Infection Control at West Middlesex University Hospital Update for the Adult Health & Social Care Scrutiny Panel 2 nd April 2007 Dr May Kyi – Director of Infection Prevention & Control Yvonne Franks – Director of Nursing & Midwifery
Presentation outline • MRSA – definitions • Targets & results • MRSA performance 2006/7 & actions • Clostridium Difficile – definition • Results & actions • Hand hygiene • Training & development
What is MRSA? • MRSA stands for Methicillin resistant Staphylococcus aureus . Staphylococcus aureus ( Staph. aureus) is a common bacteria that is carried in lots of people’s noses and skin. • MRSA is a type of Staph. aureus that has become resistant to many types of antibiotics such as methicillin. • Around 25% of the UK population harmlessly and unknowingly carry Staph. aureus on their skin. This is called colonisation, and is very different from being infected with MRSA.
Colonisation v. infection Colonisation means that I nfection with MRSA can • • the MRSA is carried in the occur when the MRSA gets nose, on the skin and into the body through a possibly in wounds but is break in the skin. not causing harm or producing symptoms. • There is no evidence that MRSA is more likely to cause • Staph. aureus and MRSA an infection than common are not normally a risk to bacteria, Staphylococcus healthy people. aureus . The main difference is that when a patient is infected with MRSA different antibiotics are required
The MRSA target • Dept of Health set a target of 60% reduction in MRSA bacteraemia (MRSA in the bloodstream) by all acute Trusts, between 2004 and 2008 • For WMUH this required a reduction from 34 cases to 14 cases per year in 2008 • Year on year reduction was achieved in the last three years from 34 to 30 to 27 cases in 2005/06 • 2006/07 has seen an increase
Total MRSA bacteraemia Total 41 45 40 34 35 30 27 30 numbers 25 20 15 10 5 0 2002-03 2003-04 2004-05 2005-06
WMUH MRSA bacteraemia rate per 10,000 bed days (as published on HPA website) rate 3.5 3 2.97 2.57 2.5 2.35 2.12 2 1.5 1 0.5 0 2002-03 2003-04 2004-05 2005-06
MRSA bacteraemia by location of blood culture taken Inpatients A&E 35 31 30 24 25 20 20 numbers 16 15 11 10 10 8 10 5 0 2002-03 2003-04 2004-05 2005-06
MRSA Bacteraemia 2006/7 • A target was set for each financial year – 19 for 2006/07 • From April to September 2006 - 19 MRSA bacteraemia cases were identified • Full investigation – root cause analysis • We sought advice from Prof Duerden at Dept of Health
MRSA bacteraemia comparison by quarter 12 10 8 2003 2004 numbers 6 2005 2006 4 2 0 Jan-Mar Apr-Jun Jul-Sep Oct-Dec
MRSA bacteraemia by location of blood culture taken Inpatients A&E 35 31 30 25 24 25 20 20 number 16 15 11 10 10 10 8 6 5 0 2002-03 2003-04 2004-05 2005-06 Apr06-Jan07
MRSA in blood cultures - monthly data with target for the month Number Target 8 7 7 6 5 numbers 4 4 4 4 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 2 1 1 1 1 0 Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- 05 05 05 05 05 05 05 05 05 06 06 06 06 06 06 06 06 06 06 06 06 07
Results of root cause analysis 19 cases investigated; • 5/19 (26%) were taken within 48 hours of admission – (4 in A&E) • 10/19 (53%) required antibiotic treatment • 7/19 (37%) had IV lines - 2 central lines • 7/19 (37%) were from care of the elderly wards • 6/19 (32%) – previous known MRSA positives
Only 53% needed treatment 10/ 19 needed antibiotics 9/ 19 did not need antibiotics (contaminated samples) • 9/10 were taken within 21 days of admission and 3 • 3/9 with previous known were within 48 hours MRSA, 2 taken on admission, one within 7 days • 5/10 had intravenous lines, 4 had related sepsis • 6/9 were taken between 22 to > 100 days • All cases have associated risk factors such as IV lines, • 4/9 had multiple organisms in pacemaker, chest drain, leg the blood culture ulcers, previous hospital • 6/9 had previous hospital attendances, long LOS, admissions; 2 had IV lines and nursing or residential home one with known MRSA positive resident chronic leg ulcer
Lessons learnt • Nearly half 9/19 (47% ) were considered to be contaminated blood cultures • Contamination could either be from the patients’ skin flora or poor technique • IV lines are the biggest risk factor • A third of cases from the care of the elderly wards • Contamination is highly associated with increased length of stay
Key actions • Vacutainer blood culture collection system • Feedback at all Q&R meetings and also introduction with training of medical staff to senior medical and nursing staff • Audit, feedback & enhanced training on • Give MRSA decolonisation treatment to line care and management high risk trauma patients • Set up a line team – revise procedures – • Work collaboratively with Integrated standardise practice. Assessment Rehabilitation Discharge Service (IARDS) team and PCTs to reduce the length of stay • Weekly line inspections by the Infection Control Team with immediate flagging of notes with reminder stickers • Inform and seek further advice from the Strategic Health Authority, Healthcare Commission and the DH • Continuing emphasis on good infection control practice, particularly hand hygiene - monitoring and feedback • Monitor and performance manage staff adherence to dress codes
What is Clostridium difficile? • Clostridium difficile is a bacteria that produces toxins (poisons). • Usually found in the gut where it is present in small numbers in 3% of healthy adults and 66% of infants • Clostridium difficile rarely causes problems in children or healthy adults, as it is kept in check by the normal (good) bacterial population of the gut • When certain antibiotics disturb the balance of bacteria in the gut, Clostridium difficile can multiply rapidly and produce toxins which cause illness such as diarrhoea • Local target for 2007/8 agreed between Trust and PCT to reduce by 10%
WMUH number of C difficile reports for over 65 years as published on Health Protection Agency website C difficile reports for over 65 years 80 75 70 61 60 50 40 35 33 30 20 10 0 January to March 2006 April to June 2006 July to September 2006 October to December 2006
Control measures for Clostridium difficile infection • Prudent antimicrobial prescribing • Isolation of infected patients • Enhanced environmental cleaning • Hand hygiene • Personal protective equipment • Staff education and training
Hand hygiene Compliance Compliance % 100 Cleanyour- Move hands 92 into new campaign 90 hospital 85 83 83 Mandatory 82 80 80 annual IC 77 77 75 training 72 72 70 started 67 66 percentage 60 60 Link nurse 57 system introduced 50 50 40 39 30 20 20 19 Became Second Senior Second Full integrated ICN left microbiologist complement ICN 10 IC team Trust appointed of staff appointed 0 1 2 2 2 3 3 3 4 4 4 4 5 5 5 5 6 6 6 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 4 1 2 3 1 2 4 1 2 3 4 1 2 3 4 1 2 3 4 Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q
Hand hygiene charts hands decontaminated % full compliance 100 90 80 70 percentage 60 50 40 30 20 10 0 2nd / 3rd / 4th / 1st / 2nd / 3rd / 4th / 1st / 2nd / 3rd / 4th / 2004 2004 2004 2005 2005 2005 2005 2006 2006 2006 2006
I nfection control training attendances March 2006 to February 2007 • Total for I nduction = 227 Total for Mandatory training = 723 (appraisal compliance – all • clinical staff) • The figures below do not include; - M&S Training attendances - Junior medical staff training at induction for August and February intakes - Ecovert staff training. Consultants Junior Nurses, Radiology Pharmacy Non-clinical Medical/ Others Hounslow doctors Midwives & Nursing PCT HCA students Induction 1 4 74 5 10 9 79 19 24 Mandatory 57 45 379 37 15 19 62 21 88
We need your help! Patients, public & staff • Health Act 2006 – devolving responsibility to front line staff • Infection control team role • Vigilance – EVERYONE • Continual training • Challenging practice • Patient information centre • Trust website http:www.west-middlesex-hospital.nhs.uk/for-patients/general- information/control-of-infection/healthcare-associated-infections/
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