Question 20

An audit has revealed your ICU has an MRSA infection rate which exceeds national benchmarks. Outline the steps you would take to improve this situation


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College answer


  • Review the audit.
  • Breakdown of hand hygiene audit data by groups of staff.
  • Observe the daily habits of the unit staff and availability of hand washing stations
  • Liaise with ID department


  • Open disclosure within the unit of the problem. Where do the staff feel the problem lies?


  • Local champions, train staff to preform hand hygiene audits, cleaning product education, hand hygiene education. Signage for staff. 5 moments of hand hygiene, visiting teams to the ICU. Ensure regulations re clothing, jewellery etc are being followed
  • Encourage all staff patients and visitors to challenge staff that do not follow unit policy

Physical cleaning

  • Is the cleaning in the unit adequate, consider closure and re-opening after cleaning?

Unit design and procedures

  • Frequency of washing or disposal of linens, curtains
  • Isolation of high-risk patient, or cohorting
  • Availability and type of hand rub
  • Review nursing ratios and nursing procedures

Antibiotic Stewardship

  • Review antibiotic usage.
  • Assess community rate of MRSA

KPIs and Re assessment

  • Audit and review that changes are improving habits

Higher marks were allocated to answers which gave a structured approach consisting of

  • Identifying the problem
  • Instituting change measures, which must include hand washing
  • Measuring the effect of the change.

Examiners Comments:

Generally answered well; generic answers without reference to the specific issue were marked poorly.


Normally this sort of "organisational approach to MRO spread" question has stereotypical elements. Even though the examiners remark that "generic answers without reference to the specific issue were marked poorly", what they gave was in fact a fairly generic looking answer, in terms of its structure. 


Commence active surveillance cultures to determine the extent and source of the problem:

  • Identifies the "reservoir" for spread
  • Allows precautions to be cost-effectively focused on the reservoir.
  • The health care workers themselves may become colonised reservoirs.
  • Performed on all patients, on admission, and then periodically (eg. weekly).
  • In facilities found to have a high prevalence on initial sampling, a facility-wide culture survey is indicated.

Control the outbreak:

  • Contact precautions to prevent new cases
    • Hand hygiene
      • Soap and water for visibly contaminated hands
      • Alcohol-based rub for routine pre-and-post-contact hygiene
      • Monitoring of compliance should be performed
    • Disposable gloves
    • Disposable gowns
    • Patients colonised by the same MRO may be cohorted together.
    • Contaminated areas should be identified by obvious cautionary signs
  • Decontamination of existing sources
    • Decontamination ("decolonisation") of MRSA/VRE patients
    • Decontamination of colonised health care workers
    • Environmental disinfection
    • Routine disinfection of equipment between patient contacts
    • Wherever possible, individualised equipment for every patient

Coordinate a response and empower a team to execute the response:

  • Infection control specialty team, composed of ICU specialists, infectious diseases specialists, senior nursing staff, laboratory staff and administration staff.
  • Allocated resources to MRO surveillance, compliance monitoring and education
  • "Champions" - staff allocated to promote the existing policies and monitor adherence

Promote adherence to the new policies

  • "Widespread campaign"
  • Awareness-rasing posters
  • Lunchtime meetings
  • Promulgated reading material
  • Education bundle as a part of mandatory employee training

Collect data regarding MRSA colonisation and the effect of your new strategies

  • Data collection and MRO colonisation record
    • Records of MRO results allow colonised patients to be identified early
  • Regular review of collected information, resistance and transmission patterns
  • Regular audit of the efficacy of implemented strategies
  • Regular comparison of policies to those of peer hospitals
  • Regular reevaluation and amendment of infection control policies


Chapter 70  (pp. 724)  Nosocomial  infections by James  Hatcher  and  Rishi  H-P  Dhillon

Widmer, A. F. "Infection control and prevention strategies in the ICU." Intensive care medicine 20.4 (1994): S7-S11.

Eggimann, Philippe, and Didier Pittet. "Infection control in the ICU." Chest Journal 120.6 (2001): 2059-2093.

Lucet, Jean-Christophe, et al. "Successful long-term program for controlling methicillin-resistant Staphylococcus aureus in intensive care units." Intensive care medicine 31.8 (2005): 1051-1057.

Dhillon, Shah, Rimawi: "Chapter 12: ICU Infection Control and Preventive Measures", page 54 in: "Bedside Critical Care Guide." by Rimawi, Ramzy H.(2013). OMICS Group eBooks

Muto, Carlene A., et al. "SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and enterococcus." Infection Control 24.05 (2003): 362-386.

Gniadkowski, M. "Evolution and epidemiology of extended‐spectrum β-lactamases (ESBLs) and ESBL‐producing microorganisms." Clinical microbiology and infection 7.11 (2001): 597-608.

Huskins, W. Charles, et al. "Intervention to reduce transmission of resistant bacteria in intensive care." New England Journal of Medicine 364.15 (2011): 1407-1418.

Kollef, Marin H., and Victoria J. Fraser. "Antibiotic resistance in the intensive care unit." Annals of internal medicine 134.4 (2001): 298-314.

Kaki, Reham, et al. "Impact of antimicrobial stewardship in critical care: a systematic review." Journal of antimicrobial chemotherapy 66.6 (2011): 1223-1230.