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
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.
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.
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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/.
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.
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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
1. MRSA Positive Contact Screening and Tracing Guidelines
2. Patient Information Sheet - Methicillin Resistant Staphylococcus aureus (MRSA)
and Decolonization Protocol Instructions
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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)
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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.
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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.
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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)
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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
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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.
If all these cultures are negative then decolonization has been a success.
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