3. Summary Table 1 NHS Highland Infection Prevention & Control targets and performance data Group Target NHS Scotland. 39.

Transcription

1 Highland NHS Board 13 August 2013 Item 5.5 INFECTION PREVENTION & CONTROL REPORT Report by Liz McClurg, Infection Control Manager and Dr Jonty Mills, Consultant Microbiologist, on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control The Board is asked to: Note the performance position for the Board. Note the progress to keep infection under control. 1. Aim The purpose of this paper is to update Board members of the current status of Healthcare Associated Infections (HAI) and Infection Control measures in NHS Highland. 2. Contribution to Board Objectives One of the Board key objectives is to reduce to an absolute minimum the chance of acquiring an infection whilst receiving healthcare and to ensure our hospitals are clean. This report presents a comprehensive view of HAI data and activities for scrutiny and feedback from the Board. 3. Summary Table 1 NHS Highland Infection Prevention & Control targets and performance data Group Target NHS Scotland NHS Highland Clostridium difficile Age 65 and over Green 39.0 (100,000 OBDs) 28.4 April 12 - March April 12 March Clostridium difficile Staphylococcus aureus bacteraemia Age 15 and over Age 15 and over New Target 25.0 (100,000 OBDs) to be achieved by 03/ (100,000) AOBDs 29.8 April12 March April June 2013 (not validated) Please note* below 21.8 April 12 March Green Green Hand Hygiene 95% 95% 98% Green Cleaning 90% 95% 95% Green Estates 90% 97% 96% Green Antimicrobial prescribing Hospitalbased Empiric prescribing 95% AMAU 94% (8 case notes out Amber

2 Group Target NHS Scotland NHS Highland of 122) Ward 96% 4A Green Surgical antibiotic prophylaxis Compliant New audit process for Colorectal Surgery not fully compliant. Amber Primary Care empirical prescribing Less than 5% 7% Amber Source: - Health Protection Scotland/ISD/Local data. * Please note that NHS Highland Local Delivery Plan Target Trajectory for Clostridium difficile cases in patients aged 15 and over at June 2013 is 34 per 100,000 OBDs. 4. Achievements NHS Highland has met the HEAT targets for Staphylococcus aureus bacteraemia (SAB) and Clostridium difficile in patients aged 65 and over as at March Challenges To influence the prevention and reduction of Clostridium difficile infections acquired in the community in the age group. To reduce MSSA bacteraemias by engaging all clinical staff in hospitals and the community in initiatives to prevent and reduce device/healthcare related infections. To deliver Infection Prevention & Control support and HAI education in care homes and adult social care settings. To address the need for risk assessment and screening for Multi-Drug Resistant bacteria (Carbapenemase producers) in light of recent Interim Guidance from Health Protection Scotland. 6. Risks The lack of qualified Infection Prevention & Control Nurse resource in North Highland to ensure that all disciplines of staff have access to specialist infection prevention & control advice and guidance has been challenging, however an experienced Infection Prevention & Control Nurse has been appointed to the vacant post in Skye, Lochaber & Wester Ross. She takes up post in September Jonty Mills Consultant Microbiologist & Lead Infection Control Doctor Liz McClurg Infection Control Manager 2 August

3 NHS Highland Healthcare Associated Infection Report March 2013 Section 1 NHS Highland Board Wide Issues 1. Staphylococcus aureus (including MRSA) Staphylococcus aureus is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. The most common form of this is Meticillin Sensitive Staphylococcus Aureus (MSSA), but the more well known is MRSA (Meticillin Resistant Staphylococcus Aureus), which is a specific type of the organism which is resistant to certain antibiotics and is therefore more difficult to treat. More information on these organisms can be found at: Staphylococcus aureus : MRSA: NHS Boards carry out surveillance of Staphylococcus aureus blood stream infections, known as bacteraemias. These are a serious form of infection and there is a national target to reduce them. The number of patients with MSSA and MRSA bacteraemias for the Board can be found at the end of Section 1 and for each hospital in Section 2. Information on the national surveillance programme for Staphylococcus aureus bacteraemias can be found at: Staphylococcus aureus bacteraemia target NHS Highland has met the HEAT target of 26.0 cases per 100,000 acute occupied bed days or lower by year ending March The annual rate, April 2012 March 2013, is 21.8 per 100,000 acute bed days (55 cases). From April 2013, NHS Boards are required to further reduce healthcare associated infections so that by year ending March 2015, Staphylococcus aureus bacteraemia (including MRSA) cases are 24.0 cases or less per 100,000 acute bed days. For NHS Highland that means no more than 60 cases. 1.2 Trends National data published by Health Protection Scotland identifies that NHS Scotland Staphylococcus aureus bacteraemia rate January March 2013 was 30.1 per 100,000 acute occupied bed days. NHS Highland rate for the same period was 21.7 per 100,000 acute occupied bed days (14 cases). 3

4 Figure 1 Funnel plot of S. aureus bacteraemia rates for all NHS Boards in Scotland against acute occupied bed days (x100, 000), January March HG = Highland April June 2013 rate (not yet validated by HPS) was per 100,000 acute bed days (18 SABs). This is an increase in the quarterly rate, which in part may be due to seasonal variation. The rate for the same period last year was 30.3 per 100,000 acute bed days. The SABs were caused by a variety of sources some of which were preventable. Figure 2 Staphylococcus aureus bacteraemia (MRSA and MSSA) cases per 100,000 occupied bed days, all ages, with 95% confidence interval (vertical lines), linear trend (Black line) and target (Red line) = 26, CI = Confidence Interval (January 2010 March 2013) New Target from April 2013 (Blue line) = 24. 4

5 1.3 Current Initiatives A new strategy for Root Cause Analyses has been implemented to improve the time taken to feedback and learn from any Staphylococcus aureus bacteraemias 2 Clostridium difficile Clostridium difficile is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. More information can be found at: NHS Boards carry out surveillance of Clostridium difficile infections (CDI) and there is a national target to reduce these. The number of patients with CDI for the Board can be found at the end of section 1 and for each hospital in section 2. Information on the national surveillance programme for Clostridium difficile infections can be found at: Clostridium difficile Target NHS Highland has met the HEAT target of 39 cases per 100,000 total occupied bed days or lower in patients aged 65 and over by year ending March The annual rate, April 2012 March 2013 is 20.8 cases per 100,000 OBDs (40 cases). National data published by Health Protection Scotland identifies that NHS Scotland Clostridium difficile infection rate in patients aged 65 years and over, January March 2013 was 24.2 cases per 100,000 bed days. NHS Highland rate for the same period was 10.3 cases per 100,000 bed days (5 cases). 5

6 National data identifies that NHS Scotland Clostridium difficile infection rate in patients aged years, January March 2013 was 28.4 cases per 100,000 bed days. NHS Highland rate for the same period was 43.9 cases per 100,000 bed days (7 cases). Figure 3 Funnel plot of CDI incidence rates in patients aged over 65 years for all NHS boards in Scotland, January to March NHS Orkney and NHS NWTC overlap, as does NHS Ayrshire & Arran and NHS Tayside. HG = Highland Figure 4 Funnel plot of CDI incidence rates in patients aged years for all NHS Boards in Scotland, January March NHS Borders, Orkney and NWTC overlap. HG = Highland Figure 5 Clostridium difficile cases per 100,000 occupied bed days, 65 years and over, with 95% confidence interval, linear trend and target (January 2010 March 2013). 6

7 From April 2013, NHS Boards are required to further reduce healthcare associated infections so that by year ending March 2015, the rate of Clostridium difficile infections in patients aged 15 and over is 25.0 cases or less per 100,000 total occupied bed days. For NHS Highland that means no more than 70 cases. 2.2 Trends April June 2013 rate (not yet validated by HPS) of Clostridium difficile infections in patients aged 15 and over is 26.4 cases per 100,000 total occupied bed days, 17 cases of which 6 were in hospital and 11 were out of hospital. Figure 6 shows the rate of Clostridium difficile infections in patients aged 15 and over from April 2012 in NHS Highland 7

8 2.3 Antimicrobial Management Table 2 shows NHS Highland progress against the 3 national indicators. Antimicrobial Indicator Hospital-based empirical prescribing In acute admission areas, antibiotic prescriptions are compliant with the local antimicrobial policy and the rationale for treatment is recorded in the clinical case note in above 95% of sampled cases. NHS Highland progress Ward AMAU Non-Compliant A variation in results over the last two months has seen median compliance from April June 2013 drop to 94%. (8 medical notes out of 122) Appropriate treatment choices were made, however the reasons for varying from guidelines were not fully documented in the medical notes. Real time feedback on the learning points is given to the individual clinical team on unexplained variation from guidelines. Ward 4A - Compliant Data for the last 15 months shows median compliance at 96%. Surgical antibiotic prophylaxis Duration of surgical antibiotic prophylaxis is less than 24 hours and compliant with local antimicrobial prescribing policy in above 95% of sampled elective colorectal and urological surgical cases. Colorectal Surgery non-compliant For colorectal surgical prophylaxis, previous audit data looked at only two simple process measures - correct antibiotic choice and single dose given. In March 2013, a more detailed audit looking at 5 separate process measures was introduced. The team are working towards the target of 95%. Real time feedback on significant variance is provided to the consultant anaesthetist and surgeon when unexplained variation from guidelines is identified. Collated feedback is circulated at the end of each month. Urological Surgery Data collection for elective urological procedures commenced in March As a robust data collection method has not yet been identified, no data is available. Primary care empirical prescribing Seasonal variation in Quinolone use (summer months vs. winter months) is less than 5%. Non-Compliant. Quinolone prescribing increased in the winter months of 2012/13 by 7% when compared to the summer months of For seasonal quinolone variation, the national measure is based on actual quantity of antibiotic prescribed with no adjustments for population or activity. Use in the most recent winter months Oct 12 March 13 is lower than the previous winter months October 11 March 12 however use in the summer months of 2012 was at the lowest so 8

9 far measured since 2008 hence the variation of 7%. NHS Highland prescription rate for quinolones is below the national average for 2012/13. Management of Infection Guidance Updates The Scottish Antimicrobial Prescribing Group has published good practice recommendations on the use of antibiotics in the frail elderly. This has been incorporated in the NHS Highland Formulary introductory section on principles of antibiotic treatment as the majority of elements apply to all patient groups, not just the frail elderly. The revised national vancomycin and gentamicin policies have been updated for use in NHS Highland, including the national gentamicin prescribing chart and online calculators. New elements include safety features to reduce the length of prescribing of gentamicin, improved awareness of potential adverse effects and warnings on the online calculator when extreme values for age, height and weight are used. Raising Antimicrobial Awareness A Q&A Document for Ward Staff The Antimicrobial Management Team has endorsed the widespread circulation of this useful document across the board area. Developed by pharmacists in South East and Mid Operational Unit, the information is aimed at ward staff and covers where to find the antibiotic prescribing policy, how variation from guidelines is monitored and managed and recommended training courses on prudent antimicrobial use. The document has been cascaded via the Lead Nurses and added to the local handbooks and induction for junior medical staff. 9

10 3 Hand Hygiene Good hand hygiene by staff, patients and visitors is a key way to prevent the spread of infections. More information on the importance of good hand hygiene can be found at: NHS Boards monitor hand hygiene and ensure a zero tolerance approach to non compliance. The hand hygiene compliance score for the Board can be found at the end of section 1 and for each hospital in section 2. Information on national hand hygiene monitoring can be found at: Trends NHS Highland Hand Hygiene Rolling Monthly Audit Programme continues across all clinical areas sustaining 98% compliance in May and June 2013 The July 2013 National Hand Hygiene Audit report shows NHS Highland compliance as 98%, National compliance was 96%. 3.2 Initiatives Hand hygiene audits continue to be undertaken monthly by all clinical areas, the results displayed and any non compliance addressed. 4 Cleaning and the Healthcare Environment Keeping the healthcare environment clean is essential to prevent the spread of infections. NHS Boards monitor the cleanliness of hospitals and there is a national target to maintain compliance with standards above 90%. The cleaning compliance score for the Board can be found at the end of section 1 and for each hospital in section 2. Information on national cleanliness compliance monitoring can be found at: Healthcare environment standards are also independently inspected by the Healthcare Environment Inspectorate. More details can be found at: Current Rates The monthly cleaning and estates audits as per the National Cleaning Services Specification demonstrated 95% compliance in May and 94% in June 2013 for domestic monitoring and 97% for estates monitoring in May and 95% in June When cleaning was monitored in the Belford hospital in June 2013, compliance was found to be 85%. Following rectification of the issues, the area was re monitored and achieved 100% compliance. 5. Outbreaks/Incidents There have been no outbreaks during June and July

11 6. Surgical Site Infections (SSI) Colorectal Surgical Site Infection NHS Highland was the first Board in Scotland to develop a colorectal surveillance programme. This has proved extremely challenging as the nature of the surgery may involve more than one wound which can be readily contaminated with body fluids, or the patient may present with a perforated bowel. By necessity the surveillance required is also very complex. As an example, previous audit data for surgical prophylaxis looked at only two simple process measures namely correct antibiotic choice and single dose given. The audit now looks at correct choice according to policy (which is now 3 drugs), timing of administration in the 60 minutes prior to knife to skin, single dose administration unless long operation or high blood loss. For a long operation, the redosing of correct antibiotic combination at the right time is checked and for high blood loss, redosing of the correct antibiotic combination is also checked. This amounts to five separate measures. The Colorectal and Infection Prevention & Control Teams continue to review all aspects of care to reduce the number of avoidable infections. Root cause analysis is carried out on elective SSIs. All wound dressings are now carried out in the refurbished clinical treatment room in Ward 4C. The variation in the type of wound dressings and the length of time dressings remain in situ is being reviewed. The Antimicrobial Pharmacist continues to support antibiotic prescribing (see page 7) Orthopaedic Surgical Site Infections There was a rise in surgical site infections post repair of neck of femur January-March 2013, with a rate of infection of 4.5%, 4 cases (National rate 1.5%). All cases have been reviewed jointly by the Infection Prevention & Control Team and the Orthopaedic department. As a result a review of wound dressings has been implemented together with a renewed focus on care of invasive devices post-operatively, particularly urinary catheters. The rate of infection post hip arthoplasty was 0% (National rate 1%). Caesarean Section Infections The recently published Health Protection Scotland Surveillance of Surgical Site Infection Annual Report for procedures carried out from January 2008 December 2012 reported that NHS Highland was one of 3 Boards who were above the 95% confidence limit for caesarean section surgical site infections detected during inpatient stay and until day 10 post operatively, January December 2012 with a rate of 4.4% (National rate 2%). There has been a significant decrease in the rate of infections since October 2012 when the practice of leaving the abdominal wound dressing insitu for 7 days post operatively was introduced. January March 2013 NHS Highland rate was 0.6% (National rate 1.3%) Table 3 shows the number of Caesarean Section SSIs September June 2012 and October May September June 2012 October May Elective procedures, 13 SSIs, Rate 5% 184 Elective procedures, 1 SSI, Rate 0.5% 281 Emergency procedures, 15 SSIs, Rate 5.3% 224 Emergency procedures, 5 SSIs, Rate 2.2% 11

12 Healthcare Associated Infection Reporting Template (HAIRT) Section 2 Healthcare Associated Infection Report Cards The following section is a series of Report Cards which provide information for each acute hospital (Raigmore, Caithness General, Belford and Lorn & Islands), and the community hospitals within each Operational Unit/CHP. The information includes 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 and estates compliance. The out-of-hospital infections report card identifies infections 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 and the community hospitals within each CHP 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 is 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 acute hospital and community hospitals in each CHP, the total 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/chp report card presents the percentage of hand hygiene compliance for all staff in table form. 12

13 Understanding the Report Cards Cleaning Compliance Hospitals strive to keep the care environment as clean as possible. This is monitored through cleaning and estates compliance audits. More information on how hospitals carry out these audits can be found on the Health Facilities Scotland website: The Report Cards show the hospitals cleaning compliance percentage in 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, care homes and the community itself. 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. 13

14 Abbreviations AOBD AMAU CDI HAI HAIRT HEAT HEI HPS ICU ISD KPI MSSA MRSA OBD PICC SAB SSI Acute Occupied Bed Days Acute Medical Admissions Unit Clostridium difficile Infection Healthcare Associated Infection Healthcare Associated Infection Reporting Template Health Improvement, Efficiency, Access, Treatment Healthcare Environment Inspection Health Protection Scotland Intensive Care Unit Information Service Division Key Performance Indicator Meticillin Sensitive Staphylococcus Aureus Meticillin Resistant Staphylococcus Aureus Occupied Bed Days Peripherally Inserted Central Catheter Staphylococcus aureus Bacteraemia Surgical Site Infection 14

15 Staphylococcus Aureus Bacteraemia (SAB) criteria Contaminated Blood Culture Staphylococcus aureus isolated from blood, and SAB diagnosis incompatible with clinical picture, i.e. no or minimal clinical signs and symptoms indicating SAB. Hospital Acquired Infection Staphylococcus aureus isolated from blood cultures taken 48 hours after admission or within 48 hours of discharge, and, The presence of clinical signs and symptoms indicating SAB Healthcare Associated Infection (HCAI) Community Infection Non hospital acquired infection (NHAI) Positive blood culture obtained from a patient within 48 hours of admission to hospital and fulfils one of the following criteria Attended a hospital clinic or seen by a healthcare worker at home or in a GP surgery within 30 days prior to the positive blood culture being taken. Was hospitalised overnight in the 90 days prior to positive blood culture being taken. Resides in a nursing, long term care facility or residential home. Positive blood culture obtained from a patient within 48 hours of admission to hospital who does not fulfil any of the criteria for a HCAI. If the SAB is not hospital acquired, but unable to determine if it is community or HCAI. 15