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Healthcare Associated Infection Control and Prevention Report to NHS Lanarkshire Board 28th November 2012 Aim The purpose of this paper is to update Board members of current status of Healthcare Associated Infections (HAI) and infection control measures, with particular reference to performance against HEAT targets and cleanliness monitoring Key issues will include

Staphylococcus aureus Bacteraemias Clostridium difficile Hand hygiene compliance Cleanliness Monitoring Education Outbreaks

Other HAI activity such as surgical site surveillance and antimicrobial prescribing will also feature. Background There is a national mandatory requirement for a Healthcare Associated Infection Control report to be presented to the Board on a bi -monthly basis utilising the template below. The HAI report will continue to be submitted to the board on a monthly basis as previously.

Summary This report highlights NHS Lanarkshire performance in relation to infection prevention and control. Site specific Information features in graph format at the end of the report

Recommendation

The Board is asked to note this report.

For further information or clarification of any issues in this paper please contact:

Dr Alison Graham, Medical Director, Kirklands, Fallside Road, Bothwell, Tel: 01698 858192.

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

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Section 2- Key Healthcare Associated Infection Headlines for November 2012

NHSL undertook a gap analysis comparing Infection Control Policy and local guidelines

which was discussed at the Scottish Infection Prevention and Control Network. A meeting

was then convened by HPS on 1st November 2012 with representation from all Boards to

further review the SICPs policy before local guidelines can be removed. The reviewed

policy will be issued to Boards in December 2012.

An NHSL Compliance and Quality Improvement Data Collection Tool for SICP’s is being

developed for testing taking account of existing relevant local monitoring tools to ensure

that frontline staff are able to demonstrate compliance with the SICPs policy and avoiding

duplication of efforts. An implementation plan is being developed by the nurse Consultant-

HAI Lanarkshire and supported by the Leading Better Care Programme.

Monthly Improvement sessions primarily for the NHSL HAI Team have commenced. And

have been well received.

Section-3 Staphylococcus aureus (including MRSA)

Current HEAT Status Staphylococcus aureus (including MRSA): The most recent HPS report on Staphylococcus Aureus Bacteraemia was published on 3rd

October 2012. NHS Lanarkshire had a quarterly (April 2012 – June 2012) MRSA bacteraemia

rate of 0.049 cases per 1000 acute occupied bed days compared to a similar rate of 0.042

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.nhsinform.co.uk/Health-Library/Articles/S/staphylococcal-infections/introduction

MRSA: http://www.nhsinform.co.uk/Health-Library/Articles/M/mrsa/introduction

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

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cases per 1000 acute occupied bed days for NHS Scotland. For MSSA bacteraemia, NHS

Lanarkshire has a quarterly rate of 0.214 cases per 1000 acute occupied bed days with a rate

of 0.259 cases per 1000 acute occupied bed days for NHS Scotland. Combining these gives a

rate of 0.263 SABs per 1000 acute occupied bed days. This is the second lowest quarterly

rate and the third successive quarterly decrease. However, a further check of the data

revealed that one MSSA bacteraemia was erroneously reported; this will be removed from

future reports, to give an overall quarterly rate of 0.255 SABs per 1000 acute occupied bed

days.

The target for 2011-2013 is for all Boards to reduce their rate of Staphylococcus aureus

bacteraemias down to a rate of 0.26 per 1000 acute occupied bed days or less by year ending

March 2013. The rate of 0.26 cases or less per 1000 acute occupied bed days was the “best

in class” rate achieved by a single board in year ending March 2010, and is a rate that is

considered to be achievable by all Boards. If activity remains at a stable level, an average of

10 Staphylococcus aureus bacteraemias per month in NHS Lanarkshire will be an

approximate target. In October there were 14 Staphylococcus aureus bacteraemias, making a

total of 75 in the 7 months since April 1st. The annual figure reported on the ISD Directory

Information System website is up to 30th June 2012 (0.3 cases / 1000 OCBDs). This compares

with a trajectory HEAT target of 0.29 cases / 1000 OCBDs in the 12 months up to the end of

June 2012 (deviation = 3.4%)

Initiatives to reduce Staphylococcus aureus bacteraemias

The NHSL Staphylococcus Aureus Bacteraemia (SAB) Improvement Plan is under review

at present. All current actions are continuing to be progressed whilst the review is

undertaken.

An updated SAB Rapid Review form has been approved by the HAI Services Manager

and is being uploaded onto LanQIP at present for testing. This will allow more robust and

meaningful analysis of data and reports to be delivered to frontline staff in real time.

A review of the feedback process to ward areas following a Staphylococcus Aureus

Bacteraemia infection is underway. This will ascertain if the process is robust enough to

support sustainable improvement. It is planned that the process will further strengthen links

with Senior Nurses and Clinical Governance forums.

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Following a recent visit form Health Protection Scotland the recommendations arising from

the SBAR relating Staphylococcus Aureus Bacteraemia are being progressed.

HPS are in the process of updating their Staphylococcus Aureus Bacteraemia fact sheet

which will highlight key measures aimed at minimising infection to frontline staff

MRSA Screening Compliance

The Key Performance Indicators are currently being tested in NHS Lanarkshire. The data

collection has been undertaken by the MRSA Compliance Nurse and the MRSA Project

Manager. Data collection so far demonstrates good compliance at two of the medical

admission units. There appears to be an issue with communications of results and follow up

screening between wards. The MRSA Compliance Group will continue to drive improvement

with the process.

Section-4 Clostridium difficile infection

Clostridium difficile infection (CDI):

NHS Lanarkshire remains on trajectory to meet our HEAT target. The target for 2011-2013 is

for all Boards to reduce from their current rate of Clostridium difficile infections down to 0.39 or

less cases per 1000 total occupied bed days in patients aged 65 and over by year ending

March 2013. Should Boards achieve a rate lower than 0.39 ahead of the March 2013 then

they should aim to at least maintain that lower rate; however formal achievement of the target

will still be measured against the 0.39 rate. The most recent HPS report on Clostridium difficile

infection was published on 3rd October 2012. In NHS Lanarkshire, there was a rate of 0.304

cases > 65 years old / 1000 acute occupied bed days for the 3 months up to the end of March

2012.

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.nhsinform.co.uk/Health-Library/Articles/C/clostridium-difficile/introduction

NHS Boards carry out surveillance of Clostridium difficile infections (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/clostridiumdifficile.aspx?subjectid=79

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The annual figure reported on the ISD Directory Information System website is up to 30th June

2012 (0.38 cases > 65 years old / 1000 OCBDs). This compares with a trajectory HEAT target

of 0.43 cases > 65 years old / 1000 OCBDs in the 12 months up to the end of June 2012

(deviation = -11.6%)

Initiatives to reduce Clostridium difficile infection

The NHSL Clostridium difficile infection (CDI) Improvement Plan is under review at

present. All current actions are continuing to be progressed whilst the review is

undertaken.

The current proforma used for enhanced surveillance of Clostridium difficile Infection (CDI)

has been reviewed with the recommendation that it will follow the same Rapid Review

Process as is applied to the Staphylococcus aureus bacteraemia process.

Section- 5 Hand Hygiene

Current Initiatives in Promoting Hand Hygiene

The HAI Manager and the Improvement Adviser are currently scoping the future role of

hand hygiene compliance assurance post March 2013 in conjunction with Health

Protection Scotland.

Hand Hygiene education sessions, in partnership with Ecolab, continue on a monthly

basis.

Further targeted education sessions have been developed for key staff groups.

Successful completions of the NHSL LearnPro Hand Hygiene module continue.

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

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Hand Hygiene compliance highlighted as one of Standard Infection Control Precautions

during Infection Control week.

New poster for surgical rub to hand. Will be distributed to all areas with CVC packs at local

education sessions.

Possibility of ‘timers’ for surgical rub/scrub in theatre areas being pursued.

Dr Stephanie Dancer to lead an education session for Medical Staff on the 21st November

2012, to encourage hand hygiene and role modelling.

Section - 6 Cleaning and the Healthcare Environment

Domestic NMF scores for NHSL premises during September – October 2012 produced an

average score of 96.0%, this being an increase of 0.4%, on the previous quarter. Within

the three acute sites, 360 audits were undertaken, of which 20 audits recorded a score

below 90%. Within CHP sites, 102 audits were undertaken of which 4 audits scored below

90%. All cleaning issues identified are rectified within 48 hours.

Ward 20 at Monklands is closed and beds re-provided in ward 8. Following

decontamination using Bioquell’s Room Bio-decontamination Service (RBDS), an

extensive refurbishment programme has commenced and is on target to be completed on

the 17th December.

Monklands laboratories work is due to commence on the 10th December to improve

functionality and provide fit for purpose facilities that will meet service demands.

Domestic Staff continue to undertake the flushing regime required in line with CEL 03

(2012) in relation to pseudomonas, this activity occurs for 81, identified little used outlets,

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

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across Wishaw, Monklands and Hairmyres. This activity is signed off daily by Domestic

Staff undertaking the task; all records are kept in the water management system log book

and in the CAFM systems maintained at the three sites.

The HAI Initiatives Service Providers meeting with representation from PSSD/ISS & Serco

will continue to meet twice a year; the next meeting is November 2012.

PSSD have been allocated £1.2 million to improve HEI/ patient environment, i.e. painting,

clinical wash hand basins, flooring, across a range of sites which will include hospitals

and health Centres. All work is due to be completed by March 2013.

Due to the poor level of compliance with Section D of NHS Lanarkshire’s Infection Control

Manual - Laundry Bagging and Labelling, laundry staff continue to be exposed to

unnecessary risk. This matter remains a “red risk” within the West of Scotland Laundry

Risk Register. It has been agreed with the Divisional Director of Nursing that laundry bags

will not be uplifted from any location where non compliance with policy is identified.

The table below demonstrates NHSL level of compliance was 55% during the audit period

25th Sept – 3rd Oct which showed an increase from 50% in September however, despite

the increase, this level of compliance is still not acceptable. Other consortium partners are

in a serious non-compliant position with minimal improvement, the exception to this being

the State Hospital. Action Plans have been sought from the consortium partners and

engagement with NHSL nursing and ICT is currently being arranged

PSSD are developing an action plan to be implemented across NHSL premises to ensure

that linen that is non-compliant will not be collected by porters/laundry staff until rectified.

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Section 7. Healthcare Environment Inspection. There have been no further HEI Inspections within NHSL since the unannounced visit to

Wishaw general on the 25th August 2012 The HEI Steering Group continues to oversee the

appropriate actions in response to any requirements identified. The HEI undertook a review of

all the 16 week action plans submitted by NHS Boards over the first 3 years of inspection and

returned the outstanding progress updates on 9th November 2012 to the Inspectorate.

Section 8. Outbreaks/ Incidents

A Problem Assessment Group has overseen an increased incidence of Clostridium difficile

in Ward 12, DME/Rehab/GORU, and Monklands in October 2012. Decontamination of

ward areas considered to be potentially contaminated has been carried out using hydrogen

peroxide vapour. The ward is now fully functional.

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Rates of Norovirus fluctuate from year to year, however, it has commenced earlier than

usual this year, and this may be indicative of a higher than normal level of Norovirus

circulating this winter. Following the start of this year’s Norovirus season at the end of

October 2012, Hairmyres Hospital and Wishaw General Hospital have seen an increase in

the numbers of patients reported with symptoms of unexplained gastroenteritis. A total of

8 wards have been closed with approximately 41 patients and 19 staff affected at

Hairmyres to date and a total of 16 patients and 9 staff were reported as symptomatic at

Wishaw General. Other ward areas have had Infection Control restrictions put in place

where only a few patients were affected. Norovirus has been isolated from some of the

specimens received. The Infection Control Team are continuing to work through and

implement the Norovirus preparedness plan and monitor suspected cases. All staff remain

vigilant for patients with unexpected sudden onset of symptoms. This is a picture currently

being seen by all NHS Boards across Scotland.

Norovirus

HPS data has demonstrated that currently for the week beginning 19/11/2012 5 NHS Boards

are reporting Norovirus activity in NHS Scotland. Lanarkshire have reported 2 hospitals for this

reporting period.

In the first report on 7/1/2008: 29 hospitals were affected and 47 wards closed. This Monday

19/11/2012 there was 13 hospitals with 19 wards closed, and 13 wards with Bays affected.

Section- 9 Other HAI Related Activity

HAI Surveillance

SSI Surveillance of elective hip and knee arthroplasties, repair of neck of femur, (hemi

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arthroplasties) and SSI Surveillance of elective and emergency caesarean section for

the period 1st September 2012 -30th September 2012 is period 1st September 2012 is

shown in the table below.

Procedure Total operations

Infections SSI %

Hip Arthroplasty 45 2 (1 Superficial) WGH(1 Organ/Space) HM

4.44

Repair of neck of femur

19 1 (Superficial) HM 5.26

Knee Arthroplasty 45 0 0.00 Caesarean Section 114 3 (Superficial) 2.63

The HAI Surveillance Team have re-located their base to Kirklands hospital to align their

roles within the wider HAI Service

• Surveillance team continue to undertake the Enhanced Clostridium difficile

surveillance across Lanarkshire. Monthly reports are sent to all ADN’s, Senior Nurses

and Senior Charge Nurses and the findings discussed with Infection Control Teams

supporting processes for improvements.

• Monthly Caesarean Section and Orthopaedic SSI rates are reported to the to Clinical

Quality Depar tmen t to issue reports for the Maternity Dashboard and the Scottish

Patient Safety Programme

Antimicrobial Prescribing

NHS Lanarkshire Antimicrobial Management Team continues to progress compliance with the

3 CEL 11 antimicrobial prescribing indicators supporting the reduction in CDAD HEAT target

by March 2013.

1. Hospital based empirical prescribing indicator: Antibiotic prescriptions are compliant with the

local antimicrobial policy in ≥95% of sampled cases.

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2. Surgical prophylaxis indicator: Surgical prophylaxis is compliant with policy and given as

a single dose in ≥95% of sampled cases.

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3. Primary Care prescribing indicator: Consumption of quinolones in winter months is ≤5%

greater than consumption in summer months.

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