Transcript Item 13: MRSA/HCAI Improvement Programme

MRSA/HCAI Improvement Programme
National Orthopaedic Pr
MRSA/HCAI Improvement Programme
Gloucestershire Hospitals NHS Foundation Trust
Report
Author: Improvement Programme Review Team
Version: 1.00
Date: Finalised 18 04 07
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
Section 4
4.1 Data Pack
2
Links:
Acknowledgements
Section 1
Section 2
Section 3
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
Section 4
4.1 Data Pack
3
Links:
Content Page
Acknowledgements
Section 2
Section 3
MRSA/HCAI Improvement Programme
1.1 Executive summary
National Orthopaedic Pr
Your MRSA enhanced data shows that you have remained above trajectory but are demonstrating positive signs of reducing numbers.
You have invited the Improvement Review Team to the organisation to seek their guidance and the team recognised there are many
examples of good practice and encouraging signs, and that you have recently galvanised action to achieve the required improvement.
You now need to direct focus for recovery and sustainability to aim to reach trajectory and deliver the target.






from October 06 to January 07 you have eliminated variance and continue to reduce your bacteraemias month on month
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 empowering the clinical teams to ascertain source and cause of all MRSA bacteraemias
within 24 hrs.
your data shows that 65% of your bacteraemias occur after 48 hours, of which 9% are within Augmented Care. You need to ensure
there are no avoidable MRSA bacteraemias in Augmented Care
you need to demonstrate a 50% improvement in General Medicine and Surgery in the next 3 months and continue with your focus
on Nephrology.
your data suggests that 35% of your bacteraemias occur pre-48 hour. Work with partners to understand cause, and reduce number
of pre-48 hour cases. Reduce by at least 20 % by July 07
ensure month on month improvements in all areas
The organisation as a whole needs to own the challenges to reduce healthcare associated infections. The infection control team will
undoubtedly provide guidance and focus with the Director of Nursing providing drive and motivation but the most gains will come from
ownership and impetus within the wards and divisions for reducing risks and leading improvement.
Whilst you clearly have frameworks in place, you may gain benefit from strengthening the performance framework to enable timely
feedback and monitoring of actions and interventions particularly with the results and actions following from Root Cause Analysis.
Achieving the target is not about working harder but using robust data and information to focus attention and a robust root cause
analysis process at ward level is key. Only then will you be in the position to focus attention on the “hot spots” and to continue to re focus
as you surmount each challenge.
There is a need for the sense of importance and urgency held by the Directors to be translated to all levels of the organisation and
requires a cultural shift in ownership. There is a need to ensure medical, clinical leads are nominated for all specialties, supported by the
ICT. Ensuring everyone understands their role, responsibility and accountability is also fundamental. Utilisation of the HIIs in specific and
focused areas as highlighted by the improved RCA will lead you to make progress faster.
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.
4
MRSA/HCAI Improvement Programme
1.2 Your key message and immediate priorities
National Orthopaedic Pr
Your key message is :
Focus, Feedback Follow-through
Turning knowledge into improved patient care to know what you do is working
Immediate implementation of the following 4 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)
commence
root cause analysis with verbal feedback within 24 hours of bacteraemia
identification
develop and share performance information that is understood by all levels of the
organisation
identify medical clinical leads with clearly identified roles and responsibilities
put Infection Prevention and Control as a standing item on all key agendas
5
MRSA/HCAI Improvement Programme
1.3 Data analysis
National Orthopaedic Pr
Data in the following slides are from your submitted MESS data October 2005
to January 2007
6
MRSA/HCAI Improvement Programme
What is the direction of travel?
National Orthopaedic Pr
MRSA Bacteraemias. 12 month rolling total.
The challenge is significant to be where you need to be in March 2008
90
80
70
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
What is the scale of your challenge
National Orthopaedic Pr
Your MRSA figures are consistently above trajectory. Recovery needs to be
sustained and the pace increased
Trajectory (T)
Actual (A)
10
9
8
7
6
5
4
3
2
1
0
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
Dec- 0 6
Jan - 0 7
You need to put a recovery plan in place to ensure you are meeting your
agreed monthly trajectory
8
MRSA/HCAI Improvement Programme
No of MRSA cases split by Pre- and Post-48 Hours
National Orthopaedic Pr
You have 35% pre 48 hours which is more than the national average (28%)
=<48hrs, 35%
>48hrs, 65%
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
No of MRSA cases split by Specialty
National Orthopaedic Pr
- A look at your problem areas
A&E
1%
3% 1%
4% 3% 5%
Cardiology
1%
Clin. Oncology
1%
C.C. Med
11%
Gen. Med
Gen. Sur
Geriatric Med
7%
37%
1%
Haematology
Med.Oncology
7%
Nephrology
Unknown
18%
Areas to target short
term are:
•General Medicine
(including Geriatric
Medicine)
•Surgery
10
Obstetrics
T&O
Urology
MRSA/HCAI Improvement Programme
No of MRSA cases split by Augmented Care & NonAugmented Care
National Orthopaedic Pr
9%
Augmented Care
No Augmented Care
91%
You have 9% of cases in Augmented Care which is less than the national average (24%)
You need to achieve zero in augmented care.
11
MRSA/HCAI Improvement Programme
No of MRSA cases by Age Band
National Orthopaedic Pr
The breakdown of your MRSA cases by age band. You have most cases in the 85-89
category.
18
16
14
12
10
8
6
4
2
0
25 29
30 34
35 39
40 44
45 49
50 54
55 59
60 64
65 69
70 74
75 79
80 84
85 89
90 94
95+
Suggestion – look at your age profile in conjunction with your actual admissions in those
age bands. You may find as a proportion of bacteraemias to attendances you have an
issue.
12
MRSA/HCAI Improvement Programme
A look at the time between bacteraemias
National Orthopaedic Pr
Time in days between MRSA bacteraemias - Gloucestershire Hospitals NHS Foundation Trust
Gloucestershire Hospitals NHS Foundation Trust
30
25
20
15
10
01/01/07
01/12/06
01/11/06
01/10/06
01/09/06
01/08/06
01/07/06
01/06/06
01/05/06
01/04/06
01/03/06
01/02/06
01/01/06
01/12/05
0
01/11/05
5
01/10/05
Days since last bacteraemia detected
35
Date of sample
Mean
Lower limit
Upper limit
Time between bacteraemias
The longer the gap between MRSA Bacteraemias (over the upper limit) the
more confidence you can have regarding practice around avoidable infections.
13
MRSA/HCAI Improvement Programme
Next Steps for you

National Orthopaedic Pr
Root Cause analysis
empowering the clinical teams to ascertain source and cause of all
MRSA bacteraemias within 24 hrs. Where are the sources of your
bacteraemias
• body site and cause (e.g. leg wound, PVC lines etc)
• which wards are your hotspot areas
• are there any workforce issues or trends


14
Where do you need to focus your efforts
Implement High Impact Interventions with clinical staff within your “hot
spot” areas and commence fortnightly audit of them, with weekly audit of
PVC’s, share the audit outcomes and learning
Use the enhanced facilities on the MESS database to analyse your
problem areas
MRSA/HCAI Improvement Programme
1.4 Suggested target milestones
National Orthopaedic Pr
Actions
Milestones
A robust recovery plan is required immediately to prioritise and focus activity to
deliver agreed monthly trajectory
To get on trajectory and sustain improvement
Immediately
carry out root cause analysis empowering the clinical teams to
ascertain source and cause of all MRSA bacteraemias within 24 hrs.
Revise
Feed
RCA process to include action points and learning
back collated information from RCA and HII audit to clinical teams
You can make significant improvement in MRSA bacteraemia by at least 50%
in General Medicine, Nephrology, Geriatric Medicine and General Surgery by
end of July 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.
Avoidable MRSA bacteraemia in Augmented Care should have been zero by
December 06 in line with national target
15
Continue to reduce MRSA bacteraemias in General
Medicine, Geriatric Medicine and Renal to achieve your
monthly run rate or less
Reduce the number of < 48hr bactereamias in line with the
improvement for >48hr bacteraemias
Ensure you have zero avoidable cases in Augmented
Care continuing monthly
MRSA/HCAI Improvement Programme
1.5 Actions for recovery and improvement

The attached planning and action matrix will be started by your programme
manager around the Improvement Team findings and quick areas to target

You have agreed a date to jointly expand this as appropriate These are
based on our key findings during our 2 day review. You may wish to further
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
16
National Orthopaedic Pr
Gloucester Action Plan updated 17 04 07
This will continue to be work in progress owned by
Gloucester Hospitals NHS Foundation Trust
MRSA/HCAI Improvement Programme
1.6 Encouraging signs
National Orthopaedic Pr

there is strong top executive engagement and clear corporate responsibility for infection
control with key appointments made to drive forward this agenda

the trust has set a challenging target of a reduction of 40% for C Diff

there is a clear organisational message to not let process impede progress

the Governors and Non Executive Director/Chair appear well informed and placed to
challenge

the organisation has a strong focus on patient safety and improving the patient experience

cohort wards have been established the team acknowledged the trust has acted quickly
and effectively

the Medical Director demonstrated how he reiterates to frontline staff the relationship
between patient experience and organisational systems (or failure of) by using a real
patient story

there is a very dedicated infection control team, members of which are valued and
respected across the Trust.
continued/…
17
MRSA/HCAI Improvement Programme
1.6 Encouraging signs
18
…/continued
National Orthopaedic Pr

there is a Deep Clean Programme in place

the review team found ward Managers had a positive attitude to driving the Quality
agenda

there were some shining examples of good clinical practice in some areas with some
excellent clinical champions and good medical leadership

there is evidence of some surveillance and early root cause analysis being undertaken
across the Trust despite the challenges. Reporting and monitoring of MRSA incidence is
improving
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
Content Page
Acknowledgements
Section 1
Section 3
Section 4
4.1 Data Pack
19
Links:
MRSA/HCAI Improvement Programme
2.1 Key themes
National Orthopaedic Pr
Performance
People
Performance frameworks
Use of data
Performance data
Audit
Pre-48 hour cases
Leadership
Divisional responsibilities
and ICT
Roles and responsibilities
MRSA
bacteraemia
reduction
Processes
Renal
20
Practices
Hand hygiene
High impact interventions
Screening / decolonisation
Antibiotics
Root cause analysis
MRSA/HCAI Improvement Programme
Findings
2.2.1 People
 there is clear and effective leadership at executive level within the organisation in
relation to infection control but the review team was not convinced that the sense of
urgency and importance and ownership is embedded at all levels of the organisation
 there is a belief that that audit is onerous and does not relate to improving care, in
pockets of the organisation
 there are no medical clinical leads for infection control, although the review team
recognized clinical champions for I&C in some areas
National Orthopaedic Pr
Leadership
Recommendations
Ensure MRSA target delivery is of equal importance to other key targets and translated to divisions, teams and
individuals 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
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
21
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 lead nurses and link nurses however the ICT is attempting
to drive this largely on its own
National Orthopaedic Pr
Divisional
responsibilities
and ICT
Recommendations
The focus of activity must be based around divisions, with the ICT enabling rather than undertaking the bulk of activity.
Clinical leads within each 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. Clear responsibilities and accountabilities must be underpinned
with focused objectives for all members of the directorate including clinical directors, lead nurses and link nurses
22
MRSA/HCAI Improvement Programme
Findings
2.2.4 People
 whilst there is evidence of infection control responsibilities within many 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
 ward staff did not openly relate IP&C activity to improving the patient experience
 roles and responsibilities were are not always fully understood in relation to priority of
other Trust targets
National Orthopaedic Pr
Roles &
responsibilities
Recommendations
Following a series of new appointments, staff changes and changing priorities and workload, re consider the role
of the DIPC and review in light of ’Winning ways: Action Area 6’
Ensure that consultants are aware of their accountability/responsibility for the IC 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, ICT and lead nurses to ensure
understanding of individual and shared responsibilities and performance manage through regular 1:1s
Implement High Impact Interventions to change behavior and to measure improvement
23
MRSA/HCAI Improvement Programme
2.3.1 Performance
Findings
 MRSA bacteraemia data is embedded in the board performance reporting arrangements.
However, the review team was not convinced that targets are set to a specific tolerance
for each division to deliver against and are own/embedded within core business
 all clinicians/multidisciplinary teams do not currently have a meaningful forum or
mechanism to individually review relevant data in a safe environment
 the ICC is viewed as not being proactive with little input from the many representatives
 IP&C is not a standing item on some key agendas
National Orthopaedic Pr
Performance
frameworks
Recommendations
Set divisional tolerance levels and display recent data at ward level to ensure all members of the team are aware
of baseline and their personal responsibility
Divisions to be held accountable through performance frameworks for their performance against the MRSA
bacteraemia reduction target
Each MRSA bacteraemia over and above the monthly trajectory should be treated as a breach and performance
managed
Review the current meeting structure and expedite plans to merge the Infection Control Committee and the
Saving Lives Group review membership to include key clinicians and terms of reference, incorporate specific
action points with named individuals as an output from each meeting.
24
MRSA/HCAI Improvement Programme
2.3.2 Performance
National Orthopaedic Pr
Findings
 reporting back of root cause analysis findings is neither robust nor timely. However the
Medical Director has piloted a case study format with some inclusion of the patient
journey timeline.
 RCA does not yet enable comprehensive identification of themes, trends and sources.
Follow up action is not always identified nor monitored
 High Impact Interventions are not implemented or audited by the “hot spot” wards and
so there is no feedback loop on improvement in practice
 the plan for IP&C audit it not frequent and focused
Use of data
Recommendations
Review the current RCA 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, etc. Ensure timely reporting of RCA findings and appropriate
feedback, across the health economy where appropriate. Performance manage and monitor and ensure
interventions are targeted
Implement appropriate HII’s in ‘hot spot’ areas with weekly audit undertaken by Link Nurses. Use the Compact
Disk from Saving Lives to ensure this is done easily and quickly. Produce and circulate data to monitor
improvement in practice
25
MRSA/HCAI Improvement Programme
2.3.3 Performance
National Orthopaedic Pr
Findings
 your data shows that 65% of bacteraemias occur after 2 days
 hotspot areas are General Medicine including geriatrics(37%), Nephrology (18%), and
General Surgery (18%)
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 key/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/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 IC activities in respect of providing
information for surveillance/monitoring.
Use rigorous methods to identify which areas in General Medicine and Geriatrics and General Surgery require focus
in addition to the attention that renal services are already 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 sit reps and share across the organisation for early use in
learning and performance management
26
MRSA/HCAI Improvement Programme
2.3.4 Performance
Findings
 35% of bacteraemias were diagnosed within 48 hours of admission, this is above the
national average (28%)
 there are fortnightly IC steering group meetings attend by the PCT
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 RCA tool to identify the source and any contributing factors
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 preventing colonisation
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
Escalate and increase the pace of action as a result of the work with the health economy partners at the
fortnightly meetings to reduce the pre-48 hour cases
27
MRSA/HCAI Improvement Programme
2.3.5 Performance
Findings
National Orthopaedic Pr
Audit
 whilst the review team was informed of some audits that had been conducted, managed
by the IC Steering Group, there were numerous ward staff who were unaware of the
audit and of the results
 there did not appear to be a mechanism for sharing learning from the audits within/across
specialties nor with future induction/education and training, personal development plans
and performance monitoring frameworks
Recommendations
Use the RCA and hot spot areas to focus work for HIIs and audit
Feed the results of audit into directorate performance management to ensure actions are monitored and owned
Establish a mechanism for sharing/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
28
MRSA/HCAI Improvement Programme
2.4.1 Process
Findings




a care bundle approach to care is adopted in renal but audit is reactive and sporadic
HII 2c has just been introduced
there is thirst to embrace improvement in the unit and many good ideas
there is currently no screening in Renal Dialysis patients on admission
National Orthopaedic Pr
Renal
Recommendations
Implement screening policy see recommendation 2.5.3
Introduce other appropriate HII’s and audit compliance, weekly at first until improvement is achieved and sustained
Process map the renal patient pathway and refine the steps in the journey.
29
MRSA/HCAI Improvement Programme
2.5.1 Practice
Findings
 infrequent audits of hand hygiene have shown a variable rate of compliance across the
organization
 the perception amongst clinical staff is that medical staff were the least compliant. This
was confirmed in the small amount of audit data available which showed compliance as
low as 10%
 aseptic non-touch technique practice standards are not fully met
National Orthopaedic Pr
Hand hygiene
Recommendations
Restate the message to all staff that improved compliance with hand hygiene is a priority for the Trust and work
towards 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 HII 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 lead nurses, 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 RCA
as the main areas of focus
Continue with the recent focus on hand hygiene and re launch the ‘Clean Your Hands campaign’ use the
opportunity of appointing medical clinical champions to re enforce the message
30
MRSA/HCAI Improvement Programme
2.5.2 Practice
Findings
 whilst a start has been made, the review team found many staff that were not as aware of
the High Impact Interventions as expected.
 the HIIs are not owned widely across the Trust and are not always being implemented in
response to the RCA, and could therefore be more focused
 the review team found evidence that the Trust guidelines for peripheral and central lines
and urinary catheters were not always followed
 documentation was often lacking, especially in the areas of line insertion and
management
 a recent focus on cannulae care has shown improvement with removal if not used within
24hrs
National Orthopaedic Pr
High impact
interventions
Recommendations
Undertake robust root cause analysis and prioritise the implementation of the HIIs for relevant areas accordingly
Ensure the utilisation of the HIIs are owned by the directorates, with clear responsibility and
accountability and linked to governance and performance. Ensure the Trust guidelines are implemented
for the insertion and management of CVCs. Audit documentation and performance manage
Observational audit at point of insertion to become everyday practice. Speed up the implementation of VIP scoring,
audit HII 2b weekly and focus on ‘hot spot’ areas first
31
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
a revised screening policy is awaiting sign off
screening in renal dialysis is not yet in line with national policy
there is a clear organisational message to not let process impede progress
National Orthopaedic Pr
Screening/
decolonisation
Recommendations
Use national evidence and the 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/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)
Implement revised screening policy as a pilot and audit compliance, sign off can come later supported by evidence
of effectiveness
Ensure the policies are interpreted and adhered to appropriately and audit compliance. Performance
manage and feed back to divisions/departments
32
MRSA/HCAI Improvement Programme
2.5.4 Practice
Findings
National Orthopaedic Pr
Antibiotics
 The antimicrobial pharmacist and medical microbiologist do not have a visible profile on
the medical and renal wards but are approachable and get involved when required
Recommendations
Formalise contact of antimicrobial pharmacist and medical microbiologist within renal and general medicine to
promote policy compliance and best practice in these hot spot areas
33
MRSA/HCAI Improvement Programme
Findings
National Orthopaedic Pr
2.5.5 Practice
 root cause analysis is currently undertaken but is not as timely or 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
 RCA is undertaken by named individuals who are not from the clinical team. RCA is
presented to clinical teams with no clear time frame for input or completion.
 appropriate and timely action is not always taken as a result of the analysis of each
MRSA bacteraemia
Root cause
analysis
Recommendations
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
Review the current RCA approach used and develop a more robust approach. 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, etc. Commence RCA within 24
hours of confirmation of an MRSA bacteraemia.
Once a more robust approach has been developed, assign responsibility for undertaking RCA to an individual
within the relevant clinical team 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
34
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
Section 4
4.1 Data Pack
35
Links:
Content Page
Acknowledgements
Section 1
Section 2
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?
 Monday morning sign off (with sit rep) of all your previous week’s bacteraemias and
upload to MESS every Monday afternoon
 call or meet with the SHA, MRSA programme manager, 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 tabled at your open Trust Board meeting
36
MRSA/HCAI Improvement Programme
National Orthopaedic Pr
Acknowledgements
The review team would like to acknowledge
all staff within Gloucestershire Hospitals NHS
Foundation Trust for their time, honesty and
hospitality during this intensive two day
review and its preparation
Links:
Content Page
Section 1
Section 2
Section 3
37