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Nursing Care in the Med/Surg Unit: Preventing the Spread of MRSA

Lucretia Shafer Pacific Lutheran University

Can You Imagine?

It is almost the end of your shift and it has been a particularly hectic day with five patients, three of whom are heavy care. As you look over the new labs you groan in despair. One of your patients, an 80 yo gentleman from a local assisted living home, in for lower extremity arterial disease (LEAD) with severe BLE ulcers with copious SS drainage, has tested positive for MRSA. As you arrange for him to be moved to a private room and the isolation cart to be put outside his door, you review your care for him over the past few hours.

Nursing Research

6 Transmission of MRSA occurs primarily via the contaminated hands of healthcare workers who do not follow appropriate infection control measures (Ott et al., 2005; Raboud et al., 2005) 6 Successful MRSA control programs consist of: =Identification and screening of patients at an increased risk of MRSA colonization and infection =Isolation or grouping of patients with MRSA =Proper hand hygiene between all patients =Hospital environment hygiene

(Ott et al., 2005; Raboud et al., 2005; Stirling, Littlejohn, & Willbond, 2004)

Nursing Interventions (cont)

6 Administer prescribed antibiotics at appropriate times for

maximum antibiotic effectiveness

(Ott et al., 2005)

Hand Hygiene

6 Hand washing is the single most important infection control

practice. Failure to perform appropriate hand hygiene is considered the leading cause of the spread of MRSA and other multi-resistant organisms (Chalmers, & Straub, 2006; Henderson, 2006; Ott et al., 2005)

6Avoid tracking wound exudate and normal body flora from surrounding skin to clean areas (Ott et al., 2005)

6 Inform patient if they are MRSA positive and provide

6 However, most hospitals accept failure rates in hand

hygiene of more than 40%

(CDC, 2004; Henderson, 2006) (Fairclough, 2006; Henderson, 2006)

instruction to help them understand the infection control protocol (Ott et al., 2005)

6 Visibly soiled hands should be washed with soap and water 6 Hands should be decontaminated preferably with an alcoholbased hand rub: =before contact with patients =before engaging in clinical procedures =after contact with patients, bodily fluids, excretions or mucous membranes =after contact with inanimate objects or medical equipment =after removing gloves

(CDC, 2004; Henderson, 2006)

6 Evaluate response to instruction (Ott et al., 2005) 6 Communicate information about patient's risk status to

appropriate healthcare team members

(Ott et al., 2005)

What is MRSA?

Staphylococcus aureus is a common bacteria carried on the face, axilla, nares, and groin of healthy people and is the single most common cause of hospital-acquired (HA) infections (Romero, Treston, & O'Sullivan, 2006). From 30% to 60% of healthy adults are carriers of S aureus (Henderson, 2006; Lines, 2006). Those who are carriers can become infected with their own bacteria. However, healthy people usually are not at risk (Banning, 2005). The antibiotic Methicillin was introduced in 1959 and in 1961, Methicillin-resistant S aureus (MRSA) was discovered in Europe. MRSA is now the cause of 40% of S aureus infections in hospitals and is a major HA pathogen worldwide (Raboud et al., 2005). HA MRSA infections are found in wounds, surgical incisions, catheters, pneumonia and sepsis and are most often spread in hospital when healthcare workers in contact with MRSA do not adequately wash their hands (Banning, 2005; Henderson, 2006; Ott, Shen & Sherwood, 2005; Raboud et al., 2005). While MRSA is no more contagious than other S aureus infections, it is more difficult to treat and is associated with significantly increased morbidity, mortality and healthcare costs (Siegel, Rhinehart, Jackson, Chiraello & the Healthcare Infection Control Practices Advisory Committee, 2006) . Control measures increase nursing workload and can cause anxiety and distress in patients (Fairclough, 2006; Raboud et al., 2005).

6 Nurses' understanding of infection control in general and

MRSA in particular directly affects their adherence to infection control policy and guidelines (Banning, 2005; Prieto & Clark, 2005).

6 Collaborate with Infection Control nurse to ensure

compliance with facility guidelines (Cox et al., 2002) team members (Ott et al., 2005)

Assessment

6 Assess skin integrity, sensory impairments, and musculoskeletal status to determine susceptibility to infection

(Ott et al., 2005)

6 Communicate patient concerns to appropriate health care 6 Encourage diversional activities such as reading, music

and TV (Ott et al., 2005)

6 Empower patients to monitor care provided by healthcare

providers infection

(Ott et al., 2005)

6 Perceived barriers to proper hand hygiene:

=skin irritation =inaccessible hand hygiene supplies =increased workload =understaffing or overcrowding

(Henderson, 2006)

6 Assess for signs of infection (vital signs, pain level, labs, skin integrity, weight, chronic disease) (Ott et al., 2005) 6 Assess knowledge level, readiness to learn and identify barriers to communication to determine susceptibility to anxiety

(Ott et al., 2005)

6 Provide discharge instructions for care of a MRSA

(Ott et al., 2005)

Nursing Diagnosis

6 Risk for infection related to antibiotic resistant organism,

hospital stay, contact with healthcare workers 6 Risk for anxiety related to knowledge deficit of antibioticresistant organisms, isolation

Breaking the Chain of Infection

Evaluation

6 Patient was not infected with MRSA while in the hospital because infection control protocol was scrupulously followed. 6 If the patient is MRSA positive: cross-contamination of patients did not occur because infection control protocol was scrupulously followed. 6 Patient verbalizes decreased anxiety, an ability to cope, and an understanding of MRSA because they were adequately informed and educated about MRSA.

Planning

Goal: MRSA cross-contamination will not occur in the hospital Objectives: 6 Patient will not be infected with MRSA during hospital stay 6 Patient will not experience anxiety r/t infection control protocol during shift

Google Images, 2007

Who Gets MRSA?

Risk factors for HA MRSA include: 6 Prolonged hospital stays or surgery 6 Residence in a long-term care facility 6 Any type of indwelling catheter 6 Prior antibiotic use 6 An immunocompromised state, including extremes in age (the elderly and the very young)

(Banning, 2005; Romero et al., 2006) Google Images, 2007

All's Well That Ends Well

You realize that your patient probably came to the hospital with MRSA and your main concern now is for your other patients. You know that you follow standard precautions by wearing gloves when required and practice good hand hygiene. You also habitually wipe down equipment that is shared between patients (stethoscopes, glucometers, BP cuffs, etc). Breathing a sigh of relief, you know that your other patients are at low risk for cross-contamination from your actions. You are also confident that by placing the patient on MRSA precautions, your hospital has significantly decreased the risk of other patients contracting a HA MRSA infection.

Infectious Agent: MRSA Reservoirs: Environment in which MRSA can survive. Hospital rooms; patients, staff and visitors; equipment. Portal of Exit: Route by which MRSA leaves the reservoir. Excretion or secretion of body fluids, in droplets or on the skin. Means of Transmission: The way MRSA is acquired. Of the six links in the chain of infection this one is the easiest one to break and is therefore the key to cross-infection control in hospital settings (Chalmers, & Straub, 2006) . Portal of Entry: The route MRSA takes to gain access to the susceptible host. It is often the same as the portal of exit. It can also include invasive devices such as urinary catheters and IV devices. Susceptible Host: Those at increased risk of acquiring a MRSA infection: see Who Gets MRSA

(Chalmers, & Straub, 2006; Siegel et al., 2006)

Nursing Interventions

6Follow Standard and Transmission-based precautions to prevent infection and cross contamination: =Practice good hand hygiene at all times (see Hand Hygiene box) =Isolate or cohort patients with identified MRSA =Ensure that isolation supplies and equipment are easily accessible =Use the appropriate Personal Protection Equipment correctly (gloves and gowns; masks and shields if needed) =Clean and disinfect all reusable equipment after each use and properly dispose of single use items

(Centers for Disease Control and Prevention [CDC], 2004; Garner, J. S., & the Healthcare Infection Control Practices Advisory Committee [HICPAC], 2005; Ott et al., 2005, Siegel et al., 2006)

Acknowledgments

Thank you to Neil Zaboy, Diane Joyce and the staff at St. Francis third floor medical for your kindness and instruction. * References available upon request

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