TO GOWN OR NOT TO GOWN?
Submitted by TO GOWN OR NOT TO GOWN? FOR MRSA PREVENTION THAT IS THE QUESTION. WHAT IS MRSA? by Amanda Zapka, SN Co-author: Paula Bylaska-Davies, BSN, MSN Massachusetts College of Pharmacy and Health SciencesTO GOWN OR NOT TO GOWN? FOR MRSA PREVENTION THAT IS THE QUESTION. WHAT IS MRSA?
Methicillin-resisitant Staphylococcus aureus (MRSA) is a staph infection that has become resistant to the beta-lactams antibiotic group, such as methicillin and other penicillin related medications. This antibiotic resistance can make MRSA a difficult infection to treat. In hospitalized patients, MRSA tends to be a life-threatening infection because of prolonged hospital stays, immunocompromised states, and invasive procedures. It can be spread through close skin to skin contact or from items that came in contact with the infection. In the hospital setting, MRSA is generally spread from the unclean hands of health care workers and the improper cleaning of shared equipment. Therefore, it is especially important that healthcare workers follow infection control policies and proper hand washing techniques to prevent the development and spread of MRSA (CDC, 2010).
WHAT IS RECOMMENDED?
The Center for Disease Control (CDC) states that standard precautions should be used for all patients and should be enough to prevent the spread of most MRSA cases. However, in acute-care settings the CDC recommends additional contact precautions be implemented when there are ongoing MRSA transmissions, current infections, previous colonization, and in other special circumstances. The basis of this recommendation was made by a “general consensus and was not necessarily evidenced-based” (Siegel, 2006, p. 26). Therefore, there is still an ongoing debate about the optimal strategies for controlling these multi-drug resistant organisms (MDROs). When there is a lack of evidenced-based research, it causes a predicament when deciding which level of precautions should be implemented in the hospital setting.
The general guideline is that standard precautions include: hand hygiene upon entering patient rooms, after coming in contact with any bodily secretions, after removing gloves, when leaving patient rooms; gloving when the likelihood of contacting infectious materials or blood is high; masks and/or goggles for procedures when an increased risk of being splashed with bodily fluids or blood is present; gowning if contamination of clothing is reasonably anticipated (CDC, 2010). While contact precautions include: single-patient rooms when available, otherwise cohorting like patients; gloving upon entering patient rooms; gowning upon entering patient rooms; the use of disposable or patient-dedicated equipment; removal and disposal of all person protective equipment before leaving the patient room (CDC, 2010).
However, large medical centers have begun implementing the use of standard precautions for MRSA infections or colonizations. These transmission-based precaution policies list that contact precautions are not instituted unless the MDRO is deemed epidemiologically significant by the infection control department.
LOOKING AT THE LITERATURE
The Center for Disease Control (CDC) recommends that contact precautions be implemented for multidrug resistant organisms (Siegel, 2006). However, large medical centers have recently changed their transmission-based precautions policies on multidrug resistant organisms (infection or colonization) to standard precautions. These precaution policies have an essential role in minimizing the risk for contracting an infection such as MRSA in hospital patients, employees, and visitors. The following literature review examines the inconsistencies related to the continuous use of protective barriers (contact precautions) for MRSA or negating these barriers (standard precautions) as a means to finding the appropriate precaution level for controlling this potentially life-threatening infection.
Grant, Ramman-Haddad, Dendukuri, and Libman (2006) examined the role of gown use versus a new protocol of non-gown use in preventing the transmission of methicillin-resistant Staphylococcus aureus (MRSA) in a community teaching hospital. Researchers concluded that, “although there was a slightly greater decrease in the number of transmissions in wards where the new protocol was implemented, this number did not significantly differ from the number of transmission in wards where the new protocol was not used” (Grant et al., 2002, p.192). However, it is important to note that a hospital-wide outbreak of Clostridium difficile diarrhea occurred during the study, possibly enhancing hand-washing compliance, and thereby making it hard to distinguish the true reason for the decrease in MRSA transmissions.
Webster and Pritchard (2009) conducted a systematic review and meta-analysis that examined the use of gowning compared to non-gowning by attendants and visitors in limiting death, infection, or bacterial colonization in infants admitted to newborn nurseries. Eight studies were utilized in this analysis, but only two were described as being satisfactory. Yet, the researchers concluded that “overall, not wearing a gown was associated with a trend towards reduction in death rate, but these results did not reach statistical significance” (Webster and Pritchard, 2009, p. 5).
Safdar, Marx, Meyer, and Maki (2006) examined the effectiveness of preemptive barrier precautions in containing methicillin-resistantStaphylococcus aureus (MRSA) outbreaks in a burn unit as well as a 27-month follow up. Full-barrier precautions (new clean gown and gloves) were utilized for all patients found to have MRSA (infected or colonized) and were later utilized for all patients on the unit as well. The results of the study suggested a decrease in the outbreak of MRSA on the unit; however they were not statistically significant when compared to pre-full-barrier precautions rates for all patients (Safdar et al., 2006). It is important to note that there was an uncontrolled study design, rendering it impossible to conclude that the implementation of preemptive barrier precautions was the defining measure in stopping the MRSA outbreak.
According to Thompson (2010), an earlier study conducted from the same intensive care unit that resulted in a 75% decrease in the acquisition rate of methicillin-resistant Staphylococcus aureus (MRSA) between 1996 and June 2008. However, this decrease in MRSA occurred at a time when the unit was moving to a new location and new measures were being implemented in the ICU. These measures included deep cleaning, improved ventilation, daily washing of all patients with Stellisept®, standardized care of lines, appropriate scrubs for doctors, and wipeable keyboards. Therefore, the previous study did not conclude the cause of the decreased rates of MRSA. As a result, a second study was conducted in the same ICU that looked at acquisition rates, MRSA contracted at admission or after, and the number of inpatient hospital days. It was confirmed that better infection control within the ICU was the factor for an overall decreased MRSA rate in the first three periods of the study (1996 to 2006). However, the study demonstrated that new infection control measures taken afterward in the ICU (from December 2006 to June 2009) had no benefit. This reduction in the acquisition rate was determined to be from a decrease in the prevalence of MRSA on admission (Thompson, 2010).
Each of the previous studies is inconclusive in defining the most effective level of precautions for preventing the spread of MRSA. All the studies resulted in an absence of statistically significant data, and could not prove the superiority of one method. Therefore, further evidenced-based research is warranted to evaluate the use of contact precautions over standard precaution in the role of preventing the spread of MRSA among hospital patients, employees, and visitors.
IMPLICATIONS FOR PRACTICE
It is important to base clinical decisions on evidenced based research findings to protect all parties involved. The decision to don gown and gloves prior to entering an infected or colonized MRSA room appears to be uncertain in some health care settings. Since MRSA organisms are transferred onto the clothes and hands of healthcare workers during routine patient contact, nurses who predominate in bedside care tend to be the culprits of cross contamination. As a result, evidenced-based MRSA transmission precaution policies are important in the field of nursing to control the spread of MDROs.
The discrepancies between standard or contact precautions implemented in some institutions demonstrates that more definitive research should be conducted to determine the most effective infection control measures in preventing the spread of MRSA. The repercussions of the lack of an evidenced-based universal standard could result in an increase of MRSA outbreaks if control measures are not properly executed. The use of contact precautions does not have a statistical significance in controlling MRSA over standard techniques accompanied by adequate hand hygiene. The possibility that contact precautions are more detrimental than beneficial to patients remains unknown.
Contact precautions can have an impact on patient care, though few studies are examining this topic. Studies found that health care providers were not as likely to enter patient rooms that were designated with contact precautions (Siegel, 2006, p.26). In addition patients on contact precautions had increased anxiety, increased depression scores, expressed greater dissatisfaction with their treatment, and had less documented care than non-contact patients (Siegel, 2006). Therefore, it is essential that further research be conducted to examine the effectiveness of evidenced-based control strategy and its effect on patient care.
Education is one of the best prevention techniques available. Better informed health care professionals, patients, and visitors are on MRSA prevention is essential. Proper cleansing and disposing of patient equipment should be completed on a regular basis, regardless of MRSA culture results. However, proper hand hygiene techniques are considered one of the best control methods in breaking the chain of infection. It is crucial to encourage hand hygiene before entering patient rooms, after contact with bodily fluids, after contact with equipment, after removing gloves, and when leaving patient rooms. These simple actions prevent patient cross contamination and offers protection to other health care providers and visitors alike.
CDC - MRSA Infections. (2010, September 16). Centers for Disease Control and Prevention. Retrieved December 6, 2010, from http://www.cdc.gov/mrsa/
Grant, J., Ramman-Haddad, L., Dendukuri, N., & Libman, M. (2006). The role of gowns in preventing nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA): gown use in MRSA control. Infection Control & Hospital Epidemiology, 27(2),; 191-194. Retrieved from CINAHL with Full Text database.
Safdar, N., Marx, J., Meyer, N., & Maki, D. (2006). Effectiveness of preemptive barrier precautions in controlling nosocomial colonization and infection by methicillin-resistant Staphylococcus aureus in a burn unit. American Journal of Infection Control, 34(8), 476- 483. Retrieved from CINAHL with Full Text database
Siegel, J. D., Rhinehart, E., Jackson, M., & Chiarello, L. (2006). Center for Disease Control. Management of Mulitdrug-Resistant Organisms in Healthcare Settings, 2006. Retrieved December 6, 2010, from www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006
Thompson, D. (2010). Hospital infection control and the reduction in intensive care unit- acquired MRSA between 1996 and 2009. Journal of Hospital Infection,76(3), 271-272. Retrieved from CINAHL with Full Text database.
Webster, J., & Pritchard, M. (2009). Gowning by attendants and visitors in newborn nurseries for prevention of neonatal morbidity and mortality.Cochrane Database of Systematic Reviews, (2), Retrieved from CINAHL with Full Text database.