MULTI RESISTANT ORGANISM POLICY
Dr Judith Hooper
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Section 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
Introduction Associated policies and procedures Aims and objectives Scope of policy Accountabilities and responsibilities Clinical risk assessment Meticillin Resistant Staphylococcus Aureus Management of patients with MRSA Management of patients in the community MRSA screening Transfer of patients with MRSA Community Acquired MRSA (CA-MRSA) including PVL Multi resistant gram negative bacilli Management of in patients with multi resistant gram negative bacilli 15. Clostridium Difficile Associated Disease 16. Management of in patients with Clostridium Difficile Associated Disease 17. Management of Patients with Clostridium Difficile Associated Disease in the Community 18. Equality Impact Assessment 19. Training Needs Analysis 20. Monitoring Compliance with this policy 21. References Appendices A Risk Assessment Guide B Key Stakeholders consulted/involved in the development of the policy/procedure C Equality Impact Assessment Tool D Sign Off Sheet regarding Dissemination of Procedural Documents
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3 3 3 3 4 4 4 5 6 8 8 8 11 11 12 12 14 14 14 14 15 16 17 18 19
Policy Statement Infection prevention and control is of prime importance within NHS Kirklees and is essential to the safety and confidence of patients, families and carers.
A Healthcare Associated Infection (HCAI) can be defined as an infection that occurs as part of health care treatment. Staff, patients and the public are more aware than ever of the risks of HCAI, including MRSA, one of the multi-resistant bacteria. The prevention and control of HCAIs is a national priority. Anti microbial resistance is becoming a global concern with rapid increases in multi-drug resistance bacteria. It is prudent to recognise that involvement across the whole health economy of patient care must occur in order to address this issue.
ASSOCIATED POLICIES AND PROCEDURES
This policy must be read in accordance with the following Trust policies, procedures and guidance: ● ● ● ● ● ● ● ● ●
Hand decontamination policy Isolation policy Waste management guidelines Incident reporting Health and safety policies Decontamination, disinfectants and antiseptics policy Standard universal precautions policy Clostridium difficile policy Dress code policy for clinical staff
AIMS AND OBJECTIVES
To manage the care of patients with a HCAI and minimise the risk of cross infection of multidrug resistant organisms. 4.
SCOPE OF THE POLICY
This policy must be followed by all NHS Kirklees employees who are developing policy and procedural documents or developing guidance for colleagues. It must be followed by all staff who work for NHS Kirklees (the PCT), including those on temporary or honorary contracts, bank staff and students. Breaches of this policy may lead to disciplinary action being taken against the individual.
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Independent contractors are responsible for the development and management of their own procedural documents and for ensuring compliance with relevant legislation and best practice guidelines. Independent contractors are encouraged to seek advice and support as required. 5.
ACCOUNTABILITIES AND RESPONSIBILITIES
The Chief Executive (CE) is accountable for ensuring that effective arrangements for infection prevention and control are in place within NHS Kirklees. The Director of Infection Prevention and Control has responsibility to provide assurance to the Board that infection prevention and control policies are in place and their compliance audited. The Infection Prevention and Control Team will ensure that the policy is reviewed as required and work with Heads of Service to implement necessary changes in practice. 6.
CLINICAL RISK ASSESSMENT
As part of the management of patients infected or colonised with multi-resistant organisms a risk assessment is required and is undertaken by a member of the Infection Prevention and Control Team (IPCT) with the clinician / GP / nurse in charge of the patient. The purpose is to assess factors related to the management of the patient. In order to undertake this risk assessment, various factors are considered pertaining to: ●
The organism, site and / or specimen type.
The patient, assessing their inmmunosuppression status, if they have any wounds, invasive devices, are expectorating sputum, receiving health care and if they are colonised or infected.
If an inpatient, where they are situated in the ward, including the susceptibility of the surrounding patients.
METICILLIN RESISTANT STAPHYLOCCOCUS AUREUS (MRSA)
Staphylococcus aureus is a gram-positive bacterium that is found in the normal flora of the nose and skin in twenty to thirty percent of healthy people. It can be transiently carried on the hands, and survives well in the environment in dust. Some strains of staphylococcus aureus are resistant to some antibiotics including flucloxacillin resistant and all cephalosporins, and also resistant to meticillin, these are referred to as meticillin staphylococcus aureus (MRSA). Both MRSA and sensitive staphylococcus aureus can colonise a person’s skin. MRSA is no more virulent or pathogenic than meticillin sensitive staphylococcus aureus, it is however more difficult to treat. MRSA does not pose a risk to healthy health care workers or family members, but can cause serious infection in vulnerable patients.
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MANAGEMENT OF IN PATIENTS WITH MRSA
This section refers to in patients at Holme Valley Memorial Hospital (HVMH). Isolation Patients who are known to be colonised or infected with MRSA should be placed in a single room. If the number of affected cases exceeds single room capacity, then cohorting with an emphasis on the importance of cohort nursing is recommended as a strategy for controlling transmission of healthcare associated infection. Patients must not share a room with a person who has chronic open wounds or invasive devices. A risk assessment will be undertaken by a member of the infection prevention and control team with the nurse in charge. Due to the nature of the type of patients at HVMH (low risk) and the reason for their stay (rehabilitation and sub acute care) patients can leave their side room for meals and rehabilitation, taking care to ensure any patients with chronic wounds and / or invasive devices are not in contact with a colonised / infected patient. However, any activities of daily living and / or dressings etc. must be undertaken in the patients own room. Whilst the patient is in their room the door must be closed. Signage Standard isolation is the type of isolation that is necessary for patients who are known, or suspected of being colonised or infected with, pathogenic micro-organisms. Therefore standard isolation precautions are required and a standard isolation sign must be placed on the outside of the door of all single rooms. Any signage placed on the door to single rooms must not breach the patientâ€™s rights to confidentiality. Hands Refer to hand decontamination policy Protective Clothing Refer to standard universal precautions policy Waste Refer to waste management guideline Linen Linen from MRSA positive patients must be treated as contaminated / infected linen and must be placed immediately into a water-soluble bag (red) and removed from the patientâ€™s bed area as soon as possible. To prevent sodden laundry from dissolving the water-soluble bag, it must be wrapped in used linen first.
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Once ¾ full the laundry bag must be tied off / fastened and placed in a red nylon laundry bag. Environmental Cleaning The room / bed area requires a thorough clean daily using hot water and detergent, including high-level damp dusting where possible. On the patient’s discharge a thorough clean is required of all surfaces of the room / bed area, mattress, bed frames, call bells, duvets and pillows, with hot water and detergent. Care must be taken when cleaning electrical equipment. The use of disinfectants (Hypochlorite) is required when there is evidence of contamination with blood or body fluids. For blood spillages a dilution of 10,000 (parts per million of available chlorine) must be used. For spillages of urine and vomit with no blood 1,000 (parts per million of available chlorine) may be used, if an in date spill kit for urine and vomit is not available. A disinfectant with a detergent action may be requested by the infection prevention and control team, for example in an outbreak situation and for a terminal clean. Window curtains and bed space curtains require changing following the discharge of a patient with a multi-drug resistant organism. Equipment Equipment must be ‘single-use’ if at all possible. All equipment that is not ‘single-use’ must be cleaned thoroughly after use with detergent and water or detergent wipes. If contaminated with blood or body fluids the use of disinfectants (Hypochlorite) are required. Dilution must be made up to 10,000 parts per million for blood spillage and 1000 parts per million for a body fluid (not containing blood). 9.
MANAGEMENT OF PATIENTS IN THE COMMUNITY (in their own homes)
Increasingly colonisation due to cross contamination with MRSA can occur in community settings. People affected with MRSA do not present a risk to the community at large and should continue their normal lives without restriction. MRSA is not a refusal to admit to a care home or a reason to exclude an affected person from having a home life. In the patient’s own home there should be no restrictions to a normal life and people with MRSA can work and socialise as usual. They do not need to restrict the contact with friends, children or the elderly but reinforce the need for hand washing. When patients are admitted to hospital, and the risk of infection is increased, the ward must be informed and a risk assessment carried out on the patient. MRSA screening on admission and commencement of suppression treatment prior to screening results known; the patient should be nursed in a single room. Community health care workers must practice standard infection control precautions as outlined in the policy.
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Infectious Waste Infectious waste is classified as infectious waste where it arises from a patient known or suspected to have an infection, whether or not the causal agent is known and where the waste may contain a pathogen. Where waste is generated by a healthcare worker for people in their own home the healthcare worker is responsible for ensuring the waste is managed correctly. There are two options for the disposal of infectious waste. Option 1 – collection by a waste contractor from the patients’ home, the householder must consent to the storage of waste for later collection. If the householder declines the healthcare worker cannot legally leave the waste. If the patient consents the waste should be stored in a suitable place to which children, pets do not have access. It is not appropriate to leave the waste unsupervised on the pavement awaiting collection. The team leader will agree and arrange this option with the waste contractor. A consignment note is not required for the movement of infectious waste from household premises. Option 2 – the healthcare worker producing the waste can transport the infectious waste back to base where waste collection arrangements are in place. Healthcare staff transporting waste in their own vehicles should ensure they are transporting the waste in a suitable UN approved container. The healthcare worker must ensure they have the Waste Transport document within the vehicle. Packaging from dressings may be placed in a domestic waste stream bag but must be placed in a plastic sack / bag first. It is not appropriate to place yellow / orange coloured bags (those found in dressing packs) in the domestic waste as this indicates that the waste is hazardous. Thin opaque sacks and / or bin liners are appropriate. Linen It must be advised that the patient / client or carer uses a pre wash cycle on the washing machine, if the patient / client is bed bound the bed clothes must be washed separately from the other laundry. Environmental Cleaning Any areas in the patient’s home where equipment is being used, eg, a table top must be cleaned before and after use. A detergent wipe, or soap and water are required. Equipment Equipment must be ‘single-use’ if at all possible. Reusable equipment to be transported back to base to be decontaminated. See Decontamination of Reusable Medical Devices Policy.
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MRSA SCREENING Refer to MRSA Screening and Suppression Guideline.
TRANSFER OF PATIENTS WITH MRSA
If a patient with MRSA is transferred to another healthcare setting (inpatient), the receiving clinical staff must be informed. This allows the receiving establishment to take necessary measures to protect vulnerable patients. In general MRSA does not present a risk to the general public. Booking of Patients for Ambulance Transport Most carriers of MRSA can be transported with other patients with no extra precautions. Arrangements must be made for patients to travel alone if the patient: ●
Has open wounds such as skin grafts or exudating wounds that cannot be covered by an impermeable dressing;
Is excessively expectorating sputum and may not be able to effectively dispose of / manage with tissues.
If in doubt seek advice from the Infection Prevention and Control Team. Patient Assessment prior to travelling in the ambulance / patient transport ●
Catheters must be emptied before discharge.
Wounds must be covered with an impermeable dressing and the wound checked for visible exudate.
If patients are expectorating sputum then staff must ensure that clean tissues are transported with the patient; consider lone transportation if the patient cannot effectively dispose of / manage tissues themselves.
COMMUNITY ACQUIRED MRSA (CA-MRSA) INCLUDING PVL
New strains of MRSA have recently emerged which cause infections in community patients who have had no previous history of direct or indirect contact with healthcare. Prevalence of these strains of MRSA is currently low and remains treatable. Risk Groups for CA-MRSA Children under 2 years of age Athletes (mainly participants of contact sports) Injecting drug users (IVDU’s) Men who have sex with men Page 8 of 18
Military Personnel Prisoners Residents in care homes/facilities Vets and pet owners Patients with post flu like illness and/or severe pneumonia Patients with concurrent soft skin tissue infections History of CA-MRSA colonisation History of antibiotic consumption in the previous year, particularly quinolones or macrolides Panton-Valentine Leukocidin (PVL) toxin Staphylococcus aureus is a common bacterium found on the skin and mucous membranes. It is predominately associated with skin and wound infections. PVL is a toxin produced by a small percentage of Staphylococcus aureus (PVL-SA) that can destroy white blood cells and cause more serious infections in wounds, joints and also (but rarely) pneumonias. Skin and soft tissue infections (SSTI’s) Staphylococcus aureus (SA) is the most common pathogen responsible for SSTI’s. PVL-SA caused SSTI’s are usually more severe and the impact on the patient can be considerable due to the need for prolonged treatment. Risk factors for PVL-SA PVL risk factors include: 1. 2. 3. 4. 5.
Contaminated items Close contact Crowding Cleanliness Cuts and other compromised skin integrity
High Risk groups for transmission of PVL-SA PVL-SA infections are highly transmissible and can spread in settings where individuals are in close physical contact or may share personal items e.g. towels. These groups include: Family/households Educational settings (including nurseries) Military personnel/barracks Close contact sports e.g. rugby, judo, wrestling Care Homes Gyms Prison settings
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Signs and symptoms PVL-SA should be suspected if an individual presents with the following: Pus producing skin lesions (boils/abscesses) which vary in severity and may be recurrent Cutaneous lesions â‰Ľ5cms in diameter, which require different treatment from smaller lesions and may be recurrent Cellulitis Pain that is out of proportion to the severity of the cutaneous findings Necrosis Infection Prevention and Control for affected people in the community The key principles of preventing and controlling the spread of PVL-SA infection in the community setting are: Early suspicion of infection, with rapid diagnosis and appropriate treatment Ensure lesions are covered with clean, dry dressings, which are changed as soon as discharge seeps to the surface Personal hygiene and good skin care (particularly those with eczema) Use separate towels and no sharing of personal items such as razors, toothbrushes, face cloths etc Ensure laundry of towels, bed linen, clothing using a hot wash (60 0C) where possible Regular household cleaning Avoid communal and recreational settings until lesions are healed if they cannot be adequately contained by a dressing. Certain facilities such as gyms, saunas, swimming pools etc should be avoided until the lesions have healed. Those who work in occupations where they may pose a risk of infection to others, such as healthcare workers, carers in nurseries, residential/care home staff, food handlers etc should be excluded from work until the lesions have healed. Refer to Appendix A â€“ Risk Assessment Guide
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MULTI-RESISTANT GRAM NEGATIVE BACILLI (GNB)
Species of this type of bacteria most commonly seen include, Escherichia Coli (E. Coli), Klebsiella, Proteus, Pseudomonas, Enterobacter, Citrobacter and Acinetobacter spp. Collectively these bacteria may be referred to as Gram-Negative Bacilli (GNBs). ●
GNBs are commonly found in the gastro-intestinal tract, in water and soil. Colonisation of hospitalised patients with a GNB is common.
Multi-resistant bacteria are seen more frequently in areas that have high usage of broad-spectrum antibiotics and where patients are immuno-compromised e.g. Critical Care and Oncology Units.
GNBs commonly achieve antibiotic resistance by producing enzymes called extendedspectrum B-lactamases (ESBLs) that destroy and confer resistance to antibiotics.
GNBs have been implicated in outbreaks of infection within Intensive Care, Neonatal and Oncology Units. They can cause urinary tract infections, pneumonia, surgical site infections and meningitis.
MANAGEMENT OF IN PATIENTS WITH MULTI-RESISTANT GRAM NEGATIVE BACILLI (GNB)
In general GNB does not present a risk to the general public or to patients in low risk areas such as community hospitals and residential or nursing homes. Isolation It is not routinely advised that a patient with a GNB is placed in a single room. Hands Refer to hand decontamination policy Protective Clothing Refer to standard universal precautions policy Waste Refer to waste management guideline Linen Linen from patients with a GNB must be treated as contaminated / infected linen and must be placed immediately into a water-soluble bag and removed from the patient’s bed area as soon as possible. To prevent sodden laundry from dissolving the water-soluble bag, wrap in used linen first. Once ¾ full the laundry bag must be tied off / fastened and placed in a red nylon laundry bag. Page 11 of 18
Environmental Cleaning The room / bed area requires a thorough clean daily using hot water and detergent, including high-level damp dusting where possible. On the patient’s discharge a thorough clean is required of all surfaces of the room / bed area, mattress, bed frames, call bells, duvets and pillows, with hot water and detergent. Care must be taken when cleaning electrical equipment. The use of disinfectants (Hypochlorite) is required when there is evidence of contamination with blood or body fluids. Dilution must be made up to 10,000 p.p.m. for blood spillage and 1000 p.p.m for a body fluid (not containing blood). A disinfectant with detergent action, may be requested by the Infection Prevention and Control Team, for example in an outbreak situation and a terminal clean. Window curtains and bed space curtains require changing following the discharge of a patient with a multi-drug resistant organism. Equipment Equipment must be ‘single-use’ if at all possible. All equipment that is not ‘single-use’ must be cleaned thoroughly after use with detergent and water or detergent wipes. If contaminated with blood or body fluids the use of disinfectants (Hypochlorite) are required. Dilution must be made up to 10,000 parts per million for blood spillage and 1000 parts per million for a body fluid (not containing blood). 15.
CLOSTRIDIUM DIFFICILE ASSOCIATED DISEASE (CDAD)
Clostridium difficile is an anaerobic bacterium that is present in the gut of 3% of healthy adults and 66% of infants. However, Clostridium difficile rarely causes problems in children or healthy adults, as it is kept in check by the normal bacterial population of the intestine. When certain antibiotics disturb the balance of bacteria in the gut, Clostridium difficile can multiply rapidly and produce toxins, which cause illness. The symptoms can vary from mild diarrhoea to severe life threatening conditions. Clostridium difficile is transmitted by clostridial spores, which are shed in large numbers by infected patients and are capable of surviving for long periods in the environment. 16.
MANAGEMENT OF IN PATIENTS WITH CDAD
Stool sample A sample of the patient’s diarrhoea stool must be taken and sent to laboratory as soon as possible (aim for the sample to be tested in the laboratory within 18 hours of taking it). The laboratory form must be fully completed ensuring any antibiotic history is noted. The member of staff obtaining sample must adhere to the standard precautions policy ensuring they are wearing protective clothing and decontaminating their hands thoroughly.
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Stool Chart The patientâ€™s frequency and type of stool using the Bristol stool chart must be completed to allow an accurate assessment of the patients systems. Isolation It is always advised that patients with diarrhoea (types 5, 6, 7 Bristol Stool Chart) are nursed in a single room until they are 48 hours symptom free. Signage Standard isolation is the type of isolation that is necessary for patients who are known, or suspected of Clostridium difficile infection. Therefore standard isolation precautions are required and a standard isolation sign must be placed on the outside of the door of all single rooms, ensuring patient confidentiality is maintained at all times. Hands Refer to Hand Decontamination Policy Alcohol gel is not recommended to be used as there is no evidence to support that alcohol is effective in killing Clostridium difficile spores. Protective Clothing Refer to Standard Universal Precautions Policy Waste Refer to Waste Management Guideline Linen Contaminated linen must be placed immediately into a water-soluble bag and removed from the patientâ€™s bed area as soon as possible. To prevent sodden laundry from dissolving the watersoluble bag, wrap in used linen first. Environmental Cleaning Clostridium difficile spores can survive in the environment, to prevent further spread a thorough environmental cleaning on a daily basis must be undertaken. Increase the cleaning of horizontal surfaces to twice daily with chlorine containing cleaning agents (at least a thousand ppm available chlorine). As special cleaning arrangements are required, the domestic must be informed of the infection risk (not of the patientâ€™s diagnosis) and of any protective measures necessary for the domestic staff member. Once the patient has been free from diarrhoea for 48 hours the room should be terminally cleaned with chlorine containing cleaning agents at least a thousand ppm available chlorine and cubicle curtains changed. This should take place even if the patient is not moving from Page 13 of 18
the single room. Terminal cleaning of the patient’s room must also be carried out at the discharge of the patient / before admitting another patient. Equipment Equipment must be ‘single-use’ if at all possible. All equipment that is not ‘single-use’ must be cleaned thoroughly after use with detergent and water or detergent wipes. If contaminated with blood or body fluids the use of disinfectants (Hypochlorite) are required. Dilution must be made up to 10,000 parts per million for blood spillage and 1000 parts per million for a body fluid (not containing blood). Transfer of patients with CDAD Where possible patients must not be transferred to other health care settings (in patient or day / out patient) whilst they are symptomatic with diarrhoea and / or until they are 48 hours symptom free. 17.
MANAGEMENT OF PATIENTS WITH CDAD IN THE COMMUNITY
Where possible community staff visiting patients with CDAD should visit the patients last so that infection is not transmitted to reduce the risk of transmission. Follow guidance above. 18.
EQUALITY IMPACT ASSESSMENT
This policy was found to be compliant with this philosophy (see Appendix B). 19.
TRAINING NEEDS ANALYSIS
The PCT is committed to the training and continuing development of all staff including independent contractors on all relevant issues surrounding infection prevention and control. All induction programmes and infection prevention and control mandatory training will include healthcare associated infections. 20.
MONITORING COMPLIANCE WITH THIS POLICY
The Trust will have key indicators for the monitoring of Infection Prevention and Control: ●
Essential Steps audits to ensure key infection prevention and control policies are being implemented
Percentage of clinical and non-clinical staff at HVMH undertaking mandatory annual Infection Control training.
Quality indicators will be part of normal performance monitoring against a set of local, regional and national standards.
Healthcare associated infection identified after completion of root cause analysis investigations. Page 14 of 18
Centres for Disease Control (1996) Guideline for Isolation Precautions in Hospitals. American Journal of Infection Control. 24, pp 24-52.
Department of Health, Health Act 2006, Code of Practice for the Prevention and Control of Healthcare Associated Infections (revised January 2008).
Department of Health and Standard Advisory Committee (2000) The path of least resistance. DH, London
Department of Health and PHLS (1995) Clostridium Difficile Infection Prevention and Management. DH, London
Department of Health (2005) Saving Lives: a delivery programme to reduce Healthcare Associated Infection MRSA. DH Publications, London.
Department of Health (2006) Safe Management of Healthcare Waste. HTM 07-01. The Stationary Office, London.
Department of Health (2006) Infection Control for Care Homes. DH, London.
Health Protection Agency (2005) Glycopeptide – Resistant Enterococci. http://www.hpa.org.uk/infections/topics-az/enterococci/GRE-QandAs.htm. Accessed 05/07/06
Joint BSAC/HIS/ICNA Working Party (2001) Review of Hospital Isolation and Infection Control Related Precautions.
10. Joint BSAC/HIS/ICNA Working Party on MRSA (2006) Guidelines for the control, and prevention of Meticillin-resistant Staphylococcus aureas (MRSA) in healthcare facilities. The Journal of Hospital Infection. Volume 63, supplement 1. ISSN 0195-6701 11. Department of Health 2008 – A Guide to Best Practice: Isolation of patients DH, London
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Appendix A Risk Assessment Guide if PVL-SA suspected DIAGNOSIS Is PVL-SA suspected? 1. 2. 3.
Are there signs and symptoms of PVL-SA? Is there a previous clinical history of PVL-SA? Is there a history or suspicion of PVL-SA within close contacts (household, family or partner) within the last 12 months?
NO Consider alternative diagnosis
YES If YES to one or more of these questions please follow risk assessment guide
SCREENING 1. 2. 3.
Swab affected site (including pus if present) Label all swabs as suspected PVL-SA infection and include relevant clinical patient information. Refer for incision and drainage if required.
WOUND CARE Advise to cover infected skin lesions with a dressing and change regularly according to the clinical assessment. Give advice regarding which dressing should be used and how often the dressing should be changed. Advise not to touch or squeeze skin lesions Advise on the importance of good hand hygiene using liquid soap and not sharing towels Re-assess wound regularly to check for signs of deterioration
INFORMATION 1. 2. 3.
Personal hygiene should be emphasised including hand washing, care to avoid sharing towels, bath water etc. Patient information supply local information leaflets on the management of SSTIâ€™s if available. Exclusion from work if working in a high risk areas for example healthcare worker. It is recommended that individuals with SSTIâ€™s refrain from communal activities until wounds have healed, for example swimming, contact sports etc.
MANAGEMENT OF SWAB RESULT PVL-SA negative Consider alternative diagnosis and treatment PVL-SA positive Refer to national PVL-SA guidelines, available from www.hpa.org.uk
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Appendix B - Key stakeholders consulted/involved in the development of the policy
Stakeholders name and designation
Key Participant Yes/No
Feedback requested Yes/No
Feedback accepted Yes/No
NHS Kirklees Infection Prevention and Control Team
Kirklees Infection Prevention and Control Committee
Senior Infection Prevention and Control Nurse, KCHS
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Appendix C - Equality Impact Assessment Insert Name of Policy - Multi Resistant Organism Policy Yes/No 1.
Does the policy/guidance affect one group less or more favorably than another on the basis of: Race
Ethnic origins (including gypsies and travellers)
Religion or belief
Sexual orientation including lesbian, gay and bisexual people
Disability - learning disabilities, physical disability, sensory impairment and mental health problems
Is there any evidence that some groups are affected differently?
If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?
Is the impact of the policy/guidance likely to be negative?
If so can the impact be avoided?
What alternatives are there to achieving the policy/guidance without the impact?
Can we reduce the impact by taking different action?
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