Nurses’ directive threatens to ruin gains in MRSA battle

Mater Dei Hospital’s hard-fought gains in the battle against the deadly superbug MRSA are being threatened by a nurses’ union directive that comes into force tomorrow, The Sunday Times has learnt.

Nurses are being instructed to stop filling in the Visual Infusion Phlebitis (Vip) score chart – a daily nursing assessment that sounds complicated but is actually a simple task put in place to minimise a patient’s risk of infection.

This practice, introduced a year ago, has led to a “massive reduction” in the type of antibiotic-resistant MRSA blood infections related to intravenous drips, according to Michael Borg,Mater Dei’s Infection Control Committee chairman.

10-15%

percentage of patients admitted to Mater Dei are unknowing carriers of the superbug

The action is part of the Malta Union of Midwives and Nurses’ attempts to change the opening hours of the hospital’s salary section and make it more accessible to its members who needed to address inaccuracies in their pay cheque.

“The first directive is a minor one, which will not disrupt any nursing practices,” the union said in a statement sent to the health authorities.

However, Dr Borg said the Vip score was a vital part of the hospital’s efforts to reduce the bloodstream infections caused by MRSA, which kill one of every three patients who contract this infection.

“One of the most important interventions in any hospital is an intravenous drip through which we not only provide patients with lifesaving fluids directly into their vein but also administer medications that cannot be given by mouth,” Dr Borg explained when contacted.

“However, this requires an unavoidable break in the patient’s skin, which can serve as a direct shortcut for microbes between the skin and the blood.”

If the patient is a carrier of MRSA, the superbug can enter into the breach in the skin and multiply underneath causing a mild skin infection, which shows up as redness, swelling and discomfort at the needle site. Unless the initial infection is detected early, the microbes will have time to enter into the vein, spreading and leading to a very severe infection.

Local research has shown that 10 to 15 per cent of patients admitted to Mater Dei are unknowing carriers of the superbug; one of the highest rates recorded anywhere in the world.

In line with the UK’s Royal College of Nurses’ guidelines, nurses examine the skin around the drip needle on a daily basis while carrying out routine patient checks and then fill in a chart with their assessment by ticking off boxes.

Dr Borg, a lead clinician on infection control, said this task was usually completed in less than a minute.

“The documentation is vital to maintain consistency of practice and ensure an effective handover from one nursing shift to the next, therefore guaranteeing quality of care to the patient; it is also essential for medico-legal reasons,” he said.

“If the Vip chart score shows an increased risk, the drip is removed, immediately pre-empting further complications from developing.”

When contacted an MUMN representative said: “This has nothing to do with MRSA. We simply instructed our members not to fill in the score chart. Nurses will still examine patients and if there’s something wrong they will call a doctor."

He added that the instruction merely instructed members to drop the paperwork and shrugged off the impact of such a “minor” directive.

“You don’t need a chart to check patients. Plus, this system, introduced three months ago, was never popular with anyone and it’s been ignored,” he added.

However, Dr Borg insisted the practice was introduced in September 2011, not just three months ago, after extensive consultation meetings with nurses and junior doctors, followed by a trial period.

Rather than being ignored, the uptake had been extremely good and recent hospital audits showed many wards had compliance rates of over 90 per cent.

He pointed out that the guidelines of the UK’s Royal College of Nurses, to which the MUMN is affiliated, clearly stipulate: “All patients... must have the IV site checked at least daily for signs of infusion phlebitis. The subsequent score and action taken (if any) must be documented.”

Dr Borg said: “If the procedure isn’t important, why would the RCN recommend the Vip score should be done at least daily and insist that all assessments must be documented even if no action is taken?”

Most hospitals in the UK filled in the Vip score several times a day, but Mater Dei opted for once a day so as not to overburden nurses.

“Even at this reduced frequency the initiative has been a spectacular success. Just a couple of years ago we would trace more than 10 MRSA blood infections a year to preceding skin infections at the site of the drip needle. Now we barely ever see one,” Dr Borg said.