Engagement Pack

1
MRSA/HCAI Performance Improvement Network The
Dudley Group of Hospitals NHS Trust Angela Murray
CNS Infection Control angela.murray_at_dgoh.nhs.uk

26th April 2007
2
Situation before the Initiative
To regain monthly trajectory, we could not have
more than two bacteraemias each for the months of
October and November and, subsequently, one
bacteraemia each month to end of March 2007.
3
People

• Clinical Staff accountability
• Awareness raising sessions
• 60 sessions Nov Dec 2006
• 55 medical staff attendance
• 70 nursing staff
• 80 AHP and HCS
• Delivered by the CEO, MD and DIPC
• Leaflet attached to payslips regarding hand
  hygiene responsibilities
• Job descriptions Matrons and Medical Service
  Heads amended to include
• Infection prevention and control

4
People

• Champions roles
• Medical champions all clinical units
• Nursing champions all clinical units
  (previously link nurses)
• AHP champions all major professional
  groups
• Champions given a list of roles and
  responsibilities
• Nursing champions meetings already held three
  monthly including AHP
• Medical champions attending infection control
  committee to give feedback on audits and
  developments in their area

5
People

• Mandatory training
• In-house training programme already available
  and accessed by nurses, AHP
• Identified gaps in medical training aseptic
  technique and line insertion
• Training programme developed following a
  training needs analysis to meet specific need of
  staff groups
• Data base to be kept by infection control,
  too early to determine uptake

6
Practices

• Root cause analysis
• 5 days to complete (set by SHA)
• - algorithm devised for notification of an
  MRSA bacteraemia
• - responsibility matron, lead nurse and
  medical service head (with ICT input)
• -action plan developed plus review meeting
  set with DIPC on progress
• -feedback to Infection Control Committee on
  their actions and progress
• Pre 48 hours bacteraemia referred to PCT
  to initiate RCA.

7
Practices

• Route cause analysis has resulted in
• -development of MRSA care pathway in
  conjunction with community ICT and HPU
• -pan borough patient information leaflet on
  MRSA
• -revised central line policy - clinician
  lead
• -updated antimicrobial guidelines
• -additional RCA training for lead nurses in
  clinical areas
• -Saving Lives modules central and peripheral
  lines being performed by nursing and
• clinical staff

8
Results

• Laboratory report a 100 increase in swabs
  received for MRSA screening (cost implication)
• ICT have noted improved compliance with screening
  of high risk patients
• Staff are now acknowledging failures in adherence
  to policies and procedures
• Requests to ICT for additional training
• Increasing numbers of requests for advice from
  clinicians
• The culture is slowly changing, staff understand
  they have to take responsibility for the
  prevention and control of infection.

9
Ongoing monitoring of progress

• Weekly CEO, medical director, nursing
  director/DIPC meetings
• Monthly Integrated Governance and Board Reports
• Matrons and medical champions feedback to
  Infection Control Committee
• SHA monitoring
• Review all infection control related incidents
• Review training uptake for new programme

10
Current situation
2006/2007 - 35 Target was 20
11
Thank you for listening

• Angela Murray
• CNS Infection Control
• 01384 244174
• angela.murray_at_dgoh.nhs.uk