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Evidenced-based practice for control of methicillin-resistant Staphylococcus aureus
FEBRUARY 2005, VOL 81, NO 2
Home Study Program
Home Study Program Evidenced-based practice for control of methici lli n -resi sta n t S t ~ ~ ~ y l uureus ~ ~ ~ c ~ u s he article “Evidenced-based practice for control of methicillin-resistant Staphylococcus aureus” is the basis for this AORN lournal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, education program profesenter for Perioperative Education. Participants receive feedback on incorrect answers. Each applicant who SUCcessfullycompletes this study will receive a certificate of completion.The deadline for submitting this study is February 29,2008. Complete the examination answer sheet and learner evaluation found on pages 377-378 and mail with appropriate fee to
AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711
This program meets criteria for CNOR and CRNFA recerti3cation, as well as other continuing education requirements. A minimum score of 70% on the multipte-choice
or fax the information with a credit card number to (303) 750-3212.
exominotion
You also may access this Home Study via AORN Online at http://www.aorn.org/jurnal/homestudy/default.
htm.
BEHAVIORAL OBJECTIVES After reading and studying the article on methcillin-resistant Staphylococcus aweus, nurses will be able to
1. describe the manifestations of a Staphylococcus aurem infection;
2. explain how antibiotics are misused, resulting in an increase in antibiotic resistance; and
3. identify methods to manage personnel who are carriers of methcillin-resistant Staphylococcus aureus.
is necessory to earn 2.5 contact houn for this independent study. Purpose/Goal: To educate perioperotive rimes obout controlling the spread of methicillinresistant Staphylococcus aureus.
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Home Study Program Evidenced-based practice for control of met hi ci llin -resi sta n t Stup hylococcus uureus Marilyn Ott, RN; Jing Shen; Sue Sherwood, RN
hospital stays may lead to loss of income, recovery delays, isolation, and increased medication costs. The consehe incidence of antibiotic-resistant quences to health care facilities are addiinfective agents is increasing tional costs associated with among health care providers and 0 increased medication costs, patients in acute care facilities.I2 One 0 increased staffing, strain of Staphylococcus auwus, (ie, 0 more frequently used laboratory Staphylococcus services, methicillin-resistant aureus [MRSA]), is resistant to methi- 0 need for special isolation procedures, cillin, oxacillin, nafcillin, cephalosporin, and and other beta-lactam antibiotics3Out- 0 prolonged hospital ~tays.”~ breaks of MRSA are occurring worldwide.4In the United States and Europe, SG I NFI C I ANCE TO NURSINGPRACC TIE the prevalence of MRSA was less than The chief reservoirs of MRSA are 3% in the early 1980sbut rose as high as infected or colonized patient^;^ howev40% in the 1990s: In Canada, the first er, health care providers also can act as case of MRSA was reported in Ontario reservoirs for MRSA and can harbor the in 1981, and since then, outbreaks have microorganisms for many months9 been reported throughout Canada.5 Transmission of MRSA occurs primarily Although the overall rates of MRSA are via the contaminated hands of health lower in Canada than those reported in care workers who do not follow approthe United States, its prevalence is priate infection control measures.** increasing substantially.’ Nurses’ hands frequently become coloMany outbreaks of infection in hos- nized with MRSA from pitals have been caused by MRSA, so MRSA infections have become a primary concern for many health care institutions? The clinical manifestations of a Staphylococcus aureus infection THE INCREASING PREVALENCE of include, but are not limited to, methicillin-resistant Stuphylococcus a u m s 0 abscesses, (MRSA1 has become a global issue and affects 0 endocarditis, nursing practice in many clinical areas. This article explores methods for effective control of 0 osteomyelitis, 0 postoperative pneumonia, and MRSA in hospital settings. 0 skin and surgical wound infe~tions.6,~ BASED ON INFECTION CONTROL guideInfections caused by MRSA can cause lines provided by the Centers for Disease severe morbidity and mortality and Control and Prevention, the College of Nurses have become a significant global health of Ontario, AORN, the World Health Organizaissue with serious consequences for all tion, and several evidence-based studies, strateareas of hospitals, especially the OR, gies for MRSA infection conk01 measures postanesthesia care unit (PACU), and include hand hygiene, contact isolation, and medical-surgical f l o o r ~ .The ~ conseAORNJ 81 hospital environment hygiene. quences to patients are pain, discomfort, (February 2005) 361-372. distress, and risk of death. Prolonged
T
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patients who are colonized or infected; 0 their own colonized or infected body sites; or 0 equipment, patient care items, or environmental surfaces contaminated with body fluids that contain MRSA.3,8,9 The College of Nurses of Ontario (CNO) provides specific guidelines for general infection control practices, which include hand washing, use of protective barriers, care of equipment, and health practices of nurses." The CNO states, 0
Infection control is integral to safe nursing practice. Nurses should be aware of the potential for transmission of infection in their practice setting and fake all measures necessary to practice." (p3) The Centers for Disease Control and Prevention (CDC) has established standard and contact precautions that clearly define methods to help control the spread of MRSA (Table 1):
RATIONALE
AND
EVIDENCE
The CNO emphasizes that "hand waslung is the single most important infection control practice."" (P'O) Hand washing is essential because personal contact is the primary mode of MRSA transmission? Appropriate hand washing effectively removes transient organisms, which prevents MRSA transmission.6J2Several research studies have found that hand hygiene is an effective method of controlling MRSA mfection. In one study, the incidence of MRSA declined during a 12-month period after health care workers received an educational intervention promoting the role of hand hygiene in the control of MRSA tran~rnission.'~ The study did not audit hand hygiene behaviors directly, however. The researchers considered constant infection rate feedback to be
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the key to achieving control of MRSA infection^.'^ Another study found that a poster campaign in conjunction with the introduction of hand decontamination with an alcohol hand-rub solution increased hand washing from 48%in 1994to 66% in 1997 (P < .001), and episodes of MRSA acquisition decreased from 2.16% to 0.93% per 10,000bed days (P < .OO~)."'P'~~~) This study supports the theory that hand decontamination with alcohol disinfectants combined with a hand-hygiene campaign and education can be effective in MRSA rnanagement.l4 One group of researchers reported a sustained increase in hand washing among health care workers in six health care units in a Chcago hospital (ie, from 23% to 5570, P < .001).The number of MRSA isolates decreased from 0.9 isolates per 1,000 patient days to 0.6 isolates per 1,000 days (P = .005).'5(p14'J The results were limited, however, because handwashing rates increased at two of the four facilities and remained unchanged at the other two facilities. It was not possible to link hand hygiene directly to MRSA management because no data were provided regarding MRSA rates among those fa~i1ities.l~ These studies indicate that increased hand washing can help control MRSA, but they also reveal that hand hygiene alone cannot solve the problem. The CDC recommends that patients who are colonized or mfected with MRSA be placed in an isolation room? There are at least two positive effects of placing colonized or mfected patients in private rooms: 0 separation can minimize close contact, thus eliminating transmission of MRSA between patients, and 0 nurses tend to wash their hands more when caring for patients who are in private rooms because they have to leave one room before going to care for a patient in another r00m.~ The effectiveness of this approach
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TABLE1
Summary of the Centers for Disease Control and Prevention's (CDC's) Methidllin-Resistant Stuphylococcus Aums (MRSA) Information for Health Care Personnel' Standard precautions 1. Wash hands after touching bcdy fluidsand contaminated items and immediately after removing gloves. Wash hands between procedures on the same patient to prevent cross contamination of dif-
ferent body sites. 2. Wear gloves when providing cam to p m e n t contamination of other patients, selfcontamination,
3. 4.
5. 6.
contamination of patient care items and environmental surfaces, and cross contaminationof different body sites on the same patient. Either surgical or examinationgloves are acceptable, depending on the task. Wear a mask and eye protection or a face shield whenever thae is the likelihood of body fluid splashing or spraying. Wear a gown to prevent c o n k h a t i o n of clothing whenever there is the likelihood of body fluid splashing or spraying. Clean and reprocess all reusable equipment after use according to facility policy to prevent transfer of microorganisms to other patients, staff members, and environmental surfaces. Ensure proper disposal of singleuse items. Handle, transport,and p'ocess used linens in a manner that prevents transfer of microorganisms to other patients, staff members, and environmental surfaces.
Contact precautions 1. Place a patient with MRSA in a private room or in a room with a patient who has an active MRSA infection (ie, cohorting) but no other infection. 2. Wear gloves and gowns accordingto standard precautions.
3. Only move isolated patients out of the room if necessary, and ensure that standard and contact precautions are followed. 4. Ensute that patient care items and equipment are cleaned and disinfected and singleuseitems are disposed of appropriately and according to hospital policy. 5. Use noncritical patient-care equipment on a single patient or cohort patients if at all possible. If it is necessary to share equipment, ensure appropriate cleaning and disinfection between patients.
Mpnngement of personnel who are MRSA Carriers 1. Culture personnel who m a y be involvd in MRSA transmission. 2. Personnel who are MRSA camers should not provide direct patient cam until their MRSA-carrier status has been resolved successfully. 3. Routine surveillancecultures, although an option, 0 must be performed frequently, 0 may incorrectly identify personnel who are colonized by MRSA but who are not linked to transmission or who may not disseminate MRSA, 0 may cause individuals to undergo treatment or be removed from patient contact unnecessarily.
Contra1 of MRSA outbreaks 1. Perform an epidemiologic assessment to identify risk factors when an MRSA-infection outbreak occurs.
2 Submit clinicalMRSA isolates for strain typing. 3. Identdy colonized and infected patients quickly and institute standard and contact precautions. 4. Perform inservice programs to re-educate all staff members regarding antibiotic-resistant
organisms. 5. Contact the local or state health department or CDC with questions or for additional help. 1. "MRSA-Methidin resistant Staphylococcus aureus informationfor heaIthcate personnel," Cmtersjbr Disease Control and P m t i o n (August 1999) http://www.cdc.gov/ncidod/hip/ARESIST /mrsahcw.htm (accessed 14 Dec 2004).
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Antibiotic Failures due to Misuse idespread use of antimicrobial medications has caused many strains of the major classes of bacteria t o become resistant t o one or more antibiotics.' This resistance has resulted i n an increasing failure of antibiotics t o successfully treat infectious diseases that previously were curable with antibiotics.
W
Misuse of antibiotics is a result of several factors. No new antibiotics have been developed and introduced in the past two decades. Frequent subtherapeutic use of antibiotics remains a problem. Patients i n outpatient settings fail t o complete a full course of antibiotic treatment. No economic incentives exist for more responsible prescription of antibiotics.' Recommendations t o minimize antibiotic resistance i n regard to antibiotic misuse include establishing and adhering t o antibiotic administration guidelines or protocols that ensure proper dosing, medication interval administration, monitoring medication levels, and avoiding harmful medication interactions; restricting the antibiotics maintained i n the facility formulay, particularly those medications that result i n rapid antibiotic resistance and easily identifiable toxicity; cycling antibiotics, which entails withdrawing a specific antibiotic medication from use for a defined time period and reintroducing it at a later date; and combining antibiotic therapy t o provide greater overall coverage.? 7. D Fogg, "Insects in the OR; multiple-procedure consent form; sterilizer testing; smoke plume; MRSA/VRE precautions, (Clinical Issues) AORN Journal(luly 2002) 270-175. 2. "Executive summary-international workshop on antibiotic resistance: Global policies aitd options Colter for international Development," at Harvard University, Cambridge, Mass, 28 Feb 2000. 3. M H Kollt$ "Optimizing antibiotic therapy in the intensive care unit setting," Critical Care 5 (August 2002) 189-295. "
was supported by one study that reported a 15.6-fold reduction in the spread of MRSA during a neonatal intensive care unit MRSA outbreak when colonized patients were placed in contact isolation compared to use of standard preca~tions.'~ Contact isolation for colonized patients, therefore, was a successful method to control the spread of MRSA. Patients who are colonized or infected with MRSA should be isolated. Nurses should be aware, however, that isolation may cause loneliness, stress, or anxiety in patients.I6Nurses, therefore, should be prepared to provide emotional support to isolated patients to reduce patients' anxiety levels and provide health education about MRSA to calm them.I6Nurses may encourage diversional activities for patients, such as reading, listening to music, or watching television. Nurses also should ensure that isolated patients receive the
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same quality of care as patients who are not isolated. Additionally, nurses can empower patients by asking them to remind all health care workers to follow infection control procedures, such as gloving, gowning, and decontaminating their hands before and after providing care.16 Contamination of the hospital environment is an important contributor to the spread of MRSA in health care facilities.I5One study found that 27% of surfaces were contaminated in the rooms (Pl4l) of patients with MRSA infe~ti0ns.I~ Contaminated objects included the floors; bed linens; patients' gowns; tables; and equipment such as stethoscopes, blood pressure cuffs, and otoscopes, especially after an instrument was used by health care workers who cared for colonized or infected patients.15It was suggested that simply cleaning the contaminated objects with alcohol swabs, as well as thoroughly
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cleaning rooms previously occupied by Artificial nails should be prohibited patients colonized or infected with because they increase the risk of transMRSA could significantly reduce bacte- mitting MRSA to patient^."'^,'^ Bacterial rial colony colony counts under artificial nails are Another group of researchers con- greater than the colony counts on natuducted a study during which they col- ral nails, and they also frequently cause lected microbiological data from tears in glove^.^,'^,'^ A 0 R ” s standards patients and environment surfaces in a strictly prohibit wearing artificial nails general surgical ward for men between in the- OR. Excerpts from January 1998 and September 1999.17The AORN’s ”Recommended study results demonstrated that a pro- practices for surgical Bacterial colony longed outbreak of a single strain of hand antisepsis/hand MRSA could not be controlled until it scrubs,” are presented in counts under was eliminated from the hospital envi- Table 2.18 ronment by a comprehensive program GENERAL ENVIRONMENTAL artificial nails of closing and cleaning contaminated CLEANING. According to recrooms that focused on removal of dust ommendations regarding from ward surfaces, furniture, floors general environmental are greater than and medical equipment.I7 cleaning measures for the the colony control of MRSA from the IMPLICATIONS FOR CDC, AORN, the World counts on PERIOPERATIVE NURSING Health Organization, and Controlling MRSA requires a combi- other regulatory agencies, natural nails, nation of factors and methods. nurses and other health According to evidence-based studies care agency personnel which is why and research results, implementing and should disinfect patient enforcing recommendations will help care equipment after each A 0RN standards combat MRSA transmission. These rec- use. This includes disinommendations include fecting objects such as strictly prohibit 0 adhering to strict hand hygiene pracblood pressure cuffs and tices, and stethoscopes with a disinwearing 0 instituting general environmental fectant approved by the hygiene measures for the control of Environmental Protection artificial nails MRSA. Agency or other appropriSTRICT HAND HYGIENE PRACESTI. Nurses ate regulatory agency. Bed in the OR. should implement strict hand hygiene linens should be handled practices. Decontamination of hands is carefully to avoid contact the single most important method to with the caregiver’s prevent the spread of MRSA and other clothes and placexin a sealed bag or equally deadly germs.16Nurses also are container.2O Surfaces should be washed encouraged to carry individual bottles with disinfectant after the colonized or of hand-rub solution (eg, alcohol-based infected patient has been transferred.” with 0.5% chlorhexidine gluconate and Nurses should understand and adhere skin emollients) or have the solution to infection control guidelines and faciliwithin easy reach in hallways and ty policies and procedures. Additionally, patient rooms.’*Hand-rub solutions are perioperative nurses should call the more convenient for nurses to use, and medical or surgical unit to which the applying them is less time consuming patient will be transferred postoperativethan washing hands. ly to inform unit nurses that the patient AORN IOURNAL
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TABLE2
Excerpts From BORN‘S Recommended Practices for Surgical Hand Antisepsis/Hand Scrubs’ AU personnel should practice general hand hygiene. 1. Practicing hand hygiene immediately before and after patient contact remains the most costeffective and simple measw for health can?workers to prevent cross contamination in the health care setting. 2. Fingernails should be kept short, clean, and healthy. 3. Artificial nails should not be worn. 4. Cuticles, hands, and forearms should be freeof open lesions and breaks in skin integrity. 5. Rings, watches, and bracelets should be removed before performing hand hygiene. 6. Lotions, if used, should be chosen based on infection control practices, approved by infection control professionals,and compatible with the hand antimicrobial agent and gloves used. 7. If hands are visibly soiled, wash them as soon as possible with plain or anlimicrobial soap and water as follows. 0 Wet hands with warm water. 0 Apply soap to the hands according to the manufacturer‘s written instructions,if given. 0 Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Pay particular attention to often overlooked areas (ie, backs of hands, fingertips,thumb, inner webs). 0 Rinse hands with warm water and dry them thoroughly with a disposable toweL 0 Use a towel to turn off the faucet. Alcohol-based hand rubs are not appropriate for use when hands are visibly duty or contaminated with proteinaceous materials (eg, blood, saliva)because these hand rubs do not m o v e soil or debris. 8. If hands are not visibly soiled, an alcohol-based hand rub may be used for routine decontamination 9. To improve adherence to general hand-hygiene recommendationsamong personnelworking in busy patient care environments, an appropriate alcohol-based agent should be available in convenient locations (eg,wall, bedside). Health c m providers may carry individual,disposable, pocketsized containers.Specific regulations may limit placement of alcohol-based products because of fire hazard considerations.Consult applicable local, state, and federal regulations for specific diredion.
Admsnistrption-comSurgicalhandanti isthandrubwithaUSFoodand pliant, d c o h d - b a x s t u g cd hand-mb product shodd XIOW a StandPrdizcd application according to e manufacturer‘s wxitten directions for use.
-fa
1. A standardized protocol for alcohol-based surgical hand rubs should follow manufacturers’ written instructions and include, but may not be limited to, the following. 0 Wash hands and forearms with soap and running water immediately before beginning the surgical hand antisepsis procedure. 0 Clean the subungual areas of both hands under running water using a nail cleaner. 0 Rinse hands and forearms under running water. 0 Dry hands and forearms thoroughly with a paper towel. 0 Dqense the manufacturer-recommended amount of the swgical hand-rub product. 0 Apply the product to the hands and forearms, following the manufadurer’s written instructions. Some manufacturers may require the use of water as part of the process. 0 Rub thoroughly until dry. 0 Repeat the product application process if indicated in the manufacturer’swritten instructions. 0 In the OR, don a sterile surgical gown and gloves. I . “Recommendedpracticesfor surgical hand antisepsishnd snubs,” in Standards, Recommended Practices, and Guidelines Denm:AORN lnc, 2004) 295-296.
is infected with MRSA. This allows adequate time for unit personnel to prepare and organize for the patient in a proactive manner. Additionally, perioperative nurses should place a sticker on patients’ charts to indicate their MIiSA status. These actions help promote both staff member and patient safety.
Perioperative nurses should communicate with PACU nursing staff members as soon as they identify that a patient with MRSA will be coming through the OR and into the I’ACU. If possible, perioperative nurses should contact the facility’s infection control nurse to help ensure continuity of care AORN JOURNAL
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TABLE3
Nursing Care Plan for Patients with Methici llin-resistant Staphy~ococcusAureus (MRSA) Diagnosis
Nculsing interventions
Risk of infection related to antibioticresistant organism
0
0
0 0
0 0 0 0
0
0
Risk of anxiety related t o know led gi. drticit ot antibiotic,resistant organisms
0
0
0
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Interim outcome criteria
Assesses preoperatively for susceptibility to infection (eg, chronic diseases, weight, laboratory values, skin integrity). Assesses skin integrity, sensory impairments, and musculoskeletal status. Implements, monitors, and maintains asep tic technique (eg,implant sferilization). Adheres to standard and transmissionbased precautions to prevent infection and cross infection by ensuring that all personnel adhere to strict hand w a s h i i guidelines;and .+ ensuring that postoperative patients with MRSA are placed in private rooms or in a room with a patient who has an active infection with MRSA (ie, cohorting) but no other infection and isolation supplies and equipment are immediately available. Administers prescribed antibiotic therapy at appropriate times. Initiates traffic control and restricts access to appropriate personnel. Administers wound site c m and applies sterile, dry surgical dressing. Avoids tracking wound exudate and normal body flora from surrounding skin to clean areas. Notes type and amounts of effluent fmm wounds and drainage tubes and notifies appropriate members of health care team regarding signrficant changes. Communicates information about patient’s risk status to appropriate members of the health care team.
The patient‘s skin remains intact and nonreddened, wound is dry, and temperature remains normothermic throughout the perioperativc period.
Determines knowledge level, assesses readiness to learn, and identifies barriers to communication. Provides instruction to enhance patient’s understanding of care for infection.. caused by antibiotic-resistant organisms. Provides education to empower patients to monitor care provided by their health care providers postoperatively. Explains sequence of events and reinfoxes teaching about treatment options. Provides dscharge instructions (ie, verbal, written) for care of infections caused by antibiotic-resistantorganisms. Communicates patient concerns to appropriate health care team members. Evaluates response to instruction.
The patient verbalizes decreased anxiety, an ability 10cope, understanding of infections caused by
antibioticresistant organisms, and vxpec ted outcomes.
Outcome statement The patient is free from signs and
S Y m P ~ ~ of infection.
The patient demonstrates ability to manage infections caused by antibioticresistant
organisms, such as MRSA. The patient participates in decisions affecting his or her plan of care.
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and appropriate handling of supplies, equipment, instruments, linen, and specimens during the intraoperative phase of care. Postoperative nursing managers can consider grouping patients with MRSA and assigning their care to specific staff members.ZThe nurse manager, infection control nurse, or nurses assigned to patients with MRSA should ensure that isolation carts are placed outside the patient's room. This helps ensure patient and staff member safety because personal protective equipment is more likely to be worn when it is available. Additionally, postoperative nurses can plan to use the same equipment until the patient is discharged, after which the nurse can ensure adequate environmental cleaning.
RECOMMENDATIONS Organisms such as MRSA have become a major challenge to everyone who provides care to patients in hospitals and other health care facilities.It can pose a serious threat to a vulnerable patient who has undergone surgery, has a wound, or requires an invasive procedure, such as insertion of a urethral or intravascular catheter.*All nurses must follow best practice guidelines to ensure patient safety and well-being.To provide efficient and safe care for patients with MRSA, nurses in all areas of the hospital should understand the epidemiology of MRSA and appropriate policies and guidelines for MRSA control measures particular to the units where they work. Additionally, all nurses should incorporate the following measures into nursing activities and care plans: maintaining good hand hygiene practice, wearing gloves and gowns when appropriate, maintaining a clean hospital environment by cleaning patient care items and equipment appropriately,
isolating patients who are colonized or infected with MRSA, and 4 providing reassurance to isolated patients and their family members to help relieve anxiety and to instill confidence and a positive attitude (Table 3). For future professional development, managers and educators must &crease staff members' knowledge of infection control practices and ensure compliance with infection control procedures. Nurses have a particular responsibility to maintain hygienic standards and to improve public knowledge of MRSA. Nurses also can take leadership roles in implementing infection control measures to protect patients, visitors, and other health care workers from the spread of MRSA. Methicillin-resistant Staphylococcus aureus outbreaks have become a serious, worldwide problem, and all nurses should take responsibility to meet the challenges of preventing and controlling the prevalence of MRSA. Well-informed nurses and nursing care based on best practices can make the difference for patients and staff members alike. *:* 0
Marilyn Ott, RN, BScN, MScN, is a lecturer in the school of nursing, McMaster University, Hamilton, Ontario.
Jing Shen is a level IV nursing student in the school of nursing, McMaster University, Hamilton, Ontario.
Sue Sherwood, RN, BScN, MEd, is a public health nurse and acting manager at Public Health and Community Services, Healthy Lifestyle and Youth Branch, Chronic Disease PreventionAdult Program, City of Hamilton, Ontario. NOTES 1. D Fogg, "Insects in the OR; multipleprocedure consent form; sterilizer testing; smoke plume; MRSA/VRE precautions," AORN JOURNAL
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(Clinical Issues) AORN lournal76 (July 2002) 170. 2. A Mitchell et al, "Nurses' experience with vancomycin-resistant enterococci (VRE)," Journal of Clinical Nursing 11 (January 2002) 126-133. 3. L L Ronk, "Surgical patients with multiantibiotic-resistant bacteria," AORN Journal 61 (June 1995) 1023-1034. 4. "Health Policy Research Bulletin," Health Canada, Applied Research and Analysis Directorate (June 6,2003) http:// ish www.hc-sc.gc.ca/iacb-dgiac/arad-draa/engl /rmdd/bulletin/microbial.html(accessed 14 Dec 2004). 5. "Controlling antimicrobial resistance: An inte rated action plan for Canadians," Pubic Health Agency of Canada (Nov 27, 1997) http://www.hc-sc.gc.ca/Wlhb-dgspsp /pu blicat/ccdr-rmtc/97vo123/23s7/23s7b-e. h tml (accessed 14 Dec 2004). 6.A T Platt, "MRSA in intensive care," Nursing Standard 15 (April 18-24,2001) 2732. 7.W E Levinson, E Jawetz, Medical Microbiology and Immunology: Examination and Board Review, seventh ed (East Norwalk, Corn: Appleton and Lange, 2002). 8.T Capriotti, "Preventing nosocomial spread of MRSA is in your hands," Dermatology Nursing 15 (December 2003) 535-538. 9."MRSA-Methicillin resistant Staphylococcus aureus information for healthcare personnel," Centers for Disease Control and Prevention (Au ust 1999)
http://www.cdc.gou/ncidod/hipf4RESIST /nzrsahcw.htm (accessed 14 Dec 2004). 10.W Afif et al, "Compliance with methicillin-resistant Staphylococcus aureiis precautions in a teaching hospital," American Journal of Infection Control 30 (November 2002) 430-433. 11.College of Nurses of Ontario, The Compendium of Standards of Practicefor
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Nurses in Ontario, second ed (Toronto: College of Nurses of Ontario, 2000) 3,lO. 12.G A Ayliffe et al, Control of Hospital Infection: A Practical Handbook, fourth ed (London: Arnold Publishers, 2000). 13. M D Nettleman et al, "Assigning responsibility: Using feedback to achieve sustained control of methicillin-resistant Staphylococcus aureus," American Journal of Medicine 16 (September 1991) 2285-232s. 14.D Pittet et al, "Effectiveness of a hospitalwide programme to improve compliance with hand hygiene," Lancet 356 (Oct 14, 2000) 1307-1312. 15.C D Salgado, D P Calfee, B M Farr, "Interventions to prevent methicillin-resistant Staphylococcus aureus transmission in health care facilities: What works?" Clinical Microbiology Newsletter 25 (Sept 15,2003) 137-144. ~- ~ _ _
16. D Raper, "MRSA: An infection control overview," Nursing Standard 17 (July 23-29, 2003) 47-53. 17. A Rampling et al, "Evidence that hospital hygiene is important in the control of methicilh-resistant Staphylococcus aureus," Journal of Hospital Znfection 49 (October 2001) 109-116. 18. "Recommended practices for Surgical hand antisepsis/hand scrubs," in Standards, Recommended Practices, and Guidelines (Denver: AORN Inc, 2004). 19.A Toles, "Artificial nails: Are they putting patients at risk? A review of the research," Journal of Pediatric Oncologic Nursing 19 (September/October 2002) 164-171. 20. "A guide to TB, VRE, and MRSA," RN 61 (July 1998) 24DD. 21. G A Ayliffe, "Recommendations for the control of methicillin-resistant Staphylococcus aureus (MRSA)," World Health Organization, ht tp://www.who.in t/emc-docu ments/antimicrobial-resistance/docs/l whoem clts96l.pdf (accessed 14 Dec 2004).
Device for Treatment of Neurological Disorders Promising new device being developed could improve the A lives of people living with neurological disorders, such as Parkinson's Disease, Tourette's Syndrome, epilepsy, depression, and eating disorders, according to a Nov 8, 2004, news release from the Lawson Health Research Institute, London, Ontario. The small, multichannel recording and stimulating device is expected to aid in the advancement of deep brain stimulation, a recommended treatment for advanced movement disorders (eg, tremors, slowness, rigidity) associated with neurological diseases. The traditional surgical approach to treating these conditions involves using a recording electrode to identify regions of the brain associated with movement disorders. The patient is awake and constrained i n a head frame during a procedure that can last six to eight hours. After target areas
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are identified, a larger electrode is surgically implanted in the brain when the patient is under general anesthesia. Stimulation therapy is delivered by a small, pacemaker-type device implanted adjacent to the patient's collarbone. The new, much smaller device would integrate the recording and stimulation functions. The recording function s t i l l could be used intraoperatively, but the emphasis would be on configuring the stimulation field with chronic recordings to save OR time and tailor the stimulation fields to reduce side effects. Simplifying the procedure could shift the majority of treatment to outpatient settings. New Canadian Technology Set to Revolutionize Treatment of Neurological Disorders (news release, London, Ontario: Lawson Health Research Institute, Nov 8,2004).
Home Study Program
Home Study Program Evidenced-based practice for control of methici lli n -resi sta n t S t ~ ~ ~ y l uureus ~ ~ ~ c ~ u s he article “Evidenced-based practice for control of methicillin-resistant Staphylococcus aureus” is the basis for this AORN lournal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, education program profesenter for Perioperative Education. Participants receive feedback on incorrect answers. Each applicant who SUCcessfullycompletes this study will receive a certificate of completion.The deadline for submitting this study is February 29,2008. Complete the examination answer sheet and learner evaluation found on pages 377-378 and mail with appropriate fee to
AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711
This program meets criteria for CNOR and CRNFA recerti3cation, as well as other continuing education requirements. A minimum score of 70% on the multipte-choice
or fax the information with a credit card number to (303) 750-3212.
exominotion
You also may access this Home Study via AORN Online at http://www.aorn.org/jurnal/homestudy/default.
htm.
BEHAVIORAL OBJECTIVES After reading and studying the article on methcillin-resistant Staphylococcus aweus, nurses will be able to
1. describe the manifestations of a Staphylococcus aurem infection;
2. explain how antibiotics are misused, resulting in an increase in antibiotic resistance; and
3. identify methods to manage personnel who are carriers of methcillin-resistant Staphylococcus aureus.
is necessory to earn 2.5 contact houn for this independent study. Purpose/Goal: To educate perioperotive rimes obout controlling the spread of methicillinresistant Staphylococcus aureus.
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Home Study Program Evidenced-based practice for control of met hi ci llin -resi sta n t Stup hylococcus uureus Marilyn Ott, RN; Jing Shen; Sue Sherwood, RN
hospital stays may lead to loss of income, recovery delays, isolation, and increased medication costs. The consehe incidence of antibiotic-resistant quences to health care facilities are addiinfective agents is increasing tional costs associated with among health care providers and 0 increased medication costs, patients in acute care facilities.I2 One 0 increased staffing, strain of Staphylococcus auwus, (ie, 0 more frequently used laboratory Staphylococcus services, methicillin-resistant aureus [MRSA]), is resistant to methi- 0 need for special isolation procedures, cillin, oxacillin, nafcillin, cephalosporin, and and other beta-lactam antibiotics3Out- 0 prolonged hospital ~tays.”~ breaks of MRSA are occurring worldwide.4In the United States and Europe, SG I NFI C I ANCE TO NURSINGPRACC TIE the prevalence of MRSA was less than The chief reservoirs of MRSA are 3% in the early 1980sbut rose as high as infected or colonized patient^;^ howev40% in the 1990s: In Canada, the first er, health care providers also can act as case of MRSA was reported in Ontario reservoirs for MRSA and can harbor the in 1981, and since then, outbreaks have microorganisms for many months9 been reported throughout Canada.5 Transmission of MRSA occurs primarily Although the overall rates of MRSA are via the contaminated hands of health lower in Canada than those reported in care workers who do not follow approthe United States, its prevalence is priate infection control measures.** increasing substantially.’ Nurses’ hands frequently become coloMany outbreaks of infection in hos- nized with MRSA from pitals have been caused by MRSA, so MRSA infections have become a primary concern for many health care institutions? The clinical manifestations of a Staphylococcus aureus infection THE INCREASING PREVALENCE of include, but are not limited to, methicillin-resistant Stuphylococcus a u m s 0 abscesses, (MRSA1 has become a global issue and affects 0 endocarditis, nursing practice in many clinical areas. This article explores methods for effective control of 0 osteomyelitis, 0 postoperative pneumonia, and MRSA in hospital settings. 0 skin and surgical wound infe~tions.6,~ BASED ON INFECTION CONTROL guideInfections caused by MRSA can cause lines provided by the Centers for Disease severe morbidity and mortality and Control and Prevention, the College of Nurses have become a significant global health of Ontario, AORN, the World Health Organizaissue with serious consequences for all tion, and several evidence-based studies, strateareas of hospitals, especially the OR, gies for MRSA infection conk01 measures postanesthesia care unit (PACU), and include hand hygiene, contact isolation, and medical-surgical f l o o r ~ .The ~ conseAORNJ 81 hospital environment hygiene. quences to patients are pain, discomfort, (February 2005) 361-372. distress, and risk of death. Prolonged
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patients who are colonized or infected; 0 their own colonized or infected body sites; or 0 equipment, patient care items, or environmental surfaces contaminated with body fluids that contain MRSA.3,8,9 The College of Nurses of Ontario (CNO) provides specific guidelines for general infection control practices, which include hand washing, use of protective barriers, care of equipment, and health practices of nurses." The CNO states, 0
Infection control is integral to safe nursing practice. Nurses should be aware of the potential for transmission of infection in their practice setting and fake all measures necessary to practice." (p3) The Centers for Disease Control and Prevention (CDC) has established standard and contact precautions that clearly define methods to help control the spread of MRSA (Table 1):
RATIONALE
AND
EVIDENCE
The CNO emphasizes that "hand waslung is the single most important infection control practice."" (P'O) Hand washing is essential because personal contact is the primary mode of MRSA transmission? Appropriate hand washing effectively removes transient organisms, which prevents MRSA transmission.6J2Several research studies have found that hand hygiene is an effective method of controlling MRSA mfection. In one study, the incidence of MRSA declined during a 12-month period after health care workers received an educational intervention promoting the role of hand hygiene in the control of MRSA tran~rnission.'~ The study did not audit hand hygiene behaviors directly, however. The researchers considered constant infection rate feedback to be
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the key to achieving control of MRSA infection^.'^ Another study found that a poster campaign in conjunction with the introduction of hand decontamination with an alcohol hand-rub solution increased hand washing from 48%in 1994to 66% in 1997 (P < .001), and episodes of MRSA acquisition decreased from 2.16% to 0.93% per 10,000bed days (P < .OO~)."'P'~~~) This study supports the theory that hand decontamination with alcohol disinfectants combined with a hand-hygiene campaign and education can be effective in MRSA rnanagement.l4 One group of researchers reported a sustained increase in hand washing among health care workers in six health care units in a Chcago hospital (ie, from 23% to 5570, P < .001).The number of MRSA isolates decreased from 0.9 isolates per 1,000 patient days to 0.6 isolates per 1,000 days (P = .005).'5(p14'J The results were limited, however, because handwashing rates increased at two of the four facilities and remained unchanged at the other two facilities. It was not possible to link hand hygiene directly to MRSA management because no data were provided regarding MRSA rates among those fa~i1ities.l~ These studies indicate that increased hand washing can help control MRSA, but they also reveal that hand hygiene alone cannot solve the problem. The CDC recommends that patients who are colonized or mfected with MRSA be placed in an isolation room? There are at least two positive effects of placing colonized or mfected patients in private rooms: 0 separation can minimize close contact, thus eliminating transmission of MRSA between patients, and 0 nurses tend to wash their hands more when caring for patients who are in private rooms because they have to leave one room before going to care for a patient in another r00m.~ The effectiveness of this approach
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TABLE1
Summary of the Centers for Disease Control and Prevention's (CDC's) Methidllin-Resistant Stuphylococcus Aums (MRSA) Information for Health Care Personnel' Standard precautions 1. Wash hands after touching bcdy fluidsand contaminated items and immediately after removing gloves. Wash hands between procedures on the same patient to prevent cross contamination of dif-
ferent body sites. 2. Wear gloves when providing cam to p m e n t contamination of other patients, selfcontamination,
3. 4.
5. 6.
contamination of patient care items and environmental surfaces, and cross contaminationof different body sites on the same patient. Either surgical or examinationgloves are acceptable, depending on the task. Wear a mask and eye protection or a face shield whenever thae is the likelihood of body fluid splashing or spraying. Wear a gown to prevent c o n k h a t i o n of clothing whenever there is the likelihood of body fluid splashing or spraying. Clean and reprocess all reusable equipment after use according to facility policy to prevent transfer of microorganisms to other patients, staff members, and environmental surfaces. Ensure proper disposal of singleuse items. Handle, transport,and p'ocess used linens in a manner that prevents transfer of microorganisms to other patients, staff members, and environmental surfaces.
Contact precautions 1. Place a patient with MRSA in a private room or in a room with a patient who has an active MRSA infection (ie, cohorting) but no other infection. 2. Wear gloves and gowns accordingto standard precautions.
3. Only move isolated patients out of the room if necessary, and ensure that standard and contact precautions are followed. 4. Ensute that patient care items and equipment are cleaned and disinfected and singleuseitems are disposed of appropriately and according to hospital policy. 5. Use noncritical patient-care equipment on a single patient or cohort patients if at all possible. If it is necessary to share equipment, ensure appropriate cleaning and disinfection between patients.
Mpnngement of personnel who are MRSA Carriers 1. Culture personnel who m a y be involvd in MRSA transmission. 2. Personnel who are MRSA camers should not provide direct patient cam until their MRSA-carrier status has been resolved successfully. 3. Routine surveillancecultures, although an option, 0 must be performed frequently, 0 may incorrectly identify personnel who are colonized by MRSA but who are not linked to transmission or who may not disseminate MRSA, 0 may cause individuals to undergo treatment or be removed from patient contact unnecessarily.
Contra1 of MRSA outbreaks 1. Perform an epidemiologic assessment to identify risk factors when an MRSA-infection outbreak occurs.
2 Submit clinicalMRSA isolates for strain typing. 3. Identdy colonized and infected patients quickly and institute standard and contact precautions. 4. Perform inservice programs to re-educate all staff members regarding antibiotic-resistant
organisms. 5. Contact the local or state health department or CDC with questions or for additional help. 1. "MRSA-Methidin resistant Staphylococcus aureus informationfor heaIthcate personnel," Cmtersjbr Disease Control and P m t i o n (August 1999) http://www.cdc.gov/ncidod/hip/ARESIST /mrsahcw.htm (accessed 14 Dec 2004).
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Antibiotic Failures due to Misuse idespread use of antimicrobial medications has caused many strains of the major classes of bacteria t o become resistant t o one or more antibiotics.' This resistance has resulted i n an increasing failure of antibiotics t o successfully treat infectious diseases that previously were curable with antibiotics.
W
Misuse of antibiotics is a result of several factors. No new antibiotics have been developed and introduced in the past two decades. Frequent subtherapeutic use of antibiotics remains a problem. Patients i n outpatient settings fail t o complete a full course of antibiotic treatment. No economic incentives exist for more responsible prescription of antibiotics.' Recommendations t o minimize antibiotic resistance i n regard to antibiotic misuse include establishing and adhering t o antibiotic administration guidelines or protocols that ensure proper dosing, medication interval administration, monitoring medication levels, and avoiding harmful medication interactions; restricting the antibiotics maintained i n the facility formulay, particularly those medications that result i n rapid antibiotic resistance and easily identifiable toxicity; cycling antibiotics, which entails withdrawing a specific antibiotic medication from use for a defined time period and reintroducing it at a later date; and combining antibiotic therapy t o provide greater overall coverage.? 7. D Fogg, "Insects in the OR; multiple-procedure consent form; sterilizer testing; smoke plume; MRSA/VRE precautions, (Clinical Issues) AORN Journal(luly 2002) 270-175. 2. "Executive summary-international workshop on antibiotic resistance: Global policies aitd options Colter for international Development," at Harvard University, Cambridge, Mass, 28 Feb 2000. 3. M H Kollt$ "Optimizing antibiotic therapy in the intensive care unit setting," Critical Care 5 (August 2002) 189-295. "
was supported by one study that reported a 15.6-fold reduction in the spread of MRSA during a neonatal intensive care unit MRSA outbreak when colonized patients were placed in contact isolation compared to use of standard preca~tions.'~ Contact isolation for colonized patients, therefore, was a successful method to control the spread of MRSA. Patients who are colonized or infected with MRSA should be isolated. Nurses should be aware, however, that isolation may cause loneliness, stress, or anxiety in patients.I6Nurses, therefore, should be prepared to provide emotional support to isolated patients to reduce patients' anxiety levels and provide health education about MRSA to calm them.I6Nurses may encourage diversional activities for patients, such as reading, listening to music, or watching television. Nurses also should ensure that isolated patients receive the
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same quality of care as patients who are not isolated. Additionally, nurses can empower patients by asking them to remind all health care workers to follow infection control procedures, such as gloving, gowning, and decontaminating their hands before and after providing care.16 Contamination of the hospital environment is an important contributor to the spread of MRSA in health care facilities.I5One study found that 27% of surfaces were contaminated in the rooms (Pl4l) of patients with MRSA infe~ti0ns.I~ Contaminated objects included the floors; bed linens; patients' gowns; tables; and equipment such as stethoscopes, blood pressure cuffs, and otoscopes, especially after an instrument was used by health care workers who cared for colonized or infected patients.15It was suggested that simply cleaning the contaminated objects with alcohol swabs, as well as thoroughly
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cleaning rooms previously occupied by Artificial nails should be prohibited patients colonized or infected with because they increase the risk of transMRSA could significantly reduce bacte- mitting MRSA to patient^."'^,'^ Bacterial rial colony colony counts under artificial nails are Another group of researchers con- greater than the colony counts on natuducted a study during which they col- ral nails, and they also frequently cause lected microbiological data from tears in glove^.^,'^,'^ A 0 R ” s standards patients and environment surfaces in a strictly prohibit wearing artificial nails general surgical ward for men between in the- OR. Excerpts from January 1998 and September 1999.17The AORN’s ”Recommended study results demonstrated that a pro- practices for surgical Bacterial colony longed outbreak of a single strain of hand antisepsis/hand MRSA could not be controlled until it scrubs,” are presented in counts under was eliminated from the hospital envi- Table 2.18 ronment by a comprehensive program GENERAL ENVIRONMENTAL artificial nails of closing and cleaning contaminated CLEANING. According to recrooms that focused on removal of dust ommendations regarding from ward surfaces, furniture, floors general environmental are greater than and medical equipment.I7 cleaning measures for the the colony control of MRSA from the IMPLICATIONS FOR CDC, AORN, the World counts on PERIOPERATIVE NURSING Health Organization, and Controlling MRSA requires a combi- other regulatory agencies, natural nails, nation of factors and methods. nurses and other health According to evidence-based studies care agency personnel which is why and research results, implementing and should disinfect patient enforcing recommendations will help care equipment after each A 0RN standards combat MRSA transmission. These rec- use. This includes disinommendations include fecting objects such as strictly prohibit 0 adhering to strict hand hygiene pracblood pressure cuffs and tices, and stethoscopes with a disinwearing 0 instituting general environmental fectant approved by the hygiene measures for the control of Environmental Protection artificial nails MRSA. Agency or other appropriSTRICT HAND HYGIENE PRACESTI. Nurses ate regulatory agency. Bed in the OR. should implement strict hand hygiene linens should be handled practices. Decontamination of hands is carefully to avoid contact the single most important method to with the caregiver’s prevent the spread of MRSA and other clothes and placexin a sealed bag or equally deadly germs.16Nurses also are container.2O Surfaces should be washed encouraged to carry individual bottles with disinfectant after the colonized or of hand-rub solution (eg, alcohol-based infected patient has been transferred.” with 0.5% chlorhexidine gluconate and Nurses should understand and adhere skin emollients) or have the solution to infection control guidelines and faciliwithin easy reach in hallways and ty policies and procedures. Additionally, patient rooms.’*Hand-rub solutions are perioperative nurses should call the more convenient for nurses to use, and medical or surgical unit to which the applying them is less time consuming patient will be transferred postoperativethan washing hands. ly to inform unit nurses that the patient AORN IOURNAL
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TABLE2
Excerpts From BORN‘S Recommended Practices for Surgical Hand Antisepsis/Hand Scrubs’ AU personnel should practice general hand hygiene. 1. Practicing hand hygiene immediately before and after patient contact remains the most costeffective and simple measw for health can?workers to prevent cross contamination in the health care setting. 2. Fingernails should be kept short, clean, and healthy. 3. Artificial nails should not be worn. 4. Cuticles, hands, and forearms should be freeof open lesions and breaks in skin integrity. 5. Rings, watches, and bracelets should be removed before performing hand hygiene. 6. Lotions, if used, should be chosen based on infection control practices, approved by infection control professionals,and compatible with the hand antimicrobial agent and gloves used. 7. If hands are visibly soiled, wash them as soon as possible with plain or anlimicrobial soap and water as follows. 0 Wet hands with warm water. 0 Apply soap to the hands according to the manufacturer‘s written instructions,if given. 0 Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Pay particular attention to often overlooked areas (ie, backs of hands, fingertips,thumb, inner webs). 0 Rinse hands with warm water and dry them thoroughly with a disposable toweL 0 Use a towel to turn off the faucet. Alcohol-based hand rubs are not appropriate for use when hands are visibly duty or contaminated with proteinaceous materials (eg, blood, saliva)because these hand rubs do not m o v e soil or debris. 8. If hands are not visibly soiled, an alcohol-based hand rub may be used for routine decontamination 9. To improve adherence to general hand-hygiene recommendationsamong personnelworking in busy patient care environments, an appropriate alcohol-based agent should be available in convenient locations (eg,wall, bedside). Health c m providers may carry individual,disposable, pocketsized containers.Specific regulations may limit placement of alcohol-based products because of fire hazard considerations.Consult applicable local, state, and federal regulations for specific diredion.
Admsnistrption-comSurgicalhandanti isthandrubwithaUSFoodand pliant, d c o h d - b a x s t u g cd hand-mb product shodd XIOW a StandPrdizcd application according to e manufacturer‘s wxitten directions for use.
-fa
1. A standardized protocol for alcohol-based surgical hand rubs should follow manufacturers’ written instructions and include, but may not be limited to, the following. 0 Wash hands and forearms with soap and running water immediately before beginning the surgical hand antisepsis procedure. 0 Clean the subungual areas of both hands under running water using a nail cleaner. 0 Rinse hands and forearms under running water. 0 Dry hands and forearms thoroughly with a paper towel. 0 Dqense the manufacturer-recommended amount of the swgical hand-rub product. 0 Apply the product to the hands and forearms, following the manufadurer’s written instructions. Some manufacturers may require the use of water as part of the process. 0 Rub thoroughly until dry. 0 Repeat the product application process if indicated in the manufacturer’swritten instructions. 0 In the OR, don a sterile surgical gown and gloves. I . “Recommendedpracticesfor surgical hand antisepsishnd snubs,” in Standards, Recommended Practices, and Guidelines Denm:AORN lnc, 2004) 295-296.
is infected with MRSA. This allows adequate time for unit personnel to prepare and organize for the patient in a proactive manner. Additionally, perioperative nurses should place a sticker on patients’ charts to indicate their MIiSA status. These actions help promote both staff member and patient safety.
Perioperative nurses should communicate with PACU nursing staff members as soon as they identify that a patient with MRSA will be coming through the OR and into the I’ACU. If possible, perioperative nurses should contact the facility’s infection control nurse to help ensure continuity of care AORN JOURNAL
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TABLE3
Nursing Care Plan for Patients with Methici llin-resistant Staphy~ococcusAureus (MRSA) Diagnosis
Nculsing interventions
Risk of infection related to antibioticresistant organism
0
0
0 0
0 0 0 0
0
0
Risk of anxiety related t o know led gi. drticit ot antibiotic,resistant organisms
0
0
0
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Interim outcome criteria
Assesses preoperatively for susceptibility to infection (eg, chronic diseases, weight, laboratory values, skin integrity). Assesses skin integrity, sensory impairments, and musculoskeletal status. Implements, monitors, and maintains asep tic technique (eg,implant sferilization). Adheres to standard and transmissionbased precautions to prevent infection and cross infection by ensuring that all personnel adhere to strict hand w a s h i i guidelines;and .+ ensuring that postoperative patients with MRSA are placed in private rooms or in a room with a patient who has an active infection with MRSA (ie, cohorting) but no other infection and isolation supplies and equipment are immediately available. Administers prescribed antibiotic therapy at appropriate times. Initiates traffic control and restricts access to appropriate personnel. Administers wound site c m and applies sterile, dry surgical dressing. Avoids tracking wound exudate and normal body flora from surrounding skin to clean areas. Notes type and amounts of effluent fmm wounds and drainage tubes and notifies appropriate members of health care team regarding signrficant changes. Communicates information about patient’s risk status to appropriate members of the health care team.
The patient‘s skin remains intact and nonreddened, wound is dry, and temperature remains normothermic throughout the perioperativc period.
Determines knowledge level, assesses readiness to learn, and identifies barriers to communication. Provides instruction to enhance patient’s understanding of care for infection.. caused by antibiotic-resistant organisms. Provides education to empower patients to monitor care provided by their health care providers postoperatively. Explains sequence of events and reinfoxes teaching about treatment options. Provides dscharge instructions (ie, verbal, written) for care of infections caused by antibiotic-resistantorganisms. Communicates patient concerns to appropriate health care team members. Evaluates response to instruction.
The patient verbalizes decreased anxiety, an ability 10cope, understanding of infections caused by
antibioticresistant organisms, and vxpec ted outcomes.
Outcome statement The patient is free from signs and
S Y m P ~ ~ of infection.
The patient demonstrates ability to manage infections caused by antibioticresistant
organisms, such as MRSA. The patient participates in decisions affecting his or her plan of care.
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and appropriate handling of supplies, equipment, instruments, linen, and specimens during the intraoperative phase of care. Postoperative nursing managers can consider grouping patients with MRSA and assigning their care to specific staff members.ZThe nurse manager, infection control nurse, or nurses assigned to patients with MRSA should ensure that isolation carts are placed outside the patient's room. This helps ensure patient and staff member safety because personal protective equipment is more likely to be worn when it is available. Additionally, postoperative nurses can plan to use the same equipment until the patient is discharged, after which the nurse can ensure adequate environmental cleaning.
RECOMMENDATIONS Organisms such as MRSA have become a major challenge to everyone who provides care to patients in hospitals and other health care facilities.It can pose a serious threat to a vulnerable patient who has undergone surgery, has a wound, or requires an invasive procedure, such as insertion of a urethral or intravascular catheter.*All nurses must follow best practice guidelines to ensure patient safety and well-being.To provide efficient and safe care for patients with MRSA, nurses in all areas of the hospital should understand the epidemiology of MRSA and appropriate policies and guidelines for MRSA control measures particular to the units where they work. Additionally, all nurses should incorporate the following measures into nursing activities and care plans: maintaining good hand hygiene practice, wearing gloves and gowns when appropriate, maintaining a clean hospital environment by cleaning patient care items and equipment appropriately,
isolating patients who are colonized or infected with MRSA, and 4 providing reassurance to isolated patients and their family members to help relieve anxiety and to instill confidence and a positive attitude (Table 3). For future professional development, managers and educators must &crease staff members' knowledge of infection control practices and ensure compliance with infection control procedures. Nurses have a particular responsibility to maintain hygienic standards and to improve public knowledge of MRSA. Nurses also can take leadership roles in implementing infection control measures to protect patients, visitors, and other health care workers from the spread of MRSA. Methicillin-resistant Staphylococcus aureus outbreaks have become a serious, worldwide problem, and all nurses should take responsibility to meet the challenges of preventing and controlling the prevalence of MRSA. Well-informed nurses and nursing care based on best practices can make the difference for patients and staff members alike. *:* 0
Marilyn Ott, RN, BScN, MScN, is a lecturer in the school of nursing, McMaster University, Hamilton, Ontario.
Jing Shen is a level IV nursing student in the school of nursing, McMaster University, Hamilton, Ontario.
Sue Sherwood, RN, BScN, MEd, is a public health nurse and acting manager at Public Health and Community Services, Healthy Lifestyle and Youth Branch, Chronic Disease PreventionAdult Program, City of Hamilton, Ontario. NOTES 1. D Fogg, "Insects in the OR; multipleprocedure consent form; sterilizer testing; smoke plume; MRSA/VRE precautions," AORN JOURNAL
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(Clinical Issues) AORN lournal76 (July 2002) 170. 2. A Mitchell et al, "Nurses' experience with vancomycin-resistant enterococci (VRE)," Journal of Clinical Nursing 11 (January 2002) 126-133. 3. L L Ronk, "Surgical patients with multiantibiotic-resistant bacteria," AORN Journal 61 (June 1995) 1023-1034. 4. "Health Policy Research Bulletin," Health Canada, Applied Research and Analysis Directorate (June 6,2003) http:// ish www.hc-sc.gc.ca/iacb-dgiac/arad-draa/engl /rmdd/bulletin/microbial.html(accessed 14 Dec 2004). 5. "Controlling antimicrobial resistance: An inte rated action plan for Canadians," Pubic Health Agency of Canada (Nov 27, 1997) http://www.hc-sc.gc.ca/Wlhb-dgspsp /pu blicat/ccdr-rmtc/97vo123/23s7/23s7b-e. h tml (accessed 14 Dec 2004). 6.A T Platt, "MRSA in intensive care," Nursing Standard 15 (April 18-24,2001) 2732. 7.W E Levinson, E Jawetz, Medical Microbiology and Immunology: Examination and Board Review, seventh ed (East Norwalk, Corn: Appleton and Lange, 2002). 8.T Capriotti, "Preventing nosocomial spread of MRSA is in your hands," Dermatology Nursing 15 (December 2003) 535-538. 9."MRSA-Methicillin resistant Staphylococcus aureus information for healthcare personnel," Centers for Disease Control and Prevention (Au ust 1999)
http://www.cdc.gou/ncidod/hipf4RESIST /nzrsahcw.htm (accessed 14 Dec 2004). 10.W Afif et al, "Compliance with methicillin-resistant Staphylococcus aureiis precautions in a teaching hospital," American Journal of Infection Control 30 (November 2002) 430-433. 11.College of Nurses of Ontario, The Compendium of Standards of Practicefor
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Nurses in Ontario, second ed (Toronto: College of Nurses of Ontario, 2000) 3,lO. 12.G A Ayliffe et al, Control of Hospital Infection: A Practical Handbook, fourth ed (London: Arnold Publishers, 2000). 13. M D Nettleman et al, "Assigning responsibility: Using feedback to achieve sustained control of methicillin-resistant Staphylococcus aureus," American Journal of Medicine 16 (September 1991) 2285-232s. 14.D Pittet et al, "Effectiveness of a hospitalwide programme to improve compliance with hand hygiene," Lancet 356 (Oct 14, 2000) 1307-1312. 15.C D Salgado, D P Calfee, B M Farr, "Interventions to prevent methicillin-resistant Staphylococcus aureus transmission in health care facilities: What works?" Clinical Microbiology Newsletter 25 (Sept 15,2003) 137-144. ~- ~ _ _
16. D Raper, "MRSA: An infection control overview," Nursing Standard 17 (July 23-29, 2003) 47-53. 17. A Rampling et al, "Evidence that hospital hygiene is important in the control of methicilh-resistant Staphylococcus aureus," Journal of Hospital Znfection 49 (October 2001) 109-116. 18. "Recommended practices for Surgical hand antisepsis/hand scrubs," in Standards, Recommended Practices, and Guidelines (Denver: AORN Inc, 2004). 19.A Toles, "Artificial nails: Are they putting patients at risk? A review of the research," Journal of Pediatric Oncologic Nursing 19 (September/October 2002) 164-171. 20. "A guide to TB, VRE, and MRSA," RN 61 (July 1998) 24DD. 21. G A Ayliffe, "Recommendations for the control of methicillin-resistant Staphylococcus aureus (MRSA)," World Health Organization, ht tp://www.who.in t/emc-docu ments/antimicrobial-resistance/docs/l whoem clts96l.pdf (accessed 14 Dec 2004).
Device for Treatment of Neurological Disorders Promising new device being developed could improve the A lives of people living with neurological disorders, such as Parkinson's Disease, Tourette's Syndrome, epilepsy, depression, and eating disorders, according to a Nov 8, 2004, news release from the Lawson Health Research Institute, London, Ontario. The small, multichannel recording and stimulating device is expected to aid in the advancement of deep brain stimulation, a recommended treatment for advanced movement disorders (eg, tremors, slowness, rigidity) associated with neurological diseases. The traditional surgical approach to treating these conditions involves using a recording electrode to identify regions of the brain associated with movement disorders. The patient is awake and constrained i n a head frame during a procedure that can last six to eight hours. After target areas
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are identified, a larger electrode is surgically implanted in the brain when the patient is under general anesthesia. Stimulation therapy is delivered by a small, pacemaker-type device implanted adjacent to the patient's collarbone. The new, much smaller device would integrate the recording and stimulation functions. The recording function s t i l l could be used intraoperatively, but the emphasis would be on configuring the stimulation field with chronic recordings to save OR time and tailor the stimulation fields to reduce side effects. Simplifying the procedure could shift the majority of treatment to outpatient settings. New Canadian Technology Set to Revolutionize Treatment of Neurological Disorders (news release, London, Ontario: Lawson Health Research Institute, Nov 8,2004).