and Plan (PSP)

General Information:Project name: Emergency department specific MRSA protocol revision Project Manager Name: Kimberly Reed, RNSite: Bronson Methodist Hospital Location: Trauma and Emergency Department

A. Project Overview: Describe the product or service of the project, the reason project will be undertaken, and the purpose of the project. Discuss the problem or opportunity this project addresses. Include the quality and safety issue this project will address. Support with current evidence-based practice literature or data specific to the project.

I am currently employed as a registered nurse in the trauma and emergency center at Bronson Methodist Hospital in Kalamazoo, MI. Bronson is a level I trauma center and offers numerous resources in providing full care and treatment to patients with life-threatening health issues. These resources enable Bronson to manage ailments such as strokes, neurological issues, cardio-thoracic and pulmonary emergencies, and multiple other health concerns. Working in an environment that has such high patient volume and turn over, I have been able to identify an opportunity for change in this particular department. MRSA/VRE is a growing concern in the present patient population. Health professionals care for patients of every age that are living with this infectious staph bacteria strain. MRSA causes an individual to be resistant to the antibiotics that are commonly used to treat ordinary staph infections (Diseases & treatments: MRSA infection, 2013). MRSA is broken down into two different types, health-care associated MRSA (HA-MRSA) and community-associated MRSA (Diseases & treatments: MRSA infection, 2013). HA-MRSA is associated with people who have been in health care settings, such as nursing homes, hospitals, and dialysis centers, and receive or received invasive procedures. CA-MRSA affects individuals that are in the general population, spread by skin-to-skin contact. CA-MRSA usually begins as a painful skin boil, and spreads easily from person to person if the proper precautions are not used. The emergency department is exposed to both types of MRSA on a daily basis. This diverse patient population poses an enormous risk of transmission between health-care workers, patients, visitors, and anyone who may be involved in the care process. We, as nurses, must be diligent in educating the importance of maintaining appropriate contact precautions and the correct way to cleanse hands, equipment, and linen after interaction with an infected person. Currently, our hospital only has one protocol regarding MRSA precautions and it is designed for the inpatient setting. The problem that I have identified is that the ER, due to the high patient volume and turnover rate, the appropriate contact precautions are not being used or followed correctly. For example, a nurse or tech may enter into a patient’s room multiple times during one visit. Due to the fast pace environment, nurses, techs, residents, and attending physicians are either gowning up every single time they enter into a room or not at all. There are two opposing factors that need to be addressed in this inconsistency of practice. The first is the increase of risk for transmission if no one is following the appropriate contact precautions of a paper gown, gloves, and mask (if indicated by cough) when directly coming into contact with the infected patient. The appropriate supplies are not utilized such as a disposable stethoscope and designated vital sign tower that are meant to stay in that room for the entire patient’s visit and properly disposed or cleaned at the end of care. The second issue is the cost of

supplies and equipment when a health care provider is using exact contact precautions every time they enter into a patient’s room, even if they are not providing direct patient care. An example of this would be to update the patient about current status or retrieve lab labels/samples. After discussing the inconsistency of practice with one of the emergency departments lead attending physicians, we came to the conclusion that the ER needs to have a protocol that is specific for our department in regards to the appropriate usage for contact precautions. We discussed the need to re-educate all staff members on the importance of PPE when providing direct patient care and using a designated stethoscope, vital signs tower, commode, and any other equipment that can be properly disposed of or cleaned at the end of a patient’s visit. We also identified the need for the triage and bedside nurse to address the patient’s history of MRSA. We identified appropriate questions that need to be included in the triage assessment about the state of the infection (active or non-active), location of infection and date diagnosed, and their current chief complaint (are there open sores on body, any complaint of cough). After presenting this issue to both the lead physician and performance improvement committee, we concur that our current policy must be updated. We agreed that new signage indicating the use of PPE when providing direct patient care, not just when entering the room. We also determined the need to stock specific isolation carts with disposable equipment and provided instruction on the cart to dispose of appropriately. The last issue we discussed was the need to have a small in-service that will provide re-education about MRSA and how our practice has become calloused to this growing epidemic. We will educate staff with face-to-face policy updates, as well as e-mails and professional signage around the department. This professional communication will provide This policy update will help to ensure and improve patient and employee quality and safety.

Quality and safety for both patients and employees include the following (Centers for DiseaseControl and Prevention, 2013):

25%-30% of the population is colonized with staph (bacteria present but not causing

infection). Approximately 1% colonized with MRSA MRSA attacks those with weakened immune systems (can include wound infections,

urinary tract infections, blood stream infections, and pneumonia)o Advanced age, underlying disease and severity of illness

Community associated MRSA presents as pimples or boils and occurs in otherwise healthy people. These individuals do not require a recent hospitalization or medical procedure (within past year)

Quality and safety for both patients and employees include the following (Collins, 2008):

Patient can develop an infection due to the emergence of their own endogenous organisms or be cross-contamination in health care setting

EVB aseptic work practices reduce risk for infection and colonization! Proper use of PPE and proper hand hygiene is paramount to reducing the risk of

exogenous transmission to a susceptible patient.o For example, microorganisms have been found in the environment surrounding a

patient and on portable medical equipment used in the room. Environmental

surfaces around a patient infected or colonized with a multidrug-resistant organism can also become contaminated. Health care workers should be aware that they can pick up environmental contamination of microorganisms on hands or gloves, even without performing direct patient care. Proper use and removal of PPE followed by hand hygiene will reduce the transient microbial load that can be transmitted to self or to others. Identified aseptic and infection control practices have been proven to reduce the dissemination of organisms to a single patient, to prevent repeated transmissions that contribute to an outbreak situation among multiple patients, or to become established in the health care environment as endemic hospital flora (Collins, 2008).

o Only use designated stethoscope, vital sign equipment, monitors, linen, any equipment stays in room and then properly taken care of after patient discharge or transfer. Remember, if you TOUCH any item that has been in direct contact with patient or are to provide DIRECT patient care, use appropriate PPE and hygiene. Educate visitors that if they are to directly touch the patient or anything that comes into contact with the patient, they must use PPE. This includes patient clothes, linen, etc. It does NOT require PPE every time one enters into the room. Gowns and PPE should be made available inside and outside the room – disposal and discontinuation of PPE should be done inside the room and not transmitted outside the room.

o Story to share: (Association for Professional in Infection Control, 2010): One nurse comes to mind who found the resolve to make significant strides within the

patient ward dealing with chronically overwhelming situations. She was administratively responsible for directing and addressing the challenges of all patients’ chronic wound infections, ongoing cross-contamination, lack of needed medical supplies and equipment, severe understaffing, working extra shifts, and still finding time to provide care and comfort to patients. By her personal efforts to improve wound care, aseptic practices, and hand hygiene among all nursing and medical staff, mortality dropped in a dramatic decline from 33 percent to 2 percent within a 9-month period. These sustained and dedicated efforts to reduce patient infections and improve patient care in light of overwhelming adversity set a standard of practice for all nurses to follow. That nurse was Florence Nightingale, defining the art of nursing in the 1850s. Although medical care is more advanced and technically more complex since that time, it was the dedication of a nurse (like you) to ensure aseptic practices despite the significant nursing demands of patient care that makes the difference for the patients—then and now (Association for Professional in Infection Control, 2010).

o It has been demonstrated that nursing and medical practices can pick up transient microorganisms from intact patient skin and from environmental surfaces. Although the amount of contamination is not quantified and the exact incidence is not apparent, it does occur. Hand hygiene and aseptic practices before caring for a susceptible patient can reduce the transient carriage and transfer of microorganisms. The protective benefits of infection control using evidence-based practices are cost effective. This contributes to optimal patient results, shield health care workers from infection, and set high standards for patient care.

So, what can we do as health care workers? : Know and understand the different aspects of MRSA and educate both staff and the

community. Ask for compliance with the lab to alert staff and update chart when drug-resistant

infections are found in patient samples Alert the other facility when you transfer a patient with a drug-resistant infection. Protect patients, visitors and staff appropriately by following precautions in regards to

MRSA and other drug-resistant infections Appropriate antibiotic use and education Remove temporary medical devices such as catheters and ventilators as soon as no longer

needed. Continue to follow procedure on not placing indwelling catheters in the emergency room as to prevent infection

What can patients and visitors do? : Ask everyone, including doctors, nurses, other medical staff, and visitors, to wash their

hands before touching the patient. Take antibiotics only and exactly as prescribed. Remember, patients who come to the ER with other complaints and have history of

MRSA can be discharged to go home! They will be leaving and need proper education (whether they have had information provided previously or not) about MRSA at home or health care facility!

Minimum Precautions for ALL PatientsFor patients with draining skin and decubiti lesions at any site, including boils or red, large, and painful pimple like lesions:

Cover lesions whenever possible and contain visibly soiled dressings or linen in the appropriate leak proof container or bag.

Wear gloves when touching drainage and wash hands well before and after gloving. Wear gowns only if soiling of clothing is likely. Do not wear gowns outside the patient’s

room. Use designated equipment and do not remove from room until properly sanitized and/or

disposed of. If patient has not been diagnosed with MRSA, treat as if active MRSA infection. Know

what community acquired MRSA infections present as. Utilize PPE when providing DIRECT care to patient

Precautions for MRSA Colonized/Infection Patients presenting to ER: with MRSA colonization/infection of skin lesions and decubiti:

Cover lesions whenever possible. Contain visible soiled dressings of linen in the appropriate leak proof container or bag. Wear gloves when touching drainage and wash hands well before and after gloving. Wear gowns only if soiling of clothes is likely – this includes direct patient contact. Do

not wear gowns outside the patient’s room. Masks are not necessary. Use designated equipment and do not remove from room until properly sanitized and/or

disposed of. Utilize PPE when providing DIRECT care to patient

For patients with MRSA colonization/infection of the urinary tract: Use standard precautions and use proper hand washing and wear gloves. Masks are not needed unless splash may be indicated. Wear gowns only if soiling of clothes is likely – this includes direct patient contact. Use designated equipment and do not remove from room until properly sanitized and/or

disposed of. Utilize PPE when providing DIRECT care to patient

For patients with MRSA colonization/infection of the respiratory tract: Wear masks only if the patient is coughing or when performing suctioning procedures; if

performing Direct patient contact, such as assessment, wear mask. Wear gowns only if clothes are likely to become soiled – includes direct patient contact. Practice good hand washing and wear gloves when handling respiratory secretions. Use designated equipment and do not remove from room until properly sanitized and/or

disposed of. Utilize PPE when providing DIRECT care to patient

 Linen after discharge and cleaning of room

All soiled linen should be bagged at the location where it is used (strip beds inside of patient room and place all linen in appropriate blue linen bag. Linen handlers must wear barrier protection, which includes gloves and gown, and take special precaution with soiled linen (Association for Professional in Infection Control, 2010)

Communicate to environmental services that a patient with drug-resistant infection was seen and treated in room and have them follow appropriate hospital policy for cleaning of room. Communicate to EVS type of infection and chief complaint, including if patient had any open lesions, cough or respiratory issues, or elimination equipment inside of room (commode, catheter, and/or incontinence).

References

Association for Professional in Infection Control. (2010, July). Nebraska summary of guidelines for the management of patients with multidrug-resistant organisms: health care settings, community settings. Retrieved from Department of Health and Human Services Nebraska: http://dhhs.ne.gov/publichealth/Documents/MDRO-Guidelines-2010.pdf

Centers for Disease Control and Prevention. (2013, April 9th). Workplace safety and health topics. Retrieved from Centers for disease control and prevention: http://www.cdc.gov/niosh/topics/mrsa/

Collins, A. (2008). Preventing health care-associated infections. In Patient safety and quality: an evidence-based handbook for nurses. Rockville, MD, US: Hughes RG. Retrieved from http://www.ncbi.nlm.giv/books/NBK2683

Diseases & treatments: MRSA infection. (2013). Retrieved from Mayo Clinic: http://www.mayoclinic.org/mrsa/

The Impact of Education on Nursing Practice. (2012, April 2). Retrieved September 2012, from American Association of Colleges of Nursing: http://www.aacn.nche.edu/media-

relations/fact-sheets/impact-of-educationUnderstanding Isolation Precautions. (2010). Retrieved from

http://www.unc.edu/~rlensley/tb2.htmYoungblut, J., & Brooten, D. (2011). Evidence-based nursing practice: why is it important?

AACN Clinical Issues, 468-476.

B. Project Goal(s): Describe the project goal(s) using SMART (specific, measurable, accurate and agreed to, realistic, and time bound) formula. These goals will be used to measure and determine the project’s success at its conclusion.

To collaborate and propose an emergency room specific MRSA protocol by December 1, 2013 that will promote the overall improvement of quality and safety of patients and staff in a cost efficient manner. There will be a 50% increase in compliance by staff by this date and measured by two random surveys regarding the new protocol on December 15th and December 30th. Survey will passed out and collected immediately. First survey will be passed out to a total of 15 PCAs, 20 RNs, 15 residents, and 10 attending physicians at random and participants recorded. Second survey will include the initial survey participants plus equal number of new employees and results compared. New signage will be used and incorporated into practice by PCAs and RNs by December 1st and documented into EPIC. There will be three different chart audits completed on December 1st, December 15th, and December 30th, that will determine if new protocol is followed for those patients with active MRSA infections. Charting will include use of signage, PPE used, family and patient education at least once during patient visit, and that appropriate equipment was placed in room and not removed until discharge.

C. Project Objectives/Deliverables: List the specific items or services that must be produced in order to fulfill the goal of the project. Objectives/deliverables should be measurable results, measurable outcomes or specific products or services. List and number in a logical order to complete the project.

Objectives:1. Complete literature review of MRSA contact precautions and transmission rates by

September 13th, 2013 - complete2. Complete literature review of MRSA protocols for emergency room practice by

September 15th, 2013 - complete3. Complete rough draft of emergency room protocol by September 16th, 20134. Collaborate with Infection Control at Bronson Methodist Hospital with submission of

rough draft by September 17th, 2013 - 5. Design new signage with Infection Control to submit to committee for approval by

September 18th, 2013 at PI meeting6. Submit rough draft with infection control suggestions and revisions to physician and PI

committee with verbal presentation at PI meeting by 18th, 20137. Submit final draft of MRSA protocol/PSP to ER physician and clinical systems approval

board by September 22nd, 2013. Post to discussion board the final, revised, and signed plan by September 22nd, 2013.

8. Submit approved final draft of MRSA protocol designed from PSP to appropriate Bronson department and committee for final approval and implementation of new signage by October 5th, 2013

9. Implement signage and MRSA protocol into nursing practice with professional communication to ER staff by October 15th, 2013

10. Submit final project by November 25th, 2013

D. Comprehensive List of Project Requirements/Activities/Tasks: List by corresponding objective the necessary specifications of the objective/deliverable. Example 1.1, 1.2, 1.3, 1.4, etcThis is a breakdown of the objectives/deliverables into their most basic components. Consider this the action plan of the project.

1. Complete literature review of MRSA contact precautions and transmission rates by September 15th, 2013 : 1.1 Delegate search of current CDC MRSA protocols and BMH policies to RN project

member, April Vanderslik, with Infection Control department by September 9th, 2013 - completed

1.2 RN project member, April Vanderslik, to complete search by September 11th, 2013 - completed

1.3 Collaborate with RN project member, April Vanderslik, to provide summary of information and current policy by September 14th, 2013 - completed

1.4 Electronically present information and literature review to ER physician, Dr. Kerschner, by September 15th, 2013

2. Complete literature review of MRSA protocols for emergency room practice by September 17th, 20132.1 RN to identify key search words by September 13th, 20132.2 RN to complete data search by September 14th, 20132.3 RN to collaborate with project member to write summary of literature search by

September 14th, 20133. Complete rough draft of emergency room protocol by September 18th, 2013

3.1 Collaborate with project member to create MRSA protocol rough draft by September 17th, 20133.2 Design new signage with Infection Control to submit to committee for approval by

September 18th, 2013 at PI meeting4. Submit rough draft with infection control suggestions and revisions to physician and PI

committee with verbal presentation at PI meeting by 18th, 20134.1 Prepare verbal presentation and handouts to present MRSA protocol information at PI meeting September 18th, 20134.2 Receive feedback and suggestions from PI committee and project members by the end of meeting on September 18th, 20134.3 Collaborate with ER physician and receive feedback for final draft by September 18th, 2013

5. Submit final draft of MRSA protocol to ER physician and clinical systems approval board by September 25th, 2013. Post to discussion board the final, revised, and signed plan by September 22nd, 2013.5.1 Revise rough draft with project member suggestions and draft a final MRSA protocol by September 29th, 2013

5.2 Discuss grammar and pertinent information to be included in staff education with both project members, PI committee, ER physician, and project member by September 29th, 20135.3 Submit revised final draft of MRSA protocol to ER physician by September 29th, 2013

6. Submit approved final draft of MRSA protocol to appropriate Bronson department and committee for final approval and implementation of new signage by October 9th, 20136.1 Submit to department by October 2nd, 2013 electronically through e-mail and fax6.2 Receive approval or suggestions by October 6th, 20136.3 Edit changes and collaborate with group and physician and resubmit by October 6th, 2013

7. Implement signage and MRSA protocol into nursing practice with professional communication to ER staff by October 27th, 20137.1 design educational posters and in-service information for staff by October 17th, 20137.2 collaborate with group members and physician about appropriate times and review of information by October 17th, 20137.3 Submit for final approval by October 20th, 2013 to appropriate department

8. Submit final project by November 25th, 20139. Implement new protocol by December 1st, 201310. Hand-out and collect survey by December 15th, 201311. Hand-out and collect second survey by December 30th, 2013

E. Timeline: Identify time estimates by hours for each objective/deliverable in hours. These are estimates only and will be updated as project progresses.

Please see the previous sections for estimated timeline of tasks and requirements. Please see WBS for breakdown of hours and milestones (generalized). Milestone Expected

CompletionDate

Actual CompletionDate

Hours Expected/Actual

Assessment

Implementation

September 22nd

October 5th, 2013

9/22/2013

40

26

Evaluation & Revision

Final Analysis

November 6th

November 22, 2013

24

10

Total 110