Infection Prevention Team Report Healthcare Associated ...

Infection Prevention Team Report Healthcare Associated Infections update Q2 2019-20 Anita Watson, Lead Nurse, Infection Prevention and Control

Infection Prevention Report Quarter 2 2019-20

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CONTENTS

Page

Introduction 2

Meticillin resistant staphylococcus aureus blood stream infections 3

Meticillin sensitive staphylococcus aureus blood stream infections 5

Clostridium difficile infections 7

Escherichia coli blood stream infections 10

Klebsiella 13

Pseudomonas aeruginosa 14

Antimicrobial resistance 14

Care homes 15

Other work streams 16

Outbreaks 16


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1. Introduction

This report is an update for the Healthier Lancashire and South Cumbria Integrated Care System (HLSC) on their healthcare associated infections (HCAIs) data. It also includes an update on the support provided from the Infection Prevention team to Lancashire County Council and Blackburn with Darwen Local Authority and to the CCGs within the council footprint. Some infections are unpreventable as a result of complex healthcare, but nobody should be harmed by a preventable infection. There are many HCAIs, but the national focus is on Meticillin resistant Staphylococcus Aureus (MRSA) bloodstream infections; Meticillin Sensitive Staphylococcus Aureus (MSSA) bloodstream infections; Gram-negative bloodstream infections including Escherichia coli (E. coli), Pseudomonas and Klebsiella; and Clostridium difficile infections (CDI). Laboratories submit data onto the Public Health England (PHE) Data Capture System. This data is checked and locked down on the 15th of each month, but minor changes can occur after this date.

The purpose of the report is to:

Alert:

The HLSC is exceeding the national rates for all reportable infections except MRSA.

CDI numbers are increasing, especially within acute trusts. When comparing the hospital onset cases (excluding the community onset - healthcare associated) there has been a 73% increase with the same time period last year.

Greater Preston CCG have breached their annual trajectory within 6 months.

Advise:

During 2017/18 the management of E. coli bloodstream infections led to 181 deaths within HLSC and cost £1.87 million.

Assure:

All MRSA bloodstream infections and CDIs are reviewed to establish if there are any lessons to be learnt

Action plans are in place to address E. coli bloodstream infections and manage the risks associated with antimicrobial resistance.

An outbreak of Klebsiella at Southport Hospital led to the NW Regional Spinal Unit being closed to admissions. An action plan has been put in place; many of the actions have now been addressed and the unit has reopened.

The following chart compares the HLSC numbers and rates with the national figures for the first 2 quarters of this year. This shows that HLSC is exceeding the National rates for all reportable infections except MRSA as follows:


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HLSC and national numbers and rates for first 2 quarters of 2019/20

Escherichia Coli (E. coli)

Total/count Rate/100,000 Population

HLSC 774 43.55

England Total 22, 726 42.03

Clostridium difficile (C. diff)

HLSC 288 16.20


Meticillin Resistant Staphylococcus aureus (MRSA)

HLSC 11 0.61

England Total 381 0.70

Meticillin Sensitive Staphylococcus aureus (MSSA)

HLSC 216 12.15


The chart shows performance of the aggregated HLSC and does not reflect the performance at Acute Provider and CCG level. At this level there is variability in the level of performance with some CCG and providers performing well against the required standard but others not performing quite so well. These will be highlighted within the sections for each organism.

2. MRSA

A zero tolerance for MRSA bloodstream infections continues, and a clinical review is undertaken for each incident to determine if there are lessons to be learned and shared. During Q2 there have been 7 MRSA bloodstream infections identified, bringing the total to 11 so far for the year. The incidents continue to be diverse with no identifiable themes for the causes. The following chart shows a breakdown of these cases.

Chart to show break down of MRSA bloodstream infections for 2019/20 to date

CCG Acute Trust Where assigned

Main contributory factor Lessons learned

Q1 B'pool BTH Acute Trust Unknown – not a Lancashire resident


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Total MRSA cases per CCG

Blackburn with Darwen 1 Fylde and Wyre 1

Blackpool 3 Greater Preston 1

Chorley and South Ribble Morecambe Bay 2

East Lancashire 2 West Lancashire 1

The following graph compares the quarterly MRSA rates within the local authorities to the national rate since April 2017. These rates include all cases whether assigned to the acute trust or non-acute trust. This shows that for Q2 the rate for Blackpool at 5.61 is significantly higher than other authorities within HLSC; this represents 2 cases of blood stream infections, whereas there were 4 cases in residents in Lancashire County Council. Blackpool and Blackburn with Darwen are above the national rate for Q2.

MB UHMB Community Awaiting review

WL Liverpool Women's Hospital

Acute Trust Neonate - preterm in ICU. Umbilical arterial catheter tip and blood culture positive for MRSA

Care of devices

EL ELHT Community Ca lung with metastases. Neutropenic sepsis

None identified

Q2 BwD 904964

ELHT Acute Urinary catheter Poor compliance and documentation of urinary catheter.

B'pool BTH Unknown – not a Lancashire resident

EL 924575

Airedale Hospital

Community Contaminated sample

MB 918931

UHMB Community Awaiting review

F&W 924841

BTH Community No significant history. Previous MRSA blood stream infection with undetermined cause in 2017.

No cause identified

GP 927516

LTH Acute Renal Review – 18th October

B'pool BTH Unknown – not a Lancashire resident


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The following graph shows the rate of MRSA bloodstream infections assigned to local acute trusts compared to the national average. This graph should not be used to compare the performance within the local trusts as different population demographics and the variety of specialities provided will impact on their rates.

3. MSSA

There is no trajectory for MSSA bloodstream infections, but surveillance continues. For Q2 there have been 120 cases reported across the 8 CCGs bringing the total to 220 so far this year; this compares with 205 for the same time period last year. 161 (73%) were diagnosed within 2 days of admission to hospital; therefore attributed as community onset.

The following graph shows the distribution between the acute hospital trust and community onset during Q2.

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1

2

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Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

2017/18 2018-19 2019-20

Rat

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ear

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Graph to compare MRSA rates for Local Authorites with the

national rate

BwD Blackpool Cumbria CC Lancashire CC National

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6

7

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

2017/18 2018/19 2019/20

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ccu

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ove

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bed

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MRSA rates - cases assigned to local Acute Trusts

BTH

ELHT

LTH

S&OHT

UHMB

National


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The graph below compares the rates of MSSA in local CCGs to the national rate. This shows that the rate for some CCGs is repeatedly above the national rate, especially Blackpool and the Pennine CCGs, with no clear explanation for this.

0

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10

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30

35

BwD B'pool CSR EL F&W GP MB WL

MSSA bloodstream infections Q2 2019/20 comparing community and hospital onset

Hospital Community

0

5

10

15

20

25

30

35

40

45

Q1 Q2 Q3 Q4 Q1 Q2

2018/19 2019/20

Graph to compare local CCG MSSA blodstream infection rates with the national rate

BwD

B'pool

CSR

EL

F&W

GP

MB

WL

National


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4. Clostridium difficile infection (CDI) CDIs are reviewed to determine if any lapses in care contributed to the onset of the infection, or poor management of the infection led to reduced outcomes for the patient, but this process is not identifying any new trends.

5. CDI CCG The CCG objective includes all cases of CDI in the registered population; whether attributed to the acute trust or the community. Across the 8 CCGs there have been 288 cases of CDI reported year to date; against a combined cumulative objective of no more than 246, so this is being breached. During the same time period in 2018/19 the figure was 244, so this has increased by 18%. Greater Preston CCG has already breached their annual objective reporting 34 cases against an annual trajectory of no more than 32 cases. This is reflected in LTH also having a significant increase in the number of cases over the summer months.

BwD CCG

B'pl CCG

CSR CCG

EL CCG

F&W CCG

GP CCG

MB CCG

WL CCG

HLSC Total

Q2 8 27 16 27 31 21 29 10 169

Total cases year to date

17 45 32 46 48 34 50 16 288

2018/19 and 2019/20 Difference +/-

↓ 23% ↑ 73% = ↑ 18% ↑ 18% ↑ 100% ↓ 17% ↑ 23% ↑ 18%

Objective – year to date

23 26 32 39 38 16 61 11 246

Q1 + Q2 Acute cases

Hospital onset healthcare associated

6 21 19 24 19 21 19 8 137

Community onset

healthcare associated1

6 10 1 9 7 6 8 2 49

Q1 + Q2 Non - Acute cases

Community onset

indeterminate onset

4 8 4 4 11 1 7 1 40

Community onset

community associated

1 6 8 9 11 6 16 5 62

1 The Community Onset Healthcare Associated cases are the significant group as in previous years

these would have counted on the community figures, whereas from April 2019 they count towards the Acute Trusts


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The following graph compares the rates of CDI in local CCGs with the national rates. The rate for the CCG shows all cases within their population; those apportioned to acute trusts and those apportioned to the community. The graph shows that most CCGs had higher than national rates during Q2, especially the Fylde Coast CCGs. Blackpool CCG are achieving their CDI trajectory they have the highest rates during Q2.

4.2 Acute Trusts CDI

The acute trusts' CDI objective is solely for the cases classed as healthcare associated; either hospital onset or community onset. The clinical teams within the trust review the cases to determine if there have been lapses in care.

All local acute trusts are breaching their trajectory. The number reported includes all cases, but there is the option to discount cases where no lapses in care have been identified. The table below includes all cases attributed to acute trusts; including those where the review demonstrates that the outcomes for the patient were not altered by a lapse in care.

BTH ELHT LTH S&OHT

UHMB Total

Q1 + Q2 2018-19

Hospital onset 23 16 23 6 11 79

Q1 + Q2 2019/20

Hospital onset healthcare associated

36 26 48 11 16 137

Community onset healthcare associated

18 13 7 3 8 49

Total Acute cases 54 39 55 14 24 186

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Q1 Q2 Q3 Q4 Q1 Q2

2018/19 2019/20

Rate

per

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popula

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Chart to compare CDI rates

BwD

B'pool

CSR

EL

F&W

GP

MB

WL

National


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Increase from 2018/19 excluding COHA cases

+57% +63% +108% +83% +45% +73%

Increase from 2018/19 including COHA cases

+134% +143% +139% +133% 118% +135%

Objective 33 26 42 8 19 128

All local acute trusts have reported a significant increase of all healthcare associated cases. This was anticipated as the community onset healthcare associated cases are now attributed to the acute trusts within the new reporting criteria, and the trajectories were amended to take this increase into account, but all areas have reported an increase in the hospital onset cases. These were the cases attributed to the acute trusts in previous reporting years.

The impact across HLSC has shown whilst the overall increase in the number of CDI is 18% there has been an increase of 73% on the hospital onset cases against the same time period last year.

LTH and BTH have undertaken in-depth reviews of their increase in cases and have implemented trust wide action plans to address this.

The graph below compares local Trusts against the national rates. As with MRSA data, comparisons should not be drawn between acute trusts, due to the varying demographics of their catchment population and the specialist services they provide; therefore, this data should be used with caution.


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5 E. coli

The reduction of Gram-negative bloodstream infections is a national priority, as often these are linked to multi-drug resistant organisms. Escherichia coli (E. coli) is the causative agent for the majority of these Gram-negative infections and is therefore the focus for the reduction plans. The ICS has held a regional event which engaged all CCGs and Acute Providers to share learning and develop a regional action plan to address the high rates.

Many cases arise in the community (83% locally during Q2), some with no recent health care involvement. Some are linked to urinary tract infections (UTI) and urosepsis, so the Advisory Committee on Antimicrobial Prescribing, Resistance and Healthcare Associated Infection agreed that there should be a continued focus on prevention and optimal management of UTIs.

NHS England and NHS Improvement have developed a toolkit with a selection of resources that could be used to reduce E coli blood stream infections and a NHS system commissioning support pack is being developed, these include preventing dehydration, preventing UTIs, correct antibiotic guidance.

The NHS has also developed a tool to calculate the impact, both on finances and mortality, on the healthcare system. The table below shows the rationale for the calculations; this example is for Morecambe Bay CCG.


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Using this tool to assess the impact of E. coli blood stream infections on the HLSC using 2017/18 data shows that the impact is 181 potentially avoidable deaths, and a £1.87M cost impact. These numbers have continued to increase since 2017/18.

Clinical Commissioning Group Hospital onset cases

Community onset cases

Approximate number of deaths associated with E Coli blood stream infections

Approximate cost to the institution (£000)

Blackburn with Darwen 19 115 17 175

Blackpool 29 118 19 190

Chorley and South Ribble 38 108 18 190

East Lancashire 51 271 41 420

Fylde and Wyre 27 95 15 160

Greater Preston 33 135 21 220

Morecambe Bay 59 253 39 405

West Lancashire 20 64 11 110

ICS total 276 1, 159 181 1, 870

Anti-microbial

susceptible

Approximate patients:

253

4 excess bed days per

patient

13% mortality

Anti-microbial

susceptible

Approximate cost:

£285,000

(£1,224 per patient

for 4 excess bed days)

Approximate deaths: 34

Anti-microbial resistant

Approximate patients: 59

5 excess bed days per

patient

16% mortality

Anti-microbial resistant

Approximate cost:

£80,000

(£1,530 per patient

for 5 excess bed days)


312 equivalent patients

(without E. coli blood

stream infection)

No excess bed days

1% mortality

No additional costs


Approximate costs

associated with E.coli:

£405,000

Approximate deaths

associated with E.coli: 39

Approximate excess bed

day costs: £370,000

Approximate A&E

attendance costs: £35,000

(£138 per patient for 253

community onset patients)


312 patients with E. coli

blood stream infections

of which:

- hospital onset: 59

- community onset: 253


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5.1 E coli CCG

The ambition is to reduce healthcare associated E. coli bloodstream infections by 10% year on year to achieve a 50% reduction by 2024. The chart below shows the progress during Q2 towards achieving this trajectory.

BwD CCG

B'pool CSR CCG

EL CCG

F&W CCG

GP CCG

MB CCG

WL CCG

Total

Total for Q1 36 45 39 94 28 36 66 31 375

Q2 Acute Cases 11 9 2 15 6 10 13 1 67

Q2 Non-acute cases

28 49 22 62 36 30 76 29 332

Total for Q2 39 58 24 77 42 40 89 30 399

Total for 2019/2020 to date

75 103 63 171 70 76 155 61 774

Ambition to date 55 57 43 101 42 54 99 25 476

Percentage breach towards the

ambition +36%

+81% +47% +69% +67% +41% +57% +144%

62%

% increase or decrease on Q1 +

Q2 2018/19 +5%

+17% -22% +8% -12% -25% +16% +20%

+2%

All areas are currently breaching their ambition to reduce the numbers, with the overall figure being breached by 62%.

West Lancashire CCG have breached their annual ambition as they are reporting 61 cases against the annual ambition of no more than 50 cases.

The figure for the same time period last year was 761, so there continues to be an increase; although the rate of increase is reducing with some areas (CSR, GP and F&W) have all seen a decrease in numbers since the same time period last year.

5.2 Acute Trusts E coli

Acute trusts do not currently have a trajectory for reducing E. coli bloodstream infections, but they are supporting their local health economy plans to work towards the 10% reduction.

The following graph compares the rates for the local Acute Trusts against the national rate.


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6 Klebsiella spp.

Klebsiella is another Gram-negative bacteria. There is not a trajectory at present, but the reduction of Klebsiella bloodstream infections is included in the 50% reduction ambition. During Q2 there were 83 cases in Lancashire with 63 (76%) of these being apportioned to the non-Acute Trust.

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BwD CCG C&SR CCG EL CCG F&W CCG GP CCG MB CCG WL CCG

Trust apportioned and non-Trust apportioned Klebsiella bloodstream infections for Q2 2019-20

Trust apportioned cases Non-Trust apportioned

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2017/18 2018/19 2019/20

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Graph to compare E coli rates in Acute Trusts to the national rate

BTH

ELHT

LTH

S&OHT

UHMB

National


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7 Pseudomonas aeruginosa

Pseudomonas aeruginosa is the other Gram negative bacteria which is included in the reduction ambition, but there are fewer cases (29 during Q1). There is currently no trajectory and mandatory surveillance commenced in April 2017. Again, the majority of these arise in the community.

8. Antimicrobial resistance

Antimicrobial resistance (AMR) has a significant impact on patients and the general population with an estimated 60,788 antibiotic resistant severe infections in England during 2018; equivalent to 165 new antibiotic resistant infections per day2. It is recognised as one of the major health challenges of our era with Professor Dame Sally C. Davies former CMO stating:

“There are few public health issues of greater importance than antimicrobial resistance (AMR) in terms of impact on society.” 3

Antibiotic prescribing and antibiotic resistance are inextricably linked; overuse and incorrect use of antibiotics are major drivers of resistance.

The target is for a sustained reduction of inappropriate antibiotic prescribing and over recent years national strategies, such as Quality Premium and CQUIN targets to reduce antimicrobial prescribing have had some success. Within Primary Care items are counted per Specific Therapeutic group Age-Sex Related Prescribing Unit (STAR-

2 English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Report 2018 – 2019 3 UK Five Year Antimicrobial Resistance Strategy 2013 to 2018

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/244058/20130902_UK_5_year_AMR_strategy.pdf

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BwD CCG C&SR CCG EL CCG F&W CCG GP CCG MB CCG WL CCG

Trust apportioned and non-Trust apportioned Pseudomonas aeruginosa bloodstream infections for Q2 2019-20

Trust apportioned cases Non-trust apportioned




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PU) and must be equal to or below 1.161 items per STAR-PU. An additional threshold is in place to reduce items to below 0.965 items per STAR-PU.

As a system, HLSC is making steady progress towards achieving the required reductions for antimicrobial prescribing. The graph below shows the AMR local indicators available on the PHE Fingertips website using the data submitted for June 2019. The graph shows that all areas are achieving the target, but there is still some work required to achieve the additional threshold.

Reduction in antibiotic usage is only part of the story to help reduce the risks of AMR. The focus should always be to prevent infections and thereby reducing the need for antibiotic therapy.

Across HLSC this work is being incorporated into to the work to reduce GN blood stream infections and is led by the Senior Responsible Officer.

9. Care homes

During Q2 the IP team continued to support those undergoing the Quality Improvement Programme. 13 homes have been visited, audited and support provided.

In addition training sessions have been provided via the Care home IPC Champions meetings and ad-hoc sepsis and nutrition and hydration workshops.

00.20.40.60.8

11.21.41.61.8

Twelve-month rolling total number of prescribed antibiotic items per STAR-PU, June 2019

Precribed Antibiotic Items Target Additional Threshold


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10. Other work streams

The work to improve hand hygiene continues with the sessions delivered to the local schools; for this quarter the focus has been the schools in the Pennine districts.

Work is ongoing to reduce the number of UTIs and the team are working with a group from east Lancashire to prevent infections and improve the management when one occurs. The team continue to promote the message to not dip urine samples to diagnose UTIs.

A Nutrition and Hydration Community of Practice has been established for care homes.

Good oral hygiene has been encouraged to prevent the number of cases of pneumonia.

The roll out of the sepsis strategy continues with training provided to GPs in addition to the care homes.

11. Outbreaks In addition to norovirus outbreaks in care homes the IPC team at LCC have also been involved and supported the following outbreaks

Klebsiella at Southport Hospital – action plan developed and being implemented

Carbapenemase-producing enterobacteriaceae at Blackburn Hospital – action plan developed and being implemented

Streptococcus A outbreak in the community – training being provided by care teams

Salmonella incident within a care home in north Lancashire – home visited and all advice provided

Cryptosporidium in a nursery in Hyndburn – nursery visited with Environmental Health Officer; advice provided.

12. Recommendations

The Director of Public Health is asked to acknowledge and approve the content of this report.

Anita Watson, Lead Nurse Infection Prevention and Control

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