Item 12 – Infection control HCAI update - East and North Herts NHS ...

Trust Board
HCAI update
May 28, 2008
Noel Scanlon
Director of Infection prevention & Control / Director of Nursing
James Quinn
Medical Director
Lorane Fitch
Lead Doctor, Infection control
Kevin Hazelwood
Antimicrobial pharmacist

MRSA target & performance 2008/9
MRSA bacteraemia incidence* v. target
100
90
No. of MRSA bacteraemias
80
70
60
50
40
30
20
10
0
2001 / 02 2002 / 03 2003 / 04 2004 / 05 2005 / 06 2006 / 07 YTD 2007/8 target 2008/9
Target 0 0 56 48 39 31 22 21
Actual 72 86 56 50 56 53 33 2
Year
Target
Actual
Infections in
year to date
April 30,
2008
UNVALIDA
TED
2
MRSA/HCAI report to Board

Monthly performance vs Recovery trajectory 2008/9
Cases M RSA Bacteraem ia
3
2
1
0
Incidence v recovery trajectory MRSA Bacteraemia
E&N Herts NHS Trust 2008/9
Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar
Month
Post 48 hour Pre 48 hour Trajectory 2008/9
3
MRSA/HCAI report to Board

MRSA cumulative performance 2006/7, 2007/8 & 2008/9
MRSA Bacteraemia Cumulative performance 2006/7 & 2007/8
60
50
40
34%
reduction
FYTD
2006/7 to
2007/8
month
30
20
10
0
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
MRSA Bacteraemias
2006/7
2007/8
2008/9
4
MRSA/HCAI report to Board

Incidence & Prevalence MRSA Bacteraemia 2007-8
Not Set
3%
Trauma &
orthopaedics
6%
ICU
9%
HDU
6%
Cardiology
6% Colorectal surgery
6%
Gastroenterology
3%
Nephrology
12%
General medicine
25%
Geriatric medicine
15%
General surgery
9%
5
MRSA/HCAI report to Board

Root causes of MRSA bacteraemia 2007-8
Risk factors in MRSA Bacteramias 2007_8 RCAs 2007_8
Unavoidable pre 48 hr
6%
Ab use
11%
Contams prob/pos
19%
Screening issue
15%
PVC
9%
Unknown
6%
Other
9%
Urine
2%
Surg wound
6%
CVC/fem/art
17%
6
MRSA/HCAI report to Board

Key actions
‣ Blood culture care bundle including
• packs containing Chloraprep 0.7ml
vial with
• ICE order comms care bundle &
training check
• Sanction of not processing blood
culture unless completed
‣ Peripheral line packs
• Mandating aseptic technique with a
dressing trolley
• Making recording date of insertion
to facilitate regular VIP score and
removal at 48-72h
o In case notes
o Beside IV line dressing
7
MRSA/HCAI report to Board

Clostridium difficile incidence 2004/5 to date
v targets 2007/8 and 2008/9
700
600
563 574
500
414
400
300
200
356
183
C Diff
incidence
Track line
target
New track line
2008/9 target
Linear (Track
line target)
100
0
2005/6 2006/7 2007/8* 2008/9 2007/8
Target
18
2008/9
Target
8
*ytd April 30, 2008 unvalidated
MRSA/HCAI report to Board

Clostridium difficile performance * v trajectory/target 2008/9‡
‡ inc. all Hosp. Acquired cases over 2yo not
just >65yo observed at >48h admission
Incidence v recovery trajectory Clostridium difficile E&N Herts NHS Trust 2007/8
40
35
Cases in patients over 65 yo
30
25
20
15
10
5
0
Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar
Month
"Hospital Inpatient" specimens "Not Hospital Inpatient" specimens Local trajectory 2008/9
9
MRSA/HCAI report to Board

Root cause analyses Clostridium difficile assoc. diarrhoea
(CDAD) April
‣ Three deaths with CDAD
• One of these where CDAD cited as 1a cause of death (CoD),
• one as 2 CoD
‣ 15 cases in April subject to remote Root cause analysis
• Antibiotics implicated in 9 cases
o
Only one of these Cephalsporins, none with Quinnolones
o 8 involving v long courses of Erythromycin, Augmentin, Amoxicillin – 6 – 17
days
– Inc. IV antbiotics for 5-11 days
– One occasion for a ‘carpet burn’ IV Rx “unknown” to medical staff ?
• Proton pump inhibitors implicated in 9 cases
• Delays in isolation for diarrhoea of unknown cause - not presumptive or
confirmed C Diff implicated in 6 cases
‣ Proposing to introduce IC Consultant led RCA with Consultant I/c Matron &
ward staff for all Colectomies, deaths & ICU admissions associated with
CDAD wef May 12 th
• T&O first case to trial new RCA Tool
10
MRSA/HCAI report to Board

Trust Care bundle (HII) compliance rates
Hand Hygiene
Environment & Safety
100
90
80
70
60
50
100
90
80
70
60
50
40
21-Mar-08 28-Mar-08 04-Apr-08 11-Apr-08 18-Apr-08 25-Apr-08
40
21-Mar-08 28-Mar-08 04-Apr-08 11-Apr-08 18-Apr-08 25-Apr-08
100
90
80
70
60
50
MRSA Screening
100
90
80
70
60
50
Peripheral Lines
40
21-Mar-08 28-Mar-08 04-Apr-08 11-Apr-08 18-Apr-08 25-Apr-08
40
21-Mar-08 28-Mar-08 04-Apr-08 11-Apr-08 18-Apr-08 25-Apr-08
11
MRSA/HCAI report to Board

Trust HII, hand hygiene, screening &
environment scores
Urinary Catheter Care
Care of Renal Dialysis Patients
100
90
80
70
60
50
40
21-Mar-08 28-Mar-08 04-Apr-08 11-Apr-08 18-Apr-08 25-Apr-08
100
90
80
70
60
50
40
21-Mar-08 28-Mar-08 04-Apr-08 11-Apr-08 18-Apr-08 25-Apr-08
Central Venous Catheter Care
Care of Ventilated Patients
100
90
80
70
60
50
40
21-Mar-08 28-Mar-08 04-Apr-08 11-Apr-08 18-Apr-08 25-Apr-08
100
90
80
70
60
50
40
21-Mar-08 28-Mar-08 04-Apr-08 11-Apr-08 18-Apr-08 25-Apr-08
12
MRSA/HCAI report to Board

Isolation audits
12
Isolated within 2hrs
No
Yes
No. of Patients
10
8
6
4
2
0
21-M ar-08 28-M ar-08 04-Apr-08 11-Apr-08 18-Apr-08 25-Apr-08
No of Days to Isolate
No. of BedDays
20
18
16
14
12
10
8
6
4
2
0
21-M ar-08 28-M ar-08 04-Apr-08 11-Apr-08 18-Apr-08 25-Apr-08
13
MRSA/HCAI report to Board

A step change in reduction of HCAI
‣ The Medical Director and Director of Infection prevention and Control have
considered the latest guidance from the Health Protection Agency, Hospital
Infection Society and the Infection Control Nurses Association in evaluating
what further steps might be taken in bringing about a step wise reduction in
the incidence of health care associated infections.
‣ A series of measures around the 10 key recommendations for each of the
current HPA, HIS and ICNA standard references for Clostridium difficile and
MRSA reduction focus upon the major modes of transmission and portals of
entry for these infections:
• Surveillance
• Hand hygiene
• Antibiotic prescribing
• Isolation
• Environmental cleansing and decontamination
• Screening and decolonisation
• Management of invasive devices
• Aseptic technique.
‣ This is being reviewed by the Trust infection control committee and will be
brought to the Executive ctee. this month
14
MRSA/HCAI report to Board