CorrectCare

Crash Course in MRSA Management in Broward County

By Carol L. Shepard, BSN, CCHP

A new medical director, a neighboring county’s medical cases and a spate of suspicious sores on jail inmates all led up to a crash course in how to fight a “superbug.”

In February 2004, media in South Florida were highlighting the problems of MRSA, a nasty superbug, in the Palm Beach County jail. As the health care manager for the five Broward Sheriff’s Office detention facilities just south of Palm Beach County, I took particular interest in the articles and the problem.

Then a call came from the director of detention. “What is MRSA and do we have it in our facilities?”

As nurses do so well, I smugly answered, “It is methicillin-resistant Staphylococcus aureas, and at any given time we have two to four cases in our facilities.” The director asked for information in layman’s terms and wanted to know if it was a problem for us. I told him about the situation to our north and we decided that we had to watch the matter carefully and be appropriately proactive.

To start, we sent a MRSA training bulletin to our detention staff to be read at roll calls, at all facilities, on all shifts, for three straight days. The training bulletin used information and color pictures taken from the Centers for Disease Control and Prevention Web site. This bulletin also was sent to our medical services vendor for its staff’s education and awareness.

As we all know, however, unless it is a red flag and an immediate issue of concern, employees tend not to pay as close attention as they should.

Fast-forward to May 10, when BSO’s medical vendor hired a new medical director who had dealt with MRSA in other county jails in Florida. The medical director asked the practitioners to look for suspicious infections, and, soon after, they found six cases of suspected MRSA in one of our facilities. It’s not a big number, but it was more than we had been accustomed to seeing.

Rapid Response
We moved quickly to keep the superbug at bay. We met with the facility captain and explained that we needed to isolate the suspected MRSA inmates and decontaminate their housing areas. We moved those first six inmates into our infirmary while awaiting the results of their cultures.

Next, we called an emergency meeting with all practitioners, health services administrators, nursing directors, detention commanders, the infection control nurse and the detention health care manager. We also notified the Broward County Health Department and reviewed our newly developed MRSA protocols with one of its physicians.

The following week, we updated health department officials on our daily operations, reviewed the MRSA protocols once more and gave them a tour of the North Broward Detention Facility where we had set up the MRSA isolation unit. They examined the unit, the infirmary and the food services area. They looked at the laundry facility and washing procedures, taking note of the wash and rinse water temperatures, the detergents used and the drying times.

After going over everything with a fine-tooth comb, the officials determined that BSO’s medical team was meeting—even exceeding—CDC guidelines for treating and handling the MRSA outbreak.

Our next move was to develop protocols to address everything from inmate housing and visitation to decontamination and release. We also had to keep the lawyers, judges and others in the legal community informed and safe.

Comprehensive Protocols
Here is what we did:

• Housing: We identified inmates with suspicious wounds and, with the assistance of the classification supervisor, set up two housing units for suspected MRSA cases: one for men, another for women. Ultimately, we formed four units: males pending and confirmed and females pending and confirmed.

• Decontamination: We established procedures for decontamination of the inmate housing areas, holding cells, transport vehicles and just about any area where a potentially infected inmate might be taken. All isolated inmates were allowed to go out for recreation and the areas they used were cleaned afterward.

We began using a disinfectant that kills MRSA bacteria on contact and also can be used as a cleaning solution. We also advised staff that, while traditional hand washing using soap and water was best, they should keep waterless hand sanitizer nearby and use it often.

• Transportation: With five detention facilities throughout the county, it was imperative that we include the transportation unit in our protocols. We decided to move all potential MRSA inmates separately from those in general population. All vehicles used to move those inmates were to be cleaned following any transports. We also instructed detention staff in the transportation unit to use universal precautions, wear gloves and wash hands often.

• Laundry: Any laundry from units where suspected MRSA inmates were housed was put first in “wash-away bags” and then in a highly visible red bag before being removed. Laundry supervisors were notified of the MRSA issue and all protocols were explained. Again, we reviewed the process to make sure the right chemicals, water temperatures and drying times were in place.

• Uniforms and linen: We decided to provide a daily linen and uniform exchange for all pending and confirmed MRSA patients. (Having a washer and dryer in the housing unit for personal laundry would be best, if practical, and personal laundry should be washed daily.)

• Food service: All pending and confirmed MRSA patients are served using disposable, Styrofoam trays. In addition, all inmates who work in the kitchen had to be medically cleared, and each worker was rechecked every week. We also had the food vendor staff keep an eye on the inmate workers for signs of MRSA.

• Medical treatment: See protocols above for suspected and positive cases. For positive cases, we initially did weekly cultures of both wound and nares, but discontinued that because the treatment protocols effectively eradicated the MRSA.

• Movement: Inmates who were identified as possible MRSA cases were taken directly to the newly formed medical isolation unit, without stopping at the intake area.

• Legal/courts: When the MRSA outbreak was first identified, we explained the situation to the judges, public defenders and personnel from the state attorney’s office, as well as BSO’s legal staff. They greatly appreciated the notice.

Initially, inmates with pending MRSA cultures were held back from going to court until their lab results either came back negative the first time or, if they tested positive, until there were three consecutive negative cultures at least one week apart. Only then were the inmates allowed to attend court. By February 2005, however, detention medical staff and health department officials decided it was safe to allow MRSA-positive inmates to attend court as long as wounds were properly bandaged.

• Visitation: Visitation continued for all inmates, and educational materials were posted in the visitation and public areas of all facilities. The training bulletin mentioned above was posted at all entrances, scanners and master control areas. Furthermore, all visitation areas used by MRSA-positive inmates were sanitized after the visit.

• Release: Inmates were released as scheduled. If a MRSA culture was still pending at the time of release, we gave the inmate educational information about the infection. Inmates who were MRSA positive were instructed to follow up on the outside. In both situations we gave the inmates the remainder of their antibiotics. We also notified the health department about inmates who had been released with MRSA.

• Education: This was one of our most important tasks. We had to notify and educate not only the inmates, medical staff and detention staff, but also the arresting law enforcement officers, the legal community, visitors, volunteers, outside vendors and the general public.

   – For the inmates, our medical and detention staff visited housing units in the jails where MRSA had been identified and explained how we were treating the problem. We also posted educational materials about the infection in all housing and intake areas.

   – The medical staff was given continually updated information and treatment protocols. We also tapped key medical personnel to help train detention staff and inmates.

   – We gave detention staff training bulletins and had medical staff attend every roll call for three days. There, they answered questions and provided additional information about MRSA.

   – We developed procedures to notify area law enforcement officers if one of their arrestees tested positive for MRSA. Detention medical staff was available to answer their questions. We also suggested that the officers complete an exposure form for their files.
 
  – We decided early on to be proactive and, through the media, notify the public about the MRSA outbreak. After discussing the matter with our legal staff, we contacted BSO’s media relations office and provided them with regular MRSA updates. The media relations office sent a news release and, initially, gave daily updates to the media.

Living With MRSA
Our compliance unit helped us track and examine the MRSA cases. It notified arresting officers of possible exposure to MRSA-positive inmates and it mapped locations where MRSA cases might have originated.

Health department guidelines dictated that any MRSA case identified within seven days of intake should be classified as a community-acquired infection. With this data, the compliance unit could track the number of MRSA cases based on where they originated: the community, a hospital or the BSO jail system. The pin-mapping results suggested that the cases were widespread in the community, but there were no discernible trends or geographic areas of severe concern.

After several months of tracking and treating MRSA in our detention facilities we knew the infection was not going to go away. On average, we continue to have 15 to 20 positive cases and another 15 to 20 pending cases at any given time. However, infected inmates make up only about .003% of an average daily population of approximately 5,200.

Looking back, the MRSA outbreak presented the Broward Sheriff’s Office with an exciting opportunity. We learned new techniques and procedures. We strengthened existing partnerships and formed new ones. We challenged our staff and saw them rise to the occasion. We were committed from the start to keep the outbreak from getting out of control and we accomplished something of which we can all be proud.

— About the author:  Carol L. Shepard, BSN, CCHP, is the health care manager for the Broward Sheriff’s Office, Ft. Lauderdale, FL.

[This article first appeared in the Summer 2006 issue of CorrectCare.]