Item 13: MRSAHCAI Improvement Programme

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MRSA/HCAI Improvement Programme Gloucestershire
Hospitals NHS Foundation Trust Report
Author Improvement Programme Review
Team Version 1.00 Date Finalised 18 04 07
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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

Links
Acknowledgements
Section 1
Section 2
Section 3
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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
Links
Content Page
Acknowledgements
Section 2
Section 3
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1.1 Executive summary

• 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.

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1.2 Your key message and immediate priorities

• 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

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1.3 Data analysis

• Data in the following slides are from your
  submitted MESS data October 2005 to January 2007

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What is the direction of travel?
The challenge is significant to be where you need
to be in March 2008
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What is the scale of your challenge
Your MRSA figures are consistently above
trajectory. Recovery needs to be sustained and
the pace increased
Trajectory (T)
Actual (A)
You need to put a recovery plan in place to
ensure you are meeting your agreed monthly
trajectory
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No of MRSA cases split by Pre- and Post-48 Hours
You have 35 pre 48 hours which is more than the
national average (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
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No of MRSA cases split by Specialty
- A look at your problem areas

• Areas to target short term are
• General Medicine (including Geriatric Medicine)
• Surgery

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No of MRSA cases split by Augmented Care
Non-Augmented Care
You have 9 of cases in Augmented Care which is
less than the national average (24) You need to
achieve zero in augmented care.
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No of MRSA cases by Age Band
The breakdown of your MRSA cases by age band. You
have most cases in the 85-89 category.
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.
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A look at the 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.
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Next Steps for you

• 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
• 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
  PVCs, share the audit outcomes and learning
• Use the enhanced facilities on the MESS database
  to analyse your problem areas

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1.4 Suggested target milestones
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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
Gloucester Action Plan updated 17 04 07 This will
continue to be work in progress owned by
Gloucester Hospitals NHS Foundation Trust
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1.6 Encouraging signs

• 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/
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1.6 Encouraging signs
/continued

• 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

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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
Links
Content Page
Acknowledgements
Section 1
Section 3
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2.1 Key themes
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
Practices
Hand hygiene High impact interventions Screening
/ decolonisation Antibiotics Root cause analysis
Renal

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2.2.1 People
Leadership
Findings

• 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 IC in some areas

Recommendations
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2.2.3 People
Divisional responsibilities and ICT
Findings

• 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

Recommendations
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2.2.4 People
Roles responsibilities
Findings

• 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 IPC activity to
  improving the patient experience
• roles and responsibilities were are not always
  fully understood in relation to priority of other
  Trust targets

Recommendations
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2.3.1 Performance
Performance frameworks
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
• IPC is not a standing item on some key agendas

Recommendations
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2.3.2 Performance
Use of data
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 IPC audit it not frequent and
  focused

Recommendations
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2.3.3 Performance
Performance data
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)

Recommendations
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2.3.4 Performance
Pre-48 hour cases
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

Recommendations
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2.3.5 Performance
Audit
Findings

• 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
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2.4.1 Process
Renal
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

Recommendations
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2.5.1 Practice
Hand hygiene
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

Recommendations
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2.5.2 Practice
High impact interventions
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

Recommendations
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2.5.3 Practice
Screening/ decolonisation
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

Recommendations
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2.5.4 Practice
Antibiotics
Findings

• 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
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2.5.5 Practice
Root cause analysis
Findings

• 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

Recommendations
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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
Links
Content Page
Acknowledgements
Section 1
Section 2
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3.1 Recommended performance reporting

• 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 weeks 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

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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
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Section 1
Section 2
Section 3