Enc L - University Hospital Southampton NHS Foundation Trust

1. IntroductionThe attached paper provides a summary report on work to reduce MRSA and Clostridium difficilewithin the Trust for Q1 in 2010-11, and also includes quarter 1 Matron reports.1.1 Summary of progress – Quarter 1 2010/11Category RAG Action /CommentTargets:Provideassuranceof basicinfectionpreventionpractice:MRSA BacteraemiareductionMRSA screeningClostridium difficileinfection reductionReduction of other post48 hour bacteraemiase.g. MSSA.Reduction of sourcerelated infections e.g.Surgical Site Infection,ventilated associatedpneumonia, invasivedevice infections.CQC assuranceframeworkHand hygiene andSaving Lives high impactinterventionsPrudent antibioticprescribing1 post 48 hr MRSA bacteraemia in Q1.Annual target for 2010/11 is no more than 7post 48 hr MRSA bacteraemias.99% of all elective and 99% of allemergency cases screened at patient levelreporting. Matched census reporting>100%.35 cases in Q1. National target for 2010/11is no more than 139 cases with a stretchtarget of no more than 110 cases for theyear.8 Post 48 hr MSSA BSI in Q1.98% compliance with SSI saving livesaudit.100% compliance with VAP saving livesaudits.Amber areas relate to cleanliness and theenvironment, failure to complete isolationrisk assessments and out of date policies.Improved action plans in place.Q1 clinical hand hygiene audit at %compliant. Medical hand hygiene audit forQ1 has not met the target of 95%compliance.NB: MSSA – Methicillin Sensitive Staphylococcus aureus as opposed to Methicillin ResistantStaphylococcus aureus.2