The research is relevant in order to identify the evaluation methods of Assir Central Hospital and Khamis Mushait Hospital in terms of combating MRSA and VRE in HAIs through vancomycin . As such the outcome of the research will provide an overview on how effective hospitals at present in combating MRSA and VRE. In addition, the evaluation methods and/or guidelines of these hospitals could contribute to the relatively few amount of literature which tells how to eliminate MRSA and VRE. Review of Related Literature
In 2002, the CDC issued guidelines that called for hospitals to “thoroughly clean and disinfect environmental medical equipment” surfaces on a regular basis (Carling, et al, 2005, p. 2). The United Kingdom’s Department of Health (DH) identifies three inter-related factors as crucial to controlling HAIs. These are surveillance, evidence-based infection control practices and the responsible use of antibiotics (Wiseman, 2006). In regards to surveillance, the British DH established a national surveillance program, the Nosocomial Infection National Surveillance Scheme (NINSS) (Wiseman, 2006).
The goal of this program was to facilitate support for surveillance of surgical site infections and bloodstream infections. Participation in this program has been voluntary, but many hospitals have chosen to make use of this standardized surveillance system, which has added tremendously to the national database on this topic (Wiseman, 2006). Reporting of infection rates provides researchers with data on the progression of antibiotic resistant strains of microbes, which, in turn, allows for underlying causes to be investigated and best practices introduced.
Reporting infection rates became mandatory in 2001 in the UK. In regard to evidenced-based infection control practices, national evidence-based guidelines in the UK were published in 2001, which “hospital environmental hygiene; hand hygiene, use of personal protective equipment, and use and disposal of sharps” (Wiseman, 2006, p. 42). The third factor identified by the DH is the responsible use of antibiotics. Antibiotic resistance at the microbial level contributes heavily to the problem.
The majority of antibiotics are prescribed within a community setting and are frequently inappropriately prescribed for the treatment of colds, coughs and sore throats (Wiseman, 2006). Guidelines for prescribing antibiotics in all settings should be based on clinical evidence and best practice guidance (Wiseman, 2006). Harrison and Lipley (2006) state that infection control experts in the UK are continuing their Wipe It Out HAI infection control campaign, which is designed to provide healthcare staff, employers, patients and visitors with the necessary resources to promote safer practices and reduce MRSA and other HAIs.
Curry and Cole (2001) report that the medical and surgical ICUs in a large inner-city teaching hospitals developed an elevate patient VRE colonization rate. A multifaceted approach was instituted to correct this problem, which involved changing behavior by “shifting norms at multiple levels through the ICU community” (Curry and Cole, 2001, p. 13). This intervention consisted of five levels of behavioral change. These encompassed: “1. intrapersonal and individual factors; 2. interpersonal factors; 3. institutional factors; 4. community factors and 5. public factors” (Curry and Cole, 2001, p. 13).
Educational interventions were developed that addressed each level of influence and behavioral change was predicated on “modeling, observational learning and vicarious reinforcement” (Curry and Cole, 2001, p. 13). These procedures resulted in a marked decrease of “VRE surveillance cultures and positive clinical isolates” within six months and this decrease has been consistent over the next two years (Curry and Cole, 2001, p. 13). Research has shown that the nutritional status of preoperative and perioperative patients can influence their risk for acquiring a HAI (Martindale and Cresci, 2005).
Inadequate nutrition, “surgical insult, anesthesia, blood transfusions, adjuvant chemotherapy/radiation/ and other metabolic changes” have been identified as contributing to suppression of the immune system (Martindale and Cresci, 2005). Furthermore, studies have also associated infection risk with glycemic control Maintaining blood glucose levels between 80 and 110 mg/dL vs. 180 and 200 mg/dL has been shown to result in fewer instances of “acute renal failure, fewer transfusions, less polyneuroopathy and decreased ICU length of stay” (Martindale and Cresci, 2005, p.
S53). Citing Ulrich and Zimring, Rollins (2004) states that getting rid of double-occupancy rooms and providing all patients with single rooms that can be adjusted to meet their specific medical needs can improve patient safety by reducing patient transfers and cutting the risk of nosocomial infections. While these researchers admit that the up-front cost of private rooms is significant, this will be offset by the savings accrued through lowers rates of infection and readmission, as well as shorter hospital stays (Rollins, 2004).
A recent study conducted by researchers at Chicago’s Rush University Medical Center found that enforcing environmental cleaning standards on a routine basis resulted in less surface contamination with VRE, “cleaner healthcare worker hands, and a significant reduction in VRE cross-transmission in an ICU” (Cleaning campaign, 2006, p. 30). These improvement in VRE contamination continued to be experienced even when VRE-colonized patients were continually admitted and healthcare workers compliance with hand hygiene procedures were only moderate (Cleaning campaign, 2006). The strategies that the researchers implemented included that they:
1. held in-services for housekeepers about why cleaning is important–emphasizing thorough cleaning of surfaces likely to be touched by patients or workers. 2. increased monitoring of housekeeper performance. 3. recruited respiratory therapists to clean ventilator control panels daily. 4. educated nurses and other ICU staff on VRE and how they could assist housekeepers by clearing surfaces that need cleaning. 5. conducted a hand hygiene campaign, including: mounting alcohol gel dispensers in common areas, patient rooms and every room entrance (Cleaning campaign, 2006, p.
30). CDC guidelines indicate that if hands are not visibly soiled, using an alcohol-based hand rub should become habitual between patient contacts. When hands are visibly soiled, use of an anti-microbial soap and water is required. If contact with C difficile or Bacillus anthracis is possible, it is recommended that the healthcare provider wash with anti-microbial soap and water, as other antiseptic agents have poor efficacy against spore-forming bacteria and the physical friction of using soap and water at least decreases the level of contamination (Houghton, 2006).
Page (2005) indicates that the CDC has joined with the US Department of Health and Human Services, the National Institutes of Health (NIH and the Food and Drug Administration (FDA) to lead a task force of 10 agencies and departments, which have developed a blueprint outlining federal actions to combat this problem. This template emphasizes the efficacy of hand-washing, among other points (Page, 2005). Potential Obstacles to be Addressed While the efficacy of hand hygiene is well accepted, it is also well known that healthcare workers “of all disciplines” frequently fail to abide by adequate hand hygiene practices (Houghton, 2006, p.2).
In fact, research has shown that adherence rates to hand hygiene guidelines are lowest in ICUs, where to the frequency of patient care contact, multiple opportunities for hand hygiene exist on a hourly basis (Houghton, 2006). These research also point out that while sterile gloves aid in preventing infection, some gloves are permeable to bacteria and all gloves have the potential to be damaged in some form during use. Therefore, effective hand antisepsis remains a crucial factor in the spread of pathogens (Parienti, et al, 2002). Summary
The clearest remedy for the insidious drain on healthcare resources and personnel due to the result of HAIs is prevention, which begins with washing one’s hands and more significantly extend to considering all hospital surfaces that could harbor pathogens. This means rethinking some healthcare institutional procedures and routinely cleaning all surfaces which are routinely touched, whether by a gloved hand or a bare hand. Stopping the spread of HAIs includes multiple factors, such as restrained and appropriate use of antibiotics. However, the first line of defense is cleaning/disinfecting procedures.
Literature Cited:
Broadhead, J.M. , Parra, D. S. , Skelton, P. A. (2001). Emerging multi-resistant organisms in the ICU: epidemiology, risk factors, surveillance and prevention. Critical Care Nursing Quarterly 24(2), 20-29. Carling, P. C. , Briggs, J. , Hylander, D. ; Perkins, J. (2005). An evaluation of patient area cleaning in 3 hospitals using a novel targeting methodology. American Journal of Infection Control 4, 1-7. Cleaning campaign targets VRE transmission. (2006). OR Manager 22(7), 30. Curry, V. J. ; Cole, M. (2001). Applying social and behavioral theory as a template in containing and confining VRE. Critical Care Nursing Quarterly 24(2), 13-19.