VOL: 97, ISSUE: 46, PAGE NO: 57
Joanne Leigh Nolan, BSc, RGN, DipHEd, is a staff nurse, general surgical high dependency unit, South Cleveland Hospital, Middlesbrough. She was awarded the Mary Fuller prize for infection control following implementation of these guidelinesMethicillin-resistant Staphylococcus aureus (MRSA) can cause a spectrum of life-threatening disorders (Humphreys, 1992), with patients in intensive care and high-dependency units at greater risk of developing the infection (Coello et al, 1997)
Methicillin-resistant Staphylococcus aureus (MRSA) can cause a spectrum of life-threatening disorders (Humphreys, 1992), with patients in intensive care and high-dependency units at greater risk of developing the infection (Coello et al, 1997)
At present our HDU follows a trust-wide policy for isolation nursing, which suggests the use of a side-room. The side-room in HDU is considered to be too far from the main area to be safe to nurse a patient. Although there was an emergency bell, a nurse would be on her own without the constant support of others. It was therefore decided to review our current guidelines and implement guidelines that did not require specific isolation in a side-room in order to ensure safe practice. The first step was to develop an action plan (Box 1).
Traditionally isolation involved separating infected patients from other patients and casual contact with health care workers by using private rooms and a combination of gloves, aprons and masks (Ellis, 1998). Studies into isolation have spanned the decades, from Williams et al (1962), who demonstrated that isolation reduced cross-infection, to Lee et al (1990), who showed a reduction in patient colonisation of MRSA from 63% to 33% when patients were nursed in isolation.
Problems faced by clinical staff in containing outbreaks of MRSA and identifying the source of an outbreak while it is evolving are well documented (Vincent et al, 1995). Difficulties include limited isolation facilities to cope with increasing numbers of cases and limited knowledge and understanding by clinical staff (Fraise et al, 1997). These factors, compounded by pressure from managers to justify resources spent on infection control, have prompted some to advocate a more flexible approach.
Having made a decision on the unacceptability of the side-room in the HDU, we decided to adopt a more flexible approach to the management of MRSA. It is vital that universal precautions are strictly adhered to in order to minimise cross-infection. Staffing levels also need to be reassessed, as it may become stressful for one nurse to work for substantial periods in relative isolation from colleagues. Employing more staff could also prove cost-effective in the long run.
The Working Party Report (1998) on the control of MRSA stated that control measures do have an impact and that the costs of not controlling MRSA are higher than those of control. The working party firmly believed that a control of MRSA is vital but agreed that a more flexible approach is more appropriate.
Development and implementation of guidelines
Following a joint meeting with the infection control team (ICT), it was agreed that specific guidelines were needed for the HDU.
Informal discussions were held with the nurses in HDU. Opinions were negative. Some found it 'ridiculous' to have to wear protective clothing each time they attended to the patient; some felt isolated when nursing in isolation and some were unsure of the correct procedures. Although the staff were given the opportunity to express any ideas both verbally and through the use of a questionnaire, the response was very poor, highlighting a negative attitude to MRSA. Key issues identified were lack of knowledge of where and when to screen patients. This information was therefore included in the guidelines. It was thought that through development of the guidelines and presenting the pertinent research findings attitudes would become more positive. Two separate guidelines were developed (Box 2 and 3).
The admission guidelines are simple to use and follow a logical sequence of events. The key aim of the guidelines was to end the existing confusion over the location of the patient. The procedures to be followed for isolation were taken from the principles of practice as set out by the local trust, which included strict universal precautions and clear and concise information for patients and their relatives. As requested by the staff, the issue of swabbing was included.
The Working Party Report (1998) suggested that all orifices and all manipulated sites must be swabbed. This was discussed with the ICT and felt to be inappropriate, as in a surgical high-dependency unit a patient may have up to four drains, a urinary catheter, a stoma, a venflon, an arterial line, a central line and/or a tracheostomy, making the amount of swabs taken for a routine screening very high. Therefore the sites as set for all wards were included, with a slight variation for surgery.
These guidelines are formulated around the terminal cleaning of the bed area after discharge of the patient to the general ward, as this was highlighted as an area requiring more knowledge. The form is locally designed and states the role of the nurses and domestic staff. This avoids confusion in responsibility in the various tasks to be performed, which had occurred in the past.
The guidelines were agreed with the HDU manager and the ICT. To encourage staff involvement their opinions were sought. To improve staff attitudes towards MRSA the collated evidence was presented and discussed, Because the initiative highlighted best practice, the nurses began to feel more positive and confident in managing MRSA.
The guidelines now provide a mechanism to ensure delivery of evidence-based care. Haines and Jones (1994) found that much emphasis has been placed on the use of guidelines as a vehicle for implementing research.
Once the guidelines had been implemented an audit was performed to assess the relevance and benefit to practice. A similar questionnaire to the initial one was given to the same nurses and received a much greater response. The feedback was very positive. All stated that they found the guidelines useful, especially those for discharge. We all agreed that this is where most confusion occurs. The guidelines ensure standardisation of cleaning procedures and provides clear, concise guidance on swab site selection. A form of documentation of the swabs taken and the results received was also required and therefore a results form was specifically devised for the HDU.
All hospitals should have policies to control MRSA transmission based on national guidance. However, while the control of MRSA is vital, there should be a more targeted and flexible approach depending on risk assessment. With our HDU planning to expand, the isolation area will have to be reassessed with the possibility of a review of the current guideline. Continual assessment to assess the effectiveness of the guidelines is required.