Further MRSA bacteraemia reduction
by reducing acquisition of MRSA
colonisation in-hospital
Julie Brooks and Graeme Jones
Infection Prevention
University Hospitals Southampton NHSFT
Drivers to control MRSA bacteraemia
Prevention of colonisation with MRSA
 Prevention of invasive MRSA infection
 Feedback and monitoring systems

J a n u a ry
0
2005
M ay
2006
J u ly
M ay
2007
2008
2009
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
D ecem ber
N ovem ber
O c to b e r
S e p te m b e r
A ugust
J u ly
June
M ay
A p r il
M a rc h
F e b ru a ry
3
J a n u a ry
D ecem ber
N ovem ber
O c to b e r
S e p te m b e r
A ugust
J u ly
June
M ay
A p r il
M a rc h
F e b ru a ry
J a n u a ry
D ecem ber
2
N ovem ber
O c to b e r
S e p te m b e r
A ugust
J u ly
June
1
A p r il
M a rc h
F e b ru a ry
J a n u a ry
D ecem ber
N ovem ber
O c to b e r
S e p te m b e r
A ugust
2005
June
14
A p r il
M a rc h
F e b ru a ry
J a n u a ry
D ecem ber
N ovem ber
O c to b e r
S e p te m b e r
A ugust
J u ly
June
M ay
A p r il
M a rc h
F e b ru a ry
M R S A B S I (n )
Actions to reduce MRSA bacteraemia in UHS
16
2009
12
10
4
8
6
4
2
No of Cases
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Apr-07
May-07
Jun-07
Jul-07
Aug-07
Sep-07
Oct-07
Nov-07
Dec-07
Jan-08
Feb-08
Mar-08
Apr-08
May-08
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
MRSA bacteraemia numbers 2007-11
SUHT MRSA BSI
2007 - 2012
2007
5
3
3
2
2011
4
5 5
4
3
3 3 3
4
2
3
2
4
2
2
1
1 1 11 1
0
Actual Cases
2 2
0
1
0 0 0 0
1
Trajectory
0 0
1
0 0 0 0
1 1
0
1
0 0
1 1
Linear Trend (Actual Cases)
4. Jan 2009: universal bio-burden reduction on admission
0 0
1
0
1
0 0
1
Combined MRSA + MSSA post-48h BSI rate is a better
measure of invasive infection prevention / device care?
Winchester
Wexham Park
Basingstoke
Frimley Park
Southampton
IOW
Portsmouth
Oxford
Recent MRSA bacteraemias in UHS

Post-48h MRSA BSI
1.
2.
3.
4.
49y. Known MRSA +ve. Erythrodermic flare of
pustular psoriasis. CVL colonisation/BSI
45y. Known MRSA +ve. Paraplegic. Communityacquired MRSA IE detected after 48h in UHS
61y. Gallstone pancreatitis requiring biliary drain.
BSI on drain flush. Acquired MRSA In UHS
97y. #NOF. Global deterioration and aspiration
pneumonia. Acquired MRSA In UHS
Recent MRSA bacteraemias in UHS

Pre-48h MRSA BSI
1.
2.
3.
4.
5.
Known MRSA +ve. Home TPN line infection
Known MRSA +ve. CML. Infected leg ulcers
Infected TKR. Acquired MRSA during rehab in
community hospital
AML. Hickman line infection. Acquired MRSA
during recent UHS admission
Osteoarthritis. Necrotising pneumonia due to
PVL-MRSA acquired either in UHS or rehab unit
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
Number of patients colonised with MRSA
predicts number with MRSA BSI
Review of relevant studies
100
80
MRSA BSI
60
40
20
Rsq = 0.7732
0
100
300
800
600
400
200
0
500
700
Total colonized and infected patients
ia
t
ric
N Me
Va eu dic
ro
C
in
l s
Tr inic cul sur e
au a ar ge
m l H Su ry
a
a
& em rge
O
r
rt ato y
ho lo
pa gy
G
ed
en
er Ur ics
al ol
M o
G ed g y
C yna ici
a
n
M rdia eco e
e d c lo
ic Su gy
G al O rg
en n er
Th era col y
or l S og
C ac ur y
lin ic ge
ic Su ry
al
O rge
nc ry
ol
og
y
C
a
E
Pa O rdi nt
lli ral olo
at
iv Su gy
e rg
M er
ed y
ic
N
R
es Op eu ine
pi th ro
ra a lo
to lm gy
ry ol
M og
ed y
ic
in
e
er
G
% MRSA +ve on admission screen
Proportion of MRSA positive emergency
admissions by admission specialty 2008-12
4.00%
3.50%
Overall +ve
Specialties with <100 screens excluded
2008-10
2011-12
2.00%
1.50%
1.00%
0.50%
0.00%
1.5%
0.85%
3.00%
2.50%
2008-10
2011-12
SUHT MRSA Acquisition
Linear (SUHT MRSA Acquisition)
Oct-11
Nov-11
Dec-11
Jun-11
Jul-11
Aug-11
Sep-11
Mar-11
Apr-11
May-11
Nov-10
Dec-10
Jan-11
Feb-11
Aug-10
Sep-10
Oct-10
Apr-10
May-10
Jun-10
Jul-10
Jan-10
Feb-10
Mar-10
Sep-09
Oct-09
Nov-09
Dec-09
Jun-09
Jul-09
Aug-09
Feb-09
Mar-09
Apr-09
May-09
Nov-08
Dec-08
Jan-09
Jul-08
Aug-08
Sep-08
Oct-08
Apr-08
May-08
Jun-08
No of Cases
Acquisition of new MRSA
colonisation in UHS 2008-2011
SUHT MRSA Acquisition
45
40
35
30
25
20
15
10
5
0
ci
al
&
Ne
rn
O
11
wb
o
&
4
T
y
at
ric
s
8
Su
rg
er
ed
i
s
...
ce
M
ed
5
Pa
ic
Ca
re
ci
en
is
t
Ne
ur
os
Sp
e
al
Th
or
ac
Ca
re
7
W
om
en
&
&
Cr
iti
c
ul
ar
er
5
nc
y
va
sc
Ca
nc
60
50
40
30
20
10
0
Em
er
ge
Ca
rd
io
No of Cases
Acquisition of new MRSA colonisation in UHS by
Care Group April 2011-February 2012
48
9
11
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
Implementing an enhanced MRSA
surveillance programme to improve patient
safety.
Julie Brooks
Head of Infection Prevention.
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)
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).
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
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 noncompliance)
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
Outcomes
No. of patients
surveillance carried
out on
Of these patients,
number acquired
MRSA at UHS
Q1/2
Q3/4
83
77
56
41
Prevention of Spread
Standard
% Compliance
Prevention of Spread
1. Isolation Risk
assessment completed
100
90
80
70
60
50
40
30
20
10
0
2. Isolated within 4 hrs of
presumptive result
Q1/2
Q3/4
3. Correct Hand Hygiene
performed
4. Isolation Posters
displayed
5. Chlorine Based Cleaning
of isolation room
1
2
3
4
Standard
5
6
6. Contact Precautions
implemented
Patient Management (Prior to result)
Standard:
% Compliance
Patient Management (prior to result)
100
90
80
70
60
50
40
30
20
10
0
1. Risk reduction
measures (hibiscrub
washes) commenced
and documented.
Q1/2
Q3/4
1
2
Standard
3
2. Additional MRSA
screening undertaken
following admission.
3. Additional risk reduction
measures (where
applicable) commenced
and documented.
Patient Management (post result)
Standard:
% Compliance
Prevention of Spread (post result)
1. MRSA positive status
documented in notes
100
90
80
70
60
50
40
30
20
10
0
2.
Q1/2
Q3/4
Topical decolonisation
(Chlorhexidine & Nasal
bactroban)
3. Additional measures /options
for MRSA in wounds etc
(where applicable)
4. MRSA Patient held record
supplied.
5.
1
2
3
4
Standard
5
6
MRSA information leaflet
given to patient
6. Medical notes labelled
Compliance with Care Bundle.
Week
Commencing
05/09/2011
12/09/2011
19/09/2011
26/09/2011
03/10/2011
10/10/2011
17/10/2011
24/10/2011
31/10/2011
07/11/2011
14/11/2011
21/11/2011
28/11/2011
05/12/2011
12/12/2011
19/12/2011
26/12/2011
02/01/2012
09/01/2012
16/01/2012
23/01/2012
30/01/2012
06/02/2012
13/02/2012
20/02/2012
27/02/2012
MRSA Surveillance Care Bundle
Division C
Division B
Division A
% All
No of
% All
No of
% All
No of
Elements
Elements Cases
Cases
Elements
Cases
0
0
2
0
1
0
0
0
0
0
1
0
0
50
2
0
0
0
1
0
0
0
0
0
0
1
0
2
0
0
0
0
0
3
0
1
0
50
2
0
0
0
0
1
0
100
1
0
2
0
100
3
0
2
0
1
0
0
3
0
2
100
1
0
1
0
0
100
2
0
0
0
1
0
0
0
1
0
0
1
60
5
0
0
100
2
0
0
67
3
0
0
1
100
1
100
2
0
100
1
100
1
0
0
100
1
100
1
0
5
0
Division D
% All
No of
Elements
Cases
0
0
0
0
0
0
0
0
1
0
2
0
0
1
0
2
100
1
100
1
0
1
100
1
100
1
0
0
50
2
0
2
0
1
0
0
2
0
1
50
2
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.

CQC Outcome 8.8 - Isolation
CQC Outcome 8.8 - Isolation
Metrics
Target
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Ap - June 11
July - Sep 11
Oct - Dec 11
Jan - Mar 12
Explanation of RAG
Rating
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%