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

2. '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

3. 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
East Sussex Hospitals NHS Trust (General Acute) 67/ / / / 0.12
Brighton & Sussex UH NHS Trust (Specialist) / / / / 0.38

4. 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

5. 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 Set up by DoH and NHS modernisation agency
(available on
HIGH IMPACT INTERVENTIONS: CVC, UC, Surgical wounds, IV cannulae,VAP, C Diff Rx
Combine with the 2002 NPSA ‘Clean your hands’ campaign

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

7. ‘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

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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’

16. 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

17. 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

18. 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
% 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

19. 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

20. Symbols

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