MRSA; Reducing Nosocomial Transmission Rates

Over the past thirty years, the community has become increasingly aware of nosocomial infection—specifically methicillin-resistant Staphylococcus aureus (MRSA). According to the Centers for Disease Control and Prevention (CDC), hospitals must commit additional resources to sponsor comprehensive infection control programs aimed at reducing the incidence of transmission in acute care facilities. An effective infection control program includes education of staff on measures for prevention and control of infection as well as access to the infection control team for support and advice. Today’s nurse must understand why “superbugs” such as MRSA are of so much concern and how best to combat the threat of cross-infection. Nurses who use evidence-based strategies to manage MRSA in a hospital environment will achieve a reduction in nosocomial transmission rates.
The incidence of hospital acquired MRSA is on the rise. According to the CDC, “over 126,000 hospitalized patients are infected with MRSA annually, leading to approximately 5,000 deaths. Hospitalized MRSA patients have an increased length of stay up to 9.1 days, with roughly $30,000 in additional costs per episode” (as cited in Forsha, 2007, p. 23). The impact on this nation’s healthcare system is dramatic. Unfortunately, this has become a global issue requiring immediate attention. In the early 1980’s, MRSA affected only 3% of the populations of the United States and Europe; however by the 1990’s, as many as 40% were infected (Ott, 2005).While the consequences to healthcare facilities include increasing costs, MRSA is rising in significance to nursing staff as well. Nurses are at increased risk of becoming colonized and ultimately face the risk of developing an active infection themselves.
Staff can easily transmit bacteria between patients when not practicing proven infection control strategies including effective hand hygiene and contact precautions. Studies such as those by Cepeda, Whitehouse, Cooper, Hails, Jones, Kwaku, Taylor, Hayman, Cookson, Shaw, Kibbler, Singer, Bellinghan, and Wilson (2005), have searched for the most effective way to reduce nosocomial transmission of infection—specifically MRSA. Cepeda, et al questioned whether isolation of infected intensive care unit (ICU) patients would reduce the rate of infection. This study was very well organized and controlled. It examined the effectiveness of placing MRSA positive ICU patients either in single room isolation or in groups, while providing designated staff to care for them. The nursing staff practiced infection control strategies that were noted to be between standard and contact precautions. According to Cepeda, et al, (2005), “Our findings challenge the prevailing view that isolation of the intensive-care unit patients who are colonized or infected with MRSA in single rooms or cohorts reduces the transmission of MRSA, over and above the use of standard precautions, in an environment which is endemic.” This supports the widely held view that a comprehensive infection control program is essential to controlling the spread of MRSA in a hospital environment.
A study conducted by the VA Pittsburgh Healthcare System (VAPHS) aimed at reducing healthcare-associated infections took a somewhat different tactic by applying principles used by the Toyota Corporation (Forsha, 2007). According to Forsha (2007), “[t]he Toyota Production System (TPS) uses a systems engineering approach to change structures and processes within an organization…our challenge was to facilitate a culture change so that nursing staff adopted TPS and the related interventions as a component of the traditional, sacred ‘nursing process’” (p. 23).
In order to bring about such transformation, full dedication from all areas of the medical center, including the executive team, was required. The employees attended a training program aimed at educating the staff on areas identified as having significant impact on infection transmission. Forsha (2007) explains the importance of active surveillance, vigilance in regard to effective hand hygiene, as well as the necessity for observance of contact precautions required when caring for infected patients. In addition to offering classes, online education, and providing RN TPS facilitators on the unit, patients and families were included in the push to reduce infection rates by inviting them to practice proper hand hygiene as well. In an effort to expand the program to other units throughout the medical center, another, more cost effective method of empowering staff was integrated into the plan. Positive deviance is an approach to spreading change that recognizes those people within a group who are able to identify solutions to problems and implement change. This method empowers the staff to take ownership of problems and discover workable solutions, thereby increasing the probability of success. The results of the study at VAPHS identify successful strategies to reduce nosocomial infection. Forsha (2007) reported that “over an 8-month period there were only two surgical site infections, compared to a previous average of 40 surgical site infections a year. Through positive deviance, VAPHS has created and implemented a staff-owned and operated MRSA prevention program that’s efficient, measurable, and sustainable” (p.26). This study demonstrates the necessity for a comprehensive infection control program in order to reduce rates of nosocomial MRSA infection.
In addition to effective hand hygiene and contact precautions, it is vital that the nurse educate the patient and family about MRSA. The patient and family should be taught methods for combating transmission as both an inpatient and after discharge. The nurse should also evaluate the patient’s response to isolation and level of anxiety and fear. Providing emotional support and distraction as needed, as well as being readily available are essential to providing quality care. It is also very important that the patient’s privacy is protected as often times feelings of alienation exist during isolation.
In summary, a comprehensive infection control program, use of contact precautions, and effective hand hygiene together will decrease nosocomial MRSA infection. Isolation of infected patients is an important component of contact precautions, however this must be in conjunction with other measures to be effective. Today’s nurse must be aware of MRSA and its threatening effects. He or she must also be prepared to educate patients and families on the subject. Anxiety about MRSA is often based on ignorance about the organism, the risk of infection and the precautions that can be undertaken to prevent transmission. It is essential that control of infection remains at the forefront of good clinical practice.

Intervention #1: Instituting a comprehensive infection control program will reduce nosocomial transmission of MRSA.
Disadvantage #1: Increased costs associated a comprehensive infection control program may be viewed negatively by hospital administrators. “Difficulty in achieving support for infection control is the Catch-22 in prevention activity. If effective, the outcome is negative, ie: no infection. Thus, it is seen to provide a service and is undervalued.” (Lindsay Nicolle,2001)
Disadvantage #2: Staff willingness to comply with precautions set forth in infection control policy is essential. “Implementation is accomplished by changing the pattern of workflow and identifying and eliminating impediments to infection prevention and isolation procedures.” (Forsha,2007) However, if the staff is unwilling to comply, this approach will not be as effective. Forsha further explains, “The nurses must adopt a “not in my house” demeanor when healthcare team members forget to comply.”
Intervention #2: Educating patients and families about the patient’s condition, treatment, and preventative measures necessary to avoid further transmission is essential.
Disadvantage #1: According to Forsha, “Staff surveys uncovered a knowledge gap regarding MRSA prevention. ..Shared learning enables staff to quickly apply innovative precautions.” Undereducated staff cannot teach patients effectively, regardless of the subject to be taught.
Disadvantage #2: “We know that a patient who has a complete understanding of what his or her diagnosis is and what needs to be done to further address it will be able to more fully participate in his or her care. Taking the information down to the level of the patient is a critical first step in helping the patient understand his or her unique situation.” (Faut Rodts,2005) Understanding the level of comprehension of a patient is of utmost importance.










References
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