NHS Board Meeting 2 February 2011 Paper 10

NHS BOARD MEETING Wednesday 2 February 2011 Subject Healthcare Acquired Infection (HAI)

Position Report

Purpose

To update the NHS Board members on the local progress against HAI HEAT targets.

Recommendation

NHS Board members are to consider and comment on the current activity to reduce HAI across NHS Ayrshire and Arran.

1. Background

1.1 This report provides NHS Board members with an update at 31 December 2010 in

the Board efforts to reduce HAI across NHS Ayrshire and Arran.

1.2 The Prevention and Control of Infection Team (PCIT) are working to achieve the requirements of the HEAT HAI targets set by the Scottish Government Health Directorates (SGHD) which include: To have no more than 91 Staphylococcus auerus bacteraemia (SAB), including

meticillin resistant Staphylococcus aureus (MRSA), over the activity year and by 31 March 2011;

To achieve a 50% reduction in cases of Clostridium difficile (C. difficile) in the 65 and over age group over a 3 year period ending 31 March 2011. This equates to a rate of 0.66 cases per 1,000 occupied bed days in those aged 65 and over.

1.3 All NHS Boards must use the standardised Healthcare Associated Infection

Reporting Template (HAIRT) in relation to all mandatory NHS Board HAI reports until the template is reviewed in the coming year. For the purposes of the NHS Board members, the HAIRT provides detail in the following HAI areas;

Overview of NHS Board performance; Performance against SABs; Performance against C. difficile; Performance against Hand Hygiene; Reports on Cleaning and the Healthcare Environment; Reports on Outbreak Management; and

Any other HAI related activity.

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2.

Current situation

2.1 The drive to achieve the HAI HEAT targets, as outlined above, remains a significant challenge to NHS Ayrshire and Arran. The PCIT continues to work closely with various clinical teams, the Scottish Patient Safety Programme (SPSP) clinical improvement team and others to achieve these targets. The following provides an overview of the current situation:

2.1.1 SABs (including MRSA) NHS Ayrshire and Arran has been working to achieve the SAB HEAT target of

no more than 91 SABs by 31 March 2011. As of 31 December 2010, this target has been exceeded with 93 SABs confirmed to date.

It is projected from the monthly average of cases that the NHS Board will breech the target with an end position of around 121 SABs at 31 March 2011.

During recent months, interventions undertaken have resulted in a reduction in the SAB rate significantly. The October – December 2010 quarter period was the lowest total since September 2006.

There has also been a significant improvement within renal services with only one SAB throughout the October – December 2010 quarter compared with eight in the previous quarter (July – September 2010).

The MRSA SABs position during October – December 2010 has shown that there were no confirmed cases compared with six cases in the previous July – September 2010 period.

The action plans in place to improve the performance continue. These include work to reduce the overall numbers of Peripheral Venous Cannula (PVC) insertion in Accident & Emergency (A&E) at the point of patient admission. There is a series of training programmes underway to reduce the number of SAB blood culture contaminants. The plan to spread the use of Central Venous Cannula (CVC) bundles is underway and the renal specific action plan continues to be closely monitored.

The HAIRT report provides more detail on the current position in appendix 1; pages 5 and 18.

2.1.2 Clostridium difficile Infections

In December 2010, there was an increase in the number of confirmed C. difficile cases in the 65 and over age group. Despite this, the total between October – December 2010 was the lowest recorded for NHS Ayrshire and Arran with a 24% reduction compared with the previous quarter (July – September 2010).

The reduction was achieved by significant decreases in Ayr Hospital, Ayrshire Central Hospital and Crosshouse Hospital. In the Biggart Hospital during the second quarter (April – June 2010), the number of cases increased significantly. In a bid to achieve reductions in these areas, the PCIT has increased the support provided to the wards to accomplish the recent downward trends.

Whilst hospital identified cases have fallen significantly, the number of cases identified via general practitioner (GP) samples has remained static. There are a number of actions currently being implemented in primary care to improve antibiotic prescribing. It is anticipated that this will be reflected in reductions in the number of community identified cases over the coming months.

The current C. difficile position will allow NHS Ayrshire and Arran to meet the initial HEAT target of a 30% reduction in cases in the 65 and over age group by

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31 March 2011. It unlikely that the new 50% reduction by year-end will be achieved.

The HAIRT report provides more detail on the position in appendix 1; page 6 and 18.

3.

Proposal

3.1 The PCIT require continued support from the NHS Board to improve the local position.

4. Consultation on development of this report

Nil.

5. Resource implications

Nil.

6. Risk assessment and mitigation

The performance reported to the NHS Board members identifies the current position and assurance can be given that major effort is being made by the PCIT to improve the situation.

7. Impact assessment and consequential changes proposed to mitigate adverse impacts identified

Nil

8.

Conclusion

8.1

The NHS Board members are to note the ongoing work programme of the PCIT to improve current performance to achieve the HAI HEAT Targets.

8.2 A progress report will be provided to every NHS Board meeting to highlight work that is completed or underway to progress the various streams of work to achieve the Board’s goals.

Dr R G Masterton

Executive Medical Director 6 January 2011

[Bob Wilson, Babs Gemmell]

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Appendix 1 Healthcare Associated Infection Reporting Template (HAIRT)

Section 1 – Board Wide Issues

This section of the HAIRT covers Board wide infection prevention and control activity and actions. For reports on individual hospitals, please refer to the ‘Healthcare Associated Infection Report Cards’ in Section 2. A report card summarising Board wide statistics can be found at the end of section 1

Key Healthcare Associated Infection Headlines for December 2010 In December 2010, NHS Ayrshire and Arran exceeded the SAB HEAT target for 2010-11. It is

projected that the year-end position will be a total of around 121 cases. This is 30 over the target of no more than 91 SABs by 31 March 2011.

There are now signs of a downward trend in the number of SAB cases compared to previous months. The total between October – December 2010 was the lowest recorded since September 2006.

The number of C. difficile cases in the same quarter has also achieved the lowest recorded level.

The current C. difficile position will allow NHS Ayrshire and Arran to meet the initial HEAT target of a 30% reduction in cases in the 65 and over age group by 31 March 2011. Following the Scottish Government revision on the target to a 50% reduction by year-end, it is highly unlikely that NHS Board will meet this.

Every effort continues by the PCIT to ensure that the lowest levels are achieved by 31 March 2011.

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Staphylococcus aureus (including MRSA)

Staphylococcus aureus is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. The most common form of this is Meticillin Sensitive Staphylococcus Aureus (MSSA), but the more well known is MRSA (Meticillin Resistant Staphylococcus Aureus), which is a specific type of the organism which is resistant to certain antibiotics and is therefore more difficult to treat. More information on these organisms can be found at:

Staphylococcus aureus : 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

Key Headlines for December 2010 In August 2010, there was a significant increase in the number of SABs confirmed which has

resulted in NHS Ayrshire and Arran being unable to achieve the year end target. In December 2010, there were 8 SABs beginning to show a level of sustainability since August 2010.

There were no renal cases in December 2010. There has been one confirmed case during October – December 2010 compared to eight in the previous quarter (July – September 2010). This clearly indicates that the multidisciplinary action plan is taking effect and this work continues.

There were also no MRSA SABs between October – December 2010 compared with six in the previous quarter.

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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. 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

Key Headlines for December 2010

• The total number of C. difficile cases has fallen by 24% between October - December 2010 compared with the previous quarter. This is the lowest quarterly total ever recorded within NHS Ayrshire and Arran.

• The decrease was driven by significant reductions in Ayr Hospital, Ayrshire Central & Crosshouse Hospital.

• The reduction was achieved by significant decreases in Ayr Hospital, Ayrshire Central Hospital and Crosshouse Hospital. In the Biggart Hospital during the second quarter (April – June 2010), the number of cases increased significantly. In a bid to achieve reductions in these areas, the PCIT has increased the support provided to the wards to accomplish the recent trends.

• The number of GP identified cases has remained relatively static over the last three quarters. A range of initiatives, led by the Primary Care Prescribing Team, are currently being undertaken to reduce the prescribing of the antibiotics as this is presenting as the highest risk of triggering C. difficile. It is anticipated that the impact of these initiatives will lead to a further reduction in the number of GP cases over the coming months.

• Further reductions in the number of hospital and community cases are achievable with work continuing in a bid to drive down the number of cases.

Hand Hygiene Good hand hygiene by staff, patients and visitors is a key way to prevent the spread of infections. More information on the importance of good hand hygiene can be found at:

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

Key Headlines for December 2010 The December 2010 hand hygiene compliance was not available at the time of constructing the

HAIRT report and will be reported at the next NHS Board report submission. The November data confirms 95% was achieved.

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Cleaning and the Healthcare Environment Keeping the healthcare environment clean is essential to prevent the spread of infections. NHS Boards monitor the cleanliness of hospitals and there is a national target to maintain compliance with standards above 90%. The cleaning compliance score for the Board can be found at the end of section 1 and for each hospital in section 2. Information on national cleanliness compliance monitoring can be found at:

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

Key Headlines Following the announced and unannounced visits to Ayr Hospital, Crosshouse Hospital and

Arran War Memorial Hospital throughout 2010, a multidisciplinary action plan is being implemented across the Board.

The December 2010 cleaning compliance was not available at the time of constructing the HAIRT report and will be reported at the next NHS Board report submission. The November 2010 data confirms that the compliance remains at 95%.

Outbreaks There were two suspected Norovirus outbreaks in December. One in Crosshouse Hospital and

one in Biggart Hospital.

Other HAI Related Activity Nil.

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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 Ayr, Ayrshire Central, Biggart and Crosshouse Hospitals 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 combined [Ailsa, Arran War Memorial, Arrol Park, East Ayrshire Community Hospital, Girvan Community Hospital and Lady Margaret Hospital) 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). Data are presented as both a graph and a table giving case numbers. More information on these organisms can be found on the NHS24 website:

Clostridium difficile :

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.

Understanding the Report Cards – Hand Hygiene Compliance

Good hand hygiene is crucial for infection prevention and control. More information can be found from the Health Protection Scotland’s national hand hygiene campaign website: http://www.washyourhandsofthem.com/ Hospitals carry out regular audits of how well their staff are complying with hand hygiene. The first page of each hospital report card presents the percentage of hand hygiene compliance for all staff in both graph and table form.

Understanding the Report Cards – Cleaning Compliance

Hospitals strive to keep the care environment as clean as possible. This is monitored through cleaning 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/ The first page of each hospital Report Card gives the hospitals cleaning compliance percentage in both graph and table form.

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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. The final Report Card report in this section covers ‘Out of Hospital Infections’ and reports on SAB and CDI cases reported to a Health Board which are not attributable to a hospital. Given the complex variety of sources for these infections it is not possible to break this data down in any more detail.

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Appendix 2

SAB 2010-11 HEAT Target

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10

20

30

40

50

60

70

80

90

100

Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11

2010-11 HEAT Target HEAT Target Trajectory Monthly HEAT Target Monthly Actual Monthly Cumulative

CDI 2010-11 HEAT Target

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50

100

150

200

250

300

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

2010-11 HEAT Target HEAT Target Trajectory Monthly HEAT TargetMonthly Actual Monthly Cumulative

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