Guideline for reporting and managing MRSA bacteraemia
Dr Judith Hooper
Infection Control Committee
NICE GUIDANCE Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgment. However, NICE guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian or carer.
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Section 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Page Introduction Associated policies and procedures Aims and objectives Scope of the guideline Accountabilities and responsibilities Root Cause Analysis investigation Equality Impact Assessment Training Needs Analysis Monitoring Compliance with this guideline References
3 3 3 4 4 4 4 5 5 6
Appendices A B C D E
Definitions Key Stakeholders consulted/involved in the development of the policy/procedure Equality Impact Assessment Tool Sign Off Sheet regarding Dissemination of Procedural Documents Procedure for reporting and managing bacteraemias
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Statement NHS Kirklees will ensure that cases of MRSA bacteraemia are thoroughly investigated, appropriate actions are taken, and lessons learned are incorporated into patient care.
Introduction NHS Kirklees has a duty of care to protect patients from harm. The Trust has in place a number of systems and controls to identify, control and manage risks to patients, staff, the public and the organisation. The following document is one of those systems which should be read and followed in conjunction with associated policies and procedures.
Associated Policies and Procedures Infection Prevention and Control Policies Risk Management Strategy Incident Reporting Policy Serious Untoward Incident Policy and Procedure Health and Safety Policies Hand Decontamination Policy Standard Universal Precautions Dress Code
Aims and Objectives Health Care Associated Infections (HCAIâ€™s) including MRSA bacteraemias and Clostridium difficile are reportable to the Strategic Health Authority and Health Protection Agency due to the impact on patient outcomes, and the need to ensure that cases are investigated, and that lessons are learnt from those investigations. NHS Kirklees is required to have in place an agreed process which ensures that all health care associated infection incidents are identified, recorded and investigated. These investigations use standard tools to identify causes, and manage actions to reduce the potential of any re-occurrence. This document sets out the process that will be undertaken in order to meet this standard. The 2007/2008 NHS Operating Framework introduced a requirement that Primary Care Trusts agree a target to reduce cases of MRSA bacteraemia and Clostridium difficile with Local Acute Trusts. These targets are monitored by local Infection Prevention and Control Teams and are discussed at Health Economy meetings.
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Scope of the Guideline This guideline must be followed by all NHS Kirklees employees, including those on temporary or honorary contracts, bank staff and students Independent contractors are responsible for the development and management of their own procedural documents and for ensuring compliance with relevant legislation and best practice guidelines. Independent contractors are encouraged to seek advice and support as required.
Accountabilities and Responsibilities The Director of Infection Prevention and Control has Board level accountability for ensuring that effective measures are in place to ensure compliance with legislation and NHS standards. The Deputy Director of Infection Prevention and Control is responsible for ensuring that the procedures are followed and reported to Kirklees Infection Control Committee. The Assistant Director of Risk, Safety and Security is responsible for ensuring that cases are fully investigated recorded and reported to the Risk Management / Governance Committees.
Root Cause Analysis Investigation Root Cause Analysis investigations will be facilitated by one of NHS Kirklees Infection Prevention and Control nurses, but may be led by staff within Kirklees Community Health Services (KCHS), if the patient acquiring the infection has received care from staff within KCHS. Detailed recording of information from all services providing care to patients will take place, then will be reviewed and analysed to identify the prime cause(s). This may include staff employed by KCHS; independent contractors, care home providers and social care providers as appropriate. An incident form will be completed by the lead investigator when information is received. Following a thorough investigation, the findings will be discussed at the Operational Coordination HCAI Group where it will be determined whether the infection was avoidable or unavoidable. Action plans will be agreed to reduce the risk of recurrence and these will be closely monitored and managed by the Infection Prevention and Control Commissioners. Appendix E identifies the process in a flow chart.
Equality Impact Assessment This guideline has been assessed and has not identified an impact.
Training Needs Analysis Training has been identified for Kirklees Community Healthcare Services. Page 4 of 11
Monitoring Compliance with this guideline NHS Kirklees will monitor compliance with this guideline using: â—? â—?
Review of RCA processes through health economy HCAI Groups. Performance indicators for KCHS.
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References Department of Health 2006, The Health Act “Code of Practice for the Prevention and Control of Health Care Associated Infections” HMSO London Healthcare Commission 2007 Healthcare associated infection: what else can the NHS do? Healthcare Commission London National Patient Safety Agency 2007 learning though action to reduce infection NPSA
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Infection prevention and control is the use of evidence based practice; training and education; policies and procedures to prevent or minimise the risk of cross infection, through a managed environment. This will minimise the risk of infection to patients, staff and visitors.
MRSA (Bacteraemia Meticillin Resistant Staphylococcus Aureus) is an organism which has developed resistance to antibiotics. This organism has then invaded the bloodstream resulting in a bacteraemia infection causing the patient to be extremely ill.
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B. Key stakeholders consulted/involved in the development of the policy / procedure Stakeholders name and designation
Key Participant Yes/No
Feedback requested Yes/No
Feedback accepted Yes/No
NHS Kirklees Infection Prevention and Control Team Assistant Director of Risk, Safety and Security Infection Control Committee (NHS Kirklees)
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C. Equality Impact Assessment Tool
Insert Name of Policy / Procedure Yes/No 1.
Does the policy/guidance affect one group less or more favourably than another on the basis of: • Race
• Ethnic origins (including gypsies and travellers)
• Religion or belief
• Sexual orientation including lesbian, gay and bisexual people
• Disability - learning disabilities, physical disability, sensory impairment and mental health problems
Is there any evidence that some groups are affected differently?
If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?
Is the impact of the policy/guidance likely to be negative?
If so can the impact be avoided?
What alternatives are there to achieving the policy/guidance without the impact?
Can we reduce the impact by taking different action?
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Appendix D Sign off Sheet regarding Dissemination of Procedural Documents Title of Document:
Guideline for reporting and managing MRSA bacteraemia
Dr Judith Hooper
17 February 2010
NHS Kirklees Infection Prevention and Control Committee
Dissemination Lead: Placed on Website: Review Date:
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APPENDIX E PROCEDURE FOR REPORTING AND MANAGING MRSA BACTERAEMIA CASES MRSA blood culture positive within 48 hours of admission are identified by the Acute Trust Microbiology Department Send incident form to Risk Management Department
RCA process facilitated by IPC Team including obtaining information and records of all primary care interventions. Joint investigation with care providers to be undertaken.
Cases of multiple admissions/outpatient episodes etc, will be jointly investigated by IPCN from NHS Kirklees and Acute Trust IPCN. Care home related cases are investigated and managed by NHS Kirklees IPCN RCA completed. Risk Management to log incident onto Trust database and report to RMOG, Governance Committee and NPSA. RMOG and ICC identify trends and patterns.
Investigation identifies lessons to be learned.
Completed RCA sent to SHA directly for CHFT patients and to NHSW for MYHT patients.
HCAI Operational Group agree if avoidable / unavoidable infection Action plan developed to address lessons learned. Progress monitored by ICC and KCHS Risk Operational Monitoring Group.
Key to abbreviations IPCN – Infection Prevention and Control Nurse RCA – Root Cause Analysis RMOG – Risk Management Overview Group NPSA – National Patient Safety Agency ICC – Infection Control Committee SHA – Strategic Health Authority NHSW – NHS Wakefield MYHT – Mid Yorkshire Hospital Trust CHFT – Calderdale Hospital Foundation Trust
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Acute Trust reports cumulative figures to SHA Board informed by Governance Committee with ICC reports / minutes