By Victor Epstein
(Bloomberg) -- Missy Baker recalls the moment when she realized that her football-playing son, Boone, didn't just have the flu.
"He told me he was paralyzed,'' Baker said. "I said, `What do you mean? I just saw you walk to the bathroom two hours ago." And he said, `Mom, I can't move my arms or legs."
Sixteen-year-old Boone, a wide receiver for Texas's Austin High School, was suffering from a recurrence of methicillin- resistant staphylococcus aureus, or MRSA, which his doctor said he got through an abrasion from playing on artificial turf, Baker said.
Texas has artificial turf at 18 percent of its high school football stadiums, according to Web site Texasbob.com. It also has an MRSA infection rate among players that is 16 times higher than the estimated national average, according to three studies by the Texas Department of State Health Services.
"This is a disease that can kill you,'' said Carolina Espinoza, a graduate epidemiology student at the University of Texas in Houston, who helped conduct one of the studies. "If I were a football player, I would be alarmed."
MRSA is a virulent strain of drug-resistant staph bacteria that plagued hospitals for decades and migrated into the general population in recent years, said Edward Septimus, an infectious disease specialist at Methodist Hospital System in Houston. Without proper treatment, it can spread to internal organs and bones after reaching the bloodstream, causing organ failure, he said.
In October, the deaths of a Brooklyn boy and a Virginia youth were blamed on MRSA infections.
At least 276 football players were infected with MRSA from 2003 through 2005, a rate of 517 for each 100,000, according to the Texas studies. The U.S. Centers for Disease Control and Prevention in Atlanta reports a rate for the general population of 32 in 100,000.
Football players often become infected at the site of a turf burn and are misdiagnosed, said David Smith, co-author of a study showing that MRSA-related hospitalizations in the U.S. more than doubled from 1999 to 2005.
"The turf burns themselves are just the kind of minor skin injury that MRSA can exploit,'' said Elliot Pellman, medical liaison for the National Football League, which also has had infections among its players.
Football dominates high school sports in Texas, which has more participants than any other state. Seventy-four schools have stadiums seating more than 10,000. The sport provides 22,041 full-time jobs and generates $2.88 billion in annual spending, said Ray Perryman, president of Perryman Group, a Waco economic and financial analysis firm.
Football also produces more MRSA infections than any other sport, said Marilyn Felkner, the epidemiologist who led the Texas studies. The department wasn't able to obtain enough data to establish a statistical link between artificial turf and MRSA infections, she said.
"So many schools had at least one case,'' Felkner said of a 2005 report showing 76 high school athletic departments with MRSA infections. "It was more schools than we would have thought.''
In Collin County, which includes parts of Dallas and Plano, six high schools had more than two infected athletes this fall, said Janet Glowicz, county epidemiologist.
MRSA causes more deaths than any of the 51 infectious diseases tracked by the CDC, including AIDS, according to CDC data. The agency doesn't require medical professionals to report MRSA cases.
Texas plans a pilot program next year making MRSA a reportable illness in three regions, said Bryan Alsip, assistant health director for San Antonio.
Researchers including Septimus blame MRSA's spread on overuse of antibiotics. A CDC report in the Journal of the American Medical Association showed that MRSA caused three times more infections than previously thought.
"This is an epidemic,'' Smith said. His report was published by the CDC in the December edition of Emerging Infectious Diseases. "It's a big problem, and it's likely to get bigger.''
Smith said the public needs to hear more about MRSA. There is no benefit in alarming people, but they have a right to know that it is a serious situation, he said.
Spreading MRSA can be prevented by frequent hand washing, covering scratches and turf burns, disinfecting whirlpools between uses, and not sharing towels or razors, the Texas health department advises.
Mike Carroll, head athletic trainer at Stephenville High School near Fort Worth, said he tells coaches to avoid saying "staph'' when they see a possible infection.
"You want people to be educated, but you don't want to create a sky-is-falling mentality,'' Carroll said.
Baker said she was shocked to learn how pervasive MRSA is. It's also persistent: Boone was originally diagnosed in October 2006, and the infection returned last January. He had three surgeries to remove infected tissue and spent three weeks in the hospital.
While Boone resumed playing football this season, fear of another relapse haunts the family. Some survivors continue to carry the bacteria, according to doctors and the CDC.
Baker said she and her husband spent a sleepless night when Boone developed a skin infection that looked like a spider bite.
"We were both wide awake and shaking with fear,'' she said. The wound cleared up the next day.
By Victor Epstein
(Tara Parker Pope for The New York Times)
Everyone knows hand washing is important. But a new study shows how washing your hands often, and at the right time, can have a big impact on your family’s risk for getting sick.
Most studies on hand washing focus on medical and food service workers. But this month’s American Journal of Infection Control focuses on washing hands at home as a way to stop infections from spreading. Several studies show hands are the single most important transmission route for all types of infections.
Even though most people know to wash their hands after using the toilet or handling a diaper, studies suggest many people are still ending up with germs, particularly those spread by feces, on their hands after leaving the bathroom or caring for a baby.
One study looked in homes of infants recently vaccinated against polio. After vaccination, the virus is known to shed in the baby’s feces. Researchers found the virus on 13 percent of bathroom, living room and kitchen surfaces. While the virus from the vaccine didn’t pose a health risk, the study shows how feces-borne viruses can travel through the home.
Another study found that in homes where salmonella cases had been diagnosed, the bacteria were still lurking in toilet bowls three weeks after the outbreak. Water splashing on the toilet seat was a source of contamination.
Doorknobs, bathroom faucets and toilet flush handles are key sources of germ transmission in the home. That’s why people should focus on cleaning such surfaces regularly and always wash hands after touching them. In one study, a volunteer touched a door handle that had been contaminated with a virus. He then shook hands with other volunteers, and further tests showed he had spread the virus to six people.
The study authors note that the timing of hand washing is key. It’s obvious to wash hands after using the toilet, after sneezing or before eating or handling food. Other crucial times for hand washing are after changing a diaper or cleaning up after a pet, or after touching garbage cans, cleaning cloths, cutting boards, dish rags and utensils that may have come into contact with raw food.
While it may be hard to believe that something as simple as regular hand washing can make a difference in your family’s health, consider what happened in Hong Kong during a 2003 outbreak of SARS, a severe and potentially deadly form of viral pneumonia. The outbreak triggered extensive public and community health measures promoting basic hygiene, including regular hand washing. Not only was the SARS outbreak contained, but other cases of respiratory illnesses, including the flu, dropped sharply.
New York Hospitals Expand Efforts To Reduce Infections
By E.B. SOLOMONT
Staff Reporter of the Sun
A coalition of New York hospitals that has been working to reduce hospital-acquired infections is expanding its efforts, just as the state Department of Health prepares to publicly report infection data for the first time next year.
The 60-hospital group plans to focus on the bacterial infection, Clostridium difficile, as well as the safety of mothers and babies just before birth and immediately after.
In broadening the coalition's focus, its organizers said they hope to change the culture of hospitals and to improve the quality of health care. The new effort also calls for educating front-line hospital staff — everyone from physicians to housekeepers — on infection control.
"As we focus on small initiatives, they'll be able to morph these initiatives into broader ways to tackle things that happen that shouldn't," the vice president of quality and patient safety at the Greater New York Hospital Association, Terri Straub, said. The effort will be underwritten by a two-year $500,000 grant from the United Hospital Fund to the GNYHA Foundation.
Hospital-acquired infections represent a serious problem around the country. Nationwide, patients develop an estimated 1.7 million infections each year.
Regional infection data is not available for New York, although hospitals here spend an estimated $2 billion each year treating preventable infections, according to a New York-based group, the Committee to Reduce Infection Deaths. On average, hospitals spend between $25,000 to $70,000 treating each infection. Recognizing the cost and the health toll of such infections, the coalition of New York hospitals began in 2004 to focus on reducing bloodstream infections associated with a type of intravenous hookup called a central line. Since then, the collective infection rate among the participating hospitals has dropped, according to data obtained from the United Hospital Fund and GNYHA, which spearheaded the collaborative. In April 2007, hospitals reported monthly infection rates of 1.76 for every 1,000 central line days, down from 5.01 in June 2005, the organizations reported.
As part of the new effort, the UHF and GNYHA will also train physicians as Quality Fellows, who would become advocates for quality improvement at their own institutions. "We wanted to try to develop a cadre of physicians in these hospitals who were basically going to quality boot camp to learn the principles, skills, tools, and strategies that broadly apply to quality improvement," the project director of the United Hospital Fund's Quality Strategies Initiative, Rachel Block, said.
Organizers said other important components of a sought-after culture change include standardizing communication among staff, and educating front-line employees regarding infection control.
For example, individuals who transport patients play a pivotal role, Ms. Straub said. "Transporters had no idea that their failure to clean a stretcher properly could impact a patient's outcome… So when they hear what a great role they have they might start to think differently," she said.
So far, the collaborative does not have plans to directly address the spread of methicillin-resistant staphylococcus aureus, a bacteria that made headlines as a "super-bug" this fall after a Brooklyn boy died from the bacterial infection. However, organizers said they hoped the initiative would have a "spillover effect" that would reduce MRSA and other infections.
From the Concord Monitor
The more steps in a procedure and the more procedures that must be done, the more likely it is that one step will be forgotten. Sometimes no harm is done. But in flying a plane, defusing a bomb or performing a medical procedure, skipping one step can prove fatal. That step could be as simple as a harried physician forgetting to wash his hands.
Some 80,000 to 100,000 people die each year from infections acquired in a hospital, according to federal estimates. Many of those deaths result from "line infections" that occur when a pathogen is introduced into the bloodstream by a catheter inserted into a vein or artery. Line infections, which in one hospital led to an average of $61,000 in additional charges, add billions each year to the nation's health care bill.
In the current issue of The New Yorker, Atul Gawande, a surgeon and Harvard Medical School professor, explains how in 2001 a doctor developed a program that reduced the line infection rate to near zero in the hospitals that adopted it. The basic tool used by that doctor, Peter Pronovost of Johns Hopkins Hospital, was the checklist.
The steps on Pronovost's checklist are simple: wash hands with soap; clean the patient's skin with antiseptic; cover the patient with sterile drapes; wear a sterile mask, hat, gown and gloves; and place a sterile dressing over the catheter line.
Pronovost tested the effectiveness of his list in several facilities, including an inner-city Detroit hospital whose intensive care unit saw a steady influx of gunshot victims. That hospital had a whopping 11 percent line infection rate. Within a year, using the checklist, the rate fell to zero, thanks in good measure to empowering nurses to call a halt if doctors forgot a step. By eliminating line infections, the hospital calculated that it had prevented 43 infections and eight deaths and saved $2 million.
New Hampshire's intensive care units already have low line infections rates. The state's 26 hospitals had just 28 in the first six months of 2006. Though the hospitals aren't using Pronovost's list, they follow a similar protocol. But the right rate, state epidemiologist Jose Montero says, should be zero. Almost all such infections are preventable, though when they occur, it's not always easy to determine whether the intensive care unit rather than an ambulance crew or emergency room staff was to blame.
Next month, the state is launching a pilot program in six facilities, including Concord Hospital, to track not just line infections in ICUs, but also whether antibiotics are administered prior to surgery and how often knee replacement surgery results in an infection. Hospitals with the lowest rates will be studied to see what they do right. Then that information will be shared with other hospitals so they can change their procedures.
Checklists like the one that has practically eliminated line infections in the hospitals that use them have been developed for a number of medical procedures - like care of patients who need a ventilator to help them breathe, for example. More lists are being developed all the time.
Unfortunately, Gawande reports, though line infection checklists could be in use nationwide within two years, hospitals have been slow to adopt them. That shouldn't be the case in New Hampshire, and thanks to efforts already undertaken and others under way, it doesn't look like it will be. The faster medical science advances, the more valuable the humble checklist - the same tool shoppers use - becomes. When doctors can do so much, there's so much to remember.
The True Scale of Health Care Acquired Infections:
The World Health Organization reports that at any given time, over 1.4 million people worldwide are suffering from infections acquired in hospitals including hospitals in the United States.
As many as 10% of patients admitted to modern hospitals in the developed world acquire one or more infections.
The risk of health care-associated infection in developing countries is 2 to 20 times higher than in developed countries. In some developing countries, the proportion of patients affected by a health care-acquired infection can exceed 25%.
By CHERIE BLACK
As she walks with her mother into the front lobby of Children's Hospital and Regional Medical Center in Washington state, a 3-year-old girl reaches above her head to squeeze some hand sanitizer into her hand. The kiosk prominently placed in the middle of Giraffe entrance lobby is taller than she is, but almost instinctively, the toddler knows to slather the antibacterial sanitizer over her tiny hands.
Before MRSA -- methicillin-resistant Staphylococcus aureus -- seeped into everyday conversations and the public wondered where the antibiotic-resistant bug would strike next, Washington hospitals were looking at ways to reduce infections within their walls.
The solution: Wash your hands.
The surprise: That so few health care professionals were regularly doing so.
MRSA, which has been common in hospitals for years, more recently began spreading outside hospital settings. Still, about 85 percent of cases take place in health-related settings, according to the federal Centers for Disease Control and Prevention.
The CDC's October report estimating that more than 90,000 Americans are sickened annually by MRSA, and nearly 19,000 die from it each year, caused mild panic and questions about what can and should be done.
In 2005, the Washington Hospital Association started a program to reduce infections. The next year, a formal hand hygiene program was launched, with patient participation in mind. Patients are encouraged to ask their doctors if they've washed or sanitized their hands before an appointment. The association also measures how much soap and sanitizer a hospital uses by counting empty bottles and comparing that number to how many patients spend the night at the hospital. They then send each hospital a monthly report.
The voluntary program involves about half the hospitals statewide, said Carol Wagner, the association's vice president for patient safety. The rest of the hospitals are using observational methods to help increase hand hygiene, she said.
The Washington Hospital Association "took this on two years ago when MRSA wasn't all over the news," Wagner said, noting a 35 percent average increase in hand hygiene compliance among hospitals in just under two years.
"Hand hygiene seems like it would be easy, but it's a cultural and physical behavior. It's a compliment to physicians that patients are participating in their care."
A 2002 CDC-published "Guidelines for Hand Hygiene in Health Care Settings" said the reasons staff members gave for not washing up regularly were not enough time, a lack of soap and paper towels, sinks inconveniently located, and patient needs taking priority over hand washing. They also believed there was a low risk of catching an infection from a patient.
Enter alcohol-based sanitizers. The guidelines showed that not only did sanitizers do a better job of disinfecting hands than soap alone, they took less time to use and were more accessible than sinks. According to the guidelines, during an average eight-hour shift, a nurse spends 56 minutes washing his or her hands with soap and water. A hand sanitizer consumed 18 minutes of the shift.
At Children's, an observer in 2001 collected data that showed about a 60 percent compliance for hand washing, said Dr. Danielle Zerr, medical director of infection control.
That "wasn't a huge surprise it's 40 to 60 percent in studies nationwide, but we wanted to attack this vigorously and get our rates up," Zerr said. "It's challenging for busy health care workers to spend the time required to frequently wash hands with soap and water. Alcohol hand sanitizers take much less time and have helped us improve hand hygiene."
Gels -- and spies -- can be credited for increased compliance at Children's, which now is up to 88 percent. The hospital has been anonymously observing and recording staff hand hygiene in all units for the past six years after realizing they should be keeping track of compliance, Zerr said.
Children's Hospital has hand gel dispensers inside and outside each room.
There's also a competition between nurses, physicians and other staff members to see who does the best with hand hygiene. Children's added hand gel dispensers to the outside and inside of all patient rooms.
"This year, hand hygiene is a hospital safety goal and we're looking more into holding people accountable for their practice," Zerr said.
"Increased awareness and concern about infections is what's driving this program. Certainly there are situations where the vast majority of the time we can reach 100 percent (compliance)"
Evergreen Medical Center in Kirkland is at or above 90 percent compliance, according to the monthly hand washing reports the hospital receives from the state.
A Washington State Hospital Association brochure is also placed in the handbook given to patients and their families. Physicians and staff also wash their hands in front of patients in rooms or treatment areas whenever possible.
Virginia Mason Medical Center launched a "wash your paws" campaign with employees last month. Buttons in University of Washington and Washington State University colors were passed out to employees which say, "Ask if I washed my paws." The idea is to encourage patients, guests and employees to constantly be aware of hand hygiene. The hospital will begin tracking compliance in 2008 in hospital departments and clinics.
Since September of last year, a hand hygiene committee has met monthly at the University of Washington Medical Center to see what can be improved. The hospital also is involved in the state's initiative and scored 85 percent compliance for the month of October, said Estella Whimbey, the hospital's associate medical director.
"The fundamentals of infection control are hand and respiratory hygiene," Whimbey said.
"It's the most important factor in reducing infections and is our No. 1 priority. Once we do that, everything else falls into place."
By Steven J. Spear and Donald M. Berwick
The choice between expanding health coverage and controlling healthcare costs is a false choice based on a false assumption: that resources committed to healthcare are used efficiently and effectively. The mistaken notion makes budgeting the key decision and masks a much better alternative. There is ample evidence that better care could be provided to more people at lower cost if care delivery were organized in a more sophisticated fashion.
Today, healthcare is delivered as it was 50 years ago, when only a limited range of illnesses could be detected and treated, and when even the most sophisticated treatments involved only a few professionals. Professionals were organized in silos: nurses in one, various types of doctors in others, and so forth. Grouping by peers afforded the benefits of professional association, such as sharing knowledge, setting standards, and camaraderie, and, for simple treatments, ad hoc, informal coordination across silos was adequate, management of patient information was simple, and piece-rate payment - paying a certain amount for each person's time - worked fine.
Medical science has advanced dramatically. Once-terminal diseases are now manageable - like AIDS - and even curable - like many cancers. But, care delivery, information, and payment systems have not kept pace with the science. Professionals are still organized in silos, despite the pressing need to integrate their work into coherent processes; information is still fragmented, despite the benefits of holistic views of patients; and payment is still piece-rate even though practitioners are no longer in any meaningful sense independent of each other.
The consequences are destructive. Too little preventive care increases the need for chronic care. Ineffective chronic care for diabetes, heart disease, and depression increases the need for costly acute care of limited effectiveness, and which often causes needless harm. The chance of being injured by hospital care is greater than one in 10, and the chance of accidental death due to mismanaged care is about one in 300. Problems are so pervasive that Medicare announced it will withhold payment for fixing some of the problems created by defects in care.
Needless suffering from badly delivered care is tragic; squandering hundreds of billions of dollars is unconscionable. In part because of these inefficiencies, the United States spends twice as much on care, per capita, as other developed nations do. US government spending alone on healthcare is enough to buy all of the healthcare per capita in many developed nations.
There is an alternative. Some organizations have started emulating outstanding nonhealthcare organizations in actively managing how the process, information, and payment pieces mesh together. The results have been sometimes spectacular.
Pioneers have reduced rates of hospital-acquired infections, falls, medication errors, and other complications - symptoms of fragmentation - by 90 percent and more, saving thousands of lives and hundreds of millions of dollars. Ascension Health, the largest Catholic healthcare system in the United States, reports pressure ulcer rates in its 67 hospitals 93 percent lower than the national average, birth injury rates 74 percent lower, and patient falls 86 percent lower. Virginia Mason Medical Center in Seattle targeted its Gastroenterology Department, freed capacity, saved millions of dollars in capital investments, and increased access by 50 percent. It taught its migraine patients how to avoid and manage recurring pain, thereby reducing emergency department visits for this by 50 percent, with sharp reductions in expensive imaging, contrary to trends for the broader, non-VMMC population of migraine sufferers. Mayo Clinic has reported more than a 50 percent drop in rates of medical injuries to patients in all three of its flagship hospitals. Hospitals that have adopted better processes to deal with 11 common challenges - such as acute heart attacks, patients on ventilators, early identification of deteriorating patient conditions - championed through the Institute for Healthcare Improvements 5 Million Lives Campaign, have documented major improvements in outcomes.
If these stories were national norms, not exceptions, the benefits to patient well-being and to costs would be staggering. Getting there need not be a fantasy. Hospitals, nursing homes, dialysis units, ambulatory surgery centers, and physician offices can improve the reliability of its own processes, and their coordination with other organizations, in managing preventive, chronic, acute, and urgent care. Medical, nursing, pharmacy, and other professional schools can complement medical science training with training in managing complex work systems, preparing their graduates to be excellent in their roles, and also in tying the pieces together in total systems of patient care. Insurers, employers, and other payers can change their buying patterns, to demand and reward coordination and uncompromising process excellence across the entire care continuum. Since the public sector is the nation's largest payer, and it supports large medical schools, it can insist on system improvement.
This is a hard sell. The wonk factor is high. Focusing on improving the processes by which care is delivered lacks the rhetorical punch of advocating for universal coverage. Making healthcare processes better is more diffuse work, done at the organizational level, not through dramatic legislative, regulatory, or fiscal flourishes. It requires leaders to get into the nitty-gritty of patient care, finding deficiencies in current approaches, confronting professional norms and habits that overvalue autonomy, tolerate unscientific variation in practice, and undervalue cooperative behaviors, and making continual improvements. But a strong link exists between the moral obligation of universal care for Americans and the hard work of redesigning and improving healthcare processes. Indeed, given the costs and waste in the healthcare status quo, redesign may be our only sustainable route to justice and financial solvency.
Schools closing for scrubbing. Sports cancelled. Worried school officials, worried parents. Confusion, conflicting advice, uncertainty.
So what's the story with MRSA? MRSA- methicillin resistant staph aureus has become a household word. MRSA used to be a hospital germ, seen in patients who were frequently hospitalized or in long-term care, especially those with medical tubes. Often, it wasn't particularly harmful; however, with time the germ has evolved, and some varieties of MRSA can now cause severe illness.
In the last five years MRSA infections have occurred in the community among people who have no history of recent hospitalizations.Community-associated or CA-MRSA infections often start as skin and soft tissue infections. Many people think they have a "spider bite" or "bug bite." The skin infections have been described as "boils" or even "little volcanoes." While resistant to methicillin, CA-MRSA can be treated by a number of antibiotics that can be given by mouth. Septra and clindamycin are two frequently used drugs. With small skin infections, often just opening and draining the abscess will work just fine.
So why all the concern? In rare cases, MRSA can cause life-threatening infections. It can cause pneumonia, a serious lung infection, or get into the bloodstream and cause a bloodstream infection called sepsis. In a few cases, the infection is so severe that the person dies from it. This is a small number of people compared to the number with treatable skin and soft tissue infections or those who have the organism on their skin but have no symptoms of infection at all. There are other germs that can do the same thing, too.
What can you do to protect yourself and your family?
Handwashing is the most important way to protect yourself against MRSA, colds and flu, and even upset stomachs and diarrhea. Most of the germs that cause illness get on our hands, then we put our hands in our mouths, rub our eyes or nose and put those germs into places that can make us ill. Warm, running water, soap and friction for 20-30 seconds, scrubbing all hand surfaces, will remove most of those harmful bugs. If soap and water aren't available, use an antiseptic hand cleaner that contains at least 60% alcohol.
A clean environment helps stop the spread of disease, too. Kids and adults in schools, day cares and other close quarters touch a lot of shared surfaces. Think about the pencil sharpener, door knobs, desks, tables, books and the many things we touch throughout the day. Keeping surfaces clean and cleaning on a regular basis is a good way to prevent transmission of germs. In sports and gym classes, it's very important that equipment that comes in contact with kids gets disinfected between and after uses. Wrestling and tumbling mats, protective helmets and pads, any shared clothing, etc., must be sanitized after each use. Schools and gyms should have a written policy on WHO is to do this, WHEN this is to be done, WHERE cleaning will take place, WHAT they will clean with, and HOW the item will be cleaned.
After sports or gym class, kids need to take a shower with soap. Who doesn't forget that first after-gym shower! Not only should everyone shower, towels shouldn't be shared. Once the person has dried off, the towel goes into the hamper or the gym bag to go home for laundering. All sports clothing and gym suits must be laundered after each use. That "lucky shirt" will be just as lucky clean as full of germs. Probably luckier, because the wearer is less likely to get an infection!
What happens if you get a MRSA infection? First, be sure to see your healthcare provider. MRSA infections are nothing to fool around with. Your provider may open the wound and drain it and give you instructions for caring for the wound while it's healing. Small wounds often do NOT need antibiotics, so you may or may not get a prescription. If you DO get antibiotics, be sure to take them exactly as prescribed. Remember, it's the last few pills that kill the hardiest bugs, so don't stop taking them until the pills are all gone. If your infection gets worse, or you have a fever, seek medical attention.
To prevent spread to others, be sure to keep your wound covered with a bandage that doesn't leak. Hands should be washed thoroughly before and after changing the dressing. Used dressings should be placed in a plastic bag that is tied up and then placed in a wastebasket. It is safe to go to school or work as long as the dressing will stay in place and not leak during the school or work day. If the wound is leaking and the drainage can't be contained, stay home until it gets manageable. If the drainage gets worse, seek medical attention.