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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
Drivers to control MRSA bacteraemia
Prevention of colonisation with MRSAPrevention of invasive MRSA infectionFeedback and monitoring systems
Actions to reduce MRSA bacteraemia in UHS
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MR
SA
BS
I (n
)
200911 22 33
44
1. April 2006: hand hygiene and saving lives care bundles2. April 2007: internal targets3. Nov 2007: low risk antibiotic policies4. Jan 2009: universal bio-burden reduction on admission
2005
MRSA bacteraemia numbers 2007-11
SUHT MRSA BSI2007 - 2012
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Actual Cases Trajectory Linear Trend (Actual Cases)
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4. Jan 2009: universal bio-burden reduction on admission
2007 2011
Combined MRSA + MSSA post-48h BSI rate is a better measure of invasive infection prevention / device care?
Southampton
Basingstoke
Frimley Park
Winchester
IOW
Portsmouth
Oxford
Wexham Park
Recent MRSA bacteraemias in UHS
Post-48h MRSA BSI1. 49y. Known MRSA +ve. Erythrodermic flare of
pustular psoriasis. CVL colonisation/BSI
2. 45y. Known MRSA +ve. Paraplegic. Community-acquired MRSA IE detected after 48h in UHS
3. 61y. Gallstone pancreatitis requiring biliary drain. BSI on drain flush. Acquired MRSA In UHS
4. 97y. #NOF. Global deterioration and aspiration pneumonia. Acquired MRSA In UHS
Recent MRSA bacteraemias in UHS
Pre-48h MRSA BSI1. Known MRSA +ve. Home TPN line infection
2. Known MRSA +ve. CML. Infected leg ulcers
3. Infected TKR. Acquired MRSA during rehab in community hospital
4. AML. Hickman line infection. Acquired MRSA during recent UHS admission
5. Osteoarthritis. Necrotising pneumonia due to PVL-MRSA acquired either in UHS or rehab unit
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
Review of relevant studies
Total colonized and infected patients
800
700
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100
0
MR
SA
BS
I
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20
0 Rsq = 0.7732
Number of patients colonised with MRSA predicts number with MRSA BSI
Proportion of MRSA positive emergency admissions by admission specialty 2008-12
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
4.00%
Geria
tric
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urger
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rthopae
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edic
ine
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c Surg
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ical
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e
% M
RS
A +
ve o
n a
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issi
on
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een
2008-102011-12
Specialties with <100 screens excluded
Overall +ve 2008-10 1.5% 2011-12 0.85%
Acquisition of new MRSA colonisation in UHS 2008-2011
SUHT MRSA Acquisition
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SUHT MRSA Acquisition Linear (SUHT MRSA Acquisition)
Acquisition of new MRSA colonisation in UHS by Care Group April 2011-February 2012
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0102030405060
No
of C
ases
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
Implementing an enhanced MRSA surveillance programme to improve patient safety.
Julie Brooks
Head of Infection Prevention.
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)
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).
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
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
Outcomes
Q1/2 Q3/4
No. of patients surveillance carried out on
83 77
Of these patients, number acquired MRSA at UHS
56 41
Prevention of Spread
0102030405060708090
100
1 2 3 4 5 6
Standard
% C
ompl
ianc
e
Q1/2
Q3/4
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
Prevention of Spread
Patient Management (Prior to result)
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.
Patient Management (prior to result)
0102030405060708090
100
1 2 3
Standard
% C
ompl
ianc
e
Q1/2
Q3/4
Patient Management (post result)
Prevention of Spread (post result)
0102030405060708090
100
1 2 3 4 5 6
Standard
% C
ompl
iance Q1/2
Q3/4
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
Compliance with Care Bundle.
No of Cases
% All Elements
No of Cases
% All Elements
No of Cases
% All Elements
No of Cases
% All Elements
05/09/2011 1 0 2 0 0 012/09/2011 0 0 0 019/09/2011 0 1 0 0 026/09/2011 0 2 50 0 003/10/2011 0 1 0 0 010/10/2011 0 0 0 017/10/2011 2 0 1 0 0 024/10/2011 0 0 0 1 031/10/2011 1 0 3 0 0 2 007/11/2011 0 0 2 50 0 014/11/2011 0 1 0 0 1 021/11/2011 0 2 0 1 100 2 028/11/2011 1 0 2 0 3 100 1 10005/12/2011 2 0 3 0 0 1 10012/12/2011 0 1 0 1 100 1 019/12/2011 0 2 100 0 1 10026/12/2011 0 1 0 0 1 10002/01/2012 0 1 0 0 009/01/2012 0 5 60 1 0 016/01/2012 0 2 100 0 2 5023/01/2012 0 3 67 0 2 030/01/2012 2 100 1 100 1 0 1 006/02/2012 1 100 1 100 0 013/02/2012 1 100 0 0 2 020/02/2012 0 5 0 1 100 1 027/02/2012 2 50
Division DMRSA Surveillance Care Bundle
Week Commencing
Division A Division B Division C
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.
CQC Outcome 8.8 - Isolation
CQC Outcome 8.8 - Isolation
Metrics TargetExplanation of RAG
Rating
Quarter 1 Quarter 2 Quarter 3 Quarter 4
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
95%>=green, 85-94% = amber, 84%<
= red88% 72% 90%
Completion of isolation risk assessments
for MRSA
100% of patients that are newly acquired
MRSA positive have a
completed risk assessment
95%>=green, 85-94% = amber, 84%<
= red35% 68% 74%
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