Root Cause Analysis following MRSA Bacteraemia: Reviewing the Patient s Journey Sharren Pells Senior Infection Control Nurse NHS Swindon Helen Forrest Infection Control Nurse Specialist NHS Swindon
Aims & Objectives For delegates to understand what is meant by the term MRSA bacteraemia To assist delegates in understanding what factors may increase the risk of a patient/client acquiring an MRSA bacteraemia To summarise and share the key findings of a recent root cause analysis (RCA), identifying recommendations for future practice
What is an MRSA Bacteraemia? Bacteraemia is the presence of bacteria in the blood. The detection of bacteria in the blood (by obtaining blood cultures) is always abnormal MRSA bacteraemia refers to a blood stream infection caused by the presence of meticillin resistant staphylococcus aureus
Scenario: Reported MRSA Bacteraemia Initial facts: In October 2010 the IP&C Team received notification of a reported MRSA bacteraemia Bacteraemia was reported as being pre 48 hrs Patient currently an inpatient but resides in Swindon NHS Swindon tasked with carrying out a root cause analysis (RCA)
Root Cause Analysis (RCA)? What is it? A retrospective review of a patient/client safety incident in this incidence the reporting of an MRSA bacteraemia. The root, or fundamental issues, is the earliest point at which action could have stopped the incident happening How is this achieved? Through a process of investigation and analysis to try and identify what, how and why it happened Why is this important? To identify any areas for improvement and make recommendations for future practice with the aim of preventing recurrence of any such incidents in the future
MRSA Data Gathering Tool - DH
What do we know about our patient? Initial review of notes: Flo 90 years old Widow 20 years Lived alone prior to moving to Care Home 8 months ago Dementia Poor mobility Frequent falls Type ll Diabetes Incontinent of urine Frequent UTIs
Has Flo required treatment or support from a health and/or social care setting in the past? May 2010 Admitted to hospital for treatment of UTI and assessment following fall Following assessment Flo was transferred to a Care Home July 2010 Admitted to hospital for treatment of UTI back to Care Home after 3 days Oct 2010 Admitted to hospital following fall. Bacteraemia reported within 2 days of admission
Now lets review Flo s journey in more detail
Timeline: May 2010 - Living at Home Flo lived in her own home prior to her hospital admission i History of being MRSA positive back in 2008 Diabetes monitored by GP and blood sugars occasionally high (10) GP prescribed oral antibiotics - trimethoprim - on 3 separate occasions during 2009/10 for recurrent UTI Microbiology report from January 2010 stated that MRSA present in urine: resistant to trimethoprim i Admitted to hospital due to falls and urinary incontinence due to urinary tract infection (UTI)
Timeline: May 2010 Flo s Admission to Hospital Admitted to hospital following fall at own home. Flo and family unable to cope due to progression of dementia, frequent falls and urinary incontinence Prescribed trimethoprim for urinary tract infection MRSA admission screen +ve commenced decolonisation therapy Discharged to care home with indwelling urinary catheter 4 days after admission
Time line: May 2010 Move to Care Home Catheter removed, incontinence managed with regular toileting and use of pads Dementia progresses UTI treated with antibiotics - GP prescribes trimethoprim Falls recorded
Timeline: July 2010 Flo goes back into hospital Fall at Care Home - confused and incontinent Admitted to hospital Catheter inserted in hospital for patient s convenience Discharged home after 3 days with urinary catheter in situ GP advises leaving catheter in
Timeline: September 2010 Care Home report the presence of cloudy smelly urine - dip stick shows nitrites Call to OOH service antibiotics prescribed (trimethoprim) th i Traumatic removal of catheter reported Catheter reinserted by nursing staff
Timeline: October 2010 Fall from chair: unwell, very confused, high temperature - admitted to hospital. MRSA blood stream infection confirmed
MRSA Data Gathering Tool - DH
Susceptibility for Bacteraemia Risk Factors: Flo s Medical History age (dementia) Frequent hospital admissions Resident in care home Recurrent infections (UTIs) Invasive device Antibiotic use History of falls Type ll diabetes +ve MRSA colonisation
Susceptibility for Bacteraemia Risk Factors: Flo s Management Hos CH MRSA screen carried out? N/A If positive, was decolonisation? treatment prescribed and completed? Prescribed Completed Patient awareness a risk factor? Frequent prescribing of antibiotics? Invasive device in situ? After 2nd admission Isolated? N/A
Susceptibility for Bacteraemia Risk Factors: Organisational Environment Evidence of adherence to following: Hos CH MRSA policy x Decolonisation policy x Screening policy x Cleaning and decontamination policy x Isolation policy n/a Discharge / Transfer Policy x x
Susceptibility for Bacteraemia Risk Factors: Practice Environment Evidence of best practice: Hos CH Saving lives: HII 6 / ANTT x n/a Essential steps: urinary catheter care / ANTT Hand hygiene and cleanliness li of environment Monitoring of antibiotics n/a X x x X GP/OOH
Summary of Initial Findings 1. High number of patient risk factors 2. MRSA decolonisation (suppression) treatment regime unclear. No recognition of previous MRSA positive urine sample results 3. Invasive device inserted during both hospital admissions i 4. Adherence to IP&C policy and care bundles not 100% 5. Antibiotics not monitored and no record of urine sample results being followed up. Inappropriate prescribing history of resistance to Trimethoprim 6. Communication poor across organisations
Further Considerations: 1) Patient Risk Factors: Aim to avoid catheterisation in patients with dementia if at all possible Consider other causes/management of incontinence Review falls history could be due to presence of catheter; unstable diabetes; nutritional or fluid intake; environment etc?
Further Considerations 2) Treatment for MRSA colonisation/infection: Were GP, Hospital and Care Home aware of previous MRSA history, including presence of MRSA in urine - resistant to trimethoprim? Had a recent MSU/CSU been obtained? Was prescribed decolonisation treatment completed after discharge from hospital? Were care home staff aware of the treatment regime for MRSA colonisation?
Further Considerations 3) Urinary Catheter: Why was Flo catheterised in hospital? Rationale? What is meant by Pt s convenience? Could long term catheter have been avoided? Managed previously without catheter No information on hospital discharge letter Traumatic removal in care home rationale for reinsertion? Information and support for care home staff confident to challenge decision making? Process for GP s decision making re: need for catheter?
Further Considerations 4) Adherence to IP&C policies: Why had care bundle compliance scores not been recorded within hospital setting? How do staff access advice re: MRSA policy/protocols within care homes? Is there a process for audit/care bundle participation p in care homes? Review of staff training needed?
Further Considerations 5) Antibiotic History (AB): Resistance to trimethoprim reported in MRSA positive urine sample earlier in year how are results communicated across services, followed up and acted upon? What was clinical picture for prescribing AB? Dipstick result etc, not sufficient i evidence that t UTI/CAUTI present. What about samples? Who is responsible for following up urine sample results?
Further Considerations 6) Communication: Cross organisational communication? Information on discharge letters? Inter Health Transfer forms (Essential Steps)? Access to relevant sample results? Monitoring of policies and care bundle scores? Sharing of RCA information o Ensure feedback
Action Plan Identified d Issue Action required Name Date 1) Record and Feedback RCA report Report to relevant risk/cg/ip&c committees (PCT/Acute Trust) Feedback to Care Home, GP & Hospital IP&C Nov 2) Management of MRSA colonisation Investigate how information is accessed/shared (results) Provide education for care home staff re: decolonisation treatments and MRSA management Audit information on hospital discharge letters -joint working IP&C ICLN Audit
Identified Issues Action Required Name 3) Management of invasive device: urinary catheter Set up joint working group to implement catheter care pathway Joint working with Acute Trust to improve information on discharge letters Audit: review number of patients leaving hospital with catheter t in situ Update sessions for Acute Trust, GP s and care home staff re: clinical implications of indwelling urinary catheters Mandatory training; CG seminars; primary care weekly bulletins; IP&C newsletters Continued dashboard scores for compliance to care bundles monthly monitoring i by Forums Continence lead Audit/Risk Discharge Liaison Team IP&CT Trust / PCT IP&CTs Service Leads
Identified Issue Action Required Name 4)Monitor Joint sharing of monthly dashboard scores CG adherence to between both PCT (provider services, GP s, Forums IP&C policy and care bundles 5) Antibiotic care homes) and acute Trust ICLN focus on rationale for taking urine IP&CT / prescribing sample; how to take a urine sample; ICLN history and obtaining urine samples appropriate information on microbiology request form Importance on follow up of results Monthly AB prescribing data Com Feedback to GPs/OOH re: AB prescribing and link to Wiltshire AB community guidelines Pharm lead
Identified Issue Action Required Name 6)Improved communication across organisations Continue implementation of Inter Health Transfers forms audit December 2010 Acute Trust to progress actions following audit of discharge letters Sharing of RCA information with all relevant services Continue work of catheter care pathway group Continued involvement in South West Quality and Patient Safety Improvement Programme CAUTI; pressure ulcers; Falls; VTE; Urgent admissions IP&CT CG Lead
Thank You
References Health and Social Care Act 2008, Code of Practice on the prevention and control of infections and related guidance MRSA bacteraemia data gathering tool, Department of Health (DH) Essential Steps to safe clean care, DH 2006 Saving Lives, Department of Health NHS Clean safe care website www.clean-safecare.nhs.uk Wiltshire antibiotic prescribing guidelines (enquire about your local policy/guidelines)
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NHS Swindon Infection Prevention and Control Team infectioncontrolteam@swindon-pct.nhs.uknhs