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referenced editorial, there are many states that do have some type of minimum staffing laws on the books, but New York is not among them at this time. 8 Leonard M. Gelman, MD, CMD New York Medical Directors Association REFERENCES 1. Evans, JM. Staffing ratios in nursing facilities: Where do we stand? J Am Med Dir Assoc 2001;2:94 –95. 2. Howard, PK. The Death of Common Sense: How Law Is Suffocating America. New York: Random House, 1994. 3. The National Citizens Coalition for Nursing Home Reform (NCCNHR). Press Release, March 14, 2001; http: //www.nccnhr.org. 4. HCFA Report to Congress. The Appropriateness of Minimum Staffing Ratios in Nursing Homes. Washington, DC: Health Care Financing Administration; July 2000; Executive Summary, page 7. 5. HCFA Report to Congress. The Appropriateness of Minimum Staffing Ratios in Nursing Homes. Washington, DC: Health Care Financing Administration; July 2000; Chapter 6, page 32. 6. HCFA Report to Congress. The Appropriateness of Minimum Staffing Ratios in Nursing Homes. Washington, DC: Health Care Financing Administration; July 2000; Chapter 3, page 37. 7. HCFA Report to Congress. The Appropriateness of Minimum Staffing Ratios in Nursing Homes. Washington, DC: Health Care Financing Administration; July 2000; Chapter 4, page 31. 8. HCFA Report to Congress. The Appropriateness of Minimum Staffing Ratios in Nursing Homes. Washington, DC: Health Care Financing Admin- istration; July 2000; Executive Summary, Attachment. MRSA in the Nursing Home I recently presented a talk at our annual symposium (Car- ing for the Ages, March 2001) on Methicillin-resistant Staph- ylococcus aureus (MRSA) in the nursing home. My talk sparked a lively discussion regarding a threshold for restric- tions in the activities of daily living of known carriers. This is an area of considerable controversy where clinical practices vary widely. My practice in this area continues to evolve. I would like to start with a statement from a position paper on “Antimicrobial Resistance in Long-Term Care Facilities” from the Society of Health Care Epidemiology in America (SHEA) published in 1996 that states, “Long-term care resi- dents colonized with antimicrobial resistant pathogens should not be restricted from participation in social or therapeutic group activities within the facility unless there is reason to think that they are shedding large numbers of bacteria and have been implicated in the development of infection in other residents.” 1 Currently, it is our practice to perform an individual assess- ment of the carrier that includes mobility, comprehension, hygiene, and ability to contain secretions. I provide the RN with a menu of extra considerations to be applied to such residents when they are out of their rooms so that a Care Plan can be formulated to maximize the isolation and containment of infectious secretions, and freedom in activities of daily living. The menu includes education of the resident regarding hygiene practices, the securing and covering of colonized sites, leaving contaminated personal items in the room, assisted hand-washing, and focused, extra environmental cleaning of surfaces touched by the resident. If the resident is still ob- served to be shedding large numbers of bacteria into the common environment during independent, unsupervised ac- tivities out of the room (that cannot be accommodated by the extra measures and the facility’s resources), staff are confused since this is inconsistent with their efforts to contain secre- tions. In addition, it has been my experience that the detec- tion of transmission based on culturing infected secretions may take time to evolve. (Individuals may carry Staphylococcus aureus before a second event such as the development of a wound, aspiration, or bladder stagnation that precipitates clinical infection and culture. 2 Nursing homes vary widely in the number of cultures performed.) It is for these reasons that I attempt to restrict all colonized individuals to supervised social and therapeutic group activities if less restrictive meth- ods cannot prevent the resident from shedding large numbers of bacteria into the common environment. This step requires significant attention to the resident’s psychosocial adaption. I thank all colleagues who expressed their thoughtful opin- ions on this difficult topic and invite continued efforts to provide workable guidelines. I recognize that any special re- strictions of known carriers become less compelling if there are significant numbers of unscreened, unknown carriers within the facility. Paul Drinka, MD Medical Director, Wisconsin Veterans Home, Clinical Professor, Internal Medicine/Geriatrics, University of Wisconsin–Madison and Medical College of Wisconsin–Milwaukee REFERENCES 1. Strausbaugh LJ, Crossley KB, Nurse BA, Thrupp LD, SHEA Long-term Care Committee. Antimicrobial resistance in long-term care facilities. Infect Control Hosp Epidemiol 1996;17:129 –140. 2. von Eiff C, Becker K, Machka K, et al. Nasal carriage as a source of Staphylococcus aureus bacteremia. N Engl J Med 2001;344:11–16. Erratum Abstract #18 on page A10 of the March issue contains an error. The amount of hypodermoclysis should be 100 ml/hr rather than 10 ml/hr. Drinka LETTERS TO THE EDITOR 201

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referenced editorial, there are many states that do have sometype of minimum staffing laws on the books, but New York isnot among them at this time.8

Leonard M. Gelman, MD, CMDNew York Medical Directors

Association

REFERENCES1. Evans, JM. Staffing ratios in nursing facilities: Where do we stand? J Am

Med Dir Assoc 2001;2:94–95.2. Howard, PK. The Death of Common Sense: How Law Is Suffocating

America. New York: Random House, 1994.3. The National Citizens Coalition for Nursing Home Reform (NCCNHR).

Press Release, March 14, 2001; http: //www.nccnhr.org.4. HCFA Report to Congress. The Appropriateness of Minimum Staffing

Ratios in Nursing Homes. Washington, DC: Health Care FinancingAdministration; July 2000; Executive Summary, page 7.

5. HCFA Report to Congress. The Appropriateness of Minimum StaffingRatios in Nursing Homes. Washington, DC: Health Care FinancingAdministration; July 2000; Chapter 6, page 32.

6. HCFA Report to Congress. The Appropriateness of Minimum StaffingRatios in Nursing Homes. Washington, DC: Health Care FinancingAdministration; July 2000; Chapter 3, page 37.

7. HCFA Report to Congress. The Appropriateness of Minimum StaffingRatios in Nursing Homes. Washington, DC: Health Care FinancingAdministration; July 2000; Chapter 4, page 31.

8. HCFA Report to Congress. The Appropriateness of Minimum StaffingRatios in Nursing Homes. Washington, DC: Health Care Financing Admin-istration; July 2000; Executive Summary, Attachment.

MRSA in the Nursing Home

I recently presented a talk at our annual symposium (Car-ing for the Ages, March 2001) on Methicillin-resistant Staph-ylococcus aureus (MRSA) in the nursing home. My talksparked a lively discussion regarding a threshold for restric-tions in the activities of daily living of known carriers. This isan area of considerable controversy where clinical practicesvary widely. My practice in this area continues to evolve. Iwould like to start with a statement from a position paper on“Antimicrobial Resistance in Long-Term Care Facilities”from the Society of Health Care Epidemiology in America(SHEA) published in 1996 that states, “Long-term care resi-dents colonized with antimicrobial resistant pathogens shouldnot be restricted from participation in social or therapeuticgroup activities within the facility unless there is reason tothink that they are shedding large numbers of bacteria andhave been implicated in the development of infection inother residents.”1

Currently, it is our practice to perform an individual assess-ment of the carrier that includes mobility, comprehension,hygiene, and ability to contain secretions. I provide the RN

with a menu of extra considerations to be applied to suchresidents when they are out of their rooms so that a Care Plancan be formulated to maximize the isolation and containmentof infectious secretions, and freedom in activities of dailyliving.

The menu includes education of the resident regardinghygiene practices, the securing and covering of colonized sites,leaving contaminated personal items in the room, assistedhand-washing, and focused, extra environmental cleaning ofsurfaces touched by the resident. If the resident is still ob-served to be shedding large numbers of bacteria into thecommon environment during independent, unsupervised ac-tivities out of the room (that cannot be accommodated by theextra measures and the facility’s resources), staff are confusedsince this is inconsistent with their efforts to contain secre-tions. In addition, it has been my experience that the detec-tion of transmission based on culturing infected secretionsmay take time to evolve. (Individuals may carry Staphylococcusaureus before a second event such as the development of awound, aspiration, or bladder stagnation that precipitatesclinical infection and culture.2 Nursing homes vary widely inthe number of cultures performed.) It is for these reasons thatI attempt to restrict all colonized individuals to supervisedsocial and therapeutic group activities if less restrictive meth-ods cannot prevent the resident from shedding large numbersof bacteria into the common environment. This step requiressignificant attention to the resident’s psychosocial adaption.

I thank all colleagues who expressed their thoughtful opin-ions on this difficult topic and invite continued efforts toprovide workable guidelines. I recognize that any special re-strictions of known carriers become less compelling if thereare significant numbers of unscreened, unknown carrierswithin the facility.

Paul Drinka, MDMedical Director,Wisconsin Veterans Home,Clinical Professor, Internal

Medicine/Geriatrics,University of

Wisconsin–Madison andMedical College of

Wisconsin–Milwaukee

REFERENCES1. Strausbaugh LJ, Crossley KB, Nurse BA, Thrupp LD, SHEA Long-term

Care Committee. Antimicrobial resistance in long-term care facilities.Infect Control Hosp Epidemiol 1996;17:129–140.

2. von Eiff C, Becker K, Machka K, et al. Nasal carriage as a source ofStaphylococcus aureus bacteremia. N Engl J Med 2001;344:11–16.

Erratum

Abstract #18 on page A10 of the March issue contains an error. The amount of hypodermoclysis should be 100 ml/hrrather than 10 ml/hr.

Drinka LETTERS TO THE EDITOR 201