Ayrshire and Arran NHS Board

Paper 4 Ayrshire and Arran NHS Board Monday 11 ember Healthcare Associated Infection Reporting Template Report Author: Bob Wilson, Infection Control Manager Sponsoring Director: Professor Hazel Borland, Nurse Director Date: 13 ober Recommendation NHS Board members are asked to review this report on Healthcare Associated Infections (HAI) with particular reference to performance against the Local Delivery Plan HAI targets -18, together with other infection prevention and control monitoring data. This report provides the full Healthcare Associated Infection Reporting Template The report topics are: Staphylococcus aureus bacteraemia (SABs) Clostridium difficile infection (CDI) Meticillin resistant Staphylococcus aureus (MRSA) Outbreaks/Incidents updates Summary National HAI Target Position 1 il 31 ober (1) SAB: To achieve a rate of no more than 0.24 cases per 1,000 acute occupied bed days by the year ending 31 ch 2018 (approximates to 84 cases per annum). (2) CDI: To achieve a rate of no more than 0.32 cases per 1,000 occupied bed days in the 15 and over age group by the year ending 31 ch 2018 (approximates to 120 cases per annum). NHS Ayrshire and Arran update There have been 64 SAB cases at month 7. This exceeds the Boards numerical target trajectory by 15 cases. The verified annual rate for the year ending e is 0.25. The projected annual rate for the year ending ember is 0.26. There have been 77 CDI cases at month 7. This is exceeds the Boards numerical target trajectory by 7 cases. The verified annual rate for the year ending e is 0.31. The projected annual rate for the year ending ember is 0.32. 1 of 20

Glossary of Terms AMU CDI CRA DRIFT GAS HAI HAIRT HPC ICM IMT KPI LDP MRSA MSSA PVC SAB UHC Ayshire Maternity Unit Clostridium difficile Infection Clinical Risk Assessment Diagnosis, Resuscitation, IV medication, Fluids and Transfusion Group A streptococcal Healthcare Associated Infection Healthcare Associated Infection Reporting Template Health Protection Scotland Infection Control Manager Incident Management Team Key Performance Indicator Local Delivery Plan Meticillin Resistant Staphylococcus aureus Meticillin Sensitive Staphylococcus aureus Peripheral Vascular Catheter Staphylococcus aureus bacteraemia University Hospital Crosshouse 2 of 20

1. SAB Update To achieve a rate of no more than 0.24 cases per 1,000 acute occupied bed days for SABs by the year ending 31 ch 2018 (approximates to 7 SABs per month). 1 il 31 ober Total SABs 25 Hospital Acquired 11 Healthcare Associated 64 cases There have been 64 SAB cases at month 7. This exceeds the Boards numerical target trajectory 28 Community Acquisition by 15 cases. The verified annual rate for the year ending e is 0.25. The projected annual rate for the year ending ember is 0.26. The Board s verified SAB rate for the year ending e was 0.25 cases per 1,000 acute occupied bed days. The projected rate for the year ending ember is 0.26 cases (Chart 1). Chart 1 Rolling Annual SAB rate against national target 3 of 20

There were 64 SABs in the first 7 months of -18; this exceeds the numerical annual target by 15 cases (Chart 2). Chart 2 SAB Target 18 Local Trajectory In the first seven months of the year 39% (25) of SABs were hospital acquired; 17% (11) were healthcare associated and 43% (28) were community acquired. This compares with 46% hospital acquired; 11% healthcare associated and 43% community acquired in corresponding period in -17. The point of entry for the organism was unknown in 26% of cases. Peripheral vascular catheters (PVCs) were the point of entry in 11% of SABs and a range of invasive devices (vascular and non-vascular) in another 13% (Table 1). SAB Point of Entry Number Unknown 17 (26%) Other 10 (17%) PVCs 7 (11%) Skin 7 (11%) Injection site related to illicit drug use 6 (9%) Vascular access devices (excluding PVCs) 5 (8%) Contaminant 4 (6%) Urinary catheter 3 (5%) Urinary Tract Infection 3 (5%) Respiratory infection 2 (3%) Total 64 Table 1 SAB Point of Entry il ober PVCs are the single most common potentially preventable cause of SABs. They accounted for 16% of SABs in -17 and whilst that proportion has dropped in the first seven months of -18 (11%) the overall low numbers means that the figures can fluctuate from month to month. More time is required before it can be determined whether this is a continuing reduction or just natural variation. 4 of 20

Reducing PVC related SABs remains the focal point of the Board s SAB reduction Strategy. The following initiatives are currently underway 1. DRIFT (Diagnosis, Resuscitation, IV medication, Fluids and Transfusion) DRIFT a mnemonic used to classify the reasons for a PVC being used. Initial quality improvement work in ward 2D University Hospital Crosshouse (UHC), has shown that it can be used effectively to reduce the number of patients who have a PVC in situ. A project, led by the Associate Nurse Director Acute Services, was undertaken in UHC and University Hospital Ayr in ober. All wards recorded on a weekly basis the number of PVCs in situ and the number in situ that met the DRIFT criteria. At the time of writing the data from this initiative is currently being analysed to determine the next steps. Alongside this work is also underway to amend the PVC insertion and maintenance documentation to incorporate DRIFT. 2. PVC Packs A Mini Competition Document for PVC Insertion Packs has been completed. Discussions are currently underway with the suppliers to determine if the feedback from the multidisciplinary user group which assessed the submitted packs can be incorporated. The intention is that this exercise will be cost neutral. 3. PVC Documentation - The above packs will also include an insertion sticker. If the packs are introduced the stickers will replace the insertion component of the current PVC documentation. Revised maintenance documentation will then be issued. 2. CDI Update To achieve a rate of no more than 0.32 cases per 1,000 occupied bed days for CDIs in the 15 and over age group by the year ending 31 ch 2018 (approximates to 10 cases per month). 1 il 31 ober Total CDIs 77 cases There have been 77 CDI cases at month 7. This is 7 above the Boards numerical target trajectory. 51 Healthcare associated 19 Community acquired 7 Unknown The verified annual rate for the year ending e is 0.31. The projected annual rate for the year ending ember is 0.32. The verified annual rate for the year ending e was 0.31. The projected rate for the year ending ember is 0.32 (Chart 3). 5 of 20

Chart 3 Rolling Annual CDI Rate At the end of ober there had been 77 cases of CDI which is 7 above the maximum local numerical trajectory (Chart 4). Chart 4 CDI Local Target Trajectory -18 Whilst there has been an increase in the CDI rate investigations by the Infection Prevention & Control Team, including strain identification, we have not identified areas of ongoing spread within the organisation. The overwhelming majority of cases are single cases and have no direct links to other cases. It should be noted that CDI rates traditionally peak in the y ember quarter and then decline in the second half of the year. 6 of 20

3. MRSA National Policy Clinical Risk Assessment (CRA) Update The national MRSA CRA Key Performance Indicator (KPI) target is for Boards to achieve a minimum 90% compliance with CRA completion. In Quarter 2 (-18) compliance was 92% - an increase of 6% on the previous quarter (Chart 5). Chart 5 MRSA KPI Quarterly Compliance 4. Outbreaks/Incidents Update 4.1 Ward/Room Closures Urquhart ward in Biggart was closed for five days in ober due to an outbreak of diarrhoea and vomiting caused by Sapovirus, an organism similar to Norovirus (Table 1). Ward Month Patients Staff Organism Room Closure Period Urquhart Ward, Biggart ober 6 5 Sapovirus (confirmed) Table 2 Ward Closure period 0 5 days 2 Outbreak of Group A Streptococcal Infection Ayrshire Maternity Unit An outbreak of Group A streptococcal (GAS) infection affecting 3 women and 1 baby with links to the Ayrshire Maternity Unit (AMU) occurred between and e. A multidisciplinary Incident Management Team (IMT) chaired by the Infection Control Manager (ICM) was convened. Membership included representatives from the clinical team, occupational health, staff side, public health and infection prevention and control. Support for the IMT was provided by Health Protection Scotland (HPS). 7 of 20

In line with national guidance an extensive staff screening exercise was undertaken by the Occupational Health Service. This resulted in 167 staff being screened. All of the swabs obtained were negative for GAS and no source of the infection was identified. The Incident was declared over on 18 ember. During the outbreak the Chief Executive sought assurance with regard to quality and safety of care in the AMU. The Infection Prevention and Control Doctor advised that that it was safe to continue to admit women to the unit and that risks to the women and their babies arising from being diverted to other maternity units would be significantly greater than being admitted to the AMU. Further assurance was also requested externally from HPS that the Board was taking all reasonable and expected steps in the investigation and management of the outbreak. HPS responded: HPS have participated in the IMT and are assured that A&A are effectively responding to this incident, taking all appropriate actions in order that women are not being put at risk. The IMT was quickly established following identification of this outbreak and a systematic approach to this incident investigation instigated in accord with the extant UK guidelines for prevention and control of GAS infection in acute healthcare and maternity settings (2012). HPS have participated in IMT discussions and support the actions taken by the IMT to date. A debrief facilitated by HPS, was held on 2 ember. The outcome of that debrief is currently being collated into a report which will be tabled at the Prevention and Control of Infection Committee; Women, Children and Diagnostics Governance Group and the Healthcare Governance Committee. It will also be shared with other Boards in Scotland via HPS for learning purposes. 8 of 20

Monitoring Form Policy/Strategy Implications Workforce Implications Financial Implications Consultation (including Professional Committees) Risk Assessment Best Value - Vision and leadership - Effective partnerships - Governance and accountability - Use of resources - Performance management Compliance with Corporate Objectives Single Outcome Agreement (SOA) Not required. This update report has no policy/strategy implications. Not required. This update report has no workforce resource implications. The continual management and monitoring of HAIs in NHS Ayrshire and Arran in driving down infection rates as far as possible will ensure that costs per patient stay (i.e. treatments, length of stay, terminal ward cleaning etc) will not be impacted upon, ensuring that costs are minimised across the organisation. The HAI update is provided to agreed NHS Boards, Healthcare Governance Committees and to the Prevention & Control of Infection Committee at every meeting (four times per year). Assessments are carried out on the HAI alert organisms by the Infection Control Nurse responsible for that particular clinical area to ensure that all necessary standard infection control precautions are initiated as appropriate in managing the patients care. Delivers effective partnerships and governance and accountability for the Board and best use of resources. Protect and improve the health and wellbeing of the population and reduce inequalities, including through advocacy, prevention and anticipatory care. Not required. This is an update report to NHS Board members. Impact Assessment Equality Impact Assessment not required as this is an update report to NHS Board members. 9 of 20

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 The Board narrowly missed the -17 SAB LDP Target 24 SAB cases in the first 3 months of the year contributing to the -18 LDP target (3 above trajectory) The Board achieved the -17 CDI LDP target 29 CDI cases in the first 3 months of the year contributing to the -18 LDP target (1 below trajectory) 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 There have been 24 SAB cases between il and e. This is three cases above the LDP Target trajectory. 10 of 20

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 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 There have been 29 CDI cases between il and e. This is 1 case below the LDP Target trajectory. 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 The HAIRT contains hand hygiene compliance obtained through local hand hygiene auditing. 11 of 20

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 The HAIRT contains cleaning and the healthcare environment compliance obtained through local auditing. Outbreaks -18 This section should give details on any outbreaks that have taken place in the Board since the last report, or a brief note confirming that none have taken place. Where there has been an outbreak then for most organisms as a minimum this section should state when it was declared, number of patients affected, number of deaths (if any), actions being taken to bring the outbreak under control and whether this was reported Outbreaks Nil to note 12 of 20

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 each acute hospital and key community hospitals in the Board, on the number of cases of Staphylococcus aureus blood stream infections (also broken down into Meticillin Sensitive Staphylococcus aureus (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 [which do not have individual cards], 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 CDI and SAB cases are presented for each hospital, broken down by month. SAB cases are further broken down into MSSA and MRSA. 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. Targets There are national targets associated with reductions in C.diff and SABs. More information on these can be found on the Scotland Performs website: http://www.scotland.gov.uk/about/performance/scotperforms/partnerstories/nhsscotland performance Understanding the Report Cards Hand Hygiene Compliance Hospitals carry out regular audits of how well their staff are complying with hand hygiene. Each hospital report card presents the combined percentage of hand hygiene compliance with both opportunity taken and technique used broken down by staff group. 13 of 20

Understanding the Report Cards Cleaning Compliance Hospitals strive to keep the care environment as clean as possible. This is monitored through cleaning and estates 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/ 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 and. 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. 14 of 20

NHS AYRSHIRE & ARRAN REPORT CARD Staphylococcus aureus bacteraemia monthly case numbers MRSA 0 0 1 1 1 0 1 1 2 0 1 0 MSSA 9 6 8 5 7 7 7 8 11 9 9 8 Total SABS 9 6 9 6 8 7 8 9 13 9 10 8 Clostridium difficile infection monthly case numbers Ages 15-64 3 3 2 2 5 1 2 4 2 2 1 5 Ages 65 5 4 16 9 4 6 6 10 11 17 4 9 Ages 15 8 7 18 11 9 7 8 14 13 19 5 14 Hand Hygiene Monitoring Compliance (%) AHP 100 100 97 98 96 97 96 97 Ancillary 96 100 92 89 80 97 92 91 Medical 95 99 96 97 98 94 93 95 Nurse 98 99 97 98 97 98 97 98 Board Total 98 99 98 97 96 98 96 97 Cleaning Compliance (%) Board Total 96 96 94 95 95 95 93 96 95 94 95 95 Estates Monitoring Compliance (%) Board Total 97 98 96 98 98 97 97 97 97 97 98 98 15 of 20

UNIVERSITY HOSPITAL AYR REPORT CARD Staphylococcus aureus bacteraemia monthly case numbers MRSA 0 0 1 1 0 0 0 0 0 0 0 0 MSSA 2 0 0 1 0 2 0 0 1 2 1 2 Total SABS 2 0 1 2 0 2 0 0 1 2 1 2 Clostridium difficile infection monthly case numbers Ages 15-64 0 0 1 0 2 0 1 1 0 1 0 0 Ages 65 1 2 1 3 0 2 3 3 1 1 1 0 Ages 15 1 2 2 3 2 2 4 4 1 2 1 0 Cleaning Compliance (%) Ayr 95 93 94 95 98 95 94 94 95 95 95 95 Estates Monitoring Compliance (%) Ayr 96 96 96 97 97 96 97 97 96 97 97 97 16 of 20

UNIVERSITY HOSPITAL CROSSHOUSE REPORT CARD Staphylococcus aureus bacteraemia monthly case numbers MRSA 0 0 0 1 1 0 0 0 2 0 1 0 MSSA 3 1 6 3 1 1 3 3 1 2 4 1 Total SABS 3 1 6 4 2 1 3 3 3 2 5 1 Clostridium difficile infection monthly case numbers Ages 15-64 0 1 0 1 0 0 0 1 1 0 0 0 Ages 65 0 0 3 1 0 1 0 1 3 2 2 1 Ages 15 0 1 3 2 0 1 0 2 4 2 2 1 Cleaning Compliance (%) Crosshouse 96 96 96 96 97 96 96 96 96 96 96 96 Estates Monitoring Compliance (%) Crosshouse 99 99 98 99 99 98 99 99 98 99 98 99 17 of 20

AYRSHIRE CENTRAL HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia monthly case numbers MRSA 0 0 0 0 0 0 0 0 0 0 0 0 MSSA 0 0 0 0 0 0 0 0 0 0 0 0 Total SABS 0 0 0 0 0 0 0 0 0 0 0 0 Clostridium difficile infection monthly case numbers Ages 15-64 0 0 0 0 0 0 0 0 0 0 0 0 Ages 65 0 0 0 1 0 0 0 0 0 1 0 1 Ages 15 0 0 0 1 0 0 0 0 0 1 0 1 Cleaning Compliance (%) ACH 96 99 92 92 96-89 94 96 92 94 94 Estates Monitoring Compliance (%) ACH 98 99 98 99 99-96 98 98 98 99 99 18 of 20

BIGGART HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia monthly case numbers MRSA 0 0 0 0 0 0 0 0 0 0 0 0 MSSA 0 0 0 0 0 0 0 0 0 0 0 0 Total SABS 0 0 0 0 0 0 0 0 0 0 0 0 Clostridium difficile infection monthly case numbers Ages 15-64 0 0 0 0 0 0 0 0 0 0 0 0 Ages 65 0 1 1 0 0 1 0 0 0 1 0 0 Ages 15 0 1 1 0 0 1 0 0 0 1 0 0 Cleaning Compliance (%) Biggart 97 97 93 96 93-93 98 93 91 97 94 Estates Monitoring Compliance (%) Biggart 95 96 94 99 96-97 94 96 96 98 96 19 of 20

NHS COMMUNITY HOSPITALS REPORT CARD The community hospitals covered in this report card include: Ailsa Hospital Arran War Memorial Hospital Arrol Park Resource Centre East Ayrshire Community Hospital Girvan Community Hospital Kirklandside Hospital Lady garet Staphylococcus aureus bacteraemia monthly case numbers MRSA 0 0 0 0 0 0 0 0 0 0 0 0 MSSA 0 0 0 0 0 0 0 0 0 0 0 0 Total SABS 0 0 0 0 0 0 0 0 0 0 0 0 Clostridium difficile infection monthly case numbers Ages 15-64 0 0 0 0 0 0 0 0 0 0 0 0 Ages 65 0 0 1 0 0 1 1 0 1 0 0 0 Ages 15 0 0 1 0 0 1 1 0 1 0 0 0 NHS OUT OF HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia monthly case numbers MRSA 0 0 0 0 0 0 1 1 0 0 0 0 MSSA 4 4 2 1 6 4 4 5 9 5 4 5 Total SABS 4 4 2 1 6 4 4 5 9 5 4 5 Clostridium difficile infection monthly case numbers Ages 15-64 3 2 1 1 3 1 1 2 1 1 1 5 Ages 65 4 2 10 3 4 2 1 6 6 12 1 6 Ages 15 7 4 11 4 7 3 2 8 7 13 2 11 20 of 20