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THE MID YORKSHIRE HOSPITALS NHS TRUST BOARD NOVEMBER 2008

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THE MID YORKSHIRE HOSPITALS NHS TRUST BOARD NOVEMBER 2008 Powered By Docstoc
					                THE MID YORKSHIRE HOSPITALS NHS TRUST BOARD
                               NOVEMBER 2008
                            EXECUTIVE SUMMARY


Paper title:      Infection Prevention, Management and Control       Part 1
                  Update for Trust Board                             Part 2
Paper Author      Susan Walker               Sponsoring              Tracey McErlain-
                  Director of Infection      Director                Burns – Chief Nurse
                  Prevention and Control

Summary of paper:
This paper written by the DIPC provides assurance to the Board that infection risks are
being managed. The report provides an update on the rates of MRSA and Clostridium
Difficile. Evidence is provided of the zero tolerance approach to avoidable infections.
Confirmation that the Trust is on target to meet end of year trajectory. The key actions in
the hygiene code report will be addressed.


Recommendations:
Receive the report.

Support the DIPC and the IPCT with the continued improvements required with hand
hygiene compliance.

Note the progress with implementation of MRSA elective screening.


Assessment of implications in respect of:

Human resources: Continued training need for all health care professionals and
management of non-conformant practice.

Equality and diversity: The actions being taken promote equality of opportunity and
should assist with avoiding unlawful discrimination.
.
Finance: None identified.

Patient safety: Preventing health care associated infections is an important patient safety
agenda for the Trust and our patients.

History: Advise on sub-committees

                    Date               Decision

Sub-committee       7 November         Subsequent reports to provide detail on hand
                    2008 IGC           hygiene compliance and antibiotic prescribing
                                       compliance
Previously          September          Confirmed zero tolerance approach supported.
considered at       2008
Trust Board
Introduction

This update report to the Board is provided by the Director of Infection
Prevention and Control (DIPC). This report provides assurance to the Board
that Health Care Associated Infection (HCAI) is being effectively managed.

The report provides an update on the incidence of the two main alert
organisms MRSA bacteraemia and Clostridium Difficile Infection (CDI) in the
period April to end of October 2008.

MRSA Bacteraemia 2008/2009


                                                      MRSA Bacteraemia
   Number of reported




                        14
                        12
                        10
        cases




                         8
                         6
                         4
                         2
                         0




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                                                               Months of the year

                                        Position to date 08-09          Monthly Target    2007-2008


At the end of October 2008 the Trust can now demonstrate that it is on target
to deliver the end of year trajectory of no more than 43 cases. In the past two
months September and October, the Trust has remained within the monthly
target of no more than 4 cases per month.


   MONTH                          APRIL         MAY        JUNE       JULY      AUG      SEPT   OCT
    CASES                           3            4           2          5        5         2     3
   TARGET                           3            3           3          4        4         4     4
    CASES                           7            1           5          9        8         6     6
     07/08

The total number of cases at the end of the first 7 month period is 24 cases
and as the statistical process control chart (SPCC) below shows we can now
demonstrate a statistical significant step change improvement.




                                                                 2
Total MRSA:

                                                                                                                                              Total
                                                                                                                           Special Cause Flag

                    15


                    10
 Individual Value




                     5



                     0


                    -5
                                                                           Oct-06


                                                                                      Dec-06




                                                                                                                                                         Oct-07


                                                                                                                                                                      Dec-07




                                                                                                                                                                                                                                               Oct-08
                          Apr-06


                                       Jun-06


                                                         Aug-06




                                                                                                 Feb-07


                                                                                                               Apr-07


                                                                                                                                 Jun-07


                                                                                                                                               Aug-07




                                                                                                                                                                                        Feb-08


                                                                                                                                                                                                          Apr-08


                                                                                                                                                                                                                      Jun-08


                                                                                                                                                                                                                                 Aug-08
                                                                                                                                          Period

It is now clear that this step change occurred in March 2008 when a number
of measures were in place to reduce MRSA bacteraemia rates. There is a
small risk of not being able to achieve the year end target due to random
variation, however, with the median now 3.25 cases per month a year end
outturn of 39 cases could be predicted.

Of note is that there is clearly an improvement in the incidence of post 48 hour
MRSA bacteraemia, (hospital acquired) again commencing in March 08.


Total Hospital Acquired MRSA



                                                                                                                          Total > 48 hrs
                                                                                                                          Special Cause Flag

                    10

                    8

                    6
 Individual Value




                    4

                    2

                    0

                    -2

                    -4
                                                                                               Oct-07




                                                                                                                        Dec-07




                                                                                                                                                                                                                                          Oct-08
                         Apr-07




                                                Jun-07

                                                                  Jul-07

                                                                             Aug-07

                                                                                      Sep-07




                                                                                                                                     Jan-08

                                                                                                                                                Feb-08

                                                                                                                                                         Mar-08

                                                                                                                                                                  Apr-08




                                                                                                                                                                                                 Jun-08

                                                                                                                                                                                                             Jul-08

                                                                                                                                                                                                                      Aug-08

                                                                                                                                                                                                                               Sep-08
                                   May-07




                                                                                                          Nov-07




                                                                                                                                                                               May-08




                                                                                                                                                                                                                                                        Nov-08




                                                                                                                                      Period



As yet a step change is not evident due to the random variation in July 2008.
Community acquired remains static as shown below.


                                                                                                                                              3
Community acquired MRSA
                                                                                                     Total < 48 hrs
                                                                                                    Special Cause Flag

                    8

                    6
 Individual Value




                    4

                    2

                    0

                    -2

                    -4
                                                                               Oct-07




                                                                                                 Dec-07




                                                                                                                                                                                           Oct-08
                         Apr-07




                                           Jun-07

                                                    Jul-07

                                                             Aug-07

                                                                      Sep-07




                                                                                                          Jan-08

                                                                                                                   Feb-08

                                                                                                                            Mar-08

                                                                                                                                     Apr-08




                                                                                                                                                       Jun-08

                                                                                                                                                                Jul-08

                                                                                                                                                                         Aug-08

                                                                                                                                                                                  Sep-08
                                  May-07




                                                                                        Nov-07




                                                                                                                                              May-08




                                                                                                                                                                                                    Nov-08
                                                                                                          Period



The Health Economy Health Care Associated Infection (HCAI) Steering Group
continues to meet on a weekly basis with continued support and input from
the Strategic Health Authority (SHA) and the Department of Health (DH). All
cases of MRSA bacteraemia are investigated using Root Cause Analysis
(RCA) methodology. The weekly DIPC panel continues to meet to receive the
findings of RCA undertaken by the clinical teams.

In the past month the Clinical Director for Surgery joined colleagues on the
panel to hear a case in surgery. The panel concluded that this case was a
hospital acquired infection but likely unavoidable.

Further evidence of clinical engagement has recently been demonstrated with
a full clinical team attending the weekly DIPC panel in November. On this
occasion the panel concluded that the case was hospital acquired and likely
avoidable and as previously described in our zero tolerance approach to
avoidable bacteraemia cases, a representative of the Chief Executive (CEO)
met the next day with the patient’s clinician and both ward sisters to reiterate
responsibility and accountability in these situations.

Clostridium Difficile Infection (CDI) 2008/2009

For the financial year 2008/09 the CDI target is based on all cases occurring
in patients 2 years and older which were hospital acquired, more than 48
hours after admission; last year the target was based on all cases in patients
65 years and over. The 2007/08 data has been entered using this criteria. As
the chart indicates the downward trend persists but is no longer statistically
significant.




                                                                                                                   4
Total cases in the MYHT
                                                                                               Special Cause Flag
  50                                                                                                 Total MYHT


  40
 Individual Value




  30



  20



  10



            0
                                                                          Oct-07




                                                                                            Dec-07




                                                                                                                                                                                      Oct-08
                                               Jul-07

                                                        Aug-07

                                                                 Sep-07




                                                                                                              Feb-08

                                                                                                                       Mar-08




                                                                                                                                                           Jul-08

                                                                                                                                                                    Aug-08

                                                                                                                                                                             Sep-08
                    Apr-07




                                      Jun-07




                                                                                                     Jan-08




                                                                                                                                Apr-08




                                                                                                                                                  Jun-08
                             May-07




                                                                                   Nov-07




                                                                                                                                         May-08




                                                                                                                                                                                               Nov-08
The incidence of CDI now seems static however there is no threat to the
target for this year.

The Trust continues to demonstrate a reduction in incidence of CDI.

                    MONTH                               APRIL                      MAY                 JUNE                     JULY                       AUG                        SEP               OCT
                     CASES                               14                         19                  10                       17                         19                         21                25
                    TARGET                               25                         25                  25                       25                         25                         25                25

At the end of the 7 month period the trajectory is set at 175 with the Trust
reporting a total of 125 cases to date.

Further analysis is being undertaken since October as a result of the
incidence over the past few months.

With the additional isolation rooms on Ward 3 at Pinderfields general Hospital
it is expected this will help improve immediate isolation of cases on symptoms
on that site.

Social Marketing Specification

Phase 1 of this project has now been completed with the project sponsor
Chief Nurse at MYHT producing a paper which the provider will use to shape
phase 2 of the proposal.

Clinical leads and infection prevention advisors were engaged to ‘describe the
problem’ in phase 1.

Phase 2 led by the SHA involves the identification of a market provider. The
provider will be asked to produce a proposal based on the paper submitted by
the Chief Nurse and agreed with the Health Economy HCAI group. The
proposal builds on the learning from RCA and the pilot will focus on two
patient areas at PGH.

                                                                                                              5
The clinical teams from these areas have been engaged in working up the
proposal.

Compliance with Hand Hygiene

Improvement in hand hygiene compliance can be demonstrated through
compliance audits. A Trust wide audit was undertaken during National
Infection Prevention and Control week during October. Hand hygiene
compliance is reported at 93% during that reporting period. It is intended to
provide update reports at Trust and directorate level in future reports. There
is a high degree of confidence that we will achieve a minimum of 95% by the
end of March 09.

MRSA Elective Screening

A working group continues to meet to plan the arrangements for achieving
100% of elective patients screened for MRSA by the end of March 2009. The
Trust as required commenced reporting nationally in October and the
performance is included in the Integrated Performance report. Present
compliance meets the existing policy which is being revised for the
commencement of Phase 1 January 2009.

Health Care Commission (HCC) - Unannounced Hygiene Code
Inspection

As previously reported this unannounced inspection was undertaken in
August 2008. The findings of this report are likely to have been made public
by the time that the Board meets. A verbal update will be provided on receipt
of the final report (unless it is available to be included on the agenda before
Board papers are issued).

Conclusion

The reduction in MRSA cases is very encouraging and puts the Trust in a very
favourable position to be able to achieve the year end target. A zero tolerance
approach is demonstrated with those cases that are deemed likely were
avoidable. In the next report detail will be provided on the analysis of recent
CDI incidence.

The Hygiene Code report is expected to be public before the month end and
the Trust will action any recommendations contained within the report.




Author:      Susan Walker, DIPC
Date:        17 November 2008
Version:     1
Status:      Report

                                      6
Circulation:   Trust Board
EIA:           Postive
Pages:         6
Filepath       S:\Susan Walker\REPORTS POLICIES\OCTOBER 2008 BOARD REPORT.doc




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