MRSA Policy Meticillin resistant Staphylococcus … Policy v 6...RNHRD Methicillin resistant Staphylococcus aureus policy 6 4.0 DEFINITIONS 4.1 Meticillin resistant Staphylococcus

RNHRD Methicillin resistant Staphylococcus aureus policy

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MRSA Policy

Meticillin resistant Staphylococcus aureus Version: 6

Name of originator/author: Jackie Cooke Infection Control Coordinator

Sponsoring Director: Rayna McDonald Director of Operations and Clinical Practice

Name of ratification committee: Infection Control committee

Date ratified: 19th September 2012

Name of approval committees & groups:

Infection Control Committee

Date approved: 19th September 2012

Date Procedural document becomes Live:

1st October 2012

Review date: 19th September 2015

Target audience: All staff

Related Procedural Documents: All infection control policies RNHRD.

Document Audit Trail

Version Date Author; name & title Key Changes

1 Oct 2003 Sara king New policy adapted from RUH and ratified

2 Feb 2005 Sara king , Amanda Pacey &, Barbara Pickford

Front sheet and logo added

3 May 2007 Sara king , Amanda Pacey &, Barbara Pickford

Screening before surgery added

4 July 2007 Sara king , Amanda Pacey &, Barbara Pickford

Reviewed and amended risks

5 March 2009 Sara king , Amanda Pacey &, Barbara Pickford

Rescreening added.

6 March 2012 Jackie Cooke Infection Control Coordinator

Change policy format, clarified practice, changes in job titles.


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INDEX

Section Page 1.0 Introduction - - - - - - - 3 2.0 Purpose and Scope of Policy - - - - - 3 3.0 Duties - - - - - - - - 3 4.0 Definitions - - - - - - - 6 5.0 Screening for MRSA- - - - - - 7 6.0 Decolonisation Treatment- - - - - - 9 7.0 Care of patients with MRSA- - - - - 11 8.0 Management of an outbreak- - - - - 13 9.0 Surveillance of MRSA- - - - - - 14 10.0 Training- - - - - - - - 14 11.0 Monitoring- - - - - - - - 14 12.0 Reference- - - - - - - - 15 Appendix 1 Flow chart - - - - - - 16 Appendix 2 Summary of Screening and treatment - - 18 Appendix 3 Policy audit- - - - - - 20 Appendix 4 MRSA Topical treatment- - - - 22 Appendix 5 Equality Impact Assessment - - - 21 Appendix 6 Dissemination Plan and Ratification & Review form 22


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1.0 INTRODUCTION Staphylococcus aureus is a common coloniser of human skin and mucosa (nasal), but can cause disease, particularly if there is an opportunity for the bacteria to enter the body. Meticillin resistant Staphylococcus aureus (MRSA) is a subset of S. aureus resistant to most -lactam antibiotics such as Meticillin and flucloxacillin that are normally used to treat S. aureus infections. Methicillin-resistant Staphylococcus aureus (MRSA) is a feature of modern day health care across the world and is now considered endemic in UK with a pool of colonised patients in the community. Staphylococcus aureus (S. aureus) colonizes approximately 20 - 30% of healthy individuals in the community of which 2-3% is MRSA. These percentages can rise in hospitalised patients. Revised guidelines for the control of MRSA infection in hospitals were released in 2006 by the joint Working Party of the Hospital Infection Society, British Society for Antimicrobial Chemotherapy, and the Infection Control Nurses Association. Reporting of MRSA bacteraemia by NHS Trusts has been mandatory in England since April 2001, with web-enabled reporting of patient-level data introduced in October 2005. Mandatory reporting of MSSA bacteraemia was introduced in January 2011.

2.0 PURPOSE & SCOPE OF THIS POLICY

The purpose of this policy is to provide guidance to staff regarding the prevention and management of patients with MRSA. The policy meets the Trust requirements of the Department of Health 2010/11 Operating Framework to ensure all patients are screening for MRSA, and subsequent decolonisation therapy if required. The aim is:

To ensure that patients are screened for MRSA in a timely fashion, either prior to or on admission;

To ensure that pathology results are obtained in a timely fashion.

To define which patients are considered to be at high risk of colonisation with MRSA;

To ensure that patients who are identified as being colonised with MRSA receive decolonisation treatment;

To provide advice on reducing the risk of cross-infection by observing good hygiene practices and isolation of affected patients.

3.0 DUTIES All staff has a responsibility for ensuring that the principles outlined within this document are universally applied.

3.1 The role of the Chief Executive The Chief Executive is ultimately responsible for ensuring that the Trust has appropriate arrangements in place to protect patients from the risks of acquiring


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Health Care Associated Infections (HCAI).The Chief Executive is responsible for the appointment of Director of Infection Prevention and Control.

3.2 The Role of Director of Infection Prevention and Control The Director of Infection Prevention and Control (DIPC) is responsible for infection prevention and chairs the infection control committee within the organisation and is accountable directly to the Chief Executive and the Board. The DIPC ensures that systems and resources are in place to facilitate implementation and compliance with this policy.

3.3 The Role of Infection Control Coordinator (ICC) The ICC provides expert advice on the application of infection prevention and control in the care setting and on individual risk assessments as required. The ICC engages with staff to develop systems and processes that lead to sustainable and reliable improvements in relation to the application of infection prevention and control.

The Infection Control Coordinator is responsible for ensuring implementation of this policy is monitored as part of the infection control committee annual audit plan.

3.4 The Role of General Managers, Matrons and Line Managers

Managers of all services must ensure that staff:

are aware of and have access to infection prevention and control policy documents

have had instruction/education on the elements of infection prevention and control

have adequate support and resources available to implement, monitor and take corrective action to ensure compliance with infection prevention and control

with health concerns or who have had an occupational exposure, are referred to the relevant agency e.g., General Practitioner or Occupational Health

include infection prevention and control as an objective in their Personal Development Plan

are trained in the practice of this document (including medical/nursing students, visitors, agency and bank staff)

investigate all incidents in relation to this policy; allocating sufficient resources to prevent further incidences occurring and reviewing the effectiveness of measures taken

have access to appropriate protective clothing under Health & Safety legislation

undertaking Exposure Prone Procedures (EPP) have undergone the required health checks/clearance

Provide feedback to staff on trends, serious incidents, results of investigations, learning opportunities and any necessary risk reduction activities required within their area.


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3.5 The Role of staff Staff providing care must ensure that they:

Comply with infection control policies and ensure Universal Infection Control Precautions at all times

All staff has a personal and corporate obligation to comply with best practice in the prevention of infection and comply with this and all other infection control related policies.

understand and apply the principles of infection prevention and control;

maintain competence, skills and knowledge in infection prevention and control through attendance at education events and/or completion of on-line training modules in line with the Trust Training Guidelines

communicate the infection prevention and control practices to be taken by colleagues, those being cared for, relatives and visitors without breaching confidentiality

have up-to-date occupational immunisations /health checks/clearance requirements as appropriate

report to line managers and document any deficits in knowledge, resources, equipment and facilities or incidents that may result in transmission of infection

Do not provide direct care while at risk of potentially transmitting infectious agents to others. If in any doubt they must consult with their line manager, Occupational Health Department or Infection Control Coordinator (ICC)

The employee has a responsibility to carry out risk assessments and to wear protective clothing in appropriate situations (Health & Safety Executive 1999)

The employee has a responsibility to report all accidents involving infection prevention and control in line with Trust Incident Reporting policy using Datix

Employees are responsible for ensuring that any breach of this policy is immediately reported to their manager.

3.6 Microbiologists Inform medical team and Infection control coordinator of all MRSA

bacteraemia and advice on appropriate further investigations and management.

Assess patients with MRSA bacteraemia and assist with RCA

Challenge inappropriate antibiotic prescribing

3.7 Medical Staff

Encourage a culture of good hand hygiene practice and lead by example

Ensure compliance with infection prevention and control policies

Ensure compliance with Antibiotic Prescribing Policy

Follow advice of microbiologists relating to treatment of MRSA bacteraemia and document this advice

Contribute to and participate in Root Cause Analysis of MRSA bacteraemia, including attendance at RCA review meetings

Complete relevant actions required following RCA


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4.0 DEFINITIONS 4.1 Meticillin resistant Staphylococcus aureus (MRSA)

A common skin bacterium resistant to a range of antibiotics

It can cause colonisation or infection

Is a subset of S. aureus resistant to most -lactam antibiotics such as Meticillin and flucloxacillin that are normally used to treat S. aureus infections.

Many are also resistant to other antibiotics such as erythromycin and ciprofloxacin.

Some strains may be described as ‘Epidemic stains’ (EMRSA) which are more likely to spread from person to person.

Staphylococcus aureus and MRSA colonises the skin, particularly the anterior nares, skin folds, hairline, perineum and umbilicus

4.2 Meticillin resistant Staphylococcus aureus (MRSA)

Is sensitive to -lactamase-stable antibiotics, such as flucloxacillin.

4.3 MRSA colonisation Carriage of MRSA in the nose, back of the throat or on the skin without

developing an infection

The patient may be unaware that they are colonised with MRSA and will not feel unwell

Most patients who are colonised with MRSA do not go on to develop an infection, but colonisation is a known risk factor.

Patients more likely to be colonised are those who: Have wounds and lesions Catheters, intravenous devices etc Have been previous MRSA positive Have been admitted from a hospital or home with

EMRSA Those transferred from hospitals abroad

4.4 MRSA infection The patient will have signs of infection, for example pyrexia,

inflammation, pain or swelling of the affected area.

Can be severe and life threatening and leading to death.

4.5 Mandatory reporting With the collection of enhanced surveillance data it is possible to

apportion data into the groups “Trust apportioned” and “non Trust apportioned” cases.

Reporting of MRSA bacteraemia by NHS Trusts has been mandatory in England since April 2001, with web-enabled reporting of patient-level data introduced in October 2005.

Mandatory reporting of MSSA bacteraemia was introduced in January 2011, using the same web-enabled system


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4.6 ROUTE OF TRAMSISSION

DIRECT-hand carriage by staff is the most common route of spread from patient to patient.

INDIRECT-The organism may be spread via contaminated equipment e.g. mattresses.

AIRBORNE-The organism may be dispersed in to the environment via skin scales or in droplets from the respiratory tract. The organism can also be found in dust and hence can be carried on air currents.

4.7 Risk of acquisition of MRSA High risk patients have an increased risk of pre-existing colonisation with MRSA and are more likely to go on to develop an MRSA bacteraemia.

• Patients who have been infected or colonised with MRSA in the past • Patients who have been admitted directly from another hospital, or from a

residential or nursing home • Patients who have been hospitalised in the UK within the preceding 6 months

or hospitalised abroad within the last 12 months • Patients who are healthcare workers or their immediate household members • Diabetic patients • Renal patients • Oncology/chemotherapy inpatients

High risk patients must be treated as if MRSA positive until a negative result is received.

5.0 SCREENING FOR MRSA See MRSA pre screening policy. The Department of Health (2009) requires all hospitals to pre screen patients for colonization of MRSA and receive a negative result before admission.

5.1 Elective Admissions All elective admissions (classified as day case or inpatient) must be screened prior to or on admission except for the following patients whom are excluded from screening admission requirements:

• Day case endoscopy

• Children/Paediatrics unless already in a high risk group

5.2 Non-elective admissions Screening of non-elective admissions must be done as soon as practicable in the admission but should not delay admission or urgent clinical treatment. Where possible these patients should be screened within 6 hours of arrival on the admitting ward and within 24hours. These patients include direct admissions from GPs and outpatient clinics or urgent transfers from other hospitals.

5.3 Screening of patient contacts If a patient is found to be colonised with MRSA all patients that have shared the same facilities (i.e. within the same bay) must be screened.


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Screening swabs must be taken from the common sites of carriage:

Nose Swab both nostrils using one swab (anterior nares)

axilla

Perineum If it is difficult to obtain a perineal swab, swab both groin areas using one swab

In addition the following areas, which may be colonised or infected, should be screened if present;

Skin Lesions / Sticky eyes Including eczema or dermatitis

Insertion sites e.g. cannula, tracheotomy, central lines, PEG

Wound sites Including pressure areas where the skin is

Catheter specimen of urine (CSU)

If catheterised

Sputum If ventilated or has a productive cough

5.3.1 Procedure for screening. 1. Explain the procedure to the patient and obtain their consent 2. Collate swabs (black topped with the transport medium) and microbiology forms.

(Please note that multiple pathology request forms must not be used). 3. Thoroughly wash and dry hands 4. If sampling a dry site or the nose, immerse swab into sterile sodium chloride 0.9%

solution. 5. Rub the swab firmly into the nostril or other areas 6. Place the swab in the charcoal transport medium 7. Correctly label swab and microbiology form with patient’s relevant clinical details

and write ‘MRSA screen request’ on the form. 8. Ensure all swabs are sent to the laboratory as soon as possible after collection. 9. Record your actions and subsequent results in the patient’s medical record 5.4 Results:

The checking of the MRSA screening results is the responsibility of the team who is looking after the patient.

For pre-admission patients it is the responsibility of the admission officer and receiving team to ensure a result is obtained prior to admission-see MRSA pre-screening policy. If a positive MRSA result is returned from the lab for the medical staff to be contacted and patient receive decolonisation treatment by the GP. If the patient requires admission prior to completion of treatment and repeat screening then the patient is admitted to a sideroom and isolated.

For in patients-If a positive MRSA result is returned from the lab for the medical staff to be contacted and patient receive decolonisation treatment and infection control precautions commenced.


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6.0. DECOLONISATION TREATMENT 6.1 Decolonisation.

As soon as a patient has been identified as an MRSA carrier or in patients where there is a high suspicion of MRSA carriage, the decolonisation regimen must be started.

Treatment must continue irrespective of whether the patient is receiving antibiotics or not.

The decolonisation regimen may only be 50-60% effective for long-term clearance, but as soon as the procedure is implemented the shedding of MRSA is lessened significantly and the risk of the patient infecting themselves or transmitting MRSA to another patient is much reduced.

Subsequent treatments should be discussed with the infection prevention and control team or a microbiologist.

A doctor must prescribe the decolonisation regime on the patient’s drug chart. The nurse must sign the prescription chart and the protocol following administration of the regime.

Patients who are appropriate for self-medication may need to be supervised initially. (Check and document supervision needs).

Treatment Summary

1. Mupirocin 2% (Bactroban ®) nasal ointment three times daily for five days.

2. Antimicrobial body and hair wash once daily for five days. Suitable products include:

Triclosan solution (Skinsan® foam or Oilatum Plus) or

Chlorhexidine gluconate 4%

6.2 Nasal Colonisation Eradication Mupirocin 2% (Bactroban ®) nasal ointment three times daily for five days

Must not be used if the patient is pregnant or breast-feeding without prior consultation with a microbiologist or infection control nurse

Advice to the patient on how to apply: 1. Wash and dry your hands 2. Place a small amount of Bactroban, about the size of a small pea, on your

little finger or cotton bud 3. Apply this to the inside of one nostril 4. Repeat steps 2 and 3 for your other nostril


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5. Press the sides of your nose together to spread the ointment around the nostril

6. Replace the cap on the tube and wash your hands

6. 3 Skin De-colonisation Antimicrobial body and hair wash once daily for five days

All of these products will have the desired effect on MRSA skin colonisation.

Skinsan is the most universally acceptable product. Oilatum plus is suitable for patients with inflammatory skin conditions (if in doubt contact their dermatologist for advice).

Chlorhexidine gluconate 4% is effective for short term use but may be drying and irritating on some sensitive skins

SKINSAN® foam (Triclosan 1%) is suitable for adults and newborn babies. It may be applied directly on to wet or dry skin either as a dry bath and wiped off with a wet cloth or applied prior to a bath or shower. Contact time is 60 seconds. When applying to the hair apply to wet hair following normal hair wash routine. There are no restrictions on use during pregnancy or lactation. OILATUM Plus® (Triclosan 2%) should be used in preference if the patient has an inflammatory skin condition. It should always be diluted with water. It is an effective cleanser and should not be used with soap. Dilute in bath water as directed on the instructions. Do not use for babies younger than 6 months. There are no restrictions on use during pregnancy or lactation. Chlorhexidine gluconate 4% w/v is an alternative to Skinsan for patients that do not have inflammatory skin conditions. Apply to wet skin and rinse off. There are no restrictions on use during pregnancy or lactation. Pay particular attention to washing hair line, axilla, groin and perineal areas and dry thoroughly Provide clean towels, clothing and bed linen daily after application of topical treatment

MRSA screening following decolonisation treatment. Patients should be screened 2 days of the completion of treatment.

Screening continues every 2 days until 3 clear consecutive screens are obtained.

Screening should be completed on all sites. High risk patient for acquiring MRSA Patients who are considered to at high risk of MRSA colonisation should also receive decolonisation treatment until MRSA screening results are available. If they are MRSA positive the treatment should be continued until the full 5 days have been completed. If they are negative treatment can be discontinued


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7.0 CARE OF PATIENTS WITH MRSA 7.1 Inform

Inform patient and provide an MRSA leaflet.

Offer explanation for the precautions required to reduce the spread of MRSA

Ensure that all healthcare staff involved in the patients care are aware of MRSA status

Document all results and commence MRSA care plan 7.2 Isolation Nursing

Isolation is required for all patients whether infected or simply colonised with MRSA and the door must be kept closed particularly during bed making and wound dressings.

Inside: clinical waste disposal, minimal equipment for each day, clutter free environment to assist with cleaning

Outside: Isolation sign, clinical notes and protective clothing

Disposable gloves and aprons should be worn for direct care or when handling items contaminated with blood/body fluids.

Remove and dispose of gloves and aprons within the room between tasks

If an isolation room is not available contact the Matron and Infection Control to review the situation. Cohort nursing of MRSA colonised patients is another approach that could be considered if isolation facilities are not available.

There is no requirement for visitors to wear protective clothing if just visiting a patient unless the visitor is particularly susceptible (i.e. if receiving renal dialysis for example) or close contact is anticipated (i.e. if having involvement in personal care).

Advise to relatives /visitors on the importance of hand washing on leaving the room

Isolation may be discontinued if three consecutive clear swabs, each one a minimum of 48hours apart, are negative for MRSA.

Care must not be compromised

Patients should not be prevented from undergoing clinical investigations or procedures but the receiving department must be informed of the patients’ MRSA status and the patient must be asked to use the hand gel on leaving their room

Rehabilitation must not be hampered due to the MRSa treatment. Risk assessment and control of the risks to other patients must be completed.

The team should plan how rehabilitation can be done with the safety of other patients with advice from the infection control team.

Therapist may see the patient on the ward.

See7.9 7.3 Hand hygiene (As Hand Decontamination Policy


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All staff and visitors must perform Hand hygiene before and after patient contact including after removal of gloves using either liquid soap or alcohol gel

Healthcare workers must adhere to the Dress Code and be ‘bare below the elbows’ when within the patient’s environment

7.4 Wound care / Urinary catheters.

All MRSA positive wounds must be referred to the Tissue Viability Nurse for assessment.

Assessment of urinary catheter if MRSA is positive in urine. Change of catheter may be required, and/or treatment with oral/IV drugs if signs of infection present.

7.5 Equipment

No special precautions are required for crockery / cutlery and they should be dealt with in the normal manner

All equipment should be cleaned daily using a disinfectant such as a chlorine based solution or disinfection wipes paying particular attention to the frequently touched points.

7.6 Waste

All waste generated in the isolation room should be disposed of as clinical waste (orange bag for infected waste)

7. 7 Laundry

Sheets and towels must be changed daily and sent in a red alginate linen bag.

Relatives may take clothes home in a domestic washing machine sized alginate-stripe laundry bag

7.8 Cleaning

The patient’s room must be cleaned daily by the domestic team using yellow colour coded cleaning equipment which is cleaned following use

Healthcare staff must clean all equipment before it is used on another patient or removed from the side room

On discharge, the patient’s room / bed area must be ‘deep-cleaned’ by the housekeeping team or deep clean team. It is advisable to give the housekeeping team as much notice as possible that a special clean will be required.

7.9 Visits to other departments. Departments

Clean the environment after the patient using a disinfectant such as a chlorine based solution

If patient is needed to seen in a department then it is preferred that the appointment is at the end of the list /day.

Assessment in the patient’s home is low risk for contamination of car if any patient’s wounds /skin lesions are covered. Cars should be cleaned and vacuumed after use.


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Portering

Portering staff must wear gloves and aprons during direct patient contact e.g. whilst assisting a patient to move from bed to a wheelchair.

Gloves and aprons must be removed and hand hygiene performed) prior to transporting the patient in a bed or chair to another department.

A fresh pair of gloves and apron must be put on at the destination if the patient requires further assistance.

Portering staff must be bare below the elbows when within the patient’s environment and during transporting the patient to allow for them to wash their hands.

7.10 Staff uniforms. Clean uniform should be worn daily to reduce the risk of contamination of the

uniform transmitting infection to other patients.

7.11 Discharge planning

Communication of patient’s MRSA status to the receiving establishment is an important part of the discharge information

They can share a room in a residential or nursing home provided that the individuals with whom they are sharing do not have open wounds, catheters or intravenous infusions

Transport services must be informed if there are any infection control issues when booking transport

Generally MRSA positive patients may travel on patient transport services with other patients. Wounds must be covered with a clean dressing and the risk of leakage minimised. However patients with MRSA in their sputum who have a productive cough should travel in isolation

GPs must be informed if MRSA results are received after discharge 7.11 Healthcare staff

Staff with eczema / psoriasis should seek advice from Occupational Health Department. Persistent skin problems should be reported.

Cuts and abrasions need to be covered with a waterproof plaster / dressing whilst at work.

Staff with MRSA colonisation or infection must inform Occupational Health Department before returning to work

Routine screening of staff is not required unless advised by the Infection control team.

8.0 MANAGEMENT OF AN OUTBREAK See outbreak policy in conjunction with the policy-

Isolate affected individual and treat as policy

Screen patients in the same bay or nearest bed.

If there is evidence of spread all remaining patients to be screened. Assessment if staff should be screened by the infection control team.

Repeat screening weekly until there has been no new cases for 3 weeks.


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If transferring patient-inform the ward /hospital and screen prior to discharge.

Additional control measures-environment cleaning, limited movement of patients to/from the area, possible closure.

9.SURVEILLANCE OF MRSA

The Infection Control Team will perform surveillance for MRSA isolates routinely as part of alert organism surveillance.

Clinical areas will be informed of all identified MRSA-positive patients by the ICNET system used by the Infection Control Team.

The Infection Control Team will perform enhanced surveillance of MRSA Bacteraemia in line with the Department of Health requirements. The results of this surveillance will be present at the Infection control committee, monthly board meetings and annual report.

Clinical and Management Teams are responsible for ensuring review/Root Cause Analysis of each clinical case of MRSA Bacteraemia, implementation of local action plans to improve practice and report to Infection control committee.

MRSA bacteraemia surveillance data will be reported to HPA by the ‘MESS’ system monthly by the infection control team.

10 .0 TRAINING It is the responsibility of managers to ensure that all staff working in their area of responsibility have received suitable and adequate training and information about infection prevention and control practices.

The Staff have a responsibility to attend training as identified in the trust’s Training Guide, reflected Training Needs Analysis matrix.

10.1 Monitoring of Training

Monitoring of training is as stated by the trust TNHRD Training Guidelines.

Non-attendance is followed-up to relevant managers by using the MLE system and re-booking is required as per the RNHRD Training Guidelines.

Training reports are reviewed by the Infection control committee who will ensure attendance is in line with Trust requirements and appropriate training with regards infection control is put in place within the Trust in line with current best practice.

Training Reports will be reported to the Clinical Risk Committee on a quarterly basis.

11.0. MONITORING

Compliance with the processes stated in this policy will be audited on an annual basis as part of the Infection Control Committee annual audit plan. The ICC and Matron will lead the audit.

The results will be analysed by the Infection Control Coordinator and Matron an action plan produced to address any issues that arise. This is reported to the Infection Control committee who will monitor all actions to completion.

These reports are also disseminated widely within the organisation.


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12.0. REFERENCES

Department of Health www.clean-safe-care.nhs.uk accessed November 2010

Department of Health. Saving Lives: reducing infection, delivering clean safe care. (2007)

Department of Health. The Health Act and Social Care 2008: Code of Practice for health and adult social care on the prevention and control of infections and related guidance. (2009)

Department of Health. Mandatory surveillance of MRSA bacteraemias. (2005)

E Jones A matron’s charter: an action plan for cleaner hospitals (2004)

Royal College of Physicians of Edinburgh. Guidance for the hospital management of Meticillin-resistant Staphylococcus aureus (2006)

CMO/CNO. Screening for MRSA colonisation PL/CMO/2006/4. London: Department of Health, 2006.

Screening for Methicillin-resistant Staphylococcus aureus (MRSA) colonisation: a strategy for NHS trusts - a summary of best practice. London: Department of Health, 2006.

Department of Health. MRSA screening – Operational Guidance (2008) and Operational Guidance 2 (2008).

Pratt et al (2001) Epic project: National Evidence based Guidelines for preventing Healthcare associated infections, journal of Hospital Infections, 47 (supplement) S1-82

APPENDIX 1


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APPENDIX 5 EQUALITY IMPACT ASSESSMENT

Equality Impact Assessment Form

INITIAL SCREENING Yes/No Comments (use the back of this form

if you require more space)

1. Does the service/ policy/procedure affect one group less or more favourably than another on the basis of:

Race No

Disability No

Gender No

Age No

Ethnic origins (including gypsies and travellers) No

Nationality No

Culture No

Religion or belief No

Sexual orientation (including lesbian, gay and bisexual people)

No

If you have answered Yes to any of the above in question 1, please answer questions 2 - 6.If you have answered No to all of the above in question 1, please refer to the guidelines for completing the Equality Impact Assessment form.

FULL IMPACT ASSESSMENT Yes/No Comments (use the back of this form

if you require more space)

2. What is the evidence that some groups are affected differently?

N/A

3. Is the impact of the policy/ guidance likely to be negative?

N/A

4. If it is negative, can the impact be avoided?

If yes, how?

N/A

5. Is the discrimination considered to be valid, legal and/or justifiable?

If yes, how?

N/A

6. What actions can be taken to reduce the impact?

N/A

When you have considered and answered questions 2 – 6 please refer to the guidelines for completing the Equality Impact Assessment form on the Mintranet for detailed guidance


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APPENDIX 6 DISSEMINATION PLAN AND RATIFICATION & REVIEW FORM

Dissemination Plan

Title of document: MRSA policy

Date finalised: March 2012

Training Plan including Timeframe:

Continue included in mandatory training

Training Plan Responsibility (name & role):

J.Cooke Infection Control Coordinator

Previous document already being used?

Yes Dissemination lead: Print name, role and contact details

J.Cooke Infection Control Coordinator

Ext 434

If yes, in what format and where?

IT and paper

Proposed action to retrieve out-of-date paper copies of the document:

As pre hospital policy

To be disseminated to:

How will it be disseminated, who will do it and when?

Paper or

Electronic

Comments

All staff Mintranet / LINKS E

Key staff Circulation of policy and noted at ICC

E

Dissemination Record - to be used once document is approved.

Date put on Trust Policy Database

1st October 2012 Date due to be reviewed

19th September 2015

Disseminated to: (either directly or via meetings, etc)

Format (i.e. paper or

electronic)

Date Disseminated

No. of Copies

Sent

Contact Details / Comments

Managers meeting E 19/09/12 J.Cooke ICC


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Ratification & Review Form

Title of document being reviewed:

* Indicates standards required by the NHSLA for all NHSLA associated documentation

Yes/No/ Unsure

Comments

1. Title

Is the title clear and unambiguous and facilitates easy identification in an index?

yes

2. Rationale/Purpose

Are reasons for development of the document stated?

yes

3. Development Process

* Is there evidence of consultation with stakeholders and users?

yes

4. Content

Style and Format; Is the document written in Arial font type, 12 point for text using the trust’s NHS logo?

yes

Terms used; Are relevant terms used in the document clear and where necessary explained?

yes

Are the statements clear and unambiguous? yes

5. Evidence Base

Is the type of evidence to support the document identified explicitly

* Are key references cited? yes

* Are supporting local documents referenced on the front sheet of the procedural document?

yes

6. Approval & Ratification

* Does the document identify which committee/group will approve it?

yes

* Ratification: Is the name of the ratification committee used for this document stated, is it in line with the Development & Management of Procedural Documents Policy

yes

7. Dissemination and Implementation

Is there an outline/plan to identify how this will be done?

yes

8. Document Control (For Note by the Author)


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Title of document being reviewed:

* Indicates standards required by the NHSLA for all NHSLA associated documentation

Yes/No/ Unsure

Comments

The document will be uploaded onto the Policy Library on Data 1 by trained administrators. It is the authors responsibility to ensure that a completed ratified copy of the document goes to the administrator and checks that it is uploaded and relevant information regarding review date etc. Is on the Trust Policy database

yes

The Administrator will archive old documentation in the central archive which is available to you on request.

yes

9*. Process to Monitor Compliance and Effectiveness

Are there measurable standards or KPIs to support the monitoring of compliance with the effectiveness of the document?

yes

Is there a plan to audit compliance with the document, is it explicit whose responsibility it is to do the audit and which committee will analyse and ensure actions are followed to completion?

yes

10. Review Date

* Is the review date identified? yes

Is the frequency of review identified? If so is it acceptable?

yes

11. Overall Responsibility for the Document

Is the authors name stated on the front sheet to ensure it is clear who will be responsible for co-ordinating the dissemination, implementation and review of the document?

yes

12. Mandatory Appendices

Is the Version Control sheet included at the front of the document?

yes

Has the Equality Impact Assessment Form been completed and attached?

yes

Has the Plan for Dissemination of Procedural Documents been completed and attached?

yes

Individual Approval

As author please sign to indicate that this form has been completed and is correct.

Name/role of Author J.Cooke Infection Control Date 17.11.11


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coordinator

Signature J.Cooke

Committee Approval

If the approval committee is approving this document, please sign and date

Name & Title of chair

Rayna McDonald Director of Operations and Clinical Practice

Date 19th September 2012

Signature R. McDonald

Committee Ratification

If you are ratifying this document, please sign and date and forward to the author.

Name & Title of chair

Rayna McDonald Director of Operations and Clinical Practice

Date 19th September 2012

Signature R. McDonald