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Microsoft word - mrsa policy.doc

MERCY HOSPITAL DUNEDIN
INFECTION CONTROL MANUAL
MRSA Policy
Page 1 of 17

Key Words: Methicillin Resistant Staphylococcus aureus, MRSA

Policy Applies to:
All staff employed by Mercy Hospital. Credentialed Specialists, Allied Health
Professionals, patients and visitors will be supported to meet policy
requirements.
Related Standards:
• Infection and Prevention and Control Standards NZS 8134.3:2008
• EQuIP 4 Standard Criterion 1.5.2
Rationale:
MRSA is common worldwide and the prevalence of MRSA is increasing in the
community and within health-care facilities throughout New Zealand.
This policy outlines procedures in place at Mercy Hospital to prevent the
introduction of and or minimise spread of Methicillin Resistant Staphylococcus
aureus
(MRSA).
Definitions:
Staphylococcus aureus:
An organism that is a natural inhabitant of the skin,
mucous membranes and the gastro-intestinal tract. MRSA are Staphylococcus
aureus
strains that are resistant to the beta-lactam antibiotics (penicillins,
cephalosporins and meropenem).
Colonisation: The organism is superficially carried on the skin, in the nose, etc.
People are not sick and do not require antibiotics.
Infection: A person has a clinical infection with the organism e.g. wound
infection, septicaemia, urinary infection etc. Infected persons usually require
systemic antibiotics.
Note: A person infected with MRSA is inevitably colonised somewhere, although
this is not always easy to determine.
High Risk New Zealand Hospitals’: Health care facilities where cross infection
with MRSA has been documented.
Cross infection: Where two or more MRSA of the same phage type have been
identified within the last six months.
MERCY HOSPITAL DUNEDIN
INFECTION CONTROL MANUAL
MRSA Policy
Page 2 of 17

Objectives:

To ensure all patients are assessed and where appropriate, screened for MRSA; To support patients who require decolonization MRSA treatment and ensure that treatment and follow up laboratory screening clearances are completed; To implement best practice risk management of patients that are infected or colonised with MRSA during their admission to prevent the spread of infection; To ensure patients and their families receive sufficient and appropriate information regarding MRSA; To ensure that staff are aware that standard precautions must be used for the care of all patients to minimise the risk of spread of MRSA; To ensure all staff where relevant, complete MRSA screening prior to commencing employment; To identify and support staff who require decolonization MRSA treatment and ensure that treatment and follow up laboratory screening clearances are completed; To ensure credentialed specialists and booking staff remain aware of current MRSA hospital outbreak status. Risk factors for MRSA Colonization/Infection
There are a number of factors associated with an increased risk of a person being
colonized with, or having an MRSA infection. These include:
• Rest home residents;
• Patients/staff with chronic lesions; e.g. dermatitis, ulcers, sores and wounds;
• Previous/multiple hospitalisations;
• Work history in healthcare facility;
• Household member who has tested MRSA positive;
• Insulin dependent diabetics, haemodialysis, IV drug users, underlying
• Long term indwelling devices; e.g. urinary catheter;
• Administration of broad spectrum antibiotics or multiple antibiotic therapy;
• Immunosuppressed patients.
Transmission
MRSA can be transferred through:
• Direct contact – person to person, most often on the hands of staff
• Indirect contact – person contact with contaminated environment e.g. linen,
MERCY HOSPITAL DUNEDIN
INFECTION CONTROL MANUAL
MRSA Policy
Page 3 of 17

Control Rationale
It is important to control MRSA because of:
• The high cost, greater frequency of side effects and poorer clinical outcomes
• The limited number of oral agents that can be used • The potential for the emergence of organisms resistant to vancomycin, which would seriously restrict the choice of agents appropriate for treating serious MRSA infections.
Implementation

Patients
Staff are made aware of the need to use standard precautions for the care of all
patients at orientation, annual updates and information posters in clinical areas.
The Infection Prevention and Control Nurse sends an electronic monthly MRSA
high risk New Zealand Hospitals report to credentialed specialists and pre
admission booking staff.
Questions relating to risk of exposure to MRSA are included on the patient
admission form and discussed as part of the pre admission process
MRSA positive patients and their whanau/family are given advice, information
and support re MRSA, decolonisation (if required) and their care in contact
isolation
MRSA positive patients are identified with an alert on TrakCare as part of the
patient admission process to indicate that contact precautions isolation
management strategies must be implemented
To ensure the prudent use of antibiotics; Antibiotic Prescribing Guidelines should
be used to maximise the therapeutic impact while minimising toxicity and the
development of resistance.

Staff
Relevant staff are informed of MRSA screening requirements and process as part
of employment.

MRSA positive staff are given advice, information and support re MRSA,
decolonisation and their employment duties.


MERCY HOSPITAL DUNEDIN
INFECTION CONTROL MANUAL
MRSA Policy
Page 4 of 17

Evaluation
Staff
• Staff health records;
• Staff with positive MRSA results are supported in decolonisation treatment
• Staff training records.

Patients
• Patient admission form - MRSA high risk status documentation;
• Positive MRSA patient Trak alert status recorded;
• Contact isolation management forms completed;
• Monthly High Risk Hospitals report circulated to relevant Mercy staff;
• Monthly reporting of MRSA patient hospital status reported to the Infection
Control Committee and the ESR Health Care Facility Antibiotic Resistance Surveillance System http ://arsurv.esr.cri.nz/
Associated Documents
External

CDC Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007); Guidelines for the Control of Methicillin-resistant Staphylococcus aureus in New Zealand. Ministry of Health 2002; Guidelines for the Control of Multidrug–resistant organisms in New Zealand, Ministry of Health, 2007; Southern District Health Board Antimicrobial Guidelines (4th edition 2010) Institute of Environmental Science & Research (ESR), New Zealand. http://arsurv.esr.cri.nz/.
Internal

Mercy Hospital Antimicrobial Guidelines (Southern District Health Board 4th edition 2010); Antimicrobial policy, Infection Control Manual; Standard Precautions policy, Infection Control Manual; Hand Hygiene policy, Infection Control Manual; By-Laws for Credentialed Specialists 2013, Hospital Policy and Information Manual; Application for Employment, Section 3, Human Resources Manual. MERCY HOSPITAL DUNEDIN
INFECTION CONTROL MANUAL
MRSA Policy
Page 5 of 17
The following processes are outlined below: 1. MRSA treatment colonisation and clearance of staff and patients infected or 2. MRSA Screening of staff 3. MRSA Screening of patients 4. MRSA high risk hospitals Appendices
1. MRSA Positive Contact Screening and Tracing Guidelines 2. Patient Information Sheet - Methicillin Resistant Staphylococcus aureus (MRSA) and Decolonization Protocol Instructions MERCY HOSPITAL DUNEDIN
INFECTION CONTROL MANUAL
MRSA Policy
Page 6 of 17

Process for the treatment, decolonisation and clearance of staff and patients
infected or colonised with Methicillin Resistant Staphylococcus aureus

(MRSA).
Assessment for Treatment
A) Patient Classification

Eradication of MRSA may be considered for the following people: • Patients undergoing elective invasive procedures e.g. surgery; • Patients with asymptomatic colonisation; • Patients with chronic skin lesions, indwelling invasive devices; • Patients who are not receiving antibiotics for other infections; • All infected/colonised patients during an MRSA outbreak; • Patients with prolonged hospitalisation (e.g. > 2 weeks), long-term care facilities, or receiving community care; • Patients who are at increased risk of septicaemia, e.g. diabetics or immune B) Staff Classification
• Staff who screen positive with MRSA will be advised to commence

Pre-treatment
Advice should be sought from the medical microbiologist or infectious disease
physician when necessary, as the distinction between colonisation and infection
may not be clear, the treatment will be determined on this diagnosis.
Systemic antibiotic treatment for other infections should be reviewed and
discontinued if possible.
A further set of screening specimens must be obtained before treatment is
commenced. This should include potential colonised/infected sites not
previously cultured.
Treatment, Decolonisation and Clearance Regime
Three consecutive negative sets of swabs (as per test for clearance screening
schedule) are required before a patient or staff member is considered clear.
(See Appendix 2, Methicillin Resistant Staphylococcus aureus (MRSA)
Information and Decolonization Protocol Instructions)

MERCY HOSPITAL DUNEDIN
INFECTION CONTROL MANUAL
MRSA Policy
Page 7 of 17

Ongoing Staff screening
Staff must continue to be screened at weekly and one month intervals or as
determined by the Infection Prevention and Control Nurse as re-colonisation may
occur.

Process for MRSA screening of staff
The listed groups of personnel (new and returning) who have direct patient
contact require screening for Methicillin Resistant Staphylococcus aureus (MRSA)
before they commence work at Mercy Hospital.

Staff with direct patient contact

The following occupational groups are required to complete MRSA screening:
• Nursing
• Theatre Suite Assistants (TSA’s)
• Anaesthetic technicians (AT’s)
• Ward assistants
• Credentialed Medical Staff
• Allied Health Professionals
• Nursing Students

Implementation:
Manager’s responsibility
All managers must ensure that employees with direct patient contact are
informed they are required to provide a negative MRSA screen prior to
commencing employment.
New Staff
Prior to commencing employment, all personnel involved in direct patient care
must present a negative MRSA screening report result to the Infection Prevention
and Control Nurse.
Note:
It takes a minimum of 4 days for laboratory results to be received. Employment start date
must allow sufficient time for MRSA test results to be processed and received by Mercy
Hospital.

Returning staff
Prior to recommencing employment, all personnel (see occupational group list
above) involved in direct patient care, which have:
• Worked in an overseas hospital in the last six months;
• Worked in a North Island hospital in the last six months;
MERCY HOSPITAL DUNEDIN
INFECTION CONTROL MANUAL
MRSA Policy
Page 8 of 17
• Worked in any hospital or residential facility that has had an MRSA outbreak • Previously MRSA positive test result must present a negative MRSA screening report result to the Infection Prevention and Control Nurse;
Nursing staff and Medical Consultants who regularly work in other hospitals
where MRSA cross infection is occurring must consult with the Infection
Prevention and Control Nurse to determine a screening regime.
If an MRSA result certificate is not presented, on, or before commencement of
employment, personnel will not be permitted to undertake patient care duties
until the certificate is sighted, and may not commence employment subject to the
availability of suitable work.
Positive MRSA screening result
Personnel (see Occupational group list above) colonised or infected with MRSA
will be removed/ delayed from direct patient care duties until cleared.


MERCY HOSPITAL DUNEDIN
INFECTION CONTROL MANUAL
MRSA Policy
Page 9 of 17

Process MRSA screening of patients
To ensure all patients are assessed as to their MRSA risk status and high risk
patients are screened prior to admission and appropriately managed post
admission

Implementation:
Pre admission Screening
All patients, as part of the pre-admission process, must be assessed by the
admitting doctor/surgeon to determine if the patient is in the ‘at risk’ category for
MRSA screening. The at risk criteria is as follows:
Been a resident or staff member in any rest home in the last 6 months; Been a patient or healthcare worker in a high risk New Zealand Hospital in the last 6 months; Been a patient or healthcare worker in an overseas hospital in the last 6 months.
It is the responsibility of the admitting doctor/surgeon to indicate the patient’s
MRSA screening status on the admission letter.
Booked patients who meet the screening high risk criteria must be informed that
they are required to be screened for MRSA prior to admission and given
information on the screening protocol.
Note: It takes a minimum of 4 days for laboratory results to be received so surgery
admission dates must allow sufficient time for MRSA test results to be processed and
received by Mercy Hospital.

Procedure for patients whose MRSA status is unknown and who meet the
High Risk Screening Criteria
Where a patient has been admitted and it is subsequently determined they meet
the MRSA screening criteria, the following steps should be taken:
• An MRSA pending alert (flashing green/yellow star) must be placed on the
• The Infection Prevention and Control Nurse and the Patient Services Manager • If the patient is an inpatient, they should be domiciled if possible in a single • The patient should continue to be managed in standard precautions. MERCY HOSPITAL DUNEDIN
INFECTION CONTROL MANUAL
MRSA Policy
Page 10 of 17

Booked patients who test MRSA positive prior to admission
• If a patient returns a positive MRSA laboratory result, the admitting doctor/surgeon and Bookings Coordinator must contact one of the following, prior to admission , to discuss treatment and admission: • Director of Clinical Services, • Patient Services Manager, or • The Infection Prevention and Control Nurse
Each case will be individually assessed for admission to Mercy Hospital by the
Director of Clinical Services, Patient Services Manager and Infection Prevention
and Control Nurse in consultation with the relevant medical specialist and where
necessary, microbiologist, to determine:
• Any delay in admission
• Appropriateness of decolonisation
• Type of surgery and length of stay
• Availability of single room for contact isolation management.
• Urgency of surgery
It is the responsibility of the admitting doctor to inform the patient of their
positive MRSA result and the additional costs incurred for isolation management
should admission be approved.
Information on MRSA and decolonisation treatment is available from the Patient
Services Manager or the Infection Prevention and Control Nurse
(See Appendix 2, Methicillin Resistant Staphylococcus aureus (MRSA)
Information and Decolonization Protocol Instructions)

MERCY HOSPITAL DUNEDIN
INFECTION CONTROL MANUAL
MRSA Policy
Page 11 of 17

Admission of an MRSA Positive Patient
• The patient’s notes must be flagged on Trak with an Alert (yellow triangle)
once the positive MRSA status has been determined. The patient must be cared for in contact isolation precautions for the duration of their stay; • The MRSA information sheet (appendix two) should be discussed with the • Isolation costs on each shift should be documented on Trak.

Positive MRSA Day Case Patients

• Where possible, the patient is to be scheduled last on patient list;
• Day case patients should be admitted directly to a single room on McAuley, if
• Staff must wear protective gowns and gloves when in direct contact with the • Isolation costs on each shift should be documented on Trak.
Informing other healthcare providers
For patients who have been newly diagnosed as MRSA positive, it is the
responsibility of Mercy Hospital to inform other patient health care providers
(e.g. rest home facility, GP, Southern District Health Board Infection Prevention
and Control Service MRSA database) of the patient’s MRSA status so patient
treatment plans can be reassessed and healthcare transmission risk management
procedures can be alerted.
MRSA High risk hospitals identification process
Credentialed specialist and relevant clinical and booking staff must be aware of
high risk healthcare facilities. Mercy Hospital provides current information on its
MRSA prevalence status to the national monitoring database system. (ESR Health
Care Facility Antibiotic Resistance Surveillance System).

Implementation:
The Infection Prevention and Control Nurse monitors the ESR database and receives
an electronic monthly high risk hospitals report from the Southern District Health
Board infection control service. The Infection and Prevention Control Nurse
publishes an electronic monthly MRSA High Risk Hospitals’ Report to the Bookings
Coordinator, PSM, Clinical Coordinators, Marinoto Clinics and Credentialed
Specialists.
Credentialed specialists and relevant clinical and booking staff assess all patients
MRSA risk status against this criteria and consult the Infection Prevention and
Control Nurse if required, for guidance re screening and risk management for
admission.
MERCY HOSPITAL DUNEDIN
INFECTION CONTROL MANUAL
MRSA Policy
Page 12 of 17
APPENDIX ONE
MRSA Positive Contact Tracing and Screening Guidelines
Type of MRSA
Index Patient
Other Patient Screening
Staff Screening
Acquired?
significant index patient contact within last 2 weeks. index patient contact within last 2 weeks. had index patient contact within the past 2 weeks had index patient contact within the past 2 weeks are found to be MRSA positive proceed as outbreak (See below) are found to be MRSA positive proceed as outbreak (See below) MERCY HOSPITAL DUNEDIN
INFECTION CONTROL MANUAL
MRSA Policy
Page 13 of 17
Type of MRSA
Index Patient
Other Patient Screening
Staff Screening
Acquired?
** Casual staff
from other
agencies are
not to nurse
positive
patients
MERCY HOSPITAL DUNEDIN
INFECTION CONTROL MANUAL
MRSA Policy
Page 14 of 17
APPENDIX TWO
Methicillin Resistant Staphylococcus aureus (MRSA)
Information Sheet
What is MRSA?
Everybody has a variety of germs/bacteria on their skin. About half the adult
population carry bacteria called Staphylococcus aureus in their nose or on their skin.
There are different types of Staphylococcus aureus. It is usually harmless but if it gets
inside the body (for example through a cut or scratch) it can cause infections and
need treatment with antibiotics.
In some instances, the Staphylococcus aureus becomes resistant to commonly used
antibiotics (meaning these antibiotics don’t work anymore). The name of one of
these antibiotics is methicillin and these resistant bacteria are known as Methicillin
Resistant Staphylococcus aureus or MRSA.
MRSA is not usually a problem for healthy people. People with MRSA on their skin do not look or feel different from anyone else. However, MRSA can cause infections if it gets into the body through broken skin, and this can be a problem for patients in hospital, especially after they have had an operation and have a surgical wound. These infections can be treated with special types of antibiotics. How do I know I have MRSA?
You may have had MRSA in the past or have had a positive wound swab.

How is MRSA spread?
In hospitals, MRSA is usually spread by a person who already has it on their skin. It
is not normally spread through the air.
How can the spread of MRSA in hospitals be prevented?
All hospitals have infection control policies in place to address this. Stopping MRSA
spreading between patients in hospital depends on staff, visitors and patients all
cleaning their hands (with waterless hand gel or by hand washing), before and after
touching other people.
If a patient in hospital is known to have MRSA either on their skin or causing an
infection, special soaps, ointments or antibiotics are sometimes given to try and get
rid of the MRSA(decolonisation treatment).
MERCY HOSPITAL DUNEDIN
INFECTION CONTROL MANUAL
MRSA Policy
Page 15 of 17

Patients with MRSA will have a room by themselves, and be cared for using contact
isolation. Hospital staff will wear gloves and aprons to reduce the chance of them
spreading the MRSA to other patients.
Will medical treatment be different for patients with MRSA?
No, the extra measures taken will not interfere with treatment or care received while
in hospital. There will be additional costs for your stay as you will be in a single
room and in contact isolation. Your surgeon will discuss these additional costs with
you.

What about family and visitors of people with MRSA?

MRSA does not harm healthy people including pregnant women, children and
babies. Visitors will be asked to wash their hands after visiting. At home, normal
hygiene practices such as washing hands before eating and after using the toilet is
advised.
Where can I get further information or advice?
Patients and their families should first seek advice from their Doctor and/or
Infection Prevention and Control Nurse at the hospital, or from their General
Practitioner.
MERCY HOSPITAL DUNEDIN
INFECTION CONTROL MANUAL
MRSA Policy
Page 16 of 17

Methicillin Resistant Staphylococcus aureus (MRSA)
Decolonization Protocol Instructions
You have isolated Methicillin resistant Staphylococcus aureus (MRSA) from pre-
admission screening. Your doctor has recommended that an MRSA
decolonisation treatment is used prior to your surgical procedure. The aim of
MRSA decolonisation treatment is to decrease the risk of infection by reducing
and clearing MRSA found on your skin.

You will be given a pack containing:

• Surgical scrub (Chlorhexidine) body wash
• Bactroban nasal ointment

How should I apply the ointment?

• Apply 3 times daily to each nostril for 5 days; • Put a pea sized amount on a Q-tip and apply to the inside of your nostril, • Do not contaminate the ointment by touching the Q-tip to the end of the ointment tube after it has been inserted in your nostril. Use the “clean” end of the Q-tip, or use a new one for the second nostril; • After application, press the nostrils together and release repeatedly for 1 minute to distribute the ointment throughout the nose; • Save remaining ointment, it may be used again if your follow-up screening
How should I use the shower body wash?

• Use every second day for 6 days, that is a total of 3 showers; • Using Chlorhexidine, clean your body (from neck down), pay close attention to the arm pits, groin, and the area between the legs; • Rinse your body completely; avoid contact with your eyes and inside your
Clean your sheets and clothing

• Change your bedding and clothing every second day after your shower; • Use a hot machine wash for bedding and clothing; a capful of Janola may MERCY HOSPITAL DUNEDIN
INFECTION CONTROL MANUAL
MRSA Policy
Page 17 of 17

Repeat MRSA screen cultures to make sure it worked
• You will need to have MRSA screening swabs. These should be taken 48 hours after completing treatment followed by 2 more sets of swabs 48 hours apart.
Swab Date:
If all these cultures are negative then decolonization has been a success.

Source: http://www.mercyhospital.org.nz/files/dmfile/MRSAPolicy.pdf

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