DOCUMENT CONTROL PAGE Title Title: MRSA Screening and Decontamination policy Version: 2 Supersedes Originator or modifier Originated By: Julie Cawthorne Approval by: Infection Control Committee Review Circulation Application Supersedes: MRSA Policy January 2006 Approval Reference Number: Infection Control Policy IC Org 03 MRSA Designation: Nurse Consultant Modified by: Jo Clubb Designation: Infection Control Nurse Sub Committee Approval Date: Expert Group Committee All Staff All Patients Issue Date: December 2008 Circulated by: Jo Rothwell Review Date: December 2010 Responsibility of: Jo Rothwell Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 1 of 26 POLICY CONTROL PAGE (2) CIRCULATION DOCUMENT Circulation List: See Infection Control Strategy 01 For Information Central Manchester and Manchester University Hospitals NHS Trust is committed to promoting equality and diversity in all areas of its activities. In particular, the Trust wants to ensure that everyone has equal access to its services. Also that there are equal opportunities in its employment and its procedural documents and decision making supports the promotion of equality and diversity. Refer to section 8 for more detail on undertaking equalities impact assessment. This document must be disseminated to all relevant staff, refer to section 10: Dissemination and Implementation The Policy must be posted on the intranet: Date Posted: Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 2 of 26 Section 1 Contents Page Introduction 5 2 Purpose 5 3 Roles and Responsibilities 5 Detail of Policy 4.1 MRSA Screening 4.1.1 MRSA screening statement of intent 4.1.2 Actions to be taken if the patient is MRSA positive prior to elective admission 4.1.3 Actions to be taken following 3 Negative MRSA screens for elective admissions 4.1.4 MRSA screening for high risk admissions 4.1.5 MRSA screening and decolonisation therapy regime for ALL patients with a previous history of MRSA colonisation/infection 4.1.6 MRSA screening procedure – sample sites 4.2 MRSA Decolonisation Therapy 4.2.1 Adults and paediatric patients over 6 weeks of age – skin decolonisation 4.2.2 Adults and paediatric patients over 6 weeks of age – nasal decolonisation 4.2.3 Neonates and paediatric patients under 6 weeks of age – skin decolonisation 4.2.4 Neonates and paediatric patients under 6 weeks of age – nasal decolonisation 4.2.5 Pre-operative preparation for patients known to have / with a history of MRSA colonisation/infection 4.3 Source Isolation 4.3.1 Source Isolation – inpatients 4.3.2 Source Isolation – outpatients 4.3.3 Source Isolation – radiology, cardiology, neurophysiology & nuclear medicine 4.6 Discharge of Patients Colonised / Infected with MRSA 5 5 5 6 5 Equality Impact Assessment 20 6 Consultation, Approval and Ratification Process 20 7 Dissemination and Implementation 20 Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 6 7 7 9 10 11 12 13 13 14 18 19 20 Page 3 of 26 8 Review, Monitoring Compliance With and the Effectiveness of Procedural Documents 21 9 References and Bibliography 21 10 Associated Trust Documents 21 11 Appendices 22 Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 4 of 26 1 Introduction Meticillin-resistant Staphylococcus aureus (MRSA) remains endemic in many UK hospitals. Specific guidelines for control and prevention are justified because MRSA can cause serious illness and result in significant health care costs. MRSA can be transmitted via 2 main routes: Contact transmission: via healthcare workers hands, or from the patient’s immediate environment. Airborne transmission: via droplets in patients who are sputum positive or via skin scales when large quantities are released into the air e.g. during bed making. 2 Purpose This document provides a framework for all members of trust staff involved in clinical care. It provides information on MRSA screening and management of patients known to have been either colonised / infected with MRSA. 3 Roles and Responsibilities The roles and responsibilities of named individuals within the organisation, with regard to their duty to comply with this policy and protect patients from the risks of acquiring healthcare associated infection, are identified in the Trust Infection Control Strategy 01 in accordance with The Health Act, Code of Practice, 2006 section2. 4 Detail of Policy. The Policy is described below under the following sections: 4.1 MRSA SCREENING 4.2 MRSA DECOLONISATION 4.3 MRSA SOURCE ISOLATION 4.1 MRSA SCREENING 4.1.1 MRSA Screening Statement of Intent All relevant elective admissions to Central Manchester University Hospitals NHS Foundation Trust are screened for MRSA prior to admission. All high risk emergency admissions are also screened for MRSA on admission. This will be extended to include all remaining emergency admissions by March 2011. All patients who test positive for MRSA on screening, prior to admission or on admission or those who have had a previous history of MRSA (including those who have had three negative screens) will be commenced on decolonisation therapy. Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 5 of 26 4.1.2 Action to be taken if the patient is MRSA positive prior to ELECTIVE admission A list of patients who should be screened prior to elective admission can be found in appendix 1. An attempt should be made to eradicate MRSA from patients listed for elective admission. They should be screened at least every week whilst receiving decolonisation therapy. If the patient has three consecutive negative screens, the decolonisation therapy may be discontinued until admission. If however, after two courses of Mupirocin nasal ointment and three weeks continuous treatment with Octenisan /Oilatum Plus body wash, the patient still remains positive a risk assessment should be undertaken for the individual patient concerned. Please contact a member of the Infection control Team for further advice in such circumstances. For elective admissions or transfers where a delay in admission may be seriously detrimental to the patient outcome, such patients should be admitted following a risk assessment by the Consultant in-charge of the case. These patients must be isolated and treated in accordance with this Policy (see section 4.3). 4.1. 3 Action to be taken following three negative MRSA screens from ELECTIVE admissions Action Rationale Patients listed for elective admission who have a previous history of MRSA colonisation / infection despite three negative screens must be screened on admission and commenced on skin decolonisation therapy. (They do not need to be isolated unless found to be MRSA positive. MRSA decolonisation therapy may reduce the risk of endogenous infection and reduce the risk of cross transmission especially if three consecutive negative screens have been established. Three consecutive negative screens however, is not a definitive indicator of the patients MRSA status. Patients who are elective admissions for surgery should commence nasal decolonisation therapy as well as skin decolonisation therapy during the pre and post operative period. Furthermore local evidence indicates that a previous history of MRSA colonisation/infection is a common factor in incidents of MRSA bacteraemia. All patients who are known to be MRSA positive / have a history of being MRSA positive, that are to undergo procedures that would usually require the use of prophylactic antibiotics must receive antibiotic therapy that has activity against MRSA, for example, Vancomycin or Teicoplanin (see adult antiinfective prescribing guidelines section 4, antibiotic prescribing guidelines for paediatric and neonatal patients, section 4). Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 6 of 26 4.1.4 MRSA screening for high risk admissions See Appendix 1 All patients who match the criteria below are considered to be high risk of MRSA infection and must be screened for MRSA within 24 hours of admission. They do not require isolation unless found to be MRSA positive Transfers from other hospitals / healthcare facilities History of admission to hospital / healthcare facility within the previous 6 months Admission from a long-term residential facility e.g. nursing home / residential home for elderly or chronically sick / respite care Patient’s with exfoliating skin conditions e.g. extensive eczema or psoriasis Previous history of being MRSA positive (despite three or more negative screens). Healthcare workers. 4.1.5 MRSA screening and decolonisation therapy regime for ALL patients with a previous history of MRSA colonisation / Infection Action Rationale Patients being admitted for an overnight stay (or longer), who have had a previous history of MRSA colonisation / infection, must be rescreened within 24 hours of admission. Local evidence from analysis of incidents demonstrates a previous history of MRSA as being a potential risk factor for MRSA bacteraemia This applies to all patients with a previous history of MRSA colonisation or infection regardless of whether or not they have had three or more negative screens for MRSA. Local evidence from analysis of incidents demonstrates a previous history of MRSA as being a potential risk factor for MRSA bacteraemia. Patients who have not had 3 negative screens should be isolated until the results of the screen are known. If necessary, seek advice from a member of the Infection Control Team regarding risk assessment. Isolation of patients with a known history of MRSA colonisation or infection will reduce the risk of cross infection Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 7 of 26 Contd. Action Rationale Patients must be commenced on This reduces the risks of topical decolonisation therapy from The patient developing an admission using either: Octenisan MRSA infection with their own body washes (unless contraindicated) MRSA during medical or Oilatum Plus. interventions Transmission of MRSA to Mupirocin or Naseptin nasal cream another patient should only be given on the advice of the Infection Control Team. See Appendix 2 and 3 Where the patient has had 3 negative screens, Octenisan or Oilatum Plus should be commenced and used continually every day during the inpatient stay. 3 negative screens indicate that the patient may have undetectable levels of MRSA and therefore the risk of transmission to others is minimal. Isolation is not required unless the patient has a positive result . Patients who have had 3 negative screens must be screened weekly throughout their hospital stay, or in line with any additional screening program already in place. Early detection of recolonisation reduces the risk of infection and transmission to others. Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 8 of 26 4.1.6 MRSA screening procedure – sample sites Action Rationale The following sites are recommended for sampling for MRSA in adults and children over 6 weeks of age The nose and perineum are the main carriage sites for MRSA. The groin is often preferred but may be less sensitive. Nose, perineum or groin, skin lesions (including pressure sores) and any manipulated clinical sites e.g. wounds / intravenous and stoma sites / urine from catheterised patients / tracheotomies and sputum if applicable. N.B Swabs taken from Clinical Sites will only be cultured for MRSA. A further sample will be necessary if further Culture and Sensitivity is required. In neonates and children under 6 weeks of age, axilla, groin, umbilicus and any manipulated clinical sites e.g. cannula, stomas, skin lesions etc. The ability to detect MRSA carriage depends on many factors including the number and patient sites sampled. Where moisture is not evident at the site to be swabbed, swabs should be dampened by dipping them in transport media or sterile saline prior to swabbing. To increase amount of bacteria picked up. Use the same swab to sample symmetrical sites e.g. Single swab for right and left nostril, single swab for right and left groin. Both sites would be treated if carriage is detected therefore it is an unnecessary expense to use separate swabs. Request screen using Clinical Work Will reduce time of ordering cards, Station (CWS). One request card can and bulk of screen. be used for multiple swabs (maximum of 8 per card) as long as each swab is clearly identified with patient details and site from which taken. Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 9 of 26 Contd. Action Rationale Additional sites i.e. the throat may be sampled if clearance of the carrier status is difficult. (This should only be done after discussion with a member of the infection control team) The role of throat carriage in the spread of infection is uncertain. If the in patient has widespread eczema or psoriasis (a heavy skin shedder) please inform the infection control team as soon as possible. A person with dry / flaky skin will shed more skin scales into the environment and will increase the risk of infection. 4.2.MRSA Decolonisation Therapy 4.2.1 Adults and paediatric patients over 6 weeks of age – skin decolonisation Action Rationale NB This is a medical treatment, it is not optional. Please ensure patient is given help in receiving the body wash as it should be applied all over the body and left on for 3 minutes. Treatment with a topical Continuous treatment for skin antibacterial lotion should colonisation reduces the amount of commence as soon as possible after MRSA on the skin and therefore the patient has been identified as reduces the risk of endogenous MRSA positive / has had a previous infection and cross infection history of MRSA colonisation / infection and should continue without interruption (unless contraindicated), during the in-patient stay If a screen for MRSA is required, it should be taken before the patient has a daily wash with Octenisan/Oilatum Plus. Screens should be taken at weekly intervals until 3 negative screens have been achieved or until advised by the infection control team. Once the patient has had 3 negative screens they no longer need to be isolated. However, they should continue to be screened every week. 3 negative screens indicate that the MRSA is at undetectable levels and isolation may be discontinued. Local evidence suggests that previous colonisation / infection with MRSA maybe a significant contributing factor to MRSA bacteraemia. Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 10 of 26 Contd. Action Patients should have a shower using Octenisan or bath with Oilatum Plus every day. Where this is not possible they should either strip wash or be bed bathed. Rationale This will reduce the level of MRSA colonisation on the patient’s skin and therefore reduce the risk of endogenous / exogenous infection. 4.2.2 Adults and paediatric patients over 6 weeks of age - nasal decolonisation Action Rationale NB This is a medical treatment, it is not optional. Patients who are treated with Mupirocin nasal ointment: A course of Mupiricin lasts 5 days (3 times per day). Once completed a further 2 days must pass before the patient can be re -screened. An indication of nasal carriage is only possible once the Mupirocin has been discontinued. A maximum of 2 courses of Mupirocin is recommended To reduce the risk of Mupirocin resistance. Naseptin Nasal Ointment may be used if further treatment is required. Used on the advice of the infection control team if nasal carriage clearance is preferable. Good oral hygiene of teeth or dentures is recommended in patients who are screen positive. To reduce the level / risk / spread of throat colonisation. Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 11 of 26 4.2.3 Neonates and paediatric patients under 6 weeks of age – skin decolonisation Action Rationale Infants > 1.8kg should have a bath or wash all over daily using disposable wipes and cleaning solution as per Neonatal Medical Unit (NNMU) skin care guidelines. Neonatal Medical Unit (NNMU) guidelines support the use of neutral pH cleansing solutions in neonates Infants < 1.8kg are washed with water The skin of premature babies is more only permeable and there is risk of absorption of cleaning solutions. Infants skin creases e.g. axilla, groin and umbilicus are dusted with Chlorhexidine acetate (CX powder) 3 times per day for 5 days. These areas are more susceptible to MRSA colonisation. Once completed a further 2 days must pass before the infant can be rescreened. It is not appropriate to continue CX powder indefinitely in neonates and clearance of MRSA can only be determined once treatment has stopped. Eradication of carriage may not be achievable. If a negative screen has not been achieved after 3 cycles of treatment the infection control team will advise on further management of colonisation. Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 12 of 26 4.2.4 Neonates and paediatric patients under 6 weeks of age – - nasal decolonisation Action Rationale Naseptin nasal ointment applied to each nostril 4 times per day for 5 days To treat for suspected nasal carriage Once completed a further 2 days must pass before the infant can be rescreened. An indication of nasal carriage is only possible once the Naseptin has been discontinued. If a negative screen has not been achieved after 3 cycles of treatment the infection control team will advise on further management of colonisation. Eradication of carriage may not be achievable. 4.2.5 Pre- operative preparation for patients known to have / with a history of MRSA colonisation/infection Action Rationale Patients who are going to theatre for a procedure must be showered / washed (including hair wash) as close to the time of the procedure as is practical using either Octenisan or Oilatum Plus . This will reduce the level of MRSA colonisation on the patient’s skin and therefore reduce the risk of endogenous / exogenous infection. If the Patient has already had 2 courses of Mupirocin a course of Naseptin may be given over the pre and post operative period please consult with a member of the Infection Control Team. Over use of Mupirocin may cause Mupirocin resistance See adult anti-infective prescribing guidelines section 4, antibiotic prescribing guidelines for paediatric and neonatal patients, section 4. Patients with a history of MRSA must be given Vancomycin/Teicoplanin if antibiotic prophylaxis is required Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 13 of 26 4.3 MRSA SOURCE ISOLATION 4.3.1 Source isolation – inpatients Objective: To minimise the risk of transmission of MRSA, directly from patient to patient, or indirectly via health care workers or patient care equipment, whilst maintaining patient safety and comfort. Equipment 1. Single room with clinical handwash basin, appropriate handwash solution and paper towels. NB. If a single room is unavailable, and following a risk assessment, a patient with MRSA colonisation / infection may be nursed on the ward next to a sink. Full contact precautions must still be applied. 2. Toilet facilities, if appropriate, preferably en suite. 3. Isolation notice for outside of door or at bed space. 4. Disposable aprons and gloves (kept outside of room by the entrance, preferably in Danicentres). 5. Alcohol hand rub (inside the room and easily accessible and outside the room by entrance, preferably in wall mounted dispensers) 6. Pedal bin lined with clinical waste bag (kept by handwash basin). 7. Separate patient’s wash bowl stored dry and inverted when not in use. 8. Patients chart/records should be kept outside the room. Action Rationale Commence MRSA ICP documentation (available in preprinted format from the printing department – order code J378). Allows "step by step" approach to the management and care of MRSA positive patients. Prepare and equip single room / bed space for isolation. Allows isolation procedures to be carried out in an organised manner. Keep equipment to a minimum To facilitate cleaning of the room / bed space and equipment. All disposable equipment must be discarded following patient discharge. Ensure an Isolation notice is fixed to bed space or outside the door, advising ‘Please See Nurse in Charge before Entering’. Will ensure that all staff / visitors seek proper advice before entering the room / bed space, thus avoiding confusion and unnecessary anxiety. Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 14 of 26 Contd. Action Rationale Inform infection control nurse of MRSA result. Infection control nurse can be used as a resource to facilitate patients’ care whilst isolated. Explain the need for isolation to patient and relatives, and allow him / her to express any anxieties she / he may have. Give patient appropriate information leaflets. Reduces anxiety and fulfils legal requirements. Gains patients’ and relatives’ trust and co-operation and involves them in their care. Commence treatment for eradication of MRSA colonisation (see section 5 and 6 above) Prompt and effective treatment will reduce the risk of cross infection and may reduce the risk of patient becoming infected with MRSA. Disposable apron and gloves should The use of protective clothing will be worn by all staff when handling the reduce the risk of contaminating patient or their immediate uniform and hands. environment, contact with their secretions and handling of contaminated dressings or linen. Meticulous attention to hand hygiene HAND HYGIENE IS THE SINGLE before leaving the room / bed space MOST IMPORTANT MEANS OF by all personnel. (Ensure there is PREVENTING CROSS INFECTION appropriate facilities i.e. soap / alcohol gel in dispensers and paper towels). The patient must have a wash all This will reduce skin carriage of over / bath / shower using a topical MRSA. antibacterial lotion, disposable wipe and clean towel daily. (See ICP for neonates for variations in care). Meticulous attention to oral / dental hygiene is required. To reduce the level / risk / spread of throat colonisation. Patient’s night-clothes and bed linen (sheets and pillow cases) should be changed daily. To reduce recontamination of patient’s skin with MRSA. Wash patient’s wash bowl after each use with soap and water, dry and store inverted after use. To remove grease, skin debris etc from washbowl Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 15 of 26 Contd. Action Rationale Check mattress and pillow covers are intact. Dispose of bed linen immediately into pink alginate watersoluble infected linen bag. The alginate bag may then be taken out of room and put into a red linen bag in the linen skip. Store spare alginate bags outside patient’s room. MRSA may be shed on skin scales into the bed linen. Prompt disposal of used bed linen into the alginate bag by the bedside will reduce the risk of environmental and uniform contamination. The alginate bag dissolves in the washing machine in the laundry releasing the linen. If the single room does not have ensuite facilities and there is a toilet nearby it may be appropriate for the patient to use it rather than keep a commode in the room. If the patient has a commode it is advisable that it is kept for his / her use only during the period of isolation. The least amount of cleaning and handling of equipment the less likely MRSA can be indirectly transmitted to another patient. Also, a mobile patient may be reluctant to use a commode. Patient should use ordinary crockery and cutlery. This should be returned to the kitchen after each meal and washed in a dishwasher. The indirect transmission of MRSA from crockery and cutlery is very unlikely providing it is washed thoroughly. Visitors do not have to wear protective clothing, unless assisting with the patient’s bodily care, but should be encouraged to clean their hands before leaving the room. Visitors do not have the same contact with other patients as health care workers, and therefore will not transmit MRSA from one patient to another. Door to the room to be kept closed, particularly during procedures which may generate staphylococcal aerosols e.g. physiotherapy, bed making, wound dressing To minimise the risk of spread of MRSA to adjacent areas. Patient to avoid social contact with other patients. To minimise the risk of spread of MRSA. In some cases it may be appropriate for patients to walk in hospital corridors or in the garden. To try and enhance the psychological well being of the patient. Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 16 of 26 Contd. Action Instruments or equipment e.g. dinamap cuffs, lifting slings etc. should be single patient use where possible. Rationale To prevent spread of MRSA to other patients. If not single patient use such items must be cleaned thoroughly before use on another patient. See Procedures and Principles for decontamination of equipment on Trust Infection Control intranet site If the patient is to be transferred to other wards / departments / hospitals, please inform the receiving area that this patient has been nursed in a single room and to contact the infection control nurse or doctor for further advice. To avoid confusion and anxiety to both staff and patient and to minimise the risk of transmission of MRSA. It is not necessary for clinical or portering staff to wear PPE during transfer but staff must take the following precautions: Cover chair / trolley with clean sheet. Wear disposable gloves and aprons if handling the patient Remove gloves and apron and clean hands before leaving the ward When transfer is complete, place sheet in alginate bag and place in infected laundry bag. If there is any leakage of fluids onto the chair / trolley surface, it must be cleaned by staff at the receiving area as per Trust guidelines found on the Intranet. Clean hands before next activity / job. Patients may feel stigmatised if staff involved with the transfer are wearing PPE. There is a risk of contaminating during manual handling of patient so PPE is advised. HAND HYGIENE IS THE SINGLE MOST IMPORTANT MEANS OF PREVENTING CROSS INFECTION Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 17 of 26 Contd. Action Rationale If the patient requires physiotherapy or occupational therapy within the department, please discuss each individual case with a member of the infection control team. Once 3 negative screens have been obtained then isolation precautions may be discontinued. Every effort should be made to ensure all patients receive therapy regardless of their MRSA status. With the exception of neonates, treatment with a topical antibacterial lotion should continue until the patient’s discharge home. Continuous treatment with a topical antibacterial lotion reduces the amount of MRSA on the skin and therefore reduces the risk of recolonisation. MRSA is no longer present in sufficient amounts to be detected and the risk of transmission is significantly reduced. 4.3.2 Source isolation – outpatients Objective: To minimise the risk of transmission of MRSA, directly from patient to patient, or indirectly via health care workers or patient care equipment, whilst maintaining patient safety and comfort. Equipment 1. Patient should be seen in a single room with clinical handwash basin, appropriate handwash solution and paper towels. 2. Disposable aprons and gloves should be available in the room 3. Alcohol hand rub should be inside every room and be easily accessible. 4. Pedal bin lined with clinical waste bag (kept by handwash basin). 5. Suitable disinfection solution for decontamination of equipment and immediate environment. Action Rationale Patients visiting outpatient clinics do not need to be isolated from others in clinic. Patients colonised with MRSA pose minimal risk to other patients in the outpatient setting During consultation, disposable apron and gloves should be worn by all staff when handling the patient or their immediate environment, contact with their secretions and handling of contaminated dressings or linen. The use of protective clothing will reduce the risk of contaminating uniform and hands. Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 18 of 26 Contd. Action Rationale Ensure meticulous attention to hand hygiene following removal of gloves. (Ensure there is appropriate facilities i.e. soap / alcohol gel in dispensers and paper towels). HAND HYGIENE IS THE SINGLE MOST IMPORTANT MEANS OF PREVENTING CROSS INFECTION Protective clothing should be disposed of in a clinical waste bin as per Trust waste guidelines. To reduce the risk of spread of MRSA to the environment and other patients. The chair / couch and any equipment that has been in contact with the patient should be cleaned with Chlorclean as per Trust decontamination guidelines, found on the intranet. Linen should be disposed of as per Trust guidelines. To reduce the risk of spread of MRSA to other patients 4.3.3 Source isolation – radiology, cardiology, neurophysiology and nuclear medicine Action Rationale For outpatients visiting these departments who are colonised with MRSA please follow section 4.3.2 above. Patients colonised with MRSA pose minimal risk to other patients in the outpatient setting Outpatients known to be colonised Inpatients are potentially more with MRSA should not be seated near vulnerable to infection due to length of to inpatients / tertiary referrals stay and the presence of invasive devices. Inpatients / tertiary referrals known to be colonised or infected with MRSA should be seen at the end of the clinic / list where possible This will allow for efficient decontamination at the end of the clinic / list to take place and to reduce the risk of transmission to other patients. Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 19 of 26 4.6 Discharge of Patients Colonised / Infected with MRSA Colonisation or infection with MRSA should not delay patient discharge home or to other healthcare or residential facilities. All those responsible for the clinical and social care of the patient should be kept informed of screen results and any treatment or decolonisation therapy required Action Rationale Inform the receiving health facility / residential home of MRSA status and current treatment. Appropriate infection control measures can be put in place prior to patient transfer to prevent transmission of MRSA to others This will allow for continuation of care in the Primary care setting if appropriate. When discharging patients home, the GP must be informed of the patient’s MRSA status and treatment in the Trust standard discharge letter 5.0 Discharge lounge Ambulant patients waiting for transfer home who are MRSA positive can be managed as per section 4.3.2 above The risk of transmission to other patients in this setting is minimal. Patients awaiting discharge / transfer who are MRSA positive and who still require a bed should be nursed next to a sink and an isolation sign displayed at the bedside. Infection control procedures should be followed as outlined in section 4.5.2 above There is an increased risk of contamination of the immediate environment and transmission of MRSA to others in patients still requiring hospital care. Equality Impact Assessment 5.1 This policy has been equality impact assessed by the author using the Trust’s Equality Impact Assessment (EqIA) framework. 5.2 The completed Equality Impact Assessment has been completed and submitted to the Equality and Diversity Department for ‘Service Equality Team Sign Off’ 5.3 There are no significant issues in relation to equality, diversity, gender, colour, race or religion are identified as raising a concern. 6.0 Consultation, Approval and Ratification Process See the Trust Infection Control Strategy 01. 7.0 Dissemination and Implementation See the Trust Infection Control Strategy 01. In addition, the policy will be disseminated and implemented through the Trust Mandatory training. Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 20 of 26 8.0 Review, Monitoring Compliance With and the Effectiveness of Procedural Documents See the Trust Infection Control Strategy 01. In addition, the policy will be audited monthly (using the guidelines within this document, appendix 3) in every clinical area and clinical department by a chosen lead (usually the Infection Control Link Practitioner). The results will be submitted online and will be disseminated to all Divisions. 9.0 References and Bibliography Guidelines for the control of epidemic meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities by the Joint BSAC/HIS/ICNA Working Party on MRSA (2006) in Journal of Hospital Infection 63S, S1 - S44 Ayliffe GAJ, Babb, JR, Taylor LJ (2001). Hospital Acquired Infection: Principles and Prevention. Third edition. Arnold, London. Ayliffe, GAJ, Fraise, AP, Geddes, AM and Mitchell, K (2000). Control of Hospital Infection: a Practical Handbook. Fourth edition. Arnold, Royal College of Nursing (2000). Methicillin Resistant Staphylococcus aureus (MRSA) guidance for nurses 10.0 Associated Trust Documents See the Trust Infection Control Strategy 01. Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 21 of 26 Appendix 1 Division Of Medicine Elective Admission Screening Programme Elective High Risk admissions (see section 4.1) Additional Screening Programme All elective Cardiothoracic Emergency Cardiothoracic On admission High Risk Emergency admissions (see section 4.1) CHDU / CSU / CCU Al patients every week All renal patients on admission Patients attending the programmed Investigation Unit (PIU) who are undergoing a high risk invasive procedure (e.g. ERCP) will be screened. All admissions to haematology ward Urgent admissions to ward 34 Renal medicine On admission and every 2 weeks during in-patient stay Screen prior to creation of vascular/peritoneal access Haematology Screen new referrals to day case unit (DCU) Ward 27 screen every 2 weeks during in-patient stay Division of Clinical Scientific Support Elective Admission Screening Programme Additional Screening Programme All admissions to General Intensive Care Unit ICU/HDU All patients every week All admissions to General High Dependency Unit Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 22 of 26 Division Of Surgery Elective Admission Screening Programme Additional Screening Programme Elective High Risk admissions (see section 4.1) Elective: Orthopaedic Vascular Urology Renal Transplant ENT Max Fax General Surgery GI Surgery Patients attending ETC for procedure under LA Emergency Trauma & Orthopaedics Screen on admission and then every 2 weeks Emergency Vascular On admission High Risk Emergency admissions (see section 4.1) Saint Mary’s Hospital Elective Admission Screening Programme Additional Screening Programme Elective High Risk admissions (see section 4.1) Neonatal Medical and Surgery every week All admissions to medical / surgical neonatal units High Risk Emergency admissions (see section 4.1) Elective Caesareans All elective gynaecological admissions Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 23 of 26 Royal Eye Hospital Elective Admission Screening Programme Additional Screening Programme Elective High Risk admissions (see section 4.1) High Risk Emergency admissions (see section 4.1) Children’s Division Elective Admission Screening Programme Elective High Risk admissions (see section 4.1) Elective admissions to Intensive Care Unit / High Dependency Unit / Burns unit and BMTU All Cystic Fibrosis patients. Neuro / Spinal surgery Additional Screening Programme PICU/HDU All patients weekly Burns Unit / BMTU All patients weekly Oncology admissions and inpatients with CVC line - monthly Renal medicine On admission and every 2 weeks during in-patient stay Dialysis patients - monthly Prior to creation of vascular/ peritoneal access High Risk Emergency admissions (see section 4.1) Manchester Dental Hospital Elective Admission Screening Programme Not applicable to day Cases Additional Screening Programme Not applicable to day Cases Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 24 of 26 APPENDIX 2 Octenisan Body Wash Octenisan body wash should be used every day as a liquid soap, for a shower, bath or wash. It is easier to use Octenisan in a shower but, it is perfectly acceptable to use the lotion for a strip wash each day. Shampoo hair with Octenisan body wash on alternate days. If the skin becomes dry and or irritated stop using Octenisan and inform the Infection Control team. 1. 2. 3. Use 30 ml of solution Leave the lotion on the skin for 3 minute before rinsing Ensure that hair and body are wet Apply all over hair and body paying special attention to the areas indicated in red Put the lotion onto a damp washcloth 4. 5. Rinse off thoroughly Dry with clean, dry towel 6. Put on clean underclothes/nightwear every day Continued on next page- Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 25 of 26 APPENDIX 3 Oilatum Plus How to use Oilatum Plus Always use Oilatum Plus diluted in water. Add 2 capfuls of Oilatum Plus to a 20cm (8 inch) deep bath or 1 capful to a 10 cm (4 inch) deep bath. Add a quarter of a capful to a bowl of water for washing. Take care: Oilatum Plus makes the skin and bath surfaces slippery. BACTROBAN NASAL OINTMENT (Mupirocin 2%) Bactroban Nasal Ointment (Mupirocin 2%) should be used for the first 2 cycles following MRSA screen positive result. Use it three times each day for 5 days. A small amount of ointment, about the size of a match head, should be placed on a cotton bud or on a gloved finger and applied to the inside of each nostril (apply to the front part of the nostril). The nostrils should be closed by pressing the sides of the nose together; this will spread the ointment through the nostrils. Document Control Policy IC Org 03 MRSA See the Intranet for the latest version. Version Number:- 2 Page 26 of 26