Implementing a patient education intervention about Methicillin-resistant Staphylococcus aureus prevention and effect on knowledge and behavior in veterans with spinal cord injuries and disorders: a pilot randomized controlled trial.

OBJECTIVES: To assess the feasibility and effect of a nurse-administered patient educational intervention about Methicillin-resistant Staphylococcus aureus (MRSA) prevention on knowledge and behavior of Veterans with spinal cord injuries and disorders (SCI/D). DESIGN: Blinded, block-randomized controlled pilot trial. SETTING: Two Department of Veterans Affairs (VA) SCI Centers. PARTICIPANTS: Veterans were recruited March-September 2010 through referral by a healthcare provider from inpatient, outpatient, and residential care settings. INTERVENTION: Thirty participants were randomized to the nurse-administered intervention and 31 to the usual care group. The intervention included a brochure and tools to assist nurses in conducting the education. OUTCOME MEASURES: Pre- and post-intervention measurement of knowledge and behaviors related to MRSA and prevention strategies and feasibility measures related to implementation. RESULTS: Participants were primarily male (95.1%), white (63.9%), with tetraplegia (63.9%) and mean age and duration of injury of 64.3 and 20.5 years, respectively. The intervention groups mean knowledge score significantly increased between pre- and post-test (mean change score = 1.70, 95% confidence interval, CI 0.25-3.15) while the usual care groups score did not significantly change (mean change score = 1.45, 95% CI -0.08-2.98). However, the mean knowledge change between intervention and usual care groups was not significantly different (P = 0.81). Overall behavior scores did not significantly differ between treatment groups; however, the intervention group was more likely to report intentions to clean hands (90.0% vs. 64.5%, P = 0.03) and asking providers about MRSA status (46.7% vs. 16.1%, P = 0.01). Nurse educators reported that the quality of the intervention was high and could be implemented in clinical care. CONCLUSIONS: A targeted educational strategy is feasible to implement in SCI/D clinical practices and may improve some participants' knowledge about MRSA and increase intentions to improve hand hygiene and engagement with providers about their MRSA status.

Patient and provider perspectives on methicillin-resistant Staphylococcus aureus: a qualitative assessment of knowledge, beliefs, and behavior.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of healthcare-associated infection. Individuals with spinal cord injuries and disorders (SCI/D) are at high risk of MRSA colonization and infection. The Department of Veterans Affairs (VA) released guidelines to prevent the spread of MRSA in Veterans with SCI/D; however, available patient educational materials did not address the unique issues for this population. OBJECTIVE: To assess perceptions of SCI/D providers and Veterans with SCI/D regarding MRSA and their educational needs about MRSA prevention, with an ultimate goal of developing patient educational materials that address the issues unique to SCI/D. METHODS: Purposive samples of SCI/D providers (six groups) and Veterans with SCI/D (one group) at two VA facilities participated in 60-90-minute focus group sessions. Qualitative data were analyzed using latent content and constant comparative techniques to identify focal themes. PARTICIPANTS: Thirty-three providers (physicians and nurses working in inpatient, outpatient, and homecare settings) and eight Veterans participated. RESULTS: Three overarching themes emerged from the analysis: knowledge about MRSA, hand hygiene, and barriers to educating Veterans with SCI/D. CONCLUSIONS: SCI/D providers and Veterans with SCI/D identified gaps in general MRSA knowledge, gaps in knowledge of good hand hygiene practices and of required frequency of hand hygiene, and barriers to educating Veterans with SCI/D during inpatient stays. Future educational materials and strategies should address these gaps.

Staphylococcus aureus rectal carriage and its association with infections in patients in a surgical intensive care unit and a liver transplant unit.

BACKGROUND: The role of rectal carriage of Staphylococcus aureus as a risk factor for nosocomial S. aureus infections in critically ill patients has not been fully discerned. METHODS: Nasal and rectal swabs for S. aureus were obtained on admission and weekly thereafter until discharge or death from 204 consecutive patients admitted to the surgical intensive care unit and liver transplant unit RESULTS: Overall, 49.5% (101 of 204) of the patients never harbored S. aureus, 21.6% (44 of 204) were nasal carriers only, 3.4% (7 of 204) were rectal carriers only, and 25.5% (52 of 204) were both nasal and rectal carriers. Infections due to S. aureus developed in 15.7% (32 of 204) of the patients; these included 3% (3 of 101) of the non-carriers, 18.2% (8 of 44) of the nasal carriers only, 0% (0 of 7) of the rectal carriers only, and 40.4% (21 of 52) of the patients who were both nasal and rectal carriers (P - .001). Patients with both rectal and nasal carriage were significantly more likely to develop S. aureus infection than were those with nasal carriage only (odds ratio, 3.9; 95% confidence interval, 1.18 to 7.85; P= .025). By pulsed-field gel electrophoresis, the infecting rectal and nasal isolates were clonally identical in 82% (14 of 17) of the patients with S. aureus infections. CONCLUSIONS: Rectal carriage represents an underappreciated reservoir for S. aureus in patients in the intensive care unit and liver transplant recipients. Rectal plus nasal carriage may portend a greater risk for S. aureus infections in these patients than currently realized.

Alternative therapy use in HIV-infected patients receiving highly active antiretroviral therapy.

The extent of use of alternative therapies, psychosocial and disease-specific variables predictive of alternative therapy use, and factors motivating the use of alternative therapies in HIV-infected patients receiving highly active antiretroviral therapy (HAART) have not been well defined. Types of alternative therapies used, demographic and medical data, coping (Billing and Moos inventory of coping with illness styles), social support (Irwing and Sarason questionnaire), sense of personal control (Pearlin's Mastery scale), quality of life (Medical Outcome Study scale), health beliefs, and adherence rate were prospectively assessed in 118 HIV-infected patients receiving HAART. Of 38% (45/118) of the patients who used alternative therapies, 56% (25/45) began using alternative therapies since the initiation of HAART. While Caucasian patients were more likely to use alternative therapies than all other patients (P = 0.015), new users of alternative therapies were more likely to be African-American (P = 0.022). Alternative therapy users reported less satisfaction with their emotional support (P = 0.027), and had greater psychological distress (P = 0.048), but were more likely to utilize problem-focused coping (P = 0.015). Patients who used alternative therapies were less likely to believe that HAART was beneficial (P = 0.06). Physicians were unaware of patients' alternative therapy use in 40% (18/45) of all patients who used alternative therapies, in 67% of herbal therapy users, and in 100% of dietary supplement users. Adherence to antiretroviral therapy, CD4 count, and HIV-RNA level were neither predictive nor affected by alternative therapy use. Despite scepticism about the benefits of HAART, resort to alternative therapies did not undermine adherence with antiretroviral therapy. Although able actively to cope with their illness, users of alternative therapies had greater psychological distress and were less satisfied with their emotional support. Interventions aimed at promoting their psychological well-being and enhancing the emotional support should be considered in these patients.

Influenza outbreak management on a locked behavioral health unit.

BACKGROUND: In January 2006, 8 patients on a locked behavioral health (BH) ward were identified with influenza-like illness (ILI) based on syndrome of fever, malaise, myalgia, cough, and rhinitis. Two patients initially had rapid antigen testing positive for influenza and confirmed by polymerase chain reaction. All patients present on the ward (N=26) had been ordered influenza immunizations 6 weeks earlier: 46% (12/26) were immunized, 42% (11/26) refused, 12% (3/26) had no record of immunization. All direct care staff who worked on the unit during the outbreak had been offered immunizations in the fall: 55% (22/40) were immunized. METHODS: When first symptoms were identified, provider notified infection control nurse and hospital epidemiologist, who instituted control measures: patients were confined to unit, unit was closed to admissions, nonimmunized asymptomatic patients were offered immunization, temperatures were recorded every 4hours, and nonimmunized providers were offered immunizations and prophylaxis. Patients with ILI were either admitted to acute care and placed in Droplet/Contact Precautions until afebrile for 48hours or managed on the unit with modified isolation. All patients remaining on the unit were instructed in hand hygiene and respiratory etiquette; asymptomatic patients were offered oseltamivir phosphate prophylaxis; and previously nonimmunized patients and staff were again offered the vaccine. RESULTS: Twenty-six patients and 28 staff were on the unit during the outbreak. Eight patients and 8 staff members reported ILI within 5 days. Of the ill patients, 3 had been immunized, 5 had not (2 refused, 3 reason unclear presumed to have refused), and 4 were admitted to acute care and placed in Droplet/Contact Precautions until asymptomatic for 48hours. Of 22 patients who remained on the unit, 4 were symptomatic; 18 asymptomatic patients took prophylaxis, and 1 refused; 8 (89%) patients who had earlier refused vaccine were immunized. Of the 40 staff members, 55% (22/40) were immunized, and 20% (8/40) were symptomatic (all presumptive, encouraged to remain off duty). Fifty percent (4/8) of symptomatic staff had been immunized. After 7 days, no new cases had been identified, and the unit was reopened to admissions. No ill effects resulted from the prophylaxis. CONCLUSION: Prompt detection of ILI and institution of control measures effectively contained the outbreak; the relatively high immunization rates among both patients and staff helped curtail spread. Refusal of immunization is a long-standing problem among BH patients and staff. Our study shows importance of immunization in preventing outbreaks in inpatient BH settings. Recommendations included development of more aggressive immunization campaign for patients and staff who historically refuse and continued high priority for provider vigilance in immunization campaign and surveillance for symptoms.