Nursing Revolution

The end of the 19th Century closed with infectious diseases unchecked by modern antibiotics. Fighting the scourge of diseases emerged the nurse, whose primary weapons were hygiene and sanitation. The new century has dawned with a new scourge of "superbugs" mutated and resistant to our modern arsenal of antibiotics.

Because of the enormous risk to patients and health care workers, as well as the cost of nosocomial infection, nurses must learn from the past to develop improved isolation, hygiene and education strategies to address the growing spread of MSRA and other anti-infective resistant organisms. The nurse's role as a frontline healthcare provider allows the nurse a number of opportunities and strategies to address the issue. Three low cost nurse strategies to address the issue include 1.the use of single use plates, trays, spoons, serving ware for MSRA/isolation patients. 2. The improved sanitation and documentation of MSRA room cleaning including charts, accucheck machines, and reusable equipment anywhere MSRA patients are located. 3. the creation of a hospital wide educational campaign, focusing on consistent isolation procedures from patient contact to discharge.
Staphylococcus aureus is a common bacteria, Methicillin-resistant Staphylococcus aureus (MSRA) is a strain that has acquired immunity to anti-infective agents. Although MRSA has been around for years, only recently have these infectious “superbugs” come to public attention. The healthcare community reaction to this growing health crisis has largely been one of disinterest (Weigelt , 2004). The motivation to adjust the current nursing and healthcare disinterest are both financial and patient focused. In 2005, the average total patient cost of treatment for one MSRA infected patient was over $9,000 (Weigelt , 2004). Combined with recent federal regulations limiting reimbursement for noscocomal infections, the financial burden for treating MRSA infected patients will shift to the health care facility. The World Health Organization (WHO) has estimated that as many as 60% of hospital acquired infections around the world are caused by drug-resistant microbes (Dragon, 2006). Infections from central venous lines account for up to 40% of hospital-acquired bloodstream infections (Dragon, 2006). The Centers for Disease Control and Prevention monitored more than 1,200 ICUs from 1992 and 2003, while 36% of Staphyloccus aureus isolates found were multi-resistant in 1992, the figure had risen to 64% by 2003 (CDC, 2006).
The first nursing strategy to combat MRSA is to close the loophole in the hospital isolation room in regards to the food tray, dishware and utensils patients eat from. In many hospitals the same food service items are used and reused for isolation patients and the general hospital population. In theory these trays and dinning ware are sanitized between use, however this system relies on minimally trained minimum wage food service staff to insure proper sanitation is achieved and enforced at all times. Although cost and resource intensive, the safest way to ensure the isolation of patients and prevent the spread of MRSA and other super bugs is to limit or eliminate the use of reusable trays and serving ware in isolation rooms.
Improved sanitation and hygiene is the next strategy in eliminating the spread of nosocomial infections within the health care facility. By documenting and verifying the sanitation of susceptible items on hospital floors with isolation patients, the chain of infection can be disrupted. Charts, Accucheck machines, hand washing stations, and anything that could touch those items are possible vectors of transmission. Routine and documented sanitation of these items and any surface they could come in contact with should be cleaned and recorded (CDC, 2007). Increased sanitation training with an emphasis on "superbugs" should be initiated hospital wide. With the profusion of electronic gear at the bedside, all offering hand-touch sites from which MRSA can spread, basic hospital cleaning should take a higher priority for infections like methicillin-resistant Staphylococcus aureus (Dancer, 2007). From nurses and doctors to food service staff and janitors the entire staff needs to be focused on eliminating the threat of nosocomial infection. As managers of patient care and the Health Care providers with the most patient contact, nurses can play a vital role in overseeing the cleaning and sanitation of the healthcare facility.
Lastly, a nurse led educational program needs to be developed to coordinate and ensure that isolation patients are handled properly from first contact to discharge. To often a laise faire attitude develops in regards to isolation procedures and MRSA. Transport personal such as EMT and other first responders need to be notified prior to transport of isolation patients so that proper isolation procedures can be taken while transporting MRSA infected patients. A recent study of a large urban ambulance fleet found 48% of ambulances were positive for MRSA (Roline, 2007). To limit financial liability and improve communication with these pre/post care providers, routine admin and discharge testing should be performed to verify that the receiving and discharged patient did not acquire MRSA while at the hospital. This can also be used as a tool to monitor and aide first responders by alerting them to the need to sanitize their vehicles/gear before and after a particular patient. Furthermore, admin/discharge testing can be used to monitor trends in MRSA infected patients.
The founders of nursing faced unsanitary hospitals without the aide of antibiotics. Today we face a similar scourge of bacterial infections with dwindling options to fight off these infectious agents. The answer to our dilemma lies in the history of nursing. By improving our isolation, sanitation and hygiene procedures, the spread of MRSA and similar “superbugs” can be slowed and even stopped. Let us look to history as we face the modern challenge of antibiotic resistant bacteria. It cannot be necessary to tell a nurse that she should be clean, or that she should keep her patient clean,–seeing that the greater part of nursing consists in preserving cleanliness (Nightengale, 1859). Thru improved hygiene, sanitation, and nursing education, the threat of MRSA and the other "superbugs" can be overcome.


Isolating MRSA infected patients is an effective intervention to prevent the spread of nosocomial MRSA infections within a hospital; however a complete isolation is an expensive proposition.

The first disadvantage is the cost/inadequate insurance coverage of the patient population. Single use disposable plates, trays and serving ware is expensive in relation to the standard reusable hospital trays, plates and serving ware. The added cost of these isolation protocols may not be covered by many current insurers. (Elixhauser, 2007). Ultimately the financial burden is passed on to the health care consumer in the form or higher hospital bills for the uninsured and higher medical insurance rates for the insured.

The second disadvantage is the enormous environmental impact using so many more disposable items will create. Although patient safety is a priority, a hospital does not exist in a vacuum, and faces the same environmental issues as the real world. Disposable plates, trays, and serving ware will need to be disposed of as hazards waste and likely incinerated like most bio-waste. The incineration of this additional waste created will negatively impact the hospitals pollution production. The current political environment of state and federal governments limiting industrial CO2 and other pollutants will impact the hospital of the future and may interfere with the drive to isolate patients from MRSA.

Admissions into US hospitals are generally via 3 routes: transported to the ED via EMS, self transported to the ED (walk ins), and scheduled admissions (non-ED). Patients admitted to the ED via EMS transport face the greatest risk of acquiring a nosocomial MRSA infection. A recent study of a large urban ambulance fleet found 48% of ambulances were positive for MRSA (Roline, 2007). Walk-ins to the ED are the next greatest at risk, as a large number of potentially infected patient mingle in the waiting room and in the ED. This melting pot of patients makes the ED the gateway for MRSA to enter the hospital, and the primary vector of hospital borne MRSA infections. The second intervention to minimize the spread of hospital acquired MRSA is to transform the ED into an isolation unit and assume all patients are carriers of MRSA. By applying MRSA isolation protocols in the ED the spread of MRSA within the ED and throughout the hospital can be reduced.

The primary disadvantage of admission/discharge testing is inadequate insurance coverage / cost. The cost of turning an MRSA testing for every patent that enters and leaves the hospital is significant. (Elixhauser, 2007). ().Who will pay for the additional testing? A large portion of urban hospital patients have little or no insurance and routine MRSA testing may not be covered for insured patients. Further complicating the issue is the cost of success. As more patients are identified as MRSA carriers, more patients will be treated for MRSA increasing costs further. More patients in the general hospital population would be treated with expensive isolation protocols, and expensive anti-infective treatments.

The second disadvantage of admission/discharge testing for all patients is the socioeconiomic impact. Hospitals in high density low socioeconiomic areas will be disproportionally affected by the increase cost of admission / discharge testing. Depressed socioeconomic communities have increased risk factors the spread of MRSA including IV drug use, homeless populations, and a larger percentage population without medical insurance. These large urban hospitals face increased cost with less income to offset those costs. The financial reality is that the hospitals most needing MRSA testing is least able to afford it.

A third disadvantage is shifting the “MRSA blame” to pre/post hospital care providers such as EMS and nursing homes (Roline, 2007). While admission/discharge test may protect the hospital from nosocomial infection related cost increases, pushing the blame on to pre/post hospital care providers such as EMS and nursing homes only shifts the cost to vital partners that can ill afford the additional costs as well. Recent Medicare rule changes that eliminate payments for nosocomial infection place the financial burden of MRSA onto the entire system. It would be a bleak future indeed to have a pristine MRSA free hospital but have no EMS to bring the patients to us and no nursing homes to discharge our patients to. Clearly shifting the financial burden around will only reduce our ability to address the MRSA conundrum.



Centers for Disease Control and Prevention (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Retrieved November 4, 2007 from http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html

Centers for Disease Control and Prevention (2006). Management of Multidrug-Resistant Organisms In Healthcare Settings. Retrieved November 4, 2007 from http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html

Dragon, N (2006). Fighting today's superbugs: infection control at the forefront. Australian Nursing Journal, 14(2), 16-9. Retrieved October 29, 2007, from Proquest

Forsha B. (2007). Best-practice protocols: Reducing harm from MRSA. Nursing Management, 38(8), 22-27. Retrieved October 29, 2007, from Proquest

Hall, S (2007, February). Infection control: implementing principles in primary care. Practice Nurse, 33(3), 47-51. Retrieved October 29, 2007, from Proquest.

Nightingale, F (1860). Notes on nursing: What it is, and what it is not. New York, NY: D. Appleton and Company.

Roline, C (2007). MRSA colonization in ambulances: Are you taking proper precautions?. Retrieved November 4, 2007, from EMS Responder.com Web site: http://www.emsresponder.com/web/online/EMS-Education-and-Training/MRSA-Colonization-in-Ambulances/5$5711

Weigelt, J, Itani, K, Stevens, D, Lau, W, Dryden, M, & Knirsch, C (2005). Linezolid versus vancomycin in treatment of complicated skin and soft tissue infections. Antimicrobial Agents and Chemotherapy 49, 2260-2266. Retrieved October 29, 2007 from http://aac.asm.org/cgi/content/full/49/6/2260

DeLoach,, C (2007). Pollution prevention workshop for the healthcare industry. Retrieved February 1, 2008, from WRPPN Web site: http://www.wrppn.org/hospital/azhospitalp2.cfm

Steiner, C., Elixhauser, A., Schnaier, J. The Healthcare Cost and Utilization Project: An Overview. Effective Clinical Practice 5(3):143–51, 2002.

Elixhauser, A, Steiner, C.(2007) .Infections with Methicillin-Resistant Staphylococcus Aureus (MRSA) in U.S. Hospitals, 1993–2005. HCUP Statistical Brief #35. July 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb35.pdf

Cantlon, (2007).Significant pathogens isolated from surgical site infections at a community hospital in the Midwest. . American Journal of Infection Control. Volume 34, Issue 8, Pages 526-529.





.