For one year (July 1999 to July 2000) we recorded the rate of postoperative infections of all types (for example, chest infections, urinary tract infections, surgical site wound infections) in patients undergoing hip or knee joint arthroplasty. Patients were treated using the standard precautions against infection used in most orthopaedic units in the United Kingdom—that is, short admission time before surgery, ultra clean air theatres, standard theatre hygiene and precautions, and prophylactic intravenous antibiotics.
In July 2000 we “ring fenced” the 28 beds in the elective orthopaedic ward. Only patients having elective orthopaedic surgery (including joint replacement) were admitted to the ward. Orthopaedic liaison nurses swabbed all patients (nose, perineum, and any skin lesions) in the community for MRSA and methicillin sensitive Staphylococcus aureus. Patients testing positive for either organism were started on a staphylococcus decontamination regimen in the community. Because of concerns about gastrointestinal carriage of MRSA, we took the approach of “once positive, always positive.” We did not allow any patient who had ever had MRSA to be admitted to the ring fenced ward. We isolated these patients on another orthopaedic ward and gave them teicoplanin prophylaxis perioperatively in addition to our standard regimen.
We excluded trauma patients, day surgery patients, and patients from other specialties from the ring fenced ward. We rigorously enforced the British Orthopaedic Association recommendations on sterile procedures in operating theatres.2
Trauma patients who were deemed low risk for MRSA (young, first admission to hospital, not been in a nursing home or other healthcare institution) were swabbed on admission to the “non-ring fenced” ward. If they had negative swabs, we allowed them into a single bedded side room on the ring fenced ward if a shortage of beds existed in the rest of the hospital and spaces were available on the ring fenced ward.
In addition to standard precautions, we instituted a code of dress and behaviour (box). Nursing staff started a regimen of wearing a disposable apron and gloves for each interaction with a patient. We installed an alcohol hand rub by each bed and instructed staff to use it before and after each consultation. Medical staff left jackets at the door to the ward and donned clean white coats for the purpose of ward rounds. The coats were left on the ward after rounds and laundered daily. Visitors were not allowed to sit on the beds.
We gave the nursing sister in charge responsibility for ensuring implementation of the infection control standards among the nurses, cleaning staff, and doctors visiting the ward. The adherence to the standards by senior nursing and medical staff led to a general change in culture within the unit and adherence by all staff.
We minimised the use of bank and agency staff and expected all such personnel to comply with the same standards as regular staff. We informed nursing agencies of the ward policy, so that any agency nurses were aware of what was expected before the start of their shift.
We took microbiology samples (urine, sputum blood cultures, or wound swabs) from any patient deemed on clinical grounds to have a postoperative infection. All clinical infections recorded were supported by positive microbiology results.