Further MRSA bacteraemia reduction by reducing acquisition of MRSA colonisation in-hospital

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Further MRSA bacteraemia reduction by reducing
acquisition of MRSA colonisation in-hospital

• Julie Brooks and Graeme Jones
• Infection Prevention
• University Hospitals Southampton NHSFT

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Drivers to control MRSA bacteraemia

• Prevention of colonisation with MRSA
• Prevention of invasive MRSA infection
• Feedback and monitoring systems

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Actions to reduce MRSA bacteraemia in UHS
2005
1. April 2006 hand hygiene and saving lives care
bundles 2. April 2007 internal targets 3. Nov
2007 low risk antibiotic policies 4. Jan 2009
universal bio-burden reduction on admission
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MRSA bacteraemia numbers 2007-11
2007
2011
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4. Jan 2009 universal bio-burden reduction on
admission
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Combined MRSA MSSA post-48h BSI rate is a
better measure of invasive infection prevention /
device care?
Winchester
Wexham Park
Basingstoke
IOW
Frimley Park
Portsmouth
Oxford
Southampton
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Recent MRSA bacteraemias in UHS

• Post-48h MRSA BSI
• 49y. Known MRSA ve. Erythrodermic flare of
  pustular psoriasis. CVL colonisation/BSI
• 45y. Known MRSA ve. Paraplegic.
  Community-acquired MRSA IE detected after 48h in
  UHS
• 61y. Gallstone pancreatitis requiring biliary
  drain. BSI on drain flush. Acquired MRSA In UHS
• 97y. NOF. Global deterioration and aspiration
  pneumonia. Acquired MRSA In UHS

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Recent MRSA bacteraemias in UHS

• Pre-48h MRSA BSI
• Known MRSA ve. Home TPN line infection
• Known MRSA ve. CML. Infected leg ulcers
• Infected TKR. Acquired MRSA during rehab in
  community hospital
• AML. Hickman line infection. Acquired MRSA during
  recent UHS admission
• Osteoarthritis. Necrotising pneumonia due to
  PVL-MRSA acquired either in UHS or rehab unit

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Recent MRSA bacteraemias in UHS

• Of 9 MRSA BSI in 2011-12
• 5/9 (56) associated with new acquisition of MRSA
  colonisation in UHS or associated rehabilitation
  facility
• Next control action to reduce MRSA bacteraemia is
  to prevent acquisition of MRSA colonisation in
  hospital

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Number of patients colonised with MRSA predicts
number with MRSA BSI
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Proportion of MRSA positive emergency admissions
by admission specialty 2008-12
Overall ve 2008-10 1.5
2011-12 0.85
Specialties with lt100 screens excluded
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Acquisition of new MRSA colonisation in UHS
2008-2011
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Acquisition of new MRSA colonisation in UHS by
Care Group April 2011-February 2012
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Reducing acquisition of new MRSA colonisation
within hospital

• Next step to reducing MRSA bacteraemia
• MRSA screening programme to facilitate
  surveillance already established
• Marker of good practice to reduce transmission of
  MDRO between patients
• Improvement will potentially reduce risk of
  healthcare transmission of other organisms of
  concern
• MSSA
• GAS
• ESBLs
• Carbapenem-R coliforms
• Preliminary work indicates scope for improvement

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Implementing an enhanced MRSA surveillance
programme to improve patient safety.

• Julie Brooks
• Head of Infection Prevention.

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Enhanced MRSA Surveillance programme

• Enhanced Surveillance of all new cases of MRSA
  acquisition
• Commenced April 2011
• Purpose
• To monitor and demonstrate compliance with
  practice standards and drive improvements where
  needed
• To provide assurance on compliance with the Code
  of Practice for Health and Adult Social Care on
  the Prevention and Control of Infection
  (particularly outcome 8.8 criterion 7 in code
  of practice)

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Standards

• Reviews compliance with elements of the MRSA
  policy (e.g. practices to prevent transmission,
  risk reduction measures, decolonisation regimes)
  as well as isolation practice (e.g. completion of
  isolation risk assessment tool  and with the
  Trust isolation target of 4 hrs, where isolation
  is assessed as being required).

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MRSA Policy

• Comprehensive MRSA Policy in place since 2009
  detailing practice standards required.
• Care bundle for the Prevention and Management of
  MRSA (Adults) Nov 2011

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Process

• Clinical area visited by IPN within 48hrs of
  confirmed new MRSA acquisition.
• Surveillance undertaken and verbal feedback back
  to nurse in charge (important to feedback good
  practice as well as non-compliance)
• For any variance against the required practice
  standard
• Report to the nurse in charge of the ward at time
  of surveillance being undertaken document that
  this has occurred.
• Request investigation/feedback action giving a 2
  week deadline for feedback.
• Ward/department manager to undertake
  investigation relating to non-compliance with
  practice standards and implement actions to
  address this.
• Provide formal feedback and actions to IPT.
• If feedback is not received within the 2 week
  deadline escalation as per IPT assurance
  framework

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Outcomes
Q1/2 Q3/4
No. of patients surveillance carried out on 83 77
Of these patients, number acquired MRSA at UHS 56 41
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Prevention of Spread
Standard
1. Isolation Risk assessment completed
2. Isolated within 4 hrs of presumptive result
3. Correct Hand Hygiene performed
4. Isolation Posters displayed
5. Chlorine Based Cleaning of isolation room
6. Contact Precautions implemented
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Patient Management (Prior to result)
Standard Standard
1. Risk reduction measures (hibiscrub washes) commenced and documented.
2. Additional MRSA screening undertaken following admission.
3. Additional risk reduction measures (where applicable) commenced and documented.
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Patient Management (post result)
Standard Standard
1. MRSA positive status documented in notes
2. Topical decolonisation (Chlorhexidine Nasal bactroban)
3. Additional measures /options for MRSA in wounds etc (where applicable)
4. MRSA Patient held record supplied.
5. MRSA information leaflet given to patient
6. Medical notes labelled
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Compliance with Care Bundle.
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Reporting/Monitoring Review

• Weekly delivery group report copied to Matrons,
  Clinical Leads and Care group Managers for
  action.
• Quarterly Matron and Care Group Clinical Lead
  report for Infection Prevention Committee, TEC
  and Trust Board)
• Quarterly Infection Prevention Report to TEC and
  Trust Board.
• Isolation compliance monitored as part of the
  CQC/Hygiene Code assurance framework. Exceptions
  reported to Infection Prevention Committee and
  Quarterly to Trust Quality Governance Steering
  Group.

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CQC Outcome 8.8 - Isolation
CQC Outcome 8.8 - Isolation CQC Outcome 8.8 - Isolation CQC Outcome 8.8 - Isolation CQC Outcome 8.8 - Isolation CQC Outcome 8.8 - Isolation CQC Outcome 8.8 - Isolation CQC Outcome 8.8 - Isolation
Metrics Target Explanation of RAG Rating Quarter 1 Quarter 2 Quarter 3 Quarter 4
Metrics Target Explanation of RAG Rating Ap - June 11 July - Sep 11 Oct - Dec 11 Jan - Mar 12
Isolation newly acquired MRSA Positive patients 100 of patients with MRSA isolated within 4 hours 95gtgreen, 85-94 amber, 84lt red 88 72 90  
Completion of isolation risk assessments for MRSA 100 of patients that are newly acquired MRSA positive have a completed risk assessment 95gtgreen, 85-94 amber, 84lt red 35 68 74