the dudley group of hospitals nhs trust - Dudley Primary Care Trust

AppendixTHE DUDLEY GROUP OF HOSPITALS NHS TRUSTINFECTION CONTROL SERIOUS ADVERSE INCIDENTSThis policy provides guidance to staff in reporting, managing and monitoringserious adverse infection control incidents. It is an important component of theTrust’s Policy on Reporting, Managing and Monitoring of Adverse Incidentsand the Trust’s Risk Management and Patient Safety Strategies.Staff should follow the Trust main policy on Reporting. Managing andMonitoring Adverse Incidents for all infection control incidents.All Infection Control incidents should be reported in the same way as otherincidents but in addition the report forms should be copied and sent to theNursing Director /Director of Infection Prevention and Control.The following should be treated as Serious Untoward Incidents and should besubject to Root Cause Analysis Investigation with Action plans developed• MRSA Bacteraemias• Infection control ward outbreaks – MRSA, Clostridium difficile, otherorganisms on advice of the ICT• Serious Infections related to invasive devices• Serious infections on advice of ICTMRSA BacteraemiasThe Strategic Health Authority requires Trusts to follow a common approach toreporting and investigating MRSA bacteraemias which is set out in Appendix 1for information. This has been incorporated into this Trust policy.This Trust is responsible for investigating all post 48 hour MRSA bacteraemias(i.e. those identified in the patients blood stream after the patients has beenadmitted for 48 hours or more).1. Staff must follow the pathway ‘Notification of MRSA Bacteraemia Infections’set out in Appendix 2.2. The Lead Nurse and Consultant ensure that all post 48 hour MRSAbacteraemias have been reported as a serious adverse incident accordingto Trust policy on Reporting, Managing and Monitoring Adverse Incidents.3. The Lead Nurse and Consultant with support from the infection controlclinical champions start the Root Cause Analysis investigation within 12hours and complete this and the action plan within 5 day hours ofnotification of bacteraemia using the proformas and guidance at Appendix3 and 4. As a minimum this investigation should include the Lead Nurse,Consultant, a member of the ICT, and an individual trained in Root CauseAnalysis. The Infection Control clinical champions should be involvedwhere possible. Other staff must be involved e.g. if the patient has been inother wards and departments.

4. The root cause analysis should be used to indicated whether the infectionwas avoidable and if there were any contributory factors. These should beclearly identified on the RCAs5. The Matron and Medical Service Head are responsible for ensuring theRCA and action plan is completed in the timescales.6. The RCA and action plan should be sent immediately to the NursingDirector/ Director of Infection Prevention and Control and the ConsultantMicrobiologist for onward reporting.7. The action plan addressing the main findings, themes and lessons learnedshould be implemented8. The RCA and action plan should be presented to the Clinical UnitManagement Team by the consultant and lead nurse and reported to thefollowing at the next available meetings:a. Infection Control Committee – presented by the Clinical Championsb. The Patient Safety Committee – presented by the Matron andMedical Service Headc. The Integrated Governance committee – as part of the PatientSafety report at the next meetingd. Trust Board – by the Director of Infection Prevention and Control(DIPC) / Governance Lead at the next meetinge. PCT / Strategic HA – by the DIPC by 15 th of each month.f. As part of MESS data – by the Consultant Microbiologist9. The Medical Service Head and Matron are accountable for the MRSAbacteraemias in the clinical unit and are responsible for monitoring theimplementation of the action plan and for reporting through the GovernanceStructure to the Integrated Governance Committee.10. Where a MRSA bacteraemia is noted to be a pre-48 hour infection (patientis clinically symptomatic and tests +ve within the first 48 hours ofadmission) in addition to the abovea. The DIPC will notify the Clinical Governance Lead/ Director ofPerformance and Quality for the relevant PCT.b. Trust staff will work with the Commissioning PCT whoseresponsibility it is to undertake a more in-depth investigation into thecausative factors.11. The Nursing Director/ DIPC, Chief Executive, Medical Director and Directorof Operations will meet on a weekly basis to review all matters related toMRSA bacteraemias.12. The Nursing Director and Consultant will ensure the Chief Executive isassured that all data submitted to MESS (Mandatory Enhanced MRSAsurveillance) is accurate and timelyInvestigation of Other infectionsRoot Cause Analysis following the Trust’s general procedure should beundertaken• Infection control ward outbreaks – MRSA, Clostridium difficile, otherorganisms on advice of the ICT• Serious Infections related to invasive devices• Serious infection on advice of ICT

THE DUDLEY GROUP OF HOSPITALS NHS TRUSTMRSA BACTERAEMIA ROOT CAUSE ANALYSIS INITIAL ACTIONSCHECK LISTPatients nameReason for AdmissionConsultantDate of admissionWardUse the MRSA pathways on Carenet as a guideActionYes / No - add reasonCheck was the patient a high risk?Was the patient screened?If yes, what was the result?Was result documented?If positive resultWas treatment started?Was this documented?Does the patient have an invasivedevice?Central line, peripheral cannula, urinarycatheter, PEG, plural drain, other (specify)Does the patient have a wound/lesionYes / No add sites & dateResult and date availableYes/ No – add whereYes/No/ DateYes / NoYes / No- add typeYes / no =describe type andlocationWere blood cultures taken?Was the blood culture taken within 48hours of admission?If yesYes/ No - Add dateYes /NoPlease email thisinformation to Ann Close –Nursing Directorann.close@dgoh.nhs.ukForm Completed by:NameGradeSignature

ACTION PLANPROBLEM DISCUSSION CONCLUSION ACTION LEADPERSONTIME SCALEREVIEW