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Challenging culture

Challenging culture . MRSA screening and seven day working Dr. Donald Dobie Consultant Microbiologist Royal Wolverhampton Hospitals NHS Trust. Dr. Donald Dobie Consultant Microbiologist New Cross Hospital, Wolverhampton. Teaching Hospital for Birmingham University Medical School

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Challenging culture

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  1. Challenging culture MRSA screening and seven day working Dr. Donald Dobie Consultant Microbiologist Royal Wolverhampton Hospitals NHS Trust

  2. Dr. Donald Dobie Consultant Microbiologist New Cross Hospital, Wolverhampton

  3. Teaching Hospital for Birmingham University Medical School • Cancer services • Cardiothoracic surgery • Renal dialysis unit • Neonatal unit

  4. Background • Infection Prevention is now a top priority • MRSA bacteraemia targets • Political pressure • Scientific interest – NHSScotland studies • Comparisons with Europe • Public and media interest

  5. MRSA in the headlines • Advice from NHS Quality Improvement Scotland was released in October ’07 • Shortly afterwards it was announced that England would be screening all elective admissions as soon as possible and all admissions by 2009! • Molecular tests a possible way forward?

  6. HTA Advice 9NHS Quality Improvement Scotland Based on data in the literature, it was estimated: • Screening agar had a sensitivityof 68% with a 6% incidence of a false-positivetest and a turnaround timeof 48 hours • chromogenic agar had 98% sensitivity, a 0.2% false-positive rate and a turnaround time of 24 hours • real-time polymerase chain reaction had 96% sensitivity with a 5% false-positive rate and a 24-hour turnaround time.

  7. HTA Advice 9NHS Quality Improvement Scotland An economic model showed that: • screening of patients admitted to both high and low-risk specialty units proved most effective at reducing MRSA prevalence rates. • screening all patients for MRSA colonisation by a laboratory test is a more effective strategy in reducing prevalence and preventing infection than screening by clinical risk assessment only. • chromogenic agar has a relatively high sensitivity and specificity at low cost, and is the most cost-effective method of screening in reducing MRSA prevalence.

  8. Implementing guidance • Two bacteraemias in October from low-risk patients who had not been screened • CEO popped into my office! • “How much..?” • I don’t know… about £300,000? • “OK. Let’s do it for everyone.” • Wanted by CEO by the next week!

  9. MRSA screening • Nose • Axilla/groin • Wounds • IV access sites • Urinary catheter exit sites

  10. MRSASelectTM • All screening swabs are plated onto chromogenic media • Two racks – morning and afternoon allow for two readings a day • Incubated for 18hrs at 37°C • Pink colonies – MRSA • White colonies or no growth – Not MRSA

  11. SAID Media • Organisms subbed from MRSASelect to SAID and incubated overnight. • Early morning subbed to Vitek 2 for sensitivity –ready by ~4pm

  12. Reporting & Action • Provisional list telephoned to IPT and/or clinical area of the affected patients • Patient informed and decolonisation with mupirocin and chlorhexidine commenced • Isolation in a side-room if possible • Occasionally NOT confirmed in which case the treatment is stopped

  13. Change in work pattern • “All admissions” screening requires swabs to be put up every day • In order to make screening work the result has to be made available every day • LEAN principles needed to smooth out workflow to minimise peaks and troughs and to maximise efficiency of working. • New working system required

  14. Previous model • Screening of high risk areas – ITU, Cardiothoracic, Vascular, Orthopaedic implant surgery (risk assessment based in OPD) and EAU (risk assessment based) • Lab open 7 days. Mon – Fri, 9 – 5 • Sat 9 – 12.30, Sun urgent/emergency work only • Outside of these hours – on–call

  15. New Model • Working 7 days – Mon – Fri 8am – 8pm • Sat – Sun 9am – 5pm • On call the rest of the time • 1 BMS plus 1 MLA throughout weekend plus 4 additional BMS on Sat am until 12.30pm and 1 additional BMS on Sunday until 12.30pm • 7 extra MLAs and 1 extra BMS

  16. Consultation under A4C • Informed of plan to change working conditions • 8-8 is sociable hours so costs no more • Three shifts - Early (8 - 4), Standard (9 - 5) and Late (12 - 8) • Weekends form part of normal working week • Time off before or after weekend worked

  17. Up and running • Estimated at an extra 120,000 specimens per year • Admissions portals not fully compliant yet • Questions remain regarding follow-up on discharge • A community screening project is currently planned with the local PCT • Otherwise working well

  18. Rapid Molecular Testing • BD GeneOhmTM StaphSR assay • Critical Care screening planned using rapid testing • Versatile • Can run blood cultures, wound swabs and nose swabs

  19. Plan for future • Molecular same day detection may be useful for emergency setting • Follow-up in the community of those MRSA positive will be necessary to reduce overall health economy burden • Decolonisation treatment for all those with MRSA should hopefully reduce the prevalence over time

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