VERSION 4 - ACHS · 1.1 Superficial SSI - hip prosthesis procedure (L) Rationale A surgical site...

INFECTION CONTROL

VERSION 4.1 Retrospective data in full

ACIR 2009 - 2016

Australasian Clinical Indicator Report 2009–2016

18th Edition

Infection Control, version 4.1

Clinical Indicators

Acknowledgements:

The Australian Council on Healthcare

Standards

Health Services Research Group

University of Newcastle

Australasian Clinical Indicator Report 2009–2016 © ACHS. This work is copyright. Requests and inquiries concerning reproduction and rights should be addressed to [email protected]

Contents

Infection Control, version 4.1 1

Infection surveillance ........................................................................................................................ 1 1.1 Superficial SSI - hip prosthesis procedure (L) 1 1.2 Deep or organ / space SSI - hip prosthesis procedure (L) 3 1.3 Superficial SSI - knee prosthesis procedure (L) 4 1.4 Deep or organ / space SSI - knee prosthesis procedure (L) 6 1.5 Superficial SSI to chest incision site - CABG (L) 7 1.6 Deep or organ / space SSI to chest incision site - CABG (L) 9 1.7 Superficial SSI - LSCS (L) 10 1.8 Deep or organ / space SSI - LSCS (L) 12

Surgical antibiotic prophylaxis (SAP) ............................................................................................ 14 2.1 Timing of SAP for the hip prosthesis procedure (H) 14 2.2 Correct SAP and dose for the hip prosthesis procedure (H) 16 2.3 Discontinuation of SAP within 24 hours of the hip prosthesis procedure (H) 18 2.4 Timing of SAP for the knee prosthesis procedure (H) 19 2.5 Correct SAP and dose for the knee prosthesis procedure (H) 20 2.6 Discontinuation of SAP within 24 hours of the knee prosthesis procedure (H) 21 2.7 Timing of SAP for the CABG procedure (H) 22 2.8 Correct SAP and dose for the CABG procedure (H) 23 2.9 Discontinuation of SAP within 24 hours of the CABG procedure (H) 24 2.10 Timing of SAP for the LSCS procedure (H) 25 2.11 Correct SAP and dose for the LSCS procedure (H) 26 2.12 Discontinuation of SAP within 24 hours of the LSCS procedure (H) 27

Haemodialysis access-associated bloodstream infection surveillance ..................................... 28 3.1 Haemodialysis - AV-fistula access-associated BSI (L) 28 3.2 Haemodialysis - synthetic and native vessel graft access-associated BSI (L) 30 3.3 Haemodialysis - CI non-cuffed line access-associated BSI (L) 31 3.4 Haemodialysis - CI cuffed line access-associated BSI (L) 32

Vancomycin Resistant Enterococci (VRE) ..................................................................................... 33 4.1 VRE infection within the ICU (L) 33 4.2 VRE infection within non-ICU areas (L) 34

Staff Immunisation ........................................................................................................................... 35 5.1 Flu vaccination for permanent staff (H) 35 5.2 Hepatitis B vaccination for permanent staff (H) 37

Occupational exposures to blood and/or body fluids .................................................................. 38 6.1 Reported parenteral exposures sustained by staff (L) 38 6.2 Reported non-parenteral exposures sustained by staff (L) 40

Characteristics of contributing HCOs ............................................................................................ 42

Summary of Results 46

Australasian Clinical Indicator Report 2009–2016 Page 1 © ACHS. This work is copyright. Requests and inquiries concerning reproduction and rights should be addressed to [email protected]

Infection Control, version 4.1 Infection surveillance

1.1 Superficial SSI - hip prosthesis procedure (L)

Rationale

A surgical site infection (SSI) is an infection that develops as a result of an operative procedure. These infections are associated with increased morbidity and mortality, prolonged hospital stays and increased healthcare costs. Surveillance of SSI rates, coupled with prompt feedback of data to surgeons and key stakeholders, has been shown to be an important strategy to reduce SSI rates. Numerator Number of superficial SSI following hip prosthesis procedures performed. Denominator Number of hip prosthesis procedures performed.

Desirable level: Low High Not specified

Type of Indicator: Process Outcome Structure

Year No.

HCOs Total

numerator Total

denominator Rate# Rate#

(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2009 155 159 20,295 0.78 0.59 1.13 40 1 2010 149 152 20,863 0.73 0.57 1.04 33 2011 158 130 21,942 0.59 0.49 0.76 21 2 2012 162 121 21,944 0.55 0.47 0.71 18 2013 155 120 22,372 0.54 0.40 0.63 31 2014 146 103 21,964 0.47 0.33 0.59 30 4 2015 149 110 24,188 0.45 0.37 0.55 21 2016 162 122 26,455 0.46 0.26 0.80 54 7 # per 100 procedures

In 2016, there were 307 records from 162 HCOs. The annual rate was 0.46 per 100 procedures.

Trends

The fitted rate improved from 0.75 to 0.42, a change of 0.33 per 100 procedures. After allowing for the changing composition of HCOs contributing over the period, the trend remained significant. The rate change was 0.32 per 100 procedures.

Trend plot of rates and centiles by year

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2009 2010 2011 2012 2013 2014 2015 2016

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A Low rate is desirable

80th centile rate

20th centile rate

Fitted rate

Aggregate rate x

Period average rate



Variation between strata

There were no significant stratum differences in 2015 and 2016.

Variation between HCOs

In 2016, the potential gains totalled 54 fewer superficial incisional SSIs, corresponding to a reduction by approximately one third.

Outliers

In 2016, there were five outlier records from five HCOs whose combined excess was 7 more superficial incisional SSIs. The outlier HCO rate was 4.2 per 100 procedures.

Funnel plot of excess events

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1.2 Deep or organ / space SSI - hip prosthesis procedure (L)

Numerator Number of deep or organ / space SSI following hip prosthesis procedures performed. Denominator Number of hip prosthesis procedures performed.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2009 152 130 20,174 0.64 0.49 0.84 31 1 2010 147 145 20,482 0.71 0.52 0.94 38 2 2011 156 143 21,604 0.66 0.47 0.84 41 3 2012 158 152 22,061 0.69 0.64 0.75 12 2013 153 131 22,686 0.58 0.45 0.72 30 3 2014 145 149 22,125 0.67 0.44 0.87 51 7 2015 149 143 24,615 0.58 0.48 0.71 25 2016 162 161 26,753 0.60 0.48 0.75 33 1 # per 100 procedures


Trends

There was no significant trend in the fitted rate.





In 2016, the potential gains totalled 33 fewer deep incisional / organ space SSIs, corresponding to a reduction by approximately one fifth.

Outliers

In 2016, there was one outlier record from one HCO whose combined excess was 1 more deep incisional / organ space SSIs. The outlier HCO rate was 4.8 per 100 procedures.

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1.3 Superficial SSI - knee prosthesis procedure (L)

Numerator Number of superficial SSI following knee prosthesis procedures performed. Denominator Number of knee prosthesis procedures performed.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2009 160 148 27,695 0.53 0.35 0.82 51 7 2010 151 178 29,186 0.61 0.51 0.77 30 2011 159 174 29,844 0.58 0.38 0.83 61 8 2012 163 129 31,302 0.41 0.34 0.58 24 2013 156 152 31,434 0.48 0.42 0.61 20 2014 147 128 31,634 0.40 0.30 0.59 32 2015 149 119 34,718 0.34 0.21 0.52 46 2 2016 161 153 38,051 0.40 0.22 0.65 68 2 # per 100 procedures


Trends







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Outliers

In 2016, there was one outlier record from one HCO whose combined excess was 2 more superficial incisional SSIs. The outlier HCO rate was 15.4 per 100 procedures.



1.4 Deep or organ / space SSI - knee prosthesis procedure (L)

Numerator Number of deep or organ / space SSI following knee prosthesis procedures performed. Denominator Number of knee prosthesis procedures performed.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2009 155 97 27,289 0.36 0.31 0.43 12 2010 149 124 28,591 0.43 0.34 0.53 26 1 2011 155 122 29,262 0.42 0.30 0.59 35 4 2012 159 112 31,001 0.36 0.25 0.50 34 1 2013 152 121 31,443 0.38 0.28 0.51 34 2014 146 123 31,814 0.39 0.30 0.49 28 2 2015 148 94 34,834 0.27 0.27 0.32 2016 160 131 38,336 0.34 0.29 0.40 22 # per 100 procedures


Trends






In 2016, the potential gains totalled 22 fewer deep incisional / organ space SSIs, corresponding to a reduction by approximately one tenth.

Outliers

There were no outlier HCOs in 2016.

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1.5 Superficial SSI to chest incision site - CABG (L)

Numerator Number of superficial SSI (in the chest incision site) following coronary artery bypass graft (CABG) procedures performed.

Denominator Number of coronary artery bypass graft (CABG) procedures performed.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2009 36 95 8,223 1.16 0.71 1.68 37 3 2010 37 90 7,781 1.16 0.85 1.45 24 1 2011 36 75 7,065 1.06 0.54 1.36 37 7 2012 34 57 6,739 0.85 0.80 0.93 3 2013 34 47 6,018 0.78 0.58 0.95 12 2014 35 72 6,199 1.16 0.80 1.61 23 3 2015 38 67 6,328 1.06 0.66 1.60 25 5 2016 37 75 5,788 1.30 0.65 2.19 37 19 8 # per 100 procedures


Trends



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Variation between strata Rates by State

Year Stratum No.

HCOs Total

numerator Total

denominator Stratum

rate# Standard

error Stratum

gains 2016 NSW 14 22 2,124 1.16 0.19 Qld 8 37 1,697 1.87 0.21 19 Vic 7 10 873 1.16 0.30 Other 8 6 1,094 0.78 0.27 # per 100 procedures

Boxplot of Rates by State



Outliers

In 2016, there were two outlier records from two HCOs whose combined excess was 8 more superficial incisional SSIs. The outlier HCO rate was 4.7 per 100 procedures.


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1.6 Deep or organ / space SSI to chest incision site - CABG (L)

Numerator Number of deep or organ / space SSI (in the chest incision site) following coronary artery bypass graft (CABG) procedures performed.




Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2009 36 70 8,160 0.86 0.57 1.27 23 3 2010 37 87 7,624 1.14 0.72 1.55 32 2 2011 36 61 7,065 0.86 0.82 0.89 3 2012 34 58 6,727 0.86 0.81 0.89 3 2013 34 54 6,138 0.88 0.81 1.08 4 2014 36 54 6,454 0.84 0.66 1.01 11 1 2015 39 54 6,610 0.82 0.76 1.00 4 2016 38 33 6,056 0.54 0.53 0.69 1 1 # per 100 procedures


Trends






There were no potential gains in 2016.

Outliers


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1.7 Superficial SSI - LSCS (L)

Numerator Number of superficial SSI following lower segment caesarean section procedures (LSCS) performed.

Denominator Number of lower segment caesarean section procedures performed.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2009 98 309 37,707 0.82 0.34 1.41 183 62 2010 99 301 37,914 0.79 0.29 1.40 192 56 2011 98 253 37,396 0.68 0.37 1.08 116 19 2012 100 194 38,581 0.50 0.33 0.66 68 8 2013 90 231 37,498 0.62 0.33 1.00 107 16 2014 73 120 17,314 0.69 0.21 0.98 84 35 2015 83 217 36,744 0.59 0.27 0.99 119 31 2016 80 206 39,312 0.52 0.24 0.77 113 79 18 # per 100 procedures


Trends



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Variation between strata Rates by Public / Private

Year Stratum No.

HCOs Total

numerator Total

denominator Stratum

rate# Standard

error Stratum

gains 2016 Private 47 57 23,955 0.32 0.047 Public 33 149 15,357 0.84 0.059 79 # per 100 procedures

Boxplot of Rates by Public / Private


In 2016, the potential gains totalled 113 fewer superficial incisional SSIs, corresponding to a reduction by approximately one half.

Outliers

In 2016, there were four outlier records from four HCOs whose combined excess was 18 more superficial incisional SSIs. The outlier HCO rate was 4.7 per 100 procedures.


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1.8 Deep or organ / space SSI - LSCS (L)

Numerator Number of deep or organ / space SSI following lower segment caesarean section (LSCS) procedures performed.

Denominator Number of lower segment caesarean section (LSCS) procedures performed.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2009 96 50 37,840 0.13 0.065 0.15 26 8 2010 97 66 39,056 0.17 0.081 0.25 35 7 2011 99 86 39,344 0.22 0.081 0.25 54 23 2012 100 62 39,750 0.16 0.095 0.15 24 4 2013 90 60 38,896 0.15 0.080 0.21 29 7 2014 74 29 17,752 0.16 0.055 0.22 19 6 2015 82 46 36,595 0.13 0.083 0.13 16 3 2016 80 63 39,182 0.16 0.071 0.15 35 20 11 # per 100 procedures


Trends



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HCOs Total

numerator Total

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error Stratum

gains 2016 Private 47 21 23,825 0.11 0.016 Public 33 42 15,357 0.24 0.020 20 # per 100 procedures



In 2016, the potential gains totalled 35 fewer deep incisional / organ space SSIs, corresponding to a reduction by approximately one half.

Outliers

In 2016, there were four outlier records from three HCOs whose combined excess was 11 more deep incisional / organ space SSIs. The outlier HCO rate was 0.75 per 100 procedures.


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Surgical antibiotic prophylaxis (SAP)

2.1 Timing of SAP for the hip prosthesis procedure (H)

Rationale

These clinical indicators were derived as they complement the surveillance of surgical site infections (SSIs) and are a fundamental component of any antimicrobial stewardship program aimed at guiding the appropriate use of SAP. There is also strong evidence in the literature that suggests that SAP is effective in reducing the risk of SSIs.

Numerator Number of patients who received surgical antibiotic prophylaxis (SAP) within 1 hour prior to induction for the hip prosthesis procedure.

Denominator Number of hip prosthesis procedures performed.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2014 8 384 403 95.3 95.2 98.0 11 7 2015 26 2,519 2,743 91.8 90.6 99.4 207 112 2016 28 2,858 3,036 94.1 92.8 98.8 142 129 53 # per 100 procedures



Year Stratum No.

HCOs Total

numerator Total

denominator Stratum

rate# Standard

error Stratum

gains 2016 NSW 9 797 805 98.4 1.80 Qld 7 773 820 94.3 1.79 34 Other 12 1,288 1,411 91.6 1.36 95 # per 100 procedures



There was relatively little variation between HCOs and so the potential gains were small in 2016.

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Outliers

In 2016, there were three outlier records from three HCOs whose combined excess was 53 fewer patients who receive surgical antibiotic prophylaxis within one hour prior to induction. The outlier HCO rate was 76.1 per 100 procedures.


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2.2 Correct SAP and dose for the hip prosthesis procedure (H)

Numerator Number of patients who received the correct surgical antibiotic prophylaxis (SAP) and dose for the hip prosthesis procedure.




Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2014 8 333 403 82.6 80.4 98.3 63 31 2015 25 2,180 2,680 81.3 73.2 97.1 423 183 2016 29 2,628 2,974 88.4 81.6 97.1 259 221 143 # per 100 procedures



Year Stratum No.

HCOs Total

numerator Total

denominator Stratum

rate# Standard

error Stratum

gains 2016 NSW 11 1,006 1,043 95.8 3.35 Qld 6 439 520 85.0 4.74 56 Other 12 1,183 1,411 84.1 2.88 164 # per 100 procedures



In 2016, the potential gains totalled 259 more patients who receive the correct surgical antibiotic prophylaxis and dose.

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Outliers

In 2016, there were nine outlier records from seven HCOs whose combined excess was 143 fewer patients who receive the correct surgical antibiotic prophylaxis and dose. The outlier HCO rate was 59.3 per 100 procedures.


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2.3 Discontinuation of SAP within 24 hours of the hip prosthesis procedure (H)

Numerator Number of patients whose surgical antibiotic prophylaxis (SAP) was discontinued within 24 hours following the completion of the hip prosthesis procedure.




Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2014 7 242 356 68.0 79.7 96.7 102 51 2015 23 1,885 2,435 77.4 62.2 95.6 444 231 2016 27 2,312 2,815 82.1 77.2 95.7 382 141 # per 100 procedures





In 2016, the potential gains totalled 382 more patients whose surgical antibiotic prophylaxis is discontinued within 24 hours.

Outliers

In 2016, there were five outlier records from four HCOs whose combined excess was 141 fewer patients whose surgical antibiotic prophylaxis is discontinued within 24 hours. The outlier HCO rate was 54.0 per 100 procedures.


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2.4 Timing of SAP for the knee prosthesis procedure (H)

Numerator Number of patients who received surgical antibiotic prophylaxis (SAP) within 1 hour prior to induction for the knee prosthesis procedure.

Denominator Number of knee prosthesis procedures performed.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2014 8 513 524 97.9 97.6 99.5 8 4 2015 22 3,213 3,377 95.1 93.2 99.5 147 59 2016 27 3,545 3,687 96.1 94.7 99.7 132 62 # per 100 procedures






Outliers

In 2016, there were three outlier records from three HCOs whose combined excess was 62 fewer patients who receive surgical antibiotic prophylaxis within one hour prior to induction. The outlier HCO rate was 73.5 per 100 procedures.


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2.5 Correct SAP and dose for the knee prosthesis procedure (H)

Numerator Number of patients who received the correct surgical antibiotic prophylaxis (SAP) and dose for the knee prosthesis procedure.




Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2014 8 442 524 84.4 62.6 99.4 79 44 2015 21 2,623 3,000 87.4 80.8 96.7 278 84 2016 28 3,362 3,690 91.1 77.8 99.1 295 137 # per 100 procedures






Outliers



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2.6 Discontinuation of SAP within 24 hours of the knee prosthesis procedure (H)

Numerator Number of patients whose surgical antibiotic prophylaxis (SAP) was discontinued within 24 hours following the completion of the knee prosthesis procedure.




Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2014 7 299 430 69.5 54.6 98.3 124 50 2015 20 2,345 2,822 83.1 66.4 97.7 411 213 2016 26 2,862 3,289 87.0 79.1 97.5 345 137 # per 100 procedures






Outliers

In 2016, there were five outlier records from five HCOs whose combined excess was 137 fewer patients whose surgical antibiotic prophylaxis is discontinued within 24 hours. The outlier HCO rate was 60.4 per 100 procedures.


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2.7 Timing of SAP for the CABG procedure (H)

Numerator Number of patients who received surgical antibiotic prophylaxis (SAP) within 1 hour prior to induction for the coronary artery bypass graft (CABG) procedure.




Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2014 1 32 32 100 100 100 2015 6 581 653 89.0 88.9 96.8 51 26 2016 6 599 675 88.7 89.0 99.6 73 34 # per 100 procedures

In 2016, there were 10 records from six HCOs. The annual rate was 88.7 per 100 procedures.




In 2016, the potential gains totalled 73 more patients who receive surgical antibiotic prophylaxis within one hour prior to induction.

Outliers

In 2016, there was one outlier record from one HCO whose combined excess was 34 fewer patients who receive surgical antibiotic prophylaxis within one hour prior to induction. The outlier HCO rate was 30.0 per 100 procedures.



2.8 Correct SAP and dose for the CABG procedure (H)

Numerator Number of patients who received the correct surgical antibiotic prophylaxis (SAP) and dose for the coronary artery bypass graft (CABG) procedure.




Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2014 1 26 32 81.3 81.3 81.3 2015 4 356 393 90.6 87.2 98.1 29 2016 4 449 476 94.3 87.6 96.9 12 7 # per 100 procedures

In 2016, there were six records from four HCOs. The annual rate was 94.3 per 100 procedures.





Outliers

In 2016, there was one outlier record from one HCO whose combined excess was 7 fewer patients who receive the correct surgical antibiotic prophylaxis and dose. The outlier HCO rate was 86.1 per 100 procedures.



2.9 Discontinuation of SAP within 24 hours of the CABG procedure (H)

Numerator Number of patients whose surgical antibiotic prophylaxis (SAP) was discontinued within 24 hours following the completion of the coronary artery bypass graft (CABG) procedure.




Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2014 1 7 32 21.9 21.9 21.9 2015 5 290 422 68.7 52.0 93.1 103 25 2016 5 393 438 89.7 81.8 96.8 31 # per 100 procedures

In 2016, there were eight records from five HCOs. The annual rate was 89.7 per 100 procedures.





Outliers




2.10 Timing of SAP for the LSCS procedure (H)

Numerator Number of patients who received surgical antibiotic prophylaxis (SAP) within 1 hour prior to induction for the lower segment caesarean (LSCS) procedure.




Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2014 3 545 600 90.8 70.3 99.9 54 34 2015 12 3,268 3,806 85.9 77.8 96.8 418 115 2016 19 4,458 4,965 89.8 74.7 98.3 425 218 # per 100 procedures





In 2016, the potential gains totalled 425 more patients who receive surgical antibiotic prophylaxis within one hour prior to induction.

Outliers

In 2016, there were seven outlier records from six HCOs whose combined excess was 218 fewer patients who receive surgical antibiotic prophylaxis within one hour prior to induction. The outlier HCO rate was 64.5 per 100 procedures.


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2.11 Correct SAP and dose for the LSCS procedure (H)

Numerator Number of patients who received the correct surgical antibiotic prophylaxis (SAP) and dose for the lower segment caesarean section (LSCS) procedure.




Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2014 3 500 600 83.3 47.8 99.2 95 59 2015 10 2,618 3,380 77.5 67.1 91.3 467 120 2016 17 3,668 4,480 81.9 56.1 94.5 567 301 # per 100 procedures






Outliers



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2.12 Discontinuation of SAP within 24 hours of the LSCS procedure (H)

Numerator Number of patients whose surgical antibiotic prophylaxis (SAP) was discontinued within 24 hours following the completion of the lower segment caesarean section (LSCS) procedure.




Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2014 3 594 600 99.0 99.0 99.0 2015 12 3,078 3,624 84.9 81.1 99.8 540 239 2016 16 3,728 4,149 89.9 85.9 98.9 376 140 # per 100 procedures






Outliers

In 2016, there were three outlier records from two HCOs whose combined excess was 140 fewer patients whose surgical antibiotic prophylaxis is discontinued within 24 hours. The outlier HCO rate was 70.8 per 100 procedures.


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-60

-40

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20

40

60

80

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0 5 10 15 20 25




Haemodialysis access-associated bloodstream infection surveillance

3.1 Haemodialysis - AV-fistula access-associated BSI (L)

Rationale

Haemodialysis access-associated bloodstream infections (BSIs) cause considerable morbidity. A proportion of infections are potentially preventable through adherence to appropriate standards of care and the avoidance where possible of devices that have more frequent occurrence of infection. Numerator Number of AV-fistula access-associated bloodstream infections. Denominator Number of patient-months for patients dialysed through AV-fistula.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2009 25 25 9,588 0.26 0.18 0.31 8 2010 26 20 12,264 0.16 0.098 0.16 8 4 2011 23 21 12,014 0.17 0.080 0.13 11 9 2012 21 5 25,509 0.020 0.037 0.049 2013 20 4 11,510 0.035 0.027 0.039 1 2014 22 5 19,337 0.026 0.029 0.061 2015 23 12 17,724 0.068 0.068 0.068 2016 22 2 19,936 0.010 0.010 0.010 # per 100 patient-months

In 2016, there were 36 records from 22 HCOs. The annual rate was 0.010 per 100 patient-months.

Trends

The fitted rate improved from 0.24 to 0.015, a change of 0.22 per 100 patient-months. After allowing for the changing composition of HCOs contributing over the period, the trend remained significant. The rate change was 0.23 per 100 patient-months.




0.00

0.05

0.10

0.15

0.20

0.25

Rate

per

100

pat

ient

-mon

ths

2009 2010 2011 2012 2013 2014 2015 2016

Year


80th centile rate

20th centile rate

Fitted rate

Aggregate rate x

Period average rate





Outliers




3.2 Haemodialysis - synthetic and native vessel graft access-associated BSI (L)

Numerator Number of synthetic and native vessel graft access-associated bloodstream infections. Denominator Number of patient-months for patients dialysed through synthetic and native vessel grafts.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2014 15 2 964 0.21 0.21 0.21 2015 20 8 1,399 0.57 0.56 0.56 2016 18 3 1,295 0.23 0.23 0.23 # per 100 patient-months






Outliers




3.3 Haemodialysis - CI non-cuffed line access-associated BSI (L)

Numerator Number of centrally inserted non-cuffed line access-associated bloodstream infections. Denominator Number of patient-months for patients dialysed through centrally inserted non-cuffed line.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2009 11 5 1,413 0.35 0.68 1.46 2 2010 14 5 259 1.93 1.85 1.85 2011 12 10 178 5.62 1.59 4.31 7 2012 13 2 354 0.57 0.57 0.57 2013 12 1 168 0.60 0.60 0.60 2014 9 0 62 0 0 0 2015 12 7 270 2.59 2.11 3.12 1 2016 12 3 149 2.01 2.01 2.01 # per 100 patient-months


Trends

The fitted rate deteriorated from 0.71 to 2.7, a change of 1.9 per 100 patient-months. After allowing for the changing composition of HCOs contributing over the period, the trend remained significant. The rate change was 1.7 per 100 patient-months.






Outliers


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1

2

3

4

5

Rate

per

100

pat

ient

-mon

ths

2009 2010 2011 2012 2013 2014 2015 2016

Year


80th centile rate

20th centile rate

Fitted rate

Aggregate rate x

Period average rate



3.4 Haemodialysis - CI cuffed line access-associated BSI (L)

Numerator Number of centrally inserted cuffed line access-associated bloodstream infections. Denominator Number of patient-months for patients dialysed through centrally inserted cuffed line.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2009 25 67 3,902 1.72 1.53 2.33 7 2010 24 97 4,259 2.28 0.94 3.79 57 26 2011 24 48 4,052 1.18 1.08 1.57 4 2012 22 42 5,615 0.75 0.25 2.21 28 10 2013 20 34 3,585 0.95 0.59 1.86 13 2014 17 27 2,035 1.33 1.33 1.33 2015 22 58 3,104 1.87 0.60 2.82 39 3 2016 23 44 3,541 1.24 1.17 1.32 2 # per 100 patient-months


Trends

The fitted rate improved from 1.6 to 1.1, a change of 0.47 per 100 patient-months. After allowing for the changing composition of HCOs contributing over the period, the trend remained significant. The rate change was 0.69 per 100 patient-months.






Outliers


0.0

0.5

1.0

1.5

2.0

2.5

Rate

per

100

pat

ient

-mon

ths

2009 2010 2011 2012 2013 2014 2015 2016

Year


80th centile rate

20th centile rate

Fitted rate

Aggregate rate x

Period average rate



Vancomycin Resistant Enterococci (VRE)

4.1 VRE infection within the ICU (L)

Rationale

According to the Australian Group on Antimicrobial Resistance (AGAR), the prevalence of VRE infection is rising in Australia. These healthcare-associated infections (HAIs) are commonly seen in high risk areas such as intensive care units, haematology and oncology units and dialysis centres.

Numerator Number of ICU associated new vancomycin resistant enterococci (VRE) healthcare-associated infections.

Denominator Number of ICU bed days.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2014 35 10 69,028 1.45 1.45 1.45 2015 45 49 138,896 3.53 0.52 3.63 42 25 2016 58 27 197,927 1.36 0.38 1.75 19 10 # per 10,000 bed days

In 2016, there were 103 records from 58 HCOs. The annual rate was 1.4 per 10,000 bed days.




In 2016, the potential gains totalled 19 fewer new VRE healthcare-associated infections, corresponding to a reduction by approximately two thirds.

Outliers

In 2016, there were three outlier records from three HCOs whose combined excess was 10 more new VRE healthcare-associated infections. The outlier HCO rate was 37.4 per 10,000 bed days.


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0 25 50 75 100




4.2 VRE infection within non-ICU areas (L)

Numerator Number of non-ICU associated new vancomycin resistant enterococci (VRE) healthcare-associated infections.

Denominator Number of non-ICU bed days.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2014 56 32 1,904,512 0.17 0.088 0.16 15 6 2015 84 128 4,068,442 0.31 0.074 0.29 98 49 2016 106 164 5,352,040 0.31 0.068 0.28 128 65 # per 10,000 bed days

In 2016, there were 185 records from 106 HCOs. The annual rate was 0.31 per 10,000 bed days.




In 2016, the potential gains totalled 128 fewer new VRE healthcare-associated infections, corresponding to a reduction by approximately three quarters.

Outliers

In 2016, there were five outlier records from four HCOs whose combined excess was 65 more new VRE healthcare-associated infections. The outlier HCO rate was 3.4 per 10,000 bed days.


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10

20

30

40

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ss

0 25 50 75 100 125 150 175




Staff Immunisation

5.1 Flu vaccination for permanent staff (H)

Rationale

Immunising staff against vaccine-preventable diseases such as influenza and hepatitis B will result in lower morbidity and mortality rates among patients and reduced absenteeism from healthcare workers. Healthcare organisations (HCOs) are encouraged to formulate a comprehensive immunisation policy for all healthcare workers. Numerator Number of permanent healthcare employees that received a flu vaccination. Denominator Number of permanent healthcare employees.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2015 53 13,385 24,285 55.1 30.1 78.6 5,712 2,414 2016 53 28,884 53,261 54.2 41.7 76.9 12,085 7,499 4,411 # per 100 permanent healthcare employees

In 2016, there were 76 records from 53 HCOs. The annual rate was 54.2 per 100 permanent healthcare employees.


Year Stratum No.

HCOs Total

numerator Total

denominator Stratum

rate# Standard

error Stratum

gains 2016 NSW 26 10,981 24,312 45.2 3.61 5,889 Qld 6 5,692 8,885 64.1 5.97 SA 6 852 1,410 60.1 15.0 Vic 9 5,878 8,445 69.5 6.12 Other 6 5,481 10,209 53.7 5.57 1,610 # per 100 permanent healthcare employees


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10

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50

60

70

80

90

100

Rate

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100

per

man

ent h

ealth

care

em

ploy

ees

“Other” NSW Qld SA Vic




In 2016, the potential gains totalled 12,085 more permanent healthcare employees who receive a flu vaccination.

Outliers

In 2016, there were 18 outlier records from 15 HCOs whose combined excess was 4,411 fewer permanent healthcare employees who receive a flu vaccination. The outlier HCO rate was 31.0 per 100 permanent healthcare employees.


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5.2 Hepatitis B vaccination for permanent staff (H)

Numerator Number of permanent Category A healthcare employees that have an up to date pathology result indicating serological immunity or evidence of vaccination for Hepatitis B.

Denominator Number of permanent Category A healthcare employees.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2015 28 9,713 13,272 73.2 51.6 94.2 2,790 1,280 2016 22 12,587 16,487 76.3 56.5 96.2 3,267 1,396 # per 100 permanent Category A healthcare employees

In 2016, there were 39 records from 22 HCOs. The annual rate was 76.3 per 100 permanent Category A healthcare employees.




In 2016, the potential gains totalled 3,267 more permanent Category A healthcare employees vaccinated for Hepatitis B.

Outliers

In 2016, there were 11 outlier records from seven HCOs whose combined excess was 1,396 fewer permanent Category A healthcare employees vaccinated for Hepatitis B. The outlier HCO rate was 53.6 per 100 permanent category a healthcare employees.


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Occupational exposures to blood and/or body fluids

6.1 Reported parenteral exposures sustained by staff (L)

Rationale

An occupational exposure as defined below may put the injured person at risk of acquiring a blood borne viral infection. International reports suggest that determining the magnitude of the occupational exposure is the first step in developing local programs and strategies designed to reduce this risk. Organisations are encouraged to collect additional data relating to the injury, such as the type of injury, the activity surrounding the injury and any factors relating to devices, equipment or human behaviour which may have contributed to the exposure. Numerator Number of reported parenteral exposures sustained by staff. Denominator Number of occupied bed days.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2009 248 3,282 9,141,719 0.036 0.022 0.042 1,246 238 2010 232 3,661 9,322,236 0.039 0.026 0.047 1,270 279 2011 246 3,449 9,308,636 0.037 0.024 0.044 1,230 311 2012 261 3,625 10,340,148 0.035 0.021 0.043 1,452 290 2013 366 4,535 13,218,078 0.034 0.020 0.037 1,933 344 2014 371 4,410 13,088,876 0.034 0.019 0.040 1,882 371 2015 347 6,433 11,831,652 0.054 0.009 0.050 5,415 2,625 2016 301 3,647 12,609,091 0.029 0.017 0.036 1,476 294 # per 100 bed days

In 2016, there were 536 records from 301 HCOs. The annual rate was 0.029 per 100 bed days.

Trends





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0.02

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100

bed

day

s

2009 2010 2011 2012 2013 2014 2015 2016

Year


80th centile rate

20th centile rate

Fitted rate

Aggregate rate x

Period average rate




In 2016, the potential gains totalled 1,476 fewer reported parenteral exposures, corresponding to a reduction by approximately one third.

Outliers

In 2016, there were 19 outlier records from 17 HCOs whose combined excess was 294 more reported parenteral exposures. The outlier HCO rate was 0.056 per 100 bed days.


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6.2 Reported non-parenteral exposures sustained by staff (L)

Numerator Number of reported non-parenteral exposures sustained by staff. Denominator Number of occupied bed days.



Year No.

HCOs Total

numerator Total


(20) Rate#

(80) Centile

Gains Stratum

Gains Outlier Gains

2009 238 1,228 9,076,198 0.014 0.008 0.014 488 131 2010 223 1,263 9,225,397 0.014 0.008 0.015 538 127 2011 239 1,478 9,146,346 0.016 0.008 0.015 755 294 2012 256 1,395 10,247,216 0.014 0.006 0.014 747 232 2013 362 1,767 13,130,031 0.013 0.008 0.013 756 215 2014 365 1,592 12,693,584 0.013 0.007 0.012 737 198 2015 338 1,361 11,491,394 0.012 0.006 0.014 703 107 2016 291 1,271 12,231,066 0.010 0.005 0.012 636 375 176 # per 100 bed days

In 2016, there were 522 records from 291 HCOs. The annual rate was 0.010 per 100 bed days.

Trends

The fitted rate improved from 0.015 to 0.011, a change of 0.004 per 100 bed days. After allowing for the changing composition of HCOs contributing over the period, the trend remained significant. The rate change was 0.003 per 100 bed days.


0.000

0.002

0.004

0.006

0.008

0.010

0.012

0.014

0.016

Rate

per

100

bed

day

s

2009 2010 2011 2012 2013 2014 2015 2016

Year


80th centile rate

20th centile rate

Fitted rate

Aggregate rate x

Period average rate




Year Stratum No.

HCOs Total

numerator Total

denominator Stratum

rate# Standard

error Stratum

gains 2016 Private 143 317 4,974,579 0.007 0.0005 Public 148 954 7,256,487 0.012 0.0004 375 # per 100 bed days



In 2016, the potential gains totalled 636 fewer reported non-parenteral exposures, corresponding to a reduction by approximately one half.

Outliers

In 2016, there were 15 outlier records from 15 HCOs whose combined excess was 176 more reported non-parenteral exposures. The outlier HCO rate was 0.030 per 100 bed days.


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0.0

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0.1

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0.1

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Rate

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s

Private Public

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Characteristics of contributing HCOs Public/ Private and Metropolitan/ Non-metro total denominators and number of HCOs by clinical indicator

All indicators Combined

Clinical Indicator Set

Public % Private % Metropolitan % Non-metro % Total Infection Control Combined HCOs 173 49% 178 51% 228 65% 123 35% 351

Indicators by Topic

Infection surveillance

Clinical Indicator

Public % Private % Metropolitan % Non-metro % Total 1.1 Superficial SSI - hip prosthesis procedure (L)

HCOs 49 30% 113 70% 116 72% 46 28% 162 Denominator 5,538 21% 20,917 79% 22,221 84% 4,234 16% 26,455

1.2 Deep or organ / space SSI - hip prosthesis procedure (L)


1.3 Superficial SSI - knee prosthesis procedure (L)


1.4 Deep or organ / space SSI - knee prosthesis procedure (L)


1.5 Superficial SSI to chest incision site - CABG (L)

HCOs 7 19% 30 81% - - - - 37 Denominator 1,562 27% 4,226 73% 5,624 97% 164 3% 5,788

1.6 Deep or organ / space SSI to chest incision site - CABG (L)

HCOs 7 18% 31 82% - - - - 38 Denominator 1,562 26% 4,494 74% 5,892 97% 164 3% 6,056

1.7 Superficial SSI - LSCS (L) HCOs 33 41% 47 59% 54 68% 26 33% 80 Denominator 15,357 39% 23,955 61% 35,172 89% 4,140 11% 39,312

1.8 Deep or organ / space SSI - LSCS (L)

HCOs 33 41% 47 59% 54 68% 26 33% 80

Denominator 15,357 39% 23,825 61% 35,042 89% 4,140 11% 39,182




Clinical Indicator Public % Private % Metropolitan % Non-metro % Total 2.1 Timing of SAP for the hip prosthesis procedure (H)

HCOs 8 29% 20 71% 19 68% 9 32% 28 Denominator 965 32% 2,071 68% 2,547 84% 489 16% 3,036

2.2 Correct SAP and dose for the hip prosthesis procedure (H)


2.3 Discontinuation of SAP within 24 hours of the hip prosthesis procedure (H)

HCOs 8 30% 19 70% 17 63% 10 37% 27

Denominator 965 34% 1,850 66% 2,112 75% 703 25% 2,815

2.4 Timing of SAP for the knee prosthesis procedure (H)


2.5 Correct SAP and dose for the knee prosthesis procedure (H)

HCOs 8 29% 20 71% 17 61% 11 39% 28 Denominator 904 24% 2,786 76% 2,310 63% 1,380 37% 3,690

2.6 Discontinuation of SAP within 24 hours of the knee prosthesis procedure (H)

HCOs 8 31% 18 69% 16 62% 10 38% 26

Denominator 814 25% 2,475 75% 2,030 62% 1,259 38% 3,289

2.7 Timing of SAP for the CABG procedure (H)

HCOs - - - - 6 100% - 0% 6 Denominator 360 53% 315 47% 675 100% - 0% 675

2.8 Correct SAP and dose for the CABG procedure (H)

HCOs - - - - - - - 4 Denominator 360 76% 116 24% 476 100% - 0% 476

2.9 Discontinuation of SAP within 24 hours of the CABG procedure (H)

HCOs - - - - 5 100% - 0% 5 Denominator 289 66% 149 34% 438 100% - 0% 438

2.10 Timing of SAP for the LSCS procedure (H)

HCOs 8 42% 11 58% 10 53% 9 47% 19 Denominator 2,053 41% 2,912 59% 4,066 82% 899 18% 4,965

2.11 Correct SAP and dose for the LSCS procedure (H)

HCOs 7 41% 10 59% 9 53% 8 47% 17 Denominator 2,004 45% 2,476 55% 3,510 78% 970 22% 4,480

2.12 Discontinuation of SAP within 24 hours of the LSCS procedure (H)

HCOs 6 38% 10 63% 8 50% 8 50% 16

Denominator 1,673 40% 2,476 60% 3,179 77% 970 23% 4,149




Clinical Indicator Public % Private % Metropolitan % Non-metro % Total 3.1 Haemodialysis - AV-fistula access-associated BSI (L)

HCOs - - - - 10 45% 12 55% 22 Denominator 10,148 51% 9,788 49% 17,492 88% 2,444 12% 19,936

3.2 Haemodialysis - synthetic and native vessel graft access-associated BSI (L)

HCOs 14 78% 4 22% 9 50% 9 50% 18 Denominator 738 57% 557 43% 1,027 79% 268 21% 1,295

3.3 Haemodialysis - CI non-cuffed line access-associated BSI (L)

HCOs - - - - - - - - 12 Denominator 145 97% 4 3% 140 94% 9 6% 149

3.4 Haemodialysis - CI cuffed line access-associated BSI (L)

HCOs 19 83% 4 17% 11 48% 12 52% 23

Denominator 2,263 64% 1,278 36% 2,921 82% 621 18% 3,541


Clinical Indicator Public % Private % Metropolitan % Non-metro % Total

4.1 VRE infection within the ICU (L) HCOs 26 45% 32 55% 48 83% 10 17% 58 Denominator 129,330 65% 68,597 35% 148,908 75% 49,019 25% 197,927

4.2 VRE infection within non-ICU areas (L)

HCOs 46 43% 60 57% 81 76% 25 24% 106

Denominator 3,122,552 58% 2,229,488 42% 4,736,848 89% 615,192 11% 5,352,040

Staff Immunisation

Clinical Indicator Public % Private % Metropolitan % Non-metro % Total 5.1 Flu vaccination for permanent staff (H)


5.2 Hepatitis B vaccination for permanent staff (H)

HCOs - - - - - - - - 22

Denominator 4,962 30% 11,525 70% 14,571 88% 1,916 12% 16,487




Clinical Indicator Public % Private % Metropolitan % Non-metro % Total

6.1 Reported parenteral exposures sustained by staff (L)

HCOs 153 51% 148 49% 193 64% 108 36% 301

Denominator 7,461,050 59% 5,148,041 41% 10,330,675 82% 2,278,416 18% 12,609,091

6.2 Reported non-parenteral exposures sustained by staff (L)

HCOs 148 51% 143 49% 188 65% 103 35% 291

Denominator 7,256,487 59% 4,974,579 41% 10,037,704 82% 2,193,362 18% 12,231,066



Summary of Results Infection surveillance

1.1 Superficial SSI - hip prosthesis procedure (L) In 2016, there were 307 records from 162 HCOs. The annual rate was 0.46 per 100 procedures.The fitted rate improved from 0.75 to 0.42, a change of 0.33 per 100 procedures. After allowing for the changing composition of HCOs contributing over the period, the trend remained significant. The rate change was 0.32 per 100 procedures. In 2016, the potential gains totalled 54 fewer superficial incisional SSIs, corresponding to a reduction by approximately one third. In 2016, there were five outlier records from five HCOs whose combined excess was 7 more superficial incisional SSIs. The outlier HCO rate was 4.2 per 100 procedures.

1.2 Deep or organ / space SSI - hip prosthesis procedure (L) In 2016, there were 307 records from 162 HCOs. The annual rate was 0.60 per 100 procedures.There was no significant trend in the fitted rate. In 2016, the potential gains totalled 33 fewer deep incisional / organ space SSIs, corresponding to a reduction by approximately one fifth. In 2016, there was one outlier record from one HCO whose combined excess was 1 more deep incisional / organ space SSIs. The outlier HCO rate was 4.8 per 100 procedures.

1.3 Superficial SSI - knee prosthesis procedure (L) In 2016, there were 304 records from 161 HCOs. The annual rate was 0.40 per 100 procedures.The fitted rate improved from 0.59 to 0.37, a change of 0.23 per 100 procedures. After allowing for the changing composition of HCOs contributing over the period, the trend remained significant. The rate change was 0.22 per 100 procedures. In 2016, the potential gains totalled 68 fewer superficial incisional SSIs, corresponding to a reduction by approximately one third. In 2016, there was one outlier record from one HCO whose combined excess was 2 more superficial incisional SSIs. The outlier HCO rate was 15.4 per 100 procedures.

1.4 Deep or organ / space SSI - knee prosthesis procedure (L) In 2016, there were 302 records from 160 HCOs. The annual rate was 0.34 per 100 procedures.The fitted rate improved from 0.41 to 0.33, a change of 0.085 per 100 procedures. After allowing for the changing composition of HCOs contributing over the period, the trend remained significant. The rate change was 0.078 per 100 procedures. In 2016, the potential gains totalled 22 fewer deep incisional / organ space SSIs, corresponding to a reduction by approximately one tenth. There were no outlier HCOs in 2016.

1.5 Superficial SSI to chest incision site - CABG (L) In 2016, there were 69 records from 37 HCOs. The annual rate was 1.3 per 100 procedures.There was no significant trend in the fitted rate. In 2016, the potential gains totalled 37 fewer superficial incisional SSIs, corresponding to a reduction by approximately one third. In 2016, there were two outlier records from two HCOs whose combined excess was 8 more superficial incisional SSIs. The outlier HCO rate was 4.7 per 100 procedures.

1.6 Deep or organ / space SSI to chest incision site - CABG (L) In 2016, there were 71 records from 38 HCOs. The annual rate was 0.54 per 100 procedures.The fitted rate improved from 1.0 to 0.70, a change of 0.30 per 100 procedures. After allowing for the changing composition of HCOs contributing over the period, the trend remained significant. The rate change was 0.26 per 100 procedures. There were no potential gains in 2016. There were no outlier HCOs in 2016.

1.7 Superficial SSI - LSCS (L) In 2016, there were 149 records from 80 HCOs. The annual rate was 0.52 per 100 procedures.The fitted rate improved from 0.78 to 0.52, a change of 0.26 per 100 procedures. After allowing for the changing composition of HCOs contributing over the period, the trend remained significant. The rate change was 0.25 per 100 procedures. In 2016, the potential gains totalled 113 fewer superficial incisional SSIs, corresponding to a reduction by approximately one half. In 2016, there were four outlier records from four HCOs whose combined excess was 18 more superficial incisional SSIs. The outlier HCO rate was 4.7 per 100 procedures.

1.8 Deep or organ / space SSI - LSCS (L) In 2016, there were 149 records from 80 HCOs. The annual rate was 0.16 per 100 procedures.There was no significant trend in the fitted rate. In 2016, the potential gains totalled 35 fewer deep incisional / organ space SSIs, corresponding to a reduction by approximately one half. In 2016, there were four outlier records from three HCOs whose combined excess was 11 more deep incisional / organ space SSIs. The outlier HCO rate was 0.75 per 100 procedures.




2.1 Timing of SAP for the hip prosthesis procedure (H) In 2016, there were 45 records from 28 HCOs. The annual rate was 94.1 per 100 procedures. There was relatively little variation between HCOs and so the potential gains were small in 2016. In 2016, there were three outlier records from three HCOs whose combined excess was 53 fewer patients who receive surgical antibiotic prophylaxis within one hour prior to induction. The outlier HCO rate was 76.1 per 100 procedures.

2.2 Correct SAP and dose for the hip prosthesis procedure (H) In 2016, there were 48 records from 29 HCOs. The annual rate was 88.4 per 100 procedures. In 2016, the potential gains totalled 259 more patients who receive the correct surgical antibiotic prophylaxis and dose. In 2016, there were nine outlier records from seven HCOs whose combined excess was 143 fewer patients who receive the correct surgical antibiotic prophylaxis and dose. The outlier HCO rate was 59.3 per 100 procedures.

2.3 Discontinuation of SAP within 24 hours of the hip prosthesis procedure (H) In 2016, there were 43 records from 27 HCOs. The annual rate was 82.1 per 100 procedures. In 2016, the potential gains totalled 382 more patients whose surgical antibiotic prophylaxis is discontinued within 24 hours. In 2016, there were five outlier records from four HCOs whose combined excess was 141 fewer patients whose surgical antibiotic prophylaxis is discontinued within 24 hours. The outlier HCO rate was 54.0 per 100 procedures.

2.4 Timing of SAP for the knee prosthesis procedure (H) In 2016, there were 41 records from 27 HCOs. The annual rate was 96.1 per 100 procedures. There was relatively little variation between HCOs and so the potential gains were small in 2016. In 2016, there were three outlier records from three HCOs whose combined excess was 62 fewer patients who receive surgical antibiotic prophylaxis within one hour prior to induction. The outlier HCO rate was 73.5 per 100 procedures.

2.5 Correct SAP and dose for the knee prosthesis procedure (H) In 2016, there were 45 records from 28 HCOs. The annual rate was 91.1 per 100 procedures. In 2016, the potential gains totalled 295 more patients who receive the correct surgical antibiotic prophylaxis and dose. In 2016, there were nine outlier records from seven HCOs whose combined excess was 137 fewer patients who receive the correct surgical antibiotic prophylaxis and dose. The outlier HCO rate was 69.0 per 100 procedures.

2.6 Discontinuation of SAP within 24 hours of the knee prosthesis procedure (H) In 2016, there were 40 records from 26 HCOs. The annual rate was 87.0 per 100 procedures. In 2016, the potential gains totalled 345 more patients whose surgical antibiotic prophylaxis is discontinued within 24 hours. In 2016, there were five outlier records from five HCOs whose combined excess was 137 fewer patients whose surgical antibiotic prophylaxis is discontinued within 24 hours. The outlier HCO rate was 60.4 per 100 procedures.

2.7 Timing of SAP for the CABG procedure (H) In 2016, there were 10 records from six HCOs. The annual rate was 88.7 per 100 procedures. In 2016, the potential gains totalled 73 more patients who receive surgical antibiotic prophylaxis within one hour prior to induction. In 2016, there was one outlier record from one HCO whose combined excess was 34 fewer patients who receive surgical antibiotic prophylaxis within one hour prior to induction. The outlier HCO rate was 30.0 per 100 procedures.

2.8 Correct SAP and dose for the CABG procedure (H) In 2016, there were six records from four HCOs. The annual rate was 94.3 per 100 procedures. There was relatively little variation between HCOs and so the potential gains were small in 2016. In 2016, there was one outlier record from one HCO whose combined excess was 7 fewer patients who receive the correct surgical antibiotic prophylaxis and dose. The outlier HCO rate was 86.1 per 100 procedures.

2.9 Discontinuation of SAP within 24 hours of the CABG procedure (H) In 2016, there were eight records from five HCOs. The annual rate was 89.7 per 100 procedures. In 2016, the potential gains totalled 31 more patients whose surgical antibiotic prophylaxis is discontinued within 24 hours. There were no outlier HCOs in 2016.

2.10 Timing of SAP for the LSCS procedure (H) In 2016, there were 30 records from 19 HCOs. The annual rate was 89.8 per 100 procedures. In 2016, the potential gains totalled 425 more patients who receive surgical antibiotic prophylaxis within one hour prior to induction. In 2016, there were seven outlier records from six HCOs whose combined excess was 218 fewer patients who receive surgical antibiotic prophylaxis within one hour prior to induction. The outlier HCO rate was 64.5 per 100 procedures.



2.11 Correct SAP and dose for the LSCS procedure (H) In 2016, there were 28 records from 17 HCOs. The annual rate was 81.9 per 100 procedures. In 2016, the potential gains totalled 567 more patients who receive the correct surgical antibiotic prophylaxis and dose. In 2016, there were nine outlier records from seven HCOs whose combined excess was 301 fewer patients who receive the correct surgical antibiotic prophylaxis and dose. The outlier HCO rate was 56.7 per 100 procedures.

2.12 Discontinuation of SAP within 24 hours of the LSCS procedure (H) In 2016, there were 26 records from 16 HCOs. The annual rate was 89.9 per 100 procedures. In 2016, the potential gains totalled 376 more patients whose surgical antibiotic prophylaxis is discontinued within 24 hours. In 2016, there were three outlier records from two HCOs whose combined excess was 140 fewer patients whose surgical antibiotic prophylaxis is discontinued within 24 hours. The outlier HCO rate was 70.8 per 100 procedures.


3.1 Haemodialysis - AV-fistula access-associated BSI (L) In 2016, there were 36 records from 22 HCOs. The annual rate was 0.010 per 100 patient-months.The fitted rate improved from 0.24 to 0.015, a change of 0.22 per 100 patient-months. After allowing for the changing composition of HCOs contributing over the period, the trend remained significant. The rate change was 0.23 per 100 patient-months. There were no potential gains in 2016. There were no outlier HCOs in 2016.

3.2 Haemodialysis - synthetic and native vessel graft access-associated BSI (L) In 2016, there were 30 records from 18 HCOs. The annual rate was 0.23 per 100 patient-months. There were no potential gains in 2016. There were no outlier HCOs in 2016.

3.3 Haemodialysis - CI non-cuffed line access-associated BSI (L) In 2016, there were 17 records from 12 HCOs. The annual rate was 2.0 per 100 patient-months.The fitted rate deteriorated from 0.71 to 2.7, a change of 1.9 per 100 patient-months. After allowing for the changing composition of HCOs contributing over the period, the trend remained significant. The rate change was 1.7 per 100 patient-months. There were no potential gains in 2016. There were no outlier HCOs in 2016.

3.4 Haemodialysis - CI cuffed line access-associated BSI (L) In 2016, there were 38 records from 23 HCOs. The annual rate was 1.2 per 100 patient-months.The fitted rate improved from 1.6 to 1.1, a change of 0.47 per 100 patient-months. After allowing for the changing composition of HCOs contributing over the period, the trend remained significant. The rate change was 0.69 per 100 patient-months. There was relatively little variation between HCOs and so the potential gains were small in 2016. There were no outlier HCOs in 2016.


4.1 VRE infection within the ICU (L) In 2016, there were 103 records from 58 HCOs. The annual rate was 1.4 per 10000 bed days. In 2016, the potential gains totalled 19 fewer new VRE healthcare-associated infections, corresponding to a reduction by approximately two thirds. In 2016, there were three outlier records from three HCOs whose combined excess was 10 more new VRE healthcare-associated infections. The outlier HCO rate was 37.4 per 10,000 bed days.

4.2 VRE infection within non-ICU areas (L) In 2016, there were 185 records from 106 HCOs. The annual rate was 0.31 per 10000 bed days. In 2016, the potential gains totalled 128 fewer new VRE healthcare-associated infections, corresponding to a reduction by approximately three quarters. In 2016, there were five outlier records from four HCOs whose combined excess was 65 more new VRE healthcare-associated infections. The outlier HCO rate was 3.4 per 10,000 bed days.

Staff Immunisation

5.1 Flu vaccination for permanent staff (H) In 2016, there were 76 records from 53 HCOs. The annual rate was 54.2 per 100 permanent healthcare employees. In 2016, the potential gains totalled 12,085 more permanent healthcare employees who receive a flu vaccination. In 2016, there were 18 outlier records from 15 HCOs whose combined excess was 4,411 fewer permanent healthcare employees who receive a flu vaccination. The outlier HCO rate was 31.0 per 100 permanent healthcare employees.



5.2 Hepatitis B vaccination for permanent staff (H) In 2016, there were 39 records from 22 HCOs. The annual rate was 76.3 per 100 permanent Category A healthcare employees. In 2016, the potential gains totalled 3,267 more permanent Category A healthcare employees vaccinated for Hepatitis B. In 2016, there were 11 outlier records from seven HCOs whose combined excess was 1,396 fewer permanent Category A healthcare employees vaccinated for Hepatitis B. The outlier HCO rate was 53.6 per 100 permanent category a healthcare employees.


6.1 Reported parenteral exposures sustained by staff (L) In 2016, there were 536 records from 301 HCOs. The annual rate was 0.029 per 100 bed days.There was no significant trend in the fitted rate. In 2016, the potential gains totalled 1,476 fewer reported parenteral exposures, corresponding to a reduction by approximately one third. In 2016, there were 19 outlier records from 17 HCOs whose combined excess was 294 more reported parenteral exposures. The outlier HCO rate was 0.056 per 100 bed days.

6.2 Reported non-parenteral exposures sustained by staff (L) In 2016, there were 522 records from 291 HCOs. The annual rate was 0.010 per 100 bed days.The fitted rate improved from 0.015 to 0.011, a change of 0.004 per 100 bed days. After allowing for the changing composition of HCOs contributing over the period, the trend remained significant. The rate change was 0.003 per 100 bed days. In 2016, the potential gains totalled 636 fewer reported non-parenteral exposures, corresponding to a reduction by approximately one half. In 2016, there were 15 outlier records from 15 HCOs whose combined excess was 176 more reported non-parenteral exposures. The outlier HCO rate was 0.030 per 100 bed days.

VERSION 4 - ACHS · 1.1 Superficial SSI - hip prosthesis procedure (L) Rationale A surgical site...

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