Healthcare Associated Infection

1. Healthcare Associated Infection SICSAG 10/10/2008 Stephen Cole

3. 2 main aims • To discuss background to HAI in Critical Care • To go over the new & updated HAI screen in Ward Watcher(TM)

4. Why Collect HAI data • Clinically relevant and of concern to patients • High Profile and Topical • Public Interest • Media Interest • Government Interest

5. Leslie Ash sues hospital for £1m over superbug Last updated at 15:39pm 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.

6. 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.

8. Critical Care Interest in HAI • Why wouldn’t 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

9. 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

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

11. Scorecard Results as per Directorate, Ninewells Hospital August 2008

12. Ward 20 Scorecard June 2008 July 2008

13. August 2008

14. Whose Data is it? • It’s your unit specific data • Audit Leads are responsible for this data • Board Chief Execs can request the data from their ICU/HDU’s • As with all SICSAG/ISD data held centrally there are written rules for release. • Be aware that FOI requests can trump these rules

15. Outcome v Process AuditWe need to move beyond patient survival as the only measure of ICU success Outcomes Audit Historical ( > 12 month lag time) Slow to react to change Death as outcome measure Process Audit Rapid reaction (weeks/months) Clinician Driven Multiple Outcomes Research & Audit opportunities

16. 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

17. 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)

18. 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.

19. 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

20. 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

21. Iorek BYRNISON 0000

22. 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.

23. HAI Ninewells ICU August 2008

29. Surveillance of Infections Acquired in Intensive Care Units Protocol Version3 (Based on HELICS protocol version 6) Dr Jodie McCoubrey (Epidemiologist, SSHAIP Team)

30. Click on this button to enter the “Hospital Acquired Infection – Surveillance “ window • HAI button WW Admission Screen

34. Pneumonia laboratory findings window

36. Infection details window The type of infection is selected e.g. BSI Infection criteria for BSI Check button Infection code and type displayed

37. Infection details window If the criteria do not meet those required by HELICS for infection diagnosis this message will appear

38. 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

39. What about other HAI’s • C.Diff • Intra Abdominal Sepsis • Peripheral line sepsis • Etc. etc

40. Infected old venflon site (2)

42. Scottish Patient Safety Program Collaboration

44. 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

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

46. 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

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