Use proven strategies for MRSA in your ED

Secret observers check for hand washing

Methicillin-resistant Staphylococcus aureus (MRSA) infections have made headlines recently, and EDs are being hit hard.

"There has been a steady incline in community-acquired cases seen in our ED over the last several years," reports Leigh Chapman, BSN, infection control practitioner at St. Joseph Medical Center in Towson, MD.

A recent study reported that nearly 19,000 people died in the United States in 2005 after being infected with a virulent drug-resistant strain of MRSA, which suggests that invasive infections with MRSA may be twice as common as previously thought.1 "The study suggests that MRSA is an important cause of infection in health care facilities in this country, and that health care facilities need to do more to control it," says John A. Jernigan, MD, MS, acting deputy chief for the Centers for Disease Control and Prevention.

To reduce the spread of infection in your ED, the most important thing emergency nurses can do is achieve 100% adherence to existing infection control recommendations, says Jernigan. "This includes hand hygiene before and after each and every patient contact, and use of gown and gloves when indicated — for example, while caring for a patient with draining wound," he says.

Isolation is a challenge

A big challenge facing ED nurses is being able to isolate MRSA patients promptly, says Durenda Juergensen, RN, BSN, MHA, director of nursing for emergency services at St. Joseph.

"The challenge comes from not always being aware that patients are MRSA carriers," she says. "MRSA is not limited to nursing home patients. Anyone can have it, from children to adults, and many do not know if they are a carrier or not. We are seeing between five to eight patients a week with MRSA who then become inpatients."

At St. Joseph, patients are isolated for up to one year after a hospital admission during which they were identified as a MRSA carrier. "This helps to protect other patients," says Juergensen. "In the ED, this information is identified during the full registration process. This then alerts the nurse to place the patient in contact isolation."

Since MRSA has not been diagnosed yet with many patients, there is a delay in isolation, says Juergensen. "But in order to help protect patients and staff, we practice universal precautions on all patients, treating all bodily fluids as contaminated," she says.

When a patient is identified as needing contact isolation, an isolation cart is immediately placed outside the patient's door and a "contact isolation" sign posted at the patient's door. "In order to assist in prompt isolation practices, we keep isolation gowns, gloves, and personal protective gear at the bedside," says Juergensen. "The patient and family are educated on performing safe isolation practices while they are in the ED."

Agency nurses continually are reminded about the ED's hand hygiene practices to help decrease the spread of MRSA, and a "secret shopper" type of process identifies staff who need additional reminders, says Juergensen. "I have implemented this process in the ED as a method to internally monitor hand washing and counsel staff on the spot with a simple reminder," she says.

An ED staff member observes 10 people each week for compliance with hand washing before and after entering patient rooms, and he or she reminds staff of the process when they are observed being noncompliant.

"The secret shopper is changed every three months," says Juergensen. "I prefer to keep the same person so that they observe consistently."

The shopper is required to do observations at different times, locations in the ED, and different days of the week, she explains. "Presently in the ED, for November 2007, we were 100% compliant with hand washing for the observations made," Juergensen reports.

Nurses are not the only ones that need reminding to do hand washing, adds Juergensen. "All medical personnel who come in contact with the patient — physicians, EMS, and other hospital staff — sometimes need reminding, too," says Juergensen. "When EMS comes in, staff will remind them by saying, 'Don't forget to wash your hands,' or 'Remove your gloves before leaving the room.'"


  1. Klevens RM, Morrison MA, Nadle J, et al. Invasive methicillin-resistant Staphylococcus aureus infections in the United States JAMA 2007; 298:1,763-1,771.


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A guidance on management of multidrug-resistant organisms is available free of charge from the Centers for Disease Control and Prevention's Healthcare Infection Control Practice Advisory Committee. To access the guidance, go to