CliniCal Practice DeveloPment
Louisa Stone
People with advanced disease approaching the end of life require sensitive consideration with regard to infection control procedures. Strict adherence to infection control guidelines designed for the acute hospital setting may not always be appropriate for terminal y il patients. This article examines the management of meticillin (methicillin)-resistant Staphylococcus aureus (MRSA) within the hospice patient population. It argues that limited evidence is available on which to base practice, noting that procedures and protocols vary across hospices. It is not the intention of the article to provide details of infection control procedures related to MRSA. That information is reported widely in the literature. Instead it wil concentrate on the prevalence of MRSA within the hospice setting and those aspects of infection control practice that have the potential to affect patients in the final stages of life, e.g. screening and isolation practices. Although it analyses the implications of MRSA precautions for hospice care practice, the findings are applicable to any environment in which dying patients receive care. Conflicts of interest: none for people near the end of their life. They also provide care for terminally ill people and infection control practices pertaining to a terminal y il patient population. It wil highlight the need for flexibility and physical, psychological, social and spiritual/ sensitivity with regard to certain aspects existential) and of er respite breaks for of infection control practice, which have the potential negatively to af ect patients in 2008a). Patients are admitted to hospices the final stage of life. Such practices include from all areas of the healthcare system. isolation of patients who test positive for evidence-based infection control practices is an essential aspect of caring for all patient populations, including those who are terminal y il . However, no standard 2001; Afif et al, 2002; Cepeda et al, 2005; hospice/palliative care infection prevention/ Suetens et al, 2006; Gaspard et al, 2009; 2004). It is a Gram-positive strain of the bacteria Staphylococcus aureus and is resistant to first-line antibiotics (Royal hospices; therefore, little is known about organisations with policies, procedures, National Institute for Health and Clinical Louisa Stone is Research Assistant, Gold Excellence (NICE), 2003; DH, 2003, 2005, al, 2009). There is a dif erence between St Christopher’s Hospice, London. At the time Pratt et al, 2007). Therefore, it is not of writing, she was Deputy Ward Manager, this article’s intention to discuss general Nuffield Ward, St Christopher’s Hospice, infection control procedures. Its aim is London. Email: [email protected] to examine the limited literature relating CliniCal Practice DeveloPment
only 0.6% occurring in a hospice (Office settings. Over the timeframe, a total of for National Statistics, 2009). However, it 120 patients transferred from either the Anderson et al, 2002; Ali et al, 2005). A is difficult to gauge the true number of MRSA deaths, as it is often the underlying be termed a ‘carrier’. Approximately 30% of the UK population are colonised with S. aureus (Tarzi et al, 2001), with the bacteria Statistics, 2009). The true prevalence, i.e. general y residing on the skin, hairline and in the nose, skinfolds, perineum and navel (RCN, 2005; DH, 2007a). Clinical infection occurs if the organism invades the carrier’s skin or deeper tissues and multiplies. In healthy individuals the presence of MRSA risk areas (British Society for Antimicrobial However, it can be life threatening in the their patients may have many of the risk al, 2006; Humphreys, 2009). Suetens et al (2006), in a 3-year cohort study, assessed in hospices in the UK. In 1998, Prentice present. Of these patients, 11 (7.1%) were northern part of Belgium (Flanders). Dates carried out a retrospective review of the were several limitations to the study, e.g. the researchers acknowledged that not all were col ected every 6 months during the new inpatients were enrol ed in the study 3-year period. After adjustment for age, sex and co-morbidities, the risk for 36-month A prospective study of factors influencing mortality remained significantly higher in admission, which may have affected results, was then conducted. In the three hospices highest ef ect of MRSA on mortality was in the proportion of patients admitted with patients with severe cognitive impairment, after admission. The study found that the prevalence of MRSA colonisation/infection hospitalised twice as frequently for MRSA community, irrespective of the setting from they were infected before admission. Risk factors for colonisation were similar to the general population. There were only a and tenderness at the site of infection. few single rooms, which delayed admission admission. Screening patients on admission 2005). Risk factors predisposing acquisition further reduced bed availability. Prentice patients went on to develop the infection. stay hospital admission; previous repeated associated with significant morbidity in a or long-term antibiotic therapy; invasive small number of palliative care patients. devices, e.g. urinary catheterisation and hospices is not wel documented. Practice intravenous cannulation; frailty/old age; of the infection in this patient population immune system (Prentice et al, 1998; Ali et directors of adult hospices/palliative care units in London and the south of England. colonisation and infection among patients mrSa prevalence/management in hospices
protocols adopted by specialist pal iative deaths occurred in a hospital setting, with care inpatient units in southern England CliniCal Practice DeveloPment
worn when coming into contact with body as touch is such an important part of care fluids or contaminated linen or dressings (Prentice et al, 1998; Parker, 2007).
(Pratt et al, 2007). The wearing of gloves microbes and transmission of microbes to patients and staff (NICE, 2003). However, the protocol. Infection control protocols/ gloves can provide staff with a false sense of infection (Boyce et al, 2004; DH, 2008b). result is positive, a decolonisation regimen patients were MRSA colonised or infected. just before starting a task and discarded possible, irrespective of the availability of immediately after it has finished (Pratt et al, isolation facilities, to reduce the number per cent isolated patients with known or of microorganisms present on an infected individual (DH, 2007b; Patel, 2007) (Figure 1). However, screening does not identify patients within the unit, e.g. going to the carrying out personal care. According to screening swabs only provide results for day centre, smoking areas, recreational and Parker (2007), it needs to be considered the body area from which they are taken, refreshment areas or cof ee shops. Seven (12.5%) units restricted al MRSA-positive providing personal care, particularly when patients. However, such restrictions mainly patients are dying. She stated: ‘Even though 2003). Dand et al (2005), as cited above, someone has an infection and is in a single reported that none of the pal iative care infection. Three-quarters of respondents felt that MRSA did not af ect admissions admissions to the inpatient unit and only and discharges. Opinion was divided about 12.5% screened patients with a history of tasks. What is important is that hands are colonisation were relevant to hospices and hospital. They pointed out that, as routine nurse does not put the individual patient screening is not part of routine practice, patients’ quality of life. Some respondents at risk of cross-infection and that hands reported that protocols resulted in patient are washed after specific tasks have been felt that routine screening could lead to decrease in quality of life. The sample was small and only covered southern England. must be aware that the wearing of gloves However, the study highlighted that there patient anxiety during the end stages of the disease process. The patient’s condition should be taken into consideration before relationships at the end of life, especial y Figure 1.
control procedures that may have a negative ef ect on terminal y il patients will mrSa decolonisation protocols
When patients are found to be MRSA positive they should not automatically be prescribed antibiotics. effect of infection control procedures
Treatment depends on clinical signs, local policies, risk to others, internal risk factors, such as presence on terminally ill patients
of invasive devices and being immunocompromised, and whether the patient is colonised or infected (in infected individuals a course of systemic antibiotics is usually required). Decolonisation protocols usually consist of applying mupirocin ointment to the anterior nares three times a day for 5–7 days rates of MRSA (Johnson et al, 2005; Girou to eradicate nasal colonisation and applying an antiseptic body lotion, e.g. triclosan or chlorhexidine, et al, 2006; Cromer et al, 2008; Beggs et to eradicate skin colonisation. Some policies recommend hexachlorophene talcum powder to the axil ae and groin, but this should not be used on broken areas of skin. Topical antiseptics, e.g. povidone iodine, et al, 2010). It is outside the remit of this silver sulphadiazine or mupirocin, may help to eliminate wound colonisation. However, it is important to article to consider hand decontamination check that the agent is appropriate for the wound and prolonged application of topical agents should be avoided. Antibiotic creams for colonised wounds should not be used because of resistance. Local wound refer to Pratt et al’s (2007) best practice care policies should be followed. In the case of chronic wounds, e.g. pressure ulcers and leg ulcers, advice should be sought. Topical agents may not be appropriate in the case of invasive devices (e.g. percutaneous wearing gloves routinely requires specific endoscopic gastrostomy tubes or urinary catheters) as there is a risk of degeneration.
consideration with regard to patients at Source: Royal College of Nursing (RCN) (2005) CliniCal Practice DeveloPment
patient is in the advanced stage of disease. isolation is unavoidable, strategies should because hospice patients are dying, their distress, e.g. ef ective communication and providing appropriate social support. The decolonised or isolated (Ali et al, 2005). study involved a small number of patients. exclusively care for patients during the end stage of terminal il ness. Patients are also admitted to hospices for symptom control, infection, or have been identified as an rehabilitation and respite. These patients asymptomatic carrier, should be isolated acknowledge. Research is required into the may be discharged home or, in some cases, to reduce the risk of infection transmission ef ect of isolation procedures within the transferred to hospital. Also, although a (Jernigan et al, 1996; Boyce et al, 2004; DH, patient may be dying, the contraction of an 2007b). This is usually achieved by placing infection unrelated to their primary disease adds unnecessarily to patient suffering. personal protective equipment (gloves and However, Ali et al (2005) deemed that the aprons) when entering the room, which is burden relating to screening and treatment safely discarded before exit. According to total number of participants (n=40) benefits for most patients. They cal ed for available, organisations should consider hospitals and one elderly care hospital. of MRSA colonisation/infection, the rates non-carriers in bays or wards. Admission Fol owing a period of hospitalisation or to a pal iative care unit for patients who isolation, the 20 patients in the control effectiveness of current hospice protocols. available (Prentice et al, 1998). The ef ect four psychological measurements relating They advised caution with regard to strict of isolating terminal y il patients must be adherence to current guidelines developed careful y considered, as there is evidence that such procedures are associated with that hospitalisation resulted in negative rigorous for hospice patients and impair quality of life. Parker (2007) recommended et al (2001) conducted a cross-sectional, that pal iative care organisations should matched control study to investigate the psychological impact of hospitalisation and MRSA isolation on older adults undergoing depression that were significantly higher ensure that terminally ill patients receive (P<0.001 and P<0.001 respectively) and effective and pertinent infection control. feelings of self-esteem and sense of control that were significantly lower (P<0.005 conclusion
relating to depression, mood, anxiety and and P<0.001 respectively) than those The prevalence and cross-infection rates anger. Statistical analysis showed that the rates of depression (t=3.00, P<0.01) and anxiety (t=2.98, P<0.01) than the non- isolated group. There was no significant promote psychological wel being. This is dif erence in the anger scores for the two particularly the case when people are at the end of their lives. Although both the involve a combination of activities in order studies cited above had smal sample sizes palliative care populations, they highlight isolation and screening procedures within the potential negative psychological ef ects the palliative care environment. EOLC
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CliniCal Practice DeveloPment
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