Engagement Pack

1
MRSA/HCAI Performance Improvement Network Site
Presentation on Root Cause analysis case
review Oxford Radcliffe NHS Trust lily.oconnor_at_or
h.nhs.uk 01865 220853
Version 1 Date
2
Summary

• Prioritised root cause analysis for all MRSA
  bacteraemia, saving lives audits and compliance
  with hand hygiene
• Needed to understand the patients journey up to
  the point when the MRSA bacteraemia was
  identified.
• All MRSA Bacteraemia were initially investigated
  by the Implementation Lead, Infection Control
  Doctor and ward staff. Case review meetings were
  held within five working days where actions were
  agreed. Results of the investigations were
  reported to executive board and to the
  Directorates/Divisions were the cases occurred.

3
Summary

• Staff involved included the DIPC/Medical
  Director, Infection Control Doctor,
  Implementation Lead, matrons, Associate chief
  nurses, consultants and ward staff.
• The main impact is the culture so that it is not
  seen as acceptable to routinely have MRSA
  bacteraemia.
• Devolving to clinical leads, matrons,
  Directorate/Divisional managers

4
Situation before the Initiative

• Ward sisters/Matrons/consultants were unaware of
  the need to audit compliance to hand hygiene,
  MRSA bacteraemia was not seen as a problem and
  finally the difference between an MRSA
  bacteraemia and a patient with positive screening
  for MRSA.
• Initial results form hand hygiene audits varied
  from 10-50 compliance. The clinical areas who
  were carrying out the audits the longest are now
  consistently reporting 90-100 compliance.

5
Situation before the Initiative
6
Intervention or change

• MRSA Bacteraemia identified on Plate round and
  reported to the infection Control Doctor and the
  Implementation Lead.
• Matron informed by Implementation Lead, Infection
  Control Nurse informed ward sister or nurse in
  charge, Infection Control Doctor informed
  Consultant responsible for the patient.
• Microbiology reviewed patient and document in
  patients notes.
• Medical/nursing team informed the patient.

7
Intervention or change

• Root cause analysis commenced within 24hrs by
  Microbiology team
• Patient reviewed by Implementation Lead and
  Infection control Doctor
• Root cause analysis continued by matron/ward
  sister
• Any staff having to carry out a root cause
  analysis for the first time were supported by
  either the Implementation Lead /Infection control
  nurse

8
Intervention or change

• Implementation Lead informed the following within
  24hrs of the MRSA bacteraemia being identified
• Divisional Director, Divisional Chair,
  Directorate manager, Directorate chair, Associate
  chief nurse, matron, consultant (if known) along
  with chief nurse and the DIPC/Medical Director.
• Root cause analysis template completed by ward
  staff.
• E-mail sent out by Implementation Lead informing
  the multidisciplinary team explaining the nature
  of the case review meeting and that the meeting
  will be arranged by Medical Directors PA.
• Implementation Lead requested Matron/ward sister
  to have hand hygiene compliance and results of
  saving lives audits for the meeting.

9
Intervention or change

• The main areas involved were as follows
• General Medicine, Geratology, ITU and Cardio
  Thoracic.
• The patient groups were predominately end of life
  care within General Medicine and Geratology
• In Cardiothoracic they were those who remained on
  the recovery unit for more than one week
• The cases on ITU were all complex cases often
  surgical

10
Intervention or change

• Root cause analysis was the most straight forward
  of all the actions to implement
• Support from Executive board and Chief Executive
• The most difficult action was inserting Infection
  control into all job descriptions and appraisals.
• Difficulty was accepting the need for this.

11
Results

• Include evidence of improvement (eg
  implementation of recommendations, regained
  trajectory, improved compliance with a policy,
  reduction in complaints, reduced length of stay,
  achievement of recovery plan etc)
• If possible demonstrate how you know the results
  are attributed to the intervention
• Include benefits, savings, improved standards,
  improvements for patients and staff, improved
  clinical outcome measures etc
• Include levels of confidence in reductions of
  MRSA bacteraemias

12
Line related bacteraemia
13
How the improvement is being maintained

• Continuing engagement of executive board, Matrons
  and clinical staff
• Continues to be a standing item at divisional and
  directorate boards, matrons report at directorate
  and any outstanding actions are reported to
  Divisional board
• Matrons remain responsible for ensuring that
  fortnightly hand hygiene audits are carried out
• Ownership at ward level for root cause analysis,
  hand hygiene audits
• Minutes of board meetings sent to the
  Implementation Lead and infection control invited
  on outstanding issues at board meetings.

14
How the improvement is being maintained

• Risk areas ITU, Renal and General Medicine /
  Geratology
• Maintaining appropriate isolating and cohorting,
  hand hygiene audits and saving lives audits
• Training and competency framework for line
  insertion
• New line insertion pack
• Guidelines for the aftercare of lines
• Pilot in ITU/Augmented care
• Urinary catheters, rationale for insertion,
  procurement and aftercare

15
How staff and patients have been involved

• Overview and scrutiny committee
• Patient and public forum
• Hospital Infection Control Committee
• Trust Board
• PALS
• Complaints

16
Thank you for listening do you have any
questions?

• Lily O Connor
• Implementation Lead
• 01865 220853
• lily.oconnor.nhs.uk