An audit of Methicillin-Resistant Staphylococcus Aureus (MRSA) in 11 health trusts has raised concerns about inconsistency in approach to screening and treatment of MRSA-positive staff, and the absence of national guidelines. The team behind the audit are calling for a national audit tool to promote evidence-based standards.
The decision to carry out an audit came about following the merger of City Hospital NHS Trust and Sandwell Healthcare NHS Trust in 2002, which formed Sandwell and West Birmingham Hospitals NHS Trust (SWBH). Prior to the merger, the trusts’ occupational health and safety services (OH) had standardised procedures to provide a consistent evidence-based service to all staff. The control of infection (COI) teams had been doing the same, and that resulted in a significant increase in the amount and type of MRSA screening undertaken.
After the merger, COI raised concerns that the numbers of MRSA-positive staff reported by OH appeared to be high. Because of this and OH concerns regarding staff compliance, follow-up treatment, rates of failure to attend treatment sessions and the monitoring of restrictions, it was felt that further investigation from a wider area was required in an effort to provide a service that protects patients and meets the needs of COI, staff, managers and OH.
In response, an audit of OH responsibilities relating to MRSA screening within the West Midlands region as a whole was undertaken in 2004 to establish practice guidelines (see box).
Concerns with MRSA screening
It is estimated that 30% of the general, healthy population are colonised with Staphylococcus Aureus with a higher percentage in hospital workers.
Overall, the highest rates of MRSA are found in specialist trusts (these are trusts that accept patients from other trusts to provide them with specialist services). The lowest rates are found in single specialist trusts which only offer orthopaedic, cancer or children’s health services. It is difficult to make comparisons between trusts because some may have higher numbers of vulnerable patients, and some trusts may be reporting patients as MRSA-positive even though the infection did not originate from that particular trust. However, over the past three years there has been a steady increase in the number of cases reported. 2
Guidance published by the Royal College of Nursing (RCN) does not recommend routine or pre-employment screening of staff for MRSA, as nasal infection can last only a few hours.4
With recent government initiatives focused on delegation of responsibility for cleanliness, ward managers and matrons should be aware of MRSA-positive staff so that effective monitoring of restrictions and the promotion of good hand hygiene can take place. It is not practical for COI or OH to monitor work restrictions.
At SWBH, the restrictions imposed on MRSA-positive staff greatly exceeded RCN recommendations and were only rescinded when three consecutive negative screening results had been received. In practice, this meant that an orthopaedic surgeon found to be MRSA-positive was restricted from operating for a minimum of four weeks. In terms of risk management, this type of restriction is likely to be impractical, and given the resource pressures faced by most trusts, is probably largely ignored.
Interestingly, one of the participating trusts recommended that MRSA-positive employees refrained from work until treatment had been completed. They also suggested that pay could be withheld as an incentive to comply. However, it may be unethical to withhold pay or to class time off for essential control of Infection purposes as sick leave.
At present, there is no national guidance, with these issues being at the discretion of each individual trust. At SWBH, the senior HR view is that time off because of MRSA should be classed as sick leave. This stance was strongly disputed by OH and also by many members of the HR team, and certainly by employees, when this was recently imposed.
There are also long-standing problems with treatment data collection and failure to attend for follow-up screening. It is often inconvenient for staff to attend for shift reasons, and also because clinical sessions are limited and fixed on one site, and it is a shuttle bus ride to the daily OH clinics. In addition, it is often difficult for OH to contact staff by telephone, which results in a contact letter and subsequent delays in commencing treatment, or re-screening.
The importance of OH seeing staff prior to commencing treatment is recognised. Follow-up screening, however, could be carried out in the clinical areas by local staff members.
There have been concerns expressed that staff may not undertake screening properly. However, if staff are trusted to administer treatment without supervision then they should be trusted to undertake screening correctly. In any case, most staff who are screened have a clinical background and are aware of their responsibilities in terms of protecting patients – it is part of every employee’s contract to observe high standards of personal and professional conduct and to adhere to the trust rules relating to policies and procedures. In addition, failure to meet required standards can result in disciplinary action and, in reality, the disciplinary procedure could be invoked for staff who fail to comply with screening and treatment of MRSA.
The issue of confidentiality also needs to be considered. Is information about MRSA-positive staff confidential? Everyone is aware when mass screening takes place and there should be no stigma attached to a positive status. And as the screening is for the benefit of patients, there does not seem to be any barrier to sharing the information with the ward manager or others who have responsibilities relating to MRSA – for example, matrons.
It should be noted that a high percentage of the hospital population will be MRSA-positive, but quite correctly, they are not being routinely screened. This raises the question of whether, and how many, staff are continuing to undertake the tasks that known MRSA-positive staff are restricted from.
Role of OH
MRSA and its consequences are given a high profile by the government and the media. But the results of this audit reveal an inconsistency in approach to the screening and treatment of MRSA-positive staff, which is cause for concern. There does not appear to be any standardised method of screening or follow-up treatment in the West Midlands. In addition, there is a discrepancy regarding the type of restrictions and the method of monitoring them.
MRSA is primarily a control of infection matter. However, OH does have a role in advising staff about treatment and follow-up. In particular, it has a responsibility to monitor skin integrity and to impose work restrictions if necessary. There should also be the facility for onward referral to a dermatologist.
Staff have an obligation to comply with treatment and follow-up screening, and this is implicit in their contract of employment. In addition, in accordance with section 7 of the Health and Safety at work Act 1974, they are required “to have regard for the health and safety of yourself and others”.
Nurses and doctors are also obliged to follow their professional codes of conduct when protecting patients from harm. Failure to comply with trust policy should be viewed as a disciplinary matter. It is clear from the audit that a standard approach should be identified to protect patients, treat employees and meet the needs of the OH and COI teams.
Outcome of audit
A meeting was arranged between the COI nurse manager, the OH nurse manager, the consultant OH physician and two of the four trust consultant microbiologists to agree a staff screening protocol which reflected evidence-based practice. The screening and reporting arrangements are depicted in the diagram (left), the screening protocol in tables 1 and 2.
Intensive therapy unit managers were consulted and were pleased with the proposed revision, as the restrictions were reduced to 48 hours, instead of the four weeks indicated by the Health Protection Agency.
An IT communication solution, in the form of a shared spreadsheet, was set up. This allowed named COI staff to enter the results of positive staff, and named OH staff to update this information, thereby allowing COI to gain access to statistics. Named members of laboratory staff have read-only access to the spreadsheet.
Managers are now notified of which members of staff have screened positive, so that restrictions can be appropriately monitored and staff temporarily redeployed as necessary, and follow-up screening now takes place in the clinical areas.
Matrons were also consulted and asked to be included in the reporting loop.
A wider audit of MRSA screening practices in other regions should be undertaken to compare these initial results and identify examples of best practice, possibly by a national organisation such as the Health Protection Agency.
The nature and purpose of providing staff statistics to COI should be defined and results shared with matrons.
COI guidelines should be reviewed and national standards, which are evidence-based, should be agreed, in terms of screening, treatment, follow-up and work restrictions. These could then be audited using a national audit tool.
A standard OH practice should be developed in line with COI recommendations.
Carol Hargreaves is an occupational health nurse manager at Sandwell and West Birmingham Hospitals NHS trust
Background to SWBH mrsa monitoring PROCEDURE prior to audit
The trust policy was developed by the COI team based, in part, on the Revised Methicillin-Resistant Staphylococcus Aureus Infection Control Guidelines for Hospitals reviewed by the combined working party of the British Society for Antimicrobial Therapy.1 There is no regional policy within the West Midlands.
At Sandwell and West Birmingham NHS Trust, COI instigated staff screening when there was a clinical reason to do so, and OH was notified of staff who had positive results. OH attempted to contact affected members of staff by:
- Phoning the ward
- Phoning the home/mobile number, if the staff member was not on duty
- Writing a letter to the home address, if the staff member could not be contacted on the ward or at home.
Prior to the audit, ward managers were not notified about members of staff who had positive screening results. The screening and treatment regime, as determined by COI was:
- Staff initially had their nose and fingers screened
- Staff with positive nasal swabs were then treated
- Staff attended OH to have skin integrity checked, collect treatment packs, receive instructions on hand hygiene and to make a follow-up appointment
- Treatment continued for the next five days, followed by two treatment-free days
- Thereafter, nose fingers and groin, regardless of previous results, were re-screened at weekly intervals until there were three consecutive negative results
- Treatment was resumed if further positive results were received
- Restrictions included wearing gloves and aprons when attending patients, refraining from undertaking dressings, administering IV medications and undertaking invasive procedures
- Restrictions remained in place for a minimum of four weeks
- OH was asked to provide weekly statistics to COI regarding numbers of MRSA-positive staff and their work location.
West Midlands NHS Trusts MRSA screening audit
The objectives of the audit were:
- To determine adherence to evidence based practice in terms of restrictions
- To determine areas of common practice relating to the OH aspects of MRSA screening
- To develop a screening model to meet the needs of SWBH NHS trust.
The sample size for the audit was determined by the trusts identified on the mailing lists used by the Association of NHS Occupational Health Nurses and the West Midlands Safety, Health and Environment group (SHE).
A postal questionnaire of 20 questions was devised to determine the type and frequency of screening, treatment administration, monitoring and follow-up undertaken. To encourage uptake, the questionnaire was supported by an accompanying explanatory letter and a commitment to present the results at a quarterly, regional SHE meeting.
Fifteen questionnaires were sent out to health trusts, and 11 returned (a response rate of 73.3%). This is an excellent return, as suggested by Kumar3 and indicates an interest in this topic.
In essence, the evidence outlined in the guidance from the Health Protection Agency states that staff should have nasal and skin lesion swabs when there is a clinical indication to do so. Consideration should be given to additional screening of the groin/perineum when staff are found to be positive.
Further screening of the throat should be undertaken for staff with persistently positive nasal swabs. They should be treated with Mupiricin and an antiseptic body wash, refrain from working in high-risk areas for the first 48 hours of treatment, and have three consecutive negative results to be considered cleared of colonisation.
None of the trusts that responded complied with all the evidence-based criteria, although most complied with at least one or more. In particular, there was little or no adherence to the evidence presented in the guidance with regard to workplace restrictions. Although this recommendation is classed as category II in the guidelines, it was implemented in only four of the trusts sampled. Similarly, while the guidance recommends that three consecutive negative results are required before an individual can be considered cleared of MRSA colonisation, only three of the 11 respondents cited this as normal practice.
There was widespread inconsistency in the notification of results, follow-up screening protocols, the type of restrictions imposed and who monitored them. No trust indicated that relevant managers were informed of positive staff results, yet two trusts indicated managerial involvement in the monitoring of restrictions, suggesting they had been made aware somehow.
Only six of the audit respondents provided staff with MRSA screening statistics, with only four OH departments undertaking this task.
Health Protection Agency guidance
The most recently published comprehensive guidance on staff screening and treatment1 was reviewed by the Health Protection Agency in 2003.2 The recommendations made in the guidance1 are adapted from the classification system recommended in the Centres for Disease Control guidelines as follows:
Category I: Recommendations are strongly supported by well-designed experimental or epidemiological studies.
An example of a category 1 recommendation is to treat staff who have skin lesions with Mupirocin or alternative agents.
Category II: Recommendations are viewed as effective by experts in the field and a consensus of the British Society for Antimicrobial Chemotherapy, Hospital Infection Society and Infection Control Nurses Association. These recommendations are based on strong rationale and suggestive evidence, even though it may not be definitive science.
An example of a category II recommendation is for staff who are nasal carriers to be treated with Mupiricin and antiseptic detergents. In most ward areas, nasal carriers may continue to work during treatment, so long as the strain of the infection is susceptible to treatment. In high-risk wards/areas, they should be excluded from work for 48 hours from the start of Mupiricin treatment.
No recommendation: an unresolved issue which cannot be categorised as there is insufficient evidence or consensus regarding efficacy.
An example in this category is that “local managers should confirm that exclusion of staff for infection control purposes is not deemed sick leave”. It seems that in practice, this will be at the discretion of individual trusts.
In accordance with the most recently published guidance on staff screening and treatment,1 the recommendations for staff screening are to undertake initial screening of the nose and any skin lesions and consider further samples, including throat, vaginal or auxillary swabs if clinically or epidemiologically indicated. Treatment of nasal carriers with Mupiricin and antiseptic detergent hair and body wash is recommended, and in exceptional circumstances, systemic treatment for throat carriers should be considered.
Table 1: Initial screening (undertaken by COI) and treatment regime
|Positive fingers||No treatment. Advice on hand hygiene to be provided. To be seen by OHA for skin inspection. Further swabbing if skin lesions evident|
|Positive nose||Mupiricin tds x 5 days/ Chlorhexidine body wash x 5 days|
|Positive nose and fingers||Mupiricin tds x 5 days/ Chlorhexidine body wash x 5 days|
Table 2: Follow up screening and treatment regime
|Positive groin only||Chlorhexidine x 5 days|
|Positive nose and groin||Mupiricin and Chlorhexidine x 5 days|
1. Revised Methicillin Resistant Staphylococcus Aureus Infection Control Guidelines for Hospitals, Report of a combined working party of the British Society for Antimicrobial Chemotherapy (2004), The Hospital Infection Society and the Infection Control Nurses Association, prepared by Duckworth G, Cookson B, Humphreys H and Heathcock R, Journal of Hospital Infection, 39:253 – 290
2. MRSA Surveillance System – Results (2004), Health Protection Agency, Communicable Disease Surveillance Centre for Department
3. Research Methodology, a step by step guide for beginners (1996) Kumar R, Sage Publications, London UK
4. Methicillin Resistant Staphylococcus Aureus (MRSA) Guidance for Nursing Staff (revised 2004), Royal College of Nursing
5. Health and Safety at Work Act (1974), Health and Safety Executive Publications