157 Control of methicillin-resistant staphylococcus aureus infections in two neonatal care units

Context Grouped cases of nosocomial bacterial infections (NBI) due to methicillin-resistant staphylococcus aureus (MRSA) were observed over a 1-year period (May 2007 to May 2008) in the neonatal intensive care unit and the unit of neonatology of a university hospital. Main purpose To assess the implementation of preventive measures and the concomittant changes of the incidence of severe MRSA infections. Method A head committee has been brought up on May 2008 (CLIN9s president, head division of paediatrics, paediatricians and nurses of the neonatal units, chief nurses, hygienists, and bacteriologists). Two operational groups consisting of 15 persons each have been set up (one for each neonatal unit). Their aim was to provide information and formation to the care givers, and also to set up an internal audit of the care practices. The teams of the neonatal units were directly involved in the identification of at risk situations using a voluntary and anonymous declaration system. Over the May 2008–December 2008 period, the two operational groups performed the analysis of the results and suggested 90 actions that were validated by the head committee. Since May 2008, a direct observation of the practices of care has been started and the data have been stored in a computer software. This observation was performed by specifically trained nurses (two full-time employments). Meetings of the operational groups have been held monthly in order to evaluate changes in clinical practices (hand hygiene, central venous catheter insertion, etc…), analyse cases of NBI (definitions according to the CDC classification) and changes in nasal MRSA carriage rate (screening started in May 2008). In each neonatal unit, panels presented the conclusions of these meetings. An independent external audit of this method has been conducted in November 2008 by the Institut National de Veille Sanitaire (INVS) and the CCLIN Est. Results Among 90 identified points of improvement, 82 (90%) actions have been implemented between May and December 2008. Hydro-alcoholic solution9s consumption doubled from June 2008. Conformity rate for hand hygiene grew from 85% (July 2008) to 94% (December 2008) in the NICU, and from 38% to 95% in the unit of neonatology. The conformity rate for central venous catheter insertion grew from 42% (September 2008) to 81% (November 2008). Between May 2007 and May 2008, 19 MRSA infections were identified (10 bacteremia, six pneumonia with positive broncho-alveolar lavage, one meningitis, two positive culture of catheters without bacteremia) versus three MRSA infections between June 2008 and May 2009 (two bacteremia, one pneumonia). The decrease in MRSA infection rate was statistically significant. The incidence of nasal MRSA carriage significantly decreased from June 2008. Discussion The main characteristics of this continuous internal audit were: A direct involvement of all care givers (nurses, doctors, technicians…), A voluntary anonymous report system that permitted to identify 90 points of improvement, A continuous evaluation of the clinical practices by ‘quality nurses’ and a monthly report to the teams. An associated decrease in MRSA infections rate. Contexte Des cas groupes d9infections nosocomiales bacteriennes (INB) a staphylococcus aureus resistant a la methicilline (SARM) observes en un an (mai 2007–mai 2008) dans une unite de reanimation neonatale (18 lits) et une unite de neonatologie (31 lits) du meme etablissement. Objectif principal Evaluation de la mise en place de mesures de prevention et de leur effet sur le taux d9infections a SARM. Methode Un comite de pilotage a ete mis en place en mai 2008 (president du CLIN, chef de service, pediatres et infirmieres des unites de soins concernees, cadres de sante, medecins hygienistes et bacteriologistes). Deux groupes operationnels de 15 personnes chacun ont ete crees (1 pour la reanimation neonatale, 1 pour la neonatologie) avec l9objectif de realiser des seances de formation et d9information du personnel ainsi qu9un audit interne des pratiques de soins. Les equipes soignantes ont ete directement impliquees dans le reperage de situations a risque par un systeme de declaration anonyme et volontaire. Au cours de la periode mai 2008-decembre 2008, les deux groupes operationnels ont assure l9analyse des resultats et ont propose au total 90 actions retenues par le comite de pilotage. Une observation directe des procedures de soins avec recueil systematise des donnees a ete mise en place des le mois de mai 2008. Cette observation etait assuree par des infirmieres specifiquement formees pour cette activite (2 equivalents temps-pleins). Des reunions mensuelles des groupes operationnels ont ete organisees pour faire le point des pratiques (hygiene des mains, pose et entretien des voies centrales…), analyser les observations d9INB averees (criteres des CDC d9Atlanta) et l9evolution des taux de portage nasal de SARM (a partir de mai 2008). Les conclusions ont ete diffusees aux equipes de soins par voie d9affichage. Un audit externe de la methode a ete realise en novembre 2008 par l9Institut National de Veille Sanitaire et le CCLIN Est. Resultats Sur 90 points d9amelioration identifies, 82 actions ont ete menees (90%) de mai a decembre 2008. La consommation de solution hydro-alcoolique a double a partir de juin 2008. Entre juillet et decembre 2008, les taux de conformite pour la desinfection des mains sont passes de 85% a 94% en reanimation, et de 38% a 95% en neonatologie. Le taux de conformite des poses des voies centrales est passe de 42% en septembre 2008 a 81% en novembre 2008. Entre mai 2007 et mai 2008, 19 INB a SARM ont ete observees (10 bacteriemies; 6 pneumopathies confirmees par LBA; 1 meningite; 2 infections sur catheters centraux sans bacteriemie) vs 3 sur la periode juin 2008-mai 2009 (2 bacteriemies; 1 pneumopathie). La reduction du taux d9INB est significative. L9incidence de la colonisation nasale a SARM a significativement diminue a partir de juin 2008. Discussion, perspectives Les principales caracteristiques de cette demarche d9auto-evaluation continue ont ete: une implication directe de tout le personnel (IDE; medecins; auxiliaires; agents techniques) des unites de soins une declaration anonyme et volontaire d9evenements precurseurs qui a conduit a identifier 90 points d9amelioration (90% d9application effective). une evaluation en temps reel de l9application des procedures par des infirmieres « qualite » avec un retour mensuel d9information aux equipes. une reduction du taux d9INB a SARM associee a ces mesures.