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Preventing and controlling methicillin-resistant staphylococcus aureus in intensive care units

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Preventing-and-Controlling-MRSA-in-ICU

Project Title

The title of the project is “Preventing and Controlling Methicillin-resistant Staphylococcus Aureus Infections in Intensive Care Units”. True to its name, the project discusses nationwide measures that should be taken to curb the spread of this pertinacious infection.

Project Aim

The immediate design of the project is to winnow out the most effective measures of fighting the contraction and spread of methicillin-resistant Staphylococcus aureus (MRSA) infections. The long-term purpose of this project is to reduce the prevalence rate of MRSA infections in an intensive care unit (ICU) by 3%, which is an ambitious, yet attainable, goal. The implementation timeline, as presented in Table 1, shows what measures and activities will be taken to successfully carry out the current MRSA prevention project. Given the unforeseen circumstances that might occur during the implementation process, it is difficult to tell with pinpoint accuracy when each activity will start. Hence, Table 1 uses monthly increments instead of exact dates to show when each activity starts and finishes. The table below provides an insight into the implementation timeline of this project, showing what it plans to achieve and when it plans to achieve it.

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MRSA Prevention Program
Activities/Milestones Year 2014, November 1 – December 31
September December
Encouraging the use of gown and gloves and providing other education for healthcare providers.
Preaching the gospel of soap and water to ICU patients and other potential victims.
Implementing other contact precautions.
Preventing transmission from colonized to uncolonized individuals.

Table 1. Timeline implementation.

The relevance of Clinical Governance to the Project

Clinical governance flashed into existence in the 1990s as a result of the National Health Service (NHS) reforms and has produced a set of tangible results since that time. For the sake of fairness, it is necessary to say that clinical governance principles apply to private sector healthcare organizations as well. According to the generally accepted definition, “clinical governance is a system through which NHS organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish”. In other words, clinical governance refers to all activities that need to be taken to ameliorate, or at least, sustain the existing standards of patient care. Similarly, it is necessary to emphasize the critical importance of NHS organizations’ accountability for improvements in the healthcare sector. Thus, in conformity with clinical governance principles, all NHS organizations should be able to adduce evidence that high standards of patient care are being upheld, regardless of processes, structures, and systems they put in place.

Clinical governance rests on several pillars, all of which, when effective, contribute to the amelioration of patient care. Among the most important pillars of clinical governance are the patient focus, information focus, staff focus, quality improvement, leadership, strategic capacity, and capability. All of these components of clinical governance are equally important and can be further divided into several subcomponents. For instance, staff focus includes staff management and performance, teamwork, education, and training, etc. Leadership is an umbrella term that covers communication, clinical audit, risk management, and staff management. Under the banner of clinical governance, NHS organizations pay meticulous attention to each of these pillars. However, for the purposes of this project, three pillars of clinical governance are of particular importance, namely leadership, staff focus, and patient focus. Undoubtedly, preventing such a formidable infection as MRSA requires deft leadership. It is ultimately the responsibility of senior medical staff to provide leadership, but nurses can also make use of leadership skills at their disposal to improve the quality of patient care, in particular in the context of MRSA prevention. Judging by its name, patient focus implies patient-tailored measures, which in the case of MRSA prevention include encouraging hand hygiene practices. Staff focus covers a range of activities that emphasize the role of nurses and other healthcare professionals in preventing MRSA infections. In this project, staff will be encouraged to use gown and gloves and will undergo specific training.

Evidence that the Issue is Worth Solving

MRSA is a dangerous bacterium that causes infections in different parts of the human body and is “the second most common cause of healthcare-associated bacteremia, responsible for approximately 20% of” healthcare-associated infections”. According to Milstone, Carroll, Ross, Shangraw, and Perl (2010), the prevalence rates of MRSA among community members have been on the rise lately. They have also established that the nationwide spread of community-associated MRSA strains is responsible for the increasing incidence of hospital-acquired MRSA. Thompson (2004) posits that ICUs should be the major battleground for combating MRSA infections because they can easily travel to other wards and hospitals. More specifically, the risk is “1% per day in the first week and 3% per day thereafter”. Overall, Thompson’s (2004) study established that the average prevalence of MRSA in ICU admissions is 8,7%. However, the situation has changed for the better recently. Thus, Calfee at al. (2014) found that the rate of HA-MRSA infections decreased by 54,2% between 2005 and 2011 due to the exertions of many hospitals to improve hand hygiene practices.

Although most of the authors cited above agree that MRSA infections are dangerous and fraught with unpleasant consequences, they also agree that these infections can be effectively prevented, provided that necessary precautionary measures are taken. According to Milstone (2010), bona fide compliance with strict hand hygiene policy and other standard precautions can decelerate the spread of MRSA. Whereas screening, hand washing, cohorting of patients, and using gloves are deemed to be effective, ward refurbishment, body cleansing, environmental cleaning, and use of gowns are generally ineffective. Humphrey (2008) argues that these measures must be combined with suitable space and facilities to be maximally effective and prevent the spread of MRSA to other wards. Thompson (2004) is one of the few researchers who believe that standard MRSA prevention and control measures have limited success. Thompson’s (2004) skepticism notwithstanding, the generally accepted belief is that MRSA infections can be successfully prevented.

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Speaking about the financial costs of the program, it is necessary to note at the outset that the cost of care for patients infected with MRSA is much higher than the cost of a prevention program. Targeted surveillance, including laboratory experiments and supply of materials, would cost $100,000 - $120,000, depending on individual circumstances, and could potentially prevent dozens of MRSA infections. Treating a single patient with MRSA infection, on the other hand, can cost up to $30,000. Likewise, the implementation of this project would require that nurses should live up to the Australian Nursing and Midwifery Council (ANMC) competency expectations. Thus, nurses should be, inter alia, fully accountable for their actions, operate in accordance with appropriate legislation, promote rigorous midwifery care, champion the rights of their patients, participate in collaborative efforts to ensure completion of the aforementioned activities, etc.

Key Stakeholders

Among the key stakeholders of this project are healthcare professionals of all calibers, ICU patients, and their families. Apparently, nurses will be the lynchpin of the project, for they will do the lion’s share of work planned under this project. They will implement contact precautions, teach patients to wash hands properly, and, what is more important, prevent transmission from colonized to uncolonized patients. The role of other healthcare professionals, perhaps senior healthcare staff, is to make sure that the project passes off smoothly. Similarly, they will coordinate the efforts of all nurses involved in the project and provide other training and education necessary for the implementation of this MRSA project to them. They will in part induce nurses to use gowns and gloves every time they are about to interact with ICU patients. The role of patients is not responsible as that of nurses and other healthcare professionals. They will need simply to obey the orders of nurses and hearken to their wise advice. Likewise, they will be encouraged to practice hand hygiene whenever necessary. Family members of ICU patients also have the power to change the outcome of the project, for they have an influence on their ill relatives. Family members will encourage ICU patients to defer to the words of nurses and indeed wash hands more attentively and frequently. In other words, all of the aforementioned stakeholders will play a significant role in the project.

CPI Tool

Clinical Practice Improvement (CPI) tool can be defined as the continuous use of improvement methodology aimed at improving the quality of patient care (McSherry & Pearce, 2011). There is a specific algorithm for the application of CPI tools to clinical processes. Once the magnitude of the problem and the purpose of the project have been articulated in measurable terms, it is necessary to decide which interventions could solve the problem. The interventions necessary to prevent and control the contraction and spread of MRSA infection in ICUs have been delineated at the outset of this project and can be seen in Table 1. Next, it is essential that these interventions should be applied in accompaniment to sequential quality improvement cycles. In other words, the immediate design of using CPI tools in this project is to enable healthcare professionals to undertake a thorough diagnostic of the reasons behind MRSA prevention program failures, which lead to patient harm and other inefficiencies and contrive ways of handling the situation. If a proper CPI tool is chosen and clinicians do everything it takes to implement it, the quality of care for patients will continuously improve.

There are a variety of CPI tools that could be used to improve care for patients in different contexts. For the purposes of this project, such CPI tool as ongoing monitoring has been chosen. The gist of this tool is that it helps healthcare professionals to better control the implementation of the prevention process. The eradication of MRSA transmission and prevention of MRSA infections in ICUs is impossible without consistent and ongoing surveillance and/or monitoring of the process. If monitors find out that the current intervention does not bring desired results, they can advocate for the use of enhanced interventions. True to its name, ongoing monitoring will take place throughout the MRSA prevention program, meaning that trends in MRSA infection and transmission will be promptly taken into account. For example, hand hygiene monitors will keep under surveillance patients’ and nurses’ compliance with the precautions of hand hygiene, providing immediate feedback to project coordinators. Likewise, monitors will provide feedback on the implementation of other components of the project. Overall, given the nature of the current program, ongoing monitoring seems to be the most applicable CPI tool.

Summary of Proposed Intervention

As outlined in Table 1, there are four basic components in this project. First, nurses will be encouraged to wear sterile gown and gloves whenever they interact with patients, especially with those who are already infected with MRSA. Thus, whenever contact with potentially infected cites occurs, the use of gloves and gowns will prevent the spread of MRSA from colonized to uncolonized patients. Senior healthcare staff will remind nurses not to wear the same gloves with different patients and teach other essentials of gloves and gowns to use. Hand hygiene is equally important for patients and nurses, but better control of nurses is needed because they can transfer pathogens to other patients and environments. Thus, nurses will be urged to perform hand hygiene after each contact with a patient, even if gloves were used. Likewise, they will wash hands between “procedures on the same patient to prevent cross-contamination of different body sites”. Other contact precautions, such as environmental cleaning and mouth, nose and eye protection, will be implemented throughout the project as well. Thus, cleaning and disinfection of rooms, with a focus on frequently used objects and equipment in the immediate proximity of patients, should be undertaken on a daily basis. Similarly, nurses will use masks, eye shields, goggles, and other protective equipment when the circumstances demand it.

Colonization prevention and decolonization is the most cumbersome element of the project. However, successful implementation of colonization prevention removes the need for decolonization altogether. Thus, this project will pay utmost attention to prevent the colonisation of the most vulnerable sites on the body. Within this process, nurses will perform wound care, antimicrobial dressing, sterilization of bacteria living on the infected surface, etc. The relevance of clinical governance to the issue is evident. In order to implement the chosen interventions, project coordinators will need to focus on both ICU patients and project staff to bring about quality improvement and henceforth sustain a high quality of patient care. Deft leadership will be necessary to make this happen.

Barriers to Implementation and Sustaining Change

It is expected that at least several barriers to MRSA prevention will occur during the project. Among the most anticipated ones are lack of equipment, lack of signs indicating that a patient needs contact precautions, isolation of patients with MRSA infections in a single room, and poor hand hygiene on the part of stakeholders. Availability of equipment and other materials necessary for the MRSA prevention project is an important concern, but it is unlikely to significantly affect the outcome of the program. Not much money is needed to purchase the necessary materials. Yet, their use is indispensable for healthcare quality improvement. Lack of signs indicating that a patient needs contact precautions is also an insignificant challenge occurring because of the slipshod management of healthcare facilities. Since the current project focuses, among other things, on leadership, removing this barrier will not be a problem at all. Isolation of patients with MRSA infections in a single room can have an array of both physiological and psychological effects on the isolated patients. Consequently, it can have a negative impact on the delivery of quality care. Nurses “have a professional duty of care to the individual patient to address not only their physical needs but also many psychosocial problems arising from their MRSA isolation”, nurses need. Overcoming this barrier may prove difficult, but attentiveness on the part of nurses will certainly mitigate the negative experiences of patients infected with MRSA. Poor hand hygiene is by far the most daunting obstacle to preventing MRSA infections. Yet, it does not mean that it cannot be eliminated. All key stakeholders in this project will be provided with various means of sanitation, such as pocket-sized sanitizers and alcohol-based hand rubs.

Evaluation of the Project

The present MRSA prevention project for ICU patients features a comprehensive process evaluation plan to ascertain whether the program is successful in meeting aggressive goals for reducing the incidence of MRSA infections. The above sections have delineated specific activities that will be carried out to achieve the main goals and objectives of the project. An internal evaluator will assess the progress of the program throughout the project period to enable project workers to introduce the necessary changes to raise project effectiveness. The process evaluator will collect information about the effectiveness of the undertaken activities to judge whether they have been implemented as planned. In other words, he/she will explain the effects of the project on ICU patients, benchmarking the results of the current project against those of similar programs. The process evaluator will begin collecting and analyzing formative data in November 2014 when the program is scheduled to start. Given the nature of the evaluation plan, it is possible that it will provide unpredicted insights into improving the outcomes of the project. The collected data will be presented to project coordinators so that they could make certain changes to improve the outcomes of this MRSA prevention project. Similarly, the evaluator will rendezvous other vital staff to provide formative feedback to them.

Overall, the outcome and impact evaluation will answer three major questions concerning the program:

  1. Were the program activities executed as planned? What barriers militated against the implementation of the planned activities?
  2. How effective was the MRSA prevention program for ICU patients in attaining its goals and objectives?

Conclusion

The current paper has shown what it will take to reduce the prevalence of MRSA infection by 3% in the ICU of a single hospital. The successful implementation of MRSA prevention program necessitates a bevy of measures and activities. They include, inter alia, use of gowns and gloves on the part of nurses, hand hygiene practices on the part of both nurses and patients, environmental cleaning, colonization prevention, and decolonization. To ensure that the MRSA prevention program goes smoothly, it is necessary to monitor the implementation of the project on all phases. Thus, such CPI tool as ongoing monitoring has been chosen for the purposes of this project. Similarly, it is essential that all stakeholders should coordinate their efforts to give more weight to the program. The costs of the prevention program may be as high as $120,000, but that is certainly cheaper than treating the occurring MRSA infections. Although there are some barriers to implementing and sustaining change, they can be effectively overcome.

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