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Avoid risk of MRSA for you and your patient
About one-third of stethoscopes used by emergency medical services is contaminated with methicillin-resistant Staphylococcus aureus (MRSA) bacteria, according to a new study. When researchers at the University of Medicine and Dentistry of New Jersey swabbed 50 stethoscopes, 16 had MRSA colonization.1 This is a frightening prospect for both ED nurses and their patients.
"All emergency departments should be concerned about preventing the transmission of multidrug-resistant organisms, such as MRSA, from person to person or environment to person," says Phyllis McClanahan, RN, ED nursing manager at Sutter Delta Medical Center in Antioch, CA.
Vickie Brown, RN, MPH, CIC, associate director of hospital epidemiology at UNC Health Care in Chapel Hill, NC, says, "While we do not know if a stethoscope contaminated with MRSA could actually lead to transmission of MRSA to a patient, shared equipment should be routinely cleaned, as well as whenever it is visibly soiled. In the case of stethoscopes, this can easily be done by wiping it with an alcohol pad after use."
Clean equipment and surfaces such as bed rails and bedside tables on a routine basis, advises Brown. "There are many excellent cleaning products on the market, such as disinfectant wipes and sprays that are quick and easy to use," says Brown. "This is important in a busy ED where there may be little time for cleaning."
High-risk surfaces include equipment and surfaces that the patient had contact with and anything that a gloved hand has touched in a room, says Samantha Vining, RN, MS, clinical nurse specialist for the ED at Albany (NY) Medical Center.
"Staff are pretty cognizant about cleaning areas in which the patient may have touched directly, but may be less aware of areas in which a gloved hand has touched: a monitor screen, cables, countertops, and door handles," she says.
Remember that cleaning the ED is a cooperative effort between nursing and housekeeping, and "patient safety is the bottom line," says Vining. "There is nothing wrong with a nurse grabbing a hospital disinfectant cloth and wiping down equipment or touch surfaces," she says. "It may, in fact, instill confidence in the patient that this nurse takes infection control seriously."
McClanahan says, "Any piece of equipment that comes into contact with a patient or their environment could become contaminated with bacteria." She recommends:
Adriene Clark-Wilkerson, RN, MSN, TNCC, CEN, Sutter Delta's ED clinical educator, recommends diligent use of santi-wipes for hospital equipment and furniture in between patient use. "Use alcohol-based hand sanitizing solution when entering and exiting patient care rooms," she says.
Use dedicated equipment for patients with MRSA
To prevent transmission of methicillin-resistant Staphylococcus aureus (MRSA), Samantha Vining, RN, MS, clinical nurse specialist for the ED at Albany (NY) Medical Center, recommends using dedicated equipment for identified patients.
"Disposable blood pressure cuffs and dedicated stethoscopes can be used, along with IV pumps that are dedicated to the room and not used on another patient until properly disinfected," she says.
The No. 1 thing you can do to stop MRSA
What is the single most important practice to prevent the spread of methicillin-resistant Staphylococcus aureus (MRSA)?
"Hand hygiene, hand hygiene, hand hygiene," says Samantha Vining, RN, MS, clinical nurse specialist for the ED at Albany (NY) Medical Center. "Fifteen seconds with soap and water or using alcohol-based cleaners are the first defense against disease transmission," she says.
According to Vickie Brown, RN, MPH, CIC, associate director of hospital epidemiology at UNC Health Care in Chapel Hill, NC, the greatest risk for spreading MRSA in the ED is by health care workers not washing their hands before and after patient care. Brown recommends providing staff with a variety of alcohol-based hand rubs, including pocket-sized containers that can be clipped to scrubs so hand hygiene is easy.
"Usually, ED staff clip a bottle onto the waistband of their scrubs," says Brown. "We stock the 2 oz. bottles in our central distribution department so they can be ordered by the ED as needed." The ED uses both Steris Corp.'s Soft N'Sure antiseptic hand gel and Gojo's Purell gel, both sold in small individual 2 oz. and 4 oz. bottles with retractable clips. (To order Gojo's clip, go to www.gojo.com/product/accessories.asp?acces_ catid=129.)
"We have done a combination of things to acquire the small bottles and clips for our ED staff," says Brown. "Since we use a lot of hand hygiene product, Gojo and Steris have given us hundreds of the clips and we purchased some as well." ED nurses were given clips and small Purell bottles at hand hygiene fairs, inservices, and when they were given the flu shot.
"The risk of transmission by hand far outweighs the risk of transmission from contaminated surfaces," says Brown. "Since MRSA can survive for hours on inanimate surfaces, no one piece of equipment or surface is really more risky than another."
Would you know if patient has a history of MRSA?
Busy ED nurses need a good system for finding out when a patient has a history of methicillin-resistant Staphylococcus aureus (MRSA), so appropriate precautions such as wearing disposable gowns and gloves can be taken, says Vickie Brown, RN, MPH, CIC, associate director of hospital epidemiology at UNC Health Care in Chapel Hill, NC.
"Placing an alert in the electronic medical record is one step we have taken to let our ED staff know when a patient has a known history of MRSA," says Brown.
Many times, however, patients come to the ED with complex emergencies that require immediate lifesaving measures, so the patient's history of exposure to MRSA might not always be readily available to staff, says Adriene Clark-Wilkerson, RN, MSN, TNCC, CEN, ED clinical educator at Sutter Delta Medical Center in Antioch, CA. "We have safety policy and procedures in place if the patient has already been treated at our facility and identified to have been exposed to MRSA in the past," she says. For example, isolation signs are placed on curtains in the treatment area, and staff members are instructed to use appropriate precautions.
When a patient registers at the ED at Albany (NY) Medical Center and has had a past infection of MRSA or a similar multidrug-resistant organism, a flag appears in the registration system alerting nurses that special precautions need to be taken. "With this information, the triage nurse knows to place this patient on precautions," says Samantha Vining, RN, MS, clinical nurse specialist for the ED. The precautions implemented are dependent on the organism that was previously identified, she says. "Oftentimes, it is contact precautions: gown and gloves for all contact with the patient, the patient's equipment, or their environment and, as always, diligent hand hygiene."
However, the largest concern regarding MRSA is the patient population who haven't been diagnosed with it yet, Vining says. "For these 'unknowns' who present with infected areas that are draining, the triage nurse should cover all open wounds and use gloves and a gown if necessary," she says.
At Holy Cross Hospital in Chicago, ED nurses can track patients who have MRSA or a history of MRSA. "This activates as soon as the patient is registered. We can then place the patient in appropriate isolation precautions, which require the use of gloves and gown," says Diane Bures, RN, TNS, CEN, the hospital's EMS coordinator.
Patient labels are designated with an "M" if they have MRSA or a history of MRSA. "We isolate them both the same," she reports. "We also ask them what past medical history they have when in triage."