Keeping it clean…… EDGH 2007 Infection control policies (MRSA) And Methods of Sterilisation Dr Hannah Rose EDGH 2007

'The ward where I caught the bug was filthy 'The ward where I caught the bug was filthy. I could have died' Sunday January 9, 2005 The Observer

DoH website MRSA rates across UK acute trusts biannually Interpret with caution Table 1b. All acute Trusts - by rate Trust Name / No MRSA bacteraemia reports rate (per 1000 bed days) for years 2001-2004 East Sussex Hospitals NHS Trust (General Acute) 67/ 0.17 52/ 0.15 60 /0.17 42/ 0.12 Brighton & Sussex UH NHS Trust (Specialist) 86/0.21 74/ 0.21 107/ 0.29 129/ 0.38

MRSA Gram positive Staphylococcus Aureus Resistant to Methicillin Rx : Vancomycin, Linezolid Skin infections, chest infn and septic shock (esp immunodefiecient population), osteomyelitis Nasal carriage in 30% population Also carried on skin, throat, perineum

What to do? 9% of UK hospital patients acquire a HAI costing £1 billion/year Equivalent annual running costs of 8 NHS hospitals Infection control team and local policies ‘Saving Lives’ program aims to reduce HCAI including MRSA by half by March 2008. Set up by DoH and NHS modernisation agency (available on http://www.dh.gov.uk) HIGH IMPACT INTERVENTIONS: CVC, UC, Surgical wounds, IV cannulae,VAP, C Diff Rx Combine with the 2002 NPSA ‘Clean your hands’ campaign

Eastbourne Policies On the intranet….. Infection control online mandatory training

‘Control of MRSA in hospitals’ Screening of all patients entering the following areas if: Transferred from another hospital In-pt in ANY hospital in last 4 weeks Previous proven MRSA carrier HIGH RISK AREA Critical care SCBU Orthopaedics Cardiology Haematology Vascular Surgery MEDIUM RISK AREA General Surgery Paeds Obstetrics

Additional screening ALL admissions to Critical Care Units (except SCBU) Weekly screening (Mondays) on pts on the unit for >5days All MRSA+ve pts and transfers in, to be isolated as far as possible until proven to be MRSA-ve. NB: need for ITU must take clinical priority

SCREENING Nose and throat swabs Skin breakdown areas Catheter specimens of urine Umbilicus (paeds)

MRSA ALERTS On the ‘bomb’ icon MRSA on the alert divider Not on the front of the file Inform the patient of status and implications Isolation notice on their door/cubicle Isolate all MRSA pts in high risk areas. Isolate MRSA pts in medium risk areas if presence of wound, catheter, drains or a cough. Isolate low risk area MRSA pts only if open discharging wound

PREVENTING SPREAD Washing hands/alcohol gel before and after patient contact/entering and leaving room Alcohol gel at every bed in Critical Care Areas Protective apron and non-sterile gloves for patient handling. Discard BEFORE leaving room. Not required if not touching patient. Visitors not required to wear aprons/gloves. Must wash hands Daily wash of room. Deep clean after pt discharged (curtains,fans,blinds,ventilation grills, sharps bins) Patients own equipment in room. If remove equipment from room – decontamination. Linen bags sealed ¾ full before leaving room Inform GP upon discharge from hospital

MRSA in Theatres No need to be last on the list Can refuse admission to theatre suite if bed, linen, clothing visibly soiled or wounds open Remove extraneous equipment, staff from theatre Nurse in main recovery with strict adherence to hand hygiene All equipment to be decontaminated Porters to adhere to hand hygiene policy too

TREATMENT No treatment for eradication of carriers Treatment for suspected/confirmed MRSA infection in conjunction with Consultant Microbiologist No routine screening or treatment for MRSA staff carriers

Policy for insertion and maintenance of CVC’s Standard CVC in use 15/20cm chlorhexidine-silver sulfadiazine impregnated quad lumen Tunnelled if CVC needed for >30d Strict asepsis WASH hands 3 mins. Alcohol gel not adequate Clean skin with chlorhexidine, not betadine (unless allergy to chlorhexidine) Don’t clean to tube tie-move out of field! Don’t allow wire to touch unsterile areas Avoid femoral route if possible Suture or stat lock. NO SILK sutures

CVC maintenance To be left in as long as clinically indicated NOT necessary to replace routinely. Only if: Evidence of new/unexplained systemic infn +ve BC with likely organisms from CVC Local infn Malfunction Consider resiting CVC’s placed outside critical care areas upon admission Resite CVC’s placed in an emergency situation asap Over wire changes ONLY in case of malfunction. NOT if infection is suspected! Swab port and allow to dry before each use! Wash hands and wear gloves TPN – designated lumen with lipid filter Don’t force blocked lumens! Cap off and label ‘blocked’

Scrubbing up well…… Decontamination is the physical removal of infected material by washing (<45o)or scrubbing to lower the ‘bioburden’. Automated/manual eg. Ultrasonic baths Disinfection is the killing of non sporing organisms Sterilisation is the killing of all micro organisms including viruses, fungi and spores. Increasingly filtration is used as a method of controlling transfer of infected material, for example the protection of ventilators

Spaulding’s Classification Critical items- items which enter vascular/sterile tissue. High risk of infn if contaminated, eg. Surgical instruments, urinary catheters, needles. MUST BE STERILE Semi-critical items – Items in contact with mucous membranes and non=intact skin but do not ordinarily break the blood barrier. Intermediate risk. Spore elimination not imperative, viruses and bacteria are. HIGH LEVEL DISINFECTION. Eg laryngoscopes Non-critical items – in contact with in tact skin. Low risk. Decontamination required. Cleaned at point of use eg BP cuffs

Methods of Disinfection Pasteurisation ‘Organic disinfection’ 20 minutes at 70°C or 10 minutes at 80°C or 5 minutes at 100°C Chemical – low/ high level (sporicidal activity with prolonged exposure) formaldehyde or 70% alcohol or 0.1-0.5% chlorhexidine or 2% gluteraldehyde *or 10% hypochlorite solution or hydrogen peroxide or Phenol Chemical – may be toxic, thus must be rinsed and thoroughly dried prior to use * removed due to concerns over skin/asthma problems in staff

Methods of Sterilisation Dry heat 150°C for 30 minutes Moist heat (steam under pressure-autoclaving) 30 minutes at 1 atmosphere 122°C or 10 minutes at 1.5 atmospheres 126°C or 3 minutes at 2 atmospheres 134°C INDICATOR TAPE USED TO CONFIRM CORRECT CONDITIONS REACHED Ethylene oxide- colourless explosive gas Gluteraldehyde 2% for >10hrs Gamma irradiation THE ABOVE DO NOT RELIABLY DESTROY vCJD, hence the increased use of disposable equipment

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Recommeded reading Sabir N., et al, Decontamination of anaesthetic equipment, BJA CEACCP Vol 4 No 4 2004 Policy for antibiotic therapy within critical care – hospital intra net