THE PENNINE ACUTE HOSPITALS NHS TRUST

MRSA Screening Arrangements for Elective Patients

Introduction

By 31st March 2009, the bulk of elective admissions should be screened for MRSA colonisation and most day cases. There is an expectation that screening and decolonisation is addressed as a whole health economy issue and that it is implemented in a coherent and coordinated way, with each element of the system playing its relevant part.

National guidance regarding screening elective admissions, however, is not completely prescriptive (there are some exclusions of groups of patients where the risk of MRSA infection is small, and for whom there could be significant cost but little or no benefit were they to be screened; there are other groups who will frequently attend hospital for a series of scheduled interventions during a lengthy programme of treatment and frequent screening and/or decolonisation will impact adversely on treatment plans). Local guidance cannot cover every clinical or operational eventuality. That is, a flexible and responsive approach will have to be taken within 3 broad screening and decolonisation pathways for elective admissions.

Existing screening arrangements for emergency admissions are unchanged at present.

Pathway 1 - Elective Surgical Patients

The majority of attendees at Pre-Operative Assessment Clinics (POAC) undergo a cardiorespiratory assessment for General Anaesthetic (GA). Elective In patients (IP) and Day Case (DC) patients who attend POAC will be screened 4-to-6 weeks prior to surgery in the clinic and then decolonised in primary care prior to admission for surgery.

In patients will be swabbed at 2 sites (nose and groin) and only 3 when clinically indicated

o Only 2 attempts at decolonisation will be made by the GPo Following decolonisation treatment the patient will be re-screened in POAC

prior to admission to ensure the treatment has been successful.o MRSA protocols will be used on admission for patients whose colonisation

was identified pre-operatively

DC patients will be swabbed once only (nasal) unless otherwise indicated

o Only 2 attempts at decolonisation will be made by the GPo Following decolonisation treatment the patient will be re-screened in POAC

prior to admission to ensure the treatment has been successful.o MRSA protocols will be used on admission for patients whose colonisation

was identified pre-operatively

“Late Notice Substitution Patients”. It may be the case that some patients are invited for surgery at late notice if an operating list is cancelled. If this is the case, the individual patient’s risk factors must be considered by the admitting Consultant team and the patient should be screened on admission (even though this may not be reported until after discharge). The admitting doctor needs to discuss with clinical colleagues whether or not to proceed to operation with or without prophylactics cover or other intervention.

Pathway 2 - Local Anaesthetic Day Cases (LADC), Elective Medical Admissions and non-orthopaedic paediatric admissions and orthopaedic paediatric admissions

There are groups of patients for whom attendance POAC is not possible or appropriate.

For the majority of patients, the following screening arrangement will be followed:

o The patient will be swabbed at the last out-patient clinic appointment before admission (1 nasal swab only)

o In order for results to be sent to the patient’s GP to initiate decolonisation treatment, the request card MUST be completed with the patient’s GP details AND details of the consultant to whom the results will be copied

o The swab results will be sent electronically to the patient’s GP (copy to consultant). The GP will initiate decolonisation treatment if positive

o The patient will be admitted without a re-screeno MRSA protocols will be used on admission for patients whose colonisation

was identified pre-operatively

For some patients who need more urgent elective admission when there clearly will not be time to decolonise prior to admission (e.g., patients on a cancer pathway):

o The patient will be swabbed at the last out-patient clinic appointment before admission (1 nasal swab only)

o In order for results to be sent to the patient’s GP to initiate decolonisation treatment, the request card MUST be completed with the patient’s GP details AND details of the consultant to whom the results will be copied

o The swab results will be sent electronically to the patient’s GP (copy to consultant). The GP will initiate decolonisation treatment if positive and if possible

o The patient will be admitted without a re-screen and decolonisation treatment completed or initiated in the hospital

o MRSA protocols will be used on admission for patients whose colonisation was identified in advance of admission.

For some patients who are admitted directly from OPD

o The patient will not be swabbed unless she/he meets established emergency patient screening criteria (e.g, vascular or orthopaedic or nursing home patient).

Paediatric orthopaedic patients will be screened and decolonised in line with current arrangements

Pathway 3 - Elective Caesarean Sections

Will be screened (2 swabs, nasal and groin) approximately 4 weeks prior to the procedure date and decolonised through antenatal clinics if necessary.

Exceptions and exclusions

The national guidance has some specific exceptions and exclusions and allows for some latitude based on local circumstances.

The following types of admission need not be screened:

o Day case ophthalmologyo Day case dentalo Day case endoscopy (including cystoscopy, bronchoscopy, colposcopy,

nasendoscopy etc., as well as colonoscopy or gastroscopy)o Minor dermatology procedures, eg, warts or other liquid nitrogen applicationso Children/paediatrics unless already in a high risk groupo Maternity/obstetrics (incl. ToP) except for elective caesareans and any high risk

caseso Day cases attending for pain management therapy should not be screened unless

there are reasons to the contrary.o Radiological patients should not be routinely screened

The following types of admission will be screened at the last clinic appointment before their admission to hospital for the start of their treatment programme and according to already-established local or national “surveillance” screening regimes during courses of treatment unless otherwise indicated:

o Patients on dialysis should be screened for MRSA on admission to the programme and then at regular intervals, determined by local practice in the light of national guidance. All patients should be screened for MRSA prior to creation of vascular or peritoneal access (2 swabs; nose and groin).

o Chemotherapy patients (incl. Intra Vesical Chemotherapy) should be screened at the beginning of a course of treatment (3 swabs; nose, throat, groin) and then at regular intervals, determined by local or national practice guidance.

o Blood transfusion patients or other patients who require frequent admission as part of a longer treatment programme should be screened before their programme begins (2 swabs; nose and groin) and during treatment as dictated by the patient’s condition and local or national practice guidance.

The following procedures have been the subject of some internal and external clinical discussion across the Trust and that discussion is summarised:

Duodenal and colonic stenting – screen only if overnight stay PEG insertion – screen Bronchoscopies – no need to screen (endoscopies) CT guided biopsies are an overnight stay, so need to be screened  TRUS Prostate biopsies – no need to screen Nephrostomy tube insertion – screen TWOC – technically an admission with a catheter, so should be screened Urodynamics patients need not be screened Out-patient solid tumour chemotherapy patients unless they require insertion of a

central line prior to commencing treatment – need not be screened

The consensus is that these groups of patients should have 2 swabs (nose and groin) taken when screening is indicated.

ConclusionIt is inevitable that screening and decolonisation arrangements will evolve in the light of further guidance from the centre and ongoing local clinical and managerial debate. The 3 arrangements described above provide a broad framework within which Divisional and Directorate screening can develop.

Marian Carroll, Director of Nursing and DIPC/Infection Prevention and Control Team March 2009

Updated August 2009.