Long-Term Outcome of Infection Control for Methicillin-Resistant Staphylococcus aureus and Kaizen Approach with Problem-Solving

Background: Methicillin-resistant Staphylococcus aureus (MRSA) results in longer hospitalization, increased expenses, and poorer patient prognosis. The aim of this study is 1) to investigate the short-term outcome of MRSA outbreak and the prevention in our surgical ward, and 2) to evaluate the long-term outcome of a 7-year experience of infection control, and 3) to report the effectiveness of intervention of quality improvement by industry problem-solving method for the eradication of a new occurrence of MRSA patients. Methods: Between April 2009 and October 2019, we retrospectively studied the improvement activity for infection control and preventative measures in our surgical ward. The daily alcohol use for hand hygiene was measured (ml/patient/day) and the monthly number of occurrences of new MRAS patients was investigated. We used the industry problem-solving method as the Kaizen of infection control for the eradication of a new Methicil-lin-resistant Staphylococcus aureus decreased amount of alcohol use for hand hygiene and the increased number of new MRSA patients. Conclusion: The daily monitoring and measuring of the amount of alcohol use for hand hygiene and to know the current number of new occurrence of MRSA patients will become a meaningful tool. By performing the Kaizen with a problem-solving method, it will contribute to the multi-professional team to visualize the process of quality improvement for infection control.


Introduction
Hand hygiene is widely recognized and promoted as a simple but effective practice to counter incidences of health care-acquired infections. However, worldwide compliance is less than optimal [1] [2]. According to reports from the Center for Disease Control and Prevention, healthcare workers do not clean their hands as often as they should [3]. Poor hand hygiene compliance among healthcare workers contributes to the spread of devastating health care-associated infection, and consequently, prolonged patient's hospital stays, disability, increased resistance to antibiotics, increased mortality and high health care costs [1].
Methicillin-resistant Staphylococcus aureus (MRSA) results in longer hospitalizations, increased expenses, and poorer patient prognosis. MRSA has been rapidly increasing worldwide over the past several decades [4]. MRSA transmission is common in hospitals, where it is spread from patient to patient on health care worker's hands by contaminated environments, or directly from patient to patient [5]. Additionally, hospitalized patients are vulnerable to MRSA infections because they often have indwelling devices, are immunosuppressed, or have had surgical procedures [5]. Treatment options are limited for patients with MRSA infections.
Poor hand hygiene is the main source of MRSA transmission within a hospital [6]. However, after applying alcohol gel, 99% of the transient organisms, including MRSA, are eradicated [7]. In an attempt to reduce the incidence of patients with MRSA, hand-hygiene awareness has become more prominent worldwide [8] [9]. Research has also identified numerous other potential sources of MRSA within hospitals and studies have proposed that healthcare workers may act as a source for MRSA transmission [10]. All persons entering a surgical ward may therefore act as an exogenous source of MRSA to susceptible patients, especially if hand-hygiene policies are not adhered to [11]. It is therefore imperative for all persons entering a surgical ward to apply alcohol gel as a means of reducing nosocomial MRSA [11].
Our surgical ward has many high-risk patients with severe complications be-Open Journal of Safety Science and Technology fore and after surgery, i.e., cardiovascular surgery using artificial valves and vascular grafts, and also thoracic and digestive surgeries. In May 2011, we had 10 MRSA patients in 49 beds and experienced an outbreak. We postponed all scheduled operations and separated the MRSA patients. The occurrence of the outbreak of MRSA has a big impact on society. By the use of strict infection standard preventative and contact preventive measures, it took 3 months to reduce the outbreak. We then continued the strict infection control measures for seven years. However, the novel experience of the outbreak was forgotten, and a thorough hand hygiene and manual compliance of infection control were lost.
The new infection of MRSA has not been erased, thus we found it difficult to maintain a strict infection control with a sense of tension and it became a challenge.
The aim of the present study is 1) to summarize the retrospective analysis regarding the short-term outcome of our past MRSA outbreak and the prevention,   (Table 1 and Table 2).

Infection Prevention and Control for the Inpatients during the MRSA Outbreak
The nosocomial center for infection control (CIC) classified inpatients as 4 types, that is, severely ill MRSA patients, MRSA-detected patients, non-MRSA general patients, and new hospitalized patients. The CIC instructed us to take appropriate infection measures corresponding to each type and we performed the 4 types of infection measures according to the newly created handling standards.

Manual about the Dressing-Exchange of Surgical Site during the Outbreak
We created a new manual regarding the dressing-exchange at the surgical site during the outbreak, which included standard precautions and infection prevention measures for the MRSA outbreak. All of the multi-professional staff carried the pocket manual describing these contents as a printed version. All the staff agreed 1) a priority on the dressing-exchange of the surgical site, 2) roles of clean and preparatory assistants, 3) standard precautions for wound dressing-exchange, and 4) procedure of dressing-exchange.

Roles of Clean and Preparatory Assistants
The role of the clean assistant: Do not remove a patient's gauze dressing. Do not put on tape. Do not touch the patient. The role of the dressing-exchange assistant: Fix gauze. Attach and detach the patient's clothes. Assist with the patient's position during wound-washing. After dressing-exchange of the wound site is done, the assistant must move to the next patient's bed and prepare it. Depending on the progress of the dressing-exchange round, separately moves the filth cart.

Standard Precautions for Dressing-Exchange
1) At the time of dressing-exchange of a patient with an open wound in the order of "first, wear gloves", "second, a mask" and "third, an apron". 2) At the time of cleaning a patient with an open wound in the order of "first, wear gloves", "second, a mask", "third, a gown", "fourth, a cap" and "fifth, goggles". 3) At the time of dressing-exchange of a patient with a bacterial infection in the order of "first, wear gloves", "second, a mask" and "third, an apron". Caution: if inclose contact with a patient or patient who has a sore or cough, wear a gown. 4) At the time of usual dressing-exchange without an infected wound in the order of "first, wear gloves" and "second, a mask". Caution: when removing drain tubes, wear an apron.

Data Collection and MRSA Surveillance
Retrospectively, clinical data were collected before and after the MRSA outbreak when the period was between April 2009 and October 2019. Before the outbreak, we did not measure the everyday amount of alcohol use in our surgical ward.

Statistical Analysis
A statistical technique was used that involved the seven techniques for qualitative analysis, which are collectively called the seven tools for quality control (QC seven tools). To analyze the frequency of appearance of the incident levels of new MRSA patients is part of the quality. The data in this study were analyzed by the breakdown of the MRSA outbreak patients, transition of the number of MRSA patients and the monthly amount of alcohol use. Changes in the variables were analyzed by comparison of before and after the intervention for the MRSA outbreak and before and after the current intervention of the Kaizen approach along with the industry problem-solving method.

Intervention of Quality Improvement Using Industry
Problem-Solving Method

Retrospective Analysis of the Patients during the MRSA Outbreak
At the MRSA outbreak, ten MRSA patients were present in the same surgical ward (49 beds), and accounted for 20.4% of the total number of hospitalized patients (10/49); these patients were in the cardiovascular (n = 4), digestive (n = 3) and thoracic surgery (n = 3) units. Table 1 and Table 2 Table 2 shows the summary of the short-term outcomes in those days with the ten MRSA outbreak patients. Regarding complications, the detected site of the MRSA, the clinical course of MRSA, and the outcomes, in two cases, the MRSA-infected wounds were covered with muscle flap and the clinical symptoms subsided. Regarding the clinical course of the ten MRSA outbreak patients, the outcome of MRSA resulted in it finally disappearing (n = 6), settled (n = 3), and patient died due to acute exacerbation of renal failure (n = 1). intervened with emergent infection control in our surgical ward. We followed the emergent infection prevention measures for our hospitalized patients and we implemented the agreed items regarding dressing-exchange of the surgical site. Figure 2 shows the dramatic change in the amount of alcohol use and the occurrence of new MRSA patients before and after the outbreak. After the alcohol hand disinfection was thoroughly implemented, the monthly average alcohol consumption per patient per day showed a dramatic increase. In June and July 2011, these months had shown a dramatic increase in the monthly alcohol use to an average of 106, 71 ml/patient/day respectively, thus it had been maintained in the range of 42 to 76 ml/patient/day for one year. In June, July, and August 2011, in which we implemented a newly revised infection control method, no new MRSA patients had been observed for one month in June 2011. Although only 2 and 1 patients were detected in July and August 2011 respectively, however, the incidence of new MRSA patients underwent a drastic decline. It took three months from the start of strict infection control to stop the MRSA outbreak. Intervention and guidance from the center for infection control (CIC) about the outbreak had been carried out in the surgical ward. After that, the number of newly MRSA-detected cases was 0 for the 5 month period from September 2011 to January 2012.

Short-Term Outcome during the Period before and after the Outbreak
In Figure 2, the number of new MRSA patients and the monthly average alcohol consumption were compared in a time series. Prior to the outbreak, the alcohol consumption for hand hygiene was very low, in contrast, it was found that the number of new MRSA outbreaks was constantly occurring every month.
It was found that after the outbreak, the nosocomial center for infection control (CIC) intervened in our surgical ward, our team approach for infection control Figure 2. Short-term outcome of changing the amount alcohol use for hand hygiene (ml/patient/day) and occurrence of new MRSA patients. dramatically increased the alcohol use for hand hygiene and consequently reduced the number of new MRSA patients. Figure 2 shows that an inverse correlation was suggested between the incidence of new MRSA patients and alcohol consumption. It has been empirically proved that a thorough manual alcohol disinfection is effective in preventing MRSA transmission. Figure 3 shows the long-term transition, that is, 6 years of occurrences of new MRSA patients and the monthly average alcohol use (ml/patient/day) after the outbreak. However, the novel experience of the outbreak has been diluted, thus the thorough hand hygiene and the manual compliance of infection control have become disregarded. In July 2013, the monthly average alcohol use for hand hygiene had gradually decreased and the level did not exceed the level of 60 ml/patient/day. In December 2014, 3 years after the outbreak, the monthly average alcohol use had decreased to a level of 40 ml/patient/day. New MRSA patients have occasionally occurred and the risk of a recurrence of the outbreak had become high. As Figure 3 shows, although there had not been any new occurrences of a MRSA outbreak, however, the new MRSA patients have not been cured. We recognized that it was difficult to maintain a strict infection control with a sense of tension and it became a challenge.

Results of the Intervention of Industry Problem-Solving Methods for the Eradication of New MRSA Patient Occurrences
To eradicate any new occurrence of MRSA patients, we newly implemented an industry total quality management and problem-solving method for infection control. The methods of problem-solving were performed in 8 steps; step-1: theme selection, step-2: current situation, step-3: setting a goal, step-4: factor analysis, step-5: measures planning, step-6: execution measures, step-7: effect confirmation, and step-8: standardization and fixing of management.
As step-1, "theme selection" was summarized that: 1) the MRSA outbreak oc-  As step-4, a "factor analysis" was performed on the root cause of the occurrence of new MRSA patients. Figure 5 shows a cause and effect diagram with five branches that are the patient, medical staff, method (skills/tools), team/organization, and task/environment. We focused on the true factors; 1) number of everyday hand hygiene is few, and the amount of alcohol use is less, 2) there was no reviewing of procedures and check sheet; 3) delay in determining MRSA-detected patient, and 4) no leader of infection control, and no education and no training of new staff.
As step-5, "measures planning, measures execution, and effective confirmation" are summarized: 1) daily averaged amount of alcohol use, and monitoring of times of hand hygiene. From April 2018, the averaged amount of alcohol use for hand hygiene increased to more than 40 ml (ml/patient/day). The averaged times of hand hygiene increased to more than 14 (times/patient/day); 2) stan- meetings and confirmation of level of understanding. As step-6, "standardization, definition of management and comprehensive evaluation" are 1) sustaining of a new standardization for the manual of standard precaution and contact infection measures, and arrangements of wound dressing; 2) regarding a new standardization of infection control, we intend to have regular study workshops of teaching and training; 3) comprehensive evaluation: from April, 2018, the risk of MRSA occurrence increased. Although one new MRSA patient was observed in May 2018, however, infection prevention measures have been continually performed. Figure 6 shows the A3 problem solving regarding the agglomeration of the Kaizen approach.

Outcome of the Implementation of the Quality Improvement with Problem-Solving Method
As step-7, Figure 7 displays the "effect confirmation", which shows the effectiveness of this industry problem-solving approach to infection control.   As step-8, "standardization and fixing of management" are described as follows: 1) from April 2018, we intended to achieve no new occurrences of MRSA patients, and we continue to perform such a goal, 2) measurement of the compliance rate of new standardized arrangements of wound dressing, removal of drain tube, and methods of wound treatment, 3) regarding the infection matters, we expanded the problem-solving approach to infection control in the surgical ward to other departments as planned (secretariat; Dr. Ayabe), and 4) we continually developed the industry problem-solving method of ASUISHI to improve the quality of healthcare at the university hospital.

Discussion
Health-care-associated infections represent a leading preventable adverse event in patients [16]. Methicillin-resistant Staphylococcus aureus is a major cause of hospital-acquired infections in many countries around the world [17] [18]. In the last decade, numerous reviews and consensus statements have endorsed policies to control the spread of nosocomial MRSA infections [19] [20] [21].
Hand hygiene is widely considered the key to prevent such infections and cross-transmission of multidrug-resistant organisms [1] [22]. WHO recommends a multimodal approach to hand hygiene promotion that includes provision of alcohol-based hand rub at the point of care, education of healthcare workers, audit and performance feedback of hand hygiene behavior, reminders in the workplace, and institutional safety culture. Existing evidence supports the effectiveness of multimodal hand hygiene promotion [1] [16] [22]- [26]. However, sustaining success remains challenging. Regarding the patient's hand washing, it is just as important as hospital workers' hand hygiene. The increased hand hygiene compliance by patients can influence the infection rates in an adult cardiothoracic step-down unit [27]. The decreased infection rates and increased compliance with hand hygiene among the patients may be attributed to the implementation of patient education and the increased accessibility and use of hand sanitizers [27].
Pittet et al. [8] reported that hand hygiene adherence was associated with lower MRSA colonization rates [8]. Bischoff et al. [28] also observed that improved accessibility to alcohol-based hand sanitizers enhanced adherence to hand hygiene. In our surgical ward in those days (Figure 1), the daily averaged amount of alcohol consumption per patient was calculated to be the low level of 8 to 14 ml/patient/day. As one complete pushing volume from the alcohol hand sanitizer supply bottle can be measured by about 3 ml, this amount can be counted as 1 hand hygiene time. Retrospectively, we considered the status of hand hygiene before the MRSA outbreak in past days. If the hand disinfection is performed twice before and after wound treatment for one patient care, in the calculation, at least 6 ml of alcohol (two pushes of alcohol supply bottle) is used for one nursing care or doctor's round for 1 patient. At that time, the levels of 8 to 14 ml/patient/day, which means that only 2 or 3 hand disinfection times were performed for one patient care for a day, was a situation that meant incredibly very low levels of hand hygiene in those days. If 10 times the patient care and wound treatment per one patient for a day were performed, the amount of alcohol use would be estimated to be at least more than the level of 60 ml/patient/day. Based on the data obtained from the surgical ward during the MRSA outbreak ( Figure 2), it was observed that if the used alcohol amount was not below the lowest level of 40 ml/patient/day, this level showed that there was decrease in new occurrences of MRSA patients. We have continued to monitor the daily alcohol consumption in the surgical ward in order not to decrease the level of 60 ml/patient/day ( Figure 2). This monitoring system serves as a convenient tool to visualize the hand hygiene status. For example, if the alcohol consumption decreased below the level of 40 ml/patient/day (equivalent to 6 to 7 hand hygienetimes), we can alert to the multi-professional staff the decreased status of the disinfection level and we can call for more implementation of hand hygiene in order to increase to more than the level of 60 ml/patient/day ( Figure 2). Since then, the raised awareness for infection control has been maintained in our surgical ward. Figure 5 and Figure 6 show the A3 sheet summary by the problem-solving method, that is the Kaizen approach for the eradication of new MRSA occurrences in the surgical ward, which is what we complied for the process of industry problem-solving with the team staff. In is important for the team members to understand and share the 8 steps of the problem-solving approach, that is to select the theme, to investigate current situation, to set a goal, to analyze factors, to measure planning, to measure execution, to confirm effects, and standardize and to fix the management. The A3 sheet ( Figure 6) included these 8 steps and visualized the total quality management in surgical ward, which displays the responsible person in rule.
The limitation of the present study is the outcome in the small surgical ward section in a single university hospital, which is based on the dynamic implementation of changing infection control activity by feedback of the daily monitoring of the level of hand hygiene, and which was retrospectively analyzed. The long-term maintaining of compliance of hand hygiene is actually very difficult.
Although performing alcohol hand hygiene is understood to be very good evidence for infection control, however, the implementation and the sustainable practice are very difficult to perform. There are some gaps between the evidence and the practice in the workplace.
As our future direction, we will expand the Kaizen approach across a section of our hospital. Although the quality improvement, such as industry problem-solving [12] [13] and the Lean Six sigma tool [15], is based on the Japanese Kaizen approach [14], these implementations and the continuity are very useful.
Kaizen is a Japanese word that means "change for the better," as popularized by Masaaki Imai [14]. In order to expand the efforts for infection prevention, not only an individual effort but also a multi-professional team effort are cross-organizationally expected to form a culture of infection control, that is, as an organization culture, both top-down instructions and a bottom-up approach are important to implement infection control measures. The organization culture is defined as the assumptions, values, and norms shared among colleagues. These beliefs are often taken for granted, but have the ability to influence an individual's thinking and behavior [29]. The organization culture can impact (positively or negatively) the organizational success and an organization's ability to implement change. The organization culture has recently gained recognition in the health care setting and is an element to consider when implementing an infec- and how to reconcile is difficult but very important. It is effective to start a Kaizen approach with an industry problem-solving method for the eradication of a new occurrence of MRSA patients, which efforts can be visualized by creating the process in an A3 sheet ( Figure 6). It is useful for a multidisciplinary approach to perform the improvement of the quality and the activity of infection control by teamwork.

Conclusion
Based on the more than 8-year long-term outcome of infection control by measuring the daily amount of alcohol use for hand hygiene and the directly-connected prevention measures for new MRSA patients, these can reconcile the theory of infection control and the implementation of everyday practical hand hygiene. By creating and performing a Kaizen approach with the problem-solving method, which can realize 7 months of zero new occurrences of MRSA and will contribute to the multi-professional team to visualize the process of quality improvement for infection control. There was an inverse correlation between the decreased amount of alcohol use for hand hygiene and the increased number of new MRSA patients.