1. Further MRSA bacteraemia reduction by reducing acquisition of MRSA colonisation in-hospital Julie Brooks and Graeme Jones Infection Prevention University Hospitals Southampton NHSFT

2. Drivers to control MRSA bacteraemia Prevention of colonisation with MRSA Prevention of invasive MRSA infection Feedback and monitoring systems

3. Actions to reduce MRSA bacteraemia in UHS 1. April 2006: hand hygiene and saving lives care bundles 2. April 2007: internal targets 3. Nov 2007: low risk antibiotic policies 4. Jan 2009: universal bio-burden reduction on admission 2005

4. MRSA bacteraemia numbers 2007-11 4 4. Jan 2009: universal bio-burden reduction on admission 20072011

5. Combined MRSA + MSSA post-48h BSI rate is a better measure of invasive infection prevention / device care? Southampton Basingstoke Frimley Park Winchester IOW Portsmouth Oxford Wexham Park

6. Recent MRSA bacteraemias in UHS Post-48h MRSA BSI 1. 49y. Known MRSA +ve. Erythrodermic flare of pustular psoriasis. CVL colonisation/BSI 2. 45y. Known MRSA +ve. Paraplegic. Community- acquired MRSA IE detected after 48h in UHS 3. 61y. Gallstone pancreatitis requiring biliary drain. BSI on drain flush. Acquired MRSA In UHS 4. 97y. #NOF. Global deterioration and aspiration pneumonia. Acquired MRSA In UHS

7. Recent MRSA bacteraemias in UHS Pre-48h MRSA BSI 1. Known MRSA +ve. Home TPN line infection 2. Known MRSA +ve. CML. Infected leg ulcers 3. Infected TKR. Acquired MRSA during rehab in community hospital 4. AML. Hickman line infection. Acquired MRSA during recent UHS admission 5. Osteoarthritis. Necrotising pneumonia due to PVL-MRSA acquired either in UHS or rehab unit

8. Recent MRSA bacteraemias in UHS Of 9 MRSA BSI in 2011-12 5/9 (56%) associated with new acquisition of MRSA colonisation in UHS or associated rehabilitation facility Next control action to reduce MRSA bacteraemia is to prevent acquisition of MRSA colonisation in hospital

9. Number of patients colonised with MRSA predicts number with MRSA BSI

10. Proportion of MRSA positive emergency admissions by admission specialty 2008-12 Specialties with <100 screens excluded Overall +ve 2008-10 1.5% 2011-12 0.85%

11. Acquisition of new MRSA colonisation in UHS 2008-2011

12. Acquisition of new MRSA colonisation in UHS by Care Group April 2011-February 2012

13. Reducing acquisition of new MRSA colonisation within hospital Next step to reducing MRSA bacteraemia MRSA screening programme to facilitate surveillance already established Marker of good practice to reduce transmission of MDRO between patients Improvement will potentially reduce risk of healthcare transmission of other organisms of concern: MSSA GAS ESBLs Carbapenem-R coliforms Preliminary work indicates scope for improvement

14. Implementing an enhanced MRSA surveillance programme to improve patient safety. Julie Brooks Head of Infection Prevention.

15. Enhanced MRSA Surveillance programme Enhanced Surveillance of all new cases of MRSA acquisition Commenced April 2011 Purpose: To monitor and demonstrate compliance with practice standards and drive improvements where needed To provide assurance on compliance with the Code of Practice for Health and Adult Social Care on the Prevention and Control of Infection (particularly outcome 8.8 – criterion 7 in code of practice)

16. Standards Reviews compliance with elements of the MRSA policy (e.g. practices to prevent transmission, risk reduction measures, decolonisation regimes) as well as isolation practice (e.g. completion of isolation risk assessment tool and with the Trust isolation target of 4 hrs, where isolation is assessed as being required).

17. MRSA Policy Comprehensive MRSA Policy in place since 2009 detailing practice standards required. Care bundle for the Prevention and Management of MRSA (Adults) – Nov 2011

18. Process Clinical area visited by IPN within 48hrs of confirmed new MRSA acquisition. Surveillance undertaken and verbal feedback back to nurse in charge (important to feedback good practice as well as non- compliance) For any variance against the required practice standard: Report to the nurse in charge of the ward at time of surveillance being undertaken & document that this has occurred. Request investigation/feedback action giving a 2 week deadline for feedback. Ward/department manager to undertake investigation relating to non-compliance with practice standards and implement actions to address this. Provide formal feedback and actions to IPT. If feedback is not received within the 2 week deadline – escalation as per IPT assurance framework

19. Outcomes Q1/2Q3/4 No. of patients surveillance carried out on 8377 Of these patients, number acquired MRSA at UHS 5641

20. Standard 1. Isolation Risk assessment completed 2. Isolated within 4 hrs of presumptive result 3. Correct Hand Hygiene performed 4. Isolation Posters displayed 5. Chlorine Based Cleaning of isolation room 6. Contact Precautions implemented Prevention of Spread

21. Patient Management (Prior to result) Standard: 1. Risk reduction measures (hibiscrub washes) commenced and documented. 2. Additional MRSA screening undertaken following admission. 3. Additional risk reduction measures (where applicable) commenced and documented.

22. Patient Management (post result) Standard: 1. MRSA positive status documented in notes 2. Topical decolonisation (Chlorhexidine & Nasal bactroban) 3. Additional measures /options for MRSA in wounds etc (where applicable) 4. MRSA Patient held record supplied. 5. MRSA information leaflet given to patient 6. Medical notes labelled

23. Compliance with Care Bundle.

24. Reporting/Monitoring & Review Weekly delivery group report – copied to Matrons, Clinical Leads and Care group Managers for action. Quarterly Matron and Care Group Clinical Lead report for Infection Prevention Committee, TEC and Trust Board) Quarterly Infection Prevention Report to TEC and Trust Board. Isolation compliance monitored as part of the CQC/Hygiene Code assurance framework. Exceptions reported to Infection Prevention Committee and Quarterly to Trust Quality Governance Steering Group.

25. CQC Outcome 8.8 - Isolation MetricsTarget Explanation of RAG Rating Quarter 1 Quarter 2Quarter 3Quarter 4 Ap - June 11 July - Sep 11Oct - Dec 11Jan - Mar 12 Isolation newly acquired MRSA Positive patients 100% of patients with MRSA isolated within 4 hours 95%>=green, 85-94% = amber, 84%< = red 88% 72%90% Completion of isolation risk assessments for MRSA 100% of patients that are newly acquired MRSA positive have a completed risk assessment 95%>=green, 85-94% = amber, 84%< = red 35% 68%74%