Background: In 2016 we saw an increase in hospital acquired infections in our Neonatal Intensive Care Unit (NICU) caused by Staphylococcus aureus (SA). SA is a common colonizer on the skin of healthy persons and can be transmitted by direct contact with skin. Most infections occurred in low birth weight neonates housed in our Small Baby Unit. Process changes occurring around this time included increased skin to skin care, meaningful touch between neonates and parents, and two person staff care. We hypothesized process changes were exposing neonates to increased amounts of SA and potentially contributing to infections.
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