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Are you ready to screen your patients for MRSA?

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MRSA screening for elective patients is to be compulsory in England. Clare Lomas finds out if the NHS is ready

By the end of March it will become compulsory for acute NHS trusts in England to screen all elective patient admissions for MRSA.

The new screening policy – a requirement of the NHS Operating Framework 2008–2009 – is the latest in a long line of infection control measures introduced by the government to help combat healthcare-associated infections in hospitals.

It would appear that policies on hand hygiene, cleaning and antibiotic prescribing have already had a considerable impact on MRSA infection rates. According to data from the Health Protection Agency, there has been a steady decline in the number of reported MRSA bacteraemia cases in recent years. The latest quarterly figures show a 13% drop from the 837 cases reported between April and June 2008, to 725 reported between July and September in the same year.

But the government wants to go further. MRSA screening is seen as a vital cog in the next phase of its battle against healthcare-associated infections, following last year’s deep clean and the success in meeting targets to halve MRSA infection rates in five years.

In its document setting out the evidence for the policy, Impact assessment of screening elective patients for MRSA, the Department of Health stated: ‘Although some trusts do screen for MRSA, it is apparent that the NHS have not implemented a consistent and comprehensive screening regime to date.’

According to the DH, around 7% of admitted patients are colonised with MRSA. The department hopes that adopting a ‘consistent and comprehensive’ approach to screening will help NHS staff to reduce the number of MRSA bacteraemia cases even further.

Its first move is to introduce screening for all elective patients. Under the new policy all elective admissions should be routinely screened for MRSA, including elective Caesareans. Exceptions include children, patients having minor dermatology procedures and obstetric patients, unless the patient is considered to be particularly high-risk.

Patients undergoing dialysis or chemotherapy should be screened at the start of treatment and then at regular intervals or if clinically indicated.

All day cases should also be routinely screened for MRSA – except day case ophthalmology, dental and endoscopy cases. However, evidence suggests compulsory screening on this scale could pose significant challenges for some trusts.

For example, South Tees Hospital NHS Trust has estimated it will have to screen a further 29,250 patients every year under the elective screening programme – a 200% increase in the number of MRSA screens already undertaken.

Although the DH has issued operational guidance on how the policy should be implemented, it will be up to strategic health authorities and their individual trusts to decide how this is done at local level.

The DH also expects to receive monthly reports on the number of MRSA screening tests carried out by each trust and the number of relevant elective admissions or day cases so that they can measure performance and compliance with the screening policy.

Some patients may require more than one test, so the number of tests performed may exceed the number of elective admissions reported. But reporting fewer tests than elective admissions will not be acceptable, according to the DH guidance.

By 31 January, every SHA in England should have submitted a report to the department outlining how their trusts intend to implement the screening programme.

Nursing Times has contacted all 10 SHAs in England to assess their progress with the planning and introduction of MRSA screening. The feedback reveals a mixed picture of progress and approaches to meeting the target.

All 10 SHAs claimed to be confident that trusts would be ready to meet the March deadline but, with under two months to go, none would confirm whether or not they had already achieved the target.

Guy Young is turnaround director for healthcare-associated infections at NHS London, which is responsible for the 31 acute trusts in the capital. He said: About half are already there and all trusts are doing some – all have policies in place to ensure the practicalities of getting it done.

‘Comprehensive elective MRSA screening is easily achievable. It is just a matter of changing the way people think about managing the screening process and ensuring that screening policies are adhered to by all staff,’ he added.

MRSA figures since mandatory surveillance 
According to the latest figures from the Health Protection Agency, the risk of becoming infected with MRSA bacteraemia is currently at its lowest for five years.The boxes below show the number of reported cases of MRSA bacteraemia since mandatory surveillance began in 2001:
YearNumber of reported cases of MRSA bacteraemia
April 2001 to March 20027291
April 2002 to March 20037426
April 2003 to March 20047293
April 2004 to March 20057233
April 2005 to March 20067096
April 2006 to March 20076381
April 2007 to March 20084448
April 2008 to September 20081562 (6 months)

Sue Webb, director of clinical workforce and development at NHS South East Coast, was equally guarded in her analysis of progress, suggesting that some screening was under way but failing to confirm that it has been implemented for all electives.

‘Across Kent, Surrey and Sussex, MRSA screening is already under way for elective admissions at every trust, with each organisation deciding on the most suitable method,’ she said.

‘We will support all trusts with the planning requirements of MRSA screening and monitor their progress against national guidelines and plans,’ she added.

Again, a statement from NHS South West said that all its trusts had action plans but it was still ‘working to ensure that all organisations with elective admissions in the South West have effective screening procedures by the end of March’.

The SHAs are largely leaving it up to the acute trusts to decide who will carry out MRSA screening, and how it will fit into the patient journey, but the majority of screening is expected to take place in pre-operative assessment clinics.

If pre-op assessment is managed effectively, MRSA screening should become part and parcel of the process,’ said Mr Young.

NHS Yorkshire and Humber, NHS East Midlands and NHS West Midlands are negotiating with PCTs to allow GPs or practice nurses to take on some screening.

Decisions about which testing methods should be used, and who will be responsible for carrying out the decolonisation of patients who test positive for MRSA,is also being left to individual trusts.

But David Thompson, acting director of patient care and partnerships and HCAI lead at NHS Yorkshire and Humber, said decolonisation was something that could also be taken on by PCTs.

‘Decolonisation needs to be done at the most effective time – usually about one week before admission. Eradication treatment could be prescribed and administered in primary care so there is as little disruption to the patient journey as possible,’ he said.

‘We have also asked all PCTs to confirm that, as commissioners, they have the mechanisms in place to ensure all providers are screening all electives by the end of March,’ he added.

NHS Yorkshire and Humber covers several large acute trusts and Mr Thompson warned that dealing with increasing numbers of MRSA-positive patients could put extra pressure on nursing staff.

‘About 1% of all patients screened will test positive for MRSA. Making patients fully aware of what this means and providing reassurance, advice and guidance could take up a lot of staff time. SHAs need to help trusts provide a clear and consistent message to patients,’ he said.

According to the DH guidance, routine decolonisation of patients is not considered a suitable long-term option and all relevant elective patients should be screened and decolonised only if necessary.

‘Routine decolonisation heads in the wrong direction,’ said Mr Young.

‘A comprehensive screening and decolonisation programme if positive is a much more appropriate way to approach screening,’ he added.

However, infection control nurses have expressed some doubts about how effective screening elective admissions for MRSA will be.

According to Martin Kiernan, president of the Infection Prevention Society, screening emergency admissions first, rather than elective patients, may have been a more effective way to approach screening from the outset.

‘Screening all elective patients may offer an opportunity to identify problem areas, but evidence shows the majority of MRSA bacteraemia tend to come from emergency admissions,’ he said.

‘It remains to be seen whether screening all elective patients will be clinically and cost effective, we will just have to wait for the data,’ he added.

Although the jury is still out on what impact the screening policy will have on MRSA infection rates, Mr Thompson warned that nurses must comply with the policy.

‘One of the reasons people get MRSA bacteraemia is because policies are not adhered to,’ he said. ‘Like any policy, this one is there for a reason and as long as it is well formulated and practical, all parts of it must be followed.’

However, nurses and their trusts face a significantly bigger challenge. MRSA screening policy is to be extended to include emergency admissions, with the prime minster having set the NHS a deadline for screening all inpatients by March 2011.

The DH estimates that a full screening programme for all inpatients – including electives and emergencies – would reduce the financial impact of MRSA from£618.75m to just£117.25m, a benefit of over£500m at a cost of just£150m.

Clostridium difficile: targets and achievements

Last year the Department of Health set a national target to reduce Clostridium difficile infections by 30% by 2010–2011, compared with a 2007–2008 baseline.

Based on data from this period, every SHA must meet or better the maximum rate of 8.5 cases C. difficile per 10,000 of the population. In addition, a minimum floor of a 20% reduction per SHA has been applied.

Data from the Health Protection Agency shows that cases of C. difficile have fallen steadily over the last few years. Latest quarterly figures from the HPA show that between July and September 2008 there was a 19% drop in the number of cases in over-65s compared with the previous quarter – from 8,696 to 7,061 cases.

This also represents a fall of 35% from the same quarter in 2007 when 10,884 cases were recorded in patients aged 65 and over between July and September.

However, a recent number of outbreaks of the infection at acute trusts in England has prompted the DH to issue updated guidance to help all NHS staff involved in the prevention and control of C. difficile to continue to reduce the rates of infection.

C. difficile infection: how to deal with the problem sets out the following 10 key recommendations:

  • Clinicians should use the SIGHT protocol when managing suspected potentially infectious diarrhoea:

S Suspect that a case may be infective where there is no clear alternative cause for diarrhoea;

I Isolate the patient and consult with the infection control team (ICT) while determining the cause of the diarrhoea;

G Gloves and aprons must be used for all contacts with the patient and their environment;

H Handwashing with soap and water should be carried out before and after each contact with the patient and the patient’s environment;

T Test the stool for toxin, by sending a specimen immediately;

  • C. difficile infection should be considered a diagnosis in its own right;

  • Trusts should provide sufficient capacity to isolate or cohort all known C. difficile patients;

  • Trusts should also develop restrictive antibiotic guidelines;

  • Trusts should establish an antimicrobial management team (AMT) to do a ward round every day to ensure cautious use of antibiotics;

  • Pharmacists should review drug charts daily to check compliance with antibiotic guidelines;

  • Consultants should review antibiotic prescribing on all ward rounds;

  • Directors of nursing should ensure that each clinical area has reliable systems in place for training, auditing and feeding back to staff on cleaning, isolation, hand hygiene and protective clothing practices;

  • Trusts should ensure that all clinical areas assess cleanliness;

  • Trusts should support the control and reduction of C. difficile infection from board level downwards.

  • 2 Comments

Readers' comments (2)

  • After reading the article on MRSA screening in hospitals I felt that I must respond by saying that my local trust Taunton and Somerset already screens everybody that comes through the door as an in-patient. Emergensie's are screened in A/E or Medical Admissions and the Elective patients are screened at their pre-op assessments, so that we can then treat as appropriate.
    Shirley Church

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  • Forewarned is forearmed. I agree as an ICP, we should screen all patients . However is the NHS going to then pay for the decolonosation process if patients screen positive, thereby burdening the patient with increased length of waiting time. What will the protocol be x1 or 3 clear swabs or where to swab and how many? are 2 or 3 neccessary and will it be nose and groin or perineum beacuse unless standardised will see a breakdown in process.
    Marian, Australia

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