Reducing MRSA Reducing MRSA Reducing MRSA Reducing MRSA Reducing MRSA Reducing MRSA Reducing MRSA Reducing MRSA • • HCAIs HCAIs are a disgrace are a disgrace • • Does your CE know about Does your CE know about HCAIs HCAIs as quickly as 4 hour wait or as quickly as 4 hour wait or waiting list breaches? waiting list breaches?
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Reducing MRSA - MRSA Action UKmrsaactionuk.net/Reducing MRSA 14th November 07/Louise Teare.pdf · Fishbone MRSA Bacteraemia Patient factors Team and Social factors Organisation and
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•• Does your CE know about Does your CE know about HCAIsHCAIs
as quickly as 4 hour wait or as quickly as 4 hour wait or
waiting list breaches?waiting list breaches?
How can a Trust succeed in How can a Trust succeed in
financial turnaround if financial turnaround if
patients are languishing on patients are languishing on
the wards with HCAIthe wards with HCAI
Trusts are required to have Trusts are required to have Trusts are required to have Trusts are required to have Trusts are required to have Trusts are required to have Trusts are required to have Trusts are required to have
•• Close contact with horsesClose contact with horses
Risk AssessmentRisk Assessment
Control ProcessControl Process
Control Control Control Control Control Control Control Control ProcesssProcesssProcesssProcesssProcesssProcesssProcesssProcesss
Directive Directive Directive Directive Directive Directive Directive Directive -------- telling people what they telling people what they telling people what they telling people what they telling people what they telling people what they telling people what they telling people what they
are to achieveare to achieveare to achieveare to achieveare to achieveare to achieveare to achieveare to achieve
Detective Detective Detective Detective Detective Detective Detective Detective -------- Alerting of unwanted actionsAlerting of unwanted actionsAlerting of unwanted actionsAlerting of unwanted actionsAlerting of unwanted actionsAlerting of unwanted actionsAlerting of unwanted actionsAlerting of unwanted actions
Risk AssessmentRisk Assessment
Control Process = Control Process =
Screening and DecolonisationScreening and Decolonisation
Infection Control IncidentsInfection Control Incidents
•• Failure to communicate infection control riskFailure to communicate infection control risk
•• Failure to comply with IVI device policyFailure to comply with IVI device policy
•• Failure to isolate patients with infectionFailure to isolate patients with infection
•• Failure to comply with Hand Hygiene PolicyFailure to comply with Hand Hygiene Policy
•• ‘‘AttireAttire’’/clothing not fit for purpose/clothing not fit for purpose
•• Failure to communicate presence of HCAI to patientFailure to communicate presence of HCAI to patient
•• Decontamination failureDecontamination failure
•• Failure to comply with MRSA PathwayFailure to comply with MRSA Pathway
•• Failure to comply with cleaning policyFailure to comply with cleaning policy
•• Failure to comply with Antibiotic PolicyFailure to comply with Antibiotic Policy
•• Delay in laboratory reports of resultsDelay in laboratory reports of results
•• Failure to comply with primary/secondary care transfer arrangemeFailure to comply with primary/secondary care transfer arrangementsnts
A defined reporting process with use of standardised definitions
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There should be an analysis of patterns and trends across all reported incidents
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An investigation method appropriate to level of investigation required, e.g. root cause analysis
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Changes should be made to improve practice as a result of above
Root cause analysisRoot cause analysisRoot cause analysisRoot cause analysisRoot cause analysisRoot cause analysisRoot cause analysisRoot cause analysis
•• Root cause analysis (RCA) is a Root cause analysis (RCA) is a
structured approach to incident structured approach to incident
investigationinvestigation
•• Involves the whole organisationInvolves the whole organisation
Establishing the IssuesEstablishing the IssuesEstablishing the IssuesEstablishing the IssuesEstablishing the IssuesEstablishing the IssuesEstablishing the IssuesEstablishing the Issues
•• CareCare--service timelineservice timeline
•• Fishbone Fishbone –– talk to all involvedtalk to all involved
The NPSA fishbone model explores eight The NPSA fishbone model explores eight The NPSA fishbone model explores eight The NPSA fishbone model explores eight The NPSA fishbone model explores eight The NPSA fishbone model explores eight The NPSA fishbone model explores eight The NPSA fishbone model explores eight
domains as shown belowdomains as shown belowdomains as shown belowdomains as shown belowdomains as shown belowdomains as shown belowdomains as shown belowdomains as shown below
•• Domain 1: Domain 1: Patient factors Patient factors Patient factors Patient factors Patient factors Patient factors Patient factors Patient factors –––––––– Very unwell with poor Very unwell with poor hygiene hygiene
•• Domain 2: Domain 2: Working Conditions Working Conditions Working Conditions Working Conditions Working Conditions Working Conditions Working Conditions Working Conditions -------- Rapid turnover of Rapid turnover of patients, staff shortages, ?? taking short cuts such as patients, staff shortages, ?? taking short cuts such as failing to comply with Trust hand hygiene policyfailing to comply with Trust hand hygiene policy
•• Domain 3: Domain 3: Task factorsTask factorsTask factorsTask factorsTask factorsTask factorsTask factorsTask factors-------- aaudit results shows hand udit results shows hand hygiene at 54.5 % compliancehygiene at 54.5 % compliance
•• Domain 4: Domain 4: Communication factorsCommunication factorsCommunication factorsCommunication factorsCommunication factorsCommunication factorsCommunication factorsCommunication factors-------- A and E failed to A and E failed to communicate the presence of an intravenous devicecommunicate the presence of an intravenous device
..
•• Domain 5:Domain 5: Team and social factorsTeam and social factorsTeam and social factorsTeam and social factorsTeam and social factorsTeam and social factorsTeam and social factorsTeam and social factors-------- role models, role models, standard settingstandard setting
•• Domain 6:Domain 6: Education and training factorsEducation and training factorsEducation and training factorsEducation and training factorsEducation and training factorsEducation and training factorsEducation and training factorsEducation and training factors-------- supervision, supervision, availability (availability (egeg Hand Hygiene, ANTT)Hand Hygiene, ANTT)
•• Domain 7:Domain 7: Equipment and resources factorsEquipment and resources factorsEquipment and resources factorsEquipment and resources factorsEquipment and resources factorsEquipment and resources factorsEquipment and resources factorsEquipment and resources factors-------- egegegegegegegeg. . . . . . . . disposable tourniquets, alcohol wipes for stethoscopesdisposable tourniquets, alcohol wipes for stethoscopes
•• Domain 8:Domain 8: Organisational and Management Organisational and Management Organisational and Management Organisational and Management Organisational and Management Organisational and Management Organisational and Management Organisational and Management –––––––– Clarity of Clarity of standards standards
IssuesIssues
•• Inadequate Hand HygieneInadequate Hand HygieneInadequate Hand HygieneInadequate Hand HygieneInadequate Hand HygieneInadequate Hand HygieneInadequate Hand HygieneInadequate Hand Hygiene -------- Audit results show 42% Audit results show 42% Audit results show 42% Audit results show 42% Audit results show 42% Audit results show 42% Audit results show 42% Audit results show 42%
compliance with hand hygiene, allowing MRSA to compliance with hand hygiene, allowing MRSA to compliance with hand hygiene, allowing MRSA to compliance with hand hygiene, allowing MRSA to compliance with hand hygiene, allowing MRSA to compliance with hand hygiene, allowing MRSA to compliance with hand hygiene, allowing MRSA to compliance with hand hygiene, allowing MRSA to
potentially spread from other patientspotentially spread from other patientspotentially spread from other patientspotentially spread from other patientspotentially spread from other patientspotentially spread from other patientspotentially spread from other patientspotentially spread from other patients
•• No evidence that the patientNo evidence that the patient’’s bed and bed space was s bed and bed space was
adequately cleaned between the last patientadequately cleaned between the last patient
•• Failure to adequately decontaminate all items of Failure to adequately decontaminate all items of Failure to adequately decontaminate all items of Failure to adequately decontaminate all items of Failure to adequately decontaminate all items of Failure to adequately decontaminate all items of Failure to adequately decontaminate all items of Failure to adequately decontaminate all items of
equipment between patients such as blood pressure equipment between patients such as blood pressure equipment between patients such as blood pressure equipment between patients such as blood pressure equipment between patients such as blood pressure equipment between patients such as blood pressure equipment between patients such as blood pressure equipment between patients such as blood pressure
cuffs, tourniquets and stethoscopescuffs, tourniquets and stethoscopescuffs, tourniquets and stethoscopescuffs, tourniquets and stethoscopescuffs, tourniquets and stethoscopescuffs, tourniquets and stethoscopescuffs, tourniquets and stethoscopescuffs, tourniquets and stethoscopes
Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan
Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan
Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan Root Cause Analysis Action Plan
immediatelyimmediatelyWard Ward
Sister and Sister and
MatronMatron
Introduce Introduce
disposable disposable
tourniquets tourniquets
Apply Apply
alcohol to alcohol to
stethoscope stethoscope
between between
each use,each use,
Ensure Ensure
phlebotomy phlebotomy
staff are staff are
properly properly
decontamindecontamin
ating their ating their
hands and hands and
tourniquets tourniquets
between between
patientspatients
Failure to Failure to Failure to Failure to Failure to Failure to Failure to Failure to
Summary of main learning points from MRSA RCA Summary of main learning points from MRSA RCA
•• Continuing skin care for all MRSA positive patients across both Continuing skin care for all MRSA positive patients across both primary and primary and
secondary caresecondary care
•• Optimal device management of patients colonised with MRSAOptimal device management of patients colonised with MRSA
•• Zero tolerance for failure to adequately decontaminate hands betZero tolerance for failure to adequately decontaminate hands between ween
patientspatients
•• Zero tolerance for failure to decontaminate all items of equipmeZero tolerance for failure to decontaminate all items of equipment between nt between
patients (patients (incudingincuding stethosopesstethosopes, , tourniqutstourniquts, beds and operating tables), beds and operating tables)
•• Zero tolerance for failure to adequately decontaminate the patieZero tolerance for failure to adequately decontaminate the patient nt
environment between patients (bed spaces and theatre environmentenvironment between patients (bed spaces and theatre environment))