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

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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

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MR

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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%

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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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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%