1. Point of Care Testing for MRSA Nigel Brenwald Department of Microbiology Sandwell and West Birmingham Hospitals NHS Trust

2. POCT – ‘The Starting Point’ MRSA screening will be required for new admissions MRSA screening will be required for new admissions Rapidity of results most likely to influence their effectiveness Rapidity of results most likely to influence their effectiveness Organisational barriers are likely to prevent rapid laboratory turnaround for foreseeable future Organisational barriers are likely to prevent rapid laboratory turnaround for foreseeable future

3. Desirable Features for POCT Rapid ‘On Demand’ ‘On Demand’ Easy to use Easy to use Clear interpretation of results Clear interpretation of results

4. Cepheid Xpert MRSA test Real-time PCR methodology Detecting orfX – SCC mec junction Detecting orfX – SCC mec junction Run on Cepheid GeneXpert System Run on Cepheid GeneXpert System

5. Cepheid Xpert MRSA test

6. MRSA POCT study Feasibility of using Xpert MRSA test as point of care test for MRSA Feasibility of using Xpert MRSA test as point of care test for MRSA Assess acceptability to staff Assess acceptability to staff Gain understanding of positivity rates when screening rolled out Gain understanding of positivity rates when screening rolled out

7. MRSA POCT Study - Design GeneXpert systems set up in Assessment and Critical Care units in two hospitals in Trust GeneXpert systems set up in Assessment and Critical Care units in two hospitals in Trust Testing set up in laboratory on City site Testing set up in laboratory on City site Systems networked Systems networked

8. Xpert MRSA

9. MRSA POCT study - Design 1000 admissions screened by Xpert MRSA test 1000 admissions screened by Xpert MRSA test Double-headed swab used to sample both nares Double-headed swab used to sample both nares One swab tested on ward, the other sent to laboratory One swab tested on ward, the other sent to laboratory Xpert MRSA test performed in laboratory during normal working hours. Xpert MRSA test performed in laboratory during normal working hours.

10. MRSA POCT study - Ward Staff training Training program by a team of laboratory staff designated as trainers Training program by a team of laboratory staff designated as trainers Provided training on sample collection, performance of test, basic cleanliness Provided training on sample collection, performance of test, basic cleanliness On Admissions units majority of testers were HCAs (band 3), on Critical Care mostly trained nurses On Admissions units majority of testers were HCAs (band 3), on Critical Care mostly trained nurses

11. MRSA POCT study - Overall results Total with paired result 988 Number with errors results 17 (1.7%) Number with invalid result 24 (2.4%) Total with valid paired result 947 Paired samples both negative 850 (89.8%) Paired samples both positive 74 (7.8%) Discrepant results 23 (2.4%) Overall agreement (Lab v Ward) 97.6%

12. MRSA POCT Study - Time to result (Ward v Lab) Ward Time (mean) Overall mean 21.4 hrs CCS CITY 23.3 hrs CCS SANDWELL 29.1 hrs MAU CITY 19.9 hrs EAU SANDWELL 22.1 hrs

13. Ward v Lab - time to result (Monday to Thursday) Site Mean Difference Range City Hosp 10hrs 11mins 22mins - 161hrs 4mins Sandwell Hosp 17hrs 54mins 1hr 20mins - 110hrs 49mins

14. MRSA POCT - Implementation Xpert MRSA test Xpert MRSA test Simple test to setup Simple test to setup Good correlation between Lab and Ward Good correlation between Lab and Ward What else needed to be considered? What else needed to be considered?

15. POCT – General Guidelines

16. MRSA POCT - Resources Staff Staff - Extra Healthcare Assistants / Nurses Siting of equipment Siting of equipment - Sufficient space for equipment and setting up Storage Storage - Swabs, Kits, pipettes Waste Disposal Waste Disposal

17. MRSA POCT - Procedure (SOP) Controlled document – describing method Controlled document – describing method Forms basis of training manual Forms basis of training manual Accreditation Accreditation

18. Quick method – ‘At a glance’ Setting up Xpert MRSA testRunning test on GeneXpert System

19. MRSA POCT - Training Trainers – Laboratory staff Trainers – Laboratory staff Trainees - Nurses / Healthcare Assistants Trainees - Nurses / Healthcare Assistants - Assessment of competency - Register of trained staff - Ongoing training Resource implication Resource implication

20. Quality Assurance Xpert MRSA Xpert MRSA - Built in’ internal control - Reagent checks Internal Quality Assurance (IQA) Internal Quality Assurance (IQA) - Testing of new batches - Checking of clinical samples External Quality Assurance (EQA)? External Quality Assurance (EQA)?

21. MRSA POCT - Safety Issues GeneXpert System - Electrical safety GeneXpert System - Electrical safety Xpert MRSA kit - COSHH assessment Xpert MRSA kit - COSHH assessment Disinfection Disinfection Waste / Sharps disposal Waste / Sharps disposal

22. IT – Data collection Microbiology computer database Microbiology Server MRSA POCT request form Patient notes GeneXpert Ward A GeneXpert Ward B Interface

23. POCT MRSA – ‘Growing the bug’ Xpert MRSA detects MRSA DNA. Xpert MRSA detects MRSA DNA. Require isolate for susceptibility testing Require isolate for susceptibility testing Positive patients – additional routine screening swabs Positive patients – additional routine screening swabs

24. SITETESTSPATIENTS CCS City373333 CCS Sandwell309287 MAU City30532650 EAU Sandwell14731342 TOTAL52084612 MRSA POCT - routine testing (Oct 2008 – April 2009)

25. POCT MRSA - positives WardMRSA Positive CCS City7.50% CCS Sandwell8.10% MAU City6.80% EAU Sandwell8.40%

26. Critical Care Services – timing of tests

27. MRSA POCT - Summary Xpert MRSA provides a high degree of accuracy when used as a POCT Xpert MRSA provides a high degree of accuracy when used as a POCT POCT - Significant reduction in time to obtain MRSA status POCT - Significant reduction in time to obtain MRSA status Rapid availability of MRSA screening results should influence the patient pathway Rapid availability of MRSA screening results should influence the patient pathway

28. MRSA POCT - Summary However, many other factors need to be considered. However, many other factors need to be considered.

29. Acknowledgements Microbiology Microbiology Beryl Oppenheim Nick Baker Becky Walker Kulvir Chana Staff on Admissions and Critical Care Units at SWBH Staff on Admissions and Critical Care Units at SWBH Cepheid Cepheid