Highland NHS Board 30 January 2018 Item 4.3 INFECTION ......Antibiotic prescribing audits (using the new format) commenced in July 2017, on wards 6C, 7A and 4C in Raigmore. The main

Highland NHS Board 30 January 2018 Item 4.3 INFECTION PREVENTION & CONTROL REPORT Report by Catherine Stokoe, Infection Control Manager and Dr Vanda Plecko, Consultant Microbiologist/Infection Control Doctor, on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control The Board is asked to: • Note the position for the Board. • Note the update on the current status of Healthcare Associated Infections (HAI) and

Infection Control measures in NHS Highland.

Contribution to Board Objectives One of the Board key objectives is “to reduce to an absolute minimum the and a Board. 1. Background and summary The table below shows NHS Highland Infection Prevention and Control targets and performance data.

Group Target NHS Highland HEAT rate

Clostridium difficile Age 15 and over

HEAT rate of 32.0 cases per 100,000 OBDs to be achieved by year ending 03/17

July-Sept 2017 26

Green (Validated by HPS)

Staphylococcus aureus bacteraemia

HEAT rate of 24.0 cases per 100,000 AOBDs to be achieved by yea ending 03/17

July-Sept 2017 26

Red (Validated by HPS)

MRSA Clinical Risk Assessment

90% or above compliance July–Sept 2017 94%

Green

Hand Hygiene 95% 95% Green Cleaning 92% 96% Green Estates 95% 97% Green

Source: - Health Protection Scotland/ISD/Local data.

Catherine Stokoe – Infection Control Manager Vanda Plecko – Consultant Microbiologist & Lead Infection Control Doctor, Feb 2018

Contribution to Highland Quality Approach Strategic Framework and Annual Objectives One of the key objectives is “to reduce to an absolute minimum the chance of acquiring an infection whilst receiving healthcare and to ensure our hospitals are clean” This report presents a comprehensive view of Infection Control and Prevention data and activities relating to annual work plan for scrutiny and feedback.

2. Staphylococcus aureus bacteraemia target (including MRSA)

The target for 2017/2018 for NHS Highland is 24 cases or less per 100,000 acute occupied bed days for Staphylococcus aureus bacteraemia (SAB) including MRSA. For NHS Highland this means no more than approximately 60 cases by 31st March 2018. 2.1 Trends NHS Highlands position showing actual case numbers as of 30th Nov 2017 (data not yet validated by HPS) is tabled below. 1st April 2017 – 30th November 2017

MSSA = 38 MRSA = 1 Total SABs = 39 Cases

Preventable = 1 (2%) Not preventable = 27 (69%) Unknown = 6 (16%) Under Investigation = 5 (13%) Hospital Acquired Cases = 11 (28%) Community Acquired Cases = 18 (46%) Healthcare Associated Cases = 10 (26%) For definitions of above classifications please see page 9

Figure 1: NHS Highland Staphylococcus aureus bacteraemia Cumulative Case numbers year on year since 2014. The information presented in the graph below is based on NHS Highland case number data.

Figure 2: Healthcare associated Staphylococcus aureus bacteraemia (SAB) incidence infection rates (per 100,000 total occupied bed days) for all NHS boards in Scotland Q3 2017. NHS Fife and NHS Highland overlap. Created and published by Health Protection Scotland.

HG – NHS Highland

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Figure 3: Community associated SAB infection incidence rates cases (per 100,000 population) for all NHS boards in Scotland in Q3 2017. NHS Orkney and NHS Western Isles overlap. Created and published by Health Protection Scotland.

HG – NHS Highland 3. Clostridium difficile The target for 2017/2018 for NHS Highland is 32 cases or less in patients aged 15 and over per 100,000 total occupied bed days. For NHS Highland this means no more than approximately 78 cases by 31st March 2018. 3.1 Trends NHS Highlands position showing actual case numbers as of 30st November 2017 (data not yet validated by HPS) is tabled below. 1st April 2017 to 30th November 2017

Total CDI Cases aged 15 and over = 41

Aged 15-64 = 10 Aged 65+ = 31

Healthcare Associated = 18 (44%) Community Acquired = 19 (46%) Unknown = 3 (7%) Under Investigation = 1 (3%) For definitions of above classifications please see page 9.

Figure 4: NHS Highland Clostridium difficile Infection age 15 and over, case numbers year on year since 2014. The information presented in the graph below is based on NHS Highland case number data

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Figure 5: Healthcare associated Clostridium difficile Infection (CDI) incidence infection rates (per 100,000 total occupied bed days (TOBD) for all NHS boards in Scotland Q3 2017. NHS National Waiting Time Centre, NHS Shetland and NHS Western Isles overlap as do NHS Grampian, NHS Lanarkshire and NHS Tayside. Created and published by Health Protection Scotland.

HG – NHS Highland Figure 6: Community associated CDI infection incidence rates cases (per 100,000 population) for all NHS boards in Scotland Q3 2017. Created and published by Health Protection Scotland.

HG – NHS Highland 4. Antimicrobial Management National Hospital Antimicrobial Prescribing Quality Indicators As noted in the last board report, the detail of these quality prescribing indicators has recently been shared with Antimicrobial Management team (AMT) across Scotland, for achievement by 31st March 2018.

Antibiotic Prescribing Measures Progress against these measures is detailed in the table below: Hospital Antibiotic Prescribing Measure (per 1000 AOBDs):

National picture of all 29 acute hospitals

Status at 31st October 2017

Belford Caithness General

Lorn & Islands Raigmore

Total antibiotic use 7/29 at target Piperacillin/tazobactam (broad spectrum drug) 29/29 at target Carbapenems (very broad spectrum drugs) 15/29 at target This data is assessed at the end of each financial quarter and discussed at the Antimicrobial Management Team. Scrutiny of the data highlights a higher than expected prescribing rate for carbapenems in Raigmore Hospital. The highest users are the oncology/haematology department (where prescribing is according to recommendations and guidelines), ITU and patient-specific recommendations by the microbiology and infectious disease consultants. A draft guideline for antibiotic use in ITU that avoids the use of carbapenems and piperacillin/tazobactam has been circulated to the intensivists for comment. Every patient recommended meropenem specifically by an infection specialist is being reviewed by the collective team in Microbiology and Infectious Diseases for discussion and learning. Note that use of alternative drugs to piperacillin/tazobactam and carbapenems will mean using two or three drug combinations to ensure the same antibiotic cover and this will increase the total antibiotic use. Antibiotic Audits Antibiotic prescribing audits (using the new format) commenced in July 2017, on wards 6C, 7A and 4C in Raigmore. The main new element of the audit is to achieve a review of intravenous (IV) therapy or oral duration of therapy in 60% of patients by December 2017, rising to 80% of patients by the end of March 2018. Data up to November shows all three wards attaining the required standard for recording the duration of oral therapy and documenting the review of IV therapy which is excellent. Further work is ongoing to enable areas to achieve the higher standard by the end of March 2018. Management of Infection Guidance Review In line with a national approach to harmonisation of antibiotic guidelines, the section on sepsis of unknown origin has been updated to avoid use of piperacillin/tazobactam. In addition, the respiratory section has been reviewed by the chest physicians and microbiologists using local resistance patterns to inform the recommendations. Co-amoxiclav is now less prominent in the guidelines and therefore use of this drug should reduce in acute hospitals. A number of antibiotic shortages are resulting in short-term alteration of the empiric guidelines. The situation is being monitored closely and action taken to maintain high quality care of patients with infections. 5. Healthcare Environment Inspections (HEI) Benchmarking continues against all the national HEI inspection reports published, in order to ensure learning is disseminated. No HEI Inspections have been carried out within NHS Highland since June 2017.

6. Outbreaks/ clusters and multidrug resistant isolates associated with NHS

Highland An outbreak of Clostridium difficile was declared on ward 2A Raigmore, on the 19th December 2017. 4 patients have been identified with Clostridium difficile toxin. Health Protection Scotland were informed and regular updates occurred. Control measures were adopted, and as of the 3rd of January 2018 the ward underwent deep cleaning, and hydrogen peroxide fogging prior to reopening on the 6th of January 2018.

An increased number of influenza cases has been identified across NHS Highland since December 2017. On the 2nd of January 2018 both wards at the Royal Northern Infirmary, Inverness were closed due to 4 confirmed cases of Influenza A. Control measures were adopted and the ward reopened on the 11th of January 2018. The closure of Sutor ward, Invergordon Hospital occurred on the 10th of January 2018 due to 6 confirmed flu cases. Control measures were adopted and the ward reopened on the 17th of January 2018. At the time of writing, Mackinnon Hospital, Skye is currently closed due to 4 confirmed flu cases; control measures are in place. Also a number of cases are being seen and managed within Raigmore Hospital, at the time of writing this has not resulted in any ward closures.

7. Escherichia coli (E.Coli) Bacteraemia surveillance

Surveillance of E.Coli bacteraemia is a mandatory requirement for all Boards to undertake. There is no national target related to this surveillance.

NHS Highlands position showing actual case numbers as of 30th November 2017 (data not yet validated by HPS) is tabled below.

1st April 2017 to 30th November 2017

Total Cases = 138 Hospital Acquired = 16 (12%) Healthcare Associated = 30 (22%) Community Acquired = 91 (65%) Not Known = 1 (1%)

It should be noted that the majority of E.Coli bacteraemia cases reported within NHS Highland are identified as community associated and are not related to urinary catheters or deemed preventable. Often they are associated with chronic urinary tract problems such as renal impairment and kidney stones. Figure 7: Healthcare associated Escherichia coli bacteraemia (ECB) incidence infection rates (per 100,000 total occupied bed days) for all NHS boards in Scotland Q3 2017. NHS Fife, NHS Forth Valley and NHS Highland overlap as do NHS Grampian and NHS Tayside. Created and published by Health Protection Scotland.

HG – NHS Highland

Figure 8: Community associated Escherichia coli bacteraemia (ECB) infection incidence rates cases (per 100,000 population) for all NHS boards in Scotland in Q3 2017. Created and published by Health Protection Scotland.

HG – NHS Highland 8. Surgical Site Infections (SSI) RAIGMORE 30 DAYS READMISSION ELECTIVE COLORECTAL SSI Currently there have been 14 infections reported from 130 procedures from January 2017 to October 2017 (10.8% SSI rate).

Figure 9: highlights the monthly SSI percentage rate in elective colorectal surgery, January 2012 to October 2017.

RAIGMORE 30 DAYS READMISSION ORTHOPAEDIC SSI

Total Hip replacement (THR) Total Hip replacement (THR) surgery continues to have a low rate of SSI. Currently there are no infections to report in 2017 (0% rate of SSI).

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Figure 10: Monthly SSI rate in Total Hip Replacement surgery Jan 2012- October 2017

Hemi-arthroplasty Surgery continues to have a low rate of SSI. Currently there has been 1 infection reported from 146 procedures between Jan 2017 to October 2017 (0.7% SSI rate).

Figure 11: Monthly SSI rate for Hemi arthroplasty surgery Jan 2012 to October 2017

NHSH 10 DAYS POST DISCHARGE CAESAREAN SECTION SSI

Elective C-Section Currently 4 infections have been reported in 2017, with 296 procedures performed (1.4% rate of SSI).

Figure 12: shows monthly SSI rate for elective C Sections, Jan 2012 to October 2017

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Emergency C-Sections Currently 8 infections have been reported in 2017 with 295 procedures performed (2.7% rate of SSI).

Figure 13: Monthly SSI rate for emergency C Section, Jan 2012 to October 2017

Figure 14: Funnel plot of caesarean section (elective and emergency combined) SSI incidence (per 100 procedures) in inpatients and post discharge surveillance to day 10 for all NHS boards in Scotland in Q3 2017. NHS Borders and NHS Dumfries & Galloway overlap as do NHS Orkney, NHS Shetland and NHS Western Isles. Created and published by Health Protection Scotland.

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Abbreviations

SAB Definitions Definitions: Hospital acquired infection (HAI): Positive blood culture obtained from a patient who has been hospitalised for ≥48 hours. OR patient was transferred from another hospital, the duration of in-patient stay is calculated from the date of the first hospital admission. OR If the patient was a neonate/baby who has never left hospital since being born. OR The patient was discharged from hospital in the 48hr prior to the positive blood culture being taken. OR A patient who receives regular haemodialysis as an out-patient. OR Contaminant if the blood aspirated in hospital Healthcare associated infection (HCAI): Positive blood culture obtained from a patient within 48 hours of admission to hospital and fulfils one or more of the following criteria: 1. Was hospitalised overnight in the 30 days prior to the positive blood culture being taken. 2. Resides in a nursing, long term care facility or residential home. 3. IV, or intra-articular medication in the 30 days prior to the positive blood culture being taken, but excluding IV illicit drug use. 4. Regular user of a registered medical device e.g. intermittent self-catheterisation, home CPD or PEG tube with or without the direct involvement of a healthcare worker (excludes haemodialysis lines see HAI). 5. Underwent any medical procedure which broke mucous or skin barrier i.e. biopsies or dental extraction in the 30 days prior to the positive blood culture being taken. 6. Underwent care for a medical condition by a healthcare worker in the community which involved contact with non-intact skin, mucous membranes or the use of an invasive device in the 30 days prior to the positive blood culture being taken e.g. podiatry or dressing of chronic ulcers, catheter change or insertion. Community infection: Positive blood culture obtained from a patient within 48 hours of admission to hospital who does not fulfil any of the criteria for healthcare associated bloodstream infection. Not known: Only to be used if the SAB is not an HAI, and unable to determine if Community or HCAI. CDI definitions Definitions: Healthcare-associated CDI: a case with onset of symptoms on day three or later, following admission to a healthcare facility on day one, OR in the community within four weeks of discharge from any healthcare facility. This may apply to the current hospital or a previous stay in another healthcare facility, e.g. in another hospital, a long-term care facility or other healthcare facilities (e.g. outpatient departments etc.) Community-associated CDI: a case with [onset outside of healthcare facilities, AND without discharge from a healthcare facility within the previous 12 weeks] OR [onset on the day of admission to a healthcare facility or on the following day AND not resident in a healthcare facility within the previous 12 weeks] Unknown association: a case who was discharged from a healthcare facility 4–12 weeks before symptom onset

IPC Annual Work plan Jan 2018 V5 Key Completed Progressing to timeframe Progressing outwith timeframe Not Progressing BLUE GREEN AMBER RED

NHS Highland Infection Prevention & Control Annual Work Plan 2017/2018

Prepared by Catherine Stokoe, Infection Control Manager. (Report as of 4/1/2018)

MISSION CRITICAL OBJECTIVES

Ref Objective Lead/ Responsible Persons

Reporting Governance Management Due Date Outcome measure

Compliance Rag Rating

Discharge Planning in Raigmore Major service change Value management Out of hospital Services –urban Inverness

1 To meet or exceed CDI HEAT target NHS Highland

Operational Unit Infection Control Leads (Lead Nurses)

Monthly Infection Prevention and Control surveillance report

COIC Local Operational unit IPC meetings / ICIG

31.03.18 Achieve annual performance rate of 32.0 per 100,000 occupied bed days or less

July –Sept 2017 (HPS validated) 26

Oct – Dec 2017 data will be published in March.

GREEN based on current quarter position

2 To meet or exceed SAB HEAT target NHS Highland


Monthly Infection Prevention and Control surveillance report

COIC Local Operational unit IPC meetings / ICIG

31.03.18 Achieve annual performance rate of 24.0 per 100,000 acute occupied bed days or less

July –Sept 2017 (HPS validated) 26

Oct – Dec 2017 data will be published in March.

RED based on current quarter position

3 To meet the mandatory requirements of the Clinical Risk Assessment MRSA Screening Compliance of 90% is achieved in Raigmore and the Rural General Hospitals.


Local Operational unit IPC meetings / IPCT meeting

COIC Local Operational unit IPC meetings / ICIG/ IPCT meeting

31.03.18 Achieve 90% compliance within Raigmore and the Rural General Hospitals.

Oct – Dec 2017 data is awaited.

July – Sept 2017 data identified compliance rate of 94 %.

GREEN for 2018 target

Less people 4 Reduce the Clinical Leads SPSP COIC/SPSP Local clinical 31.03.18 Achieve rate Year to date (Jan-Oct Green


dying in hospitals

incidence of SSI infection and maintain a rate of under • 2% C-

Section and Orthopaedic

• 10% Colorectal

for programme leadership SSI meeting 2017): C-Section ave rate 2.0% Orthopaedic ave rate 1.0% Colorectal rate 10.8%

5s Change of use of drugs

5 Achieve national antimicrobial prescribing targets as defined by Scottish Antimicrobial prescribing

Operational unit Clinical Lead/Lead Pharmacist Antimicrobial management team

Antimicrobial Management Team (AMT)meeting

ADTC / COIC

Antimicrobial Management Team meeting / Local Operational unit IPC meetings / ICIG

31.03.18 Compliant with all national targets

80% target for review of antibiotic therapy by March 2018 established in wards 6C, 7A, 4C Raigmore. All areas achieving the required standard as of Nov 2017. The total antibiotic prescribing report is monitored quarterly by AMT. Current data: Belford achieved overall compliance. All 4 acute hospitals met piperacillin/tazobactam measure; Lorn & Islands and Belford Hospital met carbapenems measure.

Amber based on current quarter position

Elective care Centre

6 Deliver national ScRap resource on antibiotic prescribing to GP practices and clusters

Operational unit Clinical Lead/Lead Pharmacist Antimicrobial Management Team

Antimicrobial Management Team meeting

ADTC / COIC

Antimicrobial Management Team meeting / Local Operational unit meetings

31.03.18 Deliver to 50% GP Practices or Clusters

Data collection underway

GREEN

7 Raise public/ staff awareness of Infection

Infection control and Prevention Team/

ICIG / Local Operational unit IPC

COIC Local Operational unit IPC

31.03.18

Compliant with objective

Proactive communication streams in place with

BLUE


prevention and control through proactive communication.

Communications meeting meetings / ICIG

Communication Department

8 Nursing and midwifery staff group demonstrate a 20% increase in the number of staff undertaking mandatory clinical IPC module by 2018.


ICIG / Local Operational unit IPC meeting

COIC/ Educational sub-governance committee

Local Operational unit IPC meetings / ICIG

31.03.18 Compliant with objective

Data to be produced quarterly by Learning and development (expectant date end of Feb 2018) Should be noted that SICEP has replaced IPC module.

GREEN

9 Improve compliance of number of nursing staff with IPC related objective in PDP by 20% by 2018


Local Operational Unit IPC meetings

ICIG/ COIC Local Operational unit IPC meetings


Information shared with Lead Nurses, review of Statutory and Mandatory prospectus updated. Concerns expressed regarding data collection and assurance method whilst we await electronic system

AMBER

10 Achieve positive HEI HAI inspections


Local Operational Unit IPC meetings

ICIG/ COIC Local Operational unit IPC meetings


HEI issued 3 requirements following visit to MacKinnon Hospital, all met.

GREEN

Abbreviations

ADTC – Area Drugs and therapeutic Committee AMT – Antimicrobial Management Team CDI – Clostridium difficile Infection

CAUTI – Catheter associated urinary tract infection COIC – Control of Infection Committee HAI – Healthcare Associated Infection

HEI – Healthcare Environment Inspection HPS – Health Protection Scotland ICIG – Infection Control Improvement Group


IPCN – Infection Prevention & Control Nurse IPCT – Infection Prevention & Control Team ICNET – Electronic Infection Control Surveillance programme

L&D – Learning and development MRSA – Meticillin Resistant Staphylococcus aureus PDP – Personal Development Plan

PVC – Peripheral Vascular Catheter SAPG – Scottish Antimicrobial Prescribing Group SAB – Staphylococcus aureus bacteraemia

SCN – Senior Charge Nurses ScRAP - Scottish Reduction in Antibiotic Prescribing (ScRAP) Programme

SOP – Standard Operating Procedures SPSP – Scottish Patient Safety Programme SSI – Surveillance of Surgical Site infections

Documents

Highland NHS Board 30 January 2018 Item 4.3 INFECTION ......Antibiotic prescribing audits (using the new format) commenced in July 2017, on wards 6C, 7A and 4C in Raigmore. The main