¶ … Best Practice to Isolate MRSA Patients in the Hospital Environment
Methicillin-Resistant Staphylococcus Aureus (MRSA) is an anti-microbial organism of concern in the healthcare field; therefore, preventing and controlling its spread within the healthcare environment is a significance function of the infection control experts. One of the preventive measures is isolation of MRSA patients. However, not all are in agreement with such a practice and this makes our topic of discussion raise the question, "Is isolation of MRSA patients in a hospital environment the best practice?"
This reviews aims to evaluate the evidence for the efficiency of isolation measures in managing the prevalence of Methicilin Resistant Staphylococcus Aureus (MRSA) and infection in the hospital environments.
Review Methods: This review relied on scholarly reviewed journals, and selected articles reporting on MRSA related outcomes and illustrating an isolation practice or policy. The paper did not impose quality restrictions on studies employing separation wards or nurse cohorting. In addition, this review utilizes studies, if they showed prospective comparisons of retrospective information.
Results/Discussion: This review accepted 46 studies; 18 using isolation wards, 9 employing nurse cohorting, and 19 had evidence of isolation policies. However, these studies lacked measures to prevent bias, and statistical analysis. In addition, four of the studies provided substantial evidence that intensive control measures including isolation showed efficiency in controlling MRSA.
Conclusion: This review recognizes that major methodological limitations and inadequate reporting in published research showing that the paper includes alternative explanations for reductions in MRSA acquisition linked with interventions.
Introduction
The prevalence of hospital acquired methicillin resistant Staphylococcus auerus (MRSA) continues to rise in the globe hence qualifying as an international health problem (French et al., 2004). The effort to manage the spread of MRSA relies primarily on three measures including hand hygiene among health practitioners (Larson, Quiros and Lin, 2007), restriction of antibiotics, and detection and isolation of infected or colonized patients (Cooper et.al, 2003; Gbanguide-Haore et al., 2008). Perception is that most transmission of MRSA within the hospital environments (French et al., 2004), between patients happens through transiently colonized health workers (Gbanguide-Haore et al., 2008); moreover, airborne transmission through contact with infected or contaminated patients is important for consideration.
The most of the rigorous forms of patient isolation included isolation wards (designed to handle the treatment of known or suspected carriers of MRSA disease) and nurse cohorting, (Talon et al., 2003) (a physical separation of MRSA patients in a part of the ward, with nurses specifically designated to care exclusively for these patients). Into the bargain, other isolation precautions include the use of single bedded patient wards, cohorts of patients on common patient rooms (Talon et al., 2003), which lacked designated staff, and barrier caution (using aprons, gowns, gloves, and masks by healthcare professionals, (Manian and Ponzillo, 2007) as the only physical measure to avoid transmission of MSRA).
However, these control precautions may place significant burden on the hospital resources and the importance of their continued use is in question (Weeber, 2005). Although there are several narrative reviews, the efficiency of isolation measures in reducing transmission and managing MSRA, lacks a systematic evaluation (Hulten et al., 2006). Nevertheless, much of the investigation carried out is quasi-experimental in nature; therefore, there is a need to consider associated threats to valid inferences. This is the primary objective of this paper, to review for evidence on the effectiveness of isolation measures in the management of MRSA within a hospital setting (French et al., 2004).
Method
Search strategy
This review utilizes a search strategy that covers the primary subject areas of the literature review (MRSA, screening, isolation of patients, and control of MRSA infection). The following databases were of significance in this review: Cochrane, TRIP, CINAHL, Medline, National Guidelines Clearing House (NGC), PubMed Clinical Queries, Johanna Briggs and EBSCO. In addition, the review utilized studies published over the year 2000.
Study selection
These review appraised abstracts and it obtained articled if the abstracts mentioned MRSA and an attempt to control it in a hospital environment. Owing to the great number of studies, which it had not anticipated, this review revised the studies that did not impose quality restrictions (Fleming et al., 2006). Therefore, the review imposed the minimum requirement, whereby the accepted studies should include a component of prospective data collection. In addition, if the studies were retrospective, comparisons should show planned and not prompted by part of the data outcome. For the studies incorporating the most rigorous forms of separation (isolation wards and nurse cohorting), lacked such restrictions. This is because such forms of isolation had the greatest influence on hospital resources and organization of services.
Data extraction
This review divided studies into phases appropriately, defining them with major changes in isolation or other elements of infection control policy and extracted data on study design, patient population, isolation facts, screening, other management measures and MRSA related results for patients. In addition, this review documented potential threats to the internal validity of the accepted studies. Therefore, there was consideration of vulnerability on each study selection, performance, and detection and attrition bias (Cooper et al., 2003). Documentation of the measures aimed to prevent bias, noted potential confounders and attempts to record, and adjusts for the measures. In addition, the primary cause of documentation...
This review excludes studies with unclear timing of interventions and main isolation policies.
Type of bias
Cause
Studies vulnerable
Measures to prevent bias
Selection bias
Variation in intervention groups on study entry
Random studies
4-35 interrupted times. Isolation altered presented data allowing for comparison
Performance bias
Variation in care patients apart from interventions under research
Studies with specified element of care was not investigated
One study showed alteration of confounders
Varied length of days
29 interrupted times
Four studies details antibiotic use
Variation in bed occupancy
31 interrupted times
Comparisons in bed occupancy between four
Detection bias
Varied outcome evaluations between intervention groups
All studies
Three studies reported blinding elements of assessors
Variation in diagnosing infections
26 studies
16 of the studies specified diagnostic criteria
Variations in screening measures
10 studies presented colonization data
This suggested that screening efforts could not explain the alterations
Attrition bias
Variations in losses to follow up between the treatment groups
26 studies outcomes with infections
No studies followed up patients after discharge to identify the hospital acquired infections
Data synthesis
This review independently evaluates the strength of evidence in each of the studies by exploring the study design, quality of data, and evidence of plausible alternative explanations of results. In addition, the review characterizes the evidence systematically by basis of "none," "weak," "of intermediate strength," and "stronger." In addition, it considers a formal meta-analysis inadequate due to heterogeneity based on outcome of measures and patient populations.
Results
The electronic search yielded 4,382 abstracts; hand searching did not generate additional papers, the appraisal of abstracts chose 254 papers, including 20 in foreign languages other than English. However, the final review involved 46 studies (Cooper et al., 2003).
Characteristics of the accepted studies
Highest level of separation
Isolation ward
Nurse cohorting
Other isolation precautions
No of studies
18
9
19
Range of study time
3 months-15 years
3.5months-4 years
1 monht-9 years
Entire hospital setting
16
3
7
Unit setting in each hospital
2
6
12
Other Control Measures
Screening
18
9
14
Topical eradication therapy
12
5
8
Hand hygiene
8
2
6
Antibiotic restriction
3
0
2
Study Design
Prospective interrupted time series
1
2
8
Retrospective interrupted time series
15
3
2
Hybrid retrospective and prospective time series
0
2
1
Retrospective cohort study
0
0
1
Non-comparative studies
2
2
3
Study Design
These review doses not find randomized trials and only four retrospective planned comparisons with predefined phases of the study (Mody et al., 2003). In most of the studies, designs faced interruptions time series, meaning time series of results measures recorded before one or more interventions. Moreover, eight of the 38 interrupted time series studies presented only collapsed information, analyzing the time series from both segment in a distinct data top. In addition, one retrospective cohort research used survey data from Dutch healthcare facilities (Talon et. al., 2003). Some ten studies did not weigh against isolation or screening measures with regard to separation or screening. A review of the 36 studies that allowed for comparisons between isolation policies showed that in 27 of the comparison, they had independence on knowledge of the data results. However, short retrospective studies with successful results were vulnerable to this challenge.
Review
The review identified some studies that researched on the use of isolation or cohorting of patients to manage the transmission of MRSA. In the review studies that illustrated the isolation of patients as an intervention to manage the transmission of MSRA; however, no concrete conclusions were available about the impact (King et al., 2006) of isolation from a third of the studies. Concerning these inadequate or lacking conclusions, the evidence provided was weak due to poor design, major confounders, or systematic bias with regression to the evidence of average (Cooper et al., 2003; Allen 2006 and Blumeberg et al. 2006). However, this review chose some studies that offered stronger evidence. In three studies, the use of isolation and other interventions was conflicting (Carrbone et al. 2002; Charlebois 2002; Cohen 2005), one showed reduced infection (Cohen, 2005; Curran et al. 2005), while another showed no infection and another managing infection for some years…
