Infection Prevention and Control in Critical Care RIE
Report April 2011 – March 2012
Acquired Infections 2011-2012 Ward 118 RIE
Patients admitted
Patients with
LOS < 2 days
n = 1188
n = 447
CVC related
bloodstream
infections
Patients with LOS
> 2 days
(CRBSI)
n=5
n = 741
CVC local
infections
n=1
SV
Hospital Acquired
Pneumonias
n=7
Bloodstream
Infections
(BSI)
n = 20
n = 47
Ventilator
Associated
Pneumonia
PN1-PN5
n = 40
Microbiologically
confirmed VAP
PN1-PN4
n = 22
CVC
generalised
infections
n=1
Total number of
infections = 56
Total number of patient
days = 5580
10.0 Infections/1000
patient days
1
Introduction
Ward 118 General ICU/HDU at the RIE is an 18 bedded unit with a notional allocation of
16 Level 3 and 2 Level 2 beds. Ward 116 HDU has 10 Level 2 beds and ward 115 has 2
Level 2 beds allocated for Critical Care patients. HEAT target data for wards 116 and 115
will be included in this report.
Infection surveillance data has been collected continually since 2005. The Hospital in
Europe Link for Infection Control though Surveillance (HELICS) criteria are used to define
ventilator associated pneumonia, bloodstream infection and central venous catheter
related bloodstream infection. The primary purpose of data collection is for local
improvement.
Hospital acquired pneumonia
Hospital acquired pneumonia is the most commonly acquired infection in critical care and
this is reflected in local data. In 2011-2012 there were 47 cases of acquired pneumonia
and 40 of these were ventilator associated pneumonia. 22 of the 47 pneumonia were
microbiologically confirmed ventilator associated pneumonia. 18 of the 47 pneumonia were
clinically suspected ventilator associated pneumonia with no positive microbiology. 7 of
the 47 pneumonia were in patients who had not been intubated and ventilated within the
48 hours preceding pneumonia.
The 40 cases of ventilator associated pneumonia occurred in 597 ventilated patients
(6.7%) who were ventilated for 3757 days giving a device associated incidence of 10.6
ventilator associated pneumonia /1000 ventilator days. Figure 1 shows the rate of clinical
ventilator associated pneumonia.
Figure 1 Ventilator associated pneumonia rate per 1000 ventilator days (includes clinically
suspected ventilator associated pneumonia PN1-PN5)
Ward 118 PN1-5 Ventilator Associated Pneumonia (VAP) per 1000 ventilator
days January 2005 - present
70
60
No. of VAP/1000
ventilator days
Process Average
50
40
UCL
30
LCL
20
UWL
LWL
10
Jan-12
Sep-11
May-11
Jan-11
Sep-10
May-10
Jan-10
Sep-09
May-09
Jan-09
Sep-08
May-08
Jan-08
Sep-07
May-07
Jan-07
Sep-06
May-06
Jan-06
Sep-05
Jan-05
0
May-05
Ventilator Associated Pneumonia/1000
ventilator days
80
Month
2
The 22 cases of microbiologically confirmed ventilator associated pneumonia occurred in
597 ventilated patients (3.7%) who were ventilated for a total of 3757 days giving a
ventilator associated pneumonia rate of 5.9 ventilator associated pneumonia /1000
ventilator days.
The microbiologically confirmed ventilator associated pneumonia incidence in 2011-2012
compares favourably to the year 2010-2011 when there were 26 cases of microbiologically
confirmed ventilator associated pneumonia in 547 ventilated patients (4.8%). These
patients had received a total of 3793 days of ventilation giving a device-associated
incidence of 6.9 cases of ventilator associated pneumonia /1000 ventilator days.
Figure 2 shows the improvement in microbiologically confirmed ventilator associated
pneumonia rate in ward 118 since 2005. A smaller winter peak is evident compared to
recent years when patients with H1N1 pneumonia had acquired secondary bacterial
pneumonia.
Figure 2 Ventilator associated pneumonia rate per 1000 ventilator days (microbiologically
confirmed ventilator associated pneumonia PN1-PN4)
Ward 118 Microbiologically Confirmed Ventilator Associated Pneumonia (VAP)
per 1000 ventilator days January 2005 - present
Ventilator Associated Pneumonia/1000
ventilator days
40
35
30
No. of VAP/1000
ventilator days
Process Average
25
20
UCL
15
LCL
10
UWL
LWL
5
Jan-12
Jul-11
Jan-11
Jul-10
Jan-10
Jul-09
Jan-09
Jul-08
Jan-08
Jul-07
Jan-07
Jul-06
Jan-06
Jul-05
Jan-05
0
Month
Bloodstream infections
In 2011-2012 there were 20 bloodstream infections in 741 patients (2.7%). The patients
stayed in ward 118 for a total of 5580 days giving an incidence of 3.6 bloodstream
infections /1000 patient days. These figures represent a significant reduction in number
and incidence when compared to the last 2 years. In 2010-2011 there were 23
bloodstream infections in 722 patients (3.2%) and the incidence was 4.0/1000 patient
days. In 2009-2010 there were 38 bloodstream infections in 629 patients (6%) and the
incidence was higher still at 6.4 bloodstream infections/1000 patient days. Figure 3 shows
a statistically significant improvement in the bloodstream infections rate.
3
Figure 3 Bloodstream infections rate per 1000 patient days
Ward 118 Bloodstream Infections (BSI) per 1000 patient days April 2006 - present
Bloodstream Infections/ 1000 patient days
25.0
20.0
BSI/1000 patient
days
Process Average
15.0
UCL
10.0
LCL
UWL
5.0
LWL
Jan-12
Jul-11
Oct-11
Apr-11
Jan-11
Jul-10
Oct-10
Jan-10
Apr-10
Oct-09
Jul-09
Jan-09
Apr-09
Jul-08
Oct-08
Apr-08
Jan-08
Jul-07
Oct-07
Apr-07
Jan-07
Oct-06
Jul-06
Apr-06
0.0
Month
The continued reduction in bloodstream infections is very encouraging. The last 11 data
points in figure 3 are below the process average representing a significant improvement
from previous years. Ward 118 remains committed to improving invasive device care.
In 2011-2012 6 Staphylococcus aureus bloodstream infections were attributed to ward 118
and 5 of these Staphylococcus aureus bloodstream infections were acquired in ward 118.
4 of the acquisitions were meticillin sensitive and 1 of the acquisitions was meticillin
resistant Staphylococcus aureus (MRSA). In 2011- 2012 none of the patients admitted to
ward 116 and none of the critical care patients admitted to ward 115 acquired
Staphylococcus aureus bloodstream infections. There were 8673 occupied bed days in
Critical Care at the Royal Infirmary Edinburgh in 2011-2012 giving an incidence of 0.58
Staphylococcus aureus bloodstream infections acquired in ward 118 / 1000 occupied bed
days compared to the NHS Lothian interim HEAT target of 0.34 Staphylococcus aureus
bloodstream infections/1000 acute occupied bed days. The target for March 2013 is 0.26
Staphylococcus aureus bloodstream infections/1000 acute occupied bed days.
4
Reducing blood culture contaminants
The guidelines for blood culture sampling have recently been reviewed to ensure best
practice following a further reduction of contamination rate.
The proportion of
contaminated blood cultures 2011-2012 was 3.8% which is a reduction compared to 20102011 when the proportion of contaminated blood cultures was 5.1%. Figure 4 shows
reduction in the proportion of contaminated blood cultures in ward 118. The data in figure
4 are based on laboratory definitions of contamination, for example, Coagulase negative
Staphylococcus or Diptheroids.
Figure 4 Proportion of Contaminated Blood Cultures
RIE 118 - Proportion of Contaminated Blood Cultures
0.18
Proportion contaminated
0.16
0.14
0.12
0.10
0.08
0.06
0.04
0.02
Prop contaminated
Warning
Jan-12
Mar-12
Nov-11
Jul-11
Sep-11
May-11
Jan-11
Mar-11
Nov-10
Jul-10
Sep-10
May-10
Jan-10
Mar-10
Nov-09
Jul-09
CL
Sep-09
May-09
Jan-09
Mar-09
Nov-08
Jul-08
Sep-08
May-08
Jan-08
Mar-08
Nov-07
Jul-07
Sep-07
May-07
Jan-07
Mar-07
0.00
UCL
Central venous catheter bloodstream infections
In 2011-2012 there were 5 catheter related blood stream infections in 589 patients that
had a central venous catheter (0.85%) with a device associated incidence density of 1.4
catheter related blood stream infections /1000 central venous catheter days, an overall
reduction on the previous year incidence of 2.1 catheter related blood stream infections
/1000 central venous catheter days. Figure 5 shows the overall improvement in catheter
related blood stream infections using a G-chart where the higher the data point, the longer
the time in between infections. The last data point is not a new infection but represents an
update (updated on 11 April 2012) to show how many central venous catheter days have
passed without a new infection.
5
Figure 5 Catheter Related Blood Stream Infection g- chart
Ward 118 Catheter Related Bloodstream Infection (CRBSI) January 2005 - present
No. of central line days since last CRBSI
2500
No. of central line
days since last
CRBSI
Average
2000
1500
UCL
1000
LCL
UWL
500
LWL
10 Jan-05
31 Jan-05
4 Feb-05
15 Mar-05
11 Apr-05
2 Jun-05
7 Jul-05
2 Aug-05
31 Aug-05
23 Oct-05
9 Nov-05
14 Jan-06
18 Feb-06
25 Oct-06
30-Jan-07
03-Mar-07
17-Apr-07
01-Jul-07
28-Jul-08
08-Feb-09
03-Jun-09
25-Aug-09
09-Feb-10
30-May-10
09-Oct-10
01-Nov-10
22-Feb-11
12-Jul-11
24-Jul-11
11-Apr-12
0
Month
Clostridium difficile
In 2011-2012 6 Clostridium difficile infections were attributed to ward 118. Four of these
infections were acquired in ward 118 in patients <65 years old. The other 2 infections were
not acquired in the unit but both were in patients >65 years old and therefore contribute to
the HEAT target. In 2011- 2012 1 Clostridium difficile infection was attributed to ward 116
but this did not contribute to the HEAT target. There were no Clostridium difficile infections
attributed to critical care patients in ward 115 in 2011-2012. There were 8673 occupied
bed days in Critical Care at the Royal Infirmary Edinburgh in 2011-2012 giving an
incidence of 0.23 Clostridium difficile infections/1000 occupied bed days which compares
favourably to the NHS Lothian interim HEAT target of 0.42 Clostridium difficile
infections/1000 occupied bed days. The target for March 2013 is 0.39 Clostridium difficile
infections/1000 occupied bed days.
There was a cluster of Clostridium difficile infections during the year 2011-2012 that was
investigated by the clinical team and the Infection Prevention and Control Team. Typing
results showed that each infection was caused by a unique ribotype of Clostridium difficile
and each patient had individual risk factors for infection. Cross infection by health care
workers was not considered to be a causal factor.
Figure 6 shows the number of patient days between Clostridium difficile infections. The
most recent data point is a new acquired infection in April 2012.
6
Figure 6 ICU associated Clostridium difficile
Ward 118 Clostridium difficile Infection January 2006 - present
5000
No. of patient days since last infection
4500
4000
Number of patient days
since last infection
3500
Average
3000
UCL
2500
LCL
2000
UWL
1500
LWL
1000
500
Feb-12
Nov-11
Aug-11
Feb-11
May-11
Nov-10
Aug-10
Feb-10
May-10
Nov-09
Aug-09
Feb-09
May-09
Nov-08
Aug-08
Feb-08
May-08
Nov-07
Aug-07
Feb-07
May-07
Nov-06
Aug-06
Feb-06
May-06
0
Month
MRSA acquisition
Acquisition of MRSA in the unit is defined as isolation of MRSA from a swab or sample
taken more than 48 hours after admission. MRSA screening compliance is audited
regularly and has improved over the course of the year.
There were 6 cases of MRSA acquisition in 2011-2012 in 741 patients (0.8%) who stayed
5580 days giving an acquisition incidence of 1.1 MRSA acquisition/1000 patient days.
This is a reduction compared to 2010-2011 during which there were 11 cases of MRSA
acquisition (1.9 MRSA acquisition/1000 patient days).
MRSA acquisitions remain low and figure 7 shows the significant improvement in MRSA
acquisitions. In 2010 ward 118 developed a guideline for MRSA suppression therapy and
the regime is now considered for all patients who test MRSA positive in the unit to reduce
the risk of cross transmission and self infection. In 2012 ward 118 introduced the national
MRSA screening programme clinical risk assessment in addition to the existing admission
and discharge swabbing regime.
7
Figure 7 MRSA Acquisitions
Ward 118 Acquired MRSA cases per 1000 patient days January 2005 - present
Acquired MRSA cases/ 1000 patient days
30.0
Acquired MRSA
cases/1000 patient
days
Process Average
25.0
20.0
UCL
15.0
LCL
10.0
UWL
5.0
LWL
Jan-05
Apr-05
Jul-05
Oct-05
Jan-06
Apr-06
Jul-06
Oct-06
Jan-07
Apr-07
Jul-07
Oct-07
Jan-08
Apr-08
Jul-08
Oct-08
Jan-09
Apr-09
Jul-09
Oct-09
Jan-10
Apr-10
Jul-10
Oct-10
Jan-11
Apr-11
Jul-11
Oct-11
Jan-12
0.0
Month
Vancomycin Resistant Enterococcus
There were 2 acquisitions of vancomycin resistant Enterococcus (0.3%) in ward 118 in
2011-2012.
Education and Quality Improvement
The data are fed back to the clinical team on a monthly basis using a simple dashboard
with annotated statistical process control charts to explain the data. The data are
presented at local and directorate quality improvement meetings as well as the local
morbidity and mortality meetings. Doctors on rotation are offered an Infection Prevention
and Control induction.
Summary
There has been a reduction in rate of ventilator associated pneumonia, bloodstream
infections, central venous catheter related bloodstream infections, MRSA acquisition and
contamination of blood cultures in the year 2011- 2012. Critical Care remains proactively
committed to infection prevention.
Odette Brooks
Infection Prevention and Control Surveillance Nurse
Critical Care/Infection Prevention and Control
Royal Infirmary of Edinburgh
Acknowledgements
Dr David Swann, Consultant in Critical Care
Dr Ian Laurenson, Consultant Microbiologist
Dr Mark Dunn, Consultant in Critical Care
Dr Kristjan Helgason, Consultant Microbiologist
Cairn Mahoney, Infection Prevention and Control Nurse Carol Rae, Infection Prevention and Control Nurse
8