Velindre NHS Trust Commentary –April 2015
Background
Velindre NHS Trust takes its commitment to prevent and reduce the risks of a
patient picking up an infection whilst being treated in this hospital extremely
seriously. We know that our patients are particularly vulnerable to infection either
as a result of the cancer weakening their immune system or from treatments
such as chemotherapy and radiotherapy that actively reduce their ability to fight
infections.
Velindre Cancer Centre is a specialty cancer (oncology) hospital with up to 50 inpatient beds. It provides non-surgical specialist services to a population of 1.5
million across South East Wales and so treats many more outpatients and day
cases than in-patients.
Due to the specialist services and small number of in-patient beds, our infection
numbers are not directly comparable with Health Boards in Wales. Therefore the
rate of infection for Velindre is reported per 1000 admissions to the hospital
rather than the 100,000 population used to calculate the figures for Health
Boards.
We carefully monitor our progress and numbers of infections every month,
quarterly and annually. We also, where possible, try and compare some of our
information with other cancer centres in England.
How are we Doing?
Overall the information in the accompanying graphs shows that the Trust has
made significant reductions in key infections since 2010.
Clostridium difficile (C. diff) Diarrhoea
C. difficile bacterial spores spread very easily in the clinical environment
without good control measures but we have been successful in reducing
the number of C.diff infections (in all age groups) in the Cancer Centre over
the last 5 years:
8 cases in 2014/15
14 cases in 2013/14
13 cases in 2012/13
21 cases in 2011/12
25 cases in 2010/11
Each infection has been investigated to identify the root cause of the patient
infection. We had seen a small increase in the number of cases April 2013 to
March 2014 particularly in those patients aged 66yrs and older but each case
was thoroughly investigated and in the majority of cases there was no evidence
to suggest that the rise was due to cross infection. In four cases where cross
infection was a factor and we took steps to reduce the risk further. These steps
have led to a 42% reduction for 2014/15 on the previous year with only 1 of these
cases identified as potentially hospital acquired. Cases of C. diff are often caused
by the use of antibiotics, rather than cross infection and as our patients often
require more than one course of antibiotics to prevent and treat serious
infections, they are at increased risk of developing C.diff. In spite of this added
risk we have been able to successfully reduce the number of C.diff infections
over the last 5 years. This has exceeded the reduction target set by the Trust for
each year for this infection and over the 5 years a 68% reduction in cases has
been achieved.
We take all cases of C. diff. very seriously and continue to take steps to:
 increase awareness in staff,
 promote the need for vigilance in infection control precautions and hand
hygiene,
 review all antibiotics prescribed and
 enhance the cleaning of the clinical area with specific disinfectants.
The Infection Control Doctor undertakes ward rounds with the antimicrobial
pharmacist on a weekly basis where possible. Further case reviews have been
undertaken and we are also ensuring effective communication with clinical staff
so that any ‘lessons learnt’ can be shared, to ensure the delivery of safe and
effective treatment and care.
Meticillin Resistant Staphylococcus aureus (MRSA) Blood Stream
Infections (bacteraemia)
Due to the nature of the care provided at Velindre Cancer Centre, bloodstream
infection or bacteraemia is a recognised risk especially when a central
intravenous device is required to deliver chemotherapy or if the patient is already
carrying MRSA on their skin. It can be seen that we have a very low rate of
MRSA blood stream infection:
0 cases in 2014/15
2 cases in 2013/14.
0 cases in 2012/13
1 case in 2011/12
4 cases in 2010/11
Each of these infections has been investigated and only 1 identified in 2010 was
recorded as acquired in this hospital. We have identified that in all cases the
MRSA bacteria was already being carried on the patient’s skin before they
were admitted to Velindre and before the blood stream infection occurred.
We actively screen all patients for MRSA skin carriage. Compliance with the
MRSA policy on the wards is audited monthly to ensure patients are
screened:
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on their first admission
if admitted from another hospital
if they have had MRSA previously
prior to surgical procedures
prior to the insertion of central venous devices.
This policy allows us to try and reduce MRSA on the patient’s skin (if
they are found to be carrying the bacteria) and reduce risks of others
being exposed to the bacteria in the clinical environment.
Meticillin Sensitive Staphylococcus aureus (MSSA) Blood Stream
Infections (bacteraemia)
Staphylococcus aureus is a common skin bacteria/organism that can cause a
bloodstream infection. MSSA is commonly associated with the use of intravenous
devices and may be due to contamination from the patient’s own skin bacteria.
Numbers of MSSA bloodstream infections in Wales have increased by 12% and
similar rises have been seen at Velindre but we also have very low rate of
MSSA blood stream infection:
2 cases in 2014/15
7 cases in 2013/14
7 cases in 2012/13
4 cases in 2011/12
Since 2011 we have only identified three cases of MSSA infection where the
infection might have been acquired at the Cancer Centre. Though the
numbers of infections for Velindre are small, each MSSA bacteraemia has been
investigated. We do know that the majority of these infections occurred in
patients with central intravenous devices. These devices are known as PICC or
Hickman lines. They pierce the skin when inserted and may need to stay in place
for up to 18 months to deliver chemotherapy. These infections may not be
attributed to cross infection or infection introduced during their hospital stay.
Velindre NHS Trust is committed to trying to reduce the number of MSSA
infections in patients. Between April 2013 and March 2014 there have been only
2 cases of MSSA bacteraemia and neither of these were Velindre acquired. This
is 4 less cases than the same time period in the previous year.
We take all blood stream infections very seriously and have an active programme
for reviewing each case and auditing clinical practices for intravenous device
insertion and maintenance.
Goal’s/Targets
Velindre NHS Trust takes a ‘zero’ tolerance approach to healthcare associated
infection and strives to eliminate all preventable HCAIs. We are using the 1000
lives plus improvement methods and using national guidance to guide our
practice including the National standards of Cleanliness and WHO hand hygiene
programme (http://www.1000livesplus.wales.nhs.uk/hcai).
Our objectives include:
 To prevent an increase in the number of C diff. infections for the year
2015/16 focusing on all age groups but especially those patients aged
over 66yrs of age. This is while accepting that, due to the small numbers
involved, further reductions may be difficult to achieve
 To continue to review antibiotic prescribing and ensure our antibiotic policy
minimises, where possible, unnecessary use of antibiotics especially
those that increase the risk of C. diff. infection.
 To implement the Velindre action plan for antimicrobial prescribing in
response to the recent nationally published antimicrobial prescribing
report.
 To continue to comply with best practice for the care of central intravenous
devices and investigate all MRSA and MSSA blood stream infections and
explore new interventions to reduce the risk further including new
technologies.
 To continue to use the 1000 Lives plus methods for improvement of the
care of medical devices e.g. urinary catheters and peripheral intravenous
devices that are often associated with bloodstream infection.
 To actively screen all new patients admitted to Velindre for MRSA
especially those who require a central intravenous device or invasive
procedure so we can take precautions for those who are carrying it
already on their skin and in their nose.
 To monitor compliance with the National Standards of Cleanliness to
ensure our environment is clean and safe where care is provided.
 To continue to monitor monthly compliance with good hand hygiene
practices in all patient areas.
 To audit clinical practices and use improvement methodologies to improve
patient care and reduce the risks of healthcare associated infections