Taking a vertical and horizontal approach to MDRO prevention

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Taking a vertical and horizontal approach to MDRO prevention

Creating the perfect program depends on your facility's needs

After reading this article, you will be able to:

  • Explain the difference between a horizontal and ­vertical approach to MDRO prevention
  • List considerations when conducting an MDRO risk assessment
  • Identify ways in which a successful horizontal approach can decrease MRSA colonization

Every healthcare facility has patients who are colonized with an MDRO, whether it's from the community, another hospital, or another patient.

Subsequently, preventing these patients from entering your facility is relatively impossible-unless you're willing to bolt the doors shut.

Instead, a more realistic approach involves preventing the spread of MDROs the moment those colonized patients enter your facility. Depending on the type of facility you work in and the risk factors in that environment, the backbone of your prevention efforts may follow either a vertical or horizontal path.

These expressions are used to delineate two different approaches to MDRO prevention, says Peggy Prinz-Luebbert, MS, MT(ASCP), CIC, CHSP, owner and consultant for Healthcare Interventions, Inc., in Omaha, NE. A horizontal approach is what Luebbert calls an "all for one" approach that focuses on tried-and-true prevention efforts on all patient populations. Essentially, you treat everyone the same, so you won't need to do anything special for a unique bug. A horizontal approach involves the following:

  • Standard precautions
  • Hand hygiene
  • Respiratory etiquette
  • Environmental cleaning
  • Aseptic technique


A vertical approach takes those same basic IC principles while adding a one-size-does-not-fit-all tactic. Each bug is treated differently and each patient has a unique infection prevention procedure. The vertical approach focuses on the following efforts:

  • Active surveillance
  • Isolation
    • Level of transmissibility
    • Mode of transmission
    • Consequences of infection

First, do a risk assessment

Which approach you decide to take really depends on what unit you are working on, the needs of your patients, and the type of procedures that are being performed. This is where the risk assessment comes in, which will help determine what kind of approach will optimize your prevention efforts.

"You need to do a risk assessment for your environment, your patients, and your bugs," Luebbert says. "Look at which one of these works best for you. There isn't one approach that works for everyone. In some environments the horizontal approach is enough, but in others you might need to use the vertical."

For example, if you are in an outpatient setting, you may want to consider the following during your risk assessment:

  • Type of patients
  • Type of procedures
  • Bodily fluids that staff members may come in contact with
  • Pathogens that may enter the facility


An outpatient surgery center may find that standard precautions for every patient is sufficient to prevent cross-contamination of potential MDROs. However, an ICU that cares for patients who are much more critical requires many more considerations to prevent potentially deadly outcomes if an MDRO like MRSA were to spread from patient to patient.

"If you're in an ICU setting where you've got lots of tubes and IVs, the patients are on a lot of antibiotics, and there is going to be a lot of people touching and treating that patient, then you might need more than just a horizontal approach," Luebbert says.


Case study: The horizontal approach in action

Luebbert put the horizontal approach into action as an IP responsible for a large healthcare system. The IC department decided to focus its targeted screening efforts on one of the high-risk areas, a rehabilitation facility that treated hundreds of inpatients and ­outpatients, including quadriplegic and paraplegic patients.

For three months staff members took nasal swabs on admission, biweekly, and on discharge. On admission the IC team found that approximately 8% of patients were colonized with MRSA, a statistic that was expected considering it fell in line with the general rate of MRSA in the community. However, they also found that an ­additional 7% of patients were colonized upon discharge, meaning they contracted MRSA while being cared for at the facility.

"You are taught in infection prevention 101 that you never culture unless you know what you are going to do with a positive result," Luebbert says. "Well, we didn't expect that, so we brought all the stakeholders together and asked, ‘What's happening here?' "

The stakeholders took a closer look at the risk factors, especially in the large gym that was used for ­rehabilitation purposes, and discovered a couple of issues that may have gone unnoticed without the screening.

First, they found that employee compliance with hand hygiene and equipment disinfection was good with patients who were on isolation precautions, but with everyone else, staff members demonstrated limited compliance because they assumed they were not colonized.

Secondly, patients and visitors were not washing their hands, which further contributed to the spread of MRSA in the facility.

"A lot of family members help out in rehab," Luebbert says. "None of them were ever washing their hands. And if the patient is colonized with it, odds are their family members are too."

After identifying these key areas of concern, the rehab center instituted strict policies with both staff members and visitors. Staff members were trained to wash their hands before and after treating each patient, regardless of whether that patient was on isolation precautions. They were also trained to disinfect gym equipment between each patient, not just after patients who were under precautions. (See the sample environmental cleaning checklist on p. 4.) 

"We didn't just wash our hands for those that were in isolation and we didn't just clean equipment for those that were in isolation-we did it for everyone," Luebbert says.

Additionally, visitors and patients were instructed to use hand sanitizer in between usage of equipment. Inpatients were also required to change into clean clothes before using the gym, and outpatients were asked to wear clean clothing to their rehab appointments.

Within six months of implementation the rehab center had less than 1% colonization.

"It's an example of a horizontal approach in that if we do this for everybody, whether they are in isolation or not, then we can show a decrease, and the culturing of MRSA ended up being a marker of how effective our standard precautions were," Luebbert says.

Reeducation and changing behaviors

Months later, however, the facility saw another spike in MRSA colonization. Upon further investigation, it found a simple explanation. The person who had been a big proponent of proper hand hygiene and disinfection in the gym had moved to another position. New staff members and students were filtering in and that strict adherence to standard precautions and appropriate disinfection was falling to the wayside. New staff members were quickly educated and the emphasis on standard precautions for every patient was reinforced. After the reeducation effort, the spike quickly dissipated.

But the spike reinforced the idea that hand hygiene and disinfection need to be integrated into everyday processes so they become second nature to staff members, Luebbert says. This is often echoed in procedures such as catheter insertion and removal, but the same principle applied for MRSA prevention.

"You can't say you need to change the catheter and then wash your hands; it needs to be when you change the catheter these are the steps that need to be followed to change the catheter. Hand hygiene is a big part of those steps," Luebbert says. "It's the same with standard precautions. It's part of the process; it's not a separate entity."