Infection Control: Methicillin Resistant Staphylococcus Aureus

Corresponding Author: Lidong Wang Department of Engineering Technology, Mississippi Valley State University, USA E-mail: lwang22@students.tntech.edu Abstract: Health care personnel come into contact with Methicillin Resistant Staphylococcus aureus (MRSA) on a daily basis. Emergency practitioners must become aware of the trend toward community and health care acquired infections and how to treat and prevent them. Medication treatment is specific to each infection. Disease prevention is mandatory to keep the number of cases decreasing. In this study, a survey of literature has been conducted on the evolution of health care acquired infection based on level of evidence. Early identification and isolation for MRSA at the point of patient entry can prevent MRSA spread and Health Care Associated Infections (HAIs).


Introduction
Health care workers and people in the general community alike are both at risk for being exposed to one of the most common virulent strains of bacterial infections seen in decades. This bacterial infection, known as MRSA, has been seen in widespread outbreaks from across the country. Most patients infected with MRSA are seen in the Emergency Room (ER) as the first point of contact for the infection. The infection causes large, painful abscesses that do not usually subside without treatment or incision and drainage (I&D). Many ER staff are not sufficiently educated to identify and isolate MRSA upon arrival to triage (Carman et al., 2011). A significant task for ER leaders and nurse practitioners is finding a solution for monitoring the number of MRSA cases and giving the appropriate treatment while sufficiently isolating the patient from others more susceptible to the infection. Out of the many skin and soft tissue infections, MRSA has increased from 59% in 2004 to 79% in 2009 (Shapiro et al., 2009). Most cases present as a "spider bite". Costly complications such as necrotizing fasciitis, sepsis and MRSA pneumonia are capable of serious consequences. Although the CDC reports a decline in MRSA infections, recent statistics still report nearly 50% infection rate (CDC, 2011). The cost of contact isolation for one patient with an active MRSA infection is around $8,000 per year (Spence et al., 2012). At least onethird of patients isolated with MRSA will go on to develop an active infection. This data and that many cases occur within 72 h of admission, reinforce the fact that the emergency room should be doing routine screening of patients and that this screening plays an important role in the total number of active MRSA infections (Guleri et al., 2011). Nurse practitioners working in the emergency room are in a primary position to effect change in policy and treatment; implementing evidence-based nursing practice as guidelines for treatment and isolation.
Cases of MRSA have declined in previous years among adults. Recent statistics from US agencies reflect a 31% reduction in invasive MRSA infections over seven years where healthcare-associated MRSA bacteremia has been a reportable disease. The drop most recently has been even steeper at 69%. The total number of patients with MRSA bacteremia fell from 2935 in2008/2009 to 924 in 2011/2012. Similarly, in most European Union countries, the proportion of MRSA among invasive S. aureus infections is stagnating, or even declining greatly (Meyer et al., 2014).
According to Kuehnert et al. (2006), statistical data for MRSA indicates a decline in infection rate but an increase in prevalence among six to 11-year-olds.
While the prevalence rates differ demographically, there is little variance in the rate of complications. Most people in the community are already colonized with MRSA but do not have active infections. Prevention and education about the spread of infectious skin infections and isolation of patients currently infected with MRSA skin infections on point of contact will help decrease the number of active cases. Nurse practitioners working in the emergency room should make priority decisions about actively isolating MRSA patients on point of care and educate patients about preventing further outbreaks such as instructing about hand-washing, hygiene and signs and symptoms of further infection and sources of transmission.
It is a well-known fact that within Europe, resistance rates in MRSA are subject to wide variation, with high rates in the south and comparatively low rates in the Netherlands and Scandinavia. MRSA strains are still common multiresistantpathogens, even though multiresistant Gram negative pathogens are on the increase. In the US, for example, the prevalence of MRSA within individual states ranges from 0/1000 patients in South Dakota to 110.8/1000 patients in Texas and it generally seems lower in the northwest than in the southeast. The Hospital Infection Surveillance System (KISS) has existed since 1997 and includes data about some selected nosocomial infections in various risk areas, such as intensive care units or surgical wards (Meyer et al., 2014). Participationin the scheme is voluntary and individual participants'data are strictly confidential. The fact that participation is voluntary explains the fact that over the years, the numbers of intensive care wards and surgical wards have varied (Meyer et al., 2014). This study examines MRSA practice issues for the emergency nurse practitioner and acute care practitioner.

Identification of Practice Issue and Infection Control
At Methodist University in Memphis, Tennessee, patients identified with skin and soft tissue infections classified as MRSA are currently not isolated from other patients or put on contact precautions upon triage or initial culture identification. There are no protocols in the ER to determine who goes on contact precautions and who does not. Based on presenting signs and symptoms, patients who are infected with MRSA receive neither a rapid nasal nor wound swabs, nor a different treatment plan than any other patient with a soft skin infection. No follow-up treatment is routinely done for patients admitted to the ER with MRSA, even when patient compliance is questionable. This lack of follow-up and protocols must be addressed. The PICO question is, "Should best practice for emergency room patients include early identification and isolation for MRSA?"PICO identifies the patient problem. It stands for Population (P), intervention (I), Comparison (C) and outcome(s) (o). Table 1 shows the colonization by health care contact within the past three months and antibiotic use in the previous month.

Search Strategy
The search was performed using the University of Phoenix's Biomedical Library and the University of Phoenix E-campus Library. Databases searched included CINAHL, EBSCO Database, Google Scholar, OVID Database, PubMed Database and Gale Database. The National Clearinghouse Guidelines and Agency for Healthcare Research and Quality were also searched. Keywords used for the searches included: Methicillin-Resistant Staphylococcus aureus, isolation procedures, MRSA and isolation, emergency room MRSA isolation procedures and MRSA protocols. All studies were fewer than five years old or less, expert opinions and guidelines were considered and the search yield was narrowed if the articles met the criteria and applied to the burning question.

Level of Evidence
The search yielded a total of 245 applicable studies or reviews. One was a systematic review, which is a Level I. Five were a level II; randomized controlled studies. Four studies were cohort studies and rated at a Level III. There was one case-control study rated as a Level IV and one expert opinion rated as a Level VI study. Approximately 3% of UK people are carriers for MRSA. The NHS planned to reduce MRSA nosocomial infections by 20% in 2012/2013. The Department of Health prompted mandatory universal screening for elective and trauma surgery at substantial cost and additional resource demand Patients providing to our service with simple upper limb trauma (O'Neill et al., 2014). Appendix A1, Appendix A2 and Appendix A3 show the level of evidence, grades of recommendations and grading of recommendations.
Level of evidence indicates applicability in practice and grade of necessity for implementing programs or pilots. A level I report is indicated for use in practice and a level IV is a mandatory implementation practice. Overall this study found that many of the recommendations could be handled simply by using wipes that kill S. aureus and other germs at desks, stretchers, keyboards, medicine carts, etc.

Grade of Recommendations and Medication Management
Numerous recommendations were relevant to the advent of early detection and early isolation of MRSA patients. Many researchers suggest that early testing in the emergency room is the best method to prevent the spread of MRSA and the best option to treat. To understand better the recommendations, the recommendations were graded using a Grading Tool (see Appendix A2) that was modified from Dicenso et al. (2004) and the Canadian Task Force on Preventive Health Services. Most of the recommendations were rated as "clear" (see Appendix A3) and several recommendations became "clear" as the studies were rated. Each study supported the early detection and early isolation of MRSA patients to prevent the spread of infection to health care workers and other patients. Emergency rooms are typically point of entry for patients with abscesses and wounds that have become significantly infected. Early detection of an MRSA infection cannot only prevent costly nosocomial infections to other patients but also can prevent health care workers from being colonized themselves. The recommendations by the researchers were unanimous in that cost containment can be made with early identification. These recommendations should take precedence in ERs of current health care settings and protocols should be developed using these as evidencebased guidelines for practice.
One researcher believed that isolation of asymptomatic MRSA patients was costly and inappropriate and did not prevent the spread of Health Care Associated Infections (HAIs). Targeting symptomatic patients such as those who present with open wounds and symptoms of active MRSA infection such as drainage, redness and fever is recommended. Early identification of a patient with active MRSA infection can receive appropriate treatment early, be put on isolation quickly to prevent transmission to other patients and protect health care workers from active infection.
A couple of studies indicated there was not much MRSA flora in the ER setting. One study looked at stethoscopes and the other study looked at environmental surfaces such as desktops, coffee cups, computer keyboards, doorknobs, chairs, etc. (Preidt, 2014). When cultured, no significant growth was indicated on the surface of these items as probably cleaning is sufficient to kill MRSA germs and if ER staff will take the time; this can prevent transmission from patient to patient (Preidt, 2014).
The recommendations will be beneficial to staff in the emergency room only if used or absorbed into practice. Evidence-based practice entails finding supporting literature to answer the burning question and implementing the evidence into practice. If emergency nurses and nurse practitioners will adopt some of the outlined practices, the MRSA infection rate will decrease and the overall MRSA HAIs will decrease as well. Figure 1 shows careful prevention of HCAI-MRSA in the emergency room (Preidt, 2014).

Incorporating Into Emergency Nursing Practice
Adams and Titler (2010) provide a foundation for promotion of evidence-based practice to improve quality health care in the hospital setting. The toolkit for promoting evidence-base practice included: "(1) selecting a topic for implementation, (2) finding and critiquing the evidence to present, (3) developing an action plan," and (4) trial and error of the plan in the clinical setting. Adams and Titler also prepared an intensive program for preparing advanced practice nurses to promote and disseminate evidence-based practice that included: Interactive work sessions, didactic teaching, consultations with experts and networking to increase peer support. Based on Adams and Titler model, several steps need to occur before early identification and isolation can occur in the emergency room. Preventing the spread of MRSA is vital to the health of staff and patients in any acute care setting. Staff and leaders alike should promote incorporating these studies into protocols and practice policies. Financial data has already shown in some studies (van Rijen and Kluytmans, 2009;Spence et al., 2012) that early detection and isolation can affect the financial cost of the hospital caring for the patient with MRSA. For a health care facility to have a less than adequate point of care testing is primarily costly and a waste of health care dollars. The CDC (2011) promotes early detection of MRSA and early treatment. Preventing the spread of MRSA among staff and patients is the priority mark for hospitals caring for MRSA patients. The patient should be cultured on admission to the ER or soon thereafter to establish a benchmark in point of care testing. Waiting longer will prolong treatment with the right medications and could prove costly in terms of other infected patients as staff move from the infected patient's room to clean room, dropping off the infection unintentionally.
Methodist University is willing to implement protocols using evidence-based nursing and will establish early detection and treatment plans for patients who present to the emergency room. About 25% of patients who present to the ER at Methodist University have wounds in the emergency department. The job of triage and the triage Nurse Practitioner will be to determine what patients fit the criteria for early detection and early isolation.
Isolating an MRSA patient requires certain equipment. To do this properly, appropriate Personal Protective Equipment (PPE) must be worn to reduce the amount of infectious material exposed to the staff. Contact Isolation requires gowns and gloves and masks are optional. Good hand washing is also essential for all staff. Staff must be properly educated about isolation procedures and hand washing as well as disinfecting the surfaces of their stethoscopes and other personal items that may have come into contact with the patient such as scissors.
Methodist University needs to develop a team of specialists to determine the needs of the units and submit the protocols and initiatives for the early identification and isolation. This team should consist of nurses, nurse practitioners in the emergency room, ER physicians, lab technicians, infection control council and administrators. All relevant research must be presented to the team and a discussion of the evidence must ensue. The best evidence, only after considering the feasibility should be implemented. Below is a list of recommendations from the literature that the best evidence is considered: • Early identification is a cost-saving move • Early identification and isolation can decrease HAIs and lead to better control of treatment of MRSA infections • Identification and isolation of MRSA in the emergency is cost-effective and screening all wounds should be employed • Keeping emergency room surfaces clean prevents the spread of MRSA to other patients and staff members The purpose of implementing change must be evaluated and re-evaluated. This ongoing process must be a part of the plan developed by Methodist University officials. Ongoing evaluation permits balances in protocols and adjustments. Also if items are being missed, alterations can be made to adjust for that as well. The purpose of initiating the protocol is to reduce the incidence of HAIs in the health care setting. Through early identification and isolation, treatment and precautions are utilized that would hinder or prevent the transmission of the infection to other patients and staff. Staff must receive adequate training on protocols and infection control. Many nurses take infection control for granted. The information must be easily incorporated into a workable education program for physicians, nurses, nurse practitioners, lab technicians and administrators. Questions will continue to arise. The need for nurses knowledgeable in evidence-based nursing is vital.
Barriers to the implementation of protocols and early identification and isolation include cooperation among staff. Some staff may see it as extra work and not want to participate. There will be time constraints for education as shifts differ and some will not want to stay for education on protocols. Overseeing all the staff's education will also be time sensitive. The sheer number of staff that needs to be educated is daunting and can lead to stress. Other preventive measures include the cost of isolation rooms, the cost of point of care testing and the limited resources available.
If the program is successful, other hospitals should look at Methodist University as an example and attempt the same level of care in their own facilities. The outreach of evidence-based medicine is that it encompasses more than one facility. If it is successful, the process should be shared. If others go online with the same program, then the program needs to be continually re-evaluated to determine further room for improvement.

Conclusion
Based on the burning question, these evidence-based studies provided have indicated that early detection, starting in the emergency room and good isolation techniques early at point of entry can prevent the spread of nosocomial MRSA to other staff members and other patients. A cost-saving preventive measure of early rapid testing of all ER patients who present with signs and symptoms and rapid isolation should be implemented without haste. New protocols should be developed following the evidence-based guidelines and ongoing evaluation provided as necessary. Sharing protocols and efforts associated with evidence-based medicine with other facilities is part of the chain of continuing improvement. Supporting evidence should indicate whether or not the protocol should be shared with other hospitals or not. In the end education and reinforcement by the evidence will make the new protocol work.     Good evidence to support the recommendation that the condition, or intervention be specifically considered (clinical encounter, organizational policy, educational practice). B Fair evidence to support the recommendation that the condition or intervention be specifically considered (clinical encounter, organizational policy, educational practice). C Insufficient evidence to support the recommendation that the condition or intervention be specifically considered (clinical encounter, organizational policy, educational practice). D Fair evidence to support the recommendation that the condition or intervention be specifically excluded (clinical encounter, organizational policy, educational practice). F Good evidence to support to support the recommendation that the condition or intervention be specifically excluded (clinical encounter, organizational policy, educational practice).
Appendix A3. Grading of Recommendations   does not seem to be a place where these effects. However, the exact timing between when an MRSA thrives. It would be a good object was cleaned, when it was used or contacted and when idea to have a sister study to it was swabbed was not quantified. These timing details may determine the effects on a unit have had a dramatic effect on the final culture results. The within the same hospital to number of times an object was touched also was not recorded.
determine the effectiveness and Moreover, a convenience sample of only20 ED objects does reliability of the study. not represent the ED as a whole and there may be items that might have been positive for MRSA but were not sampled. Among the items chosen for the study, there was a relatively diverse sampling of ED equipment and patient care areas