Date of Meeting: Validation Date: 09/07/2010. Ratified Date: 09/07/2010

Transcription

1 Document Type : Procedure Title: Management Of Staphylococcus aureus (SA) - Meticillin-Resistant (MRSA) and Meticillin- Sensitive Scope: Trust Wide Author/Originator and Title: Dr A Guleri Consutant Microbiologist Dr Palmer Consultant Microbiologist J Lickiss Nurse Consultant Infection Prevention S Mawdsley Lead Nurse Infection Prevention Unique Identifier: CORP/PROC/408 Version Number: 5 Status: Ratified Classification: Organisational Responsibility: Infection Prevention and Control Replaces: Version 4 Management Of Meticillin- Resistant Staphylococcus Aureus (MRSA) Corp/Proc/408 Description of amendments: Document to amend current MRSA procedure and include MSSA and MRSA screening [PCR and culture] and management. Also to make procedure compliant with aspects of DoH guidance to be effective from Dec Name of Committee/Directorate/ Working Group: Validated by: Hospital Infection Prevention and Control Committee N.Harper Chairman s Action Ratified by: Clinical Improvement Committee Chairman s Action Review Dates: Review dates may alter if any significant changes are made Date of Meeting: Validation Date: 09/07/2010 Ratified Date: 09/07/2010 Risk Assessment: N/A Financial Implications: N/A Which Principles of the NHS Constitution Apply? Principle 1,2,3,5,6,7 Date of Issue: 09/07/2010 Review Date: 01/10/ Does this document meet with the Race Relation Amendment Act (2000) Religious Discrimination Act, Age Discrimination Act, Disability Discrimination Act and Gender Equality Regulations? Not Applicable

2 Please note: The contents of this document are hyperlinked to open appropriate section of this document Acknowledgements to: Barrie Lunt [Senior BMS, Microbiology]; Steve Bloor [IT]; Chris Danson [Diagnostics - Manager]; Philip Houldworth [Deputy directorate Manager, Pathology]; Trevor Morris [ALERT Care - pathways co-ordinator]; Infection prevention team; Kate Woodrow [antibiotic pharmacist] and All Staff of Microbiology laboratory All comments or inquiries regarding this document may be addressed to: Dr.Guleri@bfwh.nhs.uk CONTENTS PAGE Purpose Of This Document Scope Of The procedure Staphylococcus aureus, aim of screening Role of hand hygiene, SA management SA PPE, movement, transfer and cleaning Communication and documentation Colonisation recurrence or decolonization failure Outbreaks and Occupational Health Issues Duties and responsibilities SA screening (Appendix 1) Protocol - dealing with SA (Appendix 2) Protocol Preop. management protocol of SA carriage(appendix 3) Surveillance & audit (Appendix 4) Example of death certification (Appendix 5) Integrated Care Pathway (Appendix 6) Treatment of MRSA infection Antibiotic prophylaxis in surgery

3 1. PURPOSE The purpose of this procedure is to provide instructions on the management of patients with MSSA or MRSA including: screening of patients, management of patients with carriage and/or infection caused by: SA Staphylococcus aureus i.e MRSA - Meticillin (previously Methicillin) resistant Staphylococcus aureus or MSSA - Meticillin sensitive Staphylococcus aureus prevention and control within the healthcare setting. Compliance to guidelines and measures set out in the procedure should: Reduce all SA infections including bacteraemias, potential for cross transmission and optimize treatment of infected patients, thereby enhancing patient safety, assurance and quality of care. This procedure will ensure that the trust is compliant with the Department of Health MRSA screening guidance that comes into effect on December 31, SCOPE This procedure applies to all staff working within Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust with responsibility of patient care and covers: Screening of patients for MRSA and MSSA [Appendix 1] Dealing with patients carrying MRSA or MSSA (either previously known or newly detected on screening) [Appendix 2] Topical regimes for bio-burden reduction or decolonization [Appendix 3] Treatment guidelines for infections with MRSA or MSSA [link to antibiotic formulary] Communication of MRSA or MSSA carriage status on transfer or discharge to receiving ward or hospital. Audit and surveillance of MRSA infections [Appendix 4] Trust real-time monitoring of MRSA or MSSA infections associated with length of stay 3. PROCEDURE 3.1 INTRODUCTION: Staphylococcus aureus Staphylococcus aureus [SA] infections are largely caused by two variants of the bacteria Meticillin (previously Methicillin) sensitive Staphylococcus aureus [MSSA] and Meticillin resistant Staphylococcus aureus [MRSA]. Staphylococcus aureus infections range from impetigo, folliculitis, carbuncles, abscesses, to serious infections - scalded skin syndrome, endocarditis, pneumonia, meningitis, osteomyelitis, toxic shock syndrome, bacteraemia and sepsis. SA (both MSSA and MRSA) are the most common cause of hospital acquired infections and especially surgical site infections. Serious infections are associated with increased morbidity, mortality, extended length of stay and associated health care costs. Page 3 of 26

4 A third of population may carry SA asymptomatically on their skin or mucosa, especially the nose. A breach in the skin or mucosal barrier as part of medical / surgical treatment or immuno-compromised status renders a patient susceptible to acquiring an infection. Early detection of SA carriage in patients admitted to the hospital or for planned surgery can allow for intervention with topical bio-burden reducing regimes thereby reducing potential for SA infections and cross transmission to other patients. While both MSSA and MRSA carriers will benefit from bio-burden reducing regimes, only MRSA (not MSSA) carriers also require isolation in a single room. 3.3 BACKGROUND In 2009, Blackpool Victoria Hospital won a national award and international acclaim for significant reduction in MRSA bacteraemias (78% and 80% in & ) using cutting edge technology - rapid (less than 2-hr) MRSA PCR to complement a package of interventions including a very active support to the MRSA programme from its staff. Careful analysis of data has indicated that, while total MRSA infections including bacteraemias have reduced by 24% and 46% in the last two years, MSSA infections including bacteraemia remained consistently and significantly high. The trust has been supported by all divisions in extending the scope of MRSA screening programme to include screening for both MSSA and MRSA. Every MSSA or MRSA infection has an associated cost to the trust. A 40% reduction in MSSA infections can save the trust nearly half a million pounds. 3.4 HAND HYGIENE "Scientists estimate that people are not washing their hands often or well enough & may transmit up to 80% of all infections by their hands. Hand washing may be the single most important act to help stop the spread of infection and stay healthy (Centre OF Disease Control, USA)". Poor compliance to hand-hygiene can undermine and undo the benefits of the MSSA/MRSA programme. Ensuring high compliance with hand hygiene will ensure success of this revised MSSA / MRSA screening programme. The trust is confident that its staff will actively support this programme and ensure high hand hygiene compliance for self and challenge others around them. Visibly dirty hands MUST be thoroughly washed with soap and water [refer to hand hygiene policy & pictures over hospital sinks] Alcohol gel must be used on clean hands between contact with patients or their environment [eg. Case notes, bed frame, furniture, curtains, etc]. Staff and visitors must always wash their hands on entering and leaving the isolation room/area, similarly when patients are being barrier nursed on the open ward. Patients must also wash their hands or be offered wipes before meals Please note: Hands must always be decontaminated after removing gloves as per the Hand Hygiene Policy Corp/Pol/056 Page 4 of 26

5 3.5 WHY SCREEN FOR MSSA AND MRSA? The reasons for SA (MSSA and MRSA) screening and offering bio-burden reducing regime are: Prevent contamination of SA into immediate environment [e.g. bed frame, case notes, curtains, etc], attending HCWs' and other patients. Prevent SA carrier patient from infection Early and optimum treatment of MSSA or MRSA infection Avoid empiric glycopeptides [e.g. Vancomycin] in MRSA negative patients. Complement clinical decision making during management of patients. 3.6 WHAT IS DECOLONISATION / BIO-BURDEN REDUCTION REGIME FOR SA CARRIAGE? Application of SA bactericidal preparations over 5-days reduces significantly the bio-burden of SA on the human body, thereby reducing the potential for dispersal/cross transmission or selfinfection. Regime 1 is offered to inpatients: 5-day course of nasal mupirocin 2% and chlorhexidine body wash / shampoo Regime 2 is offered to elective patients: 5-day course of Prontoderm [nasal preparation and whole body / hair foam] 3.7 MANAGEMENT OF SA (MSSA AND MRSA) This includes screening patients for SA, offering topical decolonizing or bio-burden reducing regime to MSSA / MRSA carriers, isolation in single room of MRSA (not MSSA) carriers and treatment of MSSA or MRSA infections. The protocols for MSSA & MRSA are similar, except MRSA carriers also require a single room (when possible) and different anti-mrsa antibiotics during surgical prophylaxis and/or treatment. Isolation precautions for MSSA/MRSA patients: All MRSA/MSSA patients require isolation precautions and decolonisation. Only MRSA patients require a single side room. MSSA patients may remain in cohort areas. Clinical MRSA infection, particularly those of the respiratory system, in patients with exfoliative skin conditions and exudative / supportive wound conditions must take priority for side rooms over MRSA colonisation without infection. In order to reduce the risk of SA spreading from those known to have infection/colonisation the following actions are recommended: Inform the Infection Prevention Team. All MRSA [not MSSA] patients in single rooms, whenever possible. It must be clear to any healthcare worker that the patient is being isolated. Signs must be displayed to identify to visitors that they must seek advice on appropriate precautions. If there is more than one infected/colonised patient, then cohort nursing within the ward should be practiced. Any deviation from this procedure must be clearly documented in the patient s case notes. If the clinical need (e.g. patients with tracheostomy or those at risk of wandering/falls etc) or lack of single room facilities (as a result of occupation by higher priority cases for Page 5 of 26

6 example pulmonary TB, chickenpox, diarrhoea), prevents an MRSA patient from being nursed in a side room then they should be barrier nursed in a ward bed beside a sink. It must be ensured that patients in the neighbouring beds are ones that do not have catheters, lines or wounds. On some occasions isolation may not be possible but the risk of transmission of infection may be significant and the IPC Team may advise decommissioning the neighbouring bed space. This must be clearly documented in case notes. All patients transferred from other hospitals must be isolated until results of PCR screening is known. 3.8 PERSONAL PROTECTIVE EQUIPMENT (PPE) Single use gloves and aprons must be used. Wear single-use gloves and aprons for close contact with the patient/patient environment e.g. bed making, moving and handling the patient, cleaning room /area. PPE is not required when handling prescription sheets/care plans etc as these should not have been handled without hand decontamination. Care plans etc should be kept outside the single rooms. Face protection is only required when there is a risk of mucus membrane contamination from secretions e.g. suctioning / tracheostomy care etc 3.9 MOVEMENT OF SA [MRSA/MSSA] POSITIVE PATIENTS Minimise patient transfer and movement within the Trust. All lesions should be covered where possible, if transport is essential. Decontaminate the trolley or chair after use Place patient at end of operating/investigation lists Avoid time in waiting areas Keep numbers of staff in contact with the patient to the minimum It is vital that the receiving area is notified in advance of the departure of the patient. If patient is discharged and the 5 day bio-burden reduction course has not been completed, the remaining days of treatment should be included with the discharge medication Documentation of discharge management must be on the discharge transfer letter MANAGEMENT OF INTER-WARD TRANSFERS OF NEGATIVE PATIENTS All patients who transfer between wards other than transfers from CLDU and SAU should have their MRSA/MSSA status checked on HISS or Maxims. If no alert is displayed they should be re-screened CLEANING Terminal barrier nursing cleaning as per Infection Prevention & Control Policy (CORP/POL/116) in all areas where PCR screening is not in progress. In areas where PCR based Universal screening is in place, domestic and nursing staff should use dual-purpose activated chlorine/detergent based products, (e.g. Chlorclean or Acticlor), unless otherwise advised. Page 6 of 26

7 In areas where universal screening is performed, curtain changes will take place on a monthly rolling programme so it is not necessary to change them in the event of a positive screen result unless blood or body fluid contamination has occurred COMMUNICATIONS AND DOCUMENTATION The SA Care Pathway must be commenced for all SA [MRSA or MSSA positive patients, i.e. both current or previously positive. (See Appendix ) Explanation to patient and relatives is essential. It is also important to maintain the patient s dignity and confidentiality at all times. Patient leaflets must be displayed at ward level and are available from the stationary stores. In such circumstances that leaflets are not available, the nurse in charge of the patient s care must still provide the necessary information to the patient and relevant carers/family. All staff, both regular and visiting, must be made aware of the importance of taking the necessary infection prevention precautions at handover It is the ward or departments responsibility to ensure an accurate record of the decolonisation process is communicated to the receiving ward. Symptomatic patients can undergo inpatient investigations or procedures, provided appropriate precautions are taken. Advice can be sought from the infection prevention team in such circumstances. It is the ward or departments responsibility to advise the receiving department in advance, of the SA status of the patient. The patient should be put last on the list, or should be fast tracked so that they have minimal contact with other patients in waiting areas. When transferring MRSA positive patients to other hospitals, the MRSA status must be properly communicated in advance of the transfer 3.13 PATIENT REVIEW The Department of Health (DoH) requires all hospitals to complete a compulsory Root Cause Analysis (RCA) for patients with MRSA [not MSSA] bacteraemia and to discuss the MRSA bacteraemia RCA results with PCT representatives, who are required to monitor the actions of the Trust with regard to MRSA control. The MRSA RCA must be completed by the clinical team and infection prevention & control team within 7-days. A copy of the RCA must be provided to the Director of Infection Prevention and Control (DIPC). The DoH is likely to extend this to MSSA bacteraemia in the next 12-months WHAT IF SA COLONISATION RECURS? Recurrences are common, occurring in the majority of patients who have significant comorbidity. For MRSA carriage, the policy allows for a maximum of two bio-burden reduction cycles. Further cycles within that admission should be discussed with the Microbiologist. For MSSA carriage the current policy advocates a single cycle of bio-burden reduction and no further post decolonisation screening OUTBREAKS This would be declared by the Infection Prevention and Control Team or Microbiologist when an increase in the number of infected cases or an unusual cluster of cases. The Investigation, Page 7 of 26

8 Management and Control of Outbreaks of Infectious Diseases Procedure covers management of outbreaks. (See Policy Corp/Proc/488). It is the responsibility of clinical teams to discuss an unusual cluster of cases with the IPC team or microbiologists DECEASED PATIENTS Lesions & wounds must be covered where possible. There is negligible risk to undertakers or mortuary staff. However Personal Protective Equipment should be worn OCCUPATIONAL HEALTH ISSUES Staff screening is currently recommended only when epidemiological evidence suggests that a staff member/members may be MRSA carriers and likely to be transmitting infection. Staff with skin lesions should report to Occupational Health Department (OHD) as they are at increased risk of acquisition and would require treatment. MRSA positive staff must be under the care of an OHD physician. The Microbiologist, DIPC and OHD physician should carry out a joint risk assessment with regard to appropriate measures to minimise the risk of transmission of MRSA to patients. Current policy does not extend this to MSSA infection/carriage in staff members. However, this may be discussed with the microbiologist and OHD on a case by case basis KEY DUTIES AND RESPONSIBILITIES: Link Nurses & Ward Managers Key Responsibilities IMMEDIATE ACTION: Ensure that all cases of SA carriage are promptly offered decolonising regime as soon as result becomes known to nurse in-charge. SA cases must be notified to Infection Prevention Team (IPT) during core working hours and ensure the SA Care Pathway is commenced. Decolonisation regime must be recorded here. Ensure isolation precautions for all SA carrier patients. Single room is required only for MRSA patients. If single room is not available for any reason or door of single room has to be kept open this must be clearly documented in case notes. Ensure all screening samples are promptly sent to the laboratory and logged. Microbiology laboratory offers SA PCR service between 8am 12 midnight. Phone 6952 /6951 or on call lab scientist via switch to discuss urgent testing. Review clinical results and check appropriate MRSA treatment has been promptly prescribed when needed. This may be discussed with on-call microbiologist. Draw attention of Medical Team to their responsibility for prescribing treatment according to the Antibiotic Formulary. Monitor clinical response to treatment and liaise with medical staff to ensure all appropriate treatment measures are carried out Involve the Tissue Viability Nurse if appropriate Assist Infection Prevention Control Team (IPCT) in surveillance programmes and audit Remind/challenge staff of the necessity of adhering to good hand hygiene precautions and to use Personal Protective Equipment (PPE) as appropriate. Page 8 of 26

9 Clinical Team and Directorates: Key Responsibilities Ensure that all patients have appropriate screening samples promptly sent to the laboratory. Decolonising or bio-burden reducing regime must be in place for all SA positive (previously or newly detected) patients. MRSA positive patients with clinical infection should be prescribed treatment according to antibiotic formulary (offering anti-mrsa cover). This may be discussed with on-call Microbiologist. Review daily patients clinical progress and appropriateness of antibiotics. If there is no clinical response or significant deterioration contact Microbiologist Co-operate with Director of Infection Prevention and Control (DIPC) /Microbiologist in the MRSA Bacteraemia Critical Incident programme associated with the DoH/HPA MRSA Mandatory Reporting Scheme and other MRSA RCA as requested. On discharge of the patient, it is the responsibility of consultant / clinical team to ensure e-discharge letter to the GP carries information of the MRSA status and bio-burden reducing regime and if indicated, treatment given to the patient. If the status is confirmed after discharge of the patient, the consultant/clinical team must communicate this to the GP. The GP must be responsible for dispensing the bio-burden reducing regime to the patient. If discharge occurs mid-cycle for Bio-Burden reduction ensure that the patient is discharged with sufficient treatment to complete the cycle. Ref. MRSA screening frame work Department of Health 31 st December Trust Board The board will ensure that the guideline is implemented Must support the control and reduction of MRSA, prioritising the management of patient risk and ensuring that the patient safety is not compromised by the pursuit of other strategic objectives. Must ensure that infection prevention and control education and training of all healthcare personnel actually happens and is informed by audit. The Chief Executive The Chief Executive will ensure that the guideline is implemented in all areas and will ensure that the effectiveness of the guideline is constantly reviewed. Director of Nursing and Quality Should ensure each clinical area is covered by link nurse who will have ring-fenced time to train, audit and feedback to staff on isolation, hand-hygiene, cleaning and protective clothing practices. Must ensure cleanliness in all clinical areas is assessed through regular (preferably monthly) PEAT (Patient Environment Action Teams) scores and these discussed at meetings of infection control team, cleaning staff and matrons on a regular basis. Must ensure that nurse caring for the patient should initiate and complete integrated care pathway (ICP) for every known [previous or new] MRSA carriage. Page 9 of 26

10 Executive/Clinical Directors Executive and Clinical Directors have the responsibility for the co-ordination of health and safety activities and for ensuring that decisions are implemented in accordance with this guideline. Should ensure completion of integrated care pathway (ICP) for every case of MRSA carriage and daily review of drug charts by ward pharmacist to check compliance with antibiotic formulary and 5-day stop policy for all empiric antibiotic prescriptions; Should ensure Infection management team (Microbiologist + Antibiotic pharmacist + ICN) ward rounds that provide feedback to ward doctors and consultants. DIPC / The Hospital Infection Prevention and Control Committee The hospital infection prevention committee has a responsibility to ensure that this guideline allows the Trust to comply with directions and guidance from the Department of Health and other bodies. The Infection Prevention and Control Team (IPCT) The IPCT will audit and support local audit of compliance with the policy as part of the infection control audit programme. Managers and Supervisors Have a responsibility to ensure staff and new starters are aware of and comply with this guidance on MRSA carriage within this document. Employees Have a responsibility to abide by this guideline. This guideline is enforceable through Health and Safety legislation and Trust disciplinary procedures. If employees are aware that the policy is not being complied with they must first take the issue to their line manager and if the problem is not resolved to the infection control team KEY PERFORMANCE INDICATORS The Infection Prevention Team undertake quarterly audits of wards to ensure that healthcare workers are compliant with the content of this procedure Whenever areas of non-compliance are identified during these audits, an action plan is generated and target dates are set for review The content of this procedure is incorporated into the Trust Mandatory Infection Prevention education and in annual mandatory update training 4. ATTACHMENTS. Appendix 1 - Staphylococcus aureus (SA) Screening Appendix 2 Protocol for Dealing with MRSA/MSSA Carriage Appendix 3 Pre-Operative Management Protocol of SA Carriage Page 10 of 26

11 Appendix 4 Surveillance and Audit Appendix 5 Examples of Death Certification Appendix 6 SA Integrated Care Pathway 5. ELECTRONIC AND MANUAL RECORDING OF INFORMATION Database for Policies, Procedures, Protocols and Guidelines Archive/Policy Co-ordinators office Held By: Clinical Governance Directorate and Infection Control Department Held in format: Electronic and hard copy 6. LOCATIONS THIS DOCUMENT THIS DOCUMENT ISSUED TO Copy No Location Date Issued 1 Intranet 2 Wards and Departments 7. OTHER RELEVANT/ASSOCIATED DOCUMENTS Procedure No. Title Corp/Proc/408 Management Of Meticillin-Resistant Staphylococcus Aureus (MRSA) PL/025 MRSA patient leaflet Corp/Pol/116 Infection Prevention and Control Policy Corp/Pol/056 Hand Hygiene Policy Corp/Proc/418 Hand Hygiene Procedure Corp/Strat/023 Control of Infection Strategy Corp/Proc/488 Control of Outbreaks 8. SUPPORTING REFERENCES/EVIDENCE BASED DOCUMENTS None References In Full 9. CONSULTATION WITH STAFF AND PATIENTS Name G Wood Designation Policy Co-ordinator 10. DEFINITIONS/GLOSSARY OF TERMS Page 11 of 26

12 NAME DEFINITION SA MRSA MSSA PPE PCR DeCOL CCS HCAI ICP Staphylococcus aureus Meticillin resistant Staphylococcus aureus Meticillin sensitive Staphylococcus aureus Personal protective equipment Polymerase chain reaction Decolonisation or bioburden reducing regime Clinical /culture screen [non-emergency/critical care setting, post DeCOL course] Healthcare associated infection Integrated care pathway 11. AUTHOR/DIVISIONAL/DIRECTORATE MANAGER APPROVAL Issued By Job Title J Lickiss Checked By Job Title Dr Guleri Signature Date Signature Date Page 12 of 26

13 Appendix 1 ALGORITHM: Staphylococcus aureus [SA] SCREENING MSSA or MRSA +ve referred to as SA+ TEAM PATIENT GROUP PATIENT GROUP NURS ES Emergency admission or / clinical team Admission to critical / high care (even if pre-op screen SA -ve) or Step 1 Step 2 NURSES / clinical team Step 3 NURS ES / BED MANA GERS Step 4 consult ant Clinica l team / nurses urgent requirement for SA status. Elective patients or Emergency admission known SA+ or Critical / high care admission with SA+ or weekly screening in ITU, HDU & CITU or post decolonisation screen for MRSA+ve or interward transfer (other than from SAU/CLDU) or frequent attendees or any other non-urgent requirement of SA status Check patient SA status on Maxims / HISS system for all patients MSSA/MRSA SA +ve negative Or status unknown PCR specific Nasal swab Transport red bag CHROMOgenic Culture Nose & perineal swab Transport in specific yellow bag MSSA + MRSA+ MSSA +ve MRSA +ve Prescribe bio-burden reducing regime to all newly or previously known MSSA or MRSA patients admitted to hospital Single room for MRSA+ve patients Isolation precautions for MSSA/MRSA patients with barrier sign. Commence SA ICP Ensure optimal treatment of infected patients using antibiotic formulary Clinical teams must inform GPs [e-letter] or receiving ward / theatre / hospital or investigational area of Daily review of patient & antibiotic prescription Rescreen MRSA+ve at 48h of finishing bio burden reducing regime; Ensure high level of hand hygiene & ANTT MRSA RCA for bacteraemia SA status of patient ** when is SA screening not required: Transfers from CLDU / SAU where patient were SA screened negative on admission. Day case ophthalmic cases, Elective Endoscopy day cases, Dermatology minor procedure and day case dental cases patients DO NOT require screening. Children do not require screening unless high risk [SCBU, high care, cystics, previous exposure to healthcare settings] Recurrent elective admissions (renal, haematology, oncology, rheumatology, dermatology, etc should be screened every 3-months by culture. Page 13 of 26

14 STEPS TO SA [MRSA OR MSSA] SCREENING: 1 Check SA status of patient from maxims / HISS. 2 Emergency [unscheduled] admissions to hospital or critical / high care (ITU, HDU, SHCU, CITU): Known MRSA or MSSA +ve: i. Send off a culture swab for MSSA / MRSA screen ii. Prescribe bio-burden reducing regime [if patient has not already received it during current admission] iii. Single room for MRSA+ve patients. SA status unknown / negative/ patient admit from another ward/ hospital to critical /high care (ITU/HDU/SCHU/CITU) or elective admission with urgent requirement of SA status: i. Send off PCR specific swab in red request bag for SA PCR [MSSA and MRSA] ii. MSSA or MRSA patients must be prescribed bio-burden reducing regime. iii. MRSA+ve patient must be transferred to a single room [if possible]. 3 Elective [Scheduled] admissions of previously unknown or known SA [MSSA or MRSA] +ve or inter-ward transfer of patient within current admission or transfer screening or any other requirements for a non-urgent screening result: Send off culture swab for MSSA / MRSA screen When is SA screening not required: Transfers from CLDU / SAU where patient were SA screened negative on admission. Day case ophthalmic cases, Elective Endoscopy day cases, Dermatology minor procedure and day case dental cases patients DO NOT require screening. Children do not require screening unless high risk [SCBU, high care, cystics, previous exposure to healthcare settings] Recurrent elective admissions (renal, haematology, oncology, rheumatology, dermatology, etc should be screened every 3-months by culture. SAMPLES required: PCR: Single PCR specific swab collected optimally from both anterior nares. Sent in PCR specific red bag. Charcoal swab samples cannot be processed by PCR. Culture: Standard charcoal swab. One swab each from nose [both nares] and perineum. Sent in specific yellow culture screen bag. Validity of SA pre-op MRSA screen At present the DoH has not defined screening validity Our current position is to assume that a negative screen performed within 12 weeks of surgery is acceptable provided there have been no inpatient admissions in the period between screen and Page 14 of 26

15 surgery. If admissions have taken place: culture screen the patient if over 72hrs available till surgery otherwise urgent PCR screen is required. If this cannot be done in time for surgery either:- Postpone surgery Assume positivity and manage accordingly This may change if new guidance dictates. PCR Screen: Rapid but an expensive test. For use in emergency admissions or urgent situations requiring a rapid result. PCR service offered between h. Rapid test [< 2hr hand-on-time] Specimen: Single special PCR nasal swab Transport: Special red Microbiology request form / bag Turn-around-time: TAT ranges from 2h 10 h [depending on arrival of specimen in laboratory]. Results: Positive results are telephoned to the requesting ward while all results are entered on the pathology system real-time. The responsibility of checking MRSA/MSSA status of patient lies with clinical/nursing team Culture screen [MSSA and MRSA CHROMagar] 24-48hrs hands-on-time test Specimen: Standard charcoal swabs nose and perineum Transport: Yellow microbiology form Turn-around-time: 24h 72h [Subject to arrival of specimen in laboratory]. Culture set up in afternoon/evening. Hands-on-time: Negative result 24h ; Positive result 24h [presumptive result]; 48h [confirmed result]. RESPONSIBILITY OF CLINICAL TEAMS: It is the responsibility of clinical team to clearly document contact details of person requesting the test. Illegible hand-writing or absence of contact details on request forms can cause delay in transmission of result. Laboratory staff shall bear no responsibility for such delays. Positive MRSA / MSSA results are telephoned by microbiology laboratory to the requesting ward. The responsibility of checking MRSA/MSSA status of patient lies with clinical/nursing team Page 15 of 26

16 Appendix 2 Protocol for dealing with MRSA/MSSA carriage : All patients who test positive for MRSA on screening prior to admission will receive notification by letter. All of these patients must be effectively decolonised prior to admission. These patients will be required to return to their pre-admission clinic or outpatient clinic to collect a MRSA decolonisation pack. This pack consists of a 5-day treatment course of Prontoderm foam and Prontoderm nasal gel and instructions on how to use these products. This treatment must be commenced 5 days before the anticipated admission date. If patients receive notification less than 5 days before their admission date, they are instructed to commence treatment immediately, and the course will be completed during their inpatient stay. Failure to commence and complete the bioburden reduction treatment may result in a delay in their operation/procedure. EMERGENCY admissions: Nurse caring for the SA positive patient MUST promptly upon receiving the result of SA status - affix the prescription sticker on drug chart, initiate decolonisation protocol without delay and get it signed at the first opportunity but certainly within 24h. Mupirocin 2% ointment apply locally into anterior nares [patient should taste it in back of throat] q8h X 5days. 2 nd line for mupirocin resistant strain or mupirocin hypersensitivity is Naseptin [chlorhexidine 0.1% + neomycin] apply q6h X 10 days. Chlorhexidine 4% [gluconate - Hibiscrub or equivalent] q24h X 5 day course of body wash [esp. axilla, groin, perineum] daily and shampoo hair [twice/5-day period]. Recommended contact time of 3-minutes before washing it off with water. 2 nd line for Neonates / paediatrics or hypersensitivity to chlorhexidine or exfoliative skin conditions is Octenisan Page 16 of 26

17 Appendix 3 Pre-operative management protocol of SA carriage: o MSSA +ve: Date of surgery may be booked allowing for completion of 5-days of topical regime before surgery. Patient to use 5-day bio-burden reducing regime PRONTODERM. Admit to hospital on day 5 or next morning of course completion. No single room required. Staff to use isolation precautions during entire hospital stay with a barrier sign. If urgency of surgery contact microbiologist ASAP. o MRSA+ve Depending on the urgency for surgical intervention one of the three suggested regimens may be selected for managing MRSA carriage. Please note the MRSA-cidal agents used for decolonisation offer transient bio-burden reduction in MRSA carriage. This is again limited by co-morbidities of the patient. Please discuss any query with Microbiologist or infection control team. Regime A Where emergency surgery is required This applies to both SA status +ve or result awaited {treat like +ve pending confirmation of result. PCR swabs must be taken as soon as practicable]. Ensure nasal mupirocin and chlorhexidine body wash/shampoo is commenced immediately. Complete the remaining days of the 5 day bio-burden reduction regime post operatively. Refer to trust antibiotic prophylaxis and treatment guidelines. Regime B Where surgery is non-urgent but cannot be delayed pending 3 negative MRSA screens Date of surgery may be booked allowing for completion of 5-days of topical regime before surgery. Patient to use 5-day bio-burden reducing regime PRONTODERM. Admit to hospital on day 5 or next morning of course completion. Refer to trust antibiotic prophylaxis and treatment guidelines Regime C (MRSA Only) Where the surgeon or patient considers that an attempt to clear MRSA completely is in the patients best interest and the degree of urgency allows for potential 3-4 week delay:- This option requires Treat with bio-burden reduction regime [Prontoderm for 5-days] Page 17 of 26

18 Await three negative screens taken at 48 hours then, at 1 weekly intervals thereafter. Failure to achieve three negative MRSA screens should be discussed with the Microbiologist. Admit as soon as possible after third negative screen treat as positive for MRSA Operating Theatre Management of SA positive patients and those whose status is not known at operation:- Isolate and barrier nurse patients Status unknown emergency patients should be managed as MRSA positive pending screening. If procedure requires antibiotic prophylaxis add MRSA cover: vancomycin 1g IV infusion over 100 minutes to be completed minutes before incision. For patients who require immediate surgery and/or are allergic to vancomycin: use teicoplanin 10mg/kg at induction/or 15 minutes before procedure Place at the end of the operating list where possible or delay next entry until sufficient air changes have occurred, in practice 15 minutes for a standard theatre Recover patient in operating theatre or segregated recovery area Decontaminate surfaces after procedure. Recurrance of colonisation or Decolonisation failure? Recurrences are common, occurring in the majority of patients who have significant comorbidity. For MRSA carriage, the policy allows for a maximum of two bio-burden reduction cycles. Further cycles within that admission should be discussed with the Microbiologist. For MSSA carriage only a single cycle of bio-burden reduction is advocated. Any further requirement for decolonisation should be discussed with the Microbiologist. Dr Guleri and senior nurses from preoperative assessment clinics run a DeCol failure clinic to help unwarranted delays in surgery of patients who fail to get three negative screens or if there is urgency of surgery. Page 18 of 26

19 APPENDIX 4 SURVEILLANCE & AUDIT TYPE Report To Frequency External Internal Department of Health MRSA Bacteraemia Monitoring Programme Review of MRSA Bacteraemia figures Outbreak Reports DoH / Health Protection Agency (COSERV) Trust Board HICC Divisions Quarterly Report issued to Trusts Annual Report to Parliament Benchmarked Quarterly Bi-Monthly Annually MRSA admission rates (HISS) MRSA clinical isolate rates Audit Bacteraemia Critical incident review Recording MRSA status plus time to Initiation of Barrier Nursing/ Treatment Appropriate use of MRSA Empiric Treatment Appropriate use of Antibiotics versus topical regimes for MRSA management Divisions HICC/Divisions Annually until Infection Control database in place then more frequently Rolling programme over three years Page 19 of 26

20 Appendix 5 Example of death certification Example A: If a healthcare associated infection (HCAI) was part of the sequence leading to death, it should be written in part I of the certificate, and you should include all the conditions in the sequence of events back to the original disease being treated. Ia. MRSA bacteraemia Ib. Multiple antibiotic therapy Ic. Community acquired pneumonia with severe sepsis II. Immobility, Polymyalgia Rheumatica, Osteoporosis Example B: If your patient had a HCAI that was not a part of the direct sequence, but which you think contributed at all to their death, it should be mentioned in part II Ia. Bronchopneumonia Ib. Carcinomatosis and renal failure Ic. Adenocarcinoma of the prostate II. MRSA pneumonitis infection secondary to antibiotic therapy for recurrent bronchopneumonia. Page 20 of 26

21 Appendix 6 Staphylococcus Aureus Integrated Care Pathway Staphylococcus Aureus (SA) Integrated Care Pathway Write patient details or affix Identification label Hospital Number: Name: Address: Date of Birth: NHS Number: Consultant Inclusion criteria This Integrated Care Pathway (ICP) is for use with known and newly diagnosed MRSA patients. For further advice please contact the infection control team. This Integrated Care Pathway is intended as a guide to care only and does not replace clinical judgement. Aims of this Care pathway This pathway commences when the patient has been identified as MRSA positive from either previous or new swab results. We intend to ensure we offer high quality patient care, based on evidence where available and that the care is documented comprehensively and accurately Acceptable Abbreviations MRSA Meticillin Resistant Staphylococcus Aureus MSSA - Meticillin Sensitive Staphylococcus Aureus SA - Staphylococcus Aureus ICP - Integrated Care Pathway +ve - Positive -ve - Negative Page 21 of 26

22 Document Number 001 Version August 2006 Document created by Infection control team Patient Name Hospital number Instructions for use of the Integrated Care Pathway To write in the ICP you need to give your name, job title and give a sample signature and initials. See below. Ensure each page is marked with the patients name and unique identifier i.e. hospital number. When recording an event that is predicted by the ICP, just initial against that predicted activity or intervention in the column provided. If your intervention is not in line with the ICP, i.e. you do not follow the pathway then you must record this as a variance on the Variances/Additional Information pages. Variance will allow the ICP to reflect the patients experience. The Variance /Additional Information pages are also for you to write free text about issues identified and the care given to the patient. These records must always be timed, dated and initialled. If your entry relates to an activity or intervention within the ICP, record the activity number against your entry. All ICP s are chronological so you should be able to track the care very easily. Signature Record Please use black ink and complete this section. Use initials when recording care. Print Name Job Title Bleep no or ext. Signature Initials Page 22 of 26

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24 Author/Originator Summary of MRSA/MSSA details and actions 1 IPN or nurse in charge of patient s care identifies patient as SA +ve 2 Nurse in charge of patients care informed 3 Nurse in charge to inform patient 4 Nurse in charge of care informs next of kin with patients consent 5 Patient notes or Patient allergy/attention card are labelled by IPN or ward staff 6 Nurse responsible for the patient informs them of the isolation measures and rationale. 7 Information leaflet given by ward staff 8 Any questions answered by ward staff or IPN if necessary 9 The patient agrees to comply 10 Medical team responsible for care - informed of positive status. 11 Necessary antibiotics prescribed if applicable by the doctor 12 Topical regime prescribed as per SA Policy 13 Patient barrier nursed commenced as per Infection Prevention and Control procedure 14 If patient discharged midway through treatment then this should be continued at home 15 Topical treatment for eradication has been given for 5 days as prescribed. 16 MRSA patients to be rescreened 48 hours after completion of topical treatment as per the Trust SA procedure. MSSA patients do not need to be rescreened. 17 Clinician in charge of the patient s care - notifies the GP of the SA status via the electronic discharge system. Met Unmet Date Time Variance Action Taken Page 24 of 26

25 Additional Information / Variance Unique Number Date Time Date Variance/ Additional Information Sign Outcome Date Time Sign Revision No: 2 I.D. No: CORP/PROC/408 Review Date: Title: Management Of Meticillin Resistant Staphylococcus Aureus (MRSA) Page 25 of 26

26 Additional Information / Variance Unique Number Date Time Date Variance/ Additional Information Sign Outcome Date Time Sign Patient Name. Hospital number Revision No: 2 I.D. No: CORP/PROC/408 Review Date: Title: Management Of Meticillin Resistant Staphylococcus Aureus (MRSA) Page 26 of 26