Introduction to MRSA
Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterial strain of S. aureus that that has developed a resistance to certain types of antibiotics, including methicillin, penicillin, oxacillin, and amoxicillin (Farley 2008). The types of infections differ according to whether the MRSA infection was acquired in the hospital setting (HA-MRSA) or whether it was a community acquired MRSA (CA-MRSA) infection. The most severe MRSA infections are those acquired in health care facilities and include infections of the bloodstream or surgical wounds, and pneumonia. MRSA bacteremia is often fatal, thus timely and aggressive intervention is critical in patients at high risk of death; for example, elderly patients who develop severe bacteremia in a long-term healthcare facility (Pastagia et al. 2012). Of all patients admitted to hospital with S. aureus healthcare acquired pneumonia (HCAP) around two-thirds are found to have MRSA infection. S. aureus HCAP, is associated with significant mortality and high healthcare costs, regardless of the antibiotic therapy of choice or whether the patient was infected with the MRSA strain or with Methicillin-susceptible Staphylococcus aureus (MSSA) (Shorr et al. 2010).
Critical Review and Discussion of Current Literature Related to MRSA
CA-MRSA is a different strain of organism from HA-MRSA and most often results in skin and soft tissue infection (SSTI). The infections occur around skin lesions and in areas covered by hair where they appear as pustules or boils with pus or exudate. MRSA of the nose is common and the anterior nares are the most sensitive site for determining MRSA colonization (Shurland et al. 2009). The test is also relatively simple and the cultures will detect the greatest majority of people who are colonized or infected with MRSA. In their study, Shurland et al. found that out of 193 residents who tested positive for MRSA, 165 were colonized in the anterior nares, and 119 were colonized on their skin.
Studies have shown that CA-MRSA has appeared in a variety of populations, including in homeless persons (Charlebois et al. 2002), people involved in professional sports or college sports (Romano 2006 ), closed ethnic communities (Baggett et al. 2003), prisoners (Pan et al. 2000), women who have recently given birth in a hospital (Saiman et al. 2003), and babies born in hospitals (Bratu et al. 2005). MRSA in long-term healthcare facilities (Rogers et al. 2008) has the characteristics of both HA-MRSA and CA-MRSA. Transmission occurs via the hands of health care workers and through direct contacts among residents during typical social activities (Chamchod & Ruan 2012).
Nurse practitioners should recognize the signs, symptoms, and risk factors of MRSA because this organism is bound to erupt in new populations. Some of the risk factors associated with healtchcare facility-associated MRSA include recent stay in a hospital, long-term stay in a nursing home or rehabilitation center, dialysis, long-term use of antibiotics, and indwelling medical devices like feeding tubes or catheters.
This type of MRSA is also more common in older White adults, compared to CA-MRSA which is more common in younger, non-White adults, specially in those who are HIV-positive. Other risk factors for CA-MRSA include imprisonment, recent antibiotic treatment, team sports, tattoos, being in the military, having a child in daycare, and having a member of the family infected with MRSA, suggesting that people who are in close contact with each other are at higher risk of getting infected with CA-MRSA due to the easier and multiple avenues of transmission.
CA-MRSA was first identified in 1999 by the Centers for Disease Control (CDC) where it caused the death of four children who had shown no evidence of any illness prior to acquiring the deadly infection (CDC 1999). Prior to that event, there has been a dramatic increase in the incidence of hospital-acquired MRSA, with up to half of all patients hospitalized in 2000 being thought to have acquired the disease (Chambers 2001).
Clinical symptoms of MRSA include fevers, and breaks in the integrity of the skin such as redness, swelling, and exudate. Patients with ocular infections present with keratitis (Chuang et al. 2012). In addition to the direct effects of Staphylococcus aureus, the toxins released by the organisms have their side-effects, like toxic shock syndrome. If a patient presents with any of these symptoms, the nurse practioner should swab the patient’s lesions to test for the presence of S. aureus and to determien whether S. aureus is oxacillin resistant.
The first step in the management of CA-MRSA is to take a comprehensive medical history of the current illness and to rule out necrotizing fasciitis. The next step is to obtain a sample from the lesions for laboratory testing of sensitivity. The choice of antibiotics is determined by the community and hospital epidemiology of SSTI. Whichever therapy is chosen, the patient should be evaluated within 24-48 after initiation of therapeutics to determine whether therapy should be adjusted. Special care is warranted in long-term healthcare facilities because without strict screening and elimination of the bacteria in an infected individual, the risk of MRSA transmission increases. In addition, strict hand hygiene practices are necessary for both residents and health care workers to reduce the risk of colonization.
Furthermore, studies have shown that the introduction of a new resident with MRSA into an MRSA-free long-term healthcare facility has a greater impact on an outbreak of MRSA than would the introduction of a contaminated healthcare worker into the same facility (Chamchod & Ruan 2012). Studies have also shown that the effect of transferring a patient from a long-term care facility to a hospital setting has no significant effect unless patients are routinely being moved into the same unit. On the other hand, transfers of patients from a hospital into a long-term care facility can increase the prevalence of MRSA where the populations size is smaller and the patient turnover is low (Barnes et al. 2011). Moreover, exposure to home healthcare has been shown to also increase the risk of MRSA infection, or to cause a shift from MSSA to MRSA colonization or infection, suggesting that community health care nurses play a role in increasing the spread of the disease within the community (De Angelis et al. 2011).
Many health care facilities, including short-term and long-term facilities, screen their incoming patients to determine whether they are MRSA positive, and if so, they then choose to isolate the infected patients from the general population of patients. Cheng et al. (2010) developed a comprehensive infection control program to control the spread of methicillin-resistant Staphylococcus aureus (MRSA) infection at their hospital. All patients entering the facility were tested for MRSA colonization or infection and those who tested positive were placed in single closed rooms with contact precautions. Patients who tested positive for other types of bacterial infection, such as extended spectrum beta-lactamase (ESBL)-producing Escherichia coli or Klebsiella species were placed in open cubicles with standard contact. At the same time, hand hygiene protocols were established to control MRSA transmission from healthcare worker to patient. There was a significant decrease in ICU onset bacteraemic MRSA infection but not in ESBL)-producing Escherichia coli or Klebsiella species infections. Thus, isolation of patients concomitant with hand hygiene had a significant impact on controlling the rate of MRSA infection.
However, Mody et al. (2011) consider that this approach is not feasible in a long-term setting because testing and isolation of each patient is not only expensive and inefficient but might be even unsafe and counterproductive because patients in isolation do not receive the same quality of medical care as do the rest of the patient population, and elderly patients with cognitive impairment may develop adverse psychosocial symptoms. Furthermore, Mode et al. also question the logic of focusing on a single pathogen to the exclusion of all others, for studies have shown that there are many other harmful pathogens that can colonize or infect a patient, such as vancomycin-resistant enterococci (VRE) (Hayden et al. 2008), or the antibiotic-resistant gram-negative bacilli (R-GNB) (Toltzis 2004). Mody et al suggest a different approach that centers on the identification of those patients at high risk and on the education of healthcare workers concerning the risk factors of MRSA and of other drug resistant organisms. One group of patients that are at high risk of colonization and infection are patients with indwelling medical devices such as urinary catheters and feeding tubes. Studies estimate that 50% of patients in long-term health care facilities who have catheters will develop a urinary tract infection or bacteriuria with some type of drug resistant pathogen within a year of hospitalization (Gould, Umscheid & Agarwal 2009). A similar pattern can be seen in patients who have feeding tubes, which can range from 7-41% in patients with dementia, and where around 90% of the feeding tubes have been shown to be colonized with some type of bacteria (Mitchell, Kiely & Lipsitz 1997).
Healthcare workers play a critical role in infection rates. Healthcare workers working in long-term care facilities have been found to be colonized with MRSA in 3%-20% of cases, and with VRE in 13%-41% of cases. Moreover, studies have also shown that many health care workers either do not know or do not follow recommended protocols for the prevention of transmission, including simple basic precautionary practices like handwashing after routine contact (Jackson, Jarvis & Scheckler 2004). Davis (2010) implemented a very simple intervention to improve hand-hygiene to see how this would affect the incidence of MRSA infection. The study consisted of providing strategically placed alcohol-based antibacterial dispensers for the first 6 months of the study, and then to couple this with a large bright red arrow pointing at the dispensers for the remaining 6 months of the study. The result showed that compliance improved significantly for all people entering the wards. Compliance improved in doctors from 0% - 54%; nurses, 24% - 75%; visitors, 35% - 68%; and patients 23% - 44%, strongly suggesting that all it might take is a simple intervention to decrease the spread of MRSA infection within a hospital setting.
On the other hand, Cimiotti et al. (2004) studied the relationship between length of employment in an ICU and the prevalence of bacterial infection on the hands of new graduate nurses and experienced nurses during a two-year period and found that regardless of compliance with hand hygiene protocols, the hands of both the experienced and new nurses were colonized with MRSA and the two groups shared the same strain of S. epidermidis, suggesting that eradication of MRSA is rather complicated and must be combated from different angles.
MRSA infection can cause health problems in healthcare workers severe enough to lead to long-term incapacity. The most common infection sites are the ears, nose, and throat, followed by skin infections. Secondary infection of the joints may also occur and this can be associated with skin damage (Haamann, Dulon & Nienhaus 2011).
Introduction to Leadership
Leadership in nursing and in heathcare in general is about knowing how to develop a healthcare managing plan, allocate responsibilities to implement the plan, and make the plan a reality. The best healthcare plans are ones where patients are treated with dignity and respect at all times, where the individual needs of the patient are taken into consideration, and where the work performed by each member of the healthcare team is valued and respected (Kitson 2001).
Critical Review and Discussion of Current Literature Related to Leadership
A nurse leader needs to formulate a long-term plan that organizes the issues into broad categories that helps prioritize the different sections of the plan (Leary & Allen 2006). Once the plan has been formulated the next step is to determine how to implement the plan. Hansten (2008) contends that to become a good and effective leader, a nurse must learn which duties must be delegated, and how and to whom these responsibilities can be transferred. McInnis (2009) also suggests that delegation decision-making skills are amongst the most important leadership skills a nurse leader can learn. Table 1 outlines a nursing management plan for the containment of MRSA.
Assessment and Planning
Which laboratory tests must be administered to determine whether the patient has MRSA colonization or infection?
Which tasks related to MRSA containment need daily/weekly/monthly attention?
Which tasks can be delegated?
Communication
What patient information does the team leader have to provide to staff?
What information does the staff have to provide to the team leader?
What epidemiological information is needed from or should be shared with other healthcare facilities?
What epidemiological information is needed from or should be shared with the community?
Problem Identification and Solution Implementation
Which procedures may be instituted to decrease the probability of MRSA infection?
Are there ways in which staff members can help to reduce their own risk of MRSA infection?
Are there ways in which patients can help to reduce their own risk of MRSA infection?
Which tasks place the patient at higher risk of MRSA infection?
Which tasks place members of the healthcare team at higher risk of MRSA infection?
Delegation
Which tasks and responsibilities may be delegated?
Which staff members have the right skills, experience, and training to take over the task or responsibility?
Which family members have the right knowledge and attitude to take over the task or responsibility?
Can any of the responsibility for MRSA containment be shouldered by the patient?
Conclusion
HA-MRSA and CA-MRSA can both spread quickly through a healthcare or community population and antibiotic resistant bacteria is a serious medical concern. Nurse practioners are well positioned to discover when a new drug-resistant organism has emerged in the population, due to their unique position in the chain of healthcare, and can thus help stem its spread in the population through quick intervention. However, to do so effectively, an effective and well-tested MRSA management plan must be in place.
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