Community-acquired MRSA boosts need for awareness

Hand hygiene, knowledge block cross-contamination

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 to a wider range of people in the community.

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 S. 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 S. aureus infections.

Outpatient surgery programs are seeing an increase in the number of cases of community-acquired MRSA, says Robert G. Sawyer, MD, professor of surgery and public health sciences at the University of Virginia Medical School in Charlottesville.

"Ten years ago, it was easy to identify patients who were at high risk of having MRSA," Sawyer says. Patients who had spent time in the hospital, especially the intensive care unit, and patients who had taken certain antibiotics were easy to identify as potential MRSA patients, he says. "Now, with community-acquired MRSA, healthy people coming into an outpatient surgery program can carry the bacteria and not be symptomatic," Sawyer says.

There is a significant amount of debate about the need to test all patients coming to the hospital or surgery center for MRSA, admits Sawyer. "A more practical approach might be to test patients who do have risk factors such as previous illness that required hospitalization or use of antibiotics," he suggests.

Some surgery programs also are choosing to test patients who are undergoing procedures in which an MRSA infection would produce a more serious complication, Sawyer says. "An example would be orthopedic procedures that require implants," he says. An infection could result in the need for removal of the implant and further surgery, Sawyer explains.

Ruby Day Surgery Center in Morgantown, WV, screens for potential MRSA at the pre-admission visit, but not by culturing patients, says Mary Wilson, RN, BSN, CNOR, clinical preceptor for the operating room and endoscopy. "We ask the patient if they or a family member has been diagnosed with MRSA," Wilson says. Although there has been some discussion about the need to culture patients before admission, there are concerns about the rate of false negatives in the screening, she says. "We don't want to give staff members a false sense of security with screening tests that produce false negatives," Wilson says.

There is an in-house study under way at West Virginia University Hospitals, of which her surgery center is a part, to determine the rate of false negatives, she says.

Start with good hand hygiene

Overall, the best protection for patients, physicians, and staff members is the standard infection control procedures that are commonly used in surgery, says Sawyer. Sterilization of equipment, proper hand hygiene, and thorough cleaning of the operating rooms are the best protection against the spread of MRSA, other antibiotic-resistant organisms, and all other infectious organisms, he says.

At Naugatuck Valley Surgical Center in Waterbury, CT, universal procedures and thorough cleaning of the operating rooms and recovery areas are taken seriously, says Betty Bozutto, RN, MB, CASC, executive director. "We treat every patient as if he or she is at risk for contracting or spreading an infection, and we make sure that everything in the room is clean before and after the patient is in the room," she says. Operating rooms and recovery areas are cleaned by the staff between patients, and a terminal cleaning of the operating rooms is performed at the end of the day, she says. "If we do have a patient that may have MRSA, we try to schedule him or her at the end of the day," Bozutto says.

Although her staff have not changed protocols for cleaning the operating rooms, Wilson says that a checklist completed by the cleaning staff at night is posted on the door to the operating room so that the nurses can double-check everything in the morning. "The list includes everything that is cleaned during a terminal cleaning including floors, counters, beds, sharps containers, telephones, cords on equipment, doorknobs, and cabinet handles," she says.

At Baltimore Washington Medical Center in Glen Burnie, MD, "everything in our pre-op, operating room, and recovery area is cleaned, even hard-to-clean surfaces such as computer keyboards," says Toni B. Hughes, RN, BSN, MA, CNOR, perioperative education specialist. "We have dispensers in every area that contain cloths with cleaning solutions designed to clean hard surfaces such as counters and keyboards so staff members can quickly grab a cloth to clean an area," she says.

Because hand hygiene also is a key to preventing spread of MRSA as well as other infections, Wilson's facility keeps waterless alcohol hand-wash dispensers at bedsides in the pre-op and recovery areas as well as every operating room. "Installation of the dispensers was part of a hospitalwide campaign to remind staff members to wash their hands," she explains. The campaign includes screensaver reminders as well as signs posted in all patient areas and next to all sinks, reminding people to wash hands to prevent the spread of infection, Wilson adds. Other facilities post signs in waiting rooms and public bathrooms next to waterless alcohol hand cleanser dispensers to remind visitors how to avoid spreading germs.

The development of antibacterial sutures, dressings, and catheters has created some discussion within surgery programs, but none of the experts interviewed by Same-Day Surgery are at facilities where the products are used. "We've had a few questions from surgeons about the products, but we're not using them," says Hughes. "These are products that we'll evaluate when there is enough surgeon interest."

Sawyer says, "There is not much clinical data available about the effectiveness of antibacterial products to prevent infection in surgery, and there is no product specific to prevention of MRSA." If a facility chooses to use these products, they should be viewed as an adjunct to other infection control procedures and protocols that are designed to keep the surgery department clean and sterile, he suggests.

Resource

For information about the methicillin-resistant Staphylococcus aureus (MRSA) study conducted by the Association of Professionals in Infection Control and Epidemiology, go to www.apic.org. Highlight "Research Foundation" on the left navigational bar, and then select "National MRSA Prevalence Study."