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									Agenda Item 7.1



                  Trust Board - 14 January 2010
    HEALTHCARE ASSOCIATED INFECTIONS PERFORMANCE REPORT
                     & SWINE FLU UPDATE

Report of                                                       Ruth Holt, Chief Nurse and Director of Infection
                                                                Prevention & Control

                                                                Brian Godfrey, Divisional General Manager, Diagnostics
Paper prepared by                                               & Therapeutics Division
                                                                Yvette Reece, Business Manager, Infection Prevention
                                                                & Control
                                                                Sharon Scott, Resilience Manager

Subject/Title                                                   Healthcare Associated Infections Performance Report &
                                                                Swine Flu Update November 2009
                                                                HCAI Improvement Programme Review, December
Background papers                                               2008.
                                                                The Health and Social Care Act 2008, Code of Practice
                                                                for the NHS on the prevention and control of healthcare
                                                                associated infections and related guidance.
                                                                LTHT Pandemic Influenza Plan

Purpose of Paper                                                To update the Trust Board on HCAI performance and
                                                                the Trust’s current state of preparedness in respect of
                                                                Pandemic Influenza


Action/Decision required                                        This paper is being submitted to the SMT prior to its
                                                                presentation to the Trust Board on 14 January 2010.
Link to:
                                                                Reduction of Healthcare Associated Infection
 NHS strategies and policy

Link to:
                                                                A better patient experience
 Trust’s Strategic Direction                                   Improving the way we manage our business
 Corporate objectives

Resource impact                                                 N/A

Consideration of legal issues                                   N/A

Acronyms and abbreviations                                      MRSA (Meticillin Resistant Staphylococcus Aureus)
                                                                CDI (Clostridium difficile Infection)
                                                                HCAI (Healthcare Associated infection)
                                                                DoH Department of Health
                                                                RCA (Root Cause Analysis)
                                                                PCT (Primary Care Trust)
                                                                LHE (Leeds Health Economy)
                                                                WCHN&D (Women’s, Children’s, Head, Neck and
                                                                Dental)

November HCAI Performance Report & Swine Flu Update - Y Reece Dec 2009
                                                                                                                          1
Agenda Item 7.1
                      THE LEEDS TEACHING HOSPITALS NHS TRUST
               HEALTHCARE ASSOCIATED INFECTIONS PERFORMANCE REPORT
                                & SWINE FLU UPDATE

                                                                    November 2009
1.          PURPOSE

The purpose of this report is to provide an update of Trust performance in respect of Healthcare
Associated Infections (HCAI) and the state of preparedness of the Trust in response to Pandemic
Influenza.

2.          BACKGROUND

The Trust reports performance against two Healthcare Associated Infections, MRSA bacteraemia
and Clostridium difficile infection (CDI) and on the MRSA Screening Programme.

2.1         MRSA

During November the Trust recorded 4 cases of MRSA bacteraemia all of which were allocated to the
Trust. Further investigation is currently being undertaken on two of the cases and, depending on the
outcome, the Trust may apply for reallocation of these cases to other Trusts in the region. The first
graph illustrates performance for the period August 2008 to November 2009 for the Leeds Health
Economy (LHE) with those cases allocated to the Trust since the new reporting arrangements
highlighted separately. The second graph details LHE 3-monthly rolling average performance from
July 2008 to November 2009.

                        MRSA Cases - Leeds Health Economy                                      MRSA 3-Monthly Rolling Averages - Leeds Health Economy
                                                                                                                 LHE MRSA      LHE Trajectory
                LHE Cases     LHE Trajectory   LTHT Cases     LTHT Trajectory
      25
                                                                                  18.00
      20
                                                                                  15.00

                                                                                  12.00
      15
                                                                                   9.00

      10                                                                           6.00

                                                                                   3.00
       5
                                                                                   0.00

       0
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2.2         Clostridium Difficile Infection (CDI)

During November the Trust recorded 30 cases of CDI of which 20 were apportioned to the Trust
against a trajectory of 51 cases.     The following graphs illustrate LTHT performance for
apportioned cases from August 2008 to November 2009 and 3-monthly rolling average
performance from July 2008 to November 2009.

                            Apportioned CDI Cases - LTHT                                               CDI 3-Monthly Rolling Averages - LTHT
                                                                                                                     CDI     Trajectory
                                Actual Cases    Trajectory


      80                                                                             80


                                                                                     60
      60

                                                                                     40
      40

                                                                                     20

      20
                                                                                      0

       0
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November HCAI Performance Report & Swine Flu Update - Y Reece Dec 2009
                                                                                                                                                        2
Agenda Item 7.1
3.          ACTIONS TAKEN

3.1         Patient Safety Walk Rounds

Patient safety walk rounds have taken place at LTHT since September 2008. The walk rounds are
conducted weekly by a team which includes two members from the Executive Director, Non-
Executive Director and Divisional General Manager groups and a member of the patient safety
team. The team visit at least two clinical areas, usually within the same Division, and meet staff
and patients to discuss issues related to patient safety. Sites are selected both as part of a rolling
programme and following a specific request by a clinical manager/team for a walk round. There is
a mechanism in place to ensure all actions arising out of these walk rounds are recorded and the
person with lead responsibility for the action has to send written confirmation that the action has
been completed within the agreed timescale. The members of the walk round team follow an
agreed set of guidelines and there is also a standard question set to refer to.

A quarterly report is produced and presented to the Trust Patient Safety Steering Group and
includes a summary of the actions identified at each walk round and their status. In the period July
to September 49 actions were identified but assurance of completion was only received for 25
(51%) of these actions. Performance management of outstanding actions will now take place
through the Divisions performance management meetings to ensure completion.

Key themes and trends relating to infection control were raised more frequently than any other
issue - 32 out of the 49 which equates to 65%. These included environmental issues such as
cluttered areas and clinical spaces being used for storage. Clinical staff commented that an
increase in the number of ‘dump your junk’ weeks could help wards and departments to maintain
uncluttered environments and this has now been put in place. As part of Releasing Time to Care,
wards can also request additional resources to help remove unwanted items. Concern was also
expressed regarding materials management and locally agreed actions have been put in place to
assist in a clutter-free environment. Quarterly audits are also undertaken linked to HCAI actions
and are being used to provide assurance on key areas. Where failures are identified, actions are
immediately agreed with the clinical team leaders.


3.2         Key Themes and Trends from MRSA Root Cause Analysis

Sources and root causes for the period September to November 2009 were collated and the major
contributory factor for this three month period is clearly identified as an issue with vascular access
with incomplete/missing documentation and ward environment being other key factors.
Antimicrobial therapy and appropriate MRSA decolonisation also feature. Sources for the same
period are as detailed below.

 Organisim Staphylococcus aureus - MRSA Division (All)
                      Source info
                        Central line - tunnelled      Blood culture contaminant   Central line - non-tunnelled   Hospital - acquired (HAP)
                        Intra-Abdominal abscess       Leg Ulcer                   PEG/RIG site                   Peripheral (PVC)
                        Prostetic joint infection     Stevens-Johnson syndrome    Unknown Source                 UTI - catheterised


      Count of Source info
  8


  7


  6


  5


  4


  3


  2


  1


  0
                             Sep 09                                         Oct 09                                              Nov 09

                                                                            Month


November HCAI Performance Report & Swine Flu Update - Y Reece Dec 2009
                                                                                                                                             3
Agenda Item 7.1

3.3         Antimicrobial Prescribing

The key performance indicators for antimicrobial prescribing are improving. Indication in notes and
prescriber details being clear have both improved this month. Indication of the duration of drugs
that should be used on the drug charts remained static. Seven specialties are meeting the target in
all areas -
                Cardiology
                Infectious Diseases
                Neurology
                Paediatric Cardiology
                Paediatric Liver
                Paediatric Neurology
                Paediatric Medicine

Feedback from looking at benchmarking data shows LTHT is performing much better than
elsewhere against our prescribing standards. All Divisions are actively re-briefing all prescribers on
the minimum standards expected and through improved information flows about performance are
seeking to improve these standards. The numbers of patients on antibiotics at any one time
remains much lower at 27% for November 2009, compared with 35% for November 2008. Our use
of broad spectrum antibiotics most often associated with CDI and MRSA colonisation is 18% lower
in the past year compared to the previous period. The Trust is still working with NHS Leeds to
identify a robust income stream to fund a city wide Antimicrobial Team as recommended by the
DoH. This team would improve on the current antimicrobial prescribing performance.

3.4         Environmental Cleanliness

The organisation formally audits every clinical area for its standards of cleanliness on a rolling
quarterly cycle in line with DH guidance (National specification for cleanliness in the NHS, April
2007, NPSA). Caution should, therefore, be noted as the results reflected in the attached
performance ‘dashboard’ are only reflective of those areas audited in a particular month. The
Facilities Directorate is currently reviewing its audit programme and hopes to exceed the National
DH guidance by formally inspecting all clinical areas within a period of a month. This will mainly be
undertaken on a trial basis during quarter 4.

The cleanliness scores show a slight increase in month which is a reflection of the recruitment drive
seen during October and November.

The locally defined target for our deep clean initiative has been adjusted slightly in line with our
revised programme and resource levels. The programme was re-prioritised back in November to
ensure its focus was maintained to clinical areas categorised as ‘very high’ and ‘high risk’ areas.

The Facilities Directorate was recently authorised to recruit 50 wte staff. These new recruits
continue to ‘filter’ through the system and should be complete by the end of January 2010.

The consistent shortfall between the standards being achieved and the self-imposed local targets
continues to be discussed collaboratively between Facilities, Nursing and Infection Prevention and
Control colleagues at the Cleaning Strategy Group. A target profile needs to be created that
realistically reflects the achievements of the cleaning strategy and to take account of the
rationalisation of the estate.

3.5         Swine Flu

Swine flu is decreasing across the UK. The estimated number of new cases nationally and locally
in all regions and in all age groups has fallen considerably. As of 18th December 2009, the Health
Protection Agency estimated that the number of new cases occurring each week has decreased to
approximately 9,000 from a peak in late July 2009 with estimates of over 100,000 cases per week.
The majority of patients with swine flu continue to have mild symptoms and the weekly
November HCAI Performance Report & Swine Flu Update - Y Reece Dec 2009
                                                                                                    4
Agenda Item 7.1
hospitalisation rate has also decreased in all age groups. Within LTHT, the numbers of patients
admitted with suspected swine flu have decreased to an average of 5 new admissions per day
(from an average of 9 new admissions per day at the end of July). Admissions to critical care
continue to be low with an average of 1 new admission per week (compared with an average of 2
new admissions per week at the end of July. Antiviral collection within Leeds has also been very
low at approximately 20-50 collected per day (compared with between 800-1800 per day at the end
of July).

Vaccination remains a critical part of our resilience strategy. Vaccinating those at greatest risk will
help manage pressures in health care. The DoH advises that vaccination is expected to reduce
hospitalisations by approximately 20% and reduce the number of deaths by approximately 30%.
NHS Leeds has a vaccination programme in place for the at risk population and is working hard to
ensure that as many at risk patients as possible are vaccinated in the community. Given the
current availability of vaccine and in order to promptly increase the pool of non-susceptible patients,
all Divisions have been asked to identify all inpatients who are at risk and to offer them the swine flu
vaccination during their inpatient stay, providing there is no contraindication and the patient is not
acutely unwell.

The seasonal and swine flu vaccination programme for health care workers within LTHT has been
delivered by a combination of occupational health and clinical area based vaccinators. To ensure
maximum uptake, vaccinations continue to be available at different sites throughout the Trust and
at different times. Initial supplies of the vaccine were limited so the focus was on front line health
care workers. The vaccination programme has now been extended to all staff as more vaccine has
become available. So far the Trust has successfully vaccinated 36% of all staff against seasonal
flu and 34% of all clinical and support staff against swine flu compared with 23% of staff who
received the seasonal flu vaccination in the winter of 2008/09.

Following national discussions at the DoH, a vaccination benchmark of 50% for health care workers
has been set. The Trust will continue to work hard to achieve the required 50% uptake.

4.      SUMMARY

Reducing the incidence of HCAI continues to provide a challenge to the Trust. Actions continue to
be taken to ensure the Trust is on track to deliver its action plan and that the improvements put in
place are having the desired effect. LTHT will continue to work closely with NHS Leeds and
the wider health and social care economy to ensure that we are as prepared as possible
for the coming winter months in respect of a possible flu pandemic.

5.         RECOMMENDATIONS

The Board is asked to note the content of this report and to support the actions undertaken. A
further update paper will be provided to the February Board.




Brian Godfrey                                                Yvette Reece       Sharon Scott
Divisional General Manager                                   Business Manager   Resilience Manager




November HCAI Performance Report & Swine Flu Update - Y Reece Dec 2009
                                                                                                      5
 Agenda Item 7.1

                                      HEALTHCARE ASSOCIATED INFECTIONS PERFORMANCE REPORT - NOVEMBER 2009
                                                                                  TARGET            PERFORMANCE             COMMENTS
            KEY PERFORMANCE INDICATOR                                     Local          National   Oct         Nov
MRSA Rates                                                                           6                      6           4   See Board Report narrative Section 2.1
                                                                          Oct      Nov
CDI Rates                                                                  42       45                     18          20   See Board Report narrative Section 2.2

Hand Hygiene                                                                      95%                     99%         99%
                                                                                                                            HII audits to be undertaken monthly. If ward/department scores falls below 95% then audits must be
High Impact Interventions (HII)                                                                                             done weekly until there are 3 consecutive scores of 95% or above.
                                                             HII1a                95%                 100%            99%
          Central Venous Catheter Care                       HII1b                95%                     99%         99%
                                                             HII2a                95%                     99%         99%
      Peripheral Intravenous Cannula Care                    HII2b                95%                     97%         99%
                                                             HII3a                95%                 100%            89%   The overall Trust score in this area is below target due to performance in Specialist Surgery (85%)
           Renal Dialysis Catheter Care                      HII3b                95%                     98%         96%
                                                             HII4a                95%                     96%         93%   The overall Trust score in this area is below target due to performance in Specialist Surgery (90%)
       Prevention of Surgical Site Infection                 HII4b                95%                 100%            98%
                                                             HII5a                95%                 100%            97%
           Care for Ventilated Patients                      HII5b                95%                 100%            98%
                                                             HII6a                95%                     99%         99%
               Urinary Catheter Care                         HII6b                95%                     98%         99%
           Reducing the Risk of CDI                          HII7                 95%                 100%         99%
Cleaning/Decontamination of clinical equipment               HII8                 95%                   n/a       100%
Antimicrobial Prescribing
With indication for use                                                           95%                     90%         92%
With duration or review                                                           95%                     79%         80%
Prescriber contact details legible                                                95%                     77%         79%   See Board Report narrative Section 3.3
MRSA Screening                                                                                        4853        4627      120 positive results for November which equates to 2.6%
Root Cause Analysis                                                                                                         MRSA RCA data only.
RCA Meeting arranged within time scale                                            95%                 100%        100%
Completed report received within time scale                                       95%                  67%          0%      At the time of writing, there is still one RCA report outstanding for November - see below
                                                                                                                            Case 38, Oncology & Surgery- Root cause not documented and action plan incomplete.
                                                                                                                            Case 39, Specialist Surgery - RCA report not yet received
                                                                                                                            Case 40, Specialist Surgery - Source not documented
Matches pre-determined quality criteria                                           100%                    83%         tbc   Case 41, Medicine - Further investigation being undertaken with Harrogate
Environmental Cleaning Scores                                                                                               See Board Report narrative Section 3.4
Very High Risk (Theatres, ICU)                                                    98%                     94%         96%   Increase on last month
High Risk (General Ward areas)                                                    95%                     90%         93%   Increase on last month
Significant Risk (Outpatient depts., public thoroughfares)                      92%                       91%         88%   Slight decrease on last month
Low Risk (Office areas)                                                         70%                       51%         79%   Increase on last month
Intense Clean                                                                4/month                        4           4   Note the revised target based on the number of deep clean teams
 November HCAI Performance Report & Swine Flu Update - Y Reece Dec 2009
                                                                                                                                                                                                                                  6
Agenda Item 7.1




November HCAI Performance Report & Swine Flu Update - Y Reece Dec 2009
                                                                         7
Agenda Item 7.1

                                                                  LTHT Antimicrobial Medicine Code - Snapshot Audit Results

                                            % with indication            % Abs with duration or review   % of Prescriber contact details legible    95% Target level

    100


      90


      80


      70


      60


      50


      40


      30


      20


      10


        0
                       LTHT                         LTHT                  LTHT               LTHT            LTHT                LTHT              LTHT                LTHT
                      Apr-09                       May-09                Jun-09             Jul-09          Aug-09              Sep-09             Oct-09              Nov-09




November HCAI Performance Report & Swine Flu Update - Y Reece Dec 2009
                                                                                                                                                                                8
Agenda Item 7.1
                                     LTHT Antimicrobial Medicine Code - Snapshot Audit Results - Medicine                                                                                    LTHT Antimicrobial Medicine Code - Snapshot Audit Results - Oncology & Surgery

                             % with indication     % Abs with duration or review      % of Prescriber contact details legible    95% Target level                                        % with indication      % Abs with duration or review     % of Prescriber contact details legible         95% Target level

    100                                                                                                                                                             100


     90                                                                                                                                                             90


     80                                                                                                                                                             80


                                                                                                                                                                    70
     70

                                                                                                                                                                    60
     60

                                                                                                                                                                    50
     50

                                                                                                                                                                    40
     40
                                                                                                                                                                    30
     30
                                                                                                                                                                    20
     20
                                                                                                                                                                    10
     10
                                                                                                                                                                     0
      0                                                                                                                                                                   Oncology and        Oncology and      Oncology and      Oncology and    Oncology and        Oncology and          Oncology and     Oncology and
                                                                                                                                                                            Surgery             Surgery           Surgery           Surgery         Surgery             Surgery               Surgery          Surgery
              Medicine           Medicine           Medicine           Medicine           Medicine            Medicine          Medicine            Medicine
               Apr-09             May-09             Jun-09             Jul-09             Aug-09             Sep-09             Oct-09             Nov-09                   Apr-09              May-09            Jun-09             Jul-09          Aug-09              Sep-09               Oct-09              Nov-09




                               LTHT Antimicrobial Medicine Code - Snapshot Audit Results - Specialist Surgery                                                                                       LTHT Antimicrobial Medicine Code - Snapshot Audit Results - WCHN&D

                             % with indication     % Abs with duration or review      % of Prescriber contact details legible    95% Target level                                           % with indication     % Abs with duration or review   % of Prescriber contact details legible       95% Target level

    100                                                                                                                                                             100


     90                                                                                                                                                             90


     80                                                                                                                                                             80


     70                                                                                                                                                             70


     60                                                                                                                                                             60


     50                                                                                                                                                             50


     40                                                                                                                                                             40


     30                                                                                                                                                             30


     20                                                                                                                                                             20


     10                                                                                                                                                             10


      0                                                                                                                                                              0
          Specialist Surgery Specialist Surgery Specialist Surgery Specialist Surgery Specialist Surgery Specialist Surgery Specialist Surgery Specialist Surgery          W, C, H & N         W, C, H & N       W, C, H & N        W, C, H & N    W, C, H & N          W, C, H & N          W, C, H & N       W, C, H & N

               Apr-09             May-09             Jun-09             Jul-09             Aug-09             Sep-09             Oct-09             Nov-09                   Apr-09              May-09            Jun-09              Jul-09         Aug-09              Sep-09               Oct-09              Nov-09




November HCAI Performance Report & Swine Flu Update - Y Reece Dec 2009
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