Whole-genome sequencing for methicillin-resistant Staphylococcus aureus (MRSA) outbreak investigation in a neonatal intensive care unit.

OBJECTIVE: To evaluate whole-genome sequencing (WGS) as a molecular typing tool for MRSA outbreak investigation. DESIGN: Investigation of MRSA colonization/infection in a neonatal intensive care unit (NICU) over 3 years (2014-2017). SETTING: Single-center level IV NICU.PatientsNICU infants and healthcare workers (HCWs). METHODS: Infants were screened for MRSA using a swab of the anterior nares, axilla, and groin, initially by targeted (ring) screening, and later by universal weekly screening. Clinical cultures were collected as indicated. HCWs were screened once using swabs of the anterior nares. MRSA isolates were typed using WGS with core-genome multilocus sequence typing (cgMLST) analysis and by pulsed-field gel electrophoresis (PFGE). Colonized and infected infants and HCWs were decolonized. Control strategies included reinforcement of hand hygiene, use of contact precautions, cohorting, enhanced environmental cleaning, and remodeling of the NICU. RESULTS: We identified 64 MRSA-positive infants: 53 (83%) by screening and 11 (17%) by clinical cultures. Of 85 screened HCWs, 5 (6%) were MRSA positive. WGS of MRSA isolates identified 2 large clusters (WGS groups 1 and 2), 1 small cluster (WGS group 3), and 8 unrelated isolates. PFGE failed to distinguish WGS group 2 and 3 isolates. WGS groups 1 and 2 were codistributed over time. HCW MRSA isolates were primarily in WGS group 1. New infant MRSA cases declined after implementation of the control interventions. CONCLUSION: We identified 2 contemporaneous MRSA outbreaks alongside sporadic cases in a NICU. WGS was used to determine strain relatedness at a higher resolution than PFGE and was useful in guiding efforts to control MRSA transmission.

Increasing the Connectivity and Autonomy of RNs with Low-Risk Obstetric Patients.

: Objective: RNs are adopting an ever-larger role in health care models designed to reduce costs, increase patient satisfaction, and improve patient outcomes. Most research exploring such models has focused on those involving physicians or advanced practice nurses rather than RNs. This study explored the perspectives of patients, RNs, and other providers regarding a new prenatal connected care model for low-risk patients aimed at reducing in-office visits and creating virtual patient-RN connections. METHODS: This qualitative evaluation was performed as part of a larger randomized controlled trial of the new care model. Individual interviews and asynchronous online focus groups were conducted with a total of 41 patients, up to 10 unit and connected care RNs, and up to 17 other providers (up to eight physicians and nine certified nurse midwives [CNMs]). RESULTS: Thematic analysis indicated that patients in the new care model valued connectedness and relationships with the connected care RNs, including the ability to contact them as needed outside the office setting. Patients also valued their relationships with physicians and CNMs. Physicians appreciated having more time to care for higher-risk patients, and the connected care RNs appreciated being able to work to a fuller scope of practice, although participants in all provider groups suggested the increased use of protocols and other systems to ensure patient safety and improve communication among providers. CONCLUSIONS: A prenatal connected care model for low-risk women allowed patients to decrease the number of scheduled in-person clinic visits with physicians or CNMs while building stronger nurse-patient relationships through virtual connected care visits with an RN. The results included increased patient satisfaction and greater autonomy for RNs, allowing them to work to a fuller scope of practice. Although the new model gave physicians more time in which to see higher-risk patients, CNM-patient relationships may have been limited.