Staphylococcus aureus is one of the most versatile human pathogens,1'5 and strains of 5 aureus have developed that are resistant to newer semisynthetic penicillins. While methicillin-resistant S aureus (MRSA) is increasing in extended care facilities (ECFs) across the nation, new recommendations for universal precautions have been promulgated by various federal agencies. The effectiveness of universal precautions has not been scientifically established, but it has been carried over to ECFs with little or no modification for the special problems encountered there.
As with most nosocomial infections, MRSA is spread via contact between patients, from the patient to the caregiver, from the patient to inanimate objects, and from respiratory droplets.6·7 MRSA is most commonly carried asymptomatically; therefore, carriers are seldom screened. Even when screening is done, rapid diagnostic tests are not available and very low colony counts may not be found on the culture swab, making the control of MRSA difficult. Usual cohorting and isolation methods of known cases do not seem to capture all of the cases, and MRSA spread continues. Extended care facility outbreaks of MRSA undoubtedly occur frequently, but are rarely reported in the literature8 even though large teaching hospitals, small community hospitals, and ECFs share many of the same patients and MRSA outbreak potential.
The inanimate environment of the ECF most likely plays a role in the spread of MRSA,9 possibly because geropsychiatric clients can contaminate the environment with body fluids and unwashed hands. Overcrowding or communal living in ECFs may also pose an environmental risk because clients are often grouped together in sitting rooms so they can be more easily observed by the staff. Also, in all types of institutions, heat and humidity are factors because the incidence of MRSA increases in the summer. In a study done in a burn unit for environmental persistence and viability on fomites, Garbo et al10 proposed that if a patient's normal colonized flora is replaced by environmental flora, sustained environmental contamination with MRSA may pose a serious threat.
In a recent ECF study, Thomas et al11 examined risk factors for MRSA. Those risk factors with the strongest statistical significance were nasogastric intubation and antibiotic therapy. Seriously ill patients, who tend to have complex medical and surgical problems and require invasive diagnostic and therapeutic procedures and antibiotic therapy in a crowded and cluttered environment, contribute to the spread of MRSA.12
In ECF outbreak situations, colonized and infected patients act as reservoirs for MRSA, and personnel become transient carriers. Rigorously enforced handwashing is the obvious strategy for preventing cross-infection. If, however, a patient has an MRSA respiratory tract infection, the bedding as well as the entire environment, including the air, could conceivably become heavily contaminated with MRSA, as could shared wheelchairs and other shared equipment.
TREATMENT AND CONTROL METHODS
The evidence that colonized patients act as reservoirs for the dissemination of MRSA suggests that the obvious way to eradicate MRSA is to control colonization, but there is a dearth of information regarding which potentially colonized sites should be assessed for eradication trials.6,13,14 Colonization treatment protocols also vary.15,16
Identifying patients who are colonized with MRSA is not an easy task. One of the problems with MRSA culturing is that within a colony, there can be methicillin-sensitive as well as methicillin-resistant populations.17 Misidentification, cui turi ng the wrong site, or delayed identification of MRSA undoubtedly contributes to its spread.
Traditional isolation practices (category- or disease-specific isolation) have relied on diagnosis driven systems. The diagnosis of a contagious disease causes caregivers to implement special barrier caregiving measures to prevent the spread of the disease. This has been shown to be an imperfect system in hospitals because of the presenee of unknown and undiagnosed diseases, and colonized and carrier states that exist outside the isolation room.
Universal precautions, on the other hand, are intended to prevent parenteral, mucous membrane, and nonintact skin exposures of health-care workers to blood borne pathogens: human immunodeficiency virus (HIV), hepatitis B, and others.18"24 The use of universal precautions for all hospitalized patients has included a no-touch philosophy for potential contacts with body fluids and nonintact skin. The overall goal is to change the behavior of health-care workers toward safe protective practices for preventing the transmission or acquisition of infections among both patients and employees.
The use of procedures for MRSA isolation and treatment depends on the philosophy of the institution. These vary from strict isolation to contact isolation, secretion precautions, and universal precautions. Modified isolation precautions for colonized patients have also been proven effective in some studies.25 These modified precautions usually involve a combination of universal precautions and categoryspecific isolation and some degree of patient/employee cohorting. Figure 1 illustrates a useful guide, developed by the infectious disease group at the Gainesville, Florida, Veterans Affairs Medical Center, for making isolation decisions regarding MRSA.
PROBLEM AND RESEARCH QUESTION
Following our first extensive education program for universal precautions, we noticed an increase in MRSA cases at our facility. Prior to this retrospective quasi-experimental study of MRSA in a Veterans Affairs Medical Center extended care 105-bed ward, we asked if there was an increase in cases of nosocomial MRSA after the institution of universal precautions.
We believed that following the initial classes on universal precautions, some caregivers may have begun to focus more on self-protection than on patient protection for infection control. We had seen an increase in staff members neglecting to wash their hands prior to patient contacts, and some staff members had to be reminded occasionally to wash their hands after patient contacts and to use gloves for emptying urine drainage bags. We also began to suspect that some staff members were having more than one patient contact while wearing the same pair of gloves.
We examined the infection control nurse's line lists to relate the number of cases of MRSA colonized and infected patients to the following educational programs:
* The introductory classes on universal precautions (blood and bloody body fluids) in association with category-specific isolation based on the Centers for Disease Control's universal precautions. Gloves and other barriers were to be worn when contact with blood or obviously bloody body fluids was anticipated. Known cases of hepatitis, MRSA, or other diagnosed contagious diseases were to be placed in the appropriate category-specific isolation as per previous practice. Much of the teaching regarding universal precautions centered on hepatitis B and HIV. The hepatitis vaccine was encouraged and needle safety was stressed.
* The institution of repeat classes for caregivers (the focus was more on preventing cross-infection and using traditional barrier precautions for identified MRSA cases). Intensive culturing for case-finding and the use of an antibiotic MRSA colonization protocol was done during these classes. These measures were an attempt to control the increase in MRSA cases that occurred following the first universal precautions classes.
The first identified case of MRSA in the institution occurred in February 1982 in a trauma patient who was transferred postoperatively from a tertiary care center. The MRSA was not immediately noticed due to delayed culturing of the patient's wounds and to early laboratory problems in the accurate detection of resistance, a difficulty well-documented in the literature. Later, nosocomial cases began to appear, mostly in the extended care skilled nursing unit. By 1986, there was an average of one newly colonized or infected patient per month.
PROCEDURE FOR ISOLATION OF PATIENTS WITH METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS
In 1987, in response to a report from the Centers for Disease Control,18 universal blood and body fluid precautions were encouraged in addition to traditional category-specific isolation. By November 1987, nearly all nursing employees on the unit had received training. Up until then, new nosocomial MRSA infected or colonized patients still averaged only one per month.
In January 1988, two cases occurred, followed by three in February. Finally, by the year's end, there was an average of four new nosocomially infected or colonized MRSA patients per month on the ECF unit. During the end of November and beginning of December 1988, patients were extensively cultured to identify all those who were colonized or infected. Employees underwent another round of training to reinforce the use of category-specific isolation for known MRSA patients and to stress using universal precautions not only to protect themselves, but also to protect patients from cross-infection. Some employees had been seen wearing gloves for multiple patient contacts and routine handwashing had declined.
In January 1989, all patients on the unit and all unit employees (nurses, rehabilitation therapists, physicians, inhalation therapists, and housekeepers) had their nares cultured. Eight of the 240 were positive for MRSA. Interestingly, 7 of the 8 were nursing employees (two RNs, one LPN, and four nursing assistants), and the eighth was a long-term care unit physician. These employees were treated with a colonization protocol consisting of Neosporin ointment to the nares three times a day for 10 days and rifampin 600 mg every day for 3 days. All were culture negative at 10 and 30 days after treatment was stopped. During the colonization protocol, one nursing employee in the colonized group accidentally sustained a urine collection needlestick injury from a patient with MRSA in the urine. This employee was treated with vancomycin HCl for the resultant severe cellulitis.
The average age of the 60 patients who were colonized or infected with MRSA in 1987 and 1988 was 70 years old: 10.68% were younger than 60 years old; 31.66% were between the ages of 60 and 65; 23.33% were between the ages of 66 and 70; and 23.33% were between 71 and 79. Only 1 1 % were 80 or older. The youngest (30 years old) was a quadriplegic. The oldest (95 years old) was a diabetic with a nasogastric feeding tube.
Risk factors for the 60 MRSA colonized or infected patients (some of whom had multiple risk factors) were as follows: 35.59% had dementia. 28.81% were diabetic, and 18.64% had suffered cerebrovascular accidents. Dementia appeared to be a very significant risk factor, perhaps because such patients generally are not cooperative with invasive line care requirements and have less than ideal personal hygiene.
Beginning in February 1989, patients who were colonized began to be treated with a colonization protocol consisting of a check for sulfonamide allergy; rifampin 600 mg twice a day for 5 days; double strength trimethoprim sulfamethoxazole 80/400 twice a day for 5 days; bacitracin or mupirocin to each nostril three times a day for 5 days; Chlorhexidine gluconate bath daily for 5 days; and reculture of infected or colonized sites at 2, 7, 14, and 30 days after treatment is ended.
In general, a high level of suspicion for MRSA was encouraged. All patients admitted to the unit were cultured (all wounds, stomas, and sites where invasive devices were used, such as sputum for nasogastric feeding and tracheostomy tubes and urine for bladder catheters). Despite these efforts, there was an average of three additional nosocomial patient MRSA cases per month between January and June 1989. Thus, prior to the institution of universal precautions classes, there was an average of one MRSA case per month. After this first round of classes, four cases of MRSA per month was the average. Re-education of the staff and an aggressive colonization identification and treatment protocol only brought the cases down to an average of three per month.
Despite this unit's patient case increase, the hospital- wide percentage of susceptibility of S aureus to methicillin, when examined by month between January and May 1989, showed improvement. This may have been due to increased culturing, which revealed more S aureus cases throughout the hospital and thus increasing the baseline of S aureus in general. Additionally, the rest of the hospital's patient make-up did not consist of the type of debilitated elderly patients as were found on the ECF unit.
Risk factors related to multiple system diseases in the frail elderly and staffing problems interact to spread MRSA in the ECF, as do colonized caregivers and a contaminated environment (Figure 2).
Universal precautions is a concept originally developed to meet the needs of hospital caregivers who may be unknowingly exposed to the blood-tinged body fluids of HIV patients, but preventing blood borne HIV in ECFs is not such a great problem. ECFs are generally aware of HIV-positive and hepatitis B carrier states. Even if a hepatitis B carrier is unknown, needle safety and needlestick injury screening, as well an employee vaccine programs, offer protection against employee exposure.
CAREGIVER AND ENVIRONMENTAL ROLE IN MRSA SPREAD
Although nearly every hospital follows universal precautions, most nursing homes have only lately begun to implement universal precautions for all patients.23 The apparent simplicity of universal precautions is appealing, but in the ECF, intensive physical caring may conflict with the universal precautions ideology. For example, the heavy focus on gloving can conceivably lead to the inadvertent elimination of handwashing as the primary focus for preventing infection. One may question if there is a significant difference in care requirements between hospitalized patients and those in ECFs where, in many cases, they live out their lives dependent on caregivers for all their needs. Physical needs and emotional dependence are generally greater in ECFs. Often the caregivers replace or are included as "family" for the patient. A soothing touch and hugging as displays of affection are added to physical care touching requirements. Total care lifting and moving of patients are frequent occurrences.
Perhaps one of the most important but most understudied factors for the spread of MRSAs through ECFs, is staffing levels, not necessarily staff training to increase compliance with barrier precautions. When ECF staffing is unstable, caregivers who are hurried, stressed, or unprepared to function safely can spread MRSA. The ECF clients have care requirements that are complex, time consuming, and intimate.
The interface of caring and universal precautions may not be compatible. Perhaps the *'care" requirements were not acknowledged prior to the installation of universal precautions into ECFs. Perhaps instead of universal precautions, adequate case identification by admission, history, lab work, and periodic cultures would be a more realistic approach so that traditional isolation or cohorting can take place. The extreme difficulty in controlling MRSA may be an ideal example of the difficulty ECFs have in using universal precautions. An understanding of the history of MRSA and the problems it creates in ECFs is essential to understanding the difficult patient care requirements.
Nursing studies on caring have focused on the caring process itself and have identified two dimensions of care: what the nurse does and what the nurse says; and task behaviors and affective behaviors.26 Self-actualization, growth, and development are the primary goats of caring, which include the constructs of concern, comfort, support, presence, tenderness, touching, succorance, and others.27
Certainly, nurses who have ECF experience can appreciate the magnitude of the caring task behaviors employed by direct caregivers in the ECF. Nowhere in nursing is it more evident that caring is the essence of nursing. How does caring interface with the requirements of body substance isolation or universal blood and body fluid precautions? Nursing studies need to be done to measure the outcomes brought about by this interface.
Based on this study, the Infection Control Committee has recommended that all care practitioners maintain a high level of suspicion for MRSA. Patients who can be classified as frail elderly or frail extended care clients have culture and sensitivity studies done at admission for sites where wounds are present or invasive devices are used: gastrostomy, suprapubic, and tracheostomy stomas, sputum or throat cultures for nasogastric tubes, urine cultures for bladder catheters, decubitae, unhealed surgical wounds, and weeping cellulitis.
Sanitation practices are being monitored to ensure that multi-use equipment and furniture are adequately cleaned between patient use and that, whenever possible, personal use equipment is used. Good patient personal hygiene is essential and includes bathing practices and patient education regarding handwashing, care of invasive lines and dressings, and maintenance of urinary drainage apparatus to avoid contaminating the environment. Splash of body fluid wastes from flush toilets and during whirlpool bathing. and showering may colonize unmasked caregivers in the anterior nares; therefore, masks are recommended for these activities if the patient has MRSA.
Caregivers must use adequate universal precautions for handling the body fluids of all patients as well as additional barrier precautions for known colonized or infected MRSA patients. These additional barrier precautions include wearing a mask when changing dressings, suctioning, showering, or bathing MRSA-colonized patients. This may help the caregiver avoid nasal colonization. The Infection Control Committee recommended continued use of category-specific isolation (contact, secretion precaution) as an additional barrier precaution for MRSA-colonized or infected clients.
The charts of MRSA patients are flagged to alert caregivers, and ongoing classes balance self-protection with preventing patient cross-infection. Frequent routine handwashing cannot be replaced by glove wearing for specific tasks, and hands must be washed when gloves are removed. Treatment with antibiotics is sometimes used for those ECF clients whose nares are positive for MRSA. This is an attempt to reduce the numbers of colonized patients. Practitioners are reminded that vancomycin HCl used to treat an MRSA infection will not alleviate the carrier state. Long-term nasogastric feeding tubes should be removed or replaced with gastrostomy tubes wherever possible to avoid respiratory tract MRSA colonization or pneumonia.
When cases persist despite these common sense measures, consideration could be given to locating and treating employee carriers. The role of nasal colonization of caregivers in the spread of MRSA is still not clear, but hurried caregivers who are tempted to take short cuts to save time seem likely to become colonized with MRSA. Inadequate or unmet staffing guidelines in ECFs may allow them to function with an inadequate amount of help so that constant reminders for adherence to handwashing recommendations and glove wearing become necessary. Under hurried conditions, masks are not consistently used during activities that can generate aerosolization or splash.
Cohorting requires housing all MRSA infected or colonized clients in one area where they are cared for by a specific group of caregivers. This segregation may be considered extreme because the MRSA patients and caregivers may not mingle with others, and access to therapy, hobbies, the beautician, and dining rooms is usually limited. Cohorting of colonized or infected patients was not done during this study because of the difficulty in maintaining a consistent staff and the high turnover of admissions and discharges. Cohorting is still, however, a viable option for this endemic MRSA unit and it may be needed. Nursing studies are needed on the effects of cohorting versus barrier isolation for MRSA.
In general, the role of the ECF environment in the spread of MRSA has not been adequately explored, but sanitation measures are undoubtedly important to infection prevention, especially when patients may have had mishandled invasive devices such as bladder catheters and tubing that touch floors and wheelchair wheels.
AREAS FOR FURTHER STUDY
This outbreak description suggests that the interface of caring and universal precautions should be explored. Also, it is not known what effects staffing levels have on the effectiveness of training and the spread of MRSA. The mechanism of employee colonization and its role in the spread of MRSA is unclear. Studies are needed for design and environmental aspects of the ECF that may predispose MRSA spread.
The effectiveness of aggressive MRSA colonization case finding and treatment has not been adequately measured. Cohorting was not attempted during this outbreak, but reports of its effectiveness are scanty. Dementia as a strong cofactor of MRSA colonization and infection should be explored. Dementia may be a cause of MRSA environmental transmission. The importance of aggressive hygiene measures, such as frequency and use of various antiseptic bathing solutions, should be studied, as well as alternative handwashing agents for caregivers.
MRSA strains are here to stay. The factors that appear to predispose patients to MRSA cannot always be avoided in an ECF. More intense epidemiological screening of patients who enter the ECF followed by adherence to barrier isolation schemes for MRSA-colonized individuals, as well as scrupulous handwashing and healthcare worker education regarding MRSA cross-infection may need to become routine in ECFs. Nurses should address the obvious clash between caring and universal precautions in the ECF. The fact that extreme casefinding and treatment measures and extensive staff re-education did not reduce the MRSA cases to the original level demonstrates the great difficulty in controlling this organism once it gains an endemic foothold in an ECF.
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