Cumbria Northumberland, Tyne and Wear NHS Foundation Trust IPC-PGN-21 – Management of MRSA in Hospital – V04 Iss 2 – Oct 19 Part of CNTW(C)23 – Infection, Prevention and Control Policy

Infection Prevention and Control Practice Guidance Note Management of MRSA in hospital – V04

Date issued Issue 1 – Mar 2018

Issue 2 – Oct 2019

Planned review Mar 2021 IPC-PGN 21- part of CNTW(C)23 –

Infection, Prevention and Control Policy

Issue Notes This guidance replaces all similar guidance issued by the former organisations.

Author/Designation Kay Gwynn – Modern Matron (Infection Control)

Responsible Officer / Designation

Anne Moore Group Nurse Director Safer Care

KEY POINTS

Practice Guidance Notes form part of the Trust’s Infection Prevention and Control policy, and it is expected that staff will follow the guidance contained within them unless there is a compelling reason to deviate from it. Such reasons should be documented whenever the circumstance occurs and notified to the IPC team so that modifications to future editions can be made if necessary

MRSA is commonly found on routine screening but this does not itself indicate infection which needs treatment

Attention to standard universal precautions and simple infection control precautions can prevent the transmissions of MRSA

The presence of MRSA does not bar service users from discharge or access to other services, when simple precautions are followed

Good communication is essential in the successful management of a service user with MRSA

Section Content Page No:

1 Introduction 1

2 Terminology 1

3 Patients at risk of Infection from MRSA 2

4 Routes of Acquisition 3

5 Roles and responsibilities 3

6 Patient screening 3

7 Management of patients with MRSA colonisation or infection 4

8 Specific patient management 6

9 Visits to Outpatient departments 6

10 Transfer to other departments/areas 7

11 Transfer to another hospital outside the Trust 7

12 Ambulance Transportation 8

13 Managements of Deceased Patients 8

Cumbria Northumberland, Tyne and Wear NHS Foundation Trust IPC-PGN-21 – Management of MRSA in Hospital – V04 Iss 2 – Oct 19 Part of CNTW(C)23 – Infection, Prevention and Control Policy

14 Management of Staff 8

15 Communication with patients and relatives 8

16 Communication between organisations 9

17 Discharge Planning 9

18 References 9

Appendices – attached to PGN

Document No:

Description

Appendix 1 MRSA DECOLONISATION PROGRAMME

Appendix 2 5 DAY ANTIMICROBIAL WASH PROTOCOL

Cumbria Northumberland, Tyne and Wear NHS Foundation Trust IPC-PGN-21 – Management of MRSA in Hospital – V04 Iss 2 – Oct 19 Part of CNTW(C)23 – Infection, Prevention and Control

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1 Introduction

Staphylococcus aureus is a common germ that is found on the skin and in the nostrils of about a third of healthy people

MRSA stands for meticillin-resistant Staphylococcus aureus. MRSA is a variety of S. aureus that has developed resistance to meticillin (a type of penicillin) and some other antibiotics that are used to treat infections. It is rarely found in people who have never been in healthcare establishments. MRSA is not new. It was first identified in the 1960s

If bacteria invade the skin or deeper tissues and multiply, an infection can develop. This can be minor e.g. spots, boils and other skin conditions or serious, such as septicaemia, wound infections or pneumonia

This document presents revised guidelines for the control of MRSA within Cumbria Northumberland, Tyne and Wear NHS Foundation Trust (the Trust). The aims of controlling MRSA are to:

o Reduce the risk of MRSA infection as far as possible

o Emphasise the need for high-quality routine infection control practices amongst staff at all times

This guidance note applies to all healthcare professionals within the Trust, in the care and management of patients with MRSA

2 Terminology – colonisation, infection and bacteraemia.

2.1 There is frequently confusion over some of the terminology used in describing the presence of MRSA

MRSA Colonisation is when a person carries S. aureus (including MRSA) on areas of their body such as the nose and the skin, and occasionally in folds such as the axilla (armpit) or groin. About 30% of the general population are colonised with S. aureus. It can live on a healthy body without causing harm, and most people who are colonised do not go on to develop infection. Less than 5% of colonising strains in the healthy population who have not been in hospital are meticillin-resistant, but it is more common in vulnerable people who are in contact with the healthcare system.

MRSA infections usually occur in healthcare settings and in particular in vulnerable patients/clients. Clinical infection with MRSA occurs either from the patient’s/client’s own resident MRSA (if they are colonised) or by cross-infection from another person, who could be an asymptomatic carrier or have a clinical infection. S. aureus infects a range of tissues and body systems (like those mentioned below), giving general, often ambiguous, symptoms that are common to different infections caused by other bacteria. It is therefore essential that the signs and symptoms of infection are recognised and that appropriate action is taken.

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o Wounds - S. aureus/MRSA are common causes of wound infection, after either accidental injury or surgery. This shows as a red, inflamed wound, which may also be swollen and painful. The wound may break open or fail to heal, and a wound abscess could develop

o Superficial ulcers - Pressure ulcers, varicose ulcers and diabetic ulcers (all due to poor blood supply and superficial skin damage) are often sites of MRSA colonisation or infection

o Invasive devices, for example intravenous lines, feeding lines, renal dialysis lines and urinary catheters - S. aureus/MRSA may infect the entry site of an invasive device, causing local inflammation with pus. From this, the MRSA can enter the bloodstream, causing bacteraemia. Patients/clients with urinary tract infections may have abdominal pain and a temperature, and infection often causes the urine to go cloudy and smell

o Deep abscesses - If MRSA (or any S. aureus) spreads from a local site to the bloodstream, it can lodge at various sites in the body (e.g. lungs, kidneys, bones, liver or spleen) and cause one or more deep abscesses distant from the original site. These can be painful, with high fever, a high white cell count in the blood and signs of inflammation near the infection. The patient/client will be very unwell and may have rigors (shivers) and low blood pressure (shock). This is usually linked with associated bacteremia

o Lung infections - MRSA/S. aureus can cause lung infections, although this is rare. Lung infections are most common in patients/clients who are on a ventilator with a tube in the trachea, bypassing the defences of the nose and throat. MRSA can gain entry to the lungs via the tube and cause pneumonia, which may be fatal

MRSA Bacteraemia - is when an infection spreads further into the body and MRSA/S. aureus is present in the blood. This can occur either from the patient’s/client’s own resident MRSA (if they are an asymptomatic carrier), from a local infection or by cross-infection from another person. Septicaemia can follow (this is the clinical term for a severe illness caused by bacteria in the bloodstream). The symptoms are not specific to MRSA and can be the same for other bacteria that cause septicaemia. Typically, symptoms include high fever, a high white cell count, rigors (shivers), disturbance of blood clotting with a tendency to bleed, and failure of vital organs. This is the kind of MRSA infection that has the highest death rate.

3 Patients at risk of Infection from MRSA

Certain patient groups are more at risk of infection than others. These groups include:

o Patients with underlying illness

o Patients who are immunocompromised

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o The elderly, particularly if they have a chronic illness

o Patients with open wounds

o Patients with invasive devices such as a urinary catheter, intravenous devices, PEG feeding tubes, tracheotomy

4 Routes of Acquisition

MRSA can be spread from patient to patient, staff to patient or via inanimate objects (also called fomites), for example

o Direct spread via hands due to poor compliance of hand hygiene by either health care workers and or the individual (patient, carer, relative)

o Equipment that has not been appropriately decontaminated

o Environmental contamination – staphylococci that spread into the environment may survive for long periods in dust.

5 Roles and responsibilities

Each individual has a responsibility to inform the Infection Prevention Control Nurse (IPCN) of a known or suspected case of MRSA. This can be reported using the Safeguard System

The IPC nurse will provide specific individualised patient advice

The IPC nurse will report each case of MRSA bacteraemia to Public Health England and conduct a Root Cause Analysis in collaboration with the clinical team

All staff must adhere to the IPC-PGN-02.1 - Standard Precautions Practice Guidance Note at all times when delivering patient care

The Trust will provide Personal Protective Equipment (PPE) to be worn when performing hands-on patient care or handling blood/body fluids

Hotel Services staff will be responsible for maintaining agreed standards of environmental cleanliness

Managers will ensure that all staff are aware of and follow this policy and are aware of their own roles and responsibilities to ensure safe practice

6 Patient screening

Admission screening swabs are not routinely required for most patients in our premises. They should only be taken if there are clinical signs of infection or after consultation with the IPC nurse and a full risk assessment carried

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7 Management of patients with MRSA colonisation or infection

Isolation

o The patient should be allocated a single room if the facilities exist based on local risk assessment. Patients with an MRSA positive wound should have them covered with an appropriate impermeable dressing. Patients can visit communal areas e.g. dining room, television room and can mix with other patients/residents ensuring wounds are appropriately covered

Decolonisation

o Patients should undertake a 5 day decolonisation programme which consists of body washes and nasal cream. This is specified in Appendixes 1 and 2

Universal precautions

o All body fluids must be treated as potentially infectious; therefore, safe working practices must be followed at all times

Hand hygiene

o Good hand hygiene is essential before and after patient contact using either liquid soap or alcohol hand gel (Please refer to IPC-PGN-04.1 Hand Hygiene and Alcohol Rub). Hands must be decontaminated immediately before and after every episode of direct contact with patients/clients and after any potential activity or contact that potentially results in hands becoming contaminated

Use of Personal Protective Equipment (PPE)

o Gloves- Gloves must be worn if contact with blood, body fluids, secretions, excretions or hazardous substances are likely. Disposable nitrile gloves must be discarded after each procedure. Household gloves may be used for cleaning the environment and must be correctly colour coded. Discard any gloves that are punctured or torn. (ICNA, May 2002, A Comprehensive Glove Choice)

Plastic aprons - Disposable plastic aprons are single-use items and must be worn as single-use items for one procedure or episode of patient/client care and then discarded and disposed of as clinical waste

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Masks, spectacles or visors -Masks, spectacles or visors must be worn whenever there is a risk of body fluid splashing to the eyes or mouth

Management of sharps

o Sharps must be discarded by the person who has used them directly into an approved sharps container with a correctly fitted lid. This container must not be overfilled. Sharps must not be decanted from one container to another. Needles must not be bent or broken by hand and, wherever possible, needles and syringes must be disposed of as one unit. Needles must not be resheathed. Blades must not be removed by hand. Containers must be stored safely during and after use (National Institute for Health and Clinical Excellence guidance)

Management of spillages

o Wearing an apron and gloves, clear up the spillage immediately with the single use blood spillage wipe.

o Trust laundry procedures for the laundering of sheets, towels etc. Place into alginate bag then into a red linen bag and handle as infected linen. The red bag must be placed inside a laundry skip for collection. Linen fouled with body fluids from a patient/client not thought to have an infection must be placed in a plastic bag inside a laundry skip

o If relatives wish to take home personal items home to launder they can do so. They should be advised to wash them separately and at the hottest temperature the clothes will allow

Clinical waste

o All infected or suspected infected waste should be disposed of as clinical waste (refer to Trust policy CNTW(O)24 Waste Management for further details). All clinical waste, i.e. waste contaminated with body fluids, must be discarded into a orange waste bag securely sealed and labelled with the name of the clinical area/environment for disposal. Clinical waste must not be decanted from one bag to another and must be stored safely and separate from other waste for collection. Black bags are for household waste only

Decontamination

o Equipment must be decontaminated between patient/client use. (Please also see IPC-PGN-10 - Medical Devices and Equipment – Cleaning and Decontamination) All equipment sent for repair must be accompanied by a declaration of contamination status form. Crockery and cutlery must be

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washed in a dishwasher after each patient/client use

Environmental cleaning

o Ensure that general cleaning of a patient’s room / bed area is maintained to a high standard Follow the specific cleaning instructions which are available from the hotel services or domestic services manager. Each room will be thoroughly cleaned with hot water and detergent. Domestics must use yellow colour coded equipment.

o Following patient discharge the room should be thoroughly cleaned and disinfected using a chlorine releasing agent e.g. Chlorclean, the curtains should be changed and laundered. Wall washing is NOT required unless the walls are visibly soiled with body fluids or dirt.

o All mattresses should have impermeable covering to allow through cleaning and disinfection.

8 Specific patient management

An IPC care plan to help with the management of a patient with

clinical signs of infection and following discussion with the clinician, or consultant microbiologist or IPC nurse

Patients who are colonised with MRSA do not usually need antibiotic MRSA is available from the IPC team

Any treatment required will be on an individual patient basis following discussion with the clinician, or IPC nurse and incorporating a full risk assessment

Any antibiotic treatment should only be prescribed if there are treatment

Routine screening swabs are not required and should only be taken if there are clinical signs of infection or at the discretion of the IPC nurse

Patients, who require admission to an acute hospital, may require de-colonisation therapy. Clinical staff should liase with the receiving department to establish if this would be required

9 Visits to outpatient departments

When an unexpected positive result is detected in an outpatient, appropriate management will be discussed between outpatient staff, RMO and the IPCN. (Please also see IPC-PGN-22.2 - Visits to Outpatient Departments)

A patient who is known to be MRSA-positive may attend an outpatient clinic. In this case, the following action is appropriate for all units:

Ideally such patients should be seen at the end of the clinic to minimise contact with other patients

The patient should be seen in a room which can be cleaned effectively surfaces in contact with the patient should be disinfected with disinfectant

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wipes IPC PGN 10 Disinfection and decontamination of medical equipment.

10 Transfer to other departments / areas

The presence of MRSA should not compromise patient care or treatment if the patient requires transfer to other departments / specialist areas.

The receiving ward or department should be informed before the patient leaves the ward this would ensure that infection prevention control measures can be implemented. This must be documented within the patients medical records

If patients have infected or colonised wounds or lesions they should be covered with a secure and appropriate dressing before transfer.

It is important that information about the patients MRSA status is documented within the patient transfer information and handed to the receiving department on arrival.

NOTE: An inter-healthcare infection control transfer form must be completed for all transfers of patients known of suspected of having an infectious disease. This applies to transfers within the Trust as well as to units in other healthcare settings, such as acute Trusts, and ambulance journeys. (See IPC-PGN-17-Transferring Patients with known or suspected infectious disease)

11 Transfer to another hospital outside the Trust

The receiving ward or department should be informed before the patient leaves the ward this would ensure that infection prevention control measures can be implemented. This must be documented within the patients medical records

If patients have infected or colonised wounds or lesions they should be covered with a secure and appropriate dressing before transfer.

It is important that information about the patients MRSA status is documented within the patient transfer information and handed to the receiving department on arrival

NOTE: An inter-healthcare infection control transfer form must be completed for all transfers of patients known of suspected of having an infectious disease. This applies to transfers within the Trust as well as to units in other healthcare settings, such as acute Trusts, and ambulance journeys. (See IPC-PGN-17 - Transferring Patients with known or suspected infectious disease)

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12 Ambulance Transportation

The ward staff should notify the ambulance service in advance

Normal procedures for transportation of the patient should be applied

A separate ambulance is not required

NOTE: An inter-healthcare infection control transfer form must be completed for all transfers of patients known of suspected of having an infectious disease. This applies to transfers within the Trust as well as to units in other healthcare settings, such as acute Trusts, and ambulance journeys. (See IPC-PGN-17 - Transferring Patients with known or suspected infectious disease)

13 Management of deceased patients

The precautions taken should be the same as those observed during life

Any lesion should be covered with impermeable dressings

Inform the mortuary

A body bag is not necessary

14 Management of staff

There is no evidence that MRSA poses a risk to healthy people e.g. healthcare workers. Research has shown that nurses who become colonised may have acquired the bacteria through their work, but the MRSA is usually present for a short time only. Routine MRSA screening of staff is not necessary

Members of staff who are MRSA positive from any GP specimens taken should contact Occupational Health for advice

15 Communication with patients and relatives

Patients

o An explanation and an information leaflet should be provided and where necessary access to specialist advice via the IPC nurse

o Copies of the information booklet are available via the IPC nurse and patient information services

Relatives / carers

o With the patients consent relatives and carers can be provided with appropriate access to information and advice

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o Copies of the information booklet are available from the IPC nurse and patient Information services

16 Communications between organisations

Good communications is the key to effective MRSA management. It is important when transferring individuals with MRSA infection or colonisation to another setting, to inform the person in charge at the receiving establishment

17 Discharge planning

It is essential to reduce any further infection risks within the care pathway

MRSA is not a barrier to planning discharge either to the patients own home or to a residential or nursing home

When discharging to a residential or nursing home it is vital that the home is informed of any on-going infection control risk

The importance of communication with other agencies is vital for a well-planned discharge

18 References

Journal of Hospital Infection (2006) Guidelines for the control and prevention of meticillin-resistant Staphylococcus (MRSA) in healthcare facilities by the Joint BSAC/HIS/ICNA Working Party on MRSA

Lawrence J & May D (2003) Infection Control in the Community. Churchill Livingstone. London

Department of Health (2006) The Health Act 2006. Code of Practice for the Prevention and Control of Health Care Associated Infection

Implementation of modified admission MRSA screening guidance for NHS (2014). Department of Health expert advisory committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI)

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Appendix 1

MRSA DECOLONISATION PROGRAMME

All MRSA positive results should be discussed with Infection Prevention and Control and reported through the Trust electronic reporting systems. The following standard therapy should be prescribed as indicated. For clients with known allergies or who have suffered adverse reaction to any of the products, the alternative should be prescribed. If these are also unsuitable then IPC will liaise with Microbiology to identify other options.

STANDARD THERAPY ALTERNATIVES Used in the same way

unless otherwise stated

NOTES

NOSE Mupirocin 2% nasal ointment Applied to the inside of both nostrils 2 times a day for 5 days

Naseptin Cream (Chlorhexidine 0.1% plus 0.5% Neomycin) 4 times a day for 10 days

In pregnancy and breast feeding use Naseptin Patients with known or suspected peanut allergy MUST NOT be prescribed Naseptin

SKIN Octenisan Antimicrobial wash lotion Daily for 5 days.

Other alternatives are available, however these should be discussed with IPC and RMO before prescribing

HAIR As with skin – use Octenisan Applied on the 2nd and 4th Day

Produced with permission of M.Lowery, Antimicrobial Pharmacist and Infection Prevention and Control - January 2009

Cumbria Northumberland, Tyne and Wear NHS Foundation Trust IPC-PGN-21 – Management of MRSA in Hospital – V04 Iss 2 – Oct 19 Part of CNTW(C)23 – Infection, Prevention and Control

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Appendix 2