Improving Prevention and Control of Infection Quarter 2 Report: April 2009 September 2009

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1 Improving Prevention and Control of Infection Quarter 2 Report: April 2009 September Introduction This Quarter 2 updates the Health Board on infection prevention and control issues within the BCUHB. The Health Board is committed to ensuring that infection prevention and control is a priority, and that compliance with Annual Operating Framework 12, Health Care Standard 5 and the strategies for Infection Prevention & Control are achieved. These include the key All-Wales documents Healthcare Associated Infections A Strategy for Hospitals in Wales (WAG 2004) and Healthcare Associated Infection A Community Strategy for Wales (WAG 2007). The organisation has a local delivery plan (LDP) for improving prevention and control of infection including cleanliness, covering primary, community and secondary care services and settings. Detailed progress against the LDP is reported to the Infection Prevention & Control sub-committee. The structures and reporting mechanisms for infection prevention and control are currently under review through the work of the Infection Prevention & Control Transition Workstream Group. The group has been recognised as a mark of good practice during transition. This work will be presented and agreed at the first Infection Prevention & Control Sub-Committee in January This meeting will be chaired by Mr Harri Owen-Jones, Independent Member. 2. National Standards for Hospital Cleanliness The Board is committed to implementing the Credits for Cleaning audit programme that will ensure accurate and comparable measurement of compliance with the cleanliness standards issued by the Welsh Assembly. Currently the system has been implemented within the Glan Clwyd areas with an average score of 91.8% for completed audits undertaken between April and September The system is being rolled out across the acute and community sites within BCUHB. The plan is to undertake this assessment manually during January and February, so that by the end of February all three hospitals will have been assessed. Community Health Councils have carried out their schedule of Hospital Patient Environment (HPE) assessments and overall these have been positive. The Health Board is actively working with the CHCs to address any deficiencies highlighted. Llandudno Hospital has been cited for specific improvements. Cleaning services have been benchmarked across BCUHB and work is underway to review the organisation of cleaning to ensure consistently high standards across the organisation. DC/KMW/SH Page 1 of 7

2 3. Hand Decontamination Strategy Hand decontamination remains one of the core infection reduction and control strategies. Currently elements of the NPSA cleanyourhands campaign include: 1. Access to alcohol hand rubs in patient areas. 2. Alcohol hand rubs at entrances to wards. 3. Ward based champions and community infection control link staff. 4. Training. 5. Ward based audit programme. 6. Cross audit programme by Infection Control Team. 7. Posters. 8. Standardisation of products across former Trust and some former LHB areas. This has been implemented in all acute and community hospitals and some clinics and practices within the community. Targets for hand decontamination are set at 90% in acute sites and are reported at Clinical Programme Group (CPG) and committee level. Good hand hygiene is promoted as good practice for independent contractors in primary care. The Bare Below the Elbows concept is being implemented using the Institute for Healthcare Improvement (IHI) methodology. Testing is underway for uniformed staff on 3 medical wards in Ysbyty Glan Clwyd. This program will be rolled out once reliable results are achieved at 95% or more in these test areas. 3.1 Hand Hygiene Audit Data During transition, as with many measures, differences in approach have been identified which make comparison of data across Health Board areas inappropriate. Since the formation of BCUHB in October systems are in place to afford directly comparable data across the acute sites. This will be presented with the Q3 data to the Infection Prevention & Control Committee in January. 4. Surveillance 4.1 Staphylococcus Aureus Bacteraemia Surveillance This mandatory data set is collected from laboratory positive blood culture and is an indicator of serious infections. This data includes both Methicillin sensitive Staphylococcus aureus (MSSA) and Methicillin resistant Staphylococcus aureus (MRSA), but only considers blood stream infections. The data does not indicate whether the infections are community or hospital acquired. However, all bacteraemia cases are subject to root cause analysis to identify any common factors responsible for these infections. The most recent report received from Welsh Healthcare Associated Infection Programme (WHAIP) / National Public Health Service for Wales (NPHS) is the 33 rd report in the Staphylococcus aureus bacteraemia surveillance scheme. This reports on the annual rate of Staphylococcus aureus bacteraemia from 1 st July 2008 to 30 th June 2009 for the former North Wales and North West Wales NHS Trusts, and provides trend data for Ysbyty Glan Clwyd, Ysbyty Wrexham Maelor and Ysbyty Gwynedd. The following charts are the most recent ones issued by WHAIP, covering the period up to 30 th June Please note the scales in the charts are different for each of the three sites. WHAIP will issue combined data from 1 October 2009 in line with the start date of the BCUHB organisation. The bacteraemia rates indicated for Ysbyty Glan Clwyd are particularly high during the last three quarters on the chart below (c.58/100,000 bed days) compared to the All-Wales average for the same period (c.26/100,000 bed days). Current data (to November 2009) for the Glan Clwyd area DC/KMW/SH Page 2 of 7

3 indicates a significant reduction in bacteraemias which will therefore show as an improved rate in the next report. Quarter 3 figures are being collated to include the end of December so that the IP&C sub-committee can review in detail the issues of MRSA and MSSA rates for the three hospitals and agree strategies for improvement. The former North West Wales NHS Trust s mandatory target was to reduce Staphylococcal bacteraemias (blood stream infections) associated with a central venous device (CVC) to a level below Work undertaken has resulted in a 50% downward trend and, despite some recent slippage the improvements appear to be sustainable. In the Quarter 3 report to the Board in February 2010, monthly data on MRSA and MSSA will be presented. DC/KMW/SH Page 3 of 7

4 4.2 Clostridium Difficile Associated Disease (CDAD) Clostridium difficile data is collected as part of the mandatory data set and is also a BCUHB infection reduction target for The aim is to reduce the number of cases by 25% from the level. The data below indicates that currently the Health Board is not achieving the target. There is a significant difference between the areas. Ysbyty Wrexham Maelor has had a period of increased outbreaks of Norovirus, which has contributed to the increased ascertainment of clostridium difficile. However, November has seen a significant decline in cases. Ysbyty Gwynedd have had an outbreak of C. difficile (9 cases) resulting in a rise in November Please see the Outbreak section below (p.6) for further information. The improvements achieved in Ysbyty Glan Clwyd are to be presented at the prestigious International Forum on Quality and Safety in Healthcare in Nice in C.Diff Rate over 65yrs BCU HB Combined Rate per 1000 Admissions Ystyby Gwynedd Ystyby Glan Clwyd Ystyby Maelor Combined Trust Target We anticipate that targets for reduction of rates of Clostrium diffcile will be set nationally for Wales through the Annual Operating Framework. At present BCUHB is working to the Department of Health Clostrium diffcile guidelines Clostridium Difficile Infection: How to deal with the problem (Dec 2008). 4.3 Orthopaedic Surgical Site Infections The recent report received from Welsh Health Associated Strategy Group provides data from the period 1 st January th September This data set covers elective Orthopaedic procedures for hips and knees. The data is now provided as a Health Board wide data set. Compliance is below the 95% requirement. Infection rates are below the all Wales mean. IP Form Compliance Hip Infections Knee Infections (Jan-June only) Ysbyty Glan Clwyd 76.5% 0.0% 1.1% Ysbyty Wrexham Maelor 89.4% 0.9% 2.6% Ysbyty Gwynedd 100% 1.9% 1.5% BCUHB 87.8% (target 95%) 0.9% 1.7% Wales 75.9% 1.9% 2.4% DC/KMW/SH Page 4 of 7

5 The best practice on post discharge form compliance for demonstrated by Ysbyty Gwynedd will be rolled-out across the BCUHB. 4.4 Caesarean Section Surgical Site Surveillance - 1 January September 2009 There has been an improvement in the data collection. However there is still some significant work required to assure the Board that the mandatory 95% compliance with the data set is being achieved. The CPG is developing and testing a care bundle approach to reducing the current infection rate. Form Compliance (Jan-June only) Number of Procedures Number of Valid Procedures Number of SSI Overall SSI Rate Ysbyty Glan Clwyd 98% % Ysbyty Wrexham 39% % Maelor Ysbyty Gwynedd 81% % BCUHB Total 72.6% % Wales n/a 4,351 3, % 4.5 Intensive Care Unit CVC Infection Rate from January to August 2009 This mandatory data set collects information in respect of central venous catheter infections in intensive care. Forms received by WHAIP Valid forms Line infections Catheter days Infection Rate (per 1000 catheter days) Ysbyty Glan Clwyd Wrexham Maelor , Ysbyty Gwynedd , BCUHB Total , Wales 3,038 2, , Of the total 654 catheters used across the BCUHB over 9 months, 2 catheters became infected. This equates to only 0.3%. Because the numbers of infected lines are so small a more useful measure may be to consider the time between infections. This data is not currently available across the BCUHB Ventilated Associated Pneumonia ICU Data below indicates the rate of ventilator associated infections in the ICUs. Forms Valid forms Number of Number of VAP Rate received by WHAIP VAPs by month of intubation Ventilator days Ysbyty Glan Clwyd Wrexham Maelor Ysbyty Gwynedd BCUHB Total , Wales 1,138 1, , Of the 169 patients who were cared for on a ventilator in BCUHB during the period only 6 experienced a ventilator associated pneumonia. These numbers are extremely small and each case DC/KMW/SH Page 5 of 7

6 is subject to analysis to identify possible causes. Work continues under the 1000 Lives campaign to continue to reduce these already small numbers. 5. Outbreaks of Infection An Outbreak is commonly defined as the occurrence of an illness with a frequency clearly in excess of normal expectancy. In practice in BCUHB this is usually considered to be when two or more cases are identified that may be linked by person, time or place. Area No. of Outbreaks April September 2009 Total patients affected Total staff affected Ysbyty Glan Clwyd Ysbyty Wrexham Maelor Ysbyty Gwynedd BCUHB Totals Ysbyty Glan Clwyd There have been 2 outbreaks within the Glan Clwyd area between April 2009 and September A total of 11 patients and 5 staff displayed symptoms of diarrhoea and/or vomiting during this period. Both areas only had partial ward closures during the outbreaks. Ysbyty Wrexham Maelor There have been 11 outbreaks at Ysbyty Wrexham Maelor during the period. Norovirus was once a seasonal problem. Problems with this organism are now being experienced throughout the year, particularly on the Ysbyty Wrexham Maelor site. Management and control of an outbreak consists of limiting movement of patients and staff who were in contact with the index case, in order to prevent transmission to unaffected areas of the hospital. During winter 2008/09, the infection control policy for ring-fencing beds was not fully adhered to due to the severe and sustained pressure on beds. This resulted in further spread of the illness and extended duration of the outbreak. Healthcare Inspectorate Wales (HIW) and the National Public Health Service for Wales (NPHS) have both reviewed the situation and action plans have been implemented. Since the end of March, with the support of Executive Directors, strict infection control management has been in force. Infection control advice for maintaining ward closure has been fully adhered to. During outbreaks, the Infection Control Team continues to follow up affected cases with ward staff, reinforcing the infection control precautions and advice for visitors, on a daily basis. HIW continue to work with BCUHB and unannounced visits are expected early in Ysbyty Gwynedd There has been an outbreak of Clostridium difficile on the renal ward during November. Nine toxin positive Clostridium difficile cases were identified and areas of the ward were under outbreak restrictions until all symptomatic patients could be isolated. A multidisciplinary team meeting was held and disinfection, isolation rooms, hand hygiene and antibiotic issues were identified. Actions have been taken to minimise these risks, although accessibility to single rooms for symptomatic patients remain problematic. There have been 11 outbreaks affecting 97 patients. Outbreak restrictions were applied to bays when patients could not be isolated. Clostridium difficile and Norovirus were identified in all but one of the outbreaks. DC/KMW/SH Page 6 of 7

7 6. Training and Education Training and education continues to be an essential part of the work of the Infection Control Team. The majority of staff received infection control education on induction and mandatory programmes. Training sessions include hand hygiene with updates on infection control principles. The full education programme undertaken by the Infection Control Team and attendance figures is provided in the table below. Training - Ysbyty Wrexham Ysbyty Glan Ysbyty Gwynedd BCUHB Education Maelor Clwyd Total Attendees (quarters 2&3) Summary and Conclusion In summary, Staphylocuccus aureus (SA) bacteraemia data were higher in Ysbyty Glan Clwyd (YGC) during the last 4 quarters presented. More recent data shows that SA bacteraemia rates have dropped significantly in YGC since June The target to reduce Clostridium difficile rates by 25% is not yet achieved. This is due to the tail of last winter s outbreaks in April, and higher than usual summer rates in the Wrexham Maelor. More recent data show continued improvement in YGC and a lower rate in November in the Maelor. Surgical Site Infection rates appear lower than the all-wales rates, though compliance with form submission remains an issue. Intensive Care related infections are higher than the all-wales rates, but these represent extremely small numbers. 35 outbreaks of infection occurred across the BCUHB hospitals. 67% patients affected were in the Wrexham Maelor Hospital. Significant improvements have been made during the period to ensure that Infection Prevention & Control principles are adhered to. The prevention and control of infection therefore continues to be a challenge across the Health Board. The harmonisation of surveillance and strategic direction across all areas including the community is in progress. This will ensure that effective infection prevention and control is maintained and improved and support the achievement of compliance with nationally and locally set targets for infection control. DC/KMW/SH Page 7 of 7