Current information

A total of 20 MRSA bacteraemia cases was reported across the health economy attributable to Kirklees residents in 2010-11. Of these, 13 were reported as pre 48 hour cases (Calderdale 4; MYHT 8 and Leeds 1), with the remaining 7 occurring post 48 hours of admission (CHFT 2; MYHT 4 and Leeds 1).

The patients’ ages ranged from 33 years to 91 years (last year’s age range for MRSA bacteraemia cases was from 39 to 80 years).

33 - 65 years     -    6
Over 65 years    -    14

Thirteen patients were identified as being immuno-compromised with patient risk factors identified as having chronic wounds, diabetes, chronic renal impairment, skin conditions, vascular conditions and the presence of urinary catheters.  13 of the 20 patients had a history of previous MRSA infection or colonisation.

Root cause analysis investigations of the cases were reviewed by the HCAI Health Economy Groups and categorised as 12 being avoidable cases; 4 unavoidable;  3 inconclusive and one not identified (Leeds patient).

Care of the patients was undertaken by podiatry, district nursing and GPs, as well as for some cases social care input. Ten of the cases resided in Care Homes, either nursing or residential.

Learning from the cases has been disseminated to the clinical teams to ensure learning from these incidents becomes embedded into practice. Issues identified from these cases include:

•    Contamination during blood culture procedure
•    Communication; particularly in respect of discharge planning
•    Education and audit of practice within Care Homes
•    Documentation particularly around catheter and wound management
•    Supervision and assessment of competency when family carers manage patients wounds /catheters within the community