Page 1 of 16 Policy Objective To provide Health Care Workers (HCWs) with details of the precautions necessary to minimise the risk of MRSA cross-infection. This policy applies to all staff employed by NHS Greater Glasgow & Clyde and locum staff on fixed term contracts and volunteer staff. KEY CHANGES FROM THE PREVIOUS VERSION OF THIS POLICY Removal of additional recommendations for patient in Continuing Care Areas Addition of National Clinical Risk Assessment Change from nose and groin to nose and perineum for screening Skin decolonisation changes to HiBiScrub Plus Document Control Summary Approved by and date Board Infection Control Committee on 21 May 2012 of Publication 22 May 2012 Developed by Infection Control Policy Sub-Group 0141 211 2526 Related Documents NHSGGC Hand Hygiene Policy NHSGGC Standard Precautions Policy NHSGGC Transmission Based Precautions Policy Distribution/ Availability NHSGGC Infection Prevention and Control Policy Manual and the Internet Implications of Race Equality and other diversity duties for this document Equality and Diversity Impact Assessment Completed Lead Manager Responsible Director This policy must be implemented fairly and without prejudice whether on the grounds of race, gender, sexual orientation or religion. May 2012 Assistant Director of Nursing Infection Control Board Infection Control Manager
Page 2 of 16 Contents 1. Responsibilities... 3 2. General Information on patients with MRSA... 4 3. Transmission Based Precautions for Patients with MRSA... 5 4. Audit... 10 5. Evidence Base... 12 6. Useful Links... 12 7. Glossary... 13 Appendix 1 National Screening Policy for MRSA... 14 Appendix 2 Decolonisation Regimen... 16
Page 3 of 16 1. Responsibilities Healthcare Workers (HCWs) must: Follow this policy. Inform a member of the Infection Control Team (ICT) if this policy cannot be followed. Provide information on MRSA to patients and relatives as appropriate and document in patient records. Ensure that the clinical team with direct responsibility for the patient inform those who need to know of the patient s MRSA status, e.g other wards, departments, General Practitioners, District Nurses. Managers must: Ensure that staff are aware of the contents of this policy. Support HCWs and ICTs in implementing this policy. ICTs must: Keep this policy up-to-date. Support the audit of compliance with this policy. Provide education opportunities on this policy. Provide the NHSGGC clinical governance structure with routine surveillance data. NHSGGC must: Include the surveillance of MRSA as part of the clinical governance framework. Must have clear lines of accountability/ responsibility for acting on the information received.
Page 4 of 16 2. General Information on patients with MRSA Communicable Disease/ Alert Organism Clinical Condition(s) Mode of Spread Incubation period Meticillin Resistant Staphylococcus aureus are Staphylococcus aureus bacteria that are Gram-positive and resistant to a variety of antibiotics. Various strains are endemic in hospitals. They are particularly challenging because they survive well (up to 6 months) in dry conditions. Patients may be colonised without any infection. MRSA can cause a wide range of infections, e.g. wound infections, soft tissue infections, insertion site infections, bloodstream infections, endocarditis and osteomyelitis. Contact (direct and indirect). MRSA can colonise the superficial layers of the skin of the hands and thereafter be transferred from patient to patient. Good hand hygiene with liquid soap and water or alcohol hand gel can remove MRSA. Please refer to Hand Hygiene Policy. http://www.nhsggc.org.uk/content/default.asp?page=s708_2. MRSA can be disseminated in the environment, often on skin scales, particularly during procedures such as bed-making and during wound dressings. Variable. Notifiable disease Period of communicability Persons most at risk of acquisition Persons most at risk of infection Persons who should be screened for possible MRSA carriage Persons who disperse large quantities of MRSA No. As long as MRSA can be isolated from the patient s specimens and until two negative screens have been obtained (see specimens required section on page 8). Patients who require frequent hospitalisation, or those patients who have come in from somewhere other than their own home. Patients with invasive devices, pressure sores, underlying diseases or recent antibiotic therapy. Patients who are colonised, have surgical wounds, pressure ulcers or invasive devices. Patients nursed in Intensive Care Units (ICU) have a higher risk of developing infection. Refer to Appendix 1, page 15. MRSA positive patients who have large burns or widespread exfoliating skin conditions. Patients who have nasal colonisation with upper respiratory tract infections. MRSA can also be disseminated into the environment via urinary catheters.
Page 5 of 16 3. Transmission Based Precautions for Patients with MRSA Patient Placement Care Plan available Clearance Criteria A side room should be made available for all patients colonised/ infected with MRSA. If a side room is not available the ICT will undertake a risk assessment and advise where to nurse the patient. In some instances the patient s clinical condition may not support the placement of the patient in a side room. If this is the case the ICT should be informed and the reasons documented in the patient s nursing documentation/ casenotes. Doors in side rooms should be kept closed to minimise the spread to adjacent areas. If this compromises patient care, a risk assessment should be made regarding whether the door may be kept open. This must be documented in the patient s nursing documentation/ casenotes and the IC notes. If the door is open, then it must be closed during clinical activity, e.g. bed making, chest physiotherapy. In non-acute areas a risk assessment will be undertaken by a member of the ICT. Yes. It is the responsibility of the nursing staff to commence an individual patient care plan which must be reviewed/ updated regularly. Patients should not be removed from isolation/ cohort until at least two full consecutive negative screens have been obtained. Screens should be taken at intervals of no less than 72 hours, beginning at least 48 hours after antibiotic/ decolonisation therapy has been completed. Patients should only be removed from a side room after consulting the ICT and this should be documented in the nursing notes. (Please refer to the section on Specimens Required). Clinical Waste Contact Screening Crockery / Cutlery Decolonisation Waste from patients with MRSA should be designated as clinical waste and placed in an orange bag. Contact screening should only be carried out on the advice of the ICT. No special requirements. If recommended by the ICT the clinician should prescribe and follow the decolonisation regimen. Appendix 2, page 17. If decolonisation has not been completed the regime should be given to the patient on discharge and they should be advised to continue the treatment until day 5. In non-acute areas a risk assessment will be undertaken by a member of the ICT. Decolonisation regimes should be prescribed on the drug Kardex.
Page 6 of 16 Discharge Planning Domestic Advice Equipment Exposures Furniture Hand Hygiene Last Offices Laundry Marking Notes The clinical team with overall responsibility for the patient must inform the General Practitioner and others in the community care team, of the patient s MRSA status. Domestic staff must follow the SOP for Twice Daily Clean of Isolation Rooms. http://www.nhsggc.org.uk/content/default.asp?page=s708_4 Cleans should be undertaken at least four hours apart. Allocate individual equipment, e.g. own washbowl, commodes, moving slings or slip-sheets. Decontaminate equipment as per the Decontamination Policy. http://www.nhsggc.org.uk/content/default.asp?page=s708_2 Avoid cross-infection by the use of Personal Protective Equipment (PPE) [gloves and apron] and Hand Hygiene (HH). Perform HH before and after all direct patient care, after contact with the patient s environment and after removal of PPE. Please see 5 Moments for Hand Hygiene. http://www.nhsggc.org.uk/content/default.asp?page=s710_5 Use seating made of impermeable and washable material. Keep all furniture clean and dust free. Do not remove from side room/ patient bed space, unless it has been decontaminated. Decontaminate equipment as per the Decontamination Policy, i.e. equipment should be decontaminated using a solution of 1,000ppm chlorine based detergent (i.e. 1 Actichlor Plus tablet per 1L of water = 1,000ppm). http://www.nhsggc.org.uk/content/default.asp?page=s708_2 Hand hygiene is the single most important measure to prevent cross-infection with MRSA. Refer to the Hand Hygiene Policy. http://www.nhsggc.org.uk/content/default.asp?page=s708_2 Hands must be decontaminated before and after each direct patient contact and after contact with the environment, regardless of PPE being worn. Alcohol hand rub/ gel is acceptable if hands are visibly clean. No special requirements. The risk from laundry is minimal however to prevent contamination of the environment and to comply with isolation procedures all laundry should be placed into a water soluble alginate bag then into a clear bag and then into a laundry bag. Bed linen and patient clothing should be changed daily. Yes. ICTs will implement local procedure with regard to tagging of patient records.
Page 7 of 16 Moving between wards, hospitals and departments (including theatres) Notice for Door (side room only) Outbreak Patient Clothing Patient Information Personal Protective Equipment (PPE) Patient movement should be kept to a minimum. Prior to transfer, HCWs from the ward where the patient is located must inform the receiving ward, theatre or department of the patient s MRSA status. When patients need to attend other departments the receiving area should put in place arrangements to minimise contact with other patients and arrange for additional domestic cleaning if required. There is no reason for patients not to attend physiotherapy, occupational therapy departments etc, provided the principles in this Policy and the Standard Precautions Policy are followed. In exceptional circumstances, e.g. MRSA positive patients with exfoliating skin conditions or patients who are heavily colonised may be excluded. In these instances the ICT will advise. Place a designated ICT approved notice on the door. The ICT will advise when the Outbreak Policy is to be implemented. Advise relatives that there are no special requirements but recommend washing hands thoroughly after laundry is put into the machine. Clothes should be washed at the temperatures advised on the clothing labels. Laundry leaflets are available and should be issued if required. Nursing staff should refer to the following document: Patients Clothing Bags for Contaminated Laundry Information for Clinical Staff (see link). http://www.nhsggc.org.uk/content/default.asp?page=s946 NB It should be recorded in the nursing notes that both advice and the information leaflet has been issued. The clinical team with overall responsibility for the patient must inform the patient and provide written information on MRSA to the patient and any persons caring for the patient, e.g. parent, guardian or next-of-kin, carer, as appropriate. The clinical team should document in the patient notes. Additional information can be obtained from the local ICT. General information for patients, carers and the public is produced by NHSGGC and can be viewed at: http://www.nhsggc.org.uk/content/default.asp?page=s946 Personal Protective Equipment (disposable gloves and yellow aprons) must be worn for direct contact with the patient or the patient s environment/ equipment. Gloves and aprons are singleuse and should be discarded as clinical waste after use, and hands decontaminated.
Page 8 of 16 Procedure Restrictions Referral Risk assessment required Screening on Admission / Re-admission There is no reason to place patients with MRSA at the end of operation lists. The microbiology laboratory will inform the ICT of any new/ reisolates. Ward staff to inform ICT of any re-admission of patients previously MRSA positive. It is the responsibility of clinical staff within the area to inform GPs and other hospitals or care homes of a patients MRSA status when they are being discharged or transferred. ICT to undertake a risk assessment of individual patient and the environment. In non-acute areas/ continuing care, the ICT will advise if screening is required as per National Screening Policy. See Appendix 1, page 15. Specimens required (MRSA full Screen) Anterior nares Perineum * Skin lesions/ wounds if signs of infection are present. Catheter sites, e.g. Central Venous Catheters, Hickman Lines, if signs of infection are present. Catheter urine, if signs of infection are present. Sputum from patients with a productive cough. Umbilicus (neonates only) * If patient refuses perineal screening they should be offered throat screening. Any modification to the standard screening should be recorded in the notes. NB this may need to be modified for specialist units, e.g. ENT. Screening of Staff Routine screening of staff is not recommended however during outbreaks this may be undertaken if advised by the Outbreak Control Team (OCT). During outbreaks staff should be asked about skin lesions and if appropriate referred to the Occupational Health Service (OHS). If screening is advised it will be undertaken by the OHS. Refer to Staff Screening Policy. http://www.nhsggc.org.uk/content/default.asp?page=s708_2 Surgical/ Invasive procedures Patients who are positive for MRSA - prior to any planned invasive procedure efforts should be made to minimise the level of risk of infection by using topical and systemic decolonisation and prophylactic antimicrobial therapy as advised by the microbiologist.
Page 9 of 16 Terminal Cleaning of side room / bed area Transfer or transport by ambulance, patient transport or pool cars Follow SOP for Terminal Clean of Isolation Rooms. http://www.nhsggc.org.uk/content/default.asp?page=s708_4 Patients colonised or infected with MRSA are classified into two categories by the Scottish Ambulance Service: Category 1 Most patients colonised with MRSA or who have infected wounds or skin lesions that are covered by an occlusive dressing may be transported with others and require no special precautions. Category 2 Patients who are heavily colonised with MRSA and are considered to be heavy shedders, e.g. have severe psoriasis or eczema, large wounds or burns, should be transported by themselves. The ambulance service will implement appropriate precautions to this category. The ICT should be contacted if patients fall into this category. It is the responsibility of the ward or department to inform the ambulance service of patients who fall into Category 2 when transport is arranged. Visitors Visitors are not required to wear apron and gloves unless participating in their relatives care but must be advised to perform hand hygiene with alcohol gel or liquid soap and water before entering and leaving the facility.
4. Audit NHS GREATER GLASGOW & CLYDE Page 10 of 16 Answer Questions 1-12 for each patient. (Use continuation sheet if necessary) Total number of patients in single rooms Total number of patients in cohort rooms Total number of patients receiving treatment (prescribed or otherwise) nasal body both nasal and body Question: Patient 1 Patient 2 Patient 3 Yes No N/A Yes No N/A Yes No N/A 1 Patients with MRSA are nursed in single room/ cohort or nursed beside a low-risk patient. (Observe or discuss with ward staff/ read notes). 2 Reason for not isolating patient(s) is documented in patient casenotes. (Check patient casenotes) 3 If patient isolated/ cohorted, door kept closed. (Observe. If door open check reason and document in notes.) 4 If door remains open, reason is documented in patient casenotes. 5 If patient isolated/ cohorted, designated ICT approved notice displayed on the door/ entrance to cohort. (Observe) 6 If patient(s) currently on nasal eradication as per policy, this is prescribed in the drug chart. (Check current drug charts) 7 If patient is currently prescribed nasal eradication as per policy it has not been given for longer than 5 days. (Check the current drug chart) 8 If applicable, is the patient receiving antimicrobial body wash daily. 9 MRSA screen taken 48 hours following completion of eradication treatment. (Ask staff, check notes/ lab system) 10 Room/ cohort/ bed area is clean. (Check) 11 Care Plan in use. (d and signed by staff) 12 Page 4 of MRSA Care Plan is completed and up-to-date. Questions 1-3 once per ward Total criteria Question Yes No N/A 1 Staff can state how to apply antimicrobial body wash correctly. (Ask 1 member of staff) 2 Nurse in charge is aware that room/ cohort/ bed area(s) is receiving a twice daily clean using a chlorine based detergent. 3 Current policy present in the Prevention and Control of Infection Manual. (Check Manual) Hospital: Ward & Directorate: of Audit:
Page 11 of 16 Audit of compliance with MRSA Policy Feedback Statement Number of criteria assessed (total number minus N/A) Number of criteria met Number of criteria not met (1 for each criteria assessed for each patient, and 1 for each of the 3 ward questions assessed) Question: 1 Patients with MRSA are nursed in a single room/ cohort or nursed beside a low-risk patient. 2 Reason for not isolating patient(s) documented in nursing notes. 3 If patient isolated/ cohorted, door(s) kept closed. Auditor Comment 4 If door remains open, reason is documented in patient casenotes. 5 If patient isolated/ cohorted, designated ICT approved notice displayed on the door/ entrance to cohort. 6 If patient(s) currently on nasal eradication treatment as per policy, it is prescribed in the drug chart. 7 If patient currently prescribed nasal eradication as per policy it has not been given for longer than 5 days. 8 If applicable, is the patient receiving antimicrobial body wash daily. 9 MRSA screen taken 48 hours following completion of eradication treatment. 10 Room/ cohort/ bed area is clean. 11 Care Plan in use. 12 Page 4 of MRSA Care Plan is completed and up-todate. Question Yes No 1 Staff can state how to apply antimicrobial body wash correctly. 2 Nurse in charge is aware that room/ cohort/ bed area(s) is receiving a twice daily clean using a chlorine based detergent. 3 Current policy present in the Prevention and Control of Infection Manual. Ward: of Audit: Results fed back to:
Page 12 of 16 5. Evidence Base Coia JE et al. Working Party Report. Guidelines for the control and prevention of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities. Journal of Hospital Infection 63S S1-S44. 2006. CEL 6 (2008) NHS Continuing Care. The Scottish Government Primary and Community Care Directorate. Siegel, J.D. et al Management of Multidrug-Resistant Organisms in Healthcare Settings. The Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention. 2006. Department of Health. Screening for Meticillin-resistant Staphylococcus aureus (MRSA) colonisation: A Strategy for NHS Trusts a summary of best practice. Saving Lives: a delivery programme to reduce HAI including MRSA. 2006 Tomic. V. et al. Comprehensive Strategy to Prevent Nosocomal Spread of Methicillin- Resistant Staphylococcus aureus in a highly endemic setting. Archives of Internal Medicine. 164. 2004 Siegel JD et al. Guideline for Side room Precautions: Preventing transmission of Infectious Agents in Healthcare Settings. The Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention. 2007. HPS MRSA Pathfinder Papers can be found at the following link; http://www.hps.scot.nhs.uk/pubs/publication_search/publication_detail.aspx 6. Useful Links NHS Greater Glasgow & Clyde Prevention & Control of Infection Manual. http:// Health Protection Scotland http://www.hps.scot.nhs.uk/
7. Glossary NHS GREATER GLASGOW & CLYDE Page 13 of 16 CRA DOH ENT HH HCW HDU HPS IPC ICT ICU / ITU MRSA colonisation MRSA infection NHSGGC OCT OHS OPD PPE SOP Clinical Risk Assessment Department of Health Ear Nose and Throat Hand Hygiene Healthcare Worker High Dependency Unit Health Protection Scotland Infection Prevention Control Infection Prevention Control Team Intensive Care Unit / Intensive Therapy Unit MRSA can be isolated from the patient s skin or mucous membranes but there are no clinical signs of associated infection. MRSA can be isolated from wound exudates or other body sites where there is ongoing clinical infection and the MRSA is thought to be at least one of the organisms causing that infection. NHS Greater Glasgow and Clyde Outbreak Control Team Occupational Health Service Out Patient Department Personal Protective Equipment Standard Operating Procedure
Page 14 of 16 Appendix 1 National Screening Policy for MRSA Introduction The National MRSA Screening Programme was amended in February 2011 to a universal programme of Clinical Risk Assessment (CRA) as a first line screening test for all admissions >23 hours. The CRA identifies patients at high-risk of MRSA colonisation who are then moved onto a second stage minimum two-site swab test (nose and perineum). For completion within 24 hours of admission: Part A: Part B: CRA (Clinical Risk Assessment) for all admissions >23 hours 1. Has the patient ever had a previous positive MRSA result? 2. Has the patient been admitted from a care home/ institutional setting or another hospital? 3. Does the patient have a wound/ ulcer or invasive device which was present prior to admission? If the patient answers Yes to any of the above they will move to Part B, the second stage which is full swab screen. Full Screen Swab Test includes: anterior nares perineum * Also: skin lesions/ wounds, if signs of infection are present invasive devices, e.g. Central Venous Catheters, Hickman Lines if signs of infection are present catheter urine, if signs of infection are present sputum from patients with a productive cough umbilicus (neonates only) * If patient refuses perineal screening or if there is a clinical reason that this cannot be obtained they should be offered a throat swab. Any modification to the standard screen should be recorded in the notes. Part A and B: High Impact Specialties: All admissions (>23 hours) to the following specialties (in addition to having a CRA completed) should receive a nasal and perineal MRSA screen within 24 hours of admission: ICU/ ITU/ HDU (Intensive Care/ Therapy/ High Dependency Unit) Orthopaedics Renal/ Nephrology Vascular Cardiothoracic Surgery
Page 15 of 16 Exclusions: Patients admitted to the following specialties are not required to be screened under the National Programme. (This does not mean that these categories of patient should not be screened if there is a clinical need to do so): Day cases or patients with a length of stay <23 hours (unless previously positive in which case a full MRSA screen should be taken) Psychiatry Obstetrics Paediatrics Continuing Care Admission Screening Criteria: Type of admission When should they be screened? How should they be screened? Elective patients to high impact specialties CRA and then two body site swabbing (nasal and perineal) Elective patients to non-high impact specialties Emergency patients to high impact specialties Emergency patients to non-high impact specialties Transfer Screening Criteria: Type of transfer Transfer into a high impact specialty (from any source other than a high impact specialty) * Transfer from one hospital into another hospital (within the same Board, regardless of the specialty) Transfer from one Board to another Board Transfer from one high impact specialty to another high impact specialty in the same hospital Transfer from one non-high impact specialty to another non-high impact specialty in the same hospital At pre-assessment or outpatient clinic where possible, if not, then on admission to hospital (within 24 hours of admission, and certainly prior to the elective procedure) On admission to hospital, within 24 hours of admission. It is not recommended that screening is undertaken in Accident and Emergency. When should they be screened? Once they have been transferred into their new location (within 24 hours). There is no requirement to undertake another screen. CRA and if they answer yes to at least one question, two body site swabbing (nasal and perineal) CRA and then two body site swabbing (nasal and perineal) CRA and if they answer yes to at least one question, two body site swabbing (nasal and perineal) How should they be screened? CRA and then two body site swabbing (nasal and perineal). Note: If the patient has previously been swabbed and the result is awaited from the lab, there is no requirement to again swab the patient. N/A * Transfers between Western Infirmary Glasgow (WIG)/ Gartnavel General Hospital (GGH) are not required to be re-screened as the sites operate functionally as one hospital with a single admission unit.
Page 16 of 16 Appendix 2 Decolonisation Regimen Nasal Eradication and Skin Decolonisation Prior to commencing any treatment, results from the patient s most recent MRSA screen must be available. If patients have exfoliative skin conditions any treatment must be discussed with the ICT and the clinician in charge of the patient care. Nasal Eradication Treatment Mupirocin Sensitive MRSA Mupirocin 2% in paraffin base should be applied to the inner surface of each nostril twice daily for five days. The patient should be able to taste the mupirocin at the back of their throat following application. Mupirocin should be used for five days, stopped for two then the patient should be re-screened. Mupirocin should only be used for two five-day courses and should never be used for prolonged courses or used repeatedly. Skin Decolonisation Mupirocin Resistant MRSA Nasal Naseptin applied to the inner surface of each nostril four times daily for five days should replace Mupirocin. Naseptin should be avoided in patients with peanut allergy. Please discuss an alternative with a microbiologist. Treatment Chlorhexidine Gluconate 4% w/v (HiBiScrub Plus) Use: 25mls of liquid should be used for each shower/ assisted wash, beginning with the face and working downwards, paying particular attention to the armpits (axilla) and groin area. Rinse and repeat washing with a further 25mls of liquid, this time include the hair. Rinse and dry thoroughly. If any irritation occurs discontinue use and seek advice from the local infection control team.