Compliance with contact precautions in a neonatal intensive care unit

Abstract

BACKGROUND: Horizontal transmission of methicillin-resistant Staphylococcus aureus (MRSA) in neonatal intensive care units (NICUs) is well described. Suboptimal compliance with contact precautions by healthcare workers (HCWs) is a factor in the spread of MRSA in healthcare settings. Limited data regarding compliance with contact precautions in pediatric settings is available. We describe an observational study of compliance with contact precautions during a NICU MRSA outbreak. METHOD: This is a 235-bed tertiary-care center in St. Louis with a 52-bed level III NICU. In June 2004, three patient specimens were positive for MRSA. Active MRSA surveillance utilizing nares cultures of NICU patients was initiated weekly and upon admission. Despite strict contact precautions, cohorting of MRSA-positive patients and education regarding compliance with contact precautions and hand hygiene (HH), nosocomial spread of MRSA persisted. Infection control (IC) audited HCWs compliance with contact precautions during patient contact or contact with the patients' immediate environment using a standardized data collection tool. Variables audited included HH before and after patient/environment contact, gowning, and gloving. HCWs were grouped as MD and nurse practitioner (MD/NP), nurse (RN), and other HCWs (other). Statistical analysis was performed using Fisher's exact test. RESULTS: From August through October 2004, 77 interactions were observed; five HH observations were incomplete due to an inability to view HCWs before or after contact. Audits revealed 25/72 (35%) of HCWs were compliant with HH before and after contact, 49/72 (68%) performed HH after contact, and 21/72 (29%) did no HH. HH compliance did not vary significantly between HCW groups, 5/13 (38%) of MD/NP, 8/40 (20%) of RN, and 8/19 (42%) of other did not perform any HH (p = 0.6). Overall, 55/77 (71%) HCWs gowned and 69/77 (90%) wore gloves. Statistically significant differences were noted between groups for gowning and gloving; 6/13 (46%) MD/NP, 34/41 (83%) RN, 15/23 (65%) other gowned (p = 0.03), and 9/13 (69%) MD/NP, 39/41 (95%) RN, 21/23 (91%) other (p = 0.04) wore gloves. Results were shared with NICU staff and re-education was directed to targeted HCW groups. CONCLUSION: Compliance with contact precautions is an important issue to address in MRSA outbreaks and may impact outbreak containment. Behaviors vary between HCW groups and should be considered when addressing compliance issues. Developing effective interventions to increase compliance with CP is essential to decrease nosocomial spread of microorganisms.