Runninghead

:MRSAPREVENTION1

MRSAPreventionintheCommunitySetting
AmyL.Ellsworth,AshleyD.Gillam,
JodiA.Newcomer
WesternWashingtonUniversity

MRSAPREVENTION

Introduction
VolunteersofAmerica(VOA)hasahistoryofbeingtheplacetoturnwhenin
youare
in
need.VOAisthecharitythatalwaysstepsforwardtohelpthemostvulnerable.Forover120
years,[they]havetakenonthemostdifficulttaskstohelpthemostunderserved.Theyoffera
widevarietyofservicesincludinghungerprevention,homeless
nessoutreach
,disputeresolution,
child&youthhousing&services,personalsupport,behavioralhealth,andhousingforthe
disabled.TheWesternWashingtonVOA(VOAWW)servesapproximately350,000clients
annually.Theyareabletoprovide10,000mealseverymonthtothoseinneedandhave
supported316familieseachmonthtoavoideviction.TheVOAWWhasapproximately1,000
volunteersthatprovideabout120,000hoursannually.Oneofthemostimpressivehighlightsof
theVOAistheyareabletomaximizethedollarstheyreceiveandindicatethatnearly0.86cents
ofeverydollargoesdirectlytoservicesthatimpacttheclients,familiesandcommunitiesthat
theyserve(Aboutus,n.d.).
Inthisparticularproject,wehavefocusedonpersonalsupportservicesforthedisabled
population.
Thep
ersonalsupportservicesattheVOAaimstohelpclientswithdevelopmental
disabilities
to

maintaintheirindependence(PersonalSupport,2016).Withtheamazingservice
providedbytheVOA,clientsaresupportedtostayinahomesettingwiththesameamenities
manyofusenjoy.Theseincludeanimals,familiarfaces,outings,andasupportiveenvironment
oftheirownwhichhelpsthesemenandwomenlivetheirlivestoitsfullestcapacity.
Thecommunityofinterestasitpertainstothisprojectarethecaregiversprovidingin
homeservicetotheclientsoftheVOA.Theoverallgoalhasbeentotrainthecaregivers

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regardinginfectioningeneral,inhopestodecreaseemergencyroomvisitsaswellasdecrease
exposuretoresistantinfections.Thecaregiversarethepointofcontactandgatekeeperstothe
caretheclientsreceive,theyarewiththemmorethananyoneelse.Theyprovidepersonalcareas
wellasmealpreparationandthecoordinationofoutings.IfthecaregiversunderstandMRSA
theywillbebetterarmedtoprotectthemselvesaswellastheirclients.
TheVOArequestedthatwefocusonMethicillinResistantStaphylococcusAureus
(MRSA)becausetheyarefindingwhenaclientshowssignsofaninfectiontheyaretransferred
totheemergencyroomwhichplacesthematagreaterriskforcontractingMRSA.Tounderstand
whatMRSAis,firstwehavetoaddresswhatStaphylococcusAureusisandhowitbecomes
resistant.Staphylococcusaureus(SA)isacommonbacteriumthatlivesonourskinandinour
nares
.Bacteriaofanykind,thriveinwarm,moistplacesliketheaxillary,groin,andnose.SA
cancauseinfectionssuchasboils,abscesses,septicspots,impetigo,andhastheabilityto
progressintosepticemia,andpneumonia(Nazarko,2014).
ThecomplicationscausedbyovergrowthofSAhasbeenhistoricallytreatedwithadrug
calledMethicillin.Thebacteriaadaptedtoitsenvironmentandbecameresistanttothat
medicationandthusbeingnamedMRSA.MRSAcanbelifethreateningandistreatedwithIV
Vancomycintopreventcomplications(Nazarko,2014).Theclientsinthegrouphomesare
contractingMRSAandinordertoreducethis,theVOAneed
s
aplanforpreventionand
educationtoolsfortheirstaff.Understandingtransmission,prevention,andthetreatmentplanis
essentialtocreateeffectiveinterventionstopreventMRSAprevalenceandunnecessarytripsto
theemergencyroom.

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Transmission
MRSAisrarelyspreadbyairbornetransmissionandmostcommonlyspreadbycontact
eitherskintoskinorwithsharedsurfacesorsupplies(Nazarko,2014).Inourtargetpopulation
risksfortransmittingMRSAincludestheclienthavingapreviousMRSAinfection,cellulitis,
havinga

centralcatheter,andskinulcers.Inthegrouphomesettingthereisincreasedriskfor
skintoskincontactandevenmoresorewhenthereisanentrypointsuchasanabrasionorcut.
Useofsharedorcommunityitemssuchastowels,sheetsandcouchesinthehomecanbea
sourceofspreadingaclientsMRSAinfectionaswell(Banning,2005).Crosscontaminationcan
beavoidedwithpreventiontechniquesandremovalofpotentialsitesofbacterialcolonization.
Thestaffcanusetheknowledgeprovidedtoimplementpreventiontechniquesandcleaning
guidelinestoreduceprevalenceofMRSAinthegrouphomeenvironment.
Duringourcommunityassessmentweconcludedthattherewasaknowledgedeficiton
behalfofthecaregiversinregardtoMRSAtransmission.Thecaregiverthatweinterviewed
sharedastoryofanexperiencewhenafellowstaffmembercametoanallstaffmeetingandhad
adressingonherarm.ThestaffmembersaidthatitwasMRSAandthegroupexpressedfear
aboutbeingaroundher.Thecaregiverputherarmsoutandsaid,Wealljusttriedtostayaway.
Tobettereducatethecaregivers,itisessentialtounderstandthecharacteristicsofMRSA.
BackgroundResearchonMRSA
Aqualitativestudy,conductedbyRobinson,Edgley,&Morrell(2014)suggesteda
decolonizationtechniquemightbebeneficialtoreduceprevalenceofMRSA.Decolonization
aimstokilltheMRSAinthenaresoronclientsskin.Ultimatelythestudyshowedthat

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decolonizingalonewasnoteffectiveinpreventingthespreadofMRSAtothemselvesorothers.
Educationregardingtheuseofthetreatment,cleaningregimens,andhowtopreventreinfection
wasrecommendedtoaidinsuccess(Robinsonetal.,2014).Toreducetransmission,laundering
bedding
and

clothingaswellaswipingdownallsurfaceswithaMRSAkillingsolutionis
essential.ThisstudyishelpfulinseeingthatthereisalackofknowledgeaboutMRSAand
prevention.Decolonizationmaybehelpful,butwiththedevelopmentallydelayedpopulationit
maynotbeplausible.
Aquantitative
study
conductedbyRoghmann,etal.,(2015)wasalsoreviewed.Thisstudy
helpedtoidentifytransmissionandpreventiontechniquesofMRSAinfections.Althoughthis
studywasbasedinaskillednursingfacility,therearemanysimilaritiesbetweenthoseandgroup
homes.Thestudyutilizedresidentsfrom13communitybasednursinghomes.Thestaffwere
askedtoperformcaresusingtheappropriatepersonalprotectiveequipment(PPE),suchas
gownsandgloves.ThegownsandgloveswerethentestedtoseeiftheMRSAhadtransferred.
Intheirfinalstudy,Roghmannetal.,(2015)hadapopulationcomprisedof401residents.
Ofthose,113werecolonizedwithMRSA.Postcaretestingdemonstratedgownstobe
contaminatedwithMRSA14%ofthetimeandgloves24%ofthetimeduringthe954
interactionswithMRSAcolonizedresidents.Thestudyidentifiedperformingactivitiesofdaily
living(ADLs)includingchangingoflinens,activelyposedahighriskforcontractingMRSAon
gownsandgloves.
TheRoghmannetal.,(2015)studyispertinenttoourcommunitybecausetheVOA
caregiversperformthesehighrisktaskseveryday.Theydonothavegowns,buttheydouse

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gloves.UseofthisstudypresentsagoodteachingpointthatMRSAcangettransmittedfrom
caregiversduringandafterperformingbasiccares.Intheclientshomewevisiteditwasnoted
thatbothclientshadaccesstotheentirehouse.Atonepointoneclientwentintotheother
clientsbedroom.InidentifyingthepotentialtransmissionofMRSA,thereweremanyatrisk
activities.Duringthecommunityassessment,weidentifiedtheneedtofocusonprevention
techniquesduringthesehighriskactivities.
PreventionofMRSA
Handwashingisapreventativetoolthatisconsistentthroughoutalltheresearch
reviewed.ProperhandwashingisthefirstlineofMRSAprevention.Nazarko(2014)emphasized
thattherearealsoriskswithfrequenthandwashingandalcoholgelling.Theseactscanputthe
caregiversatriskbecausetheyoftencompromisetheintegrityoftheskin.Caregiverselfcareby
useofhandmoisturizeranddryinghandsthoroughlyafterwashingarethecurrent
recommendations.
Universalprecautionsandstandardprecautionsareessentialtoreduceinfectionspreadand
keeptheclientsandcaregiverssafe.
HospitaleTool(n.d.)definesuniversalprecautionsas
treatingallhumanbloodandbodyfluidsasiftheyareinfectedwithabloodbornepathogen.
Standardprecautionsarerequiredforcareofallpatients.Standardprecautionsapplytoblood,
bodyfluids,excretions,nonintactskin,andmucousmembranes.Handwashingandappropriate
PersonalProtectiveEquipment(gloves,gown,eyewear)arepartofthe

standardprecautions.
Thesestandardsarechallengingtomaintaininagrouphomesettingwhereclientsareintheir
ownhomeandtheaimistoprovideatypicalhomelikeatmosphere.

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TheCenterforDiseaseControl(CDC,2013)hasspecificrecommendationsregarding
disinfectingsurfacesthatmaybecontaminatedwithMRSA.TheCDCrecommendsreadingthe
specificationsonallcleaningproductsinusetoidentifyhowtoapplythemtosurfaces,which
bacteriatheykillandhowlongtheproductsneedtostayonthesurfaceinordertobeeffective.
Otherspecificationstotakeintoaccountarewhetherornottheproductshouldberinsedafter
application,ifthedisinfectantissafeforthesurface,iftheproductneedsdilution,andany
personalprecautionstotakewhenapplyingtheproduct.
IntheVOAgrouphomesettinglaundryistobedoneroutinelyandclientsitemsarenot
requiredtobeseparated.Ifthereissharedequipmentitneedstobecleanedbetweenuses.An
exampleofsharedequipmentwouldbethetoilet.Keyboardsorothersurfacesthatcannotget
wetneedaprotectivecoverthatcanbecleanedroutinely.Duringourcommunityassessmentwe
foundthatlaundryisseparated,glovesareworn,andshareditemslikethetoiletarecleaned
beforeeachuse.IncollaborationwiththeotherVOAresearchgroupwefoundtheremaybe
someinconsistenciesincleaningtechniquesandfrequency.Ensuringthatcaregiversareusing
standardprecautionswillhelppreventthecontractionandspreadofMRSA.
TreatingMRSA
Decolonizationisusedbeforeproceduresandfocusesonthenose,skin,andhair.The
processusesantimicrobial2%mupirocincreamandanantimicrobialChlorhexidinegluconate
4%bodywash.Bothprocessesareusedfor5daysandaimtokilltheMRSAlivingonskin.
ThereislittleevidencetosupportdecolonizationandunfortunatelysomestrainsofMRSAare

MRSAPREVENTION

resistanttomupirocin.Chlorhexidineisalsobecomingineffectivebecauseofthenewstrainsof
MRSA(Nazarko,2014).
EffectiveantibiotictreatmentisbecomingscarceasMRSAisbecomingresistanttomost.
Banning(2005)statesthatteicoplaninandvancomycinarethemainantibioticsusedfor
treatment.Nazarko(2014)alsostatesthatvancomycinisusedeitherorally,orintravenously.
In
ordertoaccuratelyselectanantibioticfortreatment,thewoundiscultured,andthelab
determinesthesensitivitytoseewhatantibioticsmaybeeffectiveforthatparticularstrand.
Vancomycinmaybeidentifiedasthefirstlinedefense,butitcancausehearinglossandaffect
renalfunction.ThetestingallowsforotherdrugstobeutilizedifpossiblebeforeVancomycin.
Thecommunityweareassessingwillnotusethisinformation,althoughteachingthem
whatwillhavetohappeniftheclientsinfectionisnotcaughtearly,willhelpmotivatechange.
Charleboiset.al.(2002)showedthatcommunitybasedMRSAratesinovercrowdedareaswas
similartothegeneralpopulation.Thismeansthatincreasedknowledgeandeducationwillbe
effectivenotonlyfortheclientsbutalsothecaregivers.Caregiversandthegeneralpublicareat
riskforMRSAasmuchastheclientsare.
Interventions
Whendevelopinginterventions,itisessentialtothinkofalllevelsoftheorganization.At
thesystemlevel,theywillhavetoallotfundsforextratrainingmaterialsandsupervisortimeto
answerquestions.Thiswouldbeatertiaryintervention.Inprovidingthesetrainingresources,the
VOAandclientswillsavemoneybyhavingadecreaseofinfectionratesintheirhomes.Whena
clientvisitstheemergencyroomthereisnodirectcosttotheagencywhatremainsisadrainon

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federalresourcessuchasMedicaidandMedicare.ThelongtermeffectisthattheVOAmay
receivelessfundingfromtheseresourcesifgoodstewardshipisnotmaintained.
Atthecommunitylevelarethemanagersandcaregiversinourassessmentwedeveloped
anddistributedasurveydirectedtothecaregiversincludingquestionsaboutdemographics,
previousknowledgeofMRSA,andwhatteachingtoolswouldbeeffective.Indistributionwe
hadaccesstoover100caregivers,whatwefoundwasthattheaccesswasdeniedandthatthe
computersatthesitesdonotallowcaregiversontheinternet,wecouldnotdistributethesurveys.
Inoursecondattemptindevelopingasurveyforthecommunitywefocusedonthe
managers.Wegearedthequestionstowardwhattheythoughtwasbestforcaregiversandclients.
Unfortunatelythisonlyreceivedtworesponsesoutof16surveyssent.Aprimaryintervention
thatwerecommendistohaveaquiztogivetocaregiverstoassessforretentionofthe
informationtheyhavelearned.Ifacaregiveranswersquestionsincorrectlythemanagercould
assistbyexplainingthereasoningandthusbetterensuringthecaregiverhastheadequateamount
ofknowledgetocarefortheirclients.
Inourassessmentwedidhavetheopportunitytointerviewanexperiencedcaregiver.We
foundthatmostcaregiversspeakEnglishastheirsecondlanguageandthattheywerenot
familiarwithMRSA.Ourassessmentincludedthecaregiverworkspacearea.Theareathatthey
havetokeeptheirworksupplieswassmall,buttherewasabindernexttothecomputerthatthey
accesseveryday.Inassessingtheworkspacethissparkedanideatobuildafactsheetregarding
MRSA.Thisfactsheetwouldbeasimplereferenceguidethatcanbereviewedwheneverneeded
bythecaregivers.Asaprimaryinterventionitwouldbeessentialtoputitsomewherethe

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10

caregiverslookeverydaytohelpremindthemthatpotentialinfectionsneedroutineassessment.
TherecommendedfactsheetincludesadepictionofatypicalMRSAinfection,prevention
techniques,andwhattodoifitisidentified.
Attheindividuallevelitwillbehardtoformulateaplanthatwillworkforalltheclients
effectively.Theclientshavevaryingdegreesofdevelopmentaldelayswhichinhibitstheirability
tounderstandandimplementteachings.Onepreventiontacticwouldbeto

relyonthecaregivers
tohavetheclientswashtheirhandsfrequently.Washingmaybewithawashclothoratthesink
iftheyare

able.Thisrecommendedinterventionwouldalsobeaprimaryintervention.The
caregiverscouldpromotewashinghandsafterusingthebathroom,beforeandaftertheyeat,after
activitiesasagroup,indoingthistheywould

createahabitofhandwashing.
Conclusion
DuringourassessmentoftheVOAsdisabilitybranchoftheirorganizationwefound
somegapsineducationthatneededaddressed.Thecaregiversreceivealargeamountoftraining
atthebeginningoftheiremployment,andthattrainingdoesnotincludeinformationabout
MRSA.Wewouldliketoseethistrainingadded,possiblybyfutureRNBSNprogramstudents.
Theinterventionwearefocusingonisaneducationaltoolforcaregiverstohaveinthe
home.Wewanttoplacethistoolinthebinderthattheyaccessdailysotheyseeiteveryday.
Repetitionoflearningwillhelptheinformationbecomeimplanted.Wealsorecommendaquiz
doneonayearlybasistoshowknowledgeretention.Atstaffmeetingsrecognitionofthehard
workthecaregiversaredoingtohelpkeeptheirclientssafewouldbevaluableforestablishing
thecultureofpromotingacommunityofpreventionactivities.

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References
AboutUs.(n.d.).RetrievedMay24,2016,fromhttp://www.voaww.org/about
Banning,M.(2005).TransmissionandepidemiologyofMRSA:Currentperspectives.
British
JournalofNursingBrJNursing,

14
(10),548554.doi:10.12968/bjon.2005.14.10.18103
Charlebois,E.D.,Bangsberg,D.R.,Moss,N.J.,Moore,M.R.,Moss,A.R.,Chambers,H.F.,&

PerdreauRemington,F.(2002).PopulationBasedCommunityPrevalenceof

MethicillinResistantStaphylococcusaureusintheUrbanPoorofSanFrancisco.
ClinicalInfectiousDiseases,

34
(4),425433.doi:10.1086/338069
EnvironmentalCleaning&DisinfectingforMRSA.(2013).RetrievedMay11,2016,from
http://www.cdc.gov/mrsa/community/enviroment/index.html
HospitaleTool:HealthcareWideHazards(Lackof)UniversalPrecautions.(n.d.).Retrieved
May11,2016,from
https://www.osha.gov/SLTC/etools/hospital/hazards/univprec/univ.html
Nazarko,L.(2014).MethicillinresistantStaphylococcusaureus(MRSA):Aguidetoprevention
andtreatment.
BritishJournalofHealthcareAssistants,

8
(8),377383.
doi:10.12968/bjha.2014.8.8.377
PersonalSupport|VolunteersofAmerica.(2016).RetrievedApril23,2016,from
http://www.voaww.org/personalsupport

Robinson,J.,Edgley,A.,&Morrell,J.(2014).MRSAcareinthecommunity:Whypatient
educationmatters.
BritishJournalofCommunityNursing,

19
(9),436441.
doi:10.12968/bjcn.2014.19.9.436

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Roghmann,M.,Johnson,J.K.,Sorkin,J.D.,Langenberg,P.,Lydecker,A.,Sorace,B.,
Mody,L.(2015).TransmissionofMethicillinResistantStaphylococcusaureus(MRSA)

toHealthcareWorkerGownsandGlovesDuringCareofNursingHomeResidents.
Infect.ControlHosp.Epidemiol.InfectionControl&HospitalEpidemiology,

36
(09),
10501057.doi:10.1017/ice.2015.119