FRIMLEY PARK HOSPITAL NHS TRUST



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Guidelines for

Meticillin-Resistant Staphylococcus aureus

(MRSA)

Paper copies of this Document

If you are reading a printed copy of this document, you should check the Trust’s Policy website (Intranet) to ensure that you are using the most current version.

|Originator | |Dr Manjula Meda (Consultant Medical Microbiologist/IC Doctor) & |

| | |Amanda Walker (IPCN Consultant) |

|Lead Director | |Ian Fry, Director of Infection Prevention & Control |

|Version Number | |14 |

|Version/implementation date | |January 2016 |

|Ratified at | |Hospital Infection Control Committee |

| | |January 2016 |

|Review date | |January 2017 |

NB: in this document ‘meticillin’ has been used in place of the established ‘methicillin’ in accordance with the new International Pharmacopoeia guidelines.

Guidelines for

Meticillin-Resistant Staphylococcus aureus (MRSA)

Index

Page

3 Introduction

4 MRSA Screening

7 MRSA Suppression Therapy and Treatment

9 MRSA ‘Incidents’

-MRSA Bacteraemia

-Outbreak

-New cases on Orthopaedic wards

10 Patient Care

-Isolation

-Environment and Equipment

-Visitors

-Antibiotic Stewardship

-Diagnostic testing and therapy

-Theatre guidelines

12 Discharge Planning

13 Monitoring

14 References

17 APPENDIX I – MRSA Screening Algorithm

18 APPENDIX II – MRSA Screening & Suppression Chart (with Integrated Care Pathway)

20 APPENDIX III – Paediatric MRSA Screening Chart

21 APPENDIX IV – Inpatient placement of MRSA cases

22 Monitoring tool

INTRODUCTION

Staphylococcus aureus is a bacterium that has been found on skin of 30% of the population. It is a very common cause of surgical infections, boils and carbuncles. Following the introduction of Penicillin in the 1940s, some strains of Staphylococcus aureus were able to make an enzyme (penicillinase) that broke down the antibiotic and protected the bacterium, and so by 1959, 90-95% of isolates were resistant to the antibiotic (DH 2006).

There is not just one specific disease caused by Meticillin-resistant Staphylococcus aureus (MRSA). A range of tissues and body systems can be affected.

MRSA is usually carried in the nose or skin folds (such as the groin).

So far 16 epidemic strains of MRSA have been discovered (clones EMRSA-15 and 16 are thought to be more transmissible than others (RCN 2005)).

MRSA is a problem in hospitals because it can affect vulnerable individuals who are weaker, sicker or have reduced immunity when compared to the general population.

Symptoms

Symptoms can be ambiguous as they are general and are common to different infections caused by other bacteria. They can range from colonisation (when the bacteria is doing no damage but is still capable of causing clinical infection) to fatal septicaemia.

MRSA may be found in:

• Wound infections

• Superficial ulcers

• IV line infections

• Abscesses

• Lung infections

• Bacteraemia/septicaemia

MRSA SCREENING

The aim of screening is to identify MRSA-colonised patients within the hospital to allow targeting of isolation facilities. This can minimize the risk of onward transmission to other patients (BSAC/HIS/ICNA 2006). The aim is to also ensure that antibiotic therapy is appropriate to that patient.

From January 2015, at Frimley Health FT will be following the guidance in the Department of Health’s Implementation of modified admission MRSA screening guidance for NHS (DH 2014).

In line with a risk assessment of MRSA infections identified at Frimley Park Hospital in the past 5 years, staff need to screen:

1) Any Elective or Emergency in-patients admitted to/ or to be admitted for:

- Critical Care - Neonatal Unit (NNU)

- Orthopaedics - Cardiology

- Vascular Surgery - Breast Surgery

- Urology - Haematology.

2) In addition, any patients flagged as previous MRSA positive (as highlighted by PAS, Patient Centre, Realtime ADT, Winpath, or by the patient themselves)

3) Patients admitted electively or as emergencies with chronic ulcers/wounds or medical devices (such as long term catheters, PEGs, CVCs etc in situ)

4) Paediatrics in a high risk group (previous MRSA-positive or admission from another hospital or care facility) or in Neonatal Unit.

5) All patients (adult and paediatric) admitted to Frimley Health FT sites from another hospital in the UK or from a hospital overseas.

Roles & Responsibilities

• It is the ward/ department nurses’ responsibility for ensuring all pertinent patients are screened for MRSA.

• The healthcare worker providing the specimen for testing is responsible for the appropriate collection of the specimen following Trust protocol, and the timely delivery of the specimen to the laboratory.

• The pathology laboratory and Consultant Microbiologist are responsible for the accurate and timely processing of the specimen.

• It is the ward/ department nurses’ responsibility for checking for MRSA screening results and documenting the results.

• It is the ward/ department nurses’ responsibility for communicating a positive result to both the patient and the patient’s clinician.

• It is the clinician’s responsibility to act on receipt of a positive result, and for prescribing MRSA suppression therapy and review of any antibiotic treatment.

• It is the clinician’s responsibility to inform the patient’s GP of an MRSA positive result, via the summary on the patient’s discharge letter.

Requesting an MRSA screen

Follow the ‘MRSA Screening Algorithm’ found in Appendix I.

A trained and competent healthcare worker (HCW) must take the specimens for the MRSA screen in a timely manner (at pre-admission assessment for Elective patients within 12 weeks prior to admission; within 48 hours of admission for Emergency patients; at any time during admission if repeat screen is required or infection is suspected).

The HCW must ensure the paper pathology request form is completed appropriately, and ensure the specimen arrives at Specimen Reception in a timely manner.

Screening and results should be checked by the ward/department nursing staff and be recorded on the yellow ‘MRSA Screening and Suppression Therapy chart’.

Ideally transfers from other hospitals (including transfers to F1 and Neonatal Unit) should be isolated in a single room until negative admission screening results are available.

How to Screen

The reason for the MRSA screen being carried out must be explained to the patient prior to specimens being taken. An MRSA information leaflet (available on the hospital intranet) can be provided to the patient to aid explanation.

To determine the extent of MRSA carriage swabs must be taken from the following sites:

• Nose - 1 swab used for both nostrils (anterior nares).

• Groin – 1 swab used in the moist skin folds (Frimley Park Hospital) or Throat (Heatherwood & Wexham Park Hospitals)

• Umbilicus – in neonates.

• Wound - Any breech in the integrity of the skin (such as IV/CVC devices, any wounds, suprapubic catheters, drain sites). State the site that was swabbed on the Microbiology request form. Do not remove Central or IV dressings if intact – swab when dressing next changed.

• Catheter urine (if patient catheterised). Do not send this in the same bag as the wound swabs.

• Sputum (if patient has a productive cough).

Patients who have screened negative in pre-op assessment do not require admission screening.

If a patient has screened negative for MRSA at a Frimley Health FT site in the 12 weeks prior to their present admission to hospital, and have not been admitted to another care facility in the interim, please contact the IPCT for MRSA screening advice on an individual basis.

Identification & Sharing Information

Patients known by Frimley Health FT to have MRSA (or have previously had positive MRSA at his Trust) are identified as “MRSA” on the PAS/ Patient Centre system and on Realtime. Patients with positive results after July 2009, will also have ‘Known Positive MRSA’ written at the top of all Micro results on Winpath and ICE. Having reviewed the patient’s results, the IPCNs record the date that the positive swab was taken on PAS/Patient Centre.

Any identified MRSA patients admitted must have an ‘MRSA Care Pathway’ in place (Appendix II). Completing this pathway ensures that communication of the MRSA colonisation with the patient, next of kin and clinician is recorded, as is MRSA suppression treatment.

Negative results

Routine MRSA screen results will not be phoned, and is the responsibility of the ward/ department nurse caring for the patient, to check the WINPATH or ICE systems and document negative results on the yellow ‘MRSA Screening and Suppression Therapy chart’. Doctors can presume the result of the screen is negative unless informed by the nursing team of a positive result.

Negative results should be available to view on WINPATH within 48 hours of the specimen being sent, but positive results may take longer (possibly up to 5 days).

Positive results

MRSA positive results are available to clinicians by accessing the WINPATH system.

It is the responsibility of the ward/ department nursing staff caring for the patient, to check the WINPATH system and document positive results on the yellow ‘MRSA Screening and Suppression Therapy chart’.

It is the nursing staff responsibility to ensure the patient is informed of a positive MRSA result (within 24 hours of receipt of the result), and document the communication on the ‘MRSA Care Pathway’. The patient should be provided an MRSA information leaflet, and the IPCNs can be contacted for further advice for the patient.

It is the nursing staff responsibility to inform the patient’s clinician (within 24 hours of receipt of a positive result) and to ensure any antibiotic therapy is reviewed and MRSA suppression therapy is prescribed. Ensure also, that MRSA status information is shared with any clinical staff involved in that patient’s care.

As a minimum requirement for documentation of MRSA positive results, the ‘MRSA Care Pathway’ and yellow ‘MRSA Screening and Suppression Therapy chart’ must be completed.

Patients who have been found to be MRSA positive since July 2009 will also be flagged up to clinicians on the Microbiology section of the hospital pathology system.

The previous MRSA status should be recorded in all medical clerking records (electronic and/or paper).

MRSA SUPPRESSION THERAPY and TREATMENT

Treatment of MRSA-positive in-patients (ADULT)

MRSA suppression treatment must be prescribed without delay by the patient’s clinician, and should be commenced for adult in-patients (within 24 hours of receipt of a positive result) and pre-op elective patients found to be MRSA-positive from any site (ideally pre-op patients should receive suppression therapy that completes on their day of admission).

If there is a record of previous complete MRSA suppression therapy (i.e. completed the 5-day course of treatment detailed below) in the past 3-6 months, please contact the Infection Prevention & Control Team for advice. Suppression therapy should not be repeated more than twice, as resistance may be encouraged (BSAC/HIS/ICNA 2006).

The MRSA screening results and suppression treatment should be recorded on the yellow ‘MRSA Screening and Suppression Therapy chart’.

Patient MRSA suppression therapy packs are provided by the Pharmacy Department, and the packs contain an ‘MRSA Suppression Therapy Information Leaflet’, for instructions on how to complete the treatment.

1. Mupirocin 2% nasal ointment

• apply to the inner surface of each nostril (do not “poke” tube into nostril)

• rub side of nose until patient able to taste ointment

• apply three times daily for 5 days and then stop treatment (as resistance may be encouraged by prolonged use). Do not repeat once course of treatment has finished.

(NB. MRSA screening results showing resistance of the organism to mupirocin, will require treatment with Naseptin instead of mupirocin).

2. Hibiscrub body wash/shampoo (4% chlorhexidine)

• Wet skin and then apply body wash thoroughly to all areas (using it like soap) before rinsing

• Pay special attention to axillae, groin and perineal area.

• Use for hair washing also

• Use daily in bath or shower for 5 days only (then dispose of any remaining product)

• Use when bed bathing for 5 days (and then dispose of any remaining product)

• Moisturising cream and hair conditioner may be applied after use.

After each bath and hair wash freshly laundered clean clothing, bedding and towels should be used.

If patient has eczema, dermatitis or other skin condition – treat the underlying skin condition (on advice of dermatologist).

Treatment of MRSA-positive Children/ Babies

Please contact the on-call medical microbiologist for advice.

1. Mupirocin 2% nasal ointment

• Apply to inner surface of each nostril (do not “poke” tube into nostril)

• Rub side of nose until patient able to taste ointment

• Apply three times daily for 5 days and then stop treatment (as resistance may be encouraged by prolonged use). Do not repeat once course of treatment has finished.

2. Body wash/ shampoo

Please contact the on-call medical microbiologist for advice.

Treatment of MRSA-positive pre-admission patients (ADULT)

A positive screen should not delay surgery for elective patients. It is preferable for the elective surgery to take place on the last day of topical suppression therapy to ensure the maximum reduction of MRSA present on the patient’s skin.

Maternity cases screening positive for MRSA should commence suppression therapy at 37 weeks.

Clearance screening is not recommended prior to admission, and these patients should be isolated in single rooms on admission.

When prescribing anti-microbial treatments (such as peri-operative antimicrobial prophylaxis) for known MRSA-positive patients, the MRSA-positive protocol must be followed.

“Re-screening”

Re-screening after MRSA suppression therapy is not required, unless the patient is in Critical Care or Neonatal Unit (where admission and weekly screens are carried out), or unless the tests are required to check for successful treatment of infection (e.g. blood cultures, tissue samples).

If patient is colonised with MRSA the clinical team must keep MRSA cover in mind while starting empirical antibiotic therapy.

Guidance to empirical therapy is available from the trust antibiotic guidelines. Treatment for MRSA patients is highlighted under individual sections.

MRSA ‘INCIDENTS’

MRSA Bacteraemia

If a patient is found to have a positive blood culture with MRSA as the causative agent, a root cause analysis (RCA) will be undertaken.

A Consultant Medical Microbiologist must undertake a root cause analysis using the Strategic Health Authority’s document (based on the NPSA document) within 5-days of the positive result. The Microbiologist will discuss the blood culture result with the pertinent Consultant team and advise on treatment measures.

The IPC nursing team in conjunction with the pertinent Head of Nursing and the Infectious Diseases pharmacist will also undertake a Post-Infection Review (PIR) using the Trust form.

A PIR meeting will take place to discuss the findings. This meeting will involve the Chief Executive, Director of Infection Prevention and Control, Director of Nursing, Consultant Microbiologist, IPC team, the patient’s Consultant, Patient Safety Manager and pertinent Head of Nursing.

MRSA bacteraemia results will be reported onto the Public Health England Data Capture System (DCS) web-site as per DH guidance and the completed PIR document will be sent to the NHS South Cluster (previously known as ‘South East Coast Strategic Health Authority’).

Outbreak

An outbreak is defined as two or more related cases of MRSA infection (with the same sensitivity/ typing pattern) in one clinical area.

The Outbreak Control Team will be established as per the Outbreak Plan.

If patients with MRSA are unable to be nursed in single rooms, the Infection Prevention & Control Team must be informed so they can then advise on placement of patients. The reason for not isolating the patient must be recorded on their MRSA care pathway.

If an MRSA-positive patient’s clinical condition allows, they should be discharged from hospital.

New cases on Orthopaedic wards

If a patient has a positive MRSA result (who is currently nursed in a ring-fenced orthopaedic ward bay):

• Inform on-call Medical Microbiologist (via hospital switchboard)

• Isolate patient in side room

• Close the bay to admissions and re-screen all other patients in the bay.

PATIENT CARE

Good infection control practices, which should be in place for all patients, should reduce the risk of cross-infection. A standard approach must be used to care for MRSA patients in accordance with the general principles of infection control, rather than introducing differing standards (BSAC/HIS/ICNA 2006).

Patient care

Patients identified with MRSA infection or colonization should be informed of their condition (BSAC/HIS/ICNA 2006). Please provide patient with Frimley Health FT “MRSA information leaflet” (available on the hospital intranet under “Patient information”/ “Infection Control”).

It is desirable that all patients who are infected or colonised with MRSA are nursed in a single room (Appendix II – Inpatient Placement of MRSA Cases). If no single rooms are available, due to higher priority infections, the Infection Prevention & Control Team should be contacted for advice. MRSA-positive patients should not be admitted to bays with high risk patients, such as major vascular or implant surgery, or where CVCs are present.

Due to the high profile of MRSA in the Press and on TV, communication is very important. If any patient or visitors have any concerns or queries that staff feel they are unable to answer, please contact a member of the infection prevention & control team (IPCT) who will come to speak to them.

Medical, nursing and allied health personnel must raise awareness of hand washing and must lead by example. Hands must be cleaned in line with the ‘5 Moments for Hand Hygiene’.

Isolation rooms

It is desirable that all patients who are infected or colonised with MRSA are nursed in a single room.

The room will have an individual hand washing sink and a red Infection Prevention & Control ‘warning’ card on the door.

The door should be kept closed, taking into account the patient’s psychological and physical needs. If staff feel that the patient is not safe to be cared for in a room with a closed door, please discuss this with one of the IPCT who will give advice.

The door to the patient room must be kept closed during procedures likely to increase dispersal of organisms (e.g. chest physiotherapy or bed making).

Environment and Equipment

Bedding must be changed daily and prior to transfer to operating theatre. Send bedding to the laundry as infected linen. Infected linen should be first placed into a hot water-soluble alginate bag, and then into an outer impermeable bag for transport to the laundry.

Clean the room daily by damp dusting to avoid accumulation of dust and unwanted items.

Fans should not be used to control the patient’s temperature.

Room to have own cleaning equipment i.e. bucket and mop. Mop head to be changed daily.

Following patient discharge/transfer, the patient’s room will require terminal cleaning (see IPC31).

Patient equipment (e.g. commode, hoist, sling or BP cuff) should be capable of being decontaminated before use with other patients, or single-patient use equipment may be used.

Visitors

The patient’s privacy regarding diagnosis must be maintained to prevent embarrassment.

Visitors who only have social contact with the patient do not need to wear gloves or aprons, but they must clean their hands on leaving the room.

Antibiotic Stewardship

As antibiotic therapy encourages the persistence of carriage, all patients with MRSA should have their antimicrobial therapy reviewed, with a view to discontinuation at the earliest possible time. Please refer to the Frimley Health FT antibiotic guidelines.

Please contact the on-call Consultant medical microbiologist for antibiotic advice.

Antibiotic ward rounds take place three times a week, and antibiotic audit results are reported at Infection Control Committee meetings and in Matrons/Clinical Directors’ Board reports.

Diagnostic testing or therapy

A patient who has MRSA may leave wards to have essential diagnostic tests (e.g. x-rays) performed or for therapy (e.g. physiotherapy). The doctor, nurse or allied healthcare professional that arranges for the testing/therapy must inform the receiving department prior to transfer.

Any wound must be covered by a dressing prior to leaving ward or clinical area.

The patient should be called when the department is ready for them and return to the ward/clinical area immediately the testing is completed.

Staff who transfer the patient (e.g. Porters or other healthcare staff) who have only social contact with the patient, do not need to wear gloves or aprons for the transfer. However, aprons should be worn if there is to be close body contact with the patient, such as rolling the patient. Hands must be cleaned according to the ‘5 Moments for Hand Hygiene’.

MRSA Theatre Guidelines

In mechanically filtered operating theatres, the number of air exchanges should make it unnecessary to place MRSA positive patients at the end of a theatre list (BSAC/HIS/ICNA 2006). Cleaning procedures, minimising staff movement, and allowing only essential equipment in theatre, should be in place for every patient, not just exclusively for MRSA. If patient must be shaved, clippers with a disposable blade must be used (Pratt et al 2007). There is to be no shaving of patient hair in the theatre (DH 2003).

Hand hygiene is the single most important way to prevent the spread of infection, and theatre staff must clean their hands in line with the ‘5 Moments for Hand Hygiene’.

DISCHARGE PLANNING

Transfer or discharge to other hospitals

When a patient who is, or has been, MRSA-positive while in Frimley Health FT is to be transferred, the receiving hospital must be notified in advance by the person arranging the transfer. Under the Health & Social Care Act (DH 2008b) it is a legal requirement for details of the MRSA results to be recorded in the Nursing and Medical transfer letters (DH 2008b & 2006b)

Refusal to accept transfer of the patient is not justifiable on the basis of the risk posed to other patients by an individual’s carriage of or infection with MRSA. All units should have procedures in place and adequate facilities for containment of MRSA (BSAC/HIS/ICNA 2006).

Good infection control practices and routine cleaning of ambulances should suffice to prevent cross-infection.

Discharge of patients into the community setting

If the patient is being transferred for community-based care, the District Nursing Services should be informed in advance of the transfer.

For patients being discharged to Nursing/ Residential Homes or other care facilities (such as hospices or other hospitals), details of the MRSA results must be recorded in the Nursing and Medical transfer letters (DH 2008b & 2006b).

As above, MRSA carriage should not prevent transfer of a patient to a care home.

MRSA suppression therapy protocol for patients should be discontinued on discharge.

Details of a patient found to be MRSA colonised on or during a hospital stay should be communicated to the GP in their Discharge (TTO) letter.

Last offices

Colonised or infected MRSA patients do not need special precautions on death.

Monitoring

Clinical staff are required to participate in the Preventing Surgical Site Infection (High Impact Intervention no. 4) Saving Lives audits as part of the continuous audit programme. The staff undertaking the audits must promptly feedback the findings of their observations so that practice can be improved when needed (DH 2006).

The IPCT also undertake a rolling programme of audits of compliance with MRSA screening and decolonisation throughout the Trust. This audit is based on the monitoring tool on page 23 of this policy.

Compliance with this policy is monitored by the Infection Prevention and Control Nursing team:

It is monitored on a monthly basis by the IPCNs where a review of all elective and non-elective admissions is undertaken to confirm that all relevant patients have received MRSA screening.

An annual report is presented to the Hospital Infection Control Committee (HICC) by the IPCNs in April of each year. Accompanying this is the MRSA Monitoring Report which includes

a. Compliance with patient screened

b. Compliance with results available within 5 days of sent

c. Compliance with documentation (on the MRSA care pathway) that patient and clinician were informed

d. Compliance with commencement of suppression therapy within 24 hours of positive result

Any recommendations and actions are agreed and monitored six-monthly by the Main HICC.

Contact IPCT if unable to follow guidelines in clinical area.

End Note

MRSA have a gene mecA coding for a penicillin-binding protein (PBP-2A) with a reduced affinity for beta-lactam antibiotics. As a result of this, antibiotics are not able to attach to the bacterium or lyse it. MRSA is resistant to all beta-lactam antibiotics (penicillins/ cephalosporins/ carbapenems).

References:

Department of Health Jan 2015 The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance Department of Health, London.

Department of Health 2014. Implementation of modified admission MRSA screening guidance for NHS. Department of Health, London. Accessed via:



Department of Health 2010 MRSA Screening: Operational Guidance 3 Department of Health, London.

Department of Health 2010 Screening elective patients for MRSA – FAQs Department of Health, London. Accessed via: .

Department of Health 2010 Screening emergency patients for MRSA - FAQS

Department of Health, London. Accessed via: .

Department of Health Feb 2009 Screening elective patients for MRSA: frequently asked questions Department of Health, London.

Department of Health Dec 2008a MRSA Screening – Operational Guidance 2. (MRSA Guidance 2008231.pdf) Department of Health, London.

Department of Health 2007 Screening for meticillin resistant Staphylococcus aureus (MRSA) colonisation London: Department of Health. (Available at ) .

Department of Health 2006 Saving Lives: A delivery programme to reduce healthcare Associated infection including MRSA “A simple guide to MRSA” Department of Health, London .uk/reducingmrsa .

Department of Health 2003 Winning Ways: Working together to reduce Healthcare Associated Infection in England Report from the Chief Medical Officer.

Frimley Health NHS Foundation Trust Antimicrobial website.

Joint BSAC/HIS/ICNA Working Party on MRSA. 2006. Guidelines for the treatment and prevention of methicillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities Journal of Hospital Infection 63 Supplement 1.

Loveday HP, Wilson JE, Pratt RJ, Golsorkhi M, Tingle A, Bak A, Browne J, Prieto J, Wilcox M 2013 epic3: National Evidence-based Guidelines for Preventing Health-care Associated Infections in NHS Hospitals in England. Available at:

Royal College of Nursing 2005 Meticillin-resistant Staphylococcus aureus (MRSA) Guidance for nursing staff Royal College of Nursing, London.

Additional references:

Ayliffe et al.1969. Journal of Hygiene 79, 299.

Ayliffe GAJ, Babb JR, Collins BJ. 1969. Journal of Hygiene 79, 299

Ayliffe GAJ. 1991. Review of Infectious Diseases 13(sup 10): 800

Alexander et al 1983. Arch Surgery 118:347-52

Cruse 1986. Hospital Infection 2nd edition. 423-36

Davies et al. 1978. British Journal of Surgery 65-855

Lewis et al .1990. Journal of Hospital Infection 15: 35

Lowbury and Lilley. 1979. Journal of Clinical Pathology 32: 382-5

Maki DG et al 1982. New England Journal of Medicine. 307: 1562

Millward 1992 Nursing Times 88(6): 58-62

Patel SR Urech D & Werner NP. 1998. Institute of Sterile Services Management Journal 3: 19

Peterson 1986 Nursing times 31(5): 68-70

Seropian and Reynolds 1971 AM. J. Surg 121: 251-6

Schiebel JW, Jensen & Petersens. 1991. Journal of Hospital Infection. 19: 167

Whyte W 1998. Journal of Hospital Infection 11 (sup c): 2

APPENDIX I

MRSA Screening Algorithm

APPENDIX II

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APPENDIX III

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APPENDIX IV

Inpatient Placement of MRSA Cases

This priority chart should be used as a guide for placement of MRSA-colonised patients and infections, but if in any doubt (eg. if patient’s clinical condition makes it unsafe to isolate), please contact the Infection Prevention & Control Team or the on-call Consultant Medical Microbiologist.

High Risk Areas

Orthopaedics

All MRSA-positive cases must be placed in single rooms.

ITU/ HDU/ SDU/ ADU/ SCBU (Critical Care)

All MRSA-positive cases should be placed in single rooms.

If no single rooms are available, due to higher priority infections, or if isolation is inappropriate due to clinical need, Inform Infection Prevention & Control Team. The patient must not be placed in a bay with high risk patients (ie. no major vascular or implant surgery, no CVCs).

General Surgery

All MRSA-positive cases should be placed in single rooms.

If no single rooms are available, due to higher priority infections, or if isolation is inappropriate due to clinical need, Inform Infection Prevention & Control Team. The patient must not be placed in a bay with high risk patients (ie. no major vascular or implant surgery, no CVCs).

Moderate Risk Areas

Maternity

All MRSA-positive cases should be placed in single rooms.

If no single rooms are available, due to higher priority infections, or if isolation is inappropriate due to clinical need, Inform Infection Prevention & Control Team.

Urology

All MRSA-positive cases should be placed in single rooms.

If no single rooms are available, due to higher priority infections, or if isolation is inappropriate due to clinical need, Inform Infection Prevention & Control Team. The patient must not be placed in a bay with high risk patients (ie. no major vascular or implant surgery, no CVCs).

Dermatology

All MRSA-positive cases should be placed in single rooms, especially if the case is a skin disperser.

If no single rooms are available, due to higher priority infections, or if isolation is inappropriate due to clinical need, Inform Infection Prevention & Control Team. The patient must not be placed in a bay with high risk patients (ie. no major vascular or implant surgery, no CVCs).

Low Risk Areas

General Medical

All MRSA-positive cases should be placed in single rooms.

If no single rooms are available, due to higher priority infections, or if isolation is inappropriate due to clinical need, Inform Infection Prevention & Control Team. The patient must not be placed in a bay with high risk patients (ie. no major vascular or implant surgery, no CVCs).

Elderly Care and Stroke Unit

All MRSA-positive cases should be placed in single rooms.

If no single rooms are available, due to higher priority infections, or if isolation is inappropriate due to clinical need, Inform Infection Prevention & Control Team. The patient must not be placed in a bay with high risk patients (ie. no major vascular or implant surgery, no CVCs).

Monitoring the Management of MRSA Policy

Ward/Dept: Monitored on:

|Management |Yes | |No |

|MRSA swabs taken within 48 hours of admission (or prior to admission for elective patients) | | | |

|MRSA screens/swabs are recorded on yellow MRSA screening and suppression therapy chart | | | |

|When a patient’s screens are newly MRSA positive, suppression therapy must be prescribed and started within 24-hours| | | |

|of positive results (prescribed and given for 5-days as per suppression therapy chart) | | | |

|Clinician aware of MRSA positive result: they have prescribed the suppression therapy | | | |

|All results recorded on yellow ‘MRSA’ screening and suppression therapy chart | | | |

|MRSA care pathway completed as per policy | | | |

|Documented that patient has been informed of their MRSA status (checking that this was done within 24-hours of the | | | |

|result being available) | | | |

|On questioning, the patient can explain why they have been isolated/ decolonised and what other advise they were | | | |

|given | | | |

|Documented that patient nursed in an isolation room with hand hygiene sink | | | |

|Red infection control warning card on the door and door shut. | | | |

|If open, reason documented on pathway | | | |

|Management |Yes | |No |

|Staff must following Hand Hygiene Policy (PPE) and 5 moments hand hygiene from World Health Organisation (WHO) also| | | |

|FPH bare below elbow (BBE) policy | | | |

|Visitors must wash hands on leaving an isolation room or affected | | | |

|bay | | | |

|MRSA result must be recorded in transfer letter when patient is discharged/transferred to another care | | | |

|facility/another hospital, | | | |

|MRSA status recorded in GP/TTO letter on discharge | | | |

|A terminal clean (terminal clean policy) is undertaken prior to admission of a new patient to an isolation room | | | |

Comments:

Monitored by:

Signed: Dated:

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Clinical Guideline

In order to reduce the spread of MRSA health care staff should ensure that they clean their hands thoroughly between patients (RCN 2005)

Follow yellow MRSA Screening & Suppression Therapy Chart for protocol and documentation of screening

Nurse to check screening result on WINPATH 24 hours after screen

(Swabs must have reached the lab by 10am for results to be available by 12 noon the following day)

Screen: Elective and Emergency Admissions in pertinent specialties/clinical areas

(Check Pre-Op screen - Patients who have been screened

in pre-op assessment do not require admission screening)

Including: Babies admitted to NNU

High risk Paediatrics (i.e. previous MRSA and inter-hospital transfers).

MRSA-Positive

Refer to isolation prioritisation chart (on reverse).

MRSA-Negative

Continue isolation until discharge or until higher priority case requires room.

Adults: Follow suppression protocol on yellow Screening & Suppression Therapy chart.

(Babies: contact on-call Medical Microbiologist)

Do not routinely re-screen the patient after suppression therapy

NB. A positive screen should not delay admission for elective surgery. MRSA suppression protocol should be stopped on discharge of elective patients.

MRSA-Negative

Isolation not required.

Re-screen weekly in ICU/HDU/SCBU.

No

Is there a record of previous MRSA suppression therapy?

MRSA-Negative

MRSA-Positive

Yes

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