Instead of the targeted approaches to reduce MRSA and other healthcare-associated infections, we should really be focused on Universal Infection Prevention Strategies! The good news is that these Universal Infection Prevention Strategies, when FOLLOWED, not only reduce MRSA transmission rates, but also the spread of other healthcare-associated pathogens. Let’s start with a very brief history lesson for MRSA: We had an outbreak in the 50’s and 60’s of S.aureus in North America, it was firmly established as a healthcare-associated pathogen. The infection rates continued to rise in the 70’s and 80’s until MRSA infections reached epidemic proportions in the 90’s. The MRSA epidemic of the late 90’s and early 2000’s wasn’t driven by an increase in healthcare transmission or sicker inpatients getting infected, but by a strain of MRSA that developed resistance to treatment- originally called community-associated MRSA. This name was discontinued after it was shown that, in some cases, the community strain (albeit rarely) were both being transmitted in the community. Now, despite the headlines of the media, this strain didn’t “escape” from hospitals; it developed independently in the community. Ok….so that was not very brief. So now we have a contact precautions conundrum. There was a broad consensus that contact precautions for MRSA infections were necessary. And we all still support this approach…it’s called CDC guidelines. Contact precautions allow for a wide range of practice by facilities. However, questions surrounding the implementation of contact precautions still exist. This is, in part, because contact precautions have been associated with several negative outcomes. There have been studies that demonstrated that healthcare workers, including physicians, are half as likely to enter the rooms of (or examine) patients on contact precautions! Studies have also reported that patients in private rooms and on barrier precautions for multidrug-resistant organism (MDRO), including MRSA, have increased anxiety and depression scores. A number of other studies have reported significantly more preventable adverse events, greater dissatisfaction with their treatment, and less documented care than patients who aren’t in isolation. CDC encourages facilities to develop their own strategies for MRSA colonized and/or infected patients. Some facilities required gowning and gloving for all staff entering the room of a patient on contact precautions for easier evaluation of staff adherence. Other facilities require gowning only when contact with the patient is expected or only in certain areas of the patient’s room. Ironically, in most cases, hand hygiene doesn’t appear to increase in contact precaution rooms compared with noncontact precautions rooms! Here is a Contact Precaution Preview Patient Room: In long-term care and other residential settings, make decisions regarding patient placement on a case-by-case basis, balancing infection risks to other patients in the room, the presence of risk factors that increase the likelihood of transmission, and the potential adverse psychological impact on the infected or colonized patient. Gloves: Wear gloves whenever touching the patient’s intact skin or surfaces and articles in close proximity to the patient, such as medical equipment or bed rails. Put on gloves upon entry into the room or cubicle. Gowns: Wear a gown whenever clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Put on a gown upon entry into the room. Remove gown and practice hand hygiene before leaving the patient care environment. Transport: In long-term care and other residential settings, limit transport and movement of patients outside of the room to medically necessary purposes. When transport or movement in any healthcare setting is necessary, ensure that infected or colonized areas of the patient’s body are contained and covered. Remove and dispose of contaminated PPE and perform hand hygiene before transporting patients on contact precautions. Equipment: In long-term care and other residential settings use disposable noncritical patient care equipment, such as BP cuffs, or implement patient-dedicated use of such equipment. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient. Cleaning of the environment: Ensure that the rooms of patients on contact precautions are prioritized for frequent cleaning and disinfection (at least daily), with a focus on frequently touched surfaces (bed rails, bedside table, bedside commode, lavatory surfaces in patient bathrooms, doorknobs, and so on) and equipment in the immediate vicinity of the patient. So let’s take a look at Universal infection Prevention. Universal approaches that are best supported by the current literature can be broken into five groupings: bundles, environmental cleaning, patient hygiene, healthcare worker hand hygiene and antimicrobial stewardship. A bundle is an approach of implementing a number of interventions aimed at reducing a problem, such as reducing CAUTI (cath-associated urinary tract infection). Environmental cleaning: Occupying a room that previously housed a patient with MRSA or another MDRO is a known risk factor for acquiring those bacteria. Recently, studies have shown that rooms are cleaned much less than previously thought; one study noted that at over 40 hospitals, less than half of the high-touch surfaces in a patient’s room were cleaned. A luminescent gel or powder is an effective teaching method for environmental service staff learning how and what to clean. All facilities should have clear roles about who cleans what on a patient-care unit. These task need to be defined and reviewed with all staff on a regular basis. Patient hygiene. This is becoming an increasing focus for preventing the transmission of MRSA and other HAIs. Most of the data out there is focused primarily, but not exclusively, on patients in the ICU. So far, the data shows that MRSA and other HAI rates can decrease significantly when the patient is bathed daily. However, it should be noted that there are disparities in the data and some studies have shown that daily baths fails to reduce MRSA. Nevertheless, given the repeated studies in different acute care settings demonstrating reduction in at least some HAIs (MRSA, C.difficule, CLABSI, surgical site infections and VRE), there is little rational for not implementing it. Antimicrobial Stewardship has been noted to be an effective way to control MRSA and other MDROs. Antimicrobial stewardship is “as set of coordinated strategies to improve the use of antimicrobial medications with the goal of enhancing patient health outcome, reducing resistance to antibiotics, and decreasing unnecessary costs.” You’re probably thinking by now……Did she forget HANDWASHING? Nope! I am leaving the best practice for last! So here is my spiel on handwashing. We’re barcoding medications, using telemedicine to care for patients five states away and to keep electronic medical records. But for some reason, we can’t get it through our heads that something as low-tech as soap and water can increase patient safety and decrease infections. I have seen healthcare worker not wash their hands, only run their hands under water and then dry them off or do a 4 second hand wash. Every time I see this lack of handwashing I think of the movie Outbreak…..and I think to myself…..Your patient Zero! I learned my handwashing skills quickly while working in the ED. I perfected them when I went to the Oncology floor for 8 years. Here is what I know to be fact! ALL patients AND families want to see all healthcare workers who enter their room wash their hands first thing. It does not matter to them that you just washed your hands before exiting the last room you were in or that you are using hand sanitizer. They don’t care! And for good reason! As a collective group healthcare workers do not adhere to the CDC’s Handwashing Guidelines. So, yes, I can understand when patients and families get upset with us about washing our hands. Protect your patient’s, protect yourself and your co-workers and protect your family and please….just wash your hands!
Posted on: Fri, 14 Jun 2013 19:22:07 +0000