Chief Operating Office/Director of Nursing (COO)

Walsall Hospitals NHS Trust

POLICY DETAILS (All sections to be completed for new policies and updates as changes are made)Title MRSA Screening Policy

Version: 1.3Type PolicyPPG Minute 18/09.01Ratified by: TMG

Date ratified: To be ratified on the 31st March 2009 at TMG

Ratification Minute

Policy Director: Medical DirectorPolicy Lead: Infection Control Doctor

Date issued: March 2009

Review date: *: September 2009Full Review / Re-Ratification Due: **

March 2013

Summary

This policy sets out how emergency and elective patients will be screened for MRSA at Walsall Hospitals NHS Trust

INDEX

1.0 Introduction2.0 Aim3.0 Objectives4.0 Definitions / Glossary of Terms5.0 Roles and Responsibilities6.0 Main Body of Policy7.0 Impact Assessment8.0 Links to External Standards9.0 Links to Other Trust Policies10.0 Monitoring Control and Audit11.0 Best Practice, Evidence and References12.0 Appendices

Screening Policy Version 1.3March 09MB/PAK

Building Better Heath for Walsall


POLICY VERSION HISTORYAll Trust policies etc must include full version history that allows reference to archived versions of polices in place at any previous point in time.Version No

Lead Date Change Implemented

Reason for Change Change Code

1.0 Lead Infection Control Nurse

Jan 09 New policy

Types of Change leading to new version number and Process for ratificationCode Reason for Change Ratification

ProcessConsultation

Required SC Need for Significant and Substantive

Changes before review due (Including substantive changes required to comply with external standards etc)

By Ratifying Group after PPG review

Y

MC Need for minor changes before next review due

By PPG Y (limited)

OP Changes to a subsidiary policy because of recently ratified changes to an overarching policy

By PPG N

RS Managerial or Organisational Restructure

Send cover sheet and version control sheet to PPG

N

RO Change to roles or responsibilities of post (not changes to personnel)


N

TY Typographical, grammatical, spelling corrections


N

CL Clarification made in response to confusion by users or problems with misinterpretation

By PPG Y (limited)

ES In response to changes to external standards / requirements which do not require substantive change to the policy.


N

PRN Following planned review – No substantive changes


N

PRS Following planned review – Substantive changes required

By Ratifying Group after PPG review

Y

RR Policy due for full re-ratification By Ratifying Group after PPG review

Y

Limited consultation - Consultation only with staff groups directly affected by the proposed change




MRSA SCREENING POLICY

1.0 INTRODUCTION

Staphylococcus aureus (S.aureus) is one of a number of common bacteria that colonizes human skin, nasal passages and the mouth. Between 20% and 40% of the population carry this organism without any ill effects. However, given the right clinical circumstances, S. aureus can gain entry into the body via wounds or intravenous lines and cause serious infections such as abscesses, cellulitis, septicaemia and occasionally pneumonia

Reducing the number of Healthcare Associated Infections (HCAIs) is a key government target and a key target for the Trust is meeting it’s target on MRSA bacteraemias.

Screening patients will identify carriers so decolonisation treatment can be carried out and reduce the risk of the contaminating bacteria carrying an actual infection or being spread. In the past the Trust policy was to screen all emergency admissions and some electives. However by April 2009 the DoH require that the majority of electives will be screened with the exception of some groups identified by the DoH. This must be undertaken without compromising waiting list targets.

This policy sets out how and when this screening will be carried out at Walsall Hospitals NHS Trust, together with arrangements for decolonisation.

1.1 Purpose of Policy

To comply with DoH requirements and reduce the risk of colonised patients developing an infection or spreading the bacteria.

1.2 Scope and limitations

All emergency patients and all electives with the exception of patients on the DoH list of exceptions (Appendix 1)

1.3 Statement of Statutory Compliance

This policy will ensure the Trust comply with DoH requirements to screen all elective patients by April 2009 and all emergency admissions as soon as possible and definitely no later than 2011

2.0 POLICY AIM

To reduce the risk to patients of contracting an MRSA infection and support the attainment of the Trust’s target for reducing MRSA bacteraemias without compromising waiting list targets.




3.0 OBJECTIVES

To ensure systems are in place for the screening of all emergency and elective patients (apart from identified exceptions-See Appendix 1)

To ensure there are adequate arrangements for decolonisation

To support the attainment of the Trust’s target on MRSA bacteraemias

To ensure waiting list targets are not compromised

To support staff whose role includes the screening and decolonisation of patients

To ensure reporting/assurance systems are in place

To ensure systems support and complement other initiatives designed to reduce MRSA colonisation in Walsall

4.0 DEFINITIONS

4.1 Screening- An investigation by swabbing to identify the presence of MRSA

4.2 Decolonisation- An attempt to eradicate MRSA by appropriate treatment

5.0 ROLES AND RESPONSIBILTIES

51 Medical Director (MD)

The MD is responsible for presenting the policy to the ratification group, providing assurance to the group that the policy is compatible with Trust objectives and complies with all relevant statutory requirements and other standards. In addition MD has overall responsibility for implementation monitoring and compliance with policy. Finally the MD is responsible for ensuring policy is reviewed and revised as per timescales on the cover page.

5.2 Chief Operating Office/Director of Nursing (COO)

The COO is responsible for supporting the Medical Director in his role as Policy Director

5.3 Divisional Directors (DD; or equivalent)

Managers are considered to be equivalent to DD’s for the purpose of responsibilities under policies if they are responsible for management of a significant service and report directly to an Executive or Associate Director.

Responsibilities include implementation, monitoring and compliance within the Division and ensuring staff within the Division with specific




responsibilities carry these out.

DD’s responsibilities can be delegated to Divisional Heads of Nursing or Matrons.

5.4 Clinical Directors (CD) / Heads of Nursing/Divisional Matrons (DM)

The responsibilities for implementing the specific clinical requirements of the policies rest with CD’s, Head of Nursing or DM’s. These specific responsibilities relate to ensuring staff implement the policy and ensuring staff are able to undertake their duties within it

5.5 Senior Sisters (With day to day responsibility for ward management), Department Managers or equivalent.

This group will be responsible for day to day implementation of the policy. Also included will be responsibility for ensuring:

All staff are aware of their role under the policy Staff have received sufficient training and / or are competent to

implement the policy Equipment is suitable and sufficient Records are kept as specified Ensuring incidents / issues are reported as specified Monitoring / Audits and Evaluations are carried out as specified.

5.6 All Staff (with individual responsibilities under the policy)

All staff with a role in the policy are responsible for ensuring they follow procedures within it

5.7 Infection Control Team

The Infection Control Team are accountable for supporting staff in implementing and maintaining screening, monitoring and reporting on compliance and providing training if required.

5.8 Head of Performance

The Head of Performance is responsible for reporting on compliance with screening and ensuring appropriate assurance systems are in place.

5.9 Microbiology Department

The Microbiology Department is responsible for processing specimens and for issuing results as soon as possible. It is also responsible for liaising with the Infection Control Team.




6.0 SCREENING PROCEDURES

6.1 Emergency Admissions

6.1.1 Who to screen

All emergency admissions to Planned Care, Unplanned Care and those admitted from another hospital or abroad will be screened on admission. In addition patients admitted to gynaecology from nursing or residential homes or who are assessed as high risk, will be screened. .High risk obstetric patients will also be screened.

6.1.2 Where to screen

Screening swabs will be taken as follows:-

Nose (one swab should be used for both nostrils) Groin (one swab should be used for both groins) All open skin lesions (e.g. leg ulcers, pressure sores)

Additional specimens.

Invasive device entry sites. (e.g. IV lines, Peg tubes) Sputum (if productive cough) Urine (if catheter in-situ)

6.1.3 Sending specimens to the laboratory

All individual sites must be recorded on the specimen form and container The site and type of any wounds will be noted in clinical details (e.g.

surgical wound, pressure sore, leg ulcer Wound swabs should be sent on a separate specimen form and sent for

culture and sensitivity Antibiotic therapy must be completed in the space provided on the

specimen form Patient details must be clearly written or ID labels used on each layer of

the form

6.1.4 Notification of results

Results of screening swabs are electronically transmitted daily from the laboratory to the Infection Control Team via an electronic surveillance system (ICnet). The Infection Control Nurses will communicate any new MRSA positive results to the relevant ward and give advice. However it remains the responsibility of the patient’s clinical team to check results of any samples send to the laboratory.

The treatment regimes in this policy are for decolonising asymptomatic uninfected patients only The management and antibiotic treatment of serious




MRSA infections should be discussed with the consultant microbiologists.

6.1.5 Infection control measures

Infection control measures are detailed in the MRSA Policy and the Isolation Policy.

6.1.6 Decolonising Regime

One of the main armaments against the spread of MRSA is the decolonisation regimen. The aim is to rid the patient of colonising MRSA bacteria by removing it from its usual residing places- the nasal mucous membranes and the skin. The process is not absolutely successful in all cases but it is always a worthwhile task as eradication will prevent problems in the future, and even short to medium term suppression will prevent spread during the current hospital admission. A major benefit is the prevention of simple colonising MRSA proceeding to cause serious infection in patients who develop risk factors whilst in hospital, e.g. a patient admitted for an elective abdominal surgery.

Standard decolonising regimen.

Should be prescribed and administered to patients found to be MRSA positive as soon as possible. The regimen consists of:-

Nasal mupirocin (bactroban) applied to each nostril X3 /day for 5 days.

Chlorhexidine body wash lotion – applied to whole, body then washed or showered off after 1 minute - applied once a day for 5 days.

6.1.7 Assessing the effectiveness of treatment

In order to ascertain if a patient has been cleared from MRSA at least 3 negative swabs from previously positive sites should be obtained.

The 1st repeat screening swabs should be taken 48 hours after the completion of decolonisation regimen and the 2nd and 3rd at 48 intervals thereafter whilst the patient remains in hospital. This re- screening will be monitored by the Infection Control Team.

6.2 Elective admissions

6.2.1 Orthopaedic implant surgery/vascular surgery involving graft implant

Certain surgical procedures where prosthetic material is implanted are of particular concern owing to the potential effects of MRSA infection on the implant. Patients due for such surgery are asked to attend Pre-assessment clinic around two weeks prior to admission where they are screened for MRSA. Swabs will be taken from nose and groin together with open




wounds (see 6.1.2)The results are monitored by the clinic staff who refer any patients found to be colonized to their GP. The GP will organize the decolonisation treatment and undertake further screening to ensure that the patient has been decolonized prior to proceeding to surgery.

See Appendix 2 for algorythm

6.2.2 Elective admissions to Unplanned Care

Elective admissions to Unplanned Care are screened on admission as per 6.1

6.2.3 Planned Caesarian Sections

This group of patients will be screened in Ante-natal Clinic a minimum of two weeks prior to planned admission date as per 6.1.

6.2.4 Other elective patients

For all other electives with the exceptions of those listed in the DOH exception list (see Appendix 1) the following procedure will be followed.

Patients will be routinely screened when they attend Pre-assessment clinic around two weeks prior to admission and given a leaflet explaining why this is necessary (See Appendix 3)

Swabs will be taken of nose and groin together with any open wounds (See 6.1.2) for all patients other than ENT

For ENT patients swabs from nose are sufficient unless the patient is high risk or has open wounds in which case they will be screened as 6.1.2

Patients will be given an information leaflet explaining the need for the screen. (See Appendix 4) A note will be made of patients who are unlikely to be able to decolonise themselves should this be required.

Specimens will be dealt with as per 6.1.3

Positive results will be phoned to Pre-assessment Clinic by the Infection Control Team

Patients with negative screens will go forward to admission and will not require a further screen on admission

For positive patients a decolonisation kit will be prescribed by a doctor in Pre-assessment clinic or via a PDG as soon as possible after the result is received.

Where a positive result is received the patient will be contacted as




soon as possible and asked to collect a decolonisation kit. Instructions on how to use the products within it are contained within the kit (See Appendix 4)

Where a patient is unable to undertake the decolonisation treatment then arrangements will be made for this to be undertaken by the GP/district nurses.

Decolonised patients will attend for surgery as planned. Swabs will be taken on admission and appropriate antibiotic cover will be given.

Appendix 5 contains an algorithm for this group of patients

6.2.5 Patients who do not attend Pre-assessment clinic (Fast track)

On some occasions theater slots become available at short notice. In order to ensure such slots are filled patients are called who have not visited Pre-assessment clinic. Where this is the case patients will be treated as if they have positive swab results, screened on admission and given appropriate antibiotic cover.

On other occasions, owing to their condition, patients will be admitted very quickly after their out patient appointment without attending Pre-assessment. Where this is the case patients will be treated as if they have positive swab results, screened on admission and given appropriate antibiotic cover.

A third group of patients are those who are admitted regularly for checks or treatment such as check cystoscopy. On the first admission where this is the case patients will be treated as if they have positive swab results, screened on admission and given appropriate antibiotic cover. For all future admissions patients will be screened only if the visit is in excess of 6 months of a previous screening.

Appendix 6 contains an algorithm for this group of patients.

6.2.6 On Admission

On admission for surgery a check will be made by the admitting nurse to ensure screening has been undertaken. Where this is not the case patients will be treated as if they have positive swab results, screened on admission and given appropriate antibiotic cover.

7.0 IMPACT ASSESSMENT

7.1 Financial implications

The introduction of screening for elective patients will have financial implications however this is now mandatory and therefore will be funded. The




Trust will seek support from its commissioners in implementing this policy.

7.2 Risk Implications / Risk Assessment

There is a risk that introducing elective screening will impact on waiting list management. This will be managed by ensuring that procedures are implemented as described in the policy

7.3 Discrimination or other adverse effects on population groups

Impact of this policy has been assessed. It will not lead to any discrimination or other adverse events on population groups in relation to:

Ethnicity / Gender / Age / Sexuality / Religion or Belief / Disability / Status as Transgender or Transsexual Person.

8.0 LINKS TO OTHER POLICIES

Hand Hygiene and Key Principles of Infection Control

MRSA Policy

Isolation Policy

Procedure for Requesting, Sending and Transporting Microbiological Specimens

Reporting and Investigating Incidents and Near Misses Policy

9.0 LINKS TO EXTERNAL STANDARDS

Healthcare Commission C4aNHSLA Risk Management Standards 1.2.8, 2.2.8, 3.2.8 1.4..9 , 2.4.9, 3.4.9 Clinical Pathology Accreditation E1,E2,E3,E4,E5

10.0 MONITORING, CONTROL AND AUDIT

Elective screening rates will be monitored monthly as part of the Performance Report and reported to the SHA

Emergency screening rates will also be monitored monthly as part of the Performance Report

11.0 BEST PRACTICE, EVIDENCE AND REFERENCES

Screening for MRSA Colonisation-DoH November 06

Screening for Meticillin-resistant Staphylococcus aureus (MRSA) colonisation: A strategy for NHS Trusts saving Lives. DoH 2006



http://www.nhsla.co.uk/RiskManagement/CnstStandards/

http://2007ratings.healthcarecommission.org.uk/homepage.cfm


12.0 APPENDICES

12.1 Exceptions for Elective Screening

12.2 Algorythm for high risk patients

12.3 Information leaflet-screening

12.4 Information leaflet-decolonisation

12.5 Algorythm for elective admissions

12.6 Algorythm for fast track admissions

Appendix 1




Exception List

The following patient groups should not be routinely screened:-

Day case ophthalmology

Day case dental

Day case endoscopy

Minor dermatology procedures e.g. warts or other liquid nitrogen applications

Children/paediatrics unless already in a high risk group

Maternity/obstetrics except for elective caesareans and any high risk cases i.e. high risk of complications in the mother and/or potential complications in the baby, (e.g. likely to need SCBU, NICU because of size or known complications or risk factors)

Mental Health patients.

Appendix 2




MRSA SCREENING FOR HIGH RISK ELECTIVE ADMISSIONS

This category includes elective orthopaedic implant surgery and vascular surgery involving graft implantation.



Pre- Assessment Clinic. Patients to attend Pre- assessment clinic 2-3 weeks prior to admission date.All patients to be screened for MRSA. Swabs to be taken: Nose and Groin as standard; also any open wounds or ulcers, and if catheterised, a CSU.

MRSA Screen: Positive.

Patients will be contacted by Pre- assessment clinic and notified of result. Arrangements will be made via the patients GP for prescription of decontamination. For those deemed physically unable to ‘self apply’ arrangements will be made via district nurses.

Re-screening: Patients must be proved by re-screening to be MRSA negative before proceeding to operation. Re-screening starts on the second day after end of the decolonisation regimen and swabs are taken on 3 consecutive days.

MRSA Positive on re-screening.Patient should receive a further course of decolonisation regimen followed by re-screening. As before, the patient must be subsequently screened negative before proceeding to operation.

Admission for operative procedure.No need for further screening on admission.

Decolonisation regimen:Nasal Mupirocin applied to each nostril x3/day for 5 days.Chlorhexidine body wash applied to whole body and showered/ washed off x1/day for 5 days.(Further advice available from consultant microbiologist or infection control. nurses if necessary).

MRSA screen: Negative.

Patient will not be informed, but will go forward to operation, on their planned admission date, without any further intervention.


Appendix 3

Pre Admission MRSA Screening

Infection Prevention & Control Department

The Trust has access to interpreting and translation services. If you require this publication in an alternative format and/or language please contact the PALS Manager on 01922 656956. .

Walsall Hospitals NHS Trust takes MRSA and healthcare associated infections extremely seriously. We are committed to reducing infections in our hospital and giving our patients high quality health care.

Why do we screen for MRSA?

There are many people in the community who may have the MRSA germ without showing any symptoms. By screening (performing a simple swab test) before your operation, we can find out who is carrying the germ and provide treatment for you before you are admitted to hospital.

As part of the pre-operative process, patients will be routinely screened for MRSA. This helps to prevent the spread of the germ and lowers the risk of complications occurring because of it whilst you are recovering.

What is MRSA?

There are lots of germs on our skin and in the environment around us. Most of them are harmless, some are beneficial and a very small proportion can cause harm. Staphylococcus aureus is a common germ that is found on the skin and in the nostrils of about a third of healthy people. It can cause infections. MRSA stands for (M) Meticillin



MRSA Negative on re-screening.

Patient may proceed to admission for operative procedure.


(R) Resistant (S) Staphylococcus (A) aureus. MRSA are varieties of Staphylococcus aureus that have developed resistance to Meticillin (a type of penicillin) and some other antibiotics that are used to treat infections.

How can MRSA affect me?

MRSA may colonise your body and or cause an infection?

MRSA Infection

When MRSA causes an infection this means that the bacteria are causing the person to be ill. MRSA can cause simple infections such as pimples, boils or more serious problems such as wound infections, chest infections or blood stream infections (septicaemia). If a patient has an infection caused by MRSA then there are a number of antibiotics that can be given that are effective in treatment MRSA.

MRSA Colonisation

Most people who have MRSA are colonised. This means that MRSA is present on the surface of the skin and does not cause any harm to the person. People who are colonised will have no signs or symptoms of infection and feel well. However if you come into hospital to undergo a procedure, there may be an opportunity for MRSA to enter the body. This is why patients found to be colonised with MRSA will be given a skin wash to remove the germ from the skin and nasal ointment to remove MRSA from the nose

What tests are done to look for MRSA?

The nurse will take a swab from your nose and other skin sites depending on the type of surgery you are having. This involves a cotton bud swab being placed in and around your nose and your groin area. The test will not hurt but might feel a little uncomfortable. The swab/s is then sent to the laboratory for testing.

How long will the swab results take?

The results usually take 3-4 working days.

What happens next?

If your swabs are found to be MRSA negative this means no MRSA was detected then you will not hear from us and you should follow the instructions given to you about your admission to hospital for your operation,

If your swabs are found to be MRSA Positive (MRSA was detected)You will be contacted by the pre assessment clinic and asked to collect a decolonisation pack. The instructions for the nasal cream and the body wash will be provided within the pack. If you have problems with bathing or




collecting your decolonisation pack you should mention this to the nurse when they contact you.

Will my treatment be any different?

A person who has a history of MRSA may be given special antibiotics whilst in theatre but this will be assessed by your doctors and is dependant on the type of operation you are undergoing

This general guidance may not describe your particular condition and is not intended to take the place of a medical consultation or provide a medical diagnosis. If you have any questions please ask your doctor or health advisor.

Appendix 4MRSA Decolonisation Treatment Regime

During your pre-admission screening has been identified that you are colonised with Methicillin Resistant Staphylococcus Aureus (MRSA). It is therefore recommended that a MRSA decolonisation treatment, as outlined in this leaflet, is used prior to your surgical procedure to reduce the amount of MRSA you may be carrying.

Chlorhexidine surgical scrub Use once a day as a soap and shampoo substitute to wash from head to toe for five days, (you may find this easier in the bath or shower)

The solution should not be diluted but used straight onto a sponge or face cloth

.

The solution should be left in contact with the skin for at least 1 minute before rinsing it off.

Dry your skin afterwards with a clean towel.

Bactroban nasal ointment

To be applied to the inside of both nostrils three times per day for five days.

1. Wash your hands prior to applying ointment.



http://images.google.co.uk/imgres?imgurl=http://uphys.msu.edu/_images/Hand_washing.gif&imgrefurl=http://www.uphys.msu.edu/updates/index.html&usg=__m5cKU-56cZMv0s5KjbCyWSbTmuw=&h=601&w=361&sz=8&hl=en&start=8&um=1&tbnid=H9F7iMEldwPTfM:&tbnh=135&tbnw=81&prev=/images%3Fq%3Dhand%2Bwashing%26um%3D1%26hl%3Den%26rlz%3D1T4GGLJ_enGB219GB219%26sa%3DN


2. Unscrew the cap and squeeze a small amount of ointment (about the size of a match head) on to your little finger. (A cotton bud may be used instead of a little finger)

3. Apply ointment to the inside of both nostrils.

4. Close your nostrils by pressing the sides of the nose together it to spread the ointment inside each nostril.

5. Wash your hands and replace the cap on the tube.

Appendix 5

MRSA SCREENING FOR ELECTIVE ADMISSIONS AT WMH.



MRSA Screen: Positive.

Patients will be contacted by Pre- assessment clinic and notified of result.

If patient physically able to apply decolonisation regimen.

Patient will be asked to collect their decolonisation pack from Pre-assessment clinic along with application instructions.

If patient deemed physically unable to apply decolonising regimen.Arrangements will be made for this to be carried out via GP /district nurse.

Pre- Assessment Clinic. Patients to attend pre- assessment clinic 2-3 weeks prior to admission date.All patients to be screened for MRSA. (see appendix 1 for exceptions) Swabs to be taken: Nose and Groin as standard; also any open wounds or ulcers, and if catheterised, a CSU. Nose only for ENT

Admission for operative procedure.No need for further screening on admission.

Decolonisation regimen:Nasal Mupirocin applied to each nostril x3/day for 5 days.Chlorhexidine body wash applied to whole body and showered/ washed off x1/day for 5 days.(Further advice available from consultant microbiologist or infection control. nurses if necessary).

MRSA screen: Negative.

Patient will not be informed, but will go forward to operation without any further intervention.

http://images.google.co.uk/imgres?imgurl=http://uphys.msu.edu/_images/Hand_washing.gif&imgrefurl=http://www.uphys.msu.edu/updates/index.html&usg=__m5cKU-56cZMv0s5KjbCyWSbTmuw=&h=601&w=361&sz=8&hl=en&start=8&um=1&tbnid=H9F7iMEldwPTfM:&tbnh=135&tbnw=81&prev=/images%3Fq%3Dhand%2Bwashing%26um%3D1%26hl%3Den%26rlz%3D1T4GGLJ_enGB219GB219%26sa%3DN


Appendix 6

MRSA SCREENING ELECTIVE ADMISSIONS - FAST TRACK PATIENTS.

In certain circumstances patients may be brought forward for elective surgery in a relatively short time frame, usually a few days or hours. These patients will bypass the usual Pre assessment screening due to lack of time, so other arrangements must be made.

The two main situations are as follows:1. Patients fast tracked to admission to take advantage of an unexpected slot in the

surgical operative schedule, usually due to cancellation of another patient.2. Emergency elective admission; where a patient is brought forward to admission,

from clinic, rapidly for medical/ surgical reasons.



Patient then goes forward for operation.

Screening results will be available to surgical team- risk assessment may be made regarding use of additional anti -MRSA prophylactic peri -operative antibiotics. e.g. Teicoplanin 800mg pre - operatively.

Patient brought forward for admission rapidly from clinic or before scheduled admission date.

Pre- admission MRSA screen results may not be available; if not

On admission to ward. Treat patient as potentially MRSA positive. Check previous microbiology results for any evidence of past colonisation. TAKE FULL MRSA SCREEN ON ADMISSION.

Surgical team to make risk assessment depending on patient and surgical risk factors. If deemed high risk: Start decolonisation regimen, pre-op if time allows, or post-op if not. Give peri- operative prophylactic antibiotics E.g. Teicoplainin 800 mg pre op.


Further advice can be gained from the duty Microbiologist/Infection Control Team.



Documents

Chief Operating Office/Director of Nursing (COO)