ayrshire and arran nhs board
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Paper 5
Ayrshire and Arran NHS Board Monday 3 December 2018
Healthcare Associated Infection Author: Bob Wilson, Infection Control Manager
Sponsoring Director: Professor Hazel Borland, Nurse Director
Date: 5 November 2018
Recommendation Board members are asked to review this report on Healthcare Associated Infections (HAI) with particular reference to the position against the 2018-19 national HAI targets, together with other infection prevention and control monitoring data. The report topics are: Staphylococcus aureus bacteraemia (SABs) Clostridium difficile infection (CDI) Meticillin resistant Staphylococcus aureus (MRSA) Outbreaks/Incidents update
Summary
National HAI Target
NHS Ayrshire & Arran Update 1 April 2018 – 30 September 2018
(1) SAB: To achieve a rate of no more than 0.24 cases per 1,000 acute occupied bed days by the year ending 31st March 2019 (approximates to 84 cases per annum).
There have been 58 SAB cases at month 6. This is above the Board’s numerical target trajectory by 16 cases.
The verified annual rate for the year ending June 2018 is 0.28.
The projected annual rate for the year ending September 2018 is 0.28.
(2) CDI: To achieve a rate of no more than 0.32 cases per 1,000 occupied bed days in the 15 and over age group by the year ending 31st March 2019 (approximates to 120 cases per annum).
There have been 46 CDI cases at month 6. This is 14 below the Board’s numerical target trajectory.
The verified annual rate for the year ending June 2018 is 0.27.
The projected annual rate for the year ending September 2018 is 0.25.
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Glossary of Terms
BC Blood Culture CDI Clostridium difficile Infection HAI Healthcare Associated Infection HPS Health Protection Scotland IPCT Infection Prevention & Control Team MRSA Meticillin Resistant Staphylococcus aureus PVC Peripheral Vascular Catheter SAB Staphylococcus aureus bacteraemia SPC Statistical Process Chart UHA University Hospital Ayr UHC University Hospital Crosshouse
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1. Statistical Process Control Charts At the last Board meeting there was a request to see HAI related data in the Statistical Process Control Chart format. These are charts which were initially developed for industry as means of determining when fluctuations in output were due to natural variation or special cause variation. This is achieved by using statistics to set upper and lower control limits. Breaches of these limits triggers a review of the variation to ensure improvements are embedded and deteriorations are rectified. The use of SPC charts for presenting HAI related data gained ground in the mid 2000’s; they are currently used locally in the monthly executive and ward HAI reports. There are limitations to their use as they were originally designed to measure performance of processes that were controlled rather than complex multi-factorial outputs such as healthcare associated infections. They also do not necessarily give an indication of progress towards target compliance. An SPC Chart can be in control yet the levels are higher than desired. That said they can be a useful trigger for undertaking system reviews. The Board is asked to advise whether the use of SPC charts aids understanding of the data and whether they would be of value in further NHS Board papers. 2. SAB Update 2.1 Local Delivery Plan Target To achieve a rate of no more than 0.24 cases per 1,000 acute occupied bed days for SABs by the year ending 31 March 2019 (approximates to 7 SABs per month). The Boards verified SAB rate for the year ending June 2018 was 0.28 cases per 1,000 acute occupied bed days. The projected rate for the year ending September 2018 is 0.28 cases (Chart 1).
Chart 1 – Rolling Annual SAB rate against national target
There were 58 SABs in the first six months of the year; this exceeds the local numerical target by 16 cases (Chart 2).
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Chart 2 – SAB Target 2017–18 Local Trajectory
2.2 Origin of Infection The origin of all SABs is determined in line with the national surveillance protocol. Infections are firstly assessed against the hospital acquired definition i.e. is the blood culture obtained 48 hours or more after admission or on readmission if this occurs within 48 hours of discharge from hospital. If so then the infection is classified as hospital acquired. If it does not meet the hospital acquired definition it is assessed against a range of criteria that can be summarised as:
Hospitalisation overnight within the previous 30 days
Care home or long term care facility resident
Intravenous or intra-articular medication in previous 30 days
Regular user of a registered medical device e.g. urinary catheter with or without direct involvement of a healthcare worker
Underwent medical procedure which broke mucous or skin barrier in previous 30 days
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 previous 30 days
If any of the above criteria are met then the infection is classified as healthcare associated. Infections that do not meet either of the above criteria are deemed to be community acquired. The origin of infection for the SABs identified between April and September is detailed in Table 1.
Origin of Infection 2018-19
Hospital acquired 24
Healthcare associated 10
Community acquired 24
Table 1 – Origin of SAB Infections
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The monthly number of SABs has triggered the upper warning limit twice in 2018, March and June, but has not breached the upper control limit in the last 30 months (Chart 3). There is more variability in the data this year making trend projections difficult.
Chart 3 - Monthly SAB Totals April 16 – September 18 – SPC Chart The subset which is assessed as being hospital acquired is more stable (Chart 4). There was one breach of the upper warning limit in March 2018 but no breach of the upper control limit.
Chart 4 – Monthly Hospital Acquired SABs April 2016 –Sept 2018 – SPC Chart 2.3 Point of Entry The national enhanced SAB surveillance programme requires Boards to assess the point of entry of the organism into the patient. This is to determine the most appropriate interventions for prevention. The point of entry was unknown in 15 of the cases; whilst blood culture contaminants and skin infections were responsible for 9 cases each (Table 2). There were 13 vascular access device infections - 6 peripheral vascular catheters (PVCs); 4 central lines and 3 dialysis lines and fistulas. People Who Inject Drugs in the Community accounted for 6 SABs.
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SAB Point of Entry April – August 18
Unknown 15
Contaminants 9
Skin 9
PVC 6
People Who Inject Drugs 6
Central Lines 4
Dialysis Lines & Fistulas 3
Urinary Tract Infection 2
Urinary Catheter 1
Supra-pubic Catheter 1
Respiratory Infection 1
Other 1
Total 58
Table 2 – SAB Point of Entry April – September 2018 It is not always possible to determine the point of entry for 3 reasons:
Genuine Unknowns - patients may have no other signs or symptoms of infection that will guide that assessment.
Multiple Possible Points of Entry - patients may have more than 1 possible point of entry e.g. respiratory infection and urinary tract infection.
Insufficient Clinical Evidence – there may be no information that can help identify the point of entry. This may be as a result of the patient dying before any investigation could be initiated or the patient was receiving palliative care and therefore it would have been inappropriate to undertake further diagnostic tests.
In all of these circumstances the point of entry will be recorded as unknown in line with the national protocol. 2.4 Interventions 2.4.1 Peripheral Vascular Cannulas The Infection Prevention & Control Team (IPCT) launched revised PVC insertion and maintenance documentation and PVC insertion packs on the 3 September. The insertion and maintenance documentation incorporates the reasons why the PVC should be used within the mnemonic DRIFT:
Diagnosis
Resuscitation
IV medication
Fluids
Transfusion This will support staff in making the correct decisions on when to insert and remove PVCs. One of the drivers for the introduction of DRIFT is that it can help reduce the number of unnecessary PVCs insitu. In July the Infection Control Nurses commenced a monthly survey of PVC prevalence in University Hospital Ayr (UHA) and University Hospital
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Crosshouse for a six month period. This will give two months baseline data prior to introduction of the new documentation and insertion packs and 4 months post introduction to measure if there is an overall reduction in PVC prevalence. 2.4.2 Blood Culture Contaminants Blood culture contaminants are a distinct category. This is applied when the positive blood culture is thought to arise from contamination of the blood sample either by bacteria from the skin of the patient or the person taking the blood culture. The patient is not infected and does not have a bacteraemia; however Health Protection Scotland (HPS) have instructed that these should be counted in the overall bacteraemia rate. There have been nine SABs assessed as blood culture (BC) contaminants between April and September 2018. Contamination is a recognised risk when obtaining blood cultures with rates of 5% or more not uncommon, especially when they the samples are obtained in an emergency situation. Normally the contaminating organisms are other strains of Staphylococcus such as S. homini or S. epidermis. Very rarely is S. aureus deemed to be a contaminant. In 2017 -18 there were approximately 15,000 blood cultures obtained in NHS Ayrshire & Arran of which 8 (0.05%) were Staphylococcus aureus contaminants. The nine contaminants in the first six months of this year were taken in six areas:
Emergency Department – UHC x 2
Station 9 - UHC x 2
Combined Assessment Unit - UHC x 2
Labour Suite - Ayrshire Maternity Unit
Ward 4D – UHC
Ward 1A - UHC
Interventions that have taken place to reduce the level of blood culture contaminants include:
Introduction of alternative skin antisepsis
Introduction of new equipment for obtaining BCs
Development of a learn-pro module on obtaining BCs
Inclusion of BCs process into the junior doctor’s induction talks undertaken by the Infection Prevention and Control Doctor.
Feedback of contamination rates to the UHA Emergency Department. When a SAB is deemed to be a contaminant the Consultant Microbiologists will check the overall contamination rate for that area for the previous 6 months to determine if the rates are higher than expected levels. If they are then they will engage with the local clinical teams to discuss sampling technique.
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3. CDI Update 3.1 Local Delivery Plan Target To achieve a rate of no more than 0.32 cases per 1,000 occupied bed days for CDIs in the 15 and over age group by the year ending 31 March 2019 (approximates to 10 cases per month). The verified annual rate for the year ending June 2018 was 0.27. The projected rate for the year ending September 2018 is 0.25 (Chart 5). If confirmed this will be the lowest annual rate recorded by the Board since surveillance began in 2009.
Chart 5 – Rolling Annual CDI Rate
At the end of August 2018 there had been 46 cases of CDI which was 14 below the maximum local numerical trajectory (Chart 6).
Chart 6 – CDI Local Target Trajectory 2018-19
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3.2 Origin of Infection All cases of CDI are assessed against the HPS criteria to determine the origin of infection. If the positive Clostridium difficile sample is taken more than 48 hours after admission or within 4 weeks of discharge then it is deemed to be healthcare associated. If it is taken between 4 and 12 weeks after discharge from hospital it is classed as unknown origin and if it is taken more than 12 weeks after discharge then it is categorized as community acquired. The origin of CDI cases between April and August 2018 are detailed in Table 4.
Origin of Infection Cases
Healthcare associated 25
Unknown 7
Community acquired 17
Table 4 – Origin of CDI Cases April – September 2018
The IPCT collect enhanced data on all hospital identified cases of CDI. This enables the identification of areas of increased incidence and possible outbreaks as well as allowing feedback at ward level. This cases which develop 48 hours after admission are classed as hospital acquired. In the last 12 months the number of hospital identified cases of CDI has remained primarily at or below the mean as have those which are assessed as hospital acquired (Charts 7 & 8). It should be noted that the overall numbers are low therefore small monthly changes can seem quite marked on the charts.
Chart 7 – Hospital Identified Cases of CDI April 2016 – September 2018 – SPC Charts
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Chart 8 - Hospital Acquired Cases of CDI April 2016 – September 2018 – SPC Charts 4. National MRSA Clinical Risk Assessment Policy Update The national MRSA Clinical Risk Assessment Key Performance Indicator target is for boards to achieve a minimum 90% compliance with CRA completion. In Quarter 2 (2018-19) the Board’s compliance dipped slightly to 89% from 90% the previous quarter (Chart 5). This compares with a Scottish compliance rate of 84%.
Chart 5 – MRSA KPI Quarterly Compliance
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5. Outbreaks / Incidents Update 5.1 Ward/Room Closures There was a room closure in Ward 5D, UHC, as a precautionary measure after four patients developed diarrhoea. The patient’s symptoms were short lived and the ward returned to normal operation after three days. No infectious cause was identified. The ward subsequently experienced a confirmed outbreak of Norovirus in October which affected 18 patients and 7 staff. Outbreak control measures were implemented and the ward was closed for 11 days.
Ward Hospital Month Patients Staff Organism/Condition
Room Closure Period
Ward Closure period
5D University Hospital Crosshouse
September 4 0 Diarrhoea 3 days N/A
5D University Hospital Crosshouse
October 18 7 Confirmed Norovirus
N/A 11 days
Table 5: Ward/Room Closures Due to Outbreaks
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Monitoring Form
Policy/Strategy Implications
Not required. This update report has no policy/strategy implications.
Workforce Implications
Not required. This update report has no workforce resource implications.
Financial Implications
The continual management and monitoring of HAIs in NHS Ayrshire & Arran in driving down infection rates as far as possible will ensure that costs per patient stay (i.e. treatments, length of stay, terminal ward cleaning etc) will not be impacted upon, ensuring that costs are minimised across the organisation.
Consultation (including Professional Committees)
The HAI update is provided to agreed NHS Boards, Healthcare Governance Committees and to the Prevention & Control of Infection Committee at every meeting (four times per year).
Risk Assessment
Assessments are carried out on the HAI alert organisms by the Infection Control Nurse responsible for that particular clinical area to ensure that all necessary standard infection control precautions are initiated as appropriate in managing the patients care.
Best Value - Vision and leadership - Effective partnerships - Governance and
accountability - Use of resources - Performance management
Delivers effective partnerships and governance and accountability for the Board and best use of resources.
Compliance with Corporate Objectives
Patient Safety
Single Outcome Agreement (SOA)
Not required. This is an update report to NHS Board members.
Impact Assessment Equality Impact Assessment not required as this is an update report to NHS Board members.
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NHS AYRSHIRE & ARRAN REPORT CARD
Staphylococcus aureus bacteraemia monthly case numbers
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
MRSA 0 0 0 0 0 0 2 0 3 1 0 2
MSSA 8 11 1 11 6 14 3 5 12 9 11 10
Total SABS 8 11 1 11 6 14 5 5 15 10 11 12
Clostridium difficile infection monthly case numbers
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
Ages 15-64 5 1 2 2 2 1 0 1 2 2 2 2
Ages 65
plus 9 6 3 3
7 11 4 4 8 5 10 6
Ages 15
plus 14 7 5 5 9 12 4 5 10 7 12 8
Hand Hygiene Monitoring Compliance (%)
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
AHP 99 99 99 98 96 98 96 96 100 98 97 98
Ancillary 93 92 96 90 89 85 91 88 98 93 92 95
Medical 93 92 90 95 100 95 93 91 89 96 91 93
Nurse 97 91 92 96 95 92 97 98 99 97 97 98
Board Total 97 95 97 97 98 97 96 96 98 97 96 97
Cleaning Compliance (%)
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
Board Total 95 95 95 95 95 95 93 93 95 95 95 95
Estates Monitoring Compliance (%)
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
Board Total 98 98 98 98 98 98 98 96 98 97 96 97
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UNIVERSITY HOSPITAL AYR REPORT CARD
Staphylococcus aureus bacteraemia monthly case numbers
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
MRSA 0 0 0 0 0 0 2 0 0 1 0 0
MSSA 2 0 0 0 0 1 0 1 1 0 1 0
Total SABS 2 0 0 0 0 1 2 1 1 1 1 0
Clostridium difficile infection monthly case numbers
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
Ages 15-64 0 0 0 0 0 0 0 0 0 0 0 0
Ages 65
plus 0 2 0 0
2 1 1 1 0 1 1 1
Ages 15
plus 0 2 0 0
2 1 1 1 0 1 1 1
1 Cleaning Compliance (%)
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
Ayr 95 95 95 95 95 95 95 93 94 94 95 95
Estates Monitoring Compliance (%)
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
Ayr 97 96 97 96 97 97 97 96 95 95 96 96
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UNIVERSITY HOSPITAL CROSSHOUSE REPORT CARD
Staphylococcus aureus bacteraemia monthly case numbers
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
MRSA 0 0 0 0 0 0 0 0 2 0 0 2
MSSA 1 4 1 6 3 7 2 3 2 1 3 2
Total SABS 1 4 1 6 3 7 2 3 4 1 3 4
Clostridium difficile infection monthly case numbers
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
Ages 15-64 0 0 0 1 0 0 0 0 0 0 0 1
Ages 65
plus 1 2 0 1
2 4 1 1 0 0 0 1
Ages 15
plus 1 2 0 2 2 4 1 1 0 0 0 2
Cleaning Compliance (%)
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
Crosshouse 96 96 96 96 96 97 96 95 96 95 96 95
Estates Monitoring Compliance (%) Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
Crosshouse 99 99 98 98 99 99 99 97 97 98 98 98
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AYRSHIRE CENTRAL HOSPITAL REPORT CARD
Staphylococcus aureus bacteraemia monthly case numbers
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
MRSA 0 0 0 0 0 0 0 0 0 0 0 0
MSSA 0 0 0 1 0 0 0 0 0 0 0 0
Total SABS 0 0 0 1 0 0 0 0 0 0 0 0
Clostridium difficile infection monthly case numbers
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
Ages 15-64 0 0 0 0 0 0 0 0 0 0 0 0
Ages 65
plus 1 0 0 0 0 0 0 0 0 0 0 0
Ages 15
plus 1 0 0 0 0 0 0 0 0 0 0 0
Cleaning Compliance (%)
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
ACH 94 95 93 96 92 96 90 92 98 97 96 94
Estates Monitoring Compliance (%)
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
ACH 99 98 99 100 97 99 98 97 99 99 95 98
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BIGGART HOSPITAL REPORT CARD
Staphylococcus aureus bacteraemia monthly case numbers
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
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
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
Ages 15-64 0 0 0 0 0 0 0 0 0 0 0 0
Ages 65
plus 0 0 0 0
0 1 0 0 1 0 0 0
Ages 15
plus 0 0 0 0 0 1 0 0 1 0 0 0
Cleaning Compliance (%)
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
Biggart 94 93 98 94 96 93 - 94 96 92 - 95
Estates Monitoring Compliance (%)
Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
Biggart 96 98 99 97 99 96 - 94 99 96 - 97
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NHS COMMUNITY HOSPITALS REPORT CARD
The community hospitals covered in this report card include: Ailsa Hospital Arran War Memorial Hospital Arrol Park Resource Centre East Ayrshire Community Hospital Girvan Community Hospital Kirklandside Hospital Lady Margaret Staphylococcus aureus bacteraemia monthly case numbers Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
MRSA 0 0 0 0 0 1 0 0 0 0 0 0
MSSA 0 1 0 0 0 0 0 0 0 0 0 0
Total SABS 0 1 0 0 0 1 0 0 0 0 0 0
Clostridium difficile infection monthly case numbers Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
Ages 15-64 0 0 0 0 0 0 0 0 0 0 0 0
Ages 65 plus
0 0 0 0 0 0 0 0 0 0 0 0
Ages 15 plus
0 0 0 0 0 0 0 0 0 0 0 0
NHS OUT OF HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia monthly case numbers Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
MRSA 0 0 0 0 0 0 0 0 1 0 0 0
MSSA 5 6 0 4 3 5 1 1 9 8 7 8
Total SABS 5 6 0 4 3 5 1 1 10 8 7 8
Clostridium difficile infection monthly case numbers Oct
2017
Nov
2017
Dec
2017
Jan
2018
Feb
2018
Mar
2018
Apr
2018
May
2018
Jun
2018
Jul
2018
Aug
2018
Sep
2018
Ages 15-64 5 1 2 1 2 1 0 1 2 2 2 1
Ages 65 plus
6 2 3 2 3 5 2 2 7
4 9 4
Ages 15 plus
11 3 5 3 5 6 2 3 9
6 11 5