Maeve Crudge Renal Virology & Infection Control

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Mervyn Franklin
7 years ago
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1 Maeve Crudge Renal Virology & Infection Control

2 Background What is Root Cause Analysis What the Renal Directorate are doing Findings

3 Leading cause of BSI and endocarditis 724 consecutive patients with BSI, 34% developed metastatic infections, 89 of which (12%) endocarditis 12-week mortality rate 22% Fowler et al 2003

4 12 year review S. aureus BSI in 304 haemodialysis patients 31% MRSA Vascular catheter source in 83% 11% complicated infection endocarditis, discitis 9.8% RIP at 30 days Fitzgerald S et al. J Hosp Infect 2011

6 Total number of S. aureus BSI Calculate the proportion of those that are MRSA Rate of MRSA BSI/1,000 bed days is a KPI which is reported quarterly from all acute hospitals to HSE

7 MRSA BSI RATE/1,000 bed days used 2013 (data to date) HSE Target Rate 0.06 ROI total Beaumont Hospital =0.073 Similar Tertiary Hospital A= Similar Tertiary Hospital B=0.084 Of all, S. aureus BSI in Beaumont from Jan 07 June 2012, renal patients accounted for 31% Jan June 2013: 8 MRSA BSI, 3 of which in haemodialysis patients (38%) 31 MSSA BSI, 8 of which in haemodialysis patients (26%)

8 0.400 Rate of S. aureus (MRSA and MSSA) Tertiary Hospitals verus Beaumont Hospital 2006 to Q Rate per 1000 Bed Days Use Beaumont Hospital MSSA rate per 1,000 bed days used Tertiary MSSA rate per 1,000 bed days used Beaumont Hospital MRSA rate per 1,000 bed days used Tertiary MRSA rate per 1,000 bed days used Beaumont Surveillance Scientist M. Skally

9 Jan 2013 began multi-disciplinary systematic surveillance of Renal S. aureus BSI s Development of a standardised surveillance form and root cause analysis (RCA) for every case Potentially preventable causes

12 16 haemodialysis patients with S. aureus BSI One BSI acquired elsewhere Sources: Permcath 75% 1 AVF 1 fem AVG 1 deep wound/osteomyelitis Risk factors: Prior microbiology results for S. aureus exit site culture, nasal carriage Association with recent placement of haemodialysis catheter Skin irritations/ sensitivities

13 1. Introducing insertion packs and checklists for temporary line insertion by Nephrology team at ward level 2. Quarterly MRSA screening (nose & exit site) 3. Patients chlorhexidine gluconate wash pre line insertion 4. CVC care bundles rolled out May/ Junestaff educated on same, audits on going

14 5. New policy to standardise management of CVC exit site infection 6. Reviewing management of skin irritations and sensitivities 7. Increasing awareness- Education sessions for MDT

15 HAEMODIALYSIS MANAGEMENT OF EXIT SITE INFECTION Infected Haemodialysis Catheter EXIT Site 1 ST LINE ACTIONS 1. Swab exit site & order SWABCULT* 2. Apply CHG** Dressing for duration of exit site infection 3. Blood Cultures FBC & CRP 4. Commence Empiric Antimicrobials. See Management of Tunnelled line Infection Guidelines eg. Vancomycin NEGATIVE: Revert to standard care of exit site unless clinically indicated POSITIVE NASAL CARRIAGE of S. Aureus or MRSA: Decolonisation treatment for 5 days as per policy for S. aureus or MRSA Two days after completion of decolonisation regimen-repeat SWABCULT of both nose & exit site Positive; Swab Nose for MRSA/ S.Aureus under order SWAB Culture*** S. Aureus Not Isolated From Nose Managed per action 2 & 4 Other Isolate Sterile Blood Culture: Review Exit site swab culture result. Consider Oral antimicrobial treatment. Positive Blood Cultures; Treat Bloodstream infection as per discussion with clinical microbiology. Also See management of Tunnelled line Infection Guidelines Repeat Blood Culture 7 days post Treatment POITIVE; CONSULT WITH MICROBIOLOGY & Infection Control Team Negative : Revert to Standard care of Exit Site **CHG Dressing; Chlorhexidine Impregnated dressing Transplant Urology Nephrology

18 Review the possibility of MSSA screening for HD patients Increased observational audits of practice Continue Enhanced Renal Surveillance

19 Thank you!

Policy for Screening Patients for MRSA Colonisation

Policy for Screening Patients for MRSA Colonisation To whom this document applies: All staff in Colchester Hospital University Foundation Trust screening Patients for MRSA Procedural Documents Approval