SOP_Prevention Of Post Surgical MRSA In Adults

1. Running head: PREVENTION OF POST-SURGICAL MRSA IN ADULTS 1
What Are Best Practices For Preventing Or Reducing Complications Of Post-Surgical MRSA?
Statement of Research Problem
Shirl Hooper
August, 2010

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Introduction
The purpose of this paper is to investigate the problem of post-surgical MRSA in adults
within an acute care hospital setting, and identify best practices to prevent or reduce complications
of post-operative MRSA. MRSA in healthcare settings cause serious and potentially life
threatening infections, as bloodstream infections, surgical site infections (SSI), or pneumonia
(CDC, 2010), especially in patients who undergo invasive procedures, the elderly, renal or
immunocompromised. By definition, a SSI is an infection that develops within 30 days after a
surgical procedure or within one year if an implant was placed and the infection appears to be
related to the surgery. The CDC reports indicate in U.S. acute-care hospitals, SSIs account for
14% to 16% of all nosocomial infections among hospitalized patients, whereas they account for
38% in surgical patients. A culture of safety is crucial in preventing surgical site infection (SSI).
Cepeda et al. (2005) states methicillin-resistant S. aureui (MRSA) causes a fifth of hospital-
acquired infections.
Problem Identification and Significance
The problem is adults acquiring post surgical MRSA infection in an acute care hospital
setting. MRSA is a pandemic problem and spreads in various ways, including airborne
dissemination and transmission from contaminated surfaces. The hands are important vectors for
MRSA (Cooper, 2004; Huskins & Goldman, 2005). Reported reasons for not washing hands
stated by health care workers include skin irritation, inaccessible handwashing supplies, wearing
gloves, being too busy, or not thinking about it. Hand hygiene prevents cross contamination in the
hospital setting, but compliance with recommended instructions is limited. Approximately 50% of
the HAIs are due to lack of handwashing among hospital staff.

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The added complication of the health care-acquired infection causes an increased workload
on nursing, adversely effects morbidity, mortality and health care costs ( Hsu et al., 2007). One in
six patients in intensive care units (ICUs) are colonized or infected with MRSA (Cepeda et al.,
2005). MRSA increases mortality and postoperative stay in an analysis of patients undergoing
coronary artery by-pass grafting by six fold from 4.2% to 26%. According to the Recinos et al.
(2009) study of MRSA infection in surgical intensive care units state, patients with MRSA
infection had longer hospital lengths of (LOS) stay of 16.7% respectively. The estimated number
of hospital deaths from HAI is alarming and this reinforces the need for improved prevention and
surveillance.
Scope of the Problem
Health care-associated infections (HAIs) are a significant public health issue. Skiest et
al. (2007) reports since MRSA was first reported as a HAI pathogen in US hospitals, it has become
endemic in all U.S. health care facilities. To research the problem, the National Healthcare Safety
Network (NHSN) began collecting data in 2005. Of the four hundred and sixty-three hospitals
who reported the incidence of device associated HAIs in 2006-2007, the top three Units indicated
were: MICU 13%, Medical-Surgical ICU 23%, and SICU 12% respectively. The majority of
procedure associated HAIs were identified as surgical ward patients, that were associated with 1-4
of the following procedures: abdominal surgery 26%, cardiac surgery 29%, neurological surgery
12.3%, and orthopedic surgery 18.2%. The three prevalent MRSA infections reported were:
ventilator associated pneumonia (VAP) at 52%, central line associated bloodstream infections
(CLABSI) at 41%, and catheter associated infection UTI (CAUTI) at 7%.

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Dancer, et al. (2006) report that patient acquisitions were 7 times more likely to occur during
periods of nurse understaffing. (Am J Infect Control, 2006). Strict adherence to hand washing and
infection control barriers by doctors, who are the worst offenders, nursing, and other health care
professionals are a growing problem in the spread of MRSA and other microorganisms. Screening
has consistently detected > 80% of colonized-patient-days according to Kypraios et al. (2010). This
indicates that nares surveillance identifies a large majority of carriers and that polymerase chain
(pcr) testing confers a small benefit over routine culture. Estimates of the effectiveness of barrier
precautions showed an overall benefit of 25%, but this benefit varied widely across different types
of ICUs.
Research Problem Statement
Research Problem #1: What are best practices for preventing or reducing post surgical
MRSA in adults within an acute care hospital setting? Research Problem #2: What is the efficacy
of MRSA screening prior to surgery for the prevention of post surgical adult MRSA in the acute
care hospital setting? We will examine the implications of both antibiotic prophylaxsis and active
surveillance screening for MRSA in the adult patient and how it effects the rate of HA-MRSA SSIs
in the acute care hospital. Quantitative research questions focus on whether the dependent variable
is related to the independent variable (s) (Polit & Beck, 2008). The dual-purpose of this paper are
to examine the relationship between post-surgical MRSA (dependent variable) and proposed
interventions of active surveillance screening protocols and antibiotic prophylaxis. Articles and
studies referenced in the review of literature are cited to create a basis for this study.
Theoretical Framework and Literature Review
The conceptual framework for this study is Bandura's self-efficacy theory.

5. PREVENTION OF POST-SURGICAL MRSA IN ADULTS 5
Curtis (2008) states HAIs increase morbidity, mortality and medical costs. In the USA,
HAIs cause about 1.7 million infections and 99, 000 deaths per year. HAIs interventions such as
proper hand and surface cleaning, better nutrition, sufficient numbers of nurses, better ventilator
management, use of coated urinary and central venous catheters and use of high-efficiency
particulate air (HEPA) filters have been associated with significantly lower HAI
rates.
Bandyk (2008) states surgical-site infections (SSI) after arterial intervention is the most
common HAI vascular infection and an important cause of postoperative morbidity. SSIs are
caused by gram-positive bacteria, MRSA has emerged as the prevalent pathogen, which is
involved in more than one-third of cases. Common vectors for MSSA and MRSA strains are the
nasal carriage, recent hospitalization, failed arterial reconstruction, and the presence of a groin
incision, are major risk factors for developing vascular SSI. Pohfahl et al. (2009) suggests
surgical-site infections (SSI), because of MRSA, are a challenge for acute care hospitals.
Surveillance for MRSA and eradication of the carrier state reduces the rate of MRSA SSI.
Key Outcomes and Nursing Practice
According to the Nosocomial Infections Surveillance (NNIS) systems there is increasing
evidence that the level of bedside nurse-staffing influences the quality of patient care. Experience
and evidence has taught the author the spread of MRSA depends on several factors, the
immediate identification and isolation of patients at high risk of colonization with transmissible
pathogens, thoughtful antibiotic therapy, hand hygiene and cleanliness. A study by Johnston &
Bryce (2009) support this concept. Nurses are the key to implementing these measures. However
this poses a growing problem of increased length (LOS) of hospital stays, and significant

6. PREVENTION OF POST-SURGICAL MRSA IN ADULTS 6
morbidity. Inadequate staffing, especially amongst nurses, contributes to the increased
prevalence of MRSA (Coia, et al. 2006).
Doctors, administrators, nurses and other healthcare professionals must adhere to strict
compliance of hand hygiene as well as handwashing guidelines in the care of patients. Everyone is
a potential source of infection, and nurses must consider this, and offer education and interventions
as required. Ergonomics and accessibility of hand hygiene facilities are important. Coia, et al.
(2006) suggest the general principles of infection control should be adopted for patients with
MRSA, including patient isolation and the appropriate cleaning and decontamination of clinical
areas. Scenarios that improve the likelihood of adherence to strict handwashing protocol of
medical staff are visual cues developed with periodic input from hospital personnel, and added
personal protection equipment as needed when contact isolation is present. This is a primary focus
because ICU patients are vulnerable to hospital acquired infections.
Maxfield et al. (2008) reported an alarming statistic presented during a perioperative
meeting that 3.5 million patients will get an infection from a caregiver who did not wash his or
her hands. Given this and the mechanism for HA-MRSA which indicates the highest risk factor
found is poor hand hygiene of health care staff, contact of a MRSA patient and hospitalized in
previous six months. According to Perioperative Standards and Recommended Practices (2009),
sterile technique inservices for all staff members and physicians alike should be reinforced at
least twice a year. There is a tendency for people who work in a sterile setting to become
complacent after awhile. According to Roesler et al. (2008), during literature review of SSIs, it
was discovered one must not become complacent and to review, remind, educate, and be
proactive in examining processes and sterile practices in the OR.
Edmiston et al. (2007) state for a product to be labeled as a preoperative skin preparation,
the US Food and Drug Administration states that the solution must reduce (ie, must indicate time
frame within minutes of application) the number of both transient and resident microorganisms

7. PREVENTION OF POST-SURGICAL MRSA IN ADULTS 7
within the surgical field before the incision is made, and microbial regrowth should be suppressed
for six hours after the skin prep agent is applied.
An overview of proposed US legislative bills have been proposed with the last few years
indicate a need for standardized reporting practices for detected cases of MRSA. Once legislature
is standardized, this will establish guidelines for practice, and enable an audit trail to track issues or
problems to resolve present issues with our present health care system. The proposed bills in
several states in the U.S. are indicative of a precedence several states are pursuing in the prevention
and reduction of HA-MRSA in the post-surgical adult.
Conclusion
Multiple infection control techniques and strategies simultaneously may offer the best
opportunity to reduce the morbidity and mortality of HAIs. Lower antibiotic drug usage will
reduce risk of antibiotic-resistant organisms and should improve efficacy of antibiotics given to
patients (Curtis, 2008). Overall, decreased rates of SSIs from MRSA were observed after
implantation of a universal screening and eradication program for MRSA in the study hospital
(Pohfahl et al., 2009). Overall, the vascular SSI rate is higher than predicted by Center for
Disease Control National Nosocomial Infections Surveillance risk category system, and ranges
from 1% to 2% after open or endovascular aortic interventions to as high as 10% to 20% after
lower-limb bypass grafting procedures.

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Legislature in some states and countries, such as Scotland require active MRSA
surveillance protocols. It is safer and cost effective to identify and treat patients colonized or
infected with MRSA prior to admission and initiate the guidelines set forth by the CDC. There is
substantial evidence to support the use of active surveillance cultures for high-risk patients and
during outbreaks of infection and colonization with antimicrobial-resistantpathogens, as
recommended by the SHEA and the HICPAC (2008). The resistance density rate allows for
assessment of the variability of antimicrobial resistance among device-associated infections in
different patient care areas and may provide an additional way to assess the efficacy of infection
control practices in the future. Collaborating for change is crucial because what we do as nurses
through excellent patient care every day does make a difference in people’s lives.

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