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Perioperative management of multidrug-resistant organisms in health care settings

AORN Journal, Sept, 2007 by Patti G. Grota

During the past four decades, the prevalence of multidrug-resistant organisms (MDROs) and the incidence of MDRO infections have increased steadily in US hospitals, creating an increased risk to patients, including surgical patients. (1) Significantly problematic MDROs include

* methicillin-resistant Staphylococcus aureus (MRSA);

* vancomycin-resistant Enterococci (VRE); and

* extended-spectrum beta-lactamase gram-negative bacilli such as Klebsiella, Escherichia coli, and Pseudomonas.

These MDROs cause infections that are difficult and expensive to treat, resulting in increased morbidity and mortality rates and longer hospital stays. (1)

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Surgical patients are at very high risk for health care-associated MDRO infections. Engemann et al (2) reviewed the records of 479 patients to assess the effect of methicillin resistance on the outcomes of patients with surgical site infections (SSIs) caused by Staphylococcus aureus. Their study concluded that MRSA SSIs are independently associated with increased mortality rates and hospital charges for patients with these infections. Additionally, Carmeli et al (3) reported that patients with wound or abdominal infections caused by VRE were more likely to require surgery than patients without VRE infections. Thus, patients colonized or infected with an MDRO may be at increased risk of requiring surgery in addition to other adverse health care-associated consequences.

In October 2006, the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) published Management of Multidrug-Resistant Organisms in Healthcare Settings, a long-awaited national guideline for preventing and controlling MDRO infections. (4) These guidelines are designed to direct the implementation of strategies to prevent cross transmission of MDRO infections. The guidelines provide not only general recommendations for routine prevention and control of MDROs, but also additional measures called "intensified interventions" that may be initiated when the prevalence of MDROs or incidence of MDRO infections is increasing. They encourage health care facility leaders to ensure that appropriate strategies are implemented fully, evaluated for effectiveness, and adjusted to ensure a consistent decrease in the prevalence of targeted MDROs.

This article provides a brief overview of the HICPAC guidelines as they relate to perioperative nursing and the prevention of infections associated with surgery. The first tier of these recommendations addresses routine prevention and control of MDROs. The second tier of recommendations is geared toward intensified MDRO control efforts. These control efforts are interventions that are instituted when prevalence of MDROs or the incidence of MDRO infections is not decreasing despite the use of routine control measures. This article also reviews recommendations that apply to perioperative nursing and that support excellence in perioperative care.

GENERAL RECOMMENDATIONS

The HICPAC recommendations for administrative measures include making the prevention of MDRO infections a priority as an organizational patient safety goal and providing both fiscal and human resource support to prevent and control MDRO transmission. Human resource support should be evidenced by allocation of resources (eg, adequate staffing) to implement a successful MDRO prevention program. An effective MDRO prevention program should include

* an effective infection control education program,

* an innovative hand-hygiene program,

* appropriate use of standard and contact precautions,

* easy accessibility to and constant availability of personal protective equipment (PPE), and

* an aggressive environmental and equipment cleaning and disinfection program.

INFECTION CONTROL EDUCATION. The HICPAC guidelines emphasize the importance of educating health care workers about the risks and prevention of MDRO transmission. In addition to basic infection control principles (eg, hand hygiene, respiratory etiquette, isolation precautions), education should include the epidemiology of MDROs specific to the facility and actions that can be taken to prevent transmission. Educational updates should provide information to all health care workers on the effectiveness of strategies implemented to reduce rates of MDRO infections.

HAND HYGIENE. Effective hand hygiene has been identified as the most important aspect of an infection prevention program. The Joint Commission has established hand hygiene as a patient safety standard and recommends that facilities have evidence of an effective hand-hygiene program. (5) The hand hygiene patient safety standard requires that hand hygiene compliance be monitored and that compliance rates be provided to health care workers. Two suggestions for measuring improvements in hand-hygiene adherence are

* monitoring and recording adherence reported as the number of hand-hygiene episodes performed by personnel divided by the number of hand-hygiene opportunities and

Health Care Industry

Perioperative management of multidrug-resistant organisms in health care settings

AORN Journal, Sept, 2007 by Patti G. Grota

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