Using Automated Orders to Facilitate MRSA Screening and Decolonization

Background: Some hospitals have begun active surveillance with or without decolonization for MRSA-colonized patients.  Reliably including all MRSA-colonized patients in these measures has been challenging.

Objective: We hypothesized that automating orders for screening and decolonization via our electronic medical record would yield high compliance with surveillance cultures and decolonization.

Methods: We programmed our electronic medical record to (1) order a screening nasal MRSA PCR on admission, (2) order contact isolation if the admission screen is positive, (3) order a decolonization regimen of oral chlorhexidine (CHG) rinse and nasal mupirocin for five days if the MRSA screen is positive, (4) order repeat nasal MRSA PCR 14 days after completion of decolonization (hospital day #19).  Patients in the intensive care and progressive care units of two tertiary care teaching hospitals (812-bed and 324-bed) were included. All patients in these units receive daily CHG baths, so this intervention was de facto part of the decolonization.  Automation of orders began with the start of our decolonization program Aug-Oct 2009.

Results:

	MH	UH	Total
# positive for MRSA, eligible for decolonization	785	239	1024
# (%) started decolonization	726 (92)	211 (88)	937 (92)
# (%) completed decolonization	492 (68)	154 (73)	646 (69)
# (%) discharged prior to  retesting for MRSA	356 (49)	42 (20)	398 (42)
# (%) not retested for MRSA because had clinical disease	15 (2)	13 (6)	28 (3)
# (%) died prior to retesting for MRSA	35 (5)	9 (4)	44 (5)
# (%) not retested for MRSA because taking antibiotics		7 (3)	7 (3)
# (%) with (+) MRSA PCR after decolonization	48 (7)	8 (4)	56 (6)
# (%) with (-) MRSA PCR after decolonization and removed from Contact Precautions	29 (4)	5 (2)	34 (4)
# (%) removed from Contact Precautions with (+) MRSA PCR on subsequent admission	7 (24)		7 (24)

Table 1.  Results of MRSA decolonization at Clarian Methodist Hospital (August 18, 2009 through June 15, 2010) and Clarian University Hospital (October 14, 2009 through July 15, 2010).

The automated process reliably starts screening and decolonization of MRSA-colonized patients. There is considerable drop-out from the start to the finish of the decolonization and retesting process.  Deaths and discharges account for most of the drop-out.  We are now able to continue decolonization for discharged patients, but this process is not automated and we do not have reliable data on results.

Conclusions: An automated process can reliably initiate both MRSA screening and decolonization.  Further efforts and methods are needed to continue the decolonization process for discharged patients.