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June 23, 2008

The MRSA Bug

Thumbmmwr464224fig11 I just watched the video Webcast Video Editorial : Spread of MRSA : Past Time for Action, and the letter written in response to this editorial.   There are also a good number of interesting comments from a variety of health professionals about these topics.

I can’t argue against the fact that we  have a rising threat of MRSA infection within US hospitals. How many times have you worked and not seen a soul from the Housekeeping Department for hours? Or cleaned a room yourself as the admitting patient waited in the hallway? Or seen overflowing garbage in your “open chest case room?”  How often do you see physicians who don’t wash their hands after packing a wound or examining a patient? And do nurses always wash hands between every patient encounter?

What are the biggest culprits in the spread of MRSA and other superbugs within a medical facility today? Are healthcare workers the ones responsible for the spread of MRSA? I see plenty of blue and green scrubs walking down York Avenue. Where have those scrubs resided for the day?

What about basic hygiene -- the use of alcohol-based disinfectants and handwashing? Bathing patients?  Should all patients being admitted to an ICU be placed on contact isolation? (Of course, eventually there is a low supply of isolation gowns by the week‘s end…)

I do think basic education and increased awareness would be of benefit – for those who work within the system and those receiving care from the system.

This resource is not brand new, but very helpful: Questions About MRSA and Answers From the Experts

What are your thoughts? Have you made changes in your workplace? What should we be doing better?

June 23, 2008 in Beka | Permalink

Comments

Working on Palliative Care in a hospital, we see numerous patients with MRSA and VRE and even C-diff. The main emphasis is on nurse handwashing and gowning. BUT the patient can exit the room without protective gear and go around the ward, down to the cafeteria and chapel,and out to the courtyard. I'm reminded that it is a 'quality of life issue"!! "Quality of WHOSE life?" I ask.
Somewhere in the time that I have been nursing things changed, too. Nurses used to change all outer clothing when coming on the ward. Now most wear their scrubs on transit or in their cars, stopping at the store,etc. and right onto the ward to the bedside, then back home. How many even change then? We are tracking 'stuff' to and from work. It looks very unprofessional to see people on the street/in the store in scrubs. Yuck!!! I have come to realize that the health care system doesn't have the stomach to tackle this issue - convincing nurses, doctors, etc. to change is too big a challenge. So we focus on handwashing, which while very important, is only one link in the chain. And a chain is only as strong as it's eakest link.

Posted by: Susan | Dec 1, 2008 7:30:55 PM

Working on Palliative Care in a hospital, we see numerous patients with MRSA and VRE and even C-diff. The main emphasis is on nurse handwashing and gowning. BUT the patient can exit the room without protective gear and go around the ward, down to the cafeteria and chapel,and out to the courtyard. I'm reminded that it is a 'quality of life issue"!! "Quality of WHOSE life?" I ask.
Somewhere in the time that I have been nursing things changed, too. Nurses used to change all outer clothing when coming on the ward. Now most wear their scrubs on transit or in their cars, stopping at the store,etc. and right onto the ward to the bedside, then back home. How many even change then? We are tracking 'stuff' to and from work. It looks very unprofessional to see people on the street/in the store in scrubs. Yuck!!! I have come to realize that the health care system doesn't have the stomach to tackle this issue - convincing nurses, doctors, etc. to change is too big a challenge. So we focus on handwashing, which while very important, is only one link in the chain. And a chain is only as strong as it's eakest link.

Posted by: Susan | Dec 1, 2008 7:29:26 PM

One effort that can be made to curb the escalation of infections, whether it be MRSA or other, is to look closer at free standing dialysis units and the cross contamination that goes on there. When those patients become ill, they are frequent flyers at the ER and account for a large number of hospital admits and they travel from one specialty to another for all their issues. Therein begins the onslaught of a large percentage of potential infectious diseases as time is money and corporate America cares less about infection control than they do the bottom dollar.

Posted by: karen | Jul 17, 2008 9:12:20 AM

very good article

Posted by: laura snover | Jul 17, 2008 5:26:08 AM

My nursing career began in Pennsylvania where we treated MRSA and VRSA like the plague. Infectious disease MD's at the time informed us that there would be as epidemic of these organisms if they were not contained properly. Patients diagnosed were kept in isolation and there was a small 'dirty' room between the patients room and the hall. We gloved, gowned, masked, and wore protective shoe covers as well before entering the patients room and then stripped these garments in the 'dirty' room before we entered the hallway. Special procedures were followed to remove the shoe covers last as not to contaminate ourselves or the hallway. I then transferred to another region of the country and felt as though I had gone back in time. The infection policies were completely different. No wonder MRSA is everywhere!! And yes...I have personally escorted MD's to the nearest handwashing area after watching them change a MRSA wound dressing and walking out of the patients room (not bothering to wash),then picking up the patients chart. Here I go with the chart trying to disinfect it also!!
Handwashing should be a ritual with every caretaker...unfortunately it is not. I challenge you to observe your fellow workers-all of them!! You will find that our BEST preventive measure for spreading MRSA as well as a host of other infections is not being followed properly.

Posted by: Bonnie | Jul 16, 2008 2:46:36 PM

Why is MRSA always blamed on hospitals?? Has anyone gone to a school lately? They are smelly bastions of germ breeding. Every where you look kids are dribbling, drooling, coughing, sneezing, wiping snot, picking scabs and chewing their fingers, hair and clothes. It's not a surprise MRSA is all over the community. What is a surprise is that more stuff isn't....and let's not even start talking about general hygiene in the community. Don't people know how to bathe anymore?? I worked in a suburban ER for three years. I could not believe the filthy people that walked through that door. Dirty clothes, smelling of body odor and cigarettes, greasy hair. Truly disgusting. Meanwhile we are all walking around wearing gloves and washing our hands 600 times a day.

Posted by: paula walla | Jul 15, 2008 7:37:16 PM

What do you think about the lack of education for the patient regarding their infections? How many patients are told, or remember the name of the bacteria they are being treated for? Are they provided with teaching tools to prepare them for going home, and the importance of infection prevention at home? How do we educate the patients and their families if the hospitals , in general, don't want to broadcast that people are getting infections in their institutions?.

Posted by: Lori | Jul 11, 2008 8:03:34 PM

One word for you..........doorknobs. How often are the doorknobs in your facility cleaned? This is one of my pet bugaboos. We are seeing drug resistive organisms on the rise. Everyone is panicking. Let's increase levels of isolation! No.......contact isolation is appropriate. Let's increase levels of basic hygiene. Handwashing and housekeeping. Simple things like doorknobs.....clean them at least daily. Hand washing....let's get back to singing "Old McDonald had a farm". Let's get back to basics.

Posted by: Suzanne | Jul 11, 2008 8:12:18 AM

Karen, I hear you! What more should we do? What are you doing at your hospital? Would the confidential reporting system at your hospital be a place to start? If each person who notices a risk for infection would report it, would a hospital do anything anyway? Do nursing unions make a difference?

Posted by: Lori | Jul 10, 2008 12:03:45 PM

I have been an active nurse for many years. I can't tell you when everything changed. I woke up one day and the healthcare world was upside down. Nothing was sacred anymore. Handwashing, daily baths, clean beds, oral hygiene, no patient ID bands, the list goes on and on. And when we see staff not doing what they are supposed to do we "educate" them on how to do it right. When did everyone become so stupid that they didn't know washing your hands prevent infections or checking the patients ID band assures you are giving the patient the right medication, blood, surgery, etc.? We as nurses, patient advocates need to stand up,take control and stop letting them kill our patients!!!

Posted by: Karen | Jul 9, 2008 5:56:07 PM

I'm a nurse amd a recemt 'victim' of MRSA. I had a squamous cell lesion removed from my lower shin 3 wks ago. I had MOHS so my lesion was excised, left open and dressed. I was then taken to a waiting room with many other patients having MOHS and our families where we waited til the path either said, lets go get some more or it's clear; we'll get to you in a little while to close it.
Back to another OR. Being an old OR nurse, I observed closely what was going on. Everything appeared on the up and up. It was dressed and I was sent home. 48 hrs later as instruced, I removed the dressing. Full blown infection, draining pus. Severe pain, edema, fever to 102. Returned 3 days later to show them. They cultured. Told me to continue cleaning with the vinegar water soloution they recommended post op. Needless to say, it burst open, redness and edema to mid knee. Near bedfast for a week. It was staph, but I have not heard if MRSA as my surgeon off, office practitioner on vacation. Another doc started another oral antibiotic. So here I am with a golf ball size hole in my shin, dressed and elevated back to work at my desk. I forgot to call preop and ask what their infection rate was. I did that with a previous outpatient procedure. It shocked them that I would ask. This was an accredited Outpatient surgical facility. Apparently, that doesn't mean much! I know I will inquire about infections rates in the future. If I have a choice of sites to have a procedure performed, infection rate will weigh im my decision.

Posted by: Jane | Jul 8, 2008 9:33:46 AM

i work in a large hospital where housekeeping is kept at the bare minimum. you can wash your hands prior to all pt contact but if the beds and pumps are not clean and the floors not mopped daily and the bathrooms not cleaned what good will it do? i understand the importance of good handwashing for the staff but what about general cleanliness of the facility? instead of investing in the cosmetic appearance of a facility the hospitals should invest in staff. the hospital i am at recently invested one million dollars to redo the lobbies and waiting areas. i am certain the pt would rather have a clean room.

Posted by: karon l carter | Jul 7, 2008 11:55:47 PM

What is one to do if there are non-functional sinks within each patient ICU room? No hot water? Lack of paper towels being stocked by an invisible housekeeping team? Lack of isolation gowns, especially at 3 am? Hand gel dispensers that are empty and not refilled, yet remain tacked to the walls?

And what about terminal room cleaning? How is that being done in other facilities?

beka

Posted by: beka | Jul 6, 2008 4:45:55 PM

It's really too bad that people do not take personal responsibility for following hand hygiene guidelines. The hospital I work in has a sink in each patient room and alcohol foam in each doorway so there is no excuse for not washing and/or foaming. People often just cannot be bothered and the consequences of that apathy may one day catch up with all of us. On the other side of the coin, the housekeeping in our hospital is atrocious and I never feel confident that a room has been cleaned well. The lack of housekeeping staff - especially after 3pm- combined with either not knowing or not caring about the importance of their work makes it very likely that organisms remain on the surfaces and floors of patient's rooms long after the infected person has gone. It is hard to know where to focus our efforts; I just know we are all responsible and wish we realized how important it is to take the responsibility seriously.

Posted by: Mary | Jul 4, 2008 9:12:45 AM

I appreciate the infection control nurses input; but I find the comments " My facility attempts to put best practice into place, but there is room for improvement" part of the problem and not the solution. If every facility has committee meetings to decide plans, get them OK'd, initiate and teach them,then evaluate them for effectiveness, someone is still not understanding the gravity and severity of this problem. THIS very process is a big block to making a difference. It gives permission to all of us to make an attempt, even if it's half-hearted. That way ,the response to the family who has a relative who died from their hospital-aquired infection will hear as response to their concerns: "we have implemented a policy, and we are checking our employees for compliance. We'll review our policies again, and make sure everyone is following our best practices". (and..."you can't prove you got it here").
Where is the accountability? At what point do we stop the machine and FIX it? Why can hospitals say "we are following the CDC initiatives" as if it excuses them from still having infections in their facilities. I think ONE life is too many to risk. This shouldn't be a problem that we have to spend years researching, and deciding best practices. We have the tools we need to prevent transmission of infections...what else do we need? (more staffing, better personal (hygiene) care of the patients) The comments about encouraging our co-workers to use best practices makes me feel like my 3.5 year struggle with MRSA and the sequelae are worth nothing. We can make a difference.

Posted by: Lori | Jul 3, 2008 8:07:22 PM

I am very happy to see nurses focused on the infection control issue. Over the years I have addressed the handwashing issues with co-workers when I observed them not following best practice. My facility attempts to put best practice into place, but there is room for improvement. I would like to see the infection control staff making rounds and addressing non-compliant behaviors. I also advocate for visitor education. Information should be posted in all rooms for visitors, especially in the isolation rooms. I have seen both patients and visitors come out of isolation rooms and go to the kitchen on the unit. I am sure that the majority have not washed their hands before they go into the fridge!

Posted by: Jean | Jul 3, 2008 7:10:39 PM

Last month my friend called to tell me that her brother, who was being unsuccesfully treated for MRSA by a medical specialist, had sought out a naturopathic doctor, who prescribed oral and topical colloidal silver (which he purchased from a health food store). Within two weeks all that was left was a scar! I looked MRSA/colloidal silver up on the Internet, and found that , not only is colloidal silver being used successfully in other countries for MRSA, but our own scientists are proving its efficacy in killing MRSA bacteria! I was surprised that I didn't see one mention of it in this blog....so...here is one mention! I've included several sites -
http://www.silver-colloids.com/Pubs/EMSL/SaureusMRSA.pdf

http://tahilla.typepad.com/mrsawatch/mrsa_wounds_silver/index.html

Posted by: Jill | Jul 3, 2008 9:27:46 AM

Firstly, I agree with Catherine, above. I don't mind admitting that I was trained when Charge Nurses (now Unit Managers)were responsible for overseing the housekeeping of the ward, as well as reinforcing infection control procedures with all staff (and young residents(interns) DID look to us for practical information). I also remember when ward cleaners were introduced, no longer under nursing supervision, and of being on a plastics ward on a Sunday, looking on despairingly as a cleaner mopped a urine spill with the same mop and bucket used the previous day for food spills. I wonder how many nurses today know what the Riddell Walker ratio is? Which disinfectants in what concentration kill which bacteria? I wonder how many take the initiative of setting up interdisciplinary education seminars rather than thinking each discipline should be autonomous in their on-going learning? I find it very interesting that a month ago when I was visiting my critically ill daughter in an ICU in Lima,
Peru, the nurses and medical staff were meticulous in their infection control procedures, and the senior cardiologist, who was visiting my daughter, did not fail to wash his hands and don gown and mask before entering. It was interesting because when we got back home, and she was in another ICU, anyone was free to go in and out, the only regulation being no more than 2 visitors at a time! (And I had thought that Peru was not as advanced as the "West" in medical matters...).I believe with infection, as with any other health practice issue, the problem needs to be tackled from the Public Health Perspective - the bio(biological) psycho(psychological)social model (biopsychosocial). We may then be able to analyse all contributing factors and develop a holistic plan to tackle them. (from Australia)

Posted by: janet | Jul 3, 2008 12:44:15 AM

Don't you just wish you could convince your hospital system that it would be great if they could publicly claim that they have an noscomial infection rate close to 0? I'd think the doctors/staff/public would be delighted, and if I knew there was a place like that, for my next surgery I'd be making arrangements for that facility. As it is, I don't think I trust any facility right now; and that's sad. The real numbers don't lie, but lots of lies get told about the numbers, don't they? I just read the abstract for the NEJM, and there's another article about MRSA, and that over 18,000 people died in 2005 in the US from MRSA. I'm sure the numbers would be higher if everyone with an infection was cultured. Can you tell that I have a lot of opinions about this? I'd love to keep up with this dialog too.

Posted by: Lori | Jul 2, 2008 7:31:18 PM

I have been doing infection control for 15 years. One thing I have learned is that "controlling" infections is not limited to one intervention.
In order to get an infection that is spreading under control you have to come at it from many different directions.
Of course handwashing is always our 1st defense.
Then disinfecting all areas.
Reducing reintroduction.
I believe the areas that are not being focused on in the hospitals for disinfecting are the nursing stations, (including charts!) and the hallways and visitor areas (including handrails).
More money must be allocated to ensure consistant vigellance of housekeeping staff. Everyone in the team is overworked and underpaid and that's not going to get any better. But, we must ensure the cleanliness of our hospital's and not just in patients rooms and surgery.
I must add that as a nurse, I must say that the biggest concern I see, is the increase in the number of infections from surgical sites. I'm not talking about the epidermal area, but deep tissue infections that could only have come from the surgical procedure itself. By the time these are noted the patient is septic and multiple IV antibiotics must be used for extended periods of time if they are even caught timely enough to be effective.

Posted by: Deanna | Jul 2, 2008 6:37:24 PM

I could go on for an extended length of time about lack of asceptic technique in Hospitals. Most of them have been covered in the above remarks. A young intern came in to check my husbands' stump (below the knee amputation). She reached for the scissors in her pocket-- they weren't quite sharp enough so she reached in her pocket for a second scissor. I was a bit alarmed so I asked if I could get her a sterile field to work on. Her answer was "No -- she would get a nurse to come in and redress it". I mentioned -with a apprehention, what about infection??? Another young intern piped up and said "we have lots of antibiotics'-- this even startled some of the others. Later that day I went to the cafeteria-- as I paid for my lunch the cashier took my money and then returned to the clean cutlery she was sorting behind the counter. No hand washing here either.
The young intern with the scissors' was in having lunch-
--I wish I had gone over to speak to her about the danger she was in.
One more incident was when we came back to the outpatience department to have the Dr. check his 'stump' - we sat outside the examining room and watched a young workman get off the examining table-- still in his workcloths--- we were called in next-- the sheet was not changed and my husband got on the same table. An intern appeared again to redress the operation site. He started to wrap it and dropped the gauze roll. He picked it up and started --as if to wrap it. I then took the clean roll and finished the job-- I was furious-- AND so was he and the doctor. Also--no handwashing for myself or them. There wasn't a facility handy.


Posted by: Donna | Jul 2, 2008 4:59:22 PM

I was so frustrated when I typed my original post, that I wanted to try to do a better job of explaining what it is like to deal with this. I work (3 weeks in the last year) for a large hospital system. I keep thinking that if I make an effort to share information with each person I meet in the health care setting, I can make a difference. However, I can see that there are many variables that affect our exposures to bad bugs. Three and a half years ago, I am certain that hospitals had knowledge of MRSA, acinetobacter, c-diff; at least enough to try to educate the staff, instead of treating these as just another day. I blame some of this superbug problem on the "no big deal" mentality that is still present. Somehow I think we got complacent because we had universal precautions to fall back on. There are facilities with very low infection rates..how do they do it? We have to learn and implement these changes. Clearly, understaffing and increased work stress make it very hard on the employees. Visitors tracking in their own germs add to the situation; but there have always been visitors. I really do think we don't care enough about the lives we are losing...why does it take a sentinel event to make a change? How can a hospital accept the "risk" of patient's getting sick and dying from infections when there is proof that they could cut it down at least by half if they really tried? These superbugs are here to stay, and their job is to continue to evolve and evade whatever we throw at them. The virulence of some of these new resistant bacteria is frightening, to say the least. Do we blame insurers? CEO's? housekeeping? the economy? the nursing shortage? ourselves? Every nurse and doctor who says "I'm probably colonized too" gets this response from me: "now what is your personal and professional responsibility"? When they don't consider doing anything differently because it's no big deal, I want to scream. In an era where what we are told is sanitized and politically correct, and the prize goes to the organization with the most share of the pie, the patient might just lose. We have awesome opportunities to heal people, and to be healed ourselves, but not at the cost of hundreds of thousands of patients every year.

Posted by: Lori | Jul 2, 2008 2:56:59 PM

I have recently had opportunity to observe lack of infection precautions as my elderly parents were cared for in a nursing home and hospital. The nursing home did not even have a bath pan at my mother's bedside when she began hospice care-after 4 years there-what were they bathing her with? The soap dispenser in her room was inoperable more than not over those 4 years, and almost no one even used gloves or alcohol based cleaner when moving from patient to patient for linen checks, transfers up for meals, etc. When she eventually was admitted to a hospital for MRSA pneumonia, having tested negative on screenings in several past hospital stays, the nurse from the Div of Facility Services that I complained to suggested probably I had given it to her myself-saying "you're a nurse, aren't you?" I was incensed, having obviously been aware of MRSA risks and extemely careful over the years. In my father's hospitalization of many weeks, the alcohol based cleaners were now in place at every door, though used only about 50% of the time, and almost never by the MD, Xray tech, lab tech, etc. Computers were now placed in every room at one major center he was in-who cleans these? I touched them, my teenage son touched them, most all the staff and MDs are eventually going to touch them to document and look up informtion at the bedside or just outside-are these pieces of equipment, along with the BP cuffs and thermometers now hauled from room to room, soon to be the worst culprits in the spread of infection in facilities? They are hard to clean, and lack of one person hand-washing can create a tidal wave of infectious germs to all our patients and ourselves.

Posted by: Lisa | Jul 2, 2008 1:01:30 PM

Its all very well to keep on about nursing and doctors hygiene, but whilst I agree wholeheartedly with the need for scrupulous hand-washing and cleanliness, I think we need to take a look at people who visit the sick patients in our hospitals.
Only 2 days ago as I walked through the corridors of ny own working environment, I was appalled to see how many visitors were still in THEIR work attire. By this I mean work boots which have clearly been on building sites and heaven only knows where else, uniforms from other establishments etc.
Surely as well as looking at our own practices on the wards and clinical areas, the general public must also stand up and take responsibility for their own cleanliness. Its no good putting hand wash at the door of every ward or on every bed if visitors are walking around with boot, shoes covered in mud and what ever else may be found on their shoes, uniforms and overalls which they have clearly been to work in. We are all aware that visitors lounge over patients beds, route through cupboards, drink from the patients glass etc.and when asked not to although they will very often oblige and not do it whilst in your presence they will call you names and carry on as soon as your back is turned.
So I think its about time to advise the visitor of the infection risks that they bring with them when they visit straight from work in their work clothes and shoes.

Posted by: linda cooke | Jul 2, 2008 12:30:17 PM

As an Infection Control Preventionist--My focus each day I go to work is to ensure the best and safest care is delivered patients in my facility. Staff are taught and given constant instruction about the importance of hand hygiene and consistent practice of isolation precautions. I also advocate for professional accountability toward all healthcare workers...If you see something say something because silence kills. No healthcare worker wants to give a patient an infection I know that in my heart---so I will continue to promote safe infection control practices and hand hygiene. I will leave you with this..."I have never been especially impressed by the heoics of people who are convinced they are about to change the world. I am more awed by those who struggle to make one small difference after another." Ellen Goodman

Posted by: Sylvia | Jul 2, 2008 10:34:08 AM

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