Aneurin Bevan Health Board. Quarterly Infection Control Report

Transcription

1 Aneurin Bevan Health Board Wednesday 18 th November 2009 Agenda Item: 2.5 Aneurin Bevan Health Board Quarterly Infection Control Report 1 Introduction In line with Annual Operating Framework and Local Delivery Plan the following Report summarises progress with infection control targets and other significant issues relating to infection control within the Aneurin Bevan Local Health Board 2 Key Issues This report highlights key issues relating to: Pandemic Swine Flu Staph aureus, including MRSA, bacteraemia surveillance Clostridium difficile surveillance including Mandatory Infection Reduction Target Orthopaedic Surgical Site infection Surveillance Caesarean Section Surgical Site Infection Surveillance Critical Care Central Line Infection Surveillance Critical Care Ventilator Associated Pneumonia Surveillance Environment and Cleanliness Hand Hygiene Antibiotic Stewardship Infection Control Service across the wider ABHB 3 Conclusions and Recommendations Aneurin Bevan Local health Board is asked to note the contents of this report and that continuous monitoring on a quarterly basis will continue. Report Prepared by: Liz Waters, Infection Control Nurse Sponsored by: Denise Llewellyn, Director of Nursing November 2009

2 Infection Prevention and Control National Performance Report LDP Update Quarter /2010 Introduction In line with Annual Operating Framework and Local Delivery Plan the following Report summarises progress with infection control targets and other significant issues relating to infection control within the Aneurin Bevan Local Health Board. Pandemic Swine Flu The second wave of swine flu is evident amongst the population and significant plans have been made to minimise the impact on secondary care, whilst ensuring that infection control precautions are maintained. This has been a difficult piece of work because of the need to maintain targets. Nevertheless, plans are in place to cope with the predicted numbers. The expected sharp peak of cases has not yet materialised, and the current status is described as a slow burn. Pressure on acute wards has so far been moderate. However, in line with England s experience, Critical Care is managing a steady stream of seriously ill patients. Single rooms are at a premium in both sites so difficult risk assessments are being made to maintain effective infection control. 2

3 0.25 GP Flu Consultation Rates % of Population Consulting GP per Week for Flu Wales Average Gwent 0.00 England Average 31 May Jun Jun Jun Jun Jul Jul Jul Jul Aug Aug Aug Aug Aug Sep Sep Sep Sep Oct Oct Oct Oct Nov Nov Nov Nov Nov 09 Staph aureus, including MRSA, bacteraemia surveillance The organisation is fully compliant with this mandatory scheme. The rate of MRSA-positive blood culture bacteraemia has reduced further to 5 cases per 100,000 bed-days for the third quarter. Over the last year the rate has been between 5 and 7 (compared to the Welsh average rate of over 8). In the organisation this means we are detecting approximately 10 clinical cases per quarter. There are no identifiable clusters amongst the nosocomial cases. For non-resistant Staph aureus (MSSA) the rates in Wales and ABHB are not significantly different 17.4 per 100,000 bed-days in ABHB versus 17.7 in Wales. 3

4 Gwent & Wales MRSA Bacteraemia Trend 18 MRSA Bacteraemias per 100,000 Bed Days Gwent MRSA per 100,000 Bed Days Upper Control Limit Lower Control Limit All Wales MRSA per 100,000 Bed Days All-Wales Average Gwent Average Poly. (All Wales MRSA per 100,000 Bed Days) 0 Apr - Jun 2001 Jul - Sep 2001 Oct - Dec 2001 Jan - Mar 2002 Apr - Jun 2002 Jul - Sep 2002 Oct - Dec 2002 Jan - Mar 2003 Apr - Jun 2003 Jul - Sep 2003 Oct - Dec 2003 Jan - Mar 2004 Apr - Jun 2004 Jul - Sep 2004 Oct - Dec 2004 Jan - Mar 2005 Apr - Jun 2005 Jul - Sep 2005 Oct - Dec 2005 Jan - Mar 2006 Apr - Jun 2006 Jul - Sep 2006 Oct - Dec 2006 Jan - Mar 2007 Apr - Jun 2007 Jul - Sep 2007 Oct - Dec 2007 Jan - Mar 2008 Apr - Jun 2008 Jul - Sep 2008 Oct - Dec 2008 Jan - Mar 2009 Apr - Jun 2009 Jul - Sep 2009 Clostridium difficile surveillance including Mandatory Infection Reduction Target The organisation is fully compliant with this mandatory scheme. As reported in previous papers, a steep increase in the incidence of Clostridium difficile on the Royal Gwent site was noted and acted upon in the spring of The virulent type 027 strain has been identified in both the Royal Gwent and Nevill Hall as the cause of the majority of infections. The first graph indicates rates of C. difficile in ABHB (to October) and Waleswide (to June) amongst in-patients over 65 reported to the National Public Health Service. The second graph demonstrates local data of total hospitalacquired cases of all ages up until October

5 35 Gwent Clostridium difficile In-patients over 65 s Clostridium difficile per 1,000 Admissions >65 Year Gwent Clostridium per 1,000 Admissions Upper Control Limit Lower Control Limit All Wales Clostridium per 1,000 Admissions All-Wales Average Gwent Average 0 60 Healthcare Associated Clostridium difficile Monthly Cases Jan 2007 Feb 2007 Mar 2007 Apr Jan-05 Mar-05 M ay-05 Jul-05 Sep-05 N ov-05 Jan-06 Mar-06 M ay-06 Jul-06 Sep-06 N ov-06 Jan-07 Mar-07 M ay-07 Jul-07 Sep-07 N ov-07 Jan-08 Mar-08 M ay-08 Jul-08 Sep-08 N ov-08 Jan-09 Mar-09 M ay-09 Jul-09 Sep-09 Locality data up to October 2009 Royal Gwent Hospital Caerphilly & District Miners' Hospital Nevill Hall Hospital Community Hospitals 2007 May 2007 Jun 2007 Jul 2007 Aug 2007 Sep 2007 Oct 2007 Nov 2007 Dec 2008 Jan 2008 Feb 2008 Mar 2008 Apr 2008 May 2008 Jun 2008 Jul 2008 Aug 2008 Sep 2008 Oct 2008 Nov 2008 Dec 2009 Jan 2009 Feb 2009 Mar 2009 Apr 2009 May 2009 June 2009 July 2009 Aug 2009 Sept 2009 Oct Local data has indicated a small rise on the Royal Gwent Site, but not to an out of control position. In order to address this issue, more stringent trigger points for the introduction of enhanced interventions have been introduced. Occasionally, wards experience persistent cases and antibiotic usage analysis by the antimicrobial pharmacist suggests that this is not a contributory factor. The continued use of chlorine-releasing solution on the affected wards appears to finally address the problem, but can take some weeks to resolve. However, there is a problem of chlorine fumes for patients to endure and the 5

6 detrimental effect repeated exposure to chlorine has on the fabric of the environment. The IPaC team in conjunction with the Cleanliness Manager is currently undertaking a cost benefit analysis of vaporised hydrogen peroxide technology, which is recommended by the Department of Health. The cost of each case of C. difficile has been estimated at 4000 however the human cost of acquiring this hyper-toxic bacterium cannot easily be quantified. Reporting mechanisms of C. difficile are sound with the number of hospitalacquired infections being fed back to the executive lead for infection control on a daily basis and monthly via the divisional DDAD meetings. Gwent Healthcare NHS Trust chose a 30% reduction in hospital-acquired C. difficile infections as the mandatory infection reduction target for 2009/10. Figures this year suggest that the new organisation is on line to achieve this target. Comparing April-Sept 2008 with 2009, C. difficile acquisition is down by 36% as a whole and down by 43% at the Royal Gwent Hospital. Orthopaedic Surgical Site Infection Surveillance This scheme has been mandatory since January Latest data has indicated a rise in wound infections at Nevill Hall Hospital for patients who have undergone primary hip and knee replacements. In response to concerns that the data may well be inaccurate, an audit has been undertaken on all patients who underwent primary hip or knee from January 2009 to June The following local data has since been collated and can be considered accurate Elective Hip Replacement Nevill Hall Hospital Royal Gwent Hospital Aneurin Bevan Total Surgical Site Infection (%) Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 6

7 Surgical Site Infection (%) Elective Knee Replacement Nevill Hall Hospital Royal Gwent Hospital Aneurin Bevan Total Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Analysis of the new data suggests that the current Surgical Site Infection (SSI) reporting mechanism to the NPHS is inaccurate. The implementation of this scheme has been an ongoing problem since its inception in The orthopaedic directorate is strongly advised to implement a robust process for collecting this crucial information in order to identify trends and problems quickly and ensure accurate data is displayed on the NPHS web site. The new data has also identified an increase in SSI for those patients who have undergone a total knee replacement in Nevill Hall A thorough investigation is underway which will be reported to the orthopaedic directorate and incorporated into the next quarterly Board report. The investigation will compare current practice with NICE SSI guidelines (2008). Caesarean Section Surgical Site Infection Surveillance This scheme has been mandatory since January Apparently high rates in the earlier part of this scheme were due to inadequate data collection. Form completion is progressively improving, giving a more accurate picture of the number of wound infections for the recent periods 15 to 20% for the year 2009 to date, compared to the reported all-wales average of 14%. The chart shows the Aneurin Bevan Caesarean Section Wound Infection Rate Quarterly from Jan 2007 to Sept

8 Despite the reassuring decrease in C-Section infections, additional work needs to be undertaken to reduce rates further. A recent investigation into a cluster of MRSA cases at Nevill Hall has indicated issues around wound care. An action plan has been drawn up and meetings held with senior midwives and tissue viability. A standardised approach to wound care is required and a standard operating procedure will be formulated and disseminated to the acute sites fro implementation. Critical Care Central Line Infection Surveillance The organisation is fully compliant with this mandatory scheme with full ownership taken by the Critical Care directorate and minimal support required from infection control. Critical Care should also be commended for the sharing of this practice with other units within the organisation and across Wales. Almost half of all critical care patients need a central line (central venous catheter) to provide essential therapy. However, the processes of inserting and maintaining the line and giving infusions carry a risk of infection because bacteria can be introduced into the blood stream. Such infections can lead to septicaemia with significant mortality risk. The critical care team has improved practice by introducing Care Bundles, interventions that were 8

9 developed by the Institute for Healthcare Improvement in America. In order to ensure full compliance with Care Bundles, all interventions must be employed and measured on a daily basis. The organisation has empowered nurses to stop a procedure where it becomes violated. This means if a nurse assisting a doctor to insert a central line feels that the doctor has not maintained a full sterile status of the procedure, the nurse can stop the procedure and insist this is rectified before proceeding. This protects the patient from potential infections and helps to improve overall patient safety. Central Line Infection Data for Gwent Healthcare NHS Trust the measure is the number of central line infections per 1,000 patient days of central line use in critical care. No central line infections have been recorded in the Royal Gwent or Nevill Hall from January 2009 August 2009 against an all Wales rate of 0.4 per 1000 patient days. Critical Care Ventilator-Associated Pneumonia Surveillance Ventilator-associated pneumonia (VAP) has historically complicated the course of 8 to 28% of patients receiving mechanical ventilation. The mortality rate for VAP ranges from 24 to 50% and can reach 76% in some specific settings or when lung infection is caused by high-risk pathogens. In addition to the mortality risk, it is estimated that VAP adds an additional estimated cost of 20,000 to a typical admission. A Care Bundle and surveillance scheme have been established and early data are now available. The measure is of number of patients with ventilator-associated pneumonia per 1,000 patient days of ventilation. No ventilator-associated pneumonias were recorded in the Royal Gwent Critical Care Unit from January to August Nevill Hall Critical Care has recorded a rate of 4.0 per 1000 admissions from January to August 2009, against an all Wales rate of 2.5. It should be acknowledged that no VAPs have been recorded since February 2009 Environment and Cleanliness Environmental quality and cleanliness is reviewed and monitored through the Hospital Cleanliness and Environment Board. Operational Committees have convened in the Royal Gwent, Nevill Hall and within the Community and Mental Health division. Detailed action plans have been compiled with priority issues escalated up to the Environment Board. 9

10 Recent bids have been put forward based on the Board Priority Action Plan through the Capital Investment Project. Schemes include the upgrading of the Main Delivery Unit at Nevill Hall and the refurbishment of 4 wards. The newly refurbished Critical Care Unit at the Royal Gwent has reopened and both Accident and Emergency Departments have recently been upgraded. Three areas on the Board Priority Action Plan relate to space restraints the High Dependency Unit, Children s Assessment Unit and the Neonatal Unit at the Royal Gwent. Space constraints impact on infection control. Pragmatic solutions are currently being reviewed. The previous Gwent Healthcare NHS Trust recently agreed the introduction of 24-hour cleaning within the Royal Gwent which significantly improves the standard of cleanliness while ensuring valuable vacated isolation rooms are cleaned and released to new patients as soon as possible. The cleanliness service across the acute sites is moving towards the National Standards of Cleanliness with a particular focus on Nevill Hall Hospital. Four Hospital Patient Environment visits have recently been undertaken by members of the Community Health Council (CHC). Action plans are being developed and will be reviewed with the CHC within the next six weeks. Hand Hygiene The hand hygiene driver of the Safer Patient Initiative and 1000 Lives is making steady progress with the vast majority of wards compliant with the driver in the Royal Gwent, six wards in Nevill Hall, two in Caerphilly Miners and two in St Woolos. However, as indicated in previous reports the work needs to be validated. This will be undertaken by the clinical audit department within the next two weeks. The 1000 Lives hand hygiene driver is in the early stages of implementation at Caerphilly Miners. 10

11 11

12 Antibiotic Stewardship Antibiotics have been a tremendous success story for the last 75 years but this very success has led to major problems with antibiotic resistance (such as MRSA) and emergence of novel pathogens (such as Clostridium difficile). There is increasing interest in policies and guidelines to reduce inappropriate antibiotic use and improve quality of prescribing and consequently, patient outcome. 12

13 ABHB has antibiotic formularies that are regularly reviewed based on national guidelines and best-practice evidence for both primary and secondary care. A new pocket-sized edition of the secondary care guidelines has recently been issued to coincide with the intake of junior medical staff. A specialist antimicrobial pharmacist supports the work of the Antibiotic Working Group that develops the antimicrobial strategy. The amount of antibiotics used in secondary care is fed back regularly to divisions and directorates. Quality of antibiotic prescribing is monitored in the 1000 Lives campaign. At Nevill Hall a regular weekly antibiotic ward round by the consultant microbiologist, antimicrobial pharmacist and infection control nurse is held to review in detail the appropriateness of each antibiotic prescription and make recommendations for optimal practice. A Europe-wide Antibiotic Awareness Day is being held on 18 th November to promote reduced demand for antibiotics by members of the public. Simultaneously, a report on the volume of antibiotic dispensing in primary care for each locality in Wales for will be published and in secondary care there will be a point-prevalence survey of patients taking antibiotics which, why and for how long? Since early 2008 there has been a special focus and restriction placed on the use of antibiotics that are particularly associated with C. difficile cefalexin, cefuroxime and ciprofloxacin. The chart shows a correlation between the reduction in use of these drugs and the fall in the rate of hospital-acquired C. difficile. 13

14 Antibiotic Doses Issued 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 Clostridium difficile Rate v Key Antibiotic Consumption Total Key Antibiotics Cef alexin Cef uroxime Ciprofloxacin Clostridium difficile Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Clostridium difficile Cases 0 Infection Control Service across the wider ABHB Following consultation, the new Aneurin Bevan Health Board structures have been agreed. Tier 3 appointments are currently being addressed including the position of Lead Infection Control Nurse. Denise Llewellyn has requested an option appraisal to be presented to the Board outlining options for an infection control service across the wider community. A scoping exercise has been undertaken to determine the current infection control service. Conclusion Aneurin Bevan Local Health Board is asked to note the contents of this report and that continuous monitoring on a quarterly basis will continue. 14