MRSA in sputum and open door?

[NurseyTonyaLPN]

I'm an agency nurse and was working in a LTC facility. One of the residents (who just entered this facility from the hospital) had an airborne precaution sign and the offgoing nurse asked another nurse to take this patient b/c she had contact and airborne precautions. She said the airborne prec was for MRSA in the sputum. Another nurse took her, but she told me it wasn't really airborne precautions because the lady was not coughing, it is in her sputum and since she's not coughing the airborne precautions aren't really supposed to be in play, but if she starts coughing, then they are. OOOOOKKKKKKAAAAAYYYYYYY. So I go about my work. The CNA left this lady's door wide open and I went to close it. Resident said please don't close the door. I explained that b/c of her respiratory infection that it needed to be closed. Well the nurse that took over for me, told me in not a mean, but kind of condescending way that she told me it was not really supposed to be resp isolation and that she could have her door open b/c she was lonely. Even if the isolation DID only matter if she was coughing, who's to say she doesn't have a coughing fit with the door wide open spreading her germs into the hall to share with all the residents and staff? Is anybody with me or am I just being paranoid? I feel like as a lowly agency nurse I have no say so when it comes to the staff nurses who know better than me (even though this resident was new, not one they'd known forever).

[canoehead, BSN, RN]

MRSA in sputum calls for droplet precautions, which means you need wear protection if you are going within three feet of the patient. I assume the door was further than that far away, so leaving it open would be OK.

[TallGirlAni]

I agree with Canoehead.

MRSA in the sputum is droplet precautions and coughing or no coughing, droplet precautions should be used (mask within 3 feet of patient), gloves, handwashing.

[NurseyTonyaLPN]

I agree with Canoehead.

MRSA in the sputum is droplet precautions and coughing or no coughing, droplet precautions should be used (mask within 3 feet of patient), gloves, handwashing.

Hmm, I wonder why the dr ordered airborne precautions then?

[TallGirlAni]

I would question the doctor's order that this be airborne precautions. Collaborate with the doctor and suggest to him that he should change the precautions to at least droplet. I did some research on CDC's website about precautions and MRSA. Check these links out so that you can explain your patient's case to the doctor.

Although MRSA is a bacteria, and can be spread when the patient is coughing or sneezing (droplet precautions), it is not airborne (small particles lingering in the air like TB, varicella, or measles). Does she also have any of these? If she is truly in airborne precautions, then she should be in a better ventillated room (like a negative airflow room), and all people coming in contact of this patient should be wearing a special mask that he or she must be personally fitted for.

When calling the doctor, it is also nice to explain your case nicely, and have a plan in mind. Let him know what your institution's policy for airborne, droplet precautions, etc. Also let him know that other staff are closing the door and confining this patient to her room (which can be cruel if she does not have to have her door closed). You are the patient's advocate and if you do not question this and help make the proper changes, this patient can end up feeling lonely and isolated.

I always question the doctors' orders when they do not make sense to me. After all, they are human and can make mistakes. But, I do it in a professional, calm manner, not making them feel like they are wrong. Collaborating with the doctors is one of the most beneficial things you can do for your patients.

http://www.cdc.gov/ncidod/dhqp/gl_isolation_droplet.html

http://www.cdc.gov/ncidod/dhqp/gl_isolation_airborne.html

http://www.cdc.gov/ncidod/dhqp/gl_isolation_ptII.html

http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html

http://www.cdc.gov/ncidod/dhqp/ar_mrsa_healthcareFS.html

[NurseyTonyaLPN]

I would question the doctor's order that this be airborne precautions. Collaborate with the doctor and suggest to him that he should change the precautions to at least droplet. I did some research on CDC's website about precautions and MRSA. Check these links out so that you can explain your patient's case to the doctor.

Although MRSA is a bacteria, and can be spread when the patient is coughing or sneezing (droplet precautions), it is not airborne (small particles lingering in the air like TB, varicella, or measles). Does she also have any of these? If she is truly in airborne precautions, then she should be in a better ventillated room (like a negative airflow room), and all people coming in contact of this patient should be wearing a special mask that he or she must be personally fitted for.

When calling the doctor, it is also nice to explain your case nicely, and have a plan in mind. Let him know what your institution's policy for airborne, droplet precautions, etc. Also let him know that other staff are closing the door and confining this patient to her room (which can be cruel if she does not have to have her door closed). You are the patient's advocate and if you do not question this and help make the proper changes, this patient can end up feeling lonely and isolated.

I always question the doctors' orders when they do not make sense to me. After all, they are human and can make mistakes. But, I do it in a professional, calm manner, not making them feel like they are wrong. Collaborating with the doctors is one of the most beneficial things you can do for your patients.

http://www.cdc.gov/ncidod/dhqp/gl_isolation_droplet.html

http://www.cdc.gov/ncidod/dhqp/gl_isolation_airborne.html

http://www.cdc.gov/ncidod/dhqp/gl_isolation_ptII.html

http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html

http://www.cdc.gov/ncidod/dhqp/ar_mrsa_healthcareFS.html

Since the other nurse took the assignment, I didn't look at the resident's chart. I was just told by the nurse who was leaving that she was on airborne precautions b/c of mrsa in the sputum and a mask, gown, and gloves were required on entering the room, so she said I shouldn't take the resident. Another nurse was willing to take her. The airborn precaution warning was posted at her door, as well as contact. The other nurse (who did take her) said she was the one who did the admission and she said she was informed that it was only airborne if the resident was coughing, and since she wasn't, it was not airborne. The dr had still kept her on the same precautions from the hospital although they weren't necessary anymore (according to the nurse). Since I didn't look at the chart, I don't know what else was going on with the resident, if anything, but since there was some confusion I figured it was better to be safe than sorry in regards to closing the door. If it wasn't truly airborne, then airborne shouldn't have been on the door IMO. As far as collaborating with the MD, since I'm agency I don't know if I'll go back anytime soon to that facililty or not. Plus since I didn't take her as my patient, I didn't call the dr or read her chart.

Also, as far as the negative-pressure rooms, I've seen these used in hospitals but in LTC (and even some hospitals) they don't have negative pressure rooms and only keep the door shut to contain the germs. Don't know if this is right, but I've seen it many times.

[TallGirlAni]

If something is truly airborne (like TB) and the door to a room without proper ventillation is shut to contain the germs in LTC, then I feel sorry for anyone who has to enter that room without a proper mask (like an N-95 mask that each individual must be properly fit-tested for).

If you ever encounter this again in LTC, then you might want to consider letting the nurse know about these cdc threads so that he or she can properly assess the situation and make the phone call to the doctor for proper precautions orders.

For things that should be droplet precautions, if the patient is more than 3 feet from the door, then shutting the door unnecessarily and keeping them alone and confined, to me seems not only unneccessary, but cruel.

Just because the sign on the door was ordered by the doctor doesn't make it necessarily right. Things like this should be questioned, for the patient's sake. That is tantamount to saying, "well, I am giving the medication (even though it may be wrong), because the doctor ordered it. If they didn't want it given that way, then they shouldn't have ordered it to be given that way."

I would not like to have the door shut on me if it didn't have to be. As a nurse, I put myself in my patients' shoes, and advocate for them as such.

[dorimar, BSN, RN]

MRSA is contact precaution even in the sputum

[worried sick]

visiting my mother in law in the hospital, my husband and i had to put on mask on gloves. We were told that she had an infection. I asked for more information on this infection. While waiting for the info. my mother in law was coughing, sneezing and blowing her nose into the forced oxygen tube that she had on. She was really having a hard time breathing. I was helping her to drink water and comming close to her to try and hear what she was saying. A few hours later I was given papers on MRSA. This is what she has. Lung MRSA and bloodstream MRSA. My husband and I went to our hotel room and the first thing we did was to shower. In the morning my eye was a little crusty. I washed it, but it kind of hurts. We visited mom for three more days in the hospital. Now we are home. Washed everything in bleach water, but my eye still hurts. How long does it take for pink eye to come about. And could i have been infected with MRSA from mom coughing and sneezing while i was helping her at very close range? signed worried sick!!!!!!!

[tleigh7097]

If a patient has a "History" of MRSA in the sputum should the contact precautions always be followed? Does it colonize?

[2BSure]

I have cared for respiratory MRSA patients and been a respiratory MRSA patient myself (no I didn't get it from work I am not inept). In answer to the question "does it colonize" yes it does. An infectious disease specialist will would likely tell you that once a patient has a history of MRSA they should always be considered colonized. As for the airborne precautions my understanding is they are unnecessary. Any patient with MRSA infection should be under droplet precautions regardless of the system/location of infection -- this is because the likely-hood of nasal coloniztion is extremely high even if the infection being treated is limited to a wound (yes I know it is hot and uncomfortable under the mask and all that) -- some people would probably debate that and that is fine with me.

I certainly have never read about the door needing to be closed yet I know this comes up all the time. I was given an answer about the closed door issue once by a colleague. She said it was to prevent people from just waltzing in the room (as visitors often do) without donning the appropriate garb. Then she laughed and said people ignore closed doors with a big sign on it saying "all visitors report to the nurse before entering".

If you have never been in isolation of any kind I can tell you that it is bloody awful, lonely and boring. I know an open door doesn't fix that but at least you can hear noises of other living beings.

Given that we should no longer expect MRSA free facilities I am wiling to bet that every facility now has a written protocol -- of course that would mean finding a regular staff member who had a clue where it was.

The CDC websites are great for this subject.

Maybe my handle should be Typhoid Mary:jester:

[miaelaine]

so MRSA in sputum is droplet precautions, if they are coughing...it's airborne precautions. What about contact? I saw the infection control mnemonics on this site (very helpful to memorize) and they have multiresistant drug organisms (like MRSA) under Contact Precautions. How does the NCLEX classify MRSA? Pls. help. Thanks.