Forensic Nursing Chronicles

Although this entry was posted in January, 2007, nosocomial infection is still a political and safety topic in today’s health care. Reduction of health care associated infection is one of the 2010 National Patient Safety Goals, and MRSA is still a great concern in all areas of health care. It is present in all avenues of society and especially in close living conditions such as prisons, nursing homes and group homes. Most health care workers have been exposed to active MRSA infections and many are colonized as well as patients. According to the CDC "Campaign to Prevent Antimicrobial Resistance" (2002), health care practitioners are to use antibacterials wisely; yet many patients are still being treated for specimen contamination, and colonization as well as in the absence of a positive culture and for extended periods of time. Vancomycin is the drug of choice for active MRSA, and though it used to be a "last resort" drug, it is now frequently given. This is a potentially toxic drug with some serious side effects. Given IV it can cause a systemic reaction of hypotension and shock-like state with flushing (red man syndrome) and it is irritating to the vein, frequently causing thrombophlebitis. Ototoxicity can occur and is more probable with high doses and increased duration of therapy. Vancomycin can be nephrotoxic and should be used with caution in renal impaired. As stated in the above CDC publication, practitioners must "know when to say no to vanco." When it is ordered, nurses must be aware of meticulous infection control, using appropriate personal protection and educating patients and families on MRSA and infection transmission. IV sites must be monitored and changed frequently, and vancomycin infused at an appropriate rate. The patient must be monitored for side effects and toxicity and vancomycin peaks and troughs should be monitored. As nurses, we are called upon not only to help our patient heal, but to do our part in preventing infection transmission, not only in the hospital, but in all aspects of care.

Original Post
January 16, 2007
Title: Medical Malpractice Related to Nosocomial MRSA Infections

The media and government have educated the public in the “super bugs” some patients become infected with in the hospital environment. The most widely known “super bug” is methicillin resistant staphylococcus aureus (MRSA). In June 2006 there was a case brought to court regarding the death of patient who had been in the hospital for a knee joint replacement. Since the patient had not been screened for MRSA prior to hospitalization it could not be proved if he picked up the MRSA during the hospital stay. With the documented community acquired MRSA he could have had the bacteria dormant in his body when he was admitted for the planned surgery. The doctor and hospital were not found negligent in this case.

Many hospitals are fearful of similar lawsuits based on nosocomial infections. Some hospitals are now culturing high-risk patients prior to hospital admission to determine if they are colonized. There is now a nasal swab test that has a turn around time of two hours to identify MRSA. Certainly this can be helpful so that colonized patients coming in for elective procedures can have this treated and also be isolated from non-colonized patients. Patients that test positive for MRSA can be cohorted with like patients or put in private rooms. There are multiple hospitals in Europe starting to follow this intervention with positive outcomes in their nosocomial rates.

It would seem to me the hospital administrators would prefer paying for the MRSA culture versus facing the potential of law suits from patients who develop nosocomial MRSA infections while inpatient. If I had a family member going to the hospital I would much prefer they be tested for MRSA prior to a surgery as “knowledge is power” Having the knowledge of colonized MRSA prior to surgical intervention can allow for adjustments that lead to positive outcomes for the hospital, surgeon and patient. I can visualize hospitals even being forced to do it to allow them better leverage in the court system by being able to say, “this person was colonized with MRSA” prior to hospital admission. From the epidemiology stand point it would also allow the opportunity to keep the more virulent strain of community MRSA from entering the hospital environment.

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