In September 2007 an outbreak of Multi-Resistant Acinetobacter baumannii (MRAB) was detected at the Nepean Hospital Intensive Care Unit (ICU).

This had serious implications for the unit’s infection control practices, in particular for patients who already are in a critical condition.

A multi-faceted, multi-disciplinary team approach was used to analyse, address and monitor the problem. This approach was successful and MRAB was eradicated from the unit. This meant that no further MRAB were transmitted to Nepean ICU patients since September 2007, despite patients with known MRAB colonisation being admitted to ICU after September 2007.

This project is a great example of the NSW Health Acquired Infections Reduction strategy in action. It also meets the Sydney West Area Health Service Chief Executive’s KPI regarding MRAB transmission and is a direct application of the new Nepean ICU Mission, Vision and Values statements.

To eradicate Multi-Resistant Acinetobacter baumannii from the Nepean Intensive Care Unit (ICU).

MRAB transmission in intensive care patients is a serious issue that can impact upon patient experience, direct patient care, increase length of stay and even have lethal consequences. It is transmitted from patient to patient due to poor infection control practices. In September 2007 (after 1.5 years without a case of MRAB) Nepean ICU identified 4 new transmissions that were spread from a single patient. Infection control practices and culture of the unit needed to be drastically improved to prevent further transmissions of this organism.

ICU patients are screened for multi-resistant organisms (MRO) weekly. The data regarding the incidence of MRO transmission is collected by the infection control department and analysed at a monthly ICU infection control committee meeting. Problem analysis involved mapping transmission versus patient location, hand hygiene audits, review of cleaning practice/audits, cultural issues, communication issues and antibiotic usage.

Transmission rates of MRAB are described below in graphs 1 and 2. Transmitting an MRO to an ICU patient impact upon their direct care as the patient requires isolation and additional precautions, which create staff allocation difficulties and bed block. Additional precautions are also costly because staff must wear impervious gowns/gloves every time they enter the patient’s room. Patients report feeling isolated and stigmatised and the additional waste generated from the plastic gowns is an environmental concern.

NSW State Health Plan (2007) Strategic Direction 1, Make Prevention Everybody’s Business, states that what we are striving for in 2010 is a health system that puts greater effort and investment to improving health and preventing illness while continuing to treat illness effectively. This project aims to prevent MRAB infections in ICU and is therefore directly aligned with this strategic direction.

This project is also a direct application of the NSW Patient Safety and Clinical Quality Program’s strategic plan to decrease the incidence of Health Care Acquired Infections in NSW (HAI Reduction Strategy) . Additionally, the occurrence of MRAB in ICU’s is an infection control Chief Executive key performance indicator (KPI) and an indicator of Nepean ICU’s application of the unit’s new Mission, Vision and Values Statements.

After initial analysis, the CPI (Clinical Practice Improvement) team implemented the following solutions based on the 5 strategies suggested by the HAI Reduction Strategy.

• High pressure hose cleaning of beds/equipment
• Widespread damp dust environmental cleaning
• Daily education sessions
• Introduction of long sleeved impervious gowns for all contact precautions
• Memo from ICU Director to all visiting medical officers highlighting hand hygiene
• Daily hand hygiene audits
• Infection control noticeboard (plans, feedback on progress, graphs etc)
• Review of antibiotic usage with microbiologist/infectious diseases physician
• Clinical waste audit

Due to the serious nature of the problem all interventions were deemed equally important and were introduced simultaneously. Six Plan, Do, Study, Act (PDSA) cycles were completed during the project during which data collection and analysis continued. The CPI team met monthly and only minor fine-tuning of the approach was needed as the initial interventions were so successful.

The project team comprised of the NUM for governance/management issues and a selection of clinicians (ICU/Infection Control) and domestic services staff. They reported to the ICU Management Committee and Director of Intensive Care Medicine. Key stakeholders included staff from ICU, allied health, visiting teams and the patients. Tasks were divided amongst the team and the ICU staff were engaged in the process.

Compliance improved with a constant flow of information and positive reinforcement for improved performance. Staff were encouraged to use graded assertiveness to approach others who were non-compliant with the expected infection control practices. Junior staff reported feeling particularly empowered by this approach. The project team involved ancillary and allied health staff in the process and open lines of communication regarding the issue were established. Regular feedback regarding performance/project progress was provided to staff via email, a dedicated noticeboard, notices around the unit, verbally and at various unit meetings.

After the first PDSA cycle of the project MRAB transmission was eradicated from the ICU. No further MRAB has been transmitted to Nepean ICU patients (sterile or non-sterile sites) since September 2007. This is despite patients with known MRAB colonisation being admitted to ICU after September 2007. This continues to be monitored and is graphically represented below.

Graph 1 – MRAB in sterile site

 Graph 2 – MRAB in non-sterile site

This project has been spectacularly successful and is a great example of the NSW HAI Reduction strategy in action. It also meets the Sydney West Area Health Service Chief Executive’s KPI regarding MRAB transmission (reduction to zero) and is a direct application of the new Nepean ICU Mission, Vision and Values statements. The successful completion of the project also clearly demonstrates the effectiveness of the NSW Health Reduction of HAIs Program.

There are 5 simple strategies outlined in the program:

• hand hygiene
• correct antibiotic usage
• adherence to ICU central venous catheter insertion guideline
• adherence to contact precautions
• effective environmental cleaning programs in clinical care and treatment.

If all clinical areas consistently applied these strategies, the potential positive impact on our patients is limitless. Nepean ICU applied these principles in a small confined project and the implication for other clinicians is that these strategies work.

Compliance, monitoring and audits remain in place and are reviewed by the ICU Infection Control Committee on a monthly basis and changes are made according to the most recent results.  New staff is orientated to best infection control practices and further cyclical training for all has been conducted on a fortnightly basis. Regular performance evaluation and feedback to staff continues in a variety of forums. The ICU staff has taken ownership of infection control which will enable continued success. To date there has been no further MRAB in the ICU.

The success of this CPI project clearly demonstrates that the strategies from the NSW Health HAI Initiative are workable in clinical areas. It is fully dependant upon the engagement and hard work of frontline workers and proves that even in a complex and technologically demanding environment, with the sickest, most at risk patients in the hospital; good infection control practices can protect patients from an unnecessary and potentially costly HAI. Other clinical areas can be inspired by the success of this project.

Associate Director - Clinical Governance, Clinical Governance Unit
Sydney West Area Health Service
Phone: 02 9881 7524