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Policy for the Management of Meticillin Resistant Staphylococcus Aureus (MRSA) Positive Patients Within Primary Care v5 IC04 Version Number: 5 Issue Date: January 2014 Review Date: January 2017 Sponsoring Directors: Directors of Nursing NHS North Durham, NHS Darlington, Durham Dales, Easington and Sedgefield (DDES) Clinical Commissioning Groups (CCGs) Prepared By: Lead Infection Prevention and Control Nurse Consultation Process: Members of Health and Social Care Health Care Associated Infection (HCAI) Assurance Group Document History Version Date 2 Sept 2006 3 Nov 2008 4 Nov 2010 5 Jan 2014 Significant Changes * * * None * None POLICY VALIDATION STATEMENT This policy is due for review on the latest date shown about. After this date, policy and process documents may become invalid. Policy users should ensure that they are consulting the current valid version of the documentation. H:Policy Development/Infection Control v5 Page 1 of 14 EQUALITY IMPACT ASSESSMENT STATEMENT Audit Assessment Date Result Risk Audit 14.01.2014 Risks identified and risk assessment included at Appendix 1 Equality Audit 14.01.2014 No or very low potential for discrimination Human Rights Audit 14.01.2014 No breach of Human Rights H:Policy Development/Infection Control v5 Page 2 of 14 POLICY FOR THE MANAGEMENT OF METICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) POSITIVE PATIENTS WITHIN PRIMARY CARE CONTENTS Section Title Page 1 Introduction 4 2 Definitions 4 3 Management of Meticillin Resistant Staphylococcus Aureus (MRSA) Positive Patients Within Primary/ Community Care 5 4 Duties and Responsibilities 7 5 Implementation 9 6 Training Implications 9 7 Documentation 9 8 Monitoring, Review and Archiving 10 9 Equality Impact Assessment Statement 11 Non-Compliance 14 Appendices 1 H:Policy Development/Infection Control v5 Page 3 of 14 POLICY FOR THE MANAGEMENT OF METICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) POSITIVE PATIENTS WITHIN PRIMARY/COMMUNITY CARE 1 Introduction NHS North Durham, NHS Darlington and NHS DDES CCGs aspire to the highest standard of corporate behaviour and clinical competence, to ensure that safe, fair and equitable procedures are applied to all organizational transactions, including relationships with patients, their carers, public, staff, stakeholders and the use of public resources. In order to provide clear and consistent guidance, NHS North Durham, NHS Darlington and NHS DDES CCGs will develop documents to fulfil all statutory, organizational and best practice requirements and support the principles of equal opportunity for all. The aim of this policy is to provide a framework for the safe management pf Meticillin Resistant Staphylococcus Aureus (MRSA) Positive Patients within Primary Care. This policy is in line with national guidance from the Department of Health (DH). 1.1 Status This policy is an Infection Control policy. 1.2 Purpose and Scope To provide optimum care and management of patients colonised or infected with MRSA and to minimise the risk of spread to other patients and health care workers. This policy applies to all health care workers working within NHS North Durham, NHS Darlington and NHS DDES CCGs. 2 Definitions MRSA – Meticillin Resistant Staphylococcus Aureus. The name given to strains of staphylococcus aureus that are resistant to Meticillin. Meticillin – an antibiotic that is not used clinically, but Meticillin Resistant Staphylococcus is often resistant to other commonly used antibiotics. Colonised – the presence of a bacteria but the patient shows no clinical signs of infection. H:Policy Development/Infection Control v5 Page 4 of 14 Infected – patient showing clinical signs of infection 3 The Management of Meticillin Resistant Staphylococcus Aureus (MRSA) Positive Patients within Primary Care Staphylococcus aureus (S. aureus) is carried in a number of sites on the body eg nose and perineum. These areas are called carriage sites. Up to 30% of the population are nasal carriers at any one time. Staphylococcus aureus is usually a commensal, neither benefiting nor harming the host. However, if it gains access to tissues beneath the skin or mucosa it may cause infections eg abscesses, wound/chest infections. It may, rarely, cause severe systemic infections. MRSA is the name given to strains of S.aureus that are resistant to Meticillin. Meticillin is an antibiotic that is not used clinically but Meticillin Resistant S. aureus is often resistant to other commonly used antibiotics. Like Sensitive S. aureus, MRSA may colonise or cause an infection. An infection is suspected when MRSA is isolated and the patient shows clinical signs of infection. Colonisation is suspected when MRSA is isolated but the patient shows no clinical signs of infection. There is no evidence that MRSA causes more severe infections than other strains of S.aureus, but treatment is often more difficult. 3.1 Management of patients within primary care Patients who are colonised or infected with MRSA should not be prevented from visiting their GP surgery. 3.1.1 Protective Clothing Disposable plastic aprons must be worn for activities involving direct patient contact. Gloves must be worn by staff for direct patient contact, or for contact with secretions and handling of infected/soiled dressings. Within general practice aprons and gloves must be disposed of as infectious hazardous waste. Hazardous waste bins must be foot-operated and have a lid. See local waste Policy. 3.1.2 Hand Hygiene All healthcare workers must perform hand hygiene before and after each patient or environmental contact and after disposal of Personal Protective Equipment. Alcohol gel can be used as a rapid disinfectant between patient contacts if hands are visibly clean. See Hand Hygiene Policy. H:Policy Development/Infection Control v5 Page 5 of 14 3.1.3 Equipment Equipment shared between patients (eg stethoscope, tourniquet) must be thoroughly cleaned with an alcohol wipe before being used on another patient. The examination couch should be covered with disposable paper towel and changed between each patient, and the couch cleaned with detergent and water after use. Sheets and blankets should not be used within general practice unless they are changed between each patient and industrial washing machine facilities are available. 3.1.4 Communication A verbal explanation accompanied by an information leaflet available from Infection Control Nurses should be given to the patient. A leaflet can also be given to relatives. The opportunity to speak to an Infection Control Nurse can be offered if the health care worker is unable to answer any specific questions. 3.1.5 Patient Screening Routine screening is not required in the community. If a specific request is made by a hospital Infection Control Nurse or microbiologist then the following swabs should be taken: Nose – Rotate swab around the anterior nares of each nostril using the same swab for both nostrils. Groin/perineum – 4 firm strokes over groin/perineum. Nose and groin/perineal swabs should be sent with only one request card to requesting hospital and labelled ‘MRSA screen’. NB Swabs for MRSA will be screened only for MRSA. If there are signs of clinical infection at the site, a second swab should be taken for culture and sensitivity and be sent with a separate request form. 3.1.6 Eradication Therapy Should only be prescribed if clinically indicated, eg patient is being admitted to hospital for surgery and it has been specifically requested, or the treatment would reduce the risk of the patient becoming infected. If a patient is positive for MRSA from any skin site, a daily antibacterial body and hair wash with Octenisan is required for 5 consecutive days. Contact the Infection Control Nurse if the patient has a skin condition before starting this H:Policy Development/Infection Control v5 Page 6 of 14 treatment eg eczema. Octensian must be applied to moist skin and hair. Manufactures’ guidance must be followed Do not use flannels/face cloths – use disposable wipes. It is advisable that patients should use separate towels from other people. Clean clothing should be worn daily during treatment, where possible. Nasal carriage – apply Mupirocin nasal ointment to anterior nares using a cotton bud three times a day for five days. Recent studies have shown that using a combination of interventions together gave better success rates of decolonisation. It is therefore recommended that nasal Mupirocin and Octenisan should be given at the same time. If there is carriage in another site eg pressure sore, peg, wound - discuss with Infection Control Nurses. 3.1.7 Treatment of Infections Advice regarding specific anti-microbial therapy can be obtained from the Consultant Microbiologists on the respective sites: UHND DMH & BAGH Out of hours 0191 333 2333 Ext. 2430 or 2613 01325 380100 Ext. 3241 or via switchboard Via switchboard at all sites including North Tees, Hartlepool and Sunderland. 3.1.8 Confidentiality MRSA is part of a patient’s diagnosis. Personnel who do not have access to the patient’s medical/nursing notes should not be told the nature of the illness but should be given specific infection control guidelines. Giving a diagnosis inappropriately is a breach of confidentiality. 3.1.9 Staff Screening This is NOT necessary, unless requested by the Infection Control Nurse or Infection Control Doctor. 4 Duties and Responsibilities 4.1 Accountable Officer The Accountable Officer has overall responsibility for the strategic direction and operational management, including ensuring that CCG process documents comply with all legal, statutory and good practice guidance requirements. H:Policy Development/Infection Control v5 Page 7 of 14 4.2 Director of Nursing As the nominated director responsible for Infection Prevention and Control the Director of Nursing has delegated responsibility for ensuring that arrangements are in place to manage Infection Prevention and Control including the risks from the safe management of Meticillin Resistant Staphylococcus Aureus (MRSA) Positive Patients within Primary Care. In addition the Director of Nursing is responsible for ensuring that the policy is drafted, approved and disseminated in accordance with ‘Writing Policy Documents’. The necessary training and education needs and methods to implement this document are identified and resourced. Mechanisms are in place for the regular evaluation of the implementation and effectiveness of this document. 4.3 Lead infection prevention and control nurse The Lead Infection Prevention and Control Nurse will: 4.4 generate and formulate this policy, identifying appropriate processes for regular evaluation of, and the implementation and effectiveness of, this policy; notify the Policy Coordinator of any revisions to this document; ensure the policy is taken to members of the Health and Social Care HCAI Group for comment; arrange for superseded version of this document to be retained in line with national guidance. All staff All staff, including temporary and agency staff, are responsible for: compliance with relevant process documents. Failure to comply may result in disciplinary action being taken co-operating with the development and implementation of policies and procedures as part of their normal duties and responsibilities identifying the need for a change in policy or procedure as a result of becoming aware of changes in practice, changes to statutory requirements, revised professional or clinical standards and local/national directives, and advising their line manager accordingly identifying training needs in respect of policies and procedures and bringing them to the attention of their line manager attending training/awareness sessions when provided H:Policy Development/Infection Control v5 Page 8 of 14 5 Implementation 5.1 This policy will be available to all staff for the management of patients with MRSA. 5.2 All managers are responsible for ensuring that relevant staff within their departments have read and understood this document and are competent to carry out their duties in accordance with the procedures described. 6 Training Implications The sponsoring director will ensure that the necessary training or education needs and methods required to implement the policy or procedure(s) are identified and resourced or built into the delivery planning process. This may include identification of external training providers or development of an internal training process. 7 Documentation 7.1 Other related policy documents Policy for General infection control precautions Policy for decontamination of equipment 7.2 Legislation and statutory requirements Health and Safety Executive (1974) Health and Safety at Work Etc. Act 1974. 7.3 Best practice documents Coia, J.E. et al (2006) Guidelines for the control and prevention of meticillinresistant Staphylococcus aureus (MRSA) in healthcare facilities by the Joint BSAC/HIS/ICNA Working Party on MRSA, Journal of Hospital Infection 63 Department of Health (2008) MRSA Separating Fact from Fiction, London, DH 7.4 References Coia, J.E. et al (2006) Guidelines for the control and prevention of meticillinresistant Staphylococcus aureus (MRSA) in healthcare facilities by the Joint BSAC/HIS/ICNA Working Party on MRSA, Journal of Hospital Infection 63 Department of Health (2010) The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance. London, DH H:Policy Development/Infection Control v5 Page 9 of 14 Department of Health (2008) Going Further Faster II: Applying the learning to reduce HCAI and improve cleanliness, London, DH Department of Health (2008) MRSA Separating Fact from Fiction, London, DH Health and Safety Executive (2002) Control of Substance Hazardous to Health (COSHH) Regulations, London, HSE Perry,C. (2008) Exploring the evidence for screening staff for MRSA. Nursing Times, Vol.104, No 3 8 Monitoring, Review and Archiving 8.1 Monitoring The Director of Nursing, as sponsor director, will agree with the Lead Infection Prevention and Control Nurse a method for monitoring the dissemination and implementation of this policy. Monitoring information will be recorded in the policy database. 8.2 Review 8.2.1 The Director of Nursing will ensure that each policy document is reviewed in accordance with the timescale specified at the time of approval. No policy or procedure will remain operational for a period exceeding three years without a review taking place. 8.2.2 Staff who become aware of changes in practice, changes to statutory requirements, revised professional or clinical standards and local/national directives that affect, or could potentially affect policy documents, should advise the sponsoring director as soon as possible, via line management arrangements. The sponsoring director will then consider the need to review the policy or procedure outside of the agreed timescale for revision. 8.2.3 If the review results in changes to the document, then the initiator should inform the policy manager who will renew the approval and re-issue under the next ‘version’ number. If, however, the review confirms that no changes are required, the title page should be renewed indicating the date of the review and date for the next review and the title page only should be re-issued. 8.2.4 For ease of reference for reviewers or approval bodies, changes should be noted in the ‘document history’ table on the front page of this document. NB If the review consists of a change to an appendix or procedure document, approval may be given by the sponsor director and a revised document may be issued. Review to the main body of the policy must always follow the original approval process. H:Policy Development/Infection Control v5 Page 10 of 14 8.3 Archiving The Policy Manager will ensure that archived copies of superseded policy documents are retained in accordance with Records Management: NHS Code of Practice 2008. 9 Equality Impact Assessment Statement The tables below summarise reviews with respect to: 9.1 Strategic and operational risks, including risks to health and safety. Current equality and diversity legislation. Rights under the European Convention on Human Rights. Risk Audit Risk Audit for RISK CATEGORIES 1 2 3 4 5 6 7 8 Risks relating to organisational objectives Risks to patient experience/outcome Risk to or from service/business interruption Risks relating to staffing and competence Financial risks Risks to compliance with inspection/audit standards General risks to organisational reputation Specific health and safety (inc fire) risks to persons (staff, patients, public, etc) a Location (access, environment, working conditions) b Equipment (medical, electrical, other) c Hazardous substances d Lone working e Moving and handling f Potential to cause undue stress g Anti-social behaviour (violence, harassment, theft) Significant Risks Identified Yes/No Yes Yes No Yes No Yes Yes No No No No No No OUTCOME (tick appropriate box) ACTION No significant risks identified Significant risks identified Proceed with ratification process. There is some doubt about whether risks are significant or relevant. H:Policy Development/Infection Control v5 Complete a full risk assessment form and action plan for all risks identified. Include in the Appendices – see Appendix 1. Take further advice from appropriate directorate or department. If unresolved, refer to Governance and Assurance Committee. Page 11 of 14 9.2 Equality Audit Equality Audit for QUESTION RESPONSE What is the purpose of the proposed policy document (or changes to policy document)? Management of MRSA positive patients within primary/community care Correct patient management and safety No Who is intended to benefit, and how? Will the proposals involve, or have consequences for, the people the CCGs serve and employ? Is there any reason to believe that people could be affected differently by the proposals, for example in terms of access to a service, or the ability to take advantage of proposed opportunities? Is there any evidence that any part of the proposals could discriminate unlawfully, directly or indirectly, against any section of the population? Is the proposed policy likely to affect relations between certain groups of people, for example because it is seen as favouring a particular group or denying opportunities to another? Is the proposed policy likely to damage relations between any particular group(s) of people and the CCG? No No No No OUTCOME (tick appropriate box) Potential for discrimination is very low or non-existent Potential for discrimination exists There is doubt about the potential for discrimination H:Policy Development/Infection Control v5 Proceed with ratification process. Amend the document as appropriate to clarify exceptions or remove potential. If this is not possible, take further advice from Corporate Services Manager and/or the Equality Lead Manager (HR Department) Page 12 of 14 9.3 Human Rights Audit Human Rights Audit for QUESTION RESPONSE Does the policy document interfere with a Convention right? Could the actions described in the policy document touch on one of the Convention rights? Is there a victim? Are there circumstances where the right can legitimately be limited or interfered with? Does the interference meet the general criteria established by the Strasbourg authorities, ie: The action is prescribed by law It pursues a legitimate aim. It is necessary in a democratic society. No No No No No OUTCOME (tick appropriate box) No rights affected Potential to affect a right has been identified There is doubt about the potential to affect a right. H:Policy Development/Infection Control v5 Proceed with ratification process. Amend the document as appropriate to clarify exceptions or remove potential. If this is not possible, take further advice from Corporate Services Manager/Legal Advisers. Page 13 of 14 APPENDIX 1 There is a risk of non-compliance with all infection control policies which would in turn increase the risk of patients acquiring healthcare associated infections (HCAI), the organisation not achieving national targets on HCAI and not complying with inspection audits. These policies are designed to provide a framework to reduce those risks. H:Policy Development/Infection Control v5 Page 14 of 14