Eradication of methicillin resistant Staphylococcus aureus by "ring fencing" of elective orthopaedic beds
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《英国医生杂志》
1 Broomfield Hospital, Chelmsford
Correspondence to: L C Biant lcbiant@yahoo.com
Abstract
Methicillin resistant Staphylococcus aureus (MRSA) is an organism that possesses the mecA gene and the penicillin binding protein PBP2a and is resistant to methicillin and oxacillin. Deep infection after joint arthroplasty can be catastrophic, leading to further surgery, loss of the prosthesis, disability, and risk of mortality.1 MRSA is a particularly difficult organism to treat because of the need to use antibiotics that are expensive, potentially toxic, or both. Other postoperative hospital acquired infections may also result in increased morbidity and mortality and prolonged hospital stay.
Outline of problem
In the year before ring fencing, we did 417 lower limb arthroplasties. In the year after ring fencing, owing to more predictable bed management and fewer complications, we did 488 lower limb arthroplasties. The number of patients undergoing arthroplasty thus increased by 17% without any increase in theatre capacity or number of beds.
The total number of all infections (including urinary tract, chest, or superficial or deep surgical site wound infections) in postoperative patients decreased from 43/417 (nine of which were MRSA) before ring fencing to 15/488 after the introduction of ring fencing (P < 0.0001). No cases of MRSA occurred in arthroplasty patients after ring fencing (table).
Infections before and after ring fencing (P<0.0001)
Preoperatively, 8/488 patients swabbed positive for MRSA skin colonisation in the community and were admitted to a non-ring fenced ward where they were isolated and received teicoplanin prophylaxis. No postoperative infections of any kind occurred in this group during the study period.
Precautions taken to prevent infections
Staff
Hand decontamination at ward entrance and before and after each patient contact by using alcoholic rub
Clean uniform:
Daily for shift
Staff from other clinical areas in previous shift
Clean ward white coat:
Orthopaedic doctors
Visiting staff
Aprons for direct patient contact
Minimal jewellery: wedding ring or small earrings only. No wrist watches, nail varnish or polish, or false nails
Antibiotic strictly prescribed according to hospital guidelines
Urinary catheter on patients' non-operated side and off the floor
Patients and visitors
Policy:
Explained during pre-admission consultation (patients)
Explained during first visit (visitors)
Restricted hours of visiting, maximum of two visitors
Visitors to use chairs provided and not to sit on the bed
Minimum number of presents (for example, flowers, food, and drink)
Premises
Policy leaflet displayed at ward entrance
Cleaning:
Visitors' chairs and foot stools once a day
Bed frames three times a week
Nurses' stations once a day
General hospital cleaning schedule strictly enforced (kitchen, doors, sinks, toilets, bathrooms)
Bed linen changed at least once a day
Lessons learnt
Ring fencing of elective orthopaedic beds and simple infection control measures significantly reduced the incidence of postoperative infections in patients undergoing joint arthroplasty, and MRSA was eradicated. As a consequence of fewer complications and more predictable bed occupancy, as well as not having beds blocked for long periods by trauma patients and non-orthopaedic patients, we were able to do 17% more joint arthroplasties without increasing the number of operating lists, beds, or surgeons.
Staff, patients, and visitors had to undergo a major change in culture in order to implement the changes. The senior medical and nursing staff acted as role models in the implementation of new policy, as described by Ching and Seto.3
We acknowledge that the reduction in infection rate was achieved by several factors: ring fencing, simple infection control measures, and reducing the number of agency staff to a minimum. However, the model as a whole shows important and significant results.
This work showed an increase in healthcare associated infection, including MRSA, in an elective orthopaedic ward containing patients from other specialties, including trauma. The importance of the theatre environment on joint arthroplasty has been understood for many years; we have shown that the ward environment is also highly important in the rate of infection in patients having joint arthroplasty.
Plowman et al suggested that hospital acquired infection increases patients' length of stay (up to 11 days per case) and the cost of treatment (￡2917 per case).4 Although infection in joint replacement surgery may be caused by direct contamination at the time of surgery, the total infection rates can be further reduced with an appropriate ward environment. We strongly recommend the ring fencing of elective orthopaedic patients and simple infection control measures to reduce the risk of postoperative infection and allow an increase in the number of patients treated.
We thank J Dowell, M Taylor, and H Lyall, who operated on patients and participated in infection control regimens, and G Virich for help with data collection.
Contributors: LCB coordinated the project, collected the data, wrote the paper, operated on patients, and participated in infection control regimens. ELT advised on setting up the study, devised the decontamination protocol, advised on infection control procedures, and devised treatment regimens for infected patients. WWW and JDT devised, set up, and coordinated the project, educated staff in infection control procedures, operated on patients, and advised on data collection. LCB is the guarantor.
Funding: None.
Competing interests: None declared.
Ethical approval: Mid Essex NHS Trust ethics committee approved the study.
References
Amstutz HC. Complications of total hip replacements. Instr Course Lect 1974;23: 248.
British Orthopaedic Association recommendation on sterile procedures in operating theatres. London: BOA, 1999. www.boa.ac.uk/BOAsterilerec.htm (accessed 22 June 2004).
Seto WH, Ching TY, Chu YB, Ng SG, Ong SG. Evaluation of staff compliance with influencing tactics in relation to infection control policy implementation. J Hosp Infect 1990;90: 157-66.
Plowman R, Graves N, Griffin M, Roberts S, Swan A, Cookson B, et al. The socio-economic burden of hospital acquired infection. London: Public Health Laboratory Service, 2000.(Leela C Biant, specialist)
Correspondence to: L C Biant lcbiant@yahoo.com
Abstract
Methicillin resistant Staphylococcus aureus (MRSA) is an organism that possesses the mecA gene and the penicillin binding protein PBP2a and is resistant to methicillin and oxacillin. Deep infection after joint arthroplasty can be catastrophic, leading to further surgery, loss of the prosthesis, disability, and risk of mortality.1 MRSA is a particularly difficult organism to treat because of the need to use antibiotics that are expensive, potentially toxic, or both. Other postoperative hospital acquired infections may also result in increased morbidity and mortality and prolonged hospital stay.
Outline of problem
In the year before ring fencing, we did 417 lower limb arthroplasties. In the year after ring fencing, owing to more predictable bed management and fewer complications, we did 488 lower limb arthroplasties. The number of patients undergoing arthroplasty thus increased by 17% without any increase in theatre capacity or number of beds.
The total number of all infections (including urinary tract, chest, or superficial or deep surgical site wound infections) in postoperative patients decreased from 43/417 (nine of which were MRSA) before ring fencing to 15/488 after the introduction of ring fencing (P < 0.0001). No cases of MRSA occurred in arthroplasty patients after ring fencing (table).
Infections before and after ring fencing (P<0.0001)
Preoperatively, 8/488 patients swabbed positive for MRSA skin colonisation in the community and were admitted to a non-ring fenced ward where they were isolated and received teicoplanin prophylaxis. No postoperative infections of any kind occurred in this group during the study period.
Precautions taken to prevent infections
Staff
Hand decontamination at ward entrance and before and after each patient contact by using alcoholic rub
Clean uniform:
Daily for shift
Staff from other clinical areas in previous shift
Clean ward white coat:
Orthopaedic doctors
Visiting staff
Aprons for direct patient contact
Minimal jewellery: wedding ring or small earrings only. No wrist watches, nail varnish or polish, or false nails
Antibiotic strictly prescribed according to hospital guidelines
Urinary catheter on patients' non-operated side and off the floor
Patients and visitors
Policy:
Explained during pre-admission consultation (patients)
Explained during first visit (visitors)
Restricted hours of visiting, maximum of two visitors
Visitors to use chairs provided and not to sit on the bed
Minimum number of presents (for example, flowers, food, and drink)
Premises
Policy leaflet displayed at ward entrance
Cleaning:
Visitors' chairs and foot stools once a day
Bed frames three times a week
Nurses' stations once a day
General hospital cleaning schedule strictly enforced (kitchen, doors, sinks, toilets, bathrooms)
Bed linen changed at least once a day
Lessons learnt
Ring fencing of elective orthopaedic beds and simple infection control measures significantly reduced the incidence of postoperative infections in patients undergoing joint arthroplasty, and MRSA was eradicated. As a consequence of fewer complications and more predictable bed occupancy, as well as not having beds blocked for long periods by trauma patients and non-orthopaedic patients, we were able to do 17% more joint arthroplasties without increasing the number of operating lists, beds, or surgeons.
Staff, patients, and visitors had to undergo a major change in culture in order to implement the changes. The senior medical and nursing staff acted as role models in the implementation of new policy, as described by Ching and Seto.3
We acknowledge that the reduction in infection rate was achieved by several factors: ring fencing, simple infection control measures, and reducing the number of agency staff to a minimum. However, the model as a whole shows important and significant results.
This work showed an increase in healthcare associated infection, including MRSA, in an elective orthopaedic ward containing patients from other specialties, including trauma. The importance of the theatre environment on joint arthroplasty has been understood for many years; we have shown that the ward environment is also highly important in the rate of infection in patients having joint arthroplasty.
Plowman et al suggested that hospital acquired infection increases patients' length of stay (up to 11 days per case) and the cost of treatment (￡2917 per case).4 Although infection in joint replacement surgery may be caused by direct contamination at the time of surgery, the total infection rates can be further reduced with an appropriate ward environment. We strongly recommend the ring fencing of elective orthopaedic patients and simple infection control measures to reduce the risk of postoperative infection and allow an increase in the number of patients treated.
We thank J Dowell, M Taylor, and H Lyall, who operated on patients and participated in infection control regimens, and G Virich for help with data collection.
Contributors: LCB coordinated the project, collected the data, wrote the paper, operated on patients, and participated in infection control regimens. ELT advised on setting up the study, devised the decontamination protocol, advised on infection control procedures, and devised treatment regimens for infected patients. WWW and JDT devised, set up, and coordinated the project, educated staff in infection control procedures, operated on patients, and advised on data collection. LCB is the guarantor.
Funding: None.
Competing interests: None declared.
Ethical approval: Mid Essex NHS Trust ethics committee approved the study.
References
Amstutz HC. Complications of total hip replacements. Instr Course Lect 1974;23: 248.
British Orthopaedic Association recommendation on sterile procedures in operating theatres. London: BOA, 1999. www.boa.ac.uk/BOAsterilerec.htm (accessed 22 June 2004).
Seto WH, Ching TY, Chu YB, Ng SG, Ong SG. Evaluation of staff compliance with influencing tactics in relation to infection control policy implementation. J Hosp Infect 1990;90: 157-66.
Plowman R, Graves N, Griffin M, Roberts S, Swan A, Cookson B, et al. The socio-economic burden of hospital acquired infection. London: Public Health Laboratory Service, 2000.(Leela C Biant, specialist)