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Procedure for reporting and managing bacteraemia (MRSA)

Jane O’Donnell Assistant Director Infection control Prepared by:

Terry Service, Assistant Director of Risk, Safety and Security

Responsible Area: Approval Information:

Public Health Date Approved: COMMITTEE:-

Lead Director:

Dr J Hooper Version No. Approved:

Reference to Standards for Better Health Domain Core/Development standard Performance indicators

Infection Control


September 2009 Review date Department of Health 2004 Standards for Better Health First domain Safety Fourth domain Patient focused Sixth Domain HCC Hygiene Code Core Standard C4 Developmental Standard D1, D9, D11, C20

Acute Trust information on MRSA Bacteraemias

History of Document New document

CONTENTS Section No.

Page No’s 2




Associated Policies and Procedures



Aims & Objectives



Section headings



References & Bibliography



Appendices a. Consultations with individuals/groups or subcommittees’


NICE Guidance Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgement. 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.

Approval Committee: Version No: Date Approved:



Introduction/Overview In order 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 control policies • Risk Management Strategy • Incident Reporting Policy. • Serious Untoward Incident Policy and Procedure • Health and Safety Policies


Aims & Objectives Health care associated infections including MRSA Bacteraemias and C difficile are reportable to the SHA and HPA due to the impact on patient outcomes and the need to ensure that cases are investigated and controlled. The trust is required to have in place an agreed process which ensures that all health care infection incidents are identified, recorded and investigated using standard tools with actions identified and managed to reduce the potential of any reoccurrence. This document sets out the process that will be required in order to meet this standard. The DH set a target of 50% reduction in MRSA bacteraemias by 31st March 2008. In order to achieve this national reduction Mid Yorkshire NHS Trust (MYHT) have an individual target of 35 cases and Calderdale and Huddersfield Foundation Trust (CHFT) have a trajectory of 15 MRSA Bacteraemias. The targets are performance managed by a lead PCT (Wakefield for MYHT and Calderdale for CHFT). The 2007/2008 NHS Operating Framework introduced a requirement that Primary Care Trusts agree a target to reduce markedly Clostridium difficile with local Acute Trusts. The locally target agreed with CHFT is 1 case or less per 1000 bed days and MYHT 0.8 cases per 1000 bed days. The targets will be monitored by Local Infection Control Teams and reported to the Lead PCT and ultimately to the Trust Board.



Accountability 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 Assistant Director Infection Control is responsible for ensuring that the procedures are followed and reported to the Infection Control Committee. The Assistant Director of Risk is responsible for ensuring that cases are investigated, recorded and reported to the Infection control and Risk Management Committees. References & Bibliography 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 through action to reduce infection NPSA

Approval Committee: Version No: Date Approved:

Procedure for reporting and managing bacteraemias (MRSA) MRSA blood culture positive within 48hrs of admission are identified by the acute Trust Microbiology.

ICN in Acute Trust to advise ICN/HPN in Community by the next working day by fax and phone.

RCA process started by infection control team or Health Protection Team including obtaining notes and records of any primary care intervention

Cases of multiple admissions/outpatient episodes etc. to be jointly investigated by ICN from PCT and Acute Trust. Care home related cases are investigated and managed by HPA Nurses. RCA and report to be completed within 10 working days

RCA completed along with Incident Report Form and sent to Risk management, Risk management to log incident onto Trust database and report to RMOG, Governance Committee and NPSA

RMOG and ICC identify trends and patterns and update Governance committee as required through reports and minutes

RCA identifies if the reported bacteraemia is avoidable and if any lessons can be learnt

Lessons learned and agreed with clinicians to develop action plan

Completed action plan placed onto the performance accelerator including identified leads and timescales

Progress monitored by Infection Control and Governance Committee & reported through Annual report to Board

Flow chart key ICN - Infection Control Nurse HPN – Health Protection Nurse RCA – Root Cause Analysis RMOG – Risk Management Overview Group NPSA – National Patient Safety Agency ICC – Infection Control Committee SHA – Strategic Health Authority

Approval Committee: Version No: Date Approved:

Completed RCA sent to Lead PCT (Wakefield for MYHT and Calderdale for CHFT) by post/e-mail.

Lead PCT Chief Executive Signs off RCA

Lead PCT report cumulative figures to SHA,

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