MRSA and patients who smoke

[tferdaise]

Got a questions, where I work we have contact iso rooms for patients who cultures come back + for MRSA. Let me give you some info on this and I would love some feedback.

23 yr old male who's wound was swabed 2 days prior (on admission), goes to surgery for a debredment of woud. He was allowed to leave his room to go smoke. While in surgery I (the nurse) get a phone call from lab, pt's wound CX is + for MRSA. So when patient comes back from Surgery he is placed in the contact iso room. He was explained why he was place in this room and I explained to him what MRSA was. He was very insisting on going down stairs and smoke. His would is on his L foot, his drsg in C,D,I, no drainage at all. So I wraped his food in a plastic bag, had him wash his hands, and his girlfriend pushed him downstairs. He came back, got back into bed and was happy after that. Our infectious desease department wasn't happy with this, but of course, they do not have to deal with patients like the floor nurses have to.

So I'm asking you all this, what should be done with this, we (nurses) can not force patients to stay in thier rooms, some doctors say, if the patients don't want to complay with medical advice, then they should be d/c. I offered the pateint the nicotine patch but he refused it.

SO what can we do as nurses with this problem???

[Rook]

Wrapping the foot was a good idea, if they want to leave to smoke they have the right. Maybe changing the gown before leaving the room would be a good idea as well.

The only thing I'd do if a patient wants to smoke and say is non-compliant (doesn't sound like he was though) make a deal to get him to do something that needs to be done in exchange for being able to go downstairs and smoking.

Not sure what good will come from discharging (or threating to d/c) a MRSA patient who wants to smoke given that he's mostly on IV antibiotics. He's either going to leave and come back with an even worse infection a few days later or he's going to be PO'ed. Patient's really do better when then are in a good mood.

[miss81, BSN, RN]

Yep, here we have them wash there hands before leaving the room. I mean next week he'll be in the grocery store touching the lettuce and handling the apples we eat.

[AndyLyn]

We no longer allow patients outside, to smoke or for any other reason. If they're well enough to go outside, they're well enough to go home. Not that you can make that call at your facillity.

I'd talk with Infection Control and ask what their policy is. As long as the wound is covered, and you allow patients to go outside, what does IC expect you to do? What would the doctor like you to do?

I hate it when nurses are expected to make judgement calls that we have neither policy nor administration to back us up, no matter which way we go.

As a case manager, I'd push for outpatient treatment on that patient.

[Reddy,RN]

It might be morally outrageous but a negative pressure room would work.

[patwil73]

We recently had this issue come up too. As the supervisor they call me and say the patient wants to go outside and smoke and is MRSA+. What do we do?

Our policy states MRSA is a contact isolation and the patient should remain in their rooms. Our policy also states we are a non-smoking facility and you simply can't smoke here.

However policy at some time must meet reality. Patients will continue to smoke and mobile patients will not remain bed bound for days at a time. So what I instruct our nurses to do is inform the patient of our policy and document that information. If they continue to insist we instruct them that they will have to sign an AMA form and that we will contact their doctor to see if he wishes to continue care.

At this point, once either they have signed or 2 nurses have signed witnessing he is refusing to follow hospital procedure, he is free to go. We then contact the doctor who usually will say - no they will not refuse care and back he comes. After that it should never be an argument.

Also depending on where the MRSA us we will take appropriate precautions such as wrapping the wound well, providing a mask, etc.

Hope this helps

Pat

[tferdaise]

Our faclitiy is a open smoking campus, so we cant tell them they can't smoke.

Our Policy says, Pt's are only to leave thier rooms when medically needed. When I saw that I laughed. The IC people came up and we talked, the IC people stood behind the policy. So it left me the LPN to deal with this issue. So I made the call to wrap the foot up and allow him to leave and go smoke.

We no longer allow patients outside, to smoke or for any other reason. If they're well enough to go outside, they're well enough to go home. Not that you can make that call at your facillity.

I'd talk with Infection Control and ask what their policy is. As long as the wound is covered, and you allow patients to go outside, what does IC expect you to do? What would the doctor like you to do?

I hate it when nurses are expected to make judgement calls that we have neither policy nor administration to back us up, no matter which way we go.

As a case manager, I'd push for outpatient treatment on that patient.

[wooh, BSN, RN]

I remember at the hospital I used to work at, we had a meeting where the DON came and told us patients couldn't leave the floor to smoke, that was the policy. I asked what we do when they want to. We were supposed to explain the policy, use our "therapeutic communication" to convince them not to. So I said, "And when that doesn't work?" Was told, "Well they can't smoke, that's the policy." I asked, "So what do we do?" Was told again to use my "therapeutic communication" skills. Basically, management wants a policy in play to protect the hospital and blame whatever goes wrong on the nurse, without giving the nurses anything to back them up. We can't let them break the rules, we can't enforce the rules.

[kristikkc]

Most hospitals where I have worked as agency and staff have had the non smoking policy on campus. But most of the staff and MDs realized that we cannot keep a person in their rooms if they are mobile. At the hospital I'm working at now we offer a nicotine patch but the pt has a right to refuse. MRSA is explained to the pt. But if the pt wants to get outside, it is their right.

[tferdaise]

In the past when a patient push's I always get the charge nurse and then move on with my other patients. Its not worth it to sit there and convince someone not to go smoke or leave the floor, but of course that is different if the patient has a pysch hold and a order has been written that they can't leave the floor...

I remember at the hospital I used to work at, we had a meeting where the DON came and told us patients couldn't leave the floor to smoke, that was the policy. I asked what we do when they want to. We were supposed to explain the policy, use our "therapeutic communication" to convince them not to. So I said, "And when that doesn't work?" Was told, "Well they can't smoke, that's the policy." I asked, "So what do we do?" Was told again to use my "therapeutic communication" skills. Basically, management wants a policy in play to protect the hospital and blame whatever goes wrong on the nurse, without giving the nurses anything to back them up. We can't let them break the rules, we can't enforce the rules.

[wooh, BSN, RN]

But if the pt wants to get outside, it is their right.

Yep, it's their right to spread their infection throughout the hospital.