Transcript Document

MRSA/HCAI Improvement Programme
National Orthopaedic Pr
MRSA/HCAI Improvement Programme
Shrewsbury & Telford NHS Trust
Final Report
Author: Improvement Programme Review Team
Version: Final version
Date: 30th March 2007
1
MRSA/HCAI Improvement Programme
National Orthopaedic Pr
Contents
Section 1
1.1 Executive summary
1.2 Your key message & immediate priorities
1.3 Data analysis
1.4 Suggested target milestones
1.5 Actions for recovery & improvement
1.6 Encouraging signs
Section 2
2.1 Key themes
Findings and recommendations
2.2 People
2.3 Performance
2.4 Process
2.5 Practice
Section 3
3.1 Recommended performance reporting
3.2 Recovery plan
Links:
Acknowledgements
Section 1
Section 2
Section 3
2
MRSA/HCAI Improvement Programme
National Orthopaedic Pr
Contents
Section 1
1.1 Executive summary
1.2 Your key message & immediate priorities
1.3 Data analysis
1.4 Suggested target milestones
1.5 Actions for recovery & improvement
1.6 Encouraging signs
Section 2
2.1 Key themes
Findings and recommendations
2.2 People
2.3 Performance
2.4 Process
2.5 Practice
Section 3
3.1 Recommended performance reporting
3.2 Recovery plan
Links:
Content Page
Acknowledgements
Section 2
Section 3
3
MRSA/HCAI Improvement Programme
1.1 Executive summary
National Orthopaedic Pr
You met your target in year one but are struggling to meet it this year. There are pockets of good practice throughout the trust and a
general desire to be proactive rather than reactive in reducing MRSA bacteraemias but this will need a direct focus and an immediate
recovery plan implemented to reach trajectory and deliver your target.






your 06/07 (April to November) trajectory is 22 and you experienced 36 MRSA Bacteraemias
the biggest challenge you have is identifying the root cause of your bacteraemias and this requires your immediate attention.
Immediately carry out root cause analysis (RCA) to ascertain source and cause of all MRSA bacteraemias and backdate for the
last three months
your data shows that 77% of your bacteraemias occur after 48 hours, of which 33% are within Augmented Care. You need to
ensure there are no avoidable MRSA bacteraemias in Augmented Care with immediate effect and maintain this
you need to demonstrate a 50% improvement in your top 5 specialties in the next 6 months, i.e general medicine, general surgery,
nephrology and general intensive care unit
your data suggests that 23% of your bacteraemias occur pre-48 hour. Carry out immediate bespoke analysis of pre-48 hour MRSA
bacteraemias for patients admitted 3 months prior to having acquired MRSA in hospital. Work with partners to understand cause,
and reduce number of pre-48 hour cases. Reduce by at least 50% by May 07 and by at least a further 50% by August 07
ensure month on month improvements in all areas
You achieved your MRSA trajectory target last year but breached the MRSA trajectory target this year. The organisation, as a whole,
needs to maintain an attitude of awareness and diligence to assist recovery against trajectory. Commitment to infection prevention and
control is evident and the sense of importance and urgency held by the Chief Executive needs to be translated to all levels of the
organisation. Your new Divisional structure will give you the opportunity to promote joint working and enhance communication across
the organisation. Nominated clinical leads are required for all specialties to own and drive this initiative, moving away from a culture
whereby the Infection Control Team led and owned all that was associated with infection prevention and control. Ensuring everyone
understands their role, responsibility and accountability is also fundamental. Utilisation of the High Impact Interventions (HIIs) in specific
and focused areas as highlighted by the improved RCA will lead you to make progress faster. Finally, improvements in screening and the
use of antibiotics will all play an important part. Audit and surveillance are key to measuring your progress against infection prevention
and control and should be formalised and fed back to the clinical areas as soon after completion as possible.
We have highlighted a number of areas in this report which should improve your performance towards reducing the levels of MRSA
bacteraemia. The review team has included in this report key performance improvement statements with timescales for specific
improvement outcomes. You need to embed within the culture that it is an insult to give patients infections.
4
MRSA/HCAI Improvement Programme
1.2 Your key message and immediate priorities
National Orthopaedic Pr
Your key message is :
Accountable and responsible care delivery will support a reduction in
healthcare-associated infection
Immediate implementation of the following 3 actions will start you on your
journey of reducing your MRSA bacteraemias (please see the embedded
document in section 1.5 for your further actions)
initiate
root cause analysis within 24 hours of bacteraemia identification and
complete and feedback to your multi-disciplinary team within 5 days
develop and share performance information that is understood and owned
by all levels of the organisation
instil a culture that reducing MRSA bacteraemias is everyone’s responsibility
5
MRSA/HCAI Improvement Programme
1.3 Data analysis
National Orthopaedic Pr
data in the following slides are from your submitted MESS data December
2005 to November 2006
6
MRSA/HCAI Improvement Programme
National Orthopaedic Pr
1.3.1 What is the direction of travel?
MRSA Bacteraemias. 12 month rolling total.
The challenge is significant to be where you need to be in March 2008
60
50
40
30
20
7
Target
Mar-08
Feb-08
Jan-08
Dec-07
Nov-07
Oct-07
Sep-07
Aug-07
Jul-07
Jun-07
May-07
Apr-07
Mar-07
Feb-07
Jan-07
Dec-06
Nov-06
Oct-06
Sep-06
Aug-06
Jul-06
May-06
Apr-06
Mar-06
0
Jun-06
10
MRSA/HCAI Improvement Programme
1.3.2 Number of MRSA cases split by Specialty
National Orthopaedic Pr
0
0
2
0
0
1
0
0
3
Areas to target are: General Medicine & General Surgery.
8
0
0
3
2
0
1
0
0
6
0
0
2
1
0
0
1
0
4
Tota
l
0
0
2
1
0
0
0
1
4
Nov06
0
0
3
2
0
0
0
0
5
Oct-0
6
Jul-0
6
6
0
0
3
0
0
0
0
2
5
Sep06
0
0
5
2
0
0
0
1
8
Aug06
0
0
1
0
0
0
0
0
1
Jun-0
1
1
2
1
0
0
0
0
5
May06
0
0
0
1
0
0
0
0
1
Apr-0
6
6
1
0
1
0
0
1
0
0
3
Mar06
1
0
1
1
0
0
0
1
4
Feb06
Clinical haematology
Gastroenterology
General medicine
General surgery
Genito-urinary medicine
Geriatric medicine
Gynaecology
Trauma and orthopaedics
Jan-0
Dec05
- A look at your problem areas
3
6%
1
2%
25 51%
11 22%
0
0%
3
6%
1
2%
5 10%
49 100%
MRSA/HCAI Improvement Programme
National Orthopaedic Pr
Aug06
Sep06
Oct-0
6
Nov06
1
4
0
4
0
0
1
8
100% 50%
0
5
0
5
0%
1
2
0
3
33%
2
3
0
5
40%
1
3
0
4
25%
1
5
0
6
17%
0
4
0
4
0%
6
Apr-0
6
0
4
1
5
0%
Jul-0
Mar06
0
1
0
1
0%
6
Feb06
1
2
0
3
33%
Jun-0
Jan-0
0
3
1
4
0%
6
Dec05
pre 48hrs
post 48hrs
Missing admission date
Total
% pre 48hrs
May06
1.3.3 Number of MRSA cases split by Pre- and Post-48 Hours
Total
11
36
2
49
23%
The table shows that in the last 12 months, 23% of your bacteraemias were pre-48hr cases.
N.B. The national average is 28%.
Suggestion – look at your pre 48 hour patients and see if they have been to hospital in
the previous 3 months from when their MRSA Bacteraemia was identified
9
MRSA/HCAI Improvement Programme
1.3.4 Number of MRSA cases by Age Band
National Orthopaedic Pr
The breakdown of your MRSA cases by age band
9
8
7
6
5
4
3
M
is
sin 95
g +
DO
B
4
-9
9
90
-8
4
85
-8
9
80
-7
4
75
-7
9
70
-6
4
65
-6
9
60
-5
4
55
-5
9
50
-4
4
45
-4
9
40
-3
4
35
-3
9
30
-2
4
25
-2
9
20
-1
4
15
-1
9
10
-0
05
00
-0
4
2
1
0
It is recommended that you compare this MRSA Age band profile with your admission data
(esp. in the higher age bands) to ensure that no age band has a significant disproportionate
number of cases.
10
MRSA/HCAI Improvement Programme
1.3.5 What is the scale of your challenge?
National Orthopaedic Pr
Your MRSA figures have recently been above trajectory. This situation needs
to be reversed.
Trajectory (T)
Actual (A)
9
8
7
6
5
4
3
2
1
0
Dec- 0 5
11
Jan - 0 6
Feb- 0 6
M ar - 0 6
Apr - 0 6
M ay- 0 6
Jun - 0 6
Jul- 0 6
Aug- 0 6
Sep- 0 6
Oct - 0 6
Nov- 0 6
MRSA/HCAI Improvement Programme
Aug06
Sep06
Oct-0
2
1
3
33%
5
0
5
0%
3
1
4
25%
1
5
6
83%
Nov06
Jul-0
2
3
5
60%
6
Jun-0
8
0
8
0%
6
May06
1
0
1
0%
6
Apr-0
6
Feb-
Mar06
2
0
4
1
1
1
3
1
5
33% 100% 20%
06
2
2
4
50%
6
Jan-0
No Augmented Care
AugmentedCare
Total
% Augmented Care
Dec05
National Orthopaedic
Pr
1.3.6 Number of MRSA cases split by Augmented Care
&
Non-Augmented Care
Total
3
33
1
16
4
49
25% 33%
The table shows that in the last 12 months, 33% of your cases occurred in Augmented Care.
N.B. The national average is 24%.
The target is to have zero avoidable infections in Augmented Care.
12
0
0
1
0
0
1
0
0
1
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
3
0
0
3
0
0
0
1
0
1
1
1
3
0
0
5
0
0
0
0
1
1
Tota
l
Nov06
0
0
1
0
0
1
6
0
0
0
0
0
0
Oct-0
6
Jul-0
6
Jun-0
May06
Apr-0
6
Mar06
06
Feb-
6
0
0
1
0
0
1
Sep06
0
0
1
0
1
2
Aug06
Renal Unit
HDU
General Intensive Care Unit (ICU)
Combined HDU and ICU
Cardiac Care Unit or Coronary Care Unit (CCU)
Total
Jan-0
Dec05
The table below provides a breakdown of where your augmented cases are occurring.
1
1
11
1
2
16
MRSA/HCAI Improvement Programme
1.4 Suggested target milestones
National Orthopaedic Pr
Actions
Milestones
A robust recovery plan is required immediately to deliver agreed monthly
trajectory by May 2007
To get on trajectory and then move further faster
Immediately carry out robust root cause analysis to ascertain the source and
cause of your MRSA bacteraemias and identify any trends
You can make significant improvement in MRSA bacteraemia by at least 50%
in General Medicine, General Surgery and renal dialysis by end of May 2007
Carry out bespoke analysis of pre-48 hour MRSA bacteraemias and determine
how many of them have had previous hospital admissions in the previous three
months
Work closely with partner organisations to reduce number of pre-48 hour MRSA
bacteraemias. Instigate joint root cause analysis to uncover source.
In the six months between June 06 and Nov 06you had:
15 cases in General Medicine. Reduce this by at least 50%
to 7 or less by May 07
six in General Surgery. Reduce this by at least 50% to three
or less by May 07
You have reported four cases in renal dialysis in the past 3
months. Reduce this by at least 50% to two or less by May
07
Reduce pre-48 hour cases by 50% by May 07
Ensure you have zero avoidable cases in Augmented with
immediate effect
Avoidable MRSA bacteraemia in Augmented Care should be zero
Further reduction of MRSA bacteraemias by at least 50% in General Medicine,
General Surgery and renal dialysis by end of August 2007
Further work with partner organisations to reduce number of pre-48 hour MRSA
bacteraemias by a further 50% by August 2007
Maintain zero avoidable MRSA bacteraemias in Augmented Care
Month on month reduction in MRSA bacteraemias beyond trajectory
Reduction In Breaches by May 2007:
General Medicine from 10 to five or less by August 07
Nephrology from four to two or less by August 07
General Surgery from three to one or less by August 07
Reduce pre-48 hour cases by 50% by August 07
Maintain 0 by August 07
13
MRSA/HCAI Improvement Programme
1.5 Actions for recovery and improvement

We have worked through some of your actions that we suggest need to be
undertaken in the short term. These are based on our findings during our 2
day review.

You may wish to expand on these as you develop this action plan locally
for the medium to long term and consider the wider findings in section 2 of
this report
Double Click to Launch
14
National Orthopaedic Pr
MRSA/HCAI Improvement Programme
1.6 Encouraging signs
National Orthopaedic Pr

the Chief Executive and the Trust Board now have a strong focus on patient safety and
improving the patient experience

there is a very dedicated infection control team, members of which are valued and
respected across the trust.

the Director of Infection Prevention and Control is highly regarded throughout the trust by
all interviewed staff groups

the organisation has many dedicated clinicians and staff, some working in less than ideal
environments, and all committed to making a difference

the outreach team have a model for early warning signs for sepsis that could be adapted
for MRSA

there is evidence of some early root cause analysis being undertaken across the trust
despite the challenges of IT support

there are some good examples of practice in ITU, including the use of gloves and aprons,
hand hygiene, dedicated CVC management and packs and general compliance with EPIC
guidelines.
continued/…
15
MRSA/HCAI Improvement Programme
1.6 Encouraging signs
16
…/continued
National Orthopaedic Pr

there are several education streams for awareness raising, clinical training and clinical
skills updating accessible for staff

standards of cleaning were reported and observed to be very high within the trust despite
benchmarking of domestic staffing level demonstrating low numbers compared with other
trusts
MRSA/HCAI Improvement Programme
National Orthopaedic Pr
Contents
Section 1
1.1 Executive summary
1.2 Your key message & immediate priorities
1.3 Data analysis
1.4 Suggested target milestones
1.5 Actions for recovery & improvement
1.6 Encouraging signs
Section 2
2.1 Key themes
Findings and recommendations
2.2 People
2.3 Performance
2.4 Process
2.5 Practice
Section 3
3.1 Recommended performance reporting
3.2 Recovery plan
Links:
Content Page
Acknowledgements
Section 1
Section 3
17
MRSA/HCAI Improvement Programme
2.1 Key themes
National Orthopaedic Pr
Performance
People
Performance frameworks
Performance framework ownership
Use of data
Performance data
Audit
Pre-48 hour cases
Leadership
Training
Directorate responsibilities
and ICT
Roles & responsibilities
MRSA
bacteraemia
reduction
Processes
Bed management and transfers
Storage space
18
Practices
Hand hygiene
High impact interventions
Screening & decolonisation
Antibiotics
Root cause analysis
MRSA/HCAI Improvement Programme
Findings
2.2.1 People
 the Chief Executive is clearly committed to tackling MRSA and meets with the DIPC for a
one to one meeting every month, receives monthly trajectory data and is informed of
every bacteraemia as it occurs
 the review team is not convinced that the sense of urgency and importance and
ownership is embedded at all levels of the organisation
 many staff and managers expressed the view that the trust had only just taken stock of
its position with regard to MRSA relying on the fact that it achieved its trajectory target
last year
 the only clinical champion for infection control identified by staff in the trust was the
DIPC, nominated leads are not in place in all specialties
National Orthopaedic Pr
Leadership
Recommendations
Chief Executive, Trust Board, DIPC and Infection Control Team commitment to be supported by a high profile clear
communication strategy of the key messages, consistent action, and role modelling to signal the required change and
the importance and urgency of the agenda
Ensure MRSA target delivery is of equal importance to other key targets and translated to directorates, teams and
individuals objectives accordingly, to ensure delivery and then performance managed
Reducing infection must be seen to be everyone’s business with clear responsibly, accountability and performance
management
Appoint medical clinical leads within each specialty and performance manage specific objectives
Play a key role in the DH MRSA Programme Performance Improvement Network. Disseminate timely, accurate and
appropriate information to all staff to encourage a culture of continuous learning, improvement and sharing of best
practice
19
MRSA/HCAI Improvement Programme
Findings
2.2.2 People
 the trust has several ‘arms’ responsible for clinical skills training and updating. However
there is no collaborative approach to these, nor are they standardised or consistent
across the trust
 infection control team are responsible for the delivery of all mandatory training, stretching
available resources
 there is a need to review the training and ongoing compliance with aseptic procedures
and antibiotic prescribing
National Orthopaedic Pr
Training
Recommendations
Deliver a trust-wide clinical skills training strategy and consider alternatives to training techniques such as videos.
Clarify specific objectives for those with responsibility and accountability
Monitor training to observe application into practice and modify accordingly. Consider devolving responsibility for day
to day infection control and prevention to clinical level and make better use of link nurse role
Link antimicrobial prescribing to a clear policy. Review the current training in antibiotic/antimicrobial prescribing and
ensure availability for all medical staff including juniors
Deliver both multidisciplinary and junior doctor aseptic procedure training and then audit to gain local ownership and
harvest maximum gains
20
MRSA/HCAI Improvement Programme
Findings
2.2.3 People
 the review team was unable to find widespread evidence of responsibility and
objectives for infection prevention and control at Divisional level
 there are many dedicated matrons and link nurses however the DIPC is attempting to
drive this largely on his own with limited support
 the infection control team are unclear how they will be integrated into the
performance management framework
National Orthopaedic Pr
Directorate
responsibilities
and infection
control team
Recommendations
The focus of activity must be based around directorates, with the ICT enabling rather than undertaking the bulk of
activity. Clinical leads within each directorate or speciality will be key to successful implementation, supported by clear
objectives and outcome measures
Ensure that clinical leadership is engaged at Divisional level, with clear responsibilities and accountabilities for
engagement, reporting and delivering improvements. Responsibilities need to be explicit in clinical director job
descriptions
Achieving the target needs to be everyone’s business. Broaden engagement of Divisions and management teams by
strengthening performance management arrangements, setting specific Divisional and sub-divisional team targets
using a balanced score card approach to hold teams to account. Immediately identify a nominated lead for each
speciality and ensure that the role is underpinned with measurable objectives and a reporting framework
Clear responsibilities and accountabilities must be underpinned with focused objectives for all members of the
directorate including clinical directors, clinical managers,and link nurses
21
MRSA/HCAI Improvement Programme
Findings
2.2.4 People
 whilst there is evidence of infection control responsibilities within some job descriptions
and objectives, individuals and teams did not always appear to understand what that
meant for them, what they had to do differently, and where responsibilities were shared
or individual
 roles and responsibilities were not always fully understood in relation to the MRSA target
National Orthopaedic Pr
Roles &
responsibilities
Recommendations
Accelerate plans to formalise infection control in staff job descriptions and discuss thoroughly at appraisals and
personal performance development meetings, in addition to team or directorate meetings and performance
manage this
Ensure that consultants are aware of their accountability and responsibility for the infection control practice of their
juniors and are appropriate role models. Escalate their engagement in clinical governance to deliver updates and
key messages
Re state the roles and responsibilities and accountabilities of the consultants, infection control and matrons to
ensure understanding of individual and shared responsibilities and performance manage through regular 1:1s
Ensure the Medical Director has the detailed data he needs to be effective in his role
22
MRSA/HCAI Improvement Programme
2.3.1 Performance
Findings
 an adequate level of MRSA bacteraemia data is not embedded in the Board performance
reporting arrangements
 targets are not set for each Division to deliver against and own and embed within core
business
 the current forums run to address MRSA issues do not have appropriate remits or
representation by clinicians or multidisciplinary teams to ensure action and delivery
National Orthopaedic Pr
Performance
frameworks
Recommendations
Use the new Divisional structure to develop bottom up plans to combat MRSA especially in identified hotspot
areas
Include information on where hotspots are in Board papers and include a monthly update report of actions being
taken to address HCAI
Each Division to have a target set for MRSA bacteraemias each month against which its performance should be
measured even if it zero. This includes a breakdown by clinical teams and individual clinicians in
a timely manner as information becomes available
Divisions to be held accountable through performance frameworks for its performance against the MRSA
bacteraemia reduction target
Each MRSA bacteraemia should be treated as a breach and performance managed
Review the current mechanisms of engagement of clinicians and multi-disciplinary teams in the agenda and
ensure appropriately established. For clinicians, incorporate in the peer review, service mortality, morbidity review
meetings
23
MRSA/HCAI Improvement Programme
2.3.2 Performance
Findings
 whilst progress has been made to focus activity within some specialties, the infection
control team appear to be undertaking the majority of the work
National Orthopaedic Pr
Performance
framework
ownership
Recommendations
Medical Director, Deputy Chief Executive and DIPC should work together to develop a strategic approach to
reduce HCAI and to agree their individual roles, responsibility and actions
Responsibilities need to be explicit in clinical director job descriptions and job plans
Increase engagement of Divisions, identify clinical leads within each Division or speciality and implement action
plans supported by the ICT
Agree measurable outcomes with objectives that are focused and incorporated within the performance
management outcomes for the directorate
24
MRSA/HCAI Improvement Programme
2.3.3 Performance
National Orthopaedic Pr
Findings
 data related to MRSA and other targets is discussed at every public board meeting
 the trust intend to develop key performance indicators for infection prevention and
control as part of the performance management arrangements within the new divisional
structures
 feedback from root cause analysis can often be slow and of limited value above
identification of obvious factors.
 follow up action is not always monitored
 poor documentation with relation to intravenous line insertion was observed by the
review team
Use of data
Recommendations
Raise awareness of the value of MESS data in better targeting of interventions. Report all MRSA bacteraemias
as a critical incident or Serious Untoward Incident. Integrate into governance and risk arrangements. Undertake
a more robust root cause analysis on each bacteraemia to understand cause and source
Review the current root cause analysis approach used and consider using the newly developed NPSA RCA tool
or components of it to be able to identify trends in individuals, teams, environmental issues, sources, case mix
issues, collective training and development needs
Ensure timely reporting of root cause analysis findings and appropriate feedback, across the health economy
where appropriate. Performance manage and monitor and ensure interventions are targeted
Develop a standardised method for documentation of peripheral line insertion and daily assessment
performance manage completion daily
25
MRSA/HCAI Improvement Programme
2.3.4 Performance
National Orthopaedic Pr
Findings
 your data shows that 33% of your MRSA bacteraemias are within Augmented Care.
This is above the national average (24%)
 other hotspot areas are General Medicine (51%) and General Surgery (22%)
 23% of bacteraemias were diagnosed as being present within 48 hours of admission.
This is below the national average (28%)
Performance data
Recommendations
Understand sources of your bacteraemias both pre- and post-48 hours to enable focus on the hot spots. Provide
basic information and simple messages to staff on MRSA and mechanism of transfer. Adopt more rigorous and
evidence based approaches in using data in order to provide the required focus, create the sense of importance and
urgency required. Gain greater engagement across the trust and provide assurances to the Board
Use robust and timely enhanced surveillance data to identify which wards and departments have the greatest
numbers of bacteraemias and interrogate own trust data to understand sources. Use clinical leads to overcome any
data credibility issues.
Ensure a fit for purpose IT system is in place which supports infection control activities in respect of providing
information for surveillance and monitoring.
Use rigorous methods to identify which areas in General Medicine, Geriatric Medicine and General Surgery require
focus in addition to the attention that renal services should be receiving
Using the HIIs within these areas should enable faster progress to be made. Set local reduction targets, dates for
attainment and owners. Focus on your hotspots
Complete, sign off and submit MESS data weekly with situational reports and share across the organisation for early
use in learning and performance management
26
MRSA/HCAI Improvement Programme
2.3.5 Performance
Findings
 23% of bacteraemias were diagnosed as being present within 48 hours of admission,
this is below the national average (28%)
National Orthopaedic Pr
Pre-48 hour cases
Recommendations
The pre-48 hour group of patients would suggest that some of this group are readmissions or frequent attenders
with chronic conditions. Use the root cause analysis tool to identify the source and any contributing factors and
look to see if patients have been in hospital 3 months prior to contracting the bacteraemia
Work with the PCTs on further engagement and management of those cases identified
You should address specific issues in Nephrology that may relate to efficiency or permanent vascular access or
other dialysis practices, including screening and preventative decolonisation
Once the the source of the pre-48 hour bacteraemias has been identified, review screening and decolonisation
protocols in light of the findings. Your figures are suggestive of re-admissions and may require a health economy
approach with support from the SHA and PCT
Escalate the work with the health economy partners to reduce the pre-48 hour cases
Ensure RCA of your pre-48 hour cases are fed back into your organisation in a timely manner
27
MRSA/HCAI Improvement Programme
2.3.6 Performance
Findings
National Orthopaedic Pr
Audit
 whilst the review team was informed of the many audits that had been conducted, there
were numerous ward staff who were unaware of the results from these audits
 there did not appear to be a mechanism for sharing learning from the audits within or
across specialties nor with future induction, education and training, personal
development plans and performance monitoring frameworks
 most audits related to HCAI were undertaken by the infection control team
Recommendations
Use the root cause analysis tool and hot spot areas to focus work for High Impact Interventions and audit
Structure an audit calendar for the organisation and feed the results into directorate performance management to
ensure actions are monitored and owned
Establish a mechanism for sharing and spreading good practice and learning across the trust
Link the results of audit into future induction, education and training, personal development plans and
performance monitoring frameworks
Involve link nurses and clinical nurse managers more fully in audit activity, feedback and action
Ensure small frequent audits are undertaken when you are focusing on changing culture and practice. Timely
feedback is key to ensuring sustainable improvement
28
MRSA/HCAI Improvement Programme
2.4.1 Process
Findings
 the review team were made aware that there was a new devolved structure for bed
management within the organisation
 the trust has wider issues in terms of flow and bed management in relation to whole
system demand management
National Orthopaedic Pr
Bed
management
and
transfers
Recommendations
Ensure bed management policies minimise patient movement and that these are accessible, applicable and
adhered to. Due to the numbers of outliers, consider practice and policies in relation to screening and
decolonisation for high risk patients. Review the processes for identifying patients requiring isolation or precautions
on wards and spread good practice. Ensure at-risk patients are ring fenced or segregated. Review the input and
attendance of the infection control team at bed management meetings.
Ensure all staff are aware of and know how to access the flag system on the computer for current and previously
MRSA positive patients
Continue to work on improving flow and efficiency and work with partners on securing a whole system solution
which incorporates demand management, real alternatives to admission for relevant patients and proactive seven
days a week discharge planning
29
MRSA/HCAI Improvement Programme
2.4.2 Process
Findings
 on the whole, clinical areas visited by the review team appeared clean and uncluttered
 one clinical area observed to present an issue with space and storage was the renal
dialysis ward at Shrewsbury. Patient areas were very close together with little room
between one patient and the next. It is recognised this is not conducive to good infection
control management and additional stations have been opened at Telford. In addition the
trust is actively pursuing further investment for more stations.
Recommendations
Ensure sinks are accessible for all to use
Find alternative storage space for unused equipment
30
National Orthopaedic Pr
Storage space
MRSA/HCAI Improvement Programme
2.5.1 Practice
Findings
 audits of hand hygiene have shown a variable rate of compliance of across staff groups
within the organisation – 88% for nursing staff and 78% for medical staff.
 for the most part, the review team found that the alcohol hand rub or gel was available
at the point of care delivery, with the exception of one or two observed areas
National Orthopaedic Pr
Hand hygiene
Recommendations
Continue to state the message to all staff that improved compliance with hand hygiene is a priority for the trust and
set a target for compliance of 95% across the trust. Ensure all relevant staff understand the rationale behind the
need to use gloves, when to wash hands, and when to use gel or rub. Audit through the High Impact Interventions
and performance manage to ensure all staff, whether touching a patient or not, decontaminate their hands on
entry and exit to clinical areas and always at the point of care
Increase the frequency of hand hygiene audits to be undertaken by clinical managers, publish the results and take
any appropriate action. Promote the use of alcohol hand rub as the gold standard for routine hand hygiene when
appropriate
Escalate the education and awareness, training and auditing, particularly in areas identified by the root cause
analysis as the main areas of focus
Undertake daily/weekly audits in all wards and staff groups who do not adhere to the 95% hand hygiene
compliance
Ensure results are fed back weekly to all staff
Consider using league tables as a feed back measure
31
MRSA/HCAI Improvement Programme
2.5.2 Practice
Findings
 Some High Impact Interventions are used in some of the critical care areas. However the
High Impact Interventions are not owned widely across the trust and are not always being
implemented in response to the RCA, and could therefore be more focused
National Orthopaedic Pr
High impact
interventions
Recommendations
Undertake robust root cause analysis and prioritise the implementation of the High Impact Interventions for relevant
areas
Ensure the utilisation of the High Impact Interventions are owned by the directorates, with clear responsibility and
accountability and linked to governance and performance. Performance manage and audit documentation
Observational audit and challenge at point of insertion of lines to become everyday practice. Review and target the
training programmes, link audits to individual development programmes
32
MRSA/HCAI Improvement Programme
2.5.3 Practice
Findings
 there is confusion in some areas around who and when to screen
 there is a lack of consistency in applying decolonisation for high risk patients
 it was suggested to the review team that some elective patients who were screened
at pre-assessment were not decolonised prior to admission
National Orthopaedic Pr
Screening &
decolonisation
Recommendations
Use national evidence and the recent DH guidance to review and re-launch the screening and decolonisation
policies. Provide consistent clarification to staff in relation to screening of all high risk patients (surgery, critical
care, elderly care, regular or repeat admissions and admissions from nursing home or residential care homes) as
recommended in national guidance (Guidelines for the Control and Prevention of MRSA in Healthcare Facilities by
BSAC, HIS, ICNA working party on MRSA)
Use Patient Group Directives (PGD) for decolonisation of MRSA positive patients
Ensure the policies are interpreted and adhered to appropriately and audit compliance. Performance
manage and feed back to Divisions and departments
Consider rapid screening for MRSA following business case review
33
MRSA/HCAI Improvement Programme
National Orthopaedic Pr
2.5.4 Practice
Findings






Antibiotics
there is evidence that long courses of antibiotics are given
the trust has an antibiotic pharmacist for two sessions only
two sets of antibiotic guidelines exist across the trust
there is no policy for changing from intravenous to oral antibiotics
many patients were treated with intravenous antibiotics for longer than 2-3 days
large amounts of ciprofloxacin
Recommendations
Decrease use of quinolones – Consider only prescribing by referral to the microbiologist
Introduce intravenous to oral switch policy after 2-3 days
Review pharmacy skill mix workforce and ways of working with microbiology to deliver maximum gain
Implement automatic stop policy
Empower nurses to challenge antibiotic prescribing and duration
34
MRSA/HCAI Improvement Programme
Findings
National Orthopaedic Pr
2.5.5 Practice
 root cause analysis is currently undertaken by the DIPC but is not as robust as future
requirements dictate. It is not always disseminated to the clinical teams in a timely
manner, therefore it is not always owned by the Divisions and clinical teams
 there is a reluctance to take ownership for root cause analysis at directorate level
 appropriate and timely action is not always taken as a result of the analysis of each
MRSA bacteraemia
Root cause
analysis
Recommendations
Review the rationale and importance of RCA and roles, responsibilities and accountabilities within the trust and
communicate to the trust Board
Review the current RCA approach used and develop a more robust approach. Consider using the NPSA RCA tool
or components of it to be able to identify trends in individuals, teams, environmental issues, sources, case mix
issues, collective training and development needs, etc. Commence RCA within 24 hours of confirmation of an
MRSA bacteraemia and feed back of findings and action to clinical teams within 5 days.
Once a more robust approach has been developed and piloted, assign responsibility for undertaking RCA to an
individual within the relevant Division who has the time, skills and status to investigate, action and follow-up all
cases supported by infection control, DIPC and the risk management team
Ensure timely reporting of RCA findings and appropriately feed back across the health economy where
appropriate. Performance manage and monitor and ensure interventions are targeted
Each relevant consultant to report to their Divisional governance group on the findings of RCA and action taken to
support learning. Performance manage through existing governance structures
Complete the risk factors page on MESS to ensure a robust data set for learning is available to your organisation
35
MRSA/HCAI Improvement Programme
National Orthopaedic Pr
Contents
Section 1
1.1 Executive summary
1.2 Your key message & immediate priorities
1.3 Data analysis
1.4 Suggested target milestones
1.5 Actions for recovery & improvement
1.6 Encouraging signs
Section 2
2.1 Key themes
Findings and recommendations
2.2 People
2.3 Performance
2.4 Process
2.5 Practice
Section 3
3.1 Recommended performance reporting
3.2 Recovery plan
Links:
Content Page
Acknowledgements
Section 1
Section 2
36
MRSA/HCAI Improvement Programme
3.1 Recommended performance reporting
National Orthopaedic Pr
Report on actions for recovery and improvement through:
 the use of the MRSA improvement programme actions for recovery and
improvement template to track progress and report performance into existing
governance structures
 population of the non-mandatory enhanced facilities on the HPA MESS reporting
system to track and analyse key problem areas
 undertake robust root cause analysis and share widely- where are the sources of
your bacteraemias?
 body site and cause, eg leg wound, CVC lines etc
 which wards are your hotspot areas?
 are there any trends with specific clinicians?
 where do you need to focus your efforts?
 what clinical practice/culture needs to change




37
Monday morning sign off (with a situational report) of all your previous week’s
bacteraemias and upload to MESS every Monday afternoon
call or meet with the SHA lead, DH MRSA programme manager, trust
implementation lead and others from your organisation as appropriate (weekly to
begin with)
three month review with members of the PCT, SHA, Department of Health and trust
to demonstrate grip and delivery
this report needs to be put on the agenda and discussed at your open trust Board
meeting
MRSA/HCAI Improvement Programme
3.2 Recovery plan


38
National Orthopaedic Pr
your recovery plan is embedded below. Can you please populate in light of
your recent learning, our visit and this report. Please then arrange for it to be
signed by your Chief Executive and your host PCT Chief Executive and send
to your programme manager, [email protected] and Sally Batley,
Deputy Head, MRSA Improvement Programme, [email protected]
use the MRSA improvement programme actions for recovery and
improvement (embedded in section 1.5) to track progress and report
performance into existing trust governance structures
MRSA/HCAI Improvement Programme
National Orthopaedic Pr
Acknowledgements
The review team would like to acknowledge
all staff within Shrewsbury & Telford NHS
trust for their time, honesty and hospitality
during the preparation and delivery of this
intensive two day review
Links:
Content Page
Section 1
Section 2
Section 3
39
MRSA/HCAI Improvement Programme
Your key message and immediate priorities
National Orthopaedic Pr
Your
key message is :
Accountable and responsible care delivery will support a reduction in
healthcare-associated infection
Immediate
implementation of the following 3 actions will start you on your
journey of reducing your MRSA bacteraemias (please see the embedded
document in section 1.5 for your further actions)
undertake
root cause analysis within 24 hours of bacteraemia identification
and complete within 5 days
develop and share performance information that is understood by all levels
of the organisation
instil a culture that reducing MRSA bacteraemias is everyone’s responsibility
40