ISSUE: The ICN at Duke University Hospital is a 49 bed Level 3 tertiary care nursery, with 679 admits yearly. In March 2005, a baby was identified with MRSA by clinical culture. Concentric surveillance cultures found 1 additional baby. Unit-wide surveillance cultures revealed 6 more cases, with an incidence rate of 17.6%. Despite stringent control measures, a total of 15 babies had been detected by week 8, with a prevalence rate of 20%.

PROJECT: Interventions including contact isolation for all MRSA positive babies and daily IC monitoring did not control the outbreak. In week 8, IC and ICN leadership met to discuss the outbreak and together the teams partnered and identified other control measures which included: 1) The Transitional Care Nursery (ICN step-down) was converted to an isolation unit for MRSA babies only, 2) The nursing staff, respiratory therapists and medical providers caring for the isolated babies had no patient contact with ICN patients, 3) Surveillance cultures began on all new admissions from outside hospitals, 4) A “Back-to-Basics” program taught by the ICN educator was done for all persons involved in the care of neonates. This included reviews pertaining to isolation precautions, hand hygiene and equipment cleaning, 5) Hand hygiene observations were done by the ICN educator, using an IC observation tool. The results were shared with nursing, physicians and IC. While IC assumed an advisory role with this outbreak, no measure could be halted without IC approval. Primary enforcement of these measures was the responsibility of the ICN. New cases were sporadic from week 9-12, with no new cases after week 12.

RESULTS: The measures employed by the ICN were essential in controlling the outbreak. Taking ownership of the outbreak, the ICN leadership improved staff compliance to isolation precautions and helped empower the nursing staff to enforce the control measures. Violators of the IC measures were brought to the attention of ICN leadership and IC and were educated.

LESSONS LEARNED: A critical piece in the control of this outbreak was IC assisting the unit leadership in developing and overseeing the interventions to improve compliance with IC practices. While the initiation and enforcement of control measures in outbreak investigations has always been thought to be the responsibility of IC, this novel approach to an outbreak led to increased compliance, empowerment and a positive relationship between IC and ICN staff.