SUMMARY REPORT ABM University Health Board Quality & Safety Committee Date: 22 June 20 Agenda item: 4.4 Subject Prepared by Approved by Infection Prevention & Control Delyth Davies, Head of Nursing, Infection Prevention & Control Tracey Gauci, Assistant Director of Nursing, Infection Prevention and Control Presented by Rory Farrelly, Director of Nursing & Patient Experience Purpose This report provides the Quality & Safety Committee with a position report in relation to Healthcare Associated Infection (HCAI) reduction targets and key exceptions in relation to infection prevention and control (IPC) for the period January May 20. Decision Approval Information Other Corporate Objectives Excellent Population Health Excellent Population Outcomes Sustainable & Accessible Service Strong Partnerships Excellent People Effective Governance X X X Executive Summary The incidence of HCAI for the financial year (FY) 1 st April 2015 to the end of March 20, was: 52.39/100,000 population (a 5% increase compared with the same period in 2014/15). 34.23/100,000 for total Staphylococcus aureus (SA) bacteraemia (a 6% increase compared with the same period in 2014/15). 2.68/100,000 for meticillin-resistant Staph. aureus (MRSA) bacteraemia (a 36% decrease compared with the same period in 2014/15). 31.55/100,000 for meticillin-sensitive Staph. aureus (MSSA) bacteraemia (a 12% increase compared with the same period in 2014/15). Periods of Increased Incidence (PII) of Clostridium difficile infection in secondary care hospitals have been managed in accordance with Health Board policies. To date there is no evidence of a hospital or Board-wide outbreak. Outbreaks and incidents of viral gastrointestinal illnesses and influenza have caused seasonal disruption to acute care services, particularly during March 20. 1
Key Recommendations The Quality and Safety Committee is asked to note the report Assurance Framework Health and Care Standards 2.4: Infection Prevention and Control (IPC) and Decontamination Next Steps 1. Improve and sustain the implementation of control measures to attain reductions in Clostridium difficile infection and MRSA bacteraemia, and review targeted reduction measures for MSSA bacteraemia. 2. Continue to monitor the implementation of the 2015/ Clostridium difficile Improvement Plan, with Senior Management Teams providing evidence of progress against quality improvement measures. Operational Delivery Units (ODUs) must focus on and provide evidence at Performance Review of improved compliance with key antimicrobial stewardship indicators. 3. All ODUs to continue to monitor and audit the effectiveness of IPC measures in place to support improvements and adherence to required standards of practice. 2
MAIN REPORT ABM University Health Board Quality & Safety Committee 22 June 20 Agenda item: 4.4 Subject Prepared by Approved by Infection Prevention & Control Delyth Davies, Head of Nursing, Infection Prevention & Control Tracey Gauci, Assistant Director of Nursing, Infection Prevention and Control Presented by Rory Farrelly, Director of Nursing & Patient Experience PART A 1. PURPOSE This is a report to the Quality & Safety Committee on the Health Board s performance and actions in relation to: Healthcare Associated Infection (HCAI) Reduction: i. Clostridium difficile Infection ii. Staphylococcus aureus bacteraemia (bloodstream infection); both MRSA and MSSA. Viral gastrointestinal illness, outbreaks and incidents across Health Board hospitals. Influenza-like illness incidents in Health Board hospitals. 2. INTRODUCTION HCAIs impact on the Health Board s performance and reputation in relation to the provision of safe, quality healthcare. The Health board has a zero tolerance of preventable infections. A comprehensive surveillance system is the cornerstone to effective IPC and the Health Board participates in a number of mandatory national surveillance programmes. This report highlights recently published results. In addition to reducing the numbers of HCAI, the Health Board faces the challenge of minimising the impact of infections which are introduced from the community into secondary care. Between March and May 20, gastrointestinal illness presumed to be viral in nature, and influenza or influenza like illnesses had a greater impact on service provision compared to the preceding months. This was later in the year than is generally anticipated. 3
3. HEALTHCARE ASSOCIATED INFECTION REDUCTION (with associated actions) The Public Health Wales (PHW) Financial Year (FY) Report was published on 17 May 20. Results for ABMU Health Board were as follows: Clostridium difficile 274 cases of C. difficile were reported for the 2015/ FY. This was a 5% increase in numbers compared to the previous FY (see Graph 1). The rate of C. difficile per 1,000 hospital admissions increased by 7%, from 3.03 to 3.23. There were 206 inpatient cases (2.5% higher than the number of cases in the same period in 2014/15); there were 68 noninpatient cases (13% higher than the number of cases in the same period in 2014/15). ABMU Health Board had the highest incidence of Clostridium difficile infection in Wales in the 2015/ FY. Compared to the 2010/11 FY, there has been a 33% decrease in the number of C. difficile and a 31% decrease in the rate of C. difficile per 1,000 hospital admissions in this health board. Graph 1 300.0 Chart 1. Abertawe Bro Morgannwg University Health Board cumulative monthly numbers of C. difficile for Apr 15 to Mar against the equivalent period in 2014/15 250.0 200.0 150.0 100.0 50.0 0.0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Cumulative monthly numbers of C. difficile from Apr 15 Cumulative monthly numbers of C. difficile from Apr 14 ABMUHB s primary care antimicrobial prescribing is the highest in Wales and the second highest in England, Scotland and Wales combined. High primary care antimicrobial prescribing and inconsistent compliance with antimicrobial stewardship in secondary care are likely to be at the root cause of the increased incidence of Clostridium difficile infection. The results of March s Antimicrobial Stewardship Audit (Table 1) demonstrate that there has been no real improvement in compliance with antimicriobial stewardship indicators. Table 1: ABMU Totals: January 20 Target ABMU 1 2 Percentage indication for antibiotic documented on medication chart Percentage stop or review date documented on medication chart Position vs previous report No. Prescriptions Audited 95% 81.90 536 95% 65.97 526 3 Percentage of antibiotics prescribed on 95% 71.14 499 4
4 5 6 7 stickers Percentage appropriated antibiotic prescription choice Percentage of patients receiving antibiotics for more than 7 days Percentage of patients receiving surgical prophylaxis for more than 24 hours Percentage of patients receiving IV antibiotics > 72 hours 95% 94.33 476 20% 15.56 450 20% 21.43 14 30% 45.74 215 The failure to achieve a sustained reduction in the incidence of Clostridium difficile infection across the Health Board since April 2014, is multi-factorial. However, the disruption of the gut microbiota caused by antibiotics, and the worsening compliance in relation to antimicrobial stewardship, emphasises the need for medical staff to be fully engaged in prudent antimicrobial prescribing and stewardship. Infection Reduction Expectation, October 2015 to March 20 - Using the 6-month period April to September 2015 as a baseline, the Health Board agreed a 20% reduction target in the 6-month period October 2015 to March 20. As such, the total number of cases of Clostridium difficile infection was not to exceed 121 cases in the six months between October 2015 and March 20 (a monthly average of 20 cases). - From October 2015 to the end of March 20, the total number of cases within the Health Board was 122; one case over target (see Graph 2). - The average monthly number of C. difficile cases between in the baseline 6 months (April September 2015) was 25; the average monthly number of cases in the target 6 months (October 2015 to March 20) was 20; of note, the monthly average in the final 3 months (January to March 20) had reduced further to 15. Graph 2 Chart 2: ABMU Health Board maximum cumulative monthly numbers of C. difficile to achieve the 6 month (October 2015 to March 20) target and current cumulative monthly numbers for March 20 140 120 Target = 121 Target exceeded by one case 100 80 60 40 20 0 Oct-15 Nov-15 Dec-15 Jan- Feb- Mar- Maximum cumulative monthly numbers of C. difficile to achieve target Current cumulative monthly numbers of C. difficile Target 5
New FY Infection Reduction Expectation, October 20 to March 2017 - The Health Board must now build upon the improvement attained over the last three months to ensure a rate of no more than 28/100,000 population in the final six months of the reduction period (1 October 20 to 31 March 2017). - The Health Board has set month-on-month reduction projections as shown in the table below (the actual number of cases per month is shown in the second row of the table). - The number of cases in May was one case below the projection. (Table 2, Graph 3) Table 2 ABMU HB Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- 17 Feb- 17 Mar- 17 Maximum Cases ( ) 15 14 12 12 12 10 10 9 9 Actual cases 15 Graph 3 35 Chart 3: Number of C.difficile cases (Monthly) - ABMU Health Board April 2015 - March 2017 (including reduction projections for 20/17 FY) 30 25 20 15 10 5 0 Number of C.difficile cases Profile C.Difficile Key Exception Areas by site: Morriston For the FY April 2015 to March 20, there were 94 inpatient cases of Clostridium difficile infection (29% higher than the number of cases in the same period in 2014/15). 6
There were PII in the following clinical areas between January and May 20: Cardigan, Gowers Ward and Ward V. These were managed appropriately, in line with the Health Board protocol. The Executive Team has set reduction expectations for Morriston ODU for this FY. To the end of May 20, there should have been fewer than 12 cases; however, there have been 15 cases of Clostridium difficile infection identified from specimens obtained in Morriston. Neath Port Talbot For the FY April 2015 to March 206, there were 9 inpatient cases of Clostridium difficile infection (10% fewer than the number of cases in the same period in 2014/15). The Executive Team has set reduction expectations for Neath Port Talbot ODU for this FY. To the end of May 20, there should have been fewer than 2 cases. There have been 2 cases identified from specimens obtained in Neath Port Talbot; however, Clostridium difficile was identified from specimens from the same patient, who had a relapse or reinfection after 28 days. Princess of Wales Hospital For the FY April 2015 to March 20, there were 57 inpatient cases of Clostridium difficile infection (3% fewer than the number of cases in the same period in 2014/15). The Executive Team has set reduction expectations for Princess of Wales ODU for this FY. To the end of May 20, there should have been fewer than 4 cases. There has been one case of Clostridium difficile infection identified from specimens obtained in Princess of Wales. Singleton For the FY April 2015 to March 20, there were 39 inpatient cases of Clostridium difficile infection (29% fewer than the number of cases in the same period in 2014/15). Between January and May 20, there were PII on Ward 10 and Ward 12. These were managed in line with Health Board policy and remain under increased scrutiny. The Executive Team has set reduction expectations for Singleton ODU for this FY. To the end of May 20, there should have been fewer than 6 cases; however, there have been 7 cases of Clostridium difficile infection identified from specimens obtained in Singleton. 7
Actions The Health Board must continue to focus on antimicrobial stewardship initiatives: ODUs are to identify wards with the highest incidence of Clostridium difficile infection and focus antimicrobial stewardship initiatives to improve compliance with key indicators. The Executive Medical director has written to Unit Medical Directors underlining the need for improved medical engagement, more frequent audit of key antimicrobial prescribing indicators and to provide assurance of month-on-month improvement. The Big Fight campaign team has been active since February 20. There is improved notification of General Practitioners when one of their patients has been identified as having Clostridium difficile infection (either as an inpatient or an outpatient). This is raising awareness of Clostridium difficile in primary care. Experience in secondary care showed that increased awareness led to improved sampling of faeces to test for C. difficile toxin. It is possible that there may be an increase in the testing of patients presenting with symptoms of diarrhoea, which may result in increased identification of cases. Infection reduction projections have been agreed with the ODUs, who are required to present planned performance improvement actions to the end of June 20, which will be discussed and reviewed at regular performance meetings with the Executive Team. ii. Staphylococcus aureus bacteraemia (bloodstream infection); both Meticillin Resistant Staphylococcus aureus (MRSA) and Meticillin Sensitive Staphylococcus aureus (MSSA) MRSA From April 2015 to March 20, the incidence of MRSA bacteraemia was 2.68 per 100,000 population compared with a rate of 4.21/100,000 in the same time period in 2014/15. The rate in ABMU was lower than the rate for Wales for April 2015 to March 20, which was 3.27/100,000 population. The total number of cases across the Health Board (inpatient and noninpatient, from April 2015 March 20 was 14 (36% fewer compared to the same period in 2014/15, as shown in Graph 4). 8
Graph 4 25.0 Chart 4. Abertawe Bro Morgannwg University Health Board cumulative monthly numbers of MRSA bacteraemia for Apr 15 to Mar against the equivalent period in 2014/15 20.0 15.0 10.0 36% reduction 5.0 0.0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Cumulative monthly numbers of MRSA bacteraemia from Apr 15 Cumulative monthly numbers of MRSA bacteraemia from Apr 14 There were 11 inpatient cases (21% fewer than the number of cases in the same period in 2014/15); there were 3 non-inpatient cases (62.5% fewer than the number of cases in the same period in 2014/15). There were five cases of MRSA bacteraemia in the Health Board in the three months between January and March 20. ABMU Health Board currently has the second lowest incidence of MRSA bacteraemia of the major Health Boards in Wales. The implementation of Chloraprep (skin preparation solution) is considered to have contributed to the reduction in MRSA bacteraemia. The implementation of the MRSA Clinical Risk Assessment and Swabbased Screening is unlikely to have contributed to this reduction as there is limited implementation of this risk assessment across all acute sites currently. This needs addressing in line with the forthcoming recommendations from PHW following an all Wales audit of compliance. MSSA There was no specific Tier 1 target in 2014/15 for MSSA bacteraemia. The incidence of MSSA bacteraemia in the Health Board between April 2015 and March 20 was 31.55/100,000 population. The rate in ABMU was higher than the rate for Wales for April 2015 to March 20, which was 24.74/100,000 population. In ABMU between April 2015 and March 20, there were 5 cases of MSSA bacteraemia. This is 12% higher than the same period in 2014/15 (see Graph 5). There were 91 inpatient cases and 74 noninpatient cases. Non-inpatient cases accounted for 45% of all cases within the Health Board. 9
Graph 5 180.0 0.0 140.0 120.0 100.0 80.0 60.0 40.0 20.0 0.0 Chart 5. Abertawe Bro Morgannwg University Health Board cumulative monthly numbers of MsSA bacteraemia for Apr 15 to Mar against the equivalent period in 2014/15 12% increase Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Cumulative monthly numbers of MSSA bacteraemia from Apr 15 Cumulative monthly numbers of MSSA bacteraemia from Apr 14 New Infection Reduction Expectation, October 20 to March 2017 - Welsh Government has set new rate reduction expectations for Staph. aureus bacteraemias between October 2015 and March 2017. Each major health board is to ensure that a rate of no more than 20/100,000 population is delivered in the final six months of the reduction period (1 October 20 to 31 March 2017). - To achieve this, the Health Board must strive to reduce the number of cases of Staph. aureus bacteraemia to fewer than 8 cases per month. This equates to a 40% reduction in the number of cases. - The Health Board has set month-on-month reduction projections as shown in the table below (the actual number of cases per month is shown in the second row of the table). - Graph 6 illustrates progress against the reduction projections. The number of cases in May was 5 cases below the projection. Table 3 ABMU HB Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- 17 Feb- 17 Mar- 17 Maximum Cases ( ) 14 13 13 11 11 10 9 9 8 8 7 7 Actual cases 14 8 10
Graph 6 20 18 14 12 10 8 6 4 2 0 Chart 6: Number of Staph. aureus bacteraemia cases - ABMU Health Board (MRSA & MSSA combined) April 2015 - March 2017 (including reduction projections for 20/17 FY) Number of Staph. Aureus bacteraemia cases Profile Staph. Aureus bacteraemia Actions Continue with disinfection of skin prior to insertion of intravascular lines, utilising the single-use Chloraprep applicator. This procedure has been implemented fully across all sites. Repeat training across the Health Board on the use of Chloraprep prior to obtaining blood cultures; this should reduce the number of false positives, which may be a factor in MSSA bacteraemia. Continue to roll out Aspetic Non Touch Technique (ANTT) across the Board Re-invigorate hand hygiene compliance Consider the implementation of further evidence based interventions as appropriate including the use of 2% chlorhexidine based daily bathing of patients in augmented care units, the use of 2% chlorhexidine impregnated dressings for central venous catheter sites and adoption of the scrub the hub technique of port cleaning of intravenous lines. Infection reduction projections have been agreed with the ODUs, who are required to present corresponding performance improvement actions to the end of June 20, which will be discussed and reviewed at regular performance meetings with the Executive Team. a) Viral gastrointestinal illness outbreaks and incidents There has been increased viral gastrointestinal illness across the Health Board population during the last quarter of 20. A number of these cases have been admitted to hospital and this has resulted in incidents or outbreaks of infection on wards. 11
The number of incidents of confirmed or suspected viral gastrointestinal illness is shown in Table 4. The table identifies incidents that resulted in the closure of multi-bed bays only or whole wards; numbers of patient and staff cases are identified also. Month Table 4: Incidents and Outbreaks of Suspected or Confirmed Viral Gastrointestinal Illness, ABMU Health Board, January May 20 No. Wards with Viral GI illness No. Where whole ward closed Total No. Patients affected Total No. Staff affected No. incidents with Norovirus as confirmed cause Jan- 1 1 3 3 0 Feb- 3 2 32 1 Mar- 24 11 87 38 5 Apr- 8 7 64 37 2 May- 2 2 8 3 0 Totals 38 23 194 97 8 b) Influenza-like illness incidents in Health Board Hospitals Influenza-like illness had significant impact on service provision across the Health Board between January and April, with peak activity during March 20. There were 124 laboratory confirmed cases of seasonal influenza and other respiratory viruses causing influenza-like illnesses admitted to wards in ABMU; this compared to 86 cases in the same months of 2015 (see Graph 7). Graph 7 Chart 7: Cases of Influenza-like illness in ABMU 2015/ vs 2014/15 100 90 80 70 60 50 40 30 20 10 0 Jan Feb Mar Apr 2014/15 2015/ 12
4. WAY FORWARD ODUs are to provide assurance of effective implementation of Health Board policies and protocols on Clostridium difficile infection, using evidence obtained through Root Cause Analysis of cases. ODUs are required to implement interventions designed to meet the Clostridium difficile and Staph. aureus bacteraemia infection reduction projections 30 June 20. The multi-disciplinary Big Fight team members will submit a progress report to the Infection Prevention & Control Committee July 20. 5. RECOMMENDATIONS The Quality & Safety Committee is asked to note the contents of this report. 13