RCA has been widely used in the investigation of HCAIs since the introduction of the MRSA bacter- aemia target (see Chapter 3), when it became a requirement that RCA was undertaken for all MRSA bacteraemias. Since then it has been used for the investigation of Clostridium difficile infec- tion and other HCAIs, and as part of the investigation and management of clusters, periods of increased incidence and outbreaks of infection (see Chapter 4). Like audit (see Chapter 3), RCA now forms part of any HCAI reduction programme. It is also widely used for the investigation and management of patient care incidents that are not related to infection prevention and control.
Box 2.3 identifies the healthcare staff who may need to be present at an RCA/PIR meeting.
Box 2.3 Who needs to be present at an RCA/PIR?
Infection Prevention and Control Team Ward Manager
Matron
Head of Nursing
Staff nurses and IC Link Practitioners as appropriate Consultant, Registrar and Foundation Year Doctors Antimicrobial Pharmacist
Representative from the Clinical Commissioning Group
Facilities and Hotels Services Manager (if there are concerns regarding cleanliness standards) Other healthcare professionals as appropriate, such as the Community Infection Control Team,
District Nurses if the patient has had community or primary care involvement, or if the RCA is being held in a community or primary care setting
If the RCA/PIR is being held in a community or primary care setting, the patient’s GP will be involved.
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Box 2.4 Investigating an MRSA bacteraemia
•
Date and time of admission•
Type of admission (elective or emergency)•
Place of residence (own home or care facility) or contact with other health care providers (i.e. hospice/respite care)•
Reason for admission and diagnosis•
Whether the patient was known to be MRSA-positive at the time of admission (i.e. previous history of MRSA colonisation)•
Date and time of blood culture collection•
Number of positive blood culture bottles or sets•
The patient’s medical history (may identify risk factors), including any previous admissions within the last year, and the dates and results of past MRSA screens and other significant laboratory results•
Was the patient screened for MRSA on admission in accordance with Trust policy? Record the date, time and sites screened (were clinical specimens obtained from all appropriate sites?) and where the patient was screened (e.g. Emergency Department, Admissions Unit or ward).•
Did the patient have a vascular access device inserted on admission? Was it put in by the ambulance crew or inserted in the department or ward? Who inserted it, when and why?Is there an insertion and care record? How was the skin decontaminated prior to insertion?
If it was inserted by the ambulance crew, was it removed and re-sited within 24 hours of admission to hospital?
•
Was the patient pyrexial or septic on admission? Were bloods taken? What were the inflammatory markers (see Chapter 8)?•
What interventions were undertaken, and why?•
What ward was the patient admitted or transferred to, and when?The purpose of RCA, or in the case of an MRSA bacteraemia, a PIR is to determine why an incident happened, identify the critical issues or problems (root causes) that led to the incident occurring and take steps to ensure that it does not happen again. To be of value, it needs to be undertaken robustly and involve collaborative working with the multi-disciplinary team, and a detailed preliminary investigation before the RCA/PIR takes place, incorporating a timeline of events, is essential in order to piece together the ‘story’ of what happened. Box 2.4 lists the areas of compliance with infection control practice and policy that need to be investigated with regard to an MRSA bacteraemia.
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•
What was the result of the MRSA admission screen, and when was it confirmed? If positive, was the patient decolonised appropriately (i.e. decolonisation was prescribed and administered correctly for the full five days)? Was the commencement of decolonisation delayed, and if so, why? Are there gaps on the prescription chart, MRSA Patient Management Plan or MRSA Patient Pathway indicating missed doses? Who administered the decol – was the patient self-administering, or was it done by the nursing staff? Were they competent to administer the decol?•
If the patient was MRSA-positive from the admission screen, was he or she isolated or cohort nursed?•
If the patient was MRSA-negative on admission, were there other MRSA positive patients on the ward? If so, where were they nursed in relation to this patient? Had there been an increase in the number of ward-acquired MRSA colonisations amongst patients on the ward?•
Was the patient screened appropriately during his or her admission?•
Is there documentary evidence that all device-related interventions were undertaken appropriately? Examples include recording the dates and times for all interventions, recording VIP scores twice daily and removing or re-siting cannulae at 96 hours if still required, using Instillagel on insertion of urinary catheter (see Chapter 17) and not interrupting the circuit.•
Did the patient have any wounds/areas of non-intact skin or poor skin integrity?•
What were the patient’s vital signs? Did he or she develop a pyrexia? Were the inflammatory markers raised? If so, when and why? What actions were taken?•
Was the patient prescribed antibiotics at any point? If so, what were they, why were they prescribed and were they the correct antibiotics? Had the Team liaised with the Consultant Microbiologist?•
Was the patient’s overall condition improving or deteriorating?•
When was the blood culture taken, why, from which site and by whom? Was the person taking the blood culture competent to do so (evidence of competency required)? How was the skin decontaminated?•
Was the bacteraemia clinically significant, or was the blood culture contaminated through poor collection technique? Was the bacteraemia avoidable or unavoidable?The role of the IP&CT in RCA/PIR is to hold staff to account, challenge poor practice and work with staff in identifying the points for learning and developing and implementing the action plan.
However, it is also important that the process highlights and promotes good practice and that this is shared amongst healthcare teams.
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Three patients on a ward in the same bay develop C. difficile infection (see Chapter 22) over a period of three weeks. It is known that there were delays in isolating the first patient and that there have been some issues regarding clinical practice. An RCA is to be undertaken. What aspects of infection control clinical practice do you think will be relevant to the RCA (you may wish to look at Chapter 3)? What do you think the learning might be?
Reflection point
Chapter summary: key points
•
The IP&CT are the nursing and medical experts responsible for providing evidence-based best-practice advice on all aspects of infection prevention and control.•
They are the only specialist nursing and medical team with responsibility for patients, staff, the public and the environment.•
The IP&CT hold staff to account and challenge poor practice and non-compliance.•
Infection Control Link Nurses and Link Practitioners act as role models and champions for infection prevention and control within their workplace.•
Staff have a professional responsibility and duty of care to protect their patients from HCAIs, and are accountable for their actions.•
It is a requirement of registration with the Care Quality Commission that registered health- care providers are compliant with the Code of Practice on the Prevention and Control of Infections and Related Guidance.•
Root Cause Analysis/Post Infection Review of infection incidents helps healthcare teams to determine why an incident happened, identify the critical issues and problems (root causes) that led to the incident occurring and take steps to ensure that it does not happen again.Further resources are available for this book, including interactive multiple choice questions. Visit the companion website at:
www.wiley.com/go/fundamentalsofinfectionprevention
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References
Burnett E., the Infection Prevention Society and Competency Steering Group (2011). Outcome competencies for practitioners in infection prevention and control. Journal of Infection Pre- vention. 12 (2): 67–90. http://bji.sagepub.com/content/12/2/67 (accessed 1 March 2013) Department of Health (DH) (2004). The NHS Knowledge and Skills Framework (KSF). Department
of Health, London.
Department of Health (DH) (2010). Code of Practice on the Prevention and Control of Infections and Related Guidance. Department of Health, London.
Department of Health (DH) (2011). The Operating Framework for the NHS in England, 2012/13.
Department of Health, London.
Royal College of Nursing (2011). The Role of the Link Nurse in Infection Prevention and Control (IPC): Developing a Link Nurse Framework. Royal College of Nursing, London.
Nursing and Midwifery Council (NMC) (2008). The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. Nursing and Midwifery Council, London.
Contents
Fundamentals of Infection Prevention and Control: Theory and Practice, Second Edition. Debbie Weston.
© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd. Companion Website: www.wiley.com/go/fundamentalsofinfectionprevention
Audit and surveillance
3
Audit 33
Surveillance 36
Surveillance of notifiable diseases 38
Chapter summary: key points 44
References 44
Further reading 45
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Introduction
All healthcare staff are involved in audit and surveillance in some form, and it is an integral part of the Infection Prevention and Control Team’s work as they undertake activities in accordance with their annual audit and surveillance programme. This chapter explains what audit and surveillance are, their importance in the prevention and control of healthcare-associated infections and how they are undertaken, and gives examples of routine audit and surveillance activities.
Learning outcomes
After reading this chapter, the reader will: