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Paper 5

Ayrshire and Arran NHS Board Monday 27 May 2019

Healthcare Associated Infection Exception Report Author: Bob Wilson, Infection Control Manager

Sponsoring Director: Professor Hazel Borland, Nurse Director

Date: 25 April 2019

Recommendation Board members are asked to review this report on Healthcare Associated Infections (HAI) with particular reference to the position against the 2018-19 national HAI targets, together with other infection prevention and control (IP&C) monitoring data.

Summary and key messages The report topics are: Staphylococcus aureus bacteraemia (SABs) Clostridium difficile infection (CDI) Escherichia coli (E. coli) bacteraemia Meticillin resistant Staphylococcus aureus (MRSA) Outbreaks/Incidents update

National HAI Target NHS Ayrshire and Arran Update

1 April 2018 – 31 March 2019

(1) SAB: To achieve a rate of no more than 0.24 cases per 1,000 acute occupied bed days by the year ending 31st March 2019 (approximates to 84 cases per annum).

There have been 103 SAB cases at month 12. This is above the Board’s numerical target trajectory by 19 cases.

The verified annual rate for the year ending December 2018 is 0.30.

The projected rate for the year ending March 2019 is 0.28.

The Board is projected not to have met the 2018-19 target

(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 March 2019 (approximates to 120 cases per annum).

There have been 90 CDI cases at month 12. This is 30 below the Board’s numerical target trajectory.

The verified annual rate for the year ending December 2018 is 0.25.

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The projected rate for the year ending March 2019 is 0.23. If confirmed this will be the Board’s lowest recorded rate since the current surveillance programme began in 2009.

The board is projected to have met the 2018-19 target.

Glossary of Terms

CA Community Acquired CDI Clostridium difficile Infection CRA Clinical Risk Assessment E. coli Escherichia coli HA Hospital Acquired HAI Healthcare Associated Infection HCA Healthcare Associated HPS Health Protection Scotland IP&C Infection Prevention & Control IPCT Infection Prevention & Control Team KPI Key Performance Indicator MRSA Meticillin Resistant Staphylococcus aureus NCP National Catheter Passport NHSA&A NHS Ayshire & Arran PVC Peripheral Vascular Catheter QIT Quality Improvement Team SAB Staphylococcus aureus bacteraemia

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1. SAB Update 1.1 Local Delivery Plan Target 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 March 2019 (approximates to seven SABs per month). The Boards verified SAB rate for the year ending December 2018 was 0.30 cases per 1,000 acute occupied bed days (Chart 1). The Scottish rate for the corresponding period was 0.33. The projected rate for the year ending March 2019 is 0.28. The Board is projected not have met the 2018 - 19 Target

Chart 1 – Rolling Annual SAB rate against national target There were 103 SABs during the year; this exceeds the local numerical target by 19 cases (Chart 2). This compares with 107 cases in 2017-18.

Chart 2 – SAB Target 2018–19 Local Trajectory

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1.2 Origin of Infection The origins of infection for the SABs identified during the year are detailed in Table 1. There was a 12% percent reduction hospital acquired SABs and a corresponding proportional increase in those that were healthcare associated during the year. Community acquired SABs remained unchanged.

Origin of Infection 2017-18 2018-19

Hospital acquired 50 44

Healthcare associated 17 19

Community acquired 40 40

Table 1 – Origin of SAB Infections The monthly number of SABs has trended downwards since the peak in June and now fluctuates around the mean (Chart 3).

Chart 3 - Monthly SAB Totals April 2016 – March 2019 The subset which is assessed as being hospital acquired has tended to be below or just above the mean with the exception of the spike November 18 (Chart 4).

Chart 4 – Monthly Hospital Acquired SABs April 2016 – March 2019

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1.3 Point of Entry The national enhanced SAB surveillance programme requires Boards to assess the point of entry of the organism into the patient. This is to determine the most appropriate interventions for prevention. The point of entry was Not Known in 34 cases compared with 40 in 2017-18; whilst skin infections were the single largest identifiable cause responsible for 23 cases, an increase of 109%. This in part may be due to the decrease in Not Knowns (Table 2).

SAB Point of Entry 2017-18 2018-19

Not Known 40 34

Skin 11 23

Contaminants 8 13

Peripheral Vascular Catheter (PVC) 16 9

People Who Inject Drugs 7 6

Central Lines 5 5

Dialysis Lines & Fistulas 9 4

Respiratory Infection 4 3

Urinary Catheter 0 2

Urinary Tract Infection 2 1

Supra-pubic Catheter 0 1

Nephrostomy 1 1

Other 3 1

ENT 1 0

Total 107 103

Table 2 – SAB Point of Entry April 2018 – January 2019 Blood culture contaminants increased by 63% to 13. This to a degree may be reflective of the service pressures in the Emergency Departments and Combined Assessment Units. It is recognised that there is an increase in contamination rates when blood cultures are taken in emergency situations. There were seven contaminants in these four areas compared with four the previous year. The remaining six were across five different wards. To coincide with a change in the equipment used to obtain blood cultures arrangements are being made with the manufacturer for training on blood culture technique to be delivered at ward level across both University Hospital Ayr and University Hospital Crosshouse. A prime area of focus in recent years has been PVC associated SABs. This has included the introduction of revised documentation utilising the mnemonic DRIFT (Diagnosis, Resuscitation, IV medication, Fluids, Transfusion) and PVC insertion packs. There has been a 43% reduction in PVC related SABs compared with the previous year. This is in part due to a reduction in SABs associated with Cardiology and potentially in part due to the measures described above. Further time is required to determine if the reduction can be sustained. There was an increase in renal vascular access related SABs in 2017-18 which has now been reversed with a 55% reduction. Each renal related SAB undergoes a local root cause analysis with the learning shared at a multi-disciplinary education meeting.

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2. CDI Update 2.1 Local Delivery Plan Target 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 March 2019 (approximates to 10 cases per month). The verified annual rate for the year ending December 2018 was 0.25 (Chart 5). The projected rate for the year ending March 2019 is 0.23. This is the lowest annual rate recorded by the Board since the current surveillance programme began in 2009. The Board is projected to have met the CDI target.

Chart 5 – Rolling Annual CDI Rate

At the end of March 2019 there had been 90 cases of CDI which was 30 below the maximum local numerical trajectory (Chart 6). This compares with 114 cases in 2017-18, a 21% reduction.

Chart 6 – CDI Local Target Trajectory 2018-19

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2.2 Origin of Infection All cases of CDI are assessed against the Health Protection Scotland (HPS) criteria to determine the origin of infection. If the positive Clostridium difficile sample is taken more than 48 hours after admission or within four weeks of discharge then it is deemed to be healthcare associated. If it is taken between four and 12 weeks after discharge from hospital it is classed as unknown origin and if it is taken more than 12 weeks after discharge then it is categorised as community acquired. The origin of CDI cases are detailed in Table 3. There were reductions in all three categories compared with 2017-18

Origin of Infection 2017-18 2018-19

Healthcare associated 74 60

Unknown 11 8

Community acquired 29 22

Table 3 – Origin of CDI Cases

In the last 12 months the number of hospital identified cases of CDI has remained primarily at or below the mean as have those which are assessed as hospital acquired. In October there was a breach of the upper warning limit for hospital acquired cases. There was no outbreak associated with this increase and the numbers reverted to the mean in November (Charts 7 & 8). It should be noted that the overall numbers are low therefore small monthly changes can seem quite marked on the charts.

Chart 7 – Hospital Identified Cases of CDI April 2016 – March 2019

Chart 8 - Hospital Acquired Cases of CDI April 2016 – March 2019

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3. Escherichia coli (E. coli) Bacteraemias 3.1 Background The national surveillance programme requires all E. coli bacteraemias to be categorised as hospital acquired (HA), healthcare associated (HCA) or community acquired (CA). For national reporting purposes HPS combine the HA and HCA rates into one under the heading of healthcare associated. For the purposes of clarity this combined rate is referred to as HA/HCA in the analysis below. 3.1.1 HA/HCA E. coli Bacteraemia The Board’s verified HA/HCA rate for the quarter October – December 2018 quarter is 36.1. The projected rate for the January - March 2019 quarter is 42.6 (Chart 9).

Chart 9 – NHS A&A HA/HCA E. coli Bacteraemia Quarterly Rates

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The Board’s verified annual HA/HCA rate for the year ending December 2018 was 45.5 with a projected rate of 44.7 for the year ending March 2019 (Chart 10).

Chart 10 – NHS A&A HA/HCA E. coli Bacteraemia Annual Rate 3.1.2 CA E. coli Bacteraemias The Board’s verified CA E. coli bacteraemia rate for the October - December 2018 quarter is 52.5 cases per 100,000 populations (Chart 11). The projected rate for the January – March 2019 quarter is 46.4.

Chart 11 – NHS A&A CA E. coli Bacteraemia Quarterly Rate

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The verified annual rate for the year ending December 2018 is 58.6 (Chart 12). The projected rate for the year ending March 2019 is 56.7.

Chart 12 – NHS A&A CA E. coli Bacteraemia Annual Rate By definition these infections have no link to healthcare and therefore there are no healthcare interventions that can be implemented to reduce them. It may be that wider public health campaigns such as the national Hydration Campaign which was implemented earlier in 2018 will have an impact. Assessment at a national level is required to determine if this is the case. 3.3 Interventions Analysis of our local data has identified in order to achieve a meaningful reduction the primary focus has to be on reducing those HA/HCA bacteraemias deemed to be related to urinary catheters. 3.3.1 Urinary Catheter Insertion and Maintenance Bundles As part of the Scottish Patient Safety Programme the Quality Improvement Team (QIT) supported by the Continence Advisors and the Infection Prevention Control Team (IPCT) have completed a training programme across all acute wards. The included:

Roll out of revised urinary catheter insertion and maintenance bundles

Prevention of catheter associated urinary tract infections and alternatives to catheterisation

Data collection on urinary catheter usage The programme is now underway within the community hospitals 3.3.2 Implementation of the National Catheter Passport The National Catheter Passport (NCP) is a hand held personal record that functions as a communication tool for staff especially around the reason for insertion and future management plans. It also acts as an educational tool for patients and carers. The Continence Advisors will support roll out across NHSA&A, initially with the District Nursing

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Service. A multi-disciplinary quality improvement project has been established in collaboration with a GP practice in South Ayrshire to test the implementation of the NCP. 3.3.3 Enhanced Surveillance and Case Investigation From January the IPCT have initiated enhanced investigation and surveillance of all urinary catheter related E. coli bacteraemias to provide more in depth data that can inform future interventions. As the data collection is still at the early stages there insufficient information from which to draw firm conclusions as yet. 3.3.4 Urinary Catheter Related Escherichia coli bacteraemias Bacteraemia Summit On 1 April 2019 a summit was held to review the local and national data around urinary catheter related bacteraemias and to discuss current and potential interventions aimed at reducing these. There was attendance from hospital and community nursing teams, the Continence Advisory Service, QIT and the IPCT. Support was also provided by colleagues from NHS Fife who shared their approach to addressing the issue. Discussions focussed on:

Alternatives to catheterisation

Decision making on insertion and removal of urinary catheters

Urinary catheter management

Communication including to and from the patient

Organisational issues NHS Fife has identified the same themes as we have in NHSA&A. To oversee the development of a programme of interventions they have established a Board wide Urinary Catheter Improvement Group. This is a sub–group of their Infection Control Committee and its purpose is to develop and oversee the implementation of interventions and to provide assurance around the effectiveness of these interventions. A paper will be submitted the Prevention and Control of Infection Committee on 16 May 2019 detailing the findings of the summit and proposing that we adopt a similar approach to that of NHS Fife and establish a multi-disciplinary Urinary Catheter Improvement Group to drive forward our interventions. There was recognition by all parties that addressing this issue will be complex and will be a journey that requires long term focus with no quick and simple fixes. We will continue to liaise with NHS Fife and share our respective learning as we both progress on this journey. 3.4 Conclusion Achieving sustainable reductions in our HA/HCA bacteraemias is a significant challenge for all Boards. Traditional infection prevention and control interventions such as hand hygiene, isolation of infected patients and the use of personal protective equipment are already embedded in healthcare. Focus on these areas is unlikely to bring about improvements in E. coli bacteraemia rates. Different interventions are required and due to limitations in both the national dataset and the academic research base further work is required to assist in the identification of interventions.

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Due to multi-factorial causes of E. coli bacteraemias and the fact that the majority of infections arise from the patient’s own microbial flora many of these infections, including those classed as HA/HCA may not be preventable. Likewise those which are community acquired are not amenable to any identified direct healthcare interventions and are likely to require further, and as yet unidentified, broad national public health initiatives such as the Hydration Campaign. As an example, data from England demonstrates that there is seasonality associated with E. coli bacteraemias with more cases occurring in the summer months. One hypothesis, as yet unproven, is that higher summer temperatures lead to an increase in the number of elderly patients suffering from dehydration which in turn leads to an increase in E. coli urinary tract infections which in turn leads to increase in E. coli bacteraemias. In order to achieve sustained reductions in the E. coli bacteraemia rate new initiatives across the health and social care spectrum require to be identified. It is proposed that a Urinary Catheter Improvement Group be established to drive forward this agenda. 4. National MRSA Clinical Risk Assessment (CRA) Policy Update The national MRSA CRA Key Performance Indicator (KPI) target is for boards to achieve a minimum 90% compliance with CRA completion. In Quarter 4 (2018-19) the Board’s compliance increased to 93% (Chart 13). The Scottish compliance rate for that quarter has not yet been published.

Chart 13 – MRSA KPI Quarterly Compliance

5. Outbreaks / Incidents Update 5.1 Ward/Room Closures Since the last report there has been 1 outbreak of confirmed Norovirus.

Area Month Reason Patients Staff Room or Ward Closure

Ward 4D UHC March Confirmed Norovirus

4 3 Room

Table 5: Ward/Room Closures Due to Outbreaks

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Monitoring Form

Policy/Strategy Implications

The interventions described in this paper are designed to reduce patient harm and support the Board’s Healthcare Quality Strategy.

Workforce Implications

Not required. This update report has no workforce resource implications.

Financial Implications

The continual management and monitoring of HAIs in NHSA&A 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.

Consultation (including Professional Committees)

The HAI update is provided to agreed NHS Boards, Healthcare Governance Committees and to the Prevention & Control of Infection Committee at every meeting.

Risk Assessment

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.

Best Value - Vision and leadership - Effective partnerships - Governance and

accountability - Use of resources - Performance management

Delivers effective partnerships and governance and accountability for the Board and best use of resources.

Compliance with Corporate Objectives

Protect and improve the health and wellbeing of the population and reduce inequalities, including through advocacy, prevention and anticipatory care.

Single Outcome Agreement (SOA)

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.