Your biggest infection control challenge just walked through the door: a patient who is colonized or infected with MRSA (methicillin-resistant Staphylococcus aureus). How can you minimize and prevent the spread of MRSA to patients and staff? Adopting these 4 evidence-based practices is a good start.

1. Wash your hands. Our hands are the primary culprits in the transmission of the MRSA microorganism, so meticulous hand hygiene is an essential prevention tool. Have an alcohol-based hand antiseptic containing at least 60% alcohol available in all patient care areas, including in the OR for non-scrubbed personnel such as the circulating nurse and the anesthesia providers.

Your staff is more likely to use a hand antiseptic that contains a moisturizer. They'll also be more likely to use a product that's accessible, so place dispensers strategically throughout your facility. Mount dispensers by the entrances and exits of rooms and away from the hand-washing sink. In patient care areas without solid walls, you can mount the hand sanitizer on mobile stands; if that's not feasible, staff could carry small containers of hand antiseptic in their pockets. Don't place dispensers on the wall behind the heads of recovery beds, as this reduces the accessibility of the product.

At the scrub sink, install a waterless surgical scrub product with persistent action. Using waterless hand antiseptics can help reduce dry skin on the hands — a common side effect of washing or scrubbing with a traditional surgical scrub product and water. However, be sure to keep hand lotion available in staff areas such as nursing stations, the control desk and the locker room. Don't install hand lotion at the scrub sink and don't let staff bring lotion containers from home, since these can easily become contaminated. Purchase hand lotion specifically developed for the healthcare setting and use wall dispensers, which decrease the chance of contamination. Make sure the product you choose is compatible with latex exam gloves if these types of gloves are worn at your facility.

2. Wear gowns and gloves. For patients suspected or known to be colonized or infected with MRSA, AORN recommends that you use Contact Precautions in addition to Standard Precautions. This means that staff caring for MRSA-colonized or -infected patients should don gowns and gloves when coming into contact with the patient or his environment. This policy must apply across the board to pre-op, PACU and the OR, including unscrubbed personnel. Staff should remove and discard all PPE before leaving that patient's care area, and perform hand hygiene as soon as gloves are removed.

While it's ideal for the nurse to keep the patient with MRSA in a separate room in both pre-op and PACU, this set-up is not feasible in all facilities and not necessary if there is attention to proper hand hygiene and PPE. Some ASCs may determine that careful adherence to only Standard Precautions is sufficient for their population of patients. All ambulatory surgery facilities should have written procedures regarding Standard Precautions, and when and how to initiate Contact Precautions if they're necessary.

3. Clean surfaces. MRSA is thought to survive for weeks to months on various surfaces, so attention to proper environmental cleaning is essential. Use an EPA-registered hospital detergent/disinfectant with microbiocidal activity against S. aureus. In pre-op and PACU, clean all items or surfaces the patient or the healthcare worker who cared for the patient touches between patients, including the computer keyboard and mouse. Follow AORN recommendations with standardized written procedures to guide your policies for intraoperative room cleaning. Routine environmental cleaning is effective for MRSA-contaminated surfaces and equipment, so you don't have to change your standardized cleaning procedures when the patient is known to be colonized or infected with MRSA, nor should you initiate separate waste disposal policies for MRSA-contaminated disposable items.

Standard instrument reprocessing and sterilization procedures are also sufficient when dealing with a patient with MRSA. Assign common reusable equipment, such as blood pressure cuffs, to the patient from pre-op to discharge and then clean and/or disinfect them before use on the next patient. Disposable blood pressure cuffs are another acceptable option to prevent cross-contamination.

4. Tell patients to take pre-op CHG showers. You may consider adopting eradication protocols for colonized patients in certain circumstances, such as patients who have a history of a MRSA surgical site infection. As an SSI prevention strategy, the Society for Healthcare Epidemiology of America has recommended that "optimal preparation and disinfection of the operative site" occur. Since you can't control the level of personal hygiene in patients, consider requiring home pre-operative showers with chlorhexidine gluconate the night before and/or morning of surgery. When patients arrive at your facility, they should have an appropriate surgical prep done in a manner consistent with guidance from the prepping agent's manufacturer.

Knowledge is power
As healthcare delivery continues to migrate to ambulatory settings, the risk for transmitting MRSA in these settings grows. Make sure your staff's education and training include information on MRSA colonization vs. infection, how it's transmitted and the details of both Standard Precautions and Contact Precautions.