Expect a surge in drug-resistant bacteria

EDs are braced for an influx of these patients

Do you know the risk factors for community-associated methicillin-resistant Staphylococcus aureus CA-MRSA), Clostridium difficile (C. difficile), and other drug-resistant bacteria? ED nurses across the nation are reporting a dramatic surge in these cases.

"Emerging infections and antibiotic-resistant bacterial infections are a problem for every emergency department," says Jeffrey A. Murphy, RN, BSN, ED nurse at HealthEast St. John’s Hospital in Maplewood, MN. "We are braced for an influx of these patients."

Since his ED’s population of uninsured, underinsured, and homeless patients is increasing, Murphy expects to see many more cases of antibiotic-resistant infections.

A recent study found that CA-MRSA is the most common pathogen among patients with skin and soft-tissue infections at a Los Angeles ED,1 and another study reports that C. difficile is causing significant increases in morbidity and mortality in 16 states.2

"This could have tremendous implications to ED nurses," says Reneé Holleran, RN, PhD, CEN, CCRN, CFRN, nurse manager for adult transport service at Intermountain Health Care LifeFlight in Salt Lake City. "C. difficile is a bacterium that is normally in our guts, but because of antibiotic overuse, people have been getting very ill with it." It causes profuse diarrhea and has been attributed with deaths, she adds.

To improve care of patients with drug-resistant bacteria, take the following steps:

• Obtain a detailed patient history.

The Centers for Disease Control and Prevention (CDC) recommends flagging patients with a history of antibiotic-resistant infections, notes Murphy. In his ED, all patients with previous diagnoses as "isolatable" are identified in registration, Murphy says. "We have a practice of coding the admit face sheet if the patient has a history of a resistant organism," he says. "This can alert the admit nurse to place in isolation in a timely manner."

If a patient recently was hospitalized and reports a recent infection, ask whether it was resistant to antibiotics, says Jeffrey Brown, RN, administrative manager for the emergency center at William Beaumont Hospital in Royal Oak, MI.

• Put patients in contact isolation and practice hand hygiene.

Wear gloves and gown and use universal precautions when caring for these patients, Brown advises. "The patient should be in a private room for their own safety and for other patients in the ED," he adds.

Brown’s ED created isolation carts with all personal protective equipment in one spot, including disposable blood pressure cuffs, stethoscopes, masks, and gowns. It is kept in a central area to move outside the patient’s room as needed, says Brown. "If we make staff run around to too many places, they are likely to skip a step to expedite patient care," he says.

Murphy says because most of these germs are spread by physical contact, often on environmental surfaces and bed linens, it is important that providers perform hand hygiene and that environmental surfaces be disinfected after these patients have occupied care areas. This will protect other immunocompromised patients and staff, he advises. "There may be patients with these germs that have not been identified," Murphy notes. "Consistent practices of good hand hygiene, and disinfecting the environment and items shared between patients, can control transmission between those we know about and those we do not."

• Err on the side of caution.

If a nursing home patient presents to the ED with dehydration, they usually are admitted under the assumption that they are positive for C. difficile, says Brown.

"If a patient came in from an extended care facility with diarrhea and was on long-term antibiotics, we put them in precautionary measures for C. diff before we rule it out via lab," he adds.

• Know risk factors.

The CDC has identified a broad range of risk factors for CA-MRSA, including athletes, military recruits, children, Pacific Islanders, Alaskan Natives, Native Americans, men who have sex with men, and prisoners. Factors associated with the spread of MRSA skin infections include close skin-to-skin contact, openings in the skin such as cuts or abrasions, contaminated items and surfaces, crowded living conditions, and poor hygiene.3

"These risk factors are very broad and don’t seem to be too specific, but that is also the characteristic of this disease," says Murphy. "One of the most important factors is that the triage nurse conveys information regarding known antibiotic-resistant infection or risk factors and initiates isolation precautions immediately."

References

  1. Moran GJ, Amii RN, Abrahamian FM, et al. Methicillin-resistant Staphylococcus aureus in community-acquired skin infections. Emerg Infect Dis [serial on the Internet]. 2005 Jun. Available from www.cdc.gov/ncidod/EID/vol11no06/04-0641.htm.
  2. McDonald LC, Killgore GE, Thompson A, et al. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med 2005; 353:2,433-2,441.
  3. Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA): Fact sheet for healthcare providers. Minnesota Department of Health. August 2005. Accessed at www.health.state.mn.us/divs/idepc/diseases/mrsa/mrsahealthcare.html.

Sources

For more information on drug-resistant bacteria cases in the ED, contact:

  • Jeffrey Brown, RN, BSN, Administrative Manager, Emergency Center, William Beaumont Hospital, 3601 W. 13 Mile Road, Royal Oak, MI 48073. Telephone: (248) 898-6268. E-mail: JDBrown@beaumonthospitals.com.
  • Jeffrey A. Murphy, RN, BSN, Staff Nurse, Emergency Department, HealthEast St. John’s Hospital, 1575 Beam Ave., Maplewood, MN 55109. Telephone: (651) 232-7348. Fax: (651) 232-6665. E-mail: jamurphy@healtheast.org.