The Role of Isolation and Contact Precautions in the Elimination of Transmission of MRSA

Transcription

1 The Role of Isolation and Contact Precautions in the Elimination of Transmission of MRSA Marcia Patrick, RN, MSN, CIC Infection Control Director MultiCare Health System Tacoma, WA APIC/BD MRSA Presentation Financial Disclosures: Nothing to Disclose Lillian Burns, MT, MPH, CIC Infection Control Coordinator Greenwich Hospital Greenwich, CT APIC/BD MRSA Presentation Financial Disclosures: Company: BD Relationship: Speaker/Author Company: Medline Relationship: Advisory Board Company: CDC/HICPAC Relationship: Advisory Board Good Lord, what ve I got?? 1

2 MRSA Transmission A number of studies have demonstrated MRSA on environmental surfaces, medical equipment, hands and clothing of health care workers Transmission from these sources to patients and the patient environment has also been demonstrated Environmental Contamination The hands of HCW s who touched surfaces in 64 patients rooms (i.e. bedrails, tables) were positive for a variety of bacteria 34 (53%) HCW hands were positive for S. aureus (31% were MRSA) VRE (19%) Gram negative organisms (13%) C. difficile (3%) A Bhalla et al, ICHE 25:164-7,

3 Contaminated Hands MRSA was cultured on hospital computer keyboards used by clinicians Clinicians could potentially carried these microbes from room to room in the hospital on their hands Contaminated HCW Clothing 65% of HCWs gowns or uniforms were contaminated with MRSA after performing routine morning care for patients with MRSA in a wound or urine Boyce, JM, et. al ICHE, 1997, 18:

4 Contaminated HCW Clothing Physicians coats became contaminated 69% of the time with VRE or MRSA after examining patient Organisms were transferred to the hands of HCWs 27% of the time after touching their white coats Environmental Contamination 73% hospital rooms with patients infected with MRSA and 69% of rooms with patients colonized with MRSA had environmental contamination 4

5 MRSA Risk Following Colonization 30,978 patients cultured for MRSA colonization with a rapid PCR test 7.3% (2,261) of patients positive for MRSA developed infection within 6 months MRSA colonization is associated with a >10- fold risk of clinical infection compared to no colonization ENH, 2006 MRSA Transmission Risk of transmission from colonized patients was only slightly lower than the risk from infected patients Contamination of HCW gloves in the room of a patient with MRSA has been demonstrated even when there was no contact with the patient, implying environmental contamination with MRSA 5

6 The Effectiveness of Isolation in a NICU Assessed risk of MRSA transmission from patients on contact isolation Weekly cultures to screening for MRSA Isolation of positive patients Transmission reduced 15.6-fold compared to infants not in isolation JA Jernigan et al, Am J Epidemiol 143: , 1996 SHEA Guidelines For MRSA colonized or infected patients Gloves to enter the room Gowns unless no contact with patient or environment Mask > 30 articles are cited in support of isolation to prevent transmission SHEA Guidelines, pp

7 So, What to Do! Written policies to manage and isolate patients Colonized or infected placed on isolation Patients flagged for re-admission Isolation signs and supplies available Consistent following of isolation Infection Control Practices Standard Precautions for all patient encounters in all settings in which healthcare is delivered Includes masks/eye protection if splashing or spraying of face is likely Hand hygiene 7

8 Contact Precautions Contact Precautions for patients colonized OR infected with MRSA Don gowns, gloves at the door, and for patient transport Don mask with eye protection if spraying or splashing of face likely Restrict patient to room Visitors follow precautions Contact Precautions Clearly delineate isolation procedures for all aspects of patient care throughout the facility, in all departments and services, and during transport X-ray OR PACU, etc. 8

9 Patient Placement In order of preference: Private room if available Priority to those likely to contaminate environment Cohort with other MRSA positive patient(s) Consider private rooms in new construction Patient Care Items Do not share equipment and supplies between patients Use dedicated items or disposables Disinfect shared items before use for another patient Use gowns only once, discard or place in soiled linen bag 9

10 Monitor Compliance Contact Precautions, all shifts, all departments, all levels of staff Hand hygiene Environmental cleaning Not sharing equipment Take corrective action as indicated Educate Staff Transmission of MRSA Prevention measures 10

11 Environmental Disinfection Clean and disinfect frequently especially touched surfaces (e.g., bedrails, bedside commodes, bathroom fixtures, doorknobs) and equipment in the immediate vicinity of the patient Environmental Disinfection Elbow grease! Clean all surfaces Germicide contact time (10 min) Hand touch areas Change germicide, mop heads, cleaning cloths Turn-around time impact Where do you keep the elbow grease? 11

12 Continued MRSA Transmission Ensure compliance with current Infection Control measures Use patient-dedicated or single-use disposable noncritical equipment (e.g., blood pressure cuff, stethoscope) and instruments and devices Continued MRSA Transmission Increase cleaning frequency Consider assigning dedicated nursing and ancillary service staff to the care of MRSA patients 12

13 Active Surveillance Cultures When ASC are obtained, implement Contact Precautions until the culture is reported as negative Continue Contact Precautions if culture is positive If MRSA Transmission Continues Consider stopping new admissions to the unit if MRSA transmission continues Re-evaluate cleaning procedures Re-educate/retrain staff State or Local Health Department notification may be required 13

14 Discontinuation of Contact Precautions Maintain Contact Precautions for duration of hospitalization Flag for isolation on re-admission Discontinue only when serial cultures of infected site or the nares are repeatedly negative off antibiotics Summary Isolation works to prevent transmission of MRSA Compliance with isolation procedures, cleaning, hand hygiene is essential Monitor and feedback MRSA transmission rates to nursing units Be prepared to take addition measures for continuing transmission 14

15 Protect yourself Always follow proper isolation precautions References Bhalla, A, Pultz, N, et. al. Acquisition of nosocomial pathogens on hands after contract with environmental surfaces near hospitalized patients. ICHE, 2004, 25:2, Boyce, JM, Potter-Bynoe, G, et. al. Environmental contamination due to methicillin-resistant Staphylococcus aureus (MRSA): possible infection control implications. ICHE, 1997, 18: Macrae, M. B., Shannon, K. P., Rayner, D. M., Kaiser, A. M., Hoffman, P. N., & French, G.L. A simultaneous outbreak on a neonatal unit of two strains of multiply antibiotic resistant Klebsiella pneumoniae controllable only by ward closure J Hosp Infect 49, Muto, CA, Jernigan, JA, et. al. SHEA Guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and Enterococcus. ICHE, 2003, 24: CDC Guideline for Management of Multidrug-Resistant Organisms In Healthcare Settings, CA Muto, JA. Jernigan, et. al., SHEA Guideline for Preventing Nosocomial Transmission of Multidrug-Resistant Strains of Staphylococcus aureus and Enterococcus. ICHE, 2003;24:

16 QUESTIONS Thank You Marcia Patrick, RN, MSN, CIC Lillian Burns, MT, MPH, CIC 16