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Is your infection control program effective?

February 1, 2008
by LINDA WILLIAMS, RN
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It is well known that the elderly population has a substantially increased incidence and severity of many infectious diseases. In fact, the Centers for Disease Control and Prevention (CDC) estimates that 1.5 million nosocomial infections occur in long-term care residents per year, which translates to an average of one infection per resident per year. Methicillin-resistant staphylococcus aureus (MRSA) poses a particular problem for residents because this type of bacteria causes staph infections that are resistant to treatment with the usual antibiotics.

According to the CDC, MRSA occurs most frequently among patients who undergo invasive medical procedures or who have weakened immune systems and are treated in hospitals and healthcare facilities such as nursing homes and dialysis centers. MRSA in healthcare settings commonly causes serious and potentially life-threatening infections, such as bloodstream infections, surgical-site infections, or pneumonia. The most common sources of transmission are people who already have a MRSA infection or who carry the bacteria on their bodies, but do not have symptoms (colonized). The main mode of transmission to other residents is through human hands, especially healthcare workers’ hands. Hands may become contaminated with MRSA bacteria by contact with infected or colonized residents.

It is the responsibility of nursing facilities to have an infection control program to investigate, control, and prevent infections, as they are able to do so. Please review the following situation and make changes as appropriate in your facility.

The Situation

An 80-year-old woman was admitted to a nursing facility after surgical removal of hardware (from a left hip replacement) because of an infection. Four years earlier, the woman had her hip replaced and, over time, the area became increasingly painful. It wasn't until the surgeon removed the hardware that he discovered that the woman had contracted a MRSA infection that had destroyed some of the bone in her hip. After the surgery, the woman received intravenous vancomycin until her physician felt the MRSA had colonized. Afterward, the woman was transferred to the nursing facility to recover and receive care for her other diagnoses that included anemia, renal insufficiency, and urinary incontinence.

Upon the woman's arrival at the nursing facility, the nurses noted a stage I decubitus ulcer on her sacrum, along with multiple skin tears elsewhere. The ulcer was described as nonblanchable erythema of intact skin. As such, the staff decided to minimize pressure in the area, watch it closely, and report to the physician if it worsened. Sixteen days later, the redness doubled in size, so the staff notified the physician and treatment orders were obtained.

Throughout the following month, the wound worsened to a stage II ulcer, described as an abrasion. The nurses continued to update the physician and various treatment orders were initiated. Despite the nurses’ best efforts, the wound refused to improve. One day, the woman's family took her on an eight-hour outing. When she returned to the facility, the nurse asked a family member if the woman's incontinence brief had been changed. The family member replied that it hadn't. Overnight, the wound progressed to a stage III ulcer and an abscess began to form near the area. The woman soon became feverish, and her physician decided to send her to the hospital for debridement of the wound because none of the other treatments had helped. By then, two months had passed since the ulcer was first discovered.

During the surgical debridement, a large amount of foul-smelling, necrotic fascia and some muscle were removed from the wound. Afterward, lab reports revealed that the wound had been infected with MRSA. Two days later, the woman was transferred to the skilled nursing unit of the hospital for recovery. The woman slowly improved, but during the following month, she became nonresponsive in the midst of eating an evening meal. Several family members were present and they immediately summoned help. Unfortunately, the woman could not be resuscitated by the nurses and doctor on duty, who was also the medical director of the nursing facility. The death certificate stated that the woman died of an acute myocardial infarction, coronary artery disease, and cellulitis MRSA.

A year later, the woman's family filed a wrongful death lawsuit against the facility for negligent wound care that caused the decubitus ulcer to deteriorate so rapidly that it essentially taxed her heart, causing her death. The family felt that if the MRSA had been identified and treated sooner, the woman would still be alive. They asked for $125,000 to settle the case.

In response, the facility maintained that the development and progression of the decubitus ulcer was unavoidable and it did not cause the woman's death. A physician expert conceded that the ulcer should have been reported to her physician immediately upon discovery. However, the physician probably would not have initiated treatment until it worsened and became a stage II. Once that occurred, the staff remained in constant communication with the physician and together they attempted various treatments to no avail. Given the woman's history and condition upon entering the facility, there is no evidence that the decubitus ulcer could have been prevented or healed. The woman suffered from many stressors on her body that existed before her admittance to the nursing facility, including:

  • iron deficiency anemia;

  • renal insufficiency that limited the amount of protein in her diet due to danger of renal shock that could shut down her kidneys;

  • the previous infection in her hip that suppressed her already compromised immune system; and

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