National Targeted Rollout. MRSA Screening A resource pack to support the training of healthcare staff 5th February 2010
Xxxx Learning Outcomes Xxxx On completion of this course you should be able to: Give a definition of MRSA. Describe the rationale for MRSA screening. Identify the patient areas that are subject to MRSA screening. Describe how to take a nasal swab. Explain how a nasal swab is processed in the microbiology department. Describe action to be taken following a positive MRSA result. 2
Xxxx Contents Xxxx Section 1. MRSA and MRSA Screening. Section 2. Who should be screened for MRSA? Section 3. How to take a nasal swab? Section 4. Processing of a nasal swab in the Microbiology department. Section 5. Action to be taken on receipt of a positive MRSA result. Resources Appendix 1. Hand Hygiene. Appendix 2. Questions and Answers. 3
Section 1. MRSA and MRSA Screening This section will describe what MRSA is, the terms colonisation and infection and what a MRSA screen involves.
Xxxx What is MRSA? Xxxx MRSA stands for Meticillin-resistant Staphylococcus aureus. MRSA is a bacterium (micro-organism). MRSA is a type of Staphylococcus bacteria that can live on the skin of healthy people, but in some cases can also cause an infection. Staphylococcus aureus is an micro-organism that one third of the population carries on their skin and/or in their nose. MRSA is resistant to an antibiotic called meticillin thus the name Meticillin-resistant Staphylococcus aureus. It is resistant to antibiotics such as flucloxacillin, the antibiotic often used to treat Staphylococcus aureus infections. It may also be resistant to a variety of other antibiotics. Some people carry MRSA on their skin and in their nostrils without knowing it and without it causing any harm. This is called colonisation. If MRSA causes an infection these are the same types of infection caused by Staphylococcus aureus. MRSA infection can be treated with antibiotics although the choice may be more limited and treatment time prolonged. 5
What is the difference between colonisation and infection? Colonisation Many people are unaware that they carry MRSA on their skin or in their nose as it does not harm them and they have no symptoms. A patient from whom MRSA is identified but has no signs or symptoms of an infection is said to be colonised with MRSA. Infection Infection occurs when a micro-organism such as MRSA gains entry to the body. This could be via an open wound or invasive devices and multiplies (grows) in the tissue. Infections vary in severity. Patients at particular risk from infection are surgical patients, intensive care patients, immunocompromised patients and patients with open wounds or invasive devices. Symptoms of infection depend on the nature and severity of the infection. Generally there is an increase in the person s temperature. If localised infection is suspected (this is where infection is limited to a small area on the body) there may be signs of redness, swelling, pain with or without a purulent (pus) discharge. 6
How is MRSA spread? MRSA is spread by direct or indirect contact. Direct contact Direct contact occurs during skin to skin contact. For example micro-organisms can be transferred via the hands of healthcare staff who have contact with a patient who is colonised or infected with MRSA. Indirect contact Indirect contact takes place when a person has contact with a contaminated object such as equipment which is in the environment of a colonised or infected person or equipment which has been contaminated with MRSA. 7
What is MRSA screening? MRSA screening is when a patient is tested for the presence of MRSA on or before admission. MRSA screening is a microbiological test where a swab sample is taken from a carriage site (e.g. nostrils). This is the process which identifies which patients are colonised with MRSA. The nose is the most common carriage site for MRSA. 8
Section 2. Who should be screened for MRSA? This section will describe the work by NHSScotland to examine the clinical and cost effectiveness of screening and the MRSA screening programme.
Health Technical Assessment 9: The clinical and cost effectiveness of screening for Meticillin-resistant Staphylococcus aureus (MRSA) (Ritchie et al, 2007) The above report was commissioned to consider different MRSA screening strategies and appropriate management of patients admitted to acute hospitals. The report was necessary as recent UK guidance on MRSA screening was contradictory in its recommendations. The report recommended that a primary study to be set up in acute inpatient settings to assess whether screening is effective in preventing MRSA infection. This study was called the MRSA Screening Pathfinder Programme. www.documents.hps.scot.nhs.uk/hai/mrsa-screening/mrsa-screening-interim-summary.pdf 10
MRSA Screening Pathfinder Programme Three NHS Boards agreed to take part in the study to assess whether MRSA screening is effective in preventing MRSA infection. The project allowed the collection of data to inform (1) the impact of MRSA screening, (2) test the estimates of economic model assumption and (3) estimate the feasibility for roll out of MRSA screening in NHSScotland. 11
NHS Scotland MRSA screening Pathfinder Programme Summary Interim report (March 2009) MRSA screening in acute inpatient settings commenced in the Pathfinder NHS Boards in August 2008. A total of 29, 690 patients were screened for MRSA. Findings 3.8% of admissions to hospitals in Pathfinder NHS Boards, laboratory confirmed, colonised with MRSA. 1 in 5 admissions to hospital in the four specialities were found to be colonised with MRSA. These were nephrology, care of the elderly, dermatology and vascular surgery. On 8th April 2009 the Cabinet Secretary for Health and Wellbeing announced a national MRSA screening programme should be rolled out across NHSScotland. 12
MRSA Screening National Implementation Programme. Who is to be screened for MRSA? All patients undergoing elective admission to acute hospitals (excluding paediatrics, obstetrics and psychiatric admissions). All elective and emergency patient admissions, including patients transferred, to the four specialities of nephrology, vascular surgery, dermatology and care of elderly. Remember this only applies to patients who stay overnight. Day cases should not be screened. This is to be implemented by all NHS Boards by 31st January 2010. Q. Where can I get more information? You can get more information on MRSA from a leaflet called MRSA Information For Patients. You can find this leaflet in the leaflet rack on the ward or department, or please ask a member of staff to give you one. If you have any more questions about the screening, please ask a member of staff. For more general information about MRSA visit www.hps.scot.nhs.uk. This leaflet is available in other languages as well as in large print, in Braille (English only) and on audio tape. To ask for a copy of this leaflet in another language or format, please contact our communications officer at: Clifton House, Clifton Place, Glasgow G3 7LN 0141 300 1100 Other language options are available from the HPS web site: http://www.hps.scot.nhs.uk/haiic/sshaip/ mrsascreeningprogramme.aspx#leaflet MRSA screening Information for patients Note: Staff must refer to their local NHS Board MRSA screening policy as additional screening may be carried out as part of a local risk assessments for MRSA. 2009_09_22 MRSA Screening Information for Patients (V2) MRSA leaflet - nationalv2.indd 1 16/10/2009 09:06:42 13
Why are healthcare staff not being screened for MRSA? A recent literature review carried out by Health Protection Scotland found no published controlled studies examining the impact of routine screening of healthcare staff as an intervention in the prevention and control of MRSA infections in the endemic setting. In addition the following factors mean staff screening for MRSA is not currently taking place; Staff can become transiently colonised testing positive at the end of a shift and negative by the time they return to work the next day. Healthcare workers are likely to have ongoing exposure to MRSA colonised patients. Therefore, staff who test negative on one occasion may subsequently test positive. Similarly, staff who have been de-colonised may be re-colonised following treatment. Therefore further research is required to determine the clinical and cost effectiveness of staff screening for MRSA as an infection control measure. 14
MRSA Screening in NHS Boards Staff should always check local MRSA policy on MRSA screening as there may be additional screening carried out locally out with the national rollout programme. Within every NHS Board there will be a Project Manager or Team for the MRSA screening programme who can be contacted for further advice. 15
Section 3. How to take a nasal swab? This section will describe the process of taking a nasal swab.
The equipment or facilities that are required to be in place prior to taking a nasal swab This will include a swab, a microbiology specimen request form and transport specimen bag. Ensure you have a supply of information leaflets for patients on MRSA screening. These leaflets are available in alternative languages, large print and Braille. Copies can be obtained from your local MRSA Project Team. Ensure you have access to hand hygiene facilities with liquid soap and paper towels or alcohol gel/ handrub/foam. You will require non sterile gloves. Refer to local glove policy for glove type. 17
Care of the patient prior to MRSA screening Ensure the patient has privacy. Introduce yourself to the patient. Explain the procedure to the patient outlining the reason for MRSA screening, the type of swab to be taken. Provide an information leaflet for the patient on MRSA screening. Allow time for the patient to ask questions. Inform patient of local procedures for contacting them if MRSA is identified from their sample. Seek the patient s verbal consent prior to taking a nasal swab. 18
How to take a nasal swab? If patient has nasal discharge ask them to clear the discharge by blowing his or her nose into a non scented tissue. Wash your hands with liquid soap and dry with disposable paper towels. Alternatively, if hands are visibly clean use alcohol gel/handrub/foam. Put on nonsterile gloves. Refer to local policy on glove use. Open and remove sterile tipped swab applicator from transporting casing. You will require non sterile gloves. Refer to local glove policy for glove type. 19
How to take a nasal swab? Direct the swab upward to the tip of the nose. Taking care to avoid skin contact with swab. Insert the swab approximately 2cm into one of the nostril. Gently rotate around the nostril area for 3-5 seconds. Repeat this process with the other nostril using the same swab. Remove from the nostril and carefully place swab back into transport casing and secure. 20
How to take a nasal swab? Fill in the appropriate patient detail as requested (or affix patient label) on the outer aspect of the transport tube. Ensure that date and time the swab was collected are included, as well as patient location. See the following slide for information on how to complete a specimen request form. Place swab specimen and microbiology specimen form in transport specimen bag. Leave for collection in designated area as per local procedure for uplift and transfer to the laboratory. If the collection is delayed and/or the swab is left overnight, place in dedicated specimen fridge until the next collection is due. If a dedicated specimen fridge is not available refer to local policy for the transportation of specimens. 21
How to complete specimen request form There maybe slight variation due to local policy but normally the following information is required: Name / Age / Date of Birth CHI number (if available) Location (either ward area/pre-assessment clinic) Test request: culture and sensitivity Purpose/rationale: MRSA screening Date and time sample collected Antibiotic currently prescribed Specimen type (e.g. nasal swab) Reason for admission Note: the above is the minimum dataset and is mandatory. Specimens may not be processed if this is not provided. Remember only one form is required even if more than one swab is taken from the same patient. Each swab should be clearly identify the sample site. 22
Sample Microbiology Form Surname Urinary Tract Dysuria Frequency Urgency Loin pain Abdo pain Prostatitis Respiratory Tract Bronchiectasis Sinusitis COPD Pneumonia AREA LABORATORY 0131 000000 MICROBIOLOGY L A B E L Urogenital Urethral/Vaginal discharge STI Screen PID Vulvitis Balanitis Gastrointestinal Diarrhoea Nausea Vomiting Dyspepsia First Name Patient's Address Date of Birth Sex CHI No. Skin/Soft Tissue Bite Cellulitis Wound infection site of wound: Rash/lesion? Eczema Nervous System Fit/s Headache Meningism Bone/Joint Osteomyelitis Joint prosthesis Septic Arthritis Reactive Arthritis Consultant / GP Date of onset Date of Specimen Initials & Bleep ALL SAMPLES SHOULD BE ADEQUATELY LABELLED. INADEQUATELY LABELLED SAMPLES WILL NOT BE PROCESSED.? Gout ENT/Eyes Conjunctivitis Otitis media Otitis externa Sore Throat Time Ward / G.P. Address Specimen type, site and request(s) Relevant Clinical Details (continue overleaf if required) Other Inoculation Risk YES NO Antibiotic History: Previous/Current/Proposed... Dose & time (for Antibiotic Assays)... Fever (>37.8)/chills Routine/Asymptomatic/screening Pregnant Immunocompromised Diabetes NAME... DATE... REQUEST... 23
Section 4. Processing of nasal swabs in the Microbiology department. This section will describe the process of culturing the swab and antibiotic sensitivity tests within the microbiology laboratory.
What happens to the swab in the microbiology department? Bacteria need to grow to be identified in the laboratory. They are grown on special media that is called agar. The agar contains nutrients which encourage the growth of bacteria. MRSA specific agars contain antibiotics to minimise the growth of bacteria other than MRSA, and dyes to help distinguish MRSA growth from other bacteria. 25
What happens to the swab in microbiology department part 2. Each sample that arrives is given a unique identification number, and is entered into the laboratory computer system. The sample is inoculated (spread) onto the agar plate. The plate is then incubated at 37 C to encourage growth. After 24 hours the plate is removed from the incubator. The micro-organisms appear as small colonies on the plate. Coloured colonies are lifted from the plate for further work to confirm the identification of MRSA. 26
MRSA colonies (one of the MRSA specific agars) 27
Microbiology processing of a suspected MRSA Coloured colonies (blue in this example) are tested for the presence of an enzyme to confirm the micro-organism is a Staphylococcus aureus. If this test is negative, no further work is done, and a MRSA negative report issued. If the enzyme test is positive, antibiotic sensitivity testing is done to confirm whether the micro-organism is MRSA. Antibiotic testing is performed in a machine that tests the suspect microorganism against a range of antibiotics. The unique identification number of each sample means the results are electronically transferred to the laboratory computer system. 28
Time to Results Negative results should be available the following day, usually 24 hours after being processed. Remember this is not necessarily 24 hours after being taken. Positive results require the initial 24 hours and at least another 24 hours for antibiotic sensitivity work. Sometimes a further 24 hours depending on how much MRSA is grown. Turnaround times may vary as not all laboratories follow this precise method 29
Further Actions Laboratories will store all new all new samples identified as MRSA to ensure the organisms are available for further testing if required. Laboratories report all isolates to Health Protection Scotland via electronic system. 30
Reporting positive MRSA results Infection Control Teams should be informed of all new MRSA isolates promptly. Depending on local policy the Infection Control Teams or the Laboratory will inform Ward and Medical staff. Once confirmed, results will be available on local Laboratory/information systems. Results will be sent to the requestor either electronically on hard copy or both depending on local policy. 31
Section 5. Action to be taken on receipt of a positive MRSA results This section will describe what action should be taken on receipt of a positive result including who should be contacted.
Treatment of patient found to have MRSA A decolonisation regime for MRSA may be carried out. You must refer to local policy as this may differ between NHS Board areas. Further advice can be obtained by contacting your local Infection Control Team. A decolonisation regime can help reduce or remove the MRSA bacteria from hair, skin and nostrils. A decolonisation regime consists of an antiseptic wash to be used on the body and hair and a nasal ointment for the nostrils. Decolonisation products must be prescribed. Follow local procedures. Antibiotic treatment (oral or intravenous medication) will only be initiated where the patient has a MRSA infection. This is confirmed by identifying MRSA from wounds or other samples in conjunction with the patient having relevant clinical symptoms. 33
What happens if a patient is found to have MRSA and is staying in hospital? MRSA can spread to other patients therefore Standard Infection Control Precautions (SICPS) and appropriate Transmission Based Precautions (TBP) should be applied to prevent transmission or spread of MRSA. This may mean source isolation precautions are necessary and the patient may require single room facilities. As highlighted previously you must inform the Infection Control Team that MRSA has been identified and seek advice on appropriate management of the patient. A decolonisation procedure may be required and you should refer to local policy. The medical team in charge of the patient s care must be informed that the patient has been identified with MRSA. 34
If a patient is identified as having MRSA following pre-admission MRSA screening. Make sure you are aware of local policy for informing patients in the community of their MRSA status and issuing decolonisation regimes. The patient may be issued a decolonisation regime and the method of issue will vary in NHS Boards. The patient will be given supporting material advising on how to carry out the decolonisation and will be given a contact name or number to call if they require further assistance. Make sure you are aware of local policies as systems in place to support the patients in the community will vary in NHS Boards. 35
Resources www.hps.scot.nhs.uk/haiic/sshaip/mrsascreeningprogramme.aspx www.nes.scot.nhs.uk/hai www.hps.scot.nhs.uk/haiic/ic/guidelines.aspx www.nhshealthquality.org/nhsqis MRSA Screening Resource Pack - Feedback Questionnaire Please give us feedback on this resource pack by clicking on the link below. This will take you to an online questionnaire which will take a few minutes to fill in. Thank you very much for your help. www.surveymonkey.com/s/fbpwbg9 36
Appendix 1. Hand Hygiene
Regular and effective hand hygiene is the single-most important thing you can do to protect yourself and others from infection. Promoting Hand Hygiene in Healthcare was developed from the Cleanliness Champion programme and has been adapted to stand alone as a learning package. It is designed to be used by any healthcare worker, student or carer within hospital or community wishing to update, refresh or challenge personal hand hygiene knowledge and practice. This resource can be accessed by linking to: www.nes.scot.nhs.uk/hai/osc/hygiene 38
Appendix 2. Questions & Answers
Questions 1. MRSA is a virus. 2. MRSA is resistant to ALL antibiotics. 3. People who are colonised with MRSA will show signs and symptoms of an infection. 4. The most common area of carriage of MRSA is in the nose. 5. Patient admitted routinely to paediatric, obstetric and psychiatric specialities will be screened as part of the routine screening programme. 6. It is important to seek the patients verbal consent prior to taking a nasal swab. 7. It is not necessary to carry out hand hygiene prior to taking a nasal swab. 8. MRSA can take up to forty eight hours to grow in the laboratory. 9. It is not necessary to inform the Infection control team if inpatient Is identified as carrying MRSA. 10. It is vital to be aware of local policies and procedure for the screening for MRSA and decolonisation regimes as this may vary between Health Boards. True False 40
Answers to Questions 1. False. MRSA is a bacterium (micro-organisms) Slide 5. 2. False. MRSA is resistant to an antibiotic called meticillin thus the name Meticillin-resistant Staphylococcus aureus. This means it is resistant to flucloxacillin, the antibiotic often used to treat Staphylococcus aureus infections. It may also be resistant to a variety of other antibiotics. Slide 5. 3. False. A patient from whom MRSA is identified but has no signs or symptoms of an infection is said to be colonised with MRSA. Slide 7. 4. True. The nose is the most common carriage site for MRSA. Slide 8. 5. False. All elective and emergency patient admissions including patients transferred to the four specialities of nephrology, vascular surgery, dermatology and care of elderly. Remember this only applies to patients who stay overnight. Day cases should not be screened. Slide 13. 6. True. The patient should give verbal consent prior to taking a nasal swab. Slide 18. 41
Answers to Questions. Continued 7. False. Hands must be washed with liquid soap and dry with disposable paper towels prior to taking a nasal swab. Alternatively, if hands are visibly clean use alcohol gel/handrub/foam. Slide 19. 8. True. Positive results require the initial 24 hours and at least another 24 hours for antibiotic sensitivity work. Sometimes a further 24 hours depending on how much MRSA is grown. Slide 26. 9. False. You must inform infection control team that MRSA has been identified and seek advice on appropriate management of the patient. Slide 31. 10. True. It is vital to be aware of local policies and procedure for the screening for MRSA and decolonisation regimes as this may vary between Health Boards. Slide 33. 42