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Question: Critically Analyse a current policy to control MRSA within a chosen locale. You could choose to consider a Country, city or local Community Policy. You should Comment on the Impact that the policy has had and offer Suggestions for Improvements. Answer: Introduction Staphylococcus aureus lives harmlessly on the skin or in the nose of a normal healthy person. S. aureus causes infections in hospitals as well as in community patients that range from boils or infected eczema to severe infections like surgical site infections, bacteraemia, among others (Now 2012). Methicillin Resistant Staphylococcus aureus (MRSA) is a Gram-positive bacterium. MRSA is resistant to a wide variety of antibiotics. It is genetically different from various other strains of Staphylococcus aureus. MRSA can cause several complicated diseases that can range from skin infections to sepsis, pneumonia and other bloodstream infections. MRSA is highly prevalent in hospitals, nursing homes, where individuals with open wounds or provide with invasive devises like catheters or immunocompromised individuals are at a high risk of acquiring the nosocomial infection (Verkade, Ferket and Kluytmans 2014). The treatment of MRSA is difficult because it is resistant to most of the antibiotics. MRSA was first discovered in 1961 and it is found to be resistant to methicillin, penicillin, amoxicillin, oxacillin, among others (Jacobs 2014). In hospitals, MRSA can be prevented by isolating the infected individuals and keeping them in isolation. Healthcare workers and visitors are required to wear gloves, masks and other personal protective equipments. Moreover, it is also necessary to properly disinfect contaminated surfaces and infected patient laundry items (Seibert et al. 2014). This report describes the policy titled Prevention and Control Methicillin-Resistant Staphylococcus aureus (MRSA) (National Clinical Effectiveness Committee 2013). The clinical advisory group of the Royal College of Physicians Ireland (RCPI) developed this National clinical guideline. The report carries out a clinical analysis of the policy and provides necessary recommendations for improvement. Prevalence and incidence rates of MRSA MRSA is not only limited to acute care hospitals but a high prevalence is also found amongst the staff and residents of a long-term care facility, thereby making such facilities a natural reservoir for these deadly organisms. The prevalence of MRSA among the residents of the long -term care facilities ranged from 1.1% in Germany to about 20% in the United Kingdom and 30% in the United States. An 8.6% prevalence rate was reported from Irish nursing homes in the year 2000. There were vast differences in the rates of colonization ranging from 0-73% in the long-term care facilities. The rates of colonization was dependant on various factors like the prevalence of MRSA in the healthcare facilities, the colonized resident population like the patients as well as the staff and the prevention or treatment practices carried out in the healthcare facilities. Antibiotic use has been found to be associated with MRSA colonization. Percentage of MRSA carriage was reported to be ranging between 47% and 65%, of which 19-25% showed transient carriage and 9-23% showed intermittent carriage. Colonization of the patients in nursing homes was associated with higher mortality rates in Belgium. A longitudinal study carried out in UK revealed that incidence of MRSA was associated with previous or subsequent infections of MRSA, but was not associated with hospital admissions or mortality (National Clinical Effectiveness Committee 2013). A prevalence study in 2006 revealed that out of the 7541 patients of the Republic of Ireland surveyed, 369 had healthcare associated infections, of which 37 had MRSA. MRSA surveillance in the hospital ICUs of Ireland revealed that 2.9-21.2% of the patients were colonized with MRSA. There were 1240 number of reported blood stream infections in Ireland of which 33.9% had MRSA. The incidence of MRSA in Ireland, although was found to be low it was still found to be significantly higher than other European countries (Www.pfizer.ie, 2017). Key components of the policy The policy titled Prevention and Control of Methicillin Resistant Staphylococcus aureus (MRSA) National Clinical Guideline was formulated by the clinical advisory group of the Royal College of Physicians Ireland (RCPI). The key components of the policy included the precautions associated with the importance of hand hygiene, use of personal protective equipment, respiratory hygiene or coughing manners, maintenance of safety and disposal of sharps, management of blood and other body fluid spills, proper disinfection of patient clothing and other infected laundry, maintenance of environmental hygiene, disinfection of other medical devices, isolation of infected patients, movement and transfer, carrying out practices related to safe injection and practices related to infection control in association with lumbar punctures. The policy also provided information about treatment and importance of surveillance measures. Critical analysis The policy at first provides definitions for MRSA. The policy was generated keeping in mind the healthcare officials involved responsible for the care of patients or other residents or clients at risk of contracting MRSA or already having MRSA. The policy targeted the healthcare workers of the acute care hospitals, nursing homes, long-term care facilities, among others. The healthcare workers include medical practitioners, nurses or midwives, biomedical scientists, pharmacists, among others. The policy defines the emergence of community acquired MRSA. The aim of the policy was to provide effective prevention or control measures against MRSA in order to improve care of patients, minimize the patient mortality and morbidity rates and also to minimize the healthcare costs in association with MRSA. The objectives of the policy was to enhance and further bring about improvements in the control and prevention of MRSA, to improve patient care by reducing MRSA infections related to surgical site infections, respiratory tract, joint and bone infections, to improve antibiotic usage in association with MRSA infections and to raise awareness about healthcare associated infections among the healthcare professional and the public regarding appropriate measures of control and prevention, standard precautions and the importance of such implementations. Prevention measures Screening The policy describes the roles of the infection prevention and control team and other officials in the control and prevention of MRSA in Ireland. These measures include effective screening strategies. It describes the importance of early detection to control the MRSA infections. Screening was linked to isolation of patients and carrying out contact precaution measures (Huang et al. 2013). These help to prevent the transmission of MRSA, which spread by direct or indirect contact with a patient or the infected environment of the patient (Otter et al. 2013). The policy also describes that successful detection of MRSA carriages was based on the type of laboratory methods used, the nature of the samples, time when the samples are obtained and on the frequency of patient screening. The policy also provides the details of the patients likely to get screened. These include patients who had previous MRSA infections or are getting readmitted in acute care, patients admitted from one hospital t o another, patients who spent the last six months in acute or long term care settings, patients who had been transferred from a hospital situated in some other country, patients with ulcers, wounds, endoscopic gastronomy tubes, central nervous system and urinary catheters, patients undergoing medium or high risk surgeries, patients in intensive care units and special baby care units, patients provided with renal dialysis and healthcare officials who are in direct contact with patients (Zimlichman et al. 2013). Prevention in acute settings Other measures include infection control and prevention measures in acute and non acute hospital environments, in neonates and obstetrics, in community, eradication of MRSA carriages, antimicrobial stewardship and occupational health aspects in association with MRSA. Control and prevention measures in acute care settings were defined and these were contact isolation, cohorting of patients, hand hygiene, cleaning of the environment, active surveillance and antimicrobial stewardship (Calfee et al. 2014). It also describes the role of the healthcare professional in preventing overcrowding of patients and maintenance of adequate staffing. It also defines the importance of staff education and training programs. The policy also described the importance of the moments of hand hygiene. The hand hygiene guidelines included washing hands before and after patient contact, before carrying out an aseptic procedure, after contact with surroundings of patients, which may include body fluid spillage s (Chou, Achan and Ramachandran 2012). The policy also describes that the patients and visitors to carry out effective hand hygiene. Risk management was described by the use of personal protective equipments. The use of personal protective equipment is determined by the nature of the intervention, risk of exposure to body fluids including blood and the risk of contaminating skin and clothes. Proper disinfection of patient rooms, medical devices in contact with the patients and patient clothing or infectious waste substances needs to be carried out. Prevention in non-acute settings Non-acute health care centers include adult care centers, homeless centers or special schools, nursing homes, residential homes and mental care facilities. Prevention and control measures in non-acute settings involved the use of personal protective equipments and hand hygiene (Mody et al. 2015). Moreover, educating the staff about the standard screening and precautionary measures are also important. The policy describes the importance of educating the staff about invasive devices like tracheostomies, urinary catheters, among others. At homes, the precautionary guidelines mentioned were proper hand washing before and after touching of wounds, care-givers should wash their hands after contact with the infected person, use of disposable gloves, covering of cuts in the skin, disinfection of linen and cleaning of patient environment (Traverse and Aceto 2015). Prevention of neonate MRSA Neonates are at a high risk of contracting MRSA and need to be screened. The recommended site for cleaning of the neonates includes the umbilical site. On the context of detection of MRSA carriage among antenatal pregnant women, decolonization is recommended, which involves the topical use of nasal mupirocin. A lactating mother with MRSA mastitis, is recommended to carry out breast feeding and subsequently receive antibiotic therapy. Antibiotic therapy is recommended for neonates having MRSA colonization (Shrem et al. 2016). Prevention of community associated MRSA The characteristics of community associated MRSA include that the isolate should be confirmed as MRSA, patients with community associated MRSA usually reside within the community and have no associated risk factors, they are usually resistant to beta lactam antibiotics, while remaining susceptible to other antibiotics. Such patients usually have skin and other infections of the soft tissues. They can also contract pneumonia. Community associated MRSA is usually caused by Staphylococcal Chromosomal Cassette (SCC) mec types IV and V (Stefani et al. 2012). The normal sites recommended for the screening of community associated MRSA include the nostrils, skin lesions, throat, among others. The prevention strategies recommended involves carrying out hand hygiene, avoiding the use of contaminated razors, brushes, clothing and water bottles, covering of skin lesions, among others (Skov et al. 2012). The treatment recommended involves incision and drainage of surgical site infections, antibio tic therapy like the use of doxycycline, cotrimoxazole. Antibiotic therapy for surgical site infections involve the use of linezolid, clindamycin, daptomycin, among others. In severe cases, adjunctive therapy like administration of intravenous immunoglobulin can be carried out (Mantero et al. 2017). Decolonization MRSA decolonization refers to the use of systemic or topical agents for eradicating a carriage. This is carried out to prevent the spread of infection among patients. One study reported significant reduction of nosocomial MRSA infections in intensive care units was found to be caused by the use of Mupirocin along with Chlorhexidine. Another study reported that the use of Mupirocin delayed the infection but did not reduce the risk. MRSA decolonization among neonates also involves the use of Mupirocin (Fritz et al. 2013). Antibiotic Stewardship The policy claims that the prolonged use of broad spectrum antibiotics should be avoided. The policy recommends the healthcare institutions in Ireland to implement the strategies recommended in the Strategy for the Control of Antimicrobial Resistance in Ireland (SARI 2009) (Www.hpsc.ie, 2017). The policy recommends the implementation of antibiotic stewardship programs in long term care giving facilities. It also advices the consultation with a microbiologist or a infectious disease specialist before providing antimicrobial therapy for MRSA treatment, avoiding the use of antibiotics like cephalosporins, fluroquinolones and macrolides, which are known to be associated with MRSA selection and or resistance and avoiding the use of topical therapies for treatment of superficial skin infections (Kim et al. 2013). Prevention of occupational health MRSA Occupational health staff provides protection, promotion and maintenance of employee health in a healthcare organization. Their role is to reduce the infection transmission to and from healthcare workers by carrying out best practices in a legal manner. The four components that define an effective occupational health program include risk assessment and control, evaluation and education. The healthcare workers are advised to seek help from occupational health workers. The occupational health staff are required to identify healthcare workers showing MRSA risk factors and are required to provide education regarding risks in the workplace. The occupational health staff assess the healthcare workers based on their illness, MRSA risk factors, colonization sites, previous infection history, among others (Aw, Gardiner and Harrington 2013). Treatment and Surveillance The policy also provides management recommendations for MRSA, which include treatment and prophylaxis. Treatments include the use of linezolid, vancomycin and daptomycin. Administration of an intravenous glycopeptides is recommended for treatment of patients with life threatening MRSA infections (Sader, Flamm and Jones 2013). Surveillance involves the reporting of blood stream infections to the health protection surveillance center (HPSC), maintenance of records of MRSA cases, which includes patient identification, specimen and MRSA isolation site, date of positive results, hospital ward name and date of admission. Although the policy provides information about necessary precaution strategies as well as treatment and surveillance, it does not address the issues regarding to antibiotic resistance in other sectors apart from healthcare like the agricultural sectors (Vandendriessche et al. 2013). The policy also does not address the challenges associated with the development of new drugs and the potential consequences associated with laboratory modernization. Barriers and Facilitators There are some barriers that will impact the full implementation of the policy. Most of the measures provided are cost neutral since it is a modification of the previous policy with the addition of some measures. Most of the recommended measures like hand hygiene are common but there are other measures, which are specific and can give rise to resource implications. Significant numbers of acute care settings lack isolation rooms, microbiology laboratories and antimicrobial experts. The healthcare professionals do not understand their responsibilities in the prevention of infection control. The facilitators involve enabling the healthcare professionals to understand and appreciate the policy guidelines for the sake of patient care and safety. Increased awareness of the patients and the demands raised by them for obtaining high quality care can act as facilitators of the implementation of the policy. Describing the barriers associated with the implementation can also act as a facilitato r (National Clinical Effectiveness Committee 2013). Recommendations The recommendations to the policy involves the addition of information regarding the antimicrobial resistance mechanisms. Providing information about the mechanisms will help to educate the healthcare professionals and the general public about the necessary causes. It will also help them to device precaution strategies based on the mechanism. The policy only describes MRSA infection prevention in various types of healthcare settings, but MRSA can also arise in agricultural or farming sectors and can result in the transfer of infections between humans and animals. MRSA control and prevention strategies regarding the agricultural sector should also be provided in the policy. The policy should also address the challenges associated with the development of new drugs, provide details about the various ways by which the healthcare professionals can be educated about MRSA control and prevention and provide the evidence of the cost effectiveness of the prevention measures described. Conclusion MRSA is a growing concern in the hospital as well as in community based settings. MRSA can give rise to serious consequences and increase the mortality rates. This report describes the policy regarding MRSA control and prevention as developed by the clinical advisory board of the Royal College of Physicians Ireland. The aim of the policy is to provide control and prevention measures regarding MRSA in order to improve quality of patient care and reduce patient mortality, morbidity rates and healthcare costs. The policy also aims to raise awareness about hospital-acquired infections, the standard precautionary measures and their importance. The control and prevention measures include various recommendations regarding screening, acute and non-acute hospital settings, neonate MRSA, community MRSA, decolonization, antimicrobial stewardship and occupational health characteristics of MRSA. The policy also provides information about treatment and prophylaxis, surveillance and evaluation. Thu s, it can be concluded that this policy contributes in increasing the knowledge of healthcare professionals about the necessary guidelines and their importance in preventing MRSA spread. Reference List Aw, T.C., Gardiner, K. and Harrington, J.M., 2013.Occupational health: Pocket consultant. John Wiley Sons. Calfee, D.P., Salgado, C.D., Milstone, A.M., Harris, A.D., Kuhar, D.T., Moody, J., Aureden, K., Huang, S.S., Maragakis, L.L. and Yokoe, D.S., 2014. 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