GUIDELINES FOR MRSA SCREENING IN RELATION TO ELECTIVE SURGICAL ADMISSIONS Lead Executive/Director: Sandra Rote, Director of Clinical Development; Executive Lead Nurse; (Director with responsibility for Infection Prevention and Control) Name of originator/author: Carole Clive, Nurse Consultant, Infection Prevention and Control Target audience: Healthcare Staff working in surgical specialities relating to Burlingham Ward, Evesham Community Hospital and Tenbury District and Community Hospital Guidelines for MRSA Screening in Relation to Elective Surgical Admissions 19/03/2009 Page 1 of 12
CONTENTS 1.0 INTRODUCTION 3 2.0 OBJECTIVE/SUCCESS FACTOR 3 3.0 LINKS TO OTHER KEY STRATEGIES & POLICIES 3 4.0 RESPONSIBILITIES 3 5.0 WHO TO SCREEN 3 6.0 WHEN TO SCREEN 4 7.0 HOW TO SCREEN 4 8.0 TREATMENT 4 9.0 DOCUMENTATION 5 10. 0 COMMUNICATION AND PATIENT INFORMATION 5 11.0 COMPLIANCE 6 12.0 KEY POINTS 6 13.0 REFERENCES 6 APPENDIX 1 List Detailing Procedures and Requirement for MRSA Screening 7 APPENDIX 2 Algorithms detailing management 11 Guidelines for MRSA Screening in Relation to Elective Surgical Admissions 19/03/2009 Page 2 of 12
1.0 INTRODUCTION AND SCOPE In order to ensure the spread of MRSA is minimised, protect patients from infection or colonisation with MRSA and ensure those who are confirmed with MRSA are managed safely and appropriately, certain elective surgical admissions to Evesham Community Hospital and Tenbury and District Community Hospital will require an MRSA screen prior to admission. This will also enable compliance with national guidance contained within the Darzi report and also Department of Health Publications. This process is best achieved through pre-admission assessment which allows enough time for MRSA decolonisation/suppression to be undertaken before admission. 2.0 OBJECTIVE/SUCCESS FACTOR This guidance sets out to ensure that staff working within surgical units in the PCT are informed and aware of who to screen, when to screen, how to screen and, dependent upon results, what treatment is required. It is not anticipated that screening and prescription of antimicrobial agents will lead to cancellation of surgery within the Trust. 3.0 LINKS TO OTHER KEY STRATEGIES & POLICIES This guidance should be read in conjunction with: a) Trust Infection Prevention and Control Guidance (particularly including guidance on personal protective clothing, hand hygiene and care and management of MRSA). b) Primary Care Antimicrobial Prescribing Guidance. c) Trust Infection Prevention and Control plans, position statements and strategy documents. 4.0 RESPONSIBILITIES General Staff Responsibilities it is the responsibility of all clinical staff working in surgical areas of the PCT to adhere to this guidance and report breaches to the nurse in charge or their line manager. Ward and Department Managers are responsible for ensuring implementation within their area, and for ensuring all staff who work within the area adhere to the principles at all times. This includes ensuring compliance during pre operative surgical assessment and care, intra operative and post operative care. Breaches should be investigated and reported as a clinical risk. Consultant Medical Staff are responsible for ensuring their junior staff read and understand this policy and appropriate antimicrobial suppression treatment and prophylaxis is given in compliance with antimicrobial prescribing guidance. The Infection Control Team is responsible for providing expert advice in accordance with this policy, for supporting staff in its implementation, and assisting with risk assessment where complex decisions are required. They are also responsible for ensuring this policy remains consistent with the evidence-base for safe practice, and for reviewing the policy on a regular basis. 5.0 WHO TO SCREEN: Appendix 1 details an explicit list of procedures undertaken and the requirement to screen. This is available in surgical areas as a laminated version. To summarise, the procedure list stipulates that all patients will require screening with the exception of: Day case ophthalmology procedures Dental Procedures Endoscopy procedures (Gastroscopy, sigmoidoscopy, colonoscopy, flexible cystoscopies, hysteroscopies etc) Minor dermatology procedures including those undertaken as minor surgery (eg vasectomies, removal of lumps and bumps, nail evulsions and in general minor excisional procedures which could be undertaken in GP practice) Gynae procedures such as D&C or coil insertion or those where there is no wound generated. Pain Clinic Guidelines for MRSA Screening in Relation to Elective Surgical Admissions 19/03/2009 Page 3 of 12
The only time it may be necessary to screen patients attending for surgery who are normally excluded, as previous list, would be if they presented with the following risk factors: All patients admitted from the community presenting with invasive devices All patients transferred from another healthcare provider including care establishments such as nursing or residential homes All patients who are known to be a previous positive Patients who have had a hospital admission in the last 12 months Patients who are working in care procedures or who are providing care for relatives with MRSA 6.0 WHEN TO SCREEN To ensure that screens do not get missed, it is advised that they are undertaken as part of the routine pre-op process. As long as there is a valid screen within the last 28 days this will count towards the surgical screen. Please refer to Appendix 2 for algorithms relating to the screening process. 7.0 HOW TO SCREEN Because MRSA colonisation is asymptomatic it can only be identified by taking screening swabs from appropriate sites. Further details are provided within the samples guidance contained in the infection control policies and procedures binder. Screening swabs are to be taken from the following sites. As a minimum, three screening swabs need to be undertaken: anterior nares of the nose axillae groins In addition to the above, other areas which should be included in the screen are: any areas of broken, dry or damaged skin or wounds CSU if patient catheterised; All site(s) of invasive device(s) if present Sputum if productive cough Please note, as per current guidance, swabs used to sample dry skin sites must be moistened by applying drops of sterile water for injection or saline onto the cotton bud tip. It is imperative that care is taken to avoid contaminating either the cotton bud tip or shaft of the swab with your own skin flora or contaminants from the environment. All swabs must be clearly labelled with patient details and site of swab. All of the samples can go with just one microbiology form which in addition to the standard patient details and location must state, history in relation to MRSA, swabs which are enclosed, date and nature of elective procedure and any other relevant details including current antibiotics. All results will be returned to the requesting source. Please note, any unlabelled or unidentified specimens will not be processed and this may result in unnecessary treatment being prescribed. 8.0 TREATMENT With regard to patients requiring MRSA screening prior to elective surgical admission, the following treatment options should be followed to enable suppression of MRSA in a patient presenting with a single MRSA positive result from a screen: If a positive result is obtained. This will be unchanged from the current treatment guidance and will involve the following items which are contained on a PGD being prescribed for a period of a minimum of 5 days, to commence 5 days prior to the procedure being undertaken: Mupirocin 2% Nasal Ointment (Nasal Bactroban) for Mupirocin sensitive strains of MRSA. This should be applied to the inside of the nostrils (anterior nares) three times a day for a period of 5 days. Following application the sides of the nose should be pressed gently together to ensure the ointment is spread throughout the nostrils. For mupirocin resistant strains advice should be sought from the Infection Control Team. Guidelines for MRSA Screening in Relation to Elective Surgical Admissions 19/03/2009 Page 4 of 12
Octenisan Antimicrobial Body Washes these are a daily wash. To promote effectiveness of this, it is recommended that a formal programme is adopted in each area ensuring that washes are carried out in the most effective manner. Octenisan should be used as a liquid soap and shampoo and the whole body should be washed vigorously from head to toe. Particular attention should be paid to the hair, around the nostrils, axillae, groins, perineum and feet. The antiseptic should be used neat on wet skin like a shower gel, left in contact with the skin for three minutes and then rinsed off. If bathing/showering is not possible then the antiseptic should be applied onto a wet body surface using a clean flannel, left in contact with the skin for three minutes and then rinsed off. Ideally over the period of 5 days, 2 hair washes should occur using this product. Chlorhexidine Acetate Dusting Powder (CX powder) Apply as a powder daily following washing, a light dusting should be dispensed to cover axillae, umbilicus and groin area. It should not be used on badly broken skin. In addition it may be necessary to prescribe systemic antibiotics if clinical signs and symptoms of infection are apparent and also consider the need for prophylaxis during the surgical procedure. If wounds are found to be colonised these require assessment and the use of an appropriate antimicrobial agent should be considered. This could include use of Mupirocin (Bactroban) ointment/cream, if sensitive or dressings that have a silver, iodine or honey base. These should be used in accordance with wound care product formulary guidance. If there has not been an opportunity to undertake a screen within a timeframe which allows 5 days of the above treatment to be prescribed prior to surgery on receipt of a positive result, then a screen must be taken at the earliest opportunity and the patient commenced on Octenisan Daily Body Washes as a precaution until the result is received. If this result is positive, they should then be commenced on 5 full days of suppression treatment. If the screen results are negative then treatment can cease. Staff working within the surgical area will be responsible for notifying patients of results in these circumstances. Generally speaking, surgery should not be delayed and ward staff should discuss individual cases with either the infection control nurses or consultant microbiologist. 9.0 DOCUMENTATION The MRSA status of all patients must be accurately recorded in medical and nursing notes, including information on topical decolonisation therapy and specimen results. This is the responsibility of the medical and nursing teams caring for the patient. It is essential to ensure safe, effective care. 10. 0 COMMUNICATION AND PATIENT INFORMATION Patients and visitors must be provided with accurate information on MRSA. This is the responsibility of the medical and nursing team admitting or providing care for the patient. The information that should be given to all patients includes the risk of infection during procedures and, for those found to be positive, information on their care, treatment and management. Information leaflets are available to support this. Accurate information on MRSA status must be recorded and communicated to other wards and departments in order to facilitate safe care. This includes information on topical decolonisation and specimen results. It is essential that this is recorded and communicated to staff in primary and community care upon transfer to another organisation or discharge home. Guidelines for MRSA Screening in Relation to Elective Surgical Admissions 19/03/2009 Page 5 of 12
11.0 COMPLIANCE 100% compliance with this policy is expected, and the PCT is required to assure itself, its patients, commissioners and the Department of Health that this is being achieved. Surgical areas must therefore ensure that robust processes are in place to ensure that all elective patients who require screening are screened for MRSA in as timely a manner as possible and that the results of those screens are acted upon appropriately. 12.0 KEY POINTS 12.1 Overview Consider the risk of MRSA as a potential pathogen and prescribe appropriate antimicrobial therapy or surgical prophylaxis when indicated Surveillance will be performed in order to monitor trends in MRSA and facilitate prevention and control measures 12.2 MRSA Screening Screen patients by taking specimens from the correct sites, and labelling them correctly Screening of certain patients prior to elective surgical procedures. 12.3 Treatment Prescribe and administer MRSA topical decolonisation therapy correctly in line with policy Ensure patients who are MRSA positive prior to admission for surgical elective procedures receive appropriate suppression/decolonisation treatment/therapy; either to reduce the bioburden and risk of infection or eradicate MRSA. 12.4 Documentation Ensure the MRSA status of all patients is accurately recorded, including information on topical decolonisation and specimen results. This can assist in informing all future healthcare. It is imperative that a result is not considered as current if not taken within 4 weeks preceding the procedure. 13.0 REFERENCES Coia JE, Duckworth GJ, Edwards DI, et al (2006) Guidelines for the control and prevention of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities by the Joint BSAC/HIS/ICNA Working Party on MRSA. Journal of Hospital Infection. 63 (Supplement 1) Department of Health. 2008. High quality care for all: NHS Next Stage Review final report. http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh _085825 Department of Health. 2008. MRSA screening - operational guidance. http://www.dh.gov.uk/en/publicationsandstatistics/lettersandcirculars/dearcolleagueletters/dh_08 6687 Department of Health. 2006. Screening for Meticillin Resistant Staphylococcus aureus (MRSA) colonisation: a strategy for NHS trusts - a summary of best practice. http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/d H_063188 Department of Health. PL CMO (2006)4: Screening for MRSA colonisation: a summary of best practice. http://www.dh.gov.uk/en/publicationsandstatistics/lettersandcirculars/professionalletters/chiefmed icalofficerletters/dh_063138 Guidelines for MRSA Screening in Relation to Elective Surgical Admissions 19/03/2009 Page 6 of 12
APPENDIX 1 LIST DETAILING PROCEDURES AND REQUIREMENT FOR MRSA SCREENING MRSA Screening required? DESCRIPTION OF PROCEDURE Yes = No = DENTAL SURGERY Surgical removal of tooth Simple extraction of tooth Excision of dental lesion of jaw Orthodontic operations ENDOSCOPIC PROCEDURES Fibreoptic endoscopic procedures Diagnostic fibreoptic endoscopic procedures Diagnostic endoscopic examination of colon Endoscopic extirpation of lesion of colon Extirpation/lesion/lower bowel using fibreoptic sigmoidoscope Diagnostic examination of lower bowel with fibreoptic sigmoidoscope Therapeutic endoscopic operations on peritoneum GENERAL SURGERY Fixation of rectum for prolapse Perineal operations for prolapse of rectum Excision of lesion of anus Excision of haemorrhoid Dilation of anal sphincter Other operations on perianal region Other operations on anus Excision of pilonidal sinus Other operations on pilonidal sinus Excision of skin lesion Removal of inorganic substance from skin Removal of other substance from skin Opening of skin Primary repair of inguinal hernia Primary repair of femoral hernia Primary repair of umbilical hernia Primary repair of incisional hernia Repair of other hernia of abdominal wall Guidelines for MRSA Screening in Relation to Elective Surgical Admissions 19/03/2009 Page 7 of 12 If minor no all others yes Other operations on soft tissue Repair of muscle (abdomen) In the event of a positive result being obtained please contact the Infection Control Nurses or Consultant Microbiologist for further information
DESCRIPTION OF PROCEDURE GYNAECOLOGY Vaginal operations to support outlet of female bladder: TVT/repair Operations on bartholin gland Excision of vulva (skin tags/warts) Extirpation of lesion of vulva Other operations on vulva Operations on female perineum Operations on introitus of vagina Extirpation of lesion of vagina Other operations on Vagina Excision of cervix/uterus/hysterectomy Biopsy of cervix uterus Other operation on cervix Abdominal excision of uterus Vaginal excision of uterus Introduction/replacement of intrauterine contraceptive device Removal of intrauterine contraceptive device Therapeutic endoscopic operations on uterus Diagnostic endoscopic examination of uterus Unilateral salpingo oophorectomy Other excision of adnexa of uterus Partial excision of fallopian tubes Endoscopic bilateral occlusion of fallopian tubes lap sterilisation Other endoscopic operations on fallopian tubes Therapeutic endoscopic operations on ovary Other examination of female genital tract Repair of muscle (abdomen) ORTHOPAEDIC Excision of ganglion Operations on Bursa Manipulation of spine Complex reconstruction of forefoot MRSA Screening Required? YES = No = Guidelines for MRSA Screening in Relation to Elective Surgical Admissions 19/03/2009 Page 8 of 12 If minor no all others yes Only screen if wound Total excision of bone Other excision of bone In the event of a positive result being obtained please contact the Infection Control Nurses or Consultant Microbiologist for further information
ORTHOPAEDIC Continued Division of bone in foot Other internal fixation of bone Diagnostic puncture of bone Excision reconstruction of joint Fusion of joint of toe DESCRIPTION OF PROCEDURE Other primary fusion of other joint Other open operations on intra-articular structure. Stabilising operations on joint Release of contracture of joint Soft tissue operations on joint of toe Open debridement and irrigation of joint Other open operations on joint Therapeutic endoscopic operations on cavity of knee joint (arthroscopy) Diagnostic endoscopic examination of knee joint (arthroscopy) Puncture of joint Amputation of toe Carpal tunnel release Release of entrapment of peripheral nerve at wrist or other site Extirpation of lesion of peripheral nerve Other operations on peripheral nerve Excision of other fascia Release of fascia Transposition of tendon Freeing of tendon Excision of tendon Other operations on sheath of tendon Repair of muscle (limbs) Therapeutic endoscopic operations on semilunar cartilage Therapeutic endoscopic operations on other articular cartilage Excision of nail bed Total excision of nail Other operations on nail MRSA Screeings Required? YES = No - If minor no all others yes In the event of a positive result being obtained please contact the Infection Control Nurses or Consultant Microbiologist for further information Guidelines for MRSA Screening in Relation to Elective Surgical Admissions 19/03/2009 Page 9 of 12
PAIN CLINIC Epidural injection Operations on spinal nerve root Destruction of peripheral nerve DESCRIPTION OF PROCEDURE Cryotherapy to sympathetic nerve Radiofrequency controlled thermal destruction of sympathetic nerve Other operations on sympathetic nerve Introduction of therapeutic substance into subcutaneous tissue Denervation of spinal facet joint of vertebra UROLOGY Endoscopic dilation of ureter Endoscopic extirpation of lesion of bladder Endoscopic operations to increase capacity of bladder Diagnostic endoscopic examination of bladder Other operations on bladder Operations on outlet of female bladder Therapeutic endoscopic operations on urethra Other operations on Urethra Other excision of testis Operations on hydrocele sac Operations on epididymis Bilateral vasectomy Excision of lesion on penis Frenuplasty of penis Circumcision MRSA Screeings Required? YES = No - If minor no all others yes Other operations on penis In the event of a positive result being obtained please contact the Infection Control Nurses or Consultant Microbiologist for further information REFERENCES Department of Health. 2008. MRSA screening - operational guidance. http://www.dh.gov.uk/en/publicationsandstatistics/lettersandcirculars/dearcolleagueletters/dh_086687 Department of Health. 2006. Screening for Meticillin Resistant Staphylococcus aureus (MRSA) colonisation: a strategy for NHS trusts - a summary of best practice. http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_063188 Department of Health. PL CMO (2006)4: Screening for MRSA colonisation: a summary of best practice. http://www.dh.gov.uk/en/publicationsandstatistics/lettersandcirculars/professionalletters/chiefmedicalofficerletters/dh_06 3138 Guidelines for MRSA Screening in Relation to Elective Surgical Admissions 19/03/2009 Page 10 of 12
APPENDIX 2 PCT Algorithm for Regular Attendees Initial Screen at first appointment or on presentation at clinic or out patient departments prior to invasive device insertion (nose, groin, and axilla as a minimum and wounds, invasive devices, including CSU if catheter insitu). Please note these results can be instrumental in future management Result Negative Result Positive Re-screen in approximately 18 weeks Decolonisation Successful No more than 2 attempts at decolonisation prior to a procedure. Adhere to 5 day treatment plan and rescreen on day 7 Decolonisation Not Successful Consider Suppression Therapy implemented 5 days prior to procedure. NOTE: The screening process should not delay the undertaking of scheduled procedures. Due to regular attendance and to minimise inconvenience to patients, the initial screen can be undertaken in clinic with results used to inform future management. Contact Infection Control Nurses for further information on 01386 50 2552. Guidelines for MRSA Screening in Relation to Elective Surgical Admissions 19/03/2009 Page 11 of 12
PCT Algorithm for Elective Surgical Admissions Screen at pre op/admission clinic/out-patient department if indicated on PCT list (nose, groin and axilla, wounds, invasive devices, include CSU if catheter insitu Result Negative Result Positive Proceed to Surgery Proceed to Surgery starting decolonisation therapy for suppression of MRSA level 5 days prior to surgery If indicated consider preop glycopeptide prophylaxis NOTE: If it is not possible to screen with sufficient time for 5 day course of treatment prior to admission, particularly when operation is scheduled due to cancellation etc. The screen must be undertaken and patient commenced on Octenisan Daily Body Washes as suppression/decolonisation therapy to enable a maximum of 5 days prior to the procedure. If negative screen results are obtained then this can stop, if a positive result is obtained then the full 5 day decolonisation/suppression treatment (Octenisan, CX powder and Nasal preparation should be prescribed via PGD), this will obviously be for a period of 5 days, some of which will be post op. There will generally be no requirement to re-screen. This need for this will be assessed on an individual basis through liaison with the Infection Control Nurses who can be contacted on 01386 502552. Guidelines for MRSA Screening in Relation to Elective Surgical Admissions 19/03/2009 Page 12 of 12