Root Cause Analysis MRSA bacteraemia (Initial findings)

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1 Root Cause Analysis MRSA bacteraemia (Initial findings) Background The Department of Health have set out a target for Trusts to halve their MRSA bacteraemia rates by March As part of this the Trust are expect to reduce their rate by 20 percent in 2006, to a maximum of 18 cases. At the beginning of August 2006,the Trust reported a total 13 cases of MRSA bacteraemia to the Health protection Agency (HPA) in the first two quarters of the year (Q1& Q2). If this pattern continues, the Trust will be off trajectory by as early as October Action The Director of Nursing has requested further analysis of the incidents in conjunction with the Infection Control Team. This analysis will help to establish the root cause of the incidents. In addition to this, the Strategic Health Authority (SHA) has also requested that all cases this current year be investigated using root cause analysis (RCA) by individual Managers. Part of the Recovery Action Plan submitted to the SHA outlines the plan to investigate all reported cases to date. The Assistant Director of Nursing, Risk Management, facilitated by the Consultant Microbiologist, is leading this work. A brief summary of findings is detailed later in this paper. From October 2006, any incidents of MRSA bacteraemia will be recorded as a high-risk incident and investigated by the Manager of that particular area, supported by the Assistant Director of Nursing, Risk Management. In addition to the RCA investigations, a survey of peripheral cannulae took place in August (see Appendix). This was undertaken to establish a baseline of the standard of care and documentation. A working party has been established to take actions on the findings of this report. It is believed that by raising standards of practice, it will help reduce the rates of MRSA bacteraemia from peripheral lines.

2 Initial findings The cases are spread as follows: Month Number of cases April 3 May 5 June 3 July 1 August 1 Eleven cases (85%) were from medical wards and two were from a surgical ward. The wards were as follows: Number Cavell 3 Reckitt 2 McCarthy 2 Semple 2 Cloudesley 1 Montuschi 1 Victoria 2 Eight of the patients were discharged, but four are now deceased. One is still an in-patient. Risk Factors The ten risk factors for bacteraemia defined by the Health Protection Agency are: 1. Peripheral cannulae 2. Central line 3. Liver disease 4. Surgical wound 5. Ventilation 6. MRSA colonisation 7. Urinary catheter 8. Prosthesis 9. Diabetes 10. Immuno-supression

3 All 13 patients reviewed had at least one risk factor from this list, and some several. However, nine patients (69%) reviewed had at some point been cannulated and peripheral cannulae used as part of their treatment. Four (31%) had a central line inserted and six (46%) had a urinary catheter. It would appear that peripheral cannulae are the highest risk factor from this group of patients. Overview of findings As the incidents have not been explored with the relevant Managers it would be premature to make a definite conclusion to the root causes of the incidents. However, from the initial review, it appears that there are contributory factors that will appear in most cases: 1. Poor documentation. There is little or sometimes no documentation that outlines the patient s MRSA status. It is sometimes recorded in the medical notes, but rarely in the nursing notes. No patients reviewed had a care plan outlining MRSA as a problem. There is no record of patient isolation or infection control measures put in place to prevent cross-infection. The treatment of the MRSA bacteraemia is not always clearly documented, neither is eradication or screening. There are very few clear treatment plans relating to MRSA bacteraemia. 2. Cannula insertion There is little evidence to support adequate asepsis when inserting and using cannulae. Most cannulae are inserted in the Emergency Department and are not changed in accordance to guidelines. There is evidence that lines are left in longer than necessary and are not checked and changed according to guidelines. 3. Isolation There is no clear evidence of isolating patients. Some patients that are not in side rooms are able to use bathroom facilities shared by other patients with no precautions taken. There are very few clear notices that inform staff and relatives of the precautions required, particularly if the patient is in cohort isolation.

4 4. Asepsis As aseptic technique is no longer assessed as part of nurse training the standard of asepsis is generally poor. There is little evidence of good practice such as trolley cleaning, disposal of waste etc. There is evidence of IV medication being prepared in areas deemed to be inappropriate. Initial findings show that the case reviewed have some common factors that need to be incorporated into the recovery plan for Trust action.

5 Peripheral IV lines Trust wide* audit ~ Initial findings (* Excluding maternity and ITU) Background This audit of peripheral IV lines was undertaken as a consequence of the Department of Health document entitled Saving Lives (High Impact Intervention No2b) which aims to reduce the incidence of peripheral line related infections. Context: Peripheral line insertion is a commonly performed procedure in hospitals and has an associated risk of infection because of the potential for direct microbial entry to the bloodstream. Lines may be contaminated by the patient s skin flora at the insertion site or by the other organisms via the cannula hub or injection port. Elements of the accompanying audit tool were used in this Trust wide audit to establish whether and for how long cannulae remain in situ when not being used and also whether there is clear evidence of documentation relating to initial insertion and daily checks. This audit will also assist with Root Cause Analysis investigations of the Trust cases of MRSA bacteraemia.! Audit undertaken 3 rd and 4 th August 2006! All inpatients assessed excluding Maternity and ITU! 92 patients with peripheral lines were audited! 19/ 92 peripheral lines were in use at the time of the audit! 29% of patients had a cannula in situ at the time of the audit

6 Number of peripheral lines Betty Mansell 7 Cavell 5 Cloudsley 7 Coyle 5 Highgate Treatment Centre 1 Ifor 2 MAU/ McCarthy 10 Meyrick 4 Montuschi 7 NICU 9 Nightingale 6 Reckitt 13 Semple 6 Victoria 10 Total number of peripheral lines = Was date/ time of insertion documented? (n=92) Table 1 Date insertion documented Betty Mansell 0/ 7 0/ 7 Cavell 1/ 5 1/ 5 Cloudsley 3/ 7 2/ 7 Coyle 2/ 5 0/ 5 Time insertion documented Highgate Treatment 0/ 1 0/ 1 Centre Ifor (n=2) N/A N/A MAU / McCarthy 6/ 10 1/ 10 Meyrick 1/ 4 0/ 4 Montuschi 1/ 7 0/ 7 NICU (n=9) N/A N/A Nightingale 3/ 6 0/ 6 Reckitt 1/ 13 0/ 13 Semple 2/ 6 1/ 6 Victoria 3/10 1/10

7 Graph 1: % appropriate documentation (Excluding NICU and Ifor) Victoria Semple % Time insertion documented % Date insertion documented Reckitt Nightingale Montuschi Meyrick MAU/ McCarthy Highgate Treatment Centre Coyle Cloudsley Cavell Betty Mansell

8 2. Were daily checks evident? (N=92) Table 2: Daily checks evident? Betty Mansell 1/ 7 Cavell 0/ 5 Cloudsley 1/ 7 Coyle 0/ 5 Highgate Treatment Centre 0/ 1 Ifor 2/ 2 MAU/ McCarthy 0/ 10 (2xN/A) Meyrick 0/ 4 Montuschi 6/ 7 NICU 9/ 9 Nightingale 0/ 6 Reckitt 0/13 Semple 1/ 6 Victoria 0/ 10 Graph 2: % of daily checks evident Victoria Semple % daily checks evident Reckitt Nightingale NICU Montuschi Meyrick MAU/ McCarthy Ifor Highgate Treatment Centre Coyle Cloudsley Cavell Betty Mansell %

9 3. Was date/ time of last use documented? (n=92) Table 3: Date cannula last used documented? Time cannula last used documented? Cannula in use at time of audit? Betty Mansell 6/ 7 6/ 7 1/ 7 Cavell 5/ 5 3/ 5 1/ 5 Cloudsley* 6/ 7 6/ 7 Coyle 5/ 5 3/ 5 Highgate Treatment N/A N/A 1/ 1 Centre Ifor N/A N/A 2/ 2 MAU/ McCarthy 10/ 10 7/ 10 Meyrick* 3/ 4 2/ 4 Montuschi* 2/ 7 2/ 7 3/ 7 NICU N/A N/A 9/ 9 Nightingale 5/ 6 5/ 6 Reckitt* 9/ 13 8/ 13 2/ 13 Semple 6/ 6 3/ 6 Victoria 10/ 10 8/ 10 (* drug chart unavailable for 1 patient on each ward) 4a) Was cannula left in situ >24hours after last usage? (N=73) This is an approximate estimate, as date and/ or time of last usage was not always recorded. The total number of 73 excludes the19 peripheral lines still in use at the time of the audit Yes 19 (26%) No 54 (74%)

10 4b) Lines left in for >24 hours after last usage: Variation by ward (N=19) Total Reckitt 5 Semple 3 Victoria 3 Cavell 3 Meyrick 2 Nightingale 2 Coyle 1 Summary of initial findings:! Ifor and NICU identified as areas of good practice. Frequent cannula site checks are performed and appropriately documented on a Paediatric IV Infusion Cannula Site Checking form on Ifor ward. Hourly site/ line pressure checks are performed and appropriately documented on a specific observation chart. It should be noted that these areas may need to re-insert lines more frequently than other areas.! Some areas record the insertion date/ time on the cannula dressing however this is not universal practice.! There is some evidence of documentation relating to re-insertion of peripheral lines and infusions in progress, particularly in the paediatric and neonatal areas.! Appropriate documentation relating to the insertion of peripheral lines in the nursing notes is below standard across the Trust.! Daily checks of the site are rarely evident. It is vital that frequent checks are not only performed but also documented appropriately.! The audit was undertaken on a Thursday and Friday. It may be the case that results may differ slightly if this had been undertaken earlier in the week however this is purely supposition.

11 Peripheral IV Lines CHECKLIST Date: /08 /06 No. of beds: : No. of peripheral lines: Pt. No Date of insertion Time of insertion Insertion documented? ( ) Daily checks evident? ( ) Date cannula last used Time cannula last used