MRSA legislation in Maine

Christie RN2006 · Mar 8, 2009

How are "glove" and "contact" precautions different from Universal/standard ones?
As an experienced IC nurse, that worries me.

We are required to wear gloves in the room at all times with glove precautions. We can't even chart in the room without gloves on. Contact precautions requires us to wear gown and gloves.

Mammy1111 · Mar 8, 2009

Thank you to Lamazteacher for your well thought out response. I have learned a LOT in my work for this proposal. The biggest thing is that mandates come hard and that they are generally incremental. It's too bad that it is so political, because it seems that everybody, including doctors and administrators would want to stop the scourge of MRSA in hospitals. Unfortunately, that is not always the case.

I have considered adding MRSA screening of Health Care workers to include Nurses. But, like Universal Screening (vs high risk screening), it will have to come later. I would love to propose Universal screening for every patient entering hospitals, clinics, nursing homes and any crowded institutions in any state. I do have wording in my proposal to widen the scope of screening if any facility has 50% or more HA MRSA positives. So, that somewhat covers that. There are hospitals that do screen all HCWs periodically, but I just don't see that happening this time around. The first thing we need to do is get high risk screening mandated and then all the subsequent steps to prevent spread within the hospital. If this passes and we continue to be one of the highest HA MRSA infection States, then we will go from there.

Another point I'd like to make is that MRSA colonized patients can also be reservoirs of MRSA and it can spread from them to others and from them into their own surgical wounds. Gloves alone will not prevent spread from colonized or infected patients. IF a patient is colonized, it is essential that HCWs use handwashing (WITH SOAP), gloves and gowns. Add masks to the mix if there are respiratory symptoms. This is important especially if there will be close contact, such as bathing or positioning, or if there are bodily secretions on linens. It is also important to encourage the patient to do frequent handwashing.

Decolonization is addressed in my proposal for patients found to be colonized with MRSA. This is especially important for pre surgical patients. Any patient that is going into hospital for an elective surgical procedure should have a nasal (or other body part, as indicated) culture done. Preoperative decolonization with nasal bactroban and hibiclens bath would be encouraged for anybody who tests positive. Of course, this isn't always possible when a procedure or admission is an emergency. Other measures to help avoid postoperative MRSA is antibiotic predosing immediately before surgery and thermal control of body temperature. Some sutures now fight MRSA as do central line catheters and other products.

I do NOT believe that in this age of heart tranplants, curing cancer, bioinic prosthetics, stopping heart attacks and strokes, and other miraculous advances in medicine and surgery that HCWs are helpless against a little microbe called MRSA. It takes a multifaceted but standard approach, and a lot of diligence. but we can prevent it. It has been done in many hospitals in this country AND all over the world.

printsess · May 1, 2009

Kudos for going after the legislation. It's disappointing that appropriate healh information is not shared not only on behalf of the staff caring for the patient, but for the sake of the patient. Withholding the information deprives the patient of appropriate care. This should be dealt with as well. onsuming the cThe facility should be supporting you on that pursuit since they will be costs. I am in Washington State, and dealing witht he same issue. Thanks for sharing.

Mammy1111 · May 1, 2009

My original proposal got whittled down considerably, but we did get mandatory high risk MRsa screening. Isolation, cohorting, precautions, reporting, disclosure, education, infected/ill staff, etc, will all be addressed at the Maine Quality Forum. Maine State Nurses Assoc and I will be included in the process of addressing the rest of those issues. Whatever they/we come up with is what Maine Hospitals will do. There is funding for this through stimulus money. So, there is no reason to hesitate or to do something that will be ineffective. The governors office and the Health and Human Services committee both have put the pressure on the MQF to do this and to do it quickly. We have a deadline of Oct 1 to work it all out. Then it can be enacted sooner than the MQF proposed date of Jan 1 2010.

I am very optimistic that we can make Maine hospitals safer and patients more aware. A huge part of prevention is education. Nurses will be the leaders and enforcers of any new policy for Maine hospitals. They will make it work.

I encourage any nurse, group of nurses or other HCWs to do this in their states. CDC is just not doing what needs to be done to stop these preventable infections. Organize a plan and contact your State legislators and get it done!

seasoned1 · Aug 22, 2009

Are any of you aware of mandates to protect patients from staff who have MRSA?

Mammy1111 · Aug 22, 2009

I am not aware of any such mandate. But, I suppose if a patient gets hospital acquired MRSA and it can be traced back to a staff person, there is the possibility of medical liability.

There is a bill in the Senate to protect healthcare workers in cases of infections contracted while working.

My original proposal in Maine included mandating HCWs wear masks if they have an URI. The reason behind that was that nasally colonized MRSA can be spread if it is sneezed or coughed into the environment, just the same as if a patient did that. HCWs should not be working when they are sneezing and coughing and ill with a respiratory illness, but we all know they do. It that case they MUST wear masks. If there is MRSA growing in the nose, it will be contained behind a mask. And of course scrupulous handwashing is a must.

printsess · Aug 22, 2009

Washington State now has legislation that requires all patients with any history of MRSA (or any resistant bacteria) whether active or not, to be isolated for life now. It is a costly move, but it is a move that protects other patients. All patients must be asked if they have ever had the infection. There are certain patients that are screened for the infection (high risk groups have been identified).

I think it takes aggressive action like this to slow the spread. In the past MRSA was not taken seriously. Now that it is epidemic, I appreciate our legislative response. Kudos to anyone stopping the spread and protecting patients from getting it.

Lives and health are precious. Healthcare workworkers have an obligation to protect them.

Thanks for spreading the word & stopping the disease.

Mammy1111 · Aug 22, 2009

You are absolutely correct. Patients are precious and also they deserve the best and safest possible care.

Alarming increases in MRSA infection rates have gone ignored for 15 to 20 years. Every possible excuse and lie has been used. The most incredible one is when hospitals blame the patient for their infection. That one really gets me. Even if a patient screens positive on admission, it is up to the attending doc to immediately decolonize that patient, particularly if they are going to have anything invasive done. So, even if a patient carries a MRSA colonization into the hospital with them, it does not excuse the hospital from a responsibility to protect that patient (from a full blown infection) and the patients around him as well.

Unless one or a combination of both the Federal bills in the House and the Senate passes, it will take grassroots efforts in every single state to move MRSA prevention forward. WE can't afford to lose more precious lives and see more vicitims disabled by these grotesque infections. And MRSA is at the top of the heap. There are many other infections that hospitals dish out to vulnerable patients. It is really quite frightening. But, MRSA is the most deadly and the most difficult to cure and it is responsible for the most deaths. By addressing MRSA, hospitals will see a ripple effect in a reduction in other HA infections as well. It has happened everwhere there is a solid MRSA prevention

program in effect.

I am familiar with Washington State's new law. There was a huge expose' done by some investigators about Seatle hospitals. The writers won a Pulitzer for their work. It exposed the horror of MRSA in those hospitals. The findings were instrumental in making their legislative proposal successful.

printsess · Aug 22, 2009

A comment on gloves & charting.

When we have an isolated patient, we do not take the chart in the room. All charting that must be done in the room, is done with a pen that does not leave the room. The only papers that go in the room are ones the patient must sign. The rest of the charting is done without patient contact. Since we are doing our medications on the computer now, I take one of the portables (on wheels) to the door, and use the counter space to chart so that I am distanced from the patient when charting, but still able to speak to the patient. I am in contact with the patient when appropriate, but cannot chart until after I take my gloves off and wash my hands.

Every facility needs to work out an isolation protocol that really works. Then all staff need to use the same rules all the time for it to work. With this problem, there is room for creativity to solve the crisis, but not room for individuality in carrying the duties we have.

Mammy1111 · Aug 22, 2009

You are absolutely correct. The procedures must be standardized with no room for interpretation. There is way too much "opinion" and gossip about MRSA and it's prevention. It needs to be the same way all of the time and on each contact with the patient. Without that a prevention program will not work.

lamazeteacher · Aug 23, 2009

We are required to wear gloves in the room at all times with glove precautions. We can't even chart in the room without gloves on. Contact precautions requires us to wear gown and gloves.

When are the gloves changed in the room? I suspect they're changed when contaminated by blood/body fluids of the patient, with handwashing before reapplication of gloves. That's UNIVERSAL precautions.

"Contact" means just that, when in contact with the patient's blood/body fluids, a gown is to be worn if spash of blood/body fluid is expected (ie when changing dressings, drawing and administering blood, giving and removing bedpan/urinal, delivering a baby, cleaning newborns, adminiustering lady partsl medication, inserting rectal or lady partsl suppositories, dealing with nasal, oral and aural discharge such as irrigations, or any open skin lesion/burns). That's UNIVERSAL PRECAUTIONS!!

If your hospital, LTC or other facility has more than Universal, Protective/Reverse and Respiratory/droplet isolation, it is seriously in need of updating their infection control guidelines/procedure books.

Usually the charts of patients in isolation needn't be in the isolation room, if hand held computer components are used to record vitals, I&O, and other items. That piece of equipment can be cleansed before being removed from the room. Usually no pen is needed, when those are used.

When dangerous pathogens such as MRSA have been found upon culture, no other precautions than universal ones are employed. Care needs to be taken to prevent the spread of all contagious and potentially contagious microorganisms, as if they were MRSA or HIV. Signs aren't appropriate outside rooms, to preserve privacy. Anyone entering patients' closed doors must have permission from the nurse for that patient who, in privacy, will tell anyone caring for that patient, what the situation requiring isolation is, and explain/see that official precautions are followed. Those may be posted in medication rooms. :nurse:

Mammy1111 · Aug 23, 2009

"Contact Precautions" are covered in the newest term of all...."Transmission Based Precautions". An astute and educated nurse knows the disease and the method of transmission, and knows appropriate precautions to use regardless of the title.

By any term or definiition, if you do a "dirty" procedure that involves contamination of your gloves, gown and/or mask during patient care, it is necessary to stop, remove your barriers, rewash hands and put on new barriers, if you are going to be doing a "clean" procedure. ie. If you need to change the patient's bedding and gown because of incontinence or wound drainage and THEN you need to change the IV catheter, you must change your barriers. And you must change all your barriers because contact with the patients surrounding environment will contaminate your gown as well. Masks are only necessary for droplet or airborne tranmission. MRSA pneumonia is an example of droplet transmission.

The reason for changing barriers during the care of the same patient is that MRSA and other organisms can be spread from one body part to another by contaminated barriers.