New Unique Identifier: Procedure - Blackpool Teaching Hospitals … · 2015. 8. 3. · • This procedure will ensure that the trust is compliant with the Department of Health MRSA

Document Type :

Procedure

Unique Identifier: CORP/PROC/408

Version

Number: 5

Title:

Management Of Staphylococcus aureus (SA) -

Meticillin-Resistant (MRSA) and Meticillin-

Sensitive (MSSA)

Status: Ratified

Scope: Trust Wide

Classification: Organisational

Author/Originator and Title: Dr A Guleri Consutant Microbiologist

Dr Palmer Consultant Microbiologist

J Lickiss Nurse Consultant Infection Prevention

S Mawdsley Lead Nurse Infection Prevention

Responsibility: Infection Prevention and

Control

Replaces: Version 4 Management Of Meticillin-

Resistant Staphylococcus Aureus (MRSA)

Corp/Proc/408

Description of amendments: Document to amend current MRSA procedure and include

MSSA and MRSA screening [PCR and culture] and

management. Also to make procedure compliant with

aspects of DoH guidance to be effective from Dec 2010.

Risk Assessment: N/A

Name of Committee/Directorate/

Working Group:

Date of Meeting:

Financial Implications: N/A

Validated by: Hospital Infection Prevention and Control

Committee N.Harper Chairman’s Action

Validation Date: 09/07/2010

Which Principles of

the NHS Constitution

Apply? Principle 1,2,3,5,6,7

Ratified by: Clinical Improvement Committee Chairman’s

Action

Ratified Date:

09/07/2010

Date of Issue: 09/07/2010

Review Date: 01/10/2011

Review Dates: Review dates may alter if

any significant changes

are made

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

Does this document meet with the Race Relation Amendment Act (2000) Religious

Discrimination Act, Age Discrimination Act, Disability Discrimination Act and

Gender Equality Regulations? Not Applicable

Please note:

• The contents of this document are hyperlinked to open appropriate section of this document

• Acknowledgements to: Barrie Lunt [Senior BMS, Microbiology]; Steve Bloor [IT]; Chris Danson

[Diagnostics - Manager]; Philip Houldworth [Deputy directorate Manager, Pathology]; Trevor

Morris [ALERT Care - pathways co-ordinator]; Infection prevention team; Kate Woodrow

[antibiotic pharmacist] and All Staff of Microbiology laboratory

• All comments or inquiries regarding this document may be addressed to:

[email protected]

CONTENTS

PAGE

Purpose Of This Document Scope Of The procedure Staphylococcus aureus, aim of screening Role of hand hygiene, SA management SA – PPE, movement, transfer and cleaning Communication and documentation Colonisation recurrence or decolonization failure Outbreaks and Occupational Health Issues Duties and responsibilities SA screening (Appendix 1) Protocol - dealing with SA (Appendix 2) Protocol – Preop. management protocol of SA carriage(Appendix 3) Surveillance & audit (Appendix 4) Example of death certification (Appendix 5) Integrated Care Pathway (Appendix 6) Treatment of MRSA infection Antibiotic prophylaxis in surgery

Blackpool Fylde and Wyre Hospitals NHS Foundation Trust

Revision No: 5 Review Date: 01/10/2011

I.D. No: corp/proc/408

Title: Management Of Staphylococcus aureus (SA) -

Meticillin-Resistant (MRSA) and Meticillin-Sensitive

(MSSA)

Do you have the up to date version? See the intranet for the latest version

Page 3 of 26

1. PURPOSE The purpose of this procedure is to provide instructions on the management of patients with

MSSA or MRSA including:

• screening of patients,

• management of patients with carriage and/or infection caused by:

SA – Staphylococcus aureus i.e MRSA - Meticillin (previously Methicillin)

resistant Staphylococcus aureus or MSSA - Meticillin sensitive

Staphylococcus aureus

• prevention and control within the healthcare setting.

Compliance to guidelines and measures set out in the procedure should:

• Reduce all SA infections including bacteraemias, potential for cross transmission and

optimize treatment of infected patients, thereby enhancing patient safety, assurance and

quality of care.

• This procedure will ensure that the trust is compliant with the Department of Health

MRSA screening guidance that comes into effect on December 31, 2010.

2. SCOPE This procedure applies to all staff working within Blackpool, Fylde and Wyre Hospitals NHS

Foundation Trust with responsibility of patient care and covers:

• Screening of patients for MRSA and MSSA [Appendix 1]

• Dealing with patients carrying MRSA or MSSA (either previously known or newly

detected on screening) [Appendix 2]

• Topical regimes for bio-burden reduction or decolonization [Appendix 3]

• Treatment guidelines for infections with MRSA or MSSA [link to antibiotic formulary]

• Communication of MRSA or MSSA carriage status on transfer or discharge to receiving

ward or hospital.

• Audit and surveillance of MRSA infections [Appendix 4]

• Trust real-time monitoring of MRSA or MSSA infections associated with length of stay

3. PROCEDURE 3.1 INTRODUCTION:

Staphylococcus aureus

• Staphylococcus aureus [SA] infections are largely caused by two variants of the bacteria

– Meticillin (previously Methicillin) sensitive Staphylococcus aureus [MSSA] and

Meticillin resistant Staphylococcus aureus [MRSA].

• Staphylococcus aureus infections range from impetigo, folliculitis, carbuncles,

abscesses, to serious infections - scalded skin syndrome, endocarditis, pneumonia,

meningitis, osteomyelitis, toxic shock syndrome, bacteraemia and sepsis.

• SA (both MSSA and MRSA) are the most common cause of hospital acquired infections

and especially surgical site infections.

• Serious infections are associated with increased morbidity, mortality, extended length of

stay and associated health care costs.






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• A third of population may carry SA asymptomatically on their skin or mucosa,

especially the nose. A breach in the skin or mucosal barrier as part of medical / surgical

treatment or immuno-compromised status renders a patient susceptible to acquiring an

infection. Early detection of SA carriage in patients admitted to the hospital or for

planned surgery can allow for intervention with topical bio-burden reducing regimes

thereby reducing potential for SA infections and cross transmission to other patients.

• While both MSSA and MRSA carriers will benefit from bio-burden reducing regimes,

only MRSA (not MSSA) carriers also require isolation in a single room.

3.3 BACKGROUND

• In 2009, Blackpool Victoria Hospital won a national award and international acclaim

for significant reduction in MRSA bacteraemias (78% and 80% in 2008-09 & 2009-

10) using cutting edge technology - rapid (less than 2-hr) MRSA PCR to

complement a package of interventions including a very active support to the MRSA

programme from its staff.

• Careful analysis of data has indicated that, while total MRSA infections including

bacteraemias have reduced by 24% and 46% in the last two years, MSSA infections

including bacteraemia remained consistently and significantly high.

• The trust has been supported by all divisions in extending the scope of MRSA

screening programme to include screening for both MSSA and MRSA. Every MSSA

or MRSA infection has an associated cost to the trust. A 40% reduction in MSSA

infections can save the trust nearly half a million pounds.

3.4 HAND HYGIENE

"Scientists estimate that people are not washing their hands often or well enough & may transmit

up to 80% of all infections by their hands. Hand washing may be the single most important act to

help stop the spread of infection and stay healthy (Centre OF Disease Control, USA)".

Poor compliance to hand-hygiene can undermine and undo the benefits of the MSSA/MRSA

programme. Ensuring high compliance with hand hygiene will ensure success of this revised

MSSA / MRSA screening programme.

The trust is confident that its staff will actively support this programme and ensure high hand

hygiene compliance for self and challenge others around them.

• Visibly dirty hands MUST be thoroughly washed with soap and water [refer to hand

hygiene policy & pictures over hospital sinks]

• Alcohol gel must be used on clean hands between contact with patients or their

environment [eg. Case notes, bed frame, furniture, curtains, etc].

• Staff and visitors must always wash their hands on entering and leaving the isolation

room/area, similarly when patients are being barrier nursed on the open ward.

• Patients must also wash their hands or be offered wipes before meals

• Please note: Hands must always be decontaminated after removing gloves as per the

Hand Hygiene Policy Corp/Pol/056






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3.5 WHY SCREEN FOR MSSA AND MRSA?

The reasons for SA (MSSA and MRSA) screening and offering bio-burden reducing regime are:

• Prevent contamination of SA into immediate environment [e.g. bed frame, case notes,

curtains, etc], attending HCWs' and other patients.

• Prevent SA carrier patient from infection

• Early and optimum treatment of MSSA or MRSA infection

• Avoid empiric glycopeptides [e.g. Vancomycin] in MRSA negative patients.

• Complement clinical decision making during management of patients.

3.6 WHAT IS DECOLONISATION / BIO-BURDEN REDUCTION REGIME FOR SA

CARRIAGE?

Application of SA bactericidal preparations over 5-days reduces significantly the bio-burden of

SA on the human body, thereby reducing the potential for dispersal/cross transmission or self-

infection.

• Regime 1 is offered to inpatients: 5-day course of nasal mupirocin 2% and chlorhexidine

body wash / shampoo

• Regime 2 is offered to elective patients: 5-day course of Prontoderm [nasal preparation

and whole body / hair foam]

3.7 MANAGEMENT OF SA (MSSA AND MRSA)

This includes screening patients for SA, offering topical decolonizing or bio-burden reducing

regime to MSSA / MRSA carriers, isolation in single room of MRSA (not MSSA) carriers and

treatment of MSSA or MRSA infections. The protocols for MSSA & MRSA are similar, except

MRSA carriers also require a single room (when possible) and different anti-MRSA antibiotics

during surgical prophylaxis and/or treatment.

Isolation precautions for MSSA/MRSA patients: All MRSA/MSSA patients require isolation

precautions and decolonisation. Only MRSA patients require a single side room. MSSA

patients may remain in cohort areas. Clinical MRSA infection, particularly those of the

respiratory system, in patients with exfoliative skin conditions and exudative / supportive

wound conditions must take priority for side rooms over MRSA colonisation without infection.

In order to reduce the risk of SA spreading from those known to have infection/colonisation the

following actions are recommended:

• Inform the Infection Prevention Team.

• All MRSA [not MSSA] patients in single rooms, whenever possible.

• It must be clear to any healthcare worker that the patient is being isolated.

• Signs must be displayed to identify to visitors that they must seek advice on appropriate

precautions.

• If there is more than one infected/colonised patient, then cohort nursing within the ward

should be practiced. Any deviation from this procedure must be clearly documented in

the patient’s case notes.

• If the clinical need (e.g. patients with tracheostomy or those at risk of wandering/falls

etc) or lack of single room facilities (as a result of occupation by higher priority cases for






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example pulmonary TB, chickenpox, diarrhoea), prevents an MRSA patient from being

nursed in a side room then they should be barrier nursed in a ward bed beside a sink. It

must be ensured that patients in the neighbouring beds are ones that do not have

catheters, lines or wounds. On some occasions isolation may not be possible but the risk

of transmission of infection may be significant and the IPC Team may advise

decommissioning the neighbouring bed space. This must be clearly documented in case

notes.

• All patients transferred from other hospitals must be isolated until results of PCR

screening is known.

3.8 PERSONAL PROTECTIVE EQUIPMENT (PPE)

• Single use gloves and aprons must be used.

• Wear single-use gloves and aprons for close contact with the patient/patient environment

e.g. bed making, moving and handling the patient, cleaning room /area.

• PPE is not required when handling prescription sheets/care plans etc as these should not

have been handled without hand decontamination. Care plans etc should be kept outside

the single rooms.

• Face protection is only required when there is a risk of mucus membrane contamination

from secretions e.g. suctioning / tracheostomy care etc

3.9 MOVEMENT OF SA [MRSA/MSSA] POSITIVE PATIENTS

• Minimise patient transfer and movement within the Trust.

• All lesions should be covered where possible, if transport is essential.

• Decontaminate the trolley or chair after use

• Place patient at end of operating/investigation lists

• Avoid time in waiting areas

• Keep numbers of staff in contact with the patient to the minimum

• It is vital that the receiving area is notified in advance of the departure of the patient.

• If patient is discharged and the 5 day bio-burden reduction course has not been

completed, the remaining days of treatment should be included with the discharge

medication

• Documentation of discharge management must be on the discharge transfer letter.

3.10 MANAGEMENT OF INTER-WARD TRANSFERS OF NEGATIVE PATIENTS

All patients who transfer between wards other than transfers from CLDU and SAU should have

their MRSA/MSSA status checked on HISS or Maxims. If no alert is displayed they should be

re-screened.

3.11 CLEANING

Terminal barrier nursing cleaning as per Infection Prevention & Control Policy

(CORP/POL/116) in all areas where PCR screening is not in progress. In areas where PCR

based Universal screening is in place, domestic and nursing staff should use dual-purpose

activated chlorine/detergent based products, (e.g. Chlorclean or Acticlor), unless otherwise

advised.






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In areas where universal screening is performed, curtain changes will take place on a monthly

rolling programme so it is not necessary to change them in the event of a positive screen result

unless blood or body fluid contamination has occurred.

3.12 COMMUNICATIONS AND DOCUMENTATION

• The SA Care Pathway must be commenced for all SA [MRSA or MSSA positive

patients, i.e. both current or previously positive. (See Appendix )

• Explanation to patient and relatives is essential. It is also important to maintain the

patient’s dignity and confidentiality at all times. Patient leaflets must be displayed at

ward level and are available from the stationary stores. In such circumstances that

leaflets are not available, the nurse in charge of the patient’s care must still provide the

necessary information to the patient and relevant carers/family.

• All staff, both regular and visiting, must be made aware of the importance of taking the

necessary infection prevention precautions at handover

• It is the ward or departments’ responsibility to ensure an accurate record of the

decolonisation process is communicated to the receiving ward.

• Symptomatic patients can undergo inpatient investigations or procedures, provided

appropriate precautions are taken. Advice can be sought from the infection prevention

team in such circumstances. It is the ward or departments’ responsibility to advise the

receiving department in advance, of the SA status of the patient. The patient should be

put last on the list, or should be fast tracked so that they have minimal contact with other

patients in waiting areas.

• When transferring MRSA positive patients to other hospitals, the MRSA status must be

properly communicated in advance of the transfer

3.13 PATIENT REVIEW

• The Department of Health (DoH) requires all hospitals to complete a compulsory Root

Cause Analysis (RCA) for patients with MRSA [not MSSA] bacteraemia and to discuss

the MRSA bacteraemia RCA results with PCT representatives, who are required to

monitor the actions of the Trust with regard to MRSA control. The MRSA RCA must be

completed by the clinical team and infection prevention & control team within 7-days. A

copy of the RCA must be provided to the Director of Infection Prevention and Control

(DIPC).

• The DoH is likely to extend this to MSSA bacteraemia in the next 12-months.

3.14 WHAT IF SA COLONISATION RECURS?

Recurrences are common, occurring in the majority of patients who have significant co-

morbidity. For MRSA carriage, the policy allows for a maximum of two bio-burden reduction

cycles. Further cycles within that admission should be discussed with the Microbiologist. For

MSSA carriage the current policy advocates a single cycle of bio-burden reduction and no

further post decolonisation screening.

3.15 OUTBREAKS

This would be declared by the Infection Prevention and Control Team or Microbiologist when

an increase in the number of infected cases or an unusual cluster of cases. The Investigation,






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Management and Control of Outbreaks of Infectious Diseases Procedure covers management of

outbreaks. (See Policy Corp/Proc/488). It is the responsibility of clinical teams to discuss an

unusual cluster of cases with the IPC team or microbiologists.

3.16 DECEASED PATIENTS

Lesions & wounds must be covered where possible. There is negligible risk to undertakers or

mortuary staff. However Personal Protective Equipment should be worn.

3.17 OCCUPATIONAL HEALTH ISSUES

• Staff screening is currently recommended only when epidemiological evidence suggests

that a staff member/members may be MRSA carriers and likely to be transmitting

infection.

• Staff with skin lesions should report to Occupational Health Department (OHD) as

they are at increased risk of acquisition and would require treatment. MRSA positive

staff must be under the care of an OHD physician. The Microbiologist, DIPC and OHD

physician should carry out a joint risk assessment with regard to appropriate measures to

minimise the risk of transmission of MRSA to patients. Current policy does not extend

this to MSSA infection/carriage in staff members. However, this may be discussed with

the microbiologist and OHD on a case by case basis.

3.18 KEY DUTIES AND RESPONSIBILITIES:

Link Nurses & Ward Managers Key Responsibilities

• IMMEDIATE ACTION: Ensure that all cases of SA carriage are promptly offered

decolonising regime as soon as result becomes known to nurse in-charge.

• SA cases must be notified to Infection Prevention Team (IPT) during core working

hours and ensure the SA Care Pathway is commenced. Decolonisation regime must be

recorded here.

• Ensure isolation precautions for all SA carrier patients. Single room is required only for

MRSA patients.

• If single room is not available for any reason or door of single room has to be kept open

– this must be clearly documented in case notes.

• Ensure all screening samples are promptly sent to the laboratory and logged.

Microbiology laboratory offers SA PCR service between 8am – 12 midnight. Phone

6952 /6951 or on call lab scientist via switch to discuss urgent testing.

• Review clinical results and check appropriate MRSA treatment has been promptly

prescribed when needed. This may be discussed with on-call microbiologist. Draw

attention of Medical Team to their responsibility for prescribing treatment according to

the Antibiotic Formulary.

• Monitor clinical response to treatment and liaise with medical staff to ensure all

appropriate treatment measures are carried out

• Involve the Tissue Viability Nurse if appropriate

• Assist Infection Prevention Control Team (IPCT) in surveillance programmes and audit

• Remind/challenge staff of the necessity of adhering to good hand hygiene precautions

and to use Personal Protective Equipment (PPE) as appropriate.






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Clinical Team and Directorates: Key Responsibilities

• Ensure that all patients have appropriate screening samples promptly sent to the

laboratory.

• Decolonising or bio-burden reducing regime must be in place for all SA positive

(previously or newly detected) patients.

• MRSA positive patients with clinical infection should be prescribed treatment according

to antibiotic formulary (offering anti-MRSA cover). This may be discussed with on-call

Microbiologist.

• Review daily patients’ clinical progress and appropriateness of antibiotics.

• If there is no clinical response or significant deterioration contact Microbiologist

• Co-operate with Director of Infection Prevention and Control (DIPC) /Microbiologist in

the MRSA Bacteraemia Critical Incident programme associated with the DoH/HPA

MRSA Mandatory Reporting Scheme and other MRSA RCA as requested.

• On discharge of the patient, it is the responsibility of consultant / clinical team to ensure

e-discharge letter to the GP carries information of the MRSA status and bio-burden

reducing regime and if indicated, treatment given to the patient. If the status is confirmed

after discharge of the patient, the consultant/clinical team must communicate this to the

GP. The GP must be responsible for dispensing the bio-burden reducing regime to the

patient.

• If discharge occurs mid-cycle for Bio-Burden reduction ensure that the patient is

discharged with sufficient treatment to complete the cycle.

• Ref. MRSA screening frame work Department of Health 31st December 2010.

Trust Board

• The board will ensure that the guideline is implemented

• Must support the control and reduction of MRSA, prioritising the management of patient

risk and ensuring that the patient safety is not compromised by the pursuit of other

strategic objectives.

• Must ensure that infection prevention and control education and training of all healthcare

personnel actually happens and is informed by audit.

The Chief Executive

• The Chief Executive will ensure that the guideline is implemented in all areas and will

ensure that the effectiveness of the guideline is constantly reviewed.

Director of Nursing and Quality

• Should ensure each clinical area is covered by link nurse who will have ring-fenced time

to train, audit and feedback to staff on isolation, hand-hygiene, cleaning and protective

clothing practices.

• Must ensure cleanliness in all clinical areas is assessed through regular (preferably

monthly) PEAT (Patient Environment Action Teams) scores and these discussed at

meetings of infection control team, cleaning staff and matrons on a regular basis.

• Must ensure that nurse caring for the patient should initiate and complete integrated care

pathway (ICP) for every known [previous or new] MRSA carriage.






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Executive/Clinical Directors

• Executive and Clinical Directors have the responsibility for the co-ordination of health

and safety activities and for ensuring that decisions are implemented in accordance with

this guideline.

• Should ensure completion of integrated care pathway (ICP) for every case of MRSA

carriage and daily review of drug charts by ward pharmacist to check compliance with

antibiotic formulary and 5-day stop policy for all empiric antibiotic prescriptions;

• Should ensure Infection management team (Microbiologist + Antibiotic pharmacist +

ICN) ward rounds that provide feedback to ward doctors and consultants.

DIPC / The Hospital Infection Prevention and Control Committee

• The hospital infection prevention committee has a responsibility to ensure that this

guideline allows the Trust to comply with directions and guidance from the Department

of Health and other bodies.

The Infection Prevention and Control Team (IPCT)

• The IPCT will audit and support local audit of compliance with the policy as part of the

infection control audit programme.

Managers and Supervisors

• Have a responsibility to ensure staff and new starters are aware of and comply with this

guidance on MRSA carriage within this document.

Employees

• Have a responsibility to abide by this guideline. This guideline is enforceable through

Health and Safety legislation and Trust disciplinary procedures. If employees are aware

that the policy is not being complied with they must first take the issue to their line

manager and if the problem is not resolved to the infection control team.

3.19 KEY PERFORMANCE INDICATORS

• The Infection Prevention Team undertake quarterly audits of wards to ensure that

healthcare workers are compliant with the content of this procedure

• Whenever areas of non-compliance are identified during these audits, an action plan is

generated and target dates are set for review

• The content of this procedure is incorporated into the Trust Mandatory Infection

Prevention education and in annual mandatory update training

4. ATTACHMENTS.

Appendix 1 - Staphylococcus aureus (SA) Screening

Appendix 2 Protocol for Dealing with MRSA/MSSA Carriage

Appendix 3 – Pre-Operative Management Protocol of SA Carriage






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Appendix 4 – Surveillance and Audit

Appendix 5 – Examples of Death Certification

Appendix 6 – SA Integrated Care Pathway

5. ELECTRONIC AND MANUAL RECORDING OF INFORMATION

Database for Policies, Procedures, Protocols and Guidelines

Archive/Policy Co-ordinators office

Held By: Clinical Governance Directorate and Infection Control Department

Held in format: Electronic and hard copy

6. LOCATIONS THIS DOCUMENT THIS DOCUMENT ISSUED TO

Copy No Location Date Issued

1 Intranet

2 Wards and Departments

7. OTHER RELEVANT/ASSOCIATED DOCUMENTS

Procedure No. Title

Corp/Proc/408 Management Of Meticillin-Resistant Staphylococcus

Aureus (MRSA)

PL/025 MRSA patient leaflet

Corp/Pol/116 Infection Prevention and Control Policy

Corp/Pol/056 Hand Hygiene Policy

Corp/Proc/418 Hand Hygiene Procedure

Corp/Strat/023 Control of Infection Strategy 2006 – 2009

Corp/Proc/488 Control of Outbreaks

8. SUPPORTING REFERENCES/EVIDENCE BASED DOCUMENTS

References In Full

None

9. CONSULTATION WITH STAFF AND PATIENTS

Name Designation

G Wood Policy Co-ordinator

10. DEFINITIONS/GLOSSARY OF TERMS






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NAME DEFINITION

SA Staphylococcus aureus

MRSA Meticillin resistant Staphylococcus aureus

MSSA Meticillin sensitive Staphylococcus aureus

PPE Personal protective equipment

PCR Polymerase chain reaction

DeCOL Decolonisation or bioburden reducing regime

CCS Clinical /culture screen [non-emergency/critical care setting, post

DeCOL course]

HCAI Healthcare associated infection

ICP Integrated care pathway

11. AUTHOR/DIVISIONAL/DIRECTORATE MANAGER APPROVAL

Issued By J Lickiss Checked

By

Dr Guleri

Job Title Job Title

Signature Signature

Date Date






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Appendix 1 Staphylococcus aureus [SA] SCREENING

ALGORITHM:

MSSA or MRSA +ve referred to as SA+

TEAM PATIENT GROUP PATIENT GROUP

NURS

ES

/

clinical

team

Emergency admission or

Admission to critical / high

care (even if pre-op screen SA

-ve) or

urgent requirement for SA

status.

Elective patients or

Emergency admission known SA+ or

Critical / high care admission with SA+ or

weekly screening in ITU, HDU & CITU or

post decolonisation screen for MRSA+ve or

interward transfer (other than from

SAU/CLDU) or

frequent attendees or

any other non-urgent requirement of SA status

Step 1 Check patient SA status on Maxims / HISS system for all patients

MSSA/MRSA

negative

Or status

unknown

SA +ve

Step 2 NURSES

/

clinical

team

PCR specific

Nasal swab

Transport red

bag

CHROMOgenic Culture

Nose & perineal swab

Transport in specific yellow bag

MSSA + MRSA+ MSSA +ve MRSA +ve

Step 3

NURS

ES /

BED

MANA

GERS

• Prescribe bio-burden reducing regime to all newly or previously known

MSSA or MRSA patients admitted to hospital

• Single room for MRSA+ve patients

• Isolation precautions for MSSA/MRSA patients with barrier sign.

• Commence SA – ICP

Step 4

consult

ant

Ensure optimal

treatment of infected

patients using antibiotic

formulary

Daily review of

patient & antibiotic

prescription

Ensure high level

of hand hygiene & ANTT

Clinica

l team /

nurses

Clinical teams must

inform GPs [e-letter] or

receiving ward / theatre

/ hospital or

investigational area of

SA status of patient

Rescreen MRSA+ve

at 48h of finishing

bio burden reducing

regime;

MRSA RCA for bacteraemia

** when is SA screening not required: Transfers from CLDU / SAU where patient were SA screened

negative on admission. Day case ophthalmic cases, Elective Endoscopy day cases, Dermatology minor procedure

and day case dental cases patients DO NOT require screening. Children do not require screening unless high risk

[SCBU, high care, cystics, previous exposure to healthcare settings]

Recurrent elective admissions (renal, haematology, oncology, rheumatology, dermatology, etc should be screened

every 3-months by culture.






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STEPS TO SA [MRSA OR MSSA] SCREENING:

1 Check SA status of patient from maxims / HISS .

2 Emergency [unscheduled] admissions to hospital or critical / high care (ITU, HDU,

SHCU, CITU):

• Known MRSA or MSSA +ve:

i. Send off a culture swab for MSSA / MRSA screen

ii. Prescribe bio-burden reducing regime [if patient has not already received it

during current admission]

iii. Single room for MRSA+ve patients.

• SA status unknown / negative/ patient admit from another ward/ hospital to

critical /high care (ITU/HDU/SCHU/CITU) or elective admission with urgent

requirement of SA status:

i. Send off PCR specific swab in red request bag for SA – PCR [MSSA and

MRSA]

ii. MSSA or MRSA patients must be prescribed bio-burden reducing regime.

iii. MRSA+ve patient must be transferred to a single room [if possible].

3 Elective [Scheduled] admissions of previously unknown or known SA [MSSA or MRSA]

+ve or inter-ward transfer of patient within current admission or transfer screening or any

other requirements for a non-urgent screening result:

• Send off culture swab for MSSA / MRSA screen

When is SA screening not required: • Transfers from CLDU / SAU where patient were SA screened negative on admission.

• Day case ophthalmic cases, Elective Endoscopy day cases, Dermatology minor procedure and day case dental

cases patients DO NOT require screening.

• Children do not require screening unless high risk [SCBU, high care, cystics, previous exposure to healthcare

settings]

• Recurrent elective admissions (renal, haematology, oncology, rheumatology, dermatology, etc should be

screened every 3-months by culture.

SAMPLES required:

• PCR: Single PCR specific swab collected optimally from both anterior nares. Sent in PCR

specific red bag. Charcoal swab samples cannot be processed by PCR.

• Culture: Standard charcoal swab. One swab each from nose [both nares] and perineum.

Sent in specific yellow culture screen bag.

Validity of SA pre-op MRSA screen

At present the DoH has not defined screening validity

Our current position is to assume that a negative screen performed within 12 weeks of surgery is

acceptable provided there have been no inpatient admissions in the period between screen and






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surgery. If admissions have taken place: culture screen the patient if over 72hrs available till

surgery otherwise urgent PCR screen is required.

If this cannot be done in time for surgery either:-

• Postpone surgery

• Assume positivity and manage accordingly

This may change if new guidance dictates.

PCR Screen:

• Rapid but an expensive test. For use in emergency admissions or urgent situations requiring

a rapid result.

• PCR service offered between 0800 – 2400h.

• Rapid test [< 2hr hand-on-time]

• Specimen: Single special PCR nasal swab

• Transport: Special red Microbiology request form / bag

• Turn-around-time: TAT ranges from 2h – 10 h [depending on arrival of specimen in

laboratory].

• Results: Positive results are telephoned to the requesting ward while all results are entered

on the pathology system real-time.

• The responsibility of checking MRSA/MSSA status of patient lies with clinical/nursing

team

Culture screen [MSSA and MRSA CHROMagar]

• 24-48hrs hands-on-time test

• Specimen: Standard charcoal swabs – nose and perineum

• Transport: Yellow microbiology form

• Turn-around-time: 24h – 72h [Subject to arrival of specimen in laboratory]. Culture set up in

afternoon/evening. Hands-on-time: Negative result – 24h ; Positive result – 24h

[presumptive result]; 48h [confirmed result].

RESPONSIBILITY OF CLINICAL TEAMS:

• It is the responsibility of clinical team to clearly document contact details of person

requesting the test. Illegible hand-writing or absence of contact details on request forms can

cause delay in transmission of result. Laboratory staff shall bear no responsibility for such

delays.

• Positive MRSA / MSSA results are telephoned by microbiology laboratory to the requesting

ward.

• The responsibility of checking MRSA/MSSA status of patient lies with clinical/nursing

team






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Appendix 2

Protocol for dealing with MRSA/MSSA carriage :

All patients who test positive for MRSA on screening prior to admission will receive

notification by letter. All of these patients must be effectively decolonised prior to admission.

These patients will be required to return to their pre-admission clinic or outpatient clinic to

collect a “MRSA decolonisation pack”. This pack consists of a 5-day treatment course of

Prontoderm foam and Prontoderm nasal gel and instructions on how to use these products. This

treatment must be commenced 5 days before the anticipated admission date. If patients receive

notification less than 5 days before their admission date, they are instructed to commence

treatment immediately, and the course will be completed during their inpatient stay. Failure to

commence and complete the bioburden reduction treatment may result in a delay in their

operation/procedure.

EMERGENCY admissions:

• Nurse caring for the SA positive patient MUST promptly upon receiving the result of

SA status - affix the prescription sticker on drug chart, initiate decolonisation

protocol without delay and get it signed at the first opportunity but certainly within

24h.

• Mupirocin 2% ointment – apply locally into anterior nares [patient should taste it in

back of throat] q8h X 5days. 2nd

line for mupirocin resistant strain or mupirocin

hypersensitivity is Naseptin® [chlorhexidine 0.1% + neomycin] apply q6h X 10

days.

• Chlorhexidine 4% [gluconate - Hibiscrub® or equivalent] – q24h X 5 day course of

body wash [esp. axilla, groin, perineum] daily and shampoo hair [twice/5-day

period]. Recommended contact time of 3-minutes before washing it off with water.

2nd

line for Neonates / paediatrics or hypersensitivity to chlorhexidine or exfoliative

skin conditions is Octenisan®






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Appendix 3 Pre-operative management protocol of SA carriage:

o MSSA +ve:

• Date of surgery may be booked allowing for completion of 5-days of topical regime

before surgery.

• Patient to use 5-day bio-burden reducing regime – PRONTODERM. Admit to

hospital on day 5 or next morning of course completion.

• No single room required.

• Staff to use isolation precautions during entire hospital stay with a barrier sign.

• If urgency of surgery – contact microbiologist ASAP.

o MRSA+ve

• Depending on the urgency for surgical intervention one of the three suggested regimens

may be selected for managing MRSA carriage.

• Please note the MRSA-cidal agents used for decolonisation offer transient bio-burden

reduction in MRSA carriage. This is again limited by co-morbidities of the patient.

• Please discuss any query with Microbiologist or infection control team.

Regime A

Where emergency surgery is required

• This applies to both SA status +ve or result awaited {treat like +ve pending

confirmation of result. PCR swabs must be taken as soon as practicable].

• Ensure nasal mupirocin and chlorhexidine body wash/shampoo is commenced

immediately.

• Complete the remaining days of the 5 day bio-burden reduction regime post

operatively.

• Refer to trust antibiotic prophylaxis and treatment guidelines.

Regime B

Where surgery is non-urgent but cannot be delayed pending 3 negative MRSA screens

• Date of surgery may be booked allowing for completion of 5-days of topical regime

before surgery.

• Patient to use 5-day bio-burden reducing regime – PRONTODERM. Admit to

hospital on day 5 or next morning of course completion.

• Refer to trust antibiotic prophylaxis and treatment guidelines

Regime C (MRSA Only)

Where the surgeon or patient considers that an attempt to clear MRSA completely is in

the patients best interest and the degree of urgency allows for potential 3-4 week

delay:-

• This option requires

• Treat with bio-burden reduction regime [Prontoderm for 5-days]






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• Await three negative screens taken at 48 hours then, at 1 weekly intervals thereafter.

• Failure to achieve three negative MRSA screens should be discussed with the

Microbiologist.

• Admit as soon as possible after third negative screen treat as positive for MRSA

Operating Theatre Management of SA positive patients and those whose status is not

known at operation:-

• Isolate and barrier nurse patients

• Status unknown emergency patients should be managed as MRSA positive pending

screening.

• If procedure requires antibiotic prophylaxis add MRSA cover: vancomycin 1g IV

infusion over 100 minutes to be completed 30-60 minutes before incision.

• For patients who require immediate surgery and/or are allergic to vancomycin: use

teicoplanin 10mg/kg at induction/or 15 minutes before procedure

• Place at the end of the operating list where possible or delay next entry until

sufficient air changes have occurred, in practice 15 minutes for a standard theatre

• Recover patient in operating theatre or segregated recovery area

• Decontaminate surfaces after procedure.

Recurrance of colonisation or Decolonisation failure? Recurrences are common, occurring in the majority of patients who have significant co-

morbidity.

• For MRSA carriage, the policy allows for a maximum of two bio-burden reduction

cycles. Further cycles within that admission should be discussed with the

Microbiologist.

• For MSSA carriage only a single cycle of bio-burden reduction is advocated. Any

further requirement for decolonisation should be discussed with the Microbiologist.

• Dr Guleri and senior nurses from preoperative assessment clinics run a DeCol failure

clinic to help unwarranted delays in surgery of patients who fail to get three negative

screens or if there is urgency of surgery.






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APPENDIX 4 SURVEILLANCE & AUDIT

TYPE Report To Frequency

External Department of Health

MRSA Bacteraemia

Monitoring

Programme

DoH / Health

Protection Agency

(COSERV)

Quarterly Report

issued to Trusts

Annual Report to

Parliament

Benchmarked

Internal Review of MRSA

Bacteraemia figures

Outbreak Reports

MRSA admission rates

(HISS) MRSA clinical isolate

rates

Trust Board

HICC

Divisions

Divisions

Quarterly

Bi-Monthly

Annually

Annually until

Infection Control

database in place then

more frequently

Audit Bacteraemia Critical

incident review

Recording MRSA

status plus time to

Initiation of Barrier

Nursing/ Treatment

Appropriate use of

MRSA Empiric

Treatment

Appropriate use of

Antibiotics versus

topical regimes for

MRSA management

HICC/Divisions Rolling programme

over three years






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Appendix 5 Example of death certification

Example A:

If a healthcare associated infection (HCAI) was part of the sequence leading to death, it

should be written in part I of the certificate, and you should include all the conditions in the

sequence of events back to the original disease being treated.

Ia. MRSA bacteraemia

Ib. Multiple antibiotic therapy

Ic. Community acquired pneumonia with severe sepsis

II. Immobility, Polymyalgia Rheumatica, Osteoporosis

Example B:

If your patient had a HCAI that was not a part of the direct sequence, but which you think

contributed at all to their death, it should be mentioned in part II

Ia. Bronchopneumonia

Ib. Carcinomatosis and renal failure

Ic. Adenocarcinoma of the prostate

II. MRSA pneumonitis infection secondary to antibiotic therapy for recurrent

bronchopneumonia.






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Appendix 6 Staphylococcus Aureus Integrated Care Pathway

Staphylococcus Aureus (SA)

Integrated Care Pathway

Inclusion criteria This Integrated Care Pathway (ICP) is for use with known and newly diagnosed MRSA patients.

For further advice please contact the infection control team.

This Integrated Care Pathway is intended as a guide to care only and does not

replace clinical judgement.

Aims of this Care pathway

This pathway commences when the patient has been identified as MRSA positive from either

previous or new swab results. We intend to ensure we offer high quality patient care, based on

evidence where available and that the care is documented comprehensively and accurately

Acceptable Abbreviations

MRSA – Meticillin Resistant Staphylococcus Aureus

MSSA - Meticillin Sensitive Staphylococcus Aureus

SA - Staphylococcus Aureus

ICP - Integrated Care Pathway

+ve - Positive

-ve - Negative

Write patient details or affix

Identification label Hospital Number:

Name:

Address:

Date of Birth:

NHS Number:

Consultant






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Document Number 001

Version August 2006

Document created by Infection control team

Patient Name……………………

Hospital number…………………

Instructions for use of the Integrated Care Pathway

• To write in the ICP you need to give your name, job title and give a sample signature and

initials. See below.

• Ensure each page is marked with the patients name and unique identifier i.e. hospital

number.

• When recording an event that is predicted by the ICP, just initial against that predicted

activity or intervention in the column provided.

• If your intervention is not in line with the ICP, i.e. you do not follow the pathway then you

must record this as a variance on the Variances/Additional Information pages.

• Variance will allow the ICP to reflect the patients’ experience.

• The Variance /Additional Information pages are also for you to write free text about issues

identified and the care given to the patient. These records must always be timed, dated and

initialled.

• If your entry relates to an activity or intervention within the ICP, record the activity number

against your entry.

• All ICP’s are chronological so you should be able to track the care very easily.

Signature Record

Please use black ink and complete this section. Use initials when recording care.

Print Name

Job Title Bleep no or ext. Signature Initials






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Author/Originator……………………………………………… Summary of MRSA/MSSA

details and actions

Met Unmet Date Time Variance Action Taken

1 IPN or nurse in charge of patient’s care identifies patient as SA +ve

2 Nurse in charge of patients care informed

3 Nurse in charge to inform patient

4 Nurse in charge of care informs next of kin with patients consent

5 Patient notes or Patient allergy/attention card are labelled by IPN or ward staff

6 Nurse responsible for the patient informs them of the isolation measures and rationale.

7 Information leaflet given by ward staff

8 Any questions answered by ward staff or IPN if necessary

9 The patient agrees to comply

10 Medical team responsible for care - informed of positive status.

11 Necessary antibiotics prescribed if applicable by the doctor

12 Topical regime prescribed as per SA Policy

13 Patient barrier nursed – commenced as per Infection Prevention and Control procedure

14 If patient discharged midway through treatment then this should be continued at home

15 Topical treatment for eradication has been given for 5 days as prescribed.

16 MRSA patients to be rescreened 48 hours after completion of topical treatment as per the Trust SA procedure. MSSA patients do not need to be rescreened.

17 Clinician in charge of the patient’s care - notifies the GP of the SA status via the electronic discharge system.


Revision No: 2 Review Date:

I.D. No: CORP/PROC/408

Title: Management Of Meticillin Resistant Staphylococcus

Aureus (MRSA)

Do you have the up to date version? See the intranet for the latest version Page 25 of 26

Additional Information / Variance

Unique

Number

Date Time Date Variance/ Additional Information Sign Outcome Date Time Sign


Revision No: 2 Review Date:

I.D. No: CORP/PROC/408

Title: Management Of Meticillin Resistant Staphylococcus

Aureus (MRSA)

Do you have the up to date version? See the intranet for the latest version Page 26 of 26

Additional Information / Variance

Unique

Number

Date Time Date Variance/ Additional Information Sign Outcome Date Time Sign

Patient Name…………………….

Hospital number…………………

Documents

New Unique Identifier: Procedure - Blackpool Teaching Hospitals … · 2015. 8. 3. · • This procedure will ensure that the trust is compliant with the Department of Health MRSA