Evidence-Based Practice in Nursing and Health Care

Methicillin-Resistant Staphylococci (MRSA), most common Healthcare Associated Infections

The PICOT question to be discussed is: For adult patients using catheters, does the use of sterilization practices reduce the future risk of health associated infections like MRSA compared with standard procedure in one week?

The answer is yes.

The support given to answer the question will be based on peer-reviewed journals and scientific literature. A summary of the evidence will be availed in a chart plus a conclusion that summarizes evidence used will also be given.

Methicillin-resistant Staphylococcus aureus (MRSA) bacteria is resistant to several antibiotics. A significant proportion of MRSA infections in the community are on the skin. It results in alarming infections of the bloodstream, surgical site infections and pneumonia in health facilities. Studies have revealed that one person in every three individuals have staph in the nose - most of the time they don't show any illnesses (General Information About MRSA). 2% of people carry with them MRSA. No data exists highlighting the population of patients that contract skin infections due to MRSA in any community.

Any person can contract MRSA if there is a direct contact made with a wound that is infected or when personal effects like razors or towels are shared. The risk of an MRSA infection can increase in situations involving crowd activities or where skin contact is prevalent (General Information About MRSA). The people who risk such infections include children playing in a daycare, the military in their barracks and athletes. Treatments provided for MRSA skin infections might include draining the infection or taking of antibiotics. The patient should secure the services of a health professional and not try to drain the infection themselves as there is a risk that the infection might spread or someone might be infected (General Information About MRSA).

The risk of infection will be drastically reduced if proper sterilization is always done.

Healthcare-associated infections (HAIs) are acquired when patients are still being treated for a different illness in a health facility. HAIs are deadly and costly but are preventable (Preventing IV - Catheter Associated Infections). An approximate 5% of patients are likely to develop HAIs as they get treated in a health center. Included in this are IV catheter-associated bloodstream infections (CA-BSI). Approximately 250,000 CA-BSIs take place every year with around 80,000 cases taking place in ICUs.

One infection can (Preventing IV - Catheter Associated Infections):

Cost a lot of money in treatment costs - around $25,000 for every episode

Lengthen a patients stay - an extra 6-22 days in a facility

Lead to a death or disability - a mortality of 12-25%

Patients may develop bloodstream infections (BSI) where a IV device isn't used but a higher rate is likely in the case of catheter usage.

Evidence Review

The question was:

For adult patients using catheters, does use of additional sterilization practices reduce the future risk of health associated infections like MRSA with standard procedure in one week?

The answer is yes.

Evidence 1:

In 1980, the Efficacy of Nosocomial Infection Control (SENIC) study revealed that HAIs could be prevented by infection control practices and surveillance for nosocomial infections. Therefore, a key role that has been assigned to practitioners in infection control as well as epidemiologists is infection control (Sydnor and Perl, 2011). Further, HAIs lengthen a patient's stay in the hospital and increase expenditures in health care. Responding to patient risks as well as increasing costs, the Centers for Medicare and Medicaid Services (CMS) put in place a strategy to withhold reimbursement for some HAIs like catheter-associated urinary tract infections (CA-UTIs) as well as central line-associated bloodstream infections (CLABSIs). Institution specific surveillance driven by or pushed by infection preventionists (IPs) and hospital epidemiologists is required to ensure the infections are detected early and strategies to prevent and curtail HAIs are thus developed (Sydnor and Perl, 2011).

Currently, there exists several external influences like legislative mandates, accrediting agencies, payers, industry, professional societies as well as consumer advocacy groups (Sydnor and Perl, 2011). The groups are always opposing each other. Surveillance on Methicillin-resistant Staphylococcus aureus (MRSA) is an instance of such conflict. CDC makes recommendations to the effect that strategies for MRSA surveillance be done locally and is not a proponent of routine MRSA surveillance cultures (Sydnor and Perl, 2011). Society for Healthcare Epidemiology of America (SHEA) makes recommendation getting cultures of MRSA surveillance from patients that are at high risk upon their being admitted and periodically afterward; however, the guidelines cause controversy because MRSA surveillance effectiveness is being debated. In spite of the controversy, the Department of Veteran Affairs has given mandate to MRSA surveillance. The CMS is also making considerations for the withholding of MRSA infection reimbursement.

Evidence 2:

The prevention of CAUTI was not always given top priority in our acute-care hospital but the CMS regulation was put in place in 2008, thereby putting to a halt reimbursements for CAUTI forced hospitals to take some action (Stokowski, 2009). Several hospitals are putting in place several measures to reduce these infections. A recent study done by Saint and colleagues revealed that not even one strategy had wide usage across hospitals as a prevention measure. More than fifty percent of hospitals were not monitoring which specific patients were using urinary catheters or the length of time of the use of the catheters (Stowoski, 2009).

Limiting the use of catheters or minimizing the length of time of their usage is a primary strategy to prevent CAUTI (Stokowski, 2009). SHEA/IDSA guidelines make recommendations to the effect that various alternatives of urine collection such as the use of condom catheters or in-and-out cathetarization ought to be considered in place of indwelling catheters (Stokowski, 2009). Condom catheters are not only comfortable but also limit the entry of bacteria for patients that are male who do not have dementia. Suprapubic catheters also result in lower bacterial infection. Even small volumes of urine can be measured accurately by portable bladder ultrasound scanners (Stokowski, 2009). Devices like these might lead to a reduction in urinary cathetarization as a way of assessing residual volume of the urine. Fewer cases of cathetarizations means less infection cases. A hospital had its CAUTI rate reduced by 30% to 50% over a period of 12 months through the use of portable bladder scanners. Data shows that 30% of hospitals in the United States have adopted the strategy (Stokowski, 2009).

Evidence 3:

The prevention of HAIs helps enhance the safety of patients. Recently, several guidelines, meta-analysis, systematic reviews and some other evidence-based recommendations have come up to help clinicians and policy makers prevent HAIs in their hospitals (Sanjay, et al. 2013). While the availability of such information is good, it is crucial that we comprehend the view of those championing these recommendations. For example, if a recommendation is grounded on weak evidence and it is being championed by experts in a sector then the uptake of the recommendation is unlikely (Sanjay, et al. 2013).

There is limited data showing the strengths of the evidence fronted for the usage of HAI infection prevention practices. A nationwide survey of personnel in the industry assessing the strengths of the evidence supporting the practices revealed that the following practices are viewed by professionals to have strong evidence: aseptic urinary catheter insertion, alcohol-based hand rub, chlorhexide for antisepsis prior to central venous catheter insertion, avoidance of the femoral site for central venous catheter insertion, maximum sterile barriers during sterile venous catheter insertion as well as semi-recumbent positioning of the patient being ventilated (Sanjay, et al. 2013). If the implementation is to be successful then there should be an evaluation on how professionals in the field view the strengths of the evidence supporting the practices.

Evidence 4:

Proper control of infections is a key part of clinical practice management given its importance to the safety and health of patients and practitioners as well as the broader community (Fathima, 2014). With the public being increasingly concerned about HAIs, bacteria that is resistant to antibiotics and their spread all over the world, this area has become a major focus. HAIs pose a serious problem in several hospitals around the world, with an estimated 4-10% prevalence in the surveyed countries regardless of the type of infection (Fathima, 2013). The best approach to reducing infection transmission is a multi-faceted program which makes use of the latest standards that are evidence-based and also incorporates training and continuous monitoring. Evidence-based practice can be defined as the incorporation of patient values and clinical expertise with best research evidence. The best practices are grouped together to form 'care bundles', that are specific evidence-based practice sets, usually 3 to 5, which when reliably and collectively performed can improve the outcome of patients (Fathima, 2013). The major challenge facing health facilities currently is the consistent and timely implementation of proposed best practices and the incorporation of such measures into workflows so as to do away with HAIs.

The main evidence-based strategies for prevention which should be integrated by health facilities into daily practice include (Fathima, 2013):

Proper hand hygiene among the professionals in healthcare

The development of proper precautions for contact for those patients that have been colonized and known to have drug-resistant dangerous organisms like MRSA or difficile.

Development of strategies for the prevention of catheter associated infections in acute care.

Hygiene of the environment.

Surveillance of infectious diseases.

Educating patients and healthcare professionals.

Clinical studies repeatedly demonstrate that environmental surfaces that have been contaminated aid transmission of HAIs in health facilities. Disinfecting such surfaces should always be standard practice (Fathima, 2013). Patients having pathogens like methicillin-resistant aureus (MRSA), Acinetobacter, Clostridium difficile and vancomycin-resistant enterococci (VRE) always contaminate the surfaces around them. The organisms might be viable in the surroundings for a very long time. Cleaning and properly disinfecting will reduce the population of environmental pathogens and so lead to a reduction in the transmission risk and so the potential for infection (Fathima, 2013):

Routine disinfection and cleaning of the environment of the patient with disinfectants that are U.S. EPA -registered (like quaternary ammonium compounds, iodophors, phenolics and sodium hypochloryte) to be used according to the directions provided by the manufacturers.

In case of an outbreak setting or CD infection - an EPA-registered bleach or sporicidal cleaning agent should be used to clean the environment and kill the CDI spores.

Clean and disinfect environmental surfaces regularly or when they are visibly dirty.

When using a disinfectant make sure the directions given by the manufacturer are followed.

Surfaces that are frequently touched should be paid attention to. Such surfaces include carts, bed rails, taps, doorknobs and bedside commodes.

Mop heads and cloths used for cleaning should be decontaminated regularly.

Use a disinfectant to decontaminate buckets, mops as well as cloths - make sure they have dried before they are used again.

Evidence 5:

CLABSI is an intravascular therapy complication that is used in the delivery of nutrition, blood or medication. Central venous cathetarizations is made use of in invasive procedure and has been shown to drastically increase bloodstream infection risk (Beyond The Bundle). The risk is heightened when catheters are inserted in cases of nosterile emergent situations. Usage of central lines is increasingly becoming common in patients outside of the ICU (Beyond the Bundle).

CLABSIs linked to CVCs occurring in the initial 10 days of an insertion often have correlations with extraluminal biofilm formation. The currently used prevention bundle has a primary focus on extraluminal colonization prevention since the skin surrounding the site of infection is the main bacteria source (Beyond the Bundle). The first colonization takes place when the bacteria attaches to the tip of the catheter as well as the catheter's outside surface as it passes through the patients skin at the time of insertion and so it can be effectively prevented by having good hand hygiene, using maximal sterile barriers and disinfecting the skin appropriately. The CDC draft Guideline for thePrevention of Intravascular Catheter-Related Infections that was posted on November 3, 2009, Was a case when Federal Register updated and expanded evidence-based recommendations given in 2002 in the Guidelines for the Prevention of Intravascular Catheter-Related Infections. Recommendations were made that chlorhexidine skin disinfectant be used because of the effectiveness and persistence it has registered in lowering catheter colonization in cases of skin flora and serum presence at the site of insertion. The usage of both alcohol and chlorhexidine increases the drying time as well as kill rate (Beyond the Bundle).

CLABSI still pose a threat unless the prevention strategies that have been proposed are implemented. Solutions should also be found to address the pathogenic mechanism that is linked with vascular access devices (Beyond the Bundle). Practitioners in the industry ought to adopt best practices to ensure the reduction of CLASBI risk as well as associated mortality and morbidity and so lower the costs of health care. Hospitals will be instrumental in the process if they participate in collaborative efforts and also network with other hospitals that have succeeded in lowering the rates of infection (Beyond the Bundle).

Table

evidence

Summary

Evidence Rating

Study on the Efficacy of Nosocomial Infection Control