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Implementation of an Industrial Systems-Engineering Approach to Reduce the Incidence of Methicillin-Resistant Staphylococcus aureus Infection

  • Robert R. Muder (a1) (a2), Candace Cunningham (a1), Ellesha McCray (a1), Cheryl Squier (a1), Peter Perreiah (a3), Rajiv Jain (a1) (a2), Ronda L. Sinkowitz-Cochran (a4) and John A. Jernigan (a4)...



To measure the effectiveness of an industrial systems-engineering approach to a methicillin-resistant Staphylococcus aureus (MRSA) prevention program.


Before-after intervention study


An intensive care unit (ICU) and a surgical unit that was not an ICU in the Pittsburgh Veterans Administration hospital


Allpatientsadmittedtothe study units


We implemented an MRSA infection control program that consisted of the following 4 elements: (1) the use of standard precautions for all patient contact, with emphasis on hand hygiene; (2) the use of contact precautions for interactions with patients known to be infected or colonized with MRSA; (3) the use of active surveillance cultures to identify patients who were asymptomatically colonized with MRSA; and (4) use of an industrial systems-engineering approach, the Toyota Production System, to facilitate consistent and reliable adherence to the infection control program.


The rate of healthcare-associated MRSA infection in the surgical unit decreased from 1.56 infections per 1,000 patient-days in the 2 years before the intervention to 0.63 infections per 1,000 patient-days in the 4 years after the intervention (a 60% reduction; P = .003). The rate of healthcare-associated MRSA infection in the ICU decreased from 5.45 infections per 1,000 patient-days in the 2 years before to the intervention to 1.35 infections per 1,000 patient-days in the 3 years after the intervention (a 75% reduction; P = .001). The combined estimate for reduction in the incidence of infection after the intervention in the 2 units was 68% (95% confidence interval, 50%-79%; P < .001).


Sustained reduction in the incidence of MRSA infection is possible in a setting where this pathogen is endemic. An industrial systems-engineering approach can be adapted to facilitate consistent and reliable adherence to MRSA infection prevention practices in healthcare facilities.


Corresponding author

Infectious Diseases Section, VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240 (


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1.Klevens, RM, Edwards, JR, Tenover, FC, McDonald, LC, Horan, T, Gaynes, R. Changes in the epidemiology of methicillin-resistant Staphylococcus aureus in intensive care units in US hospitals, 1992-2003. Clin Infect Dis 2006;42:389391.
2.Jernigan, JA, Clemence, MA, Stott, GA, et al.Control of methicillin-resistant Staphylococcus aureus at a university hospital: one decade later. Infect Control Hosp Epidemiol 1995;16:686696.
3.Cosgrove, SE, Sakoulas, G, Perencevich, EN, Schwaber, MJ, Karchmer, AW, Carmeli, Y. Comparison of mortality associated with methicillin-resistant and methicillin-susceptible Staphylococcus aureus bacteremia: a meta-analysis. Clin Infect Dis 2003;36:5359.
4.Engemann, JJ, Carmeli, Y, Cosgrove, SE, et al.Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis 2003;36:592598.
5.Cosgrove, SE, Qi, Y, Kaye, KS, Harbarth, S, Karchmer, AW, Carmeli, Y. The impact of methicillin resistance in Staphylococcus aureus bacteremia on patient outcomes: mortality, length of stay, and hospital charges. Infect Control Hosp Epidemiol 2005;26:166174.
6.Blot, SI, Vandewoude, KH, Hoste, EA, Colardyn, FA. Outcome and attributable mortality in critically ill patients with bacteremia involving methicillin-susceptible and methicillin-resistant Staphylococcus aureus. Arch Intern Med 2002;162:22292235.
7.Whitby, M, McLaws, ML, Berry, G. Risk of death from methicillin-resistant Staphylococcus aureus bacteraemia: a meta-analysis. Med J Aust 2001;175:264267.
8.Melzer, M, Eykyn, SJ, Gransden, WR, Chinn, S. Is methicillin-resistant Staphylococcus aureus more virulent than methicillin-susceptible S. aureus? A comparative cohort study of British patients with nosocomial infection and bacteremia. Clin Infect Dis 2003;37:14531460.
9.Abramson, MA, Sexton, DJ. Nosocomial methicillin-resistant and methicillin-susceptible Staphylococcus aureus primary bacteremia: at what costs? Infect Control Hosp Epidemiol 1999;20:408411.
10.Siegel, JD, Rhinehart, E, Jackson, M, et al. Management of multi-drug resistant organisms in healthcare settings, 2006. Available at: http://www Accessed October 16, 2006.
11.Kim, PW, Roghmann, MC, Perencevich, EN, Harris, AD. Rates of hand disinfection associated with glove use, patient isolation, and changes between exposure to various body sites. Am J Infect Control 2003;31:97103.
12.Pettinger, A, Nettleman, MD. Epidemiology of isolation precautions. Infect Control Hosp Epidemiol 1991;12:303307.
13.Afif, W, Huor, P, Brassard, P, Loo, VG. Compliance with methicillin-resistant Staphylococcus aureus precautions in a teaching hospital. Am J Infect Control 2002;30:430433.
14.Pittet, D, Mourouga, P, Perneger, TV, Members of the Infection Control Program. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999;130:126130.
15.Jernigan, JA, Titus, MG, Groschel, DH, Getchell-White, S, Farr, BM. Effectiveness of contact isolation during a hospital outbreak of methicillin-resistant Staphylococcus aureus. Am J Epidemiol 1996;143:496504.
16.Muto, CA, Jernigan, JA, Ostrowsky, BE, et al.SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and Enterococcus. Infect Control Hosp Epidemiol 2003;24:362386
17.Farr, BM. Prevention and control of methicillin-resistant Staphylococcus aureus infections. Curr Opin Infect Dis 2004;17:317322.
18.Cooper, BS, Stone, SP, Kibbler, CC, et al.Isolation measures in the hospital management of methicillin resistant Staphylococcus aureus (MRSA): Systematic review of the literature. BMJ 2004;329:533.
19.Garner, JS. Guideline for isolation precautions in hospitals. The Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1996;17:5380.
20.Boyce, JM, Pittet, D. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 2002;23(12 suppl):S3S40.
21.Spear, S, Bowen, H. Decoding the DNA of the Toyota Production System. Harvard Bus Rev 1999;77:97106.
22.Garner, JS, Jarvis, WR, Emori, TG, Horan, TC, Hughes, JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988;16:128140.
23.Cleveland, W, Grosse, E. Computational methods for local regression. Statistics and Computing 1991;1:4762
24.Haley, RW, Cushion, NB, Tenover, FC, et al.Eradication of endemic methicillin-resistant Staphylococcus aureus infections from a neonatal intensive care unit. J Infect Dis 1995;171:614624.
25.Struelens, MJ, Ronveaux, O, Jans, B, Mertens, R. Methicillin-resistant Staphylococcus aureus epidemiology and control in Belgian hospitals, 1991 to 1995. Groupement pour le Depistage, l'Etude et la Prevention des Infections Hospitalieres. Infect Control Hosp Epidemiol 1996;17:503508.
26.Murray-Leisure, KA, Geib, S, Graceley, D, et al.Control of epidemic methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol 1990;11:343350.
27.Nicolle, LE, Dyck, B, Thompson, G, et al.Regional dissemination and control of epidemic methicillin-resistant Staphylococcus aureus. Manitoba Chapter of CHICA-Canada. Infect Control Hosp Epidemiol 1999;20:202205.
28.Kotilainen, P, Routamaa, M, Peltonen, R, et al.Elimination of epidemic methicillin-resistant Staphylococcus aureus from a university hospital and district institutions, Finland. Emerg Infect Dis 2003;9:169175.
29.Mangram, AJ, Horan, TC, Pearson, ML, Silver, LC, Jarvis, WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250280.
30.Manian, FA, Meyer, PL, Setzer, J, Senkel, D. Surgical site infections associated with methicillin-resistant Staphylococcus aureus: do postoperative factors play a role? Clin Infect Dis 2003;36:863868.
31.Jernigan, JA. Is the burden of Staphylococcus aureus among patients with surgical-site infections growing? Infect Control Hosp Epidemiol 2004;25:457460.
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Infection Control & Hospital Epidemiology
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