NHS Board Meeting
5 October 2011 Paper 4
NHS Board Meeting
Wednesday 5 October 2011
Subject
Healthcare Acquired Infection (HAI) Position
Report.
Purpose
To update NHS Board members on local
progress against the 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 on the local position as
at 31 July 2011, against the Board’s efforts to reduce HAI across NHS Ayrshire
and Arran.
1.2
The Prevention and Control of Infection Team (PCIT) are working to achieve the
HEAT HAI targets set by the Scottish Government Health Directorates (SGHD)
which include;
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1.3
To achieve a rate of no more than 0.26 cases per 1,000 acute occupied bed
days for Staphylococcus aureus bacteraemias (SABs); and
To achieve a rate of no more than 0.39 cases per 1,000 occupied bed days for
Clostridium difficile infections (CDIs).
All NHS Boards are required to use the standardised Healthcare Associated
Infection Reporting Template (HAIRT) in relation to all mandatory NHS Board HAI
reports. This template now includes estates monitoring data following agreed
changes across NHSScotland. For the purposes of the NHS Board members, the
HAIRT provides detail in the following HAI areas (see appendix 1);
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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 Estates;
Reports on Outbreak Management; and
Any other HAI related activity.
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2.
Current situation
2.1
The drive to achieve the new HAI HEAT targets, as outlined above, remains a
challenge to NHS Ayrshire and Arran. The PCIT continues to work closely with
various clinical teams, the Scottish Patient Safety Programme (SPSP), the Clinical
Improvement Team (CIT) and others to achieve these target by 31 March 2013.
The following provides an overview of our HAI local position up to 31 July 2011:
2.1.1
SABs (including meticillin resistant Staphylococcus aureus (MRSA))
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NHS Ayrshire and Arran are working to achieve the SAB HEAT rate of no more
than 0.26 cases per 1,000 acute occupied bed days for SABs.
This rate equates to no more than 84 SABs in the activity year. A monthly
trajectory has been set against this target of no more than 7 per month in a bid
to achieve the required year end position. This total is based on the
assumption that the occupied bed data in 2012-13 remains similar to the
baseline used by SGHD.
In July 2011, there were 13 SAB cases taking the total to 45 since April 2011.
Of the 13 cases, one relates to a sudden death at home which counts towards
the HEAT figures (see appendix 2).
The high number of cases in both June and July 2011 has resulted in the
trajectory being exceeded by 17 cases as of 31 July 2011. In order to achieve
the target by the activity year-end (31 March 2012), there must be no more
than 4.8 cases per month. There is now a very significant risk that the
organisation will not achieve the SAB HEAT target during the current activity
year. It should be noted however, that compliance with the target will not be
measured until 31 March 2013.
To date, the PCIT together with the CIT have focused their interventions jointly
on vascular access devices, in particular peripheral vascular catheters (PVCs),
central vascular catheters (CVCs) and blood culture contaminants. This has
resulted in a significant reduction in the number of SABs, related to these 3
causes. The following graph shows the reductions achieved per quarter
activity data from April 2010 to June 2011.
18
16
14
12
10
8
6
4
2
0
Apr-Jun 10
Jul-Sept 10
PVCs
Oct-Dec 10
CVCs
Jan-Mar 11 Apr - Jun 11
Contaminants
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In addition, a package of specific interventions within the renal services was
introduced in September 2010 due to an increase in renal related SABs. This
programme had an immediate impact in the number of SABs identified within
renal services. The last SAB in Ward 2F, Crosshouse Hospital was on 9
January 2011. However, it should be noted that there has been an increase in
renal dialysis related SABs in recent months and these are primarily related to
renal fistulas. A new package of interventions is being developed jointly by the
PCIT and CITs to address this newly identified challenge. The following graph
provides quarter activity data on the number of SABs in both Ward 2F and the
RDU at Crosshouse Hospital between April 2011 to June 2011.
10
8
6
4
2
0
Apr-Jun 10
Jul-Sept 10
Ward 2F
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2.1.2
Oct-Dec 10
Jan-Mar 11
Apr-Jun 11
Renal Dialysis Unit
The interventions described above have resulted in a significant change in the
source of acquisition for SABs during the period April – July 2011 compared
with the previous year as shown in the following table.
Source of Acquisition
2010-11
Community
Community Onset/Healthcare Associated
Contaminants
Hospital Acquired
23%
33%
10%
33%
2011-12
(Apr – Jun)
30%
41%
5%
23%
The PCIT are reviewing the community acquisitions to identify if there are any
specific risk factors, including health and social care that can help determine
further interventions.
CDIs
ƒ The annual rate of CDI in NHS Ayrshire & Arran continues to fall. The last
verified annual rate for the activity quarter ending in March 2011 was 0.75
cases in the 65 and over age group per 1,000 occupied bed days (see page
11). The last verified quarterly rate was 0.4 cases in the 65 and over age group
per 1,000 occupied bed days for the period January – March 2011.
ƒ NHS Ayrshire and Arran is currently working to achieve an annual rate of no
more than 0.39 cases in the 65 and over ager group per 1,000 occupied bed
days for CDIs.
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This rate equates to approximately 132 CDIs in the activity year. A monthly
trajectory has been set against this target of no more than 11 per month for
hospital and community cases in a bid to achieve the required year end
position. This total is based on the assumption that the occupied bed data in
2012-13 remains similar to the baseline used by SGHD.
There is a total of 62 CDI cases in patients aged 65 and over (April 2011 – July
2011). In July 2011, there were 15 CDI cases (see appendix 2).
To date, our local monthly trajectory is exceeded by 18 cases. It is therefore
projected that should this trend continue, then there will be an overshoot of 50
cases by activity year end. In order to meet the established trajectory there
must be no more than 9 cases per month in the 65 and over age group
compared with an average of 15.5 in the first 4 months of this activity year.
There has also been further analysis of antimicrobial prescribing data
undertaken by the Antimicrobial Management Team (AMT). The findings
indicate that further reductions in CDI rates can only be achieved by reducing
prescribing of high risk antibiotics namely, co-amoxiclav and ciprofloxacin.
The antimicrobial prescribing data also indicates that there has been an
increase in high risk antibiotic prescribing in Ayrshire Central Hospital in recent
months. This may be a precursor to a potential increase in CDI cases. The
AMT are in the process of highlighting this information to the Care of the
Elderly Consultants to inform local review of prescribing practice.
3.
Proposal
3.1
The PCIT require continued support from the NHS Board to achieve the best local
position against the national and local HAI targets.
4.
Consultation on development of this report
4.1
Nil to note.
5.
Resource implications
5.1
Nil to note.
6.
Risk assessment and mitigation
6.1
The performance reported to the NHS Board identifies the current position.
Assurance can be given that every effort is being made by the PCIT to achieve the
best end position that the organisation can achieve against the new HEAT Targets.
7.
Impact assessment and consequential changes proposed to mitigate
adverse impacts identified
7.1
Nil to note.
8.
Conclusion
8.1
NHS Board members are to note the ongoing work programme of the PCIT to
improve current performance to achieve the HAI HEAT targets.
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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 NHS Board’s goals.
Professor R G Masterton, Executive Medical Director
[Bob Wilson, Babs Gemmell]
13 September 2011
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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
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NHS Ayrshire and Arran is now working towards the new HEAT Targets for SABs and CDI with
effective 1 April 2011. These targets are to achieve a further reduction in HAI by 31 March
2013 as follows:
1. Staphylococcus aureus bacteraemia (SABs), including MRSA, cases are 0.26 or less
per 1000 acute occupied bed days; and
2. The rate of Clostridium difficile infections in patients aged 65 and over is 0.39 cases or
less per 1000 total occupied bed days.
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
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There were 13 SAB cases in July 2011 taking the total this year to 45.
The monthly trajectory is to have no more than 7 SABs per month which equals 84 SABs in the
activity year.
This total is based on the assumption that the occupied bed data in 2012-13 remains similar to
the baseline used by SGHD.
As of 31 July 2011 the trajectory has been exceeded by 17 cases. In order to achieve the yearend target, there can be no more than 4.8 cases per month. This is a significant challenge to
the organisation.
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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
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As of 31 July 2011, there is a total of 62 CDI cases in patients aged 65 and over. The
trajectory has been exceeded by 18 (trajectory is 11 per month).
Collaborative working undertaken by the Primary Care Prescribing Team and the Antimicrobial
Management Team (AMT) continues in aiming to reduce prescribing of the 4C (high risk)
antibiotics in primary care.
The AMT is now working to reduce secondary care use of co-amoxiclav and ciprofloxacin. An
increase is evident in Ayrshire Central Hospital and discussions are underway with the Care of
the Elderly Consultants to review prescribing practices.
The PCIT are continuing enhanced surveillance and investigation of all CDI cases, collecting a
more detailed antibiotic history for each patient, including primary care prescribing. This will
help identify any potential trends that may be occurring to allow appropriate interventions to be
implemented.
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
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NHS Ayrshire and Arran achieved 98% compliance in July 2011.
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Estates, 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
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NHS Ayrshire and Arran achieved 96% compliance in July 2011 following estates monitoring.
94% was achieved against cleaning and the healthcare environment.
Outbreaks
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Nil.
Other HAI Related Activity
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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
2011-12 CDI HEAT Trajectory
140
120
100
80
60
40
20
21
14
15
12
2011-12 HEAT Target
HEAT Target Trajectory
Monthly HEAT Target
Monthly Actual
ar
-1
2
M
Fe
b12
Ja
n12
D
ec
-
11
11
ov
N
ct
-1
1
O
Se
p-
11
11
Au
g-
Ju
l-1
1
Ju
n11
1
ay
-1
M
Ap
r-1
1
0
Monthly Cumulative
SAB 2011-12 HEAT Target
90
80
70
60
50
40
30
20
17
10
0
7
Apr-11
13
8
May-11
Jun-11
2010-11 HEAT Target
Jul-11
Aug-11
Sep-11
HEAT Target Trajectory
Oct-11
Nov-11
Monthly HEAT Target
Dec-11
Jan-12
Monthly Actual
Feb-12
Mar-12
Monthly Cumulative
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