EXIT SITE INFECTION DEVELOPED WITHIN 30 DAYS POST INSERTION OF TENCKHOFF. Regional Clinical Audit Report August 2012

Transcription

1 EXIT SITE INFECTION DEVELOPED WITHIN 30 DAYS POST INSERTION OF TENCKHOFF Regional Clinical Audit Report August 0 Clinical Audit Lead: Audit Facilitators: Authors: Contact Address: Lesley Lappin, Clinical Nurse Specialist/Community Dialysis Manager Roslyn Adams, Clinical Audit Nurse - Renal Services Nicola Reid, Regional Renal Audit Coordinator Tracey Powell, Regional Renal Audit Coordinator Tracey Powell, Regional Renal Audit Coordinator Lesley Lappin, Clinical Nurse Specialist/Community Dialysis Manager Helen Hannay, Clinical Nurse Specialist Renal Community Services NW Renal Audit Programme Renal Ward 36 Manchester Royal Infirmary Oxford Road Manchester M3 9WL Telephone number: Web Address:

2 ESI Audit 00 CONTENTS Page No. Contributors Executive Summary. Introduction and Background 3. Aims and Objectives 3 3. Evidence Base 3 4. Standards 4 5. Methodology 4 6. Results Summary 5 7. Discussion of Results 4 8. Recommendations 7 Appendix Appendix Glossary of Terms and Abbreviations Data Collection Form

3 ESI Audit 00 CONTRIBUTORS The following adult renal units took part in the ESI Audit: Manchester Royal Infirmary Royal Liverpool Hospital Royal Preston Hospital Salford Royal Hospital Data was provided by: Helen Hurst, Manchester Royal Infirmary Peter Livesley, Royal Liverpool Hospital Chris Wroe, Royal Preston Hospital Angela Goddard, Salford Royal Hospital Royal Preston Hospital withdraw from the North West Regional Audit in April 00 and therefore only a small amount of data was submitted; this has not been considered within this report. North West Renal Audit August 0 Page

4 ESI Audit 00 EXECUTIVE SUMMARY This audit was undertaken to obtain information about exit site infection rates within the first thirty (30) days post insertion of Tenckhoff Catheter for peritoneal dialysis (PD) patients in the North West Region. It aimed to determine any variations in the post operative exit site care across the region and it was acknowledged that there is a need to explore standardisation of exit site care across the region. The proposed health benefits would include a reduction in post insertion infection rates; prevent tunnel infections and reduce or prevent the occurrence of peritonitis; ensure the efficient functioning and patency of the PD catheter and consequently reduce the need for catheter removal or replacement. There are currently no standards relating to management of exit site infections and it is proposed that these should be developed across the region as a consequence of this audit. There were a total of 8 patients records submitted for the audit; however because of their withdrawal from the regional programme only a limited quantity of data was submitted by the Royal Preston Hospital (n=6) and their data has been omitted from this report. The number of cases analysed for this report was 66. The number of ESI s was broadly similar for RLH (36.4%) and SRH (9.7%), but markedly lower at MRI (3.4%). Factors that do not appear to have any influence on the occurrence of ESI include the use of immunosuppressants and the grade of operator. Factors that may increase the risk of developing an ESI include: whether a patient has diabetes and percutaneous insertion of catheter. Factors that may decrease the risk of developing an ESI include: increased age; surgical insertion of catheter; insertion marked pre-operatively; and prophylactic antibiotics. North West Renal Audit August 0 Page

5 ESI Audit 00. INTRODUCTION & BACKGROUND Established in 99, the North West Renal Audit Programme is a standards based programme of continuous quality improvement through clinical audit. The programme is directed by the North West Renal Audit Steering Group and the daily management carried out by the North West Renal Audit Team. The audit was prompted by the lack of national and regional standards relating to clinical practice in this area; and hence it was important to gather information regionally to see if there were any potential problems in this area. The audit reviewed the clinical practice in post-operative care following Tenchkoff insertion and was designed to identify similarities and/or differences in practice across the region. The topic was considered important as the occurrence of exit site infections can impact significantly on: the length of stay of a patient; the time required for training; it may lead to further infection (i.e. peritonitis); and adversely affect a patient s quality of life.. AIMS AND OBJECTIVES Objectives To obtain information about exit site infection rates within first thirty (30) days post insertion of Tenckhoff Catheter To determine variations in post operative exit site care across the region. Explore need for standardisation of exit site care Proposed Health Benefits Reduce post insertion infection rates Prevent tunnel Infections Reduce/prevent peritonitis Ensure functioning/patency of catheter Reduce need for catheter removal/replacement Reduce length of stay Optimise training for peritoneal dialysis 3. EVIDENCE BASE ISPD Clinical Practice Guidelines for Peritoneal Access / Renal Association Guidelines. Guideline 3.: Implantation Protocol (A): recommends renal units have clear protocols for perioperative catheter care, including the use of antibiotic prophylaxis. Guideline 4.: The Implantation Technique (B): recommend that local expertise at individual centres should govern choice of method of PD catheter insertion. North West Renal Audit August 0 Page 3

6 ESI Audit 00 Guideline 7.: Audit of PD Catheter Insertion (B): recommend regular audit at not less than months intervals of outcome of catheter insertion as part of multidisciplinary meetings of PD team. Figueiredo, A; Bak-Leong G, Jenkins, S, Johnson, D.W., Mactier, R., Ramalakshmi, S., Shrestha, B., Struijk, D., and Wilkie, M. (00). Clinical Practice Guidelines for Peritoneal Access. Peritoneal Dialysis International, 30, p STANDARDS There are currently no standards for this audit. 5. METHODOLOGY The population for the audit were all those who had a Tenckhoff catheter inserted during 00. All patients who develop an exit site infection within 30 days post insertion of a peritoneal dialysis catheter. Data will be collected from computer systems and patient notes onto a standardised data collection sheet (a proforma) or excel spreadsheet. All patients who have a peritoneal dialysis catheter inserted will be entered onto a database (directly or via a proforma) and for patients who develop an exit site infection, additional details about the exit site infection will be collected. Data to be collected: Pre-operative care including pre-operative screening of MRSA/MSSA, Details of insertion including type of surgery, type of anaesthetic and prophylactic antibiotic therapy used at insertion, Microbiology for organism identification, post operative anti-biotic and dressing protocols used and outcome. The data was collected by PD nursing staff. Healthcare professionals involved in the care of this audit include PD nurses, surgeons, clinical leads, microbiology. The information sources for the audit were patients medical notes, electronic records. Data was collected for a month period (00). North West Renal Audit August 0 Page 4

7 ESI Audit RESULTS SUMMARY 6. Demographics There were a total of 66 patient records included in the analysis and of these 37 (0.3%) had a suspected exit site infection. The total number of patients included from MRI was 58 with (3.4%) suspected cases of ESI; 44 from RLH with 6 (36.4%) suspected cases of ESI and 64 from SRH with 9 (9.7%) suspected cases of ESI. Figure 6.: Gender of patients including in ESI audit Male Female Not stated Regionally the split between males and females is approximately 65% male, 33% female and % not stated (Figure 6.). However, at MRI there are a much larger proportion of males at 8%, compared to only 5.5% females. The median age of patients included in the audit varies across the units with a median age of 54 at RLH, 58 at SRH and 63 at MRI (Renal Registry data for 009 has incident age of 64). Table 6.: Median age Median Age Median Age Male Median Age Female MRI RLH SRH Data for ethnicity shows that those patients included in the study were predominantly of white ethnic origin (65% regionally) although there is significant variation between the units; the highest percentage of 86.4% at RLH and the lowest of 56.9% at MRI. However, it should be noted that there is a high percentage of patients where the information was not submitted for both MRI (5.5%) and SRH (35.9%) and this will affect the regional figures (Figure 6.) North West Renal Audit August 0 Page 5

8 ESI Audit 00 Figure 6.: Ethnicity of patients included in ESI Audit White Afro Caribbean Asian Black African Mixed Race Oriental / Chinese Other Not Stated Regionally 4.% of all patients were recorded as having diabetes. There is variation between the individual units, but this is difficult to interpret. Regionally approximately % of patients who did not develop an ESI had diabetes; and approximately 35% of those who did develop an ESI had diabetes. There is a large percentage of data not recorded for MRI patients. Figure 6.3: Prevalence of diabetes of patients included in ESI Audit 00 Prevalence of diabetes in patients who did not develop ESI Prevalence of diabetes in patients who did develop ESI Yes No Not Stated Yes No Not Stated The prevalent of immunosuppressant did not appear to have been a factor influencing ESI with 7.8% of patients who did not develop an ESI taking an immunosuppressant; and 8.% of patients who did develop an ESI taking an immunosuppressant (Figure 6.4). North West Renal Audit August 0 Page 6

9 ESI Audit 00 Figure 6.4: Percentage of patients included in ESI audit taking an immunosuppressant Prevalance of immunosuppresants in patients who did not develop ESI Prevalence of immunosuppressants in patients who did develop an ESI Yes No Not Stated Yes No Not Stated 6. Tenckhoff insertion information Regionally % of the total numbers of patients had a percutaneous insertion and 70.3% surgical. There appears to be no standard method of insertion across the region with 79.3% of MRI patients and 95.3% of SRH patients having surgical insertion; and RLH using both methods with 45.5% surgical and 54.5% percutaneous insertion (Figure 6.5 below). Figure 6.5 Type of Tenckhoff insertion Type of insertion for those patients who did not develop an ESI Type of insertion for those patients who did develop an ESI Percutaneous Surgical Not stated Percutaneous Surgical Not stated Regionally of those patients who did develop an ESI, 9% were inserted percutaneously; in those who did not develop an ESI this figure was. Surgical insertion was similar regionally for both groups with 79% inserted surgically in patients who did not develop an ESI and 76% in those who did. North West Renal Audit August 0 Page 7

10 ESI Audit 00 The type of anaesthetic used relates to whether the insertion was percutaneous or surgical, where percutaneous the type of anaesthetic is local; generally were surgical insertion the type of anaesthetic is general. Regionally 64.3% of all the patients included in study had a general anaesthetic; 6.9% a local and it was not stated for 8.8% of patients. All surgical insertions undertaken at RLH are done under a general anaesthetic; those at SRH are under a local anaesthetic where necessary. Figure 6.6: Type of anaesthetic used during insertion of Tenckhoff for all patients included in audit General Local Not stated The grade of operator is mostly a consultant in all units (regionally 90.7% consultant,.% SpR and 7.% not stated). All patients who developed an ESI were operated on by a consultant. Figure 6.7: Grade of Operator Consultant SpR not stated In patients who did not develop an ESI the insertion was not marked pre-operatively at RLH or SRH; it was however marked 8% of times at MRI. Of those patients who did develop an ESI both patients at MRI had the insertion marked pre-operatively; of the patients at RLH and SRH 93.8% and 94.7% respectively did not have the insertion marked. North West Renal Audit August 0 Page 8

11 ESI Audit 00 Figure 6.8: Was insertion marked pre-operatively? Was insertion marked pre-operatively in patients who did not develop ESI? Was insertion marked pre-operatively in patients who did develop ESI? Yes No Not stated Yes No Not stated In the group of patients who did not develop ESI.% received prophylactic antibiotics at SRH, 78.6% at MRI and 96.4% at RLH; regionally 58.9% of patients who did not develop an ESI received prophylactic antibiotics, 7.% did not and it was unstated in 4% of cases. Of those patients who did develop an ESI 0 at MRI, 87.5% at RLH and 5.3% at SRH received antibiotic prophylaxis. Regionally 45% received prophylactic antibiotics, 43.3% did not and it was not stated in 0.8% of cases. Figure 6.9: Prophylactic antibiotics prescribed Prophylactic Antiobiotics given to patients who did not develop ESI Prophylactic antiobiotics given to patients who developed ESI Yes No Not stated Yes No Not stated There was a mixed number of patients as inpatients at time of surgery, with 37.9% at MRI, 56.3% at SRH and.4% at RLH, which is a reflection of the different types of insertion (at RLH the North West Renal Audit August 0 Page 9

12 ESI Audit 00 majority of insertion method was percutaneous with local anaesthetic. Figure 6.0 below shows that there is no significant difference between those patients who went on to develop an ESI and those who did not. Figure 6.0: Was the patient an inpatient at time of surgery? Was the patient an inpatient at time of surgery - patients who did not develop ESI Yes No Not stated Was the patient an inpatient at time of surgery - patients who did develop ESI Yes No Not stated 3 Screening of MRSA in 93.4% if cases regionally; MSSA screening in 8% of cases. patient at SRH was found to be MRSA positive. patient at RLH and 3 patients at SRH were found to be MSSA positive. Table 6. below gives the figures. Table 6. Levels of MRSA/MSSA screening MRSA screen MRSA positive done Yes No Not Stated Yes No Not Stated MRI RLH SRH 63 MSSA screen done MSSA positive Yes No Not Stated Yes No Not Stated MRI RLH 43 SRH 48 3 North West Renal Audit August 0 Page 0

13 ESI Audit 00 Post-operative antibiotic protocols were not stated or found to be not applicable (RLH) at all units. Figure 6. Was a post-operative antibiotic protocol followed? MRI RLH SRH Yes No N/A Not stated Again there was a large number of unrecorded data for whether a post-operative dressing protocol was followed (6. below); this makes this data difficult to interpret. Figure 6.: Was a post-operative dressing protocol followed? Was post-op dressing protocol followed in patients who did not develop ESI Was post-op dressing protocol followed in patients who developed ESI Yes No Not stated Yes No Not stated Not Applicable North West Renal Audit August 0 Page

14 ESI Audit Exit Site Infections The number of suspected exit site infections in the region was 37; patients at MRI (3.4%), 6 patients at RLH (36.4%) and 9 patients at SRH (9.7%). The median age of patients without an ESI was 56 at SRH and 5 at RLH; patients with an ESI had a median age of 6 at SRH and 56 at RLH). Figure 6.3 Total number of cases recorded and number of Exit Site Infections No. of patients w ithout ESI No of patients w ith suspected ESI It is difficult to make assumptions about the reasons for the higher percentage of ESI at RLH and SRH as compared to MRI; possible reasons are discussed in the discussion section of this report. A variety of organisms were grown and are shown in Figure 6.4 below. The largest groups of organism grown are 9.7% regionally described as skin flora/regional flora; 7% regionally of S/Aureus; and smaller quantities of anaerobes, proteus, pseudomonas, mixed anaerobes, MRSA and diptheroids. Figure 6.4 Type of organism grown MRI RLH SRH Region Anaerobes S/Aureus ++ Skin flora / Regional Flora Proteus & Pseudomonas No Growth Mixed anaerobes + s/aureus MRSA Diptheroids North West Renal Audit August 0 Page

15 ESI Audit 00 The number of ESI that responded to antibiotic treatment was recorded as 6 throughout the region (43.%); in some instances the catheter was removed (regionally 8.%). Figure 6.5: Number of ESI s that responded to anti-biotic treatment; number of tunnel infections; and number who developed peritonitis (00) MRI RLH SRH Region Yes No SCAN -VE Yes No ESI responded to anti-biotic treatment? Tunnel infection Peritonitis The figures related to catheter removal are very small and difficult to relate to other factors. Figure 6.6 below relates the catheter removals to initial catheter insertion method. Figure 6.6: Number of catheters removed (related to insertion method) RLH SRH Region Surgical Percutaneous North West Renal Audit August 0 Page 3

16 ESI Audit DISCUSSION 7. Review of Data There were a total of 66 patients data included in the audit, with 37 recorded as having an ESI. The gender split was more males (65%) than females (33%); with significantly more males than females at MRI (8% compared to 5%). The median age of patients was 54 at RLH, 58 at SRH and 63 at MRI with variation between the male and female populations. Renal Registry (RR) data for 009 gives the median age of all incident patients at 64.8 years (and 57. years for non-white patients); the RR data does not specify whether incident patients are PD, HD or HHD. The median ages for patients in the North West Region appears to be significantly younger in the PD populations at RLH and SRH. Interestingly the median age of patients without an ESI was 4 years younger than those that had an ESI at SRH and RLH. Data for ethnicity shows that those patients included in the study were predominantly of white ethnic origin (65% regionally) although there was significant variation between the units partly because there was a high percentage at MRI and SRH of data missing. Regionally 4.% of patients were recorded as having diabetes. There is variation between the individual units, and 39.7% data was not recorded for MRI patients. Regionally of those patients who did not have an ESI, % had diabetes; in those patients who did have an ESI the figure was greater at 35%. Regionally the figures suggest there may be some correlation with the occurrence of ESI and type of insertion; 9% of those who developed ESI had catheter inserted percutaneously as compared to only in the group who did not develop an ESI. There was little difference in the percentages of who did or didn t develop an ESI related to surgical insertion. The type of anaesthetic used relates to whether the insertion was percutaneous or surgical, where percutaneous the type of anaesthetic is local; generally were surgical insertion the type of anaesthetic is general. The grade of operator is almost exclusively a consultant in all units. Neither of these factors appear to have any correlation with the occurrence or not of ESI. Of those patients who developed an ESI, most patients at MRI had the insertion marked preoperatively but over 9 of patients at RLH and SRH did not; suggesting there may be some correlation between marking of insertion and ESIs. This may be the result of insertions being placed where they might be affected by a patients clothing; pre-marking may avoid this. The use of prophylactic antibiotics varied significantly between the units with very few patients receiving these at SRH. Regionally the different between the two groups of patients may be significant (58.9% did get antibiotics in the group who didn t get an ESI and of those who did get an ESI only 43.3% had received these). SRH now give prophylactic antibiotics prior to catheter insertion. North West Renal Audit August 0 Page 4

17 ESI Audit 00 38% of patients regionally were inpatients at the time of surgery. The occurrence of this was related to the type of insertion (i.e. more likely to be inpatient if surgical insertion); but there were no differences between patients who did develop an ESI and those who did not. Unfortunately the data did not distinguish between those patients who were already inpatients, those who were inpatients as a result of the Tenchkoff surgery and this would need to be addressed for any future audit. Post-operative antibiotic protocols were not stated or found to be not applicable at all units. Presumably post-operative antibiotics would only be used if a patient developed an infection. This question will be removed from any future audit. MRSA screening took place in 93.4% of patients within the NW region; and MSSA screening in 8% of patients within the NW region. There is no link to screening or lack of screening with the occurrence of ESIs. Information relating to post-operative dressing protocols was difficult to pin down and the units did not respond uniformly to this question. MRI follow the ISPD recommendation that post-operative dressing should be left intact for a minimum of 7 days and the PD tube kept immobilised; SRH followed ISPD guidelines in a significant amount of patients; RLH do not have strict protocols. The percentage of ESI s was broadly similar for RLH (36.4%) and SRH (9.7%), but markedly lower at MRI (3.4%). A variety of organisms were grown; regionally the most frequently recorded were skin flora and staph aureus organisms. Of those patients with an ESI 43.% regionally responded to anti-biotic treatment; 8.% of cases regionally had the catheter removed. 7. What are the limitations of the data? Did not collect adequate data on post operative antibiotic and dressing protocols Did not adequately define what was meant by inpatient at time of insertion? North West Renal Audit August 0 Page 5

18 ESI Audit Factors that impacted on ESI The following table outlines some potential factors influencing the occurrence of ESIs Table 7. Regional Factors Influencing ESI Factors that MAY increase risk of developing ESI An additional 4% of patients with diabetes developed ESI Factors that MAY decrease risk of developing ESI.5% less patients developed ESI following surgical insertion Factors that appear to have no influence on ESI Immunosuppressant use Grade of Operator Additional 9% of patients developed ESI following percutaneous insertion 3% less patients developed ESI if they received prophylactic antibiotics Additional 36.8% patients who had not had insertion marked pre-operatively developed ESI Increasing Age may have small influence with median age of those with ESI 4 years higher than those without North West Renal Audit August 0 Page 6

19 ESI Audit RECOMMENDATIONS 8. Recommendations for regional implementation Recommendations include: Pre-operative marking of exit site Use of prophylactic antibiotics 8. Audit Action Plan The following (Table 8.) outlines actions to be taken following recommendations with estimated timescales. Table 8.: Action Plan Action Coordinator for Action Timescale Result of audit to be disseminated to individual organisations Steering Group members Full report to be disseminated Autumn 0. Results to be presented at Annual NWRA Meeting Regional Renal Audit Coordinator and audit lead Results discussed at Regional Meeting September 0. Results to be disseminated by organisations and individual action plans to be produced and implemented Individual Organisations Autumn 0 Re-Audit following implementation of report recommendations Review data parameters. Liaise with Steering Group lead and PD leads in region. Re-audit 03. North West Renal Audit August 0 Page 7

20 ESI Audit 00 GLOSSARY OF TERMS AND ABBREVIATIONS APPENDIX ESI ISPD NWRA PD LOS QOL RA RR Exit Site Infection International Society for Peritoneal Dialysis North West Renal Audit Peritoneal Dialysis Length of Stay Quality of Life Renal Association Renal Registry Units MRI RPH RLH SRH Manchester Royal Infirmary Royal Preston Hospital Royal Liverpool Hospital Salford Royal Hospital North West Renal Audit August 0 Page 8

21 ESI Audit 00 DATA COLLECTION FORM APPENDIX Hospital no: Date of birth: Date ESI Suspected: Organism grown Ethnic Group: MRSA Screen done MRSA Positive Gender: Male Female MSSA Screen done MSSA positive Diabetes Yes No Prescribed Yes immunosuppressants No Date of insertion: Type of insertion: Surgical Percutaneous Anaesthetic: Local General Grade of surgeon: Consultant Registrar Insertion marked Yes pre-operatively? No Antibiotic started Yes before ESI suspected No Length of stay if hospitalised for ESI days Post operative protocol followed for antibiotics? If no, what was different? Post operative protocol followed for dressings? If no, what was different? Prophylactic Yes antibiotics used? No Date Catheter first used: Inpatient at time Yes of surgery? No If no, was the surgery Yes done as a day case? No Outcome: Responded Tunnel infection Peritonitis Catheter out Other North West Renal Audit August 0 Page