Healthcare Associated Infection

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Healthcare Associated Infection

• SICSAG 10/10/2008
• Stephen Cole

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• 2 main aims
• To discuss background to HAI in Critical Care
• To go over the new updated HAI screen in Ward
  Watcher(TM)

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Why Collect HAI data

• Clinically relevant and of concern to patients
• High Profile and Topical
• Public Interest
• Media Interest
• Government Interest

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Leslie Ash sues hospital for 1m over superbug
Last updated at 1539pm on 30.01.07
                                    
Debilitating Leslie Ash is not able to walk
unaided 2 years later
Men Behaving Badly star Leslie Ash will never
work as an actress again because of debilitating
injuries inflicted by a hospital superbug.
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Deaths soar from hospital superbugs
The Observer, Sunday September 28 2008 Almost
37,000 NHS patients have died after catching
either the MRSA or C-difficile hospital superbugs
during Labour's time in office, official figures
show. The two virulent infections claimed 36,674
lives between 1997 and 2007. Of those, 26,208
were from Clostridium difficile and 10,466 from
MRSA. Numbers dying in England and Wales from
C-difficile soared from 975 in 1999 to 8,324 last
year, a jump of about 850 per cent, while
fatalities linked to MRSA grew from 386 in 1997
to 1,593 in 2007.
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Critical Care Interest in HAI

• Why wouldnt we want to know our rates in
  Intensive Care of
• Ventilator Associated Pneumonia
• Catheter Related Blood Stream Infections
• Critical care patients have increased
• mortality and morbidity if they develop a HAI

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Why Collect HAI Data

• Board Chief Executives will be required to
  produce hospital wide figures.
• ICU Audit leads will be asked for this data on a
  monthly basis.
• SICSAG is not asking you for this data but is
  supportive of the process.
• SICSAG aims to make data provision by individual
  units as easy as possible

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Results

• Each Board will produce directorate specific
  Score cards on a monthly basis
• Data is highly processed
• Not patient specific
• Simplified Traffic light system

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Scorecard Results as per Directorate, Ninewells
Hospital August 2008
Medical Surgical Orthopaedics Ward 20 Renal Haematology/ Oncology Target
Hand Hygiene Compliance 60 (75) Incomplete (60) Incomplete (75) 69 (75) 80 (65) 75 (87) gt 90
Antimicrobial Prescribing 0 (0) 100 (100) Awaiting 100 (100) 100 (100) 100 (100) gt 95 (Orthopaedics Antibiotic Prophylaxis, All other areas Respiratory Quinolones)
Antimicrobial Prescribing 0 (0) 100 (100) (100) 100 (100) 100 (100) 100 (100) gt 95 (Orthopaedics Antibiotic Prophylaxis, All other areas Respiratory Quinolones)
Needlestick Injuries 1 (0) 0 (2) 0 (0) 3 (0) 0 (0) 1 (0) 0
HAI S. aureus Bacteraemias 0 (1) 0 (1) 0 (2) 0 (0) 0 (0) 2 (0) lt 2 (Medical Surgical) 0 (All other areas)
Education 0 (0) 0 (0) 0 (0) 0 (75) 10 (25) 0 (66.6) 100
Environmental Cleaning 89 (91) 92 (90) 91 (92) 97 (96) 94 (94) 94 (94) gt 90
New MRSA Acquisitions 5.7 (2.3) 9.4 (4.7) 2.9 (4.4) 6.8 (0) 3.4 (3.4) 0 (0) lt 3.9/1000 AOBD
New C. Diff Acquisitions 4.3 (4.4) 1.6 (4.6) 2.2 (1.5) 0 (0) 5.1 (6.8) 0 (0) lt 1.9/1000 AOBD
VAP No data received (13.25) lt 15/1000 Ventilator days
SSI Awaiting Awaiting lt 4.9 (Breast) lt 9.9 (Vascular) lt 1.5 (Ortho)
SSI (Incomplete) (2.8) lt 4.9 (Breast) lt 9.9 (Vascular) lt 1.5 (Ortho)
CVC Associated Infections No data received (0) 0 (0.7) 2.1 (5.6) lt 10/1000 Catheter days (Haem/Onc) lt 3/1000 Catheter days (All other areas)
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Ward 20 Scorecard June 2008
July 2008

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August 2008
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Whose Data is it?

• Its your unit specific data
• Audit Leads are responsible for this data
• Board Chief Execs can request the data from their
  ICU/HDUs
• As with all SICSAG/ISD data held centrally there
  are written rules for release.
• Be aware that FOI requests can trump these rules

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Outcome v Process AuditWe need to move beyond
patient survival as the only measure of ICU
success

• Process Audit
• Rapid reaction (weeks/months)
• Clinician Driven
• Multiple Outcomes
• Research Audit opportunities

• Outcomes Audit
• Historical ( gt 12 month lag time)
• Slow to react to change
• Death as outcome measure

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Additional Reasons to Collect HAI Data

• Move to Process as well as Outcomes Audit
• Rapid reaction to changes v Annual Report
• Sensitive measure of pressure on beds and need
  for more capacity
• Able to drive up standards within units over time
• Surrogate measure of Quality

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How your unit provides the required data is your
choice

• Options
• 1. Paper based System
• 2. HELICS based System
• 3. WW HAI Screen
• WW HAI Screen is a joint SICSAG/HPS initiative
• Based on HELICS protocol (but simplified)

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Advantages to using the WW system

• Familiarity with the program
• one robust computer system
• Data collection is time consuming
• 5-10min/patient/day to input data
• Extraction and processing of data additional 4-5
  hours/month
• SICSAG will extract data on a monthly basis for
  you if WW is used.

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Ninewells Hospital Experience

• Started collecting HAI pilot data in 2004/05
• Consultant input to WW on Micro Ward round
• Initial Scepticism
• Continued as part of SPI project
• All Consultants participate
• 0.6 WTE F Grade Nurse for SPI for 3 years

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Data Extraction on your own

• Needs a computer savvy enthusiast
• 4-5 hours/month minimum
• Not straightforward and depends on the WW
  intervention screen being accurately filled in.
• Thanks Ian
• SICSAG will do this for units who use WW

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Iorek BYRNISON 0000
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Interventions

• This is used to record
• Mode of ventilation, airway devices etc
• lines
• Investigations
• Feeding
• Ideally this should be updated by the end of
  every shift. If it has not been possible then it
  must be handed on as a specified task when the
  next resident comes on shift.
• All the interventions should be updated by the
  end of the following shift.

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HAI Ninewells ICU August 2008
2008

Jan Feb Mar Apr May Jun Jul Aug

Patients Total Number in ICU 33 38 38 44 36 38 45 30
  Admissions 30 34 36 36 29 35 41 26
 
 
LOS Mean 3.5 3.4 3.2 4.0 5.2 3.8 3.47 4.1
  SD 4.8 4.0 4.0 4.0 7.4 4.2 6.39 4.6
  Median 1.5 1.8 2.0 2.2 1.8 2.2 1.23 2.7
  TOTAL   99.0 95.0 175.3 186.4 144.4 156.27 123.9
 
Days of Ventilation Total 86 111 92 147 158 130 151 110
  Mean 2.9 2.9 2.4 3.3 4.4 3.4 3.4 3.7
  SD 5.6 3.6 3.1 3.1 5.7 4.1 6.1 4.2
  Median 1.5 2.0 1.0 2.0 2.0 2 1.0 2.0
 
CVC Days Mean per catheter 3.13 4.06 4.35 4.55 5.17 4.82 4.53 3.93
  SD 2.42 3.08 3.63 3.37 4.47 2.84 4.17 2.78
  Median 2 3 3.00 3.50 3.00 4 3.00 3.00
  TOTAL 72 126 148.00 255.00 217.00 188 154.00 169.00
 
Infection Rates CVCRBSIs 0 0 0 1 1 0 0 0
  VAPs 0 3 2 3 2 0 2 2
                   
  CVCRBSIs /1000 0.00 0 0.00 3.92 4.61 0.00 0.00 0.00
VAPs /1000 0.00 27.03 21.74 20.41 12.66 0.00 13.25 18.18
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Surveillance of Infections Acquired in Intensive
Care Units Protocol Version3 (Based on HELICS
protocol version 6)
Dr Jodie McCoubrey (Epidemiologist, SSHAIP Team)
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WW Admission Screen
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Pneumonia laboratory findings window
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Infection details window

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• Infection details window

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Problems

• Consistency
• Comparisons
• Missing data
• Lack of knowledge and understanding
• What do you do about patients with intractable
  intra abdominal sepsis?
• What do you do about patients who require an
  airway device but NOT ventilation

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What about other HAIs

• C.Diff
• Intra Abdominal Sepsis
• Peripheral line sepsis
• Etc. etc

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Infected old venflon site (2)
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Scottish Patient Safety Program Collaboration
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Resource Implications

• This takes time to do well.
• Irony of collecting HAI data is that the less
  conscientiously you do it the better you look
• Data needs to be validated
• We are already stretched as clinicians.
• Individual units need to make the case for
  additional resource with their own Board.
• SICSAG is supportive of this

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• Risk of league tables of HAI performance
• Is this a problem? Maybe
• Funnel plots
• Consider Annual report 2007

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Summary

• HAI is topical and clinically relevant to us in
  Critical Care
• Collaborative working with HPS, SPSP and others
  is good for Critical Care in Scotland
• Outcomes Audit plus Process Audit is more
  meaningful to our patients and to us as
  clinicians
• Resource is an issue which needs to be addressed

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Thanks

• Ninewells Hospital ICU medical and Nursing Staff.
• Ian computer Savvy Mellor
• SICSAG Staff- Angela, Jan, Lee ,Sian Diana