Rising rate of MRSA increases need for education

Identification of infection critical

Antibiotic-resistant infections are not new to the health care setting, but headlines throughout the country have increased public awareness of the potential risk of infection.

According to a study by the Association for Professionals in Infection Control and Epidemiology, methicillin-resistant Staphylococcus aureus (MRSA) accounted for only 2% of all Staphylococcus aureus health care-associated infections reported to the Centers for Disease Control and Prevention (CDC) in 1972. Today, MRSA accounts for more than 60% of Staphylococcus aureus infections.

Although there are no studies that have looked specifically at home care, infection control experts point to the need for home care staff members to be knowledgeable about these organisms in order to minimize risk. Unfortunately, even with increased publicity of MRSA in the community, not all health care providers recognize the infection.

"I went to visit my 90-year-old mother who lives on the East Coast and she showed me a wound that wasn't healing," says Marcia R. Patrick, RN, MSN, CIC, director of infection control at Multicare Health Systems in Tacoma, WA. "It was classic MRSA so we went to see her physician," she says.

Although the culture that Patrick had to insist upon did show the presence of MRSA, it became clear to Patrick and her mother that the physician did not know how to treat the infection. After visiting a vascular surgeon, then treating the wound with silver dressings, the wound healed, but not before it had grown from the size of a quarter to a 4-by-6 inch area that left a permanent scar, she points out.

"We don't always know who has MRSA or any other antibiotic-resistant infection because a patient can be a carrier without having an active infection," Patrick says. "Many hospitals are testing a wide range of patients upon admission to identify patients who may be carriers."

Although testing of all home health patients is not practical or necessary, Patrick recommends an increased awareness of the signs and symptoms of bacteria-resistant infections so that treatment can be provided early and so that home health staff can ensure good outcomes for patients.

Patients at highest risk for MRSA or vancomycin-resistant enterococci (VRE), the two antibiotic-resistant organisms seen in the community, are those with wounds, catheters, a history of boils, or patients on dialysis, says Patrick. It is critical to recognize these patients higher risk for infection and monitor them carefully, she says. "MRSA often appears as a spider bite that doesn't heal, or a wound that won't heal," she adds.

Screening patients

"We don't screen all patients for MRSA or VRE upon admission but we have an active staff education program designed to heighten awareness of these infections for all staff members," says Shannon Quaritsch, RN, MS, CPHQ, quality improvement specialist at Northwest Community Home Care in Arlington Heights, IL. Staff education includes guidelines that identify different organisms and describe the type and duration of isolation necessary to prevent spread of the infection, she says.

Inservices include case scenarios that give nurses a chance to discuss the challenges faced by home care providers when a patient must be isolated, points out Quaritsch.

Although nurses use standard precautions in patients' homes, not all nurses were handling patient education in the same way before the awareness program, she admits. "Now, all of the nurses have a checklist that they use to ensure that patients and family caregivers are taught about laundry procedures, the need to clean the patient's area frequently, and the need for gloves or aprons when dealing with body fluids," she says.

CDC prevention recommendations

The most common methods to prevent spread of the infection in the home that are recommended by the Atlanta-based CDC are:

  • Caregivers should wash their hands with soap and water after physical contact with the infected or colonized person and before leaving the home.
  • Towels used for drying hands after contact should be used only once.
  • Disposable gloves should be worn if contact with body fluids is expected and hands should be washed after removing the gloves.
  • Linens should be changed and washed if they are soiled and on a routine basis.
  • The patient's environment should be cleaned routinely and when soiled with body fluids.
  • Notify doctors and other health care personnel who provide care for the patient that the patient is colonized/infected with a multidrug-resistant organism.

One part of Northwest Community Home Care's protocol for antibiotic-resistant infections is the need to culture any unimproved wound at the two-week point, says Quaritsch.

"Pressure ulcers are more difficult to culture in the home so they generally have to be biopsied in the hospital," she adds.

Once MRSA or VRE are diagnosed, patients are started on antibiotics that are known to work on these infections and caregivers are taught how to keep the patient's area, linens, and clothing clean to prevent the spread of the infection, she says.

It is difficult to treat patients with MRSA in the home because you have to rely upon family caregivers who may not be able to take care of themselves, as well as a patient who requires additional care, says Quaritsch.

"They are also reluctant to ask for help so it is up to the nurse to notice if additional help is needed, or if the patient must be transferred to another provider until the infection is controlled," she says.

"It is not unusual for a home care patient with MRSA to go to an extended-care facility for a brief time to ensure proper treatment of the infection," she adds.

The best way to approach diagnosis of MRSA and VRE is to realize that MRSA is everywhere, says Patrick. "It all goes back to basic hygiene and washing hands," she says. "Teach patients and staff members to wash hands and the risk of infection decreases."