APRIL 17, 2010 2:06AM

MRSA, nose picking, and pulse oximetry

Rate: 14 Flag

You may have heard a discussion on NPR yesterday about MRSA.  (Methicillin-resistant staph aureus, to friends.  A nasty bug that causes nasty infections, and is hard to kill.)  As an ER nurse, I'm acutely aware of this issue, dealing regularly with the painful (and costly) incision of MRSA abscesses. 

While medical and housekeeping staff, and state inspectors,  have good intentions, I see glaring gaps in how sanitation is approached. 

The primary reservoir for MRSA seems to be in nostrils (warm, moist, frequently touched by fingers.  Well, in SOME people. . .  )

MRSA is, clearly, spread primarily by hands - either contacting other hands or touching surfaces that other hands touch.  Yet the emphasis on between-patient cleaning is on mattresses, pillows, floors, and tables.  Less commonly bedrails, and rarely pulse-oximeter probes (the little clip that reads your oxygen level from your fingertip), doorknobs, monitor buttons, or computer keyboards cleaned.

MRSA can live for several days on a surface after deposited there by hands.

At a recent state survey of a hospital where I was working, the inspectors required that plastic blood pressure cuffs be discarded after each pt (they could easily have been wiped down), and went so far as to require triage nurses to write the patient's name on each one with a Sharpie marker.  On their next visit they inspected the garbage cans to ensure that we were tossing out one reusable cuff per patient (don't EVEN get me started on how environmentally criminal this is), but made no mention of pulse ox probes, which are routinely placed on finger after finger without cleaning.  Many of those fingers have. . . how can I put this delicately?. . . been inside noses, a hotbed of MRSA colonization. 

It seems to me a major education of infection control staff and, through them, hospital staff, is in order.  I've talked this stuff up, to sometimes-glazed eyes.

Here's what would happen, if I ruled the world:

Pulse oximeter probes would be cleaned with an alcohol swab after each use.

Bedrails, doorknobs, computer keyboards, IV poles, monitor controls, chart holders, pens - anything that numerous hands touch - would be cleaned regularly.  If possible, every time they are touched.

Patients who are given a clipboard and pen to sign out would first be asked to use hand sanitizer.

Of course, much of this would be irrelevant if all staff (including - dare I say it? - physicians) would be diligent about using hand sanitizer after EVERY TIME they touch someone or something.  It's not hard, if it's available.  Which, alas, it often isn't - this leads me to believe that staff aren't using it and don't notice that it's absent.

I'd also like to see research into using heat to treat MRSA infections, as an alternative to the ever-enlarging list of drug-resistant antibiotics.  In my own experience, I've never seen it fail for superficial skin infections  - a wet washcloth in a Ziploc baggie, microwaved for 15-20 seconds, applied every hour at the first sign of infection.  It needs to be as hot as you can stand it without burning the skin.   Great caution would be required in those with sensory impairment to prevent burns, but I think research could determine the optimum temperature for effectiveness without damage.  There is, of course, not much money to be made in researching this.  Wait. . .  Ziploc?  Oh Ziploc? ? ? 


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Common sense is truly lacking in this isn't it? The fear of lawsuits and the subsequent reactions seem to be just done completely by knee jerk. As an emphysema patient those pulseox probes are a part of life and now you tell me that they don't even get wiped down after use? Ick, I've spent enough time in waiting rooms to know the frequency that fingers take regarding the nose, butt, and even armpits. Though the BP cuff is discarded even in light of the fact that it is merely wrapped around one of the few body parts that will never fit in anyones nose. It seems like a disposable sleeve for both devices would do more good for less money. Welcome back.
Thanks Bobbot. I didn't really decide to leave, just decided to do other things with my mornings, and didn't have any inspiration to write. Nice to hear from you, my friend.

It IS mind boggling, isn't it, that pulse ox probes aren't cleaned? I bring out alcohol swabs when I'm working triage, but notice they're never there unless I bring them, and I don't see anyone else use them. I've tried to suggest it, without being too annoying and arrogant - not sure how to approach this. XOXO AHC
Thanks for the tips - as he heads over to the sanitizer.
When I was a health planner, I found scholarly articles estimating that 40% of all illnesses in hospitals were caused by inadequate hospital sanitation or doctor incompetence. Folks, every time someone you know has "complications" there was a screwup involved!
Great ideas and I don't understand why they are not doing them!
I'll weigh in as one nurse to another - I INSIST on using the tape on pulse ox because of the very reason you mention. It's also less likely to come off, gives more consistent readings, is less aggravating to the patient, doesn't interfere with normal hand use, can be placed on the earlobe when required ... if anything's going to be disposable, it's the pulse ox. In the PACU I always wipe down (with a bleach cloth) everything from the monitor to the stretcher, rails, cushion, BP cuff, keyboard, table top, phone, TV control,etc. between every patient. You may have touched it, sweated on it, barfed on it, sneezed on it, bled on it - I wiped it. I give my pen and stethoscope a thorough scrub during this decontam as well, and have a 'special' pen (usually a drug rep freebie, easy to distinguish) reserved just for patients, and it gets cleaned too - I just don't use it myself.

Healthcare workers are not tested for MRSA (they make sure you're immune to measles, chicken pox, TB and mumps, but do NOT want to know your MRSA status) because it's likely we are all carriers by now. It would shut down the care system if it were shown that we are all potential sources of infection to susceptible patients.
Hi, Elisa! Thanks for the welcome back. I've missed writing, but found I was spending too much time obsessing about OS. Right now I'm obsessing about trying to grow morel mushrooms in my yard, and other stuff one can eat. You go, girl, channeling Howard Hughes. Woo hoo!

Gabby Abby - good for you. Sounds like you're thorough. What worries me is rooms cleaned by housekeeping staff who aren't really trained in why they're doing this stuff. Also, in ER, it's not practical to tape on a new pulse ox probe (about $20 each, I think) for each patient. A little cleaning would suffice, but watch, next time you're at triage.

It's not really possible to sterilize a hospital, but we could do WAAAY better with things contacted by hands. Thanks for your comments, guys!
Just as an FYI Chickie, I ran into the myth of cost for the stick on oximeters when I worked in the ER as well. They are a little less than $4 each, although I had been told they were 'very expensive' as well.
Abby: Really? Are you sure? Because I priced them (where I could find them online as a mere human, vs. hospital corporation) and they were 20-25 (adult and pedi). But buying by the gazillions might make a difference. Then there's the environmental issue - it bothers me. Seems like a quick bleach swipe would do on the others, perhaps.

Nice to connect with a fellow nurtz. AHC
"this leads me to believe that staff aren't using it and don't notice that it's absent" I've got my own bottle in my pocket. Perhaps other staff do this as well? Positive thinking here ;)
Thank you so much for the Ziploc tip! My dog has the worst skin infections and I will try that. The prednisone, antibiotics, salves and shaving have been ineffective so far this season.
Good for you, you witcher pocket sanitizer. Or pocket HAND sanitizer. And good luck with your dog - I battled that for years with my old black lab. Too generalized for the baggie treatment. He was ultimately on an anti-rejection drug for organ transplant patients, which helped, sort of. Now he's nourishing forget-me-nots in my garden. Best dog ever. . . sigh.
Great post. I wound up in the hospital for 4 days with MRSA. WASH YOUR HANDS!!!!
In one study they took cultures from doctors neckties and the results were shocking. Often the those that should know better (doctors) seem to take offense to the idea that they themselves could be germ carriers.

Of course this has been the case historically for hundreds of years. It was not considered necessary for a doctor or even a surgeon to wash his hands before treating a patient or in between patients. When Joseph Lister came along he was met with huge opposition when he began educating surgeons to wash their hands before surgery. He noticed too that doctors would often go directly from surgery (with filthy hands) to delivering a baby. Not surprisingly he also noticed that women were dying from childbirth complications in hospitals at a much higher rate than those who delivered at home with a midwife (who also washed their hands!).
You make this technical information transparent with brief, clever asides. You have a calling for science/medical writing.
This should be a wake-up call. All together, now, 1.2.3: Oh, ZIP-LOOOOCCCCC!
Pulse Oximeter thinks even when using this medical device it need to be cleaned on a regularly because of what people touch and where they put their fingers.
Yes! I agree about the handling of MRSA! Ive had MRSA abscesses lanced and drained 2xs. Lower ab just above pubic bone- not fun (or pretty). I went to the ER one day after work because my co-worker put the fear of God in me about MRSA - said waiting a week and covering the (what thought was a bite of some sort) with bacitracin wouldnt help it. The triage nurse told me to show her- I pulled down the front of my pants- she ran her finger over the abscess and said it was a spider bite. Even I know better than to touch that region of a patient without a glove- bite or abscess! Nurse was wrong- my co-worker was right. The bacitracin kept the outside of the abscess at bay- it couldnt come "out" of my body- it tunneled backwards. I was a day way from major surgery. The numbing, lancing, and draining was horrible. Lots of blood and just way too painful. In fact, I stated to the doc that I would have rather given birth again than ever go through having a needle in that area again. Lots of blood- the nurse just picked up the bloody towels- no gloves. Dropped the bloody towels in the regular towel bin. I asked the nurse if he was afraid of getting MRSA. He said he was exposed to so much bacteria and virusus everyday that his immunity was exceptional. "Yeah, but this is MRSA!", I said. Why does bloody gauze get put in the contaminated bio hazard red bin, but bloody towels get thrown in with the rest of the towels? Hopefully housekeeping/laundry personnel are supplied with masks and gloves to handle the linens.
As a student nurse, I was very concerned with MRSA. I wanted to wash all common places in my patients' rooms, like pulse oximeters and bed rails. But people got mad, they felt like I was saying they were dirty. I'd explain it was everyone else I was concerned about infecting them. This made them happy.