• Dr. D. McGrail, Infectious Disease Consultant to Infection Prevention and Control
• Carol Watson, Senior Vice President, Clinical Services
• Dr. C. Reynolds, Senior Vice President, Medical Affairs
• Acute and Skilled Care Nurse Managers

• Employees of Mercy Medical Center providing direct patient care
• Jolene Ott, Infection Prevention and Control Manager
• Stacy DeMoss, Infection Control Coordinator

Decrease the number of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) infections by 30 percent.

• Number of MRSA infections per month
• Number of VRE infections per month

• Worked with administration to understand the increased incidence of MRSA and VRE in the community.
• Developed protocols for screening patients upon admission to identify MRSA and VRE carriers.
• Educated staff about the rising MRSE and VRE prevalence in the community, the anticipated benefits of the screening program, and how to handle the anticipated increase in isolation cases on each unit.
• Changed the Contact Isolation protocol to include gown, gloves and mask as the PPE needed to enter the room, visitors included.
• Identification of carriers is accomplished by collecting a nasal swab from all nursing home residents at the time of admission.  The patient is placed into Contact Isolation until the culture is complete and negative for MRSA.
• Persons transferred from another acute care facility are placed into contact isolation. A nasal swab to rule out MRSA is collected as well as a stool specimen or rectal swab to rule out VRE. The patient remains in contact isolation until both swabs are final and negative for MRSA or VRE.
• VRE stool cultures or rectal swabs are collected quarterly from each patient on a unit. 
• If a positive is identified, the unit screens all patients one day each week until all screens are negative for 3 consecutive weeks. The unit then screens in 4 weeks. If all screens are negative the unit goes back to quarterly screens.
• Persons receiving vancomycin greater than 7 days are screened for VRE. If positive, the unit screens until all screens are negative for 3 consecutive weeks.
• Persons identified with MRSA or VRE infection or carriage are marked "CARRIER" so that on readmission to our facility, they are placed into Contact Isolation.
• Changed isolation protocol excluding visitors from the requirement to wear mask, gown and gloves to enter room.  Non-compliance became a dissatisfier for visitors and staff.  Breeches such as persons walking in the hall with PPE on, or masks worn below the nose or under the chin were noted. 
• Visitors enter the room, perform hand hygiene, then perform hand hygiene again before exiting the room.
• Beginning January 2005, total joint patients are screened for MRSA nasal carriage during pre-surgical teaching and evaluation sessions.
• If Staphylococcus aureus is identified, the patient begins daily head to toe showers using Hibiclens and twice a day Mupuricin ointment is placed into the anterior nose twice a day. Both interventions take place during 5 days. At 24 and 48 hours after completion of the shower and nasal ointment treatment, the nose is swabbed to rule out MRSA. If negative, the patient receives Ancef as the pre-op antibiotic.
• If one of the nasal swabs is positive, the Hibiclens shower and Mupuricin ointment treatment is repeated and Bactrim with Rifampin or Doxycycline with Rifampin is given twice a day during the 5 days of shower/nasal ointment treatment. Cultures are collected from the nose at 24 and 48 hours after treatment.
• Vancomycin is given for the pre-op antibiotic if the cultures are not free of MRSA. In addition, the patient is managed in Contact Isolation and marked as a "CARRIER."
• Cardiologists and vascular surgeons have now agreed to use the total joint protocol for persons scheduled for CABG or ICD or Pacer Implants. This program is under development.
• Tracked the number of MRSA and VRE infections per month and report results.
• Review every admission to be ensure that cultures are collected and appropriate isolation precautions are established.
• A new risk group has been identified in Cedar Rapids, that is persons with community-acquired MRSA (CA-MRSA). An increase was noted beginning in January 2006.
• Persons with skin and/or soft tissue infections (patients frequently report spider bites that don’t heal) are placed into Contact Isolation, the wound opened by the physician, if appropriate, and a culture collected to rule out MRSA.

• Direct patient care staff has worked very hard to accomplish this improvement.
• New sources of multidrug-resistant organisms must be identified and included in the process to hold the gains.
• Support of the nurse managers is important to the initiation and maintenance of the change.

• Prevention costs money.
• Infections cost money and increase morbidity and mortality.
• Members of the patient care team, including physical therapists, speech and occupational therapists and social workers, are staunch supporters of the process and assist visitors to understand the purpose of the precautions and encourage visitor involvement in reducing the spread of multidrug-resistant organisms.

Jolene Ott, RN, MS, CIC
Mercy Medical Center
jott@mercycare.org

Storyboard presentation at IHI's 2006 National Forum