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.

On Controlling The Spread Of Disease, Or, The State Gives Me MRSA

It has been the practice of your friendly fake consultant to keep my personal life separate from the stories you see in this space; and where exceptions have been made it has been because I felt it necessary to tell a larger story.

The story we will begin to tell today must be offered with my own life deeply intertwined in the narrative.

Sadly, it will not just be me that will be affected by the events we will here discuss. Instead, the list of victims will include some of Washington State’s most vulnerable citizens—those developmentally disabled individuals who reside in the State’s “Residential Habilitation Centers”--and the workers who care for them…one of whom is my very own spouse.

We have within the tale all the usual suspects: a lack of safety equipment, managers who fail to do their jobs, a system that’s failing to protect either its own or those who can’t care for themselves…and now, just to give things a twist, pharmaceutical soap, little orange pills, and color-safe bleach.

Before we begin in earnest, a few words about privacy. There will be some considerable restriction as to what exactly I can say in this report due to the need to protect the privacy of both the clients and the workers involved.

In the case of the clients (residents of these facilities are not referred to as patients because they might not necessarily be suffering from disease or illness—although, as with all of us, that changes from time to time) the privacy requirements are a part of the Federal HIPPA law…and in the case of the involved workers, there are concerns regarding potential retaliation.

The best place to begin the story, I suspect, is to explain exactly what MRSA is.

MRSA is a type of staph virus (Methicillin-Resistant Staphylococcus Aureus) which, as the name implies, is resistant to some or all of today’s antibiotics.

There are several strains of the virus (USA100 and USA300 being the most common) and the universe of strains is broken down into two groups: hospital-acquired and community-acquired; they are each differently resistant to different combinations of antibiotics. The particular variety of MRSA which has infected me is from the hospital-acquired group and it is resistant to Ciprofloxacin, Clindamyacin, Erythromyacin, and Oxacillin.

About 85% of the estimated 95.000 exposures in 2005 can be traced back to the healthcare system, one way or another, and about 12% are community-acquired. “Community-acquired” MRSA exposures most commonly occur in gyms, prisons, and the military, and are primarily skin infections. Depending on where you live in the US the rate of infection in the general population might vary from roughly 20 per 100,000 to 120 per 100,000.

As you might expect, age and a compromised immune system make infection more likely.

Lucky for me, there are antibiotics that our virus (The Girlfriend and I have shared so much these many years…and now we’re sharing this) is sensitive to…which is why we’re taking Doxycycline twice a day.

The virus can enter the body through cracks in the skin, inhalation, or by the sorts of blood and fluid contacts that you might expect would spread this sort of thing from one person to another.

The virus can “colonize” itself without infecting the host or it can be in an infectious state. As a result it is possible to carry the virus for some time and become infected later, or not at all. This is common to many other forms of staph as well.

Infections can occur not only in the skin, but also in the body’s other soft tissues, or in the lungs, where it can cause pneumonia.

I’m told the “warm hairy areas” of the body are the most susceptible to colonization—face and head hair, armpits, and the crotch area in particular.

Without effective treatment, MRSA can most assuredly be fatal.

When drug therapy is successful the rate of relapse can be as low as 5%.

There are variants of the virus that are resistant to virtually all known antibiotics—and even when certain antibiotics will work there may be situations where the patient’s allergic to those antibiotics.

In those cases where drug therapy cannot be employed excision (the surgical removal of the affected tissue) and maggot therapy (yes, they sometimes use maggots for removal of affected tissue) are available options.

We’ll be returning to this topic as we go deeper into the story…but at this point we should probably take some time to discuss how the spread of disease is controlled in health-care facilities.

Readers will undoubtedly be familiar with the image of a surgeon in the operating room: the surgical mask, gown, gloves and face shields that are worn in that environment are just as important in protecting the patient from acquired infections as they are in protecting everyone else from that patient.

In settings other than the OR it is just as crucial that infection control be as close to 100% effective as possible; this is why those same protective garments are now a mandatory part of every healthcare worker’s arsenal. Those of you who are regular viewers of the “Discovery Health Channel” will probably recall seeing medical personnel “gowning up” to perform a procedure.

“Best practice” guidelines are provided by the Centers for Disease Control. Those best practices are known as “Standard Precautions”…and they’re fairly simple to explain. I’ll paraphrase:

--If you’ll be in contact with someone else’s body fluids, you should assume that person—no matter who they are—is infectious.

--For your own protection (and the protecthttp://www.cdc.gov/ncidod/dhqp/gl_isolation_standard.htmlStandard Precautionsion of others) you’ll need gloves, gown, mask…and beyond that, a face shield for activities “that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions”.

--Although this will sound obvious, you don’t want to use the gloves, gown, mask, or face shield while moving from one person to another…instead, you need to change into new clean stuff before moving on to the next procedure.

By following these fairly obvious instructions you prevent “cross-contamination”—potentially saving the lives of yourself and all those with whom you will later make contact.

Which includes the family members back home, when the shift is over.

That’s where I come in.

The Girlfriend (of more than 26 years…hooray for us, eh?) informed me that we’ll be needing to take eyedrops for what we thought was her (relatively minor) case of conjunctivitis. We did, to no effect.

We were then prescribed Bacitracin Opthalmic ointment to resolve what had by now been diagnosed as MRSA (it requires a lab culture to confirm the diagnosis)…which meant putting this awful goo in our eyes four times daily…which did no good.

One week later we found ourselves in the office of an Infectious Disease Specialist

And now we have some…unusual…household routines.

In addition to the Doxycycline, we now use “Hibiclens” surgical soap for our washing and showering needs, as well putting Muriprocin ointment up our noses twice daily. The “ewww” factor is high, indeed on that one.

All clothing is now washed with color-fast bleach; and we mostly use paper towels.

All of this (except the antibiotics) for the next three months.

Hopefully it works, and the disease either is eradicated or returns to a “colonized” state.

All of this for an infection we did not have the pleasure of acquiring in Las Vegas.

So, you might be asking, if the infection control process exists, how does the infection manage to spread?

I’ve had a few conversations—and done a fair bit of reading--with the intent of finding the answer to that myself, and here’s what I’ve learned:

--Workers sometimes hang used gowns at the end of a client’s bed, go about their business, and then return later, reusing the same gown for later procedures.

--Other workers will wear the same gown for their entire shift, moving from client to client to client.

--There can be issues related to the way linens are handled and laundered that can cause the spread of infection.

--Although there are some face shields available at her facility, The Girlfriend tells me that their presence is, shall we say, sporadic—that is to say, they are not available in all of the locations where they are needed.

--There are procedures that, by their very nature, are inherently dangerous—particularly problematic are the feeding tubes which are surgically inserted directly into the client’s gastric system. These have almost universally replaced the older “nasal gastric” tubes (through the nose and into the stomach) that were often the unintentional cause of aspiration (the lungs fill with the liquid food, rather like drowning), should the tube become dislodged.

The opening in the body made to accommodate the surgically inserted tube can leak, there can be “deposits” of internal fluids on the outside of the body through the hole…and most commonly of all, the tubes can become plugged by the liquid food they are designed to transport into the body. The process of unplugging the tubes is, obviously, going to expose all and sundry to something, whether it be food or body fluids. The CDC confirms this is a huge problem.

--There is a lack of effort on the part of Infection Control management to educate and to correct these problems…and in some cases it appears that there’s a lack of awareness that these even are problems.

We will talk about this in more detail in the next part of the story, but for the moment we’ll say that since at least 2006 there have been warning signs of problems to come.

I try to keep my emotions in check when writing, as I find a dispassionate approach makes for more a clear understanding of research…not to mention an increased empathy for those about whom I write.

In this case, however, I have taken it a bit personally. You see, this is not the first potentially hazardous exposure The Girlfriend has suffered due to appallingly poor clinical practice at this facility…another subject we’ll address in considerable detail in the next installment of the story.

Since it was obvious to me that there was not going to be a change in culture imposed from the inside, I’ve decided I’m going to do it for them.

Which is why, in recent days, the emails began flowing--to the Governor, the Secretary of the State Department of Health, the Secretary of the State’s Department of Social and Health Services (the largest of Washington’s State Agencies), the Director of WISHA (the State’s OSHA equivalent), the State Attorney General (because someone’s getting a bill for my care eventually…), and the State Auditor, who is charged with investigating governmental misconduct.

(To be honest, I was a bit inaccurate in the note…I told the various parties that MRSA was the “flesh eating bacteria” disease, which was an error on my part. I blame myself, for being a bit overwrought as I wrote; and I do owe all involved an apology for the error…so Governor Gregoire, if you might see this: sorry about that—but the rest of the note is dead-on accurate.)

And that’s how we get to the part where I ask you for some help.

In the note I sent I reminded the Governor (who won in 2004 by a mere 8 votes) that not only was this affecting those vulnerable citizens who reside in the State’s facilities and the employees who are there for them--but that the problem, thanks to my infection, had now spilled into the community of…registered voters.

Not a good thing, in an election year.
But good for us, as it means we have a way to keep the Governor’s attention…focused.

So do me a favor, if you would…and drop the Governor a quick note, here at her official website, perhaps reminding her that all the State’s citizens matter when it comes to healthcare equality, or that infectious disease control is everyone’s business—even the State’s…or perhaps you might pose this question: if we can’t control MRSA, even in State facilities, how in the world are we going to control pandemic influenza in the general population when it eventually rears its ugly head?

We meet with management Monday to discuss the incident…which means part two of the story will also be a good one: we’ll talk more about past problems, we’ll asses management’s attitude today…and we’ll see if we can’t help the State find a better way going forward.

Put on your seatbelts, kids…it’s gonna be a rocky ride.

AUTHOR"S NOTE: As was mentioned by several of my new friends, MRSA is a bacterial infection, and not a viral one. My aplogy to the reader for the error.