healthcare associated infection reporting template (hairt)€¦ · apr – jun15 (not yet validated...

Highland NHS Board October 2015 Item 5.3

INFECTION PREVENTION & CONTROL REPORT Report by Catherine Stokoe, Infection Control Manager and Dr Jonty Mills, Consultant Microbiologist/Infection Control Doctor, 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 shows NHS Highland Infection Prevention & Control targets and performance data

Group Target NHS Scotland

NHS Highland

Clostridium difficile

Age 15 and over HEAT rate of 32.0 cases per 100,000 OBDs to be achieved by year ending 03/16

Jan – Mar 27.1

Jan-Mar 15 28.5

Green

Apr – Jun15 (not yet validated data) 51.71

Red (not yet validated)

Staphylococcus aureus bacteraemia

HEAT rate of 24.0 cases per 100,000

Jan – Mar 29.7

Jan-Mar 15 20.5

Green

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Group Target NHS Scotland

NHS Highland

AOBDs to be achieved by year ending 03/16

Apr – Jun15 (not yet HPS validated data) 18.96

Green (not yet validated)

Hand Hygiene 95% 95% 98% Green Cleaning 92% 96% Green Estates 95% 96% Antimicrobial prescribing (includes data from monthly audits to the end of August 2015)

Hospital- based Downstream ward audit (commenced June 2015)

95% Ward 7A 63%

Amber

Ward 4C 65%

Amber

Surgical antibiotic prophylaxis

95% 100% Green

(includes data from Q1 (Jan – Mar) of calendar year 2015)

Total antibiotic prescribing measure (primary care)

50% of GP practices at or moved towards target

53.6% 60% Green

Source: - Health Protection Scotland/ISD/Local data. Current NHS Highland Clostridium difficile case data (not yet validated by HPS) identifies our provisional rate for April – June 2015 as 51.71 against an expected rate of 32. Our position as of 1st of September 2015 is, 47 patient cases (32 cases age 65 and over, and 15 cases aged 15-65years) against the proposed target of 78 by end of March 2016. Current NHS Highland SAB case data (not yet validated by HPS) identifies our provisional rate for April – June 2015 as 18.96 against an expected rate of 24. Our position as of 1st of September 2015 is, 22 patient cases (1 MRSA, and 21 MSSA) against proposed target of 60 by end of March 2016. The Board need to note that if the same number of cases/rates occur within 2015/2016, as were reported within the previous year, we are at high risk of not attaining the CDI HEAT target come March 2016. 4. Achievements

• The transfer of Argyll and Bute Infection Prevention and Control services and governance from NHS Greater Glasgow and Clyde (NHSGG&C) to NHS Highland

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has been completed. The impact on patient care and the existing staffing workload is to be assessed in six months (October 2015).

• In order to learn from, and reduce future cases of infection, information must be gathered and data sets scrutinised by the Infection Prevention and Control Team. The attainment of funding to support a 1WTE data analyst within the IPCT will enable this to occur more effectively and provide real- time robust data to NHS Highland staff. The recruitment to this post is underway.

5. Challenges

• NHS Highland met the SAB HEAT target; our aim is to further reduce Staphylococcus aureus bacteraemias by engaging all clinical staff in hospitals and the community in initiatives to prevent and reduce invasive device/healthcare related infections.

• To continue to support all clinical staff in hospitals and the community in the prevention and reduction of infections, by focussing on prudent antimicrobial prescribing, and compliance with standard infection prevention and control precautions (SICPs).

• The Infection Control and Prevention Team in conjunction with the Health and Safety Team continue to work with staff to support them in providing personal protective equipment (PPE) training across their Operational units for preparation when dealing with infections such as TB, Flu, Ebola . This training is very resource intensive, and we are awaiting information from Health Protection Scotland to agree the National direction for future competency training for Ebola. The Health and Safety team and Infection Control Team are also working collaboratively to ensure staff are able to undergo face fit testing in the use of respirator masks, and are knowledgeable on the use of powered visors.

• The monitoring of Escherichia coli bacteraemia is to be implemented across all NHS Boards by HPS as a mandatory surveillance field in April 2016. This will have a significant impact on the Infection Prevention and Control Team, the Microbiology staff, and the supporting administration team, in terms of resource. All NHS Boards have been asked by HPS to undertake E coli bacteraemia surveillance from the 1st of September, IPCT are currently monitoring the impact this surveillance is having on workload.

• The Infection Prevention and Control nursing service across NHS Highland continue to deal with increasing workload demands such as the management of clinical infections such as chicken pox, and flu, which require contact tracing, whilst dealing with the existing demands of the service. Alongside this there are increasing workload demands from the clinical microbiology service, impacting on the Consultant Microbiologists and Infection Control Doctor work load and competing priorities. A service review, impact risk assessment and job plan review is being undertaken to ensure the service is fit for the future.

• The Infection Control Nursing team within Argyll and Bute currently has a vacancy for

a 1WTE band 7 IPCN post which is currently out to advert again. Whilst awaiting a permanent appointment an experienced IPCN has been employed on the bank for two days per week, to assist in the delivery of the service alongside the existing fulltime IPCN band 6.

http://www.google.co.uk/url?url=http://en.wikipedia.org/wiki/Pathogenic_Escherichia_coli&rct=j&frm=1&q=&esrc=s&sa=U&ei=oKpIVcn5Oe2R7Abzj4DIBg&ved=0CBoQ0gIoADAA&usg=AFQjCNHkRbps0Lo8zdiy4oFWTzXSiJQetQ

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• Obtaining accurate data from Microbiology laboratory systems remains a challenge. The business continuity plan within Microbiology acknowledges this risk, and ensures that the reporting results would be paper based. In the longer term the system needs replacing and this is scheduled to go ahead in 2016/2017 following the implementation of ‘Ultra’ into Blood Sciences.

• ICNETs (infection control software programme) integration into Argyll and Bute was scheduled to be in place by June, however due to ICNETs previous commitments outside of NHS Highland this was delayed. A business case was requested by e-Health for this work and this has been submitted, awaiting approval with e-health. It is likely that implementation and testing of ICNET will not be completed till October 2015. Whilst we await the integration of ICNET there is a risk that human factors might result in errors and delays in infection control information being received in a timely and accurate manner, due to the reliance on manual data inputting and dissemination. ICNET will remove this risk due to automatic electronic data transfer.

6. Risks

The current level of CDI cases this quarter are higher than expected, and we are actively working with Health Protection Scotland and NHS Highland staff to monitor the situation. The Infection Prevention and Control team, alongside the Executive Lead for Infection prevention and Control and the Lead Nurses, are working collaboratively to improve the process of learning from cases, and ensuring that learning is disseminated across Highland. This will include improved scrutiny of prescribing. The Infection Prevention and Control team in conjunction with the Lead Nurses continue to ensure a high level of environmental cleanliness is being maintained in order to mitigate any risk of contamination from the environment. Catherine Stokoe – Infection Control Manager Jonty Mills– Consultant Microbiologist & Lead Infection Control Doctor, October 2015

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NHS Highland Healthcare Associated Infection Report Key Healthcare Associated Infection Headlines

1. Staphylococcus aureus (including MRSA)

1.1 Staphylococcus aureus bacteraemia target The target for 2015/2016 for NHS Highland remains at 24.0 cases or less per 100,000 acute occupied bed days for Staphylococcus aureus bacteraemia (including MRSA). For NHS Highland this means no more than approximately 60 cases by 31st March 2016. 1.2 Trends NHS Highland’s SAB incidence rate for April – June 2015 is 18.96 (not yet validated by HPS) per 100,000 acute occupied bed days. NHS Highlands position as of 1st September 2015 (data not yet validated by HPS) is tabled below.

1st April 2015 – 1st September 2015

Total SABs = 22 21 MSSA cases 1 MRSA cases

4 preventable (SSI / PICC line related) 15 not preventable 3 under investigation

Hospital Acquired Cases = 4 cases Community Acquired = 5 cases Healthcare Associated = 10cases Unknown undergoing investigation = 3 cases

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 : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=346

MRSA: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252

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:

http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=30248

http://www.nhs24.com/content/default.asp?page=s5_4&articleID=346


http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=30248

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Figure 1: NHS Highland Staphylococcus aureus bacteraemia Cumulative Case numbers year on year since 2011.

Figure 2: Quarterly rolling year Staphylococcus aureus rates per 100,000 Acute Occupied

Bed Days for HEAT Target Measurement

0

5

10

15

20

25

30

Apr 12 -Mar 13

Jul 12 -Jun 13

Oct 12 -Sept 13

Jan 13 -Dec 13

Apr 13-Mar 14

Jul 13 -Jun 14

Oct 13 -Sept 14

Jan 14 -Dec 14

Apr 14 -Mar 15

Jul 14 -Jun 15 (p)

Actual Performance Target

.

Apr 12 - Mar

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Jul 12 - Jun 13

Oct 12 -

Sept 13

Jan 13 -

Dec 13

Apr 13- Mar 14

Jul 13 - Jun 14

Oct 13 -

Sept 14

Jan 14 -

Dec 14

Apr 14 -

Mar 15

Jul 14 –Jun

15 (P)

Actual Performance 21.8 21.4 25.0 25.1 25.4 23.4 22.9 22.7 22.2 21.9

Trajectory 26.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0

Target 26.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0

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1.3 Current Initiatives

• The SPSP Team and HAI Quality Improvement Facilitator for vascular devices have launched the peripheral venous catheter, central venous catheter, and midline insertion and maintenance bundle documentation.

• Targeted education has been provided alongside the launch of the peripheral vascular bundle

• The peripheral venous catheter care patient information leaflet has been reviewed and will be available shortly for ordering.

• A new policy and procedure for the management of central venous catheters and midlines has been produced.

• A repeat of the point prevalence audit for peripheral venous cannula care will be undertaken by December 2015. Alongside the introduction of a formal system for validation of all self-reported audit data, which is currently being tested across the four general hospitals.

2. Clostridium difficile

2.1 Clostridium difficile HEAT Target Current target for 2015/2016 for NHS Highland remains at 32.0 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 year ending March 2016. 2.2 Trends NHS Highland’s CDI incidence rate for April – June 2015 is 51.71 (not yet validated by HPS) is higher than expected for this quarter, and as a result the Infection Prevention and Control team advised Health Protection Scotland of the situation. Health Protection Scotland fed back that they were satisfied that the Board have in place all the correct procedures and measures to prevent and control infection. We continue to liaise closely with them. NHS Highlands position as of 1st September 2015 (data not yet validated by HPS) is tabled below.

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. 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:

http://www.hps.scot.nhs.uk/haiic/sshaip/ssdetail.aspx?id=277

http://www.nhs.uk/conditions/Clostridium-difficile/Pages/Introduction.aspx

http://www.hps.scot.nhs.uk/haiic/sshaip/ssdetail.aspx?id=277

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1

st April 2015 –

1st September 2015

Total CDI cases = 47 Aged 15 + Aged 15 – 64 = 15

Aged 65 + = 32 Hospital Acquired Cases = 4 cases; Community Acquired = 17 cases (including 2 re-occurrences) Healthcare Associated 27 Unknown 3 under investigation

The Infection Prevention and Control team in conjunction with the Lead Nurses are continuing to ensure a high level of environmental cleanliness is maintained in order to mitigate any risk of contamination from the environment. Each CDI case is reviewed, and learning is shared with local teams. The IPCT are now keen to enhance this process further, through the collection of root cause analysis data and the engagement of the executive management team when cases are being discussed with clinical teams, however it should be acknowledged that this process is very resource intensive. NHS Highland is also part of a wider team across NHS Scotland looking at the introduction of an antibiotic (Fidaxomicin) which has been linked to the reduction in the incidence of CDI relapse. This antibiotic has been prescribed, but it is too early to note its impact on our patients care and treatment. Figure 3: NHS Highland Clostridium difficile infection cumulative case numbers age 15 years and over year on year since 2011.

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Figure 4: Quarterly rolling year Clostridium difficile Infection Cases per 100,000 occupied bed days for HEAT Target Measurement

2.3 Current Initiatives

• A scoping exercise is underway in order to undertake antimicrobial ward rounds within Raigmore hospital as a pilot project within September.

• A business case is in progress to review the use of Fidaxomicin for recurrent CDI cases.

• A review of the methodology used to discuss clinical cases, capture and analyse surveillance data is underway.

2.5 Antimicrobial Management Table 2: shows NHS Highland progress against the 3 national indicators.

Antimicrobial Indicator NHS Highland progress Data June 2015 to August 2015

Hospital-based prescribing – downstream ward duration audit In one medical and one surgical continuing care ward, data is collected from at least 5 patients per week on antibiotics and the following measures are assessed: indication documented; antibiotic choice in line with guidance; review date of IV antibiotics within 72 hours of starting and duration of oral therapy is documented on the drug kardex. The target is ≥ 95% for

Ward 7A – Non-Compliant Data collection commenced in June 2015 so limited trend analysis is available. Median compliance with all elements of the audit is 63%. The documentation of a review date or duration of therapy has dropped in August with the new intake of medical staff so the details of the audit have been reinforced as part of the feedback. As with the previous audit, feedback is provided verbally and in printed form to the staff on the ward each month with opportunity to discuss any issues

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

Apr 12 - Mar13

Jul 12 -Jun 13

Oct 12 -Sept 13

Jan 13 -Dec 13

Apr 13-Mar 14

Jul 13 -Jun 14

Oct 13 -Sept 14

Jan 14 -Dec 14

Apr 14 - Mar15

Jul 14 - Jun15

Actual Performance Target

Apr 12 - Mar 13

Jul 12 - Jun 13

Oct 12 - Sept 13

Jan 13 - Dec 13

Apr 13- Mar 14

Jul 13 - Jun 14

Oct 13 - Sept 14

Jan 14 - Dec 14

Apr 14 - Mar 15

Jul 14 – Jun 15 (P)

Actual Performance

31.9 27.3 28.7 28.8 30.2 33.7 34.6 36.9 38.5 41.1

Trajectory N/A 37.0 37.0 37.0 37.0 37.0 37.0 34.0 32.0 32.0 Target N/A 32.0 32.0 32.0 32.0 32.0 32.0 32.0 32.0 32.0

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each measure. This data collection process has been modified and is not comparable to the previous downstream audit data.

arising. This format is welcomed by the clinical teams on 7A.

Ward 4C – Non-Compliant Data collection commenced in June 2015 so limited trend analysis is available. Median compliance with all elements of the audit is 65%. The documentation of a review date or duration of therapy is a new process for the clinical teams so demonstrating reliability in conjunction with a change in junior medical staff is challenging. Feedback is delivered by email and has generated dialogue with the clinical teams so improvements should follow over the next few months.

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 surgical cases.

Compliant Data to end of August 2015 show median compliance remains at 100% with surgical prophylaxis in elective colorectal procedures using the more stringent audit criteria as previously detailed. Issues around timely administration of a second dose improved significantly in the last 3 months with the time of the second dose being written on a white board in Theatre.

Total antibiotic prescribing Total antibiotic prescribing rate is 1.8 items per 1000 patients per day or less. Target 50% of GP practices to meet or move towards the target.

Compliant Data from January to March 2015 shows 60 out of 100 practices across NHS Highland have met the total prescribing indicator as previously reported. This compares favourably with the national figure of 53.6% across Scotland and NHS Highland was one of 7 boards to achieve the indicator. Further work to investigate areas with high prescribing rates is ongoing in conjunction with the primary care prescribing advisors team.

Antimicrobial Ward Rounds Following a survey of the maturity of Antimicrobial therapies (AMTs) by Scottish Antimicrobial Prescribing Group, NHS Highland Antimicrobial Management team (AMT) identified the development of antimicrobial ward rounds as a priority for the future. A pilot project is currently being scoped in Raigmore with ward rounds planned to start in September for 2 months. Evaluation of the pilot outcomes will determine if resource can be identified to support a sustained service with potential expansion. It is recognised that this service will require significant input from Microbiology and Infectious Disease consultants. Management of Pre-operative Urine Samples Prior to Orthopaedic Surgery Protocol for pre-operative urine sampling prior to orthopaedic surgery has been discussed extensively with the orthopaedic surgeons and GPs and agreement has been reached that will allow identification of at risk patients and ensure treatment of symptomatic Urinary tract infection (UTI) as per guidelines. The information has been discussed by GP Sub-group and circulated to members.

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Investigation of Unintended Consequences of Antibiotic Prescribing Fruitful discussion with the Renal and Ear Nose and Throat (ENT) teams has identified a number of areas for future work on possible consequences of the antimicrobial stewardship programme. In ENT, a review of hospital admissions for infective complications of upper respiratory tract infections will be undertaken looking specifically for any changes in the admission rate for tonsillar abscess and mastoiditis. Existing data base information in the Renal Department will be reviewed to identify any patients who have received haemodialysis or had a renal biopsy where either gentamicin or vancomycin are thought to be causative factors of it. In addition, a project to review gentamicin levels from the laboratory aims to quantify the proportion of gentamicin therapy course that may be longer than 72 hours. Datix reports around gentamicin and vancomycin prescribing issues have been reviewed resulting in a change to the peri-operative checklist and anaesthetic record. Ward pharmacists will be delivering one-to-one training with FY1s to improve understanding and practical issues around prescribing and monitoring therapy. The AMT is required to work on such areas and report the outcomes to Scottish Antimicrobial Prescribing Group. 3 Hand Hygiene

3.1 Hand Hygiene Reporting Each Board is responsible for monitoring and reporting hand hygiene compliance data. 3.2 Trends NHS Highland Hand Hygiene Rolling Monthly Audit Programme continues across all clinical areas. Compliance rates are being sustained above 98% in July August 2015.

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/

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:

http://www.hps.scot.nhs.uk/haiic/ic/nationalhandhygienecampaign.aspx

http://www.washyourhandsofthem.com/

http://www.hps.scot.nhs.uk/haiic/ic/nationalhandhygienecampaign.aspx

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4. Cleaning and the Healthcare Environment

4.1 Current Rates The monthly cleaning and estates audits as per the National Cleaning Services Specification demonstrated 96% compliance in July and August 2015 for domestic monitoring, and 96% for estates monitoring in July and August 2015. The Independent Peer/Public Peer Review audits are to be carried out across NHSH over September 2015. 4.2 Healthcare Environment Inspections Unannounced HEI follow up inspection to Mid Argyll Community Hospital and Integrated Care Centre on 12-13 May 2015

The 16 week action plan is due for submission to the Healthcare Environment Inspectorate on the 15th Sept. The two requirements and three recommendations made, have been met.

Unannounced inspection to Lorn & Islands Hospital occurred on Tuesday 14 to Wednesday 15 July 2015.

This was the first inspection of the hospital against the new Healthcare Improvement Scotland Healthcare Associated Infection (HAI) Standards (February 2015). The finalised report was published on the 8th September 2015. 3 requirements and 3 recommendations were made. An action plan has been developed following the visit and good progress has been made to address all the requirements.

5. Outbreaks associated with NHS Highland No outbreaks to report 6. Surveillance 6.1 MRSA Clinical Risk Assessment (CRA) Screening Audit

As part of the national mandatory MRSA Screening Programme required by HPS, quarterly compliance is reviewed to provide assurance that CRA compliance is at or above 90%. The compliance within our board for financial year 2014/15 was 66%; the Scottish annual compliance figure was 78%, with compliance varying across the NHS Boards.

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:

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


http://www.nhshealthquality.org/nhsqis/6710.140.1366.html

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NHS Highland compliance with the CRA is measured quarterly. The Infection Prevention and Control team conduct the data collection, and raise any issues with compliance at the time of the audit with the clinical teams. For quarter 1, (April-June 2015) compliance was 75%.

Following the identification of this compliance level the Infection Prevention and Control team have been raising awareness through the local clinical teams and the local infection prevention and control (IPC) groups. Educational sessions are also planned in September and October on the IP&C risk assessment document which includes the MRSA clinical risk assessment tool. This tool is also embedded into the common admission document, and the new assessment bundle. The IPCT have also developed an MRSA policy compliance audit which will look at screening, the completion of the CRA, as well as other key policy elements. A point prevalence audit using this tool will occur across NHS Highland in November.

6.2 Surgical Site Infections (SSI)

NHS Highland continues to monitor SSI rates through mandatory and voluntary surveillance. The clinical teams alongside the Infection Prevention & Control Surveillance team, the Scottish Patient Safety Programme team and the HAI Quality Improvement Facilitators (HAI QIF) (work stream; Colorectal surgery) are working jointly to review all incidents of infection, and ensure that care practices are evidence based and maintained. Colorectal Surgical Site Infection Colorectal SSI rate Jan 2014 – Dec 2014 was 9.7% a significant improvement on the comparable figure for 2013 of 15.63%. For Jan – July 2015 the current SSI rate is 9.9%. Figure 5 highlights the monthly SSI percentage and is annotated to identify when improvements have been introduced or compliance achieved. It also indicates that between January and June 2015 there are five consecutive data points all decreasing. This indicates a trend which is statistically significant. Figure 5 shows monthly SSI rate in elective colorectal surgery, Jun 2011 -July 2015

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Figure 6: Number of cases between infections following colorectal surgery March 2012 – July 2015

The IPC surveillance team continue to work closely with the Colorectal team and Quality Improvement Facilitator, as part of the Acute Adult SPSP work stream, (CEL(19)2013). The group currently meet monthly and the following are the outcome measures

• 95% or greater compliance of the SSI ward and theatre bundles by end December 2015

• Less than 10% SSI in Colorectal surgery by end December 2015

Figure 7: Shows median length of stay for elective colorectal SSI Cases 2012-2014

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Figure 7 demonstrates the median length of stay for SSI’s and non SSI between 2012 and 2014. The relevance of this data is to be discussed at the next colorectal improvement meeting on the 21st September 2015. Orthopaedic Surgical Site Infections Total Hip replacement surgery continues to have a low rate of SSI on the comparable figures for 2013 - 0.25%, 2014 – 0.66% and Jan to July 2015 - 0.44% Figure 8 shows the monthly SSI rate in Total Hip Replacement surgery Jan 2010-July 2015

Figure 9: Shows monthly number of days between Total Hip Replacement surgery resulting in an SSI, May 2010 to September 2015

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Hemiarthroplasty SSI rate for 2014 – 1.7%, (2013 – 2.9%). An increase is noted from the previous year, in the rate between Jan-July 2015, which currently is 3.2%. Root cause analysis on the four cases has been conducted and fed back to the clinical teams.

Figure 10: Shows monthly SSI rate for Hemi arthroplasty surgery Jan 2010 to July 2015.

Figure 11: Shows monthly SSI rate for fracture Neck of Femur, excluding hemi arthoplasty Jan 2010-July 2015

Neck of femur ex Hemiarthroplasty SSI rate for 2014 – 0.7% (2013 – 1.8%) An increase is noted in the rate from the previous year, between Jan-July 2015, which currently is 2.0%.

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Figure 12: shows monthly SSI rate for fracture Neck of Femur excluding hemi arthroplasty 2010 to July 2015

Figure 13: shows number of days between fracture neck of Femur surgery excluding hemiarthroplasty, surgery resulting in an SSI, 2010 to July 2015

An increase in the number of SSI’s for fractured neck of femur surgery was identified in April/May 2015. The surveillance team highlighted this to the orthopaedic and theatre teams, in order to ensure all practices and cleaning regimes were correct and in place, and the

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Infection Prevention and Control Team are meeting with the orthopaedic team to address learning. Root cause analysis (RCA) continues to be conducted on each SSI diagnosed. Caesarean Section (C-Section) Infections Elective C-Section SSI rate for 2014 was 0.7% (2013 - 1.4% SSI rate). A small increase is noted from the previous year, in the rate between Jan-July 2015, which currently is 2.3%. Figure 14: shows monthly SSI rate for elective C Sections, 2010 to July 2015

Figure 15: shows number of days between elective C-Section surgery resulting in an SSI, 2010 to July 2015

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Emergency C-Section SSI rate for 2014 was 1.9%. (2013 - 2% SSI rate). Emergency C-Section SSI rate for Jan-July 2015 is 1.1% Figure 16: shows monthly SSI rate for emergency C-Section, 2010 to July 2015

Figure 17: shows number of days between emergency C-Section, surgery resulting in an SSI, 2010 to July 2015

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Abbreviations

ADTC Area Drugs & Therapeutics Committee

AMT Antimicrobial Prescribing Team

AMAU Acute Medical Admissions Unit

CHP Community Health Partnership

CDI Clostridium difficile Infection

CMO Chief Medical Officer

CNO Chief Nursing Officer

CPE Carbapenemase-producing Enterobacteriaceae

CVC Central Venous Catheter

ECDC European Centre for Disease Prevention & Control

GDP General Dental Practitioner

HAI Healthcare Associated Infection

HAI QIF Healthcare Associated Infection Quality Improvement Facilitator

HAIRT Healthcare Associated Infection Reporting Template

HEAT Health Improvement, Efficiency, Access, Treatment

HFS Health Facilities Scotland

HPS Health Protection Scotland

HSE Health and Safety Executive

JAG Joint Advisory Group

MSSA Meticillin Sensitive Staphylococcus Aureus

MRSA Meticillin Resistant Staphylococcus Aureus

PICC Peripherally Inserted Central Catheter

PPI Proton Pump Inhibitor

PVC Peripheral Venous Catheter

RIDDOR Reporting of Injuries, Diseases & Dangerous Occurrences Regulations 1995

SAB Staphylococcus aureus Bacteraemia

SHPN Scottish Health Planning Note

SHTM Scottish Health Technical Memoranda

SPC Statistical Process Chart

SAPG Scottish Antimicrobial Prescribing Group

SICPs Standard Infection Control Precautions

SPSP Scottish Patient Safety Programme

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Hemiarthroplasty: An operation used to treat fractured hip similar to a total hip replacement,

but involves only half of the hip.

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 (also broken down into MSSA and MRSA) and Clostridium difficile infections, as well as hand hygiene and cleaning compliance. In addition, there is a single report card which covers all community hospitals [which do not have individual cards], and a report which covers infections identified as having been contracted from outwith hospital. The information in the report cards is provisional local data, and may differ from the national surveillance reports carried out by Health Protection Scotland and Health Facilities Scotland. The national reports are official statistics which undergo rigorous validation, which means final national figures may differ from those reported here. However, these reports aim to provide more detailed and up to date information on HAI activities at local level than is possible to provide through the national statistics. Understanding the Report Cards – Infection Case Numbers Clostridium difficile infections (CDI) and Staphylococcus aureus bacteraemia (SAB) cases are presented for each hospital, broken down by month. Staphylococcus aureus bacteraemia (SAB) cases are further broken down into Meticillin Sensitive Staphylococcus aureus (MSSA) and Meticillin Resistant Staphylococcus aureus (MRSA). More information on these organisms can be found on the NHS24 website: Clostridium difficile: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=2139&sectionID=1 Staphylococcus aureus : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=346 MRSA: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252&sectionID=1 For each hospital the total number of cases for each month are those which have been reported as positive from a laboratory report on samples taken more than 48 hours after admission. For the purposes of these reports, positive samples taken from patients within 48 hours of admission will be considered to be confirmation that the infection was contracted prior to hospital admission and will be shown in the “out of hospital” report card. Targets There are national targets associated with reductions in C.diff and SABs. More information on these can be found on the Scotland Performs website: http://www.scotland.gov.uk/About/Performance/scotPerforms/partnerstories/NHSScotlandperformance

http://www.nhs24.com/content/default.asp?page=s5_4&articleID=2139&sectionID=1


http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252&sectionID=1

http://www.scotland.gov.uk/About/Performance/scotPerforms/partnerstories/NHSScotlandperformance

http://www.scotland.gov.uk/About/Performance/scotPerforms/partnerstories/NHSScotlandperformance

22

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. More information on how hospitals carry out these audits can be found on the Health Facilities Scotland website: http://www.hfs.scot.nhs.uk/online-services/publications/hai/ Understanding the Report Cards – ‘Out of Hospital Infections’ Clostridium difficile infections and Staphylococcus aureus (including MRSA) bacteraemia cases are all associated with being treated in hospitals. However, this is not the only place a patient may contract an infection. This total will also include infection from community sources such as GP surgeries and care homes and. The final Report Card report in this section covers ‘Out of Hospital Infections’ and reports on SAB and CDI cases reported to a Health Board which are not attributable to a hospital.


23

NHS HIGHLAND REPORT CARD NHS Highland Staphylococcus aureus bacteraemia (SABs) monthly case numbers

Sep 2014

Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

MRSA 1 1 0 1 0 0 0 0 0 0 0 1 MSSA 5 6 4 3 5 4 4 1 4 7 7 2 Total SABS

6 7 4 4 5 4 4 1 4 7 7 3

NHS Highland Clostridium difficile infection monthly case numbers

012345678

Dec-

13Ja

n-14

Feb-

14M

ar-1

4Ap

r-14

May

-14

Jun-

14Ju

l-14

Aug-

14Se

p-14

Oct

-14

Nov

-14

Dec-

14Ja

n-15

Feb-

15M

ar-1

5Ap

r-15

May

-15

Jun-

15Ju

l-15

Aug-

15

SAB's NHS Highland

MRSA

MSSA

Total SABS

0

2

4

6

8

10

12

C.difficile NHS Highland

Ages15-64

Ages 65plus

Ages 15plus

24

Sep

2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Ages 15-64

5 1 3 1 1 0 0 1 5 2 2 5

Ages 65 plus

6 6 4 9 4 4 6 8 6 7 8 3

Ages 15 plus

11 7 7 10 5 4 6 9 11 9 10 8

Hand Hygiene Monitoring Compliance (%) Sep

2014 Oct

2014 Nov 2014

Dec 2014

Jan 2015

Feb 2015

Mar 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Board Total 99 98 99 96 99 99 99 98 99 99 98 99 AHP 98 99 100 97 100 99 98 97 100 99 100 100 Ancillary 100 98 99 99 97 100 100 100 99 100 97 100 Medical 99 98 98 92 98 97 99 97 95 97 97 94 Nurse 99 99 99 97 99 99 99 99 99 98 99 100 Cleaning Compliance (%)

Sep 2014

Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Board Total

96 96 97

96 96 97 96 96

96 96 96 96

Estates Monitoring Compliance (%) Sep

2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Board Total 96 97

99

98 97 96 96

97

97 93 97 97

25

NHS HIGHLAND RAIGMORE HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia (SABs) monthly case numbers Sep

2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015


1 3 0 1 0 0 3 1 1 2 0 0

Clostridium difficile infection monthly case numbers Sep

2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Ages 15-64

0 0 1 0 1 0 0 0 1 0 0 1

Ages 65 plus

0 0 0 2 0 0 1 4 1 2 1 1

Ages 15 plus

0 0 1 2 1 0 1 4 2 2 1 2


2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Total 99 99 100 99 97 99 98 99 98 99 98 98 AHP 100 100 100 100 100 100 100 100 100 100 97 97 Ancillary 98 98 100 100 93 100 97 100 98 100 98 97 Medical 96 100 100 97 98 96 96 98 93 99 97 98 Nurse 100 99 99 98 98 98 98 99 100 96 99 100 Cleaning Compliance (%) Sep

2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Total 96 96 97 97 97 97 97 97 96 96 96 96 Estates Monitoring Compliance (%) Sep

2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Total 96 97 99 98 97 97 96 96 96 95 97 97

26

NHS HIGHLAND CAITHNESS GENERAL HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia (SABs) monthly case numbers Sep

2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015


0 0 0 0 0 0 0 0 0 0 0 0


2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Ages 15-64

0 0 0 0 0 0 0 0 0 0 0 0

Ages 65 plus

1 0 0 0 1 0 2 1 1 0 0 0

Ages 15 plus

1 0 0 0 1 0 2 1 1 0 0 0


2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Total 100 99 100 99 98 100 100 100 100 97 100 98 AHP 100 100 100 100 100 100 100 100 100 100 100 100 Ancillary 100 100 100 100 - 100 100 100 100 100 100 100 Medical 100 96 100 96 95 100 100 100 100 89 100 90 Nurse 100 100 100 100 100 100 100 99 100 99 100 100 Cleaning Compliance (%) Sep

2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015


2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Total 96 97 99 99 98 99 100 99 99 98 99 98

27

NHS HIGHLAND BELFORD HOSPITAL REPORT CARD

Staphylococcus aureus bacteraemia (SABs) monthly case numbers Sep

2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015


0 0 0 0 0 0 0 0 0 0 0 0


2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

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 1 0 0 0

Ages 15 plus

0 0 0 0 0 0 0 0 1 0 0 0


2014 Oct

2014 Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Total 100 100 100 100 100 100 99 100 100 100 100 98 AHP 100 100 100 100 100 100 96 100 100 100 100 100 Ancillary 100 100 100 100 - - 100 100 100 100 100 100 Medical 100 100 100 100 100 100 100 100 100 100 100 90 Nurse 100 100 100 100 100 100 100 100 100 100 100 100 Cleaning Compliance (%) Sep

2014 Oct

2014 Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015


2014 Oct

2014 Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Total 100 99 99 100 99 98 98 99 98 99 100 98

28

NHS HIGHLAND LORN & ISLANDS HOSPITAL REPORT CARD


2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015


0 0 0 0 0 0 1 0 0 0 0 1


2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Ages 15-64

0 0 0 0 0 0 0 0 0 0 0 0

Ages 65 plus

0 0 1 0 1 0 1 0 0 0 1 0

Ages 15 plus

0 0 1 0 1 0 1 0 0 0 1 0


2014 Oct

2014 Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015


2014 Oct

2014 Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015


2014 Oct

2014 Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Total 91 91 91 92 93 91 92 91 94 92 92 93

29

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 Sep

2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015


0 2 0 0 0 0 0 0 0 0 0 0


2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

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


2014 Oct

2014 Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Total 100 97 100 100 100 100 96 100 97 100 94 96 AHP 100 100 100 100 - 100 96 100 100 100 100 100 Ancillary 100 89 100 - - 100 100 100 100 100 89 100 Medical 100 100 100 - - 100 100 100 88 100 89 83 Nurse 99 99 99 100 100 100 100 100 99 100 99 100 Cleaning Compliance (%)

Sep 2014

Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Total 94 96 99 96 96 96 93 96 96 93 83 95 Estates Monitoring Compliance (%)

Sep 2014

Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Total 95 99 98 99 99 97 96 96 96 95 97 97

30

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 Sep

2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015


0 0 0 0 1 0 0 0 0 0 0 0


2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Ages 15-64

0 0 0 0 0 0 0 0 0 0 0 0 Ages 65 plus

0 1 0 1 0 0 0 1 0 0 0 0

Ages 15 plus

0 1 0 1 0 0 0 1 0 0 0 0


2014 Oct

2014 Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015


2014 Oct

2014 Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015


2014 Oct

2014 Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Total 98 98 95 99 97 98 98 97 98 98 98 98

31

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


2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015


0 0 0 0 0 0 0 0 0 0 0 0


2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

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

Hand Hygiene Monitoring Compliance (%)

Sep 2014

Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015


2014 Oct

2014 Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Total 97 97 98 99 96 97 96 97 98 97 97 97

32

Estates Monitoring Compliance (%) Sep

2014 Oct

2014 Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Total 97 97 97 96 97 97 95 88 94 94 94 96 NHS HIGHLAND OUT OF HOSPITAL REPORT CARD

Staphylococcus aureus bacteraemia monthly case numbers Sep

2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015


5 2 4 3 4 4 3 1 3 5 7 2


2014 Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

Ages 15-64

5 1 2 1 0 0 0 1 4 2 2 4 Ages 65 plus

5 5 3 6 2 4 6 3 3 5 6 2

Ages 15 plus

10 6 5 7 2 4 6 4 7 7 8 6

healthcare associated infection reporting template (hairt)€¦ · apr – jun15 (not yet validated...

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