Device-Related Bacteraemia - a Surrogate Marker of HCAIs

Mike Cooper

Consultant Microbiologist and DIPC

Royal Wolverhampton NHS Trust

Comparative Performance Data

• MRSA bacteraemia data

• probably was a reasonable surrogate marker of HCAI

• no longer a useful marker if interventions aimed specifically at MRSA bacteraemia

• lost any residual use as a surrogate marker when MRSA screening was introduced

• Need alternative means of identifying areas for improvement

Hospital Acquired Bacteraemia

All significant positive blood cultures

Compare date positive blood cultures taken with dates of admission and last discharge

HAB = first significant positive blood culture taken more than 48/24 post admission or within 2/52 of discharge, or from frequent attendees (e.g. renal dialysis, haematology and oncology patients)

All positive blood cultures Remove contaminants

Exclusions Work out likely source/ cause of bacteraemia

Hospital Acquired Bacteraemia

• Majority of HABs not due to poor care

• unavoidable

• Need to refine so can concentrate on potentially preventable ones?

• Device Related Hospital Acquired Bacteraemia (DRHABs)

• fulfills criteria for HAB and the source of the bacteraemia is proved or likely to be a medical device:

• patient had a medical device in situ at the time the blood culture was taken or has had a device removed recently

• isolate is a pathogen that could be associated with that device

• no other likely source for the bacteraemia

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Cumulative Device Related Hospital Acquired Bacteraemia (DRHABs) from April 2009

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Cumulative Device Related Hospital Acquired Bacteraemia (DRHABs) from April 2009

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Cumulative Device Related Hospital Acquired Bacteraemia (DRHABs) from April 2009

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Cumulative Device Related Hospital Acquired Bacteraemia (DRHABs) from April 2009

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Cumulative Device Related Hospital Acquired Bacteraemia (DRHABs) from April 2009

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DRHAB Monthly Average Numbers 2009-10 2010-11 2011-12 2012-13 2013-14

Device-Related HABs: 11.67 8.75 7.75 8.33 6.70

Line 7.58 5.33 5.25 6.08 3.70

Urinary catheter 1.25 1.83 1.67 1.67 2.30

VAP 1.17 0.58 0.33 0.08 0

Biliary* 0.33 0.25 0 0 0

Nephrostomy 0.33 0.17 0.42 0.33 0.20

Pacemaker 0.33 0 0 0 0.30

PEG 0.08 0.08 0 0 0

Unknown 0.58 0.33 0 0.08 0

*From 2011-12 onwards, only ‘early’ biliary infections included as DRHABs

DRHAB Monthly Average Numbers 2009-10 2010-11 2011-12 2012-13 2013-14

Device-Related HABs: 11.67 8.75 7.75 8.33 6.70

Line 7.58 5.33 5.25 6.08 3.70

Urinary catheter 1.25 1.83 1.67 1.67 2.30

VAP 1.17 0.58 0.33 0.08 0

Biliary* 0.33 0.25 0 0 0

Nephrostomy 0.33 0.17 0.42 0.33 0.20

Pacemaker 0.33 0 0 0 0.30

PEG 0.08 0.08 0 0 0

Unknown 0.58 0.33 0 0.08 0

*From 2011-12 onwards, only ‘early’ biliary infections included as DRHABs

DRHAB Monthly Average Numbers 2009-10 2010-11 2011-12 2012-13 2013-14

Device-Related HABs: 11.67 8.75 7.75 8.33 6.70

Line 7.58 5.33 5.25 6.08 3.70

Urinary catheter 1.25 1.83 1.67 1.67 2.30

VAP 1.17 0.58 0.33 0.08 0

Biliary* 0.33 0.25 0 0 0

Nephrostomy 0.33 0.17 0.42 0.33 0.20

Pacemaker 0.33 0 0 0 0.30

PEG 0.08 0.08 0 0 0

Unknown 0.58 0.33 0 0.08 0

*From 2011-12 onwards, only ‘early’ biliary infections included as DRHABs

DRHAB Monthly Average Numbers 2009-10 2010-11 2011-12 2012-13 2013-14

Device-Related HABs: 11.67 8.75 7.75 8.33 6.70

Line 7.58 5.33 5.25 6.08 3.70

Urinary catheter 1.25 1.83 1.67 1.67 2.30

VAP 1.17 0.58 0.33 0.08 0

Biliary* 0.33 0.25 0 0 0

Nephrostomy 0.33 0.17 0.42 0.33 0.20

Pacemaker 0.33 0 0 0 0.30

PEG 0.08 0.08 0 0 0

Unknown 0.58 0.33 0 0.08 0

*From 2011-12 onwards, only ‘early’ biliary infections included as DRHABs

DRHAB Monthly Average Numbers 2009-10 2010-11 2011-12 2012-13 2013-14

Device-Related HABs: 11.67 8.75 7.75 8.33 6.70

Line 7.58 5.33 5.25 6.08 3.70

Urinary catheter 1.25 1.83 1.67 1.67 2.30

VAP 1.17 0.58 0.33 0.08 0

Biliary* 0.33 0.25 0 0 0

Nephrostomy 0.33 0.17 0.42 0.33 0.20

Pacemaker 0.33 0 0 0 0.30

PEG 0.08 0.08 0 0 0

Unknown 0.58 0.33 0 0.08 0

*From 2011-12 onwards, only ‘early’ biliary infections included as DRHABs

What Made a Difference Initially?

• Performance Management: • organisation and Divisions

• For lines: • single policy for all line insertion, use and care • central line database • central venous access training

• For others: • joint community/hospital Catheter Working Group • Critical Care ‘VAPteraemia courts’ • work on developing a care bundle for the prevention of VAPs in

Neonates

• But were initial improvements actually due to Hawthorne effect?

What has Made a Further Difference?

• Introduction of an IV Team

• education on line access and care

• placement of long-term peripheral lines

• Electronic package (VitalPACS) for central lines and urinary catheters

• Urinary catheter associated infections CQUIN

• focus and ownership

• Scrutiny meetings

Conclusions

• DRHABs can highlight areas of potentially avoidable HCAI and patient harm

• Interventions can produce reductions in some device-related infections

• DRHAB documentation and database management are extremely time consuming, but worthwhile if the result is improvements in patient care

Acknowledgements

• Sue Rowlands

• James Parr