NHS GRAMPIAN
Healthcare Associated Infection Report
September 2010
Introduction
Healthcare associated infection, hand hygiene and cleaning data are routinely collected and monitored by the Infection Control Committee. All Boards are required to produce the attached report for discussion at Board meetings and subsequent publication on their websites.
Aim
To assure the Board that infection rates and interventions are monitored and that appropriate action is taken to reduce the number of healthcare associated infections in NHS Grampian.
Discussion
· There were 3 cases of MRSA bacteraemia in July, the highest number since January 2010.
· Meeting the HEAT target for all Staphylococcus aureus bacteraemias (MRSA and MSSA) continues to be a challenge for NHS Grampian. However, several initiatives are being implemented and are described in the attached report that to try to reduce these infections.
· NHS Grampian continues to be on target meet the HEAT target for Clostridium difficile infections.
· There have been no outbreaks of Clostridium difficile in Grampian since the last report.
· Hospital level hand hygiene data are now available and included in this report.
Key Risks
One very high risk remains on the Infection Control Risk Register relating to a single system for identifying cleaned equipment. As a new system for identifying cleaned equipment is now being introduced and the identification of clean and dirty equipment storage areas at ward level is being investigated, the Infection Control Committee will review the level of this risk at its next meeting.
Conclusion
The Board will continue be kept fully informed of the ongoing improvement work around healthcare associated infection via this regular report.
Recommendation
The Board is requested to note the content of this report.
Dr Roelf Dijkhuizen Pamela Harrison
Medical Director Infection Control Manager
September 2010
Healthcare Associated Infection Reporting Template (HAIRT)
Section 1 – Board Wide Issues
Key Healthcare Associated Infection Headlines for August 2010
· There were 3 cases of MRSA bacteraemia in July, the highest number since January 2010.
· Meeting the HEAT target for all Staphylococcus aureus bacteraemias (MRSA and MSSA) continues to be a challenge for NHS Grampian.
· NHS Grampian continues to be on target meet the HEAT target for Clostridium difficile infections
· There have been no outbreaks of Clostridium difficile in Grampian since the last report
Staphylococcus aureus (including MRSA)
Further actions to address the HEAT target for Staphylococcus aureas bacteraemias are being implemented including:
1. Further analysis of the source of each bacteraemia (see Figures 1 and 2). The graphs below show that a significant number of bacteraemias do not have an immediately apparent cause and therefore root cause analysis of these cases now takes place.
The graphs also appear to show a large number of ‘other’ sources of infection. This category includes a range of sources that would be difficult to graph but include, for example, bacteraemia as a result of discitis.
Although from these graphs it would appear that there are relatively few cases that develop as a result of peripheral or vascular line insertion, some of these cases would be included in the ‘multiple’ category. Also, current thinking suggests that while line insertion may not have taken place during this hospital admission but a previous one and could therefore still be the underlying cause of the bacteraemia.
Figure 1
Figure 2
2. In conjunction with the Scottish Patient Safety Programme, Ambulatory Care services at Aberdeen Royal Infirmary are now exploring the use of care bundles for insertion of peripheral vascular catheters.
3. Continuation of the implementation of such care bundles throughout NHS Grampian as part of the Scottish Patient Safety Programme.
4. Continuation of the MRSA Screening Programme across NHS Grampian.
5. Advice from NHS Quality Improvement Scotland and Health Protection Scotland is being sought to implement continuous improvement methodologies and support ward staff (see SBAR Report in Appendix 1).
Clostridium difficile
NHS Grampian continues to be on trajectory to meet the original HEAT target for CDI. Since the announcement earlier this year of the increase of this target to a 50% reduction by 31 March 2011, the Infection Prevention and Control Team now scrutinise each case thoroughly to consider whether any antibiotic prescribing has been appropriate and the impact of other prescribing risk factors, such as the use of antacid medication or steroids.
Hand Hygiene
The NHS Hand Hygiene Campaign 8 th Bi-Monthly Audit Report July confirmed that NHS Grampian achieved a compliance figure of 95%.
The 9th bi-monthly National Hand Hygiene Audits were completed at the end of July and the compliance score has increased to 96%, although this is unverified at present.
Ongoing issues with the BOXI reporting system mean that hospital level hand hygiene data are still not available.
Cleaning and the Healthcare Environment
Cleaning audit compliance remains well above target at 94% for NHS Grampian. This is despite the introduction of more rigorous cleaning audit processes following the Healthcare Environment Inspectorate (HEI) inspection of Aberdeen Royal Infirmary at the end of last year.
The Infection Control Committee continues to monitor progress on any outstanding actions from the HEI actions plans developing following the inspections of ARI and Dr Gray’s Hospital.
The HEI inspection of Royal Aberdeen Children’s Hospital will take place on 22 and 23 September 2010.
Outbreaks
There have been no outbreaks since the last Board report.
Other HAI Related Activity
Antibiotic Prescribing
Antibiotic prescribing trend information for Acute Hospitals and Primary care can be found in Appendix 2. The first graph shows ‘4C’ trend data and cases of CDI over the same time period. Both graphs demonstrate that all areas are showing a reduction in the use of these antibiotics.
Data collection for the Empirical Antimicrobial Therapy audit has been in place for several months on the triage ward at Woodend Hospital and is ongoing in the Infection Unit, Aberdeen Royal Infirmary. Plans are to initiate it in the AMAUs in ARI and Dr Gray’s Hospital are well advanced. The results of the audits are entered onto an Extranet site to allow for
national reporting. The first report will soon be made available publicly and will allow “benchmarking” against other hospitals and Boards in Scotland. It is vital that the consultants overseeing the data collection are aware of the public nature of the data and are leading on
encouraging any improvements required.
SNAP CAP (Scottish National Audit Project for Community Acquired Pneumonia) antimicrobial prescribing data collection had been undertaken on the respiratory wards until recently, however it has been identified that AMAU and A&E are more appropriate locations for this audit. A project group of 6 of the main centres in Scotland (and including NHSG) is currently working on further developing the audit of care of patients with Community Acquired Pneumonia.
Surgical Site Infections
Statistical process control charts (used to provide feedback to staff) for Caesarian section, hip/knee arthroplasty and breast surgical site infections are contained within Appendix 3. Caesarian section and orthopaedic data date back to 2008 but breast surgery data only started to be collected in 2009.
Surveillance of breast surgical site infections commenced in NHS Grampian in March 2009 as part of the voluntary surveillance for Health Protection Scotland (HPS). At present it has been rolled out in Ward 42 Aberdeen Royal Infirmary but does not cover the implant surgery carried out in the Plastic Surgery Unit, the day cases in Ward 7 Short Stay Unit, or any cases carried out in Dr Gray’s Hospital in Moray. It is hoped that this year the participating wards can be extended to include these. An average of 53 procedures per month were carried out in Ward 42.
Surveillance of hip and knee arthroplasties has been ongoing in NHS Grampian (NHSG) since April 2004, as part of the mandatory surveillance programme for Health Protection Scotland. Two hospitals in NHS Grampian carry out these surgical procedures; Woodend Hospital and Dr Gray’s Hospital. In general, the infection rate this year has been slightly lower than last year, apart from a sudden one-off rise in June 2009. The rate for the last 5 months of the year is below the centre line (average) and if it remains so for the next few months, the centre line will be lowered, indicating a sustained improvement in infection rates.
Caesarean Section Surgical Site Infection Surveillance has been ongoing since 2005, as part of the mandatory surveillance for Health Protection Scotland. Two hospitals carry out Caesarean sections; Aberdeen Maternity Hospital and Dr Gray’s Hospital. The infection rates have fallen since November 2008 and have remained relatively steady since then.
There will be increased scrutiny of the use of prophylactic antibiotics in the coming year, in particular whether or not they conform to local guidelines. Further information on other initiatives to reduce the number of surgical site infections in NHS Grampian will be provided in the next report.
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 of cases of Staphylococcus aureus blood stream infections (also broken down into MSSA and MRSA) and Clostridium difficile infections, 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 aureus bacteraemia (SAB) cases are presented for each hospital, broken down by month. Staphylococcus aureus bacteraemia (SAB) cases are further broken down into Meticillin Sensitive Staphylococcus 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: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=2139§ionID=1
Staphylococcus aureus: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=346
MRSA: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252§ionID=1
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:
http://www.washyourhandsofthem.com/
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 in both 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:
http://www.hfs.scot.nhs.uk/online-services/publications/hai/
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) bacteraemia cases are 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.
Appendix 1
Summary SBAR Feedback to NHS Grampian following a HPS & QIS SAB support initiative visit at the request of the Chief Nursing Officer for Scotland
Date of Visit: 19/8/2010 Date of SBAR: 2/9/10
In attendance: E. Curran HPS, J. Ley NHS QIS
From NHS Grampian: Dr Roelf Dijkhuizen, Dr Annmarie Karcher, Roy Browning, Jenny Ingram, Pamela Harrison, Carolyn Sinclair
S / The CNO requested that HPS work in partnership with NHS QIS to assist the NHS boards, which did not achieve their SAB HEAT target for March 2010 to achieve the modified target of an additional 15% reduction by March 2011. The national SAB data and current trend suggests that NHS Grampian is not on target to achieve the March 2011 SAB HEAT target.B / HPS / QIS acknowledged NHS Grampian’s work to date on reducing SABs.
NHS Grampian had an initial 35% SAB HEAT target reduction. In the baseline year there were 244 SABs. By March 2010 this was reduced to 182 SABs - a 25.4% reduction. This was an actual reduction of 62 SABs from the baseline year, but 23 above the SAB HEAT target for March 2010. During the HEAT target period there was a 44.6% reduction in MRSAs, and a decrease in MSSAs of 17.1%. The target for March 2011 is not to exceed 135 SABs. This is equivalent to a monthly target of no more than 12 (11.3) SABs.
A / The priority areas for current and future action in NHS Grampian include:
· Reduction of contaminated blood cultures from A&E – and the medical directorates generally.
· Optimising invasive device use, including ensuring there is a clear criteria for a decision to insert a PVC as part of an insertion bundle or checklist (ie is the device necessary; hand hygiene; skin prep; no-touch technique; documentation), primarily for A&E and acute receiving wards.
· Optimising vascular access device (VAD) care through reliable use of the PVC bundle throughout and daily device check until the PVC bundle is reliably used.
· Standardising the system of all VADs so that PVCs, CVCs, PICCs and mid-line catheters all had the same dressing, the same needle free device and the same short arm extension.
· Identifying why haematology and oncology have more SABs than in other areas.
· Although there are good working relationships between the infection control team and SPSP, there is not currently sufficient SAB prevention activity to reach the March 2011 HEAT target.
· Whilst the system for collection of SAB data was thorough their still seems to be a high number of primary sources of infection classified as “unknown” which needs further exploration.
R / Next steps: NHS QIS will provide:
· Further tailored improvement support as requested by NHS Grampian.
· Follow-up discussion to agree support, timescales, and clarity of measures to demonstrate local improvement.
· The SAB HEAT Driver Diagram and Change Package to map current activity against, link to integration with SPSP, and help reshape the NHS Grampian SAB HEAT action plan where appropriate.
HPS will:
o Provide NHS Grampian with information data from other boards that have produced additional tools to reduce PVC-related SABs.
o Provide NHS Grampian with additional information on reducing contaminated blood cultures.
o Offer assistance in reducing the number of SABs of unknown primary causes and providing clear messages on the problem caused by contaminated blood cultures and vascular access devices.
Appendix 2