Impact of decolonization on methicillin-resistant Staphylococcus aureus transmission and infection in a neonatal intensive care unit.

BACKGROUND: The value of decolonization as a strategy for preventing methicillin-resistantStaphylococcus aureus (MRSA) in the neonatal intensive care unit (NICU) remains to be determined. OBJECTIVE: After adding decolonization to further reduce MRSA transmission in our NICU, we conducted this retrospective review to evaluate its effectiveness. METHOD: The review included patients who were admitted to our NICU between April 2015 and June 2018 and were eligible for decolonization including twice daily intranasal mupirocin and daily chlorhexidine gluconate bathing over 5 consecutive days. Patients were considered successfully decolonized if 3 subsequent MRSA screenings conducted at 1-week intervals were negative. The MRSA acquisition rate (AR) was calculated as hospital-acquired (HA) MRSA per 1,000 patient days (PD) and was used to measure the effectiveness of the decolonization. RESULTS: Of the 151 MRSA patients being reviewed, 78 (51.6%) were HA-MRSA, resulting in an overall AR of 1.27 per 1,000 PD. Between April 2015 and February 2016, when only the decolonization was added, the AR was 2.38 per 1,000 PD. Between March 2016 and June 2018 after unit added a technician dedicated to the cleaning of reusable equipment, the AR decreased significantly to 0.92 per 1,000 PD (P < .05). Of the 78 patients who were started on the decolonization, 49 (62.8%) completed the protocol, 11 (14.1%) remained colonized, and 13 (16.7%) were recolonized prior to NICU discharge. CONCLUSION: In a NICU with comprehensive MRSA prevention measures in place, enhancing the cleaning of reusable equipment, not decolonization, led to significant reduction of MRSA transmission.

Simulation Prepares an Interprofessional Team to Evacuate a 60-Bed Level 4 Neonatal Intensive Care Unit.

In August 2011, a 5.8 magnitude earthquake struck the Baltimore/Washington, District of Columbia, corridor. The event identified a critical requirement to prepare our interprofessional team to evacuate approximately 60 neonatal patients. A needs assessment indicated that 60% of staff members had little or no knowledge of the unit's evacuation plan and 55% of respondents were not aware of their specific role in an emergency evacuation. The neonatal intensive care unit educators in collaboration with the unit's medical team, the leadership team, the hospital emergency management team, and the unit practice and professional council coordinated the design, implementation, and assessment of the simulated evacuation activity. To encourage realism within the simulated activity, prepared manikins were placed in patient rooms and assigned varying levels of acuity. The training session began with a prebrief session that included a description of the evacuation plan, delineation of roles, responsibilities based on scope of practice, use of the evacuation equipment, and unit emergency bags. Participants engaged in a debrief session following each session during which the staff notably expressed an increased confidence with the evacuation plan, roles, and operation of the evacuation equipment. In addition, the debriefing allowed for identification of latent threats, which the planning group used to streamline the evacuation process.

Reduction in Unintended Extubations in a Level IV Neonatal Intensive Care Unit.

OBJECTIVES: Unintended extubations (UEs) lead to significant morbidity in neonates. A quality improvement project was initiated in response to high rates in our level IV NICU. We targeted creating and sustaining UE rates below the published standard of 1 per 100 ventilator days. METHODS: This project spanned 4 time periods: baseline, epoch 1 (December 2010-May 2012), sustain, and epoch 2 (May 2015-December 2017) by using standard quality improvement methodology. Epoch 1 interventions included real-time analysis of UE events, standardization of taping, patient positioning and movement, accurate event reporting, and change in nomenclature. Epoch 2 interventions included reduction in daily chest radiographs (CXRs) and development of a high-risk tool. Patient and event characteristics were statistically compared across time points. RESULTS: Of the 612 UE events recorded over 10 years, 249 UEs occurred from May 2011 to 2017 involving 184 unique patients. UE rates decreased by 43% (from 1.75 to 0.99 per 100 ventilator days; epoch 1) and were sustained until a notable spike. Epoch 2 interventions led to a further 31% rate reduction. Single CXR use decreased by half. Median corrected gestational age at the time of an event was 35 weeks (interquartile range: 29-41). Seventy percent of infants experiencing an UE required reintubation, 29% had a previous event, and 9% had a code event. CONCLUSIONS: A decrease in UE below benchmarks can be achieved and sustained by standardization and mitigation interventions. This decline was also accompanied by a reduction in use of CXRs without increasing UE events.