TITLE: UNIQUE IDENTIFIER Assigned by Sharepoint VERSION No 1.2 LEAD AUTHOR S NAME Allison Charlesworth LEAD AUTHOR JOB TITLE Matron Infection Prevention ACCOUNTABLE DIRECTOR Rob Dearden, Director of Nursing APPROVED BY Screening Group, QSOG DATE APPROVED March 2009 EFFECTIVE FROM March 2009 REVIEW DATE January 2014 extended to 31 st July 2014 LOCATION OF COPIES 1. SharePoint Guideline ASSOCIATED Instructions for screening/re-screening POLICIES & PROCEDURES and colonisation suppression POLICIES REPLACING N/A REVIEW DATE REVIEWED BY January 2013 Allison Charlesworth Page No Trust Statement of Intent 2 1. Introduction 2 2. Scope 2 3. Policy Statement 2 4. Responsibilities 2 5. Implementation 6 6. Record Keeping 7 7. Equality & Diversity 7 8. Consultation 8 9. Monitoring and Evaluation 9 10. Glossary of terms 10 11. References 10 Appendices Appendix 1 - Instructions for Screening and Colonisation Suppression Regimen for Elective Caesarean Section Appendix 2 - Instructions for Screening and Colonisation Suppression Regimen for All High Risk Obstetric Women Appendix 3 - Instructions for Screening and Colonisation Suppression Regimen for High Risk Paediatric/Neonate Patients Appendix 4 - Screening Pathway Pre-Operative Assessment and Outpatients 1
Appendix 5 - Instructions for Screening and Colonisation Suppression Regimen for Haematology and Oncology Day Unit (HODU) Appendix 6 - Screening Pathway Emergency/Acute Admissions All the above appendices sit as separate documents on SharePoint. 2
Trust statement of intent Airedale NHS Foundation Trust is committed to meeting its legislative responsibilities in preventing and reducing healthcare associated infections (HCAI) with regards to screening and colonisation suppression treatment. The Trust undertakes to implement appropriate procedures to ensure that all relevant patients are screened and treated in accordance with the Department of Health Screening Operational Guidance 2008. Implementation of the policy will demonstrate compliance with this guidance and assurance will be achieved through monitoring arrangements detailed in section 9 of this policy 1. Introduction 4.4 In the pursuit of lowering infection rates and the prevention of HCAI the screening of all elective and non-elective patients for Meticillin Resistant Staphylococcus aureus () is a requirement following advice from the Department of Health to review current practices in regard to screening and colonisation suppression programmes. This in turn will provide assurance to patients and the public that Airedale NHS Foundation Trust is working hard to reduce the risks involved with HCAI. The operating framework 2008/09 originally set out the commitment to introduce screening for all elective patients from 2008/09 and all emergency admissions as soon as practicable. The operating framework for 2009/10 reiterated this commitment and firmed up the requirement for all emergency admissions to be screened no later than 2011. This policy must be read in conjunction with the Guideline. Guideline 2. Scope This policy is mandatory and applies to all Airedale NHS Foundation Trust clinical staff in all clinical areas of the Trust. It must be used in conjunction with the other Trust policies and supporting procedures. 3. Policy Statement 3.1 This policy details how Airedale NHS Foundation Trust will implement and maintain an screening programme for all relevant patients and how compliance with this programme will be monitored. 4 Responsibilities 4.1.1 The Trust The Trust Board has overall responsibility for ensuring that adequate resources are provided for infection prevention and control and for monitoring the impact of the Screening Policy of the Trust and its management. 4.1.2 Chief Executive The Chief Executive on behalf of Airedale NHS Foundation Trust has overall responsibility for ensuring systems are in place to support the screening programme. 3
4.1.3 Medical Director The Medical Director is responsible for ensuring that all medical staff within the Trust are aware of their responsibility and accountability, and work in accordance with this policy. 4.1.4 Director of Nursing Will ensure the policy for screening is in place and is implemented appropriately. 4.1.5 Directors, Senior/General Managers and Matrons Directors, Senior/General Managers and Matrons are responsible for implementing this policy in the areas under their control. They will ensure: that ward and department managers apply this policy across their areas of responsibility. that procedures pertinent to the specialty are in place, in liaison with the Infection Prevention Team (). that staff co-operate with regular audits of compliance to the policy. monitoring of staff attendance at mandatory infection prevention safety updates to ensure they receive relevant information on screening 4.1.6 Ward and Departmental Managers Ward and Departmental Managers will ensure: that safe systems of work are in place and reviewed/updated as required in conjunction with the. that all staff are aware of the requirements of this policy. 4.1.7 All staff Staff must ensure they understand and adhere to the policy. In addition the individual must ensure they have received training and education as defined in the Training Matrix to enable them to correctly follow the policy and recognise that failure to follow the policy will be seen as negligence. Director of Infection Prevention and Control (DIPC) Will provide monthly screening figure reports for general surgery, orthopaedics, Medical Admissions Unit and Pre-assessment Clinic, provide periodic reports for the Trust Board and ensure that techniques for the screening process are acceptable. Infection Prevention Team () Will be responsible for: Ensuring the ongoing coordination of advice and training to the nursing staff concerning screening. 4
Monitoring progress in relation to screening. Pathology Department Will ensure testing is carried out using recommended methods and that results are communicated to relevant staff as soon as results are known. Heads of Service, Medical Staff, Senior Matrons, Clinical Leads, Ward and Department Managers Have a responsibility to: Ensure staff comply with the requirements of the policy and associated procedures. Ensure that the policy is brought to the attention of clinical staff and observed by them. Ensure that every member of staff has an understanding of the content and its application. Ensure that the appropriate resources and training are made available to support the screening programme within their sphere of responsibility. Responsibilities of individual members of staff It is the responsibility of all clinical staff to: Ensure they are familiar with this policy and associated guidelines and procedures. Ensure they have received sufficient training. Ensure that they report incidents of infection that may result in spread between patients. Patients Groups Screening Arrangements Maternity Women for elective caesarean section and women identified as high risk during pregnancy will be screened as per criteria detailed in appendix 1 and appendix 2. Paediatrics and Neonates All high risk paediatric and neonatal patients will be screened as per criteria detailed in appendix 3. Elective Inpatients Surgery This group will be screened as part of their pre-operative assessment as per criteria detailed in appendix 3 5
Elective Inpatient Medicine and Local Anaesthetic Surgery This group will be screened in outpatients as per criteria detailed in appendix 4. Regular Attendees Oncology and Haematology Patients who attend the Haematology and Oncology Day Unit will be screened as per criteria detailed in appendix 5. Emergency/Acute Admissions screening will be done on admission to the receiving ward as per criteria detailed in appendix 6. Direct Access Those patients who are admitted directly onto lists will be screened by their GP prior to admission if required and colonisation suppression treatment commenced prior to admission if isolated. Contracted out Work The Trust will ensure that all patients who are treated as part of the elective work we contract out will be either screened at Pre-operative Assessment Clinic at Airedale or screened at the contracted provider units. Education and Training Education and training will be provided by the. Cascade training will be adopted in Ward/Departmental areas as appropriate. Screening Methods Screening swabs will be taken from the anterior nares (nose) any skin ulcers, wounds, severe skin disease and any invasive devices. Screening/Re-screening and Colonisation Suppression screening results are valid for 18 weeks, therefore if procedure is not carried out within 18 weeks of the screen a new screen will be required. Testing Methods The microbiology laboratory will carry out the tests using a method recommended currently for testing and screening. The method used is broth enrichment culture followed by agar subculture. This method allows negative cultures to be reported at 24 hours and positive cultures at 48 hours from the time they are setup in the laboratory. Colonisation Suppression Regimen The primary colonisation suppression regime for inpatients consists of: 6
Bactroban nasal ointment. Apply to nostrils three times a day as per instructions for 5 days. Hibiscrub body wash as per instructions for 5 days. An alternative if patient has skin problems is Oilatum Plus. Screening/Re-screening and Colonisation Suppression Alternative colonisation suppression regimens will be considered by the and Consultant Microbiologist for outpatients and those patients who have had 2 courses of the primary colonisation suppression treatment within 6 months but continue to be positive on screening. NB: If a patient screens positive for and their admission cannot be delayed, then the patient must be admitted to a single room AND colonisation suppression commenced. Patient Information The minimum requirement is that all patients must receive a verbal explanation of screening prior to taking any swabs. In addition information leaflets are available via the and on SharePoint and Colonisation Suppression Leaflets Further detail on provision of patient information can be found in the relevant appendices. GP Information Following a verbal communication with the GP surgery, the relevant documentation will be faxed to a secure fax at the GP s surgery. GP Letters and GP Fax Form Further detail on provision of GP information can be found in the relevant appendices. Patient Refusals In the unlikely event that a patient refuses to be screened, a clear explanation of the consequences of this should be explained and the likely delays that may be incurred while appropriate measures are put in place to treat the patient. The will advise and support staff as necessary and speak with the patient if required. Future Screening Airedale NHS Foundation Trust will continue to assess locally all patient admission groups for screening according to risk as advised in the guidance. Results 7
Communication of screening results will occur as detailed in appendix 1 to 6. 5 Implementation 5.1 Task Detail Responsible Timescale Distributing and implementing the policy Trust Polices Sharepoint page In the weekly staff brief e- bulletin Team brief SQUID Newsletter Infection Prevention Team Immediately following ratification Training sessions Infection prevention mandatory updates. please refer to: Infection Prevention Training Strategy Infection Prevention Team Monthly Addition of monitoring to Committee forward plans 6 Record Keeping This policy will result in the following classes of records being created, which will observe the following retention regimes (please refer to Records Management Guidelines on SharePoint for guidance, and list as appropriate): Record Type Retention period Disposal method Laboratory reports 30yrs Archive/delete Care Pathway 8 years Shredding Surveillance Sheet 6 years Shredding Daily record sheet 6 years Shredding 7 Equality & Diversity 7.1 Airedale NHS Foundation Trust is committed to the overarching principles of Equality and Diversity. As such the organisation values and supports its entire staff. We are committed to ensuring all forms of prejudicial, unfair basis and/or actions which result in discriminatory practices are eliminated. The Trust makes this stand based not only on meeting its legislative duties but also a moral strand on ensuring equitable outcomes for all of its staff and patients. 7.2 The Foundation Trust is continually working towards eradicating all forms of harassment and discrimination, exclusion, victimisation, harassment and bullying and working to ensure it meets its legal duties by ensuring that: unlawful discrimination, harassment and victimisation and other conduct prohibited by the Equality Act 2010 are eliminated 8
equality of opportunity between people from different groups; is advanced and good relations between people from different groups are fostered. 7.3 The Trust treats any complaints it receives very seriously and as such any complaint received in respect of this policy or associated policies (in terms of application or adherence) will be investigated by Foundation Trust Staff. The process undertaken will also ensure that complainants, patients, relatives and carers are not discriminated against on the grounds of disability, gender, marital status, sexuality, colour, race, nationality, ethnic origin, religion, belief or age. Additionally, the Trust will ensure that no individual is treated in a detrimental manner as a result of having made a complaint. 7.4 The policy will be continually reviewed to ensure that there are no elements within the policy, practice or procedures that are prejudicial on any grounds in respect of the protected equality characteristics mentioned above. Using the guidance produced under the auspices of Equality legislation, this document has also been equality impact assessed and is attached at the end of the document. 8 Consultation 8.1 9 Monitoring and Evaluation 9.1 Person / Group Date Date Business development and performance 2009 2012 HODU 2009 2012 General Medicine 2009 2012 General Surgery/Orthopaedics 2009 2012 Maternity 2009 2012 Microbiology laboratory 2009 2012 Outpatients Department 2009 2012 Paediatrics 2009 2012 Pre-operative assessment clinic 2009 2012 Primary Care Trust 2009 Strategic Health Authority 2009 9
10 Glossary of terms Who How Frequency Dept / Service Covered Presented to Monitoring of action plan Completion / exception reported to Senior Sisters/Charge Nurses Reporting of compliance Via Infection Prevention Assurance Group Reporting of screen positive results 11 References Each meeting Every positive result Trust Trust DIPC Excel report Monthly General surgery, orthopaedics. Medical Admissions Unit and Preoperative Assessment Clinic positive patient follow up prevalence screening audit Every new positive inpatient DIPC Board report As requested by Trust Board Ward/department staff Risk Management Team Performance Management Team Training updates Reporting of missed screens and delays in prescribing of colonisation suppression via AEF Performance reports Trust Ward/department staff Managers Matrons Ward/department staff N/A Infection Prevention Implementation Group N/A Infection Prevention Assurance Group Annual Trust All mandatory training sessions Each incident Each meeting Trust Trust Board Trust Board Trust Board Trust Trust Assurance Group Trust Trust Board Trust Board Trust Board 10
11.1 Screening for Colonisation - A Strategy for NHS Trusts: a summary of best practice. Department of Health (2008) Screening Operational Guidance. Department of Health (2008) Screening Operational Guidance 2. Department of Health (2008) The Health and Social Care Act 2008, Code of Practice for the NHS on the Prevention and Control of Healthcare Associated Infections and Related Guidance. Department of Health (2008) Operating Framework 2008/9. Department of health (2007) Saving Lives: a delivery programme to reduce Health care Associated Infection (HCAI) including. Department of Health (2006) The Health Act 2006, Code of Practice for the Prevention and Control of Health Care Associated Infections. Department of Health (2006) Saving Lives: a delivery programme to reduce Health care Associated Infection (HCAI) including. Department of Health (2006) Standards for Better Health, Department of Health (2004) Winning Ways Working Together to Reduce Healthcare Associated Infection. Department of Health (2003) Getting Ahead of the Curve. A strategy for combating infectious diseases (including other aspects of health promotion). Department of Health (2002) The Management and Control of Hospital Infection. Health Service Circular (2000) HSC 2000/002 The Management and Control of Hospital Acquired Infection in Acute Trust in England in 2000. National Audit Office (2000) Hospital Infection Control. Health Service Guidance HSG (95) 10. Department of Health (1995) 11