Disclosure Status (B) B Can be disclosed to patients and the public

Policy: ICP12 MRSA Policy Version: ICP12/V7 Ratified by: Trust Management Team Date ratified: 11 March 2015 Title of Author: Infection Control Nurse Title of responsible Director Director of Nursing & Patient Experience Governance Committee Patient Safety & Safeguarding Date issued: 18 March 2015 Review date: February 2018 Target audience: All clinical staff and Managers Disclosure Status (B) B Can be disclosed to patients and the public EIA/Sustainability N/A Other Related Procedure or Documents: West London Mental Health NHS Trust Page 1 of 17

Equality & Diversity statement The Trust strives to ensure its policies are accessible, appropriate and inclusive for all. Therefore all relevant policies will be required to undergo an Equality Impact Assessment and will only be approved once this process has been completed Sustainable Development Statement The Trust aims to ensure its policies consider and minimise the sustainable development impacts of its activities. All relevant policies are therefore required to undergo a Sustainable Development Impact Assessment to ensure that the financial, environmental and social implications have been considered. Policies will only be approved once this process has been completed West London Mental Health NHS Trust Page 2 of 17

Version Control Sheet Version Date Title of Author ICP12/01 ICP12/02 March 2005 October 2007 Nursing directorate Director of Nursing ICP12/03 12.06.09 Infection Control Team ICP12/04 26 th Nov 09 Infection Control Team ICP12/05 8 th Feb 11 Infection Control Status New Policy Revised Policy Policy issued as working document Comment Approved at 22 nd May 09 CSSG meeting and issued on 12.06.09 as a working document policy under consultation ending 10 th July 09 Policy Approved. Policy approved at 26 th Nov 09 Operations board. Issued Revised Policy under consultation ending 15.02.11 Appendix 3 added to policy. Presented to Policy Review Group on 31 st January 2011 for approval approved, following consultation period. 19 th Feb 11 ICP12/06 Feb 13 Infection Control Revised substantive Policy Issued No comments from consultation Revised Policy To be presented to April 2013 PSS and TMT. Approved Nov 2013 Amendments made to section 5. Policy re-issued 22.11.13 ICP12/07 Feb 2015 Review Approved at March 2015 TMT West London Mental Health NHS Trust Page 3 of 17

Content Page No. 1. Flowchart 5 2. Introduction 5 3. Scope 5 4. Definition of MRSA 6 5. Duties 7 6. Systems and Recording 8 7. Screening Treatment Follow Up of Treated Individuals Treatment of Staff Carriers 8. General Principles 9 9. Standard Infection Control Precautions 10 10. Precautions Required when Caring for MRSA Patients 12 Transmission Precautions Cleaning and Disinfection 8 11. Transfer and Discharge of Colonised or Infected Patients 12 Within the hospital Visits to Outpatients and specialist departments Ambulance transportation Transfer to another hospital 12. Discharge of Patients 13 13. Deceased Patients 13 14. Training 13 15. Monitoring 13 16. Fraud Statement 13 17. References 13 18. Supporting Documents Glossary of Terms / Acronyms Appendices 14 Appendix 1 MRSA Eradication Protocol Appendix 2 - HCAI Risk Assessment Checklist Tool 15 16 West London Mental Health NHS Trust Page 4 of 17

1 FLOWCHART Admission to ward Planned admission to an acute hospital Transfer back to ward from an acute hospital Do they fall into specific high risk group (see section 7 of policy) Screen 72 hours prior to admission Screen for MRSA Yes No Positive Result Negative Result Positive Result Negative Result Screen for MRSA No further action Commence treatment No further action Commence treatment No further action Positive Result Negative Result Re-swab Commence treatment Re-swab Blue Swab West London Mental Health NHS Trust Page 5 of 17

2 INTRODUCTION 2.1 This policy provides guidelines for the care of patients with MRSA and aims to rationalise the approach to patients with MRSA. The control and prevention of MRSA remains important and the guidelines provide a targeted approach to its control. The care and treatment of patients with MRSA should not be compromised by their MRSA status and the guidelines provide a flexible approach based on risk assessment/management. 2.2 Staphylococcus aureus is an organism that up to one third of the population carry on their skin or in their noses without any associated problems. MRSA can live on the body of healthy people without causing infection. It becomes a problem only when it enters the body. MRSA can infect wounds, ulcers, abscesses, catheter entry points and cause inflammation, prevent wounds from healing and can lead to blood poisoning (bacteraemia). 2.3 Whilst MRSA infection is difficult to treat, the bacterium is not difficult to kill in the environment with routine cleaning. Regular monitoring of environmental cleanliness is essential to ensure that clinical areas are kept clean to an acceptable standard. 2.4 The Code of Practice for the Prevention and Control of Healthcare Associated Infections requires all NHS bodies to minimise the risk to patients. 2.5 Targeted screening, colonisation reduction regimes and effective management through infection control precautions and isolation (where appropriate) have been introduced to meet these standards. 3 SCOPE 3.1 This policy applies to all patients and staff in the Trust. 4 DEFINITION OF MRSA 4.1 MRSA stands for Meticillin-resistant Staphylococcus aureus. 4.2 Staphylococcus aureus is a Gram-positive bacterium, which colonises the skin, particularly the nasal passages and warm moist areas of skin and the umbilicus in babies. The bacterium can live in these areas without detection and without causing symptoms, this is known as colonisation. If the bacteria invades the tissues or other systems and multiplies, a patient may go on to become infected. 4.3 An infection may be recognised when the presence of the bacteria results in a host reaction and the patient becomes symptomatic resulting in infection of for example a wound, respiratory, skin or urinary tract infection. 4.4 MRSA acts in exactly the same way as Staphylococcus aureus and causes the same range of infections. What makes MRSA different is its resistance to antibiotics. Some antibiotics are effective but may be more difficult to use and can cause side effects. However, rather than developing a MRSA infection, it is more common for people who acquire MRSA to be carriers. These people are termed as colonised, West London Mental Health NHS Trust Page 6 of 17

which means the organism lives harmlessly on the skin or in the nose or throat, and does not cause any problems. 4.5 Infection occurs when the individual is more susceptible. This includes patients who have had surgery, are immunocompromised, are receiving antibiotic therapy, are undernourished, have chronic wounds/ulcers. 4.6 The risk to healthy staff and visitors is very low, but it must be remembered that staff can be a source or vector for transmission. 5 DUTIES 5.1 Chief Executive The Chief Executive is responsible for ensuring that the Trust has policies in place and complies with its legal and regulatory obligations. 5.2 Accountable Director The Director of Nursing and Patient Experience is responsible for the development of relevant policies and to ensure they comply with NHSLA standards and criteria where applicable. They must also contain all the relevant details and processes as per P3. They are also responsible for trustwide implementation and compliance with the policy. 5.3 Managers Managers are responsible for ensuring policies are communicated to their teams/ staff. They are responsible for ensuring staff attend relevant training and adhere to the policy detail. They are also responsible for ensuring policies applicable to their services are implemented and routine screening is completed on admission. 5.4 Policy Author Policy Author is responsible for the development or review of a policy as well as ensuring the implementation and monitoring is communicated effectively throughout the Trust via CSU leads and that monitoring arrangements are robust. 5.5 Local Policy Leads Local policy leads are responsible for ensuring policies are communicated and implemented within their CSU as well as co-ordinating and systematically filing monitoring reports. Areas of poor performance should be raised at the CSU/ Directorate SMT meetings. 5.6 All Staff All staff are responsible for working to the Infection Prevention and Control policy West London Mental Health NHS Trust Page 7 of 17

6 SYSTEMS AND RECORDING 6.1 Where recorded Documented on RiO 6.2 When recorded If screening takes place should be recorded and when results are received. Staff should also record on RiO if patient falls into high risk group and refuses to be screened 6.3 Recorded by Doctors/staff 7 SCREENING 7.1 Recommendations suggest that Individuals in mental health Trusts should be screened only if they fall into specific higher risk groups. Guidance from the Department of Health has suggested several categories which should be considered for screening. These are as follows: Those admitted following recent surgery (nasal and wound screen) Those admitted following recent admission to an acute trust. (nasal screen) Recent Intravenous drug users (nasal and wound/abscess screens) Those who self harm (nasal and wound screens) Those with acute chronic wounds e.g. leg ulcers Those with indwelling devices such as catheters (nasal and wound or catheter site screens) and PEG tube Those who have previously had a MRSA positive result Therefore screening for MRSA falls into two distinct categories 7.2 Screening prior to admission to acute trusts for elective procedures. Service Users attending Acute Trusts for elective surgery will require pre-operative screening. This would ordinarily be performed at a preoperative assessment clinic. 7.3 Screening following transfer back from an acute hospital admission, transfer to another health care facility or those whose clinical presentation means that they fall into one of the higher risk groups, e.g. if an individual develops leg ulcers or self harms, causing an open wound whilst within our care. 7.4 Method for Screening 7.4.1 Always use blue swabs in transport medium 7.4.2 First time screening you could use one swab for nostrils then perineum then use one swab for each site if affected (one swab for both left and right nostrils) 7.4.3 Always moisten the swab before use (saline or transport medium) 7.4.4 Rub the swab over area a few times West London Mental Health NHS Trust Page 8 of 17

7.4.5 Clearly label the swab and complete the request form legibly. State the site swabbed on each specimen and request form, W/S is not sufficient, the wound site must be clearly stated, (e.g. W/S left leg ulcer). 7.4.6 Send swabs to the laboratory as soon as possible and avoid taking swabs at weekends and prior to or during bank holidays. 7.5 Treatment 7.5.1 Patient treatment will usually be as follows but will be guided by the Infection Control Team. Eradication Apply a match-sized amount of Mupirocin 2% ointment (Nasal Bactroban) on a cotton bud to each nostril 3 times a day for 5 days. If MRSA is resistant to Mupirocin, use Naseptin instead of Bactroban Check Chlorhexidine allergy status Apply aqueous Chlorhexidine Gluconate solution 4% to wet skin during washing in place of soap once a day for 5 days, use to shampoo hair on days 1 and 4. 7.6 Follow up of treated individuals: 7.6.1 After the course of the above treatment has been completed, you need to wait 48 hours before re-screening the individual to see whether the MRSA has been eradicated. 7.7 Treatment of staff carriers: 7.7.1 Staff who are aware that they are MRSA carriers must inform Occupational Health. 7.7.2 Staff who are MRSA carriers must be followed up in the Occupational Health Department, in consultation with the Infection Control Team. Confidentiality must be maintained at all times and any results must be sent to the OHD not the member of staff s working area. 7.7.3 A full screen should be carried out prior to commencement of topical treatment; this should be performed in the Occupational Health Department. 7.7.4 Staff who are nasal carriers should commence the eradication protocol described above and may continue to work in all clinical areas of the Trust. 7.7.5 Staff who have infected lesions, e.g. eczema, should have a risk assessment carried out by Occupational Health and may be excluded from duty, if appropriate. All infected lesions should be covered by an occlusive dressing whilst on duty. West London Mental Health NHS Trust Page 9 of 17

8 GENERAL PRINCIPLES 8.1 The primary objective of infection control is to prevent the acquisition and spread of infection by patients and staff. 8.2 Infection control is the responsibility of all staff associated with patient care. 9 STANDARD INFECTION CONTROL PRECAUTIONS 9.1 These measures apply at all times for all patients and all staff: Hand washing or cleansing with alcohol hand rub Wearing of gloves and disposable aprons for contact with body fluids, lesions and contaminated materials High standards of cleaning of the environment Safe disposal (including segregation) of waste Safe disposal of linen Adequate decontamination of equipment 9.2 The course of action to be taken when a patient is first found to be MRSA positive depends on a variety of factors including: the type of clinical area layout of ward and isolation facilities available patient factors including the individual patient s mental health the ease with which the organism will spread and cause disease. 10 PRECAUTIONS REQUIRED WHEN CARING FOR MRSA PATIENTS (INFECTED) 10.1 Transmission Precautions 10.1.1 A risk assessment of the patient should be carried out and the patient placed appropriately either in a single room or cohort nursed with other MRSA positive patients. The patient s medical and psychological well being should not be compromised by unnecessarily restrictive infection control practices. The Infection Control Team should be contacted for advice in case of doubt. 10.1.2 Correct hand washing is the single most effective and economic measure in the control of infection. Staff should wash their hands with soap and water or cleanse their hands with alcohol hand rub before and after contact with the patient and their immediate environment. 10.1.3 Gloves do not replace the need for hand washing. They should be worn by staff for contact with body fluids, when handling the patient or their immediate environment or when handling contaminated dressings or linen 10.1.4 All staff handling the patient or having contact with their immediate environment must wear disposable aprons. West London Mental Health NHS Trust Page 10 of 17

10.1.5 Relatives/visitors do not routinely need to wear aprons and gloves but must wash their hands before entering and leaving the area. If participating in care they should wear aprons and gloves as above. 10.1.6 The door should be kept closed to minimise spread to adjacent areas. If this is likely to compromise patient care, for instance in the elderly confused patient, a risk assessment should be made as to whether the door may be kept open. 10.2 Cleaning and Disinfection 10.2.1 Routine: Instruments or equipment (e.g. stethoscopes, sphygmomanometers, lifting slings etc.) should, where possible, be designated for individual patient use and, if to be used on other patients, must be disinfected before subsequent use. Once a patient has been identified or before admission with MRSA. Contact should be made with Domestic Services to initiate terminal cleaning procedures. If it is a new admission, a bedroom and bathroom where possible should be identified and cleaned prior to patient moving on to the ward. If a patient is identified on the ward immediate cleaning arrangements should be made to Domestic Services for patient s room to be cleared of belongings from the floor and surface areas before cleaning is initiated. 10.2.2 Daily Duties: Clean all hard surfaces using specified sanitizer/chemicals supplied by the Domestic Services. Cleaning to include door handles, light switches etc. Arrangements to be made by ward staff with patient consent to allow access am and pm for bedroom and bathroom to be cleaned and sanitized. A schedule of cleaning will identify each area to be signed by Domestic staff as a record of cleaning for these areas. (Local arrangements will be made to where these are on display in patient areas or nursing office). All staff must promptly inform Ward Manager and/or Supervisor of any abnormalities observed/occurred during shift i.e.; accidents/incidents, impossibility of carrying out allocated duties etc. All mops, cloths and PPE will be disposed of as infectious waste on the ward area. Follow colour coding, infection control and health and safety regulations at all times. 10.2.3 Terminal Clean: When a patient is either discharged/moved to another area or cleared of infection, contact should be made with Domestic Services who will initiate a full ward clean starting at the rear of the ward working towards the entrance door including the patient s bedroom and bathroom, all mops, cloths and PPE will be disposed of as infectious waste. Cleaning will include walls, floors, hard surfaces etc. West London Mental Health NHS Trust Page 11 of 17

Any equipment should be wiped with a disinfectant solution or 70% alcohol wipes. If physically soiled the equipment should be cleaned first. Therapy beds should be cleaned according to manufacturer s instructions. 10.2.4 Ward Closure: In the event of an outbreak the decision to close a clinical area will only be made after a risk assessment by the Infection Control Team and in consultation with managers. Alternative cleaning procedures will be used in the event of an outbreak. 11 TRANSFER AND DISCHARGE OF COLONISED OR INFECTED PATIENTS 11.1 Within the hospital: 11.1.1 Transfer of MRSA affected patients to other wards should be minimised to reduce the risk of spread but this must not compromise other aspects of care such as rehabilitation. If transfer is essential, please refer to ICP26 Risk Assessment Policy for Admission, Transfer or Discharge. 11.1.2 Lesions should be occluded where possible with an impermeable dressing during transfer. 11.1.3 Anyone in contact with the patient should wear disposable plastic aprons. 11.1.4 Aprons must be removed when contact with the patient has finished and disposed of as infectious waste. 11.1.5 All staff who handle the patient or their immediate environment should wear gloves. 11.1.6 Any trolley or chair used should be cleaned with 70% alcohol or a disinfectant solution. 11.1.7 Any used lined should be disposed of as infected linen. 11.1.8 Staff must wash their hands thoroughly or use alcohol hand rub after dealing with the patient and cleaning the trolley or chair. 11.2 Visits to Outpatients and specialist departments 11.2.1 If patients known to be MRSA positive are to visit other departments or OPD for investigation or treatment, staff in the receiving department should be informed in advance, so that a risk assessment can be carried out and infection control measures implemented. These should include: Hand washing and standard infection control precautions Patients should spend the minimum time in the department. West London Mental Health NHS Trust Page 12 of 17

In-patients should be sent for as close to the appointment time as possible, outpatients may wait in a communal waiting area. Staff coming into direct contact with the patient should wear disposable gloves and aprons. Equipment and the number of staff attending should be kept to a minimum Surfaces with which the patient has had direct contact should be wiped with 70% alcohol or a disinfectant solution. Any used linen should be disposed of as infected linen. Staff must wash their hands thoroughly or use 70% alcohol hand rub after dealing with the patient. 11.3 Ambulance transportation The ambulance service should be notified of the patients status in advance only if felt necessary by the Infection Control Team. There is no evidence that ambulance crew or their families are put at risk by transporting patients with MRSA. To minimise the risk of MRSA transfer to other patients who may be at risk of MRSA infection, ambulance crews should use alcohol hand rub after contact with a patient with MRSA in addition to good basic infection control practice. Most MRSA carriers may be transported with others in the same ambulance without any special precautions except changing the bedding used by the MRSA carrier. However if transport of a potentially heavy disperser is necessary (e.g. a patient with a discharging lesion which cannot be occluded by an impermeable dressing, or with colonised skin lesions), advice should be obtained from a member of the Infection Control Team. It may, in these cases, be necessary to transport the patient alone and for ambulance staff handling the patient to wear a plastic apron, to use an alcohol hand rub and to wipe own surfaces with 70% alcohol afterwards. 11.4 Transfer to another hospital 11.4.1 MRSA infection or colonisation should not be a barrier to good clinical care, therefore inter-hospital transfers for good clinical reasons should not be prevented, however unnecessary movement should be avoided. If transfer is essential please refer to ICP26 Risk Assessment Policy for Admission, Transfer or Discharge. 11.4.2 Notification of infected or colonised patients is the responsibility of the transferring hospital. Before transfer: - The clinician responsible for the patients care must inform the receiving area - The patient s MRSA status must be clearly recorded on transfer documentation. West London Mental Health NHS Trust Page 13 of 17

12 DISCHARGE OF PATIENTS MRSA should not hinder a patients discharge The General Practitioner and other healthcare agencies involved in the patients care should be informed. MRSA carriers will not normally require special treatment after discharge. If a course of treatment still needs to be completed the Infection Control Team will advise. If the patient is discharged to a nursing or convalescent home the medical and nursing staff should be informed in advance. Carriage of MRSA is not a contraindication to the transfer of a patient to a nursing or convalescent home. Patients should be made aware that there is no risk to healthy relatives or others outside the hospital (unless they are hospital workers, where the advice of the Infection Control Team should be sought). 13 DECEASED PATIENTS The infection control precautions for handling deceased patients are the same as those used in life. Any lesions should be covered with an occlusive dressing. Plastic body bags are not necessary. 14 TRAINING 14.1 All Permanent and Bank Staff employed by the Trust to participate in Trust Mandatory Induction programme which includes infection control training. 14.2 Please refer to M12 Mandatory Training Policy 15 MONITORING For training requirements please refer to the mandatory passports within the M12 Mandatory Policy 16 FRAUD STATEMENT No fraud statement is required for this policy. 17 REFERENCES Ayliffe et al, (1998), Working Party Report, Revised guidelines for the control of meticillin-resistant Staphylococcus aureus infection in hospitals, Journal of Hospital Infection, 39: 253-290 West London Mental Health NHS Trust Page 14 of 17

18 SUPPORTING DOCUMENTS DH (2005) Saving Lives: A Programme to Reduce Healthcare Infection Including MRSA. ICP1 Infection Prevention and Control Policy DH (2006) Screening for MRSA Colonisation. PL/CMO/2006/4, PL/CNO/2006/4. DH (2006) Essential Steps to Safe, Clean Care department of health MRSA Screening Operational Guidance The Health and Social Care Act: Code of practice for Prevention and Control of Health Care Associated Infections and related guidance (Dept of Health 2010) Essential Standards of Quality and Safety (Care Quality Commission 2010) 19 GLOSSARY OF TERMS/ACRONYMS MRSA HCAI NHS NHSLA SMT CSU WS OHD PPE OPD PDR Meticillin-resistant staphylococcus aureus Health Care Associated Infection National Health Service National Health Service Litigation Authority Senior Management Team Clinical Service Unit Wound Site Occupational Health Department Personal Protective Equipment Out Patient Department Personal Development Review 20 APPENDICES Appendix 1 - MRSA Eradication Protocol Appendix 2 - HCAI Risk Assessment Checklist Tool West London Mental Health NHS Trust Page 15 of 17

Appendix 1 MRSA ERADICATION PROTOCOL Patient Name Hospital Number Ward Treatment commenced / / 200 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Mupirocin 2% ointment 10:00 X X (Nasal Bactroban) 16:00 X X 3 times per day 22:00 X X Chlorhexidine Gluconate 10:00 X X S washes C Daily R Chlorhexidine Gluconate shampoo twice during the 5 day protocol (days 1 & 4) when completed No other topical treatment unless instructed by the Infection Control Team This regime must be prescribed on the individual patient s prescription sheet! X X E E N Notes Please keep this record with the patients care plan Mupirocin 2% ointment (Nasal Bactroban): Apply a match-sized amount to each nostril on a disposable cotton bud 3 times a day Aqueous Chlorhexidine Gluconate solution: Apply once daily to wet skin during bathing in place of soap, use to shampoo hair on days 1 and 4 NB always rinse off thoroughly and take care if patient has delicate skin Day 8 Screening Always use swabs with culture/transport medium Only use one swab for each site (one swab for both left and right nostrils) Always moisten the swab before use (saline or transport medium) Send swabs to the laboratory as soon as possible and avoid taking swabs at weekends where possible. Remember each swab costs approximately 15 to process! Post eradication screens Dates of 1 st screen 2 nd screen... 3 rd screen 1 st Screen all negative - screen on 1 st and 7 th day following result, any positives recommence protocol 2 nd Screen all negative continue to 3 rd screen; any positives recommence protocol 3 rd Screen all negative patient is negative any positives recommence protocol. Reference: Ayliffe et al, (1998), Working Party Report, Revised guidelines for the control of methicillin-resistant Staphylococcus aureus infection in hospitals, Journal of Hospital Infection, 39: 253 Appendix 2 West London Mental Health NHS Trust Page 16 of 17

HCAI Risk Assessment Checklist Tool Admission Transfer Discharge Where From..Where To...Date: Patient/Service User details: Name: ----------------------------------------------------------------- Consultant: ------------------------------------------------- DOB: ------------------------------------------------------------------ GP: ----------------------------------------------------------- Address: -------------------------------------------------------------- Current Patient Location: ------------------------------- MRSA Yes No NK Is the patient known to be infected or colonised with MRSA? * Is the patient from a nursing or residential home or another Trust? * Has the patient any wounds/skins lesion/ pressure sores? * Has the patient a history of frequent acute hospital admissions? Has the patient had an MRSA screen undertaken? If yes: Where ---------------------------------------When ----------------------- Result ------------------------------ (NK= not known) NB: If yes to any questions * consider high risk and undertake MRSA screening NB: If MRSA positive on admission or positive on screening please refer to MRSA policy. Diarrhoea Yes No NK Does patient have diarrhoea? Is the diarrhoea thought to be of an infectious nature? Has a specimen been sent? Has an organism been identified? If yes: Where------------------------------------ When--------------------------- Result--------------------------- Has patient had treatment? If yes: What----------------------------------------------------------- and when completed------------------------------- NB: Patients with diarrhoea caused by Clostridium difficile toxins or enteric pathogens such as E.coli or salmonella should be isolated in single room until 48 hours symptom free. Other communicable disorders Does the patient have or is suspected of having any of the following communicable disorders: Smear positive TB Chicken pox or shingles Influenza Impetigo Scabies Other please specify: ------------------------------------------------------------------ If any of the communicable diseases have been ticked (affirmed) please contact the Trust Infection Control Nurse and proceed to isolate patient (See ICP4) Other factors which predisposes to HCAI Yes No Does the patient have a urinary catheter or other indwelling device in situ? Is the patient receiving enteral feeding? Is the patient currently receiving antibiotics? If yes to any of these ensure care plan includes specific care of patient with i.e. urinary catheter and observe for any signs of infection. Assessment undertaken by ---------------------------------------------------------------------------- (write/type Name) West London Mental Health NHS Trust Page 17 of 17