Counterintuitive: Move To EHR spikes rates?

Be on alert during implementation phase

Your move to an electronic health record (EHR) system will save you time and money while increasing your ... infection rates? How could this happen?

If you said increased use of electronic equipment like computer keyboards, you are on to something.

"Well in advance of EHR implementation, educate and assign responsibility to clean keyboards and other patient care equipment," says Virginia Bren, MPH, RN, CIC, infection control coordinator at Altru Health System, Grand Forks ND.

Reporting the unusual outbreak this year in Baltimore at the annual conference of the Association for Professionals in Infection Control and Epidemiology, Bren concluded electronic health record systems — which are designed to improve the quality and safety of care —may ironically be associated with increased transmission of infections during implementation.1

In preparation for an EHR system, which went live in the hospital on April 1, 2010, computers and keyboards were installed at multiple locations. During this time, information was issued about how to clean keyboards and mice, but this message had to compete with many EHR learning priorities, she reports. After the new records system was implemented, hospital onset methicillin-resistant Staphylococcus aureus (MRSA) in a medical ICU (MICU) rose from zero to 2.2 per 1000 census days, and the surgical ICU (SICU) rate rose from 1.3 to 2.0 per 1000 census days. Overall, hospital department rates rose from 0.2 to 0.4 per 1000 census days. Compliance to hand hygiene and to isolation precautions prior to and after EHR implementation was more than 90%, she reported, but noted that hand hygiene surrounding keyboarding activity was not audited. In addition, staffing turnover occurred in the MICU in conjunction with implementation of the new records system, with nine inexperienced nurses coming on board, Bren reported. Patient census was not significantly different prior to or after EHR implementation.

In July 2010 as MRSA increased, the infection prevention informed leadership, distributed educational tools and met directly with staff. Interventions focused on environmental cleaning and hand hygiene. Responsibility was assigned to clean patient care equipment regularly, including keyboards, computer mice, and barcode scanners. Environmental Services introduced a room cleaning checklist and microfiber cloths. By October 2010, the MICU's MRSA rate regained zero, but the SICU and the combined hospital rates were not less than prior to EHR implementation.

"One of the lessons learned was that analyzing MRSA data more frequently during an EHR transition could have identified rate increases earlier," Bren concluded. "Observing hand hygiene behavior before and after using keyboards, mice or equipment that goes between patients may strengthen cleaning and hand hygiene practices."


  1. Bren VR, Hansen SG, Hargreaves J. Increased hospital onset MRSA after transition to electronic health record system. Abstract 11-111. Association for Professionals in Infection Control and Epidemiology. June 27-29, 2011. Baltimore, MD.