MRSA Objective  
A new Objective for MRSA: National Quality Board and Department of Health stakeholder engagement

The stakeholder engagement activity overseen by the National Quality Board on a new MRSA Objective to continue to reduce infections in the NHS closed on the 24th July 2009.

Key questions raised by the National Quality Board and Department of Health are outlined with our response:


What is your response to the view that we set a national bar that organisations need to meet?



The Objective should be no avoidable infections.  Setting a national bar is perverse in that it states there is a level that is acceptable.  There will always be some infections, and it is not possible to define an irreducible minimum.  As far a bacteraemias are concerned, there are some Trusts who are achieving zero MRSA bacteraemias through the interventions in Saving Lives being rigorously implemented.  If a Trust has a bacteraemia then the common sense approach is to carry out the route cause analysis to identify why and put measures in place to avoid it again, but sometimes it is not always possible to identify why, provided the methodology used is sound and the Trust Board considers this as a priority on their agenda at Board meetings, then that is the Objective we are seeking - "Every Infection Matters" (Bedford Hospital NHS Trust)



We have shown examples of the median and the best-performing quartile for this bar, what do you think of these?



There are some Trusts that need much tougher targets, whilst others have an outstanding track record, and continue to improve.  There is an opportunity to bring performance in line across the board and having more specific local targets will achieve a better outcome for patients.




What is your response to the idea that organisations meeting the "national minimum standard" should continue to be challenged?  We have suggested either asking for this improvement to be determined locally or setting a 10% reduction.  What do you think of these suggestions?



Current poor performers should have to reduce their infections rates by 60% year on year, those in the median should reduce by 50% year on year, those who have fewer infections should reduce year on year, and those with zero should aim to maintain this performance.  A common sense approach to registration with the CQC and meeting those requirements would need to be taken.  "No avoidable infections" is an Objective that all Trusts should be aiming for, the targets suggested here could save around 1,500 people getting a bacteraemia if the 2008/09 baseline is used (1 April 2008 - 31 March 2009) 

-      Trusts in the bottom quartile should achieve a 60% reduction year on year, to 19 bacteraemias

-     Trusts with 20-39 bacteraemias should achieve 50% reduction year on year

-     Trusts with 19 bacteraemias should achieve a 15% reduction year on year, zero being an aspiration, and no more than 9 in a year


There is a very strong case to support the publication of urinary and catheter infections, the Renal Units use of metrics to drive performance has to be applauded, which is why MRSA Action UK and other patient groups support the wider publication of infection rates.  The UK arguably has the best data collection system in the world and we should use it to drive performance and drive down infection rates.




How do you think the Objective should be applied over a number of years?  We have suggested either a fixed goal for organisations to aim at, or a yearly recalculation to drive improvement.  Which of these options do you prefer, or is there another option that would make more sense?



The formula outlined above would require yearly recalculation and makes more sense, whilst the target set by John Reid was a key driver in the achievements seen nationally, we started at a much higher level, now the focus needs to be local.




What do you think the timetable for delivery should be?  We suggest that this should be decided according to how challenging the Objective is - a year or a number of years.



The baseline should be from 1 April 2008 - 31 March 2009.  Since year on year improvements are a requirement in the Public Service Level agreements, this is not an unreasonable goal, and is measurable.




Using a three year rolling average to measure performance (instead of the total over one year) has also been suggested - over what period do you think performance against the Objective should be measured?



At this stage some Trusts are not performing as well as they could, until all Trusts have the ethos of "no avoidable infections" performance needs to be considered on an annual basis.




Do you agree with the assessment of the equality and human rights issues regarding the Objective set out in the impact analysis document?  Do you believe there are other areas we should consider?



The MRSA Objective should be extended beyond MRSA bloodstream infections.  "Rate of MRSA cases" in the Operating Framework commitment implies all MRSA infections, and as such we should be striving to include at least surgical site infections, as there is data collection already happening in hospital trusts where high risk procedures are measured. The public do want an overall reduction in all infections and feedback shows they feel misled when headlines in local papers state "zero MRSA" in hospital trusts, when in fact this only relates to bloodstream infections. 


MRSA Action UK believe there must be a strong emphasis on the use of route cause analysis supported by the Care Quality Commission's assessments as this will send a strong message to healthcare providers across the wider healthcare economy that we should take a zero tolerance approach to avoidable infections, the use of route cause analysis will identify which infections were avoidable and ensure measures are taken to avoid future occurrences.  We are pleased to see it is the intention for CQC to increase the frequency of the periodic review with a view to a quicker response to addressing areas of concern.  This will focus providers' and commissioners' minds.


For the denominator bed day rates enables good time series analysis as this has been used in the past, however admissions may be more attractive to 'non-statisticians' for clarity.  Showing the number of MRSA bacteraemias as a proportion of admissions (excluding zero days) would be a very clear way of presenting the data, and will help people who want to make a choice about where they are treated, people wanted to know the individual risk to them based on their own circumstances, this latter point also supports our view that data should be published at hospital level on the NHS choices scorecard.  We would recommend admissions as the denominator with bed day rates also published, at least in the first year, for comparison.


MRSA Action UK supports the view that there should be no adjustment for case mix. It could send the wrong message in terms of tolerance, trusts need to manage risk based on their particular case mix.


MRSA Action UK believe a Statistical Confidence interval should be published for the purposes of performance management and comparability, the mandatory Surgical Site Infection data collection shows confidence intervals so this is a useful tool.  There should be a uniform approach to publishing performance data on MRSA for both people managing performance and the public.


MRSA Action UK welcome the opportunity get PCO's engaged, splitting between 48-hour cases would help to achieve this engagement, and give a fairer reflection on Trust performance.


C.difficile has very different controls and as such trying to put the same time factors on detection may give the impression that we are 'over standardising' the issues rather than looking at why we are using these metrics. 


Other metrics can be used to look at performance with other providers, for example the use of performance measures being collected from Care Homes on residents HCAI status in care plans, whether these are admissions or discharges, this encourages partnership working and helps the NHS meet its constitutional obligation to provide all patients with a care plan, and discuss the treatment of colonisation and / or infection.




The impact analysis document discusses the potential costs and benefits of meeting the Objective.  We would welcome further input to refine our estimates.  In particular your assessment of the likely local costs and resource implications of delivering this type of Objective? Are there any pieces of evidence we should consider to enable us to fine tune our assessment of the resources required within Trusts to deliver the Objective?



We believe is it vital to get the resources required right, therefore you would need to look at the expenditure of Trusts with the best track record on preventing bacteraemias, it may be that in the short term the investment needed will be substantial, however longer term the cost benefits will show with the numbers of people contracting infections reducing.  You cannot put a price on life and quality of life.




MRSA Action UK

24 July 2009


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