Evaluating implementation of methicillin-resistant Staphylococcus aureus (MRSA) prevention guidelines in spinal cord injury centers using the PARIHS framework: a mixed methods study.

Salva N Balbale,Kenzie A Cameron,Charlesnika T Evans,Timothy P Hogan,Marylou Guihan,Jennifer N Hill,Barry Goldstein

doi:10.1186/s13012-015-0318-x

Abstract

BackgroundTo prevent methicillin-resistant Staphylococcus aureus (MRSA) in Spinal Cord Injury and Disorder (SCI/D) Centers, the “Guidelines for Implementation of MRSA Prevention Initiative in the Spinal Cord Injury Centers” were released in July 2008 in the Veterans Affairs (VA) Health Care System. The purpose of this study was to use the Promoting Action on Research Implementation in Health Systems (PARiHS) framework to evaluate the experiences of implementation of SCI/D MRSA prevention guidelines in VA SCI/D Centers approximately 2–3 years after the guidelines were released.MethodsMixed methods were used across two phases in this study. The first phase included an anonymous, web-based cross-sectional survey administered to providers at all 24 VA SCI/D Centers. The second phase included semi-structured telephone interviews with providers at 9 SCI/D Centers. The PARiHS framework was used as the foundation of both the survey questions and semi-structured interview guide.ResultsThe survey was completed by 295 SCI/D providers (43.8 % response rate) from 22 of the 24 SCI/D Centers (91.7 % participation rate). Respondents included nurses (57.3 %), therapists (24.4 %), physicians (11.1 %), physician assistants (3.4 %), and other health care professionals (3.8 %). Approximately 36 % of the SCI/D providers surveyed had not seen, did not remember seeing, or had never heard of the MRSA SCI/D guidelines, whereas 42.3 % of providers reported that the MRSA SCI/D guidelines were fully implemented in their SCI/D Center. Data revealed numerous barriers and facilitators to guideline implementation. Facilitators included enhanced leadership support and provider education, focused guideline dissemination to reach SCI/D providers, and strong perceived evidence supporting the guidelines. Barriers included lack of awareness of the guidelines among physical therapists and physician assistants and challenges in cohorting/isolating MRSA-positive patients and following contact precautions.ConclusionsSuccessful implementation of MRSA infection prevention guidelines in SCI/D settings requires (1) guideline dissemination that reaches the full range of SCI/D providers working in inpatient, outpatient, and other care settings, (2) provider education that is frequent and systematic, (3) strong leadership support, and (4) that barriers unique to the recommendations are addressed. These findings may be used to inform selection of implementation strategies and optimize infection prevention beyond MRSA as well as in other specialty care populations.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-015-0318-x) contains supplementary material, which is available to authorized users.

Highlights

To prevent methicillin-resistant Staphylococcus aureus (MRSA) in Spinal Cord Injury and Disorder (SCI/D) Centers, the “Guidelines for Implementation of MRSA Prevention Initiative in the Spinal Cord Injury Centers” were released in July 2008 in the Veterans Affairs (VA) Health Care System
The sampling frame was identified through VA electronic mailing lists (LISTSERVs) of providers working in SCI/D Centers and a contact list of MRSA Prevention Coordinators (MPCs) across the country
In line with the PARiHS model, we explored the different elements of context, evidence, and facilitation associated with guideline implementation across the nine sites as well as provider perceptions related to implementation of the SCI/D MRSA prevention guidelines

Summary

Introduction

To prevent methicillin-resistant Staphylococcus aureus (MRSA) in Spinal Cord Injury and Disorder (SCI/D) Centers, the “Guidelines for Implementation of MRSA Prevention Initiative in the Spinal Cord Injury Centers” were released in July 2008 in the Veterans Affairs (VA) Health Care System. Components of the initiative included (1) active surveillance and screening cultures (ASCs), (2) use of contact precautions by health care providers if patients are found to be MRSA positive, (3) hand hygiene, and (4) cultural transformation through staff and leadership engagement [5] The success of this initiative has been presented elsewhere including declines in MRSA infection rates in intensive care unit (ICU) and non-ICU settings [6, 7]. The “Guidelines for Implementation of MRSA Prevention Initiative in the Spinal Cord Injury Centers” ( referred to as SCI/D MRSA prevention guidelines) were released in July 2008 [10] These guidelines (Additional file 1) addressed specific elements of SCI/D care, such as the inclusion of wounds and/or pressure ulcers as part of ASCs. The SCI/D MRSA prevention guidelines emphasized hand hygiene in patients and providers before and after urinary catheterization and bowel care, addressed appropriate cleaning of shared equipment, and highlighted the need for contact precautions and environmental cleaning. Similar to the ICU and non-ICU settings, significant decreases in MRSA infection rates have been seen in VA SCI/D Centers [7]

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