NHS GRAMPIAN
MRSA POLICY FOR
HOSPITAL SETTINGS
June 2003
Grampian NHS Board
Grampian University Hospitals Trust
Grampian Primary Care Trust
TABLE OF CONTENTS
Section PAGE
Aim 1
1 Introduction 1
2 Assessment 1
3 Selective Admission Screening Policy 1
4 Management of MRSA Cases 4
4.2 Laboratory Testing 4
4.3 Treatment of Infection and Decolonisation Protocol 4
4.3.1 Treatment of MRSA infection 4
4.3.2 Treatment of infected wounds 4
4.3.3 Decolonisation of MRSA 4
4.3.4 Decolonisation of normal skin 5
4.3.5 Decolonisation of abnormal skin 5
4.3.6 Colonised wounds 5
4.3.7 Decolonisation of nasal carriage 5
4.3.8 Decolonisation of throat carriage for adults 5
4.3.9 Decolonisation for throat carriage for
children and neonates 5
4.3.10 Urine 5
4.4 Patient Isolation 6
4.5 Decontamination 7
4.6 Clinical Waste 7
4.7 Laundry/Linen 7
5 Communication 7
5.1 With Patients and Relatives 7
5.2 Healthcare Workers 7
5.3 With Other Healthcare Establishments 8
6 Transfer and Discharge of Colonised or Infected patients 8
6.1 Within the Hospital 8
6.1.1. Visit to Outpatients and Specialist
Departments 8
6.1.2. Theatre 8
6.2 Discharge of Patients 9
6.3 Ambulance Transportation 9
6.4 Care of Deceased Patients 9
7 Screening of other Patients and Staff 9
7.1 Hospital Patients 9
7.2 National Health Service Staff 10
7.3 Pre-Employment Screening 10
7.4 Environmental Screening 10
Appendix 1 – Contact personnel 11
Appendix 2 – Screening 12
Appendix 3 – Swabbing Techniques 13
Appendix 4 – Detection and Testing of MRSA 14
Appendix 5 – Allergies/Hazard List 15
Appendix 6 – MRSA Hospital/Ward Transfers 16
Appendix 7 – Discharge Information/Communication 17
Appendix 8 – Patient Information Leaflet 18
Appendix 9 – Staff Information Leaflet 20
Appendix 10 - Definitions 22
2
AIM
This policy aims to ensure prompt identification and effective, appropriate management of
MRSA positive individuals in Grampian.
THIS POLICY MUST NOT BE ALTERED IN ANY WAY. IF YOU HAVE ANY CONCERNS
REGARDING THE SUITABILITY OR APPLICATION OF ANY OF THE FOLLOWING POLICY
CONTACT THE INFECTION CONTROL TEAM (APPENDIX 1)
1 INTRODUCTION
Approximately 30% of the population carry the organism Staphylococcus aureus (S. aureus).
This is a bacterium that is normally found in the nose and on skin. Although most healthy
people are unaffected by it, it does have the potential to cause infection in those who have
severely reduced resistance e.g. some ill patients in hospital.
MRSA (Methicillin Resistant Staphylococcus aureus) is a form of S. aureus. It is transmitted in
the same way, and causes the same range of infections as other strains of S. aureus.
However it has developed resistance to the more commonly used antibiotics. This makes
infections caused by MRSA more difficult and costly to treat, which is why every effort must be
made to prevent its spread.
The majority of individuals are COLONISED that is when the organism lives harmlessly on the
body with no ill effects as opposed to INFECTED which is when the organism penetrates tissue
and causes disease. Further definitions can be found in Appendix 10.
In order to control and minimise the spread of MRSA there must be compliance with the
following:
Standard Precautions (Formerly known as Universal Infection Control Precautions) e.g.
thorough hand hygiene
Cleaning (domestic etc) must be of an acceptable standard
Adherence to Infection Control Policies i.e. Isolation, Clinical Waste, Laundry etc
Education on infection control policy
Strict adherence to antibiotic policies
Minimal movement of patients and staff between wards, units and hospitals
Adequate resources for compliance
2 ASSESSMENT
Patients/clients should be individually assessed in conjunction with the MRSA protocols.
Individual risk factors, such as the number of positive sites, invasive procedures undertaken,
and vulnerability must be considered when deciding courses of action. The appropriate
Infection Control Team will give advice (Appendix 1).
3 SELECTIVE ADMISSION SCREENING POLICY.
Patients/clients from the following categories should be screened (Appendix 2) immediately
on admission / transfer into hospital (Appendix 6):
Known previous MRSA (even if deemed negative/cleared)
Transfer from hospitals /care homes outwith Grampian
Transfers from wards with existing MRSA positive patients
If concerned contact Infection Control Team (Appendix 1)
3
4 MANAGEMENT OF MRSA CASES
4.1 ACTION
Isolate index case. Infection Control Team will authorise the marking of medical notes
(Appendix 5)
Full MRSA screen of index case (Appendices 2 and 3)
When required screen nose, throat, skin lesions and manipulated sites (IV’s etc) of other
patients in the ward area/unit (Screening of other patients and staff Section 7)
Wards must inform the Infection Control Team as soon as known or presumed positive
cases are admitted/re-admitted/transferred (Appendix 6 and 7)
4.2 LABORATORY TESTING- Appendix 4
4.3 TREATMENT OF INFECTION AND DECOLONISATION PROTOCOL
It is essential that current local policy be adhered to however in the unlikely event of any
adverse reaction please stop the treatment and seek advice promptly.
4.3.1 Treatment of MRSA infection
Patients who demonstrate clinical signs of infection will require treatment with the
appropriate antibiotics. The agent used will depend on the site of infection. If the individual
is receiving systemic antibiotics these should be completed before undertaking a full MRSA
screen. Once treatment is complete, a full MRSA screen should be undertaken to establish
which sites, if any, are still positive (see Appendix 2).
Advice can always be obtained from a microbiologist.
It is important that the treatment should be based on the current set of full MRSA screening
swabs.
It is easier for both patients and staff if the treatment for the identified sites all commence at
the same time
4.3.2 Treatment for infected wounds
Where possible all wounds should be covered by an occlusive dressing
Advice on appropriate systemic antibiotics should be sought from the Medical
Microbiologist.
Do not apply
Topical treatments to acute infected surgical wounds
4.3.3 Decolonisation of MRSA
Appropriate decolonisation should be considered when the patient’s clinical condition allows
e.g. wounds, tracheostomy sites are healed, lines are removed. Once decolonisation is
complete, a full MRSA screen should be undertaken to establish which sites, if any, are still
positive (see Appendix 2).
The eradication procedure used will depend upon which body sites are colonised with
MRSA.
Site Action
Nasal carriage only Nasal decolonisation only
Throat carriage Nasal and throat decolonisation
Axilla or groin carriage Nasal and body decolonisation
4
4.3.4 Decolonisation of NORMAL skin
Skin products should not be diluted. Advice can be sought from the Infection
Control Team
st
1 Line – Direct application of 4% chlorhexidine (Hibiscrub) to all skin using
a damp disposable cloth or freshly laundered flannel, daily for 5 days i.e.
use chlorhexidine as a soap substitute and rinse off. Wash hair twice in the
5-day period with chlorhexidine.
Alternatives include 2% triclosan (aquasept) or 7.5% povidine-iodine.
Hair conditioners and body lotions can be used after treatment if required.
4.3.5 Decolonisation of ABNORMAL skin
As it is difficult to eradicate MRSA from abnormal and/or chronic skin conditions,
treatment should not be attempted until advice has been sought from a
dermatologist or medical microbiologist,
4.3.6 Colonised wounds
Seek advice from Infection Control Team or tissue viability team.
4.3.7 Decolonisation of nasal carriage
st
1 Line – Mupirocin (“Bactroban”) nasal ointment 3 times daily to inner
surface of each nostril for 5 days
Apply with cotton wool bud
In the event of mupirocin resistance:
“Naseptin” cream (0.5% neomycin plus 0.1% chlorhexidine) provided the organism
is neomycin susceptible . Further advice can be sought from Infection Control Team
(Appendix 1)
4.3.8 Decolonisation for throat carriage for adults
Oral hygiene is very important as teeth/dentures have been known to harbour
MRSA.
st
1 Line adults - Oral trimethoprim 200mg twice daily and 500mg fusidic acid
tablets twice daily for 5 days. If using fusidic acid liquid 750mg, twice daily
for 5 days.
For children and neonates please contact the Medical Microbiologist
(Appendix1)
In the event of fusidic acid resistance or patient intolerance:
Oral rifampicin 600mg once daily and trimethoprim 200mg twice daily (if
susceptible) for 5 days.
Patients may require an anti-emetic.
4.3.9 Decolonisation for throat carriage for children and neonates
Before treating children and neonates advice must be sought from the Medical
Microbiologist (Appendix1)
4.3.10 Urine
Elimination of MRSA from urine is not usually possible in the presence of a urinary catheter.
If treatment is required discuss with the Medical Microbiologist and the clinician managing
the patient.
5
4.4 PATIENT ISOLATION
Source/Standard isolation should be instituted for affected patients in all clinical areas. (For
further information see local Trust Isolation Policy)
If you have any concerns regarding the suitability or application of isolation
procedures contact the Infection Control Team (Appendix 1)
Standard isolation should preferably be in a single room. The following may be suitable on
the advice of the Infection Control Team:
- In a designated ward or part of ward
- Cohort nursing
There should be an information card with “Isolation Practices Apply” on the door.
The door should be closed at all times. If it is felt this is detrimental to the well being of
patient this may be relaxed after consultation with the Infection Control Team
All health care workers as part of normal patient isolation and standard infection control
practice should follow Standard Precautions (Formerly known as Universal Infection
Control Precautions). It is essential that appropriate hand hygiene is carried out at all
times, especially when there is handling of the patient, their immediate environment and
on removal of protective clothing.
Individual specific circumstances should be evaluated by the Infection Control Team and
appropriate advice given. This may include extending the use of disposable gloves
(vinyl/latex) and disposable plastic aprons where there is handling of the patient, their
immediate environment.
Disposable aprons, gloves and alcohol hand rub should be positioned outside the
isolation room/bed space. Protective clothing must be donned outside the room/bed
space, removed inside the room/bed space and disposed of in the clinical waste bag.
Visitors need not wear protective clothing if they only have social contact with the patient
but must wash hands on leaving the room/bed space.
Essential equipment only should be kept in an isolation room. Disposable items should
be discarded into clinical waste bags after use. Waste bags should be sealed before
leaving the room/bed space. Non disposable items should be decontaminated before
removal from the room/ bed space
Linen should be treated as infected and placed in red alginate bags. These should be
sealed before leaving the room/bed space. The red alginate bag should be placed in a
red plastic bag for transportation to laundry.
Use normal crockery and cutlery utensils. Disposable crockery and cutlery are not
required.
Patients may use bath /shower if appropriate preferably after other patients. Facility to be
decontaminated after each use (see local Trust Cleaning & Disinfection Policy)
All nursing and medical notes and charts must not be kept in the patients room/bed space
All staff from other departments/clinical areas eg Physiotherapy, Radiology, should report
to the nurse in charge before entering the room.
6
4.5 DECONTAMINATION
(For further information see local Trust cleaning and disinfection Policy)
The ward staff should inform domestic staff if there is an isolation room in use. The room
must be cleaned last with designated equipment.
Liquid soap, 70% alcohol hand rub and antiseptic hand wash should be available for staff
hand disinfection after contact with an affected patient.
Equipment such as stethoscopes should be designated for the isolated patient only or be
suitably decontamination before being used out of the isolation area.
Equipment to be used on other patients must be effectively decontaminated before re-
use. Clean with hot water and detergent, then wipe with 70% alcohol solution.
Decontamination of special beds and mattresses - follow the manufacturers' guidelines or
contact the Infection Control Team.
Following the discharge of an MRSA patient the room must be cleaned thoroughly using
general purpose detergent and hand hot water.
Rooms can be reused immediately once terminal isolation cleaning is complete and the
room is dry.
4.6 CLINICAL WASTE
For further information see local Trust Clinical Waste Policy
All disposable waste generated from the room should be treated as ‘Clinical Waste’. All
clinical waste bags must be sealed before removal from the room/ bed space. Trust policy
for the disposal of clinical waste that must be followed at all times.
4.7 LAUNDRY / LINEN
In hospital all clothing and linen should be treated as “infected” and placed into red
alginate bags which should be sealed prior to being placed in a red plastic bag for
transportation to laundry.
No laundry should be washed in the clinical area.
All clothes, night clothes and bed linen to be changed daily
Privacy screens/bed curtains should be laundered when the patient is deemed clear of
MRSA and/or discharged prior to the room/area being re-used.
Window curtains/blinds should only be changed when visibly soiled unless there is an
environmental risk from
- patients with heavy skin shedding eg psoriasis
- contamination with secretions
- long length of stay
5 COMMUNICATION
Ensuring good communication about a patient’s MRSA status is a responsibility of all staff
associated with patient care.
5.1 WITH PATIENTS AND RELATIVES
Patients found to be colonised or infected with MRSA should be informed of this. The patient
and their visitors must have the implications and their subsequent care explained to them. The
advice to the patient should include the importance of good personal hygiene particularly
thorough hand hygiene. Contact the Infection Control Team if any doubt arises. A
patient/relative information sheet is available (Appendix 8)
5.2 HEALTHCARE WORKERS
Other members of the Healthcare Team e.g. OT, Physiotherapists, Hotel Services, etc must
also be informed so that appropriate precautions can be taken to prevent the spread of MRSA.
A staff information leaflet is available (Appendix 9)
7
5.3 WITH OTHER HEALTHCARE ESTABLISHMENTS
Communication of accurate, up-to-date information about a patient's status and treatment
must be provided to the relevant receiving healthcare establishment (Appendix 7).
6 TRANSFER AND DISCHARGE OF COLONISED OR INFECTED PATIENTS
Inter hospital and ward to ward movement should be avoided, or kept to a minimum where
possible.
6.1 WITHIN THE HOSPITAL
Normal patient care/rehabilitation should not be restricted for those found to be colonised with
MRSA
6.1.1 VISIT TO OUT-PATIENTS AND SPECIALIST DEPARTMENTS
MRSA infection/colonisation should never compromise the patient’s care.
Keep visits to other departments to a minimum. If the visit is necessary for the care of the
patient make prior arrangements with the department staff.
When transferring patients;
Occlude any lesions with an occlusive dressing.
Staff should follow Standard Precautions (Formerly known as Universal Infection
Control Precautions) at all times. Thorough hand hygiene is essential. During
transfer gloves and aprons should only be used when in contact with blood
and body fluids.
Treat linen as ‘infected’.
Clean chair/trolley after transfer before using on another patient.
In the department
The patient should be treated at the end of the session.
The patient should attend the department when it is ready to undertake the
procedure, so as little time as possible is spent there.
Staff should follow Standard Precautions (Formerly known as Universal Infection
Control Precautions). Thorough hand hygiene is essential.
Numbers of staff and items of equipment used should be kept to a minimum.
Surfaces should be cleaned after contact with the patient, see Cleaning,
Disinfection and Sterilisation Policy.
Linen should be treated as infected linen.
The transfer chair or trolley should be kept in the department and used for the
return journey.
Clean chair or trolley after return and before use by another patient.
6.1.2 THEATRE
MRSA should preferably be eliminated prior to surgery. If this is not possible the following
should be performed;
Shower/bathe the patient using an antiseptic detergent solution (directly
apply the solution)
Cover the affected lesion with an occlusive dressing where possible.
Clean the adjacent area with 70% alcohol.
Apply nasal mupirocin before the operation if the patient is a nasal carrier
The need for prophylaxis with Vancomycin or Teicoplanin should be
discussed with a medical microbiologist
The patient should be treated at the end of the list.
If possible segregate MRSA positive patients during recovery
Theatre surfaces in contact with or near the patient should be
decontaminated in line with theatre cleaning protocol
8
This should be part of normal theatre cleaning schedule
6.2 DISCHARGE OF PATIENTS
Carriers should be discharged promptly from hospital when clinical condition
allows
The General Practitioner and other community services must be informed of
a patient’s current positive MRSA status as part of the discharge information
process by doctors letter/telephone and by ward staff prior to discharge
(Appendix 7).
Staff at a care home should be informed in advance of discharge but
carriage of MRSA is not a contraindication to admission to these
establishments (Appendix 7).
The Infection Control Team should be informed of a MRSA patients’
transfer/discharge (Appendix 7).
6.3 AMBULANCE TRANSPORTATION
The Scottish Ambulance Service classifies patients who are MRSA positive into two
categories
Category 1
Most patients colonised by MRSA or who have infected wounds or skin lesions which
are covered by an occlusive dressing may be transported with others and require no
special precautions.
Category 2
Patients who are heavily colonised by MRSA and are considered to be heavy
shedders, eg have severe psoriasis or eczema,
Patients who have infected exposed wounds or skin lesions eg external
fixation devices, burns etc should be transported by themselves.
Patients who are clinically infected
Patients who are colonised in the upper respiratory tract and present with
active symptoms, eg cough
Patients in category 2 should not be transported with others. The Ambulance Service
will implement appropriate precautions applicable to this category.
6.4 CARE OF DECEASED PATIENTS
The precautions for handling these patients are the same as when alive (ie
Standard Precautions (Formerly known as Universal Infection Control
Precautions)
Lesions should be covered with an impermeable dressing
Body (cadaver) bags are not necessary since there is no risk to healthy
contacts unless the deceased patient has extensive burns, skin loss and/or
extensive discharging wounds
There are no contraindications for Last Offices including viewing
7 SCREENING OF OTHER PATIENTS AND STAFF
7.1 HOSPITAL PATIENTS
In open wards normally only the patients occupying the beds immediately
next to the affected patient should be screened
Where the patient is in a bay the other patients occupying the bay should be
screened
9
7.2 NATIONAL HEALTH SERVICE STAFF
Exclusion from work to be discussed between Infection Control Team and the
Occupational Health Service
When staff screening is required the Occupational Health Department should
perform it.
Where possible screening should occur at the beginning of a shift before any
contact with affected patients.
Initial screen should be of the nose and throat (and skin lesions where
relevant)
Staff shown to have nasal or skin lesion carriage should also be screened for
throat, axilla and groin carriage
Staff carriers should be treated according to the eradication protocol
depending on sites of colonisation
When a member of staff is identified as carrying MRSA the decision as to
whether they should continue to work will be taken after discussion with the
Infection Control Team and their future management will be followed up by
the Occupational Health Service
7.3 PRE-EMPLOYMENT SCREENING
Targeted screening of new members of staff will be carried out at the discretion of the
Occupational Health Service
7.4 ENVIRONMENTAL SCREENING
This may be instigated by the Infection Control Team if felt necessary.
10
Appendix 1
CONTACT PERSONNEL
Organisation Name & Title Number
NURSING
Grampian University Anne Smith, Infection Control 01224 552118 Ext 52118 Bleep
Hospital Trust Nurse 2313
ARI, Foresterhill Diane Pacitti, Infection Control 01224 559431 Ext 59431
Woodend Hospital Nurse Bleep 3443
Frances Murray, Infection Control
Nurse
Grampian University Hilarie Fryer, Infection Control 01343 543131 Ext 67571
Hospital Trust (Dr Grays) & Nurse Bleep 07623 810848
Grampian Primary Care
Trust (Moray)
Grampian Primary Care Roy Browning Infection Control 01224 663131 Switchboard
Trust Nurse 01224 556747 Ext 56747
Louise McBeath Infection Control Bleep: 07699 616196
Nurse
NHS Grampian Jayne Leith, Public Health Infection 01224 558636 Ext 58636
Health Protection Team Control Nurse
Summerfield House Fiona Browning, Public Health 01224 558539 Ext 58639
2 Eday Road Infection Control Nurse
Aberdeen AB15 6RE
Medical Microbiologist
Grampian University Dr T M S Reid, Consultant 01224 681818 Switchboard
Hospitals Trust & Microbiologist 01224 553507 Ext 53507
Grampian Primary Care Dr I M Gould, Consultant 01224 554952 Ext 54952
Trust (Aberdeen & Elgin) Microbiologist
Foresterhill, Aberdeen
Public Health Doctors
Grampian NHS Board Dr Helen Howie, Consultant in 01224 558520 Ext 58520
Health Protection Team Public Health Medicine (CD&EH)
Summerfield House
2 Eday Road Dr Arun Mukerjee, Consultant in
Aberdeen AB15 6RE Public Health Medicine (CD&EH) 01224 558520 Ext 58520
11
Appendix 2
SCREENING
TECHNIQUE: Swabs should be moistened with sterile saline and rubbed firmly over the
area to be screened. Send promptly to the Microbiology Laboratory.
Label as “Known MRSA screening swabs”
MRSA Swab Sites
1. If MRSA is initially identified from a routine
swab or specimen, i.e. urine, wound, etc., then
a full MRSA screen should be undertaken. A
(Send as “known MRSA”) B
2. A full screen includes the following:-
A) Nasal swab (where suitable, use
one swab for both nostrils)
B) Throat swab (back of throat)
C) Axillae (use ONE swab only for left and right)
D) Groin (use ONE swab only for left and right) C
The following should also be included as
part of a full screen (if applicable):-
E) Individual wounds/lesions or abnormal
skin (e.g. eczema), also include peg/
gastrostomy sites.
F) A CSU (if patient catheterized).
G) Please label all swabs accurately and consistently
including description and site.
D
3. Once a full screen has been undertaken to establish
MRSA status DO NOT undertake further swabbing until
MRSA treatment or decolonisation has been undertaken.
4. Post-treatment swabbing should commence at
least 48 hours after treatment/decolonisation
has finished. This comprises of three full MRSA
st
screens at least 48 hours apart (GUHT 1 results must be
nd rd
negative before 2 and 3 sets are taken).
5. Once three consecutive full MRSA post-treatment
screens are identified as negative (all individual
swabs) then a patient is deemed CLEAR of MRSA.
Please make sure that clearance of MRSA is confirmed by
Microbiology or the Infection Control team.
6. Please allow at least three working days for results.
12
Appendix 3
SWABBING TECHNIQUES
Nasal swab
Nose
Dip the swab in sterile saline/water
and swab round both nostrils using
the same swab.
Throat
Rub the back of the throat firmly
with a swab. (Do not swab other
areas of the mouth unless
requested).
Throat
Rub the back of the throat firmly
with a swab. (Do not swab other
Throat areas of the mouth unless
Swab requested)
Axillae / Groin
Using a non-touch technique, dip the swab in sterile saline/water and swab the area required. One
swab can be used for both axillae and another swab for both groins.
Wounds
Dip the swab in sterile saline/water, then zig-zag and rotate it across the wound. Do not let the
swab touch the surrounding skin. Send a sample of exudate or pus if present.
Clearly identify the wound type, location, etc. Use the same identification details each time e.g.
“sacral sore left buttock”
Abnormal Skin (e.g. eczema, etc)
Dip the swab in sterile saline/water then rotate the swab over the abnormal skin area.
Clearly identify the abnormal skin area (i.e. type, site, etc). Use the same identification details each
time.
13
Appendix 4
DETECTION AND TESTING OF MRSA
MRSA Screen
Each specimen is processed individually
Plate onto ORSAB agar (Oxacillin Resistance Screening Agar Base)
Incubate at 37ºC for up to 48 hours
Identify and test colonies of S. aureus (see below)
Routine isolates
All isolates of S. aureus are tested for susceptibility to methicillin using oxacillin 1mg disc
on Mueller Hinton agar at 35C for 16 –18-hours
Isolates showing reduced zone size compared to the susceptible control or colonies within
the zone should be tested further.
Identification and Testing of MRSA
Confirm as S. aureus by repeat coagulase test
DNAse test
Disc susceptibility to oxacillin co-trimoxazole
penicillin linezolid
erythromycin quinupristin
clindamycin rifampicin
tetracycline ciprofloxacin
gentamicin
Confirm if necessary as oxacillin resistant by E test (mic mg/L)
Phage typing takes place in a reference laboratory. Note: Isolates from patient
known to have MRSA need only be confirmed as S. aureus and grow on ORSAB
agar (Oxacillin Resistance Screening Agar Base)
Reporting
The duty doctor and the Infection Control Nurse should be informed as soon as a new
case of MRSA is suspected.
The first isolate from each patient should be reported “Growth of Methicillin resistant
Staph. aureus” with full susceptibilities.
Subsequent isolates should be reported referring to previous specimens for
susceptibilities.
14
Appendix 5
ALLERGIES/HAZARD LIST
NOTE: If important clinical problems arise that are potentially relevant to the future care of this
patient, they MUST be recorded here.
Examples include:
adverse drug reactions
difficulty with intubation
transmissable diseases, such as HIV or Hepatitis
colonisation by antibiotic resistant organisms
ALLERGIES NOTES BY HAZARD YEAR
FILING SEQUENCES
The contents of the medical record are divided into FOUR groups for filing purposes
GROUP A Correspondence, letters and summaries
GROUP B Written case records, Anaesthetic Consent and Operation
GROUP C Investigation reports
GROUP D Nursing, Drug Sheet Charts
There is an index divider in front of each of the above groups of documents, the Master
Registration Card serving for Group A. The instructions for filing within the group are
printed on the divider.
The MASTER REGISTRATION CARD (which contains the Index of Contents on the
reverse side) should always be the first document visible when opening the record.
IMPORTANT
The filing sequences laid down must be strictly adhered to by all users of the record
15
Appendix 6
MRSA HOSPITAL/WARD TRANSFERS
The receiving ward / hospital must be informed of the known (or suspected)
current MRSA status of the patient (including any screening undertaken).
If a patient has been screened for any reason (e.g., as a contact)
the receiving ward / hospital must be informed.
PATIENT
Is the patient known / suspected
to be affected with MRSA? Or has
been previously positive and deemed
clear
YES NO
Has the patient shared a room with a
known or suspected MRSA patient?
Can the receiving ward/
hospital isolate the patient?
IMPORTANT
Standard isolation should preferably YES NO
be in a single room. For further
information see paragraph 4.4. or
speak to Infection Control Team
Has the patient been Patient can be transferred
screened? without MRSA screening
YES NO
NO
Speak to Infection Are the results available? Screen as
Control Team Policy
YES
Positive Negative
Transfer and isolate
as MRSA Policy Isolate to
bed space
Treat/Decolonise in
accordance with MRSA
Policy
For further information contact the Infection Control Team or Medical Microbiologist
16
Appendix 7
Discharge/ Admission Information / Communication
When a known or suspected MRSA patient is due for admission and/or discharge/transfer the following
information should be relayed to the receiving establishment:
Patient Name (Date of Birth and Identification Number), MRSA Status (Positive sites), Treatment/
Decolonisation Details (date treatment commenced) and any screening undertaken.
Communication Channels
Patient from: Home / Other Care Home
Community Hospital / Ward
Information to GP / District Home / Care
Ward Staff Manager Matron
be given by: Nurse (Nursing / Medical) / Staff
Information to
be passed to
receiving ward ADMISSION
prior to
admission.
IN-PATIENT HOSPITAL
Information to be passed
to receiving area prior to DISCHARGE / TRANSFER
discharge / transfer)
Ward Staff
(Nursing / Medical)
Patient Home / Other Nursing Residential
to: Community Hospital / Ward Home Home
Information to be GP / District Ward Staff Matron / Home / Care
given to: Nurse (Nursing / Medical) Staff Manager
If a patient is identified as being positive after discharge, information must be passed on to the
appropriate person by the Infection Control Team.
17
Appendix 8
Can it be treated?
Patient Information Leaflet
Some antibiotics are still effective against
MRSA but they are very powerful and For further advice regarding
may cause side effects. Because of this MRSA please contact the
they are reserved for patients with serious trained ward staff, or the
infections such as bone infections and Home Manager
septicaemia (blood poisoning) etc.
It is essential that we extend every effort MRSA
to prevent the spread of this germ rather
than depend on treating it with antibiotics. (Methicillin Resistant
NHS Grampian Staphylococcus
Area Control of
Infection Committee Aureus)
May 2003
Patient/Relative
Information
Leaflet
Issued by the Grampian NHS Board
Health Protection Team
Grampian NHS Board Grampian University
Summerfield House, 2 Eday Road Hospitals NHS Trust
Aberdeen AB15 6RE Grampian Primary Care NHS
Tel 01224 558520
Fax 01224 558566
Trust
18
What is MRSA? Is MRSA harmful? What precautions should be taken
Many people are unaffected by
MRSA is a germ (a bacterium called Thorough handwashing, ensuring the
Staphylococcus aureus, but when symptoms
Staphylococcus aureus) which has web spaces and finger tips are cleaned,
are present they usually take the form of boils,
become resistant to many antibiotics with soap and water followed by careful
wound infections and urinary tract infections
normally used to treat infections. This hand drying
(particularly in patients with a catheter). In
has happened in part as a result of hospital it is necessary to prevent the spread
inappropriate use of antibiotics over the after visiting the toilet
of MRSA to areas where seriously ill patients
last 30 years or so. are cared for due to the difficulty of treating the
skin to skin contact
infection with antibiotics.
Staphylococcus aureus can normally be with hospital patients
found on the skin, the groin area, and in The reason that MRSA causes no problems in
the nose and throat and for the most part contact with surfaces
some people and infection in others is unclear
causes no problems. Under certain which may have
but is probably related to additional underlying
circumstances Staphylococcus aureus MRSA on them,
medical conditions, eg after an operation. For
(and MRSA) can be pathogenic which eg. wound dressings
this reason the presence of MRSA in hospitals
means that it is able to cause infection. is taken more seriously.
handling catheters or
catheter bags
Fit, healthy individuals are unlikely to develop
How does it spread? an infection caused by MRSA and if they do it
and before
is likely to be a mild wound infection which
would probably clear up spontaneously without
visiting ill patients in
MRSA is like any Staphylococcus aureus antibiotics.
hospital
in that it can be carried in the nose, throat,
skin and in the groin areas without handling catheters or
causing infection. This is called catheter bags
colonisation. MRSA is generally spread Household and personal laundry
on the hands when hands are not feeding the very
thoroughly washed. The germs can be young and elderly
spread from the nose and throat for During your stay in hospital we would ask
example through coughing, sneezing. that all your personal laundry is taken home All surfaces should be dusted regularly
to be washed. using a damp cloth to prevent the build
MRSA can also survive in the up of dust
environment in dust that is largely made At home all laundry should be washed at the
up of human skin scales. If dust is hottest temperature possible for the fabric. Soiled dressings should be placed in a
allowed to collect the germ can survive for Laundry does not need to be washed plastic bag for disposal and hands
long periods and it is possible for staff and separately. As always, hands should washed thoroughly.
patients to become colonised from this thoroughly washed after handling soiled
source. laundry.
MRSA is extremely unlikely to cause
problems in healthy people living at home. 19
Appendix 9
Staff Information Leaflet
I’m p re g na n t, w ill it h a rm m y b ab y ?
For further advice
M R S A is n o m o r e lik e ly to h a r m a b a by in t h e
regarding MRSA contact
your Infection Control
u t e r u s ( o r o u t o f it ) t h a n a ny o t h e r S t a p h . a u r e u s .
T h e s e o r g a n is m s a r e c a r rie d o n t h e s k in by a Nurse MRSA
c o n s id e ra b le p r o p o r t io n o f t h e p o p u la t io n a n d .
a r e n o t a s s o c ia t e d w it h d a m a g e t o o r lo s s o f t h e
fo e tu s . (Methicillin Resistant
Staphylococcus
W h a t a b o u t m y f a m il y
? NHS Grampian
Aureus)
Area Control of
Infection Committee
F a m ily m e m b e rs a t h o m e a re a t n o m o r e ris k o f
a c q u ir in g in fe c tio n , n o m a tte r w h a t th e ir a g e ,
fr o m M R S A th a n fr o m o rd in a r y S ta p h . a u re u s
May 2003 Staff
th a t m a n y o f th e m w ill b e c a r r y in g . B e c a u s e
th e y a r e n o t e x p o s e d to th e a n tib io tic s e le c tio n
Information
p r e s s u r e s o f h o s p ita ls th e y a r e v e r y u n lik e ly to
b e c o m e c o lo n is e d w ith M R S A . Leaflet
Grampian NHS Board
Grampian University Hospitals NHS
Issued by the
Trust
Health Protection Team Grampian Primary Care NHS Trust
Grampian NHS Board
Summerfield House, 2 Eday Road
Aberdeen AB15 6RE
Tel 01224 558520
Fax 01224 558566
20
What type of infections does it
How does it spread? cause?
What is MRSA? MRSA is likely to cause the same type
MRSA is like any Staph.aureus. It can be of infections as ordinary Staph.aureus.
MRSA is Staphylococcus aureus resistant to carried in the nose, throat and/or on the skin of These are usually infections of the skin
all lactam drugs including, methicillin, people without causing any infection such as wound infections or boils.
flucloxacillin, penicillins, cephalosporins and (colonisation). Failure to follow normal hygiene Occasionally it may cause urinary tract
all related drugs. Some strains are, in procedures such as washing hands after infections and more rarely may cause
addition, resistant to other groups of antibiotics examining a patient or changing dressings etc. deep infections such as abscesses,
such as Macrolides (eg Erythromycin), may result in spread of the organism, on the bone infections or septicaemia. It is
Aminoglycosides (eg Gentamicin) and hands, to other patients. this last group in particular that can be
Quinolones (eg Ciprofloxacin) extremely difficult to treat.
MRSA can also survive in the environment.
Dust is largely made up of human skin scales,
Where has MRSA come from? ordinary Staph.aureus and MRSA can be shed
from carriers on these skin scales and survive Will MRSA harm me?
As a result of heavy use of antibiotics over the for long periods if dust is allowed to collect. It is
last 30 years or so some strains of possible that patients and staff may then Fit healthy individuals are unlikely to
Staph.aureus have become resistant to many become colonised from this source. develop infections due to MRSA. It
antibiotics. The continued use of antibiotics they do they will most probably be
results in these resistant strains being selected Some people are heavy shedders of superficial wound infections which often
out in hospital bacterial populations. Staph.aureus. If the strain they carry is MRSA clear without antibiotics anyway.
this may be the source of the spread of the
organism. Even with good hygiene practice if There is concern about hospital in-
Does it matter?
an individual member of staff carried MRSA in patients developing infections because
their nose they may spread the organisms to they are already unwell and debilitated
There is no difference between MRSA and
patients while examining them or changing and therefore more likely to acquire
ordinary Staph.aureus - both are potentially
dressings. infection. Also they may be subjected
pathogenic ie able to cause infection.
However when MRSA does cause an to invasive procedures such as
infection this can be very difficult to treat How do I stop MRSA spreading? catheterisation which increases the risk
because it is resistant to most available of infection.
antibiotics. Often the only agent active
against MRSA is Vancomycin that has to be As the most likely way of spreading MRSA is on Finally patients are often receiving
given intravenously and is potentially toxic. your hands, thorough hand washing using soap antibiotics which, by killing their normal
It is therefore better to control the spread of and water followed by careful hand drying after bacteria, allow resistant organisms such
this organism, and minimise the risk of any contact with patients or potentially as MRSA to colonise their skin.
patients developing an infection. contaminated surfaces, is the best way to
minimise the risk of spread. It is also important
to clean (damp dust) all horizontal surfaces,
push buttons etc regularly to prevent build up of
dust where MRSA (or ordinary Staph.aureus)
may persist.
21
Appendix 10
Definitions
Colonisation colonisation is when the organism lives harmlessly on the body with no ill effects
Infection is when the organism penetrates tissue and causes disease (usually when the
skin is breached e.g. due to surgery, or when the immune system is impaired
e.g. due to an underlying medical condition).
Systemic relating to or affecting the body as a whole, rather than individual part and
organs
Agar gel medium to used to culture bacteria
NB The majority of MRSA carriers are ‘colonised’ as opposed to ‘infected’
22