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| Jennifer Lemmon RN, ICC, BN, Clinical Nurse Consultant, Infection Control, St Vincent's Hospital & Sacred Heart Hospice |
The Nursing Unit Manager of the orthopaedic ward contacted the Infection Control Nurse Consultant because she was concerned that six of her nursing staff were complaining of a rash.
On inspection of the nursing staff, the rash was mainly confined to both upper forearms and mid way up the arms of the staff. There was no itch associated with the rash. The Nurse Consultant suspected that the staff may have scabies. Immediately, precautions were implemented and the source of the scabies was investigated and identified.
An 80 year old woman (Mrs X) who had been in hospital for 28 days was diagnosed with crusted (Norwegian) scabies. All staff who had contact with this patient underwent treatment against scabies. No other patients in the orthopaedic ward acquired scabies.
This paper highlights the difficulties in diagnosing Norwegian scabies in the elderly and demonstrates the importance and benefits for health care workers when ensuring that Universal Precautions are maintained at all times.
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Norwegian scabies, also known as crusted scabies is caused by the same parasite Sarcoptes scabiei, as the typical scabies mite (Bennett & Brachman, 1992: 49; Huffam & Currie et al., 1997: 13). However there are a number of differences between Norwegian scabies and typical scabies. One difference is that Norwegian scabies affecting immunocompromised patients results in a severe infestation of millions of parasites, whereas in the healthy person the parasite numbers are small (Clark & Friesen, 1992: 217). The clinical manifestations are also usually different to the typical scabies. Norwegian scabies may present as a generalised dermatitis with widely distributed burrows, extensive scaling and sometimes vesiculation arid crusting (Benenson, 1995: 415). Typical scabies usually presents as lesions prominently around finger webs, anterior surfaces of the wrist, elbows, anterior folds, belt line and causes severe itching especially at night (Benenson, 1995: 415).
The severe itch that is usually reported with typical scabies may be reduced or absent in Norwegian scabies, hence the difficult in diagnosis (Benenson, 1995: 415; Clark & Friesen, 1992: 217). Scabies especially Norwegian are highly contagious, however as this paper will shows, strict compliance with Universal Precaution as practiced by nursing staff on the orthopaedic ward, ensured that no other patient acquired the nosocomial scabies.
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Mrs X, an 80 year old woman was admitted to the orthopaedic ward with a fractured left neck of femur following a fall at the nursing home where she lived. She previously had been admitted to a smaller hospital for six days prior to being transferred to our hospital. The patient's previous medical history included Pulmonary Fibrosis, Ischaemic Heart Disease and she was reported to be confused at times.
On admission, Mrs X had a history of weakness in the limbs, headaches, visual disturbance and chest pain. She presented to the hospital with a shorten rotated left leg, a leg ulcer and complained of a itchiness to her body. The nurse who was caring for the patient at the time of admission informed the resident doctor of the itch and the generalised rash. The doctor ordered phenergan 25mg nocte and calamine lotion PRN to the skin.
The day after admission, Mrs X was transferred to the operating theatre for insertion of an Austin Moores prothesis to her left hip, she was transferred to the Intensive Therapy Unit post operatively as she required intubation due to her chronic lung condition.
When Mrs X was transferred back to the orthopaedic ward five days later, she again complained of a itchiness to her body. The nurse reported the complaint and a Registrar from the Dermatology department consulted the patient and suspected the patient had Psoriasis.
Following the first operation, 24 days later Mrs X again returned to the operating theatre for a closed reduction to the left hip. Twenty eight days after admission and two days after the nursing staff complained of a rash a Dermatologist through visual observation diagnosed the patient with Norwegian scabies and commenced the patient on Ivermectin 15 mgs stat and Quellada body solution.
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The Nursing Unit Manager of the orthopaedic unit contacted the Infection Control Nurse Consultant because she was very concerned that six of her nursing staff were complaining of a rash.
On inspection of the nursing staff, it appeared that the rash was mainly confined to both upper forearms and mid way up the arms of the staff or above the glove line and below sleeve cuffs. The Nurse Consultant suspected the staff had scabies. With the assistance help of the Nursing Unit Manager, control measures were immediately implemented and the source of the scabies was subsequently identified.
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As no index case had been identified, nursing staff were asked to carefully review all patients skin condition. One patient in particular, was identified as having a skin disorder and a review of the nursing notes revealed that she had previously complained of a itchiness of her the skin. This patient was suspected of having scabies. Staff in contact with Mrs X were requested to practice contact isolation, wear gloves and long sleeved gowns when repositioning the patient and put linen into a plastic bag prior to placing it in the normal linen bag.
The incubation for scabies without previous exposure can be two to six weeks before the onset of itching (Benenson, 1995: 416; Clark & Friesen, 1992: 219). Therefore staff were prophylactically treated, as the patient had been in long term care and numerous staff and departments were involved. All staff including staff from the operating theatres and the intensive therapy unit who had skin to skin contact with Mrs X were treated and close contacts of the staff members were also advised to seek treatment. Staff were advised to wear long sleeved gowns and gloves when other patients required repositioning or where there was a risk of skin to skin contact until their treatment was completed. Normally to prevent nosocomial transmission, affected staff would be excluded from work (Bennett & Brachman, 1992: 49). However, due to the large number of staff affected and the possibility that most of the nursing staff may have been exposed to Mrs X this was not possible.
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Norwegian scabies can be difficult to diagnosis due to the different clinical manifestation from that of typical scabies. Scabies in long term care facilities have been reported to cause disruption to the normal operation for months (Degelau, 1992: 421). Usually associated with immunocomprised patients, Norwegian scabies can be devastating to an acute care facility especially when undiagnosed. Contact isolation should be followed on severe ill or immunocompromised patients with a rash of unknown diagnosis.
In this case, the delay in diagnosing and the debilitating condition of the patient, resulted in numerous staff members being affected. The Nurse Consultant organised an inservice for staff on the same day she was notified of the staff with rashes. Scabies and in particular Norwegian scabies was discussed at length with staff highlighting modes of transmission, incubation period and prevention methods.
As shown in this paper the staff only had rashes between the forearm and cuff sleeves. This was most likely due to the nursing staff following Universal Precautions and only those areas of the staff skin being exposed to Mrs X's skin when she required position changes. Fortunately, due to the staff following correct procedures wearing gloves and good handwashing no other patients acquired nosocomial transmission of scabies and no further staff were reported with rashes.
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