MRSA care in the community: why patient education matters.

CLINICAL FOCUS

MRSA care in the community: why patient education matters Jude Robinson, Alison Edgley, Jane Morrell

Jude Robinson, Infection Prevention and Control Matron, Nottingham CityCare Partnership; Alison Edgley, Associate Professor of Social Sciences in Health; Jane Morrell, Associate Professor in Health Research, Queen's Medical Centre, University of Nottingham Email: [email protected]

ABSTRACT

In primary care, patients are prescribed decolonisation treatment to eradicate meticillin-resistant Staphylococcus aureus (MRSA). This complex treatment process requires the patient to apply a topical antimicrobial treatment as well as adhering to rigorous cleaning regimens to ensure the environment is effectively managed. A pilot study was carried out that involved developing an enhanced, nurse-delivered education tool, training a community nurse to use it, then testing its use with a patient. Three interviews were carried out: one with a patient who received usual care, one with a patient who received the enhanced education and one with the community nurse who delivered the enhanced education tool. The patient who received the enhanced education reported better knowledge and understanding of the application of treatment than the patient who did not. These results are interesting and point the way forward for larger research studies to build on the learning from this limited exploration and develop more effective management of MRSA in primary care.

KEY WORDS

w Infection control w MRSA w Education w Qualitative interviews

436

length of hospital stay, increases treatment costs and increases risk of death (Robotham et al, 2011). Therefore, in primary care, patients that are found to be MRSA positive from a clinical swab or sample are screened and, if necessary, decolonised to try and prevent severe infections and bacteraemias caused by MRSA (Department of Health (DH), 2012). There are limited MRSA guidelines specifically for community settings for managing MRSA. However, there has been a rise in concern regarding community-acquired MRSA infections affecting young and otherwise healthy individuals (Skov et al, 2012). Patients with MRSA in the community are often those accessing health care elsewhere in secondary care (Sastre et al, 2013).

Decolonisation treatment The aim of decolonisation treatment is to remove MRSA from the skin and nostrils by using a topical antimicrobial bodywash and intranasal ointment (Robotham et al, 2011). This has to be used for 5 days consecutively (Coia et al, 2006) to reduce the amount of MRSA that could lead to infection or transmission to others (Robotham et al, 2011). If decolonisation treatment fails after two attempts, then the patient is deemed chronically colonised (Coia et al, 2006). Patients will only be treated again upon risk assessment (for example, if a patient is scheduled for surgery or if they have medical devices in situ). While undergoing this treatment, it is essential that the patient also ensures that the environment is clean to prevent re-colonisation and/or re-infection. This involves regularly cleaning the home as well as changing and cleaning bedlinen, towels and clothes daily (Coia et al, 2006).

Post-treatment decolonisation Post-treatment screens are carried out 48 hours after completing treatment to ascertain the effectiveness of the treatment (Loveday et al, 2006). A study carried out to explore treatment failures of patients with MRSA in an outpatient environment found that treatment failure occurred in 21% of patients (Labreche et al, 2013). Decolonisation may fail for various reasons, including poor adherence or non-adherence by patients. This is a particular risk if patients undertake decolonisation treatment without nursing supervision. For example, older people may find decolonisation regimens challenging (Gould, 2011).

© 2014 MA Healthcare Ltd

T

he bacteria Staphylococcus aureus is found on the skin and in the nostrils of around a third of healthy people (Health Protection Agency (HPA), 2010). Meticillin-resistant Staphylococcus aureus (MRSA), which is a type of Staphylococcus aureus, can live on the skin (colonise) without causing harm (Orsi, 2008). Patients who have MRSA on their skin can contaminate the items that they touch as well as shedding MRSA into the air, which can persist in the environment for prolonged periods of time unless removed through cleaning (Skov et al, 2012). MRSA is quick to exploit any opportunity to produce infections, which, in more vulnerable patients, can become life threatening (Stone, 2009; Rohde and Ross-Gordon, 2012). Patients with MRSA in primary care account for the majority of MRSA infections (Forcade et al, 2011). Infections can lead to MRSA bacteraemias, which occur when MRSA has gained access to the bloodstream (HPA, 2010), causing severe illness in patients who show clinical signs of sepsis (HPA, 2013). Patients who develop an MRSA bacteraemia have a higher rate of mortality than patients with other types of infections (Flayhart et al, 2005). MRSA infection increases

British Journal of Community Nursing September 2014 Vol 19, No 9

Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.113.111.210 on September 28, 2015. For personal use only. No other uses without permission. . All rights re

CLINICAL FOCUS

MRSA in primary care Managing patients with MRSA in primary care is complex and very different to managing patients with MRSA in a hospital setting (Forcade et al, 2011). In primary care, patients have to manage their environment themselves and health professionals have little influence over the environment in which patients live (Skov et al, 2012). MRSA lives in the environment; therefore, it is vital that patients adhere to the environmental factors that can prevent spread and re-colonisation (DH, 2008). In contrast, in a hospital setting, nurses and cleaning staff are able to manage the environment by ensuring linen, clothing and towels of patients are changed daily and hospital wards are clean. In hospitals, where possible, treatment is assisted and supervised by a nurse to ensure optimal adherence and optimal management of the environment (Harbarth et al, 1999). It is not possible to assist and supervise all patients in primary care with treatment because nurses are not with patients 24 hours a day. For this reason, it is important that patients are effectively informed about how to use the treatment correctly to enable the most effective result. It is recognised that poor understanding of treatment instructions might inhibit a patient’s ability to adhere to the treatment as prescribed and to manage their environments

appropriately (Shrank and Avorn, 2007). Effective treatment rests in part on providing adequate information to patients so that they can effectively treat themselves within their own home (Guilbeau and Broussard, 2010).

Patient understanding of MRSA Newton et al (2001) carried out a study that established that patients infected with MRSA understand little about their condition. This, coupled with public anxiety regarding MRSA, makes management of the condition difficult (Bellamy, 2008). Duncan and Dealey (2007) also undertook a study using 109 questionnaires to establish patients’ feelings regarding their MRSA status and their understanding of what MRSA is.They found that 74% of the people questioned felt that there was not enough information about MRSA. Easton et al (2009) surveyed 1000 members of the public accessing GP practices. They also found that patients felt stigmatised when diagnosed with MRSA and wanted more information about MRSA from primary care. The research seems to suggest that specific education about MRSA and its management in primary care is needed (Rohde and Ross-Gordon, 2012). The call for health-care providers to implement new and effective strategies for

VaccinePorter Carrier Systems ®

The cool, must-have bag this season The Helapet VaccinePorter® range is the ideal solution for the controlled transit of vaccines and solutions which require conditions between +2°C and +8°C. Fully replaceable components make our system simple to use and cost effective to maintain. Use MediCool® chill packs to maintain internal temperature for up to 8 hours even with multiple openings.


When temperature matters, VaccinePorter® carriers truly deliver.

Scan to generated at BeQRious.com learn more

Helapet Limited Telephone 0800 230 0191 E-mail [email protected] www.helapet.co.uk


437


iStockPhoto/ksass

CLINICAL FOCUS

Staphylococcus aureus colonies on a blood agar plate. In primary care, patients that are found to be MRSA positive from a clinical swab or sample are screened and, if necessary, decolonised to try and prevent severe infections and bacteraemias

Educational tool

educating patients about their health conditions is now strong (Stromberg, 2005). Questions have also arisen regarding who provides this education. Justification for the allocation of additional resources to patient education (Shimbo et al, 2004) is, however, contentious because the relationship between patient education, health outcomes and health service use is not well understood (Duke et al, 2009). Despite this, improved knowledge about treating MRSA within the community setting will arguably improve outcomes.

An educational tool was developed using local guidelines for managing patients with MRSA (Friberg et al, 2012). It included information about the treatment process as well as the importance of and rationale for maintaining a clean environment. It was peer reviewed by three senior infection prevention and control nurses. This guide was then used by the nurse with a patient. The nurse using the guide had received additional training. The educational tool included a knowledge check to ascertain patients’ learning. Interviews were carried out with the nurse (Lisa) who had received training in the use of the enhanced educational tool; a patient (Julie) who received the enhanced education (EE); and a patient (George) who received usual care (UC). The names of all participants have been changed to ensure anonymity.

Method Aim

The aim of this study was to explore the effect and suitability of providing enhanced education about MRSA treatment in a community setting.

Results

Information received

Full ethical approval was granted by NRES Committee East Midlands (Nottingham 1) for this pilot study. NHS permission was granted by Nottingham CityCare Partnership.

Objectives The objectives were: w To develop an educational guide for nurses to use to educate patients with MRSA w To explore, using interviews, the effect and suitability of providing enhanced education about MRSA from the patient and community nurse's perspective.

438

Julie (EE) had two instances of being diagnosed with MRSA. For the first she had received UC, and for the second episode, when she took part in this study, she had received the EE. She was able to compare the information she was provided from both episodes of care. George had also had MRSA previously and had received UC on both occasions. Both patients were asked how they had used the decolonisation treatment:

‘The cream, I just put it up my nose. Three times a day for five days, and the screen wash—a couple of caps in the sink and used the sponge, you know, wiped myself all over with sponge and that and then wiped myself over with a towel. I washed my


Ethical approval



CLINICAL FOCUS

hair two or three times in it as well.’ (George) ‘I was given more information the second time, like “leave it on for a minute and wash your hair”, and with the nasal, before, when I did the nasal treatment I only had to do that once a day; I had no information—just that I had to put that up my nose and wash your body with the lotion. I wasn’t told how far up the nose you had to put it, whereas this time I was told to rub it in and make sure you can taste it (because it tastes horrible), and do it three times a day. So that wasn’t said the first time round. This time I took more time rather than just going to wash it and take it off again—just seemed pointless the first time around. Nobody told me about washing my hair with it before, either.’ (Julie)

‘[Face-to-face contact] is more personal, and you can ask questions, whereas if you’re out there you can feel a bit nervous asking a question, but with it being one on one it was fine. I prefer that way.You can read that much information on the internet and leaflets but it’s not the same as hearing it one on one.’(Julie) Julie reported considerable confidence in the nurse and identified the significance of having someone with specialist knowledge of MRSA:

‘The answers were explained very well, because she knew what she was talking about … whereas, the practice nurse, she needs to know a little about everything, so she can’t know a lot about everything, so a specially trained person was ideal.’ (Julie) Clearly, while educating patients is one step towards ensuring effective treatment, their capacity and willingness to adhere to advice is not without its problems (Labreche et al, 2013). The interview with Julie highlights some of the challenges of maintaining a clean home environment, especially for someone who is not very well:

Julie (EE) reported better knowledge and understanding than George (UC) of the application of treatment, which may indicate some effect from the enhanced education. It is interesting that George used a towel to dry himself after applying the treatment, rather than washing it off. This could have implications on the success of treatment, since if the towel was not clean and washed daily, it may become contaminated with MRSA, which would cause the patient to become recolonised. He also stated the frequency of washing hair, but did not specify a time period for this.

‘It was tiring, it was hard work. Every day, changing your bedding, hoovering up. I mean, it's tidy anyway but to have to hoover every day, have to change your bedding every day, have to change towels every day. Towels are not an issue, because you just throw them in the washing machine. But, it's knowing what your routine is every single day. So if we were given information to try and prevent it before we got it, because not everybody cleans up, not everybody changes their duvets and clothes every day. … It was more frustrating with having to change bedding every day, change towels and, I mean, I change my clothes every day anyway. It was just more work, so even though I’m already ill, it's making me even more tired because of what I’ve got to do.’ (Julie)

Knowledge about preventing the spread of MRSA Patients were asked whether they knew how to prevent the spread of MRSA:

‘No. I was told to wash my bedding every couple of days.’ (George) ‘Ensure cleanliness within the home, wash hands more often. Whenever possible wash your hands. … I wash my hands more. I have soap in every sink, so I’ve changed that.’ (Julie)

The nurse’s perspective It was important to establish that the patient appreciated the enhanced education. It was also important to identify how nurses delivering the enhanced education felt about its use. Nurse Lisa reported feeling that the education she delivered was more effective than the information the patient had received previously by community nurses:

George reported the wrong information: bedding should be changed daily (DH, 2008). He was also unable to report other ways in which he could prevent the spread of MRSA. Julie, on the other hand, suggested that she knew how to prevent the spread of MRSA. She showed that she knew that increased handwashing is an important way of preventing the spread of MRSA. Indeed, it has been established that this is the most effective way of preventing transmission. Julie therefore demonstrated her knowledge of an essential part of the education.

Asking questions about MRSA When both patients were asked about their understanding of MRSA, Julie reported feeling able to ask the community nurse questions that were concerning her about MRSA. Conditions associated with cleanliness are known to be stigmatising, and the literature highlights the anxiety that patients face when diagnosed with MRSA (Easton et al, 2009). Enhanced education arguably helps to reduce anxiety because of the stigma associated with dirtiness:

440

This suggests that Nurse Lisa found it an acceptable and appropriate way of delivering education in relation to MRSA together with effective treatment processes for patients in the community.

Discussion Although this study was small, it does seem to establish several things. First of all, simply providing patients with topical treatment regimens is insufficient; they also need infor-


‘It was obvious that she really didn’t know the first time what she was doing and maybe that’s where the failing was. I don’t know, but this time she knew exactly what she was supposed to be doing because I was able to check using the knowledge check at the end of the educational tool.’ (Nurse Lisa)



CLINICAL FOCUS

mation about how and when to use it. Establishing that the nasal treatment needs to go right up inside the nose is as important as knowing the frequency of use. Second, maintaining a clean environment is an essential part of the treatment. Again, it would seem that patients need information about what counts as a clean environment. It is not enough that something looks clean. For patients with MRSA, this means changing bedding, clothing and towels every day, as well as hoovering and wiping surfaces. The DH (2008) stipulates that, while undergoing treatment outside a hospital setting, towels, clothes and bedlinen should be changed daily while undergoing decolonisation treatment to reduce the chance of becoming re-colonised with MRSA. It is also important to wash hands frequently. Having the importance and relevance of the cleaning activities explained is likely to make an important contribution to compliance and thus efficacy of treatment. Third, even when knowledge about the importance of a clean environment is established, it is this feature of the treatment regimen that is arguably the most complex and challenging to fulfil. If the patient feels unwell, is frail or has comorbidities, then his or her ability to comply is likely to be compromised. Clearly, when patients are in hospital this aspect of managing the environment is taken care of by hospital staff.

Conclusion


The development of an enhanced educational tool was only tested on one patient and one member of staff. It is not possible, therefore, to establish conclusive findings. However, because the study compared one patient who had received the intervention with one who had not, the study did appear to suggest differences that improved knowledge matters both for practitioners and patients and is therefore more likely to ensure treatment is adhered to and effective. The study also highlighted that maintaining a clean environment is extremely challenging, especially for patients who may not be well. An educational tool may go some way toward addressing the problem of re-colonisation. Further, larger studies are required to build on the findings from this limited exploration and develop a more effective management of MRSA in primary care. BJCN Bellamy E (2008) An evaluation of patient satisfaction regarding the care and information provided by infection control nurses relating to MRSA. Br J Infect Control 9(3): 6–10. doi: 10.1177/1469044607088373 Coia JE, Duckworth G, Edwards JDI, Farrington M, Fry C, Humphreys H, Mallaghan C, Tucker DR (2006) Guidelines for the control and prevention of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities. J Hosp Infect 63(suppl. 1): S1–44 Department of Health (2008) Advice for those affected by MRSA outside of hospital. Hillingdon Hospitals NHS Foundation Trust. http://tinyurl.com/kscxoyl (accessed 8 January 2014) Department of Health (2012) New Year ambitions to reduce healthcare associated infection. Press release, 13 January. http://tinyurl.com/pfuqhqv (accessed 8 January 2013) Duke SS, Colagiuri S, Colagiuri R (2009) Individual patient education for people with type 2 diabetes mellitus. Cochrane Database Syst Rev 2009(1): 1–48. doi: 10.1002/14651858.CD005268.pub2 Duncan CP, Dealey C (2007) Patients' feelings about hand washing, MRSA status and patient information. Br J Nurs 16(1): 34–8 Easton PM, Marwick CA, Williams FLR et al (2009) A survey on public knowlede and perceptions of methicillin-resistant Staphyolococcus aureus. J Antimicrob

Chemother 63: 209–14. doi: 10.1093/jac/dkn447 Flayhart DJ, Hindler F, Bruckner DA et al (2005) Multicentre evaluation of BBL CHROMagar MRSA medium for direct detection of methicillin-resistant Staphylococcus aureus from surveillance cultures of the anterior nares. J Clin Microbiol 43(11): 5536–40 Forcade NA, Parchman ML, Jorgensen JH et al (2011) Prevalence, severity, and treatment of community-aquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin and soft tissue infections in 10 medical clinics in Texas: a south Texas amulatory research network (STARNET) study. J Am Board Family Med 24(5): 543–50. doi: 10.3122/jabfm.2011.05.110073 Friberg F, Granum V, Bergh A (2012) Nurses' patient-education work: conditional factors—an integrative review. J Nurs Manag 20(2): 170–86. doi: 10.1111/j.13652834.2011.01367.x Gould D (2011) MRSA: implications for hospitals and nursing homes. Nurs Stand 25(18): 47–56 Guilbeau JR, Broussard LP (2010) Community-associated methicillin-resistant Staphylococcus aureus (MRSA): an overview for nurses. Nurs Women's Health 14(4): 310–17. doi: 10.1111/j.1751-486X.2010.01561.x Harbarth S, Dharan S, Liassine N, Herrault P, Auckenthaler R, Pittet D (1999) Randomised, placebo-controlled, double-blind trial to evaluate the efficacy of mupirocin for eradicating carriage of methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother 43(6): 1412–16 Health Protection Agency (2010) MRSA and C. difficile infections fall by a third. http://tinyurl.com/336m4rh (accessed 4 February 2013) Health Protection Agency (2013) Bacteraemia: general information. http://tinyurl. com/kg5wpmz (accessed 4 February 2013) Labreche MJ, Attridge RT, Du LC et al (2013) Treatment failure and costs in patients with methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections: A south Texas ambulatory research network (STARNet) study. J Am Board Family Med 26(5): 508–17. doi: 10.3122/jabfm.2013.05.120247 Loveday HP, Pellowe CM, Jones SRLJ, Pratt RJ (2006) A systematic review of the evidence for interventions for the prevention and control of meticillin-resistant Staphylococcus aureus (1996–2004): report to the joint MRSA Working Party (Subgroup A). J Hosp Infect 63(suppl. 1): S45–70 Newton JT, Constable D, Senior V (2001) Patients' perception of methicillinresistant Staphylococcus aureus and source isolation: a qualitative analysis of sourceisolated patients. J Hosp Infect 48(4): 275–80 Orsi GB (2008) MRSA: an old and new enemy. Healthcare Infect 13: 73–5 Robotham JV, Graves N, Cookson BD et al (2011) Screening, isolation, and decolonisation strategies in the control of methicillin-resisitant Staphylococcus aureus in intensive care units: cost effectiveness evaluation. BMJ 343: 5694–707. doi: 10.1136/bmj.d5694 Rohde RE, Ross-Gordon J (2012) MRSA model of learning and adaptation: a qualitative study among the general public. BioMed Health Services Res 12: 88–96. doi:10.1186/1472-6963-12-88 Sastre A, Roberts RF, Presutti RJ (2013) A practical guide to community-aquired MRSA. J Fam Pract 62(11): 624–9 Shimbo T, Goto M, Morimoto T et al (2004) Association between patients education and health-related quality of life in patients with Parkinson's disease. Qual Life Res 13(1): 81–9 Shrank WH, Avorn J (2007) Educating patients about their medications: the potential and limitations of written drug information. Health Affairs 26(3): 731–40 Skov R, Christiansen K, Dancer S et al (2012) Update on the prevention and control of community-acquired metacillin-resisitant Staphylococcus aureus (CA-MRSA). Int J Antimicrob Agents 39(3): 193–200. doi: 10.1016/j.ijantimicag.2011.09.029 Stone PW (2009) Economic burden of healthcare associated infections: an American perspective. Expert Rev Pharmacoecon Outcomes Res 9(5): 417–22. doi: 10.1586/erp.09.5 Stromberg A (2005) The crucial role of patient education in heart failure. Eur J Heart Fail 7(3): 363–9


KEY POINTS

w Environmental factors are an essential part of decolonisation treatment w Improved patient knowledge of MRSA is likely to ensure treatment is adhered to and effective

w Enhanced patient education around MRSA is needed in primary care w Maintaining a clean environment is extremely challenging, especially for patients who may be unwell

441


Measles 2015: why public health matters to critical care.

Viewpoint: Why Disclosure Matters.

Why quality matters.

Why strategy matters now.

Why China matters.

Why it matters.

Patient Education. The Nutrition Needs of Patients With Chronic Kidney Disease in Health Care Community Settings.

Why and how inequality matters.

Why the distribution of medical errors matters.

Why history matters to nursing.

Why health insurance literacy matters.

Why the cost of fast food matters.

Why veterinary school accreditation matters.

Patient education in the rural community health center.

Why continuity matters: Ian McWhinney's insights for 21st-century medical education.

Why money matters in ecological valuation.

Why geodiversity matters in valuing nature's stage.

Education of community and health-care providers.

Patient education preferences in ophthalmic care.

[Patient education of depression in primary care].

Why public trust in health care systems matters and deserves greater research attention.

Patient Home Visits: Measuring Outcomes of a Community Model for Palliative Care Education.

Genetics, genomics, breeding - why scale matters.

Gastroenterology issues in schizophrenia: why the gut matters.