Update on the reporting and monitoring arrangements and post-infection review process for MRSA bloodstream infections March 2018
We support providers to give patients safe, high quality, compassionate care within local health systems that are financially sustainable.
Contents 1. Introduction... 2 2. Purpose of the post- infection review... 3 3. Overview of requirements... 4 4. Changes to national statistics... 6 5. Reporting MRSA bloodstream infections... 7 Annex 1: NHS trusts required to undertake post-infection review.. 8 Annex 2: CCGs required to undertake post-infection review... 10 1 > Contents
1. Introduction Patients want to know they are receiving the very best quality of care and reducing the risk of bloodstream infections (BSI) forms part of this. It is essential that we sustain the significant reductions in the meticillin resistant Staphylococcus aureus MRSA BSI and keep the focus on clean, safe care. The government considers it unacceptable for a patient to acquire an MRSA BSI while receiving care in a healthcare setting. It has set healthcare providers the challenge of demonstrating zero tolerance of MRSA BSI through a combination of good hygienic practice, appropriate use of antibiotics, improved techniques in the care and use of medical devices as well as adherence to best practice guidance. The zero tolerance approach to MRSA was reiterated in Everyone Counts: Planning for Patients 2014/15 to 2018/19 published in December 2013, and this approach remains a priority for the NHS. This document outlines the new reporting and monitoring arrangements and postinfection review (PIR) process for MRSA BSI which is part of our Single Oversight Framework. It will support commissioners and providers of care to deliver zero tolerance on MRSA BSI. It amends and supersedes the current requirements for conducting post-infection review on all MRSA BSI outlined in the PIR guidance first published in March 2013 and updated in March 2014 and April 2014 All providers have to be registered with the Care Quality Commission. Mandatory reporting of BSI forms part of this registration under The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance. The mandatory reporting of MRSA BSI will continue as before. Each MRSA BSI must be entered on the Public Health England (PHE) healthcare associated infections data capture system (HCAI DCS). From April 2018 the only change will be to the PIR process. 2 > Annex 1: NHS trusts required to undertake post-infection review
2. Purpose of the postinfection review A post infection review is a process that helps organisations to identify how an MRSA BSI case occurred and identify actions that will prevent it reoccurring. The PIR is conducted by a multidisciplinary clinical team that reviews the BSI event and identifies the factors that contributed to it. The PIR process will: help identify factors that may have contributed to a MRSA BSI case help identify any parts of the patient s care pathway which may have contributed to the infection to prevent a similar occurrence help providers of healthcare and clinical commissioning groups (CCGs) to identify any areas of non-optimal practice that may have contributed to the MRSA BSI help promptly identify the lessons from the case, improving practice for the future identify the organisation best placed to ensure that any lessons learnt are acted on. The PIR process requires strong partnership working by all organisations involved in the patient s care pathway. This close collaboration will enable them to jointly identify and agree both the possible causes and any factors contributing to the patient s MRSA BSI. 3 > Annex 1: NHS trusts required to undertake post-infection review
3. Overview of requirements NHS trusts, foundation trusts and clinical commissioning groups requirements for April 2018 onwards Before April 2018 all MRSA BSI cases underwent a formal post-infection review: https://improvement.nhs.uk/uploads/documents/post-infection-guidance.pdf From April 2018 this requirement will be modified so that formal reviews must only be undertaken for organisations with the highest rates of infection (excluding specialist trusts). This change has been made to refocus trusts and CCGs on infection prevention and control and to focus teams attention on Gram-negative infections and antibiotic resistance. Note all MRSA BSI should still be subject to robust clinical review, regardless of the requirement for PIR. Trusts and CCGs should continue to undertake patient safety reviews on all cases to identify best practice and areas for improvement/learning. See Annex 1 for NHS trusts required to undertake PIRs. See Annex 2 for CCGs required to undertake PIRs. Post-infection reviews will become a local process Currently, the PIR is administered via the healthcare associated infections data capture system (HCAI DCS) hosted by Public Health England. With the move to targeted reviews it will become the responsibility of local teams in the trusts and CCGs, with associated oversight by regional NHS England teams. The HCAI DCS will retain the historic cases and data, but will not allow PIR-related case capture or tracking for cases from April 2018 onwards. 4 > Annex 1: NHS trusts required to undertake post-infection review
Post-infection reviews threshold From April 2018, PIRs will only be required for organisations above a certain MRSA BSI rate threshold, set to capture approximately the top 15% of CCGs and nonspecialist NHS trusts. For 2018/19 based on the previous year s data, this is likely to be CCGs with a rate of 1.6 or more community onset MRSA BSI per 100,000 population and trusts with a hospital onset MRSA BSI rate of 1.7 per 100,000 bed-days or more. Any CCG or trust with a rolling rate that breaches this threshold within year will also have to begin doing PIRs. The rate threshold is a pragmatic method while we develop and evaluate statistical tools to identify trusts or CCGs in which cases have exceeded predicted values. NHS England will maintain oversight of CCG performance and CCGs and NHS Improvement will have oversight of the acute providers performance. In the first instance trusts and CCGs with rates above the threshold are listed in Annexes 1 and 2. This will be reviewed on a rolling 12-monthly basis. 5 > Annex 1: NHS trusts required to undertake post-infection review
4. Changes to national statistics Currently, the MRSA cases are assigned to trusts and CCGs based on the outcome of the PIRs. From April 2018, MRSA BSIs will be reported by time of infection onset versus time of patient admission. Cases where the infection onset is >2 days after admission will be considered hospital-onset cases; all other cases will be considered to be community-onset. Compared with the PIR assignment based method in 2016/17: hospital onset vs trust-assigned cases would have been 313 vs 315 community-onset vs community-assigned would have been 510 vs 232. Using the infection-onset based method, it will not be possible to categorise a case as third party so this option will no longer be used. In 2016/17, third-party cases accounted for 276 out of 823 cases. 6 > Annex 1: NHS trusts required to undertake post-infection review
5. Reporting MRSA bloodstream infections When an MRSA BSI has been identified, it is the responsibility of the organisation from which the sample originated to ensure that the full mandatory dataset is recorded on the DCS (for example, in the case of a GP, the CCG is the responsible organisation and will involve any other provider organisation as necessary). The acute trust hosting the laboratory that processes the sample will usually undertake the actual data entry. (In the case of a centralised laboratory used by several trusts, that laboratory will have the facility to input on behalf of the appropriate trust). Reporting blood specimen contaminants Contaminated blood cultures should continue to be reported as part of mandatory reporting on the HCAI DCS, and the PIR should be completed indicating any agreed contaminants. In these circumstances, the organisation at which the blood culture specimen was taken will be assigned the case as it is best placed to ensure that any lessons learned are acted upon. Targeted post-infection reviews When PIR processes are required the existing templates should be used for this process if there is not a local system agreed. https://improvement.nhs.uk/uploads/documents/post-infection-guidance.pdf 7 > Annex 1: NHS trusts required to undertake post-infection review
Annex 1: NHS trusts required to undertake postinfection review Trust name London North West Healthcare NHS Trust East Kent Hospitals University NHS Foundation Trust Trust type Hospitalonset rate per 100,000 bed-days 3.2 2.8 Bradford Teaching Hospitals NHS Foundation Trust Teaching 2.7 Kingston Hospital NHS Foundation Trust Epsom and St Helier University Hospitals NHS Trust City Hospitals Sunderland NHS Foundation Trust West Suffolk NHS Foundation Trust Barking, Havering and Redbridge University Hospitals NHS Trust Dartford and Gravesham NHS Trust Medway NHS Foundation Trust 2.7 2.3 2.2 2.2 2.1 2.1 2.1 Leeds Teaching Hospitals NHS Trust Teaching 2.0 South Tees Hospitals NHS Foundation Trust 2.0 8 > Annex 1: NHS trusts required to undertake post-infection review
The Whittington Hospital NHS Trust 2.0 Central Manchester University Hospitals NHS Foundation Trust Teaching 1.9 Heart of England NHS Foundation Trust Wrightington, Wigan and Leigh NHS Foundation Trust 1.9 1.9 Barts Health NHS Trust Teaching 1.8 Burton Hospitals NHS Foundation Trust North Bristol NHS Trust Surrey and Sussex Healthcare NHS Trust Airedale NHS Foundation Trust County Durham and Darlington NHS Foundation Trust 1.8 1.8 1.8 1.7 1.7 York Teaching Hospital NHS Foundation Trust Teaching 1.7 9 > Annex 1: NHS trusts required to undertake post-infection review
Annex 2: CCGs required to undertake post-infection review CCG name Community-onset rate per 100,000 population NHS Bolton CCG 4.3 NHS North Somerset CCG 4.3 NHS Bristol CCG 4.2 NHS Vale Royal CCG 3.9 NHS West Norfolk CCG 3.4 NHS West Suffolk CCG 3.1 NHS Corby CCG 3.0 NHS Aylesbury Vale CCG 2.9 NHS Isle of Wight CCG 2.9 NHS Southend CCG 2.8 NHS West Lancashire CCG 2.7 NHS Camden CCG 2.5 NHS Ashford CCG 2.4 NHS Castle Point and Rochford CCG 2.3 NHS Manchester CCG 2.1 NHS Ealing CCG 2.0 NHS Hillingdon CCG 2.0 NHS North & West Reading CCG 2.0 10 > Annex 2: CCGs required to undertake post-infection review
NHS Nottingham North and East CCG 2.0 NHS Darlington CCG 1.9 NHS Dartford, Gravesham and Swanley CCG 1.9 NHS Leeds West CCG 1.9 NHS Northumberland CCG 1.9 NHS South Kent Coast CCG 1.9 NHS Islington CCG 1.8 NHS Mid Essex CCG 1.8 NHS High Weald Lewes Havens CCG 1.7 NHS Southport and Formby CCG 1.7 NHS St Helens CCG 1.7 NHS West Cheshire CCG 1.7 NHS East and North Hertfordshire CCG 1.6 NHS East Lancashire CCG 1.6 NHS East Staffordshire CCG 1.6 NHS Leeds South and East CCG 1.6 NHS Salford CCG 1.6 NHS Tameside and Glossop CCG 1.6 11 > Annex 2: CCGs required to undertake post-infection review
Contact us: NHS Improvement Wellington House 133-155 Waterloo Road London SE1 8UG 0300 123 2257 enquiries@improvement.nhs.uk improvement.nhs.uk Follow us on Twitter @NHSImprovement This publication can be made available in a number of other formats on request. NHS Improvement March 2018 Publication code: CG 46/18