VRE patient's on same unit with immunocompromised pt's??

[nurs4kids]

VRE is new to me, as I can never recall us having a patient with it. We received a patient from another hospital, with VRE. On the same unit, we have a hiv+ child who is being cared for by the same nurse. This concerns me terribly, but I've been "blown-off" by my coworkers and by infection control nurse. It just seems highly risky to me to have the same nurse caring for both these patients..this would seem to be a death-wish for the hiv pt if cross-contamination should occur.

We ARE using strict-strict contact isol with the VRE pt, but from the info I've read on the internet, this stuff is mean.

What is the policy at other institutions?

Thanks!

[megmermaid]

VRE:

Vancomycin resistant enterococcus

MRSA:

Methicillan resistant staph aureus

Both are antibiotic resistant microbes...scary stuff

[Steph2078]

Hi all,

I totally agree with you about this isolation issue. On my floor we have several percaution patients usually at all times. About 6 right now, and thats common! And we also have several HIV patients on our floor. I haven't really noticed if the nurses were caring for both of those patients at the same time. I'll have to pay more attention. However my issue was that a man on my floor has been in his own precaution room for about two weeks now. He walks by me every day and waves on his way down to have a cig!!! Also helps himself to the kitchen!! I have spoke to the CNS, nurses and infection control about this and he still walks by me 25 times a day!! I work at the front desk and have have just started school, but I think that this is obviously common sense!! They spoke with this man and told him about it and then told me if he sanitizes his hands in and out and changes his clothing it's ok!! He doesn't do this though! Go figure!! Thought I'd share my 2 cents!

Stephanie

[NurseDennie, BSN, RN]

I agree - I suspect that these things are done in respect fo the almighty $$$

When we first heard about VRE, it was unusual to have one in the whole house. And that person had 1:1 nursing care. Not necessarily a hideously sick patient, and it was boring for the nurse.

When I had "the" VRE patient, I wore street clothes in and changed to scrubs, and didn't wear the scrubs home, of course. I was scared to death of taking that home. I gowned, too, of course, but still....

Love

Dennie

[aus nurse]

nurs4kids you are right to be concerned. It sounds really dangerous to me to be nursing these patients on the same floor with the same staff caring for them. Where I work all the super bug patients are nursed on the Infectious Diseases unit. I have worked there a few times (I am on the float pool) and they break their patient allocation down to a nurse only caring for patients with the same bug. Specific precautions are in place for specific bugs, including those air flow control rooms can't think of the name:rolleyes: ) In Australia we all wear a uniform to work, but on this ward you change into scrubs and then change back at the end of the shift.

[nurs4kids]

Thanks for all the replies..

at least now I know I'm not just paranoid. The same nurse STILL has both patients ..I give. They are also taking this VRE patient all over the hospital..for xrays, pt/ot, etc. VRE's never been a problem for us..this is actually the first patient I can recall. But at the rate we're going now, we'll be lucky if it's the last!

[rncountry]

Ok, from an infection control nurse.

First of all it needs to be understood that it is likely everyone of you are caring for a VRE patient and do not know it. You don't know unless a culture has been taken, and the chances of a patient having colonized VRE is quite high for anyone who has been on long term antibiotics. Since you don't know that the patient you are caring for doesn't have it than there is no isolation, there are not any specific precautions being taken. So the roommate who may be immunocompromised is exposed Yes? The only way to avoid this to swab every single patient that is admitted to your facility, and that is, needless to say, quite cost prohibitive.

Next, there is a difference between someone who is colonized and someone who has active infection. In this I mean that the person who is colonized is not as likely to be able to spread the microbe as one with an active infection. The CDC recommends a private room for VRE and MRSA patients or cohorting of the same. IF appropriate hand hygeine is being followed then the risk to other patients is very small. And yes, that means not only nurses but all direct care givers. Think of it this way. A person can carry TB, as a colonization, but never active infection. This patient is not contagious to the general public, and is only if active symptoms begin. If a person tests positive to the mantoux skin test than a chest xray is done. If the chest xray does not show any sign of TB, that person no longer has to receive cxay every three years like they used to do, but only has to fill out a yearly questionarie regarding symptoms, if there are positive answers to the questions than chest xray is done. A colonized VRE patient is quite similar, as is colonized MRSA. At a conference I attended last year it was estimated that probably 40% of healthcare workers are colonized. Should we then swab all healthcare workers and rule them out to take care of immunocompromised patients? At one time the CDC did recommend that all healthcare workers be swabbed, but that was at the beginning of the MRSA panic. It was found to not only unwieldy, but also not effective in determining if it was appropriate for the HCW to be taking care of patients or not.

A couple years back a study was done in Belgium on VRE. A group of med students volunteered for the study. At the beginning each was swabbed for preexisting VRE so that only those with clean cultures were in the study. They were given two weeks of antibiotic therapy and then swabbed again. 67% came back VRE positive. Moral of the story is to not use antibiotics when not needed.

Next please remember that these patients are going home. Do we expect family members to take isolation precautions after the patient is discharged? Of course not. Why? Because the patient going home is not likely to have an active infection anymore. They are colonized.

It is necessary for me to explain that I work at a Select Specialty facility. That means we are a hospital within a hospital. We take long term vent weaning, long term infections, difficult and non healing wounds. The other aspect of my job is wound management. These three catagories are the bulk of our patients. All of these particular things put the patient into a high risk catagory for MRSA/VRE. Every one of my patients are swabbed for both when admitted, and when preadmission screening is done we look for it so we know ahead of time if there is either. All MRSA/VRE patients are put into contact isolation regardless of whether they are active or colonized. This is done for the protection of all patients. Mind you I have only 33 beds I am responsible for, and this is not a feasible activity for facilities that are large, for one there is simply not enough infection control nurses to follow up on every single patient in large facilities. In the third quarter of last year I did a study. Nearly 20% of our patients had a known MRSA/VRE prior to admit, just over 15% cultured out after admission. Together this is 35% of the patient population. Our rates of noscomial transmission are extremely low, though there are no national benchmarks to compare it to. I believe they are low however because we insist that appropriate contact precautions are followed. BY EVERYONE. Not simply the nurse. I have spent a great deal of time in educating, and when necessary I contact dept heads so they ensure their people are following the posted guidelines. This includes physicians. I have the happy occurance of working with a ID doc as the chair for infection control who backs our policies to the hilt. Physicians caught not using precautions gets a letter from the infection control committee, signed by it's members. We are working on bylaws that would allow penalites to physicians who are none compliant.

Tracy, I am not saying your concern is not valid, only that it is impossible to know if the patient you think is clean is in reality not. So you may be unknowingly be dragging something from that patient to another. Much better to know and to ensure appropriate guidelines are followed because you have a much better chance of protecting immunocompromised patients that way, regardless of what a patient assignment is. No matter what to ensure you are not taking something to another patient hand hygiene is the biggest key.

There are resistant strains of pseudomonas out there now, and they potentially may be much worse than MRSA/VRE. Particularly for vent patients. Aspergillis is much more likely to kill a patient than is MRSA/VRE if not treated quickly. Especially if it gets into the heart values.

So everybody, use your hand hygiene guidelines right(only 17% of HCW's do) and if you know someone has MRSA/VRE than use the contact precautions appropriately. If this is done then what mix of patients you have in your assignment does not matter. That is why infection control is not uptight about the patient assignment, they fully expect that guidelines will be followed.

[RNonsense]

Nicely stated RN country...thanks for the info. We try to put them on different teams on my ward...

[Pamelita]

I work in VRE and MRSA paradise!!! in my hospital, I think 80% of the patients have Mrsa, its horrible. I don' t know why we end up with all those patients!!

[renerian, BSN, RN]

Pamelita..........................wow that is very high.....................who is carrying it? Wondering......

renerian:eek: