healthcare associated infection reporting template · web viewheather gourlay- senior manager...

Healthcare Associated Infection Report August 2015 data

Section 1 – Board Wide Issues

Heather Gourlay- Senior Manager Prevention and Control of InfectionSandra McAuley – Clinical Nurse Manager Prevention and Control of Infection Data 21/09/15

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Key Healthcare Associated Infection Headlines Staphylococcus aureus Bacteraemia – 1 SAB to report in August which is

a total of 6 SAB since April 2015.

(See page 3 for additional information)Clostridium difficile infection- Nil to report

Hand Hygiene- Combined Hand Hygiene Compliance and Technique 99%.

Increase in Medical Staff compliance from previous reporting period from 92% to 99%. Next audit due end September.

Cleaning and the Healthcare Environment- Facilities Management ToolHousekeeping Compliance- 98.4%

Estates Compliance- 99.7%

Surgical Site Infection1 Superficial CABG SSI to report in August

Other HAI Related ActivityProblem Assessment Groups (PAG) - Locally convened group to further investigate an HAI issue (not outbreak) which may require additional multidisciplinary controls

PAGs in August Update ProgressMycobacterium chimaeria

The Board is continuing to assist Health Protection Scotland in its response to this European alert. To date all repeat water samples and all air samples have been negative. The next Incident Management telephone conference will be held on the 17th

September 2015.

Ongoing

S.aureus bacteraemia

The Prevention and Control of Infection Team are working closely with the clinical teams involved and clinical educators to identify and address risk factors that may contribute to SAB acquisition. This work is detailed within our local SAB Action Plan.

Ongoing

Section 1 of the HAIRT covers Board wide infection prevention and control activity and actions. For reports on individual departments, please refer to the ‘Healthcare Associated Infection Report Cards’ in Section 2.

Staphylococcus aureus (including MRSA)

GJNH approach to SAB prevention and reduction It is accepted nationally within HPS that care must be taken in making comparisons with other Boards data because of the specialist patient population within GJNH.All SAB isolates identified within the laboratory are subject to case investigation to determine future learning and quality improvement.

Small numbers of cases can quickly change our targeted approach to SAB reduction.

The epidemiology of SAB infections has changed locally in the last 2 quarters as a result we approached HPS in August for further support/assurances re our corrective action plan. This focuses on the following;

Personal Protective Equipment IABP and PVC Insertion Site care IABP and PVC Education Environment/Storage Equipment

Broad HAI initiatives which influence our SAB rate include- Hand Hygiene monitoring MRSA screening at pre-assessment clinics and admission Compliance with National Housekeeping Specifications Audit of the environment and practices via Prevention and Control of Infection

Annual Reviews & monthly SCN lead Standard Infection Control Precautions and Peer Review monitoring

Participation in National Enhanced SAB surveillance- gaining further intelligence on the epidemiology of SAB.

SSI Related SAB


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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

http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=30248

http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252


Introduction of MSSA screening for cardiac and subsequent treatment pre andPost op as a risk reduction approach. Surgical Site Infection Surveillance in collaboration with Health ProtectionScotland and compared with Health Protection Agency data to allow rapid identification of increasing and decreasing trends of SSI. Standardisation of post op cardiac wound care. Development and implementation of a wound swabbing protocol and competency.

Device Related SAB SPSP work streams continue to implement and aim to sustain compliance in PVC and CVC bundles. Introduction of Lan Qip allows assessment of compliance locally and help target interventions accordingly. Work is underway to review and implement PICC and IABP bundles.

Contaminated samples Blood Culture collection system to reduce risk of false positive contaminants.

SAB LDP Heat Delivery Trajectories Boards are expected to achieve a rate of 0.24 cases per 1,000 acute occupied bed days or lower by year ending March 2016. Boards currently with a rate of less than 0.24 are expected to at least maintain this, as reflected in their trajectories. GJNH have not achieved our LDP target of 0.12. In order to achieve the national trajectory for SAB reduction for 2015/16 we must have less than 12 identified SAB cases by March 2016 (n= 5 Oct 15- Mar 16).

Our current rolling quarterly SAB rate April 15- Jun 15 is 0.41 per 1000 occupied bed days.

Apr-Jun 14 Jul-Sep 14 Oct-Dec 14 Jan-Mar 15 Apr-Jun 15 Jul-Sep 150.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

SAB RATE LOCAL/NATIONAL TRAJECTORY BY QUARTER by 1000aobd

LOCAL RATE NAT TRAJECTORY LOCAL TRAJECTORY

Between April 15 and August 15 we have noted an increased incidence in SAB cases. 6 are confirmed cases and 2 cases are attributed to the GJNH via another health board and microbiologically are different strains of S.aureus Heather Gourlay- Senior Manager Prevention and Control of InfectionSandra McAuley – Clinical Nurse Manager Prevention and Control of Infection Data 21/09/15

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All SABs identified are subject to root cause analysis in conjunction with the clinical area concerned to determine a source and identify improvement interventions where required.

In these recent cases the sources have been attributed to PVC and IABP use with the majority of patients presenting with additional complex underlying health issues. The Prevention and Control of Infection Team are working closely with the clinical teams involved and clinical educators to identify and address risk factors that may contribute to SAB acquisition. This work is detailed within our local SAB Action Plan.

IABP

PICC PV

C

012345

HOSPITAL ACQUIRED SAB SOURCES AUG 14- AUG 15

Series1

SOURCE OF SAB

COUNT

2EAST

2WEST CCU 2C

CDU3W

EST3EA

ST NSD SDU

ICU1ICU2

HDU2HDU3

4 WEST

0

1

2

3

4

S.aureus Bacteraemias (SAB) by area Aug 14- Aug 15

Area

SAB

SOURCE INTERVENTION Planned Competition Date

IABP Development/Update of PICC I and M End August


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bundlesDevelopment/Update of IABP I and M bundles

End August

Review of PICC and IABP policies with educators- an subsequent additions to policy

End August

Testing device leaflet for patients in NSD Currently testingPCIN visit re devices in NSD End August

PVC PVC Insertion bundle is not a feature on LanQip, scoping how these process measures can be demonstrated.

End August

HEI Preparedness group to consider device education for patients

Meeting 17th August

Standardise PVC Competencies End September

Clostridium difficile

CDI LDP Heat Delivery Trajectories

Boards are expected to achieve a rate of 0.32 cases CDI per 1,000 occupied bed days by year ending March 2016. This relates to people aged 15 and over. Boards currently with a rate of less than 0.32 are expected to at least maintain this, as reflected in their trajectories.

Our current CDI rate April 15- Jun 15 is 0 per 1000 occupied bed days.

Hand Hygiene


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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 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/ssdetail.aspx?id=277

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

GJNH approach to CDI prevention and reductionOur numbers of CDI cases are low in comparison with other Boards, which is likely to relate to our specialist patient population.

Actions to reduce CDI- Ongoing alert organism surveillance and close monitoring of the severity of

cases by the PCIT.

Unit specific reporting and triggers.

Implementation of HPS Trigger Tool if trigger is breached.

Implementation of HPS Severe Case Investigation Tool if the case definition is met

Typing of isolates when two or more cases occur within 30 days in one unit.

http://www.hps.scot.nhs.uk/haiic/ic/nationalhandhygienecampaign.aspx

http://www.washyourhandsofthem.com/

May /June 2015 Bi Monthly Hand Hygiene Report Summary

84%

85%

86%

87%

88%

89%

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Com

bine

d S

core

%

Audit Dates

Jul-12 Sep-12 Jan-13 Mar-13 May-13 Jul-13 Oct-13 Jan-14 Mar-14 May-14 Jul-14 Sep-14 Nov-14 Jan-15 Mar-15 May-15 Jul-15Series1 98% 98% 100% 99% 99% 98% 98% 95% 98% 97% 97% 99% 97% 97% 97% 97% 99%

HH Combined (Opportunity and Technique)Score

Series1


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GJNH approach to Hand Hygiene The latest Board bimonthly audits showed combined compliance score is 99%. Medical Staff Compliance has improved since last audit. Next Audit Sept.

Local and national data shows sustained improvement in compliance overall since March 2014, although there are still small pockets of clinical areas that do not demonstrate sustained compliance. The PCINs are working closely with these areas to facilitate quality improvement through corrective action plans.

Quality assurance of Hand Hygiene data continues to be undertaken on a monthly basis.

70%

75%

80%

85%

90%

95%

100%

Jul-1

2

Sep

-12

Nov

-12

Jan-

13

Mar

-13

May

-13

Jul-1

3

Sep

-13

Nov

-13

Jan-

14

Mar

-14

May

-14

Jul-1

4

Sep

-14

Nov

-14

Jan-

15

Mar

-15

May

-15

Jul-1

5

Com

plia

nce%

Audit Dates

Jul-12 Sep-12

Jan-13

Mar-13

May-13 Jul-13 Oct-

13Jan-14

Mar-14

May-14 Jul-14 Sep-

14Nov-14

Jan-15

Mar-15

May-15 Jul-15

Nurse 99% 99% 100% 99% 99% 100% 100% 99% 99% 95% 99% 99% 98% 99% 99% 99% 100%Medical 92% 98% 100% 100% 96% 97% 97% 93% 95% 100% 99% 98% 96% 100% 98% 94% 99%AHP 98% 100% 100% 100% 100% 100% 95% 96% 96% 100% 99% 97% 92% 98% 97% 98% 97%Ancilliary/Other 100% 100% 100% 100% 100% 95% 100% 93% 100% 100% 94% 100% 100% 100% 100% 100% 100%

HH "Opportunity Taken" Compliance Board Level

Nurse

Medical

AHP

Ancilliary/Other

40%

50%

60%

70%

80%

90%

100%

Com

plia

nce

Audit Dates

Jul-12 Sep-12 Jan-13 Mar-13 May-13 Jul-13 Oct-13 Jan-14 Mar-14 May-14 Jul-14 Sep-14 Nov-14 Jan-15 Mar-15 May-15 Jul-15Nurse 100% 100% 100% 100% 99% 99% 100% 100% 100% 95% 99% 99% 98% 98% 98% 99% 100%Medical 100% 100% 100% 100% 94% 100% 100% 100% 100% 100% 96% 98% 96% 99% 95% 94% 99%AHP 100% 98% 100% 100% 100% 100% 100% 100% 100% 97% 95% 97% 92% 100% 97% 98% 97%Ancilliary/Other 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 94% 100% 100% 91% 100% 100% 100%

HH " Correct Technique" Compliance Board Level

Nurse

Medical

AHP

Ancilliary/Other

Hand Hygiene Compliance by AreaHeather Gourlay- Senior Manager Prevention and Control of InfectionSandra McAuley – Clinical Nurse Manager Prevention and Control of Infection Data 21/09/15

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AREA REVIEWED COMPLIANCE2C 100%THEATRE 3 100%3 WEST 100%3 EAST 100%CDU 100%OPD 100%2D 100%ICU 1 100%CCU 100%2 WEST 100%ICU 2 100%SDU 100%NSD 100%HDU 2 95%HDU 3 95%

AREASTAFF GROUP KEY MOMENT TAKEN

PERFORMED CORRECTLY

HDU 3 DOCTORAFTER CONTACT WITH SURROUNDINGS NO NA

HDU 2 AHP BEFORE PT CONTACT NO NA

Action taken – Non complaint staff were spoken to at time of audit and reminded of hand hygiene requirements and key moments


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Cleaning and Maintaining the Healthcare Environment

Housekeeping FMT Audit Results

80.0082.0084.0086.0088.0090.0092.0094.0096.0098.00

100.00

HDU2 HDU3 Operating Theatres

2 East 2 West 3 East 3 West 4 West CDU SDU(prev

HDU1)

CCU 2C&D(prev.

CCU 1/2)

ICU 1 ICU 2 NSU Theatre Recovery

Theatres + Cath Lab

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

HDU2 HDU3Operating Theatres 2 East 2 West 3 East 3 West 4 West CDU

SDU(prev HDU1)

CCU 2C&D(prev .

CCU 1/2) ICU 1 ICU 2 NSUTheatre

Recovery Theatres + Cath Lab

Aug-14 97.35 97.65 98.96 98.20 95.84 98.37 97.30 97.76 96.88 94.85 96.37 97.50 97.25 97.68 98.45Sep-14 98.59 97.23 98.44 97.38 94.97 96.28 97.68 98.62 99.59 95.87 97.48 95.13 96.18 100.00 97.98Oct-14 97.40 97.63 97.62 95.35 96.42 95.04 96.75 97.25 100.00 94.25 97.65 95.85 96.24 99.23 99.62Nov-14 97.33 96.57 96.61 95.34 96.09 95.64 96.30 97.25 99.22 95.51 96.90 95.73 96.70 99.61 98.68Dec-14 97.66 97.20 97.40 95.84 96.29 95.82 96.68 97.50 99.33 94.63 97.10 96.04 96.75 99.23 98.31Jan-15 98.51 99.12 97.92 96.98 94.91 96.22 95.24 96.22 98.91 100.00 97.69 97.08 95.41 98.23 99.24 99.56Feb-15 98.68 98.17 100.00 97.63 97.15 96.03 97.14 97.60 99.42 99.81 97.83 97.77 96.56 97.94 100.00 99.55Mar-15 99.20 99.14 98.96 97.27 98.08 96.75 98.30 98.62 100.00 99.44 97.54 98.75 99.64 98.84 99.24 99.09Apr-15 98.57 99.09 99.48 97.67 98.20 97.68 98.17 99.18 99.67 97.06 98.72 97.14 97.76 99.23 100.00

May-15 99.44 99.47 100.00 98.48 96.86 98.26 98.93 98.90 98.46 99.05 98.73 98.60 97.92 99.24 100.00Jun-15 99.32 99.28 100.00 98.94 98.41 98.54 98.51 99.72 99.82 98.14 98.68 99.05 98.88 100.00 100.00Jul-15 99.28 99.09 99.36 98.44 98.54 98.20 98.88 98.39 98.98 98.74 99.35 99.25 97.45 99.23 99.45

Aug-15 98.79 98.67 99.48 98.25 97.83 97.44 98.89 98.55 99.82 97.60 98.92 96.95 97.76 98.43 98.66

HOUSEKEEPING FMT AUDIT RESULTS

Antimicrobial Management TeamThe focus of the AMT has been on auditing documentation of indication and review of antibiotics in wards 3East and West as part of the national prescribing indicator audit as well as preparing for the annual point prevalence survey which this year will be carried out at the same time as the national carbapenem prescribing audit, results will focus future work.


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Other HAI Related ActivityMRSA Screening Compliance – August Data demonstrates variable compliance in CCU/ ICU2 /HDU2 and HDU3 with admission, 10 day and weekly MRSA screening and a marked improvement since the previous reporting period. Action plans have been developed by these areas, long terms it is anticipated a trigger in Wardview will resolve this issue.

Table 1 below, demonstrates compliance with MRSA screening by area for July; on admission, at 7 days and at 10 days.

Tables 2, 3 and 4 demonstrate the same compliance over a 6 month period February 2015-July 2015.

Table 1Aug-15 3WEST 3EAST 2C 2D CCU NSD ICU2 ICU1 HDU2 HDU3 SDU 2EAST 2WEST

SAMPLE SIZE 19 19 8 8 3 4 11 10 8 8 9 28 30

OPD 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

COMPLIANCE

ADMIT 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

COMPLIANCE

SAMPLE SIZE na 3 na na 1 1 4 na 1 1 na 1 1

10 DAY SCREEN na 100% na na 0% 100% 0% na 0% 0% na 100% 100%

COMPLIANCE

SAMPLE SIZE na na na na na 1 1 na na na na na 1

7 DAY SCREENna na na na na 100% 0% na na na na na 100%

COMPLIANCE

*NA- No patients suitable for audit

Sample size- Number of patients in unit at time of audit

Long Term Patient Screeningo All patients should be rescreened on Day 10 and weekly thereafter.

o Compliance is monitored via reviewing a sample of eligible patients against submitted MRSA screens.

o SCNs are informed of results at the time of audit and action plan required to improve compliance


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Table 2 3WEST 3EAST 2C 2D CCU NSD ICU2 ICU1 HDU2 HDU3 SDU 2EAST 2WEST

Jan 100% 100% 100% 100% 100% 100% 100% 100% 100% 90% 100% 100% 100%

Feb 100% 100% 75% 100% 100% 100% 100% 100% 100% 100% 100% 100% 80%

Mar 100% 100% 100% 67% 100% 100% 100% 100% 100% 100% 83% 100% 100%

Apr 100% 100% 100% 100% 100% 86% 83% 100% 100% 100% 100% 100% 100%

May 100% 100% 100% 100% 100% 89% 100% 100% 100% 100% 100% 100% 100%

June 100% 100% 100% 100% 100% 88% 100% 100% 100% 100% 100% 100% 94%

July 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

August 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

3WEST 3EAST 2C 2D CCU NSD ICU2 ICU1 HDU2 HDU3 SDU 2EAST 2WEST

MRSA Admission Screening Compliance

Apr

May

June

July

August

Mar

Table 3

3WEST 3EAST NSD ICU2 HDU2 HDU3 2EAST 2WEST CCU

Jan 100% 100% 100% 100% 100% 100% 100% 100% na

Feb 100% 100% 100% 100% 100% 100% 100% 100% na

Mar 80% 100% na 0% na na na na na

Apr 100% 100% 75% 100% na 0% na na na

May 100% 100% 40% 100% na 50% 100% 100% na

June 100% 75% na 50% na 0% 100% 50% na

July na 100% 100% na na na 100% 100% na

August na 100% 100% 0% 0% 0% 100% 100% 0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

3WEST 3EAST NSD ICU2 HDU2 HDU3 2EAST 2WEST CCU

10 day MRSA screening compliance

Feb

Mar

Apr

May

June

July

August

Please note not all areas have long term patients. These areas have been omitted from the graph


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Table 4 3WEST 3EAST NSD ICU2 HDU2 2EAST 2WEST

Jan 100% 100% 75% 100% 100% 100% 100%

Feb 100% 100% 100% 100% 100% 100% 100%

Mar 100% na 100% 100% na na na

Apr 100% na 100% 100% na na na

May 100% na 100% 100% na na 100%

June 100% na 100% 100% na na na

July na na na na na na na

August na na 100% 0% na na 100%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

3WEST 3EAST NSD ICU2 HDU2 2EAST 2WEST

7 day MRSA Screening Compliance

Mar

Apr

May

June

July

August

Please note not all areas have long term patients. These areas have been omitted from the graph.

Healthcare Associated Infection Reporting Template (HAIRT)Heather Gourlay- Senior Manager Prevention and Control of InfectionSandra McAuley – Clinical Nurse Manager Prevention and Control of Infection Data 21/09/15

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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 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 NumbersClostridium difficile infections (CDI) and Staphylococcus aureus bacteraemia (SAB) cases are presented for each hospital, broken down by month. Staphylococcus aureus bacteraemia (SAB) cases are further broken down into Meticillin Sensitive Staphylococcus aureus (MSSA) and Meticillin Resistant Staphylococcus aureus (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.

TargetsThere are national targets associated with reductions in C. difficile and SABs. More information on these can be found on the Scotland Performs website:

http://www.scotland.gov.uk/About/Performance/scotPerforms/partnerstories/NHSScotlandperformance

Understanding the Report Cards – Hand Hygiene ComplianceHospitals 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.

Understanding the Report Cards – Cleaning ComplianceHospitals 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. 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.


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http://www.hfs.scot.nhs.uk/online-services/publications/hai/

http://www.scotland.gov.uk/About/Performance/scotPerforms/partnerstories/NHSScotlandperformance

http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252&sectionID=1




NHS BOARD REPORT CARD

Staphylococcus aureus bacteraemia monthly case numbersSept2014

Oct2014

Nov2014

Dec 14

Jan15

Feb 15

Mar15

Apr15

May15

Jun15

Jul15

Aug15

MRSA 0 0 0 0 0 0 0 0 0 0 0 0MSSA 1 0 0 0 0 0 1 2 1 1 1 1Total SABS

1 0 0 0 0 0 1 2 1 1 1 1

Clostridium difficile infection monthly case numbersSept2014

Oct2014

Nov2014

Dec 14

Jan15

Feb 15

Mar 15

Apr15

May15

Jun 15

Jul15

Aug15

Ages15-64

0 0 0 0 0 0 0 0 0 0 0 0

Ages 65+ 0 0 0 0 0 0 0 0 0 0 0 0Ages 15 + 0 0 0 0 0 0 0 0 0 0 0 0

Hand Hygiene Monitoring Compliance (%)Sept2014

Oct2014

Nov2014

Dec 14

Jan15

Feb 15

Mar 15

Apr15

May15

Jun 15

Jul15

Aug15

AHP 97 95 98 97 95Ancillary 100 100 100 100 100Medical 98 100 100 95 92Nurse 99 99 99 98 99Board Total

99 97 97 97 97

Cleaning Compliance (%)Aug2014

Sept2014

Oct2014

Nov2014

Dec 14

Jan15

Feb 15

Mar15

Apr15

May 15

Jun15

Jul 15

Aug15

Board Total 97.6 97 97.7 96.7 97 97.4 98.4 98.5 98.5 98.8 98.7 98.9 98.4

Estates Monitoring Compliance (%)Aug2014

Sept2014

Oct2014

Nov2014

Dec 14

Jan15

Feb 15

Mar15

Apr15

May 15

Jun 15

Jul15

Aug15

Board Total 99.5 98.6 98.5 98.9 99 98.1 97.3 98.4 98.2 98.3 99.2 99.5 99.7


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Surgical Site SurveillanceCABG and CABG +/- Valve SSI Local Data Infection rates remain below the upper control limit

-1%1%3%5%7%9%

CABG- Monthly Surgical Site Infection Rates

SURGICAL SITE INFECTION RATE

CENTRE LINE

UPPER CONTROL LIMIT

HPA 2009-2014 ( INPATIENT AND READ-MISSION)

-1%1%3%5%7%9%

Valve Replacement +/- CABG Surgery- Monthly Surgical Site Infection Rates

SURGICAL SITE INFECTION RATECENTRE LINEUPPER CONTROL LIMITHPA Rate 2009-2014

*A surgical site infection is defined a superficial, deep or organ space infection occurring within 30 days of operation. Definitions of superficial, deep and organ space are defined in Health Protection Scotland Surgical Site Infection Surveillance Protocol.Heather Gourlay- Senior Manager Prevention and Control of InfectionSandra McAuley – Clinical Nurse Manager Prevention and Control of Infection Data 21/09/15

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Jan 15- superficial sternumApril 15- superficial sternumJun 15- 1 superficial sternum (inpatient) - 1 deep sternum (readmit)Aug 15-1 superficial sternum (inpatient)

Jan 15 Superficial sternumJul 15 Deep Sternum

Orthopaedic SSI Local data

Infection rates remain below the upper control limit

-0.5%

0.0%

0.5%

1.0%

1.5%

2.0%

Knee Replacement- Monthly Surgical Site Infection Rates

SURGICAL SITE INFECTION RATECENTRE LINEUPPER CONTROL LIMIT

Infection rates remain below the upper control limit

-0.5%

0.0%

0.5%

1.0%

1.5%Hip Replacement - Monthly Surgical Site Infection Rates

SURGICAL SITE INFECTION RATECENTRE LINEUPPER CONTROL LIMIT

*A surgical site infection is defined a superficial, deep or organ space infection occurring within 30 days of operation. Definitions of superficial, deep and organ space are defined in Health Protection Scotland Surgical Site Infection Surveillance Protocol.


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Dec 14-deep infectionMay 15- 1 deep infection

Jun 15- 1 superficial infection- readmit

HAIRT Table of Abbreviations


of 17

CABG Coronary Artery Bypass GraftCDI/C.difficile Clostridium Difficile InfectionCVC Central Venous CatheterDMT Domestic Monitoring ToolE.coli Escherichia coliFMT Facilities Monitoring ToolHAI Healthcare Associated InfectionHA MRSA Hospital Acquired Meticillin Resistant Staphylococcus AureusHEI Healthcare Environment InspectionHIS Healthcare Improvement ScotlandHH Hand HygieneHPS Health Protection ScotlandIABP

Intra-aortic balloon pump IC Infection ControlICAR Infection Control Audit ReviewLan Qip Lanarkshire Quality Improvement ProgrammeLDP Local Delivery PlanMRSA Meticillin Resistant Staphylococcus AureusMSSA Meticillin Sensitive Staphylococcus AureusPCINs Prevention & Control of Infection NursesPCIT Prevention & Control of Infection TeamPICC Line Peripherally inserted central catheter linePVC Peripheral Venous CannulaSAB Staphylococcus aureus bacteraemiaSCN Senior Charge NurseSICP s Standard Infection Control PrecautionsSPSP Scottish Patient Safety Programme SSI Surgical Site InfectionTBPs Transmission Based PrecautionsVAP Ventilator Associated Pneumonia

healthcare associated infection reporting template · web viewheather gourlay- senior manager...

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