Author: Improvement Programme Review Team Version: Final version Date: 30 th March 2007

1. MRSA/HCAI Improvement Programme Shrewsbury & Telford NHS Trust Final Report Author: Improvement Programme Review Team Version: Final version Date: 30th March 2007

2. Contents • Section 1 • 1.1 Executive summary • 1.2 Your key message & immediate priorities • 1.3 Data analysis • 1.4 Suggested target milestones • 1.5 Actions for recovery & improvement • 1.6 Encouraging signs • Section 2 • 2.1 Key themes • Findings and recommendations • 2.2 People • 2.3 Performance • 2.4 Process • 2.5 Practice • Section 3 • 3.1 Recommended performance reporting • 3.2 Recovery plan Links: Acknowledgements Section 1 Section 2 Section 3

3. Contents • Section 1 • 1.1 Executive summary • 1.2 Your key message & immediate priorities • 1.3 Data analysis • 1.4 Suggested target milestones • 1.5 Actions for recovery & improvement • 1.6 Encouraging signs • Section 2 • 2.1 Key themes • Findings and recommendations • 2.2 People • 2.3 Performance • 2.4 Process • 2.5 Practice • Section 3 • 3.1 Recommended performance reporting • 3.2 Recovery plan Links: Content Page Acknowledgements Section 2 Section 3

4. 1.1 Executive summary • You met your target in year one but are struggling to meet it this year. There are pockets of good practice throughout the trust and a general desire to be proactive rather than reactive in reducing MRSA bacteraemias but this will need a direct focus and an immediate recovery plan implemented to reach trajectory and deliver your target. • your 06/07 (April to November) trajectory is 22 and you experienced 36 MRSA Bacteraemias • the biggest challenge you have is identifying the root cause of your bacteraemias and this requires your immediate attention. Immediately carry out root cause analysis (RCA) to ascertain source and cause of all MRSA bacteraemias and backdate for the last three months • your data shows that 77% of your bacteraemias occur after 48 hours, of which 33% are within Augmented Care. You need to ensure there are no avoidable MRSA bacteraemias in Augmented Care with immediate effect and maintain this • you need to demonstrate a 50% improvement in your top 5 specialties in the next 6 months, i.e general medicine, general surgery, nephrology and general intensive care unit • your data suggests that 23% of your bacteraemias occur pre-48 hour. Carry out immediate bespoke analysis of pre-48 hour MRSA bacteraemias for patients admitted 3 months prior to having acquired MRSA in hospital. Work with partners to understand cause, and reduce number of pre-48 hour cases. Reduce by at least 50% by May 07 and by at least a further 50% by August 07 • ensure month on month improvements in all areas • You achieved your MRSA trajectory target last year but breached the MRSA trajectory target this year. The organisation, as a whole, needs to maintain an attitude of awareness and diligence to assist recovery against trajectory. Commitment to infection prevention and control is evident and the sense of importance and urgency held by the Chief Executive needs to be translated to all levels of the organisation. Your new Divisional structure will give you the opportunity to promote joint working and enhance communication across the organisation. Nominated clinical leads are required for all specialties to own and drive this initiative, moving away from a culture whereby the Infection Control Team led and owned all that was associated with infection prevention and control. Ensuring everyone understands their role, responsibility and accountability is also fundamental. Utilisation of the High Impact Interventions (HIIs) in specific and focused areas as highlighted by the improved RCA will lead you to make progress faster. Finally, improvements in screening and the use of antibiotics will all play an important part. Audit and surveillance are key to measuring your progress against infection prevention and control and should be formalised and fed back to the clinical areas as soon after completion as possible. • We have highlighted a number of areas in this report which should improve your performance towards reducing the levels of MRSA bacteraemia. The review team has included in this report key performance improvement statements with timescales for specific improvement outcomes. You need to embed within the culture that it is an insult to give patients infections.

5. 1.2 Your key message and immediate priorities Your key message is : Accountable and responsible care delivery will support a reduction in healthcare-associated infection Immediate implementation of the following 3 actions will start you on your journey of reducing your MRSA bacteraemias (please see the embedded document in section 1.5 for your further actions) • initiate root cause analysis within 24 hours of bacteraemia identification and complete and feedback to your multi-disciplinary team within 5 days • develop and share performance information that is understood and owned by all levels of the organisation • instil a culture that reducing MRSA bacteraemias is everyone’s responsibility

6. 1.3 Data analysis data in the following slides are from your submitted MESS data December 2005 to November 2006

7. 1.3.1 What is the direction of travel? The challenge is significant to be where you need to be in March 2008

8. 1.3.2 Number of MRSA cases split by Specialty - A look at your problem areas Areas to target are: General Medicine & General Surgery.

9. 1.3.3 Number of MRSA cases split by Pre- and Post-48 Hours The table shows that in the last 12 months, 23% of your bacteraemias were pre-48hr cases. N.B. The national average is 28%. Suggestion – look at your pre 48 hour patients and see if they have been to hospital in the previous 3 months from when their MRSA Bacteraemia was identified

10. 1.3.4 Number of MRSA cases by Age Band The breakdown of your MRSA cases by age band It is recommended that you compare this MRSA Age band profile with your admission data (esp. in the higher age bands) to ensure that no age band has a significant disproportionate number of cases.

11. 1.3.5 What is the scale of your challenge? Your MRSA figures have recently been above trajectory. This situation needs to be reversed. Trajectory (T) Actual (A)

12. 1.3.6 Number of MRSA cases split by Augmented Care & Non-Augmented Care The table shows that in the last 12 months, 33% of your cases occurred in Augmented Care. N.B. The national average is 24%. The target is to have zero avoidable infections in Augmented Care. The table below provides a breakdown of where your augmented cases are occurring.

13. 1.4 Suggested target milestones

14. 1.5 Actions for recovery and improvement • We have worked through some of your actions that we suggest need to be undertaken in the short term. These are based on our findings during our 2 day review. • You may wish to expand on these as you develop this action plan locally for the medium to long term and consider the wider findings in section 2 of this report Double Click to Launch

15. 1.6 Encouraging signs • the Chief Executive and the Trust Board now have a strong focus on patient safety and improving the patient experience • there is a very dedicated infection control team, members of which are valued and respected across the trust. • the Director of Infection Prevention and Control is highly regarded throughout the trust by all interviewed staff groups • the organisation has many dedicated clinicians and staff, some working in less than ideal environments, and all committed to making a difference • the outreach team have a model for early warning signs for sepsis that could be adapted for MRSA • there is evidence of some early root cause analysis being undertaken across the trust despite the challenges of IT support • there are some good examples of practice in ITU, including the use of gloves and aprons, hand hygiene, dedicated CVC management and packs and general compliance with EPIC guidelines. continued/…

16. 1.6 Encouraging signs …/continued • there are several education streams for awareness raising, clinical training and clinical skills updating accessible for staff • standards of cleaning were reported and observed to be very high within the trust despite benchmarking of domestic staffing level demonstrating low numbers compared with other trusts

17. Contents • Section 1 • 1.1 Executive summary • 1.2 Your key message & immediate priorities • 1.3 Data analysis • 1.4 Suggested target milestones • 1.5 Actions for recovery & improvement • 1.6 Encouraging signs • Section 2 • 2.1 Key themes • Findings and recommendations • 2.2 People • 2.3 Performance • 2.4 Process • 2.5 Practice • Section 3 • 3.1 Recommended performance reporting • 3.2 Recovery plan Links: Content Page Acknowledgements Section 1 Section 3

18. 2.1 Key themes Performance People Performance frameworks Performance framework ownership Use of data Performance data Audit Pre-48 hour cases Leadership Training Directorate responsibilities and ICT Roles & responsibilities MRSA bacteraemia reduction Processes Practices Hand hygiene High impact interventions Screening & decolonisation Antibiotics Root cause analysis Bed management and transfers Storage space

19. 2.2.1 People Leadership Findings • the Chief Executive is clearly committed to tackling MRSA and meets with the DIPC for a one to one meeting every month, receives monthly trajectory data and is informed of every bacteraemia as it occurs • the review team is not convinced that the sense of urgency and importance and ownership is embedded at all levels of the organisation • many staff and managers expressed the view that the trust had only just taken stock of its position with regard to MRSA relying on the fact that it achieved its trajectory target last year • the only clinical champion for infection control identified by staff in the trust was the DIPC, nominated leads are not in place in all specialties Recommendations

20. 2.2.2 People Training Findings • the trust has several ‘arms’ responsible for clinical skills training and updating. However there is no collaborative approach to these, nor are they standardised or consistent across the trust • infection control team are responsible for the delivery of all mandatory training, stretching available resources • there is a need to review the training and ongoing compliance with aseptic procedures and antibiotic prescribing Recommendations

21. 2.2.3 People Directorate responsibilities and infection control team Findings • the review team was unable to find widespread evidence of responsibility and objectives for infection prevention and control at Divisional level • there are many dedicated matrons and link nurses however the DIPC is attempting to drive this largely on his own with limited support • the infection control team are unclear how they will be integrated into the performance management framework Recommendations

22. 2.2.4 People Roles & responsibilities Findings • whilst there is evidence of infection control responsibilities within some job descriptions and objectives, individuals and teams did not always appear to understand what that meant for them, what they had to do differently, and where responsibilities were shared or individual • roles and responsibilities were not always fully understood in relation to the MRSA target Recommendations

23. 2.3.1 Performance Performance frameworks Findings • an adequate level of MRSA bacteraemia data is not embedded in the Board performance reporting arrangements • targets are not set for each Division to deliver against and own and embed within core business • the current forums run to address MRSA issues do not have appropriate remits or representation by clinicians or multidisciplinary teams to ensure action and delivery Recommendations

24. 2.3.2 Performance Performance framework ownership Findings • whilst progress has been made to focus activity within some specialties, the infection control team appear to be undertaking the majority of the work Recommendations

25. 2.3.3 Performance Use of data Findings • data related to MRSA and other targets is discussed at every public board meeting • the trust intend to develop key performance indicators for infection prevention and control as part of the performance management arrangements within the new divisional structures • feedback from root cause analysis can often be slow and of limited value above identification of obvious factors. • follow up action is not always monitored • poor documentation with relation to intravenous line insertion was observed by the review team Recommendations

26. 2.3.4 Performance Performance data Findings • your data shows that 33% of your MRSA bacteraemias are within Augmented Care. This is above the national average (24%) • other hotspot areas are General Medicine (51%) and General Surgery (22%) • 23% of bacteraemias were diagnosed as being present within 48 hours of admission. This is below the national average (28%) Recommendations

27. 2.3.5 Performance Pre-48 hour cases Findings • 23% of bacteraemias were diagnosed as being present within 48 hours of admission, this is below the national average (28%) Recommendations

28. 2.3.6 Performance Audit Findings • whilst the review team was informed of the many audits that had been conducted, there were numerous ward staff who were unaware of the results from these audits • there did not appear to be a mechanism for sharing learning from the audits within or across specialties nor with future induction, education and training, personal development plans and performance monitoring frameworks • most audits related to HCAI were undertaken by the infection control team Recommendations

29. 2.4.1 Process Bed management and transfers Findings • the review team were made aware that there was a new devolved structure for bed management within the organisation • the trust has wider issues in terms of flow and bed management in relation to whole system demand management Recommendations

30. 2.4.2 Process Storage space Findings • on the whole, clinical areas visited by the review team appeared clean and uncluttered • one clinical area observed to present an issue with space and storage was the renal dialysis ward at Shrewsbury. Patient areas were very close together with little room between one patient and the next. It is recognised this is not conducive to good infection control management and additional stations have been opened at Telford. In addition the trust is actively pursuing further investment for more stations. Recommendations

31. 2.5.1 Practice Hand hygiene Findings • audits of hand hygiene have shown a variable rate of compliance of across staff groups within the organisation – 88% for nursing staff and 78% for medical staff. • for the most part, the review team found that the alcohol hand rub or gel was available at the point of care delivery, with the exception of one or two observed areas Recommendations

32. 2.5.2 Practice High impact interventions Findings • Some High Impact Interventions are used in some of the critical care areas. However the High Impact Interventions are not owned widely across the trust and are not always being implemented in response to the RCA, and could therefore be more focused Recommendations

33. 2.5.3 Practice Screening & decolonisation Findings • there is confusion in some areas around who and when to screen • there is a lack of consistency in applying decolonisation for high risk patients • it was suggested to the review team that some elective patients who were screened at pre-assessment were not decolonised prior to admission Recommendations

34. 2.5.4 Practice Antibiotics Findings • there is evidence that long courses of antibiotics are given • the trust has an antibiotic pharmacist for two sessions only • two sets of antibiotic guidelines exist across the trust • there is no policy for changing from intravenous to oral antibiotics • many patients were treated with intravenous antibiotics for longer than 2-3 days • large amounts of ciprofloxacin Recommendations

35. 2.5.5 Practice Root cause analysis Findings • root cause analysis is currently undertaken by the DIPC but is not as robust as future requirements dictate. It is not always disseminated to the clinical teams in a timely manner, therefore it is not always owned by the Divisions and clinical teams • there is a reluctance to take ownership for root cause analysis at directorate level • appropriate and timely action is not always taken as a result of the analysis of each MRSA bacteraemia Recommendations

36. Contents • Section 1 • 1.1 Executive summary • 1.2 Your key message & immediate priorities • 1.3 Data analysis • 1.4 Suggested target milestones • 1.5 Actions for recovery & improvement • 1.6 Encouraging signs • Section 2 • 2.1 Key themes • Findings and recommendations • 2.2 People • 2.3 Performance • 2.4 Process • 2.5 Practice • Section 3 • 3.1 Recommended performance reporting • 3.2 Recovery plan Links: Content Page Acknowledgements Section 1 Section 2

37. 3.1 Recommended performance reporting Report on actions for recovery and improvement through: • the use of the MRSA improvement programme actions for recovery and improvement template to track progress and report performance into existing governance structures • population of the non-mandatory enhanced facilities on the HPA MESS reporting system to track and analyse key problem areas • undertake robust root cause analysis and share widely- where are the sources of your bacteraemias? • body site and cause, eg leg wound, CVC lines etc • which wards are your hotspot areas? • are there any trends with specific clinicians? • where do you need to focus your efforts? • what clinical practice/culture needs to change • Monday morning sign off (with a situational report) of all your previous week’s bacteraemias and upload to MESS every Monday afternoon • call or meet with the SHA lead, DH MRSA programme manager, trust implementation lead and others from your organisation as appropriate (weekly to begin with) • three month review with members of the PCT, SHA, Department of Health and trust to demonstrate grip and delivery • this report needs to be put on the agenda and discussed at your open trust Board meeting

38. 3.2 Recovery plan • your recovery plan is embedded below. Can you please populate in light of your recent learning, our visit and this report. Please then arrange for it to be signed by your Chief Executive and your host PCT Chief Executive and send to your programme manager, kath.harris@dh.gsi.gov.uk and Sally Batley, Deputy Head, MRSA Improvement Programme, sally.batley@dh.gsi.gov.uk • use the MRSA improvement programme actions for recovery and improvement (embedded in section 1.5) to track progress and report performance into existing trust governance structures

39. Acknowledgements The review team would like to acknowledge all staff within Shrewsbury & Telford NHS trust for their time, honesty and hospitality during the preparation and delivery of this intensive two day review Links: Content Page Section 1 Section 2 Section 3

40. Your key message and immediate priorities • Your key message is : • Accountable and responsible care delivery will support a reduction in healthcare-associated infection • Immediate implementation of the following 3 actions will start you on your journey of reducing your MRSA bacteraemias (please see the embedded document in section 1.5 for your further actions) • undertake root cause analysis within 24 hours of bacteraemia identification and complete within 5 days • develop and share performance information that is understood by all levels of the organisation • instil a culture that reducing MRSA bacteraemias is everyone’s responsibility