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MANAGEMENT OF PATIENTS WITH MRSA OR OTHER MULTI RESISANT ORGANISMS

VIEWS: 26 PAGES: 21

									Section Eleven

MRSA SCREENING AND MANAGEMENT OF PATIENTS WITH MRSA

Version: 1.0 Committee Approved by: Date Approved Author: Responsible Directorate: Date issued: Review date: Clinical Quality and Patient Safety Group 5th December 2008 Infection Prevention and Control Team Nursing and Quality Standards 5th January 2009 December 2010

Version Control Sheet

Document Title: Policy for MRSA Screening and Management of Patients with MRSA Version: 0.1 Drafts: 0.1, 0.2 etc First approved version V1 Draft reviews of approved versions: V1.1, V1.2 etc Next approved version V2 The table below logs the history of the steps in development of the document. See example below

Version
V0.1 First Draft V1

Date
Oct 2008

Author
Sue Ross, Head of Infection Prevention (HOIP) Sue Ross, Head of Infection Prevention (HOIP)

Status
Draft

Comment
Draft for first discussion

5/12/08

Approved

Approved by Clinical Quality & Patient Safety Group

Standards for Better Health Map Domain: Safety Core Standards C4a C4c NHSLA Risk Management Standards Map Standard 4, Clinical Care, Criterion 9 Performance Indicators Audit of bed management and use of isolation facilities

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CONTENTS
1. 2. 3. 4. 5. 6. 7. 8. 8.1 8.2 8.3 8.4 8.5 8.6 9. Introduction ....................................................................................................... 4 Meticillin Resistant Staphylococcus Aureus ................................................ 4 Routes of Transmission ................................................................................. 4 Risk Assessment ............................................................................................ 4 Infection Prevention and Control Measures ................................................. 5 Treatment ......................................................................................................... 6 Discharge/Transfer of Patients ...................................................................... 6 MRSA Screening and Decolonisation ........................................................... 6 MRSA Screening of Patients on Admission/Transfer .................................. 7 MRSA Screening Sites/Swabs ....................................................................... 7 MRSA Screening and Decolonisation of Health Care Workers ................... 7 MRSA Screening and Decolonisation – Others ............................................ 7 Decolonisation - In-Patients ........................................................................... 7 Decolonisation Regime for In-Patients ......................................................... 8 References ....................................................................................................... 8

Appendices 1. MRSA Care Plan 2. Intercare Transfer Form 3 . MRSA Information Leaflet

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1.

Introduction Antibiotic resistant strains of certain organisms have been emerging in hospitals across the United Kingdom for some years. These organisms have become increasingly resistant to the commonly prescribed antibiotics used within the hospital environment. Control of spread of multi-resistant bacteria including Meticillin Resistant Staphylococcus aureus (MRSA) is necessary to minimise risk to other patients and has been argued as being cost effective.

2.

Meticillin Resistant Staphylococcus Aureus Staphylococcus aureus are Gram-positive bacteria that are found in the normal flora of the nose in 20-30% of healthy people and on the skin. It can be transiently carried on the hands and survives well in the environment in dust. Staphylococcus aureus strains, which are resistant to Meticillin, are referred to as Meticillin-Resistant Staphylococcus aureus and have the potential to be resistant to many other antibiotics. MRSA are no more virulent or pathogenic than Meticillin Sensitive Staphylococcus aureus, they are however more difficult to treat. Most patients from whom MRSA is isolated are colonised with this organism rather than infected. This is when the bacteria does not cause an actual infection, but is present on/in the patients’ body. A proportion of vulnerable patients become infected particularly if they have had a recent operation/invasive procedure, have a malignancy or the presence of an implanted device. These patients then may develop illness such as wound infections, skin infections, urinary tract infections, pneumonia for example. MRSA does not pose a risk to healthy staff or family members or their social or work contacts.

3.

Routes of Transmission The routes of transmission are:
 

Direct contact spread - via the hands of health care workers, patients, visitors or from patient to patient. Indirect spread – via the patient to the environment and from the environment to another patient.

4.

Risk Assessment Patients who have been identified with a multi-antibiotic resistant bacteria either through notification from the laboratory or another hospital are required to be isolated. In the event of a single room not being available, a risk assessment will need to be undertaken to decide which patients are isolated (see Section 10 of NHSWD Infection Prevention & Control Policy). Staff caring for the patient should perform the risk

assessment in consultation with the Infection Prevention Team. The following factors need to be taken into account when performing this risk assessment:
   

Site or specimen from which multi-antibiotic resistant bacteria have been isolated e.g. wound swab, sputum, and tracheostomy Whether the patient is infected or is colonised Susceptibility of other patients on the unit Dispersal – e.g. patients who have leaking wounds, faecal/urinary incontinence, coughing and expectorating or tracheostomies and exfoliating skin conditions

5.

Infection Prevention and Control Measures  Any patient known to be colonised or infected or with a history of MRSA must be isolated in single room accommodation following the Trust’s Isolation Policy, with an infection risk poster displayed on the outside of the sideroom/cubicle door. Ensure the patient and/or relatives are informed and written information/leaflets are provided to them. Hands must be thoroughly washed and dried using soap and warm water or, if hands are visibly clean alcohol hand gel can be used, before and after any patient contact (See Section 2 of the NHSWD Infection Prevention Policy). Disposable plastic aprons must be worn for all direct patient contact and when working in the patients immediate environment. Gloves must also be worn when dealing with blood and/or other body fluids (Refer to Section 2 of the Infection Prevention Policy). Visitors who only have social contact with the patient do not need to wear gloves or aprons, but must clean their hands on leaving the room/bed space. Waste and linen should be dealt with according to the Infection Prevention Policy. Trust policy (See Section 2 of the NHSWD Infection Prevention Policy). All equipment that has been in contact with the patient or their environment should be decontaminated according to the Trust Decontamination Policy (See Section 4 of the NHSWD Infection Prevention Policy). Tourniquets and blood pressure cuffs must be single patient use. Routine cleaning of the patient’s room/bed area and contents must be performed twice a day using a 1000ppm chlorine releasing and detergent agent, e.g. Chlorclean, using disposable cloths, and separate mops (mopheads should not be reused) and buckets, particular attention should be paid to all horizontal surfaces, beds, bed bases, curtain rails etc (MRSA for example can survive for several months on a dusty surface).

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   

Following discharge/transfer of the patient, the room/bed area and its contents must be thoroughly cleaned as above. Bed curtains must also be changed. Efforts should be made to prevent the dispersal of dust, the use of fans should be discouraged. All healthcare workers should protect cuts and abrasions with a waterproof plaster. Healthcare workers suffering from exfoliating skin conditions e.g. eczema should avoid nursing patients with MRSA. Healthcare workers with skin lesions/skin conditions or known to have a MRSA positive sample should seek immediate advice from the Occupational Health Deptartment. If a patient with known multi resistant bacteria dies, the body does not have to be placed in a cadaver (body) bag, standard precautions must still must be followed. The MRSA care plan for each patient identified with MRSA should be completed (Appendix 1)

 

6.

Treatment Advice, if required, regarding the management of patients with MRSA should be sought from the Consultant Microbiologist.

7.

Discharge/Transfer of Patients  If the patient is to be transferred to another ward/hospital the receiving unit and the Infection Prevention Team must be informed beforehand. (Out of hours contact the Consultant Microbiologist via switchboard) If the patient is being discharged into the care of a community health care worker or Care Home, the unit should inform them of the patient’s infectious status using Appendix 2 (Inter Care Transfer Form). Having MRSA does not prevent patients from being discharged to other health/social care facilities.





8.

MRSA Screening and Decolonisation Colonised and infected patients are the primary reservoir of MRSA infection for others. Screening and decolonisation are one of the recommended measures to identify these patients, thereby allowing appropriate measures to be taken to reduce invasive infections and prevent cross infection.

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8.1

MRSA Screening of Patients on Admission/Transfer On admission to the Unit, staff must check and ensure that all patients transferred from MYHT have been screened on their admission. All patients received from other routes (e.g. GP, Nurse referal) will be screened for colonisation within a 4 hour period as part of the admission procedure

8.2

MRSA Screening Sites/Swabs The following sites should be screened within 4 hours of the patients admission:      Nose Axilla Groin or perineum Any open wounds and skin lesions Invasive device sites e.g. intravenous/arterial lines and urinary catheters

ONE swab should be used for both nostrils and one swab for both sides of the groin and one swab for both axilla. If the area is dry first moisten the swab with sterile water or saline. If a large area is being screened ensure the whole surface is swabbed by using a sweeping motion across. Place the swab(s) immediately into the transport media and send to the laboratory requesting MRSA screen. 8.3 MRSA Screening and Decolonisation of Health Care Workers Screening and decolonisation of healthcare workers for infection prevention and control purposes should not be undertaken and would only be advised in certain circumstances by the Infection Control Doctor. 8.4 MRSA Screening and Decolonisation – Others Screening and decolonisation of other groups of people for example parents/family members/carers for infection prevention and control purposes should not be undertaken and would only be advised in certain circumstances by the Infection Control Doctor. 8.5 Decolonisation - In-Patients All patients found to have MRSA following screening or those patients found to have MRSA from samples/specimens taken during their stay on Bevan Unit will require decolonisation treatment. The patient will need to be informed of their result and given an MRSA information leaflet (Appendix 3).

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8.6

Decolonisation Regime for In-Patients   Nasal bactroban – apply the ointment with a cotton wool swab or finger to the inner surface of both nostrils 3 times per day for 5 days Octenisan wash – use neat as a liquid soap and shampoo for 5 days (shampoo hair on day 2 and day 4) Step 1 - Wet skin and hair before application Step 2 - Apply the Octenisan to a disposable wash cloth/wipe Step 3 - Wash the whole body, paying particular attention to the axilla, umbilicus and perineum, observe a contact time of 3 minutes. For hair – apply Octenisan to hands and work well into the hair, observe a contact time of 3 minutes Step 4 – Rinse it all off Step 5 – Dry with a fresh clean towel Clean towels should be used each day and bed linen changed everyday throughout the 5 days of the decolonisation regime. On completion of the decolonisation regime repeat screening is not necessary. The decolonisation regime may not completely eradicate the MRSA; however it will reduce the number of bacterial on the skin and reduce the risk of the patient becoming infected. If patients are found to have MRSA following the completion of their decolonisation regime then a second decolonisation regime may need to be given, however no more than two decolonisation regimes are recommended during the same admission.

9.

References  NHSWD Infection Prevention and Control Policy (2007)  Saving Lives: reducing infection, delivering clean and safe care: Screening for Meticillin – Resistant Staphylococcus Aureus (MRSA) colonisation. A Strategy for NHS Trusts: A summary of best practice. DH 2007  Guidelines for the control and prevention of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities by the Joint BSAC/HIS/ICNA Working Party on MRSA. Journal of Hospital Infection. 2006  The Health Act 2006: Code of practice for the Prevention and Control of Health Care Associated Infections. DH 2006
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Appendix 1 Wakefield District PCT Patient Care Management Plan
Name: ______________________________ Unit No: ________________

PROBLEM:

Patient has been identified as having Meticillin Resistant Staphylococcus aureus (MRSA) To effectively treat and decolonise the patient and prevent the spread of infection to others

NEED:

Site/specimen positive for MRSA 1. 5. 2. 6. 3. 7. 4. 8.

9. 10. 11. 12.

NURSING ACTION:  Isolation – nurse the patient in a single room where possible/dependant upon risk assessment e.g. risks to patient safety. The patient must not be moved out of the single room unless on clinical or safety reasons.  Decolonisation – decolonise the patient as per the policy
Date commenced Day 1 Day 2 Day 3 Day 4 Day 5 Date completed & signature

Treatment regime
(sign appropriate box)

Bodywash; Octensian Hairwash; Octensian Nasal cream; Bactroban  

   

Hand decontamination – decontaminate hands with liquid soap and water or alcohol had gel before and after all patient contact. Protective clothing – aprons should be worn for all direct patient contact. Facial protection (if splashing of body fluid to face) and gloves should also be worn when dealing with blood and/or body fluids. Waste – dispose of waste according to policy. Linen – laundry should be treated as used unless contaminated with blood and/or body fluids as per policy. Decontamination – decontaminate all equipment that has come into contact with the patient as per policy. Environmental cleaning – thoroughly clean the room/bed space with Chlorclean daily and on patient discharge/transfer using disposable cloths and separate mops and buckets. Particular attention should be paid to all horizontal surfaces, bed frame and base, mattress, locker, and curtain rails:
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

- change bed screening curtains if visibly soiled or if patient was a heavy disperser of MRSA e.g. patients with exfoliating skin conditions or a tracheostomy. - prevent the dispersion of dust e.g. by not using fans and shaking used linen. Communication – ensure the patient (or relative/carer if the patient is not capable of understanding) is informed that they have MRSA and are given an information leaflet on MRSA. Discuss with the patient the infection control interventions that will be required. Visitors – do not restrict visiting (including children). Visitors who only have social contact are not required to wear protective clothing, but should be advised to wash their hands or use the alcohol hand gel before leaving. Visits to departments and theatres: Inform the department in advance Ensure any wounds are covered Arrange for the visit to be at the end of a session/working day Arrange with the department so that the patient is only sent for when they are ready and they are returned to the ward immediately after the procedure (do not have the patient sat in the waiting area of the department) Patient Transfers – the patient must only be transferred to other wards within the Trust for clinical reasons. Inform the Infection Prevention and Control Team if the patient is transferred from Bevan Unit. The intercare transfer form must be completed. Antibiotics – contact the Consultant Microbiologist (via Hospital Switchboard) for advice on antibiotics.

Nurses Signature ________________________ Date & Time ________________ References and Further Reading: NHSWD Infection Prevention Control Policies (2007) Date & Time Discussed with Patient/carer specific needs identified to additional care plan Signature and full title

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Appendix 2
CARE TRANSFER FORM Date: ______________________ Dear Colleague Patient details: (insert label if available) Name: Address: Consultant: GP:

Phone number: NHS number: Unit number: Date of birth:

Transferring facility – hospital, ward, care home, community setting: Phone number:

Date of transfer:

Next of kin: Phone number: Aware of transfer: Weight if known

Medication/copy of documentation attached YES / NO Allergies

BMI

OPD appointments /follow up care e.g. District Nurse referral etc

Abilities on transfer where appropriate Please tick No assistance required Mobility Minimal assistance Fully Dependent Equipment required – please comment

Moving/Handling needs Personal Hygiene & Oral Care
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Patient Name: Unit Number: No assistance required Eating & Drinking (include any special diet or if needs assistance / or MUST score if appropriate) Communication (include hearing, sight or speech problems) Minimal assistance

NHS Number: DOB: Fully Dependent Equipment required – please comment

Breathing If oxygen required please specify rate and hours per day _______________________. oxygen ordered: __________________________

Elimination Any aids used – Pads  Catheter  Catheter size ______

Date catheter last changed ______________ Takes aperients – YES/NO _______________ Resting/Sleeping – please specify Date last had bowel movement

Signature of person completing the form: ………………………………………………….
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Print name: ……………………………… ………………………………… Patient Name: Unit Number: Pain Management/Symptom Control

Date:

NHS Number: DOB:

Mental Health Cognition Fully orientated 

Short term memory loss 

Confused 

Please include any presentations prior to transfer:

History of short or long term memory less and wandering:______________________ Level of orientation to time, place & person: _________________________________ Level of understanding/comprehension: ____________________________________ MOOD Any evidence of low mood anxiety or mood fluctuations: _______________________ ____________________________________________________________________

Behavioural State Any issues relating to behaviour prior to transfer: ____________________________ Any risks to self or others as a result of this behaviour e.g. wandering: ______________ Any need for mental health services: _______________________________________ Social and Spiritual needs

Any relevant specialised assessments e.g. SALT, Physio, please include any information or assessments

Additional Information

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Signature of person completing the form: ……………………………………………………………. Print name: ……………………………… ………………………………… Patient Name: Unit Number:
Aetiology of Wound

Date:

NHS Number: DOB:

Date of wound first noted Site of wound

Size of wound Maximum depth and maximum width and depth in cms Wound depth / Grade of pressure Ulcer a) Superficial b) Partial c) Full thickness Stage of healing (%) a) Epithelialisation (pink) b) Healthy granulations (red) c) Slough (yellow) d) Necrotic tissue (black) e) Other Wound margin / surrounding skin a) Health / intact b) Dry / scaling c) Eczema d) Fragile e) Oedematous f) Macerated g) Erythema Odour a) None b) Slight c) Offensive Wound Exudate a) Clear b) Red c) Green d) Yellow Amount a) None b) Low c) Medium 14

d) High / Strike through Infection a) None seen b) Clinical signs present c) Wound swab sent d) Result obtained e) Action taken – please state

Patient Name: Unit Number:
Treatment Plan Frequency of dressing change Cleansing Skin Preparation Primary dressing Secondary dressing(s)

NHS Number: DOB:

Waterlow Risk Assessment Score on Transfer

Level of Risk 10+At risk 15+At risk 20+Very high risk

Pressure Relieving Equipment used in hospital Mattress: Foam Overlay Foam Replacement Air Overlay Air Replacement Other_______________ Cushion: Foam Air / Gel Referral to District Nurses via Single Point of Contact

Pressure Relieving Equipment required for discharge Mattress: Foam Overlay Foam Replacement Air Overlay Air Replacement Other_______________ Cushion: Foam Air / Gel Are Tissue Viability Nurses involved?

Frequency of repositioning Please state repositioning regime whilst in bed

Length of time able to sit out in a chair. Please specify

Dressings supplied Please specify

Date referred:

Yes No

If yes, date last seen …………………… 15

Signature of person completing the form: ……………………………………………………….. Print name: ……………………………… Patient Name: Unit Number: Date: …………………………………. NHS Number: DOB:

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Infection Control Information
Is patient a known infection risk? Has the patient been exposed to others with an infection e.g. diarrhoea and/or vomiting? Yes / No Yes / No

If the answer to the above is no, move onto the next section. If the answer is yes, complete the remainder of this section. Are the Infection Control teams aware of the transfer?  Hospital Team  PCT Team  YAS Team  SWYMT Team     08448 118110 01924 327112 07824 540434 01924 327063

Please identify the confirmed or suspected organism: Organism: Organism: Organism:  Confirmed  Confirmed  Confirmed  Suspected  Suspected  Suspected Yes / No

Does the patient have diarrhoea? (please indicate bowel history for the last week using Bristol stool form scale overleaf Type: 1 2 3 4 5 6 7

Yes / No Is the diarrhoea thought to be of an infectious nature? Other relevant specimen results (including admission screens – MRSA, GRE, C difficile, multiple resistant organisms) Include treatment information e.g. antimicrobial therapy, decolonisation treatment Specimen: Date: Result: Treatment:

Did the patient require isolation? Is the patient aware of their infection status?

Yes / No Yes / No

Signature of person completing the form ………………………………………………… Print name: ……………………………………….. ….………………………..
Infection Control – November 2008

Date

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Infection Control – November 2008

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Appendix 3

Infection Control – November 2008

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Infection Control – November 2008

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Infection Control – November 2008

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