Reducing MRSAReducing MRSAReducing MRSAReducing MRSAReducing MRSAReducing MRSAReducing MRSAReducing MRSA

•• HCAIsHCAIs are a disgraceare a disgrace

•• Does your CE know about Does your CE know about HCAIsHCAIs

as quickly as 4 hour wait or as quickly as 4 hour wait or

waiting list breaches?waiting list breaches?

How can a Trust succeed in How can a Trust succeed in

financial turnaround if financial turnaround if

patients are languishing on patients are languishing on

the wards with HCAIthe wards with HCAI

Trusts are required to have Trusts are required to have Trusts are required to have Trusts are required to have Trusts are required to have Trusts are required to have Trusts are required to have Trusts are required to have

Assurance Processes that:Assurance Processes that:Assurance Processes that:Assurance Processes that:Assurance Processes that:Assurance Processes that:Assurance Processes that:Assurance Processes that:

•• organisation is minimising organisation is minimising

prevention of infection riskprevention of infection risk

•• Controlling infection effectively Controlling infection effectively

where it occurswhere it occurs

ToolsToolsToolsToolsToolsToolsToolsTools

•• Risk Assessment of all admissionsRisk Assessment of all admissions

•• Infection Prevention Incident ReportingInfection Prevention Incident Reporting

•• SurveillanceSurveillance

•• Deaths associated with HCAIDeaths associated with HCAI

•• Learning from complaints and litigation and Learning from complaints and litigation and

SUIsSUIs

Risk AssessmentRisk AssessmentRisk AssessmentRisk AssessmentRisk AssessmentRisk AssessmentRisk AssessmentRisk Assessment

•• Known to be MRSA positiveKnown to be MRSA positive

•• From a nursing home / residential homeFrom a nursing home / residential home

•• Has been a patient in any hospital in last 6 monthsHas been a patient in any hospital in last 6 months

•• Any healthcare worker Any healthcare worker –– community or acute settingcommunity or acute setting

•• RenalRenal dialysisdialysis patientpatient

•• Patient with long term invasive device e.g. urinary catheterPatient with long term invasive device e.g. urinary catheter

•• Patient with chronic skin breaks, to include pressure soresPatient with chronic skin breaks, to include pressure sores

•• Chronic diabetic patientsChronic diabetic patients

•• Close contact with horsesClose contact with horses

Risk AssessmentRisk Assessment

Control ProcessControl Process

Control Control Control Control Control Control Control Control ProcesssProcesssProcesssProcesssProcesssProcesssProcesssProcesss

Directive Directive Directive Directive Directive Directive Directive Directive -------- telling people what they telling people what they telling people what they telling people what they telling people what they telling people what they telling people what they telling people what they

are to achieveare to achieveare to achieveare to achieveare to achieveare to achieveare to achieveare to achieve

Preventive Preventive Preventive Preventive Preventive Preventive Preventive Preventive -------- Stopping unwanted actionsStopping unwanted actionsStopping unwanted actionsStopping unwanted actionsStopping unwanted actionsStopping unwanted actionsStopping unwanted actionsStopping unwanted actions

Detective Detective Detective Detective Detective Detective Detective Detective -------- Alerting of unwanted actionsAlerting of unwanted actionsAlerting of unwanted actionsAlerting of unwanted actionsAlerting of unwanted actionsAlerting of unwanted actionsAlerting of unwanted actionsAlerting of unwanted actions

Risk AssessmentRisk Assessment

Control Process = Control Process =

Screening and DecolonisationScreening and Decolonisation

DirectiveDirectiveDirectiveDirectiveDirectiveDirectiveDirectiveDirective

•• Screening policy in place stating Screening policy in place stating

level of screening expectedlevel of screening expected

•• Decolonisation policy in place Decolonisation policy in place

stating actions required, including stating actions required, including

community follow upcommunity follow up

PreventivePreventivePreventivePreventivePreventivePreventivePreventivePreventive

•• PAS Alerts of MRSA status to PAS Alerts of MRSA status to

remind staff of screeningremind staff of screening

requirementsrequirements

•• Identification of Identification of ‘‘revolvingrevolving’’ door door

patientspatients

DetectiveDetectiveDetectiveDetectiveDetectiveDetectiveDetectiveDetective

•• Escalation procedures in place for when Escalation procedures in place for when

policies not followed (policies not followed (ieie: generation of : generation of

internal incident reporting)internal incident reporting)

Infection Control IncidentsInfection Control Incidents

•• Failure to communicate infection control riskFailure to communicate infection control risk

•• Failure to comply with IVI device policyFailure to comply with IVI device policy

•• Failure to isolate patients with infectionFailure to isolate patients with infection

•• Failure to comply with Hand Hygiene PolicyFailure to comply with Hand Hygiene Policy

•• ‘‘AttireAttire’’/clothing not fit for purpose/clothing not fit for purpose

•• Failure to communicate presence of HCAI to patientFailure to communicate presence of HCAI to patient

•• Decontamination failureDecontamination failure

•• Failure to comply with MRSA PathwayFailure to comply with MRSA Pathway

•• Failure to comply with cleaning policyFailure to comply with cleaning policy

•• Failure to comply with Antibiotic PolicyFailure to comply with Antibiotic Policy

•• Delay in laboratory reports of resultsDelay in laboratory reports of results

•• Failure to comply with primary/secondary care transfer arrangemeFailure to comply with primary/secondary care transfer arrangementsnts

A defined reporting process with use of standardised definitions

����

There should be an analysis of patterns and trends across all reported incidents

����

An investigation method appropriate to level of investigation required, e.g. root cause analysis

����

Changes should be made to improve practice as a result of above

Root cause analysisRoot cause analysisRoot cause analysisRoot cause analysisRoot cause analysisRoot cause analysisRoot cause analysisRoot cause analysis

•• Root cause analysis (RCA) is a Root cause analysis (RCA) is a

structured approach to incident structured approach to incident

investigationinvestigation

•• Involves the whole organisationInvolves the whole organisation

Establishing the IssuesEstablishing the IssuesEstablishing the IssuesEstablishing the IssuesEstablishing the IssuesEstablishing the IssuesEstablishing the IssuesEstablishing the Issues

•• CareCare--service timelineservice timeline

•• Fishbone Fishbone –– talk to all involvedtalk to all involved

•• Five WhysFive Whys

TimelineTimelineTimelineTimelineTimelineTimelineTimelineTimeline

MRSA screen MRSA screen

negneg10 Dec10 Dec

Re Re –– admittedadmitted

MRSA MRSA

bacteraemiabacteraemia

26 Dec26 Dec

Discharged Discharged

wellwell21 Dec21 Dec

OperationOperation13 Dec13 Dec

Emergency Emergency

Admission via Admission via

A and EA and E

10 Dec10 Dec

FishboneFishbone

MRSAMRSAMRSAMRSA

Bacteraemia

Patient

factors

Team and

Social

factors

Organisation and

Management

factors

Communicati

on factorsTask

factors

Equipment

and resource

factors

Working

conditions

factors

Education

and Training

factors

The NPSA fishbone model explores eight The NPSA fishbone model explores eight The NPSA fishbone model explores eight The NPSA fishbone model explores eight The NPSA fishbone model explores eight The NPSA fishbone model explores eight The NPSA fishbone model explores eight The NPSA fishbone model explores eight

domains as shown belowdomains as shown belowdomains as shown belowdomains as shown belowdomains as shown belowdomains as shown belowdomains as shown belowdomains as shown below

•• Domain 1: Domain 1: Patient factors Patient factors Patient factors Patient factors Patient factors Patient factors Patient factors Patient factors –––––––– Very unwell with poor Very unwell with poor hygiene hygiene

•• Domain 2: Domain 2: Working Conditions Working Conditions Working Conditions Working Conditions Working Conditions Working Conditions Working Conditions Working Conditions -------- Rapid turnover of Rapid turnover of patients, staff shortages, ?? taking short cuts such as patients, staff shortages, ?? taking short cuts such as failing to comply with Trust hand hygiene policyfailing to comply with Trust hand hygiene policy

•• Domain 3: Domain 3: Task factorsTask factorsTask factorsTask factorsTask factorsTask factorsTask factorsTask factors-------- aaudit results shows hand udit results shows hand hygiene at 54.5 % compliancehygiene at 54.5 % compliance

•• Domain 4: Domain 4: Communication factorsCommunication factorsCommunication factorsCommunication factorsCommunication factorsCommunication factorsCommunication factorsCommunication factors-------- A and E failed to A and E failed to communicate the presence of an intravenous devicecommunicate the presence of an intravenous device

..

•• Domain 5:Domain 5: Team and social factorsTeam and social factorsTeam and social factorsTeam and social factorsTeam and social factorsTeam and social factorsTeam and social factorsTeam and social factors-------- role models, role models, standard settingstandard setting

•• Domain 6:Domain 6: Education and training factorsEducation and training factorsEducation and training factorsEducation and training factorsEducation and training factorsEducation and training factorsEducation and training factorsEducation and training factors-------- supervision, supervision, availability (availability (egeg Hand Hygiene, ANTT)Hand Hygiene, ANTT)

•• Domain 7:Domain 7: Equipment and resources factorsEquipment and resources factorsEquipment and resources factorsEquipment and resources factorsEquipment and resources factorsEquipment and resources factorsEquipment and resources factorsEquipment and resources factors-------- egegegegegegegeg. . . . . . . . disposable tourniquets, alcohol wipes for stethoscopesdisposable tourniquets, alcohol wipes for stethoscopes

•• Domain 8:Domain 8: Organisational and Management Organisational and Management Organisational and Management Organisational and Management Organisational and Management Organisational and Management Organisational and Management Organisational and Management –––––––– Clarity of Clarity of standards standards

IssuesIssues

•• Inadequate Hand HygieneInadequate Hand HygieneInadequate Hand HygieneInadequate Hand HygieneInadequate Hand HygieneInadequate Hand HygieneInadequate Hand HygieneInadequate Hand Hygiene -------- Audit results show 42% Audit results show 42% Audit results show 42% Audit results show 42% Audit results show 42% Audit results show 42% Audit results show 42% Audit results show 42%

compliance with hand hygiene, allowing MRSA to compliance with hand hygiene, allowing MRSA to compliance with hand hygiene, allowing MRSA to compliance with hand hygiene, allowing MRSA to compliance with hand hygiene, allowing MRSA to compliance with hand hygiene, allowing MRSA to compliance with hand hygiene, allowing MRSA to compliance with hand hygiene, allowing MRSA to

potentially spread from other patientspotentially spread from other patientspotentially spread from other patientspotentially spread from other patientspotentially spread from other patientspotentially spread from other patientspotentially spread from other patientspotentially spread from other patients

•• No evidence that the patientNo evidence that the patient’’s bed and bed space was s bed and bed space was

adequately cleaned between the last patientadequately cleaned between the last patient

•• Failure to adequately decontaminate all items of Failure to adequately decontaminate all items of Failure to adequately decontaminate all items of Failure to adequately decontaminate all items of Failure to adequately decontaminate all items of Failure to adequately decontaminate all items of Failure to adequately decontaminate all items of Failure to adequately decontaminate all items of

equipment between patients such as blood pressure equipment between patients such as blood pressure equipment between patients such as blood pressure equipment between patients such as blood pressure equipment between patients such as blood pressure equipment between patients such as blood pressure equipment between patients such as blood pressure equipment between patients such as blood pressure

cuffs, tourniquets and stethoscopescuffs, tourniquets and stethoscopescuffs, tourniquets and stethoscopescuffs, tourniquets and stethoscopescuffs, tourniquets and stethoscopescuffs, tourniquets and stethoscopescuffs, tourniquets and stethoscopescuffs, tourniquets and stethoscopes

Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan

ImmediatelyImmediatelyMatronMatronZero Zero

Tolerance Tolerance

rule to rule to

apply apply

InadequaInadequaInadequaInadequaInadequaInadequaInadequaInadequa

te Handte Handte Handte Handte Handte Handte Handte Hand

HygieneHygieneHygieneHygieneHygieneHygieneHygieneHygiene

Traffic Traffic

LightsLightsReview/Review/

OutcomeOutcome

Date Date

CompletedCompletedTarget Target

DateDateBy By

WhomWhomActionActionIssueIssue

Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan

ImmediatelyImmediatelyWard Ward

SisterSisterBed and Bed Bed and Bed

Space Space

Standing Standing

operatingoperating

Procedure to Procedure to

be be

implementedimplemented

No No No No No No No No

evidence evidence evidence evidence evidence evidence evidence evidence

bed and bed bed and bed bed and bed bed and bed bed and bed bed and bed bed and bed bed and bed

space space space space space space space space

adequately adequately adequately adequately adequately adequately adequately adequately

cleaned cleaned cleaned cleaned cleaned cleaned cleaned cleaned

betweenbetweenbetweenbetweenbetweenbetweenbetweenbetween

patientspatientspatientspatientspatientspatientspatientspatients

Traffic Traffic

LightsLightsReview/Review/

OutcomeOutcome

Date Date

CompletedCompletedTarget Target

DateDateBy By

WhomWhomActionActionIssueIssue

Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan

immediatelyimmediatelyWard Ward

Sister and Sister and

MatronMatron

Introduce Introduce

disposable disposable

tourniquets tourniquets

Apply Apply

alcohol to alcohol to

stethoscope stethoscope

between between

each use,each use,

Ensure Ensure

phlebotomy phlebotomy

staff are staff are

properly properly

decontamindecontamin

ating their ating their

hands and hands and

tourniquets tourniquets

between between

patientspatients

Failure to Failure to Failure to Failure to Failure to Failure to Failure to Failure to

adequately adequately adequately adequately adequately adequately adequately adequately

decontaminatdecontaminatdecontaminatdecontaminatdecontaminatdecontaminatdecontaminatdecontaminat

e all items of e all items of e all items of e all items of e all items of e all items of e all items of e all items of

equipment equipment equipment equipment equipment equipment equipment equipment

between between between between between between between between

patientspatientspatientspatientspatientspatientspatientspatients

such as blood such as blood such as blood such as blood such as blood such as blood such as blood such as blood

pressure pressure pressure pressure pressure pressure pressure pressure

cuffs, cuffs, cuffs, cuffs, cuffs, cuffs, cuffs, cuffs,

tourniquets tourniquets tourniquets tourniquets tourniquets tourniquets tourniquets tourniquets

and and and and and and and and

stethoscopesstethoscopesstethoscopesstethoscopesstethoscopesstethoscopesstethoscopesstethoscopes

Traffic Traffic

LightsLightsReview/Review/

OutcomeOutcome

Date Date

CompletedCompletedTarget Target

DateDateBy By

WhomWhomActionActionIssueIssue

Summary of main learning points from MRSA RCA Summary of main learning points from MRSA RCA

•• Continuing skin care for all MRSA positive patients across both Continuing skin care for all MRSA positive patients across both primary and primary and

secondary caresecondary care

•• Optimal device management of patients colonised with MRSAOptimal device management of patients colonised with MRSA

•• Zero tolerance for failure to adequately decontaminate hands betZero tolerance for failure to adequately decontaminate hands between ween

patientspatients

•• Zero tolerance for failure to decontaminate all items of equipmeZero tolerance for failure to decontaminate all items of equipment between nt between

patients (patients (incudingincuding stethosopesstethosopes, , tourniqutstourniquts, beds and operating tables), beds and operating tables)

•• Zero tolerance for failure to adequately decontaminate the patieZero tolerance for failure to adequately decontaminate the patient nt

environment between patients (bed spaces and theatre environmentenvironment between patients (bed spaces and theatre environment))

PCT Performance ManagementPCT Performance ManagementPCT Performance ManagementPCT Performance ManagementPCT Performance ManagementPCT Performance ManagementPCT Performance ManagementPCT Performance Management

•• Formal performance management of Formal performance management of

issues identified against agreed issues identified against agreed

parametersparameters

PCT Performance ManagementPCT Performance ManagementPCT Performance ManagementPCT Performance ManagementPCT Performance ManagementPCT Performance ManagementPCT Performance ManagementPCT Performance Management

•• Sustained improvement in Hand Hygiene Sustained improvement in Hand Hygiene

audit resultsaudit results

•• Evidence of use disposable tourniquetsEvidence of use disposable tourniquets

•• Evidence of correct use of IVI documentationEvidence of correct use of IVI documentation

•• Evidence of continuing skin care for MRSA Evidence of continuing skin care for MRSA

positive patients across primary and positive patients across primary and

secondary caresecondary care

Take Home ThoughtsTake Home ThoughtsTake Home ThoughtsTake Home ThoughtsTake Home ThoughtsTake Home ThoughtsTake Home ThoughtsTake Home Thoughts

·· Any HCAI is a disgraceAny HCAI is a disgrace

·· The CE needs to know about cases of HCAI at least as quickly as The CE needs to know about cases of HCAI at least as quickly as

breaches in the 4 hour waitbreaches in the 4 hour wait

·· If patients are languishing in hospital with infection, how can If patients are languishing in hospital with infection, how can

trusts possibly be delivering financial turnaroundtrusts possibly be delivering financial turnaround

·· Every ward sister and every matron needs to know what cases of Every ward sister and every matron needs to know what cases of

HCAI HCAI -- colonised or infected they have at any time on their ward colonised or infected they have at any time on their ward

and be accountable for systems in place necessary to controland be accountable for systems in place necessary to control

·· Trusts need to make it clear to anyone not complying with HCAI Trusts need to make it clear to anyone not complying with HCAI

systems that such behaviour is unacceptablesystems that such behaviour is unacceptable

·· Do Trusts have sufficient pace and urgency indicating to Do Trusts have sufficient pace and urgency indicating to

everyone the importance of the HCAI agenda ?everyone the importance of the HCAI agenda ?