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1 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Previous document(s) being replaced Location Policy No Policy Name RHCH CP055 Meticillin Resistant Staphylococcus aureus policy BNHH IC/231/10 Control of Meticillin Resistant Staphylococcus aureus clinical care protocol Document Summary Specific guidelines for the control and prevention of spread of MRSA are justified because MRSA is known to cause serious illness, results in significant additional healthcare and human costs, and yet may be controlled with effective infection prevention and control measures. Patients who are colonised with MRSA are at increased risk of developing MRSA infection. Infection may range from mild to the more serious systemic infection, and even death (Joint Working Party 2006). The Trust s objective is to reduce the spread of MRSA, ensure that patients are treated promptly and effectively and minimise its impact in high risk patients and key clinical areas. Ownership Author Linda Swanson Job Title Specialist Practitioner in Infection Prevention and Control Document Type Level Level 1 Related Documents Document Details Hand Hygiene Policy Standard Precautions Policy Protective Isolation Policy Trust Empirical Prescribing Guidelines for Adults Care of Patients at Death Policy Relevant Standards CQC Outcome Outcome 8 NHSLA Standard N/A Equality Impact Completed by Equality and Diversity Lead Assessment Date Completed 7 January 2013 Final Document Approval Committee Policy Approval Group Date Approved 21 January 2013 Other Specialist Committee(s) Infection Prevention Control Committee committee(s) recommending approval Date Recommended 27 November 2012 Final Document Committee Executive Committee Ratification Date Ratified 24 January 2013 Authorisation Authoriser Mary Edwards Job Title Chief Executive Officer Signature Date Authorised 25 January 2013 Dissemination Target Audience All Trust Staff Dissemination and Implementation Plan Action Owner Due by Publicise detail of new document via Intranet and Midweek message IPCT and Communication Team Within 1 week of publication Communication sent to all senior Managers advising BNHH Healthcare Library On publication publication of policy The policy will be available on the intranet and website BNHH Healthcare Library and Communication Team Within 1 week of authorisation Review Expiry date January 2016 Page 1 of 55

2 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION Review date October 2015 Document Control Document Amendments Version No. Details Key amendments to note By whom Date 1 Review of BNHFT & WEHCT policies to produce harmonised HHFT policy Linda Swanson Both RHCH and BNHH policies have been reviewed, updated and combined. New DOH 2010 screening guidance for elective procedures has been added Changes to screening for regular attendees has been added Management of Periods of Increased Incidents and Outbreaks of MRSA included Management of repatriated patients included Introduction of weekly screening and monitoring of compliance in RHCH and AWMH Addition of theatre management of the MRSA positive patient Revised patient information leaflets Revised GP letters Revised screening tables added September Minor amendment Minor amendment to appendix H Linda Swanson May 2013 Page 2 of 55

3 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION Contents 1. Introduction Purpose Scope Explanation of Terms Duties Use of Antibiotics MRSA Screening Staff MRSA Screening Patient MRSA Screening Use of Swabs Management of MRSA Positive Patients and MRSA Contacts Isolation Options for the MRSA Positive Patient Treating the MRSA Positive Patient A Positive Result in High Risk Elective patients A Positive Result in All Other Elective Patients A Negative Result in All Elective Admissions Emergency Surgery for Those at High Risk of MRSA Transferring the MRSA Positive Patient Repatriation of Patients Visitors Cleaning of MRSA Isolation Rooms Care for the MRSA Positive Patient at Death Stakeholders Engaged During Consultation Dissemination and Implementation Training Monitoring Compliance with the Document References Associated Documentation Contributors Appendix A Equality Impact Assessment Tool Appendix B NHS Patient Information Leaflet: Going into hospital Appendix C NHS Patient Information Leaflet: A Positive Result Appendix D Basingstoke and North Hampshire Hospital Pre- Assessment GP Letter Appendix E Royal Hampshire County Hospital Pre- Assessment GP Letter Page 3 of 55

4 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION Appendix F Andover War Memorial Hospital Pre- Assessment GP Letter Appendix G Staff Screening Appendix H Patient Screening Sites to Screen Appendix I How to Swab Appendix J Domestic/Housekeeping Staff Standard Precautions/Procedures for the Cleaning of MRSA Isolation Rooms Appendix K Nursing Staff Cleaning Responsibilities for the MRSA Isolation Room Appendix L - Management of the MRSA Positive Patients in Theatres Appendix M- Rapid MRSA Screening Page 4 of 55

5 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION 1. Introduction Staphylococcus aureus is a very common bacterium carried harmlessly on the skin or nose of around 30% of the population. Sometimes the bacterium can cause skin infections such as boils. These infections are normally mild and are easily treated. However some strains of the Staphylococcus aureus bacterium have developed resistance to some of the more commonly used antibiotics such as Flucloxacillin and are called MRSA. MRSA stands for Meticillin Resistant Staphylococcus Aureus. It is this resistance to certain antibiotics that makes MRSA different, as it can be more difficult to treat if it does cause an infection. People can carry MRSA in the same way as the more common sensitive Staphylococcus Aureus without causing harm to themselves or others. MRSA was first identified in hospitals but it is now found in the general community and in care homes. 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) the affected person either on the skin, 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, working in a health care environment 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. As MRSA can easily spread, usually by direct skin contact with a patient, their environment or hospital equipment, patients are barrier nursed in single rooms or cohort bays according to infection control policies to prevent cross infection/colonisation. Hand colonisation has proven to be a significant cause of cross infection; therefore hand decontamination is one of the most important measures in helping to reduce the spread of this infection. The importance of MRSA control has been the main focus of national MRSA guidelines in hospitals (DOH 2008). 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, and that control measures have an impact on its management. Not controlling MRSA has significantly higher financial and human cost implications to NHS Trusts than the cost of simple and effective control methods such as screening for MRSA, adherence to effective hand hygiene, isolation precautions and the use of personal protective equipment. 2. Purpose Specific guidelines for the control and prevention of spread of MRSA are justified because MRSA is known to cause serious illness, results in significant additional healthcare and human costs, and yet may be controlled with effective infection prevention and control measures. Patients who are colonised with MRSA are at increased risk of developing MRSA infection. Infection may range from mild to the more serious systemic infection, and even death (Joint Working Party 2006). The Trust s objective is to reduce the spread of MRSA, ensure that patients are treated Page 5 of 55

6 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION promptly and effectively and minimise its impact in high risk patients and key clinical areas. Infection prevention and control measures have a significant impact on both the reservoir of MRSA in the patient environment, and therefore the rate of infection in patients. They are part of a programme of infection prevention and control which, implemented effectively, can also help to reduce the impact of many other infections. 3. Scope This policy extends to cover and will be applied fairly and consistently to all Hampshire Hospitals NHS Foundation Trust employees regardless of their protected characteristics as defined by the Equality Act 2010 namely age, disability, gender reassignment, race, religion or belief, sex, sexual orientation, marriage or civil partnership, pregnancy and maternity, length of service, whether full or part-time or employed under a permanent or a fixed-term contract, irrespective of job role or seniority within the organisation. Where an employee has difficulty in communicating, whether verbally or in writing, arrangements will be put in place as necessary to ensure that the processes to be followed are understood and that the employee is not disadvantaged during the application of this policy and related procedures. In line with the Equality Act 2010, the Trust will make reasonable adjustments to the processes to be followed where not doing so would disadvantage an employee with a disability during the application of this policy. This policy compliments professional and ethical guidelines and the Nursing and Midwifery Council (NMC) Code of Professional Conduct (NMC 2008). Infection control is the responsibility of all staff associated with patient care. A high standard of infection control is required on all wards and units, although the level of risk may vary. It is an important part of total patient care. It is essential that infection control is seen as an organisational responsibility and priority, that adequate isolation facilities and resources are provided, and that appropriate infection control staff and support services are available. 4. Explanation of Terms Bacteraemia - the presence of bacteria in the blood. Blood is usually a sterile substance therefore the presence of bacteria is abnormal and indicates infection Bacterium - one-celled organisms that have the potential to cause disease Micro-organism - an organism of microscopic size MRSA - abbreviation for meticillin resistant Staphylococcus aureus an organism generally found in the nose or on the skin of a small percentage of the population which is resistant to a lot of commonly used antibiotics Page 6 of 55

7 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION MSSA - abbreviation for meticillin sensitive Staphylococcus aureus an organism which is found naturally in the nose or on the skin of around 30% of the population and which is generally harmless Colonisation - the presence of bacteria on the skin without causing disease in a person Decolonisation - the removal or reduction of bacteria present on the skin Contact a person who has been nursed in the same bay/ward as a known MRSA positive patient 5. Duties Post Holders Chief Executive Officer (CEO) The CEO has overall responsibility for the strategic and operational management of the Trust ensuring there are appropriate strategies and policies in place to ensure the Trust continues to work to best practice and complies with all relevant legislation. Director of Infection Prevention and Control (DIPC) - The DIPC is the Trust Director responsible to the board for the delivery of infection prevention and control standards. Director of Nursing - The Director of Nursing will ensure that the Divisional Directors take clinical ownership of the policy. Divisional Operational Directors - The Divisional Operational Directors will ensure that all health care workers comply with this policy and that all health care workers attend mandatory infection prevention and control training. They are responsible for ensuring adequate facilities and resources are available to adhere to this policy. Microbiologists and Pharmacists - Microbiologists and Pharmacists are responsible for ensuring prudent use of antibiotics based on a regularly updated overarching Trust Empirical Prescribing Guidelines for Adults. Clinical Service Managers/Leads - The Clinical Service Managers/Leads will ensure that a printed copy of this policy is available in all of their areas. They will ensure that all health care workers comply with this policy and that all health care workers attend mandatory infection prevention and control training. Infection Prevention and Control Team (IPCT) - The IPCT will act as a resource for information and support. They will provide education in relation to this policy which includes mandatory training. They will monitor the implementation of this policy via audit within clinical areas and be responsible for regularly reviewing and updating it. The IPCT will monitor MRSA screening compliance on a monthly point prevalence Page 7 of 55

8 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION basis and report compliance to the Executive Boards, DIPC, Clinical Service Leads, Ward Managers and at Divisional Governance Boards. Health4Work and the Health and Safety Advisor - Health4Work and the Health and Safety Advisor will act as a resource for information, and support and consult with managers, the Infection Prevention and Control Team and healthcare workers regarding MRSA screening of staff and the use of personal protective equipment Managers - All ward managers are responsible for ensuring that all relevant patients and staff are screened for MRSA in line with this policy and that each staff member reads and adheres to the standards required by this policy. All Trust employees - All Trust employees will comply with this policy and inform the Infection Prevention and Control Team about any issues or concerns relating to the policy. All staff will attend mandatory Infection Prevention and Control training annually. 6. Use of Antibiotics Excessive use of antibiotics promotes the spread of existing strains of MRSA through reduction in colonisation, resistance in patients and by giving resistant strains a survival advantage in a hospital setting. Antibiotic usage should be guided by the Trust Empirical Prescribing Guidelines for Adults but as a brief guide should consider the following: Ensuring that antibiotics are given at the correct dosage and for an appropriate duration as inappropriate antibiotic use promotes the emergence and spread of antibiotic resistance, Antibiotic use should be reviewed by the clinical team each day. Antibiotic use, dose, route and indication should be documented in the patient s notes, Avoidance of inappropriate or excessive antibiotic therapy and prophylaxis, Limiting the use of glycopeptide antibiotics to situations where their use has been shown to be appropriate. If possible prolonged courses should be avoided, Reduce the use of broad spectrum antibiotics, particularly third generation cephalosporins and fluoroquinolones, to what is clinically appropriate, because exposure to these are independent risk factors for MRSA colonisation and infection, Instituting antibiotic stewardship programmes to include surveillance of antibiotic resistance, antibiotic consumption, and on-going prescriber education. 7. MRSA Screening Routine decolonisation of all patients is not considered to be an alternative option to screening (DOH 2010). Some patient groups are considered to have higher risk factors for MRSA. They include those who may have received recent treatment from other hospitals in the UK or abroad, those who have come from residential/nursing Page 8 of 55

9 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION homes, those who are healthcare workers themselves and those who have previously been positive to MRSA. There are also those who are admitted from the community setting who have no apparent risk factors but whom have been found to be MRSA positive. For this reason it is now recommended that all elective and emergency patients are screened for MRSA either within 28 days prior to elective/planned admissions, or within 48hrs of admission in the case of emergency admissions. There are exceptions to this as there are some groups of patients in whom the risk of MRSA is small, and the cost of screening significant with little or no benefit (DOH 2010). Therefore routine screening of the following groups of patients is not generally recommended unless there are clinical reasons to the contrary or they also fall into the high risk patient category: Day case ophthalmology (emergency ophthalmology patients must be screened) Day case dental Day case endoscopy Minor dermatology procedures e.g. warts or other liquid nitrogen applications Children/paediatrics unless in a high risk group (e.g. cystic fibrosis) Maternity/obstetrics except for elective caesareans, high risk cases e.g. high risk of complications in the mother and/or potential complications in the baby (e.g. likely to need SCBU/NICU because of size or known complications or risk factors) and those patients who are healthcare workers themselves Minor procedures such as lumbar puncture, joint injections or minor hand surgery such as carpal tunnel decompression Patients who are not receiving any medical or surgical treatment e.g. those in respite care, or day cases attending for pain management therapy, and attendances for clinical immunology Terminations of pregnancies Non-invasive radiological patients Mental health patients (it should be noted however that mental health service users may have other clinical conditions which put them at risk of MRSA and therefore they should be screened for that reason) (DOH 2010) 8. Staff MRSA Screening Routine screening of staff is not recommended (DOH 2008). Staff screening may be indicated in exceptional circumstances such as continued transmission on a ward/unit despite active control measures, where epidemiological aspects of an outbreak are unusual, or if there is suggested persistent MRSA carriage by staff (Coia et al. 2006). For further information regarding staff screening please see Appendix G. Page 9 of 55

10 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION 9. Patient MRSA Screening Sample collection is the responsibility of the staff member admitting emergency patients or running pre-assessment or outpatient clinics. For One Stop patients in whom the 18 week target may be compromised consideration may be given to providing the patient with a screening pack and advising upon self-screening within 28 days prior to the expected admission. It is the pre-assessment staff s responsibility to assess the suitability of patients for self-screening and to provide the screening pack. It is the responsibility of the requesting person to check patient results. The essential site to sample is the anterior nares (nose) as this is the most common carriage site for MRSA. The secondary sites are the groin, plus any wounds/skin breaks, a catheter specimen of urine if a catheter is present. It is not necessary to swab the axilla. Any cannulas and CVC 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 individually 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. For out of area screening it is the pre-admission areas/nurses/clinics responsibility to ensure that all admissions are screened in line with this policy. Consideration may be given to providing the patient with a screening pack and advising upon selfscreening within 28 days prior to the expected admission. It is the pre-assessment staff s responsibility to assess the suitability of patients for self-screening and to provide the screening pack. It is the responsibility of the requesting person to check patient results. 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 re-screen is required. Please see section 14 and 15 for management of a positive result in elective patients. For details on Rapid MRSA Screening please see Appendix M The appropriate sites for screening are detailed in Appendix H. 10. Use of Swabs Further details of which swabs to use and an explanation of how to use swabs can be found in appendix I. 11. Management of MRSA Positive Patients and MRSA Contacts During office hours MRSA positive results are reported to the Infection Prevention and Control Team by Microbiology. The Infection Prevention and Control Team will inform the relevant areas. Outside of office hours MRSA positive results are reported to The Consultant Microbiologist who will inform relevant areas. Page 10 of 55

11 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION Any Healthcare Associated Infection (HCAI) of MRSA Bacteraemia will initiate commencement of root cause analysis investigation within 12 hours of confirmation of the positive result. The root cause analysis investigation team will be assembled by and led by the Director of Infection Prevention and Control. The root cause analysis investigation will be completed and reported within 10 days of confirmation of the positive result. A pre-48-hour admission positive MRSA bacteraemia will be reported to the Community Infection Prevention and Control Team within 12 hours of receipt of confirmation. If a single case of MRSA is found on a ward (index case) - Patients found to be MRSA positive must be either discharged if the clinical condition allows or isolated into a single room with ensuite facilities if clinically safe to do so. Alternatively they may be cohort nursed if deemed suitable and only following discussion with the Infection Prevention and Control Nurses. In cases where it is considered clinically unsafe to isolate a patient into a standard single room all attempts must be made to isolate those patients into visible single rooms close to the nursing station, or to obtain extra staff for 1:1 nursing. If this is not possible the bay in which the MRSA positive patient remains must be closed to all further admissions/transfers, with the exception of discharges home or transfers due to clinical need e.g. ITU/HDU. If transfer is clinically necessary the receiving area must be informed of the infection risk. Any exceptions to this must be discussed with the Consultant Microbiologist. If a patient is in a bay and a presumptive/preliminary result (24 hour result) has been made available to the ward - The patient must be isolated into a single room with ensuite facilities if clinically safe to do so. Their bed space in the bay must then be deep cleaned, including curtain change following which the bay may re-open. Swabbing of contacts is not deemed necessary in this case. If a patient is in a bay at the time of an MRSA positive result (not a preliminary result) and they have been in that bay for 24 hours or more the patient be isolated into a single room with ensuite facilities if clinically safe to do so, and their bed space must be deep cleaned once they have vacated it. Once this has happened all remaining patients in that bay are considered to be MRSA contacts and must be given a full MRSA screen. The bay is then closed to admissions and transfers. Patients may be discharged home from the bay. Only once MRSA has been ruled out for these contacts (all results are negative) should the bay re-open. Any exceptions to this must be discussed with the Consultant Microbiologist, Lead Infection Prevention and Control Nurse. If a patient is in a bay at the time of their MRSA positive result, and they have been in that bay for less than 24 hours - The patient must be isolated into a single room with ensuite facilities if clinically safe to do so and their bed space must be deep cleaned once they have vacated it. All remaining patients in that bay must be given a full MRSA screen. Once this has occurred the bay may re-open whilst awaiting the Page 11 of 55

12 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION test results. If further patients in the bay are subsequently found to be MRSA positive the Consultant Microbiologist/Infection Prevention and Control Team will advise on the necessary course of action. Those patients whom are considered high risk for MRSA must be isolated into a single room upon admission to hospital, and a full screen for MRSA obtained. It is the admitting unit/ward s responsibility to ensure that this occurs. These high risk patients are not suitable to be cohort nursed with other MRSA positive patients until proven positive again upon this admission and deemed suitable for cohorting by the Infection Prevention and Control Nurses. If the screen result is negative upon this admission they may be de-isolated and are considered safe to nurse in general bays. Those patients admitted as contacts from wards/bays/areas where MRSA is known to be present should be isolated until MRSA carriage has been excluded using a full screen. Identification of 2 or More MRSA Positive Patients on a Ward - Identification of 2 or more MRSA positive patients on a ward may constitute a Period of Increased Incidence (PII) or an outbreak. The decision on declaring a PII or an outbreak will be taken by the Director of Infection Prevention and Control based upon epidemiological evidence of the cases and risk factors for other patients involved. The Infection Prevention and Control Team will advise on the necessary actions to take following declaration of an outbreak. These actions may include bay closures/ward closures, screening of other patients on the ward, screening of staff, sending of positive samples to external laboratories for phage typing, and the instigation of either PII or outbreak meetings. Wards will only be closed on infection control grounds following recommendation from the Consultant Microbiologist, and after discussion with the ward manager, Consultants, Management and the Infection Prevention and Control Team. The Consultant Microbiologist will make the decision when to close and re-open a ward. Prior to re-opening of affected wards/bays/rooms a terminal clean is required using a hyphochlorite solution (Actichlor Plus ) at a strength of 1:1000 ppm, and all curtains must be changed. It is the responsibility of the ward manager to liaise with the domestic department to organise the terminal clean. Reporting and Investigating PIIs and Outbreaks All PIIs and outbreaks must be reported as an incident by completing a Datix form. It is the responsibility of the ward manager to ensure that this has happened. Ward closures are reported as Serious Incidents Requiring Investigation (SIRI) and should be reported as such by the Clinical Service Lead/Manager (CSL/CSM) of the area. Outbreaks will also be reported and investigated as a SIRI. In the event that an outbreak of MRSA is declared an outbreak control meeting will be convened by The Director of Infection Prevention and Control. Page 12 of 55

13 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION 12. Isolation Options for the MRSA Positive Patient A single room with ensuite facilities is always the preferred option for isolating the MRSA positive patient (DOH 2010). All attempts must be made to ensure that this level of isolation is achievable, including the provision of extra nursing staff if necessary to ensure the safety and well-being of the patient being cared for in isolation. Failure to isolate must be recorded as an incident and a Datix form completed. If the MRSA positive patient is deemed too clinically unstable to move by the responsible clinician then a risk assessment to keep the patient in a bay/open unit must be performed by the clinicians and the IPCT. This will be based upon the site of the MRSA, the risk of transmission and the immune status of the remaining patients. The bay will be closed to further admissions/transfers except urgent clinical transfers. Patients may be discharged home from the closed bay. Setting up an area to cohort nurse MRSA positive patients outside of the isolation ward must only be done in consultation with the Director of Infection Prevention and Control/Duty Consultant Microbiologist, the IPCT and the CSL/CSM for the area. A risk assessment will be performed based upon the resistancy of the MRSA, the individual patients affected, their transmission potential, underlying medical conditions, suitability of the area to be used for cohort nursing, and the staffing levels of the area concerned. Separate staff will be designated to work in the MRSA cohort bay. They must remain segregated and not made to work in other areas on the ward at the same time. Those staff working in the cohort area/bay must not work in other clinical areas for at least 48hrs post exposure to the cohort area. 13. Treating the MRSA Positive Patient Although complete eradication of MRSA is not always possible, treatment and a decrease of MRSA carriage can reduce the risk of transmission in healthcare settings. Decolonisation will also reduce the risk of infection e.g. via inoculation in the patient s own surgical wound during an operation. Following identification of an MRSA positive patient, decolonisation will be considered successful once 3 full negative MRSA screens taken 1 week apart post treatment have been obtained (HPA 2009). Once this has occurred the positive patient may be removed from isolation and is considered safe to nurse in a general ward environment. The efficacy of any decolonisation regimen will depend on the presence of wounds, skin lesions and foreign bodies such as urinary catheters, nasogastric tubes and haemodialysis lines. It also requires the thorough application of the topical treatments which are recommended for MRSA positive patients, regardless of the site of infection. Systemic antibiotic therapy may also be recommended by the Consultant Microbiologist in cases of suspected/confirmed systemic infection. Topical treatment is for 5 days and consists of: Page 13 of 55

14 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION Chlorhexidine gluconate 4% in a surfactant solution 500ml Directions: use once each day. Use neat solution to wash all over the body and rinse off with clean water. Wash hair on two occasions during the 5 day treatment period, ideally day 1 and day 5. Mupirocin 2% nasal ointment 3g Directions: apply a small amount to the inner surface of both nostrils three times daily for 5 days. NB Please note that patients MRSA sensitivities may vary. In some cases Mupiricin may not be suitable. In those with fragile/sore skin or Chlorhexidine allergy use Octenisan once daily as a whole body wash paying particular attention to the axilla and groin area. Allow 3 minute contact time. In neonates the Chlorhexidine/Octenisan wash should be diluted 50/50 with water. For further advice please contact The Infection Prevention and Control Team/Consultant Microbiologist. Once treatment has been completed allow 48 hrs before re-swabbing the patient s nose, groin plus any wounds and a catheter specimen of urine (CSU) if catheter present. Continue to isolate and barrier nurse. If the re-swab is positive again the patient may restart another 5 day course of the same treatment protocol. Continue to isolate and barrier nurse. The maximum number of topical treatments recommended is 2. If the patient remains MRSA positive following 2 courses of treatment they must be treated as colonised. There is no need to keep re-testing/swabbing the patient even on weekly ward screens-unless their clinical condition changes. Please discuss with a member of the Infection Prevention and Control Team/ Consultant Microbiologist if further advice required. Continue to isolate and barrier nurse. Patients discharged during a course of treatment should complete their topical treatment and course of antibiotics if prescribed. There is no requirement for patients colonised with MRSA to continue extended screening/eradication protocols after discharge. However treatment may continue if there is an anticipated readmission to hospital, especially for a planned invasive procedure or if deemed necessary by the patient s clinician/general practitioner (GP). It is the responsibility of the ward staff, nurses and doctors, to be aware of each patient s MRSA status and at what stage of treatment they are. Delays in screening/treating patients may result in extended isolation periods and extended length of stay in hospital. The detrimental psychological effect of isolation is well documented therefore staff should make every effort to ensure that complete sets of screening samples, checking of results and commencement of treatment is carried out in a timely manner. Page 14 of 55

15 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION Patient Information Those patients found to be newly identified as MRSA positive should be provided with an MRSA hand-held record (Blue Book). The ward staff/infection prevention and control nurses must ensure this is provided for inpatients on the wards. Pre- Assessment clinics will supply these books to their patients, and GPs will give them to patients identified via samples taken in the community. Each time a patient visits the Trust, for any reason, these records should be checked and updated so that recent information on screening and treatment are logged. Other Trusts within the area will also be providing these hand-held records to their newly identified MRSA patients. All patients diagnosed as MRSA positive must have access to information regarding their infection. This may be via an information leaflet, discussion with nursing/medical teams or via the blue book. Examples of patient information leaflets can be found at appendix B and C. The Infection Prevention and Control Nurses are available for advice, and should be informed in the event of any patient requesting specialist advice/information regarding their infection. Informing the patient s GP The GP and others involved in the patient s community care should be informed of the patient s individual MRSA status at discharge via the discharge summary letter and the patient s hand held records. In the event that an inpatient has been discharged home from a ward when the MRSA positive result becomes known a letter confirming their MRSA status will be sent by the Infection Prevention and Control Team to the patients GP. In the event that a patient seen in a pre-assessment clinic is diagnosed as MRSA positive it is the responsibility of the pre- assessment clinic nurses to: Inform the patient of the positive result by telephone and establish if the patient can return to the pre-assessment clinic to collect a prescription for treatment For those patients collecting prescription from pre-assessment clinics ensure that doctors (Drs) have completed an outpatient department (OPD) prescription for patient For those patients unable to attend the pre-assessment clinic and whom are collecting prescriptions from GPs fax positive result to GP surgery with a covering letter (Appendix C, D and E) detailing treatment to be prescribed 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 RHCH &AWMH inform the consultant so that the patient s admission date can be adjusted or facilitated The patient then commences 5 days of the prescribed treatment. Two clear days after completion of the treatment the patient needs to attend the preassessment clinic/opd to be re-swabbed for MRSA Page 15 of 55

16 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION If time allows before admission date the patient returns again at weekly intervals for MRSA swabbing until 3 sets of consecutive weekly swabs are obtained. If this is not possible and the admitting clinician wishes to admit the patient before MRSA clearance is obtained then the patient must be managed as a positive case, isolated upon admission, and placed last on the operation list where possible 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 to enable admission date to be re-instigated if previously deferred due to positive result In the absence of the pre-assessment staff the surgical/orthopaedic bleep holder must 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 14. A Positive Result in High Risk Elective patients High risk elective patients are: Orthopaedics (especially those involving metal work/prosthesis) vascular grafts breast implants and complex surgery cardio thoracic diabetic patients Every effort should be made to limit or suppress MRSA colonisation prior to surgery. Three negative weekly swab results should be obtained in addition to Mupirocin nasal ointment and a Chlorhexidine 4% body-wash should be given prior to theatre and consideration should be given to the use of prophylactic antibiotics. All options can be discussed with the Consultant Microbiologist. Appendix L includes guidance for management of the MRSA positive patient in theatres. 15. A Positive Result in All Other Elective Patients All other elective MRSA positive patients will commence topical treatment 4 days prior to their day of admission, and be admitted on day 5 of their topical treatment. The aim is to minimise the risk of infection by carrying out surgery on Day 5 of the topical treatment when MRSA colony counts are considered to be at their lowest. On the morning of surgery they will have Mupirocin nasal ointment applied and a Chlorhexidine 4% body-wash. The patient will be admitted into a single room and barrier nursed and placed last on the procedure list where possible. Consideration should be given to the use of prophylactic antibiotics; this can be discussed with the Consultant Microbiologist. Page 16 of 55

17 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION Appendix L includes guidance for management of the MRSA positive patient in theatres. 16. A Negative Result in All 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 required. In the case of a negative MRSA swab in Maternity elective admissions taken at 36 weeks, 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. 17. Emergency Surgery for Those at High Risk of MRSA Those who are considered to be at high risk of MRSA (previously MRSA positive patients, from nursing/residential homes/healthcare workers, etc.) admitted as an emergency admission but requiring emergency surgery prior to their MRSA status being known must be isolated upon admission to hospital, and commence decolonisation prior to surgery and continue post-surgery until MRSA screening results are known. Consideration should be given to using the rapid MRSA screen prior to theatre if clinical condition allows. Consideration should also be given to the use of prophylactic antibiotics. Further guidance can be sought from the Consultant Microbiologist. 18. Transferring the MRSA Positive Patient MRSA positive patients may require transfer to other departments for necessary investigations. Their MRSA status must never be used as a sole indicator to cancel necessary clinical investigations. Visits by MRSA patients to other departments should be kept to a minimum. Prior arrangements should be made with senior staff of the department concerned to minimise any risk. Departmental staff with any skin abrasions or exfoliate skin conditions e.g. eczema, must not have direct patient contact with the MRSA positive patient. The receiving department must: See or treat patients at the end of the working session, wherever possible Keep equipment in the area to a minimum Keep the number of staff attending to a minimum Staff in contact with the patient or the patient s environment (bed/chair) should wear a disposable apron and gloves. The apron and gloves must be removed and disposed of into the orange waste stream once treatment is completed. Hands must be decontaminated following the removal of the apron and gloves. Page 17 of 55

18 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION MRSA positive patients must return to the ward as soon as possible following an investigation/procedure. Following surgery they may be allowed to recover in the main recovery area unless they have an MRSA sputum/chest infection, in which case they should ideally be recovered away from other patients. During this time it is of the utmost importance that strict attention is paid to infection control precautions such as hand hygiene and the use of personal protective equipment 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 contact with the patient e.g. trolley, couches. should be wiped clean with an Actichlor Plus solution at a strength of 1:1000 ppm. Linen should be disposed of into the alginate bag and then into plastic linen bags. Contaminated equipment and rubbish should be disposed of or decontaminated as usual. A deep clean of the bed space is recommended. MRSA positive patients may be transferred to other hospitals, healthcare providers, or nursing and residential homes, but the transfer must be preceded by a full handover of the patient s infectious status and the treatment and isolation required for that infection. Information regarding precautions to be taken must also be communicated to ambulance crew/transport staff prior to the transfer occurring. It is the responsibility of the transferring nurse to ensure that all staff involved in the transfer have had the infection status communicated to them. If a patient is discharged to a residential care facility the receiving medical and/or nursing staff should be informed in advance of the patient s infection status by the nursing/medical staff transferring the patient. Colonisation or infection with MRSA is not a contra-indication to the transfer of a patient to a nursing or convalescent home. The carriage of MRSA is not a valid reason for exclusion from residential care homes. 19. Repatriation of Patients Patients repatriated from other hospitals/healthcare facilities are considered to be high risk admissions and should always be repatriated into a single room where possible. A patient may be repatriated directly into a ward bay only if all options for isolation have been exhausted and only if the following criteria are met: They have had a negative MRSA screen within the last 7 days prior to transfer They receive a full MRSA screen directly upon admission to HHFT 20. Visitors 20.1 Visiting Healthcare Professionals Visiting healthcare professionals must: Visit the MRSA positive patient last if at all possible and where the clinical condition allows Page 18 of 55

19 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION Ensure that they are bare below the elbows, wash or gel hands and put on gloves and yellow apron before entering the room if they anticipate contact with the patient and/or their environment Minimise the number of healthcare professionals entering the room at any one time Limit the amount of equipment taken into the room Not place equipment on the patient s bed Not sit on the patient s bed Place all equipment near the door when ready to leave the isolated room Remove gloves and apron whilst inside the isolated room and place in the orange waste stream Wash hands thoroughly Collect any equipment and leave the room Use the alcohol hand gel after leaving the room Clean all items removed from the room with an Actichlor plus solution at a strength of 1: Visiting Friends and Relatives of an MRSA positive patient Friends and relatives visiting an MRSA positive patient do not need to wear personal protective equipment such as gloves and aprons unless they are providing direct hands on personal care. Instead they should be advised to cover any broken skin with a waterproof dressing, gel their hands upon entering the isolation room, and wash/gel their hands upon leaving the isolation room. It is safe for pregnant women and children to visit patients with MRSA. If there are specific areas of concern contact the Infection Prevention and Control Team for advice. Normal social contact such as hugging, kissing and holding hands can continue. If friends/relatives of an MRSA positive patient are visiting other people in the hospital, they are advised to see these first and visit the person in isolation last. 21. Cleaning of MRSA Isolation Rooms The standard precautions and procedures for the cleaning of MRSA isolation rooms by Domestic/Housekeeping staff can be seen in Appendix J. The MRSA isolation rooms cleaning responsibilities of nursing staff are described at appendix K. 22. Care for the MRSA Positive Patient at Death The presence of MRSA does not necessitate the use of a zipped body (cadaver) bag. White envelope bags will be used as is standard within the Trust. 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 55

20 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION The occlusion of any leaking wound with non-permeable dressing, Placing the body within a zipped plastic body bag, Placing a danger of Infection sticker on the outside of the body bag. The inappropriate use of body bags can cause great distress to bereaved families. The Infection Prevention and Control Team must be contacted for advice by the ward or mortuary staff if they are unsure if a zipped body bag is required. Further guidance can be found in the Care of Patients at Death Policy. 23. Stakeholders Engaged During Consultation Group / Individual Consulted Date of Consultation Infection Prevention & Control (Lead Infection Prevention & Control Nurse, Hazel Gray) 04/10/2012 Director Infection Prevention & Control (Dr Matthew 09/10/2012 Dryden) Health & Safety (Health & Safety Advisor, Paul Knight) 27/11/2012 Safeguarding (Trust Safeguarding Lead, Stephen O Connor) 27/11/2012 Information Governance (Information Governance Manager, 27/11/2012 Adam Spinks) Risk and Compliance Manager (Katharine Carter) 27/11/2012 Healthcare Library (Paul Bradley) 27/11/2012 Equality and Diversity Lead (Nicky Smith) 27/11/2012 Infection Prevention Control Committee 27/11/2012 Consultant Microbiologists: Dr Nicki Hutchinson, Dr Jorge 01/11/2012 Cepeda, Dr Fatima El-Bakri, Dr Roberta Parnaby, Dr Kordo Saeed Divisional Directors: Dr Carl Brookes, Dr Myrddin Rees, Dr 27/11/2012 Jeremy Hogg Divisional Operations Directors: Mark Johnson, Julie 27/11/2012 Maskery, Diane Blanchard Clinical Service Managers/Leads: (Trish Le Flufy, Jo Carter, 27/11/2012 Nick Maich, Andrea Gook, Pippa Woodcock, Vicky Jarman, Julie Heyes, Joan Palmer, Janine Child, Margaret Beattie, Julie MacPherson, Julie Cairns, Liz Terraciano, Arlene Wellman, Vicky Rowse, Lorraine Amos, Christine Saunders) Operational Service Managers: (Cathy Williams, Beth 27/11/2012 Norton, Kathy Barton, Simon Barson, Julia Uzzell, Natasha Martin, Sara Sparks, Harkamal Heran, James Montgomery, Yvonne McWean, Tracey Gwyther, Phil Tarling, Caroline Brunt) Page 20 of 55

21 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION 24. Dissemination and Implementation The policy will be disseminated as described in the table below. Action(s) Owner Publicise detail of new document via Intranet and IPCT and Communication Team Midweek message Communication sent to all senior Managers BNHH Healthcare Library advising publication of the policy The policy will be available on the intranet and BNHH Healthcare Library and website Communication Team 25. Training Individuals in the Trust should receive annual infection prevention and control training to ensure they are aware of their responsibilities. Infection prevention and control training will be delivered as outlined in the Trust training needs analysis and will be conducting in line with the Trust Learning and Development Policy. 26. Monitoring Compliance with the Document Minimum requirements Compliance with policy Root Cause Analysis of HCAI MRSA Bacteraemia * Requirement Reviewed by Infection Prevention and Control Team Infection Prevention and Control Team Method of Monitoring MRSA Screening Point Prevalence Internal Audit Root Cause Analysis Template Frequency of Review Monthly Within 12 hours (if occurred) Committee where Monitoring is Reported to Infection Prevention and Control Committee Serious Event Review Group * In line with DOH (2007) recommendations the root cause analysis process will be commenced within 12 hours of a reported case of Health Care Associated Infection (HCAI) of MRSA Bacteraemia, and will be completed and reported within 10 days of receipt of confirmation. Where HCAI of MRSA has been confirmed as the cause of death of a patient (is listed on Part 1 of the death certificate) this will be reported as a Serious Incident Requiring Investigation. A pre-48-hour positive MRSA bacteraemia will be reported to the Community Infection Prevention and Control Team within 12 hours of receipt of confirmation during office hours 27. References COIA, J. E., et al., Guidelines for the control and prevention of Meticillinresistant staphylococcus aureus (MRSA) in healthcare facilities. Journal of Hospital Infection. 635 (2006), pp. S1-S44. Page 21 of 55

22 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION DEPARTMENT OF HEALTH, Screening for Meticillin-resistant staphylococcus aureus (MRSA) colonisation: a strategy for NHS trusts: a summary of best practice ents/digitalasset/dh_ pdf (Accessed on 21/10/12). DEPARTMENT OF HEALTH, The Health Act 2006: Code of practice for the prevention and control of healthcare associated infections. DOH. ndguidance/dh_ (Accessed on 14/09/12). DEPARTMENT OF HEALTH, MRSA screening operational guidance. (Accessed on 13/07/12). DEPARTMENT OF HEALTH, Screening elective patients for MRSA- FAQs. DOH. asset/dh_ pdf (Accessed on 03/09/12). HEALTH PROTECTION AGENCY, Meticillin Resistant Staphylococcus aureus (MRSA) Screening and Suppression Quick Reference Guide for Primary Care - for consultation and local adaptation. HPA. (Accessed on 14/09/12). Sexton, T., et al Environment reservoirs of methicillin-resistant Staphylococcus aureus in isolation rooms: correlation with patient isolates and implications for hospital hygiene. Journal of Hospital Infection, 62 (2006), pp Associated Documentation Hand Hygiene Policy Standard Precautions Policy Isolation Policy Trust Empirical Prescribing Guidelines for Adults Care of Patients at Death Policy 29. Contributors Contributor Job Title Lead Infection Prevention and Control Nurse Director Infection Prevention and Control (DIPC) Contributor Name Hazel Gray Dr Matthew Dryden Page 22 of 55

23 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION Appendix A Equality Impact Assessment Tool PART 1 To be completed by the document owner Document Title: Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy Could the application of this document have a detrimental equality impact on individuals with any of the following protected characteristics? (See Note 1) Yes/No Comments Age Disability Gender reassignment Race Religion or belief Sex Sexual orientation Marriage & civil partnership Pregnancy and maternity If you have identified any potential detrimental impact, do you consider this to be valid, justifiable and lawful? If so, please explain your reasoning. If you have answered no to question 2, has the policy been amended to remove or reduce any potential detriment? If you answer yes, please summarise the changes made If you answer no. please explain why not Based on the answers to questions 1 3 do you consider that a detailed equality analysis is needed? No No No No No No No No No N/A N/A No NAME: Linda Swanson JOB TITLE: Infection Prevention and Control Nurse DATE: 14 September 2012 Page 23 of 55

24 Hampshire Hospitals NHS Foundation Control of Meticillin Resistant Staphylococcus Aureus (MRSA) Policy - HH(1)/IC/610/13 Due for latest review October CHECK THE INTRANET FOR THE LATEST VERSION PART 2 To be completed by the Trust s Equality and Diversity Lead Brief Summary of potential impact of this document and whether sufficient consideration has been given to the Equality Duty The application of this policy is completely clinically based and ensuring control of MRSA within the patient and employee population is the priority, however the Trust would endeavour to continue to meet patients and employees individual needs as far as is practicable. Is this document recommended for publication without amendment? Is this document recommended for publication but with recommended amendments? Please specify. Yes/No Yes N/A Comments Is this document not recommended for publication without amendments being made? Please specify? N/A Is it recommended that this document requires a more detailed equality analysis to be undertaken prior to publication? Specify with which, if any, individuals and groups you have consulted in reaching your decision. No None NAME: Nicky Smith JOB TITLE: Equality & Diversity Lead DATE: 7 th January 2013 Note 1 Under the terms of the Equality Act 2010 s public sector Equality Duty, the Trust has a legal responsibility to think about the following three aims of the Equality Duty as part of our decision making and policy development. Eliminate unlawful discrimination, harassment and victimisation; Advance equality of opportunity between people who share a protected characteristic and people who do not share it; and Foster good relations between people who share a protected characteristic and people who do not share it. Page 24 of 55

25 Appendix B NHS Patient Information Leaflet: Going into hospital About MRSA Information for people going into hospital [Type text] Easy read

26 This is an Easy read version of a leaflet called MRSA Screening A positive result. This leaflet is for people who need to go into hospital for an operation or other treatment who are carrying the MRSA germ. You may like to have someone to support you when you look at this leaflet. Patient Information leaflet: Going into Hospital v.1 Page 26 of 55

27 What is in this leaflet? What is MRSA? 2 Carrying MRSA.2 Going into hospital 4 What is an MRSA infection?..6 Getting rid of MRSA.7 Side effects 10 Can I have visitors in hospital? 11 What happens when I leave hospital?...12 How to find out more 13 Patient Information leaflet: Going into Hospital v.1 Page 27 of 55

28 What is MRSA? MRSA is short for Meticillin-Resistant Staphylococcus Aureus. MRSA is a type of germ that cannot be killed by an antibiotic called meticillin. (Antibiotics are drugs for treating some types of germs). But doctors can treat MRSA with other sorts of antibiotics. Carrying MRSA Do not worry if you have been told that you are carrying MRSA. Carrying MRSA does not mean that you are ill. Lots of people carry MRSA on their skin or in their nose. Patient Information leaflet: Going into Hospital v.1 Page 28 of 55

29 And you are not a risk to: other healthy people older people pregnant women children or babies. The MRSA germs will not usually cause you any problems. Patient Information leaflet: Going into Hospital v.1 Page 29 of 55

30 Going into hospital It may be a problem if you carry MRSA and you need to go into hospital. The MRSA germ can be a problem if it gets inside your body. This could be through a sore, or a wound from an operation, or a hole for a medical tube. Before you go into hospital, you may have some tests called screening. If you are carrying MRSA, you may not be able to go into hospital straight away. You may need treatment to get rid of as much of the MRSA as possible before you go into hospital. Patient Information leaflet: Going into Hospital v.1 Page 30 of 55

31 Your doctor or the hospital will explain the treatment to you and how to get the treatment. The treatment will mean that you are less likely to: get ill from MRSA yourself give MRSA to other patients. Patient Information leaflet: Going into Hospital v.1 Page 31 of 55

32 What is an MRSA infection? If MRSA gets into your body through a break in your skin you may get ill. This is called an MRSA infection. An MRSA infection may just cause redness or a bit of swelling round a wound. But it might cause more serious chest or blood infections. If you have an MRSA infection, doctors will use antibiotics which are not meticillin to treat you. Patient Information leaflet: Going into Hospital v.1 Page 32 of 55

33 Getting rid of MRSA You may need to get rid of MRSA from your skin before you go into hospital. Your doctor or nurse will talk to you about what you need to do. This usually means: washing your body with a special body wash using a special hair wash, and using a special cream in your nose. Patient Information leaflet: Going into Hospital v.1 Page 33 of 55

34 You may also need to: change your clothes every day change your bed sheets and pillowcases every day. You will usually need to do these things for 5 days or until you have your operation or treatment in hospital. Patient Information leaflet: Going into Hospital v.1 Page 34 of 55

35 You do not usually need to be in hospital while you are getting rid of MRSA from your skin. And you will not usually need to be checked for MRSA again before you go into hospital. But if your operation is urgent and you need to go into hospital quickly, you may need to have treatment for MRSA in the hospital. This might be in a side room in the hospital. If you have had MRSA before you may need special antibiotics. Your doctors will decide what sort of antibiotics you need. Patient Information leaflet: Going into Hospital v.1 Page 35 of 55

36 Side effects Side effects are things that may happen to you because of a treatment you are having. There are not usually many side effects from MRSA treatment. But you might have some small side effects like a rash. If you get a rash or are worried about any other problems, you should stop the treatment and talk to your doctor. Patient Information leaflet: Going into Hospital v.1 Page 36 of 55

37 Can I have visitors in hospital? Yes, you can have visitors. You are not risk to visitors, including pregnant women and children. But visitors should always wash their hands and use the special alcohol hand rubs when they visit anyone in hospital. Visitors should always do this when they go into or leave any room or area in the hospital. You should always check the rules about visitors with your hospital nurse. Patient Information leaflet: Going into Hospital v.1 Page 37 of 55

38 What happens when I leave hospital? Once you leave the hospital, you can carry on as normal. The hospital will tell your GP that you have been treated for MRSA. Your GP will talk to you about any extra treatment or tests you may need to make sure the MRSA has completely gone. Patient Information leaflet: Going into Hospital v.1 Page 38 of 55

39 How to find out more If you are worried about MRSA, you can talk to: your local NHS clinic nurse your practice nurse, or your GP. You can also find out more about MRSA at Crown copyright 2009 Produced by COI for the Department of Health About MRSA screening Easy read Patient Information leaflet: Going into Hospital v.1 Page 39 of 55

40 What if I have had MRSA before? If you have a history of MRSA you may be given special antibiotics. This will be decided by doctors and depends on the type of operation or procedure you are having. Can I still have visitors? Yes. You can still have visitors, including children and pregnant women. You are no risk to them. But always check the rules on visiting with your nurse. Visitors should always wash their hands and use the alcohol hand rubs when visiting anyone in hospital. They should do this when they enter or leave a patient s room or other areas of the hospital. What will happen after I leave hospital? Once you are at home, you can carry on as normal. Your GP will be informed of the fact that you have been treated for MRSA. They will discuss with you any necessary followup and may take further swabs to see if the MRSA has been fully removed Remember, if you are worried about MRSA talk to your local NHS clinic nurse, your GP or Practice Nurse, or look on the NHS Choices website where you can find out more about MRSA. Appendix C NHS Patient Information Leaflet: A Positive Result Did you know? MRSA has been around for many years, it was first identified in the 1960s. In England, MRSA infection rates in hospitals are falling. Compared to four years ago*, the number of MRSA infections has more than halved. * Between 2003/4 and 2007/8 MRSA bloodstream infections across England fell by 57% Crown Copyright p Apr 09 Patient Information leaflet: A positive result v.1 Page 40 of 55

41 What is MRSA? MRSA is a type of bacteria (germ). It stands for Meticillin Resistant Staphylococcus Aureus. It is a type of bacteria that has become resistant to a group of antibiotics called Meticillin. But doctors can still treat MRSA with other sorts of antibiotics. I ve been told I carry MRSA, what does this mean? Do not worry. Many people carry MRSA on their skin or in their nose. It does not make them ill and they are not a risk to healthy people. This includes older people, pregnant women, children and babies. We all carry lots of bacteria and usually it doesn t cause a problem. But when a person goes in to hospital carrying MRSA and has a procedure that involves breaking the skin, then the MRSA can get in to the body and may cause an infection. If we find out you are carrying MRSA before you go into hospital we can use a simple treatment to get rid of as much of it as possible. This means the chances of you getting an MRSA infection, or passing MRSA on to another patient, are much smaller. You will be contacted by the hospital or your GP, who will let you know what you need to do next. They will explain more about the treatment and how to get it. If you are carrying MRSA on your skin you may not be able to have your planned operation or procedure straight away. You may need to be treated first to protect you, and other patients, from getting ill. What is an MRSA infection? When MRSA causes an infection, this means that the MRSA bacteria are causing the person to be ill. The MRSA will have got into a person s body and they are said to be infected with MRSA. It can be a mild infection causing redness and swelling at a wound site. But it can also cause more serious chest or blood infections. If a patient has an infection caused by MRSA then antibiotics, other than Meticillin, are used. What is the treatment used to get rid of MRSA from my skin? Your doctor or nurse will discuss the treatment with you. It usually involves using an antibacterial wash or powder and using a special cream in your nose. You may be asked to change your clothes, sheets and pillowcases every day, usually for 5 days. You do not need to be in hospital whilst you are using the treatment. You should continue until the day of your operation or procedure or until the 5 days is complete. You should not usually need to be screened again before you come in to hospital. What if my operation is urgent? If your operation is urgent and you need to go into hospital quickly then you may be started on the treatment as soon as possible and might be admitted to a side room in the hospital. Are there any side effects of the treatment? The treatment has few side effects and generally any side effects will be mild, such as skin irritation. If you develop a rash, stop treatment and ask you clinic or doctor for advice Patient Information leaflet: A positive result v.1 Page 41 of 55