Guidance on Local Healthcare Associated Infection (HAI) Surveillance Programmes and producing a Local Surveillance Programme

Transcription

1 Guidance on Local Healthcare Associated Infection (HAI) Surveillance Programmes and producing a Local Surveillance Programme Health Protection Scotland July 2009

2 Introduction At a clinical level hand hygiene is considered to be the single most important means of preventing healthcare associated infections (HAI). For the infection control team, the single most important means of preventing and controlling HAI is an effective, data-driven local infection control surveillance programme that provides evidence for the rationale, efficacy, patient safety and benefit of their infection control programmes and the evaluation of infection control within clinical areas. Therefore, NHS Boards number 1 priority in relation to infection prevention and control is to be assured that infection control teams use data effectively to prevent and control infection and measure the efficacy of their programmes and the actions of their front-line clinical colleagues. This paper provides guidance on the characteristics of effective local data-driven local infection control systems and gives examples of what this may look like in practice. HPS July 2009 Page 2 of 15

3 Purpose and differences between Local and National Surveillance Programmes National surveillance uses locally collected data: To monitor disease trends over time To develop epidemiological knowledge of HAI To identify differences between individual NHS boards performances To facilitate benchmarking between NHS Boards Local surveillance should enable individual NHS boards: To rapidly identify and resolve infection control triggers To quantify the burden and risk of HAI to the NHS Board To reduce the burden from HAI To evaluate the efficacy of their infection control teams. Local HAI surveillance should provide near real time continuous assessments of infection risks throughout the organisation. It should focus on individual wards and management units. As local HAI surveillance focuses on smaller areas of health care activity, it should be able to identify problems occurring at these levels, i.e. every clinical unit. National HAI surveillance by contrast is only able to determine if there are issues occurring at the level of whole NHS Boards. To completely understand and direct programmes surveillance data may need to be analysed at multiple levels within any given organisation, e.g. at ward, directorate, service, specialty, hospital and at the level of the NHS Board. Although many alert organisms and clinical conditions must be monitored continuously, because they generally have a low incidence or prevalence, they are not useful as continuous proxy markers of the effectiveness of infection prevention and control practices at local ward or unit level. Only a few organisms are useful as proxy markers for continuous monitoring of local infection control practices. MRSA and C. difficile are the two organisms used for this in Scotland currently. However, organisms including ESBLs, or VRE, i.e. organisms with low prevalence in the community and/or unique resistance pattern, should also be surveyed to detect any obvious cross-transmission that may be occurring and which should require HPS July 2009 Page 3 of 15

4 investigation. Paediatric hospitals could use the seasonal RSV outbreaks for the same reason. All clinical teams in the NHS need data to improve and understand their performance, local surveillance data fed back to clinical teams is critical to enabling clinical teams become data rich. It is not just clinical teams that need local surveillance data to act, managers at all levels of the organisation need data to monitor various situations within the clinical areas under their supervision to facilitate effective management and utilisation of resources. The management should receive data feedback from ICTs appropriate to their sphere of influence. HPS July 2009 Page 4 of 15

5 Recommendations 1. There should be a local surveillance programme in each NHS Board which the objectives and efficacy of which is reviewed annually by clinical governance/risk management, HAI Executive Lead and externally via monitoring of HAI standards. 2. The local surveillance programme includes the following: The aims and objectives of the local surveillance programme The limitations of the local surveillance programme The specification of what organisms and clinical conditions are under surveillance Explanations and definitions used in the surveillance programme The Trigger Levels for clinical areas by alert organism category in all clinical areas Trigger Responses and resolution of triggers including completion of action plans for system changes Definitions of outbreaks and response Details of the methods of analysis of data Distribution and methods of data feedback Examples of what the local surveillance plan could look like are included in the next few pages. HPS July 2009 Page 5 of 15

6 A Sample and Supporting Schematics Blue writing indicates what should be in the local surveillance programme, Black writing gives supporting information The Aims and Objectives of our The Objectives for our are to provide information that will inform, direct and evaluate infection control activity within our NHS Board. This will be achieved by: o Detecting from the analysis of routine laboratory data, alert signals (significant increases) in all clinical areas of alert organisms/communicable diseases (see specifications) in all individual clinical settings within the NHS Board. o Setting trigger levels points at which the ICT will respond by investigating to identify possible system failures, and assessing each new case/isolate in the context of whether a potential trigger level has been reached. o Monitoring and feeding back the numbers of new patients in all clinical areas with ward/clinical area acquired MRSA and C. difficile (and other organisms/infection categories if they can be used as a quality indicator), allowing ongoing assessment of the stability and control of infection control systems. o Generating the local epidemiology of alert organisms and clinical diseases enabling the risks to patients in the NHS Board to be quantified and the infection control programme to be tailored to the NHS Board s needs. o Determining the incidence and trends of alert organisms that are associated with healthcare and those which although not healthcare associated require numeration to determine the overall burden of disease within the NHS Board. o Evaluating the infection control care of patients with communicable diseases and alert organisms report on the numbers of failures to isolate, cross-transmission incidence and appropriate device utilisation. o Identifying the most effective targets for infection prevention to be included in the annual programme. o Evaluating the success of the infection control team s surveillance and infection control programmes. (These objectives are schematically illustrated in Table 1 and Schematic I) The limitations of our local surveillance programme The limitations of our local surveillance programme are as follows: o The system relies on the assumption of consistency in sending specimens and alerting the infection control team. o It is not always possible to determine where all alert organisms and communicable disease are acquired. o Any significant turnaround times that delay detection and control of infection HPS July 2009 Page 6 of 15

7 o Resource limitations should also be recorded here which should include any competency deficits within the infection control team. Specifications of what is under surveillance List the activities and organisms that are included in the surveillance or confirmation that the list includes all criteria in Table 1. Explanations and definitions used in the surveillance programme Provide an explanation of how the surveillance progamme operates and the definitions to be used, e.g. ward acquired, hospital acquired. Supporting Information: Definitions are critical for effective surveillance programmes; they ensure that data are comparable over time within a unit and between units. For consistency and validation, wherever possible national definitions for surveillance should be used in local surveillance. Where there are no national definitions, organisms should be defined relative to the objectives of the surveillance. NHS boards should have these local definitions documented and applied consistently to facilitate inferences to be generated from the data. The Trigger levels for clinical areas by alert organism category List the trigger levels for individual clinical areas for alert organisms / clinical conditions that are under surveillance and confirm that all clinical areas are aware of the triggers set by ICTs. Supporting information: A trigger is not synonymous with the term outbreak. Some triggers may be outbreaks but some will be natural variation in the incidence. A trigger is a more sensitive point at which the ICT becomes concerned that there may be the possibility of deteriorations in systems causing an increase in cases and decides intervention is necessary to ensure patient safety. (Guidance on setting Triggers has been prepared by HPS link) Trigger Responses and resolution of triggers including completion of action plans for system changes When a trigger level is reached the ICT will, having confirmed the numerator and denominator data are correct deploy a Trigger Tool to identify and rectify infection control problems. Results of the Trigger Tool utilisation will be sent to the ward manager, consultant in charge and reviewed by clinical governance and risk management committees. Supporting Information: An Alert Signal Algorithm is shown as Schematic 2. Trigger Tools that could be available to ICTs are contained in the Schematic 3. The response schematic is shown in Schematic 4. HPS July 2009 Page 7 of 15

8 Definitions of outbreaks An outbreak is defined as either two or more linked cases of the same illness, associated in person, place or time, or as a situation when the observed number of cases in an illness unaccountably exceeds the expected number (SEHD 2005). If an outbreak is detected without a trigger point being detected the NHS Board Outbreak Plan will be deployed. Supporting information: definitions used in national surveillance will not be the same as those used for local surveillance. ICTs should be clear regarding the need for different definitions. Local surveillance definitions will be more inclusive. Details of the methods of analysis of data Specify precisely the methods used to analyse the data and how frequently this is done. The communications chains that will be activated should problems arise should also be specified. Supporting information: The critical issue in reporting is being able to differentiate normal variation from special case variation. In order to do this effectively, inferential analyses are required to allow real time detection, of both improvements and deteriorations. To provide the means of rapid detection and rapid response, the use of statistical process control (SPC) charts has been advocated (Harrington, Watson et al. 2007; Thor, Lundberg et al. 2007; Curran, Harper et al. 2008). This allows real time detection, of both improvements and deteriorations (Benneyan 1998; Benneyan 1998). It must be clear what the SPC is measuring, for example if the SPC is measuring the number of new cases of MRSA then an exception will identify only that the number of new cases identified in the ward is significantly increased. However, if the SPC is measuring ward-acquired MRSA then an out of control signal could represent a significant change in infection prevention and control practices. It is not easy to identify where all MRSAs are acquired, but epidemiological definitions consistently applied can for all the limitations provide a useful measure of care (Curran et al 2002). SPCs are easy to use and interpret. They are also easy to incorrectly produce and therefore misinterpret. Consequently NHS Boards will need support to get this method of surveillance and feedback deployed within their area. Quality assuring SPCs produced locally will be essential until those producing and interpreting them have sufficient knowledge and experience to do so. SPCs require 25 data points before a valid control limit can be produced. Where these data are unavailable the use of run charts can assist local teams in estimating variance and exceedance. A good local surveillance programme using SPCs will be capable of detecting in real time significant problems; it will not be capable of identifying what the problems are. To do this there must be action or trigger tools based on the evidence in the literature that can rapidly detect the cause of an alert signal. As different organisms have different modes of transmission and control measures that halt that transmission, the trigger tools must be organism specific. As a minimum each NHS Board should have HPS July 2009 Page 8 of 15

9 trigger tools designed to identify the cause of cross-transmission for the 3 main causes of HAI outbreaks, i.e. MRSA, Clostridium difficile infection (CDI) and Norovirus. (Schematic 3 shows trigger tools that could be developed NB Norovirus and CDI Trigger Tools are now available). Paediatric hospitals may also consider a respiratory trigger tool as standard. Such tools can be based on cause and effect charts such as those produced to support the HPS/SPSP bundle work. They also have been advocated in the literature (Curran, Benneyan et al. 2002; Coia, Duckworth et al. 2006). The cause and effect charts describe all elements of a system (people, environment, equipment and methods) that the evidence suggests has previously contributed to transmission. These are generated from the evidence based guidelines (O'Grady, Alexander et al. 2002; Pratt, Pellowe et al. 2007). The deployment of these trigger tools should be a collective responsibility involving clinical as well as infection control staff. Distribution and methods of data feedback List the data produced, how it will be analysed and presented, who will receive the data and the time frame for sending out reports. Supporting information: There should be evidence that those who receive information from the ICT understand the message being communicated, the implications of the data and the actions that need to be taken. HPS has produced a communications assessment tool that may help the ICT provide evidence of effective communication. HPS July 2009 Page 9 of 15

10 Table 1 The suggested criteria, rationale, information sources and analysis (adapted for NHS Scotland from SHEA/HICPAC position paper- Cohen et al 2008) Local Surveillance Criteria Rationale: Local Surveillance is done Information and Analysis of local surveillance data Any multi drug resistant organisms To enable ICTs to be data driven, i.e. devise and execute Sources of information colonisation or infection and programmes which will prevent and control infection, o Routine surveillance of clinical isolates Clostridium difficile specifically: o Active surveillance where indicated o To detect variations (natural and unnatural) in data that o Information from clinical colleagues Specific other listed organisms, could indicate potential problems in local infection control Analysis of data e.g.: Legionella spp, blood stream systems and enable a real time response to infection control triggers, e.g. increases in numbers of patients o Daily: All new cases are assessed against a preset trigger level for each organism in every clinical area infections with environmental with alert organisms. o Daily: Prevalence review of the numbers of patients in all organisms Communicable diseases with the o To produce local epidemiology and thereby quantify the burden and risk of HAI to the NHS Board by and identify where ICTs should focus resources commence clinical situations with alert organisms or communicable diseases to assess the risk to non colonised/infected patients and the need for additional actions. potential for cross-infection in a programmes for the greatest impact o Monthly: assessments of trends of key organisms for healthcare setting (See TBP) o To evaluate the infection control care afforded to patients out of statistical control episodes within clinical units thereby identifying risks to both o Quarterly: assessments of trends, out of statistical Participation in national programmes patients and the organisation and suggesting resources control episodes and current and potential risks to reduce infection: and requirements to resolve them. o Annual report on burden, trends and targets for action o Mandatory SAB o To evaluate the effectiveness of the ICT. in the following 12 months o Mandatory CDI o Mandatory 2 SSI procedures All programmes actions and reports require oversight by risk management/clinical governance, HAI Executive Lead and the NHS Board ICC. For many clinical areas the background level is zero and the trigger level will be 1. Any breach of a trigger level or out of statistical control episode will result in the immediate deployment of a Trigger Action Plan As well as making individual areas data rich, data must be distributed through the management system to enable managers to participate in reducing risk and optimising patient safety. HPS July 2009 Page 10 of 15

11 Schematic 1 Objectives for a Continuous local surveillance of communicable diseases/alert organisms (CD/AO) Variation Assessments (SPC) Unnatural Variation Natural variation Local Epidemiology Care Evaluation ALERT SIGNAL Trigger Response 1. Real Data Check 2. Patient Population Variations 3. Systems Analysis Stable and in Control Identify potential system changes to reduce variation. What numbers of patients With what CD/AO In what clinical areas Where is burden greatest Causes of infection, e.g. Resource evaluation failures to isolate Cross-transmission incidence Device utilisation device related problems appropriateness Real time detection Real time response Prompt return to normal levels Ongoing continuous drive to improve infection prevention and control in local areas through data feedback. Annual Programme containing targeted actions for: Quality Improvement, Resource allocation, Audit, Training, Education. Approval and oversight from Clinical Governance Risk Management HAI Executive HPS July 2009 Page 11 of 15

12 Local Surveillance Programme Schematic 2 Trigger Alert Algorithm Level 1 Identify if the alert is due to a numerator change or error To account for the alert, are there: o Changes or errors to the collection or processing specimens? o Changes or errors to the method of surveillance: the application of definitions, data collection, data analysis and data quality? o Standardised methods applied the same way throughout the surveillance period? o Discrepancies between laboratory and infection control data? o Double counting? Level 2 Identify if the alert is due to a denominator variation or error To account for the alert: o Has the population of the ward changed recently, i.e. is the population now more at risk of acquiring infection? o Has the patient population increased recently so that the rise is proportionate to the increase in population? If the alert is from benchmarked national data or similar unit, are there special demographic features (intrinsic risks) that could account for this alert? o Age of patient population o Co-morbidity of patient population o Deprivation category of population Level 3 Identify using an Organism Specific Trigger Tool where in the system the alert has originated Environment Equipment People Methods Safe, clean, fit for Safe, sufficient, Sufficient, Evidence based, purpose fit for purpose competent, correctly done, committed quality control HPS July 2009 Page 12 of 15

13 Schematic 3 Examples of Trigger Response Plans that should be available to ICTs MRSA CDI (HPS Tool available) Norovirus (HPS Tool available) SSI UTI includes CA-UTI Gastro-intestinal infection (Other) Other Generic IC problem (contact + skin scales) Trigger Response specific to organism or condition Generic droplet/ airborne (e.g. RSV) TB Infestation SAB CVC related BSI Other BSI HPS July 2009 Page 13 of 15

14 Schematic 4 How the Alerts result in Risk Assessment and a Trigger Response Unnatural Variation ALERT SIGNAL Clinical Setting ICT Alerted Risk Assessment using Watt Grade How bad is it? How bad is it likely to get? Trigger Response Real Data Check Patient Population Variations Systems Analysis Execute Communication Plan Watt Grade Green Communicate within NHS Board Watt Grade Yellow Communicate locally within directorate NHS Board and HPS Watt Grade Orange Watt Grade Red Highest Alert Full, NHS Board, HPS, SGHD and others as appropriate, e.g. Local authority, SEPA, Water Authority, HSE. HPS July 2009 Page 14 of 15

15 Local Surveillance Programme References Benneyan, J. C. (1998). "Statistical quality control methods in infection control and hospital epidemiology, part I: Introduction and basic theory." Infect Control Hosp Epidemiol 19(3): Benneyan, J. C. (1998). "Statistical quality control methods in infection control and hospital epidemiology, Part II: Chart use, statistical properties, and research issues." Infect Control Hosp Epidemiol 19(4): Cohen AI, Calfee D, Fridkin SK et al (2008) Recommendations for metrics for multidrug- resistant organisms in healthcare settings: SHEA/ HICPAC position paper Infection Control and Hospital Epidemiology 39(10): Coia, J. E., G. J. Duckworth, et al. (2006). "Guidelines for the control and prevention of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities." J Hosp Infect 63 Suppl 1: S1-44. Curran, E., P. Harper, et al. (2008). "Results of a multicentre randomised controlled trial of statistical process control charts and structured diagnostic tools to reduce ward-acquired meticillin-resistant Staphylococcus aureus: the CHART Project." J Hosp Infect 70(2): Curran, E. T., J. C. Benneyan, et al. (2002). "Controlling methicillin-resistant Staphylococcus aureus: a feedback approach using annotated statistical process control charts." Infect Control Hosp Epidemiol 23(1): Harrington, G., K. Watson, et al. (2007). "Reduction in hospitalwide incidence of infection or colonization with methicillin-resistant Staphylococcus aureus with use of antimicrobial hand-hygiene gel and statistical process control charts." Infect Control Hosp Epidemiol 28(7): O'Grady, N. P., M. Alexander, et al. (2002). "Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention." MMWR Recomm Rep 51(RR-10): Pratt, R. J., C. M. Pellowe, et al. (2007). "epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England." J Hosp Infect 65 Suppl 1: S1-64. SGHD (2005). "Managing incidents presenting actual or potential risks to the public health." Guidance on the roles and responsibilities of the incident control team SGHD: SGHD (2006) A Revised framework for National Surveillance of Healthcare Associated Infection in Scotland HDL 38:, Edinburgh Thor, J., J. Lundberg, et al. (2007). "Application of statistical process control in healthcare improvement: systematic review." Qual Saf Health Care 16(5): HPS July 2009 Page 15 of 15