Guidelines for screening elective patients for
Methicillin Resistant Staphylococcus Aureus
(MRSA)
Version:
Ratified by:
Date ratified:
March 2009
Name of originator/author:
David Dellow
Name of Responsible Individual
(Sponsor) and Committee (if
appropriate):
Infection Control Committee
Date Issued:
Review Date:
Target Audience:
Signed: …………………………………………………………………………….
Chris Pocklington, Chief Executive
Signed: …………………………………………………………………………….
Director of Infection Prevention and Control
DKD Guidelines for screening elective patients for MRSA 03/2009
1
Contents
1. Introduction
2. MRSA Control Measures for all patients
3. Elective patient pathway
3.a
If patients TCI date is prior to result being available:
3.b
If an Elective Patient is found to be MRSA negative with no history of
previous MRSA infection:
3.c
If an Elective Patient is found to be MRSA negative but with history of
previous MRSA infection:
3.d
If the patient has been found to be MRSA positive and is identified as
clinically urgent:
3.e
If the patient has been found to be MRSA positive and has not been
identified as clinically urgent:
4. Screening process
5. Patient placement in the Jenny Ackroyd Centre:
6. Appendix
1. Radiology MRSA Screening Pathway
2. Cancer Services MRSA Screening Pathway
3. Women’s Health MRSA Screening Pathway (to follow)
4. Elective MRSA Screening Pathway
5. MRSA Positive letter to GPs
6. MRSA Positive letter to GPs
7. Eradication protocol for GPs
8. How to use Stellisept
9. Health Protection Agency MRSA Information for patients leaflet
10. DOH MRSA Screening Operational Guidance 2. December 2008
11. Assurance Framework
DKD Guidelines for screening elective patients for MRSA 03/2009
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PRINCESS ALEXANDRA HOSPITAL NHS TRUST (PAHT)
Guidelines for screening elective patients for
Methicillin Resistant Staphylococcus Aureus (MRSA)
1.
Introduction
MRSA are strains of Staphylococcus aureus which are resistant to multiple antibiotics. Some
strains of the organism have a propensity to spread and are known as EMRSA (E=Epidemic).
MRSA survives in the environment in dry conditions and dust.
Some Patients may be colonised with MRSA, causing them no harm, but infection may occur in
susceptible patients or surgical patients. This group of patients are at greater risk of developing
wound infections, respiratory infections and septicaemia.
These guidelines should be read with reference to the Hand Hygiene Guidelines, Personal
Protective Equipment guidelines and Enhanced Infection Control Guidelines.
Routes of Transmission




2.
Direct personal contact with skin
Shed from contaminated fomites e.g. bedding or shed from skin
Shed from wounds colonised with the organisms
From one host (patient or staff) to another (nasal colonisation)
MRSA Control Measures for all patients
It is important to control the spread of MRSA, therefore immediate recognition of the risk of
colonisation or infection through microbiological screening, followed by isolation of the patient
are essential. The aim is to eliminate the carriage of MRSA and to prevent cross infection.
The essential measures to reduce the spread of MRSA are:
 Staff training in enhanced infection control precautions
 Correctly performed hand hygiene techniques
 Use of gloves and aprons for ALL direct contact with patients, their lesions, body
fluids, the immediate environment and contaminated materials
 Waste and linen segregation
 Provision of appropriate isolation facilities
 Screening suspected cases of MRSA and follow up on known positive cases
 Mandatory attendance at essential infection prevention and control training by all
clinical and support staff to ensure compliance with agreed The Health Act 2006
Code of Practice for the Prevention and Control of Health Care Associated Infections.
DKD Guidelines for screening elective patients for MRSA 03/2009
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3.
Elective patient pathway
This document looks solely at the Elective patient pathways, emergency patients will be dealt
with separately.
In line with Department of Health Operational Guidance 2 (2008) in conjunction with the NICE
Guidelines (Surgical Site Infection - Prevention and treatment of surgical site infection) October
2008 all elective surgical patients should be screened for MRSA, (this including elective
caesarean sections and ERCPs). The following groups of patients are excluded unless they are
in the high risk group stated below




Day Case Ophthalmology and Dental patients
Day case endoscopy cases including cystocopies
Minor Dermatology cases (e.g. wart treatment)
Dolphin Ward patients (unless they have been admitted in the last 6 months or
previously known to be MRSA positive)
High risk patients requiring screening:





All patients admitted from residential or nursing homes or other hospitals
All patients with a hospital in patient stay in the previous 6 months
All patients with a previous history of MRSA colonisation or infection
All patients with long-term indwelling devices such as urinary catheter
All patients with Diabetes
The Trust has also taken the decision that we will continue to screen patients who are admitted
via the Radiology Department for the following procedures Vertebroplasty, Angioplasty,
Stenting, Antegrade Ureteric Stenting or any other procedure that requires an over night stay.
Also those patients who have Groshong, Hickman and Picc lines inserted in Galen House.
(Radiology MRSA Screening Pathway Appendix 1)
(Cancer Services MRSA Screening Pathway Appendix 2)
(Women’s Health MRSA Screening Pathway Appendix 3) to follow
Elective patients will be screened at their Pre Operative Assessment appointment no sooner
than 3 weeks prior to their admission date. The swabs will be taken in Main Pre Operative
Assessment, the Eye Unit, ADSU, the Breast Unit, the Maternity Department, Galen House and
Radiology.
PAS has been set up so that patients with a history of ESBL or MRSA will be highlighted on the
patient details by the clerical staff in the Microbiology staff. The patients that have an MRSA
positive result, at any time, have a permanent record on PAS. This PAS record must be
checked for all elective admissions.
3.a

If patients TCI date is prior to result being available:
The patient will be admitted on planned TCI date, but will be isolated until result is
known
3.b
If an Elective Patient is found to be MRSA negative with no history of previous
MRSA infection:
 Then the patient will be admitted as planned.
DKD Guidelines for screening elective patients for MRSA 03/2009
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3.c
If an Elective Patient is found to be MRSA negative but with history of previous
MRSA infection:
 Then the patient will be admitted as planned, but will be isolated on admission.
 The POA Department will ensure the theatre department is also informed of the result.
 The POA Department will inform the Admissions Department to ensure patient is isolated
on admission.
3.d
If the patient has been found to be MRSA positive and is identified as clinically
urgent then the following route will be taken:
The POA Department will contact the following:
 The clinician responsible for the patients care and a decision made as to the risk /
benefits of proceeding as planned or removing the patient from the waiting list, while the
eradication protocol is undertaken, as per Trust Access Policy.
 The patients GP who will be faxed the results (Appendix 6), the eradication protocol
(Appendix 7) and told to commence the patient on this protocol.
 The patient, to discuss the result and treatment pathway, including commencement of
the eradication therapy, the need for isolation on admission. The POA will also send to
the patient the information sheet (Appendix 9) highlighting the key facts about MRSA
along with a copy of the eradication protocol.
 The admission department to enable a sideroom to be identified for admission.
 The theatre department is also informed of the result.
The patient would still retain and be admitted on the original TCI date.
3.e
If the patient has been found to be MRSA positive and has not been identified as
clinically urgent then the following route will be taken:
The POA Department will contact the following:
 The admission department so the patient is removed from the waiting list.
 The patients GP who will be faxed the results, the eradication protocol (Appendix 7) and
told to commence the patient on the protocol. The GP will also be informed that the
patient has been removed from the waiting list, (Appendix 5) while under going the
eradication protocol. The GP will then have the responsibility to ensure that the patient
has 3 sets of MRSA Negative swabs following the protocol. Once this has happened
then the GP must contact the Admissions Department, who will then rebook the patient
for admission within three weeks.
 The patient, to discuss the result and treatment pathway, including commencement of
the eradication therapy, the need for isolation on admission. The POA will also send to
the patient the information sheet highlighting the key facts about MRSA along with a
copy of the eradication protocol
 The theatre department is also informed of the result.
If the patient has been removed from the waiting list due to being MRSA positive, has
undertaken the eradication therapy, and subsequently has three negative swabs, it is then the
GP’s responsibility to contact the Admissions Department, who will then rebook the patient for
admission within three weeks. The Admissions Department will then contact the POA
department and arrange a new POA date two weeks prior to the new admission date. The
Admission s Department will then contact the patient with these new dates.
DKD Guidelines for screening elective patients for MRSA 03/2009
5
If the patient remains positive following two cycles of the eradication protocol, then the GP will
need to re refer the patient back to the surgeon, so that a risk/benefit assessment can be
performed, in conjunction with the Infection Control Team.
For oncology patients, the result of the MRSA screen should not delay the surgery. The risk
benefit analysis should be done immediately.
4.
Screening process:
For the purpose of screening elective patients, the process should consist routinely of 3 swabs
a) Nose swab both nostrils with one swab
b) Throat swab
c) Groin swab both groins with one swab
The screening process should also include any other possible sites of infection ie skin breaks or
sores, surgical drain sites, tracheostomy sites or intravenous or indwelling device sites.
All swab forms should be clearly labelled as Pre Operative Assessment MRSA Screen and the
intended place of admission.
If the patient has an indwelling urinary catheter then a CSU for MRSA should also be sent.
5.
Patient placement in the Jenny Ackroyd Centre:
To reduce the risk to surgical patients an attempt is made to restrict the patient access to the
Jenny Ackroyd centre.
On admission patients with positive MRSA results will commence the MRSA Care pathway and
remain in isolation.
Tye Green Ward
 No patient with a history of MRSA or ESBL will be admitted
 No patient with unknown MRSA status will be admitted
 Any patients, other than elective orthopaedic patients, should not be admitted, without
escalation and discussion with the following
o Infection Control Team
o Lead / On call Orthopaedic Surgeon
o Associate Director / Operational / Service manager Elective
o Site Manager / On Call Executive
Kingsmoor ward
 Patients with known positive, negative or unconfirmed MRSA status will be admitted
 Elective patients with known or previous history of MRSA will be isolated in side room
 Patients awaiting swab results will be isolated in side room
Netteswell Ward
 Only patients with negative MRSA status will be admitted
Melvin Ward
 Only patients with negative MRSA status will be admitted
DKD Guidelines for screening elective patients for MRSA 03/2009
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Appendix 1:
PRINCESS ALEXANDRA HOSPITAL
RADIOLOGY DEPRTMENT
MRSA SCREENING PATHWAY
All patients requiring an overnight stay in the hospital require MRSA screening. The procedures
that need admission are Vertebroplasty, Angioplasty, Stenting, Antegrade Ureteric stenting or
any other procedure that requires an over night stay.
Once the x-ray request form has been received and prioritised, the nursing team will contact the
patient. The patient will be required to attend the department for pre assessment and swabbing
by the radiology nursing staff.
A waiting list card will be sent to admissions indicating that screening has taken place.
The results of the screening will be checked by the radiology nurses, and indicated on the
screening log, if the outcome is positive the trusts eradication protocol will be consulted and
treatment either by the GP or referring team will be commenced as soon as possible.
If the MRSA screening is negative the patient will be admitted as soon as possible, if there is a
delay with the patient’s admission, the date of the negative swabbing must be identified as after
three weeks the screening will have to be performed again.
Patients who require a Hickman or Groshong line insertion will at their pre assessment with the
oncology nursing staff have there MRSA screening performed. This will be checked by the
radiology nursing team prior to their appointment. The care pathway for central lines is followed
and documented in the notes.
X-ray request
Nursing team
to contact
patient
Patient attends the
department for screening
Positive result
8th, 10th and 12th day
swabs taken
Eradication protocol
commenced
Screening
checked
Negative
Patient‘s
procedure
performed
Negative
Patient’s
procedure
performed
Waiting list card
completed
Recommence
treatment
If still positive
consult the
infection
control team
DKD Guidelines for screening elective patients for MRSA 03/2009
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Appendix 2:
PRINCESS ALEXANDRA HOSPITAL
Cancer Services
MRSA SCREENING PATHWAY
All patients requiring an insertion of a Groshong, Hickman and PICC for the safe delivery of their
chemotherapy treatment.
Once the referral for chemotherapy has been received in the department the patient will be
contacted to attend for a pre-assessment appointment. The patient will be required to attend the
department for pre assessment and swabbing by the chemotherapy nursing staff.
The results of the screening will be checked by the nurses, and indicated on the screening log, if
the outcome is positive the trusts eradication protocol will be consulted and treatment either by
the GP or referring team will be commenced as soon as possible.
If the MRSA screening is negative the patient will be admitted as soon as possible, if there is a
delay with the patient’s admission, the date of the negative swabbing must be identified as after
three weeks the screening will have to be performed again.
The care pathway for central lines is followed and documented in the notes.
Chemotherapy
referral
received in
dept
Nursing team
to contact
patient
Patient attends the
department for preassessment and screening
Positive result
8th, 10th and 12th day
swabs taken
Eradication protocol
commenced
Screening
checked
Negative
Patient‘s
procedure
performed
Negative
Patient’s
procedure
performed
Referral to
radiology or Picc
service
Recommence
treatment
If still positive
consult the
infection
control team
DKD Guidelines for screening elective patients for MRSA 03/2009
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Appendix 4:
Elective MRSA Screening Pathway
MRSA Screen at
POA
MRSA Negative
MRSA Positive
Clinically Urgent
MRSA Positive
Non Urgent
Admit as
planned
Confirm with clinical
team, risk / benefit
re proceeding
Remove from
waiting list
Inform GP
Start Protocol
Clinically Urgent
or Oncology
to proceed
Clinically Non
Urgent to
proceed
3 MRSA
negative swabs
GP contacts
Admissions Dept
Inform GP
Start Protocol
Admit on original
TCI date
Isolate on admission
Admissions give
new TCI date within
3 weeks
Admissions give
new POA date 2
weeks prior to TCI
date
MRSA Positive
MRSA Screen at
POA
MRSA Negative
Following two cycles of eradication protocol if
patient is non urgent and remains MRSA
positive, discussion should occur between both
the clinical team responsible for the patient and
the Infection Control Team re treatment plan.
DKD Guidelines for screening elective patients for MRSA 03/2009
Admit
Isolate on admission
9
Appendix 5:
MRSA Cancellation letter to GPs
The Princess Alexandra Hospital
NHS Trust
Tel: 01279 444455 ext 3061
Fax: 01279 827133
Date………………………….
Dear Dr ……………………..
I have seen your patient ……………………………………………………………………………………
D.O.B………………........Hospital Number……………………………. …… In the Pre Assessment
Clinic for ………………………………………………..surgery. This was planned for ……………….
The patient was swabbed pre operatively and has been found to be MRSA positive.
A decision with the clinical team has been made and the above named patient has been removed
from the waiting list, whilst they under go the MRSA eradication protocol.
Please find lab report and protocol for treatment enclosed.
Could you please prescribe the treatment required as per protocol (see attached form)
and ensure that the patient is swabbed on days 8, 10, and 12.
If still positive please repeat the treatment.
Once the patient has completed the eradication protocol and has had 3 negative swab results,
please contact the Trusts Admission Department to arrange a new admission date. This will normally
be within 3 weeks. Please could you forward any information to show the patient is fit to proceed with
surgery (Ie negative swab results).
Thank you.
Yours sincerely
DKD Guidelines for screening elective patients for MRSA 03/2009
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Appendix 6:
MRSA Positive letter to GPs
The Princess Alexandra Hospital
NHS Trust
Tel: 01279 444455 ext 3061
Fax: 01279 827133
Date………………………….
Dear Dr ……………………..
I have seen your patient ……………………………………………………………………………………
D.O.B………………........Hospital Number……………………………. …… In the Pre Assessment
Clinic for ………………………………………………..surgery. This was planned for ……………….
The patient was swabbed pre operatively and has been found to be MRSA positive.
A decision with the clinical team has been made and the above named patient will continue with their
planned admission date.
Could you please prescribe the treatment required as per protocol (see attached form)
and ensure that the patient is swabbed on days 8, 10, and 12.
Please find lab report and protocol for treatment enclosed.
If still positive please repeat the treatment.
If you have any concerns regarding the patients fitness for surgery please contact the Pre Operative
Admissions Department.
Please could you forward any information to show the patient is fit to proceed with surgery (Ie
negative swab results).
Thank you.
Yours sincerely
DKD Guidelines for screening elective patients for MRSA 03/2009
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Appendix 7:
Copy eradication protocol for GPs
The Princess Alexandra Hospital
NHS Trust
Eradication Protocol for MRSA positive pre operative
patients who are Mupirocin sensitive
Day 1



Wash hair with Stellisept wash
Wash body with Stellisept wash
Apply Mupirocin nasal ointment to both nostrils 3 times a day
Day 2


Wash body with Stellisept wash
Apply Mupirocin nasal ointment to both nostrils 3 times a day
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
As Day 2
As Day 2
As Day 2
Normal wash
Normal wash
 Nurse to take swabs from throat, groins and nose, (use 1 swab for both
nostrils). Swab wound and collect urine sample if appropriate i.e. if
catheterised
 Normal wash
Normal wash
 Nurse to take swabs from throat, groins and nose, (use 1 swab for both
nostrils). Swab wound and collect urine sample if appropriate i.e. if
catheterised
 Normal wash
Normal wash
 Nurse to take swabs from throat, groins and nose, (use 1 swab for both
nostrils). Swab wound and collect urine sample if appropriate i.e. if
catheterised
 Normal wash
Day 9
Day 10
Day 11
Day 12




Please circle swab 10 times round each nostril using same swab, 5 times to back of
throat and each groins.
Ensure Stellisept is left on the skin for a minimum of 30 seconds
If any of the swabs from day 8, 10 and 12 are positive (isolated). Please restart the
protocol from Day 1.
If all swabs results are negative from day 8, 10 and 12 please contact the Trusts
Admission Department so the patient can be re dated.
DKD Guidelines for screening elective patients for MRSA 03/2009
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Appendix 8:
How to use Stellisept
Stellisept med+med
foam-Englisch11_07.pdf
Appendix 9:
Health Protection Agency MRSA Information for patients leaflet
MRSA_leaflet.pdf
Appendix 10:
DOH MRSA Screening Operational Guidance 2. December 2008
P:\My Documents
dec 07\MRSA\Letter from Christine Beasley and David Flory.pdf
Appendix 11:
Assurance Framework for MRSA Guidelines.
The guidelines will be approved and compliance monitored by the Infection Control Committee.
The Guidance will be Reviewed Annually by the Infection Control Team.
The reviewed Guidelines will be available to all staff on the Public Folders in the Infection
Control Manual File.
The Governance Committee Monitor Compliance with all Infection Control Standards. The
Director of Infection Prevention and Control attends the Governance Committee quarterly.
The Associate Directors for Each Process Unit are responsible for Auditing Compliance and
Reporting to the Infection Control Committee quarterly.
The Department and Service Managers are responsible to ensure training and awareness of the
guidelines is undertaken in their area.
The Lead Nurse for Infection Prevention and Control is responsible for the dissemination of the
document and the coordination of the annual review.
To ensure compliance with the screening guidelines, the Trusts Information Department will co
ordinate the monthly return via Unify.
This will be done by identifying the patients who should have been swabbed by case code on
PAS and then this number cross referenced against the path record of those that have been
swabbed.
All Business Units will have the MRSA Screening Compliance figures discussed at their board
meetings quarterly and at monthly governance meetings. The AD for the business Unit will
develop an Action Plan to address poor compliance
DKD Guidelines for screening elective patients for MRSA 03/2009
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Audits to support the MRSA reduction
Audit
Responsible Person
Body Map
Matrons
Feedback
frequency
Hand Hygiene Audit
Matron
To ICT
Matrons, Ward
Managers Ads
& Board
Members
Daily at least 5
days a week
PEAT & PEAG
Domestic Manager
with ICT & Matrons &
Estates with Patient
rep Quarterly
Environmental
hygiene / audit
Screening
compliance
Mandatory SSI Audit
Domestic
Supervisors
Matrons
Jonathan Sellar
Trust Board
Annually
To Domestic
Manager
To CFM
ICC & Business
Board Meetings
Unify report
Joint Nurse
Specialist
DKD Guidelines for screening elective patients for MRSA 03/2009
Monthly
Quarterly with
Patient Rep and
Annual for Self
Assessment score.
Daily
Weekly
Monthly
Quarterly
14