CRS delayed MRSA patients being isolated

02 Oct 2007

Problems with the Care Records System installed at Buckingham Hospitals NHS Trust resulted in delays to potentially infectious patients with MRSA not being isolated.

The problem arose as after the new system was turned on historic infection control alerts then had to be manually entered onto the system in the six weeks following go-live

The trust says that between March and July this year potentially infectious patients with MRSA were not isolated for between two and 17 days, because of problems with the Cerner-supplied CRS recently installed at the trust by Fujitsu under the NHS IT programme.

Isolation of patients with infections MRSA forms part of the standard procedure to reduce the spread of hospital acquired infections (HAIs).

Buckingham was one of the first trusts in the South to implement the Cerner Millennium CRS system provided by Fujitsu. The trust’s Wycombe and Amersham sites went live with the system in September 2006. Implementation at Stoke Mandeville Hospital (SMH), also part of the trust, has been postponed until problems with the CRS can be resolved.

Trust board papers state: “The historical MRSA infection alerts needed to be put onto the CRS system manually following ‘go live’. This took approximately six weeks to do during which time there was a possibility that some MRSA positive patients may have slipped through undetected if medical notes were not available.”

The papers add: “There have been several other problems with the system which have resulted in a small number of patients not being isolated promptly. Solutions to these problems are currently being worked on. Implementation on the SMH site was postponed in order to resolve some of the problems the trust has experienced with CRS on the W&A sites first.”

The trust has also reported information governance concerns about the inability to audit the use of CRS system supplied, meaning that the trust is unable to track the use of the system. Trust papers say there are “concerns about no facility to audit the use / inappropriate use of the system, of data sharing and of consent”.

Reader's Comments

Change management

john.cartwright@jowic.co.uk

02 Oct 07 09:01

It seems from the article that it wasn't the CRS that was the problem, but the change management activies around the deployment, ie; not putting the Infection Control data in before hand OR implementing interim processes to mitigate the risk.

The responsibility for these activities should remain with the Trust.

Not so easy

02 Oct 07 15:01

Forcing the Trust to manually re-enter this information because the contracts failed to make data transfer a supplier responsibility, or enable significant information to be electronically moved is not entirely their fault. From a safety perspective, manual re-keying should be a last resort.

The inflexibility of the LSP approach, and the weaknesses in the CRS solution, together with the many bureocratic processes put in place has been enough to overwhelm most of the sites taking the solution so far.

So very easy to blame the Trust, also very inaccurate.

Not just MRSA

director@doctors.org.uk

02 Oct 07 17:30

'Trust papers say there are “concerns about no facility to audit the use / inappropriate use of the system, of data sharing and of consent”.'

While the MRSA issue may make the headline, the article describes a wide range of very serious problems with this implementation, to which there are no simple fixes. The one I quote above is the one most likely to worry patients. This, I suggest, is likely to require very much more than an ordinary program of change management.

Anyone else thinking of implementing Millenium has been warned. I think the Trust has been very wise to postpone any further implementations unless and until all these problems have been sorted out.

Re: Not so easy

sue.wilson@swbh.nhs.uk

03 Oct 07 09:46

You are right in that Data Migration is not so easy, but I am afraid I actually agree with the first reader. The Trust needed to ensure its Infection Control process would be safe-guarded post live of the new PAS

I have similar issues with one of our legacy PAS systems, in that not all the Infection Control alerts are in the new PAS. I can object, but I can't blame the CRS for my failure to find a work around to capture them and provide continuity to the Trust.

Also MRSA is a clinical alert and I am sure the issue is more concerned with the fact that the Trust is migrating to a system which has alerts developed to support an electronic patient record, not a PAS. I would think that there would be difficulties in migrating these alerts to a quite different Class of IT system. Clinical Alerts in an EPR are usually built quite differently.

We may at times be disappointed when we lose functionality we have in our legacy PAS systems. However, it should never negate our responsibility to find workarounds to maintain care delivery systems.

Finding workarounds?

03 Oct 07 11:04

Whilst the Trusts clearly have responsibilities locally (and - of course - it's always been hard to pin down anything on NPfIT / CfH), you do have to wonder about the whole approach to the design and implementation of what's being offered here.

MRSA and blame

04 Oct 07 22:04

Given that most senior execs at Stoke Mandeville NHS Trust were replaced, no wonder the execs are going to blame the software!

Yes it was their fault to not incorporating and managing MRSA and CDT risks, irrespective of the software.

A good hospital infection control team gets the lab results for MRSA and CDT and notifies staff to enable immediate patient isolation. IMHO there is no good reason why the lab staff and infection control staff escape should from any blame.

(post edited by EHI)

No defined alerts in old PAS system

05 Oct 07 09:31

Any alerts in the old IRC PAS system would have been free text in a comment field. This makes migration near impossible. The casenotes should have MRSA markings and should be checked. The excuse may sound plausible but does not ring true.

Old fashioned values!

05 Oct 07 12:59

Call me old fashioned but how can delay in isolation of a potentially infected patient possible be blamed on an IT system - where is the clinician/ nurse responsibility to deal with the information coming from the lab in a timely fashion and isolate and treat the patient appropriately?

Results Delay

05 Oct 07 14:31

Most hospitals still use standard swabs/cultures to detect MRSA. These results can take several days. As a result patients known to have (or be at high risk of) MRSA are flagged so that they can be nursed in isolation until the results are back.

You might think that asking the patient would suffice but it is amazing how much patients fail to remember about their previous medical history.

The actual MRSA problem in CRS is.....

05 Oct 07 16:09

The Millennium CRS DOES NOT TRANSFER this information with the patients record !!!

If a paient is re-admitted, moved to a new new bed or side-room, transferred to another ward - the software simply lost all the alerts.

So it didn't matter how many times it was put in - the data and therefore the alert was lost.

Q:Why didn't the staff simply look at the notes? A: Ever tried to get notes in a DGH at 10pm ?

(It does NOT happen)

Q: why didn't the Nurses ask the patient? A: patients who have spent 4 hours in A&E before admission, then an ambulance across the county because A&E admissions is in a different place to the wards means that the patient is semi-conscoius and the A&E, plus the ambulance are now infected and ready for the next poor person.

Q: Did the staff know this problem with millennium existed? A: YES

Q: Did Fujitsu do something about it in a timely manner? A: NO

Q: Has the problem been resloved? A:, well it was, then the software retro-graded the solution nd it started happening again

Q: who actually informs the ward nurses? A: the overstretched, unperpaid Infection control nurses; most of whom are having problem with involuntary hair loss , now living in sound-proofed billets at the side of the Hospital to stop the screams of anguish reaching the administrators.

Just so you know

IT to aid performance

11 Oct 07 13:48

Last centuary, when we procured our existing PAS, we demanded a facility to flag alerts at the points where Outpatient bookings were being made, Waiting lists manipulated, A&E clerking - all the entry points we could.

We also persuaded the Infection control team to maintain this information on the PAS, as a patients MRSA can clear up over time.

So a decision to put a patient in a side room or at the end of a clinic, and being prepared to take extra precautions is improved and enhanced by our technology, without having to rely on getting the paper casenotes to these locations.

That NCRS fails to do this, along with many other innovations that the NHS has learned to build into their IT to support care over decades is absolutely a fault of the IT, the choice of supplier, and the method of delivery.

This does not absolve staff of vigilence, handwashing and cleansing. There are more citizens outside hospital with MRSA than patients in hospital, and any system should be designed to help reduce the risks.

I'm a bit amazed... quick solutions are available but planning also needs to be absolute..

john_nelmes@hotmail.com

17 Oct 07 14:33

It seems everyone has an interesting contribution to make and that there is an element of positive comment from all concerned parties. So, ignoring such things as financial/legal responsibility and any focus on who's to 'blame', I'd just like to add some simplistic suggestions here...

Firstly, there are automated and generic solutions which are able to resolve all these issues much, much quicker than six weeks. Secondly, on a more human front, if a team has appointed a suitable 'Architect' (who has combined clinical and IT expertise) to advise on planning for this situation (i.e. before the system went live..!!) .. then representatives of Administration, Nursing Management and Infection Control Teams would have been brought together to resolve such matters using an objective Compliance methodology beforehand.. (OK, if you want, call it Change Management or whatever .. but it all boils down to effective communications..) The above two considerations would ensure that any additional data would have been added within a week.. and before the go live date..!!

One further comment ... in these modern days, any legacy data should never, ever be lost or difficult to migrate to a newly installed system... and that includes in some of the cases other contributors to this topic have described.. And even better, this exercise can also be done generically without any concern for supplier brands.

We know the above because this is the type of data management service we already supply in other environments... so hope this might help others feel that all is not lost... no matter who's to blame..?!! Cheers..