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Sunday, April 13, 2008

On How The State Gave Me MRSA (Part II), Or, What, Me Worry?

We began a story this week that describes how poor clinical practice in a State-operated healthcare facility holds the potential to cause great injury and death to those vulnerable adults living in the facility, the workers charged with their care—and to members of the public who have never even set foot in the facility.

You might say it’s a bit of a “canary in a coal mine” situation, with pandemic flu hovering on the horizon and all. You also might say that since MRSA kills as many people in the US every year as six 9/11s the pandemic is already here.

So in today’s second installment, we’ll look a bit further: into facility management that now contends they are not required to follow guidelines that the Centers for Disease Control says “apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered”…into the concept that where your care is delivered should determine what protective equipment workers might require…and into a “magic ambulance” that apparently has the power to make you hazardous to some people--but not to others.

And just to add a twist--we have a Governor seeking re-election whom we hope to convince to put on her “superhero cape” by publicly coming to the rescue and making infectious disease control in all State facilities an important priority of her next Administration.

Because after all, do we really need six more avoidable 9/11s this year? And next year? And the year after that?

For those just coming to the story, let’s recap where we’ve been so far:

The Girlfriend (of over 26 years!), a nurse working for the State of Washington in one of the five “Residential Habilitation Centers” serving developmentally delayed individuals, recently brought home MRSA, which we now share—in our eyes.

MRSA, as you’ll recall, is one group among the variety of drug resistant organisms with which today’s medicine contends—drug resistant meaning that some, or virtually all, of today’s antibiotics will not “cure” the infection. There are several strains of MRSA, each with different drug-resistance characteristics. All this is discussed in more detail in the first installment of our adventure.

One reason this occurred is because the facility is lacking the most basic equipment required to prevent the spread of infection…and I’m not talking high-tech equipment here, either. For example, the facility does not see the need for sufficient eye protection for its medical care providers; this despite the fact that numerous procedures performed by each nurse daily (as well as other medical staff) “are likely to generate splashes or sprays of blood, body fluids, secretions and excretions” to quote again from the CDC.

IV. Standard Precautions
Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting and apply the following infection control practices during the delivery of health care.

--excerpted from the CDCs “Guidelines for Isolation Precautions in Hospitals

There is also a failure of perception among management, who maintain that the community of clients residing at the facility are somehow epidemiologically “safe”…meaning the current facility policy is that the Standard Precautions which apply to everyone else practicing healthcare, everywhere else in the world (including Tamil, India) do not apply when working with this client population.

The likely outcome is that MRSA will spread among the vulnerable adults—and the staff--that this facility (and the other four like it) serves, and considering that 1 in 5 who get MRSA die as a result of the infection…well, 1 in 5 are probably going to die from an avoidable cause.

As we said before, it’s estimated that about 18,000 who were exposed to MRSA in 2005 died from the infection…which is about 20% of the annual total of 100,000 “avoidable” hospital deaths in the US.

Presumably there will be other members of the community beyond the facility affected as well…just like me, and just like the friends and relatives of some of you who have commented on the first story.

The Girlfriend and I are in the middle of an irritating series of adaptations designed to make it less likely that the MRSA bacteria will either re-infect us, or remain present in a dormant, or “colonized” state, ready to reappear without warning at some future time.

The most annoying adaptation?
I’ve just finished putting antibacterial ointment up my nose, as I do twice a day. To recreate the sensation, stick a Vaseline-covered Q-tip up each nostril. (Warning: stunt nose used for demonstration purposes only. Do not try this at home. Trust me, it sucks.)

Of course, the surgical soap we use constantly is a bit of a pain as well…

But enough about me.

The more important question is…how did the facility react when presented with the news that they have an infection control problem?

Well, that’s where it gets weird.

There seems to be a feeling that it is the type of facility that determines what sort of precautions are applied, rather than making a decision about the correct choice of protective equipment based on the procedure being performed.

A phone call to the Washington State Department of Health confirms this line of thinking goes farther than just this facility—the individual to whom I spoke (I did not identify myself as gathering news, so I’ll leave their name out of the discussion) answered my question about whether Standard Precautions should be applied at all healthcare facilities by telling me that it might depend on whether a nursing home is a healthcare facility…as opposed to a hospital.

Further discussion brought us to a point where we decided a better answer might be found by consulting with others at the Department of Health—and I’m awaiting that person’s return call as of this writing. (Please note that it is the weekend as I write, so the fact that no return call has yet occurred should not be construed as somehow sinister.)

If this line of thought is carried to its logical conclusion, here’s what we get:

Client X is an individual who is fed through a “G tube” (a tube that is surgically implanted and delivers liquid food directly into the individual’s stomach) in a nursing home which we’ll call “Site R”.

In that environment, according to current policy at our imaginary “Site R”, the only required protective gear while working with the tubes is gloves and a mask. What kind of work? A nurse might plug in a feeding or medicine tube, inject medicine into a port using a syringe, or “flush” a plugged food tube to allow it to again deliver food. Any of these interactions can easily cause the splashes or sprays of body fluids that spread disease.

Now suppose Client X were to encounter a medical difficulty requiring a move to the hospital. According to the CDC guidelines (and the “facility-based “logic we’ve seen so far) that same G tube work would require gloves, a non-permeable gown (no liquid getting through), a face mask, and eye and mucous membrane protection for the worker (the clear plastic “face shields” you see in use, or something similar).

Meaning that either something happened in the “magic ambulance” on the way to the hospital that made Client X more hazardous than he was before…or “facility based” logic makes no sense.

My guess: the ambulance ain’t that magic.

In this conversation we’re talking about MRSA…but imagine if Client X has undiagnosed Hepatitis C…or AIDS?

Is the nursing home worker less entitled to protection than the hospital worker?
Is it sound public policy that some healthcare workers are allowed to spread MRSA, hepatitis, HIV, and who knows what else…but not hospital workers?

As we previously mentioned, what comes home from work is going to get into the community—but did you know drug resistant bacteria are also now appearing in other species besides humans?

Try to imagine avian flu and MRSA in one superbug and you might understand why infection control is so, so, so critical.

If you need a further demonstration, the next time you’re walking down the street, try this exercise: count the people you see, from one to dead.

One to dead, you say?
How’s that work?

It works like this: MRSA kills 1 in 5…so when you see people during the day, all you have to do is count “1, 2, 3, 4…dead”. Repeat the process a few times, and you begin to get an idea of the reality of a pandemic.

We’ve covered a lot of ground today, so let’s wrap it up:

It is beginning to appear that many in the infection control community believe the location where healthcare is delivered is how you decide what protection the worker needs.

Others would tell you that disease is disease is disease…and if you plan on doing open heart surgery, it shouldn’t matter if you do it in a hospital, or a makeshift clinic in the real “Site R”…or in a bullring, for that matter…you still need to take the same precautions, every single time, if you want to prevent 18,000 or so deaths next year.

In my State of Washington the Governor is running for re-election…and she only won by 8 votes last time…so I’m trying to encourage folks to send her a note expressing your feelings about all of this here. I hope to encourage her to turn this to her advantage and make it an “issue that matters”—and Governor Gregoire, as I’ve said before, it’s always good to save the lives of registered voters in an election year.

It’s your lives and mine that are at stake here; so let’s put some pressure on and see if we can’t cut six 9/11s down to five next year.

If nothing else, you’ll have earned the appreciation of your grateful antibodies.

Author’s Note: We aren’t done yet. In part 3 we’ll discuss the response from the Health Department, we’ll be calling new experts…and we’ll be discussing the history of intimidation that the employer involved here is trying to overcome.

Stay tuned.


jmb said...

Oh, oh. Not looking good, this story.
I certainly would write to your Governor if I lived in your state or even country, but I live next door you see.

The facility you are talking about is no doubt equivalent to a stand alone extended care facility here. The hospital where I worked had an acute care unit (where I worked), an extended care unit and a pysch unit all under the one umbrella, ie management, so it was easier to provide the same pretentative equipment everywhere as necessary. The same infectious disease people oversaw all facilties as did we on the safety committee.

Well good luck with your fight, don't accept budgetary restrictions as an excuse. What needs to be done, has to be done, regardless of the cost, for the cost could be greater if you don't.

fake consultant said...

it is indeed not looking good, from a logic perspective.

there is some good news to report in part III...and, unfortunately, also some "more of the same" news to report as well.

as to dropping a note to the gov...the more opinions she hears--especially medically informed opinion--the better, and after all, you are our neighbor, which does give you some "standing" on the issue--especially since keeping it under control right next door matters in your future as well.