Procedures for Prevention and Management of MRSA / Carbapenemase-producing Enterobacteriaceae (Antimicrobial Resistance) in Care Settings in Shetland

Transcription

1 Procedures for Prevention and Management of MRSA / Carbapenemase-producing Enterobacteriaceae (Antimicrobial Resistance) in Care Settings in Shetland Adapted from: Grampian NHS Board Policies 2007, and Model Infection Control Policies (Transmission Based), HPS ICT 2007 and HPS/NHSNSS Interim Guidance: Non-prescribing control measures to prevent cross transmission of Carbapenamase-Producing Enterbacteriaceae in acute settings Date: September 2014 Version number: Version 4.4 Revised to incorporate changes to MRSA Screening Programme 2011/12 and CMO/SGHD (2013)14: Antimicrobial Resistance Author: Wendy Hatrick Review Date: September 2016 Approved by: Infection Control Team September 2014 If you would like this document in an alternative language or format, please contact Corporate Services on

2 Contents Appendices Appendix A Patients to be screened for MRSA 6 Appendix B Flow Chart for (i) MRSA / (ii) CPE Screening Process (i) and (ii) 7/8 Appendix C Procedures for taking nasal/perineal/rectal swabs 9 Appendix D Flowchart for decolonisation after a positive MRSA result 12 Appendix E Swabbing other sites 13 Appendix F Hospital / ward transfers of MRSA positive patients 14 Appendix G Admission & Discharge Communication 15 Appendix H Glossary 16 Nb. Patient and staff MRSA and CPE leaflets can be found on the NHS Shetland Infection control webpage at 1 Introduction Contact Precautions How do you decide which precautions are required? 19 2 Screening of patients before or on admission to hospital National Screening Programme Aims of Screening The Clinical Risk Assessment (CRA) Patients to be screened (asked the CRA questions) in Shetland Patients excluded from screening Patients to be swabbed Reasons for not swabbing Taking the swabs Laboratory testing Patient placement following clinical risk assessment Action whilst awaiting the result Action in the event of a negative result Action in the event of a positive result Action in the event of a positive result: infection control procedures 27 3 Decolonisation of MRSA and CPE Decolonisation of nasal carriage Decolonisation of NORMAL skin 28 Page 2 of 41

3 3.3 Other regimes Repeat screening post decolonisation Patient Decolonisation of CPE 30 4 Management of MRSA cases in hospital setting Notifying the Infection Control Team Treatment of MRSA infection Infection control Movement of colonised or infected patients within the hospital Care of Deceased Patients Other screening in the hospital setting Discharge of Patients from Hospital 36 5 Ambulance Transportation General Infection Control Precautions: Exceptional circumstances: 37 6 Control of MRSA in the Community Management of patients in the community with MRSA Infection Control Screening Transfer from home or care centre to hospital 39 7 Communication Medical Records Patients/Residents and Relatives Staff and Healthcare Workers Other Healthcare Establishments 40 8 References 41 Page 3 of 41

4 Amendments Date Section Amendment June 2010 Chapter 2 Procedures for screening of patients included in national MRSA Screening Programme added (i.e. elective admission and admissions / transfers to care of the elderly wards) June 2010 Para 2.4 Information on laboratory procedures added June 2010 Chapter 3 Decolonisation of patients identified through MRSA Screening Programme added June 2010 Para 3.4 Further detail on repeat screening post-decolonisation added June 2010 Chapter 4 Further detail of management of positive patients in hospital added June 2010 Chapter 5 Ambulance transportation: chapter updated June 2010 Appendix 1 Contact Personnel: Changed to Appendix H (Infection Control Team) and updated June 2010 Appendix 2 Screening: Changed to Appendix E (Taking a Full Screen) June 2010 Appendix 3 Swabbing techniques: included in Appendix E June 2010 Appendix 4 Detection and testing of MRSA: deleted (content moved to para 2.4) June 2010 Appendix 5 Allergies / hazard List: deleted June 2010 Appendix 6 MRSA hospital / ward transfers: renamed Appendix F and reformatted June 2010 Appendix 7 Discharge / admission communication: renamed Appendix G June 2010 Appendix 8 Patient information leaflet: renamed Appendix J and reformatted June 2010 Appendix 9 Staff information leaflet: renamed Appendix K and reformatted June 2010 Appendix 10 Definitions: renamed Appendix I (Glossary) and updated June 2010 Appendix A Patients to be screened for MRSA in Shetland: added June 2010 Appendix B Flowchart for screening process: added June 2010 Appendix C Procedure for taking a nasal swab: added June 2010 Appendix D Flowchart for decolonisation following a positive nasal swab: added Aug 2011 Throughout Revised to include new local Consultant Microbiologist post Aug 2011 Throughout Revised to differentiate between screening and swabbing. Aug 2011 Chapter 2 Revised to incorporate changes to national MRSA Screening programme Aug 2011 Chapter 3 Revised to incorporate changes to national MRSA Screening programme Aug 2011 Appendix A Patients to be screened for MRSA in Shetland: revised to incorporate changes to national MRSA Screening programme Page 4 of 41

5 Aug 2011 Appendix B Flowchart for screening process: revised to incorporate changes to national MRSA Screening programme Aug 2011 Appendix C Procedure for taking a nasal swab: Revised to incorporate procedure for perineal swabbing Aug 2011 Appendix D Flowchart for decolonisation following a positive nasal swab: amended to include perineal swabbing Aug 2011 Appendix H Membership of ICT: updated Aug 2011 Appendix L Patient Information Leaflet MRSA Screening Programme: added Sept 2014 Throughout Revised to incorporate HPS/NHSNSS Interim Guidance: Nonprescribing control measures to prevent cross transmission of Carbapenamase-Producing Enterbacteriaceae in acute settings Page 5 of 41

6 Appendix A Appendix A: Patients to be screened for MRSA in Shetland 1. The following patients should be screened using CRA (Clinical Risk Assessment) questions (unless patient does not consent or they are excluded for specific clinical reasons) Elective admissions (screen before admission if possible) All patients, aged 16 or over, who are booked to be admitted to hospital for at least one night Excludes patients being admitted to obstetric units (in Shetland or on mainland); paediatric wards (on mainland), or psychiatric wards (on mainland). Emergency admissions (screen on admitting ward) All patients, aged 16 or over, who are expected to be admitted to hospital for at least one night Excludes patients being admitted to obstetric units (in Shetland or on mainland); paediatric wards (on mainland) or psychiatric wards (on mainland) Transfers (screen on admitting ward): All patients transferred to GBH from other hospitals, aged 16 or over, who are expected to be admitted to hospital for at least one night 2. CRA Questions: Has the patient any previous history of MRSA colonisation or MRSA infection at any time in the past? Is the patient currently resident in a care home or institutional setting (e.g. prison, homeless hostel), or transferred from another hospital (either within or outwith own NHS Board)? Does the patient have a wound/ulcer or invasive device which was present before admission to this hospital? [an invasive device is a device which temporarily enters the skin, resulting in a skin break] 3. The following patients should be swabbed: minimum of two sites (nasal and perineal) All patients who answer yes to one or more CRA questions All patients admitted to High Dependency Unit for at least one night (regardless of CRA answers) 4. The following patients should be isolated (if possible and appropriate) pending MRSA result All in-patients who answer yes to one or more CRA questions Page 6 of 41

7 Appendix B (i) Appendix B (i): Flowchart for Screening Process (MRSA) Decision to admit patient to hospital Planned admission for at least one night Clinical risk assessment If not expected to stay one night then no further action required Emergency admission expected to stay at least one night Clinical risk assessment Not high risk Answers yes to one or more questions Answers yes to one or more questions Not high risk No further action required Info to patient & consent to take nasal swab & perineal swabs (as a minimum). Take swabs as per procedure Isolate / cohort / barrier nurse until result known No further action required Document Document Negative for MRSA both sites Positive for MRSA either or both sites If swab not taken, document in notes Positive for MRSA either or both sites Negative for MRSA both sites Patient fulfils PGD criteria Does not fulfil PGD criteria: check with consultant Continue to take appropriate infection control precautions when in hospital Either not clinically appropriate or no patient consent Clinically appropriate and patient consent Decolonisation therapy advised Patient consents Decolonisation not advised Document Patient does not consent Decolonisation and repeat swabbing as per national protocol (see Decolonisation Flowchart) AND Decolonisation and repeat swabbing as per national protocol (see Decolonisation Flowchart) AND Can be coded as medically unavailable for purposes of 18 week RTT targets until decolonisation successful or clinician decision to stop attempting decolonisation (see Decolonisation Flowchart) Continue to take appropriate infection control precautions whilst in hospital until clear of MRSA Page 7 of 41

8 Appendix B (ii) - CPE flow diagram clinical risk assessment/infection control precautions and screening (HPS 2014) Appendix B (ii) Nb. ADDITIONAL Q BESIDE FIRST DIAMOND: Has the patient a history of admission to hospitals or holiday dialysis outside of Scotland in the last 12 months? Page 8 of 41

9 Appendix C Appendix C: Procedure for taking nasal perineal and rectal swabs 1. Screening for MRSA: For nasal and perineal swab (or stool sample) The following procedure should be employed to obtain nasal and perineal swabs for MRSA culture.* The following equipment is required for each swab; Sterile swab for culture in Amies medium or charcoal medium (single sterile tipped applicator swab/ plastic outer transport case with transport medium). Check expiry date. Laboratory request form (specimen bag attached). Before collection hand hygiene should be performed and then disposable gloves and disposable apron should be put on. Please note that of all body sites being swabbed the perineum should always be the last in the swabbing sequence. Collection Procedure For nasal swab 1. If patient has nasal discharge ask them to clear the discharge by blowing his/her nose into a non scented tissue. 2. Do not attempt to clear the discharge with swabs as this may be excessively traumatic. 3. After washing hands, put on clean gloves. 4. Open and remove sterile tipped swab applicator from transport casing. 5. Taking care to avoid other contact with swab, insert the swab approximately 2 cm (approx ¾ inches) into the first nostril next to the nasal septum. 6. Rotate the swab against the anterior nasal mucosa for 3 5 seconds. 7. Using the same swab, repeat for other nostril. 8. Carefully place used swab back into transport tube and secure. For perineal swab 1. Ask the patient to loosen their clothing. 2. Open and remove sterile tipped swab applicator from transport casing. 3. Taking care to avoid other contact with swab, rotate the swab against the perineal skin (the area between the anus and external genitalia) for 3 5 seconds. 4. Carefully place used swab back into transport tube and secure. 5. If a throat swab is being taken in the absence of a perineal swab, the procedure is as given below: Page 9 of 41

10 For throat swab (only if perineal swab not possible: not as effective as perineal swabbing) 1. Open and remove sterile tipped swab applicator from transport casing. 2. Taking care to avoid other contact with swab, rotate the swab against the tonsillar area and pillars of the faeuces for 3 5 seconds. 3. Carefully place used swab back into transport tube and secure. Two site swabbing (nasal and perineal) is the minimum required for the MRSA screening programme. Any wounds, skin breaks or sites of invasive devices should also be sampled on another swab. If additional sites are swabbed due to nature of the procedures to be undertaken, additional body sites should be considered. These include axilla, throat and groin. Refer to Appendix E for further details on the swabbing from other sites. 2. Screening for CPE: For rectal swab (or stool sample) 1. A rectal swab is the sample of choice for CPE screening. Alternatively, a stool sample can be sent (e.g. in children or if patient refuses a rectal swab). 2. A rectal swab should be taken using a routine bacteriology swab. The swab is inserted gently into the rectum, and rotated gently to ensure faecal material is sampled. Place the swab back into the transport medium and transport the specimen to the microbiology laboratory. 3. Stool samples should be collected in the same way as they are for routine culture. 4. Patients with wounds or lesions should have these swabbed using a bacteriology swab (in addition to the rectal swab or stool sample). 5. Patients with urinary catheters should have a Catheter Specimen Urine sent (in addition to the rectal swab or stool sample). 6. Use a routine Bacteriology request form. Request M,C&S and in the clinical details write: For Carbapenemase Producing Enterobacteriaceae (CPE) screen. 3. For all swabs 1. Fill in appropriate patient details as requested or affix patient label on outer aspect of transport tubes. Ensure recording of date and time swab was collected as well as the location (either ward, pre-admission clinic etc). 2. Complete the specimen request form as per local laboratory protocol. This would normally include the following information: Page 10 of 41

11 Name Date of Birth CHI number if available. Location: eitherward / area / pre-operative assessment clinic / GP practice Anatomical site of swab (nasal, perineum, wound, rectum etc) Investigation required: eg MRSA screen Reason for screen: e.g. High risk on CRA; 1 st post decolonisation; 2 nd post decolonisation etc Date and time sample collected Antibiotics currently prescribed 3. Place swab in specimen bag and secure. 4. Leave for collection in designated area as per normal procedure for uplift and transfer to the laboratory. If pick up is delayed and swab is likely to be left overnight place in dedicated specimen fridge until the next collection is due. Page 11 of 41

12 Appendix D Appendix D: Flowchart for decolonisation following positive MRSA result * Patient may be admitted at any stage if clinically required, but should be managed in hospital as MRSA positive until 3 consecutive negative results Nasal and/or perineal swab MRSA positive Clinician decision to attempt decolonisation AND patient consent Nasal mupirocin, three times daily for five days Daily bathing in chlorhexidine body wash for five days (and wash hair twice) Supplied by Hospital Pharmacy via POA nurse if out-patient 2 days (48 hrs) after completing therapy repeat nasal & perineal swabs as per procedure 1 st MRSA negative Still MRSA positive 48 hour gap: repeat nasal swab (2 nd post decolonisation screen) 2 nd attempt at decolonisation: Repeat steps 2-4 above 2 nd MRSA negative MRSA positive again Still MRSA positive after two attempts at decolonisation 48 hour gap: repeat nasal swab (3 rd post decolonisation screen) 1 st MRSA negative 48 hour gap: repeat nasal swab (2 nd post decolonisation screen) 3 rd MRSA negative MRSA positive again MRSA positive again after two attempts at decolonisation 2 nd MRSA negative Considered clear of MRSA. Remove medically unavailable code Admit to hospital as planned* Clinician review: Recommended to refer to microbiology after two failed attempts at decolonisation And / or admit and manage as MRSA positive MRSA positive again after two attempts at decolonisation 48 hour gap: repeat nasal swab (3 rd post decolonisation screen) 3 rd MRSA negative Page 12 of 41

13 Appendix E: Swabbing other sites Appendix E Sites that may be screened Nose (A) Throat - back of throat (B) Axillae (C) A B Groin (D) Perineum Individual wounds/lesions or abnormal skin (e.g. eczema) C PEG / gastrostomy sites CSU (if patient catheterized) Umbilicus in neonates Sputum from patients with a productive cough Methods D For all sites, preparation of swab and labelling / packaging is as per Appendix C Nose as per Appendix C Throat as per Appendix C Axillae - Using a non-touch technique, swab the area required. One swab can be used for both axillae. Groin - Using a non-touch technique, swab the area required. One swab can be used for both groins Perineum as per Appendix C Wounds Take the swab and zig-zag and rotate it across the wound. Do not let the swab touch the surrounding skin. Send a sample of exudate or pus if present. Clearly identify the wound type, location, etc. Use the same identification details each time e.g. sacral sore left buttock. Abnormal Skin (e.g. eczema, etc) Rotate the swab over the abnormal skin area. Clearly identify the abnormal skin area (i.e. type, site, etc). Use the same identification details each time. Page 13 of 41

14 Appendix F Appendix F: Hospital / ward transfers of MRSA positive patients The receiving ward / hospital must be informed of the known (or suspected) current MRSA status of the patient (including any screening undertaken). If a patient has been screened for any reason (e.g. as a contact) then the receiving ward / hospital must be informed. MRSA status of patient. Is the patient: Currently known / suspected to be MRSA positive Or Previously positive and deemed clear YES NO Can the receiving ward/ hospital isolate the patient? Has the patient shared a room with a known or suspected MRSA patient? IMPORTANT Standard isolation should preferably be in a single room. For further information see. or speak to Infection Control Team YES Has the patient been screened? NO Patient can be transferred without MRSA screening YES NO NO YES Negative Transfer and isolate as per receiving ward / hospital MRSA procedures Speak to Infection Control Team Screen as per procedure Are the results available? NO YES Treat/Decolonise in accordance with MRSA procedures Manage as positive until results known Positive Page 14 of 41

15 Appendix G Appendix G: Admission & Discharge Communication When a known or suspected MRSA patient is due for admission and/or discharge/transfer the following information should be relayed to the receiving establishment: Patient Name (Date of Birth and Identification Number), MRSA Status (Positive sites), Treatment/ Decolonisation Details (date treatment commenced) and any screening undertaken. Note that most patients being admitted electively will now be screened, and decolonisation attempted where necessary, prior to admission. Communication Channels Patient from: Home / Community Other Hospital / Ward Care Centre/ Residential establishment Via POA Information to be given by: GP / District Nurse Ward Staff (Nursing / Medical) Care centre manager or Staff POA team Information to be passed onto admitting ward before or on admission Admitted to hospital ward Discharge / transfer Information to be passed onto receiving area by ward staff before discharge / transfer Home / Community Other Hospital / Ward Care Centre/ Residential establishment Information to be given to: GP & district nurse Ward Staff (Nursing / Medical) Care Centre manager or staff If a patient is identified as being positive after discharge, information must be passed on to the appropriate person by the Infection Control Team. Page 15 of 41

16 Appendix H: Glossary HAI Colonisation Infection POA Systemic MRSA CPE Healthcare Associated infection colonisation is when the organism lives harmlessly on the body with no ill effects is when the organism penetrates tissue and causes disease (usually when the skin is breached e.g. due to surgery, or when the immune system is impaired e.g. due to an underlying medical condition). Pre-operative assessment relating to or affecting the body as a whole, rather than individual part and organs Meticillin Resistant Staphylococcus Aureus Carbapenemase-Producing Enterobacteriaceae Page 16 of 41

17 1 Introduction This policy aims to ensure identification and effective, appropriate management of MRSA and carbapenemase producing Enterobacteriaceae (CPEs) positive individuals in hospital and community settings in Shetland. The emergence of multidrug resistant bacteria has been of increasing concern for a number of years and particularly since the identification of resistance to extended-spectrum β- lactams in Gram-negative bacteria. CPEs were first identified in Europe in the 1990s and since then there has been a sustained increase. Carbapenems are often viewed as the last therapeutic option to treat complex infections caused by multidrug resistant bacteria and this makes the increase of CPE a major public health concern. Approximately 30% of the population carry the organism Staphylococcus aureus (S.aureus). This is a bacterium, which is normally found in the nose and on skin. Most healthy people are unaffected by it, however it does have the potential to cause infection in those who have severely weakened immune systems. MRSA (Meticillin Resistant Staphylococcus aureus) is a form of S. aureus. It is transmitted in the same way, and causes the same range of infections as other strains of S. aureus, however it has developed resistance to the more commonly used antibiotics. This makes infections caused by MRSA more difficult and costly to treat, which is why every effort must be made to prevent its spread. The majority of individuals are COLONISED which is when the organism lives harmlessly on the body with no ill effects as opposed to INFECTED which is when the organism enters tissue and causes disease. Further definitions can be found in Appendix H. In order to control and minimise the spread of MRSA there must be compliance with the following: Standard Precautions (formerly known as Universal Infection Control Precautions) Cleaning (domestic etc) must be of an acceptable standard Adherence to Infection Control Policies i.e. Clinical Waste, Laundry etc Infection control training Strict adherence to antibiotic policies Adequate resources for compliance Increasingly there are a number of individuals in the community who have acquired MRSA however MRSA is essentially a hospital problem. There are a number of reasons for this: Invasive procedures are frequently carried out in hospitals, which is an important route of infection Hospitalised patients have lowered resistance to infection There is widespread use of antibiotics in hospital People affected by MRSA do not present a risk to the community at large and should continue their normal lives without restriction. Many individuals are discharged into Page 17 of 41

18 Care Centres and this should pose no problem to their ongoing care or that of the other residents as long as a few basic precautions are taken. This procedure will describe the key precautions to be considered when delivering care to those with infections such as MRSA which are spread by contact. Patients in Shetland Hospitals / clients in community settings in Shetland should be individually assessed. This procedure provides guidance when patients are given a MRSA diagnosis in a Shetland hospital, prior to transfer back to a Shetland hospital or in a Shetland community setting. Individual risk factors, such as the number of positive sites, invasive procedures undertaken, and vulnerability must be considered when deciding courses of action. The Infection Control Team will give advice ( 1.1 Contact Precautions What are contact precautions? Contact precautions are a set of infection control measures (to be used in addition to Standard Infection Control Precautions* (SICPs) which are designed specifically to prevent and control the transmission of infectious agents* spread by direct and indirect contact to patients/clients and health and social care workers during provision of care. These precautions include: isolation, hand hygiene, use of personal protective equipment (PPE), care of equipment and environment including decontamination, safe handling of linen and waste Why are contact precautions important within health and social care settings? It is important to prevent infectious agents that could be present on for example a patient s/client s skin/mucous membranes or immediate environment, being transmitted via contact to others and resulting in Healthcare Associated Infection (HAI). This is the most common mode of transmission of infectious agents in care settings and therefore it is essential that all healthcare and social care workers understand how to prevent spread via this route When are contact precautions required? The need for contact precautions will vary depending on the patient/client, the setting, and the infectious agent and the procedures/activities being undertaken. For example highly dependent in-patient areas such as intensive care require different considerations than areas such as mental health settings. Further advice may be required from local Infection Control/Health Protection Teams Within non-acute settings, such as care homes, community clinics or during home care, individual risk assessments are required. Contact precautions are required in all health and social care settings when a patient/client is known or suspected to be infected or colonised with certain infectious agents or epidemiologically important organisms that can be spread by contact. They include precautions to be taken with patients: Page 18 of 41

19 with active infections who are incubating infectious disease who are asymptomatic but suspected to be infectious who are colonised with pathogenic microorganisms 1.2 How do you decide which precautions are required? Not all elements may be required for every patient/client or situation. The use of risk assessment should be applied when assessing the requirement for precautions and further specialist advice should be sought from local Infection Control/Health Protection Teams as required. Examples of infections spread by contact and of Healthcare Associated Infection (HAI) concern: Antibiotic resistant bacteria e.g. Meticillin resistant Staphylococcus aureus (MRSA), Glycopeptide resistant enterococci (GRE) & multi-resistant Gram negative bacilli Clostridium difficile infection/clostridium difficile Associated Disease (CDI) Norovirus Others causing concern identified locally including those resistant to antibiotics Remember other infections are spread via contact, droplets and airborne e.g. influenza, RSV. ( some infectious agents are spread by more than one route) Carbapenemase-Producing Enterobacteriaceae Page 19 of 41

20 2 Screening of patients before or on admission to hospital The Gilbert Bain Hospital is free from endemic MRSA and Carbapenemase- Producing Enterobacteriaceae (CPE). Every effort should be taken to ensure that this continues to be the case. Because of this the following procedures must be observed. 2.1 National Screening Programme There is a national MRSA Screening Programme, first implemented in 2010 and revised in Initially the programme only included (in Shetland) elective admissions and patients transferred or admitted to Ronas Ward. The revised programme includes all patients admitted to hospital in Shetland, aged over 16, who are expected to remain in hospital for at least one night.this includes both elective and emergency admissions. (Patients admitted to the maternity unit are excluded). The main elements of the revised MRSA Screening Programme are as follows: A move away from screening just elective admissions and admissions to high risk specialties to screening all admissions using a clinical risk assessment (CRA) which consists of three questions. Only those patients found to be high risk on CRA are swabbed. Two site swabbing (nose and perineum) will be introduced as this has been shown to be more effective than just the nasal swab. Patients admitted to high impact specialties (vascular/cardiothoracic surgery, orthopaedics, intensive care or renal medicine) will be swabbed regardless of clinical risk assessment. The introduction of the revised programme will incorporate all the high risk patients that were previously screened in Shetland as per local procedures. Patients who are not included in the national screening programme do not require screening for MRSA as routine. However there may be patients in Shetland who are outwith the national screening programme but who are identified as requiring screening for clinical reasons Interim Guidance: Non-prescribing control measures to prevent cross transmission of Carbapenemase- Producing Enterobacteriaceae in acute settings Interim guidance in dealing with patients who are at risk of having Carbapenemase- Producing Enterobacteriaceae (CPE) and patients from whom CPE has been isolated is also included here, that will be superseded by either, a UK wide developed guidance, or by review of new evidence. The main elements of the guidance are as follows, screening of: All inter-hospital transfers from healthcare facilities outside Scotland or patients with a history of admission to a hospital outside Scotland in the last 12 months (including holiday dialysis patients), and/or Patients with a known history of infection or colonisation with CPE in the last 12 months Page 20 of 41

21 Patients falling into the categories above must be isolated in a single room, preferably with en-suite facilities, and screened (by single site rectal or faecal swabbing) on admission. 2.2 Aims of Screening The aim of screening patients for MRSA is to identify patients that are colonised or infected with the organism. These patients can then be managed appropriately to reduce the risk of self-infection and of transmitting the organism to other patients. These measures aim to reduce the negative impact that MRSA has on patients and the additional burden on healthcare resources. The aim of the introduction of screening patients for Carbapenemase Producing Enterobacteriaceae (CPEs) is to produce a set of recommendations based on scientific evidence (where available) and consensus of expert opinion to prevent cross transmission of CPEs within acute healthcare settings in NHSScotland. 2.3 The Clinical Risk Assessment (CRA) The six CRA questions should be asked as part of the pre-operative assessment / admission procedure. The questions are: MRSA Screening: 1. Has the patient any previous history of MRSA colonisation or MRSA infection at any time in the past? 2. Is the patient currently resident in a care home or institutional setting (e.g. prison, homeless hostel), or transferred from another hospital (either within or outwith own NHS Board)? 3. Does the patient have a wound/ulcer or invasive device which was present before admission to this hospital? [a skin break and an invasive device is a device which temporarily enters the skin, resulting in a skin break or entry through a portal of entry in body e.g. urinary catheter? CPE Screening: 1. Is the patient aware of any previous history of CPE colonisation or infection at any time in the last 12 months? 2. Has the patient been transferred from a hospital outside of Scotland? 3. Does the patient have a known history of admission to hospitals or holiday dialysis outside of Scotland in the last 12 months? If any of the questions cannot be answered (i.e. don t know ) this is treated as a no. Patients answering yes to one or more should be swabbed. Patients in high impact specialties should be swabbed regardless of CRA. (The only high impact specialty in the Gilbert Bain Hospital is the two bedded High Dependency Unit within the surgical ward). 2.4 Patients to be screened (asked the CRA questions) in Shetland Elective admissions: Page 21 of 41

22 all patients attending the POA clinic for assessment prior to a surgical procedure that will require an overnight admission to hospital (i.e. excluding all patients who are not planned to stay overnight) any other surgical patients who do not attend POA (should be screened at their outpatient appointment by POA nurse or out-patient nurse; or in community by community nursing team) all other patients who have an admission planned to Ward 1,Ward 3 or Ronas (should be screened at their out-patient appointment by POA nurse or out-patient nurse; or in community by community nursing team) If screening has not been done pre-operatively, then it should be done on admission to hospital Elective patients should be CRA screened and swabbed (if required) at preassessment if possible If not then CRA screened and swabbed upon admission within 24 hours if possible Patients from outside Scotland should be screened and swabbed Emergency admissions all patients admitted as emergencies who require at least an overnight stay hospital (i.e. excluding all patients who are not planned to stay overnight) Patients should be CRA screened (and patient placement based on) and swabbed (if required) upon admission within 24 hours if possible It is not recommended that screening takes place within A&E Patients from outside Scotland should be screened and swabbed. 2.5 Patients excluded from screening Although the national programme excludes patients who are being admitted to paediatric, psychiatric or obstetric wards (eg the GBH maternity unit), it theoretically does include children, psychiatric patients and obstetric patients who are electively admitted to any other ward for at least one night In Shetland, there may be a small number of children who require an elective overnight admission to Ward 1 or 3. As NHS Shetland is the only Board where this is an issue, the national MRSA Screening Programme Board has advised that the local Infection Control Team should make the decision regarding children. We have agreed locally children and teenagers aged under 16 will be excluded from the screening programme. 2.6 Patients to be swabbed MRSA: All patients who answer yes to one or more CRA questions CPE: All patients who answer yes to one or more CPE screening questions All patients admitted to the High Dependency Unit (The only high impact specialty in the Gilbert Bain Hospital is the two bedded High Dependency Unit within the surgical ward.) Page 22 of 41

23 2.7 Reasons for not swabbing As with all medical procedures and tests, any patient can decline consent for MRSA swabbing. For all high risk patients who do consent, the expectation is that they will be swabbed (but not necessarily offered decolonisation) However, there may be good reasons for not swabbing as part of the programme, eg if they have recently already had a MRSA swab or decolonisation therapy. There are no time intervals defined nationally, so this would be a matter of clinical judgement. Also, the current local procedures recommended an interval of at least 48 hours between finishing antibiotic therapy and taking a MRSA swab Rarely, there may be other clinical reasons for not swabbing certain sites (facial trauma for example). Also if perineal swab not possible this can be substituted with a throat swab, however this is not as effective as perineal swabbing in detecting MRSA colonisation If a decision is made not to screen a patient for any of the above reasons, then this should be clearly documented in the notes. See Appendix A for a summary of the patient groups who should be screened and swabbed. See Appendix B and C for the screening procedure flowcharts. 2.8 Taking the swabs Following explanation of procedure, patients should be provided with a patient information leaflet (Appendix L and Appendix N) and given the opportunity to read the leaflet and discuss fully with clinical staff. Clinical staff should emphasise that MRSA screening detects colonisation not infection and that patients may receive treatment as a result of a positive screen. Verbal consent to have nasal, perineal, rectal and faecal swab taken, should be sought from the patient prior to screening. The procedures for obtaining the swabs are contained in Appendix C. Please note that privacy and comfort should be assured before commencing screening. The minimum screen will be a nasal swab and a perineal swab. (Appendix C). Any wounds, skin breaks or sites of invasive devices should also be sampled on another swab. Additional sites may be swabbed due to nature of the procedures to be undertaken i.e. axilla or throat. However the diagnostic return from axilla swab screening is likely to be very small and may only be of interest for procedures directly involving the axilla. Patients with indwelling urinary catheters should also have a urine sample sent for MRSA testing (Appendix E) If a perineal swab not possible this can be substituted with a throat swab. However this is not to be as effective as detecting MRSA colonisation, and should only be done when perineal swabbing is not possible. See Appendix C for procedures for nasal and perineal swabbing. 2.9 Laboratory testing The sample should be tested used chromogenic agar. If the colour change is suggestive of MRSA colonies, a confirmatory coagulase test and sensitivity testing should be carried out. Mupirocin resistant strains should be referred to the Consultant Microbiologist. Page 23 of 41

24 [Further detail on the laboratory testing and identification of MRSA is contained in the national laboratory Standard Operating Procedures (BSOP 29) produced by the Health Protection Agency.] Flowchart: Laboratory testing of MRSA samples MRSA Screening Swab Plate swab onto chromogenic agar and incubate in O2 at 37 C for hours Colonies suggestive of MRSA Colonies not suggestive of MRSA If new isolate confirm isolate is coagulase positive. Confirm identification and perform sensitivity testing using Vitek II or conventional antibiotic susceptibility testing Known positive: confirm isolate is meticillin resistant as per laboratory protocol Negative result reported New MRSA positive result reported Previously known MRSA reported 2.10 Patient placement following clinical risk assessment Patients in hospital who are identified as high risk through CRA or who are MRSA positive should be isolated whenever possible. If isolation is not possible, MRSA positive patients should be cohorted. If it is not possible to isolate or cohort, then patients may be separated and barrier nursed. Isolation, cohorting and separation are defined below. Isolation: Patient is placed in a single room with hand washing facilities, ideally with ensuite toilet and shower where available. Isolation should be undertaken according to the HPS Infection Control Contact Precautions Policy and Procedure. Page 24 of 41

25 Cohorting: Patient is placed in a room and cared for by dedicated nursing staff along with other patients who are MRSA positive. Cohorting should be undertaken according to HPS Infection Control Contact Precautions Policy and Procedure. Separated: Patients who are MRSA positive are housed within the same room as patients who are not MRSA positive but are separated by at least three feet from any adjacent persons by use of: cubicles or use of closed bed curtains. This is considered to be a step down from full cohorting. These patients do not have separate nursing staff but are barrier nursed Patient placement based on CRA result: CRA negative - open ward CRA positive and swab screen result pending: - isolated or cohorted together CRA positive and swab screen positive - isolated or cohorted together CRA positive (questions 4-6) and swab screen result pending isolated CRA positive and swab screen positive - the patient(s) must be screened weekly thereafter until the Infection Control Doctor, in conjunction with clinical colleagues, is satisfied that there is no further risk of cross transmission 2.11 Action whilst awaiting the result For MRSA screening samples submitted to the laboratory during the week, a positive result should be available within 24 hours. However a negative result will take hours to confirm. MRSA testing can be done at the weekend but other urgent laboratory work may be prioritised For patients in the community, no action is required until the result is known For patients in hospital: all patients who answer yes to one or more of the CRA questions are assessed as high risk and should be isolated, cohorted or barrier nursed until MRSA status is known (as per paragraph 2.10) However, there may be clinical reasons for not isolating an individual patient. If the clinical judgement is that there is a greater risk to the patient s health and wellbeing by nursing them in an isolation room compared with barrier nursing in a bay; then cohorting or separation and barrier nursing can be used Clinically necessary admission / treatment should not be delayed whilst awaiting the result of the screen For the purposes of the 18 week referral to treatment target, the patient can be coded as medically unavailable whilst awaiting the result Action in the event of a negative result The result should be recorded in the patient s notes In-patients may be nursed / managed using standard infection control precautions, no additional precautions are necessary. Page 25 of 41

26 Note that a negative screening result does not mean that the patients will remain MRSA free for any specified length of time Action in the event of a positive result The MRSA result should be recorded in the patient s notes and both the patient s consultant and GP should be informed. [Note that the Public Health Department receives copies of all MRSA positive lab results and will notify the GP of all such positive results] Most patients with a positive result will be offered decolonisation therapy and decolonisation should be carried out before admission if possible. The standard local procedure for decolonisation (regardless of whether one or both sites are positive) is nasal mupirocin and chlorhexidine body wash If the decision is made to do ahead with decolonisation prior to admission, then the POA team will obtain the therapy from hospital pharmacy and either ask the patient to come into the Unit to collect it or will send it out to the patient s GP practice or community nursing team (depending on individual practices) There is a local PGD for supply of mupirocin by POA / out-patient nurses if appropriate. It may be more convenient for some patients to receive their treatment via their GP or community nursing team For in-patients, the therapy will be prescribed in the usual way on the drug kardex Not all patients will be offered / receive decolonisation therapy. The clinician caring for the patient may decide not to decolonise on clinical grounds; the patient may not consent, or there may not be sufficient time to decolonise before admission. If decolonisation is not carried out, the reason should be stated in the patient s notes Decolonisation should not adversely affect the waiting times targets: if a patient requires decolonisation then they can be coded as medically unavailable and the 18 week referral to treatment clock would stop. (In the same way if other medical problems needed to be treated before admission) However urgent admission or surgery should not be delayed to wait for a MRSA result; to decolonise or to re-screen: the consultant caring for the patient makes this decision Following decolonisation, three consecutive negative screens taken at least 48 hours apart are required to consider the patient decolonised. The first postdecolonisation screen should be taken at least 48 hours after completing the course of treatment. Note that the second and subsequent screens should be taken even if previous result not yet received. Assuming all the post decolonisation results are negative, then it would take generally days from commencing treatment to receiving final screening result (depending on weekends). For patients requiring repeat swabs prior to admission, the POA team will ask the patient to return to the POA unit for the swab (or to go to community nurse or GP practice) If the first attempt at decolonisation is unsuccessful, then the process should be repeated. If still unsuccessful, then the patient should be reviewed: referral to the Page 26 of 41

27 consultant microbiologist is recommended in the national protocol. The patient may require to be admitted to hospital whilst colonised with MRSA, in which case they should be nursed in isolation, or barrier nursed, and other relevant infection control precautions taken If a patient is discharged whilst on decolonisation therapy, it is appropriate that they complete the treatment at home. But no further screening is necessary unless they are due to be re-admitted If a patient has already been discharged when a positive MRSA screening result is reported, then the GP should be informed. Generally decolonisation will not be required, unless the patient is due to be re-admitted There is currently no national guidance on repeating the screening process for patients who remain in hospital for a long period of time. Repeat screening does not therefore need to be undertaken for patients who remain in hospital unless there is a clinical indication (for example a patient who has been MRSA positive requiring further surgery) Where CPE colonisation / infection IS identified: In high risk clinical areas e.g. in Shetland the HDU, and renal units: The identification of a new patient case with CPE will require weekly screening of all patients in the unit while any patient remains positive for CPE. In other clinical areas e.g. general medical/surgical wards: The identification of a new patient case with CPE will require all patient contacts to be screened for CPE e.g. those who have shared / sharing the same bay/room Action in the event of a positive result: infection control procedures No specific infection control procedures are required for patients at home in the community. Refer to the current MRSA procedures for further guidance regarding patients in care centres and those attending primary and community health care services Patients who have a positive screening result but have not been successfully decolonised before they are admitted to hospital (for whatever reason) should be nursed in isolation if possible, or barrier nursed until successful decolonisation is completed. If decolonisation is not to be carried out or is not successful then they may need to remain in isolation or be barrier nursed until they are discharged (contact the Infection Control Team if further advice required) Refer to Chapter 4 for further advice regarding infection control precautions for patients going to theatre etc. See Chapter 3 and Appendix D for further information on decolonisation Page 27 of 41

28 3 Decolonisation of MRSA and CPE Decolonisation may be undertaken as an outpatient / in the community for patients screened before elective admission, or on the ward for patients screened on admission. Once decolonisation is complete, a further MRSA screen should be undertaken after 48 hours to establish which sites, if any, are still positive. The eradication procedure used will depend upon which body sites are colonised with MRSA. The standard decolonisation regime for nasal and/or perineal carriage identified through the MRSA Screening Programme is nasal decolonisation with mupiricin and skin decolonisation with chlorhexidine (Appendix D). 3.1 Decolonisation of nasal carriage Mupirocin ( Bactroban ) nasal ointment 3 times daily to inner surface of each nostril for 5 days. Apply with cotton wool bud. In the event of mupirocin resistance: Naseptin cream (0.5% neomycin plus 0.1% chlorhexidine) provided the organism is neomycin susceptible. Further advice can be sought from Infection Control Team (Appendix H). 3.2 Decolonisation of NORMAL skin Skin products should not be diluted. Direct application of 4% chlorhexidine (Hibiscrub) to all skin using a damp disposable cloth or freshly laundered flannel, daily for 5 days i.e. use chlorhexidine as a soap substitute and rinse off. Wash hair twice in the 5-day period with chlorhexidine. Alternatives include 2% triclosan (aquasept) or 7.5% povidine-iodine. Hair conditioners and body lotions can be used after treatment if required. 3.3 Other regimes Decolonisation for throat carriage in adults Oral hygiene is very important, as teeth/dentures have been known to harbour MRSA. Oral trimethoprim 200mg twice daily and 500mg fusidic acid tablets twice daily for 5 days. If using fusidic acid liquid, 750mg twice daily for 5 days. In the event of fusidic acid resistance or patient intolerance: Oral rifampicin 600mg once daily and trimethoprim 200mg twice daily (if susceptible) for 5 days. Patients may require an anti-emetic. Nasal decolonisation should be undertaken at the same time. Page 28 of 41

29 3.3.2 Decolonisation of ABNORMAL skin As it is difficult to eradicate MRSA from abnormal and/or chronic skin conditions, the decolonisation protocol should not be commenced until advice has been sought from a dermatologist or medical microbiologist Colonised wounds Seek advice from the Infection Control Nurse or NHS Grampian Consultant Microbiologist (Infection Control Homepage at Decolonisation for children and neonates Before treating children and neonates advice must be sought from the NHS Grampian Consultant Microbiologist ( Urine Elimination of MRSA from urine is not usually possible in the presence of a urinary catheter. If treatment is required discuss with the Microbiologist and the clinician managing the patient It is essential that current local policy be adhered to however in the unlikely event of any adverse reaction please stop the treatment and seek advice promptly. 3.4 Repeat screening post decolonisation Screening should be repeated 48 hours after decolonisation therapy. If any sites remain positive then decolonisation should be repeated. A further screen should be taken 48 hours after the second course of decolonisation. If any sites remain positive following two course of therapy, then the advice should be sought from the microbiologist before commencing any further course of decolonisation. Refer to the Decolonisation Flowchart (Appendix D) A patient is deemed to be clear of MRSA after three negative post decolonisation screens, each taken 48 hours apart. It is not necessary to await the result of one screen before taking the next one, as long as a 48 hour gap interval is left Patients should remain in isolation / being barrier nursed until they have had three negative screens However, in some circumstances it may prove very difficult to eradicate MRSA from certain sites eg in catheterised patients or patients with chronic skin conditions. It may then be more appropriate to cease decolonisation attempts. Repeated screening and barrier nursing / isolation. This should only be done following discussion with the Infection Control Team and a risk assessment of the individual patient and their circumstances Repeated screening or decolonisation does not need to be undertaken if the patient is discharged from hospital. Although it is appropriate to continue a decolonisation regime once started. (Refer to section 6 on Control of MRSA in the Community). Page 29 of 41