Control of Methicillin Resistant Staphylococcus Aureus (MRSA) Clinical Care Protocol IC/231/10

Transcription

1 BASINGSTOKE AND NORTH HAMPSHIRE NHS FOUNDATION TRUST Control of Methicillin Resistant Staphylococcus Aureus (MRSA) Clinical Care Protocol IC/231/10 Supersedes: Control of Methicillin Resistant Staphylococcus Aureus (MRSA) March 2009 IC/231/09 Owner Name Linda Swanson Job Title Infection Prevention and Control Nurse Final approval Name Infection Control Committee committee Date of meeting 23 July 2010 Reviewed Infection Control Committee 10 December 2010 Authoriser Name Dr Nicki Hutchinson Job title Director of Infection Prevention and Control Signature Date of authorisation 15/12/2010 Review date (maximum 3 years from July 2013 date of authorisation) Audience (tick all that apply) Trust staff NHS General public Standards Standards for Better Health NHSLA Hygiene Code 2009 Related policies Policy numbers and names Glove Policy IC/354/09 Hand Hygiene Policy IC/230/10 Cleaning and Decontamination Policy IC/32/07 Last Offices Policy Equality Impact Assessment Date completed by policy owner HS/375?10 13 May 2010 Reviewed in accordance with The Health and Social Care Act 2008: Code of Practice for health and adult social care on the prevention and control of infections and related guidance as published 16 December 2009 Page 0 of 34

2 Implementation Plan Summary of changes Infection prevention and control team contact details Updated to include the Health Economy Wide Screening Guidelines for Hampshire Updated to include DoH Screening Guidelines 2008 Updated to comply with Hygiene Code 2009 Screening and treatment flowcharts Roles and Responsibilities Related Policies Action needed and owner of action All staff need to be aware of the screening criteria for their areas and how to best manage those patients who are MRSA positive. Page 1 of 34

3 Contents Page 1.0 Introduction Roles and Responsibilities Training Patient Education Monitoring of Compliance MRSA Screening Who to Screen What swabs are available? When to use blue lidded Transwabs When to use PCR swabs How to use the swabs What areas to swab Pre Admission Short notice Admissions On Admission Who not to Screen Post Admission Sites to screen Procedure to follow negative MRSA swab result Elective Admissions Procedure to follow positive MRSA swab result Elective Admissions MRSA treatment regime Post treatment swabbing regime Emergency Admission MRSA Screening MRSA Management Discharging the MRSA Positive Patient Managing the MRSA Positive Patient Ward Management during an Outbreak of MRSA MRSA Isolation Precautions Daily Cleaning and Disinfection by Nursing and Housekeeping Staff Patients Personal Property Housekeeping Staff Standard Precautions for Daily Isolation Room 14 Cleaning 13.0 MRSA Information for Health Care Staff ie. Physiotherapists, 15 Phlebotomists and Medical Staff 14.0 Recommendations to Nursing Staff re Visitors to MRSA Patients Surgical Operations Tests for Clearance in Patients Staff Screening Protocol Transfer of Positive Patients to another Ward Transfer of Patients to Other Departments for Investigations Preparation During Procedure After Procedure Advice for Portering Staff Transporting MRSA Patients Transportation of MRSA Patients by Ambulance Staff Infection Control Procedure for Last Offices 19 References 21 Appendix 1: MRSA Screening Flowcharts 22 Appendix 2: Examples of Patient Information Leaflets 26 Appendix 3: Isolation Priorities 30 Appendix 4: Assurance Framework 31 Appendix 5: How to Perform Swabbing 32 Page 2 of 34

4 Infection Prevention and Control Team as at July 2010 DR NICKI HUTCHINSON HAZEL GRAY LINDA SWANSON BRUCE WAKE SANDY KIRK HEATHER PEACOCK SHEENAGH ECKETT Director of Infection Prevention and Control Consultant Microbiologist Infection Control Doctor Basingstoke and North Hampshire Hospital Basingstoke Senior Infection Prevention and Control Nurse Ext 4446 Bleep 2364 Infection Prevention and Control Nurse Ext 3734 Bleep 2366 Infection Prevention Surveillance Co-ordinator Ext 3904 Bleep 2433 IV Nurse Specialist Bleep 2370 Infection Prevention Administration Assistant Ext 6774 Infection Prevention and Control Assistant Ext 3735 Page 3 of 34

5 1.0 Introduction Methicillin sensitive Staphylococcus aureus (MSSA) is a common bacterium, which may be carried naturally in the nose or on the skin of healthy people, and not cause any problems. Alternatively, it may be the cause of wound or skin infections, and rarely blood stream infections. Methicillin, Cloxacillin and Flucloxacillin have been the mainstay of treatment of Staphylococcus aureus infections for over 35 years. Strains resistant to this group of penicillins emerged shortly after their introduction to clinical practice, and are referred to as Methicillin-resistant staphylococcus aureus (MRSA). There are many different strains of MRSA and some spread more easily than others. In most cases MRSA will not actually be causing an infection but is merely present (colonising), for example, in the nose, in a wound, pressure sore or some other site. The key risk factors for being colonised with MRSA are previous hospital admission in the UK or abroad, residing in a nursing home, previous positive results and transfer from another hospital. Colonisation increases the risk of infection in the colonised patient as well as the risk of cross infection to others. Because MRSA can easily spread, usually by direct skin contact, patients are barrier nursed according to the Infection Control Protocol to prevent cross infection/colonisation. Hand colonisation has proven to be a significant cause of cross infection; therefore hand decontamination is the most important measure in reducing the spread of this infection. The issues surrounding the importance of MRSA control have been the main focus of the national guidelines for the control of MRSA in hospitals. These guidelines have been prepared and recently reviewed by the combined working party of the British Society for Antimicrobial Chemotherapy, the Hospital Infection Society and the Infection Control Nurses Association. The working party recommends control measures to reduce spread of MRSA based on evidence that MRSA may be as virulent as MSSA that control measures do have an impact and the costs of not controlling MRSA are higher than those of control. The guidelines state that control of MRSA is still worthwhile. The Department of Health (DOH) advise that MRSA screening should be carried out for all elective admissions from March 2009, and all emergency admissions by 31 st December This BNHFT clinical care protocol is therefore based on the national guidelines mentioned above and the recent DOH target for screening all hospitalised patients for the presence of MRSA. It incorporates the Health Economy Wide Screening Guidelines for Hampshire (2010). 2.0 Roles and Responsibilities Every staff member has a responsibility to ensure that hospital acquired infections are kept to a minimum in the Trust. All clinical staff have a responsibility to ensure that they have attended the Trust s mandatory Infection Prevention and Control training and that they have attended the necessary update sessions. All clinical staff members need to ensure they are aware of the screening protocol for the Trust. 3.0 Training The Infection Prevention and Control Team (IPCT) are responsible for providing training on MRSA and its control. All clinical staff need to be aware of how MRSA is Page 4 of 34

6 spread and what they can do to reduce this spread. All clinical staff should attend an update session on MRSA and the Trust s screening protocols annually. 3.1 Patient Education The IPCT provide information leaflets on MRSA, some of which are supplied by the National Health Protection Agency. The IPCT also provide patient held information and screening and treatment records. This leaflet is available on the intranet. Clinical staff must ensure that information leaflets are available to patients and visitors, and seek advice from the IPCT for any further information that might be required. 4.0 Monitoring of Compliance In an era of quality improvement, it is important to consider the use of performance indicators in order to evaluate practice and make improvements where necessary. Whilst the IPT undertakes such evaluation and feeds back results, staff are encouraged to evaluate their own practice too. Examples: Audit of screening data. Monitoring of MRSA positive cases (colonization and infection). Root cause analysis of bloodstream infections with MRSA. Audit of MRSA positive patient s management (isolation, topical treatment etc). Please see the assurance frame work under Appendix MRSA Screening Who to Screen MRSA screening must be carried out for ALL elective admissions within 28 days of expected admission, and ALL emergency admissions within 24 hrs of the admission, with some exceptions (see 5.3 below) 5.1 What swabs are available? There are 2 types of swabs available for MRSA screening the blue lidded Transwab and the purple lidded PCR swabs. The purple lidded swabs are to be used for the rapid PCR testing (please see below). 5.2 When to use blue lidded Transwabs The blue lidded Transwab should be used for all MRSA screening unless the results are required urgently (i.e. within a few hours). 5.3 When to use PCR swabs PCR swabs are purple tipped and should only be used for urgent MRSA screen results i.e. surgical admissions who require urgent intervention and there is a lack of an MRSA screen or there will not be enough time to wait for a chromogenic test. They should not be used routinely or in place of the ordinary blue lidded swabs and are only licensed for nose swabbing eg if you have a patient with wounds/catheter they are not suitable to be swabbed with the PCR swab, the blue tipped Transwabs should be used. 5.4 How to use the swabs Do not handle the cotton tip of the swab otherwise this could lead to inaccurate swab results. Use the colour lidded end to handle the swab. Explain to the patient the Page 5 of 34

7 rationale for swabbing and the procedure you are about to follow. Ensure an information leaflet is given to all patients swabbed. These are available on the Intranet- Patient Information- Infection Control- MRSA Screening Inpatient Information. In the case of elective pre-admission screening a patient information leaflet is also available on the Intranet-Patient Information-Infection Control-MRSA Screening Before Your Procedure (please see Appendix 2 for examples). In the case of the nasal cavities gently insert the swab into the cavity and use a gentle sweeping motion to obtain samples of the nasal flora. Use the same swab to do both cavities. Without touching the cotton tip place the swab inside the labelled transport tube. If a full screen is required (i.e. following a positive nasal result) then repeat the same process for the groin. Use another single swab to swab both groin areas. If there are any wounds use a separate swab for each wound clearly stating the site of the wound. If there is a catheter present collect a catheter specimen of urine and send in a separate MRSA screening bag to the laboratory (in case of leakage). 5.5 What areas to swab Please refer to the screening flow charts for the type of admission which will indicate the areas to be swabbed (Appendix 1). 5.6 Pre Admission The following groups of patients should be screened: All elective pre-operative patients and planned admissions. These patients may be screened most conveniently at pre-assessment clinics. This can usefully be linked to the designation of the relevant surgical wards, especially orthopaedic wards, as a ring-fenced MRSA-free zone. These patients to include: o Elective Orthopaedics o Elective Cardiothoracics to include day case angiography patients o Elective Surgical and Gynaecology patients to include patients for planned interventional radiology procedures The DTC and Ophthalmology will screen all cases except: o Day case endoscopy o Day case ophthalmology o Dental cases All planned admissions to the Basing Unit for chemotherapy, blood transfusions etc. All planned admissions to medicine e.g. for transfusions, paracentesis etc Elective i.e. planned caesarean section patients to include expectant mothers who should be screened at 36 weeks gestation if they are due to have a planned caesarean section. To include other obstetric patients who meet any of the other risks (i.e. works as a healthcare worker/known past MRSA positive). NB. Emergency ophthalmology patients should be screened (as opposed to elective ophthalmology admissions) as they tend to be a different group of patients undergoing different procedures and have a higher risk of infection (DoH, 2010). 5.7 Short notice admissions If a patient is to be admitted less than three weeks after the outpatient visit at which their admission is discussed, then the medical staff should arrange for the MRSA screening swabs to be taken by the outpatient nurses prior to the patient leaving outpatients. Page 6 of 34

8 5.8 On Admission All Emergency Admissions All of these patients must be screened on admission by the admitting nurse and definitely within 24hrs of their admission, if their hospital stay is likely to be or exceed 24hrs. Critical Care Patients to include patients nursed in the following areas: Intensive Treatment/Therapy Units (ITU), High Dependency Units (HDU). These patients to be screened on admission to the unit and definitely within 24hrs of their admission. All patients previously known to be MRSA positive All oncology/chemotherapy inpatients. 5.9 Who not to screen The following groups do not need to be routinely screened for MRSA: Day case endoscopy Day case ophthalmology Day case dental Day case endoscopy Minor dermatology procedures performed in outpatients e.g. warts, other liquid nitrogen applications or skin biopsy. Children/paediatrics unless already in a high risk group Mental Health Patients unless they meet the category above (5.8) 5.10 Post Admission Weekly screening will only continue for those patients in high risk areas. These high risk areas are: ITU HDU Wessex Ward Orthopaedic Elective Wards Orthopaedic Trauma Wards 5.11 Sites to Screen The sites for screening are detailed in the flowcharts provided for each admission type (Appendix 1). Sample collection is the responsibility of the staff member admitting emergency patients or running pre-assessment or out patient clinics. The essential site to sample is the anterior nares (nose) as this is the most common carriage site for MRSA and most patients who are positive at other sites have positive nose samples although a small proportion do not. The secondary sites are the groin if the patient has previously been positive plus any wounds and a CSU specimen of urine if a catheter is present. Any cannulas and CVP line sites should also be swabbed when the dressing change is due (it is not recommended to disturb a sterile dressing unnecessarily in order to swab). Any skin lesions/wounds should be swabbed including all surgical wounds, leg ulcers, pressure sores, trauma wounds, supra-pubic catheter sites, peg sites, and any other skin break such as eczema, dermatitis and psoriasis. Please follow the swabbing guidelines on the flow charts for each type of admission (Appendix 1). Page 7 of 34

9 5.12 Procedure to follow re negative MRSA swab result in Elective Admissions A negative MRSA swab result is deemed current if taken within 28 days prior to admission. If the swab result is greater than 28 days prior to admission an MRSA rescreen is recommended. In the case of a negative MRSA swab in Maternity Elective Admissions, the negative swab result will be valid until delivery. A current negative MRSA swab result indicates that a patient does not need isolating or treating for MRSA upon admission Procedure to follow re positive MRSA swab result in Elective Admissions Once found positive the pre assessment nurses will inform the patient of the positive swab result by telephone and establish if the patient can come to preassessment clinic to collect the prescription for suppression therapy. If the patient is collecting prescriptions from GP fax result to GP surgery, with details of treatment to be prescribed. If the patient is collecting from pre-assessment clinic get doctor to complete OPD prescription form Inform the information room of the patient s status so that a side room can be arranged. This should be documented on patient s notes for admission. The patient then commences 5 days of the prescribed treatment. Two clear days after completion of the treatment the patient needs to attend the pre-op clinic to be re-swabbed for MRSA. If time allows before admission date the patient returns again a week following the re-swab for a second set of swabs for MRSA. Place an MRSA highlight sticker inside the front cover of the patient s notes. Inform the information room when first set of clear swab results are collected, so admission date can be sorted if deferred. In the absence of the pre-op Sister in Surgical Pre-assessment the C Floor bleep holder will need to either contact the patient or the patient s GP so that treatment may be commenced as soon as possible. This is to minimise any delays/disruptions to treatment MRSA treatment regime MRSA suppression therapy consists of a 5 day course of Bactroban/Mupiricin nasal ointment applied nasally three times a day (TDS), and a Chlorhexidine 4% bodywash used to wash all over the body once daily (OD). The Chlorhexidine body wash should also be used to wash the hair twice within the 5 day treatment period. Please note that patients MRSA sensitivities may vary. In some cases Mupiricin may not be suitable. In this instance advice should be sought from the Infection Prevention and Control Team Post treatment swabbing regime Two days following treatment the patient should be swabbed again (nose, groin and any wounds). If this comes back as positive a further course of treatment should be repeated as above. The patient should then be re-swabbed 2 days after completing the second course of treatment. If still positive no more topical treatment can be given. Infection Prevention and Control will advise on course to take if this arises. NB: Once one negative screen has been achieved the patient should be admitted as soon as possible and isolated in a side room for duration of stay. It is not necessary to obtain three negative screening results before surgery is undertaken. However it Page 8 of 34

10 is up to the consultant responsible for the patient to decide on this based on the risks involved for their individual areas. In the case of surgical admissions who require urgent intervention, and there is a lack of an MRSA screen, please screen the patient (nasal swab only) using the purple tipped PCR swabs on the ward. This will give a rapid test result, but should not be used as the routine method of testing. 6.0 Emergency Admission MRSA Screening All emergency admissions must be MRSA screened upon admission to the hospital within 24hrs of the admission. The sites for screening are detailed in the flowcharts provided for each admission type (Appendix 1). Sample collection is the responsibility of the staff member admitting emergency patients The essential site to sample is the anterior nares (nose) as this is the most common carriage site for MRSA and most patients who are positive at other sites have positive nose samples although a small proportion do not. The secondary sites are the groin if the patient has previously been positive, plus any wounds and a CSU specimen of urine if a catheter is present (DOH, 2008, Health Economy Wide Screening Guidelines, 2010). Any cannulas and CVP line sites should also be swabbed when the dressing change is due (it is not recommended to disturb a sterile dressing unnecessarily in order to swab). Any skin lesions/wounds should be swabbed including all surgical wounds, leg ulcers, pressure sores, trauma wounds, supra-pubic catheter sites, peg sites, and any other skin break such as eczema, dermatitis and psoriasis. Please follow the swabbing guidelines on the flow charts for each type of admission (Appendix 1). In the event that a patient has been discharged prior to the MRSA positive result, the IPCT will send a letter to the GP with a copy to the Consultant and to the Community IPCN. The IPCT will flag the patient s MRSA positive status on the ADT system so that this information is available for future admissions. 6.1 MRSA treatment regime. MRSA suppression therapy consists of a 5 day course of Bactroban/Mupiricin nasal ointment applied nasally TDS, and a Chlorhexidine 4% bodywash used to wash all over the body OD. The Chlorhexidine body wash should also be used to wash the hair twice within the 5 day treatment period. Please note that patients MRSA sensitivities may vary. In some cases Mupiricin may not be suitable. In this instance advice should be sought from the Infection Prevention Team. 6.2 Post treatment swabbing regime Two days following treatment the patient should be swabbed again (nose, and any wounds). If this comes back as positive a further course of treatment should be repeated as above. The patient should then be re-swabbed 2 days after completing the second course of treatment. If still positive more topical treatment is not likely to be effective, and the patient is considered to be MRSA colonised. The patient will continue to need isolation nursing for the duration of their hospital stay. This group of patients will not require any further MRSA screening this admission unless there is Page 9 of 34

11 concern regarding their clinical condition/wounds etc. MRSA colonised patients will require MRSA screening upon future admissions in line with the flow charts for each type of admission. 7.0 MRSA Management 7.1 Discharging the MRSA Positive Patient 1. The patient should be discharged from Hospital if the clinical condition allows. It is essential that the information given on the discharge summary reflects the infection status of the patient. 2. If a patient is to be discharged to another care setting e.g another hospital/community hospital/ nursing home there should be clear communication with the receiving areas re the infection status of the patient. 3. The infection status of the patient should be clearly communicated to any transport organisation used to transport the patient. 4. No special precautions are required by the patient returning to their home, other than maintaining good standards of hand hygiene, especially if dressing wounds/ providing personal care for another family member. An information leaflet on advice on living with MRSA at home is available from the Department of Health at: care.nhs.uk/articlefiles/events/mrsa_advice.pdf 7.2 Managing the MRSA Positive Patient Please note that the clinical need of a patient may override the infectious status of the patient eg if a patient is MRSA positive but requires a vision bed on the ward for safety reasons this takes priority. In these situations it is the responsibility of the responsible clinical team to document this in the patient s notes. It is also recommended that these patients are discussed with the IPCT/ Microbiologist who will be able to advise on the risk management strategy required. Please also note that there is no investigation/treatment that should be denied to a patient because of their infectious status. Each patient must be assessed on an individual basis to reduce the potential risk of cross infection, the IPCT can be contacted for advice. If discharge is not possible then the MRSA positive patient must be isolated in a side room with en suite facilities. If single side rooms are not available the MRSA positive patient may be suitable to be nursed in a designated MRSA cohort bay along with patients with the same strain of MRSA. The bay should be closed to general admissions. Decision making on patient placement may be aided by the use of the Isolation Priorities flowchart (Appendix 3). If cohorting patients with the same strain of MRSA is not possible then the MRSA positive patient may be suitable for placement in a bay with patients who have been assessed as at a low risk of contracting MRSA and at low risk of adverse affects of MRSA, and preferably with short lengths of stay (Centres for Disease Control and Infection, 2007). Please contact the Infection Prevention and Control Team (IPCT) for advice on this. It is recommended that the bay is closed to general admissions until the MRSA positive patient can be accommodated into a single side room and the bed space deep cleaned. The remaining patients in the same bay as the MRSA Page 10 of 34

12 positive patient are deemed to be contacts and should be screened for MRSA from nose and any wounds if present once the MRSA positive patient has been moved out into a side room. Take CSU if urinary catheter in situ. If the MRSA positive patient has been in the bay for 24hrs or less the bay may be used for admissions. If the MRSA positive patient has been in the bay for greater than 24hrs the results of the contacts must be known prior to admitting further patients into that bay. Patients from the affected bay should not be transferred to other wards until discussed with the IPCT. If it is an emergency then please inform the receiving ward that a side room is required. It is recommended that the IPCT are contacted for advice on screening of the other patients and re-opening of the bay. 8.0 Ward Management during an Outbreak of MRSA Wards will only be closed on infection control grounds following discussion with the Consultant Microbiologist and after informing the ward manager. The IPCT should be kept informed of any ward/bay closures. Ward staff will be advised of any decision. It is the responsibility of ward staff to inform the domestic services of a ward closure plus details of any extra cleaning that will be required. Affected patients should not be transferred to other wards within the Trust unless discussed with the IPCT. It is the responsibility of the ward staff to ensure effective communication is maintained between departments about the infectious status of patients going for procedures/investigations. 9.0 MRSA Isolation Precautions These guidelines should be followed with all MRSA positive patients. Patients requiring isolation may be sent to other departments for essential investigations. In this event you should notify the department in advance so that they may take the necessary precautions. This is particularly important for theatres. Any instructions to portering staff must be given at ward level. Door Label Charts/Patient Documents Protective Clothing A standard isolation precautions label/sign must be fixed to the door of the patient s room. Should remain outside the room. Apron and gloves must be worn by all staff that have or anticipate contact with either the patient or the patient s surroundings. Eye protection (spectacles or goggles) should be worn whenever splashing of blood or other body fluid is a possibility. Hand Washing Hands must be decontaminated prior to contact with the patient and/or the patient environment in Page 11 of 34

13 accordance with The 5 Moments for Hand Hygiene (please refer to the Hand Hygiene Policy ). If hands are visibly clean alcohol gel may be used before and after entering the isolated room. TSSU Equipment Other Equipment Instruments and other TSSU items should be returned to TSSU as normal. Disposable equipment should be used wherever possible. Non-disposable equipment for example, sphygmomanometers, stethoscopes, tourniquets, thermometer, should be left in the room whenever possible and disinfected when the patient is discharged according to Infection Control Policy. Disposal of Waste Clinical waste should be put into the yellow clinical waste bins which should be stored inside the room. Sharps i.e. needles, syringes, scalpels, blades, transfusion and infusion equipment and cannulae must be disposed of safely after use into a yellow sharps bin. The sharps bin should not be left in the room. The sharps bin should never be overfilled, and should be labelled and securely locked prior to sending for incineration. Disinfectant Actichlor Plus must be made up fresh as required (1,000 ppm). This is used for disinfection of surface and non-autoclavable equipment. See Cleaning and Decontamination Policy for more details. Nitrile gloves should be used when cleaning with Actichlor Plus (see Glove Policy for details) Daily Cleaning and Disinfection by Nursing and Housekeeping Staff Domestic staff, wearing a plastic apron and nitrile gloves, should do daily cleaning. The same colour coded bucket and mop (Yellow) with detachable head may be used in each isolation room on a ward. The mop head only must be changed after each room and sent for disinfection. Bucket and handle should be wiped clean with actichlor + between rooms. Furniture, non-carpeted floors and all surfaces should be cleaned as usual with a fresh disposable cloth and actichlor + Crockery & Cutlery Mattresses & Pillows Wash in ward dishwasher or main kitchen dishwasher. Mattresses, pillows and pressure relieving aids should have an intact waterproof cover and be washed with Actichlor Plus. Page 12 of 34

14 Linen Excretion Precautions All bed linen should be placed in a red water-soluble bag and tied in the room. Place in red plastic bag immediately, kept outside the room. If patient is ambulant, allocate a separate toilet or commode. If patient is not ambulant the non-disposable bedpan, contents, toilet paper and cover should be disposed of in the usual way and the bedpan disinfected at 80 0 C for at least one minute. If no bedpan washer available the slipper pan should be cleaned with warm water and Actichlor + and dried and left inverted. Disposable bedpans, contents, toilet paper and cover should be disposed of into the sluice hopper and then placed into the bedpan macerator. The bedpan holder should be returned to the patients room and disinfected on termination of isolation precautions. Spillages of Bloods & other body fluids Blood or other body fluid splashed on furniture, equipment or floors must be wiped up immediately using absorbent paper towels and a Chlorine releasing agent (e.g. 10,000 ppm solution of Actichlor +). Protective nitrile gloves (please see Glove Selection Risk Assessment in Glove Policy for details) and a plastic apron must be worn when wiping up spillages. Please note, Actichlor Plus may damage some metals and fabrics. Carpets must be steam cleaned. Do not use Actichlor Plus on carpets. Baths, shower bases, hand basins should be cleaned and disinfected as usual with a bleach scouring powder. Use a disposable cloth. Toilets lavatory pans should be cleaned with bleach scouring powder, using a lavatory brush. The lavatory seat and flush handle should be wiped with a solution of Actichlor Plus using a disposable cloth. Deep cleaning Please inform Housekeeping Staff as early as possible that a room requires a deep clean. Clean thoroughly following the daily cleaning routine. Ventilate if possible. Change any curtains. Room may be put into use as soon as it is dry. Death of a Patient Patients do not require a cadaver bag (body bag). Page 13 of 34

15 11.0 Patients Personal Property Clothing Personal Effects Children s toys Patients clothing should normally be laundered by their relatives. Soiled personal clothing should be placed in a plastic bag. Advise relatives to have clothing washed in a domestic washing machine. Wallets, jewellery, watches, books, radios etc. may be wiped with alcohol impregnated wipes if visibly soiled. Children should use their own toys and take them with them on discharge. If possible wash at home on a hot cycle (60 C) 12.0 Housekeeping Staff Standard Precautions for Daily Isolation Room Cleaning The ward sister or nurse in charge should inform domestic services manager/ supervisor of any patient being nursed in isolation. Equipment All isolation cleaning equipment is colour coded. Collect a colour coded dust control mop and a bucket with mop from your Supervisor. The same colour coded bucket and mop with detachable head may be used in each isolation room on a ward. The mop head only must be changed after each room, placed in a water soluble bag and sent for disinfection. Bucket and mop handles must be wiped with Actichlor Plus solution between rooms. In addition, all equipment must be cleaned on completion of work and before storing. Protective clothing A plastic apron and disposable gloves, located outside the room, must be worn in the isolation room. Cleaning and Disinfection Clean all horizontal surfaces and furniture daily with a fresh solution of detergent (general purpose). USE A FRESH MOP HEAD DAILY Baths, shower bases and hand basins should be cleaned and disinfected as usual with bleach scouring powder or equivalent. Lavatory pans should be cleaned with bleach scouring powder or equivalent, using a lavatory brush. Shake excess water from the brush. The lavatory seat and flush handles should be wiped with an Actichlor + solution. Page 14 of 34

16 Deep cleaning Deep cleaning means a thorough clean of an unoccupied room when the patient no longer requires isolation nursing for a specified infection. Damp dust using general purpose detergent and water paying particular attention to dust collecting areas such as corners, crevices, easy chairs, door handles, bed frames and horizontal surfaces. An Actichlor Plus solution should then be used to disinfect the same areas Open the windows and ventilate if possible. Change any curtains Linen Hand washing Disposal of Waste Spillages of Blood & Other Body Fluids All linen should be placed in a red water-soluble bag and tied in the room. Outside the room put this bag into a red plastic bag. Always decontaminate hands thoroughly prior to and following glove usage. If hands are visibly clean then use alcohol gel. If hands are visibly contaminated or there has been significant exposure to bodily fluids the healthcare worker must wash their hands with soap and water. All clinical waste should go into a yellow plastic bin inside the room (but not aerosol cans). Replace the yellow plastic bag at least daily. Tie at the neck with a plastic tie before leaving the room. Blood or other body fluids splashed on furniture, equipment or floors must be wiped up immediately by nursing staff using absorbent paper towels and a strong solution of Actichlor Plus (10,000 ppm). Protective gloves (Nitrile) and a plastic apron must be worn when wiping up spillages. Goggles/eye protection should be worn where there is a risk of splashing to the eyes. Please note: Do not use solutions of Actichlor Plus on carpets. See Decontamination policy MRSA Information for Health Care Staff i.e. Physiotherapists, Phlebotomists and Medical Staff Procedure: When visiting a patient who is known to be MRSA positive. 1. Remove white coat if worn, decontaminate hands, put on gloves and apron before entering the room/bay if contact with either the patient and/or their environment is anticipated. Page 15 of 34

17 2. Take into the room the minimum items of equipment required i.e. syringe, needle, bottles and sharps box. Do not place these items on the bed. 3. Do not sit on the patient s bed when you are in the room. 4. When you have completed the procedure and are ready to leave the room, place items to be taken out of the room near the door. 5. Remove gloves and apron and place in yellow waste bag/bin. 6. Decontaminate hands thoroughly. 7. Collect your equipment and leave the room. To prevent possible infection risk all cuts/abrasions/wounds should be kept covered at all times with a waterproof dressing whilst at work. Any staff with a chronis skin complaint such as eczema should avoid having physical contact with these patients if at all possible. If You Have Any Questions Please Contact the Infection Prevention and Control Team 14.0 Recommendations to Nursing Staff regarding Visitors to MRSA Patients It is safe for pregnant women and children to visit MRSA positive patients if necessary. Social physical contact such as kissing and hugging and holding hands is safe and should never be discouraged. Normal sexual relations should not be compromised. When visiting MRSA patients: 1. There is no need for visitors to wear gloves and/or aprons unless they are directly involved with patient care or are to visit other patients in the hospital. 2. If visiting other patients in the hospital please see these first and visit the MRSA patient last. 3. Visitors should be asked to decontaminate their hands when leaving the cubicle/ side room or bay. 4. Visitors should not sit on the patient s bed. 5. Visitors should be discouraged from having hands on contact with other patients. 6. If visitors have questions about MRSA these should be answered either by the nursing or medical staff. The IPCT will provide advice and assistance where required Surgical Operations Every effort should be made to eliminate MRSA prior to surgery, however, if this is not possible the following should be performed: - 1. Patients known to be MRSA positive should be regarded as contaminated cases and operated on at the end of the morning or afternoon list. Page 16 of 34

18 2. Change the patient s clothes and bed linen before they go to theatre. 3. Cover any affected lesion with an impermeable dressing if applicable. 4. Start topical treatment with nasal Mupiricin and Triclosan Wash before surgery. 5. The need for antimicrobial prophylaxis for colonised or infected patients should be discussed prior to surgery with the Consultant Microbiologist. 6. Patients should be allowed to recover in the recovery room and attending staff should wear gloves and aprons. If the patient has an MRSA chest infection they should ideally be recovered separately from other patients. 7. Theatre surfaces in close contact or near the patient such as the operating table or instrument trolley should be decontaminated with an Actichlor Plus solution before being used by the next patient Tests for Clearance in Patients Once 3 sets of negative screens taken 1 week apart have been achieved, the patient may be de-isolated for the duration of their hospital stay. If they are re-admitted at any point in the future they will be treated as high risk patients and should follow the treatment pathway as indicated by the admission type flowcharts (Appendix1) Staff Screening Protocol No screening of staff should be undertaken without consultation with a member of the IPCT. Screening of staff for MRSA will not routinely be carried out. In exceptional circumstances e.g. an outbreak; the IPCT may request staff screening. Staff screening may include medical, nursing, support staff (particularly physiotherapy, occupational therapy and phlebotomy) and may include housekeeping staff. The ward manager must provide a list of staff names and dates of birth in the above categories and liaise with the IPCT about the taking of swabs. Staff screening in the first instance will consist of swabs of nose and any wounds or areas of broken skin (e.g. eczema or psoriasis). Nasal Swabs Wounds/Broken Skin Use a single swab for both anterior nares (nostrils). Any wounds (cuts/grazes) should be swabbed by the individual. Staff with broken skin (e.g. eczema, psoriasis) should refer themselves to Occupational Health for assessment. Staff who have previously been MRSA positive should have a nose, groin and wound/catheter screen. Staff colonization can be due to transient carriage, therefore it is essential to take swabs at the beginning of a shift prior to having any patient contact Transfer of Positive Patients to another Ward Transfer of patients to other wards should be avoided but if necessary should ideally be discussed with the IPCT. If this is not possible and in an emergency, please Page 17 of 34

19 ensure the receiving ward is aware of the infection status of the patient, has a side room and can isolate the patient. If there is any difficulty please contact the IPCT. The patient should be given clean clothing and transferred to a clean bed leaving the original linen behind on the ward. The patients lesions/wounds should be occluded whenever possible with an impermeable dressing Transfer of Patients to Other Departments for Investigations Visits by MRSA patients to other departments should be kept to a minimum but not refused. Prior arrangements should be made with senior staff of the department concerned. Departmental staff with any skin abrasions or exfoliate skin conditions e.g. eczema, must not have direct patient contact Preparation See or treat patients at the end of the working session, wherever possible. Keep equipment to a minimum in the area. Keep the number of staff attending to a minimum. Staff in contact with the patient or bedding should wear a disposable apron. Gloves should be worn for direct patient contact or if coming into contact with blood or body fluids During Procedure Employ meticulous aseptic techniques. Avoid cross contamination of other patients After Procedure Return the patient to the ward as soon as possible. After surgery patients should be allowed to recover in the main recovery area unless they have an MRSA chest infection, in which case they should ideally be recovered away from other patients. It is very important that infection control procedures are followed to avoid cross infection. Where possible, one nurse should care for the patients exclusively during their time in recovery. Any equipment or surfaces coming into direct patient contact e.g. trolley, couches etc. should be wiped clean with an Actichlor Plus solution. Linen, contaminated equipment and rubbish should be disposed of or decontaminated as usual. Decontaminate hands as per the 5 Moments for Hand Hygiene (please see the Hand Hygiene Policy for details) Advice for Portering Staff Transporting MRSA Patients 1. Porters collecting patients should decontaminate their hands before entering the room and put on a clean plastic apron and gloves. These are removed when contact with the patient s trolley or chair has ceased. Page 18 of 34

20 2. Masks are not necessary (unless specifically instructed to wear them). 3. Use the same trolley or chair for the return journey. After the patient has returned to the ward the trolley or chair must be cleaned with an Actichlor Plus solution before being used for other patients. Plastic aprons and gloves should be removed and placed in the yellow clinical waste bag. Hands should be decontaminated following this (please see Hand Hygiene Policy for details) Transportation of MRSA Patients by Ambulance Staff Please ensure that Ambulance Control is informed that the patient is MRSA positive when arranging transport. This will ensure the ambulance staff can take the following precautions: Stretcher Cases The attendant should wear fresh disposable gloves and a plastic apron. Masks are not required. Keep direct patient contact to a minimum. Ensure that any skin lesions have been covered with occlusive dressings. Following Transfer of the Patient All used linen should be treated as infected according to hospital policy. Wipe the trolley and any other patient contact surfaces with an Actichlor Plus solution. Ambulance staff must decontaminate their hands following patient contact/glove removal. Ambulance doors should be kept open during cleaning and until surfaces are dry, after which the ambulance can be returned to service. Ambulance and Wheelchair Patients Ensure that any skin lesions have been covered with occlusive dressings. Other precautions are not required. Routine screening of ambulance personnel is not necessary due to the very short contact time. If further advice is needed clarification must be sought from a member of the IPCT Infection Control Procedure for Last Offices The presence of MRSA does not necessitate the use of a body (cadaver) bag. Preparation of the body at Ward Level Last offices are performed on all deceased patients. This procedure includes washing, tidying, identifying and shrouding the body. Staff who perform last offices should wear the appropriate protective clothing. Certain other preparations may be required at ward level in individual cases. These may include: Page 19 of 34

21 The occlusion of any leaking wound with non-permeable dressing. Further precautions will be required for high risk cases thought to be infected with the following: Hepatitis B, Hepatitis C, HIV (AIDS), Invasive Group A Streptococcal infection, Tuberculosis, Meningococcal septicaemia and other rare diseases e.g. dysentery, anthrax, plague, rabies, viral haemorrhagic fevers, yellow fever, typhoid and diphtheria. For all cases preparations may be required as previously stated plus: Placing the body in disposable sheets with a zippable plastic body bag. The inappropriate use of body bags can cause great distress to bereaved families. The IPCT must be contacted for advice by the ward or mortuary staff if they are unsure if a body bag is required or not. For further details/advice please see the Last Offices Policy. Page 20 of 34

22 References Department of Health (2008) ref MRSA screening operational guidance. Department of Health. (2008) Advice for those affected by MRSA outside of hospital. Clean safe care. Accessed 7 th May Department of Health and Human Services. (2007). Centre for Disease Control and Prevention: Standard Precautions. Accessed 10 th May Department of Health. (2010). Screening emergency admissions- FAQ. Accessed 23 rd June _FAQs_-_Apr_2010.pdf Duckworth G, Cookson B, et al. (1998) Revised guidelines for the control of methicillin-resistant Staphylococcus aureus infection in hospitals. Journal of Hospital Infection 39: Joint working party of the British Society of Antimicrobial Chemotherapy, the Hospital Infection Society, and the Infection Control Nurses Association (July 2005) Guidelines for the Control and prevention of Meticillin-Resistant Staphylococcus aureus (MRSA) in Hospitals MRSA Screening Group. Health economy wide screening guidelines. Hampshire 2010 Wilson J (2001) Infection Control in Clinical Practice (2 nd edition) London: Bailliere Tindall Page 21 of 34

23 Appendix 1: MRSA Flowcharts MRSA SCREENING EMERGENCY ADMISSIONS ON ADMISSION TO WARD ALL PATIENTS AGE 16+: Risk Assess the patient If High Risk Patient isolate immediately HIGH RISK PATIENTS are: From nursing/care home Previous positive Multiple hospital admissions Transfer from another hospital Swab all patients: Nose swab for MRSA Plus groin swab if previous positive patient Plus urine if catheter present Send swabs to Microbiology requesting MRSA screen Await results Positive result Negative result Isolate immediately if not already isolated Start suppression therapy Remove isolated high risk patients from side room HIGH RISK AREAS: ITU, WESSEX AND ORTHOPAEDICS: Continue weekly screens of nose and groin plus urine if catheter present and wound if present Please contact the Infection Prevention Team on Ext or bleep 2364 for any queries Page 22 of 34

24 MRSA SCREENING ELECTIVE ADMISSIONS CHECK PRE-ADMISSION SCREENING RESULT IS WITHIN 28 DAYS OF ADMISSION (If no test result available and urgent surgery is required consider rapid test) Swab all patients: Nose swab for MRSA Plus groin swab if previous positive patient Plus urine if catheter present Plus wound if present Positive Result Negative Result Do full screen (nose, groin, wounds, +/- CSU) to establish extent of colonisation. Commence course of topical treatment ie Triclosan wash once daily and Mupricin* nasal ointment TDS for 5 days. Have 2 clear days from treatment then reswab. These patients must be isolated upon admission to hospital. May be nursed in bay on admission to hospital Positive re-swab? Negative re-swab? Commence 1 final treatment course as above, re-screen as above-if another positive result continue to barrier nurse and seek IPCT advice Continue to screen at weekly intervals until 3 clear sets of swabs obtained HIGH RISK AREAS: ITU, WESSEX AND ORTHOPAEDICS: Continue weekly screens of nose and groin plus urine if catheter present and wound if present Please contact the Infection Prevention Team on Ext infectioncontrol@bnhft.nhs.uk or bleep 2364 for any queries Page 23 of 34

25 MRSA SCREENING EMERGENCY MATERNITY ADMISSION EMERGENCY MATERNITY ADMISSIONS ARE: PRE 36 WEEKS GESTATION ON ADMISSION TO WARD ALL PATIENTS AGE 16+: Risk Assess the patient If High Risk Patient isolate immediately HIGH RISK PATIENTS are: From nursing/care home Previous positive Multiple hospital admissions Transfer from another hospital Post natal re-admission Swab all patients: Nose swab for MRSA Plus groin swab if previous positive patient Plus urine if catheter present Send swabs to Microbiology requesting MRSA screen Await results Positive result Negative result Isolate immediately if not already isolated Start suppression therapy Remove isolated high risk patients from side room Post Natal re-admissions: Screen all re-admissions Mother and Baby nose, plus groin swab if previous positive, include any wounds and CSU if catheter, plus umbilicus on Baby Please contact the Infection Prevention and Control Team on ext or bleep 2364 for any queries Page 24 of 34

26 MRSA SCREENING ELECTIVE MATERNITY ADMSSION ELECTIVE MATERNITY ADMISSIONS ARE: ALL 36 WEEKS GESTATION & CAESAREAN SECTION EL CHECK PRE-ADMISSION SCREENING RESULT IS WITHIN 28 DAYS OF ADMISSION If no test result available and urgent surgery is required consider rapid test Swab all patients: Nose swab for MRSA Plus groin swab if previous positive patient Plus urine if catheter present Pl d if t Positive Result Do full screen (nose, groin, wounds, +/- CSU) to establish extent of colonisation. Commence course of topical treatment ie Triclosan wash once daily and Mupricin* nasal ointment TDS for 5 days. Have 2 clear days from treatment then reswab. These patients must be isolated upon admission to hospital. Negative Result A negative 36 week gestation result will be deemed valid until delivery May be nursed in bay on admission to hospital Positive re-swab? Negative re-swab? Commence 1 final treatment course as above, re-screen as above - if another positive result continue to barrier nurse and seek IPCT advice Continue to screen at weekly intervals until 3 clear sets of swabs obtained Post Natal re-admissions: Screen all re-admissions Mother and Baby nose, plus groin in swab if previous positive, include any wounds and CSU if catheter plus umbilicus on Baby Please contact the Infection Prevention and Control Team on ext infectioncontrol@bnhft.nhs.uk or bleep 2364 for any queries Page 25 of 34

27 Appendix 2: Examples of Patient Information Leaflets (printer friendly versions are available on the Intranet) Page 26 of 34

28 Page 27 of 34

29 MRSA Screening Inpatient Information Why do I have to be screened? The Department of Health have made it compulsory for all acute NHS trusts in England to screen all planned operations, some day case patient admissions and all emergency admissions for MRSA to help combat healthcare-associated infections in hospitals. What is MRSA? MRSA is an antibiotic resistant strain of a common bacteria called staphylococcus aureus. It stands for methicillin resistant staphylococcus aureus. Staphylococcus aureus is commonly found on humans and often lives on your skin not causing you harm. It can sometimes cause a number of common infections. Usually having staphylococcus aureus in your nose or on your skin will not harm you as the bacterium is not normally a risk to healthy people. People who carry it are not aware they do, and most of them will not have any symptoms. MRSA is a strain of staphylococcus aureus that can no longer be treated by methicillin (a type of antibiotic). However, we can still treat MRSA. It is estimated that around 7% of all patients who are admitted to hospital have the MRSA bacterium on their skin or in their nose already, even though they may feel well. How is MRSA spread? MRSA is mainly spread from person to person through hand contact. This is why washing your hands and using alcohol-based hand gels are so important. Good hand hygiene is one of the most important and effective ways of stopping the spread of MRSA. Page 28 of 34

30 What is screening and why is it being done? MRSA screening involves testing all patients over the age of 16 who are admitted to this hospital so we can identify those patients who are already carrying this bacteria. MRSA is more likely to cause an infection in people who are unwell or who have wounds, such as those already in hospital. This is why it s so important to identify those people in a hospital who have MRSA on their body. It may help to prevent them from acquiring an infection due to the MRSA and from potentially spreading it to others. Also, if we can identify those patients who have MRSA on their body when they come into the hospital, we can make sure that they receive the best and most appropriate care and treatment for it. What does screening mean? Screening means that swabs will be taken from your nose and any other areas that the nurse thinks appropriate - usually wound sites, or anywhere the skin is broken. These swabs will be sent to the laboratory to be tested for MRSA and the results usually take three to four days. The nurse on the ward or the doctor will speak to you if your results come back as positive. If you have already been discharged, we will send your results to your GP. What happens if you find MRSA in my sample? MRSA can be treated. If you are found to be positive to MRSA, we may offer you treatment for it. Treatment may not always be appropriate for everybody but we will discuss this with you at the time. The treatment consists of a daily antibacterial body wash and the application of an antibacterial nasal cream. This will continue for five days and then you will have a rest period of no treatment for two days and then have another MRSA screen taken. Your nurse or doctor will explain your treatment and discuss the most appropriate care with you. If you are an inpatient in the hospital with MRSA we will usually care for you separately from other patients in a side room or in a bay with people with the same type of infection. Infection Prevention and Control Team Basingstoke and North Hampshire Hospital Aldermaston Road Basingstoke Hampshire RG24 9NA Infection Prevention and Control Team, BNHFT April, 2010 Review April, 2011 ELE/ 030/ 2010 Basingstoke and North Hampshire NHS Foundation Trust Page 29 of 34

31 Appendix 3: Isolation Priorities Page 30 of 34