Engagement Pack

1
MRSA/HCAI Performance Improvement Network Site
Presentation on 26th April 2007 Portsmouth
Hospitals NHS Trust Sue Harriman Consultant
Nurse Infection Control suzanne.harriman_at_porthosp.
nhs.uk
Version 1 Date 26th April 07
2
Summary

• Hand hygiene
• Focus on Hotspots
• Strengthening the performance framework
• Accountability
• Renal Patients

3
Situation before the Initiative
The History

• Portsmouth Hospitals Three hospitals with
  approximately 1100 beds. Renal speciality,
  serving a large geographical area with a large
  transient population and significant areas of
  deprivation.
• MRSA Bacteraemia bottom ten specialists Trusts
• Clostridium difficile 41 / 44 Trust Bottom ten
  2004
• DH set target of 60 reduction in MRSA
  bacteraemia
• 20 year on year from April 2005 2008
• Year one failed to reduce MRSA by 20 - 8.5?
• PHT Invited the DH Improvement Team to help us

4
Our Performance
Our Performance Vs TrajectoryActual Vs Trajectory
5
Our Hotspots
6
Intervention or change Medical Division

• RCA told us chronic colonisation, potentially
  contaminated specimens
• Search and destroy / bio-burden reduction
• Risk assessment as you arrive at the door in ED
  and MAU
• High risk Avoidance therapy TO, Gen Surg,
  Critical care,
• All patients flagged as MRSA ve via PAS
  reviewed Matrons daily to ensure ICP followed and
  decolonisation commenced.
• Use of HII league tables
• Aseptic technique for blood cultures using
  sterile gloves and Chloraprep
• Competency based training for phlebotomy and
  cannulation no assumption of competence -
  Clinical Identification Number

7
Intervention or change Performance Framework
and Accountability

• Divisional targets managed by Divisional
  Governance Teams traffic lighted poor results
  / non-compliance reported to Clinical Governance
  Committee
• Ownership of RCA by clinicians
• All MRSA SUIs and RCAs presented in person by
  clinicians to CEO
• Clinical Champions group established lively,
  highly effective
• IC in all JDs and actively addressed during
  Appraisal process

8
(No Transcript)
9
Intervention or change Performance Framework
and Accountability

• Divisional targets managed by Divisional
  Governance Teams traffic lighted poor results
  / non-compliance reported to Clinical Governance
  Committee
• Ownership of RCA by clinicians
• All MRSA SUIs and RCAs presented in person by
  clinicians to CEO
• Clinical Champions group established lively,
  highly effective
• IC in all JDs and actively addressed during
  Appraisal process

10
Intervention or change - Renal

• Wessex Renal Transplant Service
• 2.4 million population served
• 350 haemodialysis patients
• 1 main unit and 5 satellite units
• 15 line usage

11
Renal MRSA Bacteraemias 2006
12
Renal Practice Changes So Far

• Hand Hygiene education re-launch of the trust
  policy
• Individual tourniquet and tapes for patients with
  fistula
• Decolonisation policy all high-risk individuals
• prior to line insertions
• six-monthly if remain colonised
• Alcoholic Chlorhexidine
• Use of Biopatch Chlorhexidine patches for
  insertion site
• Use of Taurolidine anti-microbial lock
• Re-visited the neck line policy for commencing
  and discontinuing HD- introduction of iodine soak
  for 3 mins
• HD via catheter designated a two-person aseptic
  procedure
• Only treat symptomatic infections neck-line
  pathway developed
• Blood cultures to be taken peripherally staff
  re-educated
• Root Cause Analysis
• Still to come audit HIIs, change dialysis
  documentation, update line insertion protocols,
  doctors to adhere to Naked Below the Elbow

13
Renal MRSA Bacteraemias 2006-2007
14
Results

• MRSA
• MRSA overall reduction since trajectory set ?24
• MRSA reduction April 2005 April 2006 ?17
• Clostridium difficile
• C. diff overall reduction since Jan 2005 ?12.75
• C. diff reduction 2006 ?9.25
• Management of outbreaks of DV - Number of
  patients affected
• 2004 / 05 2278
• 2005 / 06 - 612
  ?73 on previous year
• 2006 / 07 365
  ?40 on previous year
• National Prevalence Data
• Rate of HCAI for QAH 6.5
  ?1.7 below national average
• Rate of HCAI for SMH 5.9
  ?2.3 below national average
• Rate of HCAI for RHH 0
  ?8.2 below national average

15
How the improvement is being maintained

• Clinical Champions working to ensure all
  engaged
• Still at the beginning of the journey Many
  initiatives yet to take effect
• Culture change tangible change
• Need to work with public / media poor
  reputation difficult to shake off

16
The Next Steps

• PPIF main agenda item Increasing public
  involvement
• Naked Below the Elbow
• Light boxes for all clinical areas
• Aseptic Technique, use of CIN
• More screening, rapid diagnostics
• Clutter cleanliness lean methodology 5S
  approach

17
How the organisation is learning

• Everyone is talking about it culture change
• Renal Department
• Trust number one priority
• Challenges Financial balance, working with PCT
  partners
• Good SHA and DH support and liaison
• Improving working in partnership with
  neighbouring Trusts

18
Tips for other sites

• Use your clinical champions listen to them
• This is the not the sole responsibility of the
  Infection Control Team
• Work alongside the DH they really do help
• Be brave and challenge historical practice

19
Thank you for listening do you have any
questions?

• Contact details
• Sue Harriman
• Consultant Nurse Infection Control
• 02392 286000 Ext 3270
• Suzanne.harriman_at_porthosp.nhs.uk

20
Wessex Renal Transplant Service in
collaboration with SUHT
Local features of infection Redness, pain,
induration and/or purulent exudate without
systemic features?
Swab exit site
Treat with oral Flucloxacillin2 250mg q.d.s for 5
days, inform Portsmouth3
Tunnelled catheter?
No
Yes
Yes
Purulent exudate and/or redness / induration
extending beyond cuff up tunnel?
Discuss with Portsmouth3 regarding removing line
Purulent exudate?
Yes
No
No
Discuss with Portsmouth3 regarding removing line
Review at each dialysis session. Review and
rationalise antibiotic therapy with culture
result.
No
No
Algorithm 2
Deterioration in local signs or failure to
resolve?
Development of systemic features?
Yes
Yes
21
Algorithm 2
Systemic features of infection Fever, rigors, ?
WBC /or CRP?
Investigate / treat other identified infection
Yes
Any obvious other source of infection chest,
urine, abdomen, skin (other than line site),
wound etc. etc.?
Assume catheter-related sepsis
No
Take peripheral and line blood cultures (ensuring
use of strictly aseptic technique), stating
source of culture on microbiology request form
Any positive catheter-related cultures (swab/
blood) in last 7 days?4
Yes
No
Treat infection with parenteral antibiotics as
directed by the culture and sensitivity results
Any local features of catheter infection?
Yes
No
Swab exit site
Vancomycin5 1g iv
Inform Portsmouth3 Observe for 48 hours. Review
and rationalise antibiotic therapy with culture
result. Any further temperature?
Review and rationalise antibiotic therapy with
culture result
Vancomycin5 1g iv
Yes
Discuss with Portsmouth3 regarding removing line
/ transferring patient
Review at each dialysis session. Observe for
deterioration in local signs or systemic features
No
Yes