MRSA and your or protocol/policy

carcha · Nov 9, 2003

In the past few months we have had 2 deaths. In other OR's I have worked in we had to leave in the et tube, lines ect until the patient was seen in the morgue. Here I was told to remove the lines and everything else. I can find no policy in my workplace. Does the AORN say anything about this.

shodobe · Nov 9, 2003

carcha, if we have a death in the OR, haven't had one in years,(knock on wood), we will call the County Coroners office and give them details on the death. They have, in the past given us permission to remove all IVs, ETs, etc without them being present.

On the subject of MRSA patients in the OR, I guess we don't have anything special. We treat the patient and the room no different than other cases. I'm not sure if that is right but we haven't gotten anything in writting from our Infection Control nurse. No reported deaths post-op or whatever. Mike

stevierae · Nov 9, 2003

Originally posted by carcha
In our or when we have an MRSA, patient, we clear the room or non essential furniture, have two clean nurses in the or and one to circulate outside. when we finish we recover the patient in the or and then we shower and change while the or is cleaned and the walls are washed down. Is our practice up to date, over the top, rubbish or what. What do u do?

Carcha, I have worked in ORs where they do as you described with MRSA and VRE patients--even one where they had engineering come in and do something weird to the ventilation system, so that the air in the room was exhausted to the outside (literally, OUTDOORS, or so they said) but I don't know that any of that was necessary. or if they were following any infection control guidelines by doing so.

They also made a big point of telling housekeeping, "This patient had MRSA (or VRE)" whether houskeeping did anything different, I don't know. Maybe they cleaned everthing with bleach. I always thought, with universal precautions we treat every case as an infectious case, so why do we have to do anything different with MRSA or VRE?

Also, they used to change the soda lime canisters on the anesthesia machines after any MRSA or VRE patient, and did not use the room for the rest of the day; even after terminal cleaning and even if it caused the schedule to get behind (letting a perfectly good room go to waste.)

Somehow, I think the overkill is similar to what we saw in the early '80s with AIDS patients--people tend to freak out when they are uninformed or underinformed about a disease process--with AIDS, however, we really WERE uninformed, as HIV had not yet been pinpointed as the cause.

One thing I do agree with is recovering these patients in an isolation room in PACU--I figure it can't hurt if one is available--but it may not be at all necessary, as long as universal precautions are followed.

I don't know--I've never seen any written infection control guidelines, at least hospital or unit based ones, that say one way or another if isolation is necessary--I think they are in isolation rooms in ICU (these patients are usually pretty sick, and immunocompromised for other reasons, so I think the rationale for isolation is to protect THEM from the many bugs in an ICU setting--not because of paranoia on the part of the staff surrounding MRSA or VRE.)

I wish an infection control nurse would drop in to this discussion area and give us her thoughts.

chris_at_lucas_RN, RN · Nov 10, 2003

Hi--I am so glad you posted this!

I worked for my first 6 months as a nurse extern, in an open 4 bed ICU. Twice we had patients with this type of infection. One had MRSA in a knee capsule and was hacking and productively coughing the entirety of her stay. Known IV drug user and alcoholic.

The other had VRE. I don't remember any other particulars, just that nobody told me until I had been taking care of him for two days.

I believed both these patients should be in private rooms on closed units, or at least in rooms with other with the same infections. I couldn't even get aprons/gowns! Of course I use gloves and wash my hands, but there is a reason we take special care, isn't there?

I got some heat over mentioning that I felt this probably wasn't the best place for them--and then found on the CDC website that it is standard to house them in private rooms or with "cohort infections."

Later, I learned on a med surg floor where I was floated for a couple of days, that they hang the boxes of gowns on the doors and put a sign on the door that gloves and gowns were to be worn.

One would think that infection prevention and control would top the list of safety concerns, wouldn't one?

Sharon · Nov 10, 2003

Hello,

Steveirae asked for members of the infectious disease forum to drop in on this discussion. MRSA and VRE are Biosafety Hazard 3 infections. The following recommendations from CDC are for handling of specimens in the laboratory setting. I believe they are applicable to any clinical setting. The complete list of reccommendations for all four biosafety levels are at the following link. http://www.cdc.gov/od/ohs/biosfty/bmbl4/bmbl4s3.htm

Biosafety Level 3 (BSL-3)

All procedures involving the manipulation of infectious materials are conducted within biological safety cabinets or other physical containment devices, or by personnel wearing appropriate personal protective clothing and equipment. The laboratory has special engineering and design features.

It is recognized, however, that some existing facilities may not have all the facility features recommended for Biosafety Level 3 (i.e., double-door access zone and sealed penetrations). In this circumstance, an acceptable level of safety for the conduct of routine procedures, (e.g., diagnostic procedures involving the propagation of an agent for identification, typing, susceptibility testing, etc.), may be achieved in a Biosafety Level 2 facility, providing 1) the exhaust air from the laboratory room is discharged to the outdoors, 2) the ventilation to the laboratory is balanced to provide directional airflow into the room, 3) access to the laboratory is restricted when work is in progress, and 4) the recommended Standard Microbiological Practices, Special Practices, and Safety Equipment for Biosafety Level 3 are rigorously followed. The decision to implement this modification of Biosafety Level 3 recommendations should be made only by the laboratory director.

B. Special Practices

11. All open manipulations involving infectious materials are conducted in biological safety cabinets or other physical containment devices within the containment module. No work in open vessels is conducted on the open bench. Clean-up is facilitated by using plastic-backed paper toweling on non-perforated work surfaces within biological safety cabinets.

15. The Biosafety Level 3 facility design and operational procedures must be documented. The facility must be tested for verification that the design and operational parameters have been met prior to operation. Facilities should be re-verified, at least annually, against these procedures as modified by operational experience.

16. Additional environmental protection (e.g., personnel showers, HEPA filtration of exhaust air, containment of other piped services and the provision of effluent decontamination) should be considered if recommended by the agent summary statement, as determined by risk assessment, the site conditions, or other applicable federal, state, or local regulations.

Additional references

Emerging and Re-emerging Infectious Disease

MRSA/VRE

http://science.education.nih.gov/supplements/nih1/diseases/activities/activity5_vrsa-database.htm

Sharon

Infectious Disease forum moderator

chris_at_lucas_RN, RN · Nov 10, 2003

I have no issue with universal precautions being employed with patients with known MRSA or VRE. My deal probably had more to do with just the comings and goings of sharing space with other patients and being cared for by the same nurses, with no barrier to remind one to, for example, get a little alcohol gel before straightening out the bed covers of the next patient.

I found this:

Contact Precautions consist of:

1) Placing a patient with MRSA in a private room. When a private room is not available, the patient may be placed in a room with a patient(s) who has active infection with MRSA, but with no other infection (cohorting).

It is cut and pasted from

http://www.cdc.gov/ncidod/hip/ARESIST/mrsahcw.htm

I guess what got to me was when I asked about whether someone with VRE or MRSA ought to be in an open ICU or in one with walls and doors (the other four ICU's in my hospital actually do have walls and doors between patients' rooms and the nurses' station and common area), productive coughing and all, I was told (and I still can't believe this) by my unit manager that since the actual site of the infection was not upper respiratory, one could not assume that there was MRSA or VRE in the droplets.

I thought we were to assume that it WAS until proven otherwise.

Is this not critical thinking?

Looking for input etc from seasoned nurses. I'm still a student.....

Sharon · Nov 10, 2003

You have hit two sore points in the issues of managing Biosafety Level 3 infections.

1. Should all orifices and fluids be tested on admissions?

2. Is it okay to assume an organism is contained within the body just because it has not been tested for?

Currently I would say that the general opinion, which I don't agree with, No to answer one and Yes to answer two. The good news is that there is the beginning of a shift after MRSA/VRE and SARS to the opposite opinions.

I don't believe you will see a rapid change unless there is more personal injury litigation due to iaotrogenic infection or we have another serious outbreak of a Biosafety Level 3 infection.

If any other nurses from infectious disease forum check in they can weigh in but I have not seen a patient with MRSA limited to a contained body space in over 15 years. In all hospital outbreaks I have been involved in staff were transmitting it asymptomatically from their naris. Therefore my assumption was everyone had it present in his or her naris until proven otherwise.

carcha · Nov 11, 2003

Thank u all for keeping me up to date, and I must say, lately, I have been asked, "Where is the MRSA", however I must say we treat all MRSA patients the same. I would love to know from other OR staff, do u have an outside circulating nurse, what do u do with your dirty instruments, what do u clean the OR with. I was surprised that one piece or info mentioned showering. What does AORN recommend. Does the research support our precautions?