Running head: IS MRSA CAUSED BY DECREASED LEVEL OF STAFF?

Are Nosocomial Infections Such as MRSA Caused by a Decreased Level of Staff Members in Acute Care Settings? Ryan Simpson, Chris Rogers, Kimberly Coats, Kayla Palmer, Michael Fairchild Dixie State University

IS MRSA CAUSED BY DECREASED LEVEL OF STAFF?

Are Nosocomial Infections Such as MRSA Caused by a Decreased Level of Staff Members in Acute Care Settings? Nosocomial infections such as MRSA have been on the rise since they were discovered in the early 1960s. Since then, there has been an increased awareness of healthcare associated infections, and preventative measures are constantly being studied and reviewed to help reduce the spread. There are many years worth of evidence-based practice (EBP), and the research is continuously being analyzed so that healthcare professionals and the facilities, in which they work, can reduce the spread of nosocomial infections to those who are most susceptible, the patient. Methicillin-resistant staphylococcus aureus (MRSA) is a common and constantly changing cause of nosocomial infections. MRSA is responsible for increasing the patients recovery time and length of stay at the hospital, and is a major expense that is assumed by the facility where the infection was acquired. Practice Question Nosocomial infections such as MRSA are constantly being analyzed by the knowledge gained from evidence-based practice. MRSA is a huge cost to healthcare facilities across the nation and the transmission of MRSA from the nurse to patient, or from vectors contaminated by the MRSA bacteria have been raising at an alarming rate. Nurse to patient staffing ratios do play a role in the transmission of the infection, but upon further research there are other simple preventative measures that can provide additional safety to the patient and the healthcare community. The simple task of hand hygiene seems like such a simple preventable measure to stop the spread of infection but when staffing levels are low and a patient overload occurs even the simplest of tasks can be overlooked. The research found, leans towards the spread of MRSA

IS MRSA CAUSED BY DECREASED LEVEL OF STAFF?

from poor nurse to patient ratios, but other factors also have a huge impact on the spread of MRSA. This project will investigate the best methods for preventing the transmission of MRSA. Patient, Population or Problem Mrs. Halcomb stated, 2008 The transmission of MRSA in acute health care settings continues to rise. The spread of infection by the hands of healthcare workers remains one of the top concerns. There is also ongoing debate about the role of the environment as a potential vector of MRSA transmission. There is evidence that MRSA can survive on objects such as packaging for up to thirty-eight weeks (p. 50-77). The Center for Disease Control and Prevention suggest that the spread of MRSA occurs from direct contact with a persons infected skin. If a person contaminated with MRSA touches a surface or touches inside their nose the bacteria can survive and infect other people through direct contact. Healthcare workers caring from patient to patient with contaminated hands and using contaminated equipment are frequent causes of the spread of MRSA. Colonized or infected body sites of the healthcare worker also leave the patients vulnerable to infection (CDC, 2013). Further evidence suggests that MRSA can compound problems of understaffing in hospitals through its effect on staff workloads and staff availability. Nursing workloads for those involved in the management of healthcare associated infections have been shown to rise as a result of an increase in both patient length of stay and severity of illness resulting from infection. Workloads for nurses caring for patients with infections caused by multi-resistant organisms are increased because of the increase in infection control and therapeutic activities that these infections require; however, such situations are seldom accompanied by increases in staffing

IS MRSA CAUSED BY DECREASED LEVEL OF STAFF?

levels, and thus represent an additional work burden on nursing staff (Clements, 2008, p. 42734). There are an estimated two-million patients that suffer from nosocomial infections yearly. MRSA is a huge contributor in the healthcare associated infections and nearly onehundred thousand people die each year from infections acquired in a healthcare setting. These nosocomial infections account for 4.5 billion dollars per year (Ochsner, 2009, p. 27-37). With the problem of nosocomial transmissions of MRSA there have been discussions of which type of preventative care is necessary to prevent nosocomial infections. Interventions The Society for Healthcare Epidemiology of America (SHEA), Centers for Disease Control and Prevention (CDC), National Guideline Clearinghouse (NGC), and the Institute for Healthcare Improvement (IHI), has come forth with strategies to prevent the transmission of MRSA. All of these organizations have similar guidelines and include: antibiotic stewardship which is the appropriate use of antibiotics with consideration to dose and duration of use, environmental decontamination, the use of dedicated equipment, contact precautions, grouping of patients with MRSA infections, contact isolations including a mask, staff education to prevent the transmission of MRSA, proper hand hygiene, and maintenance of appropriate staffing ratios (Upshaw, 2012, p. 77-81). A high nurse to patient ratio is one important step in a multi-step strategy to reduce the spread of nosocomial infections such as MRSA in an acute-care setting. Hand washing and disinfection remains the most effective strategy to eliminate health care associated infections (HAI). Strict hand hygiene as outlined by the CDC guideline needs to be maintained at all times.

IS MRSA CAUSED BY DECREASED LEVEL OF STAFF?

Although the burden of HAI is enormous, it has been estimated that 15-32% of cases can be prevented and economic losses reduced. At the level of the hospital, rigorous interventions including screening of new admissions and isolation of high-risk patients are effective in reducing incidence of MRSA and lead to cost savings, both in endemic and epidemic scenarios. Less intensive interventions based on isolation or use of more effective hand hygiene and disinfection products, have also proved successful (Clements, 2008, p. 427-34). Comparison The different interventions are similar in their ultimate goal, eradicate MRSA. They all work with the process of destroying the MRSA bacteria either on the nurses hands, inside the patients body, and on the equipment used. They destroy these bacteria either by isolating it to a particular area, frequent hand washing or by using antibiotics to work with the patients body to destroy MRSA at a cellular level. Outcome Yet, despite widespread knowledge of the problem, health care providers continue to remain a major source of nosocomial infection. Studies of hand-hygiene practices have demonstrated low compliance rates, although coordinated efforts to address this problem have demonstrated significant improvements in adherence to hand hygiene, and subsequent reduction in nosocomial infection rates demonstrated a clear link between cross transmission of nosocomial infection in the ICU and understaffing, and factors that result in multiple staff-patient contacts, emphasizing the importance of good hand hygiene (Francis, 2008, p. 223-255).

IS MRSA CAUSED BY DECREASED LEVEL OF STAFF?

The Following Question was Developed Is the rate of nosocomial infections such as MRSA increased when nurse to patient ratio is decreased? Evidence The research in evidence-based practice is constantly being analyzed so that healthcare professionals can continue to improve on reducing the spread of nosocomial infections. MRSA is a common nosocomial infection that increases the patients length of stay in hospitals and is a major expense assumed by the facility where the infection was acquired. The transmission of MRSA continues to rise, mainly by the hands of healthcare workers via nurse-patient contact or direct contact with a contaminated object. Understaffing is also a major contributor to the spread of MRSA. Infection control precautions and therapeutic communication with patients is more time consuming, and simple steps such as hand hygiene can unfortunately be overlooked by the nurse. Maintaining appropriate staffing ratios along with following the proper guidelines for the prevention of the spread of MRSA and other nosocomial infections will save the hospital money decrease the spread of infections, and ultimately save lives. Search Items and Results of Search Originally our PICO questions were much broader; as we began to research we realized that we were going to need to narrow down our question. We decided to limit our search to the United States of America. Eventually we decided to focus our research particularly on the increased infections of MRSA. Each member of our group located a particular article according to our decided search terms and the final question that we decided to go with.

IS MRSA CAUSED BY DECREASED LEVEL OF STAFF?

Study 1 Peer reviewed: To determine whether staffing and bed occupancy rates had an immediate or delayed impact on the number of new MRSA acquisitions in a well-staffed ICU, and whether these variables could be used as predictors of future MRSA acquisitions. (Kong, Cook, Patterson, Whitby, & Clements, 2012, p. 333) Population: ICU patients (chosen at random according to bed occupancy) Sample size: 796 beds Results: The risks posed by high workloads may have been mitigated by good compliance with infection control measures, nurse training and adequate staffing ratios in the ICU. Consequently, staffing policies and the infection control practices in the ICU do not need to be modified to address the rate of new MRSA acquisitions. (Kong, Cook, Patterson, Whitby, & Clements, 2012, p. 333) Our questions was answered, we wanted to know if there is a correlation between staffing levels and MRSA infections. Yes there is, however it can be overcome by compliance with hand hygiene procedures. We feel that this article supports our theory that work load and staffing levels will affect the rate of infection if non-compliant with hand washing procedures Study 2 Cohort research: They evaluated two strategies, conditional logistic regression and generalized estimating equation, to analyze the case-crossover study. The study was performed among critically ill patients in the medical intensive care unit (Hugonnet, Villaveces, & Pittet, 2007, p. 1323).

IS MRSA CAUSED BY DECREASED LEVEL OF STAFF?

Population: critically ill ICU patients Sample size: 366 patients Results: A comparison of the three study designs showed that lower nurse staffing was associated with an approximately 50% increased risk of nosocomial infections. (Hugonnet, Villaveces, & Pittet, 2007, p. 1323) Our question was significantly answered with the evidence from this study. Study 3 Review of another study: This review presents evidence for the role of hospital overcrowding and understaffing in the failure of MRSA control programs. Mechanisms for the interaction between overcrowding, understaffing, and MRSA infection are described and the role of MRSA in compounding the problem is outlined, leading to the hypothesis of a vicious cycle. Finally, methods of MRSA control are discussed in this context and more effective decision frameworks are proposed for resource allocation by health policy makers and hospital managers (Clements. et al, 2008, p. 427). Population: Adults chosen at random Sample size: Millions, Worldwide Results: The drive towards greater efficiency by reducing the number of hospital beds and increasing patients throughout, has led to highly stressed healthcare systems with unwelcome side-effects. Overcrowding and understaffing have had a negative effect on patient safety and quality of care, evidenced by the flourishing of healthcare-acquired MRSA infections in many

IS MRSA CAUSED BY DECREASED LEVEL OF STAFF?

countries, despite intense efforts to control and prevent these infections occurring (Clements. et al, 2008, p. 427). Our question has been very well answered within this study review. It clearly states that there is a direct correlation between understaffing and MRSA infections. Study 4 Cohort study: This paper examines health-care restructuring activities undertaken across North American hospitals over the past decade related to hospital care by nursing professionals (i.e. hospital nurses versus practical nurses or aides). It identifies fundamental lessons learned and highlights important priority research areas that must be undertaken to ensure that future initiatives achieve the intended effect of improving patient outcomes. (Tourangeau, Stone, & Birnbaum, 2003, p. 160) Population: Health care worker, Nurses, Management Sample size: Insufficient information Results: Nurse staffing levels in intensive care units (ICUs) have been found to be inversely related to incidences of antibiotic-resistant organisms such as methicillin-resistant Staphylococcus aureus (Tourangeau, Stone, & Birnbaum, 2003, p. 160). This study proves that there is a direct correlation of nurse staffing levels and incidences of MRSA.

IS MRSA CAUSED BY DECREASED LEVEL OF STAFF?

10

Study 5 Review of a study: By understanding the preventive strategies associated with reducing HA-MRSA transmission, the medical-surgical nurse can impact mortality rates and healthcare costs. He or she should model and enforce adherence to prevention strategies, such as hand hygiene, contact isolation, and other evidence-based strategies (Upshaw-Owens, & Bailey, 2012, p. 79). Population: Nurses in an acute care setting Sample size: not given Results: A needed continuation of EBP to provide the best research of how to prevent the transmission of MRSA. Nurses need to follow guidelines and be held accountable (UpshawOwens, & Bailey, 2012, p. 79). This study was not conclusive on the correlation of nurse staffing levels and the incidences of MRSA. However, they did recommend the need for more research to provide EBP to limit the transmission of MRSA. Summary of Evidence and Practice Recommendation Conclusion Through all the research, we have come to the conclusion that understaffing of nurses and increasing their workload, will contribute to new acquisitions of MRSA. Implementing stricter and more adequate hand hygiene practices is proven to be the main factor in the eradication of MRSA. When nurses have a heavier work load they are less likely to focus on the most important intervention; hand hygiene. It is our recommendation that hand hygiene practices are retaught and that as possible the work load of nurses is not to exceed their abilities.

IS MRSA CAUSED BY DECREASED LEVEL OF STAFF?

11

References Centers for Disease Control and Prevention. (2013). mrsa. Clements, A., Halton, K., Graves, N., Pettitt, A., Morton, A., Looke, D., & Whitby, M. (2008). Overcrowding and understaffing in modern health-care systems: Key determinants in methicillin-resistant staphylococcus aureus transmission. The Lancet Infectious Diseases, 8(7), 427-34. Francis, D. (2008). Iatrogenesis: The nurse's role in preventing patient harm. Evidence - Based Geriatric Nursing Protocols for Best Practice, 223-255. Halcomb, E. J. (2008). Role of mrsa reservoirs in the acute care setting. Systematic Reviews: Joanna Briggs Institute, 50-77. Hugonnet, S., Villaveces, A., & Pittet, D. (2007). Nurse staffing level and nosocomial infections: Empirical evaluation of the case cross-over and case-time-control designs. American Journal of Epidemiology, 165(11), 1321-1327. Kong, F., Cook, D., Patterson, D., Whitby, M., & Clements, A. (2012). Do staffing and workload levels influence the risk of new acquisitions of methicillin-resistant Staphylococcus aureus in a well-resourced intensive care unit?. Journal of Hospital Infection, 80, (4), 331-339. Ochsner, J. (2009). Infection control and prevention: A review of hospital-acquired infections and the economic implications. US National Library of Medicine National Institutes of Health, 9(1), 27-31.

IS MRSA CAUSED BY DECREASED LEVEL OF STAFF?

12

Tourangeau, A. E., Stone, P. W., & Birnbaum, D. (2003). Hidden in plain view: The importance of professional nursing care. Clinical Governance, 8(2), 158-163. Upshaw-Owens, M., & Bailey, C. A. (2012). Preventing hospital-associated infection: MRSA. Medsurg Nursing, 21(2), 77-81.