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Preventing hospital-associated infection: MRSA.

Methicillin-resistant Staphylococcus aureus (MRSA) is a common and continuously growing cause of nosocomial and community-acquired infections (Raygada & Levine, 2009). MRSA is a bacterium resistant to many antibiotics. In the early 1960s, MRSA was identified in England and identified in the United States toward the end of the same decade (Raygada & Levine, 2009). MRSA may be present in wounds, blood, urine, or sputum, and may have its origin in the community (CA-MRSA) or hospital (HAMRSA). The prevalence of S. aureus and MRSA colonization was identified as 32% (89.4 million persons) and 0.8% (2.3 million persons) respectively in the United States (Kuehnert et al., 2006). The presence of both HA-MRSA and CA-MRSA continue to rise at alarming rates. Attention on reducing and preventing MRSA is evident in regulatory agencies like the Joint Commission. Joint Commission National Patient Safety Goals highlight the importance of preventing MRSA in the hospital by continuing to include NPSG.07.03.01 "implement evidence based practice to prevent health care associated infections due to multidrug-resistant organisms in acute care hospitals" as part of the 2012 goals. The goals include nine elements and continue to emphasize the importance of hand hygiene, contact precaution compliance, cleaning and disinfecting patient care equipment, as well as education and monitoring.

Health care-associated or hospital-acquired MRSA differs from CAMRSA in terms of epidemiology, phenotype, and genotype (Raygada & Levine, 2009). Risk factors for CA-MRSA and HA-MRSA also are different. Risk factors for HA-MRSA are age, antibiotic use, prolonged hospitalizations, central line insertions, dialysis, MRSA colonization, and proximity to a patient with MRSA colonization or infection. Raygada and Levine (2009) also reported risk factors for CA-MRSA as injectable ding use, skin trauma, higher body mass index, cosmetic body shaving, physical contact with a person who has a draining lesion or is a carrier of MRSA, incarceration, association with military personnel, previous skin infection with MRSA, and men who have sex with men.

The Centers for Disease Control and Prevention (CDC, 2011) reported the proportion of health care-associated MRSA-related infections has increased from 2% of S. aureus infections in U.S. intensive-care units in 1974, to 64% in 2004. In the United States, MRSA accounts for 46% of S. aureus isolates from inpatient nonintensive care units and more than 50% in all ICU settings combined (Williams, Callery, Vearncombe, & Simor, 2009). Fairclough (2006) reported MRSA caused 20% of hospital-acquired infections. Although MRSA first was identified in the 1960s, community-associated infections have increased in the past decade and may be replacing nosocomial MRSA strains (Raygada & Levine, 2009).

Recent media attention and patient safety initiatives, such as The Institute for Healthcare Improvement's Saving 5 Million Lives Campaign (IHI, 2006) and the Joint Commission's National Patient Safety Goals (2008), have led many hospital-based health care workers to attempt aggressively to eliminate the presence of HA-MRSA. Although hospital-acquired infections once were accepted as a possible consequence of hospitalization, they are now targeted as disorders that lead to longer hospital lengths of stay and increased costs. Additionally, HA-MRSA has led to increased morbidity and mortality and is associated with severe infections (Raygada & Levine, 2009).

Denise Murphy, MPH, RN, CIC, vice president, Barnes-Jewish Hospital, Washington University Medical Center, noted hospitals must change their cultures and procedures in order to promote a zero tolerance for noncompliance with known prevention measures. Decreased hospital-acquired infections are anticipated to decrease cost and improve quality of care for hospitalized patients in the United States. For example, leaders at dozens of hospitals have reported they have sustained zero cases of specific HA-MRSA infection among ventilated patients for long periods of time (IHI, 2006).

Compliance Challenges

Compliance with the National Patient Safety Goals and other initiatives related to prevention of hospital-acquired infections has been a challenge for many hospitals. IHI (2008) reported that despite Joint Commission (2008) efforts related to prevention, rates of hospital-acquired infection remain unacceptably high. Nurses and other health care professionals need current information to prevent hospital-acquired infections. According to the Joint Commission (2008), MRSA infections can be prevented; however, prevention efforts must be supported by infection control practices that address patient populations as well as staff members. Teaching daily prevention strategies to nurses and other health care professionals will decrease HA-MRSA related infections.

Although the number of HAMRSA infections continues to increase, the literature suggests strategies that focus on compliance with these preventive strategies can have a significant impact on decreasing hospital-acquired infections (Calfee et al., 2008; Joint Commission, 2008). Some examples of preventive strategies include hygiene, contact isolation, and in certain cases, screening surveillance. Muto and colleagues (2003) identified the impact of rigorous infection control practice on controlling MRSA, concluding that transmission was one of the main reasons for the rise in MRSA rates.

The National Patient Safety Goal 07.01.01 addresses the reduction of hospital-acquired infections (Joint Commission, 2008). The Joint Commission (2008), the World Health Organization (WHO, 2009), the CDC (2006), and the Society for Healthcare Epidemiology of America (SHEA) (Muto et al., 2003) have drawn attention to the need to reduce the occurrence of hospital-acquired infection, including MRSA. Hand hygiene guidelines have been published by the WHO (2009) and the CDC (2006). In addition, the Joint Commission (2008) indicated unanticipated deaths related to hospital-acquired infections should be considered sentinel events. Recommendations regarding reduction of HAMRSA infection are readily available to health care professionals. Among these recommendations are hand hygiene practices, use of contact isolation, staff education, and early identification and isolation of persons who are colonized with MRSA (Shukla, Nixon, Archarya, Korim, & Pandey, 2009).

The demand for public reports of quality indicators has led hospitals to invest in appropriate programs to decrease hospital-acquired infections. Noble (2009) cited the U.S. Department of Human Services' conclusion that failure to follow best practices may result in the spread of infection. Reports about the prevalence of HA-MRSA and outcomes of effective prevention strategies can improve awareness and increase compliance with hand hygiene, contact isolation, and other prevention methods. For example, one of the main causes of HA-MRSA transmission from patient to patient continues to be through the contaminated hands of health care workers (Williams et al., 2009). However, hand hygiene compliance rates remain inconsistent, possibly due to low institutional commitment to hand hygiene practices and workers' poor understanding of their value (Cromer et al., 2008).

Prevalence and Consequences

In order to describe changes in the prevalence of MRSA as a cause of health care-associated infections, Klevens and co-authors (2006) reviewed National Nosocomial Infection Surveillance data collected in 1992-2003. During this time, the authors reported an increase in the proportion of methicillin-resistant Staphylococcus aureus isolates from 35% in 1992 to 64.4% in 2003. The Association for Professionals in Infection Control and Epidemiology, inc. (APIC) also completed a survey of all members about the prevalence of MRSA during a specified time period (Jarvis, Schlosser, Chinn, Tweeten, & Jackson, 2007). Hospitals from every state participated in the study. The prevalence of 46.3 cases per 1,000 inpatients was much higher than previous reports in the literature. Despite some variation among different surveys, agreement exists that the frequency of MRSA infection has increased in the United States. In particular, findings of the APIC survey (Jarvis et al., 2007) indicate the number of infected patients may be much higher than previously thought.

A statistical brief written by Elixhauser and Steiner (2007) for The Agency for Healthcare Research and Quality highlighted primary and secondary consequences of MRSA in U.S. hospitals from 1993 to 2005. Length of hospital stay for patients with MRSA infections increased by 30% from 2004 to 2005, as over 368,000 patient stays for MRSA infection were reported in 2005 alone. Authors found cost to care for patients with MRSA infections was higher than cost for other hospitalized patients, with lengths of stay nearly twice that of patients without MRSA. The mortality rate was much higher in patients with MRSA (4.7% vs. 2.1%). In addition, older adults were more likely to be hospitalized with MRSA infections.

Prevention

Several for-profit and not-for-profit groups, governmental agencies, and public health groups have published guidelines or evidence-based strategies to prevent the transmission of MRSA. The sources selected for review were the SHEA, CDC, IHI, and the National Guideline Clearinghouse (NGC). These sources were selected because of the organizations' reputation and involvement in health care.

The SHEA recommended systems-based strategies to prevent the transmission of MRSA (Muto et al., 2003). Systems should be developed to focus on the identification of patients with MRSA colonization or infection. Antimicrobials are included in the guidelines. According to Muto and colleagues (2003), antimicrobial stewardship includes appropriate use of antibiotics with consideration to dose and duration of use. In addition to antimicrobial stewardship, the guidelines recommended education, hand hygiene, environmental decontamination, use of dedicated equipment, contact precaution, grouping of patients with known MRSA infection, and decolonization therapy in subpopulations under specific circumstances.

In addition to the SHEA guidelines, Henderson (2006) supported use of antibiotic stewardship, hand hygiene, staff grouping, maintenance of appropriate staffing ratios, reduction in lengths of stay, contact isolation (including mask), active microbiologic surveillance, and better staff education to prevent transmission of MRSA infection. Henderson suggested poor staffing ratios may contribute to noncompliant hand hygiene behaviors that allow the spread of bacteria such as MRSA. Rodriguez, Ford, and Adams (2011) recommended involvement of clinical staff during unit renovations or construction. Their involvement during the planning phase may contribute to greater clinical functionality as well as better compliance with hand hygiene and isolation precautions.

Both the CDC and SHEA recommended contact precautions for patients infected or colonized with MRSA (Calfee et al., 2008; CDC, 2010; Muto et al., 2003). Contact isolation includes patient placement, staff gloving and gowning, patient transport limits, use of disposable noncritical care equipment, and daily cleaning of patient rooms/ environments (CDC, 2010). These recommendations are an addition to standard precautions. The CDC and SHEA guidelines differ regarding isolation mask utilization. The CDC does not consider a mask to be a routine part of contact isolation, but the SHEA guidelines (Muto et al., 2003) suggest a mask may prevent transmission of MRSA by decreasing the nasal acquisition of MRSA from health care workers.

The 5 Million Lives Campaign provided a list of five key minimal components of care that may prevent MRSA: hand hygiene, decontamination of the environment and equipment, active surveillance, contact precautions for infected and colonized patients, and promotion of device bundles for the care of patients with central venous catheters and ventilators (Griffin, 2007). Contact isolation supplies, such as gowns and gloves, should be readily available for staff. In addition, affected patients should be provided private rooms if possible.

Bundles offer structured ways of improving patient care and outcome by using three to five evidence-based practices that have been shown to improve patient outcomes (Haraden, 2011; IHI, 2006). "A bundle is a collection of processes needed to effectively and safely care for patients undergoing a particular treatment with inherent risk" (Joint Commission, 2008, p. 6). Two bundles promoted through the 5 Million Lives Campaign are the central line bundle and the ventilator bundle. Although bundles are similar to checklists, they are based on level I scientific evidence. Their unique characteristics include ownership and accountability, level I evidence, specific criteria, and an all-or-none measurement (completing all steps of the bundle without omissions) (Haraden, 2011).

Best practice recommendation to decrease transmission of MRSA, similar to those of SHEA and the CDC, were published by the NGC (Calfee et al., 2008). These include risk assessment; monitoring of programs; promotion of compliance with CDC and WHO hand hygiene recommendations; contact isolation for colonized or infected patients; cleaning and disinfection of equipment and the environment; education of health care personnel, patients, and their families; implementation of a laboratory-based alert system that immediately notifies health care providers of the infection; implementation of an alert system that identifies re-admitted or transferred MRSA-colonized or infected patients; and provision of MRSA data and outcome measures to key stakeholders.

The NGC (Calfree et al., 2008) recommendations for contact isolation include wearing an isolation gown and gloves on entry into the patient's room and removing them prior to exiting the room. The action of wearing gloves does not replace the need for hand hygiene. The NGC reported the following information from The Healthcare Infection Control Practices Advisory Committee Guidelines regarding the recommendation related to discontinuing contact isolation:

When active surveillance testing is used to identify MRSA-colonized patients, contact precautions are to be continued throughout the duration of hospital stay; a reasonable approach to subsequent discontinuation would be to document clearance of the organism with 3 or more surveillance tests in the absence of antimicrobial exposure (Siegel, Rhinehart, Jackson, Chiarello, and Healthcare Infection Control Practices Advisory Committee, 2007). When to consider retesting patients to document clearance is debatable, but 3 to 4 months after the last positive test results is commonly used as the time frame. Some hospitals may choose to consider MRSA-colonized patients to be colonized indefinitely. (Calfee et al., 2008)

Interventions

The management of multidrug-resistant organisms in health care settings has been categorized to include seven types of interventions (CDC, 2006). They include administrative support, judicious use of antimicrobials, surveillance, standard and contact precautions, environmental measures, education, and decolonization. Following a review of national guidelines from several countries, Humphreys (2007) noted the CDC guidelines provided helpful, sensible, practical advice in several areas.

According to the CDC (2011), single rooms are preferred for patients who require contact isolation. However, when multiple-patient rooms cannot be avoided, a 3 foot or greater spatial separation is required between the infected/colonized patient and the other patient. Gowns and gloves must be utilized for all patient contacts, as well as contacts with potentially contaminated areas in the patient's environment. Personal protective equipment must be donned before a health care provider enters the room and removed prior to exiting the room (CDC, 2011).

Active surveillance culturing involves obtaining cultures, typically from patients' nares at the time of hospital admission, in order to identify anyone who is colonized and start isolation early to reduce transmission to other patients (Diekema & Climo, 2008). According to Calfee and co-authors (2008), active surveillance testing is based on the premise clinical cultures will identify patients who are colonized with MRSA and these tests tend to identify only a small percentage of colonized hospital patients. Mixed results from several research studies indicated the usefulness of active surveillance is controversial (Calfee et al., 2008). The NGC recommended an active surveillance testing program should be part of a multifaceted strategy to control and prevent MRSA transmission under specific circumstances, as when transmissions continue to occur despite implementation of basic practices (Calfee et al., 2008).

Pofahl and co-authors (2009) studied MRSA eradication in a subset of patients who underwent operations identified under the Surgical Infection Prevention Project. If screening results were negative, contact isolation was stopped. Patients scheduled for elective surgery also were screened and treated with 2% nasal mupirocin (Bactroban[R]) twice daily for 5 days; 4% chlorhexidine gluconate (Hibiclens[R]) bathing would be added on days 1, 3, and S of the mupirocin treatments. A statistically significant reduction in MRSA did occur. Limitations of this study included implementation of other interventions to reduce MRSA infection rates during the study. For example, patients at high risk for carriage of MRSA and vancomycin-resistant enterococci were screened and placed in isolation upon admission.

Hand hygiene has been supported consistently as an important intervention (CDC, 2006; WHO, 2009). According to the CDC (2006), alcohol-based hand antiseptics should contain isopropanol or ethanol. The WHO (2009) recommended two techniques for hand hygiene, including hand washing or hand rubbing. Hand hygiene when using a hand rub should occur over 20-30 seconds prior to touching a patient, before clean/aseptic procedures, after body fluid exposure, after touching a patient, and after touching a patient's surroundings. The WHO materials offered visual demonstrations and tools to ensure correct performance of hand hygiene.

Conclusion

The CDC (2006), Joint Commission (2008), WHO (2009), NGC (Calfee et al., 2008), and SHEA (Muto, 2003) have offered recommendations to prevent the transmission of HA-MRSA. Medical-surgical nurses should follow the recommendations, and also hold peers and members of other disciplines accountable for adherence to the recommended prevention strategies. They must be knowledgeable regarding the prevalence of MRSA in their states and hospitals, and on their individual nursing units. By understanding the preventive strategies to reduce the transmission of MRSA, they can impact mortality rates and cost for their patients. Medical-surgical nurses should model and enforce adherence to basic preventive strategies such as hand washing and contact isolation. They should teach patients and families about preventive strategies and model good hand hygiene. As patient advocates, they also can hold other members of the health care team accountable for practicing good hygiene. Nurse leaders should ensure programs are implemented to monitor compliance with preventive strategies and initiate appropriate interventions if compliance is not evident.

REFERENCES

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Centers for Disease Control and Prevention (CDC). (2006). Management of multidrug-resistant organisms in healthcare settings, 2006. Retrieved from http:// www.cdc.gov/hicpac/mdro/mdro_0.html

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Fairclough, S.J. (2006). Why tackling MRSA needs a comprehensive approach. British Journal of Nursing, 15(2), 72-75.

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Haraden, C. (2011). What is a bundle? Retrieved from http://www.ihi.org/knowledge/Pages/ImprovementStories/Whatls aBundle.aspx

Henderson, D.K. (2006). Managing methicillinresistant staphylococcf. A paradigm for preventing nosocomial transmission of resistant organisms. American Journal of Infection Control, 34(5), S46-S54.

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Klevens, R.M., Edwards, J.R., Tenover, EC., McDonald, L.C., Horan, T., & Gaynes, R. (2006). Changes in the epidemiology of methicillin-resistant staphylococcus aureus in intensive care units in U.S. hospitals, 1992-2003. Clinical Infectious Diseases, 42, 389-391.

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Muto, C.A., Jernigan, J.A., Ostrowsky, B.E., Richet, H.M., Jarvis, W.R., & Boyce, J.M. (2003). SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of staphylococcus aureus and enterococcus. Infection Control and Hospital Epidemiology, 24, 362-382.

Noble, D.B. (2009). Patient education on MRSA prevention and management: The nurse's vital role. MEDSURG Nursing, 18(6), 375-378.

Pofahl, W.E., Goettler, C.E., Ramsey, K.M., Cochran, K., Nobles, D.L., & Rotondo, M.F. (2009). Active surveillance screening of MRSA and eradication of the carrier state decreases surgical-site infections caused by MRSA. Journal of the American College of Surgeons, 208(5), 981-986.

Raygada, J.L., & Levine, D.P. (2009). Methicillin-resistant staphylococcus aureus: A growing risk in the hospital and the community. America Health & Drug Benefits, 2(2), 86-95.

Rodriguez, M., Ford, D., & Adams, S. (2011). Does proper design of an ICU affect compliance with isolation practices? Critical Care Nurse Quarterly, 34(1), 36-45.

Shukla, S., Nixon, M, Archarya, M., Korim, M.T., & Pandey, R. (2009). Incidence of MRSA surgical-site infection in MRSA carriers in an orthopaedic trauma unit. The Journal of Bone & Joint Surgery (British), 91(2), 225-228.

Siegel, J., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2007). Management of multidrug-resistant organisms in healthcare settings, 2006. American Journal of Infection Control, 25(10 Suppl. 2), S1665-S1983.

Williams, V.R., Callery, S., Vearncombe, M., & Simor, A. (2009). The role of colonization pressure in nosocomial transmission of Methicillin-resistant staphylococcus aureus. America Journal of Infection Control, 37, 106-110.

World Health Organization (WHO). (2009). SAVE LIVES: Clean your hands. Retrieved from http://www.who.int/gpsc/5 may/background/5moments/en/

ADDITIONAL READING

National Guideline Clearinghouse (NCG). (2008). Strategies to prevent transmission of methicillin-resistant staphylococcus aureus in acute care hospitals. Retrieved from http://www.guideline.gov/ summary/summary.aspx?doc_id=13397 &nbr=006808&string=MRSA

Marcella Upshaw-Owens, MS, RN, CMSRN, NE-BC, is Director, Baylor University Medical Center, Desoto, TX.

Catherine A. Bailey, PhD, RN, is Associate Professor, College of Nursing, Texas Woman's University, Dallas, TX.
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Title Annotation:Evidence-Based Practice
Author:Upshaw-Owens, Marcella; Bailey, Catherine A.
Publication:MedSurg Nursing
Date:Mar 1, 2012
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