Implementing a comprehensive Surgical Site Infection (SSI) bundle that includes screening your most vulnerable patients for Methicillin-resistant Staphylococcus aureus (MRSA) takes planning, patience and perseverance. We achieved 100% SSI bundle compliance within 3 months of implementation and reached our goal by reducing our SSI rate from 2.9% to 1.2%. Here's how we did it.

More than CHG

As part of our SSI bundle, we provide patients at Nemours/ Alfred I. duPont Hospital for Children with chlorhexidine gluconate (CHG) cloths. In 2016, we implemented additional items into our SSI bundle for our implant patients. For these patients, in addition to our standard bundle elements, we added a MRSA screening protocol and a nasal betadine swab.

Implant patients have a greater risk of developing SSIs. When a patient with an implant develops an SSI, she might have to have the implant removed and replaced, which prolongs hospitalization. While an SSI has a financial impact no matter the case, the cost is significantly higher with implant recipients. Additional costs of an SSI in these patients can range upwards of $25,000 to $30,000.

While the MRSA screening initiative focuses on the implant patients, the process can be easily adapted to all patients if the need arises.

Once we decided to move forward with the MRSA screening process, the challenges were significant and sometimes surprising. We do about 1000 surgeries a month. Of those, about 100 are implant patients.

To move this new screening process forward, we needed to engage and educate every nurse, surgeon and anesthesiologist. As a clinical nurse specialist in perioperative services, I collaborated with our physician leadership to attend all the division meetings. The entire team needed to understand what the bundle was and the implication of the practice change. If there was an orthopedics meeting at 6 in the morning, we were there. If there was a general surgery meeting at 6 in the evening, we made sure to go. For our nurses, we rolled out web-based training for the entire staff and did in-services on all the nursing units.

MRSA screening has to be completed before the patient goes to the OR, so timing and planning is key. We had to make sure everybody was aware of the expectation before the process was implemented, this ensured success of the screening program.

Once the bundle was fully implemented, we knew auditing was integral to its success. We monitored bundle adherence manually through chart audits and eventually with help from our EMR, through a report. The report, which I receive every day, lists each of our SSI bundle items, along with the documentation of the bundle elements. If anything is listed as incomplete or incorrectly documented, I do a manual chart audit. Depending on the non-compliant item, I either go back to the nursing team to determine the contributing factors or to the physician leadership who will then address the non-compliance with their teams.

Ultimately, each division weighed in on exactly what constituted an implant. That helped us standardize the protocol and eliminate confusion.

Our EMR played another key role. When a case is scheduled, the surgeon is able to identify if the patient is going to be receiving an implant. A "yes" creates a visual cue — a picture of a little screw that shows up on our status boards throughout the perioperative area. The screw is also visible in the patient list, so anyone who treats a particular patient can see that he should have had a MRSA screening and a betadine nasal swab completed in addition to the standard SSI bundle elements. The surgical team should be aware of the results of the MRSA swab prior to entry into the OR.

We contact families 48 hours before surgery to give them arrival times and day of surgery specific instructions. The RN who makes the call makes sure that there is a valid result on the chart, or notes that the swab has yet to be done. If the swab hasn't been completed, we ask families if they're in the area and are able to stop in to our outpatient lab. If it is inconvenient for the family, our pre-op holding patient flow supervisor assigns someone to be responsible for the screening on the day of surgery.

Once we have the results, we have an algorithm that dictates the recommended prophylaxis, which depends on the procedure. For patients who test positive for MRSA, we add Vancomycin to the pre-incision prophylaxis. And, if those patients are allergic to Vancomycin, we use a decision tree based on recommendations from our infectious disease physicians.

Another challenge: getting results

Obtaining timely and reliable results turned out to be another barrier we had to overcome. It takes only 3 seconds to swirl a swab inside a patient's nose, but what happens after that can be unpredictable.

As a result of process improvements and patient satisfaction initiatives, we eliminated our pre-admission testing (PAT) clinic. This process change added value to patients and their families. We provide pre-op teaching to families over the phone. We discuss safety measures and the SSI bundle components, but the families were no longer required to come to the hospital before surgery. This required us to get creative about getting MRSA swabs.

Initially, we mailed the swabs to patients' families, along with an illustrated educational pamphlet. Families were instructed to swab the child and drop the swab off at their insurance approved local lab for testing. However, there were obstacles there, too. Some insurance mandated labs do not have a PCR (polymerase chain reaction) machine, so they had to run the test as a culture. The problem with this is it forced the labs to run the test as a culture, which takes 3 days, versus the 2 hours for a PCR. Additionally, we saw many inconsistencies with the outside labs. For example, occasionally we'd get results back and it would turn out that the swabs had been tested for something other than MRSA.

Our own machines

In 2018, our hospital decided that the quality and reliability of accurate MRSA results was necessary to improve outcomes for our patients. All the MRSA screenings are now completed in our own lab at the hospital. We have 2 PCR machines, so time and space were not concerns to support this new initiative. Now, when patients come in to meet the surgeon, usually a couple of weeks before the surgery, we have them present to the outpatient lab for their MRSA screening. If the schedule changes, or if there is an add-on surgery, we can do the testing on the day of surgery. Children who live outside the immediate vicinity of the hospital are able to stay the night before surgery at the Ronald McDonald House.

Trauma patients and emergency surgery require the same protocol, however, we will not delay surgery for the MRSA screening. Antibiotic stewardship is a priority for our organization, and therefore, an antibiotic is not used unless indicated.

Although Nemours has not had a problem getting reimbursed for the MRSA swabs because they are considered part of the surgical encounter, we realized that even if we weren't being reimbursed, the cost to us is negligible compared to the overall value of preventing an SSI.

Crucial elements

Ultimately, there were several keys to success. One was making sure we provided first-hand education with everybody involved. We would not have been able to move forward if we had to rely on e-mail, flyers, or word of mouth. Auditing and in-the-moment feedback were crucial to the success of our implementation. Buy-in from all the key stakeholders was also essential to ensuring compliance and giving feedback. Looking back on this journey, while there were challenges along the way, we overcame them as a team and the success far exceeded our expectations. OSM