Document title: Document number: Staff involved in Development (job titles): Document author/owner: Directorate: Department: For use by: Methicillin Resistant Staphylococcus aureus (MRSA) Procedure DN339 Consultant Microbiologist Infection Prevention and Control Nurse Specialist Consultant Microbiologist Infection Prevention and Control Nurse Specialist Nurse management Infection Prevention and Control All clinical Staff Review due: June 2019 This is a controlled document. Whilst this document may be printed, the electronic version maintained on the Trust s Intranet is the controlled copy. Any printed copies of this document are not controlled. Papworth Hospital NHS Foundation Trust. Not to be reproduced without written permission. Key points: Guidance on management of hospital inpatients with MRSA. Roles, responsibilities and measures to be undertaken to identify, treat and limit spread. Monitoring and audit. Page 1 of 54
Section No. Contents Page 1 Introduction 3 2 Duties 3 3 General information 3 4 Screening 4 5 How to screen 5 6 Surgical procedures 6 7 Inter-hospital transfers 7 8 Flowcharts for surgical procedures 8 9 Topical treatment 11 10 Isolation 12 11 Patient information 13 12 Contact bays 13 13 Cohort bays 14 14 Outbreak 14 15 Ward closure 15 16 Specialist departments 15 17 Patient discharge 16 18 Risk management, liability, monitoring and audit 18 19 References 19 Appendices 20-54 Page 2 of 54
1 INTRODUCTION The objective of this document is to guide staff on the necessary steps required to identify patients with MRSA, manage them effectively and optimise the topical treatment required for those who are found to be positive thus reducing the risk to the individual and to minimise the potential of cross-infection to other patients and staff. Clinical staff have a professional responsibility to ensure they have the required knowledge to be able to provide the patient and their relatives with appropriate information, to reduce the anxiety and stress experienced by patients when they are informed MRSA has been identified. 2 DUTIES All staff have a professional responsibility to: To comply with this procedure To ensure understanding of this procedure and related documents, relevant to their role, to ensure the delivery of the appropriate care for patients identified with MRSA To ensure the Trust is compliant with Department of Health requirements on MRSA screening To seek clarification from their line manager or the Infection Prevention and Control team, if unsure about any part of the procedure or other related document To be aware of the current version of this procedure and other related documents and how to access them 3 GENERAL INFORMATION ON METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) Staphylococcus aureus is a bacterium carried harmlessly in the nose and on the skin of approximately 20-40% of the population, known as colonisation. If the bacteria enters the body, e.g. through a wound, intravascular device, urinary catheter or respiratory tract, it can cause infection. It is transmitted most easily from patient to patient on the hands of healthcare workers. Methicillin Resistant Staphylococcus aureus (MRSA) is not killed by many of the antibiotics used to treat staphylococcal infection. It is resistant to Penicillin, Flucloxacillin and all of the Cephalosporins (e.g. Cefuroxime, Cephradine), and may also be resistant to Erythromycin, Ciprofloxacin and Gentamicin. Although MRSA causes the same types of infection as Methicillin sensitive Staphylococcus aureus, MRSA can be more difficult to treat. If MRSA is transmitted in the hospital, it can put vulnerable patients at higher risk of healthcare associated infection. It is the responsibility of all staff associated with patient care to prevent the spread of MRSA. Page 3 of 54
HOW IS IT SPREAD? Contact with the patient or patient s environment Hand contact is the most common route of transmission. The most effective way to prevent transmission is by performing correct hand hygiene at the point of care. Refer to the Trust Hand Hygiene Procedure DN009. Patient equipment should be kept to a minimum in the single room and cleaned between each patient use. Refer to the Trust Cleaning and Disinfection Procedure DN011. Airborne MRSA can be dispersed on skin scales or from the respiratory tract (in sputum) into the immediate environment. Patients with MRSA infected/ colonised wounds, burns or respiratory tract are more likely to disperse MRSA via the airborne route. Transmission can be reduced by isolation of the patient into a single room, with the door closed at all times. Refer to the Trust Isolation Procedure DN 089. WHICH ARE THE MOST COMMON SITES OF COLONISATION? Nose Throat Perineum Groin Wounds Intravenous catheters Urine-if catheterised Leg ulcers 4. SCREENING All overnight admissions across all directorates on each admission must be screened for MRSA. Surgical patients these patients only need to be screened if their preadmission screen was taken over 3 months ago or they have other risk factors identified, please see DN339 There is no need to screen any other out-patients or day case attenders unless advised by infection control. Page 4 of 54
SCREENING OF INPATIENTS Hospital inpatients should be screened as follows: On admission to CCA if the patient has not been screened in one of the categories above After MRSA clearance treatment (see section 7) Weekly if they have been positive for MRSA in the past Weekly on CCA Screening a patient for MRSA should not delay the patient s clinical pathway Record all MRSA screens taken, the date, the result and action to be taken in the patient s clinical records history sheet and complete a blue screening sticker each time a screen is taken. 5. HOW TO TAKE AN MRSA SCREEN For more detailed information, please see Appendix 12. Wash hands before opening swabs Take swabs from the following sites, using a separate dry swab moistened with sterile saline or sterile water: Nose Throat Perineum/ Groin Order the test on ICE Ordercomms. In addition, clinical samples should be taken from the following sites where applicable: Intravascular device sites Catheter urine Wounds ( use black transport medium swab) Leg ulcers (use black transport medium swab) Use separate forms for all clinical samples, marked MRSA screen Ensure all details are completed in full and document if the patient is known to be a previous MRSA carrier Negative MRSA results should be available at 24 hours from receipt in the lab Positive results should be available at 48 hours from receipt in the lab Page 5 of 54
1 st new MRSA isolate results will be telephoned to the relevant departments by the Infection Prevention and Control nursing team during working hours Monday- Friday At weekends these results will be telephoned to relevant departments by the on - call microbiologist 6 SURGICAL PROCEDURES: The MRSA status of a patient will determine what surgical antibiotic prophylaxis they will receive. There are four categories of MRSA status: 1) MRSA positive 2) MRSA negative 3) MRSA unknown high risk 4) MRSA unknown low risk The checking of MRSA status prior to surgery is to be carried out by ward staff. Please follow the flowchart containing guidance in Appendix 13. A repeat screen must be taken on admission to the ward and the patient must be deemed as MRSA unknown or negative (refer to 6. 2 below). All admissions must be risk assessed in order to decide if they are high or low risk unknown, past positive or currently positive or negative. 6.1 Current MRSA positive patients: Where possible, topical treatment should be given to clear MRSA carriage before elective surgery in accordance with appropriate treatment flowchart as shown on pages 8, 9 and 10 6.2 MRSA status unknowns/past positives Please refer to flowchart in Appendix 7 to determine level of risk and actions to be taken in terms of isolation and antibiotic prophylaxis. Criteria for high risk unknown patients: Patient admitted from a residential/nursing home/other hospital Inpatient for 24 hours in another hospital since last screen Receiving dialysis Previously MRSA positive patients without 3 consecutive negative screens since positive Refer to appendix 7 and complete the MRSA Unknowns ICP and send to theatre with the patient. Criteria for low risk unknowns: Patients who have never been screened & have not been admitted to hospital/residential or care home for 24 hours Page 6 of 54
Patients who have been screened but the screen was taken over 3 months previously Past positives that have had 3 negative screens since the positive result and have had the last negative screen within 1 month Refer to appendix 7 and complete the MRSA Unknowns ICP and send to theatre with the patient. Criteria for negative: No history of MRSA Negative screen at pre-admission within the last 3 months Once the patients MRSA status has been determined appropriate antibiotic prophylaxis should be given. Refer to the antibiotic prophylaxis guideline for surgical procedure DN027. Theatre surfaces in contact with the MRSA unknown / positive patient must be cleaned and disinfected after the procedure. MRSA unknown/positive patients may be recovered in the main recovery area providing a dedicated nurse is responsible for their care. If this is not possible, the patient should be recovered in the main theatre. If the patient is being transferred to the Critical Care Unit, they must be risk assessed for the need to be isolated in a side room (see above) PPE- refer to trust procedure: Personal Protective Equipment DN441. After removing PPE, staff hands should be washed with soap and water. An alcohol hand gel may be used if hands are not visibly soiled. For further information refer to Hand Hygiene Procedure DN 009. 7. Inter-hospital transfers All inter-hospital transfers should be washed in Octenisan until a negative MRSA admission screen (multi-site and any relevant clinical site as in section 5 above) is received Page 7 of 54
8. Flowcharts A) Cardiac Surgery Pre-operative screening and treatment flowchart MRSA status unknown (not screened at angio or re-admitted since last screen) Pre-admission clinic Explain to patient the need to screen and treat pre-operatively Patient admitted for surgery Emergency transfer Did not attend pre-admission MRSA screen taken MRSA screen taken Given Topical treatment pack & instructions to start 5 days before admission Determine level of risk and refer to appropriate ICP Results should be available by admission If not available ring #6290 Start topical treatment ASAP if possible 5 days before surgery Positive Results not available Negative Choose appropriate prophylaxis Isolate continue topical treatment for a further 48 hours Vancomycin prophylaxis Determine level of risk and refer to appropriate ICP Stop topical treatment If results are negative STOP isolation and treatment Swab 48 hours following completion of topical treatment Repeat swabs at a further 7 days Repeat swabs at a further 7 days If all are negative stop isolation Page 8 of 54
B) Thoracic Surgery Pre operative screening and treatment flowchart MRSA status unknown Out patient clinic/pre-admission clinic Explain to patient the need to screen and treat pre-operatively Patient admitted for surgery Emergency transfer Did not attend pre-admission MRSA screen taken MRSA screen taken Given Topical treatment pack & instructions to start 5 days before admission Determine level of risk and refer to appropriate ICP Results should be available by admission If not ring #6290 Start topical treatment ASAP if possible 5 days before surgery Positive Results not available Negative Choose appropriate prophylaxis Isolate continue topical treatment for a further 48 hours Vancomycin prophylaxis Determine level of risk and refer to appropriate ICP Stop topical treatment If results are negative STOP isolation and treatment Swab 48 hours following completion of topical treatment Repeat swabs at a further 7 days Repeat swabs at a further 7 days If all are negative stop isolation Page 9 of 54
C) Pulmonary Endarterectomy MRSA screening Pathway Routine MRSA swab on the day of admission for phase II as per the Papworth Hospital Trust Procedure Results faxed to Pulmonary Hypertension Nurse Support Office of MRSA swabs from admissions of Phase II in referring centres MDT meeting following coronary angiogram Patients are added to active waiting list after IVC filter insertion and review at MDT meeting with coronary angiogram Ring patient and send letter to GP with requirement for MRSA screening swabs. Three recommended screening sites; nose, throat and skin site. Results faxed to PHNSO (PEA nurses/admin to follow up the results) Positive MRSA result Treat with recommended decolonisation protocol; Octenisan wash and Bactroban nasal ointment On admission treat as pos unless 3 neg. screens received No overnight admissions to hospital prior to admission for surgery - treat as MRSA negative. Put fax in patient notes. Rescreen on admission. Negative MRSA result Overnight admission to any hospital since last screen, re swab at the GP when ringing patient with date for surgery If no results available treat as MRSA unknown. Document in notes and inform ward nurses and booking office. Refer to MRSA unknown ICP/flowchart MRSA negative- Inform booking office and put results fax in the patient s notes. If Positive or result not available, inform Infection control team/ward nurses and booking office and treat as positive/unknown. Put fax in patient notes. Page 10 of 54
9. MRSA DECOLONISATION TREATMENT All patients who test positive for MRSA on screening prior to admission should receive topical decolonisation treatment. It is the responsibility of Papworth Hospital NHS Trust to ensure arrangements for the patient to receive treatment are made. If the patient s MRSA is reported as mupirocin resistant please discuss with the IPCT before starting topical treatment. Standard decolonisation clearance treatment (see Appendix 6 for patient guidance on usage at home) for patients identified as colonised/infected with MRSA.. Mupirocin 2% (Bactroban Nasal Ointment ) 3 times daily to each anterior nare of the nostril for 5 days. The patient should be able to taste Mupirocin at the back of the throat after each application Octenisan for bathing or showering each day for 5 days. Special attention should be paid to known carriage sites e.g. axilla, groin and perineal area. Shampoo with Octenisan on the first and third days of treatment. Ensure hair is rinsed well. Mupirocin 2% (Bactroban Skin Preparation) once daily to small broken skin sites but use nasal preparation on large raw areas or mucosa Mupirocin 2% (Bactroban Nasal Ointment ) to areas near plastic items i.e. IV lines, chest drains. Bed linen, towels, disposable washcloths and clothing /nightwear should be changed daily throughout the treatment period. For patients with dermatological conditions (e.g. eczema or dermatitis) the advice of a dermatologist may be useful. If any skin irritation or other problem develops the treatment should be stopped and the Infection Prevention and Control Team (IPCT) contacted. Post treatment screening: Once the five-day topical treatment regime is completed, three consecutive negative screens are required before the patient is considered to be MRSA negative. The first screen should be taken at 48 hours after stopping clearance treatment and the next two taken at subsequent weekly intervals If any of the post-treatment screens are positive, recommence topical treatment protocol for a further 5 days and follow the same screening cycle. If the patient remains positive after two cycles of topical treatment, contact the IPCT for advice before any further treatment is commenced Page 11 of 54
10. ISOLATION WHO SHOULD BE ISOLATED Previous carriers of MRSA on admission to hospital Inter-hospital transfers when MRSA status unknown Patients newly found to have MRSA Patients known to still carry MRSA Patient admitted to CCA from another hospital and MRSA status unknown In all cases refer to the Priority for use of side rooms guideline DN317. o For guidance on isolation of CF patients who are positive for MRSA in sputum please see Trust Procedure DN539 Infection Control Guidelines for Patients with Cystic Fibrosis. o For further guidance on isolation see Trust Isolation Procedure DN89 & the Isolation Rooms: Priority for Use Procedure DN317. HOW TO ISOLATE Isolate the patient in a single room with door closed and red contact precautions sign. Commence Integrated Care Pathway and topical treatment (Appendix 4) Screen other patients who have been in close contact (i.e. in the same room or bay) for more than 24 hours( See section 10) Equipment should be designated for the isolated patient Disposable plastic aprons and disposable gloves as PPE procedure DN441 Surgical masks to be worn for wound care, tracheal suction and physiotherapy, or stripping the bed linen After removing gloves, hands must be washed with soap and water or an alcohol hand gel can be used. On leaving the ward or department, hands should be washed with liquid soap and water and dried or use an alcohol hand gel. The door of the isolation room should be kept closed at all times, to minimise transmission. If this poses a patient safety risk or the patient has a psychological issue, please document in nursing notes and discuss with the IPCT Patients who are mobile may exercise out of their room, with footwear worn, as long as they do not have contact with other patients and perform hand hygiene on exiting and entering their room. Please discuss each individual case with the IPCT Page 12 of 54
11. INFORMATION FOR PATIENTS AND RELATIVES It is the responsibility of the nurse caring for the patient at the time the result becomes available, to explain the results to patient and relatives and offer them the patient/visitors leaflet on MRSA, available on the Infection Control page on the Trust intranet The IPCT will visit patients who have new 1 st isolate results within 24 hours of the result becoming available, during normal working hours Monday- Friday The MRSA procedure is available to the public, copy on request or via the hospital internet. Visitors do not need to wear gloves and aprons unless providing close, personal care, but must perform hand hygiene before entering and when leaving the room. They should be shown how to do this by ward staff 12. CONTACT BAYS In first instance, discuss with the Infection Prevention and Control Team (IPCT), or on call microbiologist out of hours The following applies only if the patient has been in the bay for >24 hours Screen all patients in the bay occupied by the MRSA positive patient, once the patient with MRSA has been moved into single room: ( contacts ) On a surgical/cardiology ward, a bay with patients who have been contacts of an MRSA positive patient must be kept closed to admissions and transfers until the results of the MRSA screen of those contacts are known, as these wards receive patients who are having invasive procedures In Critical Care, The contacts should be isolated into single rooms where possible. If not possible then contact precautions should be taken in the bay for these contact patients until a negative screen is obtained. If there is evidence of ongoing transmission of MRSA then the bay must be closed to admissions and transfers, this will be done on the advice of the IPCT. Inform receiving wards of MRSA contact prior to transfer, as the patient will require isolation on the ward until results are available On a medical ward, patients may be admitted to a contact bay with patients who have been contacts of an MRSA positive patient. Patients who have drains, long intravascular lines, urinary catheters or wounds (including pressure sores) should not be admitted to the MRSA contact bay until the results of the MRSA screens are known Page 13 of 54
If new MRSA results are received from the contact bay screening, further measures will be decided by the IPCT in discussion with the ward and patient care/bed manager When the patient has been transferred to a side room, the bed space should be cleaned with combined detergent/disinfectant and the curtains changed before another patient is admitted to the bed space 13. COHORT BAYS Where side rooms are unavailable, the patients known to be MRSA positive can be nursed together in a designated bay Patients with MRSA and other organisms at risk of cross infection should not be nursed in the MRSA only cohort bay unless discussed with the IPCT Bays in which MRSA positive patients are being barrier-nursed as a cohort must not accept admissions or transfers of patients who are not known to be MRSA carriers Contact precautions must be implemented for each individual patient within the bay Personal Protective Equipment must be used for each patient episode Hand hygiene should be performed according before and after contact with the patient or their environment, please refer to the Trust Hand Hygiene Procedure DN9 14. OUTBREAK OF MRSA ON THE WARD An outbreak has occurred when there is evidence of patient-to-patient spread. The decision to declare an outbreak situation will be taken by the Infection Prevention and Control Team IF AN OUTBREAK IS DECLARED: Isolate patients carrying MRSA, re-screen and commence topical treatment. If all side rooms are occupied, it may be necessary to barrier nurse positive patients in a dedicated MRSA cohort area or bay ( Priority for use of Isolation rooms DN 317) An outbreak meeting will be called by the IPCT In an outbreak it may be necessary to: Screen all patients on the ward for MRSA carriage Check that staff do not have damaged skin on their hands that may increase the risk of MRSA transmission. Any staff with suspected infected hand lesions should contact occupational health for further advice An MRSA screen may be required from each staff member. The IPCT will advise on this see Appendix 9 Page 14 of 54
Any decision to close individual bays or wards areas will be made by the IPCT after discussion with the relevant area. Refer to the Trust Ward Closure Procedure DN332 15. WARD CLOSURE This may be necessary to prevent the spread of MRSA to new patients, and to stop MRSA being established on other wards in the hospital. The decision to close a ward, and the period of closure will be determined at the Outbreak Control Meeting. Patients must not be admitted to a closed ward. WHEN A WARD IS CLOSED: Patients may be discharged home or to a nursing home, but may not go to other wards unless they are transferred into a side room and isolated until the results of the MRSA screen is known Nursing staff, including Bank staff ideally should not nurse patients on other wards. If staffing levels make this impossible, nurses may go to a different ward on a different shift Medical staff cannot be restricted in the same way. To ensure that they do not carry the organism around the hospital they must comply with contact precautions, isolation procedures and hand hygiene, at the point of care, between patients and on leaving the ward. The closed area should be visited last, where possible Other healthcare workers, e.g. physiotherapists, should if possible work with one ward. If this is not practical, again, they need to give particular care to hand hygiene and Isolation procedures. Staff should visit the closed areas last Hands must be washed with soap and water between patients and on leaving the ward or department The ward will remain closed to new admissions until the Infection Prevention & Control Team are assured that there are no further cases Before the ward is re-opened, it should be deep cleaned thoroughly with particular attention to horizontal surfaces where dust and skin scales settle. Change all curtains and ensure blinds are thoroughly cleaned. Linen should be treated as infected 16. SPECIALIST DEPARTMENTS (Radiology, Respiratory Physiology etc) Transfer of patients known to be MRSA positive, to other departments, should be risk assessed according to clinical need The transferring ward must inform the receiving department of the patient s MRSA status to allow appropriate infection, prevention and control precautions to be implemented Page 15 of 54
TRANSPORTING PATIENTS between Departments: Staff should wear disposable aprons and gloves according to PPE procedure It is not necessary for patients to wear masks, aprons or gloves The trolley or chair should be cleaned after patient contact with a combined detergent and chlorine based product at a dilution of 1000ppm available chlorine After transporting patients, staff must wash their hands soap and water or use an alcohol hand gel Ambulance staff need only clean the trolley or bed, which has been in contact with the patient, they do not need to clean the ambulance unless there has been soiling CARING FOR PATIENTS WITH MRSA WITHIN THE SPECIALIST DEPARTMENT: Staff in contact with the patient should wear PPE according to PPE Procedure DN441 Exposed equipment should be kept to a minimum, according to clinical need Surgical masks must be worn for aerosol generating procedures Clinical waste and linen should be treated as an infectious risk Equipment and surfaces, which have come in contact with the patient, should be cleaned with a combined detergent and chlorine based product at a dilution of 1000ppm available chlorine Staff hands must be washed thoroughly with soap and water or an alcohol hand gel after contact with the patient and equipment 17. DISCHARGE/TRANSFER OF PATIENTS WITH MRSA Carriage of MRSA should not be a reason for delaying discharge either to the patient s home or to a nursing/residential home, or for transfer to another hospital The nursing or residential home should be informed prior to discharge by the discharging ward If the patient has commenced topical treatment in hospital they should be encouraged to complete the cycle at home. The patient needs to be reassured that MRSA is a low risk to relatives or others outside the Page 16 of 54
hospital environment. Please inform the patient that post treatment screening is carried out by the GP The GP, District Nurse and other health care professionals involved in the patient s care in the community should be informed of the patient s MRSA status by the Papworth Hospital ward staff,within the content of the discharge paperwork (Appendix 10) The Infection Prevention and Control Nurse team are responsible for informing the GP and Patient of new MRSA positive results by letter, if the patient is found to be positive pre-operatively, pre day case procedure, or the result becomes available after the patient has been discharged home ( Appendix 1 & 2 & 10). Copies of the letters sent are available to view on the TOMCAT system The Infection Prevention and Control Nurse team are responsible for informing the nearest referring hospital s Infection Prevention and Control Team, (in proximity to the patients home area), of new MRSA results, if the result becomes available after the patient has been discharged home. Copy available to view on TOMCAT(Appendix 3 & 10) If a patient with MRSA is discharged to another hospital, it is the responsibility of the Papworth Hospital transferring ward staff to inform the receiving hospital of the patient s MRSA status (including whether the patient carries MRSA now, or has done in the past) and complete the Infection Control Transfer form which can be found within the Transfer and Discharge procedure DN096. Carriage of MRSA should not delay transfer to another hospital. If problems are encountered, please inform the Infection Prevention & Control Team CAR TRANSPORT Patients may travel in a car with other patients who have no open wounds or invasive devices such as long intra-vascular lines, drains or catheters. AMBULANCE (Including Papworth Internal Ambulance) Papworth Hospital ward staff to inform Ambulance Control of patient s MRSA status when booking A patient with MRSA should not share the ambulance with another patient who has open wounds or invasive devices PPE to be worn according to PPE procedure DN441 After removing gloves, staff should wash hands thoroughly with liquid soap and water, or an alcohol hand gel may be used It is not necessary for patients to wear masks, aprons or gloves The trolley or chair should be cleaned after patient contact, with combined detergent and disinfectant wipes Page 17 of 54
Ambulance staff need only clean the trolley or bed that has been in contact with the patient. They do not need to clean the ambulance unless there is obvious soiling 18 RISK MANAGEMENT / LIABILITY / MONITORING & AUDIT Please refer to the monitoring table in DN296 which shows the mechanism for monitoring the controls assurance framework in place for infection prevention and control at Papworth Hospital. The Infection Prevention & Control Committee is responsible for developing measurement tools, reviewing/monitoring practice and instituting action plans as necessary. Infection Prevention & Control Audit Programme (IC Shared Drive) Monthly surveillance of Isolation Precautions (Appendix8 (IC Shared drive) The IPCT will inform the ward staff by telephone of all patients identified with a new isolate of an alert organism as soon as the result is available, during normal working hours (Mon-Fri), so that treatment and control measures are instituted promptly. At weekends these results will be telephoned to the ward by the on-call microbiologist. The ward staff should inform the medical team who can then discuss the need for treatment if indicated, with the microbiologist. A monthly surveillance of patients requiring isolation will be undertaken by the Infection Prevention & Control nurses to ensure that the appropriate control measures are taken. Page 18 of 54
19 REFERENCES Guidelines for the control and prevention of Meticillin-Resistant Staphylococcus aureus (MRSA) in healthcare facilities by the Joint BSAC/HIS/ICNA working Party on MRSA. Journal of Hospital Infection (2006) 63 Supplement 1 DH 2010 Saving Lives: High Impact Intervention 4 Care Bundle for the Prevention of Surgical Site Infection Page 19 of 54
Appendix 1 Date GP Details Dear Dr Your patient was found to be a carrier of Methicillin resistant Staphylococcus aureus (MRSA) on routine screening while a patient at Papworth. They were discharged prior to the results being available and have been informed of the results by letter (copy enclosed). Topical treatment and further screening are at your discretion (treatment protocol and patient guidance enclosed for information). Should this patient need to be re-admitted to a hospital, would you please inform the admitting staff the patients was an MRSA carrier. If you require further information please contact me on the number below. Yours sincerely Copy: Patient s notes Date Page 20 of 54
GP details Dear Dr This patient has recently attended Papworth Hospital and has been referred for cardiac surgery. Routine screening has shown the patient is colonised with Methicillin Resistant Staphylococcus aureus (MRSA). It is part of the normal flora and not causing infection. The patient has been informed of the result by telephone, with follow up letter (copy enclosed). Our protocol for treating patients awaiting surgery who are MRSA carriers is as follows: 5 day course of topical decolonisation treatment to be started as soon as possible or minimum of 5 days prior to admission for surgery (copy of treatment protocol and patient instructions enclosed for information). If timescales allows, post treatment swabbing (nose, throat, groin) to be carried out following completion of topical treatment. Three consecutive sets of swabs are required to be taken, the first set 48 hours after completion of treatment, the second set 7 days after the first post treatment screen and the third set 7 days after the second post treatment screen. If you or the patient would like to discuss this, or have any queries, please contact me on the telephone number below. Thank you for the help with this matter. Yours sincerely Copy: Patient s notes Appendix 2 Page 21 of 54
Date Dear During your recent admission to Papworth Hospital, routine swabs for MRSA were taken. Your results show that you are a carrier of MRSA. Some people carry MRSA on their skin or in the nostrils and are unaware, because it does them no harm and they have no symptoms, known as colonisation. Further information can be found within the enclosed MRSA leaflet or from the Papworth Hospital website Clinical Quality Infection Control page. MRSA skin carriage (colonisation) can be treated with topical washing lotion and nasal cream. Please contact your GP to arrange an appointment to discuss the results and possible treatment. Your GP has been sent a copy of this letter. If you are readmitted to hospital, please inform the medical staff that you have been a carrier of MRSA. If you require further information please contact me on the number below. Yours sincerely Copy: Patient s notes Appendix 3 Page 22 of 54
Date Dear Infection Control Team, For your information this patient was recently identified as MRSA positive whilst at Papworth Hospital and may at some stage be re-admitted to your hospital. If you require any further information regarding this patient, please do not hesitate to contact me on the number below. Yours faithfully, Page 23 of 54
Appendix 4 Methicillin Resistant Staphylococcus Aureus (MRSA) Integrated care pathway Standard: All patients known to be MRSA positive will be placed appropriately, receive timely and effective treatment and undergo follow up screening. Addressograph D E T A I L S: Ward: Consultant: Named Nurse: Date of Procedure: Date and site of first positive specimen result Date topical treatment to start Date topical treatment to finish Notes labelled with alert stickers PAS /TOMCAT alert (IPC team to do) Date Signature Initials Date All members of staff who use this integrated care pathway should complete this signature section, using black ink. Print Name Job title Initials Signature Date Page 24 of 54
Actions to be taken Date Signature Variance code Inform patient of positive result and explain isolation precautions Transfer patient to a single room Isolate into single room Display appropriate isolation sign on door Ensure door is closed Ensure alcohol hand rub is available outside the room Ensure personal protective equipment (PPE) is available outside the room Provide patient with written and verbal information on MRSA Provide relatives with written and verbal information on MRSA Obtain Doctors signature for topical treatment prescription and commence MRSA topical eradication treatment within 24 hours of positive result Once treatment is commenced ensure patient is provided with a disposable washcloth and towel daily Remove all unnecessary clutter and equipment from the room Screen patient contacts as per ward/trust MRSA procedure Variance codes M1 Single room not available M2 Unable to close door (Document reason) M3 Unable to provide written information (Document reason) M4 Unable to provide verbal information (Document reason) M5 Unable to commence topical treatment within 24 hours (Document reason) M6* Patient unable to use Triclosan (Aquasept ) or Octenisan Document reason M7* Patient unable to use Mupirocin (Bactroban ) Document reason *Please inform infection prevention & control team if patient has a skin condition, eg Psoriasis, Eczema, ulcerated or broken areas, as use of Aquasept may be contraindicated. Page 25 of 54
Prescription for the Clearance of MRSA Addressograph (Minimum of Name & Hospital Number) Whole cycle (Treatment, 3 sets of swabs, await results) takes 21 days Signature: Date: 5-Day Topical Treatment Plan Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Date Mupirocin (Bactroban 6 12 22 6 12 22 6 12 22 6 12 22 6 12 22 Nasal Preparation) Apply to nose 3 times a day For 5 days Mupirocin (Bactroban Skin Preparation) Apply to small broken skin sites Once daily. Apply nasal prep to areas near plastic items i.e. I/V lines, chest drains. Use nasal prep on large raw areas or mucosa. Octenisan FOR DAILY BATHING Apply to wet skin Octenisan USE AS A SHAMPOO Apply on day 1 and 3 (NB if patient for surgery, give a stat dose of 1 gm Vancomycin at induction if prophylaxis required) Is this the first/second MRSA elimination treatment? (Please circle) First Second MRSA screen swabs are taken 48 hrs after topical treatment finishes (day 8), then 7 days (day 15) after this and then 7 days (day 22) later. Patient is only clear when third set of swabs found to be negative. Screen Patient Date Taken Result due Pos / Neg 48 hrs after completion of treatment (Results are due 2 days after screen) 7 days after 1 st screen 7 days after 2 nd screen If ALL 3 screens are negative, discontinue Isolation but screen weekly If ANY of the 3 screens are positive, commence 2 nd cycle of treatment BUT, if after 2 cycles of treatment patient is still positive, contact Infection Prevention & Control Nurse before any further cycles are commenced, ext. 4685/6032 S T O P Page 26 of 54
Treatment days 1-5 Actions: Maintain isolation precautions Provide disposable washcloth and towel daily Change bed linen daily Change clothing/ nightwear daily Day 1 Date & initial Day 2 Date & initial Day 3 Date & initial Day 4 Date & initial Day 5 Date & initial De clutter and tidy room Check room has been cleaned by domestic Page 27 of 54
Multi professional communication sheet Date Communication Signature Page 28 of 54
Date Communication Signature Page 29 of 54
Appendix 5 Instruction leaflet and prescription TOPICAL TREATMENT OF Methicillin Resistant Staphylococcus aureus (MRSA) CARRIAGE AT HOME Dear Patient INSTRUCTIONS FOR TOPICAL TREATMENT OF Methicillin Resistant Staphylococcus aureus (MRSA) CARRIAGE AT HOME We would like you to follow these instructions in order to reduce the risk of MRSA. If a District Nurse is treating you, please show her that you have this sheet. You have been supplied with Mupirocin 2% (Bactroban Nasal Ointment ) and Octenisan skin cleanser PLEASE FOLLOW THESE INSTRUCTIONS: 5 DAYS TREATMENT AS FOLLOWS: 1 Mupirocin 2% (Bactroban Nasal Ointment ) nasal ointment: use a small amount (size of a cotton bud) and smear it just inside each nostril three times a day for five days. 2 Octenisan for bathing or showering each day for five days. The lotion should be applied directly on to wet skin with a clean flannel or sponge. Rinse well. 3 Shampoo with Octenisan on the first and third days of treatment. Use on wet hair, rub well into the scalp, rinse and then use normal shampoo/conditioner as required. If there is any skin reaction to the soap or ointment, stop its use and discuss it with the pre-admission clinic nurse. If you do not understand some of the instructions on the sheet, or are unable to follow them for any reason, please contact the ward or pre-admission clinic nurse on 01480 364100. Clothing and laundry: While having the treatment, a clean flannel/ cloth and towel should ideally be used for bathing/ showering each day. After bathing, you should put on clean clothes. The bed linen should be changed frequently, ideally daily while you are having the treatment. You should ensure that you keep one towel for your own personal use during the five days that you are using the antiseptic lotion. Used clothing, sheets and towels can be safely machine or hand-washed using as hot a wash cycle as is safe for the fabric. Page 30 of 54
Prescription for the Clearance of MRSA Patient Addressograph Lab (minimum of Name & Hospital Number) Whole cycle (Treatment, 3 sets of swabs, await results) takes 21 days Signature: Date: 5 Day Topical Treatment Plan Date Mupirocin 2% (Bactroban Nasal Ointment ) Apply to nose 3 times a day for 5 days Mupirocin 2% (Bactroban Skin PREPARATION) Apply to small broken skin sites once daily. Apply nasal prep to areas near plastic items ie I/V lines, chest drains. Use nasal prep on large raw areas or mucosa. Octenisan FOR DAILY BATHING Apply to wet skin Octenisan TO USE AS A SHAMPOO Apply on day 1 and 3 Day 1 Day 2 Day 3 6 12 22 6 12 22 6 12 22 6 12 22 6 12 22 Day 4 Day 5 Day 6 S T O P Is this the first/second MRSA elimination treatment? (Please initial box) First Second MRSA screen swabs are taken 48 hrs after topical treatment finishes (day 7), then 7 days (day 14) after this and then 7 days (day 21) later. Patient is only clear when third set of swabs found to be negative. Page 31 of 54
Appendix 6 Instruction leaflet and prescription for Pre-operative Cardiac Surgery. Dear Patient INSTRUCTIONS FOR TOPICAL TREATMENT OF Methicillin Resistant Staphylococcus aureus (MRSA) CARRIAGE AT HOME We would like you to follow these instructions in order to reduce the risk of MRSA. If a District Nurse is treating you, please show her that you have this sheet. You have been supplied with a prescription for Mupirocin 2% (Bactroban Nasal Ointment ) and Octenisan skin cleanser Please take to your prescription to local pharmacy if instructed to by the Cardiac Support Team. The pharmacist will supply you with an antiseptic lotion, and a nose ointment. The lotion is used as soap for a shower/bath and shampoo. The ointment is for the inside of your nose. Make sure that you wash your hands after applying the ointment. PLEASE FOLLOW THESE INSTRUCTIONS: - 5 DAYS TREATMENT AS FOLLOWS: 1 Mupirocin 2% (Bactroban Nasal Ointment ) nasal ointment: use a small amount (size of a cotton bud) and smear it just inside each nostril three times a day for five days. 4 Octenisan for bathing or showering each day for five days. The lotion should be applied directly on to wet skin with a clean flannel or sponge. Rinse well. 5 Shampoo with Octenisan on the first and third days of treatment. Use on wet hair, rub well into the scalp, rinse and then use normal shampoo/conditioner as required. If there is any skin reaction to the soap or ointment, stop its use and discuss it with the pre-admission clinic nurse. If you do not understand some of the instructions on the sheet, or are unable to follow them for any reason, please contact the ward or pre-admission clinic nurse on 01480 364100. Clothing and laundry: While having the treatment, a clean flannel and towel should ideally be used for bathing/ showering each day. After bathing, you should put on clean clothes. The bed linen should be changed frequently, ideally daily while you are having Page 32 of 54
the treatment. You should ensure that you keep one towel for your own personal use during the five days that you are using the antiseptic lotion. Used clothing, sheets and towels can be safely machine or hand-washed using as hot a wash cycle as is safe for the fabric. Page 33 of 54
Prescription for the Clearance of MRSA Patient Addressograph Lab (minimum of Name & Hospital Number) Whole cycle (Treatment, 3 sets of swabs, await results) takes 21 days Signature: Date: 5 Day Topical Treatment Plan Date Mupirocin 2% (Bactroban Nasal Ointment ) Apply to nose 3 times a day for 5 days Mupirocin 2% (Bactroban Skin PREPARATION) Apply to small broken skin sites once daily. Apply nasal prep to areas near plastic items ie I/V lines, chest drains. Use nasal prep on large raw areas or mucosa. Octenisan FOR DAILY BATHING Apply to wet skin Octenisan TO USE AS A SHAMPOO Apply on day 1 and 3 Day 1 Day 2 Day 3 6 12 22 6 12 22 6 12 22 6 12 22 6 12 22 Day 4 Day 5 Day 6 S T O P Is this the first/second MRSA elimination treatment? (please initial box) First Second Is this the first/second MRSA elimination treatment? (Please initial box) MRSA screen swabs are taken 48 hrs after topical treatment finishes (day 7), then 7 days (day 14) after this and then 7 days (day 21) later. Patient is only clear when third set of swabs found to be negative. Screen Patient 48 hrs after completion of treatment 7 days after 1 st screen 7 days after 2 nd screen Date Taken Result due Pos Neg Isolate on admission. Prescribe another two days to cover the day of operation and the 1 st post operative day. Check Vancomycin prescribed for surgical prophylaxis. Page 34 of 54
Appendix 7 This document must be sent to theatre with the patient Methicillin Resistant Staphylococcus Aureus (MRSA) UNKNOWN and previous positive MRSA (with 3 negative screens) surgical patients If unsure of antibiotic prophylaxis, contact the Microbiologist Integrated care pathway Standard: This pathway is to be used for all MRSA UNKNOWN and previous positive MRSA (with 3 negative screens) surgical patients. Addressograph D E T A I L S: Ward: Consultant: Named Nurse: Date of Procedure: All members of staff who use this integrated care pathway should complete this signature section, using black ink. Print Name Job title Initials Signature Date Page 35 of 54
Flow chart to determine if patient is a high or low risk MRSA unknown Is the patient high or low risk MRSA UNKNOWN? High risk criteria: Patient admitted from a residential/nursing home/ other hospital Inpatient for 24 in another hospital since last screen Receiving dialysis For known currently positive MRSA patients, including past positives without 3 consecutive negative screens, or past positive with the last negative screen not being within a month of surgery, use ICP in DN339 App 4. Low risk criteria: Patients who have never been screened & have not been admitted to hospital/residential or care home for 24 hours Patients who have been screened but the screen was over 3 months previously Past positives that have had 3 consecutive negative screens since the positive result and have had the last neg screen within 1 month * See note If High risk: Take admission screen Isolate patient Commence topical decolonisation treatment Send this ICP with the patient to theatre (App 7). Use antibiotic prophylaxis option which includes Vancomycin Refer to DN027 Antibiotics for surgical prophylaxis Note patients allergy status If Low risk: Take admission screen Isolate patient is able Commence topical decolonisation treatment Send this ICP with the patient to theatre (App 7).Use standard prophylaxis Refer to DN027 Antibiotics for surgical prophylaxis Note patients allergy status *Note: MRSA Past positives who match the criteria above, must be isolated on admission and screened Page 36 of 54
Is the patient high or low risk? Actions to be taken if high risk Transfer patient to a single room Isolate into single room Screen patient on admission Display appropriate isolation sign on door High Low Tick as appropriate Date Signature Variance code Ensure door is closed Ensure alcohol hand rub is available outside the room Ensure personal protective equipment (PPE) is available outside the room Obtain Doctors signature for topical treatment prescription and commence MRSA topical eradication treatment Once treatment is commenced ensure patient is provided with a disposable washcloth and towel daily Remove all unnecessary clutter and equipment from the room Follow pathway in DN027 if the patient is MRSA status unknown with high risk of MRSA infection, for surgical prophylaxis guidance. Send this document to theatre with patient Actions to be taken if low risk Isolate into single room if able Date Signature Variance code Screen patient on admission Display appropriate isolation sign on door Ensure door is closed Ensure alcohol hand rub is available outside the room Ensure personal protective equipment (PPE) is available outside the room Obtain Doctors signature for topical treatment prescription and commence MRSA topical eradication treatment Once treatment is commenced ensure patient is provided with a disposable washcloth and towel daily Remove all unnecessary clutter and equipment from the room Follow pathway in DN027 if the patient is MRSA status unknown with low risk of MRSA infection, for surgical prophylaxis guidance Send this document to theatre with patient Variance codes M1 Single room not available M2 Unable to close door (Document reason) M3 Unable to commence topical treatment (Document reason) Page 37 of 54
M4* Patient unable to use Triclosan (Aquasept ) or Octenisan Document reason M5* Patient unable to use Mupirocin (Bactroban ) Document reason *Please inform infection prevention & control team if patient has a skin condition, e.g. Psoriasis, Eczema, ulcerated or broken areas, as use of Aquasept may be contraindicated. Prescription for the Clearance of MRSA Addressograph (Minimum of Name & Hospital Number) Signature: Date: 5-Day Topical Treatment Plan Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Date Mupirocin 6 12 22 6 12 22 6 12 22 6 12 22 6 12 22 (Bactroban Nasal Preparation) Apply to nose 3 times a day For 5 days Mupirocin Continue (Bactroban Skin until after Preparation) surgery or Apply to small negative broken skin sites MRSA Once daily. screen Apply nasal prep result to areas near received as plastic items i.e. appropriate. I/V lines, chest Then stop! drains. Use nasal prep on large raw areas or mucosa. Octenisan FOR DAILY BATHING Apply to wet skin Octenisan USE AS A SHAMPOO Apply on day 1 and 3 (NB if patient for surgery, give a stat dose of 1 gm Vancomycin at induction if prophylaxis required) Page 38 of 54
Discontinue topical treatment after surgery or if past positive MRSA once a negative admission screen is received For any questions or queries please contact the IPCT on bleep 186/on call Microbiology. Multi professional communication sheet Date Communication Signature Page 39 of 54
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Isolation Room Appendix 8 Monthly Surveillance Month... Standard: Clinical practices will reflect infection control guidance and Isolation procedure DN089, to reduce the risk of cross infection to patients, whilst providing appropriate protection to staff. MONTHLY ISOLATION SURVEILLANCE Standard: Clinical practice will reflect infection prevention & control guidance and the Isolation procedure DN89, to reduce the risk of cross infection to patients, whilst providing appropriate protection to staff Stool chart if Front of stool Reason for isolation Door enteric chart Ward Bed number Hospital number (organism) Single closed Correct Correct PPE precautions completed room Y/N Y/N sign Y/N Y/N (Y/N) (Y/N/NA) Page 42 of 54