Conundrum
Having seen MRSA evolve from strictly an organism acquired in a hospital or nursing home setting to one that is now a stronger, more virulent bug that is community acquired more often than not, we are pretty proud of our efforts to reduce the number of Hospital Acquired MRSA infections.
Several years ago we began with an Ad hoc committee to affect change, with introducing "Best Practices", enhanced Hand Hygiene Campaigns, Isolation/PPE emphasis and education, and MRSA screening for "high risk" patients. The latest goal of this project, for 2009 was to reduce MRSA HAI by 30% and we did just that and have been able to maintain this thus far in 2010.
Screening was being done on pre-operative patients scheduled for total joint replacement surgeries and fractured hips. We also screened all new admissions to ICU. If found, the patient was treated with five days of Bactroban, twice a day which worked well for the pre-op patients who completed the five-day regimen before the day of surgery and did not require any type of isolation when admitted. Those who were admitted, either ICU patients or those with fractured hips, were placed on CONTACT Isolation until the antibiotic therapy was completed.
Now the committee advised screening for all hemodialysis patients as well as all nursing home residents who were admitted, as these populations are also considered as high-risk for MRSA. We actually did start the screening for the dialysis patients but much discussion resulted about the nursing home residents. We already know that the local nursing homes have large numbers of MRSA infections/colonizations and would we be getting the bang for our buck if we were to screen each and every one? The lab certainly didn't think the results would warrant the additional expense and the need to add another FTE to do the work.
My conundrum comes with knowing that MRSA is endemic in the area nursing homes, and that quite possibly each resident admitted for care in this acute care facility would be positive, what do we do about it? If tested and positive, with or without symptoms or illness, we would be oblidged to provide a private room with isolation and in times of even moderate to high census, private rooms are at a premium. Even co-horting becomes difficult in times of high census which is when most of these admissions occur.
Another part of the conundrum is that most of these residents have been here in the recent past and because we flag their charts with an alert that the patient has had MRSA on the previous admission, do we automatically place the resident in isolation until we can rule out an active infection? Again this is very difficult to do but is exactly what is being done now. Add in the question of treatment for actual infection vs. colonization, because antibiotic stewardship causes us to more closely evaluate the need for more antibiotics which add to the vicious cycle of drug resistance.
Please post your comments because we are very aware that nursing homeresidents with MRSA are cared for differently at their home institution for the obvious reasons, but while in the hospital setting, it is very hard to apply a strict policy for isolation need when so many variables exist. Thank you. Pat
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