Eliminate Orthopedic Surgical Site Infections: Quality Improvement

Some quality improvement efforts have focused on the prevention of methicillin-resistant Staphylococcus aureus (MRSA). Balbale et al. (2015) aimed to prevent MRSA in Spinal Cord Injury and Disorder (SCI/D) Centers (p. 130). Hence, the purpose of their research was to assess the Promoting Action on Research Implementation in Health Systems (PARiHS) framework and its related outcomes after the implementation of (SCI/D) MRSA prevention guidelines. These guidelines were provided in the year 2008 in the Veterans Affairs (VA) Health Care System and, therefore, the study was conducted nearly 2-3 years after their publication.

The study used a mixed methods approach in two different phases. The initial phases involved the collection of data across 24 VA SCI/D Centers. An unspecified, web-based cross-sectional survey was administered during the first phase. Another phase involved data collection through semi-structured telephone interviews with nine SCI/D Centers. The PARiHS framework provided the basis for data collection in both phases.

The results identified facilitators to guideline implementation as increased leadership support and provider education, focused distribution of guidelines to reach intended SCI/D facilities, and evidence to support guidelines. Conversely, barriers included a lack of awareness of the guidelines among “practitioners and issues associated with isolation of MRSA-positive patients and adhering to contact standards” (Balbale et al., 2015, p. 130). It was generally concluded that effective implementation of MRSA infection prevention guidelines needed the following: (1) effective distribution of the guidelines to reach targeted facilities and practitioners, (2) provision of frequent, systematic provider education, (3) enhanced leadership support, and (4) addressing specific noted barriers. These results could be used to guide the choice of the most effective implementation methods and enhance infection control beyond MRSA in other specialty sections of hospitals.

Hospital-acquired infections that emanate from MRSA are responsible for morbidity and mortality (Mehta et al., 2013). The study sought to determine the “MRSA prevalence density rate at a specialty orthopedic hospital, compare the density rate across different institutions and to measure admission prevalence density of MRSA and compliance rates” (Mehta et al., 2013, p. 2367).

The study method involved MRSA screening and decolonization protocol. Screening was conducted using nasal swabs while specific nasal and skin antisepsis were administered to all patients. The rate of compliance was also measured, as well as institution-wide surveillance for subsequent comparison.

The result showed significant reduction in prevalence density rate. For instance, after the implementation of the decolonization protocol, the prevalence density rate declined to 0.83 per 1000 patient-day from 1.23 per 1000 patient-day while admission prevalence declined by 33% at the specialty hospital. The compliance rate was reported at 95%. Mehta et al. (2013) concluded that a staphylococcal decolonization protocol implementation at specialty orthopaedic hospital was responsible for a decline in the prevalence density of MRSA.

Jokinen et al. (2015) observed that MRSA was responsible for a widespread hospital-related epidemic in Finland in 2001. The researchers sought to describe the outcome of infection control and screening practices for MRSA (Jokinen et al., 2015).

The method involved calculating data collected from clinical and screening samples. Pulsed-field electrophoresis (PFGE) or spa typing was used for strain typing, and strain distribution were analyzed against sample type, epidemic year, and transmission site. Stepwise infection control interventions were adopted while screening protocols were increased.

The results showed that cases of hospital-acquired MRSA significantly declined from the year 2011 and the rate of epidemic strain reduced. In addition, the number of hospital-acquired MRSA cases noted from clinical samples also declined after the expansion of screening protocols. Further, enhanced use of hand-rub led to a decline in transmissions. It was therefore concluded that implementation of universal screening and other interventions was effective in controlling MRSA epidemics. MRSA strain also changed over time.

It has been observed that MRSA blood stream infection (BSI) was common in some healthcare facilities, and it was related to about 10% – 20% of mortality (Duerden, Fry, Johnson, & Wilcox, 2015). Between 2001 and 2004, England introduced mandatory reporting of MRSA BSI alongside target reductions for all national healthcare providers. After the implementation of multiple national infection prevention initiatives and the use of teams of experts in hospitals, significant changes were observed.

The study method was descriptive in nature. As such, the authors focused on elements that mainly influenced public health infection prevention efforts that, which successful in controlling MRSA infection.

The results showed important lessons and opportunities for controlling MRSA. Hospitals require several vital changes to control MRSA and diagnose no MRSA BSIs. However, emerging threats from Gram-negative bacilli, such as multiple antibiotic-resistant strains, are major drawbacks to such achievements. For instance, increasing cases of Escherichia coli BSIs have been reported in England, and they are currently more widespread than MRSA BSI. Overall, MRSA and other related pathogens require targeted interventions and sustained comprehensive surveillance.

For the past 100 years, Staphylococcus aureus has been noted as a microbial pathogen with abilities to produce suppurative and toxigenic chemicals, which are mainly life-threatening (Charles et al., 2016). While MRSA is the most common, it is now declining following national screening, intervention programs and high impact interventions.

The methods involved selective, differential, or chromogenic media nasal screening to ascertain MRSA colonization in surgical patients before admission, after screening and suppression, assessment conducted was to determine a reduction of surgical site infection. Culture methods were used to detect MRSA colonization.

The results demonstrated that nasal decolonization ‘gold standard’ was topical mupirocin, but incorrect application of mupirocin was related to improved staphylococcal resistance. The researchers concluded that the relative risk of MSSA or MRSA surgical site infection was the most effective approach for choosing an appropriate universal or targeted surveillance strategy.

Various strategies, including care bundles, have been formed to minimize surgical sit infection (SSI) (Tanner et al., 2015). Based on conflicting reports provided by individual studies, this article aimed to evaluate the efficacy of care bundles in minimizing SSI among patients undergoing colorectal procedure.

The research methods involved a “systematic review and meta-analysis of randomized controlled trials, quasi-experimental studies, and cohort studies of care bundles to reduce SSI” (Tanner et al., 2015, p. 66). Literature was obtained from different databases and clinical trials registers. It covered materials studied between 2012 and June 2014. The quality of all articles were based on the Downs and Black checklist. Raw data were obtained for calculating pooled relative risk using Cochran Review Manager. Further, publication bias was assessed, and sensitivity analysis was performed to determine the impact of specific data sets on pooled relative risks.

Results highlighted care bundles, including major interventions. These interventions included the use of antibiotic, necessary hair removal, glycemic management, and normothermia (Tanner et al., 2015, p. 66). The findings demonstrated a lower SSI rate of 7% for care bundle against 15.1 percent of standard care group. In addition, the pooled relative risk effect was clinically significant and could assist at reducing health risks associated with SSI. It was concluded that evidence-based, surgical care bundle imperatively lowered risks of SSI in patients undergoing surgical procedures.

Healthcare personnel often interacts with MRSA in the course of their work (Alexandera & Wang, 2015). It is also necessary for emergency practitioners to understand trends associated with hospital acquired infections, related treatment and prevention options. Alexandra and Wang (2015) observed that treatment was specific to a given infection, and disease prevention was the most effective measure to control rates of infections. The study methodology involved a review of literature on the development of healthcare acquired infection based on evidence levels.

The findings indicated that early identification and isolation for MRSA during admission were imperative for controlling the spread of MRSA and healthcare acquired infections. Moreover, evidence-based findings showed that early detection and rapid testing for all ER patients who presented signs and symptoms of MRSA required immediate interventions.

The authors concluded that new protocols were necessary based on evidence-based guidelines and continuous assessments. In addition, there was a need to share protocols and efforts related with evidence-based medicine with other hospitals for sustained quality improvement. Nevertheless, sharing of protocols with other facilities should be based on supporting evidence because of uniqueness of every facility. Finally, education and reinforcement were necessary to enhance effectiveness of new protocols.

MRSA screening is important for identification and isolation of MRSA colonized patients to curtail the spread of nosocomial (MacFadden, Elligsen, Robicsek, Ricciuto, & Daneman, 2013). MacFadden et al. (2013) recognized extensive use of screening and sought to assess its possible clinical application in predicting MRSA resistance.

The study methods involved a 2-year retrospective cohort study that sampled documented patients with MRSA and MRSA prior screening. Tests characteristics, such as specificity and sensitivity, were used to predict MRSA resistance and infecting isolates.

Results indicated that screening for MRSA predicted methicillin resistance in infecting isolate. However, it is imperative to note that the interval of 48 hours to obtain screening swabs resulted in increased sensitivity and specificity leading to possible negative outcomes. Hence, timing was important for reliable tests for swab and isolate collection in showing methicillin resistance in isolates and swabs. As such, it is imperative to consider negative results for isolating methicillin resistance.

MRSA colonization and related hygiene risks do not spare any form of healthcare facilities, including military medical field healthcare camps (Micheel et al., 2015). In military care environments, there are limited diagnostic options for straightforward identification of MRSA isolates. This study aimed to evaluate a stepwise use of two various selective agars for a direct detection of MRSA during screening analyses.

The methodology involved subjecting of nasal swabs to thioglycollate broth enrichment and screening on CHROMagar MRSA selective agar for detection of MRSA (Micheel et al., 2015). Suspicious colonies were identified, subsequently confirmed and isolated by using a different selective agar, chromID MRSA. Mass spectrometry and biochemical techniques were used to detect every isolate from the selective agars.

Study results showed that suspicious colonies could be identified from the samples. However, some strains could not be identified. As such, further tests and confirmation were necessary to identify MRSA. In this case, the researchers concluded that the use of the selective agar CHROMagar MRSA independently was not specific to guarantee accurate diagnoses of the availability of MRSA. As such, it was observed that the use of at least two selective agars through a stepwise strategy lessened non-specificity with a tolerably limited sensitivity loss. Therefore, a stepwise screening for MRSA was recommended for medical facilities with limited resources.

Some healthcare facilities, such as Mafraq Hospital, conduct over 10,000 surgical procedures each year. In this case, high volumes of high-risk procedures require a system for ensuring safe procedures and controlling surgical site infection (SSI) (Ng & Awad, 2015). SSI is associated with adverse health outcomes as previously observed. Impacts related to mortality, morbidity, and escalating cost of care have necessitated the need for solutions to reduce SSI and reduce healthcare associated infections. Most SSIs can now be prevented.

Mafraq healthcare facility conducts various surgical interventions that include 14 specialty areas. The facility has a team of experts for infection prevention and control. In addition, the team is responsible for surveillance of every patient who undergoes surgical procedures covered under the Centers for Disease Control and Prevention (CDC) and National Healthcare Safety Network (NHSN) Operative Procedure Category. Over the period of observation, surgical site infections increased but based on specific procedures and pathogen.

The study design also accounted for the role of multidisciplinary team drawn from various units, including “infection prevention and control (IPC), nursing, operating room (OR) nurse manager, operating room nurse educator, pharmacy, and physicians (infectious diseases, anesthesia, and surgery)” (Ng & Awad, 2015, p. 2). The team focused on developing and implementing effective interventions to lessen and eliminate SSIs, assess and monitor compliance with standards. The team ensured that effective improvement measures were selected based on evidence-based outcomes found in various international guidelines.

Overall, it was concluded that SSIs were common in busy surgical healthcare facilities but they could be controlled. A multidisciplinary team approach was effective to reduce and monitor progress and compliance. They focused on assessments of results, gap analyses, and implementation of quality improvement efforts to reduce the spread and infections associated with MRSA. The researchers also showed that appropriate interventions were found in evidence-based clinical guidelines from reputable organizations, such as the CDC. Therefore, effective medical care and attention could help healthcare facilities to control SSIs.

The Proposed Project: Implementation of an MRSA Screening Protocol: A Quality Improvement Project to Eliminate Orthopedic Surgical Site Infections

Action Item Expected Outcome Date of Completion
Project Initiation Engage all hospital leaders and stakeholders – Clinicians, Physicians, Anesthesiologist, and Nurse
Build Ownership and Buy-in – the role of senior administrative leadership
Appoint a program leader
Communication channels and information sharing paths
Assess Current Practices and MRSA Risks – quality, risks, safety, processes and practices in the operating room
Developed a gap analysis chart
30thJune 2016
Support and change management processes Formation of pilot teams, raising awareness and assessing resistance –
Finding practitioners passionate about patient quality improvement
Raised awareness by presenting evidence against MRSA
Share new proposed practices across various departments
Training on staff skills
15thJuly 2016
Full Implementation of Screening Protocols / Quality Improvement Efforts Implement Protocols
Sustain the New Practices
1 December 2016
A focus on Evidence Based Practices for MRSA Identify gaps for improvement 31 December 2016
Identify Additional Opportunities for Quality Improvement Advance and sustain quality improvement efforts 31 January 2017


Alexandera, C. A., & Wang, L. (2015). Infection Control: Methicillin Resistant Staphylococcus Aureus. American Journal of Infectious Diseases, 11(3), 74-82. Web.

Balbale, S. N., Hill, J. N., Guihan, M., Hogan, T. P., Cameron, K. A., Goldstein, B., & Evans, C. T. (2015). Evaluating implementation of methicillin-resistant Staphylococcus aureus (MRSA) prevention guidelines in spinal cord injury centers using the PARIHS framework: a mixed methods study. Implementation Science, 10, 130. Web.

Charles, E., Nathan, L., Blake, B., Maureen, S., Gary, S., & David, L. (2016). Is Staphylococcal Screening and Suppression an Effective Interventional Strategy for Reduction of Surgical Site Infection? Surgical Infections, 17(2), 158-166. Web.

Duerden, B., Fry, C., Johnson, A. P., & Wilcox, M. H. (2015). The Control of Methicillin-Resistant Staphylococcus aureus Blood Stream Infections in England. Open Forum Infectious Diseases, 2(2), 1-12. Web.

Jokinen, E., Laine, J., Huttunen, R., Arvola, P., Vuopio, J., Lindholm, L.,… Syrjänen, J. (2015). Combined Interventions are Effective in MRSA Control. Infectious Diseases, 47(11), 801-807. Web.

MacFadden, D. R., Elligsen, M., Robicsek, A., Ricciuto, D. R., & Daneman, N. (2013). Utility of prior screening for methicillin-resistant Staphylococcus aureus in predicting resistance of S. aureus infections. CMAJ, 185(15), E725-E730. doi: 10.1503/cmaj.130364.Web.

Mehta, S., Hadley, S., Hutzler, L., Slover, J., Phillips, M., & Bosco III, J. A. (2013). Impact of Preoperative MRSA Screening and Decolonization on Hospital-acquired MRSA Burden. Clinical Orthopaedics and Related Research, 471(7), 2367–2371. Web.

Micheel, V., Hogan, B., Köller, T., Warnke, P., Crusius, S., Hinz, R.,… Frickmann, H. (2015). Screening agars for MRSA: evaluation of a stepwise diagnostic approach with two different selective agars for the screening for methicillin-resistant Staphylococcus aureus (MRSA). Military Medical Research, 2, 18. Web.

Ng, W. K., & Awad, N. (2015). Performance improvement initiative: prevention of surgical site infection (SSI). BMJ Quality Improvement Programme, 4(1), 1-3. Web.

Tanner, J., Padley, W., Assadian, O., Leaper, D., Kiernan, M., & Edmiston, C. (2015). Do surgical care bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients. Surgery, 158(1), 66-77. Web.

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