Reducing Healthcare-Associated MRSA Infections on a Surgical Unit

St. John’s Regional Health Center
Springfield, Missouri, USA

The team from St. John's Regional Health Center is a participant in IHI's Learning and Innovation Community on Reducing Hospital-Acquired Infections.
Ravi Nerella, MD, Hospitalist
Judy Walker, BSN, Nursing Director, 7C Surgical Unit
Patti Reynolds, BSN, Infection Control Coordinator
Diana Henderson, BSN, Executive Director of Quality
Brenda Hollier, RN, Quality Analyst
Team Sponsors:
Ronnie Brownsworth, MD, Senior Vice President, Medical Management Services
Lynn Smith, Vice President, Performance Improvement
Initial Aim:
To sustain 30 percent reduction of surgical site infections (SSIs), bloodstream infections (BSIs), and healthcare-associated pneumonia (HAP) due to methicillin-resistant Staphalococcus aureus (MRSA) by focusing on prevention of transmission on 7C Surgical Unit. Sustain compliance at greater than or equal to 90 percent on process measures for reliable hand hygiene, contact precaution for isolation patients, and appropriate room cleaning/disinfections on 7C Surgical Unit. Achieve 98 percent compliance obtaining admission active surveillance cultures (ASC) in adult intensive care units (ICU), pediatric ICU, and the burn unit.
Selected Pilot Unit:
7C Surgical Unit (general surgery, trauma, ENT, Urology, Plastics, and Medical overflow) with an average daily census of 26. This unit was selected as a pilot because of supportive leadership and indicators from baseline date of an opportunity for improvement with the MRSA measure.

Process Measures:
  • Percent of targeted patients with admission active surveillance culture collected
  • Percent of environmental cleanings completed appropriately
  • Percent of patient encounters with compliance for contact precautions
  • Percent of patient encounters with compliance for hand hygiene
Outcome Measures:
  • Days between MRSA infections
  • Rate of occurrence of MRSA SSI, BSI, and HAP per 1,000 patient days

Hand Hygiene:
  • Cultures collected quarterly on selected co-workers’ hands
  • Strategic placement of hand hygiene dispensers on the unit
  • Provide alcohol-based hand rub for patients on bedside table
  • Implement “hands up” campaign — the standard phrase or action to use if you observe another co-worker NOT performing hand hygiene when appropriate
  • Encourage patients and their families to remind health care workers to practice hand hygiene
    • “It’s okay to ask” button with scripting
    • “It’s okay to ask” sign hung in patient rooms
    • Director of Nursing makes patient rounds and completes hand hygiene upon entry 
      • Utilize scripting to engage patients to encourage health care workers to complete hand hygiene
      • Provide patient and family members with the “It’s okay to ask” brochure
  • Monitor health care workers’ adherence to hand hygiene practices and provide real-time feedback
    • Positive reinforcement provided to workers regarding appropriate hand hygiene compliance
    • Physician-to-physician conversations regarding non-compliance
    • Director of Nursing addresses front-line co-worker/ancillary staff non-compliance
  • Infection Prevention Specialist (IPS) attends monthly staff meeting and reviews process and outcome measures
Contact Precautions:
  • Educate workers to complete hand hygiene before donning personal protective equipment (PPE)
  • Floor stock isolation kits standardized  with dedicated equipment
  • Educate workers to utilize computer forcing function that designates type of isolation on diet orders
  • Identify isolation patients by placing a sticker on patient menu and placing in designated area for dietary staff
  • Visual aid placed on isolation holders as a reminder to encourage hand hygiene prior to donning PPE
  • Assign daily monitoring and stocking of isolation holder supplies
  • Provide patient with isolation precautions frequently asked questions (FAQs) pamphlet  
  • Workers to obtain items from nourishment room for isolated patients and family members
Room Cleaning and Disinfection:
  • Identify clean equipment with red “door knocker” tag
  • High touch cleaning checklist provided to workers
  • Three-step process to notify Environmental Services (EVS) that isolation room needs terminal cleaning, which includes laundering privacy curtain
MRSA Active Surveillance Cultures (ASC) in the Adult ICUs, Pediatric ICU, and Burn Unit:
  • Educate workers on MRSA active surveillance processes
  • Monitor ASC compliance by unit









Summary of Results / Lessons Learned / Next Steps

Accomplishments on the Pilot Unit:

  • 308 days since last MRSA infection on pilot unit (as of 12/16/2008)
  • Achieved our outcome goal and process goals for infection reduction
  • Hand hygiene >90 percent on pilot unit for five months


Lessons Learned:

  • Utilize the FMEA tool to assess risk and identify priorities for improvement
  • A picture is worth a thousand words — the project “tipping point” occurred when we began to culture hands and equipment of workers [see image above depicting culture on worker's hand and culture on stethoscope equipment]
  • Reducing HAI must be kept at the forefront of workers’ minds (e.g., posters, staff meeting presentations, transparency of data)
  • Personalizing infections: We were surprised when we surveyed our pilot unit and discovered workers “thought they did not contribute to the infections.” They assumed infections were acquired on another unit or from another co-worker. We discussed contributing factors relating to the infection of “Mr. Jones in room 7000.” We encouraged co-workers to be a part of the dialogue that established personal accountability and allowed us to discuss the patient, rather than a number on a run chart.    

Contact Information
Brenda Hollier (Huddleston)
St. John’s Regional Health Center

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