2007-01-20
Research plan
Experiences in patients colonized with Methicillin Resistant StaphylococcusAureus
and knowledge, attitudes and behaviour of Health Care Workers
Maria Lindberg
Centre for Research and Development
Uppsala University/County Council of Gävleborg
SE 801 88 GÄVLE
and
Department of Public Health and Caring Sciences
Section for Caring Sciences
UppsalaUniversity
UppsalaSciencePark
SE 751 83 UPPSALA
Introduction
Staphylococcus aureus (S. aureus) is a gram positive bacterium which is normally present on the skin of a great deal of humans. It is most commonly found on particularly warm and moist areas such as nasal mucosa, groin, axilla, perineum and toe-web, and up to 50 % of the general population are nasal carriers of S. aureus. In healthy people this carriage is rarely a problem since S. aureus neither harm nor benefit its host. But when a person is vulnerable, for example in hospital, elderly or immune compromised; it is more likely to cause clinical disease (Cookson, 2005; Tarzi, Kennedy, Stone, & Evans, 2001). S. aureus is one of the most frequently isolated pathogens in both community and hospital practices. The organism has been found to be a common bacterial agent recovered from skin and soft tissue infections, pneumonia, hospital-acquired post operative wound infections andblood stream infections(Doern, Jones, Pfaller, Kugler, & Beach, 1999; Giacometti et al., 2000; Pfaller et al., 1999).
A change in the antimicrobial sensitivity of S. aureus was identifiedin the1960´s and became the gate for Methicillin Resistant Staphylococcus Aureus (MRSA). This means that beta-lactams, like penicillin and ampicillin, are ineffective against most of the isolated strains, and this has become a major problem in health care world wide(Bukhari et al., 2004; Cookson, 2005; Hackbarth & Chambers, 1989; Tiemersma et al., 2004).MRSAandsensitive S. aureus occur as asymptomatic colonization which is far more common than infection. Colonization may be transient or persistent and can last for years. Higher rates of carriages (colonization) than in the general population are observed in intravenous drug users (IDU), persons with insulin-dependent diabetes, patients with dermatologic conditions, patients with long-term indwelling intravascular catheters, and health care workers(Chambers, 2001).
Tiemersma et al (2004) has described the proportion of MRSA in Europe 1999-2002. Geographic variation showed a north-south gradient with the lowest MRSA prevalence in northern Europe (Iceland, Denmark, Netherlands and Sweden) and highest prevalence in southern Europe (Greece, Malta, United Kingdom and Ireland)(Tiemersma et al., 2004).
A large health-care associated outbreak of MRSA occurred in Sweden in the late 1990s and MRSA was made a notifiable diagnosis in Sweden in 2000, and since then the number of reported MRSA-cases has continued to increase. In a Swedish study (Stenhem et al., 2006) the increased number of reported MRSA-cases is described, from 325 in 2000 to 544 in 2003. Twenty five per cent of the cases, however, were infected abroad. The domestic cases were predominantly found through cultures taken on clinical indication and the cases infected abroad through screening. The authors also found considerable regional differences in MRSA-incidence and age-distribution of cases, although age over 60 has the most cases of MRSA(Stenhem et al., 2006). The prevalence of MRSA in Sweden is though low, about 1%, and the number of reported MRSA-cases was 975 in 2005 (Smittskyddsinstitutet, 2006a)
Health care associated infections (HAI), also known as nosocomial infections or cross infections, including MRSA are common. A HAI is generally defined as “an infection occurring in a patient in a hospital or other health care facility in whom the infection was not present or incubating on admission to that hospital/facility”(Ducel, Fabry, & Nicolle, 2002, p. 1). Hospitals are known as a source of the emergence, selection and spread of multi-resistant bacteria that can cause severe clinical syndromes that are difficult and expensive to treat and may even become incurable. The concept of HAI also includes infections acquired by health care workers (HCW) as a result of their work within the health care system.HAI have a substantial impacton morbidity and mortality and prolongs the duration of hospital stay, require additional diagnostic and therapeutic interventions, and generate added costs to those already incurred by the patients underlying diseases (Pittet et al., 2005).In the case of MRSA, patients who already have an MRSA colonization or infection are common sources of transmission. Thus the MRSA is in general transmitted by the hands of contaminated HCWs(Hardy, Hawkey, Gao, & Oppenheim, 2004).
In a questionnaire study 113 surgical out-patients were asked about if they had heard of MRSA, fifty patients (44 %) had, mainly via the media (58 %) or from hospital staff (44 %). The patients’ reactions to the possibility of acquiring MRSA revealed that 52 % would feel afraid and 38 % would feel angry. Of the patients 10 % stated that they would not be concerned and none would be ashamed(Hamour, O'Bichere, Peters, & McDonald, 2003). MRSA-infected patients were interviewed about their views of the infection and the experience of source isolation.MRSA was perceived as an infective agent by 15 participants. Six participants attributed the cause of their infection with MRSA as a direct result of the hospital stay and treatment, although they were unclear about the exact mechanism of transmission. MRSA was perceived as not serious by nine of the participants and seven thought is was a serious problem. Isolation in a side room was perceived to have both positive, e.g. greater freedom from routine and greater privacy,and negative, e.g. lack of attention from nursing staff and loneliness, aspects by participants(Newton, Constable, & Senior, 2001).
Standard hygiene precautionsaim to prevent direct and indirect contagion. Direct contagion occurs from a patient to staff or contrary and indirect contagion is when transferred from a patient to another via the hands and/or clothes from staff members. Standard hygiene precautions include consistent hand hygiene with alcohol based hand disinfection before clean and after dirty work evenwhenpvc/latex gloves are used. Aprons for single use or reuse and pvc/latex gloves are used within work with risk for body contact and/or body fluids and within areas around the patient(Socialstyrelsen, 2006).Harris et.al concludes that HCW understand the importance of hand washing, but tend to overestimate their own compliance(Harris et al., 2000).
Houang and Hurley(1997) studied the knowledge and practices of hospital staff in infection control.The result indicate a need to find ways to educate and motivatestaff to comply with infection control measures(Houang & Hurley, 1997).Mann and Wood (2006) showed that 58 % of medical students did not know the correct indications for using alcoholic hand gel and 35 % did not know the correct use of gloves(Mann & Wood, 2006).In Swedish hospitals ethanol hand rub (rather than hand washing) hasbeen used as a standard for preventing HAI since the 1970s(Smittskyddsinstitutet, 2006b).HCWs compliance to handwashing has been described as low as 13 %. The result showed that of the 298 handwashing indications that were identified through the observations of 23 nurses, only 45 resulted in handwashing and of the 34 indications from six observed doctors hands were washed in none (Karabey, Ay, Derbentli, Nakipoglu, & Esen, 2002).Compliance with hand cleansing protocols has been most frequently investigated in nurses because this group represents not only the majority HCWs in hospitals, but also the group of HCWs with the largest number of opportunities for hand cleansing during patient care.Factors associated with poor compliance to hand hygiene include heavy workloads, performing activities with cross-transmission, glove use and involvement in technical specialities (Pittet et al., 2000). In a study (Randle, Clarke, & Storr, 2006)amulti-modal campaign was used for improvement of hand hygiene compliance. An increase in hand hygiene compliance from 32% to 63% is described, with 74% of staff reporting increased compliance throughout the campaign(Randle, Clarke, & Storr, 2006).The multi-modal campaign has been proven to produce a sustained improvement in hand hygiene compliance, with reduced rates of HAI and MRSA transmission(Pittet et al., 2000).Patterns of hand hygiene in the community and in healthcare settings represent a complex, socially-entrenched and ritualistic behaviour(Whitby, McLaws, & Ross, 2006; Whitby et al., 2007).The theory of Planned Behaviour (TPB) was used to examine health care workers intention to hand washing. The authors argues that hand washing results in two distinct behavioural practices, inherent and elective hand washing, and that the model explains 64% and 76%, respectively, of the variance in behavioural intention.(Whitby, McLaws, & Ross, 2006).
It is a well known fact that the spread of antibiotic resistant bacteria’s in hospitals, like the MRSA,is facilitatedby health care workers non-compliance to hygiene routines.To prevent the spread, it is necessary to describe health care workers knowledge and attitudes in relation to compliance to hygiene routines. In addition, it is also valuable to describe the daily life and their perception of care among MRSA colonized patients.
Definitions
MRSA Colonization: The presence and multiplication of micro organisms without tissue invasion or damage. MRSA should be laboratory-confirmed.
MRSA infection: The organism gets past the persons normal defences and becomes a pathogen; examples includewound infections, pneumonia, urinary tract infections and blood stream infections.Symptoms are present.
Objective
The objective of the present research project is todescribe the prevalence of MRSA in a Swedish region andto explore the pattern of the epidemiological investigation process.Further is the objective to a) describe the experience of being colonized with MRSA; b)examine nurses’ compliance to hygiene routines and describe the experience of caringfor people with MRSA; c) describe health care workers knowledgeof MRSA and attitudes to hygiene routines; and d) develop and preliminary test astructured educational programmeregarding MRSA and hygiene routines.
Specific aims
Study I: The aim is toa) describe the occurrence of subgroups and stems of MRSA in the Uppsala-Örebro region, Sweden and b) investigate the pattern of epidemiological investigation process in a laboratory-confirmed case(s) of MRSA colonization, as well as to identifyfactors associated with risk for being colonized.
Study II: The aim is to describehow individuals with verified colonized MRSA experience their daily life.
Study III: The aim is toa) observeinfection ward workers compliance to hygiene routines in the care for MRSA patients and b)describeinfection ward workers behaviour and attitudes to care for patients with colonized MRSA.
Study IV: The aim is to a) compare knowledge before and after group information concerning hygiene and MRSA given to staff in primary health care settings; b) describe health care workers knowledge of MRSA; and c) develop and preliminary test a structured educational programme for health care workers regarding MRSA and hygiene routines.
Study descriptions
Study I
Design: a) descriptive retrospective register study;and b) descriptive prospective casestudy.
The aim is toa) describe the occurrence of subgroups and stems of MRSA in the Uppsala-Örebro region, Sweden and b)investigate the pattern of epidemiological investigation process in a laboratory-confirmed case(s) of MRSA colonization, as well as to identifyfactors associated with risk for being colonized.
Material and Methods
Approval to carry out the study will be gathered from the director of the involved medical institutions. Data is accessible via registers of diagnoses and data collection will be gathered through available databases.The main question of interest is; what subgroups and stems are present in the Uppsala-Örebro region?The data will be compiled from the year of 2004 to 2006.
Regarding the pattern of epidemiological investigation process acase, from each County, will serve as the starting point for data collection and MRSA is thereafter described as an epidemiological investigation.Risksfactors for being colonizedwith MRSA will be gathered, andvariables like patients contacts with health care, domestic contacts and/or hospital visits abroad, other diagnoses in patients like diabetes, treatment for end stage renal disease, dermatologic conditions, wounds, long-term indwelling intravascular catheters and use of urinary cathetersare of interest.
Study II
Design: explorative interviewstudy
The aim is to describehow individuals with verified colonized MRSA experience their daily life.
Method
Approval to carry out the study will be gathered from the director of the involved medical institution. Data collection will be made with a phenomenographic approach. This approach aims to describe the different ways individuals have understood a particular phenomenon, and the variations in these understandings is of particular interest. It is a method for the study of people’s conceptions of meaningful information in a second order perspective and a way to study how people understand the world around them, a way to study peoples thinking or understanding of what is commonly called “the reality”(Wenestam, 2000). The predicted time for conducting an interview is 60 minutes.A semi-structured interview guide withentry questions like“Describe an ordinary day of your life”and “Has the MRSA carriage affected your life in any way?” will be used. If MRSA has affected their life a question like “Tell me about a day when you felt that MRSA has been an obstacle in your daily life” will be asked. Follow up questions like “How do you mean?” and/or “Can you explore that?” will be used for data collection. The goal with this procedure is to let the informants talk freely about the phenomenon. Demographical data like age, gender, educational level, work situation, marital status and time since MRSA diagnose will be gathered. The interviews will be audio taped and then transcribed verbatim (in extenso) directly after the interview has beencarried out. The informants are achieved from the units’ register of diagnoses and an information letter will be sent home to the informants with a question of voluntary participation in the study and a statement that their participation will be guaranteedconfidentiality. The researcher will phone the informants one week after the letter has been sent, time and place for interview will be booked with the informants that accept participation in the study. Individuals who can not be reached by telephone will get a remind-letter after two weeks, with instructions to send in aformulary if they want to participate in the study. Demographics of non-participants will be kept in a record to describe attrition. Data like age, gender and any spontaneously given reason for not participate will be registered.
Informants
The present study focuses on individuals with verified colonized MRSA, in the County of Gävleborg. During 2005, 24 new cases of MRSA were discovered in this area; and during 2006, 16 new cases were discovered. A convenience sample of informants will be carried out in the actual unit. The individuals should have been diagnosed with MRSA for at least six months ago and for 24 months as the longest. The number of participants is planned to 20, and informants will be asked for participation until the number is achieved.
Individuals who does not speak or understand Swedish or who has a physical or psychological obstacle for communication will be excluded.
Data analysis
Data is planned to be analysed according to phenomenographic approach. The transcribed interviews will be read through to get acquainted with them in detail, and to get a feeling for the total variation and the limits in the material. Thereafter are statements about the phenomenon, i.g. experience of daily life, identified; and significant statements made by the informant will be selected to give a short but representative version of the interview. These statements will thereafter be categorised and compared in order to find sources of variation or agreement.This means that statements which appear to be similar will be put together into categories that will be named. These named categories will be compared with each other, with regard to similarities and differences, and the purpose of this is to be able to describe the different ways the informants has experienced the phenomenon, i.g. their daily life.These qualitatively different ways of experiencing the phenomena will be presented as the so called “outcome space”. The outcome space, is defined by the presentation of the list of qualitatively different conceptions of the phenomenon centred in the data material(Sjostrom & Dahlgren, 2002; Wenestam, 2000).
Study III
Design: a)descriptive observational study;and b)explorative interview study.
The aim is toa) observe infection ward workers compliance to hygiene routines in the care for MRSA patients and b) describe infection ward workers behaviour and attitudes to care for patients with colonized MRSA.
Method
Approval to carry out the study will be gathered from the director of the involved medical institutions. Data collectionwill be divided into two phases, observationsand interviews.In the observational phase of the study, a protocol regarding hygiene routines will be used for data collection.Variables like wearing gloves; apron, clothing, wearing jewels, hand washing/ -disinfection, what measures they make, etc will be observed. The observer (ML) plans to observe hygiene routines within the work health care workers perform in 20 MRSA cases during six hours. The results will be presented with descriptive statistics.