Root Cause Analysis following

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Root Cause Analysis following

MRSA Bacteraemia

MRSA Bacteraemia:

Reviewing the Patient’s Journey

Reviewing the Patient s Journey

Sharren Pells Helen Forrest

Senior Infection Control Nurse

Infection Control Nurse Specialist

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Aims & Objectives

• For delegates to understand what is meant by the term MRSA bacteraemia

• To assist delegates in understanding what g g

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 recent root cause analysis (RCA), identifying recommendations for future practice

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What is an MRSA Bacteraemia?

• Bacteraemia is the presence of bacteria in the

blood The detection of bacteria in the blood (by 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 infection caused by the presence of meticillin resistant staphylococcus aureus

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Scenario:

Reported MRSA Bacteraemia

Initial facts: Initial facts:

• In October 2010 the IP&C Team received notification of a reported MRSA bacteraemia 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

(5)

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. p g The root, or fundamental issues, is the earliest point at which action could have stopped the incident happening

How is this achieved? How is this achieved?

• Through a process of investigation and analysis to try and identify what, how and why it happened

Wh i hi i ?

Why is this important?

• To identify any areas for improvement and make

recommendations for future practice – with the aim of recommendations for future practice with the aim of preventing recurrence of any such incidents in the future

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What do we know about our patient?

Initial review of notes: Flo

• 90 years old • Widow 20 years • Widow 20 years

• Lived alone prior to moving to Care Home 8 months ago • Dementia • Poor mobility • Poor mobility • Frequent falls • Type ll Diabetesyp • Incontinent of urine • Frequent UTIs

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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

Oct 2010

• Admitted to hospital treatment of UTI and

assessment following fall • Following assessment Flo

p following fall.

Bacteraemia reported ithi 2 d f

Following assessment Flo was transferred to a Care Home

within 2 days of admission

July 2010

• Admitted to hospital for treatment of UTI back treatment of UTI – back to Care Home after 3 days

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Now lets

i

Fl ’

review Flo’s

journey in

j

y

more detail…

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Timeline: May 2010 - Living at Home

Fl li d i h h i t h h it l d i i • Flo lived in her own home prior to her hospital admission • History of being MRSA positive back in 2008

• Diabetes monitored by GP and blood sugars • Diabetes monitored by GP and blood sugars

occasionally high (10)

• GP prescribed oral antibiotics - trimethoprim - on 3GP prescribed oral antibiotics trimethoprim on 3 separate occasions during 2009/10 for recurrent UTI

• Microbiology report from January 2010 stated that MRSA

i i i i h i

present in urine: resistant to trimethoprim

• Admitted to hospital due to falls and urinary incontinence due to urinary tract infection (UTI)

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Timeline: May 2010

Flo’s Admission to Hospital

• Admitted to hospital following fall at own home. Flo and family unable to cope due to

p

o a d a y u ab e to cope due to

progression of dementia, frequent falls and urinary incontinencey

• Prescribed trimethoprim for urinary tract infection • MRSA admission screen +ve commenced

• MRSA admission screen +ve – commenced decolonisation therapy

Di h d t h ith i d lli i

• Discharged to care home with indwelling urinary catheter 4 days after admission

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Time line: May 2010

Move to Care Home

• Catheter removed, incontinence managed withCatheter removed, incontinence managed with regular toileting and use of pads

• ‘Dementia progresses’ • Dementia progresses

• UTI treated with antibiotics - GP prescribes trimethoprim

trimethoprim • Falls recorded

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Timeline: July 2010

Flo goes back into hospital

• Fall at Care Home - confused and incontinent

Flo goes back into hospital

• Admitted to hospital

• Catheter inserted in hospital for ‘patient’sCatheter inserted in hospital for patient s convenience’

• Discharged home after 3 days with urinary • Discharged home after 3 days with urinary

catheter in situ

GP advises leaving catheter in • GP advises leaving catheter in

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Timeline: September 2010

• Care Home report the presence of cloudy smelly urine dip stick shows nitrites

urine - dip stick shows nitrites

• Call to OOH service – antibiotics prescribed

(t i th i )

(trimethoprim)

• Traumatic removal of catheter reported • Catheter reinserted by nursing staff

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Timeline: October 2010

Fall from chair:

ll unwell, very confused, high temperature -admitted to hospital admitted to hospital.

MRSA blood stream i f ti fi d infection confirmed

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Susceptibility for Bacteraemia Risk Factors: Flo’s Medical History

↑ age – (dementia) _√

Frequent hospital admissions _√ Frequent hospital admissions _√

Resident in care home _√

f ( ) _√

Recurrent infections (UTIs) _√

Invasive device _√ Antibiotic use _√ History of falls _√ History of falls _√ Type ll diabetes _√ √

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Susceptibility for Bacteraemia

Risk Factors: Flo’s Management

g

Hos CH

MRSA screen carried out? √ N/A MRSA screen carried out? √ N/A If positive, was decolonisation

treatment prescribed and completed? P √ib d

?

Completed

treatment prescribed and completed? Prescribed Completed

Patient awareness a risk factor? √ √ Frequent prescribing of antibiotics? √ √

√ √

Invasive device in situ? √ _{After 2nd}√

admission

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Susceptibility for Bacteraemia

Risk Factors: Organisational Environment

g

Evidence of adherence to following: Hos CH

MRSA li _√

MRSA policy _√ x

Decolonisation policy _√ x

Screening policy _√ x

Cleaning and decontamination policy _√ x

Isolation policy _√ n/a

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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 n/a x

H d h i d l li f

Hand hygiene and cleanliness of

environment √ x

X

Monitoring of antibiotics X X

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Summary of Initial Findings

1 High number of patient risk factors 1. High number of patient risk factors

2. MRSA decolonisation (suppression) treatment regime unclear. No recognition of previous g g p

MRSA positive urine sample results

3. Invasive device inserted during both hospital d i i

admissions

4. Adherence to IP&C policy and care bundles not 100%

not 100%

5. Antibiotics not monitored and no record of urine sample results being followed up.

urine sample results being followed up. Inappropriate prescribing – history of resistance to Trimethoprim

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Further Considerations:

1) Patient Risk Factors:

• Aim to avoid catheterisation in patients with • Aim to avoid catheterisation in patients with

dementia if at all possible

C id th / t f

• Consider other causes/management of incontinence

• Review falls history – could be due to presence of catheter; unstable diabetes; nutritional or fluid intake; environment etc?

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Further Considerations

2) Treatment for MRSA colonisation/infection:

• Were GP Hospital and Care Home aware of • Were GP, Hospital and Care Home aware of

previous MRSA history, including presence of MRSA in urine - resistant to trimethoprim?

MRSA in urine resistant to trimethoprim? • Had a recent MSU/CSU been obtained? • Was prescribed decolonisation treatment • Was prescribed decolonisation treatment

completed after discharge from hospital?

• Were care home staff aware of the treatment • Were care home staff aware of the treatment

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Further Considerations

3) Urinary Catheter: 3) Urinary Catheter:

• Why was Flo catheterised in hospital?

Rationale? What is meant by Pt’s convenience? y • Could long term catheter have been avoided?

Managed previously without catheter

• No information on hospital discharge letter

• Traumatic removal in care home – rationale for

i ti ?

reinsertion?

• Information and support for care home staff – confident to challenge decision making?

confident to challenge decision making?

• Process for GP’s decision making re: need for catheter?

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Further Considerations

4) Adherence to IP&C policies:

Wh h d b dl li t

• 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 in care homes?

p p

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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

d t d ?

up and acted upon?

• What was clinical picture for prescribing AB?

Di ti k lt t t ffi i t id th t

Dipstick result etc, not sufficient evidence that UTI/CAUTI present. What about samples? Who is responsible for following up urine sample

is responsible for following up urine sample results?

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Further Considerations

6) Communication:

• Cross organisational communication?Cross organisational communication? • Information on discharge letters?

Inter Health Transfer forms (Essential Steps)? • Inter Health Transfer forms (Essential Steps)? • Access to relevant sample results?

• Monitoring of policies and care bundle scores? • Sharing of RCA informationS a g o C o a o

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Action Plan

Id tifi d I A ti i d N D t

Identified Issue Action required Name Date

1) Record and Feedback RCA

•Report to relevant risk/CG/IP&C committees (PCT/Acute Trust)

IP&C Nov

Feedback RCA report

committees (PCT/Acute Trust) •Feedback to Care Home, GP & Hospital

2) Management of MRSA colonisation

•Investigate how information is accessed/shared (results)

•Provide education for care home

IP&C

•Provide education for care home staff re: decolonisation treatments and MRSA management

ICLN

•Audit information on hospital

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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

Continence lead

Audit/Risk urinary catheter _{•Joint working with Acute Trust to}

improve information on discharge letters • Audit: review number of patients

l i h it l ith th t i it

Audit/Risk Discharge

leaving hospital with catheter in situ •Update sessions for Acute Trust, GP’s and care home staff re: clinical

i li ti f i d lli i

Liaison Team IP&CT

implications of indwelling urinary catheters – Mandatory training; CG

seminars; primary care weekly bulletins; IP&C newsletters

Trust / PCT IP&CTs

IP&C newsletters

•Continued dashboard scores for

compliance to care bundles – monthly it i b F

Service L d

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Identified Issue Action Required Name

4)Monitor • Joint sharing of monthly dashboard scores CG

4)Monitor adherence to IP&C policy

d

• Joint sharing of monthly dashboard scores between both PCT (provider services, GP’s, care homes) and acute Trust

CG Forums

and care bundles

5) Antibiotic ₎ • ICLN focus on rationale for taking urine IP&CT /

prescribing history and obtaining urine

g sample; how to take a urine sample; appropriate information on microbiology request form

ICLN

obtaining urine samples

request form

•Importance on follow up of results

•Monthly AB prescribing data

C

•Feedback to GPs/OOH re: AB prescribing and link to Wiltshire AB community guidelines

Com Pharm lead

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Identified Issue Action Required Name

6)Improved communication across

•Continue implementation of Inter Health Transfers forms – audit December 2010 •Acute Trust to progress actions following

IP&CT CG

organisations _{audit of discharge letters}Acute Trust to progress actions following

•Sharing of RCA information with all relevant i

CG Lead

services

•Continue work of catheter care pathway group

g p

•Continued involvement in South West Quality and Patient Safety Improvement Programme CAUTI; pressure ulcers; Programme – CAUTI; pressure ulcers; Falls; VTE; Urgent admissions

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References

• Health and Social Care Act 2008, Code of Practice on the prevention and control of infections and related guidance

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-safe-care.nhs.uk

Wilt hi tibi ti ibi id li ( i • Wiltshire antibiotic prescribing guidelines – (enquire

Root Cause Analysis following