Policy for Screening Patients for MRSA Colonisation

Transcription

1 Policy for Screening Patients for MRSA Colonisation To whom this document applies: All staff in Colchester Hospital University Foundation Trust screening Patients for MRSA Procedural Documents Approval Committee Issue Date: March 2009 Document reference 112a Date(s) reviewed: Approved by: Clinical Executive Board Date approved: 31 st March 2009 Next Review date: 31 st March 2011 Version No: 1 Responsibility for review: Director of Infection Prevention and Control (DIPC) Contributors: See consultation document page 2. Archiving information held by Secretary of the Procedural Document Approval Committee Procedure: 112a Page 1 of 11

2 1. Procedural, Development, consultation Proposal Form Title: Policy for Screening Patients for MRSA Colonisation Procedure Guideline Protocol Standard Tick the box Name of person presenting document: Tony Elston Director of Infection Prevention and Control Denise Hagel, Director of Nursing Reason for document development: Development of screening policy in line with the Department of Health guidelines to screen all elective admissions for MRSA Names of development team (including a representative from all relevant disciplines): Surgical Matron Matron, Essex County Hospital Ward Manager Elective Care Centre Senior Midwife Director of Service Improvement Manager, Microbiology Department BMS3 Microbiology, Project Manager Associate Director of Midwifery and Governance Service Manager, Ambulatory Care Consultant Paediatrician Consultant Microbiology Who has been consulted? Director of Infection Prevention and Control (DIPC) Associate Director Planned Care Senior Matron, Planned Care Director of Operations Director of Nursing Does this document require presentation and agreement from Health & Safety Committee or Joint Staff Committee prior to PDAC approval? Yes No Specify groups of staff to whom the document relates: All staff screening elective and admissions for MRSA Source of supporting evidence (references etc.) Saving Lives: reducing infection, delivering clean and safe care. Saving Lives: a delivery programme to reduce Healthcare Associated Infection, including MRSA - Screening for Meticillin-resistant Staphylococcus aureus (MRSA) colonisation: A strategy for NHS trusts: a summary of best practice. The Health Act 2006 (updated January 2008) Code of Practice for the Prevention and Control of Healthcare Associated Infections Are there resource implications? Yes No If yes please detail them: Increased resources for clinics to manage screening Increased resources for processing samples in Microbiology Department Does the Procedure/Guideline meet latest NHSLA, Standards for Better Health requirement? Yes No Does this Procedure/Guideline include children, if applicable? Yes No If yes has the relevant person been included? Yes No A Trust review will occur every two years unless national guidance states otherwise. DATE: 31 st March 2009 Procedure: 112a Page 2 of 11

3 Contents Page No. Review, updating and archiving of the document 1 Document Development & Consultation Process 2 Contents Page 3 Introduction 4 Definition of Terms 4 MRSA Screening Policy 5 How to Screen for MRSA Colonisation 7 How to Deal with the Results 7 Follow Up of Patients Who Have Screened Positive 8 On Admission to Hospital 9 Evidence Base 9 Monitor compliance and audit 10 Dissemination, implementation and access to the document 10 Appendix 1 MRSA Screening Flowchart 11 Procedure: 112a Page 3 of 11

4 Introduction The purpose of this document is to deliver MRSA screening in line with Department of Health Guidance March Definition of Terms MRSA Meticillin resistant Staphylococcus aureus. This is an antibiotic resistant type of the bacterium Staphylococcus aureus. Carriage of MRSA MRSA, like meticillin sensitive Stapyhlococcus aureus can be carried in several sites of the body (most commonly the nose) without causing any harm. Screening for MRSA This is a method for detecting MRSA in people who carry the organism. It involves taking a bacteriological swab. This swab is then processed in the microbiology laboratory by techniques that detect MRSA. MRSA positive A person who has had MRSA detected from a body site is termed MRSA positive. MRSA negative A person whose screening swabs did not detect MRSA is termed MRSA negative. Elective Admissions A person who is booked to come into the hospital at a future date is termed an elective admission. Emergency Admissions A person who is sent (or attends A&E) for admission to hospital for immediate treatment is termed an emergency admission. Decolonisation Regime Removing MRSA colonising the nose and skin by applying an antibiotic nasal ointment and using an antiseptic body and hair wash. Procedure: 112a Page 4 of 11

5 MRSA Screening Policy Patients that need to be screened from April 2009 Elective Admissions All patients (including those for arthroscopy and laparoscopy) require screening when the decision to be put on the waiting list for surgery is made. Exceptions to elective screening: Day case ophthalmology Day case dental Children/paediatrics unless in a high risk group (see below) Day case endoscopy i.e. all endoscopy of the GI tract, bronchoscopy, cystoscopy, hysteroscopy, laparoscopy, Dermatology Gynaecology, Maternity and Obstetrics Screen all patients requiring surgery. Screen when initial assessment is made in the clinic. Screen elective caesareans at weeks, and decolonise patients at 38 weeks (see section on decolonisation regime for details). Screen mothers if there is a high risk of complications in mother and/or baby because of size or other known complications at weeks and decolonise at 38 weeks (see section on decolonisation regime for details). All gynaecology patients need to be screened when the decision to admit is made (see elective admissions above). Paediatrics All known previous positive patients. All patients transferred back from tertiary centres. All immuno-suppressed patients. Procedure: 112a Page 5 of 11

6 Emergency Admissions This will be updated by April 2011 Transfers of patients Between wards of CHUFT From hospitals outside of CHUFT All patients on renal dialysis programmes Patients admitted to Critical care The following groups need to be screened on admission to EAU: Known as being MRSA positive in the past. Identified as being MRSA positive in the past. Lives in a nursing home or residential home. Has transferred directly from any hospital including abroad. Has been a patient in any hospital in the last 6 months. If partner/spouse/main carer is known to be MRSA positive. Has a long term invasive device placed by healthcare worker e.g. urinary catheter. Has long term invasive device placed by self e.g. urinary catheter. Has chronic skin breaks including pressure sores. Known to be diabetic and has a wound. Known to be receiving renal dialysis. Immuno-suppressed inpatients receiving Chemotherapy, patients with blood disorders with neutrophil count <1 or long term steroid use. Is a healthcare worker from community or acute setting. Patients should be screened by the admitting ward of CHUFT when they are transferred between wards except from transfers from EAU. Patients who have been transferred directly from any hospital including abroad should be screened by the admitting ward. Patients should be screened on admission to the programme, then at monthly intervals thereafter. Patients should be screened prior to insertion of vascular or peritoneal access for renal dialysis. All patients need to be screened on admission to the unit, regardless of where they were referred from. All patients require decontamination regime started on admission and documented on the ITU treatment charts. All patients should be screened at weekly intervals. Procedure: 112a Page 6 of 11

7 How to screen for MRSA colonisation Inform patient and get consent Sites to screen What swabs to use Discuss the procedure and give patients a copy of relevant leaflet ( Screening of patients for MRSA prior to planned surgery or Screening for patients known to be MRSA positive or at risk of acquiring MRSA ) prior to planned surgery or before obtaining consent. Nose(both nostrils, using the same swab) Perineum Any skin lesion If catheter is present catheter specimen of urine Sites of catheters and stomas Sputum if present Cotton tipped bacteriology swabs The swab may be moistened in the charcoal medium or sterile saline and then rubbed over the skin at the appropriate site. Once the swab is taken Record the screen in the patients notes It should be placed into the charcoal medium and then put in a specimen bag. A Microbiology form should be completed using correct source codes, and listing the sites sampled. This form should be sent in the same specimen bag as all the screening specimens from the same patient but use an additional bag/form if there are more than 3 swabs. The screen and form should be sent to the microbiology laboratory. Details of the date and time of the screen should be recorded in the patient s notes by the person performing the screen. How to deal with the results Patients who are MRSA Negative Results of screen to be noted and filed in the patient s record. Patients should be informed of their result at preadmission or when they next attend the hospital Patients who are screened MRSA Positive Emergency admissions The results will be available on the pathology system. Elective admissions Antenatal patients Gynaecology patients The results of elective patients who screened positive will be printed at the Elective Care Centre on a daily basis. In addition, results are available on the pathology system. The results of antenatal patients will be sent to the antenatal clinic. Results will be available on the pathology system. The midwife looking after the patient will organise decolonisation at 38 weeks. Results will be available on the pathology system. Procedure: 112a Page 7 of 11

8 Recording of result Annotation of record PAS Alert Notification of GPs Results of screen to be noted in patient s record and the paper result to be filed in pathology section of patient s notes by staff in the Elective Care centre Notes to be annotated with green MRSA sticker on the alert section of the case notes (a red page at the front of the case notes) or on the inside back cover of old notes by the Infection control team The Infection Control Team will record MRSA Alert in the general alert section of the PAS record The GPs should be notified of any positive results. The microbiology department will send a copy of the report to the GP. Follow up of patients who have screened positive MRSA Positive Patients will be decolonised by the provider team in the community Decolonisation of MRSA Positive Patients The community Infection Control Nurse will receive notification of patients who have screened MRSA positive The Community Infection Control Team will organise for patients to receive decolonisation regime in the community. All patients who are screened positive should be informed of the result and given the leaflet MRSA your questions answered. Any concerns that the patient has should be addressed as fully as possible by PAC, or midwife who may refer to I/C. Patients screened positive should be given a decontamination regime (see appendix 1). This regime should be given within the 18 week pathway. Decolonisation regime for MRSA positive patients Hair Nose Skin Wash at commencement of protocol with an antiseptic shampoo, e.g. 4% chlorhexidine, repeat once more during 5 day treatment period, ideally on day 4 MUPIROCIN (Nasal Prep) t.d.s for 5 days (use Polyfax nasal cream if MRSA is Resistant to Mupirocin) Wash body using 4% aqueous Chlorhexidine (Hibiscrub) for 5 days. Re-screening to check for clearance Re-screening for patients for joint replacement surgery and vascular implant surgery This is not necessary except for patients undergoing joint replacement, and vascular implant surgery. Patients who are MRSA positive in these groups will require screening in the same sites as before. This will be organised by the community decolonisation team. Re-screening should be done two days after their last dose of mupirocin and hibiscrub i.e. at day seven of the decolonisation regime. If these screens are positive, then an additional decolonisation Procedure: 112a Page 8 of 11

9 regime should be given as above. The re-screening process should be repeated. If the screens are again positive, a discussion about the management of the patient should be had between the consultant caring for the patient and the consultant microbiologist. On admission to hospital Ward staff must be aware of the patients MRSA status When making theatre lists The patient s MRSA status should be highlighted by the admitting nurse. If the patient has screened as MRSA positive prior to admission, he/she should be managed as if MRSA positive, despite having received decolonisation. The patient should be isolated in a side room and appropriate infection control precautions started (see MRSA Policy on Trust intranet). Surgeons, theatre staff and the anaesthetists must be aware of the patient s MRSA status and this should be highlighted to staff. MRSA positive patients require special precautions i.e. appropriate antibiotic prophylaxis and additional cleaning after their procedure. Appropriate antibiotic prophylaxis according to patient s MRSA status. See antibiotic prescribing policy for surgery. ( ) On discharge MRSA positive patients should be last on the operating list and the theatre cleaned after the procedure. Patients should be given guidance on caring for their wound. Once discharged the patient s room should be high cleaned according to Trust policy. Evidence base Department of Health, Saving Lives: reducing infection, delivering clean and safe care. Department of Health, Saving Lives: a delivery programme to reduce Healthcare Associated Infection, including MRSA - Screening for Meticillin-resistant Staphylococcus aureus (MRSA) colonisation: A strategy for NHS trusts: a summary of best practice. Department of Health letter: MRSA Screening Operational Guidance gateway ref: Department of Health letter: MRSA Screening Operational Guidance 2 gateway ref: nr11123 The Health Act 2006 (updated January 2008) Code of Practice for the Prevention and Control of Healthcare Associated Infections. Procedure: 112a Page 9 of 11

10 Monitoring of compliance with this policy Compliance with the policy The DIPC will monitor compliance with this policy and will report monthly to the Board the number of elective patients screened and the number of elective procedures performed, presented as a percentage. This data will be provided to the DIPC by the Infection Control Data Manager. Dissemination, implementation and access to this policy This policy will be disseminated to all staff through the management systems of the Trust. Clinic staff will be informed of this policy by the matron for the service. The policy will be implemented by staff appointed to manage the screening, processing and follow up of patients with MRSA Access to this policy will be through the policies and procedures site of the Trust Intranet. Procedure: 112a Page 10 of 11

11 Appendix 1 Patient identified as requiring invasive surgery MRSA Screening Flowchart Patient directed into FFA clinic for anaesthetic assessment and MRSA screening Is patient fitness assessed and swabs taken NO Is patient an inpatient or day case? YES Inpatient daycase request card coded and sent to pathology dept, FFA form completed Pathology dept. report electronically to ECC (within 5 working days) the MRSA +ve patients to be decolonised patient swabbed and assessed at preassessment telephone preassessment undertaken and patient booked into FFA clinic to be swabbed ECC team to document results in patients records. FFA updated. Community infection control team to be notified of positive cases by the laboratory. Is patient a vascular or joint replacement patient? NO No further action required YES Repeat MRSA swab appointment 2 days after decolonisation completed ie on day 7 Only required for vascular or joint replacement patients Update FFA with MRSA details and file in medical records prior to preassessment/admission Procedure: 112a Page 11 of 11