Infection Prevention Guidance: MRSA: Screening and Management of Patients with MRSA

Infection Prevention Guidance: MRSA: Screening and Management of Patients with MRSA (Including Panton-Valentine Leukocidin (PVL) MRSA) Reference No: Version: 3.1 Ratified by: G_IPC_20 LCHS Trust Board Date ratified: 12 th July 2016 Name of originator/author: Name of approving committee/responsible individual: Date Approved: 8 th June 2016 Date issued: November 2017 Review date: June 2018 Target audience: Distributed via: Infection Prevention Team, LCHS Infection Prevention Committee, LCHS All staff Via the LCHS NHS Trust intranet 1 Chief Executive:Andrew Morgan

Version Infection Prevention Guidance: MRSA: Screening and Management of Patients with MRSA Section/Para/ Appendix Version Control Sheet Version/Description of Amendments Date Author/Amended by 1 New guideline which March 2012 IP&C Team amalgamates guidelines: 1. GuIC002 MRSA Screening and Management of Patient with MRSA 2. Gu10 PVL Associated Staph infections 3. PGD 983 Mupirocin Nasal Ointment 2 Front page Update footer July 2104 L Roberts Whole document Change Infection July 2014 L Roberts Prevention and Control Team to Infection Prevention Team. Change Link Persons to Link Champions. Change Learning Academy to Workforce and Transformation Section 8 Added definition of Cohort July 2014 L Roberts nurse Section 12 Added SystmOne Read July 2014 L Roberts Code Section 12.2 Added GP s responsibility July 2014 L Roberts Section 13 Amended MRSA July 2014 L Roberts decolonisation and suppression regime Section 23 Added Post Infection July 2014 L Roberts Review (PIR) Appendix H and I Updated information for July 2014 L Roberts IP&C Notification Framework Appendix M Flow chart updated July 2014 L Roberts 3 Section 9 Amended revised June 2016 L Roberts admission screening Appendix M MRSA screening record June 2016 L Roberts removed 3.1 Whole document Changed footer and Oct 2017 L Roberts headers Replaced Triclosan with Octenisan Appendix K Removed Oct 2017 L Roberts Appendix E and L Replaced with update Oct 2017 Oct 2017 Copyright 2017 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be reproduced in whole or in part without the permission of the copyright owner. Chief Executive: Andrew Morgan 2

Infection Prevention and Control Guidance: MRSA: Screening and Management of Patients with MRSA Contents Version Control Sheet... 2 Policy Statement... 5 1. Background... 6 2. Purpose of guidance... 6 3. Key personnel responsibilities... 6 3.2. Managers... 6 3.3. Employees... 7 3.4. Education and Workforce Development... 7 3.5. Infection Prevention Link Champions... 7 4. Training... 7 5. Monitoring and Audit... 7 6. What is MRSA?... 8 6.1 Colonisation or infection?... 8 6.2 Transmission of MRSA... 9 7. MRSA prevention and control strategies... 9 8. General principles... 9 9. MRSA Screening... 10 9.1 Criteria for screening... 10 Those patients that have been previously colonised or infected with MRSA... 10 9.2 MRSA Screening sites... 10 10. Microbiological sampling technique... 11 11. Specimen storage collection & transportation... 11 12. Results of MRSA screening... 11 12.1 Follow up Screening... 11 12.2 Screening in nursing residential homes or own home... 12 12.3 Screening of staff... 12 12.4 Patient Refusal of screening... 12 13. MRSA Suppression and Decolonisation Regimes... 12 14. Mupirocin resistance... 14 15. Allergies... 14 16. Positive MRSA Patients in Community Hospital Environments... 14 16.1 Admission... 14 16.2 Transfer/ Movement of patients to other Hospitals / Wards/ Departments... 14 16.3 Visitors... 15 16.4 Discharge of Patients... 15 16.5 Transportation... 15 16.6 Deceased patients... 16 17. Patient specific interventions... 16 17.1 Personal hygiene... 16 17.2 Information... 16 17.3 Wound Care... 16 17.4 Invasive devices... 17 18 Staff specific interventions... 17 18.1 Personal Protective Clothing (PPE)... 17 18.2 Hand Hygiene and Alcohol Hand Rubs... 17 19 Environment specific interventions... 17 19.1 Nursing Medical Equipment... 17 19.2 Linen and Clothing... 17 Chief Executive: Andrew Morgan 3

19.3 Daily Environmental Cleaning... 17 19.4 Terminal cleaning... 18 20. Advice: Positive MRSA Patients being discharged to non-nhs beds in Care Homes... 18 21. Management of MRSA positive patients in their own homes... 19 22. Risk Management.... 19 23. RCA, Surveillance and Mandatory Reporting.... 19 24. Resources... 19 25. Evidence Base... 20 Appendix A: SystmOne screen... 21 Appendix B: Inter-healthcare Infection Prevention & Control Transfer Form... 22 Appendix C: MRSA Screening Categories... 23 Appendix D: MRSA Decolonisation/suppression Integrated Care Pathway (ICP)... 25... 28 Appendix F - MRSA Labels DO WE NEED... 30 Appendix G: GP Letter... 31 Appendix H: MRSA Integrated Care Pathway (IPC)... 33 Appendix I: MRSA Bacteraemia Framework for Action (Strategic)... 35 Appendix J: Local Overview for Post Infection Review Process for MRSA Bacteraemia... 36 Appendix L: MRSA Pathway... 38 Appendix M: Patient Group Direction for the Supply and/or Administration of... 38 Mupirocin 2% Nasal Ointment... 39... 39 Patient Group Direction for the Supply and/or Administration of... 39 Mupirocin 2% Nasal Ointment... 39 Appendix N: PVL Guidance... 50 1. PVL-associated Staphylococcal Infections... 50 1.1 Risk factors... 50 1.2 Transmission... 50 1.3 When to suspect a PVL-SA infection... 51 1.4 Clinical Management... 51 1.5 Suppression Therapy... 51 1.6 Screening... 52 1.7 Inpatient settings... 52 1.8 Transfers to other wards/facilities... 53 1.9 Mobilisation... 53 1.10 Personal Hygiene... 53 1.11 Patient visitors... 53 1.12 Management of hospital staff colonised/infected with PVL-SA... 53 1.13 Cadaver care... 53 1.14 Additional information... 54 1.15 PVL template letter... 55 Appendix O: Equality Analysis... 59 Chief Executive: Andrew Morgan 4

Infection Prevention Guidance: MRSA: Screening and Management of Patients with MRSA Policy Statement Background The purpose of this guidance is to implement a co-ordinated approach to the management and control of MRSA in line with current NHSLA, Department of Health and Best Practice requirements. Statement This guidance is comprehensive, formally approved and ratified, and disseminated through approved channels. It will be implemented for staff of Lincolnshire Community Health Services NHS Trust (LCHS) Responsibilities Compliance with the guidance will be the responsibility of all LCHS staff. Training Dissemination The Infection Prevention Team, Infection Prevention Link Champions and Clinical Educators will support/deliver/disseminate any training associated with this guidance. Via the LCHS NHS Trust intranet Resource implication This guidance has been developed in line with the NHSLA, Department of Health and best evidence requirements to provide a framework for staff within NHS Organisations to ensure the appropriate production, management and review of organisation-wide policies and guidance. Chief Executive: Andrew Morgan 5

Infection Prevention Guidance: MRSA: Screening and Management of Patients with MRSA 1. Background The control of Meticillin Resistant Staphylococcus aureus (MRSA) is still an important component to the provision of patient care and strenuous efforts to prevent spread are worthwhile. Pre-admission screening, suppression therapy, antibiotic stewardship and effective patient management are considered to be key strategies for preventing the spread of MRSA. To assist in minimising the spread of MRSA (either colonisation or infection) all staff should follow standard principles of infection prevention and control. 2. Purpose of guidance The purpose of this guideline is to inform of best practice in the care and management of patients and the control of MRSA in primary healthcare settings (i.e. at home, in health centres and in community hospitals). This guidance sets out the requirements for MRSA screening and the management of patients found to be MRSA positive. It is based on the 'Guidelines on the Control & Prevention of MRSA in Healthcare Facilities' (BSAC/HIS/ICNA Working Party 2006) and MRSA Screening Guidance (DH 2006-2010) and the Implementation of Modified Admission MRSA screening guidance for NHS (2014). 3. Key personnel responsibilities 3.1. The Infection Prevention Team The Infection Prevention Team will: Review the guidance in response to the publication of any urgent communications from the Department of Health. Assist managers with the audit of compliance with the guidance as part of the Infection Prevention & Control audit programme. Participate in the development and facilitation of mandatory Infection Prevention & Control training via corporate mandatory induction, non clinical and clinical mandatory annual updates, as identified within the Organisation Mandatory Training Matrix co-ordinated by Education and Workforce Development team Assist managers in the mandatory reporting of MRSA screening rates. 3.2. Managers Managers have the responsibility for the standards of clinical practice by their staff in the health care setting. They must: Ensure all individuals are appropriately trained and have attended the Lincolnshire Community Health Services NHS Trust (LCHS) Induction programme (to include Infection Prevention and Control). Inform new employees of their responsibilities under this guidance. Ensure that all employees within their area of responsibility comply with this guidance. Ensure that their staff are available to attend annual mandatory training according to their specific job role. Follow up non-attendance of their staff where this has been identified by the Education and Workforce Development Administrator. Where necessary provide MRSA screening data to the Infection Prevention Team. Chief Executive: Andrew Morgan 6

3.3. Employees All employees have a responsibility to abide by this guidance and any decisions arising from the implementation of it. Any decision to vary from this guidance must be fully documented with the associated rationale stated. Employees also have a responsibility to attend mandatory training/update training as identified within the Organisation s Mandatory Training Matrix. 3.4. Education and Workforce Development The Education and Workforce Development has a responsibility to ensure the coordination of the learning and development of staff, as identified within the Education and Workforce Development Policy. In relation to this guidance they will: In conjunction with the Infection Prevention Team, develop and facilitate education sessions to staff groups, Identify and follow-up non attendance at mandatory training sessions with Line Managers, Provide reports to the Infection Prevention Team and relevant designated Organisation Committees providing information on attendance at mandatory training, evaluation of mandatory training and proposed action required. 3.5. Infection Prevention Link Champions Business Unit Managers should ensure, through their Heads of Clinical Services, that each clinical area is covered by an Infection Prevention Link Champion (DH 2008), whose role and job description should include (as a minimum) training, auditing and feeding back to staff on: isolation hand hygiene new policies, procedures, guidance and resources and raise and action environmental and practice issues. 4. Training The Infection Prevention Team, in conjunction with Workforce and Transformation, Clinical Educators and the Infection Prevention Link Champions will provide/facilitate education to all staff via induction, clinical and non clinical mandatory and ad hoc sessions. Education and Workforce Development will produce statistics describing the rate of completed training programmes. Bespoke training is provided to nominated leads through the LCHS Link Champion scheme. These link champions will in turn, be responsible for cascading relevant training to staff within the team, clinical area/department. 5. Monitoring and Audit It is the responsibility of the business unit manager to ensure that audit is conducted with regard to the implementation of this policy. The Infection Prevention Team can assist the managers with the provision of audit tools. Data with regard to MRSA screening will be monitored and reported monthly to the Trust Board via the Infection Prevention monthly report. Non-concordances with regard to delivery of this policy will be reported via Datix and via the Infection Prevention report to the Board. Any action plans will be monitored by the Infection Prevention Committee or the Quality and Risk Committee as appropriate. Chief Executive: Andrew Morgan 7

Minimum requirement to be monitored Process for monitoring e.g. audit Responsible individuals/ group/ committee Frequency of monitoring/audit Responsible individuals/ group/ committee (multidisciplinary) for review of results Responsible individuals/ group/ committee for development of action plan Responsible individuals/ group/ committee for monitoring of action plan Appropriate groups of patients have been screened in line with document. Monthly data returns by community hospitals Business Unit General Manager Monthly IPC Committee and Quality and & Risk Committee IPC Committee IPC Committee Care pathway audit Audit Ward Managers Annually IP&C Committee Ward manager/ IPC committee IPC Committee 6. What is MRSA? Staphylococcus aureus is a bacterium, which is carried as a skin commensal by approximately 30% of the population; usually in moist sites such as the nose, axilla and perineum. On intact skin its presence is harmless. MRSA is a variant of Staphylococcus aureus which has developed resistance to commonly used antibiotics e.g. Flucloxacillin, and is now endemic both in hospitals and the community setting with the numbers of individuals colonised or infected with MRSA increasing both nationally and locally. 6.1 Colonisation or infection? Colonisation This is when the service user carries the organism on/in their body, but do not suffer any harmful effects, or associated problems e.g. when MRSA is identified in a wound swab but the wound is healing well. The majority of patients who are identified as MRSA positive will be colonised. They will not have an active infection. However, it will be necessary in some instances to implement a suppression and / or decolonisation regime (section 9 onwards) As soon as the regime is implemented, the presence and shedding of MRSA are reduced significantly and the risk of the patient infecting themselves or transmitting MRSA to others is much reduced Patients colonised with MRSA can be safely transferred or discharged home. They should be informed that there is no risk of infection to healthy relatives or other contacts and that social interaction should not be compromised. Information should be provided to patients and relevant others, e.g. GP in a format that is appropriate to their needs e.g. leaflets. Infection Infection happens when the bacteria multiply and show recognised signs and symptoms of infection in the form of inflammation, pain, swelling fever, redness etc. Pus may also be present at the affected site e.g. wounds. Chief Executive: Andrew Morgan 8

Conditions such as wound infections, septicaemia (blood stream infection) or osteomyelitis may occur. In circumstances where antibiotics may be required, the decision should be made in consultation with the GP and/or Microbiologist. 6.2 Transmission of MRSA Endogenous transmission This occurs when a person with MRSA spreads the bacteria from one part of their body to another. Encouraging patients to wash their hands and discouraging them from touching wounds, damaged skin or invasive devices will minimise the risk of the endogenous spread. Exogenous transmission This occurs when organisms are transferred from person to person by direct contact with the skin (e.g. hands), via contaminated environments or equipment. Skin scales may contaminate all surfaces if they become airborne, e.g. during activities such as bed making, using a fan, if the affected service user is heavily colonised or has a condition such as eczema/psoriasis. Staphylococci that are shed into the environment fall on horizontal surfaces and may survive for long periods in dust. Adopting a clean as you go approach is essential. 7. MRSA prevention and control strategies The risk from MRSA, in terms of morbidity and mortality is considered to be different in different clinical areas. Lincolnshire Community Health Services provides a variety of health care interventions from a mix of settings, therefore the strategy adopted for preventing and controlling MRSA may vary. The following guidance outlines the approach that will normally be taken within the primary care setting. It is not possible to be prescriptive for all circumstances as decisions need to be based on the individual and the local situation. 8. General principles Any patients identified with a clinical infection with MRSA should be immediately treated and the full decolonisation regime commenced. Infected wounds should be dressed in line with the LCHS wound formulary (see Section 17.3) and where appropriate, following discussion with the Consultant Microbiologist, antibiotics given. Any service user who meets the requirements of the National MRSA Screening Programme (DH 2006) should be screened and suppression therapy commenced. Any refusal to partake or any other variances to screening must be fully documented. In healthcare settings e.g. wards, it is preferable to isolate colonised patients however following risk assessment it may be permissible to cohort nurse MRSA positive patients. (Cohorting grouping of infectious patients together.) If isolation facilities are unavailable, or patient is at increased risk due to isolation e.g. falls, an MRSA colonised patient may be nursed on the open ward adjacent to a hand hygiene sink, ensuring standard precautions are maintained. Where practicable, during departmental visits, it is advised to see the MRSA positive service user at the end of the session in order to reduce the risk of spread to other patients/staff/environment. If good basic hygiene precautions are followed, people colonised with MRSA are not a hazard to other patients, members of their family, visitors or staff, including babies, children and pregnant women. Chief Executive: Andrew Morgan 9

MRSA positive patients should not be refused treatment, investigations or therapy because of MRSA status (DH 2006). Colonisation with MRSA should not be a reason for preventing admission to a nursing or residential home (DH 2006). People with MRSA should be treated like any other service user: with dignity, respect and in confidence. It is vital that if a known MRSA positive service user is to be admitted or re-admitted to hospital or residential/nursing home, it is the responsibility of the transferring healthcare worker to notify the appropriate ward/department/care home. An inter-healthcare transfer form must accompany the patient (Appendix A). 9. MRSA Screening In accordance with guidance (DH 2014) admission screening must be focussed on high risk MRSA positive patients. 9.1 Criteria for screening It will only be necessary to complete admission screening for those patients from High risk units i.e. vascular, renal/dialysis, neurosurgery, cardiothoracic surgery, haematology/oncology/bone marrow transplant, orthopaedics/trauma, intensive care units (adult/paediatric ICUs, Neonatal Intensive Care Units, High dependency units, Coronary Care Units) and/or Those patients that have been previously colonised or infected with MRSA 9.2 MRSA Screening sites The following swabs are routinely required as part of the MRSA screening process: Nasal one swab for right and left nostril Groin one swab for right and left groin In addition, where applicable, sampling may take place from: All wounds, Urine, where the patient is catheterised, Ostomy sites e.g. jejunostomy, urostomy, colostomy or suprapubic catheter sites and tracheostomy sites Intravenous cannulae and /central venous/ midlines e.g. PICC line sites where in place, Specimens of sputum where the patient has a productive cough The date, time, site of screening, specimen results and any variances to screening must be recorded on the MRSA Screening SystmOne template. A new field Identify why MRSA screening is not indicated has been added to the Inpatient Obs/Bloods/Infection Cont template on SystmOne that will permit auditing of compliance with the care pathway. The template should be completed for all admissions to an inpatient bed in the Community Hospitals. (See appendix A) Chief Executive: Andrew Morgan 10

It is the responsibility of the service undertaking the specimen collection to follow up the results and to ensure that appropriate actions as detailed in this document are followed. 10. Microbiological sampling technique The sampling technique must be in line with the Management of Specimens Guidance. Best practice includes: Ensuring the swab is moist prior to swabbing dry areas e.g. dip into sterile normal saline, Labelling samples clearly using correct patient details, Containing the specimen in the designated bag and transport container and Send to the laboratory for processing at the earliest opportunity. Sampling may be undertaken at any time including after personal care (see MRSA decolonisation/suppression protocol) 11. Specimen storage collection & transportation Where there is an unavoidable delay in processing the specimen (e.g. at the weekend), they can be stored at 4ºC in a designated specimens fridge (not used for food or medications) and sent to the laboratory at the earliest opportunity. All specimens must be collected, contained, stored and transported in accordance to the LCHS Management of Specimens Guidance. 12. Results of MRSA screening The results should be recorded onto the appropriate field of the SystmOne Inpatient Obs/Bloods/Infection Cont template. Negative results Patients that have a negative result for MRSA should be informed and offered decolonisation/suppression therapy as detailed in the Screening and Suppression Therapy Pathway; i.e. wash daily with an approved anti-bacterial skin wash (Appendix D). Positive result Patients that are positive for MRSA should be informed and provided with a copy of the leaflet which may be found at Appendix E). Inpatients and those who are scheduled to undergo elective surgery should follow the MRSA Screening and Suppression Therapy Pathway. It is imperative that this group of patients are effectively decolonised/suppressed (see Appendix D). A system of identifying previously positive patients should be maintained by marking the notes with a yellow MRSA sticker, which should be placed in the left bottom inside cover of the notes and on the alert sheet (see Appendix F). The same applies to electronic systems for patient records e.g. within the Patient Status Marker, Demographic Box and Read Code added on SystmOne. Where a patient has been screened in hospital and discharged before the results are available and the sample has tested positive to MRSA, the patient s GP and the Infection Prevention Team must be informed (see letter Appendix G and Inter-healthcare transfer form Appendix B). 12.1 Follow up Screening Follow up screening is confined to: In-patients undergoing MRSA Decolonisation/suppression regimes Chief Executive: Andrew Morgan 11

Pre assessment cases who are due to undergo implant surgery (orthopaedic, vascular and breast implant) and who are found to be MRSA positive at pre assessment screening. 12.2 Screening in nursing residential homes or own home Routine screening for MRSA is not advocated in the community. However, there may be occasions where this must be undertaken: prior to a hospital admission or, as a follow up to a decolonisation regime commenced prior to discharge from hospital. where an outbreak situation exists or is suspected (e.g. outbreak of MRSA involving intermediate care beds in a residential home) This is the responsibility of the GP. 12.3 Screening of staff Screening of staff is not routinely recommended (BSAC/HIS/ICNA Working Party 2006). The Infection Prevention and Team, in conjunction with the Consultant Microbiologist, may advise staff screening where particular epidemiological features indicate that staff are linked to cases of MRSA Infection / outbreaks (DOH 2010). The screening will be managed by the Infection Prevention and Control Outbreak group and/or Occupational Health Department. Staff found with persistent carriage other than the nose e.g. skin lesions should be referred to the Occupational Health Service who will undertake an individual risk assessment, as a result of which they may be referred for specialist management e.g. ear, nose and throat, dermatology (BSAC/HIS/ICNA Working Party 2006). 12.4 Patient Refusal of screening Patients cannot, of course, be forced to comply with a request to screen for MRSA. In the unlikely event that a patient refuses to be screened, the rational for the procedure and potential consequences should be explained to them, in particular possible delays in appropriate treatment (DOH 2010). All patient refusals to be screened must be fully documented in the care pathway/systmone MRSA screening template and reported as a variance in the MRSA screening data. 13. MRSA Suppression and Decolonisation Regimes Topical suppression/decolonisation therapy is used to interrupt transmission of MRSA. All inpatients, where this is clinically appropriate, within LCHS Community Hospitals will be offered an antibacterial skin wash and shampoo irrespective of their current MRSA status for the duration of their inpatient stay. As soon as a patient is identified as an MRSA positive and it is clinically appropriate a suppression/decontamination regimen should be commenced. This comprises of the use of an antibacterial body wash and shampoo and the application of an antibacterial nasal ointment The regime normally comprises of a five day topical suppression/decolonisation therapy cycle using a topical skin wash or foam and a topical nasal ointment followed by repeat screening. Chief Executive: Andrew Morgan 12

Generic Name Propriety Usual dose Notes name Octenisan Continue to use daily Apply directly to wet skin as liquid soap on a disposable cloth/wipe & lather well. Leave for 60 seconds prior to rinsing. Octenisan Shampoo twice a week Dry hair using a hospital towel towel to go into infected linen Mupirocin (2%) Or where Mupirocin resistance has been demonstrated: Bactroban nasal ointment Naseptin Apply three times daily for five days. Apply four times daily for 10 days The nostrils should be closed by pinching the sides of the nose together at each application (spreads the ointment through the nares) Stop for 2 days. A further 5 days treatment may be used for treatment failure Chlorhexidine Hydrochloride (0.1%) /Neomycin (0.5%) Repeat screening swabs should be taken at day 8. (i.e. 5 days treatment + 2 days rest, swab. Restart therapy immediately following re-screening). Regardless of result the patient requires 3 negative screens before being deemed as reduced risk. Therefore once repeat screens have taken place it is important that the suppression/decolonisation cycle continues, following the 3 rd screen restart suppression/decolonisation until the results are available. Once three negative screens have been obtained, and if the patient remains in hospital, continue with topical skin wash only (unless contraindicated). If the second screen is positive discuss with the Consultant Microbiologist (see appendix D). Chief Executive: Andrew Morgan 13

A PGD had been developed for the prescribing of Mupirocin. The current version may be located on the website. It is the responsibility of the clinician to assess the clinical state of the patient, concurrent therapy and potential adverse reactions and drug interactions that may arise prior to the issuance of the medications. 14. Mupirocin resistance If the strain of S. aureus is reported as Mupirocin-Resistant or if deviation from these recommendations is considered, the management of the patient should be discussed with a Consultant Microbiologist. 15. Allergies The carrier for the Naseptin is nut based and should not be used for any patient who is known to experience nut allergies. Please discuss alternative treatments with the Consultant Microbiologist. Where a patient is known to be allergic to/or develops a rash associated with the Octenisan Skin products an alternative product such as HiBiscrub plus skin wash (Chlorhexidine 4%) may be used. 16. Positive MRSA Patients in Community Hospital Environments 16.1 Admission All patients must be screened for MRSA on admission (other than those identified at appendix B) Where the patient falls into the category below, they must be isolated ideally in a single room with en suite facilities until the screen results are known and / or the results are negative for MRSA. known to have be previously positive for MRSA transferred from other hospitals in the UK and abroad transferred from care homes those identified as positive on admission screening Where a single room is unavailable consideration should be given to separate patients who are colonised with MRSA from non colonised patients. Where they are to be nursed on the open ward it is advisable that the MRSA positive patients are located on the ward next to the hand hygiene sink and that a risk assessment is completed to determine the risk of spread of MRSA to others. Where the numbers of MRSA positive patients on the ward are greater than 2 cases, please inform the infection prevention and team/bed manager for further advice. The Screening and Suppression therapy and/or the MRSA Suppression/Decolonisation pathway must be implemented and actions documented (see Appendices D and H). Any variance from this must be discussed with the Infection Prevention Team and fully documented in the patient s records and a Datix completed. 16.2 Transfer/ Movement of patients to other Hospitals / Wards/ Departments Unnecessary movement of MRSA positive patients should be avoided. A risk assessment must be undertaken prior to movement of an MRSA positive patient onto the open ward from a side room (note: if the need occurs outside of normal working hours the on call manager should be consulted). Please inform the Infection Prevention Team at the earliest opportunity. Chief Executive: Andrew Morgan 14

If mobilisation is required when a patient is isolated in a single room, the patient can leave the room to allow mobilisation in an area away from the ward, e.g. main corridor. This does not mean that the patient can wander freely around the ward where close contact with other patients is inevitable. The distinction must be explained carefully to patients who may find it confusing. Support services may continue. Standard precautions still apply to this group of services. Please inform the Infection Prevention Team of any issues that may arise at the earliest opportunity. If transport of an isolated patient to another department/area is necessary please liaise with the receiving department at a minimum, infected lesions should be covered with a dressing and the patient infected with airways infection asked to cover the mouth if coughing or sneezing. Ideally they should be seen at the end of the list or at the end of the session, if possible. If transfer of the patient is to other healthcare facilities, staff must verbally inform the receiving facility and inter-healthcare transfer form must be completed and accompany the patient. 16.3 Visitors It is advisable that visitors are restricted to the minimum. Visitors must be encouraged to wash their hands on entering and before leaving the room. Visitors are unlikely to have contact with infectious material so there is usually no reason for them to wear PPE. 16.4 Discharge of Patients MRSA positive patients should be discharged promptly from hospital when their clinical condition allows. MRSA carriage should not delay discharge. MRSA positive patients will not normally require special treatment after discharge from hospital. However, decolonisation regimes should be completed. The General Practitioner and other health care agencies involved in the patient's care should be informed by ward staff via the discharge summary. Positive results received by the Infection Prevention Team after the patient s discharge is to be communicated to the GP via letter (see Appendix G). If the patient is discharged to a care home or other healthcare providing facility, they should be informed in advance by the ward discharging the patient and on the accompanying Inter-healthcare Transfer form (see appendix B). 16.5 Transportation Requiring ambulance transport should not be a barrier to a patients discharge. When requesting an ambulance, the Ambulance Service must be informed that the patient is colonised/infected with MRSA. This is helpful in assisting the Ambulance Service to make a risk assessment. The vast majority of patients fall into the following category: Patients who are able to keep their colonised/infected areas of skin enclosed by dressings or normal clothing. These patients may travel with other patients and no protective action is necessary. Patients should have received their decolonisation treatment and wear clean clothing before travel. Chief Executive: Andrew Morgan 15

Ambulance staff will follow their local Infection Prevention and Control Guidance, however, it may be useful for staff to indicate where the nearest waste bins and hand hygiene facilities are. 16.6 Deceased patients The infection prevention & control precautions for handling deceased patients are the same as those used in life. A body bag is not necessary for MRSA colonisation/infection (Guidance on the Management of Patients in Isolation). 17. Patient specific interventions 17.1 Personal hygiene Good hand hygiene technique should be encouraged. Patients should be discouraged from manipulating invasive devices and/or open wounds to reduce the risk of cross infection. If a single room with en suite facilities is not available, the patient may use communal facilities but these must be cleaned thoroughly after use. If patients are leaving an isolation room for this purpose, they must be advised this does not mean they can move freely around the ward 17.2 Information Patients should be provided with a copy of the leaflet (see appendix E). They should be reassured that there is no risk to healthy relatives or others outside the hospital. There is no indication for routine screening before hospital discharge to the community 17.3 Wound Care All wound dressing management plans should be designed to follow the principles of moist wound healing undertaken in line with LCHS NHS Trusts Asepsis Non Touch Technique (ANTT) using products selected to optimally manage the patient s symptoms while encouraging wound healing. Once a thorough assessment of the wound has been carried out and the wound is considered to be critically colonised, locally infected or has spreading infection, wound appropriate management with a topical antimicrobial is preferred (Wounds UK 2010). Choice of antimicrobial dressing must be based on the ability of the dressing to manage increased exudation, remove necrotic tissue if appropriate, reduce malodour, conform to the site and shape of wound, perform wound bed preparation functions (European Wound Management Association (2006). Choice of antimicrobial dressing will also depend on the patient s medical history, overall condition, patient tolerance and known sensitivities. Frequent reassessment of the wound bed and surrounding tissues is advocated to ensure appropriate management (EWMA 2006). Any breaks to the skin should be kept covered at all times. Strike through of exudate to outer dressings should not occur advise patients/carers on actions to be undertaken if it does and who/how to contact a relevant healthcare professional to attend to the dressing site. Practitioners are advised to refer to the current wound management formulary guidelines and/ or obtain advice from the tissue viability nurse specialist. Antibiotic therapy is generally not required or prescribed for wound colonisation alone, due to the added problem of selecting for more resistant micro-organisms (Patel 2007.) but will be required where there are symptoms of infection. Chief Executive: Andrew Morgan 16

Where wound care is delivered in the patient s home, dressings associated with infected wounds must be disposed of via clinical waste streams in line with the NHSL/LCHS Waste guidelines. It is not necessary to do this for colonised wounds/colonised patients. Where associated wastes are created in the Community Hospital environment or a health centre; the waste must be disposed via the clinical waste stream. 17.4 Invasive devices The presence of an invasive device such as a PEG tube, tracheostomy or urinary catheter often extends the period of colonisation. Topical agents may not be appropriate here as there is a risk of degeneration of jejunostomy tubes and continuous ambulatory peritoneal dialysis (CAPD). Use a standard ANTT when handling the device and remove it as soon as clinically possible. 18 Staff specific interventions 18.1 Personal Protective Clothing (PPE) Disposable aprons and gloves should be worn when undertaking procedures where close contact with the patient environment is envisaged and where there may be contact with blood / bodily fluids (LCHS Standard Infection Prevention and Control Precautions). 18.2 Hand Hygiene and Alcohol Hand Rubs Good hand hygiene technique must be practiced by everyone. The LCHS Hand hygiene and alcohol hand rub guidance must be adhered to. Any areas of broken skin on the hands of staff must be fully covered with occlusive dressings. 19 Environment specific interventions 19.1 Nursing Medical Equipment Only necessary nursing / medical equipment should be taken into the isolation room. Where possible single use/ disposable/ dedicated equipment should be used. If the patients are nursed on the ward equipment must be decontaminated following each patient contact. All reusable equipment, where used in isolation, must be decontaminated as per local guidance. This process should be recorded and audited together with regular checks of equipment. All opened items such as tissues/wipes/dressings should be for individual patient use only and should be discarded once isolation has been discontinued. 19.2 Linen and Clothing Most linen generated from MRSA positive patients should be handled as soiled linen (refer to Management of Linen Guidance). Linen soiled with exudates or other body fluids must be managed as infected linen and handled of via the red alginate infected linen route 19.3 Daily Environmental Cleaning The extent of the daily cleaning of isolation rooms/bed spaces occupied by MRSA positive patients will be as laid out in local cleaning schedules. Dedicated disposable equipment must be used for this purpose in line with NHS cleaning/colour coding requirements. Chief Executive: Andrew Morgan 17

Isolation rooms/bed spaces should be cleaned daily paying particular attention to horizontal surfaces, en suite facilities, the floor and any items potentially frequently handled by the patient such as doorknobs, bedrails and switches. The isolation rooms/bed spaces must be free of clutter to enable environmental cleansing to take place effectively. Disposable crockery and cutlery is not necessary as these items can be reprocessed safely in a dishwashing machine. 19.4 Terminal cleaning Terminal cleaning of an isolation room/bed spaces after the discharge, transfer or death of a patient with MRSA should be thorough. Reference must be paid to the local environmental cleaning guidance, Cleaning vacated bed spaces and Decontamination Guidance. All areas should be cleaned using chlorine-containing cleaning agents (at least 1,000ppm available chlorine), and the curtains should be changed. Careful attention must be paid to patient bed areas, toilets, bathrooms and sluices, commodes and bedpans. Where in place, steam cleaning of soft furnishings is advisable. Nursing staff are responsible for ensuring that a terminal clean has taken place prior to next use of the room. Where the patient was not MRSA positive (but was isolated until results known), a standard clean is acceptable. 20. Advice: Positive MRSA Patients being discharged to non-nhs beds in Care Homes There can be a great deal of concern in care homes and long term care facilities about MRSA. This is almost always due to anxiety about the significance and spread of MRSA. If standard infection prevention & control precautions especially hand hygiene are followed, patients with MRSA are not a risk to other patients, staff, visitors or members of their family (including babies and pregnant women). Patients should be encouraged to live a normal life without any restriction and they do not need to be isolated. They can join other residents in communal areas, receive visitors and go out of the home for visits. In care homes where people with open post operative wounds or intravascular devices are being cared for, it is recommended that infection prevention and control advice should be sought. At a minimum it is recommended that: Standard infection prevention & control precautions and hand hygiene are followed Room sharing with another service user who has an invasive device in situ (e.g. catheter) is avoided, where practicably possible. Any ulcers or wounds should be covered with an appropriate dressing Clinical procedures and dressings should be carried out in the patient s own room. The door should also be closed during care activities Bed linen should not be carried around the care home. It should be bagged or placed in a skip to facilitate its transfer to take to the laundry for washing Staff should carry out dressings/procedures on other patients before attending to dressings for those with MRSA If staff have eczema or psoriasis they should avoid performing intimate nursing care on patients with MRSA Chief Executive: Andrew Morgan 18

Carers, patients and relatives should be given information about their condition and shown how to wash and dry their hands properly to prevent the spread of infection. In some cases there may be a need to commence decolonisation of the service user in primary care. The GP will be informed by the laboratory. If the service user may have acquired the organism whilst in hospital and discharged to the community prior to result being available, the Hospital Infection Prevention & Control Team should inform the GP or Nursing/Residential (N/R) homes. Efforts should be made to decolonise those patients as far as practically possible. 21. Management of MRSA positive patients in their own homes No additional infection prevention & control precautions are required when patients are cared for in their own homes. Where practicably possible, health care staff should visit MRSA positive patients last in the morning or afternoon. If this is not possible, a risk assessment of the day s visits should be undertaken and see the high risk susceptible patients before the MRSA service user. Usual infection prevention and control practices must still be followed. Carers, patients and relatives should be given information about the condition and shown how to wash and dry their hands properly to prevent the spread of infection. Equipment used by health care staff used in the home should be cleaned with infection prevention and control approved detergent wipes after use. Health Care staff should avoid taking non essential equipment into the home. 22. Risk Management. A local incident reporting form (IR1) must be completed via Datix if the following is experienced: Non compliance with this guideline Issues raised in relation to the screening and management of MRSA positive patients MRSA blood stream infection (bacteraemia). 23. RCA, Surveillance and Mandatory Reporting. All pre-48-hour MRSA bacteraemia should be reported as an adverse incident through the organisation s own governance structures. Each MRSA Bacteraemia case must be reported as a Serious Incident (SI). Afterward, relevant Trust and Primary Care Trust are involved in a root cause analysis (RCA)/ Post Infection Review (PIR) of the case so that necessary changes to practice can be identified and acted upon. The RCA/PIR will be facilitated by the Ward Manager/Team leader and supported by the Infection Prevention Team and will require collaborative working to facilitate all cases of MRSA bacteraemia being reviewed through the appropriate method and enable lessons to be learned to prevent future infections. (Appendix I and Please refer to Trust guidelines G_IPC_07 IP&C Notification Framework for further details. 24. Resources. Best Practice Guidance and monitoring tools: Up to date information may be obtained from the Lincolnshire NHS web site. Posters and Leaflets: Up to date information may be obtained from the NHS England web site. Chief Executive: Andrew Morgan 19

25. Evidence Base. Bowler PG, Jones SA, Davies BJ, Coyle E (1999) Infection control properties of some wound dressings. J Wound Care 8(10):499 502 DH Screening for MRSA colonisation a strategy for NHS Trusts: a summary of best practice, DH MRSA Screening Operational Guidance 1 July 2008, Gateway reference 10324 DH MRSA Screening Operational Guidance 2 Gateway reference number 11123, DH MRSA Screening Operational Guidance 3 Gateway reference number 13482 DH Implementation of modified admission MRSA screening guidance for NHS (2014) European Wound Management Association (EWMA) (2006) Position Document: Management of wound infection. London MEP Ltd HPA (2008) Guidance on the diagnosis and management of PVL-associated Staphylococcus aureus infections (PVL-SA) in England. PVL sub-group. Keshtgar MR, Khalili A, Coen PG, Carder C, Macrae B, Jeanes A, Folan P, Baker D, Wren M, Wilson AP. Impact of rapid molecular screening for meticillin-resistant Staphylococcus aureus in surgical wards. Br J Surg 2007; Nov 27 Lipp C, Agostinho A, James G, Stewart P (2010) Testing wound dressings using an in vitro wound model. Journal of Wound Care 19(6) pp 220-226 Patel S. (2007) Wound Essentials, Volume 2, 2007. Phillips E, Young T (1995) Meticillin-resistant Staphylococcus aureus and wound management. Br J Nursing 4(22): 1345 9 RCN (2005) Wipe It Out: Meticillin-resistant Staphylococcus aureus (MRSA) Guidance for nursing staff Wounds UK (2010) Best Practice Statement: The use of topical antiseptic/antimicrobial agents in wound management. Aberdeen Chief Executive: Andrew Morgan 20

Appendix A: SystmOne screen Chief Executive: Andrew Morgan 21

Appendix B: Inter-healthcare Infection Prevention & Control Transfer Form Patient/client details: (insert label if available) Name: Address: Consultant: GP: Current patient/client location: NHS number: Date of birth: Transferring facility hospital, ward, care home, other: Contact no: Receiving facility hospital, ward, care home, district nurse Contact no: Is the ICT/ambulance service of transfer? Yes/No aware Is the ICT aware of transfer? Yes/No Is this patient/client an infection risk? Please tick most appropriate box and give confirmed or suspected organism Confirmed risk Organism: Suspected risk Organism: No known risk Patient/client exposed to others infection e.g. MRSA Yes/No with Relevant specimen results (including admission screens for MRSA) including antimicrobial therapy. Specimen: Date: Result: Other information: Is the patient/client aware of their diagnosis/risk of infection? Yes/No Does the patient/client require isolation? Yes/No Should the patient/client require isolation, please phone the receiving unit in advance. Name of staff member completing form: Print name: Contact number: For further advice, please contact your Infection Prevention Team Chief Executive: Andrew Morgan 22

Appendix C: MRSA Screening Categories It is essential that all emergency and elective admissions and ward attenders are screened for MRSA to include: Accepted exclusions to routine screening are: patients who are palliative, day case ophthalmology, day case dental, day case endoscopy, minor dermatology plus the category detailed below. MRSA: Additional category of patient excluded from routine screening The Infection Prevention Committee for Lincolnshire Community Health Services has approved the following additional group of patients who may be excluded * from routine MRSA admission screening Patients admitted for Sleep Studies to Treatment Room (INP 109) Welland Ward Johnson Community Hospital Spalding Road, Pinchbeck, Spalding, PE11 3DT The rationale supporting this decision is based upon The procedure is low risk and no invasive interventions result from assessments the patient is admitted into a dedicated area away from the main inpatient area 23 Chief Executive: Andrew Morgan

Local Controls Rationale for action Clinical practice Staff delivering care will adhere to local infection prevention and control guidelines Reduction of spread of micro-organisms Cleaning The equipment & environment is cleaned after use and bed linen replaced Patient location The patient will not be admitted into a bed on the main unit High risk patients* Will be screened for MRSA as per main document * Important note: High risk patients Where a patient admitted for sleep studies has a skin condition (e.g. a chronic or acute wound, eczema, psoriasis etc) and or/an invasive device (e.g. an indwelling urinary catheter, Hickman line, peg device etc.) they must be screened for MRSA as per local policy. 24 Chief Executive: Andrew Morgan

Appendix D: MRSA Decolonisation/suppression Integrated Care Pathway (ICP) MRSA Decolonisation/suppression Integrated Care Pathway (ICP) Patient s Name. DOB... NHS Number Ward / Area.Consultant / GP. Inclusion Criteria - This ICP is for use with known and newly diagnosed MRSA positive adult patients. Exclusion Criteria - This ICP is not for use with patients 16 years or younger. -Discuss treatment regime with a Consultant Microbiologist where peanut allergy and/or resistance to components of suppression therapy is known Signature Record - All members of staff using this Integrated Care Pathway complete this section. You can then use initials when recording care. Print Name Job Title Signature Initials Please ensure this pathway is completed fully. Once decolonisation has commenced continue for 3 cycles or until 3 negative screens have been obtained. Continue with suppression therapy (Octenosan wash) even with negative screens. Decolonisation therapy MUST continue until 3 consecutive negative results are received or the patient is discharged home, whichever comes first. It is recommended that mupriocin is used for a maximum period of 10 days. This would ordinarily require a 5 day course + 2 days rest then re -screen and if re-screen is positive continue muprirocin for a further 5 days PGD Ref No: 983 Patient Group Direction for the Supply and/or Administration of Mupirocin 2% Nasal Ointment Name NHS no History 1. Date of admission 2. Admitted from where? Hospital Care home Home 3. Does the patient meet any of the following At Risk criteria? Other. Previous MRSA carrier From another Hospital Transfer from Abroad Nursing / Residential Care Home Colonisation / infection on admission e.g. transfer form 25 Chief Executive: Andrew Morgan

4. MRSA first isolation (if known) NA Date: Site/s: 5. Patient informed of screening process? Yes No Leaflet/s provided If no state reason. 6. Admission screening swabs taken? Date taken Site Results: positive/ negative Anterior nares. Groin Other please state 7. Was the full MRSA screen taken within 24 hours of being admitted? Yes No Date: If No, why (state) e.g. weekend Initials:.... Nursing / Medical Interventions YES NO Date Time Initials Isolation 1. Has the patient been isolation in single room? Room No Isolate Contact IPCT 2. Are there en-suite facilities Designate toilet Use commode Contact IPCT 3. Has an explanation been given to the patient/relatives as to why they have been isolated? 4. Standard precautions implemented by all HCW s that have contact with the patient. 5. Are hand washing facilities available. to include alcohol hand rub Explain Leaflet/s Obtain / locate resources Obtain Suppression therapy 6. Commenced on daily suppression therapy e.g. Skinsan 7. Patient provided with information on suppression therapy? YES NO Date Time Initials Obtain and commence Obtain Name NHS No. Suppression/Decolonisation 1st Treatment (please enter in box below initials and date) Antibacterial wash Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 SCREEN Antibacterial hair wash 26 Chief Executive: Andrew Morgan

Mupirocin Nasal Ointment 2% * caution see above exclusion criteria Re-swab result Positive Negative x x x x x x x x x Suppression/Decolonisation 2nd Treatment (please enter in box below initials and date) Antibacterial wash Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 SCREEN Antibacterial hair wash Mupirocin Nasal Ointment 2% * caution see above exclusion criteria Re-swab result Positive Negative If still positive after second cycle of suppression/decolonisation discuss with Microbiologist/IP&C Team. Suppression/Decolonisation 3rd Treatment (please enter in box below initials and date) Antibacterial wash X X X X X X X X X Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 SCREEN Antibacterial hair wash Omit Mupirocin as per PGD max 10 days treatment Re-swab result Positive Negative Continue with decolonisation until 3 rd result is received. X X X X X X X X X 27 Chief Executive: Andrew Morgan

Appendix E: Leaflet Skin to skin contact does not necessitate aprons and glove use, but good hand washing before and after contact with you is encouraged. What will happen if I go into hospital? If you know when you are going into hospital then it is advisable that you let your District nurse/practice nurse/gp know that you are colonised with MRSA as soon as possible. They will be able to assist you with any swabs and treatment needed beforehand. If required, where will swabs be taken from? If you need swabs to be taken prior to admission to hospital then the nurse will swab your nose, your groin and any wounds you may have. If you have a urinary catheter in place or a productive cough, then samples may be taken from there. If treatment is required prior to your admission to hospital then that will be arranged by the hospital or by your GP. If you need treatment you will be given some special soap to wash hair and body, daily for 5 days. Also you will be given some cream to put up your nose for 5 days. The hospital or the nurse will arrange for you to have some more swabs taken after the treatment has finished. What if I go into hospital as an emergency admission? If you are admitted to hospital as an emergency patient, please tell the doctors and nurses that you are colonised with MRSA, or get a relative to do this for you. What will happen when I am in hospital? MRSA can be a problem in hospitals where there are many patients close to each other with large wounds and who may have a poor ability to fight infections. If you go into hospital you may be nursed in a room by yourself or with others who have this bacteria, to limit the spread to other vulnerable patients. For more information on MRSA please contact your: District Nurse, GP/Practice Nurse, Local Infection Prevention Team V 1 June 2009 V5 Review Oct 2016. Next due Oct 2018 MRSA Meticillin Resistant Staphylococcus aureus 28

29 What does MRSA stand for? MRSA stands for Meticillin (M) Resistant (R) Staphylococcus (S) aureus (A). Meticillin (M) refers to the antibiotic. Resistant (R) means that some antibiotics do not work in treating this bacteria. Staphylococcus (S) aureus (A) refers to the bacteria (also known as Staph aureus). Staphylococcus aureus the bacteria. Between 30 50% of the population have Staphylococcus aureus living completely harmlessly on the skin, nose and / or wound. This is normal. Staphylococcus aureus can cause common minor infections such as spots, boils, abscesses or minor skin infections. These bacteria only cause a potential problem (serious infection) if they gain entry through skin that is broken if you have a cut, a sore or a deep wound. The difference between Staphylococcus aureus (see above) and MRSA (see below) is that MRSA is resistant to more antibiotics than Staphylococcus aureus. MRSA Most people found to have MRSA are said to be colonised (where the bacteria is sitting in their skin or wound) and will remain well, not look or feel different; it will not cause them to be ill. It does not cause a problem for healthy people. You would not know if you were colonised unless swabs were taken. MRSA can potentially infect when it gets an opportunity to enter the body, for example through a cut or deep wound. It can cause infections such as wound, chest or bloodstream infections How do people get MRSA? MRSA is most commonly spread by touch. If a person gets MRSA on their hands, they may pass it to other people if they do not wash their hands properly. Likewise, it can live in unclean environments. Do patients colonised with MRSA, in the community have to be treated? No, not all patients in the community with MRSA require treatment. People usually live quite healthily with the bacteria on them. However, if you have to go into hospital for surgery, then treatment may be started at home to reduce the number of this bacteria on your skin and in your nose. Your health professional will guide you through this. What can be done to prevent the spread of the bacteria? At home. MRSA is not usually a problem to other individuals in the home. If someone in the same household is ill, your family doctor or nurse will be able to tell you if any special precautions are needed. Washing hands. It is good practice for you and your visitors to wash your hands when they may be dirty, after using the toilet and before and after preparing or eating food. A good neutral liquid soap is more than sufficient as long as all areas of the hands have contact with the soap, it is rinsed off completely and the hands are thoroughly dried. to wash hands. Alcohol hand rubs are good when used appropriately, but they do not replace the need to wash hands. Laundering of clothing. At home, clothes, bed linen and other items an be washed in normal domestic washing machines it is advisable to wash the items on a hot wash (above 65, wash instructions permitting). Tumble drying and ironing also helps remove any residual bacteria. Cleaning of home There is no special additional cleaning required in the home above what you normally do. But keeping surfaces dust free and regular vacuuming helps. Visitors Visitors may come and go as you wish. We, however, would advise you that you encourage your visitors to wash their hands as required. Social life / Work life / School Life / Personal Life There are no special precautions or restrictions within your work, social, school or personal life. Life can continue as normal. Will anything specific happen in other areas of the community, e.g. GP Surgery? In other health care areas, for example, GP surgery, Dentist or Nursing home; it helps staff to know if someone has MRSA so that they can take additional precautions, where required, to protect people who may be vulnerable. Staff will wear gloves and aprons when coming into contact with your blood/bodily fluids.

Appendix F - MRSA Labels MRSA DATE... MRSA DATE... MRSA DATE... MRSA DATE... MRSA DATE... MRSA DATE... MRSA DATE... MRSA MRSA DATE... MRSA MRSA DATE... MRSA DATE... DATE... DATE... MRSA MRSA MRSA DATE... DATE... DATE... Chief Executive: Andrew Morgan 38

Appendix G: GP Letter Infection Prevention Team John Coupland Hospital Ropery Road, Gainsborough Tel: 01427 816500 Calls via Typetalk are welcome Fax: 01427 816512 Website: www.lincolnshire.nhs.uk <add GP Name/Address > Dear Dr. <add GP Name>> Patient name: NHS number: DOB: Home address: Sample type(s) and Date: Please place a tick the relevant box: This patient was discharged prior to a positive MRSA result being received and may require topical suppression/decolonisation therapy and follow up (as indicated below). This patient was diagnosed as MRSA positive on this admission and completed a full course of suppression/decolonisation treatment. This patient was discharged on topical suppression/decolonisation therapy. If this patient requires decolonisation, please follow the following regimen and subsequent screening as described below: Area Regime Directions Duration Skin Antimicrobial body wash (e.g.octenisan) Wet skin. Pour solution onto a clean damp washcloth or directly onto the skin. Wash all over paying particular attention to axillae, perineum and groin areas. Leave solution in contact with the skin for at least 60 seconds. Rinse off thoroughly. Dry with a clean and dry towel. Daily for 5 days 31

Hair Nasal Antimicrobial body wash Mupirocin 2% in paraffin base.* (eg Bactraban) Wash hair with solution in place of shampoo. Rinse well. Dry hair as usual Apply a pea size amount to inner surface of each nostril. Alternate days TDS for 5 days *In cases of Mupirocin resistance, Neomycin-Chlorhexidine nasal cream (Naseptin) should be prescribed (if Neomycin sensitive). Apply to both nostrils 4 times daily. Discuss the treatment regime with Consultant Microbiologist if patient is known to have an allergy to any of the product ingredients. Where a patient is unable to use Octenisan due to skin sensitivities etc, the recommended alternative product is HiBiScrub Plus whole body wash. The swabs should be taken from the following areas: Anterior nares - both nostrils, using one swab (moistened with sterile water or saline prior to swabbing). Groin, Any skin lesions or wound sites Catheter sites and CSU if present (please ensure that you request Urine for MRSA screening ) Tracheostomies Sputum (from patients with productive cough). Please ensure the swab request form states follow-up MRSA screen post treatment. For any additional information please contact the Infection Prevention Team. Thank you for your assistance. Yours sincerely CC Infection Prevention Team (for information) <add team name & address> 32

Appendix H: MRSA Integrated Care Pathway (IPC) Patient s Name.. NHS Number. DOB... Ward / Dept.Consultant / GP Inclusion Criteria - This ICP is for use with all admitted adult patients who are MRSA positive. Exclusion Criteria - This ICP is not for use with patients 16 years or younger. Signature Record - All members of staff using this Integrated Care Pathway complete this section. You can then use initials when recording subsequent care. Variances Any variance from this pathway must be recorded on the MRSA SystmOne template, the variance sheet, dated and initialled. Print Name Job Title Signature Initials History 8. Date of admission 9. Admitted from where? Hospital Care home Home 10. Does the patient meet any of the following At Risk criteria? 11. MRSA first isolation (if known) 12. Patient informed of the positive screening result 13. Have the care notes been flagged indicating positivity? Other. Previous MRSA carrier From another Hospital Transfer from Abroad Nursing / Residential Care Home Colonisation / infection on admission e.g. transfer form NA Date: Site/s: Yes No Leaflet/s provided If no state reason. 33

MRSA Integrated Care Pathway Patient s Name. NHS Number.. Nursing / Medical Interventions Isolation 8. Has the patient been isolation in single room? YES NO Date Time Initials Room No Isolate Contact IPT 9. If no? 10. Has a risk assessment been completed with regard risk factors associated with patient or other patients on the ward 11. Is the patient nursed adjacent to the hand hygiene sink 12. Are there en-suite facilities Designate toilet Use commode Contact IPT 13. Has an explanation been given to the patient/relatives as to why they have been isolated? 14. Standard precautions implemented by all staff that have contact with the patient. 15. Are hand washing facilities available? to include alcohol hand rub Explain Leaflet/s Obtain / locate resources Obtain Suppression therapy 16. Commenced on daily suppression/decolonisation therapy e.g. Octenisan & Mupirocin Nasal ointment in line with appendix?c 17. Patient provided with information on suppression therapy? YES NO Date Time Initials Obtain and commence Obtain Outcomes Isolation 18. Was an MRSA Bacteraemia identified Yes No within 3 days of admission? Date:. Date completed RCA 19. Patients screening results Positive Follow Decolonisation pathway. Date Time Initials 20. Date of discontinuation of MRSA Integrated Care pathway Negative Follow Suppression pathway. Date / Time Variance Initials 34

Appendix I: MRSA Bacteraemia Framework for Action (Strategic) Pathology Laboratory Notifies Acute Infection Prevention Team of positive MRSA bacteraemia Actions for Acute Trust IPCN Enter Core data onto DCS system DOA + 1 Day Usually assigned to CCG to lead DOA + 2 Day Usually assigned to Acute Trust to lead Inform CCG of the relevant Primary Care Organisation. In addition inform the ICNs for NL & NE Lincs PCOs. The CCG will allocate responsibility to relevant Organisations & Teams for completing DCS form and lead investigations. The CCG will ensure that the information as per the DCS data form is collected within 7 days, so that data can be inputted on to the DSC system. CCG decide further local review meeting Produce Action plan Identify Themes Acute Trust Mini investigation using PIR form to review recent relevant hospital episode and review of blood culture practice At this stage agreement of the case will be agreed. If no agreement is reached then the DPH will convene a review and adjudicate within 2 weeks and log the result ADIPC - identified lead for Acute Trust investigation. Allocate responsibility to relevant Branch for completing PIR proforma investigations Arrange an MRSA Rapid Review Group meeting and carry out initial review within 7 working days Liaise with relevant CCG to ensure relevant community information is collected. Input community and Acute information onto DCS system within 7 working days Local action plan to be agreed by the group and implemented overseen by Matron Further DIPC review meeting led by DIPC Produce Trust-wide action plan Identify Themes Assurance: Monitoring of action plans by board 35

Appendix J: Local Overview for Post Infection Review Process for MRSA Bacteraemia Same Day The result received Day 1 Core record entered onto DCS (MESS by Acute Trust) System determines assignment of PIR and sets PIR due date Day 3-7 NLG Acute Trust to lead CCG to lead Collect data using PIR form Collect data using PIR form Responsible for inputting data Responsible for inputting data Systems checks PIR has been completed Day 8 Systems processing checks re assignment Chief Executive: Andrew Morgan 36

Appendix K : Skinsan Chief Executive: Andrew Morgan 37