Healthcare Associated Infections Report HAIRT

Healthcare Associated Infection Reporting Template (HAIRT)

Section 1– Board Wide Issues

Key Healthcare Associated Infection Headlines for November2010

This section should open with a few key headlines relating to HAI activity in the Board. These can either highlight good progress or potential issues e.g.

There were zero cases of Clostridium difficile infection (CDI), or Staphylococcus aureusbacteraemia (SAB) in Dr Gray's Hospital or WoodendHospital in August and September.

Staphylococcus aureus (including MRSA)

Current HEAT Status

Following non-achievement of last year’s HEAT target of 35% reduction of Staphylococcus aureusbacteraemia(SAB) rates by March 2010, NHS Grampian continues to face challenges in meeting its further 15% reduction in SABs to meet the new target for2010/2011.

The HPS quarterly report on the surveillance of Staphylococcus aureus bacteraemias which was published on 6 October showed that at the end of June the reported SAB rate in NHS Grampian was 0.404episodes per 1000 acute occupied bed days (AOBDs) compared with 0.326 for NHS Scotland as a whole.

For MRSA bacteraemia the rate was 0.007 episodes per 1000 AOBDs compared with 0.061 in NHS Scotland. For MSSA bacteraemia the rate was 0.396 cases per 1000 AOBDs

compared with 0.265 in NHS Scotland. NHS Grampian’s MRSA bacteraemia rate is lower than the national average but our MSSA bacteraemia rate is higher.

Initiatives to reduce Staphylococcus aureus bacteraemias

The CNO (2010)1 letter, ‘National Support Framework for NHS Boards’ (published on 29 September) outlines the development of a nationalframework to support boards when responding to HAI incident/outbreaks, aswell as HEI findings and surveillance exceedence. It is also intended to offerboards the assurance that support being asked for is appropriate for

responding to the particular circumstance being faced. This framework iscurrently being tested through the provision of support to Boards in thedelivery of the additional 15% SAB target to be met by end March 2011. This support is being delivered by NHS Quality Improvement Scotland’s iiiP Team who will be working with the Infection Prevention and Control and Scottish Patient Safety Teams in NHS Grampian to implement specific interventions designed to reduce the number of SABs that occur. These have previously reported but the most important interventions are:

The development of ‘critical moments’ for PVC insertion in Accident and Emergency in Aberdeen Royal Infirmary (ARI). These are 5 ‘must do’ parts of the PVC insertion procedure which should be done under all circumstances, even emergencies.
The testing of a blood culture pack (for taking specimens of blood) in ITU in ARI that ensure that specimens are not contaminated before reaching the laboratory. Contaminated specimens can lead to patients being incorrectly diagnosed and unnecessarily treated for a SAB.

Clostridium difficile

Current HEAT Status

NHS Grampianis currently on trajectory to meet our HEAT target. Revision of theClostridium difficile HEAT target in May 2010 now gives NHS Grampian a HEAT target to reduce the rate of Clostridium difficile infection in patients over 65 years old by atleast 50% by April 2011. This means that the rate of CDIs should be no greater than 0.381 per 1000 AOBDs in patients over the age of 65 by April 2011. Please note that this template, and specifically the HEAT target graphs on Page 7cannot be amended to reflect this latest target.

The HPS quarterly report on the surveillance of CDIwhich waspublished on 6 October showed that at the end of June the reported CDI rate in patients over 65 years old in NHS Grampian was 0.48 episodes per 1000 AOBDscompared with 0.326 for NHS Scotland as a whole.

Initiatives to reduce Clostridium difficile infections

NHS Grampian continues to embed the recently reviewed antibiotic prescribing guidelines for primary care. This has been reinforced with a communication to all NHS Grampian GPs/primary care nurse prescribers/practice nurses providing further reminders about the rate of CDIs that are diagnosed in primary care and the prudent use of antibiotics for common winter illnesses.

Please also see the section on page 4 regarding compliance with antibiotic prescribing.
Hand Hygiene

The NHS Hand Hygiene Campaign 9thBi-monthly Audit Report which was published in September confirmed that NHS Grampian achieved a compliance figure of 96%, a 1% improvement on the previous results.

Cleaning and the Healthcare Environment

Cleaning

Cleaning audit compliance remains well above target at 94% for NHS Grampian. This is despite the introduction of more rigorous cleaning audit processes. TheNHSScotland National Cleaning Services Specification Quarterly Compliance Report for Quarter 2 (Jul-Sept) is due to be published by Health Facilities Scotland on 25 November 2010.

Cleaning compliance is currently lower in WoodendHospital than across NHS Grampian as a whole. Actions to address this include:

Head of Service to request external verification of audit results as there appears to be inconsistency in results.
Head of Service to highlight concerns and seek clarification of approach at future National Monitoring Operations Group and Domestic Services Advisory Group.
Domestic Manager to discuss with the DayHospital manager issue of patient related duties taking priority over cleaning duties.

Healthcare Environment

The recent Healthcare Environment Inspectorate(HEI) visit to Royal Aberdeen Children’s Hospital resulted in 11 requirements and 9 recommendations, despite being considered at the time to be a positive visit.

Overall, the inspection team found evidence that NHS Grampian is working hard to comply with the majority of NHS QIS HAI standards to protect patients, staff and visitors from the risk of acquiring and infection. In particular:

the hospital was clean
isolation practices are good and the management of patients with known or suspected infection is clear, and
there is clear understanding of relevant issues and what should be in place for antimicrobial prescribing for paediatric patients.

However, the team did find that further improvement is required in the following areas:

reporting arrangements and links between the Royal Aberdeen Children’s Hospital and the paediatric ward at Dr Gray’s Hospital require to be formalised
recognition and consideration needs to be given to surveillance data and information on display to make it meaningful and suit the needs of patients and visitors, and
public involvement should be increased at the Royal Aberdeen Children’s Hospital to ensure young people and/or parents are involved in infection prevention and control activities.

A full action plan was developed and is available on the HEI website. A member of the HEI Group at RACH will be asked to provide regular updates to the Infection Control Committee.

Outbreaks

There have been no outbreaks of healthcare associated infection since the last report.

Other HAI Related Activity

Antimicrobial Prescribing

The most recent Scottish Antimicrobial Prescribing Group Empirical Prescribing Report, published in August 2010, provides an update on progress made by NHS Grampian against the 3 CDI HEAT Target antibiotic indicators. These indicators are:

Hospital-based empirical prescribing: antibiotic prescriptions are compliant with the local antimicrobial policy and the rationale for treatment is recorded in the clinical case note in ≥95% of sampled cases

Surgical antibiotic prophylaxis: duration of surgical antibiotic prophylaxis is <24 hours and compliant with local antimicrobial prescribing policy in ≥ 95% of sampled cases

Primary care empirical prescribing: seasonal variation in quinolone use (summer months vs. winter months) is < 5%

Locally data is collected from Acute Medical Assessment Units in Aberdeen Royal Infirmary and WoodendHospital and following graphs demonstrate an increase in compliance with all 3 indicators.

Antibiotics compliant with empirical prescribing policy

Median: 100% Target: ≥95%Change in Median from May 2010: +8%

Indication for antibiotic treatment recorded in notes

Median: 100% Target: ≥95%Change in Median from May 2010: +8%

Combined measure: policy compliant and indication documented

Median: 100% Target: ≥95%Change in Median from May 2010: +10%

Healthcare Associated Infection Reporting Template (HAIRT)

Section 2 – Healthcare Associated Infection Report Cards

The following section is a series of ‘Report Cards’ that provide information, for each acute hospital [and key community hospitals – delete if appropriate] in the Board, on the number ofcases ofStaphylococcus aureusblood stream infections (alsobroken down into MSSA and MRSA) and Clostridium difficileinfections, as well as hand hygiene and cleaning compliance. In addition, there is a single report card which covers all community hospitals [which do not have individual cards], and a report which covers infections identified as having been contracted from outwith hospital. The information in the report cards is provisional local data, and may differ from the national surveillance reports carried out by Health Protection Scotland and Health Facilities Scotland. The national reports are official statistics which undergo rigorous validation, which means final national figures may differ from those reported here. However, these reports aim to provide more detailed and up to date information on HAI activities at local level than is possible to provide through the national statistics.

Understanding the Report Cards – Infection Case Numbers

Clostridium difficile infections (CDI)and Staphylococcus aureusbacteraemia(SAB) cases are presented for each hospital, broken down by month. Staphylococcus aureus bacteraemia(SAB) casesare further broken down into Meticillin SensitiveStaphylococcus aureus (MSSA) and Meticillin Resistant Staphylococcus aureus (MRSA). Data are presented as both a graph and a table giving case numbers. More information on these organisms can be found on the NHS24 website:

Clostridium difficile:

Staphylococcus aureus:

MRSA:

For each hospital the total number of cases for each month are those which have been reported as positive from a laboratory report on samples taken more than 48 hours after admission. For the purposes of these reports, positive samples taken from patients within 48 hours of admission will be considered to be confirmation that the infection was contracted prior to hospital admission and will be shown in the “out of hospital” report card.

Understanding the Report Cards – Hand Hygiene Compliance

Good hand hygiene is crucial for infection prevention and control. More information can be found from the Health Protection Scotland’s national hand hygiene campaign website:

Hospitals carry out regular audits of how well their staff are complying with hand hygiene. The first page of each hospital report card presents the percentage of hand hygiene compliance for all staff inboth graph and table form.

Understanding the Report Cards – Cleaning Compliance

Hospitals strive to keep the care environment as clean as possible. This is monitored through cleaning compliance audits. More information on how hospitals carry out these audits can be found on the Health Facilities Scotland website:

The first page of each hospital Report Card gives the hospitals cleaning compliance percentage in both graph and table form.

Understanding the Report Cards – ‘Out of Hospital Infections’

Clostridium difficile infections and Staphylococcus aureus (including MRSA) bacteraemiacasesare all associated with being treated in hospitals. However, this is not the only place a patient may contract an infection. This total will also include infection from community sources such as GP surgeries and care homes and. The final Report Card report in this section covers ‘Out of Hospital Infections’ and reports on SAB and CDI cases reported to a Health Board which are not attributable to a hospital. Given the complex variety of sources for these infections it is not possible to break this data down in any more detail.