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Essential Nursing Care of the Critically Ill Patient 121

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membranes of the mouth and nose. Specific sequences epidemic proportions. Multiple strains of MRSA have
have been outlined for putting on and taking off PPE, been identified, and in many studies ICUs have the
that minimise the risk of contamination. 119 highest incidence. 127 In the past decade vancomycin-
resistant Enterococcus (VRE) has become a serious health
Epidemic outbreaks of SARS occurred in Canada, China,
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Hong Kong, Singapore and Vietnam, and it has been issue in Australia. As with MRSA, VRE transmission is
reported in over 25 countries since the WHO issued its associated with contact. Other resistant organisms found
global alert in March 2003. 132 SARS was transmitted in critical care areas include coagulase-negative Staphylo-
between patients, healthcare workers and hospital visi- coccus, Pseudomonas aeruginosa, Acinetobacter spp, and
126
tors, and large within-hospital outbreaks were associated Steno trophomonas maltophilia.
with aerosol-generating procedures such as bronchos- MRSA is endemic in hospitals throughout the world, and
copy, endotracheal intubation and the use of aerosol critical care units have a central role in its intra- and
therapy, 132 which are commonplace in critical care areas. interhospital spread. 127 Patients who are colonised nasally
In Hong Kong, more than 20% of cases were healthcare with MRSA have a significant risk of wound infection,
workers. 133 Because of the high level of morbidity and and the risk of MRSA infection is higher in patients who
mortality associated with SARS, 134 the risk to healthcare have previously been colonised with MRSA and in those
staff is considerable and during the Hong Kong SARS out- who have been admitted to hospital on a previous occa-
break, healthcare workers wore full head covers with a sion. It has been found that the longer the patient remains
visor. 135 in ICU the higher the risk of MRSA infection. 127

Previous research has demonstrated relatively low rates There are a number of methods for reducing the spread
of compliance with standard precautions, ranging from of MRSA (see Table 6.13), although not all methods may
16–44%. 136 The SARS outbreaks emphasised the need for be effective, 133 and if the organism is not identified, its
effective infection-control procedures, especially for air- spread will continue unseen. Another key component of
borne pathogens such as the SARS coronavirus (SARS- management of MROs is surveillance, such as the routine
CoV). With airborne pathogens such as Pulmonary TB or screening for MRSA and VRE of all patients on admission
SARS-CoV, Airborne Precautions 137 using N95 masks to critical care areas and on a regular basis thereafter.
(face mask with 95% or greater filter efficiency), gowns Once diagnosed, it is common practice to isolate MRSA
and gloves are implemented to reduce the spread of the patients to reduce cross-infection; however, there is recent
organism, plus the use of negative air pressure rooms and evidence that questions its necessity. 139
strict control of family visiting. 137 Additional measures
may include the use of high-efficiency bacterial filters to Healthcare Associated Infections
filter patients’ expired air, closed suction systems and Nosocomial, or hospital- or healthcare-acquired, infec-
ventilator scavenging systems. 135
tion (HAI) is a major problem in critical care that may
The more recent Influenza H1N1 pandemic alerted every- affect up to 20% of patients, with a mortality of around
one to the need for vigilance in infection control. The use 30%. 122 Critically ill patients are 5–10 times more likely
of Droplet Precautions are the main feature of infection to become infected than hospital ward patients. 126
control for Influenza, along with early testing. 138 The Multiple-drug-resistant bacteria are a worldwide problem;
Influenza outbreak also drew attention to the need for their acquisition by patients can lead to infection with
vaccinations. All healthcare workers and especially the same bacteria, 123 and multiple antibiotic therapy
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those in critical care should be knowledgeable of the vac- encourages the proliferation of resistant organisms.
cinations that may be available to them through their The introduction of antibiotic stewardship assists in
employers and those that are recommended by local focusing on the optimal use of antibiotics. 119
jurisdictions.
Medical devices or therapies may expose the patients to
potential risk of acquiring a HAI. This risk may occur
during the insertion procedure or subsequent mainte-
Practice tip nance care of the medical device, unless appropriate tech-
niques are used. The use of an aseptic technique during
Reminder: hand hygiene is performed before putting on PPE insertion of a device is a feature of infection control,
and after removing PPE. Hand hygiene is also performed after asepsis being the elimination of pathogens. Aseptic non-
removal of gloves. touch technique (ANTT) is a format for guiding practice
in the application. 140,141 Standard ANTT involves standard
hand hygiene, a general aseptic field and non-sterile or
sterile gloves and is used for minor procedures which are
Multi-Resistant Organisms simple and of short duration, that is, less than 20 minutes.
MRO is a collective term for a number of infections from Examples of procedures would include simple wound
multi-resistant organisms. While the early diagnosis of dressings and intravenous cannulation or urinary cathe-
an MRO and immediate implementation of organism- terisation by proficient practitioners. Surgical ANTT is
specific Transmission-based Precautions is key to man- used for complex or lengthy procedures such as insertion
agement, it is true that Methicillin-resistant Staphylococcus of a central venous catheter and involves the use of full
aureus (MRSA) and extended-spectrum beta-lactamase- barrier precautions (sterile gown and gloves, face mask),
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producing Enterobacteriaceae (ESBL-E) have reached extensive drapes and critical aseptic field. Box 6.5