The Board is asked to: Note the position for the Board. Note the progress to reduce and manage healthcare associated infections.

Highland NHS Board 25 Item 4.5 INFECTION PREVENTION & CONTROL REPORT Report by Catherine Stokoe, Infection Control Manager and Dr Vanda Plecko, Consultant Microbiologist/Infection Control Doctor, on behalf of Heidi, Board Nurse Director & Executive Lead for Infection Control The Board is asked to: Note the position for the Board. Note the progress to reduce and manage healthcare associated infections. Contribution to Highland Quality Approach Strategic Framework and Annual Objectives Contribution to Board Objectives One of the key objectives is to reduce to an absolute minimum the chance of acquiring an infection One of whilst the Board receiving key healthcare objectives and is to ensure reduce our to hospitals an absolute are clean minimum the chance of This acquiring report an presents infection a comprehensive whilst receiving view healthcare of Infection and Control to ensure and Prevention our hospitals data are and clean. activities This report relating presents to annual a comprehensive work plan for scrutiny view of and HAI feedback. data and activities for scrutiny and feedback from the Board. 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. 1. Background and summary The table below shows NHS Highland Infection Prevention and Control targets and performance data. The quarterly data presented below for Clostridium difficile and Staphylococcus aureus NHS Highland is calculated using ember 2013 occupancy data due to unavailability of bed days data for NHS Highland. However NHS Highland bed occupancy will be presented in the tember Healthcare associated infection report published by Health Protection Scotland. Clostridium difficile Staphylococcus aureus bacteraemia Group Target NHS Scotland NHS Highland Age 15 and over HEAT rate of 32.0 cases per 100,000 OBDs to be achieved by year ending 03/17 HEAT rate of 24.0 cases per 100,000 AOBDs to be achieved by year ending 03/17-27 33-41* - 36* 35* 26* Red (HPS validated) Red (HPS validated) Red (HPS validated) Red (HPS validated) Hand Hygiene 95% 97% Green Cleaning 92% 95% Green Estates 95% 97% Green Source: - Health Protection Scotland/ISD/Local data.

Our final annual rate position for Staphylococcus aureus bacteraemia cases for / is 30.0 cases per 100,000 occupied bed days, an exceedance of 6.0 cases on the defined HEAT target. For Clostridium difficile Infection our final annual rate position is 32.0 cases per 100,000, occupied bed days is calculated, thus the HEAT target has been achieved. Achievements NHS Highland have met the Clostridium difficile infection HEAT target. The Infection Prevention and Control Nursing Team have assisted Healthcare Improvement Scotland in the development of a new inspection tool and process. Challenges The E-Health teams within NHS Highland and NHS Greater Glasgow & Clyde, and the ICNET (infection control software programme) Project team continue to progress with the automated transfer of microbiological data from NHS Greater Glasgow & Clyde to Argyll and Bute. Expected completion date is 30 th tember. Whilst we await completion of this automated transfer, a reliance on manual data inputting and dissemination of laboratory results may result in errors or delays in infection control information. The Data analyst post appointed on a fixed term contract ended on the 31 st. The loss of this post has resulted in a reduction of a dedicated review of healthcare associated infection cases, and the associated information generated from this post. Currently the Infection Control and Prevention team are exploring ways in which to continue the provision of this posts roles and responsibilities. Work, supported by Service Planning and the Director of Nursing, is underway with E-Health to develop a system for automated data reports. Microbiology Laboratory samples generated by Argyll and Bute are currently all being processed through NHS Greater Glasgow and Clyde laboratories due to local staffing issues in the Oban laboratory. This is a temporary measure and is being closely monitored by the NHS Highland laboratory manager. The reporting of samples from NHS Greater Glasgow and Clyde laboratories to Argyll and Bute is in process via an email submission of a daily spreadsheet and follow up phone call. This system is human dependant leading to the possibility of error which is acknowledged on the risk register. Catherine Stokoe Infection Control Manager Vanda Plecko Consultant Microbiologist & Lead Infection Control Doctor,

NHS Highland Healthcare Associated Infection Report 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: http://www.nhs.uk/conditions/staphylococcal-infections/pages/introduction.aspx 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. Information on the national surveillance programme for Staphylococcus aureus bacteraemias can be found at: http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=30248 1.1 Staphylococcus aureus bacteraemia target The target for /2018 for NHS Highland is 24 cases or less per 100,000 acute occupied bed days for Staphylococcus aureus bacteraemia (SAB) including MRSA. For NHS Highland this means no more than approximately 60 cases by 31 st 2018. 1.2 Trends NHS Highlands position as of 31 st (data not yet validated by HPS) is tabled below. 1 st MSSA = 7-31 st MRSA = 0 Total SABs = 7 Cases Preventable = 0 Not preventable = 5 Unknown = 1 Under Investigation = 1 Hospital Acquired Cases = 2 (29%) Community Acquired Cases = 4 (57%) Healthcare Associated Cases = 1 (14%) Contaminant = 0 (0%) Undergoing investigation = 0 (0%) Total = 7 For definitions of above classifications please see section 2 page 15 Figure 1: Funnel plot of SAB rates (per 100 000 AOBDs) for all NHS boards in Scotland in Q1. HG NHS Highland 3

Figure 2: NHS Highland Staphylococcus aureus bacteraemia Cumulative Case numbers year on year since 2014. The information presented in the graph below is based on NHS Highland case number data. Cumulative Case Numbers 80 70 60 50 40 30 20 10 0 NHS Highland staph aureus Bacteraemia- Cumulative chart 2014-2015 Aug t 2015- - -18 Heat Target to 31-3- 17 All SAB cases undergo a multi-disciplinary team review in order to identify any learning. The action plan developed to implement actions to reduce staphylococcus aureus bacteraemia is in place and monitored through the Infection Control Improvement Group and Control of Infection Committee. 1.3 Current Initiatives A review of practice, performed by the external company Becton Dickinson, on the insertion and management of peripheral vascular devices has occurred. The Infection Control Policy was observed in all but one insertion procedure. Information from this review is currently being shared with the clinical teams. A trial of a pre-filled Saline syringe is underway in NHS Highland. Saline is used to flush through peripheral vascular devices to keep the devices functioning. The use of a prefilled syringe reduces the risk of contamination, needle stick injuries, and releases time to care. 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: http://www.nhs.uk/conditions/clostridium-difficile/pages/introduction.aspx NHS Boards carry out surveillance of Clostridium difficile infections (CDI), and there is a national target to reduce these. Information on the national surveillance programme for Clostridium difficile infections can be found at: http://www.hps.scot.nhs.uk/haiic/sshaip/ssdetail.aspx?id=277 2.1 Clostridium difficile HEAT Target The target for /2018 for NHS Highland is 32 cases or less in patients aged 15 and over per 100,000 total occupied bed days. For NHS Highland this means no more than approximately 78 cases by 31 st 2018.

2.2 Trends NHS Highlands position as of 31 st (data not yet validated by HPS) is tabled below. 1st to 31 st Total CDI Cases aged 15 and over = 9 Healthcare Associated = 2 (22%) Community Acquired = 3 (33%) Unknown = 0 (0%) Under investigation = 4 (45%) Aged 15-64 = 2 Aged 65+ = 7 For definitions of above classifications please see section 2 page 16 Figure 3: Funnel plot of CDI incidence rates (per 100 000 TOBDs) in patients aged 65 years and above for all NHS boards in Scotland in Q1. NHS Orkney, NHS Shetland and NHS Western Isles overlap. HG NHS Highland Figure 4: Funnel plot of CDI incidence rates (per 100 000 AOBDs) in patients aged 15-64 years for all NHS boards in Scotland in Q1. NHS Borders, NHS National Waiting Times Centre, NHS Western Isles and NHS Shetland overlap. HG NHS Highland 5

Figure 5: NHS Highland Clostridium difficile Infection Age 15 and over, case numbers year on year since 2014. The information presented in the graph below is based on NHS Highland case number data Cumulative Case Numbers 100 90 80 70 60 50 40 30 20 10 0 NHS Highland Cumulative toxin Positive age 15 and over Aug t 2014-2015 2015- - - 2018 Heat Target to 31-3-17 2.3 Current Initiatives The trial of an Ultra-violet light decontamination machine has occurred within Raigmore Hospital. This technology is proven to reduce the viral and bacterial load of the environment and enhance the effectiveness of manual cleaning. This machine remains in use within Raigmore hospital and is being utilised to support the enhanced decontamination of the environment and equipment. A trial of a similar product from an alternative company is to occur in, as part of the procurement review. The initial trial of the telehealth medicine system Florence has occurred. The aim of Florence is to provide support and advice to patients diagnosed with Clostridium difficile infection through an interactive text messaging system. Further trials are planned, prior to the implementation of the system in the autumn. 2.4 Antimicrobial Management Response to Draft National Guidelines The Antimicrobial Management Team (AMT) provided feedback on the recently circulated Draft Review of Clostridium difficile infection (CDI) Guidance from Health Protection Scotland, mainly in relation to the advice around children and CDI. National Hospital Antimicrobial Prescribing Quality Indicators The detail of these indicators has recently been shared with Antimicrobial Management Teams (AMTs) across Scotland, for achievement by 31 st 2018. There are separate indicators for consumption of antibiotics and for review of therapy. The first quality indicator aims to reduce antibiotic use in acute hospitals. Success will be measured as a 1% reduction in total antibiotic use along with a similar reduction in use of specific drugs (carbapenems and piperacillin/tazobactam). Baseline data for each indicator (as quantity of antibiotic per 1000 admissions) has yet to be shared with boards and is not routinely available from the national database, HMUD (hospital medicines utilisation database). The second quality indicator continues to focus on documentation and outcome of review of intravenous antibiotics and documentation of duration of oral antibiotics. This is an

expansion of the currently reported audit as data should be collected from at least 3 wards in the main acute hospital. Data for these indicators will be collected using a function on the new NHS Highland Antimicrobial prescribing app. Data to the end of for the current audits in Raigmore ward 7A and 4C show the teams are close to achieving the required standard of 95% already; (ward 7A are at 76% and ward 4C at 78%). Antibiotic Shortages The ongoing national shortage of aztreonam has resolved to some extent but the shortage of piperacillin/tazobactam has commenced with very limited stock available at a vastly inflated price. Clinical teams have implemented the alternative guidance provided and protected stock remains available for severely unwell patients. It is worth noting that the shortage of piperacillin/tazobactam means usage has reduced significantly. Alternative treatment options contain more than one drug therefore total antibiotic use is likely to increase during the measurement period for the national quality prescribing indicators. This has been fed back to the Scottish Antimicrobial Prescribing Group (SAPG). Gentamicin Duration Review A review of how long patients are receiving gentamicin has concluded; results showed that 67% of patients received 3 days or less. A higher incidence of patients having a duration of 4 days was identified on the Surgical wards, and was associated with a restriction in oral intake. The 3 day authorisation code will remain in place in order to prompt a discussion with an infection specialist prior to prescribing. The continuation of gentamicin therapy for longer than 72 hours increases the risk of toxicity and SAPG have recommended that therapy should be reviewed and where possible stopped at 72 hours. The gentamicin prescription form has space for prescribing 3 doses (usually every 24 hours) in an attempt to limit the duration and prompt the review. National Point Prevalence Survey (PPS) report National point prevalence surveys (PPS) are undertaken every five years in Scotland in order to take stock of the current epidemiological situation and to review local and national policy. A rolling point prevalence survey was carried out across all Scottish hospitals in late. Data were collected from a variety of sources by the local Infection Prevention and Control teams and Antimicrobial Pharmacist. The report was published in, and is available to view via the weblink below: http://www.hps.scot.nhs.uk/pubs/detail.aspx?id=3236 Overall the report concludes that the current prevalence of healthcare associated infection (HAI) in acute hospitals within NHS Scotland is 4.6%, and in the non-acute hospitals 3.2% which, whilst significantly lower than five years ago, still represents one in 22 patients at any one time, or 55,500 infections every year. The patient population is notably older and sicker in comparison to five years ago and the most common HAI across NHS Scotland (urinary tract infection and pneumonia) reflects this at risk population. NHS Highland data from the survey identifies our prevalence rate in acute hospitals as 6.0% (26 cases), compared to 4.9% (22 cases) in 2011. In the non-acute hospitals a rate of 1.1% (1 case) identified from the survey, compared to 0.7% (1 case) in 2011. NHS Highland data does not reflect the national findings for HAI type. The most common cause of HAI recorded across NHS Highland was surgical site infection although a 5.4% decrease on the previous recorded rate was noted (2011 data 36.4%; data 31%) and the second 7

most common HAI related to pneumonia (2011 9.1%; 31%, although it should be noted that actual case numbers are low; 2 in 2011 and 9 in ). Within NHS Highland the median age of patients in both acute and non-acute hospitals was higher in than 2011, (a 7 year increase in acute, and a 22 year increase in non-acute). A larger proportion of patients were also noted to have severe co-morbidities that were expected to be ultimately or rapidly fatal (a 14% increase in data in acute settings, and a 40% increase in data in non-acute). These findings reflect the continuing change in the demographics of the Scottish population. The number of people aged 65-74 years and 75 years and older in Scotland has increased by 24% and 31%, respectively between 1996 and.the number of people aged 75 years and over is projected to increase by approximately 29% between 2014 and 2024. A number of risk factors were associated with the higher prevalence of HAI reported across NHS Scotland in this survey: higher co-morbidity score, having undergone surgery since admission to hospital, being cared for in a surgical specialty and being cared for in a high dependency unit (HDU) or ICU. Patients cared for in surgical specialties or in ICU and HDU are particularly vulnerable to infection due to extrinsic risk factors such as surgical procedures and invasive devices. The use of devices remained largely unchanged across NHS Scotland, although the survey does indicate that a higher number of devices are in use within non acute hospital settings. Within NHS Highland we noted that our use of invasive devices has remained largely unchanged across both settings. The only risk factor reported to be associated with a higher HAI prevalence in the non-acute patients across NHS Scotland was increased age; this reflects NHS Highland data. The report also indicates that across NHS Scotland there has been significant improvement in practice in the prescribing agenda in recent years, although antibiotic prescribing in hospitals was found to be significantly higher than five years ago. Within NHS Highland the prevalence rates of Antimicrobial Prescribing in the acute setting remained the same as in 2011, whilst a slight increase was noted in the non-acute settings likely reflecting the change in patient acuity (2011 data 10.4%; data 16.3%). 3 Hand Hygiene Reporting 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: http://www.washyourhandsofthem.com./ http://www.washyourhandsofthem.com./documents/hand-hygiene-and-nhs-scotland/your-5-moments-for-handhygiene/5-moments-credit-card.aspx Each Board is responsible for monitoring and reporting hand hygiene compliance data. 3.1 Current Hand Hygiene Compliance Rates NHS Highland Hand Hygiene Rolling Monthly Audit Programme continues across all clinical areas, and compliance rates are being sustained above the 95% target. Compliance data for this year (uary to ) identifies an average of 97% for hand hygiene compliance across NHS Highland. Any areas identified during the audits, as requiring action, are reported immediately to the relevant person for actioning. 4. Cleaning and the Healthcare Environment

Keeping the healthcare environment clean is essential to prevent the spread of infections. Information on national cleanliness compliance monitoring can be found at: http://www.hfs.scot.nhs.uk/online-services/publications/hai/ Healthcare environment standards are also independently inspected by the Healthcare Environment Inspectorate. More details can be found at: http://www.nhshealthquality.org/nhsqis/6710.140.1366.html Each Board is responsible for monitoring and reporting the cleanliness of hospitals. 4.1 Cleaning and Estates audit data The monthly cleaning and estates audits, conducted as per the National Cleaning Services Specification and through the use of Synbiotix (the Facilities Management Scotland web based audit tool), demonstrate compliance rates are being sustained above the locally defined targets (92% domestic monitoring and 95% estates monitoring). The data for this year (uary to ) identifies an average compliance of 95% for domestic monitoring, and 97% for estates across NHS Highland. Any areas identified during the audits, as requiring action are reported immediately to the relevant person A series of unannounced Independent Public Peer Review audits is in progress; these occur across all hospital sites in NHS Highland. Work is underway to implement the revised NHS Scotland National Cleaning Services specification. The revised document allows NHS Boards too accurately and effectively risk assess specific tasks in order to determine the frequency of cleaning, based upon the risk to the patient and also public perception. Progress is reported through the Soft Facilities Management group and monitored through the Infection Control Improvement Group. 4.2 Healthcare Environment Inspections (HEI) The report for the HEI Inspection of Raigmore Hospital theatre department (7 th and 8 th ruary ) was published on the 18 th of, and the subsequent 16 week follow up report has been submitted. This was a very positive visit and the requirements (outlined below) have been met. Requirement 1: NHS Highland must ensure that where audit data suggests compliance with standard infections control precautions is below the accepted standard, action plans are developed, implemented and monitored to support improvement in practice. Requirement 2: NHS Highland must ensure that, where data suggests compliance with standard infection control precautions is below the accepted standard; this information is presented to the Executive team and senior managers in such a way that allows poor compliance to be more visible. This will enable support and continuous improvement in infection prevention and control practice. The report for the HEI Inspection of MacKinnon Memorial Hospital (18 th and 19 th ) was published on the 27 th of. This was a very positive visit and resulted in three requirements, outlined below. An action plan has been submitted, and all requirements have been addressed. Requirement 1: NHS Highland must ensure that audit results are fed back to staff to provide assurance, drive improvement and communicate any risks. Requirement 2: NHS Highland must ensure that the current version of Health Protection Scotland s National Infection Prevention and Control Manual is available to staff. This includes any hard copies of infection prevention and control policies. Requirement 3: NHS Highland must ensure that all waste is disposed of in line with Health Facilities Scotland s Scottish Health Technical Note 3 (2015) and that all staff involved in the management of waste are aware of their responsibilities. 9

Benchmarking continues against all the national HEI inspection reports published, in order to ensure learning is disseminated. 5. Outbreaks/ clusters and multidrug resistant isolates associated with NHS Highland The closure of ward 1 Belford Hospital for 7 days occurred between 16/5/17 24/5/17 due to respiratory symptoms in 7 patients. Influenza B was confirmed in four patients. 6. Surveillance 6.1 MRSA Clinical Risk Assessment (CRA) Screening Audit In 2010 Health Protection Scotland provided a Clinical Risk Assessment tool comprising of three questions, to NHS Boards in order to ensure a consistent risk-based approach to mandatory MRSA swab screening is undertaken. As part of the national mandatory MRSA screening Programme, quarterly compliance data is submitted by NHS Boards to provide assurance that Clinical Risk Assessment (CRA) compliance is at or above 90%. MRSA Key Performance Indicator Compliance % 2014/ 2015 - Q4 2015/ Apr- Q1 2015/ t Q2 2015/ Q3 / Q4 / - Q1 / t Q2 / Q3 / 2018 Q4 NHS Highland NHS Scotland 71% 75% 72% 78% 76% 84% 86% 86% 77% 78% 83% 78% 83% 80% 82% 84% 82% 79% The Infection Prevention and Control clinical risk assessment (CRA) tool which includes the MRSA clinical risk assessment and screening process are embedded into the common admission document. Staff are required to complete a CRA on all acute admissions as per the defined criteria. Monitoring of compliance by the Infection Prevention and Control Nurses occurs across NHS Highland, and areas with poor compliance are provided with additional support to ensure compliance. Quarter 4 data has identified a reduction in compliance; a high number of new staff in the ward areas has been identified as a possible reason. This is being addressed with the local teams by the Lead Nurse and the local Infection Prevention and Control groups through education. 6.2 Escherichia coli (E.Coli) Bacteraemia surveillance As of 1 st of the surveillance of Escherichia coli (E. Coli) Bacteraemia became a mandatory requirement for all NHS Boards to undertake. Data is collected by the Infection Prevention and Control Team in conjunction with the relevant clinical teams, and cases discussed to identify learning. The data collected and presented below highlights the local case numbers. Figure 6: Funnel plot of EColi bacteraemia (ECB) incidence rates (per 100 000 Total Occupied bed days) in healthcare associated infection cases for all NHS boards in Scotland in Q1. NHS Forth Valley and NHS Highland overlap

HG NHS Highland NHS Highlands position as of 31 st (data not yet validated by HPS) is tabled below. 1st Total Cases = 39 31 st Hospital Acquired = 4 (10%) Healthcare Associated = 9 (23%) Community Associated = 26 (67%) Not Known = 0 (0%) Under investigation = 0 (0%) It should be noted that the majority of E.Coli cases reported within NHS Highland are identified as community associated and are not related to urinary catheters or deemed preventable. Often they are associated with chronic urinary tract problems such as renal impairment and kidney stones. 6.3 Surgical Site Infections (SSI) NHS Highland continues to monitor SSI rates through mandatory and voluntary surveillance. The RAIGMORE clinical teams 30 alongside DAYS READMISSION the Infection Prevention ELECTIVE & Control COLORECTAL Surveillance team SSI and the Scottish Patient Safety Programme team (Acute adult workstream: SSI) are working jointly to review incidents of Colorectal infection, and SSI ensure rate for that - care practices is are 13.3%, evidence compared based and to maintained. - 2015 rate of 9.1%. Figure 7: highlights the monthly SSI rate elective colorectal SSI percentage and is annotated to identify when improvements have been introduced or compliance achieved. 35 30 25 20 15 10 5 0 Raigmore Monthly SSI rate following elective colorectal surgery 2011 - SP TP SPSP SK NC A&T D & AA EM date SSI% Base line median extended median 11

KEY FOR GRAPH ANNOTATION Chloroprep skin prep SP Mar-13 Closure Tray, Tegaderm & pad TP Jun-13 SPSP SPSP -14 New Consultant NC Mar-15 Skin Prep 100% compliance SK -15 Prophylactic Abx compliance >90% A&T Mar-15 Temperature >36º C compliance >80% A&T Mar-15 Mr Docherty left D -15 Theatre Tech bundle TT -15 New Surgeon Ali Amin AA -16 Definition of Emergency changed EM Apr-17 Colorectal SSI rate was 13.3%. This compares to previous rates of 2015 9.1%; 2014 9.7%; and - 2013 15.7%; currently there have been 5 infections reported from 45 procedures between to (11% SSI rate). The monthly Colorectal improvement meeting have been reinstated. Rapid root cause analysis will be conducted on all SSI s and action plans will be developed where required. RAIGMORE 30 DAYS READMISSION ORTHOPAEDIC SSI Total Hip replacement (THR) surgery continues to have a low rate of SSI. Currently there are no infections have been reported in (0% rate of SSI). The THR SSI rate was 0.24%. This compares to previous rates of - 2015 0.28%; 2014 0.66%; and 2013 0.25%. Figure 8: Monthly SSI rate in Total Hip Replacement surgery 2010- % of infection 10 8 6 4 2 0 NHSH Monthly SSI rate for Total Hip Replacement 2010 to Date SSI% Hemi-arthroplasty surgery continues to have a low rate of SSI. Currently there has been 1 infection reported from 63 procedures between to (1.6% SSI rate). SSI rate was 0%. This compares to previous rates of - 2015 2.4%; 2014 1.7%; and 2013 2.9%.

Figure 9: Monthly SSI rate for Hemi arthroplasty surgery 2010 to 20 NHSH Monthly SSI rate for Hemi Arthroplasty 2010 to 15 % of infection 10 5 0 SSI% Neck of femur excluding Hemi-arthroplasty surgery continues to have a low rate of SSI. On the 31 st it had been 630 days since the last surgical site infection. - data identifies a rate of 0%. This compares to previous rates of - 2015 1.1%; - 2014 0.7%; - 2013 1.8%). Surveillance on these procedures within NHS Highland ended on 31 st. Figure 10: Monthly SSI rate for fracture Neck of Femur (#NOF) excluding hemi-arthroplasty 2010 to 31 st Mar % of infections 12 10 8 6 4 2 0 NHSH Monthly SSI rate for #NOF 2010 to (excluding Hemi arthroplasty) Surveillance suspended 2011- Date SSI % NHSH 10 DAYS POST DISCHARGE CAESAREAN SECTION SSI Elective C-Section Currently 3 infections have been reported in with 122 operations performed (2.5% rate of SSI). SSI rate for - is 2.7%. This compares to previous rates of - 2015 2%; - 2014 0.7%; and - 2013 1.4%. 13

Figure 11: shows monthly SSI rate for elective C Sections, 2012 to % of infections 16 14 12 10 8 6 4 2 0 NHSH SSI rate for elective C Sections 2012 to Date Percentage of infections median extended median Emergency C-Section Currently 5 infections have been reported in with 111 operations performed (4.5% rate of SSI). SSI rate for - is 2.4%. This compares to previous rates of - 2015 2.5%; - 2014 1.9%; and - 2013 2%. Figure 12: Monthly SSI rate for emergency C Section, 2012 to % of infections 18 16 14 12 10 8 6 4 2 0 NHSH SSI rate for emergency C Sections 2012 to No Infections date % infections Bi monthly multi-disciplinary RCA meetings are held between the midwifery, obstetric, theatre and infection control team to review all C-section s resulting in an SSI. The SSI action plan continues to be implemented, and monitored through the SSI group. The Surgical site infection prevention bundle continues to be tested and implemented within the Theatre department. Currently a review of theatre drapes is underway in light of a larger body mass index being associated with recent SSI cases.

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 in the Board, on the number of cases of Staphylococcus aureus blood stream infections 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. 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. SAB cases are further broken down into Meticillin Sensitive Staphylococcus aureus (MSSA) and Meticillin Resistant Staphylococcus aureus (MRSA). For each hospital the total number of cases for each month, been reported as positive from a laboratory report, on samples taken more than 48 hours after admission. Understanding the Report Cards Hand Hygiene Compliance Hospitals carry out regular audits of how well their staff are complying with hand hygiene. Each hospital report card presents the combined percentage of hand hygiene compliance with both opportunity taken and technique used broken down by staff group. 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. Understanding the Report Cards Out of Hospital Infections CDI and SAB (including MRSA) bacteraemia cases are presented as Out of Hospital Infections and are not attributable to a hospital. This section identifies those infections from community sources such as GP surgeries and care homes, and those from positive samples taken from patients within 48 hours. Abbreviations SAB Definitions Definitions: Hospital acquired infection (HAI): Positive blood culture obtained from a patient who has been hospitalised for 48 hours. OR patient was transferred from another hospital, the duration of in-patient stay is calculated from the date of the first hospital admission. OR If the patient was a neonate/baby who has never left hospital since being born. OR The patient was discharged from hospital in the 48hr prior to the positive blood culture being taken. OR A patient who receives regular haemodialysis as an out-patient. OR Contaminant if the blood aspirated in hospital Healthcare associated infection (HCAI): Positive blood culture obtained from a patient within 48 hours of admission to hospital and fulfils one or more of the following criteria: 1. Was hospitalised overnight in the 30 days prior to the positive blood culture being taken. 2. Resides in a nursing, long term care facility or residential home. 3. IV, or intra-articular medication in the 30 days prior to the positive blood culture being taken, but excluding IV illicit drug use. 4. Regular user of a registered medical device e.g. intermittent self-catheterisation, home CPD or PEG tube with or without the direct involvement of a healthcare worker (excludes haemodialysis lines see HAI). 5. Underwent any medical procedure which broke mucous or skin barrier i.e. biopsies or dental extraction in the 30 days prior to the positive blood culture being taken. 6. Underwent care for a medical condition by a healthcare worker in the community which involved contact with non-intact skin, mucous membranes or the use of an invasive device in the 30 days prior to the positive blood culture being taken e.g. podiatry or dressing of chronic ulcers, catheter change or insertion. Community infection: Positive blood culture obtained from a patient within 48 hours of admission to hospital who does not fulfil any of the criteria for healthcare associated bloodstream infection. Not known: Only to be used if the SAB is not an HAI, and unable to determine if Community or HCAI. 15

CDI definitions Definitions: Healthcare-associated CDI: a case with onset of symptoms on day three or later, following admission to a healthcare facility on day one, OR in the community within four weeks of discharge from any healthcare facility. This may apply to the current hospital or a previous stay in another healthcare facility, e.g. in another hospital, a long-term care facility or other healthcare facilities (e.g. outpatient departments etc.) Community-associated CDI: a case with [onset outside of healthcare facilities, AND without discharge from a healthcare facility within the previous 12 weeks] OR [onset on the day of admission to a healthcare facility or on the following day AND not resident in a healthcare facility within the previous 12 weeks] Unknown association: a case who was discharged from a healthcare facility 4 12 weeks before symptom onset ADTC Area Drugs & Therapeutics Committee AMAU Acute Medical Admissions Unit CDI Clostridium difficile Infection CNO Chief Nursing Officer HEAT Health Improvement, Efficiency, Access, Treatment GDP General Dental Practitioner HAI QIF Healthcare Associated Infection Quality Improvement Facilitator HPS Health Protection Scotland JAG Joint Advisory Group CPE Carbapenemase-producing Enterobacteriaceae PICC Peripherally Inserted Central Catheter PVC Peripheral Venous Catheter PPI Proton Pump Inhibitor RIDDOR Reporting of Injuries, Diseases & Dangerous Occurrences Regulations 1995 SHPN Scottish Health Planning Note SICPs Standard Infection Control Precautions IPCT Infection prevention & control team AMT Antimicrobial Prescribing Team CHP Community Health Partnership CMO Chief Medical Officer CVC Central Venous Catheter ECDC European Centre for Disease Prevention & Control HAI Healthcare Associated Infection HAIRT Healthcare Associated Infection Reporting Template HSE Health and Safety Executive HFS Health Facilities Scotland MRSA Meticillin Resistant Staphylococcus Aureus MSSA Meticillin Sensitive Staphylococcus Aureus SAB Staphylococcus aureus Bacteraemia SPC Statistical Process Chart Hemiarthroplasty: Operation to treat fractured hip (only involves half of hip) SHTM Scottish Health Technical Memoranda SAPG Scottish Antimicrobial Prescribing Group SPSP Scottish Patient Safety Programme

NHS HIGHLAND REPORT CARD NHS Highland Staphylococcus aureus bacteraemia (SABs) monthly case numbers 15 SAB's NHS Highland MRSA MSSA Total SABS 10 5 0 Aug- - -14 - - -15 - Mar- Apr- Jun-15 Jul-15 Aug- - -15 - - -16 - Mar- Apr- Jun-16 Jul-16 Aug- - -16 - - -17 - Mar- Apr- MRSA 0 0 0 0 0 0 0 0 0 1 0 0 MSSA 4 12 8 1 4 7 11 7 3 6 1 6 Total SABS 4 12 8 1 4 7 11 7 3 7 1 6 NHS Highland Clostridium difficile infection monthly case numbers C.difficile NHS Highland 12 10 8 6 4 2 0 15-64 65 15 Aug-14-14 -14-14 -14-15 -15 Mar-15 Apr-15-15 Jun-15 Jul-15 Aug-15-15 -15-15 -15-16 -16 Mar-16 Apr-16-16 Jun-16 Jul-16 Aug-16-16 -16-16 -16-17 -17 Mar-17 Apr-17-17 15-64 65 15 0 1 3 1 1 1 2 3 0 3 1 1 5 4 4 8 7 8 5 5 4 6 0 7 5 5 7 9 8 9 7 8 4 9 1 8 17

Hand Hygiene Monitoring Compliance (%) Board Total 97 98 97 98 95 95 98 95 98 98 97 97 AHP 98 97 97 98 95 98 98 98 99 97 99 91 Ancillary 97 97 97 99 94 92 98 91 99 100 98 100 Medical 95 97 96 96 94 90 99 94 95 96 94 96 Nurse 99 99 98 98 97 99 98 97 97 99 98 99 Cleaning Compliance (%) Board Total 96 96 96 94 96 96 96 95 95 95 95 95 Estates Monitoring Compliance (%) Board Total 98 98 98 97 97 97 97 97 97 97 97 97

NHS HIGHLAND RAIGMORE HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia (SABs) monthly case numbers MRSA 0 0 0 0 0 0 0 0 0 0 0 0 MSSA 0 1 1 0 0 1 2 0 0 0 0 2 Total SABS 0 1 1 0 0 1 2 0 0 0 0 2 Clostridium difficile infection monthly case numbers 15-64 65 15 0 0 0 0 0 0 1 0 0 1 0 0 1 2 0 2 2 1 2 1 0 0 0 1 1 2 0 2 2 1 3 1 0 1 0 1 Hand Hygiene Monitoring Compliance (%) Total 91 91 93 93 92 90 92 91 96 97 94 96 AHP 89 89 93 87 81 93 89 91 96 96 97 97 Ancillary 89 89 88 93 97 78 89 86 97 100 93 100 Medical 88 88 94 95 90 90 92 91 90 96 89 90 Nurse 97 97 95 95 99 97 98 97 99 97 98 98 Cleaning Compliance (%) 95 95 96 91 97 96 95 93 95 93 93 94 Estates Monitoring Compliance (%) Total 98 98 98 98 96 97 95 97 98 97 96 97 19

NHS HIGHLAND CAITHNESS GENERAL HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia (SABs) monthly case numbers MRSA 0 0 0 0 0 0 0 0 0 0 0 0 MSSA 0 0 0 0 0 0 0 0 0 0 0 0 Total SABS 0 0 0 0 0 0 0 0 0 0 0 0 Clostridium difficile infection monthly case numbers 15-64 65 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 3 0 0 0 0 0 1 0 0 0 0 0 3 0 0 0 Hand Hygiene Monitoring Compliance (%) Total 100 99 97 96 92 94 98 90 99 100 97 99 AHP 100 100 100 100 100 100 100 100 100 100 100 100 Ancillary 100 100 100 100 75 100 100 75 100 100 100 100 Medical 100 95 86 84 91 76 100 88 96 100 88 94 Nurse 100 100 100 98 100 100 98 96 100 100 98 100 Cleaning Compliance (%) Total 94 95 95 94 95 94 96 96 94 95 96 95 Estates Monitoring Compliance (%) Total 100 99 97 96 94 93 94 94 95 95 95 95

NHS HIGHLAND BELFORD HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia (SABs) monthly case numbers MRSA 0 0 0 0 0 0 0 0 0 0 0 0 MSSA 0 0 0 0 0 0 0 0 0 0 0 0 Total SABS 0 0 0 0 0 0 0 0 0 0 0 0 Clostridium difficile infection monthly case numbers 15-64 65 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Hand Hygiene Monitoring Compliance (%) Total 100 100 100 100 97 92 100 90 99 95 99 95 AHP 100 100 100 100 100 100 100 100 100 83 100 83 Ancillary 100 100 100 100 100 80 100 75 100 100 100 100 Medical 100 100 100 95 89 88 100 88 100 100 100 100 Nurse 100 98 98 100 100 100 98 96 97 98 97 98 Cleaning Compliance (%) Total 96 95 95 96 96 97 97 96 95 96 96 97 Estates Monitoring Compliance (%) Total 100 100 100 100 100 100 100 100 100 100 100 98 21

NHS HIGHLAND LORN & ISLANDS HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia (SABs) monthly case numbers MRSA 0 0 0 0 0 0 0 0 0 0 0 0 MSSA 0 0 0 0 0 0 0 0 0 0 0 0 Total SABS 0 0 0 0 0 0 0 0 0 0 0 0 Clostridium difficile infection monthly case numbers 15-64 65 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 Hand Hygiene Monitoring Compliance (%) Total 95 99 98 100 98 100 100 100 97 97 94 99 AHP 100 100 100 100 100 100 100 100 100 100 97 100 Ancillary 91 100 100 100 100 100 100 100 100 100 100 100 Medical 90 95 90 100 93 100 100 100 86 89 80 97 Nurse 100 100 100 99 100 98 100 100 100 100 100 100 Cleaning Compliance (%) Total 97 98 98 95 97 98 96 97 98 97 99 99 Estates Monitoring Compliance (%) Total 95 95 97 98 99 99 97 96 98 95 97 96

NHS HIGHLAND NORTH & WEST OPERATIONAL UNIT COMMUNITY HOSPITALS REPORT CARD The community hospitals covered in this report card include: Dunbar Hospital, Thurso Town & County Hospital, Wick Lawson Memorial Hospital Golspie Migdale Hospital, Bonar Bridge MacKinnon Memorial Hospital, Broadford Portree Hospital, Isle of Skye Staphylococcus aureus bacteraemia monthly case numbers MRSA 0 0 0 0 0 0 0 0 0 0 0 0 MSSA 0 0 0 0 0 0 0 0 0 0 0 0 Total SABS 0 0 0 0 0 0 0 0 0 0 0 0 Clostridium difficile infection monthly case numbers 0 0 0 0 0 0 0 0 0 0 0 0 15-64 0 0 0 0 0 0 0 0 0 0 0 0 65 15 0 0 0 0 0 0 0 0 0 0 0 0 Hand Hygiene Monitoring Compliance (%) Total 100 99 99 100 100 94 100 100 100 100 99 95 AHP 100 100 100 100 100 100 100 100 100 100 100 83 Ancillary 100 100 100 100 100 100 100 100 100 100 100 100 Medical 100 100 100 100 100 76 100 100 100 100 100 100 Nurse 100 97 97 100 99 100 98 98 100 100 97 98 Cleaning Compliance (%) Total 94 94 95 92 96 95 94 95 95 94 94 96 Estates Monitoring Compliance (%) Total 97 99 96 96 95 96 95 94 98 97 96 96 23

NHS HIGHLAND SOUTH & MID OPERATIONAL UNIT COMMUNITY HOSPITALS REPORT CARD The community hospitals covered in this report card include: Ross Memorial Hospital, Dingwall County Community Hospital, Invergordon Royal Northern Infirmary Community Hospital, Inverness Town & County Hospital, Nairn Ian Charles Hospital, Grantown on Spey St Vincent s Hospital, Kingussie For the purposes of monitoring New Craigs Psychiatric Hospital is included in this report card. Staphylococcus aureus bacteraemia (SABs) monthly case numbers MRSA 0 0 0 0 0 0 0 0 0 0 0 0 MSSA 0 0 0 0 0 0 0 0 0 0 0 0 Total SABS 0 0 0 0 0 0 0 0 0 0 0 0 Clostridium difficile infection monthly case numbers 0 0 0 0 0 0 0 0 0 0 0 0 15-64 0 1 0 1 0 0 0 0 0 0 0 0 65 15 0 1 0 1 0 0 0 0 0 0 0 0 Hand Hygiene Monitoring Compliance (%) Total 98 98 98 97 98 99 100 99 100 98 98 98 AHP 100 98 97 97 100 100 100 100 100 100 100 98 Ancillary 100 97 97 97 95 96 100 100 100 99 96 100 Medical 95 98 100 96 97 100 100 96 100 96 100 94 Nurse 98 98 98 96 98 98 99 98 99 98 97 99 Cleaning Compliance (%) Total 95 96 96 93 95 96 96 96 97 97 96 96 Estates Monitoring Compliance (%) Total 97 97 98 97 97 98 98 97 98 98 95 99

NHS HIGHLAND ARGYLL & BUTE CHP COMMUNITY HOSPITALS REPORT CARD The community hospitals covered in this report card include: Argyll & Bute Hospital Lochgilphead Campbeltown Hospital Cowal Community Hospital, Dunoon, Dunaros Community Hospital, Isle of Mull Islay Hospital Mid Argyll Community Hospital & Integrated Care Centre, Lochgilphead Victoria Hospital & Annex, Rothesay Staphylococcus aureus bacteraemia (SABs) monthly case numbers MRSA 0 0 0 0 0 0 0 0 0 0 0 0 MSSA 0 0 0 0 0 0 0 0 0 0 0 0 Total SABS 0 0 0 0 0 0 0 0 0 0 0 0 Clostridium difficile infection monthly case numbers 0 0 0 0 0 0 0 0 0 0 0 0 15-64 1 0 0 0 0 0 0 0 0 2 0 0 65 15 1 0 0 0 0 0 0 0 0 2 0 0 Hand Hygiene Monitoring Compliance (%) Total 98 98 95 100 93 97 100 96 92 97 100 92 AHP 100 93 88 100 86 96 100 92 100 100 100 73 Ancillary 100 100 92 100 94 91 100 100 93 100 100 100 Medical 93 100 100 100 100 100 100 93 92 88 100 94 Nurse 97 100 100 98 91 100 98 97 84 100 100 100 Cleaning Compliance (%) Total 98 97 97 94 95 96 94 94 95 96 96 96 Estates Monitoring Compliance (%) Total 98 99 99 96 97 99 95 98 97 96 100 99 25

NHS HIGHLAND OUT OF HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia monthly case numbers MRSA 0 0 0 0 0 0 0 0 0 1 0 0 MSSA 4 11 7 1 4 6 9 7 3 6 1 4 Total SABS 4 11 7 1 4 6 9 7 3 7 1 4 Clostridium difficile infection monthly case numbers 0 1 3 1 1 0 1 3 0 2 1 1 15-64 3 1 3 5 5 8 3 4 1 4 0 5 65 15 3 2 6 6 6 8 4 7 1 6 1 6