Rehab possible with drug-resistant infections

Protocol allows patients to leave their rooms

The Nebraska Methodist Hospital in Omaha has developed an infection control protocol that allows an infected patient to participate in normal rehabilitation activities, such as working on equipment in the therapy gym.

"Health care settings are facing a crisis in preventing and controlling rapidly increasing emergent multiple drug-resistant microorganisms and the spread of those organisms," says Sandra Vyhlidal, RN, MSN, CIC, epidemiology coordinator at the hospital.

In the past, rehab patients who were under infection control procedures were confined to their rooms, and the therapists, wearing gowns and gloves, came to them. This procedure limited the therapy activities to use of portable equipment that could be brought to the patients’ rooms, Vyhlidal points out.

"When patients are admitted under precautions or in isolation, it restricts the rehabilitation department’s ability to offer them the services they need to get stronger and go out into the community or home," she says.

The organisms the hospital is most concerned with are methicillin-resistant Staphyloccus aureus (MRSA) and vancomycin-resistant enterococci (VRE). The most common body sites where those organisms are found are the urinary tract, surgical sites, and the bloodstream, she says. MRSA and VRE can spread by person-to-person contact or through contact with contaminated surfaces.

Healthy people not at risk

"Usually the patient has been treated multiple times with multiple antibiotics in the acute care setting. They may have had pneumonia, bladder infections, or wound infections, and by the time they get to rehab, the bacteria is resistant to a lot of antibiotics," she says.

Healthy people are not at risk from the bacteria, but they can spread them to other people who are at risk, Vyhlidal says. "There is not so much risk to the staff as to the staff giving it to someone else," she adds. For instance, a healthy staff member could transmit the infection to a premature grandchild, a relative undergoing chemotherapy, or a friend with AIDS. Weak, debilitated patients, such as the frail elderly who might be in the hospital for a total hip replacement, also are at risk.

Once patients get an infection, it lengthens their stays and increases the amount of time it takes for them to recover, she says.

The infection control department became concerned when there were several documented cases of MRSA and VRE at the same time. A genetic study showed the organism probably came from the same source, which suggested it had been transmitted within the hospital. After the protocol was started, the hospital has had no further evidence of cross-contamination.

All patients tested

All patients are given a nasal cavity and a rectal screening as part of their routine lab tests. The infection control practitioner reviews all candidates for initiating the protocol.

If a patient is admitted under the infection control protocol, his or her room is marked "Contact Precautions," which alerts the staff to wear gloves and gowns in the room and that items in the room are confined to use by the patient. Those items include the electronic thermometer, the blood pressure cuff, the bed, and chairs, among other things.

Here are the other parts of the protocol:

• Patients are screened for the bacterial infections during the admissions process.

• Patients bathe with Cida Stat (CHG 2%), a special antibacterial soap that kills bacteria, and they put on clean clothes or a clean gown whenever they leave their rooms.

• Staff wear gloves and gowns whenever they assist the patients with ambulation or perform other activities that require patient contact.

• The patients, staff, and visitors wash their hands frequently with the Cida Stat soap.

• Family members are taught to remove their gowns and gloves and wash their hands before leaving the room.

• Therapy items such as gait belts, walkers, temporary knee braces, and other assistive devices are dedicated to each patient and may not be swapped among rooms.

• All surfaces and therapy equipment in the patient rooms or used by the patients are disinfected with a phenolic agent.

The infection control staff researched MRSA and VRE and found that the bacteria were commonly found on blood pressure cuffs, bed railings, and bed thermometers. Staff took samples in the precaution rooms after the housekeepers had disinfected them and still could culture the bacteria.

In their clinical trial, staff used a special no-dip procedure and found no bacterial growth on the items in the patient room. When performing the no-dip procedure, the housekeeper uses one clean rag dipped in a phenolic solution on one surface area, then discards it. Another clean, dipped rag is used on another surface, and so on until all the surfaces in the room are disinfected. The housekeeper repeats the procedure, cleaning all surfaces in the room with a clean rag twice. The normal procedure takes 30 minutes, while the no-dip cleaning takes 45 minutes.

"The procedure is cost-effective because all the rags are laundered for re-use," Vyhlidal says.