Control of a methicillin-resistant Staphylococcus aureus (MRSA) cluster in critical care by reinforcing hand hygiene and standard precautions

ISSUE: The risk of healthcare-associated MRSA colonization and/or infection is considered to be greater for the patient in the critical care environment. Transmission of MRSA in a hospital setting usually occurs by indirect contact via the hands of healthcare workers. To minimize transmission, contact precautions (CP) have been recommended and used by many facilities. Standard precautions (SP) are used for patients with MRSA at this medical center. From April–July 2002, 22 patients in intensive care unit (ICU) and/or coronary care unit (CCU) and cardiovascular intensive care unit (CVICU) became colonized or infected with MRSA. DNA testing revealed that two clones were operational in the cluster. PROJECT: An infection control services (ICS) investigation included observation of patient care practices, interaction with staff to determine factors that might be contributing to MRSA transmission, DNA testing, literature review, audits of waterless alcohol degermer (degermer) use, and consultation with the hospital epidemiologist and the department of health services epidemiologist. No change from established infection control policy was initiated. An interventional partnership program was established between ICS and critical care, respiratory care services, and associated departments. Procedures and practices were observed, analyzed, and reported back to staff along with ICS recommendations to curtail transmission. RESULTS: Staff members (care partners, registered nurses, respiratory therapists, and physicians) were observed for intervals lasting approximately 30 minutes. Lapses in basic infection control practice were observed. The majority of identified problems centered on missed opportunities for the use of the degermer and/or handwashing and breaches in SP. Degermer audits determined that usage was suboptimal. ICS interventions focused on the importance of hand hygiene, emphasizing use of the degermer and reinforcing the principles of SP. Healthcare workers with direct patient contact were discouraged from wearing artificial nails and staff members were reminded to report any skin conditions to employee health services. The cluster terminated with these interventions. LESSONS LEARNED: Adhering to the principles of SP and hand hygiene was sufficient to end a cluster of healthcare-associated MRSA colonization and/or infection. This approach was relatively easy to implement and saved considerable resources by avoiding the institution of: new policies for CP, culturing patients on admission to the unit, culturing of staff, and cohorting of patients or staff.