MRSA policy - Hampshire Hospitals NHS Foundation Trust

Methicillin Resistant Staphylococcus Aureus Policy 

MRSA 

Authorities 

Document Control Information 

Author: 

Sue Dailly, Lead Nurse 

Infection Control 

Type: 

Policy 

Sponsor: 

Paula Shobbrook, Director 

of Infection Prevention and 

Control 

Reviewer(s): Members of the Infection 

Control Committee and 

Nursing and Midwifery 

Policy Group 

Approval 

body: 

Infection Control 

Committee 

and Policy Advisory Group 

Scope: 

Major 

Trust Reference CP055 

Number: 

Issue Number: 4 

Status: 

Published 

Effective Date: April 2010 

Review Date: April 2013 

Disposal Date: April 2035 

Document Authorisation Control 

Prepared By: 

Sue Dailly 

Lead Nurse Infection Control 

Signature: 

Authorised Officer 

Martin Wakeley 

Chief Executive 

Signature: 

Authorities 


Author: Sue Dailly Lead Nurse IC Type: Policy 

Sponsor: Director of Infection Prevention and Scope: 

Major 

Control 

Reference: 

CP055 


Date April 2010 Status: Published 

Page 1 of 55

DOCUMENT CONTROL 

Document Amendments 

Winchester & Eastleigh Healthcare NHS Trust 

MRSA POLICY 

Number Details By Whom Date 

1.0 Original document 

2.0 Amended to match Trust Policy for the 

Management of Controlled Documents 

and NHSLA Standard and new national 

guidance on MRSA screening 

3.0 Amended to include new MRSA 

screening guidance 

3.4 Document format alignment to NHSLA 

Standards 

4.0 Document format changed to match PCT 

wide MRSA screening and treatment 

regime 

Sue Dailly ICN 3/02/08 

Sue Dailly ICN 02/2009 

Steven Jennings 

Divisional 

Governance 

Head 

Sue Dailly 

12/03/09 

January 

2010 

Review Timetable 

Date Reason By Whom Date Completed 

February 

2013 

Three yearly review cycle for 

policy document. If national 

guidance changes the policy will 

be reviewed sooner 

Infection 

Control 

Team 

Distribution List 

No 

Title 

1 Infection Control Team 

2 Members of the Infection Control Committee 

3 Trust Intranet 

4 Winchester & Eastleigh Healthcare NHS Trust Website 

5 Holders of Infection Control Manual 

Authorities 



Sponsor: Director of Infection Prevention and Control Scope: Major 

Reference: CP055 



Page 2 of 55



RELATED TRUST POLICIES 

LTP09 Methicillin Resistant Staphylococcus aureus Patients in Theatre Policy 

CP07 Single Use Devices Policy 

CP03 Disinfection, Decontamination and Cleaning Policy 

CP008 Incident Management & Reporting Policy Including the Management of 

Serious Untoward Incidents 

CP014 Antibiotic Policy for adults 

CP030 Overarching Decontamination Policy 

OP052 Waste Disposal Policy 

CP061 Policy for the Intraward Transfer of Patients with Infection Control 

Issues 

CP070 Deceased Infected Patient Policy 

CP072 Training Policy for Employees of WEHCT in Infection Control 

CP073 Hand hygiene policy 

CP079 Trust policy for uniform and clothing worn whilst delivering direct 

clinical care 

CP080 Theatre Uniforms 

OP010 Trust Induction Policy 

OP006 Risk Management & Patient Safety Policy 

OP036 Risk Register Policy 

PG011 Antimicrobial Prescribing Guidelines (Adults) 

CPr049 Theatres MRSA Policy 

Authorities 







Page 3 of 55



Contents 

Section Title Page 

1.0 PURPOSE 6 

2.0 SCOPE 6 

3.0 ROLES AND RESPONSIBILITIES 6 

4.0 INTRODUCTION 7 

5.0 ANTIBIOTICS 8 

6.0 MRSA SCREENING 8 

7.0 DECOLONISATION AND TREATMENT 11 

8.0 WARD STAFF RESPONSIBILITY 12 

9.0 POST TREATMENT 12 

10.0 CONTACT SCREENING 13 

11.0 ISOLATION OPTIONS 13 

12.0 HIGH RISK AREAS 13 

13.0 MEDIUM RISK AREAS 14 

14.0 LOW RISK AREAS 14 

15.0 COHORT BAY OF PATIENTS WITH MRSA 14 

16.0 SURVEILLANCE 15 

17.0 IF A SINGLE CASE IS FOUND ON A WARD 15 

18.0 IF 2 OR MORE CASES ARE FOUND IN A WARD 16 

THIS MAY CONSITUTE AN OUTBREAK 

19.0 BANK AND AGENCY STAFF 17 

20.0 STAFF SCREENING 17 

21.0 VISITS BY MRSA POSITIVE PATIENTS TO OTHER 18 

DEPARTMENTS 

22.0 PATIENTS WITH MRSA HAVING A SURGICAL 18 

PROCEDURE 

23.0 TRANSFER OF PATIENT TO ANOTHER HOSPITAL 19 

24.0 TELLING PATIENTS AND RELATIVES 20 

25.0 INFORMATION FOR HEALTHCARE STAFF 20 

VISITING THE WARD 

26.0 VISITORS – FRIENDS AND RELATIVES 21 

27.0 PATIENT DISCHARGE 21 

28.0 PATIENT EQUIPMENT 21 

29.0 CLEANING, WASTE AND LINEN 22 

30.0 DECEASED PATIENTS 22 

31.0 TRAINING IMPLICATIONS 22 

32.0 MONITORING COMPLIANCE WITH AND 23 

EFFECTIVENESS OF THE POLICY 

33.0 DEFINITIONS 23 

34.0 REFERENCES 24 

Authorities 







Page 4 of 55



Appendix 1 Admission Screening 27 

Appendix 2 Decolonisation 32 

Appendix 3 Isolation procedures 35 

Appendix 4 Kingfisher ward 36 

Appendix 5 MRSA cohorts 37 

Appendix 6 Patient visits to other departments 38 

Appendix 7 Patients going to theatre 40 

Appendix 8 Transfer of patients to another hospital 41 

Appendix 9 Cleaning, waste and linen 42 

Appendix 10 Control of VISA and VRSA 44 

Appendix 11 MRSA staff screening regime 46 

Appendix 12 Criteria for elective screening exemptions 53 

Appendix 13 Equality Impact Assessment Tool 54 

Appendix 15 Communication log 55 

Authorities 







Page 5 of 55



1.0 PURPOSE 

1.1 Specific guidelines for the control and prevention of spread are justified 

because MRSA can cause serious illness and results in significant additional 

healthcare costs. Approximately a third of those colonized with MRSA will 

develop an infection, including invasive infection which may result in 

death (Joint Working Party 2006). 

1.2 The Trust’s objective is to reduce the spread of MRSA and minimize the impact 

in high risk patients and key clinical areas. Controls have a substantial impact 

on both the reservoir of MRSA patients and the attack rate of MRSA 

bacteraemia. MRSA control measures as part of an infection control 

programme can also reduce the impact of other multi-resistant bacteria in ill 

patients 

2.0 SCOPE 

2.1 This policy extends to cover all Winchester and Eastleigh Healthcare NHS 

Trust. This policy will also apply to honorary contract holders and staff 

employed by other organizations, who work with the Winchester and Eastleigh 

Healthcare NHS Trust patients and for the Trust’s other staff. 

2.2 This policy complements professional and ethical guidelines and the NMC Code 

of Professional Conduct (NMC 2008). 

2.3 Infection control is the responsibility of ALL staff associated with patient care. A 

high standard of infection control is required on ALL wards and units, 

although the level of risk may vary. It is an important part of total patient care. 

2.4 It is essential that infection control is seen as an organizational 

responsibility and priority, that adequate facilities and resources are 

provided, and that appropriate infection control staff and support services are 

available. 

3.0 DUTIES, ROLES AND RESPONSIBILITIES 

3.1 Chief Executive Officer(CEO) 

The CEO has overall responsibility for ensuring the Trust has appropriate 

strategies, policies and procedures in place to ensure the Trust continues to 

work to best practice and complies with all legislation. The CEO has overall 

responsibility for the provision of adequate isolation facilities to enable national 

guidance on the control of MRSA to be implemented. There is a mandatory 

requirement for the CEO to report all cases of MRSA bacteraemia to the Health 

Protection Agency. 

Authorities 


Author: Helen Williams Type: Policy 

Sponsor: Chief Executive Scope: Major 

Reference: 

OP001 

Issue Number: 3.4 


Page 6 of 55



3.2 Line managers 

Are responsible for ensuring this policy is accessible for all staff and that they 

have read and understood the content. Line managers are responsible for 

ensuring any changes in practice are implemented, and any further training 

needs identified and addressed. Line managers assist with the root cause 

analysis (RCA) which will be carried out on all cases of MRSA bacteraemia. 

3.3 All staff 

All staff must ensure that their practice follows the current policies. Information 

regarding the failure to comply with the policy (e.g. lack of training, inadequate 

equipment) must be reported to the line manager and the incident reporting 

system used where appropriate. 

3.4 Infection Control Team(ICT) 

The Infection Control Team reports cases of MRSA bacteraemia on behalf of 

the Trust, to the Health Protection Agency (HPA) via the national reporting 

system and within the Trust. Advice is provided to healthcare staff on treatment 

and isolation requirements of patients with MRSA. Data are collated and shared 

within the Trust for patient management, RCA performance, NHS Hampshire 

and South Central SHA reporting. Formal review is via the Infection Control 

Committee, Patient Safety Committee and learning is also shared with the 

Infection Control divisional Leads. 

4.0 INTRODUCTION 

4.1 Methicillin Sensitive Staphylococcus aureus (MSSA) is a common bacterium 

which is carried naturally in the nose of many (about 1 in 3) healthy people and 

may not cause any problems. Alternatively, it may be the cause of wound or 

skin infections. 

4.2 When this bacterium becomes resistant to certain antibiotics it is referred to as 

MRSA – Methicillin Resistant Staphylococcus aureus. MRSA was first reported 

in 1961. There are many different strains of MRSA and some spread more 

easily than others. 

4.3 Data available to date strongly implicate MRSA as a significant cause of 

hospital acquired infection resulting in additional mortality and morbidity as well 

as contributing to healthcare costs. 

4.4 Patients and the public are increasingly seeing MRSA and rates of MRSA 

infections as indicators of the quality of patient care. They require assurance 

that all healthcare professionals are taking reasonable and sensible precautions 

to minimize spread. 

Authorities 







Page 7 of 55



4.5 Control measures have been shown to be effective, resulting in reduced 

mortality as well as helping to contain healthcare costs. Consequently the 

national MRSA Working Party is of the strong opinion that an active MRSA 

control programme, as part of an overall infection control strategy within a 

hospital, continues to be the recommended approach. 

4.6 Good infection control practice should be placed at the centre of clinical 

practice and requires explicit support of the organisational executive to 

ensure that it is seen as having an appropriate position within the 

organisation and can be enforced as a matter of clinical governance. 

5.0 ANTIBIOTICS 

5.1 Excessive use of antibiotics promotes the spread of existing strains of 

MRSA through reduction in colonization resistance in patients and by 

giving resistant strains a survival advantage in a hospital setting. 

5.2 Antibiotic usage should be guided by the following: 

Authorities 

1 Ensuring that antibiotics are given at the correct dosage and for an 

appropriate duration because inappropriate antibiotic use promotes the 

emergence and spread of antibiotic resistance 

2 Avoidance of inappropriate or excessive antibiotic therapy and prophylaxis in 

all healthcare settings. 

3 Limiting the use of glycopeptide antibiotics to situations where their use has 

been shown to be appropriate. If possible prolonged courses should be 

avoided. 

4 Reduce the use of broad spectrum antibiotics, particularly third generation 

cephalosporins and fluoroquinolones, to what is clinically appropriate, 

because exposure to these are independent risk factors for MRSA 

colonization and infection. 

5.3 Instituting antibiotic stewardship programmes to include surveillance of 

antibiotic resistance and antibiotic consumption, and prescriber education will 

help to manage MRSA within a Trust. See CP014 Antibiotic Policy for 

adults for further details 

6.0 MRSA SCREENING 

6.1.1 Patients sometimes bring MRSA into our hospitals without their or our 

knowledge, sometimes from other hospitals in Britain or abroad where they 

have received treatment or from the community. Patients from residential and 







Page 8 of 55



nursing homes may also bring MRSA into our hospitals. Occasionally other 

patients from the community who may have no known risk factors are identified. 

For these reasons all elective and emergency patients will now be screened for 

MRSA, either pre-admission or on admission, except those excluded by DH 

guidance ( see page 19 for details) 

6.1.2 The aim of screening is to identify all positive patients before or on admission to 

the hospital, to allow decolonisation treatment to reduce their risk of infection. 

This also enables the Trust to target the use of isolation and cohort facilities in 

order to minimize the risk of onward transmission to other patients. 

6.1.3 In most cases MRSA will not actually be causing an infection but is merely 

present (colonising) for example the nose or groin. MRSA colonisation does 

make the person a potential source of spread to others. Colonized and infected 

patients are the primary reservoir of MRSA for others, and their identification by 

active screening allows focusing of effective but limited infection control 

resources (Farr 2002). 

6.1.4 Since February 2008 all emergency medical admissions have been screened 

for MRSA. Screening of all elective surgical patients commenced in February 

2009 and the programme was rolled out by April 2009, with monitoring 

throughout 2009. Screening all other emergency patients commenced in 

December 2009 and will roll out in advance of the December 2010 DH deadline. 

The SHA have requested all emergency patients are screened for MRSA by 

March 2010. The aim is universal MRSA screening of ALL appropriate elective 

and emergency patients from 2010 onwards. 

• See Table 1 for details of admission screening regime for each ward 

6.2 What MRSA screening swabs to take and when 

6.2.1 Wounds include sites of intravenous cannula (IV), central vascular access 

device (CVAD) and other line insertion sites, all skin lesions, leg ulcers, 

pressure sores, surgical and trauma wounds, cuts and grazes. 

6.2.2 MRSA may also be found on other specimens submitted for clinical reasons, 

such as sputum. In such cases follow up specimens from the same site should 

be included as part of the screening set. 

6.2.3 Patients who are persistently colonised will require a throat swab to be taken. 

6.2.4 Screening table: definitions 

High risk patients - Admissions from Nursing Homes, Residential homes, other health 

or social care institutions, anyone admitted within last 12 months. Hospital transfers or 

Authorities 







Page 9 of 55



transfers from any health care institution abroad, IV drug users. Those who play 

contact sports (e.g. rugby, football, martial arts) 

CSU – take sample if catheter present on admission 

Table 1 

NOSE 

SKIN 

BREAKS 

GROIN 

[Only if 

no skin 

break] 

CSU* [Only sample 

if catheter in place on 

admission] 

MEDICAL DIVISION 

All emergency Admissions √ √ √ √ 

All elective admissions √ √ √ √ 

All previous MRSA +ve or high risk 

√ 

patients √ √ must do 

√ 

SURGICAL WARDS 

Emergency Admissions √ √ √ √ 



√ 


√ 

ITU/HDU admissions √ √ √ √ 

ORTHOPAEDIC WARDS 

All emergency Admissions √ √ √ √ 



√ 


√ 

MATERNITY 

All elective caesarean sections √ √ √ √ 


patients √ √ 

√ 

must do 

√ 

MRSA contacts (Ante-natal) √ √ 

√ 

must do 

√ 

Works in health care environment 

(48 hours after last working day √ √ 

√ 

must do 

√ 

GYNAE WARD 

Emergency Admissions √ √ √ √ 



patients √ √ √ √ 

NORTHBROOK 

Emergency & Elective High Risk 

Patients* √ √ 

√ 

must do 

√ 


patients √ √ √ √ 

ALL DIVISIONS/WARDS 

Inpatient MRSA contacts √ √ √ √ 

NEO-NATAL UNIT 

Post natal admissions √ √ Umbilicus/Ear 

Hospital Transfers & Andover Birth √ √ Umbilicus/Ear 

Authorities 







Page 10 of 55

Centre 



Emergency admissions/from home √ √ Umbilicus/Ear 

6.3 Emergency Re-admission of previously MRSA positive patients 

6.3.1 Patients who have had MRSA in the past must have a full screen on admission, 

and be isolated in a single room until the MRSA screening result is known. 

They should not be cohort nursed with other MRSA patients until proven 

positive on this admission and found to be suitable to be cohort nursed with 

others. Please inform Infection Control via phone or email when a patient who 

has had MRSA in the past is admitted. Please check the patient’s medical 

notes for MRSA stickers and specific details on the patients electronic CRS 

(Care Records Service) clinical records for electronic alerts and yellow stars. 

6.3.2 Patients admitted from areas where MRSA is known to be present, or have 

had MRSA in the past, should be isolated until MRSA carriage has been 

excluded. 

6.3.3 MRSA positive patients should not be admitted to the Treatment Centre. 

6.4 Routine screening 

6.4.1 Regular (weekly/monthly) screening of all patients on high risk units may be 

requested due to an outbreak or unusual event. At present, there is regular 

weekly screening of all patients in ITU / NNU. Regular screening is not carried 

out on any other wards. 

7.0 DECOLONISATION AND TREATMENT 

7.1 Complete eradication is not always possible but a decrease of MRSA 

carriage can reduce the risk of transmission in healthcare settings. 

7.2 Decolonisation will also reduce the risk of infection eg via inoculation in the 

patient’s own surgical wound during an operation. See Appendix 7 for details of 

prophylaxis and care of patients having a surgical procedure. Theatre staff to 

refer to the LTP09 MRSA Theatre Policy for further specific information. 

7.3 The efficacy of any decolonisation regimen will depend on the presence of 

wounds, skin lesions and foreign bodies such as urinary catheters, nasogastric 

tubes and haemodialysis lines. It also requires the thorough application of 

topical treatments. 

Authorities 







Page 11 of 55



7.4 Higher success rates are reported for eradicating MRSA from hospitalized 

patients using a protocol that includes mupirocin® nasal ointment, daily 

chlorhexidine i.e. Hibiscrub baths, systemic therapy and removal and 

replacement of all foreign bodies (e.g. catheters) and routine cleaning of the 

environment. Using a combination of interventions together gives a better 

success rate of decolonization. 

7.5 Each patient’s MRSA infection must be assessed individually. 

Treatment whether oral or IV should follow CP014 Antibiotic Policy for 

adults (available on the intranet). Consultant Microbiologists are available 

for advice. 

• See Appendix 2 for details of decolonisation options and treatment. 

8.0 WARD STAFF RESPONSIBILITY 

8.1 It is the responsibility of the ward staff, nurses and doctors, to be aware of each 

patient’s MRSA status and at what stage of treatment they are. Delays in 

screening patients means they remain isolated in side rooms for unnecessary 

periods of time. The detrimental psychological effect of being isolated in a 

single room is well documented, so staff should make every effort to ensure 

that complete sets of screening samples are taken on time and the progress of 

results and treatment is documented. An MRSA care plan should be used to 

record and monitor a patient’s progress (template found on the Intranet under 

Infection Control documents). 

8.2 Starting sometime in 2010 patients newly identified as having MRSA will be 

provided with an MRSA Hand Held records book. The Infection Control nurses 

will supply the inpatients on the wards with these books. Pre-Assessment clinics 

will supply these books to their patients, and GPs will give them to patients 

identified via samples taken in the community. Each time a patient visits the 

Trust, for any reason, these records should be checked and up-dated so that 

recent information on screening and treatment are logged. Other Trusts within 

the area will also be providing these hand held records to their newly identified 

MRSA patients. 

8.3 Treatment at discharge 

8.4 Patients discharged during a course of treatment should complete their topical 

treatment and course of antibiotics if prescribed. There is no requirement for 

patients colonized with MRSA to continue extended eradication protocols after 

discharge. Treatment may continue if there is an anticipated re-admission to 

hospital, especially for a planned invasive procedure. 

Authorities 







Page 12 of 55



8.5 The general practitioner (GP) and others involved in the patient’s community 

care should be informed of the patient’s individual MRSA status at discharge via 

the discharge letter and the patient’s hand held records. 

8.6 If a patient is discharged to a residential care facility the medical and/or nursing 

staff should be informed in advance. 

8.7 Colonisation or infection with MRSA is not a contra-indication to the transfer of a 

patient to a nursing or convalescent home. The carriage of MRSA is not a valid 

reason for exclusion from residential care homes. 

9 POST TREATMENT 

9.1 A full screen must be taken on day 3 after antibiotic and topical treatment has 

finished. 

9.2 Full screen to include, nose, groin, skin breaks, any wounds and CSU if 

catheter present. Other samples may be required if the patient had MRSA at 

other sites e.g. sputum/throat. 

9.3 If the patient is still MRSA positive, topical treatment will be re-commenced. 

After two episodes of treatment the individual will be reviewed. A course of 

Mupirocin® treatment should not be given more than twice, within a short period 

of time, without consulting the Infection Control Team. (ICT) 

9.4 There is no evidence that once colonised any group of patients remain 

permanently MRSA free after a decolonisation regime. It should be assumed 

that previously positive patients are always potentially carrying MRSA. 

10 CONTACT SCREENING 

10.1 MRSA contacts should be screened once the patient with MRSA has been 

moved from the ward bay. Nose, skin breaks /wound swabs or groins and 

CSUs must be taken. 

11.0 ISOLATION OPTIONS 

11.1 The provision of MRSA isolation precautions must take into consideration: 

1 Ward speciality 

2 Whether affected patients are likely to be heavy skin shedders 

3 Whether patients are at high risk of developing invasive infection e.g. 

patients with multiple trauma, major life saving surgery, patients on 

immuno-suppressive therapy 

4 Design of ward 

Authorities 







Page 13 of 55



5 Provision of side rooms 

6 Resistance pattern, virulence and potential transmissibility of the 

organism 

See Appendix 10 for advice regarding Vancomycin Resistant Staphylococcus 

aureus and Vancomycin Intermediate Staphylococcus aureus 

• Patient’s medical and psychological welfare should not be 

compromised by unnecessarily restrictive infection control practices 

12 High Risk Areas 

12.1 High risk areas include wards or units where the consequence of uncontrolled 

MRSA is serious because of the risk of invasive infection and difficulties in 

treatment e.g. ITU, neonatal intensive care, orthopaedic, trauma and 

vascular wards and those where patients are having implants. 

12.2 No patient with MRSA will be admitted to an elective orthopaedic ward. 

12.3 On all the other high risk wards patients must be isolated in a single room 

unless their clinical condition would be compromised by being isolated. The 

patient’s condition must be reviewed daily and infection control precautions 

taken within the bay. When the patient can be safely isolated provision should 

be made promptly to move the patient into a side room or cohort bay. All 

patient contacts must then be screened. 

13 Medium risk areas 

13.1 Medium risk areas include admission wards, general surgery, paediatric, 

general medicine and elderly medicine. 

13.2 Ideally these patients should be isolated in single rooms. Cohorting patients in 

a defined area of the ward and using designated staff may be a necessary 

alternative to using single rooms where there are more cases of MRSA than 

side rooms available. Such areas should be capable of physical separation 

from other ward areas. 

13.3 MRSA positive patients should not be admitted to the Treatment Centre. 

14 Low risk areas 

14.1 These are areas where patients are at a low risk of invasive infection but the 

patients are at a high risk of colonisation e.g. nursing homes, psycho-geriatric 

and long term care facilities. Hence, consideration must be given to a 

balance between risk of infection and need for rehabilitation and social contact. 

Authorities 







Page 14 of 55



14.2 In these area patients at high risk of transmission of MRSA should be 

isolated e.g. skin shedders and those with throat colonisation and a 

productive cough. 

Authorities 

• See Appendix 3 for details on how to barrier nurse a patient with MRSA 

• See Appendix 4 for protocol for Kingfisher ward 

15 COHORT BAY OF PATIENTS WITH MRSA 

15.1 The site co-ordinator and the IC team will allocate patients to the MRSA bay in 

consultation with ward staff. It is important to check at which sites the MRSA 

patient is positive, whether he/she is on treatment and that the patient is 

suitable to be placed in the bay (Cooper 2003). 

15.2 Patients admitted to an MRSA bay must have MRSA positive 

microbiology results from this admission or within the last 14 days. These could 

include results from a specimens sent by a GP or from a recent previous 

admission (within the last 2 weeks). 

15.3 Patients who have been identified as being MRSA positive more than 14 days 

ago, or have a history of being MRSA positive, cannot be admitted into the 

MRSA bay until they are proven to be still MRSA positive. These patients 

should be admitted into a side room and screened. They can be transferred 

into an MRSA bay if they are found to be positive, AND are compatible with the 

other patients in the bay i.e. same antibiotic pattern and similar sites positive. 

15.4 Not all patients with MRSA are suitable for nursing in a bay with other 

MRSA patients. The ICT will assess the individual patient’s suitability. 

• See Appendix 5 for details on how to set up and run a cohort bay of MRSA 

patients 

16 SURVEILLANCE 

16.1 Surveillance is carried out as part of the hospital’s infection control programme 

and is an element of clinical governance. 

16.2 Surveillance data are collected on : 

• Number of new cases of MRSA 

• Ward 

• Source of their MRSA e.g. hospital or community acquired 

• Colonisation or infection 







Page 15 of 55



• Mandatory bacteraemia data 

16.3 Surveillance data are fed back to staff on a quarterly basis and are discussed at 

the Infection Control Committee. These data are used to target infection control 

resources e.g. increased education. RCA findings on bacteraemias are fed 

back contemporaneously to relevant staff and more widely when appropriate for 

learning. 

17 IF A SINGLE CASE IS FOUND ON A WARD 

If a single case of MRSA is found on a ward (index case): 

17.1 The MRSA positive patient should be discharged from hospital if the clinical 

condition allows, or isolated in a single room and barrier nursed if discharge is 

not possible. 

17.2 Patients in the same bay should have one set of screening swabs taken from 

their nose, skin breaks / wounds, groins and CSU if a catheter is present. 

17.3 Patients should not be transferred from the contact bay to other ward until 

discussed with the Infection Control Team (in an emergency please inform the 

receiving ward that a side room is required). 

17.4 Once the bed, fittings and furniture have been cleaned and the curtains in the 

bed space changed, the empty bed in the bay can be used. 

18 IF 2 OR MORE CASES ARE FOUND IN A WARD THIS MAY CONSITUTE AN 

OUTBREAK 

18.1 If the contacts of the index case are found to be MRSA positive the 

following action MAY BE requested by the Infection Control Team. 

Each incident will be considered on an individual basis as the risk for 

patients varies with different specialities. 

1 Close affected bay to admissions and transfers 

2 Close ward to admissions and transfers 

3 Contact screen all patients on the ward 

4 Screening of staff 

18.2 Factors influencing consideration of ward closure to admissions 

include: 

1 Risk status of patients to be admitted 

2 Number of cases of MRSA present on the ward 

3 MRSA strain e.g. virulence, resistance 

Authorities 







Page 16 of 55



4 Ward/unit staffing levels 

5 Ability to isolate/cohort colonised patients and contacts during 

quarantine. 

18.3 Wards will only be closed on infection control grounds, following 

recommendation from the Consultant Microbiologist, and after discussion with 

the ward manager, Consultants, Management and the Infection Control Team. 

18.4 Patients maybe discharged home or to a nursing or residential home, other 

wards or other hospitals ONLY after discussion with the Infection Control Team. 

18.5 Before re-opening to new admissions the ward/unit must have a terminal clean, 

including the changing of curtains. 

18.6 Ward closure to new admissions may need to be considered in certain 

circumstances on the basis of risk assessment. The Consultant 

Microbiologist will make the decision when to close and re-open a ward. 

18.7 Any ward closure has to be reported on PRISM and as a SUI (serious untoward 

incident). Details must be sent to the Director of Infection Prevention and 

Control (DIPC) and the Head of Patient Safety and Healthcare Governance. 

18.8 Discharge screening from the affected area may be instituted by the Consultant 

Microbiologist. 

18.9 If an outbreak is declared, an outbreak control meeting will be convened by the 

DIPC (see Ward Closure Policy). In the event of a major outbreak, the Major 

Outbreak Plan should be followed (available in the Infection Control Manual or 

on the Trust intranet). 

19 BANK AND AGENCY STAFF 

19.1 Where possible ward staff should avoid using bank and agency staff to care for 

patients known to be MRSA positive or are being barrier nursed. This is 

because these staff move around the wards and increase the potential of 

spreading MRSA. BUT the needs and care of the patient must take priority and 

where it is necessary bank and agency staff can care for patients known to 

have MRSA. Ward staff must check the competence of bank and agency staff 

to carry out isolation nursing safely. Good hand hygiene is critical to the 

prevention of spread of MRSA. 

20 STAFF SCREENING 

20.1 Screening of staff is not recommended routinely. Staff screening is indicated if: 

Authorities 







Page 17 of 55



1 New carriers are found among the patients 

2 Transmission continues on a unit despite active control measures 

3 If epidemiological aspects of an outbreak are unusual 

4 Or if they suggest persistent MRSA carriage by staff 

20.2 New staff should be screened for MRSA if they have ever been MRSA positive. 

A full screen must be taken. If they are clinical staff and will be working in the 

surgical or orthopaedic unit/ ITU / NNU. A nasal swab should be taken and 

swabs from any skin breaks/wounds if present. Staff can begin work before the 

results are known. 

20.3 MRSA screening of new staff will be co-ordinated by the Occupational 

Health and Safety Department (OH&S). MRSA screening due to an outbreak 

will be coordinated by the Infection Control team. Coordination of treatment and 

follow up screening will be carried out by the Occupational Health & Safety 

Department. 

20.4 Care is needed to distinguish between transient carriage (i.e. carriage 

which is lost within a day or so of removal from contact with MRSA positive 

patients which carries little risk of onward transmission) and prolonged carriage 

(especially associated with throat colonization and skin lesions). 

20.5 This is best achieved by screening staff as they come on duty at the 

beginning of their shift, and not as they leave. 

20.6 Nurses, doctors, physiotherapists, other allied health professionals and nonclinical 

support staff should be considered for screening. Locum and agency 

staff may need to be screened if the Infection Control Team deems it 

necessary. 

20.7 Please see Appendix 11 for advice on staff screening and the OH&S 

Department data sheets (also available from OH&S department) on swabbing, 

treatment and working restrictions for staff. 

21 VISITS BY MRSA POSITIVE PATIENTS TO OTHER DEPARTMENTS 

21.1 Visits by MRSA positive patients to other departments should be kept to a 

minimum. If it is necessary either for investigation, treatment or to visit 

another member of the family, prior arrangements should be made with the 

staff of the receiving department, so that control of infection measures can be 

implemented. 

• See Appendix 6 for details of safe movement of patients around the 

hospital and visits to other departments. See also CP061 Policy for the Intra 

ward transfer of patients with Infection Control issues. 

Authorities 







Page 18 of 55



22 PATIENTS WITH MRSA UNDERGOING A SURGICAL PROCEDURE 

22.1 Following the circulation of the Department of Health Operating Framework for 

2008/9 all elective patients must be screened for MRSA. This includes 

medicine, surgery, family services and orthopaedics. 

22.2 MRSA operational guidance issued in 2008 clarified the criteria for elective 

screening exemptions: 

• Day case ophthalmology 

• Day case dental 

• Day case endoscopy 

• Minor dermatology procedures 

• Paediatrics – unless high risk 

• Maternity except elective caesarean sections and high risk cases 

If these patients have previously had MRSA they should be screened prior to 

admission, like any other elective MRSA positive patient. See Appendix 12 for 

updated information regarding inclusion or exclusion criteria for elective MRSA 

screening. Any changes will be communicated directly to staff involved in 

elective screening of patients and updated on the trust intranet and Infection 

Control intranet site. 

22.3 Elective patients who are found to be MRSA positive following screening will be 

divided into 2 different patient pathways. 

22.4 High Risk Patients 

• Orthopaedics – especially prosthetic 

• Vascular grafts 

• Breast implants and complex surgery 

• Cardio thoracic 

• Diabetic patients 

• Any other individual patient the admitting Consultant diagnoses as high 

risk on a case by case basis. 

These patients will complete a course of decolonisation treatment provided by 

the Trust, or GP, and have 2 sets of negative swabs prior to admission. When 

admitted he/she will be isolated in a single room and re-commence a course of 

topical treatment prior to surgery. MRSA appropriate prophylactic antibiotics will 

also be given for the surgical procedure. 

If the patient remains MRSA positive he/she will be admitted immediately after a 

course of treatment with all the precautions listed above. Antibiotic prophylaxis 

appropriate for MRSA must be given in all such cases. 

Authorities 







Page 19 of 55



All other patients 

All other patients will commence topical treatment 6 days prior to their day of 

admission. The aim is to minimise the risk of infection by carrying out surgery 

immediately after a course of topical treatment. On the morning of surgery they 

will have mupirocin® nasal ointment applied and a chlorhexidine wash i.e. 

Hibiscrub. They will be admitted into a single room and barrier nursed. MRSA 

appropriate prophylactic antibiotics will also be given. No post treatment 

screening swabs will be taken unless clinically required. 

Previously MRSA positive patients and those who are high risk of having MRSA, e.g. 

those living in nursing homes who are admitted as an emergency and require surgery 

before their MRSA status is known must commence decolonisation prior to surgery 

and continue post surgery. Prophylactic antibiotics must cover MRSA. 

22.5 No MRSA positive patient should be admitted to the Treatment Centre. 

• See Appendix 7 for details, also see CPr049 Theatres MRSA Policy 

23 TRANSFER OF PATIENT TO ANOTHER HOSPITAL 

23.1 Refusal to accept transfer of a patient is not justifiable on the basis of the risk 

posed to other patients by an individual’s carriage of, or infection with, MRSA. 

All units should have procedures in place and adequate facilities for 

containment of MRSA. 

23.2 Identification of infected or colonised patients is the responsibility of the 

transferring hospital. Before transfer a member of the clinical team for the 

patient, at the transferring hospital, must inform the ward staff at the receiving 

hospital of the patient’s status. 

23.3 Patients with MRSA do not need to wear a mask when travelling in the 

ambulance. 

See Appendix 8 for details of how to transport patients with MRSA 

24 TELLING PATIENTS AND RELATIVES 

24.1 The implications of MRSA colonization, infection and treatment should be 

explained to the patient and if appropriate close relatives, at the time of 

diagnosis and ideally prior to transfer into a single room, isolation facility or 

designated cohort area. 

Authorities 







Page 20 of 55



24.2 All visitors entering an isolation room must wear gloves and apron. Thorough 

hand hygiene should be carried out once the gloves and apron are removed. 

Parents caring for their children should wear an apron but do not need to wear 

gloves. Parents and relatives who are staying at the hospital and using 

communal facilities must be careful with hand hygiene and use the alcohol gel 

each time they leave the isolation room. 

24.3 Information leaflets should be available giving general information on 

MRSA to the recipient ( on intranet or contact Infection Control Department for 

copies). Patients should be informed that there are minimal risks to healthy 

relatives and contacts outside the hospital, and their normal social interaction 

should not be compromised. 

24.4 Patients should be informed that if they are hospitalized in the future, they 

should advise admitting staff that they have been identified as carriers of MRSA 

in the past, to ensure that they are managed appropriately. They should take 

their MRSA hand held records book with them when seeing healthcare staff 

whether at the hospital or in the community eg GP surgery. 

25 INFORMATION FOR HEALTHCARE STAFF VISITING THE WARD 

e.g. doctors, phlebotomists, physiotherapists, pharmacists (Boyce 2002) 

1 Staff must be bare below the elbow. Wash or gel hands and put on gloves 

and apron before entering the room. Minimal numbers of staff for the 

interaction planned should enter the isolation room or cohort bay. 

2 Take into the room the minimum items of equipment required. Do not place 

these items on the bed. 

3 Do not sit on the patient’s bed when you are in the room. 

4 When you have completed the procedure and are ready to leave, place the 

items near the door. 

5 Remove gloves and apron and place in orange waste bag. 

6 Wash hands thoroughly. 

7 Collect your equipment and leave the room. 

8 Use the alcohol hand gel after you have left the room. 

9 All items removed from the room must be cleaned before use on another 

patient. 

Authorities 







Page 21 of 55



26 VISITORS – FRIENDS AND RELATIVES 

26.1 It is safe for pregnant women and children to visit patients with MRSA. If there 

are specific concerns please contact the Infection Control Team for advice. 

Patients’ social contact such as hugging, kissing and holding hands 

should continue. 

26.2 If visiting other people in the hospital, to see these first and visit the person in 

isolation last. 

26.3 Relatives and visitors should wear gloves and apron when entering the room. 

They should remove their PPE, wash their hands with soap and water and use 

the alcohol hand gel before they leave the ward. 

27 PATIENT DISCHARGE 

27.1 There is no requirement for patients colonized with MRSA to continue extended 

eradication protocols after discharge, unless there is anticipated re-admission to 

hospital, especially for a planned invasive procedure. They should complete the 

course of treatment already commenced whether topical or systemic. 

27.2 The GP and others involved in the patients community care should be informed 

of the patient’s individual MRSA status at discharge in the discharge letter. The 

MRSA hand held record should also be updated. 

27.3 If a patient is discharged to a residential care facility the medical and/or 

nursing staff should be informed in advance. 

27.4 Colonisation or infection with MRSA is not a contra-indication to the 

transfer of a patient to a nursing or convalescent home. The carriage of MRSA 

is not a valid reason for exclusion from residential care homes. 

28 PATIENT EQUIPMENT 

28.1 All equipment on the ward must be single use, single patient use or able to be 

decontaminated prior to use by another patient. 

28.2 Single use items or single patient use items must be disposed of in an orange 

waste bag after use or after the patient is discharged /transferred. Please refer 

to 07 Single Use Devices Policy 

24.3 For the cleaning of non-disposable items please refer to the CP03 

Disinfection, Decontamination and Cleaning Policy. 

Authorities 







Page 22 of 55



29 CLEANING, WASTE AND LINEN 

29.1 Management of the environment and equipment should be considered as 

central to decrease the spread of MRSA. General principles should be adopted 

to minimize the bacterial burden. The ability of MRSA to survive in dust 

demonstrates the need for dust minimization, the removal of bacteria from 

surfaces, and the appropriate disposal of contaminated waste and linen 

(Duckworth 1990). There should be planned, periodic and thorough cleaning of 

the whole ward, including bedding and curtains (French 2004). 

• See Appendix 9 for further details 

30 DECEASED PATIENTS 

30.1 The infection control precautions for handling deceased patients are the same 

as those used in life, but the mortuary should be informed if the patient has 

MRSA or any other infection or colonization with a resistant organism. 

30.2 Use a body bag the same as for other patients without MRSA – unless there are 

circumstances which deem a more robust body bag necessary e.g. 

haemorrhage. 

30.3 There is negligible risk to mortuary staff or undertakers provided that 

standard precautions are followed. For more details please see CP070 - 

Deceased Infected Patient Policy. 

31 TRAINING IMPLICATIONS 

• Infection control training on basic principles is part of the Trust wide mandatory 

training scheme for all staff and is monitored via attendance records, as per 

CP072 - Training Policy for Employees of WEHCT in Infection Control. 

• Training is offered to all staff at induction , as per OP010 - Trust Induction 

Policy 

• Training is offered to all staff at annual update 

• Antibiotic and infection control audits and updates are made quarterly to the 

Infection Control Committee and sent to every clinical team and ward 

• Specialty based training is offered via divisional meetings on an ongoing basis. 

• The link nurses /practitioners participate in a specialist programme of on going 

training. 

• It is the responsibility of individuals and their line managers to ensure 

attendance at training. The Training Department feedback non attendance to 

line managers and it is their responsibility to follow up non attenders and ensure 

their subsequent attendance. 

Authorities 







Page 23 of 55



• E learning for infection control is acceptable on alternate years once face to 

face induction is completed. E learning is accompanied by certification which 

can be used in evidence at appraisal. 

• The workbook approach is acceptable in alternate years 

32 MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF THE POLICY 

• There is a regular programme of audits, led by the DIPC and co-ordinated by 

the Infection Control Team, which are reported to the Infection Control 

Committee e.g. Hand Hygiene, use of Isolation facilities, infection control policy 

compliance, High Impact Interventions. 

• Divisional audits are reported via the divisions to the Infection Control 

committee 

• MRSA surveillance and trends are reported to the Infection Control Committee 

(ICC) 

• Mandatory MRSA and MRSA bacteraemia surveillance is reported to the ICC, 

divisions and Trust Board. 

• Serious Untoward Incidents (Infection) are discussed at ICC and reported to the 

Patient Safety Committee Protection Agency and Strategic Health Authority, as 

per CP008 - Incident Management & Reporting Policy Including the 

Management of Serious Untoward Incidents, OP006 – Risk Management & 

Patient Safety Policy and OP036 - Risk Register Policy 

• Antibiotic usage is monitored and audited by the Antibiotic Pharmacist and 

reported to the ICC and Drugs and Therapeutics Committee , as per PG011 - 

Antimicrobial Prescribing Guidelines (Adults) 

• Monthly reports on infection control and surveillance are taken by the DIPC to 

the Trust Board. 

• Training attendance reports are presented to the ICC 

• Training and education attendance is monitored by the Education Centre and 

reported to individual managers and collectively to the Integrated Governance 

Committee 

33 DEFINITIONS 

MSSA 

MRSA 

Methicillin Sensitive Staphylococcus aureus is a common 

bacterium which is carried naturally in the nose of healthy people 

and may not cause any problems. Alternatively, it may be the 

cause of wound or skin infections. 

When MSSA becomes resistant to certain antibiotics it is referred 

to as MRSA – Methicillin Resistant Staphylococcus aureus. MRSA 

was first reported in 1961. There are many different strains of 

MRSA and some spread more easily than others. 

Authorities 







Page 24 of 55



CSU 

Cohort 

Isolation 

Catheter urine sample. Abbreviation used to identify a sample of 

urine taken from a urinary catheter. 

a well-defined group of patients who have had a common 

experience or exposure i.e. have MRSA and are cared for 

together in a bay. 

nursing the patient in a single room with barrier nursing 

precautions (the wearing of gloves and apron/gown for hands on 

contact). 

MRSA contact - a person who has been nursed in the same room as a person 

with MRSA or a member of staff who has been in contact with a person with 

MRSA. 

34 REFERENCES 

1 Ambulance Association (2008) National guidance and procedures for 

infection prevention and control. 

2 Boyce,J.Pittet,D. (2002) Guidelines for hand hygiene in healthcare settings: 

recommendations of the Healthcare Infection Control Practices Advisory 

Committee and the Hand hygiene task force. Journal of Hospital 

epidemiology 23(sple) S3-41 

3 Cooper,B. Stone,S. et al (2003) Systematic review of isolation policies in 

the hospital management of methicillin resistant Staphylococcus aureus: a 

review of the literature with epidemiological and economic modelling. 

Health Technical Assess 7 1-94 

4 Duckworth, G. Jordan,J.(1990) Adherence and survival properties of an 

epidemic methicillin resistant Staphylococcus aureus compared with those 

of methicillin sensitive strains. Journal of Medical Microbiology 32 195-200 

5 Farr,B, Jarvis,J.(2002) Would active surveillance cultures help control 

healthcare related methicillin resistant Staphylococcus aureus. Infection 

Control Hospital Epidemiology 23 65-8 

6 French, G. et al (2004) Tackling contamination of hospital environment by 

methicillin resistant Staphylococcus aureus (MRSA): a comparison between 

conventional terminal clean and hydrogen peroxide decontamination. 

Journal of Hospital Infection 57 31-7 

Authorities 







Page 25 of 55



7 Joint Working Party (2006) Guidelines for the control and prevention of 

methicillin resistant Staphylococcus aureus in healthcare facilities. Journal 

of Hospital Infection 635, S1-55 

8 Nursing and Midwifery Council (2008) Code of Professional Conduct. 

9 Department of Health (2008) Screening for MRSA colonisation – a strategy 

for NHS Trusts: a summary of best practice. 

10 Department of Health (2008) MRSA screening – operational guidance. 

11 DH guidance on elective screening implementation 2009 

12 HNS Hampshire Health Economy Wide MRSA Screening Guidance 

2009 

Authorities 







Page 26 of 55

Appendix 1 

1.1 Admission Screening 



1.2 Following the circulation of the Department of Health Operating Framework for 

2008/9 all elective patients must be screened for MRSA. This includes 

medicine, surgery, family services and orthopaedics. 

• MRSA operational guidance issued in 2008 clarified the criteria for elective 

screening exemptions: See appendix 12 for further details 





• Paediatrics – except high risk 



admission, like any other elective MRSA positive patient. 

1.3 Who to screen 

A - Elective surgery – Pre Admission screening 

1.3.1 Patients awaiting elective admission should be screened before admission 

either in the pre-assessment clinics or Out Patient Department. 

34.1 Elective patients who are found to be MRSA positive following screening will be 

divided into 2 different patient pathways. 

34.2 High Risk Patients 

• Orthopaedics – especially prosthetic 

• Vascular grafts 

• Breast implants and complex surgery 

• Cardio thoracic 

• Diabetic patients 

• Any other patient the consultant feels is at high risk 

These patients will complete a course of decolonisation treatment provided by 

the Trust, or GP, and have 2 sets of negative swabs prior to admission. When 

admitted they will be isolated in a single room and re-commence a course of 

topical treatment prior to surgery. MRSA appropriate prophylactic antibiotics will 

also be given. 

Authorities 







Page 27 of 55



1.3.2 For High Risk procedures if after 2 courses of decolonisation treatment the 

patient is still MRSA positive the decision must be made between the 

consultant and consultant microbiologist how best to reduce the risk of MRSA 

infection whilst going ahead with the procedure. 

1.3.3 A side room will need to be arranged on the trauma orthopaedic or emergency 

surgical wards as patients with MRSA must not be admitted to the elective 

orthopaedic ward or the Treatment Centre. The patient should be admitted 

immediately after a course of treatment, isolate in a single room, recommence 

topical treatment and antibiotic prophylaxis appropriate for MRSA must be 

given in all such cases 

1.3.4 All other patients 

All other patients will commence topical treatment 6 days prior to their day of 

admission. The aim is to minimise the risk of infection by carrying out surgery 

after a course of topical treatment. On the morning of surgery they will have 

mupirocin® nasal ointment applied and a chlorhexidine wash. They will be 

admitted into a single room and barrier nursed. MRSA appropriate prophylactic 

antibiotics will also be given. No post treatment screening swabs will be taken 

unless clinically required. 

1.3.5 Previously MRSA positive patients and those who are high risk of having MRSA, 

e.g. those living in nursing homes who are admitted as an emergency and require 

surgery before their MRSA status is known must commence decolonisation prior to 

surgery and continue post surgery. Prophylactic antibiotics must cover MRSA. 

1.3.6 The date of admission need not be delayed but the patient should be admitted 

to a single room and be placed on the end of the list. Prophylactic antibiotics 

which cover MRSA should be prescribed to cover the procedure – see CP014 

Antimicrobial Policy and current guidelines. 

1.3.7 Patients for the Treatment Centre who are MRSA positive during preassessment 

will be admitted to another ward for their surgical procedure. No 

cases of MRSA are to be admitted to the Treatment Centre. They will receive 

decolonisation treatment immediately prior to admission. On admission, the 

patient will be placed in a single cubicle, be last on the theatre list and receive 

antibiotic prophylaxis to cover MRSA – please refer to current Trust CP014 

Antimicrobial Policy. 

1.3.5 Patients who are at a continuing high risk of acquiring MRSA between the time 

of pre-admission screening and that of admission, (e.g. resident in a nursing 

home) must be re-screened on admission and should be isolated until the 

results of the screening swabs are known. 

Authorities 







Page 28 of 55



B - All surgical emergency patients must be screened on admission 

1.2.1 Swabs to be taken within 24 hours of admission. Some patients are at greater 

risk of having MRSA these patients include: 

• Frequent re-admissions to any healthcare facility 

• Direct inter hospital transfers 

• Recent in-patient in hospitals abroad or in the UK 

• Residents of residential care facilities – rest homes or nursing homes 

• Injecting drug users 

• Those with immuno-compromised 

• Members of contact sports teams 

• Individuals with eczema, psoriasis, dermatitis 

1.2.2 These patients should have nasal swabs, skin breaks/wounds or groin swabs 

and CSUs taken. 

1.2.3 Ideally these patients should be isolated until the results of their screen are 

known. Priority should be given to isolating patients from residential and 

nursing homes and patients transferred from another hospital. 

C – Surgical patients known to have been infected or colonised with MRSA in 

the past 

1.3.1 Patients who have had MRSA in the past should have a yellow and black 

sticker on the front of their notes, or inside the front cover of new sets of notes 

and details in their computerised CRS notes. An alert and yellow star should 

be present or entered on the Trust electronic patient records. 

1.3.2 Patients with a history of being MRSA positive within the last 12 months must 

commence topical treatment pre-operatively, after screening, but prior to the 

results being known. If they are found negative the treatment should be 

discontinued. 

1.3.3 These patients require a full screen: nose, groin, skin breaks / wounds and a 

CSU if a catheter is present on admission. These patients should be admitted 

to a side room and barrier nursed until their screening swabs are MRSA 

negative. If a complete set of swabs/samples is negative these patients can 

be moved into a bay with other non-MRSA positive patients 

D - Medical Elective Admissions 

1.4.1 All elective medical patients must be screened prior to admission for MRSA. If 

found MRSA positive, decolonisation treatment should take place immediately 

prior to admission, or on admission if the admission date precludes treatment in 

Authorities 







Page 29 of 55



advance. On admission to be placed in a side room and barrier nursed and 

decolonisation to continue or be commenced. 

1.4.2 Elective medical patients who are frequent attendees e.g. chemotherapy or 

haematology patients must be screened once on presentation and then no 

more frequently than 6 monthly. 

E - Medical emergency admissions 

1.5.1 Patients admitted as a medical emergency will be screened on admission with 

nose and skin breaks/wound or groin swabs. If previously MRSA positive to 

have a full screen taken. 

G - ITU 

1.6.1 All admissions/transfers to ITU will be screened within 24 hours of admission. 

Take a full screen: nose, groin, skin breaks/wounds and CSU if catheter 

present. Patients on the elective orthopaedic ward, who are MRSA negative, 

can return to the elective orthopaedic ward without waiting for screening results, 

if they have been on the unit for less than 48 hours and not in close contact to a 

patient with MRSA. Weekly MRSA screening will be carried out. Swabs will be 

taken from the nose and wounds or groins. 

H – NNU 

1.7.1 All admissions from labour ward/theatre will have nose, groin, umbilicus and ear 

swabs taken. One set of swabs will suffice for both Group B Streptococcus and 

MRSA investigations. 

1.7.2 Any inter hospital transfer, including babies from the Andover Birth Centre, will 

have nose, groin, umbilicus and ear swabs taken. 

1.7.3 Any emergency admission from home will have nose, groin, umbilicus and ear 

swabs. 

1.7.4 Weekly MRSA screens will be carried out. Swabs to be taken from nose and 

wounds or groins. 

I - Elective Orthopaedic ward 

1.8.1 All patients for elective orthopaedic surgery involving an implant must be 

screened at pre-assessment clinic. Nose, skin breaks/wounds or groins and 

CSU are required. If the patient has had MRSA in the past they must have a 

full screen: nose, groins and skin breaks / wounds and CSU if catheter present. 

Authorities 







Page 30 of 55



1.8.2 No medical patients are to be admitted or transferred to the elective orthopaedic 

ward. Surgical and orthopaedic patients who have been screened MRSA 

negative within the last 10 days can be transferred to the elective orthopaedic 

ward. They must be screened again within 24 hours of transfer. If they are 

positive they will be moved off the elective orthopaedic ward and their contacts 

screened. 

J - Trauma orthopaedic ward 

1.9.1 All patients will be screened on admission or transfer to the ward. Those who 

have been positive in the past must be admitted into a side room and barrier 

nursed until found to be MRSA negative on this admission. All MRSA positive 

patients must be isolated and barrier nursed. If the number exceeds single 

room capacity then an MRSA bay must be established and managed so as to 

minimise the risk of spread (see Appendix 5). Patients who are at risk of being 

MRSA positive should ideally be isolated until found negative. 

1.9.2 All emergency orthopaedic patients must be screened for MRSA on admission 

so they can be transferred to the elective or trauma orthopaedic ward when a 

bed becomes available. 

1.9.3 Patients with a history of being MRSA positive within the last 12 months must 

commence topical treatment pre-operatively, after screening, prior to the results 

being known. If they are found negative the treatment should be discontinued. 

Authorities 







Page 31 of 55



Appendix 2 

Decolonisation 

2.0 Nasal decolonisation 

2.0.1 The Infection Control Team will advise staff which topical treatment is required 

by each patient. 

2.0.2 Mupirocin 2% (Bactroban®) is a paraffin based antibiotic applied to the inner 

surface of each nostril 3 times a day for 5 days. The patient should be able to 

taste Mupirocin at the back of the throat after the application. Mupirocin should 

not be used for more than 5 days or used repeatedly, (no more than two 

courses consecutively) as resistance will be encouraged. Mupirocin is not 

specifically licensed for pregnant women, and its usage on pregnant women 

should be discussed with the Consultant Obstetrician or Microbiologist. . 

2.0.3 Naseptin® ointment qds for 10 days should be used for those patients whose 

strain of MRSA is resistant to mupirocin at a high level. (In low level mupirocin 

resistance it is still possible to use mupirocin. The laboratory report will indicate 

if the strain is mupirocin resistant. 

2.0.4 Polyfax ointment tds for 10 days maybe used as an alternative. 

2.0.5 Tea tree topical treatment may very occasionally be recommended for some 

patients particularly if there is mupirocin resistance or for those where 

decolonisation with the above has been unsuccessful, or where carriage is 

persistent. 

2.1 Unbroken SKIN decolonisation 

2.1.1 4% Chlorhexidine gluconate aqueous solution (Hibiscrub®) body wash/ 

shampoo (or Octennisan® if skin is fragile or for those aged under 8 years of 

age) are useful in eradicating or suppressing skin colonisation. In particular use 

pre-operatively to reduce the risk of surgical site infections. 

2.1.2 Patients should bathe/wash daily for 5 days. The skin should be moistened 

and antiseptic detergent applied thoroughly to all areas before rinsing, in a 

shower or bath. Special attention should be given to skin creases, axilla, groin 

and perineal areas. 

2.1.3 If possible hair should be washed with antiseptic detergent (Hibiscrub®) or 

Octennisan® twice during the 5 day regime. 

Authorities 







Page 32 of 55



2.1.4 After each bath/shower/wash, clean clothing/nightwear, bedding and towels 

should be provided. 

2.1.5 For patients with eczema, dermatitis or other skin conditions: 

2.2 Throat 

First attempt to treat underlying condition. 

Secondly try Dermol 500® for skin and hair wash. 

2.2.1 Corsodyl® mouth wash/gargle will be prescribed for any patient on topical 

treatment for MRSA. This is not suitable for paediatrics or neonates. 

2.2.2 Systemic treatment of throat carriage should only be considered in exceptional 

circumstances e.g. where there is evidence that there is transmission from a 

throat carrier in a continuing outbreak or when the patient carrying MRSA in the 

throat has experienced episodes of invasive infection. 

2.2.3 Systemic treatment should only be prescribed on the advice of the 

microbiologist and with appropriate monitoring. If treatment is required it should 

be restricted to one course of treatment. Possible side effects must be 

explained to the patient. Systemic treatment should be given in conjunction 

with nasal mupirocin and skin decolonisation. 

2.2.4 Throat carriage may be associated with the presence of foreign bodies 

e.g. nasal gastric tube or dentures. An ENT opinion may be useful if 

structural/physiological abnormalities are suspected. 

2.2.5 Gargling is rarely effective at eradicating MRSA colonisation unless the 

person is able to gargle for 2 minutes 3 times a day. 

2.3 MRSA in urine 

2.3.1 A patient clinically diagnosed as having a urinary tract infection should receive 

antibiotics to which it is susceptible. If in doubt contact the consultant 

microbiologist. If the urine is only colonised, systemic treatment may not be 

indicated. 

2.4 MRSA in Catheter urine 

2.4.1 Catheter urines routinely colonize with organisms. However, if the patient has 

an infection then systemic treatment maybe required. The catheter must be 

changed whilst the patient is on the course of antibiotics. 

Authorities 







Page 33 of 55



2.4.2 If the catheter urine is colonized, no systemic treatment is recommended. 

Antibiotic cover is required for a change of catheter. Please see CP014 

Antibiotic Policy for information or, in complex cases, contact Consultant 

Microbiologists for advice. 

2.5 Colonised Skin lesions/ wounds 

2.5.1 Small clean wounds can be treated using Bactroban® tds for 5 days. 

This is useful for small wounds (



Appendix 3 

Isolation procedures – single rooms 

3.1 Single rooms with en-suite facilities are the preferred standard of 

accommodation. However a designated toilet and bathroom should be allocated. 

3.2 A yellow barrier nursing sign detailing isolation precautions must be displayed 

prominently on the side room door or at the entrance to the bay or isolation ward. 

These are available from the Infection Control Nurses. 

3.3 The room door should be kept closed to minimize spread to adjacent areas. If 

this compromises patient treatment the door must be kept shut during procedures 

that may generate staphylococcal aerosols such as chest physiotherapy and bed 

making. 

3.4 High standards of hand decontamination are required to minimise the risk of 

cross infection. Hands must be thoroughly decontaminated with chlorhexidine 

(Hibiscrub®) and water before and after patient contact, and alcohol gel used on 

leaving an isolation facility/side room. 

3.5 Yellow disposable aprons and gloves must be worn by all staff handling the 

patient or having contact with their immediate environment. Staff may need to 

wear surgical masks, along with eye protection, during sputum inducing 

procedures like suctioning and chest physiotherapy. 

3.6 Staff from other wards and departments e.g. physiotherapy, phlebotomy, other 

medical teams, social worker should only enter after permission and instruction 

from the nurse in charge. This also applies to visitors who assist with the 

patient’s bodily care. All visitors should put on a yellow apron and gloves before 

entering the room, wash their hands before leaving the room, and use alcohol gel 

after exiting. 

Outside the isolation room 

Non-sterile gloves 

Yellow Aprons 

Alcohol gel 

Linen bag (when required) 

Patients observation and drug charts 

Inside the isolation room 

Orange waste bag 

Chlorhexidine (Hibiscrub®) 

Alginate bag for linen(when required) 

Minimal equipment necessary 

Authorities 







Page 35 of 55



Appendix 4 

Kingfisher ward isolation and decolonisation regime. 

4.1 Background 

4.2 Rehabilitation wards are considered low risk in the 2006 national guidance. 

4.3 Screening on transfer 

4.4 On transfer (including RHCH) or admission from the community, please screen 

nose, skin breaks/wounds or groins and catheter urine if catheter in situ. 

Previously positive patients admitted from the community must have a full screen 

on admission. Those already on MRSA treatment regimes should be screened 

according to their treatment care plan. 

4.5 Isolation 

4.6 Ideally isolate all patients with MRSA but if side rooms are limited, priority should 

be given to those who are skin shedders or throat/sputum positive and have a 

productive cough. All other patients can be nursed in a bay. 

4.7 All MRSA positive patients will be treated, in-line with our present regime, if and 

when they are identified. 

4.8 Protection 

4.9 Good quality hand hygiene is essential, as per CP073 - Hand hygiene policy 

4.10 All staff and patients must have their wounds covered. An ‘MRSA free’ bay may 

need to be allocated if Kingfisher ward begin receiving patients with sutures or 

clips still in situ post operation. Surgical wounds must remain covered until 

completely healed. 

4.11 Gloves and aprons must be changed between patients and worn for intimate 

care. Yellow aprons will be used when caring for patients with MRSA or who are 

being barrier nursed for another reason. 

4.12 Ward must have high quality cleaning by housekeeping staff and nursing staff. 

Must be carefully monitored by ward sisters and infection control link nurse and 

immediate remedial action taken if the quality or frequency of cleaning 

deteriorates. 

4.13 Curtains should be changed on a planned programme every 3 months. 

4.14 Screening of patients for MRSA should take place at RHCH if a patient is 

readmitted. 

Authorities 







Page 36 of 55



Appendix 5 

How to cohort nurse patients with MRSA 

5.1 Patients suitable to be nursed in an MRSA bay 

MRSA nose only 

MRSA nose and wound only (providing wound is covered) 

MRSA in CSU only 

MRSA in CSU and nose only 

Patients with MRSA in other sites who are on treatment 

5.2 Patients not suitable to be nursed in an MRSA bay 

MRSA in throat and coughing 

MRSA in sputum and coughing 

MRSA positive wound which cannot be occluded 

MRSA nose, and groin and not on any treatment, or is a treatment failure. 

Surgical patients who are wound negative or have a prosthetic implant/internal 

fixation 

MRSA positive patients with an exfoliating skin condition e.g. eczema 

Patients with a resistant strain of MRSA e.g. mupirocin resistance 

5.3 Patients with MRSA in a bay of patients who are MRSA negative 

5.3.1 Patients who are found to be MRSA positive on this admission will only be 

nursed in a bay with patients who are MRSA negative under exceptional 

circumstances i.e. if they would be clinically, mentally or physically at risk if 

nursed in a single room, or if nursed on a different speciality ward. The 

patient’s doctor and senior ward nurse will make the decision whether the 

patient is safe to be nursed in a single room or on another speciality ward. If 

the patient remains in the bay the Infection Control Team must be informed if 

this situation occurs so that specific infection control measures can be carried 

out. The patient must be reviewed at least daily, and when able to, moved into 

a single room. The Infection Control team will assist in co-ordinating the 

contact screening. 

5.3.2 Only under exceptional circumstances should the above advice be over ruled. 

When the number of single rooms becomes inadequate, the Infection Control 

team should be contacted to review current side room allocation, and when and 

where an MRSA bay could be made. Outside of hours the site co-ordinator, in 

consultation with consultant microbiologist if advice is necessary, will allocate 

patients to an MRSA bay. 

Authorities 







Page 37 of 55



5.4 Elderly care / rehabilitation wards 

5.4.1 Patients, who are MRSA positive only in wounds which can be occluded, can 

be nursed in a bay with patients who are MRSA negative. 

5.5 General surgical wards 

5.5.1 Patients with MRSA at any site will be nursed in a side room or in a bay with 

other MRSA positive patients. The only exception is if it is clinically necessary 

for the patient to be nursed in an observation bay and not in a side room. The 

patient’s doctor and senior ward nurse will make the decision. The Infection 

Control team must be informed if the situation occurs so that specific infection 

control measures can be carried out and contact screening can be organised. 

5.6 Orthopaedic wards 

5.6.1 Patients with MRSA will be moved off the elective orthopaedic ward. Elective 

orthopaedic patients with MRSA will be accommodated in side rooms on the 

trauma orthopaedic ward. 

Authorities 







Page 38 of 55



Appendix 6 Patient visits to other departments 

6.1.1 Visits by MRSA positive patients to other departments should be kept to a 

minimum. If it is necessary either for investigation or treatment, prior 

arrangements should be made with the staff of the receiving department, so 

that infection control measures can be implemented. 

These include: 

1 See these Patients at the end of the working session if possible. 

2 The patient should spend the minimum time in the dept, and should not 

be left in communal waiting areas with other patients. 

3 Staff coming into close or physical contact with the patient should wear 

disposable aprons and gloves. 

4 Equipment and the number of staff attending should be kept to a 

minimum. 

5 Surfaces with which the patient has had direct contact should be 

decontaminated with 1000ppm hypochlorite – Actichlor Plus®. . 

6 Linen should be treated as infected. 

7 Staff should decontaminate their hands after contact with the patient. 

8 For theatres please refer to LTP08 Methicillin Resistant patients in 

Theatre Policy. 

6.2 Intra hospital patient transfer 

6.2.1 Movement of patients with MRSA within a hospital should be kept to a minimum 

to reduce the risk of cross-infection, but this should not compromise other 

aspects of care, such as rehabilitation. The receiving ward should be notified of 

the patient’s MRSA status in advance of the transfer to minimise their contact 

with other patients. Transport of the infected/colonised patient should be 

undertaken carefully. Transfer letter to be completed. 

7 Infection control precautions 

1 Lesions of staff should be occluded with an impermeable dressing. 

2 Porters who have physical contact with the patient should wear 

disposable yellow plastic aprons to protect their clothing whilst in contact 

with the patient. 

3 Aprons should be removed when contact with the patient has finished 

and disposed of as clinical waste. Apron and gloves do not need to be 

worn whilst wheeling the patient down the corridor. 

4 Gloves need only be worn if staff transporting the patient has skin 

abrasions, or hands in contact with the patient. 

5 The trolley or chair should be decontaminated after use. 

6 All linen disposed of as infected. 

7 Staff should decontaminate their hands thoroughly after dealing with 

the patient and cleaning the trolley or chair. 

Authorities 







Page 39 of 55



Appendix 7 Patients going to theatre 

7.1.1 Prior to any planned invasive procedure, efforts should be made to minimize 

the risk of infection through topical and sometimes systemic decolonization, 

and prophylactic antimicrobial therapy. 

7.1.2 For high risk patients – decolonisation will take place at least 2 weeks prior to 

admission allowing time for patients to have two sets of negative swabs prior to 

admission. For all other patients, topical decolonisation should commence preoperatively 

and continue for a total of five days, with surgery taking place on 

day 6 for maximum effect. For patients who remain positive, decolonisation will 

commence pre-op and continue post op. 

7.2 As part of pre-op preparation 

1 Bath/shower the patient with an antiseptic detergent e.g. Hibiscrub®, applied 

direct to skin as soap and rinsed off. 

2 Cover affected lesions with an impermeable dressing. 

3 Change all the bed linen and place patient in a clean gown. 

4 Apply Mupirocin to the nose before the operation if the organism is sensitive 

- preferably commencing 24 hours pre-op. 

5 Consider appropriate prophylactic antibiotic cover for surgical procedures in 

colonised or infected patients (see CP014 Antibiotic Policy on the 

intranet). Complex cases can be discussed with consultant microbiologists. 

6 Consideration should be given to placing patients at the end of the operating 

session but with effective ventilation systems there should be an adequate 

number of air exchanges to provide a safe environment within 15 minutes of 

removal of the MRSA patient from the operating theatre. Time is still 

needed for thorough cleaning and drying (see below) so procedures at the 

end of the list may still be most practical. 

7.3 Within the theatre 

1 After the procedure all the theatre surfaces in close contact or near the 

patient, such as the operating table or instrument trolley should be 

decontaminated with 1,000ppm hypochlorite – Actichlor Plus®. 

2 Low risk patients can go to the main recovery room, high risk patients e.g. 

those who are skin shedders should be recovered in the theatre. 

3 Patients may be allowed recovery after surgery in the operating theatre or 

an area not occupied by other patients to avoid possible contamination of 

the usual recovery area. The patients should be segregated as far as 

possible within the recovery area, and nursed by staff dedicated to their 

care, employing standard precautions of gloves, aprons and thorough hand 

hygiene. 

Please see the LTP09 Methicillin Resistant Patients Theatre Policy for further 

information 

Authorities 







Page 40 of 55



Appendix 8 

8.1 Transfer of patients to another hospital 

8.1.1 Refusal to accept transfer of a patient is not justifiable on the basis of the risk 

posed to other patients by an individual’s carriage of, or infection with, MRSA. 

All units should have procedures in place and adequate facilities for 

containment of MRSA. 

8.1.2 Identification of infected or colonised patients is the responsibility of the 

transferring hospital. Before transfer a member of the clinical team for the 

patient, at the transferring hospital, must inform the ward staff at the receiving 

hospital of the patient’s status. 

8.2 Ambulances/hospital vehicles 

8.2.1 The risk of cross infection from an MRSA colonised or infected patient to other 

patients in an ambulance is minimal. Good infection control practices and 

routine cleaning should suffice to prevent cross-infection. Ambulance staff 

should be informed in advance if a patient has MRSA. 

8.2.2 Most MRSA carriers maybe transported with other patients in the same 

ambulance without any special precautions. High risk categories of patients 

e.g. immuno-compromised should not be transported in the same ambulance 

as a known MRSA positive patient or those with an infection e.g. chest 

infection. 

8.3 Infection control precautions 

1 Skin lesions should be covered (patients and ambulance crew). 

2 Ambulance staff should use an antibacterial hand gel after contact with 

all patients. 

3 Linen must be changed. 

4 Surfaces wiped with detergent and water. 

5 The patient does not need to wear a mask when travelling in the 

ambulance. 

. 

Reference: ‘National guidance and procedures for infection prevention and control’ by 

the Ambulance Association (2008). 

Authorities 







Page 41 of 55



Appendix 9 Cleaning, waste and linen 

Cleaning 

9.1 Management of the environment and equipment should be considered as 

critical to decrease the spread of MRSA. General principles should be 

adopted to minimize the bacterial burden. The ability of MRSA to survive in 

dust demonstrates the need for dust minimization, the removal of bacteria 

from surfaces, and the appropriate disposal of contaminated waste and 

linen. 

9.2 An enhanced level of cleaning requires additional time to enable the daily 

removal of organic material, undertaken wearing gloves and apron. Yellow colour 

coded bucket and cleaning equipment must be used. Mop head must be changed 

and sent for laundering after use in each isolation area. 

9.3 There must also be adequate removal of all of the dust particularly from areas 

like ventilator ducts, radiators and equipment like fans. 

9.4 There should be planned, quarterly, thorough cleaning of the whole ward 

including bedding and the laundering or steam cleaning of curtains. 

9.5 The quality of the cleaning of isolation rooms and equipment will be audited 

regularly by housekeeping, Matrons, Execs and the Infection Control Team. 

9.6 Cleaning regime after discharge/transfer of patient 

9.6.1 MRSA contaminated patient areas should be cleaned thoroughly after 

each patient’s discharge with 1,000ppm hypochlorite – Actichlor Plus®. 

This includes locker, table, bed frame, chair, floor and all patient contact 

surfaces. Sinks, toilets, baths and showers are to be cleaned as usual 

and again after the patient has been discharged. 

9.6.2 Curtains should be removed and laundered or steam cleaned if not 

single use disposable curtains. 

9.6.3 Pillows and mattresses should be checked for damage and cleaned. 

9.6.4 All disposable items should be disposed of as clinical waste. If in doubt 

ask a member of ward based nursing staff first. 

9.6.5 If possible room should be decontaminated using the Bioquell method.. 

Authorities 







Page 42 of 55



9.7 Waste 

9.7.1 All disposable items, e.g. aprons and gloves must be disposed of as 

clinical waste in an orange plastic bag in the room. Needles, syringes 

and other sharps must be placed in a sharps container. 

9.8 Linen 

9.8.1 All linen from patients infected or colonised with MRSA should be 

considered to be contaminated. All linen must be placed inside an 

alginate bag and tied whilst in the patient’s room then placed inside a red 

plastic bag outside the room. Curtains should be removed and 

laundered or steam cleaned after the patient is discharged or transferred. 

The room maybe decontaminated using Bioquell after the patient has left 

the room. 

9.9 Patients clothing 

9.9.1 Patients’ clothing should normally be laundered by their relatives. Soiled 

personal clothing should be placed in a plastic bag. Advise relatives to 

wash the clothing separately at home. Ward staff on wards where 

patients’ clothes that are laundered on site (Clifton and RDU) should 

place the items of clothing in an alginate bag, and a clear plastic bag. 

This clothing will be hot washed and there is a risk delicate fabrics will be 

damaged. 

Authorities 







Page 43 of 55



Appendix 10 

10 Control of vancomycin intermediate and resistant Staphylococcus aureus 

(VISA and VRSA) 

10.2.1 Antibiotic resistance flourishes when antimicrobial drugs are overused, 

misused and dispensed at levels lower than treatment guidelines dictate. 

Virtually all strains of S.aureus with reduced sensitivity to glycopeptide 

antibiotics, so far, are thought to have arisen from pre- existing 

reservoirs of MRSA, usually in patients with chronic and underlying 

disease who have received multiple and/or prolonged courses of 

glycopeptide treatment. 

10.3 Action to be taken on identification of a VISA or a GISA 

(glycopeptide-intermediate S.aureus). 

10.3.1 Laboratory staff to immediately inform Consultant Microbiologist and 

infection control team who will contact the clinician and ward staff. 

Infection Control Team will ascertain patient’s movements and identify all 

contacts. 

Health Protection Agency will be notified by the Consultant Microbiologist or 

appropriate delegate. 

10.4 If patient is still an inpatient 

a. Isolate patient in single room with en suite toilet facilities and a hand wash 

sink. 

b. Strict barrier nursing must be carried out with the door closed. 

c. The number of healthcare staff having contact with the patient should be 

reduced. 

d. Healthcare staff with chronic skin conditions should not be involved in direct 

care of the patient. 

e. Ward will be closed to admissions whilst screening of all patients on the 

ward takes place. Patients may be discharged home but cannot be 

transferred to another ward, hospital or institution until their screening 

results is known. 

f. No fans to be placed in the patient’s room. 

10.5 Infection Control procedures 

10.5.1 Uniforms should not be taken home to launder, staff to wear theatre 

scrub suits under their gowns/aprons and to change on site before going 

home. Disposable masks and eye protection should be worn for 

procedures likely to generate aerosol/splashing. (As per CP079 Trust 

Authorities 







Page 44 of 55



policy for uniform and clothing worn whilst delivering direct 

clinical care and CP080 Theatre Uniforms) 

10.5.2 Hand hygiene with an antibacterial preparation must be used before and 

after any patient contact. Visibly soiled hands should be washed with 

chlorhexidine first prior to alcohol gel, as per CP073 - Hand hygiene 

policy. 

10.5.3 Non-disposable items which cannot easily be cleaned should be 

dedicated for use only by infected/colonised patient as per CP030 - 

Overarching Decontamination Policy. 

10.5.4 Linen should be treated as infected, as per CP030 Overarching 

Decontamination Policy. 

10.5.5 All waste discarded into clinical waste bins, as per OP052 - Waste 

Disposal Policy. 

10.5.6 Transfers between institutions should be avoided unless essential and 

the receiving institute made aware of the patients colonization/infection 

status prior to transfer, as per CP061 Policy for the Intraward 

Transfer of Patients with Infection Control Issues. 

10.5.7 After discharge, the room must be thoroughly cleaned with 

1,000ppm hypochlorite Actichlor Plus® paying special attention to 

horizontal surfaces. Curtains must be changed, as per CP030 

Overarching Decontamination Policy. 

10.6 Screening of patient and ALL contacts since admission 

10.6.1 Patients 

10.6.2 Nose, groins, skin breaks/wounds and manipulated sites (eg IV cannula 

sites) of the index case and all other patients on the ward/unit should be 

screened for carriage of VISA/GISA or VRSA. Screening may need to 

be extended to other areas the index case has had contact with. 

10.7 ALL Staff caring for VISA patient 

10.7.1 Nose, and groins of healthcare workers and others with close physical 

contact with the case should be screened. Staff who maintain contact 

with the patient will require weekly screening until patient is discharged. 

Authorities 







Page 45 of 55



10.7.2 Feedback of results, maintenance of confidence and support are 

required. Treatment will be prescribed. Colonized staff should be 

excluded from work until eradication has been achieved. 

Appendix 11 

11 MRSA staff screening regime 

11.2 Which sites to swab from staff 

11.3 Nose and areas of abnormal or broken skin. 

11.4 All positive results will be phoned to the member of staff by the 

Occupational Health & Safety Dept in the working week. Topical treatment will 

be provided by the Trust. Follow up screening will be co-ordinated by the 

Occupational Health & Safety Dept. Out of hours treatment packs are held in 

A&E and occasionally staff will be contacted by their duty manager out of hours 

if positive results are identified over a weekend or bank holiday. 

11.5 A minimum of 2 screens at weekly intervals (while not receiving 

antimicrobial therapy) should be performed before a previously positive staff 

member can be considered to be clear of MRSA. Consider the individual’s risk 

of transmission to patients when agreeing their continuation or return to work. It 

is recommended only staff with colonised or infected hand lesions should be off 

work whilst receiving courses of clearance therapy. 

11.6 Staff colonised or infected with Vancomycin Intermediate 

Staphylococcus aureus (VISA) or Vancomycin Resistant Staphylococcus 

aureus (VRSA) must be excluded from work until they have had 3 negative 

samples. 

11.7 Staff with persistent carriage at a site other than the nose should be 

considered for appropriate specialist opinion – e.g. dermatologist, ENT surgeon. 

Authorities 







Page 46 of 55



Employee Safety & Occupational Health Department 

INSTRUCTIONS FOR STAFF WHO HAVE A POSITIVE MRSA RESULT 

NAME 

WARD 

Your recent initial nasal swab has been reported to be positive to MRSA 

therefore as a healthcare worker you must comply with the treatment and follow 

up screening detailed below. 

Because of possible restrictions on working, you MUST inform the senior nurse/line 

manager on duty so that staffing levels can be adjusted if necessary. 

STANDARD TREATMENT – PACK A 

STAGE 1 

Date Treatment 

to Commence: 

……………….. 

STAGE 2 

PRIOR TO COMMENCING TREATMENT 

1. Swab nose, groins and any skin breaks/ wounds. 

(One swab should be used for both nostrils, another for 

both groins and another for both groins). 

3. Now commence treatment below. 

TREATMENT 

All 3 Treatment products to be used as detailed 

below. Please notify OH or Infection Control if you 

have any hypersensitivity to the products below 

Day 1 

day 

Day 2 

day 

Day 3 

day 

Day 4 

day 

Day 5 

day 

 

 

 

 

 

1. Apply Bactroban® nasal cream - 3 times a day for 5 

Days 

2. Gargle with Corsodyl® for 2 minutes (minimum) - 3 

times a day for 5 days – Leave an interval of 30 

minutes between using the mouth wash and toothpaste 

if possible. 

3. Wash with Hibiscrub® – 2 times a day for 5 days 

paying particular attention to axillae, groin and skin 

creases. Not for use on the face. 

N.B In the event of a resistant strain being reported 

you will be contacted again and treatment may vary 

Authorities 







Page 47 of 55



STAGE 3 

Day 8 

day 

Date: 

Day 13 

day 

Date: 

Please Note: 

AFTER TREATMENT 

Re-swab all sites as above after 2 clear days following 

treatment 

(before attending shift / work that day). 

Re-swab all sites as above after a further 5 days (before 

attending shift / work that day) unless you are informed 

that the swab results on ‘Day 8’ remain positive in which 

case you will be advised on further treatment. 

1. It is important that you continue the treatment for the full 5 days. 

2. If any of the re-swab results are MRSA positive the Occupational Health 

Adviser will contact you again and a further 5 day treatment schedule is likely to 

be recommended. 

3. After the second treatment you will be informed of the results. If any of the reswab 

results remain MRSA positive the Consultant Microbiologist will be 

contacted by the Occupational Health Adviser who will in turn contact you 

regarding any treatment and work. 

IF YOU HAVE ANY FURTHER WORRIES OR CONCERNS PLEASE CONTACT 

INFECTION CONTROL 5170 OR THE OCCUPATIONAL HEALTH DEPARTMENT 

4326 

WORKING ARRANGEMENTS - High Risk Areas (ICU, HDU, elective orthopaedics 

or NNU) 

Treatment Day 1 Day 2 Day 3 Day 4 

Day 5 

Do not work on Day 1 and Day 2 

unless you can work with no 

patient contact i.e. if you can carry 

out an administrative role. 

Return to work from day 3 without 

restriction on work activities 

WORKING ARRANGEMENTS - Theatre Staff 

Authorities 







Page 48 of 55




Day 5 

Continue working from Day 1. 

You must not undertake or assist 

in invasive procedures i.e. work as 

a surgeon, ‘scrub nurse’, insert 

central lines or cannulate for the 

first 2 days but may work in other 

areas 

Anaethetist? 

May resume normal work activities 

from day 3 

WORKING ARRANGEMENTS - Lower risk areas (All other Clinical areas not 

indicated above) 


Day 5 


You must not carry out aseptic 

techniques or invasive procedures 

for day 1 and 2. 


from day 3 

This includes IV drugs and Stoma 

Care 

IF YOU OR YOUR MANAGER HAS ANY CONCERNS PLEASE CONTACT 


4326 

Authorities 







Page 49 of 55



Employee Safety & Occupational Health Department 

INSTRUCTIONS FOR STAFF WHO HAVE A POSITIVE MRSA RESULT 

NAME 

WARD 

Your recent swab has been reported to be positive to MRSA and resistant to the 

standard treatment therefore as a healthcare worker you must ensure that you 

fully comply with the treatment and follow up screening detailed below. 

Because of possible restrictions on working, you MUST inform the senior nurse/your 

manager on duty so that staffing levels can be adjusted. 

STAGE 1 

Date 

Treatment 

to Commence: 

…………….. 

………... day 

STAGE 2 

Day 1 

day 

Day 2 

day 

Day 3 

day 

Day 4 

day 

Day 5 

day 

Day 6 

day 

Day 7 

day 

 

 

 

 

 

 

 

RESISTANT TREATMENT – PACK B 

PRIOR TO COMMENCING TREATMENT 

1. Swab nose, groins and any skin breaks/wounds. 

(One swab should be used for both nostrils, another for 

both grains and another for both groins). 

3. Now commence treatment below. 

TREATMENT 

All 3 Treatment products to be used as detailed below. 

Please notify OH or Infection Control if you have any 

hypersensitivity to the products below 

2. 

3. 1. Apply Naseptin® nasal cream - 4 times a day for 10 

days. 

4. 

2. Gargle with Corsodyl® for 2 minutes (minimum) - 4 

times a day for 10 days – Leave an interval of 30 

minutes between using the mouth wash and toothpaste 

if possible. 

3. Wash with Hibiscrub® – 2 times a day for 10 days 

paying particular attention to axillae, groin and skin 

creases. Not for use on the face. 

N.B It is important that you continue the treatment for 

the full 10 days. 

Day 8 

day 

Day 9 

day 

Authorities 







Page 50 of 55



Day 10 

day 

STAGE 3 

Day 13 

day 

Date: 

Day 18 

day 

Date: 

Please Note: 

AFTER TREATMENT 

Re-swab all sites as above after 2 clear days following 

treatment (before attending shift / work that day). 

Re-swab all sites as above after a further 5 days (before 

attending shift / work that day) unless you are informed that 

the swab results on ‘Day 13’ remain positive in which case 

you will be advised on further treatment. 

1. It is important that you continue the treatment for the full 10 days. 

2. If any of the re-swab results are MRSA positive the Occupational Health 

Adviser will contact you again and a further treatment schedule is likely to be 

recommended. 

3. After the second treatment you will be informed of the results, if any of the reswab 

results remain MRSA positive the Consultant Microbiologist will be 

contacted by the Occupational Health Adviser who will in turn contact you 

regarding any treatment and work. 

IF YOU HAVE ANY FURTHER WORRIES OR CONCERNS PLEASE CONTACT 


4326 

WORKING ARRANGEMENTS - High Risk Areas (ICU, HDU, elective orthopaedic 

ward and NNU) 


Day 5 

Do not work on Day 1 and Day 2 

unless you can work with no 

patient contact i.e. if you can carry 

out an administrative role. 

Return to work from day 3 without 

restriction on work activities 

WORKING ARRANGEMENTS - Theatre Staff 

Authorities 







Page 51 of 55




Day 5 


You must not undertake or assist 

in invasive procedures i.e. work as 

a ‘scrub nurse’, central lines or 

cannulate for the first 2 days but 

may work in other areas 

Change as before to include staff 

who are not nurses 


from day 3 

WORKING ARRANGEMENTS - Lower risk areas (All other Clinical areas not 

indicated above) 


Day 5 


You must not carry out aseptic 

techniques or invasive procedures 

for day 1 and 2. 


from day 3 

This includes IV drugs and Stoma 

Care 

IF YOU OR YOUR MANAGER HAS ANY CONCERNS PLEASE CONTACT 


4326 

Authorities 







Page 52 of 55



Appendix 12 – Criteria for elective screening exemptions 

Following the circulation of the Department of Health Operating Framework for 2008/9 

all elective patients must be screened for MRSA. This includes medicine, surgery, 

family services and orthopaedics. If the criteria of patients for exclusion of MRSA 

screening changes this appendix will be amended and circulated by the Infection 

Control Team to staff involved in elective MRSA screening. 

• MRSA operational guidance issued in 2008 clarified the criteria for elective 

screening exemptions: 





• Paediatrics – except high risk 



admission, like any other elective MRSA positive patient. 

Authorities 







Page 53 of 55



Appendix 12 - Equality Impact Assessment Tool 

To be completed and attached to any controlled document when submitted to the appropriate 

committee for consideration and approval. 

Yes/No 

Comments 

1. Does the policy/guidance affect one group 

less or more favourably than another on the 

basis of: 

• Race 

• Ethnic origins (including gypsies and 

travellers) 

• Nationality 

• Gender 

• Culture 

• Religion or belief 

• Sexual orientation including lesbian, gay 

and bisexual people 

• Age 

• Disability - learning disabilities, physical 

disability, sensory impairment and mental 

health problems 

No 

No 

No 

No 

No 

No 

No 

No 

No 

No 

2. Is there any evidence that some groups are 

affected differently? 

3. If you have identified potential 

discrimination, are any exceptions valid, 

legal and/or justifiable? 

4. Is the impact of the policy/guidance likely to 

be negative? 

5. If so can the impact be avoided? No 

No 

No 

No 

6. What alternatives are there to achieving the 

policy/guidance without the impact? 

7. Can we reduce the impact by taking 

different action? 

No 

No 

If you have identified a potential discriminatory impact of this procedural document, please refer it to the 

Head of Corporate Services, together with any suggestions as to the action required to avoid/reduce 

this impact. For advice in respect of answering the above questions, please contact: 

Board Secretary Tel No: 01962 825903 

Authorities 







Page 54 of 55



Appendix 13 – Communications Log 

Ref Policy Date of 

Issue 

To Whom 

OP999 An example 09/09/1999 A Member of Staff 

Signed as read 

and 

Understood 

Authorities 







Page 55 of 55

MRSA policy - Hampshire Hospitals NHS Foundation Trust

Create successful ePaper yourself

Delete template?

Save as template?