New England Baptist Hospital: Testing
Patients for MRSA and Staph aureus
Before Inpatient Surgery

Patients asking for the lab test that “goes after the bad bug”


		Ellen Jo Baron, PH. D.
		Director, Clinical Microbiology Lab, SHC Professor, Dept. of Pathology, Stanford Med School

The New England Baptist Hospital (NEBH) in Boston is an orthopedic center of excellence, performing over 6,000 inpatient surgeries a year and another 4,000 outpatient cases. Surgeries comprise 83% of their service, and 75% of that is orthopedics. Post-surgical infections in bones and joints are among the most difficult and costly to manage and patient morbidity rises dramatically if the organism reaches the bloodstream. The hospital has established a multidisciplinary infection control team with the audacious goal of achieving a zero surgical site infection rate. Part of the team’s effort involves empowering patients to participate in an eradication program for methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA). Since the team was formed in 2003, the overall infection rate has dropped from 0.7% to 0.4%.

In the summer of 2005, the infection control team, directed by Maureen Spencer, R.N.,M.Ed, CIC, noticed an increase in secondary bacteremias due to MRSA and MSSA, associated with surgical site infections. This raised a red flag, since there is an increased risk of adverse outcomes with septicemia. This occurrence also coincided with national and international interest in rising rates of MRSA in the community and healthcare settings.

Fortunately, Susan Cohen, MT(ASCP), S.M., Microbiology Supervisor, had saved the MRSA and MSSA isolates from orthopedic patients for more than a year. A large sample of isolates was sent to a reference lab for pulsed-field gel electrophoresis. Testing revealed that there was no point source outbreak or significant patient-to-patient transmission in the hospital. It became clear that the organisms causing the infections were from the patients’ own skin flora. To test this hypothesis, the infection control team cultured 133 patients in the operating room searching for MRSA or MSSA in their noses. Results showed that 29% of the patients had MSSA and 4% had MRSA in their noses. This confirmed the team’s suspicions, that many patients coming in for surgery were already colonized. Maureen Spencer broached the topic at a Patient Care Assessment Committee meeting, saying, “we need to do something about this—bacteremia carries an increased risk of morbidity and mortality.” Fortunately, someone with the ability to carry the momentum forward was listening. Diane Gulczynksi, R.N., M.S., Senior Vice President for Patient Care Services, initiated research on the problem. After educating herself about healthcare-acquired MRSA (HA-MRSA) and community-acquired MRSA (CA-MRSA), she learned about active surveillance and prevention measures implemented in European hospitals and at the Evanston Hospital, Evanston, IL (read article in On-Demand, vol. 1, issue 1).

Gulczynksi realized that NEBH had a unique opportunity to go one step further. Why not perform active surveillance screens, using rapid test technology, in the pre-admission process? It would identify positive patients even before they arrived at the hospital and they could take appropriate measures to reduce colonization. She prepared a white paper on the eradication of MRSA and S. aureus prior to surgery and recommended opportunities for NEBH to meet the challenge. It had worked in other settings and she was sure it would work at NEBH. ^1-6

She presented her research to the hospital’s Board of Trustees and Administration in January, 2006 and requested the Board’s support for her goal: “to identify strategies to eradicate HA-MRSA from New England Baptist Hospital’s surgical patients.” The program is now two years old, and has made substantial strides towards that goal, including upgrading the hospital’s rapid testing technology (now Cepheid GeneXpert^® System).

Program Implementation

The three pillars of support necessary for implementation of a successful MRSA control program are:

A strong administrator who advocates for the program (and sees to it that the necessary funding is provided)
A proactive Infection Control Team
An energetic and committed Microbiology Department

All three factors were poised for action at NEBH in February 2006. Gulczynksi’s report to the Board of Directors was convincing enough to secure the financial support needed to hire an additional Medical Technologist for the Microbiology Laboratory and a Patient Care Technician (PCT) for the Pre-Admission Screening Department. These positions were filled in the spring of 2006.

The new PCT’s title was MRSA Coordinating Technician, with responsibilities to collect the nasal swabs, communicate with the patients and caregivers, and manage the paperwork. The other PCTs in the Pre-Admission Screening Department were then cross-trained to perform the same functions.

Initiation of the program required extensive and continuous communication among the healthcare team. Coordination included Information Systems, which developed a special test code that automated immediate results reporting to the patient’s unit and the pre-admission clinic. At the beginning, weekly meetings were held with Infection Control, Microbiology, Operating Room nurse managers and pre- and post-surgical services representatives, Housekeeping (which assists with patient room disinfection and maintaining isolation), Pre-Admission Services, and Information Services. Now, says Cohen, the system is running so smoothly that they rarely need to meet anymore.

Susan Cohen initially chose to validate the GeneOhm (BD, Cockeysville, MD) system performed on the Cepheid SmartCycler PCR instrument. The initial validation consisted of the laboratory running 150 patient nares swabs in parallel with culture on a colistin-nalidixic acid agar and a regular sheep blood agar plate. Initially no proficiency testing (P.T.) survey was available, and samples were shared with two other facilities using the SmartCycler. The College of American Pathologists now offers P.T. for MRSA surveillance and sharing samples is no longer necessary.

Due to staffing and method requirements, the Microbiology Laboratory initially tested samples twice a day, Monday through Friday. Because patients were tested approximately 10 days before their surgery date, this testing schedule provided adequate turnaround times. However, patients admitted for emergency surgery and those who could only visit the pre-admission clinic on weekends were excluded. Nevertheless, the lab was ready and the program was formally launched for a pilot trial on spinal surgery patients in July 2006 using Cepheid’s SmartCycler test.

Testing Process

The Pre-Admission Screening Department collects nasal swabs, which are sent to the Microbiology Lab. The swabs are plated for a standard culture to detect MSSA with results available the next day and are then processed for MRSA by PCR with results available in hours. Patients are given a decolonization protocol that includes a prescription for 2% mupirocin nasal ointment (Bactroban) and 2% chlorhexidine (Hibiclens).

If the tests show colonization with either MRSA or MSSA, the patient is called at home by the MRSA Coordinating Technician and instructed to begin the decolonization protocol. A prescription is called to the pharmacy and the patient is instructed to purchase the bottle of Hibiclens. The topical decolonization protocol has shown a 78% eradication of S. aureus at the time of surgery⁷. Patients positive for MRSA are re-tested at time of admission. If test results are still positive for MRSA, contact precautions are used in the operating room and throughout the hospitalization. All patients who initially tested positive for MRSA receive vancomycin for surgical prophylaxis. Prior to active surveillance for MRSA, patients would have received cefazolin, which would have been ineffective. Most impressively, overall MRSA infections at NEBH have dropped dramatically, more than 50%, from previous years. The overall national average infection rate for orthopedic surgery is 1.5%. NEBH’s rate is 0.4%.

Introducing the GeneXpert® System

The GeneXpert test replaced the SmartCycler test in May 2007, allowing universal patient testing whenever the patient arrives, including weekends. In addition, the moderate complexity allows the Microbiology specimen processor (their Planter) to perform the test, speeding up results to the patient and freeing the Microbiology Technologists to concentrate on other more complex testing. The GeneXpert System has made it feasible to entertain moving the testing to all admissions, not limiting it to inpatient surgical patients as initially practiced.

The NEBH team has tested more than 10,000 patients for MRSA and MSSA to date, Judging from both the community’s response and in 2007, the prestigious Betsy Lehman Award, given annually to the Boston area hospital with the best new program for innovations in patient care, NEBH has succeeded magnificently. In addition to the obvious success in lowering the rate of MRSA infections in their patients, Maureen Spencer, R.N., is also enthusiastic about broader aspects of the program. Testing and reporting results on colonization gives the MRSA Coordinating Technician the opportunity to provide patient education on hand hygiene and risks for transmission both inside and outside of the hospital, regardless of whether the patient is actually colonized with MRSA, MSSA, or neither. She points out,“even if we only focus on inpatients, imagine the patient care education we can accomplish. And the patients have loved it.” The program has been so successful that patients are now actively seeking out NEBH for their surgeries because it is the hospital that “looks for the bad bug.”

Susan Cohen is also extremely satisfied, especially now that the hospital can offer two-hour turnaround 24/7 with much less labor and effort using the GeneXpert test. She concludes “If we have access to a better technology, aren’t we obligated to provide that for our patients? We should feel a responsibility to provide the best care that we can for our patients. Our entire hospital team never lost sight of that.”

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References

CDC: Four pediatric deaths from community acquired MRSA – Minnesota and North Dakota, 1997–1999. MMWR. 1999; 48: 707–710.
Manangan LP, Jarvis WR: Prevention of methicillin-resistant MRSA, methicillin-resistant Staphylococcus epidermis (MRSE), and vancomycin-resistant enteroccci (VRE) colonization/infection. Antibiotics for Clinicians. 1998; 2: 33–38.
Lowy F: Staphylococcus aureus infections. New England Journal of Medicine. 1998; 339: 520–532.
Johnson AP, Pearson A, Duckworth G: Surveillance and epidemiology of MRSA bacteremia in the UK. Journal of Antimicrobial Chemotherapy. Sept. 2005; 56(3): 455–62.
Wilcox MH, Hall J, Pike H, Templeton PA, Fawley WN, Parnell P, Verity P: Use of perioperative mupirocin to prevent methicillin-resistant Staphyloccus aureus (MRSA) orthopaedic surgical site infections. Journal of Hospital Infection. 2003; 54(3): 196–201.
Sankar B, Hopgood P, Bell KM: The role of MRSA screening in joint-replacement surgery. International Orthopaedics. June 2005; 29(3): 160–163.
Spencer M, et al. Eradication of Methicillin sensitive Staph aureus and Methicillin resistant Staph aureus before Orthopedic Survery. Society for Hospital Epidemiologists of America. Poster Presentation, April 8, 2008.