Rutland Regional Medical Center
Hospital Quality Improvement Projects
Project Name: Perioperative Eradication of Staph aureus
Project Aim: To eradicate perioperative colonization with Staph aureus in order to reduce the
risk of surgical site infections for patients undergoing elective total joint procedures.
Time Frame: May 2009 - ongoing
Background:
Surgical site infections (SSI) are an infrequent but serious complication of total joint arthroplasty
with rates around 1.5 %. Orthopaedic surgical site infections cause substantial morbidity,
prolong hospital stay, lead to readmission and increase healthcare costs. Carriers of Staph aureus
are two to nine times more likely to acquire Staph aureus surgical site infections than non
carriers. Thus, interventions designed to eradicate nasal carriage preoperatively will decrease
surgical site infections.
Description:
In 2009, RRMC and Vermont Orthopaedic Clinic implemented a program to eradicate Staph
aureus colonization in patients undergoing elective total joint procedures (hips, knees and
shoulders) as well as certain spine procedures. This was the first eradication program of its kind
in the State of Vermont. The process is managed during the perioperative period by the surgeon,
pre-op nurses and infection control.
The methods used are adapted from New England Baptist Hospital (NEBH) in Boston who
performs over 6000 orthopaedic procedures each year. Following implementation, NEBH
reported 78% eradication of MRSA prior to surgery and demonstrated a 50% reduction in
surgical site infections due to Staph aureus.
The method we use includes preoperative identification of staph aureus and MRSA by nasal
swab and culture. Patients with Methicillin Sensitive Staph aureus (MSSA) carriage receive a
five day treatment course of Mupirocin and standard preoperative prophylaxis. Patients with
Methicillin Resistant Staph aureus (MRSA) carriage receive a five day treatment course of
mupirocin and preoperative prophylaxis with Vancomycin or an agent with activity against
MRSA. All patients are instructed to bath once a day for 5 days prior to surgery with
chlorhexidine.
The surgical site infection rate for orthopaedic clean cases at Rutland Regional Medical Center is
low. On average, our clean case infection rate is 0.6% which is lower than the 1-2% comparative
rate. This project is part of our commitment to work toward zero infections.
Measures:
% of Patients Undergoing Elective Joint Replacement with MRSA colonization
% of Patients Undergoing Elective Joint Replacement with MSSA colonization
% of Preoperative eradication of MRSA colonization
Orthopaedic Clean Case Surgical Site infection rate
Results:
To date we have screened 558 patients. Three percent of patients screened were colonized with
MRSA and eighteen percent were colonized with MSSA. Perioperative MRSA eradication was
successful in all (16) patients. All patients are monitored for surgical site infections for one year
post implant.
% of Preoperative eradication of MRSA
Number of
Patients
% of
Patients
MRSA positive 16 3%
Total Patients 558
Pre-operative MRSA Eradicated* 16 100%
*Two patients were not available for re-testing.
Conclusions: A small percentage of patients scheduled for total hip and knee procedures were
identified through pre-operative screening to be colonized with MRSA. All patients treated
according to the protocol were negative for MRSA at the time of surgery. Of the patients
identified with MRSA colonization, no patients developed MRSA surgical site infections. Over
the course of review, the number of patients with surgical site infections through March has
decreased. This study is limited due to small sample size. This study does not take into account
other measures that were concurrently implemented to reduce infections.
Contact information:
Denise Simpson, BS, CIC, CPHQ
Director of Performance Improvement
e-mail: dsimpson@rrmc.org
Nancy Meszaros, RN, BSN
Infection Control Preventionist
e-mail: nmeszaros@rrmc.org
Reference:
Maureen Spencer, RN, MEd, CIC, Diane Gulcyznski, RN, MS, CNOR, Susan Davidson, MD,
John Richmond, MD, New England Baptist Hospital, Boston, Mass. Abstract 118 “Eradication
of Methicillin Sensitive Staphylococcus aureus and Methicillin Resistnat Staphylococcus aureus
Before Orthopedic Surgery.” 18th Annual Scientific Meeting of the Society for Healthcare
Epidemiology of America (SHEA), April 5-8, 2008.
Nalini Rao MD, FACP, PSHEA, Barbara Cannella RN, Lawrence S. Crossett MD, A.J. Yates Jr
MD, Richard McGough III MD. "A Preoperative Decolonization Protocol for Staphylosoccus
aureus Prevents Orthopaedic Infections." Clin Orthop Relat Res (2008): 1343-1348.
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