Starting up an MRSA unit.

One nursing home company's innovative response to a growing need in infection control

In 1990, Evergreen Healthcare, Inc. opened its first unit specifically for patients with methicillin-resistant staphylococcus aureus (MRSA). In doing so, it helped initiate a trend: A growing number of patients and payers for care are turning to nursing homes with subacute capabilities for treatment of infections caused by these organisms, which have become resistant to a number of antibiotics due, according to scientists, to the widespread use of third-generation cephalosporins and an increasing number of immunosuppressed patients. Nursing homes confronting this challenge must address several problems: how to treat these patients, and do so without perpetuating or exacerbating the resistance problem; how to control the spread of infection; and how to accomplish these goals without lengthy hospital stays.

At Evergreen, the 26-bed MRSA unit is part of Pine Tree Manor in Indianapolis, a 179-bed long-term care facility with 42 beds certified for skilled care. In considering the feasibility of developing a unit exclusively for MRSA patients, Evergreen examined the need for such a program in its area, as well as the capabilities of its long-term care facilities. A review of the literature and consultation with our corporate DON revealed an obvious and growing need. Not only had the number of methicillin-resistant S. aureus strains grown from 1.8% in 1976 to 16% in 1988, the patients infected with MRSA were becoming increasingly difficult to place, as well. Wound care and IV antibiotic therapy was within the scope of a nursing home with sub-acute capabilities.

But discharge planners often found themselves dealing with a reluctance by nursing homes to admit MRSA patients reminiscent of that seen with AIDS patients.

Pine Tree Manor was already providing a range of subacute services with an emphasis on wound care. All of Pine Tree's RNs and LPNs were IV-certified and had extensive experience with starting and maintaining central and peripheral lines. Most of the RNs and LPNs were also long-time employees of Pine Tree. Thus, most of the added costs for the MRSA unit involved training, education and follow-up inservices.

Once the decision was made to open the unit, Pine Tree worked closely with the Indiana State Board of Health and the U.S. Centers for Disease Control to ensure adherence to strict infection control guidelines.

Patient Diversity

The MRSA unit serves a diverse group of patients, ranging in age from 30 to 80 years, and admitted from hospitals, home, and other long-term care facilities. All patients on the unit have methicillin (or oxacillin)-resistant S. aureus, confirmed by culture. MRSA has a broad spectrum of presentation. As a localized infection, the organism can develop in a decubitus, a surgical wound, a feeding tube site, etc. MRSA can also manifest as a systemic infection in the respiratory or urinary tract or as MRSA pneumonia. Patients can also become colonized with MRSA, i.e., the organism is present upon culture but there is no evidence of any infectious process and the patient is asymptomatic.

Care plans are highly individualized, depending on the circumstances of the case. In general, treatment for localized infections consists of state-of-the-art wound care, with an emphasis on moist wound healing, scrupulous dressing changes, patient turning and other measures to heal existing wounds and keep healthy skin intact. A plastic surgeon consults frequently on the care of these patients.

Because of the potential for exacerbating the resistance problem, systemic antibiotic therapy is reserved for patients with active systemic infections. Patients are usually treated with a 10 to 14-day course of IV vancomycin hydrochloride, after which the vancomycin levels are monitored to ensure therapeutic levels.

Patients colonized with MRSA require no antibiotics. However, the dormant organism may be activated at any time, and localized or systemic MRSA infections can recur if the immune system becomes depleted or the patient becomes ill. For this reason, special attention is paid to sound nutrition and hydration in all patients on the unit.

The average length of stay on the unit varies, and the duration of treatment is widely variable. The prognosis, even for those with systemic infections, is generally favorable, and some patients are able to return home after relatively short-term treatment.

Staffing

Pine Tree's 30 nurses and 50 CNAs rotate through the MRSA unit. There are 4 to 5 RNs on the unit during the day shift and RNs on call 24 hours/day. We opted for rotation over permanent assignment to help prevent burnout.

We attribute our favorable outcomes to intensive, ongoing staff education that stresses scrupulous attention to infection control. The entire staff is trained in infection control during orientation and again in quarterly infection control inservices. The following topics are covered:

* The definition of MRSA.

* The modes of transmission (direct contact; MRSA is not airborne).

* Isolation policy and procedures. Different types of contact isolation are required for different manifestations of the infection -- for example, drainage and secretion isolation for patients with a draining wound. The level of isolation is further dictated by our ability to monitor and contain the infection; patients with localized MRSA infections can interact with others in the facility as long as the wound exudate is contained (ie, not saturating the dressing); those with MRSA in the urinary tract are free to interact with other residents as long as they are continent or have on an incontinence-containing device.

* Universal precautions. The staff is instructed to follow universal precautions throughout the nursing home, regardless of the resident being cared for. Emphasis is placed on diligent hand washing. Procedures for contact with bodily fluids and proper disposal are taught in detail.

* Quality of life issues. Drainage and secretion isolation doesn't mean isolating the patient from human contact and caring. The need for the human element of patient care is role-modeled as frequently as possible by our nurse managers, who let staff know that as long as they have the knowledge required to deal with MRSA safely, touching or hugging a patient places them in no danger. Patients' family members are also educated about MRSA and reassured about their own safety in dealing with their relative.

The staff is tested on the information after each session, and any employee who fails the test is given one-on-one instruction until he or she is able to pass. Because Pine Tree accepts many types of wounds for treatment, the nursing staff is also required to attend quarterly skin care inservices.

Medical support for the unit is provided by Pine Tree's two co-medical directors, who are on the premises weekly and on 24- hour call. However, this type of unit requires medical support from a medical director and consulting physicians who are not only highly accessible, but also have expertise in wound care and infection control. The MRSA unit is also served by Pine Tree's two physical therapists, two occupational therapists, a speech therapist, social worker and an activities director who provides both group and bedside activities. Our dietician consults and follows up on every admission.

Conclusion

As nursing homes have discovered in admitting patients with MRSA, a special unit isn't required to care for these patients as long as infection control guidelines are followed strictly. The success of our program prompted Evergreen to open a second MRSA unit at Heritage Manor of Alexandria North in Alexandria, LA, in 1993. Clearly, this is an emergent situation in which properly staffed and equipped nursing homes can play a key role.

Karen Meek, RN, has been Director of Nursing at Pine Tree Manor in Indianapolis, IN since 1991. She has held hospital positions in neonatal intensive care and hemodialysis.