Paper 3 Ayrshire and Arran NHS Board Monday 2 February 2015 Healthcare Associated Infection Position Report Author: Sponsoring Director: Bob Wilson, Infection Control Manager Alison Graham, Medical Director Babs Gemmell, Business Manager Date: 7 January 2015 Recommendation The Board is asked to review the latest update against the Healthcare Associated Infection HEAT Targets and other HAI related activity. Summary Since 1 April 2013, the Infection Prevention and Control Team (IPCT) have worked towards achieving the HAI HEAT targets which are: To achieve a rate of no more than 0.32 cases per 1,000 occupied bed days for Clostridium difficile Infections (CDIs) in the 15 and over age group by the year ending 31 March 2015; and To achieve a rate of no more than 0.24 cases per 1,000 acute occupied bed days for Staphylococcus aureus bacteraemias (SABs) by the year ending 31 March 2015. The organisation is currently over the local trajectory levels set against the HAI HEAT targets from 1 April – 30 November 2014: CDIs – There is a total of 99 cases placing the organisation 19 cases above the local trajectory level. SABs – There is a total of 87 cases placing the organisation 31 cases above the local trajectory level. All NHS Board’s are required to use the standardised Healthcare Associated Infection Reporting Template (HAIRT) for all mandatory HAI reporting as can be found in Appendix 1. 1 of 18 Glossary of Terms AMT Antimicrobial Management Team CDI Clostridium difficile Infection HAI Healthcare Associated Infection HAIRT Healthcare Associated Infection Reporting Template HEAT Health, Efficiency, Access, Treatment HEI Healthcare Environment Inspectorate HPS Health Protection Scotland ICN Infection Control Nurse IPCT Infection Prevention & Control Team MRSA Meticillin Resistant Staphylococcus aureus MSSA Meticillin Sensitive Staphylococcus aureus NES National Education for Scotland NHS National Health Service PPE Personal Protection Equipment PVC Peripheral vascular cannula SAB Staphylococcus aureus bacteraemia SBAR Situation Background Assessment Recommendation Report SOP Standard Operating Procedure UHA University Hospital Ayr UHC University Hospital Crosshouse VHF Viral Haemorrhagic Fever 2 of 18 1. Staphylococcus aureus Bacteraemias . A numerical target of no more than 7 cases per month has been established to allow real time monitoring of the organisation’s progress against the SAB HEAT target. Since 1 April 2014, there have been 87 SABs cases (Chart 1). This places the organisation 31 SABS above the locally set trajectory. The organisation has now exceeded the HEAT target by 3 cases at month 8 of the activity year confirming that the organisation will be over the target by 31 March 2015. Forty-six percent of the cases were hospital acquisitions (40 cases), 22% were community acquired (19 cases) and 32% community onset/healthcare associated (28 cases). During November 2014, there were 7 SABs (3 hospital acquisitions and 4 community onset/healthcare associated). The probable source of each case included 2 contaminants, 1 PVC, 1 Renal Fistula, 1 Central Line and 2 Other. The verified SAB rate for the quarter ending September 2014 was 0.36 (Chart 2), this compares with 0.42 for the quarter ending June 2014. The organisation was above the Scottish mean for the quarter ending September 2014. The projected SAB rate for the quarter ending December 2014 is 0.34. A comparison of annual rates with other mainland territorial boards shows that NHS Ayrshire and Arran shifted in the first six months of the year from having one of the lowest SAB rates to slightly above the Scottish mean of 0.31 (Chart 3). TOTAL87 SAB CASES (31 SABS above the local trajectory) Chart 1 – SAB HEAT Target 2014-15 monthly position (Year 2) 3 of 18 Chart 2 - NHS Ayrshire and Arran Rolling Annual SAB rate Chart 3 - Mainland Territorial NHS Boards Rolling Annual SAB Rate . A review of each SAB is undertaken by the Infection Control Nurses (ICNs) and Consultant Microbiologists. Those considered to be potentially preventable undergo a multi-disciplinary review by an ICN, Consultant Microbiologist, Consultant(s) and Senior Charge Nurse(s). The findings of the review are collated into an SBAR for feeding back to the relevant clinical team(s). The process is well established with strong clinical involvement. There is however some further work required in the process which includes: reporting the findings via the relevant clinical governance routes; actions followed through to ensure completion; and themes collated and shared to ensure wider learning. The primary focus for further SAB reductions continues to target those associated with vascular access. Renal services developed a comprehensive action plan to address the renal fistula related SABs. Implementation of the Action Plan is being monitored via the Medical Services Clinical Governance Committee. There are indications that the action plan is now having an impact with only 2 fistula related SABs between occurring between July - December 2014 compared with 6 between April - June 2014. A comprehensive review of PVC management procedures including insertion process; maintenance process; documentation; monitoring/auditing arrangements; and training requirements/resources is required. However it has not been possible to commence this work due to the very significant IPCT resource that has had to be directed to ensuring Ebola preparedness across the organisation. This work will be prioritised early in 2015. A programme of work aimed at reducing blood culture contamination rates is currently being led by the clinical team in the Emergency Department at UHC. Consideration is required as to how this can be extended to other areas of the organisation. It should be noted that in the absence of any vascular related SABs, the organisation would still be above the HEAT Target trajectory as a result of the increase in SABs with other primary causes. All NHS Boards in Scotland are participating in a programme of enhanced surveillance of SABs from 1st October 2014. This will standardise the definitions used across Scotland and have the ability to review all Board’s data. This will facilitate benchmarking and the sharing of good practice between NHS Boards. 4 of 18 2. Clostridium difficile Infections . In order to allow real time monitoring of the organisation’s progress against the CDI HEAT target, a numerical target of no more than 10 cases per month has been established. Since 1 April 2014, there have been 99 CDI cases (Chart 4). This places the organisation 19 cases above the locally set trajectory. Of the 99 cases, 63 were out of hospital cases. In November 2014 alone, there were 12 CDI cases, of which 8 were out of hospital cases (67%). At this stage in the activity year, it is unlikely that the organisation will achieve the HEAT Target 2014-15. In order to achieve the target, there can be no more than 5.25 cases per month in the remaining 4 months which is a significant challenge to the organisation. The verified annual rate for CDI in the 15 and over age group for the year ending September was 0.36. This is the lowest annual rate since mandatory testing of all stool samples for Clostridium difficile toxin was introduced in April 2009. The projected rate for the year ending December 2014 is also 0.36 (Chart 5). If confirmed this will be the first quarter in which a decrease in the CDI rate was not recorded. TOTAL 99 CDI CASES (19 CDIs above local trajectory) Chart 4 - CDI HEAT Target 2014 – Position at Month 15 (Year 2) Chart 5 - NHS A&A Rolling Annual CDI rate (15 and above) 5 of 18 . The most significant contributing factor to the development of a CDI is antibiotics in both primary and secondary care. There has been an increased focus on the use of high risk antibiotics known as the 4Cs which has played a significant role in achieving the earlier reductions. However all antibiotics present an increased risk to a patient in developing a CDI. Therefore to achieve lower levels, the overall number of antimicrobials prescribed must be reduced and this continues to be reinforced throughout the organisation. The Antimicrobial Management Team (AMT) continues to engage with clinical teams in primary and secondary care to review prescribing practices from local antimicrobial usage and resistance data. The aim is to reduce the overall level of antimicrobial prescribing in order to slow the development of antimicrobial resistance, as well as reduce the CDI risk associated with antibiotic usage. 3. Viral Haemorrhagic Fever / Ebola Preparedness There has been a considerable amount of work undertaken to date in ensuring that local arrangements are in place for any suspected cases that potentially present in the organisation. Training sessions have been undertaken since 17 November 2014. At the time of writing this report, 104 members of staff have attended the training. Further sessions are planned throughout January 2015 and into February 2015. Areas prioritised for training included: . Accident & Emergency Departments – University Hospitals Ayr and Crosshouse . Ward 2D, Infectious Disease Unit – University Hospital Crosshouse . Intensive Care Units - University Hospitals Ayr and Crosshouse . Anaesthetic Team – University Hospital Crosshouse . Clinical Decisions Unit – University Hospital Ayr . Arran War Memorial Hospital . Lady Margaret Hospital Ongoing work includes: . Developing a process for transferring possible cases from the Accident and Emergency Department at University Hospital Crosshouse to Ward 2D Infectious Diseases Unit. Liaising with clinical services to advise them on local operational plans 4. Norovirus Season There have been three confirmed Norovirus Outbreaks in December 2014. The wards affected were 3D (Gastroenterology/Short Stay Medical) and 4E (Medical) in the University Hospital Crosshouse and Roseburn Ward in East Ayrshire Community Hospital. All three outbreaks were successfully managed with only short term closure and no spread to other areas of the hospitals. 6 of 18 Monitoring Form Policy/Strategy Implications Not required.