- Email: [email protected]
Infection control for MRSA in a psychiatric hospital
General Hospital Psychiatry xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
Infection control for MRSA in a psychiatric hospital Gwen A. Levitt, D.O. ⁎ Maricopa Integrated Health Systems, Box 856 Phoenix, AZ 85016
a r t i c l e
i n f o
Article history: Received 19 October 2013 Revised 15 January 2014 Accepted 5 February 2014 Available online xxxx Keywords: MRSA Infection control Mentally ill Psychiatric
a b s t r a c t Objective: This article examines the challenges in treating methicillin resistant Staphlococcus Aureus (MRSA) in an acute psychiatric inpatient unit Method: The article outlines a case study of one particularly difficult patient who presented to an acute psychiatric hospital with a large wound that was MRSA positive and reviews the dilemmas facing mental health providers. Results: The outcome of the case presented suggests that hospital policies interfered with the psychiatric treatment and recovery of an acutely ill patient as well as create possibly unnecessary costs. Conclusions: Hospitals should review their infection control policies to curb the spread of infection among patients and staff in an acute psychiatric setting. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Medical professionals all face the challenge of treating patients with methicillin-resistant staphylococcus aureus (MRSA) infection. It is estimated that the prevalence of MRSA infection in the general population is about 6% [1]. A US population-based survey of noninstitutionalized patients demonstrated a 31.6% rate of MRSA colonization and .89% rate of infection [2]. In 2006, a nationwide hospital survey demonstrated an overall MRSA prevalence rate of 46.3 per 1000 patients, 34 per 1000 infections, and 12 per 1000 colonized patients [3]. Many infections were found incidentally, and most cases were not seen to be pathogenic [4]. The prevalence of MRSA colonization in the seriously mentally ill population is estimated at 5.2%; 2.9% were newly colonized, and 29% of this patient population presented with active skin and soft tissue infection [1]. In a national hospital survey, it was estimated that 70% of MRSA infections were health care acquired [3]. Although basic hand hygiene is seen as the key factor in stopping nosocomial infections, one study involving intensive care units, over a 6-month period, demonstrated that rates of infection were unrelated to hand washing [5]. Educational efforts around hand hygiene have been disappointing [6]. One report found that with observation and education, the rate of hand washing only increased by about 8% over the 6 months of the study [5]. Health care workers were three times more likely to wash their hands after seeing a patient compared to a physician [7]. In a study completed in an emergency room setting, 58.2% of nurses, 18.6% of residents, and 17.2% of attending physicians washed their hands during a contact with a patient [8]. In another report, 60% of staff washed their hands before or after visiting a patient, while only 9% ⁎ Corresponding author. Tel.: +1 602 954 0186. E-mail address: [email protected].
washed before and after an exam; suggesting that personal protection was more important to health workers than protecting patients from nosocomial infections [7]. 2. MRSA policies A typical hospital policy for positive MRSA patients, as suggested by the Centers of Disease Control (cdc.gov), is to isolate the patient in a single room with a private toilet. Modified contact precautions include hand hygiene when the patient uses the toilet or leaves the room. Staff is to use proper hand hygiene and to gown and glove while performing any tasks requiring direct contact with the patient. Once the antibiotics are completed, three consecutive nasal–axillary–groin swabs, 24 h apart, and/or swabs of the infection site will be obtained. Contact precautions and the private room can be discontinued after all swabs are negative; in about 4 to 5 days. Patients with a history of MRSA are isolated as well, and put on modified contact precautions until one swab is found negative; a process that takes about 48 h to complete. Newer policies state that patients suspected of having a history of MRSA must undergo three consecutive nasal–axillary–peri-rectal swabs, 24 h apart. This slows the return of results to about 4 to 5 days. Peri-rectal swabs are far more invasive than groin area swabs and may be much more difficult to obtain. (Swabs for MRSA are always a challenge to obtain from an acutely mentally ill patient especially if the area is a sensitive one such as the groin or rectal area.) 2.1. Effects of isolation There has been no convincing evidence that contact isolation adds any protection against infection [7,9]. Patients in isolation are half as likely to be seen by health care workers than those in the general
0163-8343/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.genhosppsych.2014.02.005
Please cite this article as: Levitt G.A., Infection control for MRSA in a psychiatric hospital, Gen Hosp Psychiatry (2014), http://dx.doi.org/ 10.1016/j.genhosppsych.2014.02.005
2
G.A. Levitt / General Hospital Psychiatry xxx (2014) xxx–xxx
wards. On a more positive note, health care workers who do go into isolation rooms are more likely to wash their hands than they would have for a patient who is not isolated [7]. In a survey of 13 general hospitals, anxiety, depression, insomnia, withdrawal, disorientation, regression and hallucinations were noted in a third of patients isolated in laminar flow rooms [10]. In one report, anxiety levels were raised in isolated patients who were tested for psychological distress as compared to those in the general wards; and the anxiety was not related to the isolation per se but due to concerns about the illness, severity and complications of the infection and length of stay [11]. This same report noted that patients with a past history of mental illness were prone to higher anxiety scores and experienced behavioral issues when isolated compared to those without mental illness. In a study by Catalano et al. [12], it was documented that patients in isolation for MRSA had almost a twopoint increase in symptoms assessed using the Hamilton Depression Rating Scale and over three-point increase in anxiety on the Hamilton Anxiety Rating Scale. Controls, patients not in isolation, demonstrated an almost two-point decrease in depression and almost 50% reduction in anxiety using the above-mentioned scales. Unintended “side effects” of isolation have been observed. Rehabilitation is hampered by the limitations of access to the patient, length of stays increase due to difficulties in placements accepting patients with MRSA, and there is an overall decline in the morale of the patients [11]. 2.2. MRSA in inpatient psychiatric units In a psychiatric inpatient setting, diagnosis and treatment of MRSA may be delayed due to the often uncooperative nature of an acutely mentally ill patient. The lack of education about infectious diseases, especially in mental health workers, is also a contributory hindrance. An online survey of MRSA education demonstrated that 63% of psychiatric nurses (RN-P) and 44% of behavioral health technicians (BHTs) could not identify multidrug resistant organisms (MDROs) as being bacterial in origin. Only 69% of RN-Ps and 38% of BHTs were able to link MDRO infections as a cause for increased lengths of stay, increased costs and mortality. Eighty-eight percent of the RN-Ps were able to adequately identify their hospital's infection control plan related to MDRO [13]. Mental health treatment in most psychiatric inpatient settings is in the form of groups. Other types of therapy that might be offered in an inpatient setting require regular close interactions with staff and therapists. Many of the activities and therapies offered take place off the unit. Adherence to hand washing and other contact precaution measures is often difficult to ensure as there are many opportunities for ongoing transmission and acutely ill patients may be unable or unwilling to follow the requirements. Some facilities may not be able to easily isolate patients in a single room, and many have communal bathrooms and shower areas. Meals may be served cafeteria style in an open dining area. In a report, one psychiatric hospital had an infection control procedure for MRSA, but the psychiatric ward setting and the acute illness of the patient made it impossible to follow. To address the problem, the MRSA patient was instructed to use proper hand washing technique but was not required to be isolated. Staff, however, was required to use hand sanitizer with every interaction with the MRSA patient and to appropriately disinfect common areas used by said patient. The MRSA patient was ordered mupirocin nasal ointment five times a day for 5 days. After a week, none of the peers or staff tested positive for MRSA [14]. 3. Case presentation The patient was a 35-year-old male with major depression and alcohol dependence. He was started on a seratonergic re-uptake
inhibitor. He began to demonstrate paranoia, and a novel antipsychotic was added. He would drop himself to the ground and crawl on his hands and knees, causing bruising and inflammation. He developed a temperature and became “stiff.” The antipsychotic was immediately stopped for suspected neuroleptic malignant syndrome. He was admitted to a medical unit and found to have an open suppurating wound of his knee. Cultures were positive for MRSA, and he was treated for 3 weeks on intravenous (iv) antibiotics. The knee wound was quite extensive; covering the entire patella with areas of full thickness deterioration. The patient required medical restraints to stop him from climbing out of bed and removing ivs and bandages. He was placed on constant supervision. After 3 weeks, the patient was transferred back to the psychiatric unit. He still appeared to be psychotic. He remained on constant supervision to monitor his hand hygiene, stop him from removing his bandages and crawling on the floor. He was physically debilitated and unsteady on his feet and was unable to understand the need to use a walker or wheelchair. He would defecate and urinate on himself; refusing to wear a diaper. He would not feed himself or even move his body when staff needed to care for him. He was put on a program of hourly position change and range of motion exercises. He was essentially a “total care” patient. Staff constantly gave him verbal prompts for hand hygiene. They hung signs all over the room as visual aids and reminders. These seemed minimally effective in his confused state. More often than not, during the height of his illness, staff had to wash his hands for him. He was placed in a hospital bed to impede him from getting up on his own; which did contain him most of the time. Despite having constant supervision, it was often difficult to stop him from dropping to the ground and crawling. To protect his knees, staff purchased foam knee pads from a local hardware store. Thick fleece sweat pants were purchased for him to wear for a layer of cushioning. Since he was confined to his room, exercise mats were placed on the floor as another layer of protection. He often would prefer sleeping on the mats, rather than in the bed. All these measures helped to allow for the wound to completely granulate in, over time, and the wound did not become re-infected. The recreational therapy department was actively involved to keep him occupied during waking hours; in order to engage and divert him. They provided music, puzzles and games. Due to this patient's high level of disorganization, he was really unable to engage in these activities. The only television on the unit was in the common area, so this was not available to him for a good portion of his stay. As he improved with low-dose antipsychotics and high-dose antidepressants, he was allowed increased time out in the public areas, but with constant supervision. Staff was vigilant in reminding him to wash his hands and sanitizing the areas he was using. The more time he was able to be out in the common areas, the more cued in he became. He was able to attend on-unit groups and activities and start to socialize with peers. He began to care for himself and wash his hands without prompting. His level of depression seemed to resolve much more quickly once he was able to be in the milieu. At the time of discharge, after 4 months, his knee wound was fully healed. No other patients were identified as having acquired a MRSA infection during his time in the hospital. 4. Conclusion The ancillary costs associated with treating MRSA appears to be of little benefit in impacting the rate of infection or promoting the well being of patients on an inpatient psychiatric ward. In the case presented above, isolation of the patient essentially afforded him no psychotherapeutic intervention, but only pharmacotherapy. Isolation also prevented him from socializing with peers and staff as well as being exposed to day-to-day cues and routines. This patient's length of stay was severely impacted by contracting MRSA. Clearly, his
Please cite this article as: Levitt G.A., Infection control for MRSA in a psychiatric hospital, Gen Hosp Psychiatry (2014), http://dx.doi.org/ 10.1016/j.genhosppsych.2014.02.005
G.A. Levitt / General Hospital Psychiatry xxx (2014) xxx–xxx
medical issue prolonged his stay, by at least 3 weeks in the medical ward, if not more, and his psychiatric condition prolonged his recovering from MRSA by a considerable amount as well. The psychiatric unit had to block a two-bedded room for one person for 2 1/2 months. A psychiatric inpatient bed costs about US$1000/day; this equates to US$75,000 in lost revenue. Constant supervision could not stop him from dropping to the floor but merely to contain him in isolation and attempt to have the patient use proper hygiene. There may have been an added “incentive” for staff to use contact precautions, knowing the patient was infected, and being prompted by the posted signage to wash their hands. Staff was noted to have a high level of frustration with this particular patient due to his increased level of care and inability to assist himself. This may also have deterred staff from intervening and engaging with the patient more often, knowing he was MRSA positive. Constant supervision of this patient for 3 months costs about US $45,000. (A BHT makes an average of about US$13 an hour.) The impact of the “extraordinary” measures, such as knee pads, fleece sweat pants and use of exercise mats, cannot really be estimated. It does speak to the ingenuity and creativity of the staff in trying to assist this patient. None of these items negatively affected his recovery. If nothing else, it did make staff feel less helpless in dealing with a very ill and refractory patient. Infection control policies are designed for the general medical wards. Hospitals need to revise these policies to accommodate the needs of patients with acute psychiatric conditions; taking into account the physical setting of the psychiatric unit, the mental state and the therapeutic needs of the patient. Valuable and costly resources are used by staff to impose and monitor the hospital's infection control policies; regulations that are often times ignored, “bent” or circumvented due to the inability to enforce them. This can detrimentally impact patient care and recovery and drives costs up
3
exponentially. More studies are needed to critically examine infection control policy's impact on containing the spread of these diseases along with a cost–benefit analysis; especially on acute inpatient psychiatric wards.
References [1] Farley J, Ross T, Krall J, Hyat M, Caston-Goa A, Perl T, et al. The prevalence, risk factors and molecular epidemiology of methicillin-resistant staphylococcus aureus nasal and axilliary colonization among psychiatric patients on admission to an academic center. Am J Infect Control 2013;4:199–203. [2] Graham P, Lin S, Larson E. A US population-based survey of staphylococcus aureus colonization. Ann Intern Med 2006;144(5):318–25. [3] Jarvis W, Schlosser J, Chinn R, Tweeten S, Jackson M. National prevalence of methicillin-resistant staphylococcus aureus in inpatients at US health care facilities, 2006. Am J Infect Control 2006;35(10):631–7. [4] Peel R, Stolarek I, Elder A. Isolating patients with MRSA can have long term implications. Is it time to stop searching for MRSA? BMJ 1997:315–57. [5] Simmons B, Bryant J, Neiman K, Spencer L, Arheart K. The role of hand washing in prevention of endemic intensive care unit infections. Infect Control Hosp Epidemiol 1990;11(11):589–94. [6] Cooke R, Umasankar R, Goddard S. Basic hygiene should help contain MRSA. Is it time to stop searching for MRSA? BMJ 1997:315–57. [7] Kirkland K, Weinstein J. Adverse effects of contact isolation. Lancet 1999;354:1177–8. [8] Meegs M, Giles B, Chisholm C, Cordell W, Nelson D. Hand washing frequency in an emergency department. J Emerg Nurs 1994;20(3):183–8. [9] Dance D, Cunningham R, Gaunt P, Stewart V, Swales J. Environmental hygiene is an important part of care. Is it time to stop searching for MRSA? BMJ 1997:315–57. [10] Kellerman J, Rigler D, Siegel S. Psychological effects of isolation in protected environments. Am J Psychiatry 1977;134(5):563–5. [11] Wilkins E, Ellis M, Dunbar E, Gibbs A. Does isolation of patients with infections induce mental illness? J Infect Control 1988;17:43–7. [12] Catalano G, Houston S, Catalano D, Butera A, et al. Anxiety and depression in hospitalized patients in resistant organism isolation. South Med J 2003;96:2. [13] Hannon-Engel S, Fantasia H. Are you survey ready? Online evaluation of a multidrug resistant organisms educational program in a behavioral health hospital. Perspect Psychiatr Care 2011;47:138–44. [14] Letters to the editor. J Hosp Infect 2010;75:324–37.
Please cite this article as: Levitt G.A., Infection control for MRSA in a psychiatric hospital, Gen Hosp Psychiatry (2014), http://dx.doi.org/ 10.1016/j.genhosppsych.2014.02.005
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
Infection control for MRSA in a psychiatric hospital Gwen A. Levitt, D.O. ⁎ Maricopa Integrated Health Systems, Box 856 Phoenix, AZ 85016
a r t i c l e
i n f o
Article history: Received 19 October 2013 Revised 15 January 2014 Accepted 5 February 2014 Available online xxxx Keywords: MRSA Infection control Mentally ill Psychiatric
a b s t r a c t Objective: This article examines the challenges in treating methicillin resistant Staphlococcus Aureus (MRSA) in an acute psychiatric inpatient unit Method: The article outlines a case study of one particularly difficult patient who presented to an acute psychiatric hospital with a large wound that was MRSA positive and reviews the dilemmas facing mental health providers. Results: The outcome of the case presented suggests that hospital policies interfered with the psychiatric treatment and recovery of an acutely ill patient as well as create possibly unnecessary costs. Conclusions: Hospitals should review their infection control policies to curb the spread of infection among patients and staff in an acute psychiatric setting. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Medical professionals all face the challenge of treating patients with methicillin-resistant staphylococcus aureus (MRSA) infection. It is estimated that the prevalence of MRSA infection in the general population is about 6% [1]. A US population-based survey of noninstitutionalized patients demonstrated a 31.6% rate of MRSA colonization and .89% rate of infection [2]. In 2006, a nationwide hospital survey demonstrated an overall MRSA prevalence rate of 46.3 per 1000 patients, 34 per 1000 infections, and 12 per 1000 colonized patients [3]. Many infections were found incidentally, and most cases were not seen to be pathogenic [4]. The prevalence of MRSA colonization in the seriously mentally ill population is estimated at 5.2%; 2.9% were newly colonized, and 29% of this patient population presented with active skin and soft tissue infection [1]. In a national hospital survey, it was estimated that 70% of MRSA infections were health care acquired [3]. Although basic hand hygiene is seen as the key factor in stopping nosocomial infections, one study involving intensive care units, over a 6-month period, demonstrated that rates of infection were unrelated to hand washing [5]. Educational efforts around hand hygiene have been disappointing [6]. One report found that with observation and education, the rate of hand washing only increased by about 8% over the 6 months of the study [5]. Health care workers were three times more likely to wash their hands after seeing a patient compared to a physician [7]. In a study completed in an emergency room setting, 58.2% of nurses, 18.6% of residents, and 17.2% of attending physicians washed their hands during a contact with a patient [8]. In another report, 60% of staff washed their hands before or after visiting a patient, while only 9% ⁎ Corresponding author. Tel.: +1 602 954 0186. E-mail address: [email protected].
washed before and after an exam; suggesting that personal protection was more important to health workers than protecting patients from nosocomial infections [7]. 2. MRSA policies A typical hospital policy for positive MRSA patients, as suggested by the Centers of Disease Control (cdc.gov), is to isolate the patient in a single room with a private toilet. Modified contact precautions include hand hygiene when the patient uses the toilet or leaves the room. Staff is to use proper hand hygiene and to gown and glove while performing any tasks requiring direct contact with the patient. Once the antibiotics are completed, three consecutive nasal–axillary–groin swabs, 24 h apart, and/or swabs of the infection site will be obtained. Contact precautions and the private room can be discontinued after all swabs are negative; in about 4 to 5 days. Patients with a history of MRSA are isolated as well, and put on modified contact precautions until one swab is found negative; a process that takes about 48 h to complete. Newer policies state that patients suspected of having a history of MRSA must undergo three consecutive nasal–axillary–peri-rectal swabs, 24 h apart. This slows the return of results to about 4 to 5 days. Peri-rectal swabs are far more invasive than groin area swabs and may be much more difficult to obtain. (Swabs for MRSA are always a challenge to obtain from an acutely mentally ill patient especially if the area is a sensitive one such as the groin or rectal area.) 2.1. Effects of isolation There has been no convincing evidence that contact isolation adds any protection against infection [7,9]. Patients in isolation are half as likely to be seen by health care workers than those in the general
0163-8343/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.genhosppsych.2014.02.005
Please cite this article as: Levitt G.A., Infection control for MRSA in a psychiatric hospital, Gen Hosp Psychiatry (2014), http://dx.doi.org/ 10.1016/j.genhosppsych.2014.02.005
2
G.A. Levitt / General Hospital Psychiatry xxx (2014) xxx–xxx
wards. On a more positive note, health care workers who do go into isolation rooms are more likely to wash their hands than they would have for a patient who is not isolated [7]. In a survey of 13 general hospitals, anxiety, depression, insomnia, withdrawal, disorientation, regression and hallucinations were noted in a third of patients isolated in laminar flow rooms [10]. In one report, anxiety levels were raised in isolated patients who were tested for psychological distress as compared to those in the general wards; and the anxiety was not related to the isolation per se but due to concerns about the illness, severity and complications of the infection and length of stay [11]. This same report noted that patients with a past history of mental illness were prone to higher anxiety scores and experienced behavioral issues when isolated compared to those without mental illness. In a study by Catalano et al. [12], it was documented that patients in isolation for MRSA had almost a twopoint increase in symptoms assessed using the Hamilton Depression Rating Scale and over three-point increase in anxiety on the Hamilton Anxiety Rating Scale. Controls, patients not in isolation, demonstrated an almost two-point decrease in depression and almost 50% reduction in anxiety using the above-mentioned scales. Unintended “side effects” of isolation have been observed. Rehabilitation is hampered by the limitations of access to the patient, length of stays increase due to difficulties in placements accepting patients with MRSA, and there is an overall decline in the morale of the patients [11]. 2.2. MRSA in inpatient psychiatric units In a psychiatric inpatient setting, diagnosis and treatment of MRSA may be delayed due to the often uncooperative nature of an acutely mentally ill patient. The lack of education about infectious diseases, especially in mental health workers, is also a contributory hindrance. An online survey of MRSA education demonstrated that 63% of psychiatric nurses (RN-P) and 44% of behavioral health technicians (BHTs) could not identify multidrug resistant organisms (MDROs) as being bacterial in origin. Only 69% of RN-Ps and 38% of BHTs were able to link MDRO infections as a cause for increased lengths of stay, increased costs and mortality. Eighty-eight percent of the RN-Ps were able to adequately identify their hospital's infection control plan related to MDRO [13]. Mental health treatment in most psychiatric inpatient settings is in the form of groups. Other types of therapy that might be offered in an inpatient setting require regular close interactions with staff and therapists. Many of the activities and therapies offered take place off the unit. Adherence to hand washing and other contact precaution measures is often difficult to ensure as there are many opportunities for ongoing transmission and acutely ill patients may be unable or unwilling to follow the requirements. Some facilities may not be able to easily isolate patients in a single room, and many have communal bathrooms and shower areas. Meals may be served cafeteria style in an open dining area. In a report, one psychiatric hospital had an infection control procedure for MRSA, but the psychiatric ward setting and the acute illness of the patient made it impossible to follow. To address the problem, the MRSA patient was instructed to use proper hand washing technique but was not required to be isolated. Staff, however, was required to use hand sanitizer with every interaction with the MRSA patient and to appropriately disinfect common areas used by said patient. The MRSA patient was ordered mupirocin nasal ointment five times a day for 5 days. After a week, none of the peers or staff tested positive for MRSA [14]. 3. Case presentation The patient was a 35-year-old male with major depression and alcohol dependence. He was started on a seratonergic re-uptake
inhibitor. He began to demonstrate paranoia, and a novel antipsychotic was added. He would drop himself to the ground and crawl on his hands and knees, causing bruising and inflammation. He developed a temperature and became “stiff.” The antipsychotic was immediately stopped for suspected neuroleptic malignant syndrome. He was admitted to a medical unit and found to have an open suppurating wound of his knee. Cultures were positive for MRSA, and he was treated for 3 weeks on intravenous (iv) antibiotics. The knee wound was quite extensive; covering the entire patella with areas of full thickness deterioration. The patient required medical restraints to stop him from climbing out of bed and removing ivs and bandages. He was placed on constant supervision. After 3 weeks, the patient was transferred back to the psychiatric unit. He still appeared to be psychotic. He remained on constant supervision to monitor his hand hygiene, stop him from removing his bandages and crawling on the floor. He was physically debilitated and unsteady on his feet and was unable to understand the need to use a walker or wheelchair. He would defecate and urinate on himself; refusing to wear a diaper. He would not feed himself or even move his body when staff needed to care for him. He was put on a program of hourly position change and range of motion exercises. He was essentially a “total care” patient. Staff constantly gave him verbal prompts for hand hygiene. They hung signs all over the room as visual aids and reminders. These seemed minimally effective in his confused state. More often than not, during the height of his illness, staff had to wash his hands for him. He was placed in a hospital bed to impede him from getting up on his own; which did contain him most of the time. Despite having constant supervision, it was often difficult to stop him from dropping to the ground and crawling. To protect his knees, staff purchased foam knee pads from a local hardware store. Thick fleece sweat pants were purchased for him to wear for a layer of cushioning. Since he was confined to his room, exercise mats were placed on the floor as another layer of protection. He often would prefer sleeping on the mats, rather than in the bed. All these measures helped to allow for the wound to completely granulate in, over time, and the wound did not become re-infected. The recreational therapy department was actively involved to keep him occupied during waking hours; in order to engage and divert him. They provided music, puzzles and games. Due to this patient's high level of disorganization, he was really unable to engage in these activities. The only television on the unit was in the common area, so this was not available to him for a good portion of his stay. As he improved with low-dose antipsychotics and high-dose antidepressants, he was allowed increased time out in the public areas, but with constant supervision. Staff was vigilant in reminding him to wash his hands and sanitizing the areas he was using. The more time he was able to be out in the common areas, the more cued in he became. He was able to attend on-unit groups and activities and start to socialize with peers. He began to care for himself and wash his hands without prompting. His level of depression seemed to resolve much more quickly once he was able to be in the milieu. At the time of discharge, after 4 months, his knee wound was fully healed. No other patients were identified as having acquired a MRSA infection during his time in the hospital. 4. Conclusion The ancillary costs associated with treating MRSA appears to be of little benefit in impacting the rate of infection or promoting the well being of patients on an inpatient psychiatric ward. In the case presented above, isolation of the patient essentially afforded him no psychotherapeutic intervention, but only pharmacotherapy. Isolation also prevented him from socializing with peers and staff as well as being exposed to day-to-day cues and routines. This patient's length of stay was severely impacted by contracting MRSA. Clearly, his
Please cite this article as: Levitt G.A., Infection control for MRSA in a psychiatric hospital, Gen Hosp Psychiatry (2014), http://dx.doi.org/ 10.1016/j.genhosppsych.2014.02.005
G.A. Levitt / General Hospital Psychiatry xxx (2014) xxx–xxx
medical issue prolonged his stay, by at least 3 weeks in the medical ward, if not more, and his psychiatric condition prolonged his recovering from MRSA by a considerable amount as well. The psychiatric unit had to block a two-bedded room for one person for 2 1/2 months. A psychiatric inpatient bed costs about US$1000/day; this equates to US$75,000 in lost revenue. Constant supervision could not stop him from dropping to the floor but merely to contain him in isolation and attempt to have the patient use proper hygiene. There may have been an added “incentive” for staff to use contact precautions, knowing the patient was infected, and being prompted by the posted signage to wash their hands. Staff was noted to have a high level of frustration with this particular patient due to his increased level of care and inability to assist himself. This may also have deterred staff from intervening and engaging with the patient more often, knowing he was MRSA positive. Constant supervision of this patient for 3 months costs about US $45,000. (A BHT makes an average of about US$13 an hour.) The impact of the “extraordinary” measures, such as knee pads, fleece sweat pants and use of exercise mats, cannot really be estimated. It does speak to the ingenuity and creativity of the staff in trying to assist this patient. None of these items negatively affected his recovery. If nothing else, it did make staff feel less helpless in dealing with a very ill and refractory patient. Infection control policies are designed for the general medical wards. Hospitals need to revise these policies to accommodate the needs of patients with acute psychiatric conditions; taking into account the physical setting of the psychiatric unit, the mental state and the therapeutic needs of the patient. Valuable and costly resources are used by staff to impose and monitor the hospital's infection control policies; regulations that are often times ignored, “bent” or circumvented due to the inability to enforce them. This can detrimentally impact patient care and recovery and drives costs up
3
exponentially. More studies are needed to critically examine infection control policy's impact on containing the spread of these diseases along with a cost–benefit analysis; especially on acute inpatient psychiatric wards.
References [1] Farley J, Ross T, Krall J, Hyat M, Caston-Goa A, Perl T, et al. The prevalence, risk factors and molecular epidemiology of methicillin-resistant staphylococcus aureus nasal and axilliary colonization among psychiatric patients on admission to an academic center. Am J Infect Control 2013;4:199–203. [2] Graham P, Lin S, Larson E. A US population-based survey of staphylococcus aureus colonization. Ann Intern Med 2006;144(5):318–25. [3] Jarvis W, Schlosser J, Chinn R, Tweeten S, Jackson M. National prevalence of methicillin-resistant staphylococcus aureus in inpatients at US health care facilities, 2006. Am J Infect Control 2006;35(10):631–7. [4] Peel R, Stolarek I, Elder A. Isolating patients with MRSA can have long term implications. Is it time to stop searching for MRSA? BMJ 1997:315–57. [5] Simmons B, Bryant J, Neiman K, Spencer L, Arheart K. The role of hand washing in prevention of endemic intensive care unit infections. Infect Control Hosp Epidemiol 1990;11(11):589–94. [6] Cooke R, Umasankar R, Goddard S. Basic hygiene should help contain MRSA. Is it time to stop searching for MRSA? BMJ 1997:315–57. [7] Kirkland K, Weinstein J. Adverse effects of contact isolation. Lancet 1999;354:1177–8. [8] Meegs M, Giles B, Chisholm C, Cordell W, Nelson D. Hand washing frequency in an emergency department. J Emerg Nurs 1994;20(3):183–8. [9] Dance D, Cunningham R, Gaunt P, Stewart V, Swales J. Environmental hygiene is an important part of care. Is it time to stop searching for MRSA? BMJ 1997:315–57. [10] Kellerman J, Rigler D, Siegel S. Psychological effects of isolation in protected environments. Am J Psychiatry 1977;134(5):563–5. [11] Wilkins E, Ellis M, Dunbar E, Gibbs A. Does isolation of patients with infections induce mental illness? J Infect Control 1988;17:43–7. [12] Catalano G, Houston S, Catalano D, Butera A, et al. Anxiety and depression in hospitalized patients in resistant organism isolation. South Med J 2003;96:2. [13] Hannon-Engel S, Fantasia H. Are you survey ready? Online evaluation of a multidrug resistant organisms educational program in a behavioral health hospital. Perspect Psychiatr Care 2011;47:138–44. [14] Letters to the editor. J Hosp Infect 2010;75:324–37.
Please cite this article as: Levitt G.A., Infection control for MRSA in a psychiatric hospital, Gen Hosp Psychiatry (2014), http://dx.doi.org/ 10.1016/j.genhosppsych.2014.02.005