The killer bug that is MRSA
The bacteria causes a third of wound infections in hospitals (Nazarko, 2006 and 2007) and about 12% of bacteraemias (Wilson et al, 2011a). While methicillin sensitive strains (MSSA) are part of the normal flora, the methicillin resistant Staphylococcus aureus (MRSA) does not occur in healthy people (Akpinar et al, 2009). Both cause the same range of infections but MRSA spreads more rapidly, is more difficult to treat and results in higher mortality and greater hospital costs (Gould et al, 2009; Calfee, 2011). UK has one of the highest rates of MRSA infections in Europe (Leaper, 2006; Goldie, 2008).
MRSA rates act as indicators of quality of care (Bisset, 2010), therefore reducing MRSA and MSSA rates has become one of the 12 aims of the Scottish Patient Safety Programme. The SPSP (2011a and b) has been developed in order to improve safety and healthy outcomes in acute hospital settings through the use of evidence-base tools and standarised approaches.
In my reflections I use the framework developed separately by Borton and Driscoll (Bulman, 2008). It consists of three questions : What? (a description), So What? (an analysis), And What? (proposed actions). It's a simple and clear structure that seems to work in a word-limited accounts. According to Jasper (2003) this model grounds well theory in practice experience.
WHAT?
The epithelial layer of skin is usually resistant to Staphylococcus aureus infections so its mostly immunodeficient patients that become affected (Otto, 2012). I chose such a patient, an 80 year old lady who had hip replacement surgery. I will refer to her as Mrs Brown.
Mrs Brown had many risk factors for contracting a Staphylococcus aureus infection: age, underlying health problems, a prolonged hospital stay, poor wound healing and an indwelling catheter (Alemu, 2011). She was a resident of a care home and these settings act as reservoirs for MRSA (Barness and Jinks, 2008). Being a surgical patient put her at additional risk and so did IV treatment which may be an independent risk factor for developing MRSA (Byrne et al, 2011).
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MRSA spreads mostly by hands therefore hand washing is a basis of prevention (Mamhir et al, 2010) and can reduce infection rates by 95% (Biset, 2010). While attending to Mrs Brown needs, I was following strict hand hygiene procedures before any direct contact with her or potentially contaminated equipment, as well as after such contact.
As most contamination occurs during patient's care (Akpinar et al, 2009), we were wearing apron and gloves while attending to it. We also took care of her urinary catheter and venflon sites which can be an easy route of MRSA entry (Bisset, 2010). Venflon charts filled daily helped to assess if there was any further need for venflon and acted as a reminder to remove it. We were also adhering to aseptic procedures when the dressing needed change.
Mrs Brown shared her room with an emergency patient who turned out to be MRSA positive. Such patients are reservoirs for the spread of MRSA (Gould, 2011) so the infected patient was transferred to a medical ward for treatment. All beds were occupied at that time therefore Mrs Brown could not be moved, and her room became an isolated place. There was a warning poster at the entry to make everybody aware of more strict contact precaution procedures, with gloves and aprons are used for all nursing procedures (Zastrow, 2011). We would disposed of them all after a single use and before leaving the room. All laundry was put into red linen bags destined for infected linen and any kind of waste was disposed in a clinical waste bag.
I was not aware if Mrs Brown was told or guessed that she came into contact with MRSA. Telling what precisely caused infection can be considered a breech of confidentiality but people in contact are entitled to information helping them to protect themselves (Gould, 2011). Failure to provide relevant information can be considered as harm done to patient and acting against the non-maleficence principle (Edwards 1996). However, the awareness of possible infection and being isolated had a negative impact on Mrs Brown. MRSA is the problem that patients fear the most, more than pain, anaesthesia or surgery (Gould, 2011) so Mrs Brown required reassurance. The next day the results of her second MRSA screen came negative and she was moved to another room. The contaminated room was disinfected which was essential because MRSA can last up to 7 months on surfaces (Kramer, 2006).
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SO WHAT?
I was aware that healthcare workers can quickly become carriers of MRSA (Barness and Jinks, 2008). Research has shown that 10.6% of students nurses became contaminated after hospital placement (Akpinar et al, 2009). I feared that once contaminated I might pass the bacteria onto vulnerable patients.
The cleanliness champions programme, set up by the Scottish Executive to improve hygiene standards in healthcare (NHS Education for Scotland, 2011), gave me confidence about MRSA prevention strategies. Staphylococcus aureus is also the most researched and described pathogen (Gould, 2011). I was aware, however, that its control required cooperation of the healthcare team. Hand washing is central to infection contol and its the responsibility of clinical teams to demonstrate good hand washing practice (Dunkan and Dealey, 2007). Compliance was generally good in the ward but I noticed it deteriorated when the ward was busy. Easily available alcohol gels which effectively destroy MRSA and take less time than hand washing (Gould, 2009), helped in this aspect. Having a notice displayed on the board informing how many days have passed since the last acquired infection helped to motivate the team further. Visitors were reminded to wash their hands by posters hanging everywhere.
I realised however that Staphylococcus aureus control is more complex than I had thought. The current approach is based on cleanliness, which is an obvious solution (Fairclough, 2006) . It reassures patients and seems to work as MRSA in the past three years is at its lowest levels (Scottish Government, 2011). Yet one of the two major hospital MRSA strains started to decline before control measures were implemented so it may be a result of the biological trend rather than cleanliness (Wilson et al, 2011a). Moreover, enhanced cleaning does not significantly affect the rates of acquiring MRSA (Wilson et al 2011b).
Stress on cleanliness puts responsibility on individuals adhering to infection control measures and away from available resources which does not seem to be fair. Research has shown that MRSA control relates to factors like nurse-to-patient ratio, bed occupancy, reduced length of stay of patients, large number of acute admissions, lack of isolation rooms (Simoens, Ophals and Schuermans, 2009). Cunningham, Kerhohan and Rush (2006) point out that it is easier to focus on the compliance of infection control procedures than on resources factors. They warn that producing more guidelines and plans of action
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may not eradicate the problem. Bed occupancy levels higher than 82% can undermine infection control efforts (Fairclough, 2006). I did notice that discovery of an MRSA patient coincided with100% of bed occupancy in the ward and staff shortages .
My further doubts are related to the screening programme. The Department of Health (2006) strategy to control MRSA includes identification of MRSA carriers. Screening of emergency admissions does help in reducing general MRSA infection rates (Guleri et al, 2011). My experience showed, however, that the results of screening emergency patients were not quick enough, putting vulnerable patients at risk of contact. There are new quicker methods of testing for MRSA but they are expensive options (Alemu, 2011) which takes us back to resources problem.
There is also an issue of consent. Patient's understanding and consent is part of the duty of care (Nursing and Midwifery Council, 2008), one of the fundamental human rights (McHale 2007) and an expression of autonomy (Griffith and Tengnah 2011). Patients have the right to refuse screening. Moreover, screening benefits other patients rather than carriers and it can raise anxiety levels and feeling of being stigmatized (Gould, 2011). The same relates to contact precautions which may violate the ethical principles of non-maleficence and beneficence, cause loneliness, feeling of stigmatization, higher levels of depression and anxiety, and low self-esteem (Zastrow, 2011). I did notice such reaction on Mrs Brown. Nurses have the legal duty to give an evidence-based information in a way that patients can understand (McHale and Gallagher 2003) and we should have made more of an effort to explain and give reassurance.
AND WHAT?
Full control of MRSA is probably impossible, and single measures introduced to limit its spread may not be succesful as there are several factors involved: detecting and isolating infected or colonized patients, rational antibiotic prescribing, hand hygiene and cleanliness (Fairclough, 2006), nurse-to patient ratio and bed occupancy (Kennely, 2010). There is no one simple solution (Duerden, 2010) and multiple interventions may be needed (Zastrow, 2011).
Yet MRSA prevention is my personal responsibility as well. Entering into contract with a patient creates a professional and legal duty of care (Scales 2009) which includes student
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nurses (Royal College of Nursing 2011). Professional duty requires identifying, minimizing
and preventing any risk of harm (Lesser 2007). There is much I can do myself by adhering to strict infection control procedures and particularly complying to hand hygiene. Making a good example can improve overall compliance in the ward, and next time I will improve my efforts. I will also take time to explain the rationale behind isolation procedures to minimize stress and enhance patient's understanding.
Prevention of Staphylococcus aureus infections in an important SPSP goal which, when implemented successfully, can significantly reduce costs and patient's suffering. Much can be done by adhering to cleanliness procedures. Yet I agree with the McArdle et al (2006) conclusion that cleanliness, without addressing factors like crowding and staffing levels, may not be successful.
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