Point of Care TestingPoint of Care Testingfor for MRSAMRSA

Nigel BrenwaldNigel BrenwaldDepartment of MicrobiologyDepartment of Microbiology

Sandwell and West Birmingham Hospitals Sandwell and West Birmingham Hospitals NHS TrustNHS Trust

POCT – ‘The Starting Point’POCT – ‘The Starting Point’

MRSA screening will be required for new MRSA screening will be required for new admissionsadmissions

Rapidity of results most likely to influence Rapidity of results most likely to influence their effectivenesstheir effectiveness

Organisational barriers are likely to prevent Organisational barriers are likely to prevent rapid laboratory turnaround for foreseeable rapid laboratory turnaround for foreseeable futurefuture

Desirable Features for POCTDesirable Features for POCT

RapidRapid

‘ ‘On Demand’On Demand’

Easy to useEasy to use

Clear interpretation of resultsClear interpretation of results

Cepheid Xpert MRSA testCepheid Xpert MRSA test

Real-time PCR methodology Real-time PCR methodology

Detecting orfX – SCCDetecting orfX – SCCmecmec junction junction

Run on Cepheid GeneXpert SystemRun on Cepheid GeneXpert System

Cepheid Xpert MRSA testCepheid Xpert MRSA test

MRSA POCT studyMRSA POCT study

Feasibility of using Xpert MRSA test as Feasibility of using Xpert MRSA test as point of care test for MRSApoint of care test for MRSA

Assess acceptability to staffAssess acceptability to staff

Gain understanding of positivity rates Gain understanding of positivity rates when screening rolled outwhen screening rolled out

MRSA POCT Study - DesignMRSA POCT Study - Design

GeneXpert systems set up in Assessment GeneXpert systems set up in Assessment and Critical Care units in two hospitals in and Critical Care units in two hospitals in TrustTrust

Testing set up in laboratory on City siteTesting set up in laboratory on City site

Systems networkedSystems networked

Xpert MRSAXpert MRSA

MRSA POCT study - DesignMRSA POCT study - Design

1000 admissions screened by Xpert 1000 admissions screened by Xpert MRSA test MRSA test

Double-headed swab used to sample both Double-headed swab used to sample both naresnares

One swab tested on ward, the other sent One swab tested on ward, the other sent to laboratoryto laboratory

Xpert MRSA test performed in laboratory Xpert MRSA test performed in laboratory during normal working hours.during normal working hours.

MRSA POCT study - MRSA POCT study - Ward Staff trainingWard Staff training

Training program by a team of laboratory Training program by a team of laboratory staff designated as trainersstaff designated as trainers

Provided training on sample collection, Provided training on sample collection, performance of test, basic cleanlinessperformance of test, basic cleanliness

On Admissions units majority of testers On Admissions units majority of testers

were HCAs (band 3), on Critical Care were HCAs (band 3), on Critical Care mostly trained nursesmostly trained nurses

MRSA POCT study - MRSA POCT study - Overall results Overall results

Total with paired resultTotal with paired result 988988

Number with errors resultsNumber with errors results 17 (1.7%)17 (1.7%)

Number with invalid resultNumber with invalid result 24 (2.4%)24 (2.4%)

Total with valid paired resultTotal with valid paired result 947947

Paired samples both negativePaired samples both negative 850 (89.8%)850 (89.8%)

Paired samples both positivePaired samples both positive 74 (7.8%)74 (7.8%)

Discrepant resultsDiscrepant results 23 (2.4%)23 (2.4%)

Overall agreement (Lab v Ward)Overall agreement (Lab v Ward) 97.6%97.6%

MRSA POCT Study - MRSA POCT Study - Time to result (Ward v Lab)Time to result (Ward v Lab)

WardWard Time (mean)Time (mean)

Overall meanOverall mean 21.4 hrs21.4 hrs

CCS CITYCCS CITY 23.3 hrs23.3 hrs

CCS SANDWELLCCS SANDWELL 29.1 hrs29.1 hrs

MAU CITYMAU CITY 19.9 hrs19.9 hrs

EAU SANDWELLEAU SANDWELL 22.1 hrs22.1 hrs

Ward v Lab - time to result Ward v Lab - time to result (Monday to Thursday)(Monday to Thursday)

SiteSite Mean Mean DifferenceDifference RangeRange

City HospCity Hosp 10hrs 11mins10hrs 11mins22mins -22mins -

161hrs 4mins161hrs 4mins

Sandwell HospSandwell Hosp 17hrs 54mins17hrs 54mins 1hr 20mins -1hr 20mins -110hrs 49mins110hrs 49mins

MRSA POCT - ImplementationMRSA POCT - Implementation

Xpert MRSA testXpert MRSA testSimple test to setupSimple test to setupGood correlation between Lab and WardGood correlation between Lab and Ward

What else needed to be considered? What else needed to be considered?

POCT – General GuidelinesPOCT – General Guidelines

MRSA POCT - ResourcesMRSA POCT - Resources

StaffStaff- Extra Healthcare Assistants / Nurses- Extra Healthcare Assistants / Nurses

Siting of equipmentSiting of equipment

- Sufficient space for equipment and setting up- Sufficient space for equipment and setting up

StorageStorage- Swabs, Kits , pipettes- Swabs, Kits , pipettes

Waste Disposal Waste Disposal

MRSA POCT - Procedure (SOP)MRSA POCT - Procedure (SOP)

Controlled document – describing methodControlled document – describing method

Forms basis of training manualForms basis of training manual

Accreditation Accreditation

Quick method – ‘At a glance’Quick method – ‘At a glance’

Setting up Xpert MRSA test Running test on GeneXpert System

MRSA POCT - TrainingMRSA POCT - Training

Trainers – Laboratory staffTrainers – Laboratory staff

Trainees - Nurses / Healthcare AssistantsTrainees - Nurses / Healthcare Assistants

- Assessment of competency- Assessment of competency

- Register of trained staff- Register of trained staff

- Ongoing training- Ongoing training

Resource implicationResource implication

Quality AssuranceQuality Assurance

Xpert MRSA Xpert MRSA - Built in’ internal control- Built in’ internal control

- Reagent checks- Reagent checks

Internal Quality Assurance (IQA)Internal Quality Assurance (IQA)- Testing of new batches- Testing of new batches

- Checking of clinical samples- Checking of clinical samples

External Quality Assurance (EQA)?External Quality Assurance (EQA)?

MRSA POCT - Safety IssuesMRSA POCT - Safety Issues

GeneXpert System - Electrical safetyGeneXpert System - Electrical safety

Xpert MRSA kit - COSHH assessmentXpert MRSA kit - COSHH assessment

Disinfection Disinfection

Waste / Sharps disposalWaste / Sharps disposal

IT – Data collectionIT – Data collection

Microbiology computer database

Microbiology

Server

MRSA POCT request form

Patient notes

GeneXpert Ward A GeneXpert Ward B

Interface

POCT MRSA – ‘Growing the bug’POCT MRSA – ‘Growing the bug’

Xpert MRSA detects MRSA DNA.Xpert MRSA detects MRSA DNA.

Require isolate for susceptibility testingRequire isolate for susceptibility testing

Positive patients – additional routine Positive patients – additional routine screening swabs screening swabs

SITE TESTS PATIENTS

CCS City 373 333

CCS Sandwell 309 287

MAU City 3053 2650

EAU Sandwell 1473 1342

TOTAL 5208 4612

MRSA POCT - routine testing MRSA POCT - routine testing (Oct 2008 – April 2009)(Oct 2008 – April 2009)

POCT MRSA - positives POCT MRSA - positives

Ward MRSA Positive

CCS City 7.50%

CCS Sandwell 8.10%

MAU City 6.80%

EAU Sandwell 8.40%

Critical Care Services – Critical Care Services – timing of teststiming of tests

MRSA POCT - SummaryMRSA POCT - Summary

Xpert MRSA provides a high degree of Xpert MRSA provides a high degree of accuracy when used as a POCTaccuracy when used as a POCT

POCT - Significant reduction in time to POCT - Significant reduction in time to obtain MRSA statusobtain MRSA status

Rapid availability of MRSA screening Rapid availability of MRSA screening results should influence the patient results should influence the patient pathwaypathway

MRSA POCT - SummaryMRSA POCT - Summary

However, many other factors need to be However, many other factors need to be considered. considered.

AcknowledgementsAcknowledgements

MicrobiologyMicrobiology

Beryl OppenheimBeryl Oppenheim

Nick BakerNick Baker

Becky WalkerBecky Walker

Kulvir ChanaKulvir Chana Staff on Admissions and Critical Care Staff on Admissions and Critical Care

Units Units at SWBHat SWBH

CepheidCepheid