Management of the Surgical Patient with a Multi-resistant ...



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|Department |Policy / Procedure |Section / Number |

|Perioperative Services |Management of the Surgical Patient with a MRO |Infection Prevention |

| | |7.15 |

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Adopted:

Reviewed/Revised:

For prior revision descriptions, contact dept manager/admin specialist

Substantive Revisions 3/14: Under purpose, listed MROs to include Methicillin Resistant Staphylococcus aureus (MRSA) and Vancomycin Resistant Enterococcus (VRE), Extended Spectrum Beta Lactamase (ESBLs), Carbapenem Resistant Enterobacteriaceae (CRE) and C. difficile.

Revised job title instructions/responsibilities to reflect current processes.

Deleting use of gown and gloves for persons transporting patients who are not touching the patient during travel

POLICY: All Operating Room personnel will follow Contact Precautions based on Management of the Patient with Multi-resistant Organisms (MRO) to prevent the transmission of these organisms between patients and employees.

PURPOSE: To protect surgical patients from multi-resistant organisms (MRO) such as Methicillin Resistant Staphylococcus aureus (MRSA), Vancomycin Resistant Enterococcus (VRE), Extended Spectrum Beta Lactamase (ESBLs), Carbapenem Resistant Enterobacteriaceae (CRE) and C-difficile.

REFERENCES:

Pre-Operative MRSA, VRE, ESBL, CRE Screening Made Easy

Infection Prevention/Control and Employee Health: Multi-Resistant Organism (MRO) Protocol and Resources Index

Infection Prevention/Control Implementation Provisions for Operational Policy D-07-013: Hand Hygiene

Infection Prevention/Control Implementation Provisions for Operational Policy D-07-009: Standard and Transmission Based Precautions

Perioperative Standards and Recommended Practices, Current edition. Retrieved from:

CDC Guideline for Hand Hygiene in Health-Care Settings. MMWR. October 25, 2002/Vol.51/no.RR-16.

Muto, c., et al. SHEA Guideline for Preventing Nosocomial Transmission of Multi-drug-Resistant Strains of Staphylococcus aureus and Enterococcus. Infection Control and Hospital Epidemiology 2003; 24:362-385.

Anesthesia Department Policies: Management of the Surgical Patient with a MRO

RESPONSIBILTIES: Perioperative Services

Infection Prevention/Control and Employee Health

DEFINITIONS: Contact Precautions: Used when caring for patients who are infected or colonized by a microorganism/parasite that spreads by direct contact (skin to skin) with the patient or by indirect contact (touch) with a contaminated object in the infected/colonized patient’s environment (bed rail, dressing, commode, etc). Examples: MROs (MRSA, VRE, ESBL, CRE), and Clostridium difficile (C. diff).

Hand Hygiene:

• Wash at sink with an approved non-antimicrobial soap and water for 15 seconds (required if patient has gastrointestinal illness or is in Contact Enteric Precautions, such as for C. diff.

• Use an alcohol-based waterless antiseptic.

Personal Protective Equipment (PPE): For Contact Precautions consists of yellow gown and gloves. Use mask and eye protection if needed for specific task.

INSTRUCTIONS/RESPONSIBILITIES:

A. Surgeon or Designee:

1. Identify patient with history of MRO (Multi-Resistant Organism):

• Orange or green Epic banner (MRSA and VRE only)

• Epic problem list

• Other patient history

2. If completing CM orders, indicate patient has history of MRO.

3. If MRSA, order screening culture per Pre-Operative MRSA, VRE, ESBL, CRE Screening Made Easy and notify patient of testing requirement.

4. Day of surgery:

• If precautions required, follow protocol for Contact Precautions as posted to prevent transmission to other patients and/or healthcare workers.

• Use PPE (gloves and yellow gown) for direct patient contact.

• Always complete hand hygiene (soap and water or alcohol-based waterless antiseptic) after removing PPE; soap and water is required after exposure to diarrheal stool.

B. Surgery Scheduler:

1. Note orange or green Epic banner or history of MRO on CM orders.

2. When scheduling in Picis, enter MRO/Multi-Resistant Organism in Precautions field. Once entered, this information will appear on the surgery schedule.

C. Preop Coordinators:

1. Identify patient with history of MRO on Picis schedule or during Epic review.

2. Review Epic for MRO history and/or MRSA screening results.

• If history of MRSA and screening not ordered or completed, staff message surgeon/support staff for follow up.

• Continue monitoring Epic for MRSA screening results and document on electronic book.

3. Enter MRSA screening culture results and/or isolation requirement in Picis Preop Manager:

• At TASC, also notify OR front desk to place isolation requirement on schedule.

4. Call Infection Preventionist if any questions or if no orange or green banner in Epic.

E. All Perioperative Personnel:

1. Note Multi Resistant Organism on surgery schedule and requirement for Contact Precautions/Contact Enteric Precautions on schedule or in Picis Preop Manager.

2. If Precautions required, follow protocol for Contact Precautions/Contact Enteric Precautions as posted to prevent transmission to other patients and/or healthcare workers.

3. Educate patient and visitors/support person about precautions, including providing visitor education sheet, and document education in progress note.

4. Use PPE (gloves and yellow gown) for direct patient contact or when transporting patient.

5. Always remove PPE before leaving patient’s room/patient care area or the OR.

6. Always complete hand hygiene after removing PPE; soap and water is required after exposure to diarrheal stool.

7. Dedicate, when feasible, patient specific equipment (i.e., BP cuffs, oximeters) that may follow patient throughout stay.

8. Clean and disinfect reusable equipment and all surfaces with an approved agent before reuse.Use wipes impregnated with sodium hypochlorite (bleach) for surface and equipment cleaning/disinfection when patient has acute (symptomatic) gastrointestinal illness caused by C. difficile, norovirus or an unknown pathogen.

D. Preoperative Area:

1. Admit patient to private room or cubicle with curtain drawn.

2. Post Contact Precautions sign outside room or cubicle:

• DA-3610 for MRSA, VRE, ESBL or CRE

• DA-3609 for C-diff

3. Place Precautions cart with PPE outside room or cubicle.

4. Follow “All Perioperative Personnel” instructions in E. above.

5. Instruct patients to perform hand hygiene (soap and water or alcohol-based waterless antiseptic) [soap and water is required if patient has acute (symptomatic) gastrointestinal illness]:

• Before using the restroom if not in private room.

• After using the restroom.

• After coughing, sneezing, rubbing or blowing nose.

• Before and after touching wounds or dressings.

6. Instruct patient family/visitors to perform hand hygiene [soap and water is required if patient has acute (symptomatic) gastrointestinal illness]:

• After touching/providing any care for patient.

• Before leaving patient’s room.

7. Instruct patient/family/visitors to use cough etiquette (cough or sneeze into bent elbow)

E. Patient Care Technician / Transporter:

1. Note Multi Resistant Organism on surgery schedule and check with Charge RN if patient requires isolation.

2. Note Contact Precautions/Contact Enteric Precautions sign and presence of isolation cart outside patient care area.

3. Wear PPE for direct patient contact.

4. Follow protocol for Contact Precautions./Contact Enteric Precautions when cleaning rooms:

5. Disinfect all reusable items (gel pads, tourniquets) and dispose of items that cannot be disinfected (egg crates, safety straps).

6. Clean and disinfect OR surfaces, equipment, and gurney per routine protocol.

7. Use wipes impregnated with sodium hypochlorite (bleach) for surface and equipment cleaning/disinfection when patient has acute (symptomatic) gastrointestinal illness caused by C. difficile, norovirus or an unknown pathogen.

8. Always perform hand hygiene after removal of PPE [soap and water is required if patient has acute (symptomatic) gastrointestinal illness.]

F. Circulator:

1. Post Contact Precautions/Contact Enteric Precautions sign on OR doors.

2. Place Precautions cart with PPE outside OR.

3. Wear PPE for all direct patient contact.

4. Enforce use of PPE for all staff having direct patient contact.

5. Remove PPE when direct patient contact is no longer occurring.

6. Always complete hand hygiene after removing PPE and before touching clean supplies or equipment.

7. Hand Hygiene with soap and water is required if patient has acute (symptomatic) gastrointestinal illness.

8. During the case, assure all staff remove PPE before leaving the OR.

9. Wear PPE at end of case or any time during the case when direct patient contact is required.

H. All Other Assisting Personnel:

1. Wear PPE for direct patient contact, i.e. positioning, touching patient.

2. Always complete hand hygiene after removing PPE.

I. Scrub Personnel:

1. Wear PPE for direct patient contact, i.e positioning patient.

2. Always complete hand hygiene after removing PPE.

3. Routinely process instruments, linen, and trash.

J. PACU Phase I & II:

1. Patients will be placed in Precautions by:

• Recovering patient in private room and posting Contact Precautions/Contact Enteric Precautions sign on door.

• Spatially separating patient from other patients.

• Using curtain and placing Contact Precautions/Contact Enteric Precautions sign near entry.

2. Patient assignment in Phase I will be one RN to one patient.

• RN will wear PPE while patient is in Phase I.

• PPE will be removed and hand hygiene performed when RN leaves patient bedside to perform other tasks such as retrieve medications and/or care supplies.

3. In Phase II, staff use PPE when care requires direct patient contact.

• Always remove PPE and perform hand hygiene before caring for another patient; soap and water is required if patient has acute (symptomatic) gastrointestinal illness.

• Always complete hand hygiene after removing PPE.

Reviewed by:

Approval:

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