Infection Prevention and Control
Annual Report
2012
Joanne Flanagan, Infection Prevention and Control Nurse Specialist (CNS)
PAGE TITLE
PAGE
Introduction
1
Infection prevention and control structures
2
Committee membership
2&3
The Infection prevention and control Team
Infection prevention and control policies, procedures and
guidelines
3
Education and Training
3
Hand hygiene
World Health Organisation 'Five Moments of Hand hygiene'
3
3&4
4
Sleeves Up' Campaign
4&5
Hand hygiene compliance
5&6
Data Collection
5
Blackrock Clinic Targets
6
Hand hygiene education attendance
6
Audits and Actions taken
7&8
Clostridium difficile Infection rates
Staphlococcus aureus and Meticillin Resistant Staphlococcus
aureus
8&9
10 & 11
Vancomycin Resistant Enterococci rate
13
Other Organisms requiring Isolation
14
Extended Spectrum Beta- Lactamase producers
Carbepenem- Resistant Enterbacteriaceae
14 & 15
15
Surgical Site Infection rate for Cardiac Surgery
15, 16 & 17
Surgical Site Infection rate for Orthopaedic Surgery
17, 18 & 19
Outbreak of Infection
19
Project Development
19
Environmental Hygiene
20
Vaccination Programme
20 & 21
Antimicrobial Therapy
21, 22, 23, 24, 25 & 26
INTRODUCTION
The term “Healthcare Associated Infection” (HCAI) encompasses any infection caused by an
infectious agent acquired as a consequence of a person’s treatment or is acquired by a
healthcare worker in the course of their duties.
The Health Information and Quality Authority (HIQA) is an independent Authority which
was established under the Health Act 2007 to drive continuous improvement in Ireland’s
health services. In May 2009 HIQA launched The National Standards for the Prevention and
Control of Healthcare Associated Infections. These twelve standards are a key component in
maximising patient safety and improving quality of care. Blackrock Clinic also is accredited
by Joint Commissioner International (JCI).
The Infection Prevention and Control (IP&C) Annual Report provides an opportunity to
highlight the infection prevention and control activities that have been put in place in the
hospital throughout 2012.
The prevention and control of infection is valued and given high priority in Blackrock Clinic.
A programme of activities to embrace national initiatives and to reduce infection rates has
been developed and implemented. The activities which contribute to infection prevention and
control are carried out by all departments within the hospital. Infection prevention and control
is the responsibility of all healthcare workers and is incorporated into everyday practice.
The objective is to engage staff at all levels in order to maintain a culture that supports
infection prevention and control practices across the entire hospital.
The IP&C programme has a multi-faceted role in preventing the development and
transmission of disease, which includes surveillance of healthcare associated infections,
resistant organisms and the prevention of infection and control of existing infection.
1
INFECTION PREVENTION AND CONTROL STRUCTURES
The hospital’s Chief Executive is ultimately responsible for the prevention and control of
infection in Blackrock Clinic however infection prevention and control is the responsibility of
all staff.
The Infection Prevention and Control Committee (IPCC) is chaired by the Matron (Director
of Nursing) and the CEO sits on the Committee. The Committee is responsible for providing
an infection control strategy in Blackrock Clinic.
The IP&C committee analysed surveillance figures, infection control audits, outbreak reports
and also ratified all updated and new infection prevention and control policies, procedures
and guidelines throughout 2012.
MEMBERSHIP OF THE INFECTION PREVENTION AND CONTROL COMMITTEE 2012
NAME
TITLE
Bryan Harty
Chief Executive
Carmel Mangan
Matron
Dr. Anne Gilleece
Consultant Microbiologist
Dr. Lynda Fenelon
Consultant Microbiologist
Dr. Kirsten Schaffer
Consultant Microbiologist
Joanne Flanagan
Infection Prevention and Control CNS
Dr. George Duffy
Medical Consultant
Mr. Colin Riordan
Surgical Consultant
Dr. Harry Beauchamp
Medical Consultant
Dr Ailin Roger
Registrar
Brian McEntee
Pharmacist
Miriam McKeown
ICU Manager
Edel Costigan
Quality Manager
Daryl Simpson
Assistant Director of Nursing
Rosemary Leonard
Theatre Manager
Agnes O’Gorman
Day Unit Manager
Joan Giltrap
Accommodation Manager
Maria Hayes
Cardiothoracic Clinical Nurse Specialist
Mary O’Gorman
Theatre Clinical Nurse Specialist
2
Susan Healy
General Surgical Clinical Nurse Specialist
Lisa Cadden
Oncology Clinical Nurse Specialist
Claire Hogan
Orthopaedic Clinical Nurse Specialist
Michael McGowan
Facilities and Project Manager
THE INFECTION PREVENTION AND CONTROL TEAM (IP&CT)
The IP&CT includes the IP&C Nurse specialist and Consultant Microbiologist. The IP&CT
continues to provide operational direction and advice to clinical and non-clinical staff within
the Hospital. The IP&CT is supported by the microbiology laboratory.
INFECTION PREVENTION AND CONTROL POLICIES, PROCEDURES AND GUIDELINES
The IP&C policies, procedures, guidelines and programmes are available on Q-Pulse. The
IP&CT has a programme for revision of these as per hospital policy.
EDUCATION AND TRAINING
Education is a key component in reducing avoidable infection. All new staff starting in the
hospital receive hand hygiene education as part of their orientation programme. Nursing staff
receive a more extensive orientation where the infection control nurse specialist signs each
nurse off on their competencies. In 2012, 95 new staff attended the orientation programme.
Existing clinical staff receive regular education sessions which focus on specific topics,
relating to infection prevention and control. This may be on a new product or updated
changes on an existing policy. Other education sessions are delivered in addition and include
informal ward based sessions, telephone advice, information leaflets and posters.
Alongside the Infection Prevention and Control Nurse, the CNS in each specialty has assisted
in staff education in relation to infection control throughout 2012.
HAND HYGIENE
Hand hygiene includes washing your hands with soap and water and cleaning your hands
with an alcohol based hand rub. In 2011, Blackrock Clinic started measuring hand hygiene
using the same audit tool as all other hospitals in Ireland. In 2012 Blackrock Clinic
commenced submitting our audit results to the Health Protection Surveillance Centre (HPSC)
hand hygiene database. This allows our compliance rate to be benchmarked against other
3
hospitals in Ireland. All healthcare provider groups including physicians, contracted
employees and students are included in the audits.
WORLD HEALTH ORGANISATION (WHO) ‘FIVE MOMENTS FOR HAND HYGIENE’
The newly developed Five Moments for Hand Hygiene has emerged from the WHO
Guidelines on Hand Hygiene in Health Care to add value to any hand hygiene improvement
strategy. Quite simply, it defines the key moments for hand hygiene with a view to
overcoming misleading language and complicated descriptions. It presents a unified vision
and promotes a strong sense of ownership.
The Five Moments not only aligns with the evidence regarding the spread of HCAI but it is
interwoven with the natural workflow of care and is designed to be easy to learn, logical and
applicable in a wide range of settings. The illustration overleaf shows the Five moments of
hand hygiene.
OUR ‘SLEEVES UP’ CAMPAIGN
In March 2012 we introduced ‘Sleeves Up’ campaign in Blackrock Clinic. Initially ‘Hand
Hygiene’ and ‘Sleeves Up’ were audited separately. This allowed for a focus to be placed on
the physical attire of healthcare workers.
4
WHAT IS THE PURPOSE OF THIS INDICATOR AND WHY IS IT IMPORTANT?
This hand hygiene indicator measures healthcare worker compliance in Blackrock Clinic and
benchmarks against other hospitals in Ireland. Hand hygiene is universally accepted as the
single most important method of infection prevention and control. Wrists must be bare to
wash your entire hand and wrist correctly.
HAND HYGIENE COMPLIANCE, PERIOD 4 2012
The overall compliance for period 4, 2012 in Blackrock Clinic was 89.6%. This includes a
breakdown of disciplines and the Five Moments of hand hygiene.
Table 1 Staff compliance with hand hygiene
Table 2 Compliance with each moment of hand hygiene
DATA COLLECTION
The IP&C Nurse Specialist inputs the data to the HPSC database on a quarterly basis. We
started to benchmark our data with the HPSC in Period 3 2012. There has been an
improvement with our hand hygiene compliance from period 3 to period 4 (see graph
overleaf).
5
Hand hygiene compliance in Blackrock Clinic 2012
Overall complaince for period 3 = 88.1%
Overall compliance for period 4 = 89.6%
100.00%
96.70%
94.10%
Hand hygiene compliance
95.00%
90.90%
90.00%
89.80%
90%
90%
88.90%
88.50%
88%
86.70%
86.70%
86.70%
86.70%
Period 3
Period 4
85.00%
83.30%
80.00%
75.00%
WSU
ACU
PFU
FNU
ICU
DU
ED
Period 3
86.70%
96.70%
86.70%
90%
86.70%
83.30%
86.70%
Period 4
88.90%
94.10%
89.80%
88%
88.50%
90%
90.90%
Table 3 Hand hygiene compliance for period 3 and period 4 2012
BLACKROCK CLINIC TARGET FOR 2012
Our aim was to achieve 85% compliance in hand hygiene audits in 2012.
HAND HYGIENE EDUCATION ATTENDANCE FOR 2012
Hand hygiene education is mandatory education and our aim was to achieve a 100%
attendance in 2012. See graph overleaf for results.
6
Hand Hygiene education attendance 2012 in Blackrock Clinic
Overall Attendence in 2012 is 76%
120%
100%
100%
100%
100%
100%100%
100%100%
94%
91%
86%
80%
86%
75%
70%
60%
69%
66%
64%
61%
67%
63%
60%
52%
Hand hygiene
attendance
47%
39%
40%
22%
20%
ward
closed
IT
E
UA D
LI
TY
RA
P
DI HY
S
OL
IO
A
G DM
LE
IN
NA
LL
A
CA
RD LA
B
IO
PH LO
AR G Y
M
AC
Y
Q
EY
AN E
G
EN RA I O
G
IN DI O
EE L
R
AC I NG
CO
CA
M
TE M
O
T
5t RIN
h
FL G
O
O
R
T
O
IC
U
DU
G
AC
U
W
SU
FN
U
PF
U
FN
U
0%
Table 4 Hand hygiene education attendance
AUDITS
Quarterly hand hygiene audits (210 hand hygiene opportunities) were carried out and results
submitted to the HPSC. The IP&C Nurse Specialist carried out the audits. Our aim is to get
more auditors trained by the HPSC to assist in these audits in 2013.
WHAT ACTIONS HAVE BEEN TAKEN OVER THE LAST YEAR?
A number of actions have been taken over the last year including:
•
To Benchmark our hand hygiene results with the Health Protection Surveillance
Centre (HPSC).
•
A new campaign called ‘Sleeves up’ was launched in March 2012.
•
We increased communication with the physician group. There were numerous
leaflets, letters and audit results and presentation given to the physicians to remind
them about the importance of hand hygiene compliance.
•
Hand hygiene education took place as a part of orientation programme for all new
staff.
•
Night supervisors and CNS in theatre were trained to carry out hand hygiene
education. This helped increase education attendance for off peak staff.
7
•
One of our aims was to introduce a hand hygiene E learning tool. The committee
decided to wait until the HSE tool is completed. This will compliment the audit tool
we currently use from the HPSC.
•
Dedicated hand hygiene sinks are available in all patient rooms and clinical areas.
AN INTRODUCTION TO CLOSTRIDIUM DIFFICILE INFECTIONS (CDI) RATES
Clostridium difficile is a bacterium that can cause infections of the gastrointestinal system.
Clostridium difficile infection (CDI) happens when antibiotics kill the good bacteria in the
gut and allow Clostridium difficile to grow and produce toxins that can damage the bowel.
CDI can cause infections ranging from diarrhoea (common) to rare but serious complications
that require prolonged treatment with antibiotics and sometimes surgery. In extreme cases
CDI can result in death. The elderly and immunocompromised are particularly at risk for
these complications
NATIONAL ENHANCED SURVEILLANCE OF CLOSTRIDIUM DIFFICILE
•
In Q3 2012 there were 400 cases of Clostridium difficile infection (CDI) from 43
acute hospitals reported to the enhanced surveillance system. This gives a national
CDI rate of 2.5 cases per 10,000 bed days used. This is less than that reported last
quarter 4 (2.7 cases) and for the same period in 2011 (2.7 cases).
•
Overall there is a small decrease in the incidence of CDI in 2012. (Median CDI rate =
1.8 cases) compared to 2011 (median CDI rate = 2.2 cases). The significance of this
decline is difficult to determine due to changes in C. difficile testing methodologies
across laboratories during this time period. The table overleaf shows the national
quarterly trend of CDI since 2009.
8
Table 5 National Clostridium difficile rates in Irish hospitals
HOW DOES BLACKROCK CLINIC COMPARE TO OTHER PRIVATE HOSPITALS?
We commenced enhanced surveillance with the HPSC in Quarter 4, 2011. In Blackrock
Clinic there was a decrease in CDI from quarter 2 to quarter 3, 2012. The table below
highlights the CDI infection rate in private hospitals since 2009. We have been included in
this surveillance since 2011.
CDI cases per 10,000 BDUs
3.5
3
2.5
2
1.5
1
0.5
0
Q3
Q4
2009
Q1
Q2
Q3
Q4
2010
Private rate
Q1
Q2
Q3
Q4
2011
Q1
Q2
Q3
2012
Your Rate
Table 6 Clostridium difficile rates in private hospitals in Ireland
9
2009
2010
2011
2012
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4 Q1
Q2
Q3
National Rate
2.8
3.3
3.0
2.6
2.8
2.9
3.6
3.0
2.7
2.9 2.6
2.7
2.5
Private rate
0
0.8
0.5
0.5
1.9
1.6
1
1.6
0.8
1
0.5
0.7
1.2
N/A
N/A
N/A
N/A
N/A
N/A
N/A N/A
N/A
1.8 0.9
1.8
1
Blackrock
Clinic rate
Table 7 the national CDI rates, private CDI rates. This also refers to Blackrock Clinic rate.
STAPHYLOCOCCUS
AUREUS
(S
AUREUS)/
METICILLIN-RESISTANT STAPHYLOCOCCUS
AUREUS (MRSA) BACTERAEMIA
Meticillin-resistant Staphylococcus Aureus (MRSA) is a strain of staphylococcus aureus
bacterium that is resistant to a number of antibiotics. S aureus normally lives on human skin
and in the noses of about 25% of the general population (a process called colonization).
However S aureus can cause skin infections such as boils and abscesses and more serious
diseases such as bloodstream and respiratory infections.
Infections that occur in people who have been in hospital or who have had other healthcare
encounters are referred to as healthcare-associated MRSA (HA-MRSA). Risk factors for HAMRSA infection includes invasive procedures such as surgery, insertion of indwelling
catheters or intravenous tubing.
Another type of MRSA infection is associated with acquiring the organism in the community
(CA-MRSA). Factors that have been associated with the spread of CA-MRSA include close
skin-to-skin contact and openings in the skins such as abrasions.
10
Table 1. Total number of S aureus
No.
Estimated
Total S.
bloodstream infections, numbers of
Laboratories
% Pop/n
aureus
meticillin-susceptible and meticillin-
MSSA
MRSA
%MRSA
Coverage
resistant S. aureus, and proportion (%)
MRSA reported to the HPSC as part of
the European Antimicrobial Resistance
Surveillance Network (EARS-Net)
over the period 2004-2012.
Year
2004
41
96
1,323
770
553
41.8%
2005
42
98
1,424
832
592
41.6%
2006
42
98
1,412
820
592
41.9%
2007
44
98
1,393
857
536
38.5%
2008
43
98
1,303
864
439
33.7%
2009
43
100
1,309
954
355
27.1%
2010
40
100
1,251
946
305
24.4%
2011
41
100
1,095
832
263
24.0%
2012*
41
100
1,060
818
242
22.8%
Table 8 the total number of episodes of Staphylococcus aureus bloodstream infections,
numbers of meticillin-susceptible and meticillin-resistant S. aureus, and proportion (%)
MRSA reported to the Health Protection Surveillance Centre (HPSC) as part of the European
Antimicrobial Resistance Surveillance Network (EARS-Net) over the period 2004-2012.
SOME FACTS ABOUT MRSA ON A NATIONAL LEVEL
In quarter 4 of 2012, 23.9% of S aureus were MRSA (68 of 285). MRSA decreased from
41.9% in 2006 to 22.8% in 2012, which is provisionally the lowest annual proportion since
surveillance began in 1999. Between the peak in 2005/2006 and 2012, the numbers of MRSA
decreased by 59%.
11
Table 9 The map illustrates the distribution of MRSA in EARS-Net (previously EARSS)
countries in 2011 (Map downloaded from ECDC’s TESSy database on 22/10/2012)
MRSA per ward in Blackrock Clinic in 2012
This is measured per bed days used
0.25%
0.20%
0.20%
0.15%
0.13%
MRSA on Adm
0.10%
0.10%
Hospital Acquired
MRSA
0.10%
0.06%
0.05% 0.05%
0.04%
0.05%
0.02%
0%
0.00%
ICU
WSU
ACU
FNU
PFU
Table 10 The MRSA rate per bed days used (BDU) in Blackrock Clinic in 2012
12
VANCOMYCIN RESISTANT ENTEROCOCCI (VRE) INCIDENCE RATE
Vancomycin Resistant Enterococci (VRE) is a type of Enterococci bacteria that is resistant to
the antibiotic Vancomycin. Enterococci are bacteria found in the gastrointestinal tract (bowel)
in most healthy people. They can also be found on the skin and in wounds. This is normal and
is called colonization. In some people, especially those who are very ill, Enterococci can
cause an infection.
In quarter 4 of 2012, 46.5% of E. faecium in Ireland (53 of 114) were VRE. The HPSC
reported that VRE increased from 33.4% in 2007 to 46.8% in 2012, which is provisionally
the highest annual proportion reported to date.
There was no hospital-acquired VRE in 2012. All the VRE diagnosed in Blackrock were
diagnosed on admission screening swabs process.
The number of patients that were diagnosed with VRE on admission to Blackrock
clinic in 2012
3.5
3
3
2.5
2
2
Diagnosed on
admission
1.5
1
1
0.5
0
0
0
0
0
0
0
0
0
Jun
Jul
Aug
Sep
Oct
Nov
Dec
0
Jan
Feb
Mar
Apr
May
Table 11 The number of patients diagnosed with VRE in Blackrock Clinic in 2012
The laboratory surveillance identified other organisms that required isolation in 2012. There
were no trends noticed amongst these organisms.
13
Patients with other organisms that required isolation in 2012
4.5
4
4
3.5
3
3
Dengue
fever,Herpes
meningitis,
TB, Flu
2.5
2
On Admission
HA
2
2
Campylobacter/ TB
1.5
Scabies
Shingles
Lyme
1
1
1
Campylobacter
0.5 Salmonella
Meningitis(HA)
1
Shingles
1
Campylobacter
Legionella
0 0
0
0 0
0
0 0
0
0
0
0 0
0 0
0
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
0
Jan
Table 12 The other organisms that required isolation in 2012.
EXTENDED SPECTRUM BETA-LACTAMASE (ESBL)-PRODUCERS
ESBLs are bacteria that live in the bowel and that cannot be treated by commonly used
antibiotics. For most patients, ESBLs lives harmlessly in the bowel and do not cause
infection. However, sometimes ESBLs can cause infection in patients. Patients who have
already taken a lot of antibiotics are more at risk of developing ESBLs. The reason for this is
that the bacteria are more exposed to antibiotics, and are therefore more likely to develop
‘resistance’ to that antibiotic, so that antibiotic no longer works.
In Europe, invasive E. coli isolates are reported as part of the European Antimicrobial
Resistance Surveillance System (EARSS, http://www.rivm.nl/earss/). In Ireland, the
proportion of E. coli isolates that were tested for presence of ESBL, and tested positive,
increased from 1.3% in 2004 (11/861) to 2.7% in 2005 (30/1132 tested) [1,2]. The 2004
EARSS report comments that the proportion of E. coli resistant to third generation
cephalosporins increased from 1.5% 2001 to 2.9% (P<0.0001) in 2004, probably due to
increased dissemination of ESBL producers. The increase was consistent across the countries
surveyed by EARSS.
14
The number of patients diagnosed with ESBL in Blackrock Clinic in 2012
4.5
4
4
3.5
3
3
3
Number of pts
3
2.5
On Admission
2
Healthcare associated
2
Emergency dept
2
1.5
1
1
1
1
1
1
0.5
0 0 0
0 0 0
Jan
Feb
0 0
0 0
0 0 0
0 0
0 0
0 0
0 0
0
0
0 0
0
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Table 13 The number of patients that were diagnosed with ESBL in Blackrock clinic in 2012.
CARBAPENEM-RESISTANT ENTEROBACTERIACEAE (CRE)
Carbapenem antibiotics have been invaluable for the treatment of infections caused by multi
resistant Gram-negative organisms over the last decades. The increasing rates of gramnegative isolates expressing carbapenem-hydrolyzing enzymes are posing a significant threat
for the usage of carbapenem antibiotics. Detection of unidentified carriers is essential for
successful control. Active surveillance was introduced in 2011. The Committee’s
recommendation is to screen patients who have been inpatients for more than 48h in
healthcare facilities reporting outbreaks with CRE as per HPSC website. There were no cases
of CRE detected in Blackrock Clinic in 2012.
SURGICAL SITE INFECTION (SSI) SURVEILLANCE
CARDIAC SURGERY SSI SURVEILLANCE
The overall cardiac surgery SSI infection rates have reduced since 2009. Many interventions
have been put in place from the entire cardiac team to achieve this reduction. The SSI’s are
broken down into categories i.e. superficial, deep and organ space SSI. There is a weekly
cardiac surgery team meeting on William Stokes Unit. At these meetings each patient is
discussed. Also on the agenda are new interventions introduced, such as the introduction of
silicone dressings (to avoid blistering caused by adhesives), sternal binders as a prophylactic
15
measure in reducing sternal dehiscence (mainly for at-risk patients) and education of all staff
about the importance of aseptic technique.
Deep surgical site infection (SSI) rate 2012 is 0% for Cardiac surgery
100%
90%
80%
70%
SSI as a %
60%
50%
Deep SSI
40%
30%
20%
10%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
0%
Table 14 the deep wound infection rates in 2012.
Cardiac surgical site infection (SSI) rate 2012 in Blackrock Clinic
Overall SSI Rate = 2.9%
Superficial SSI Rate = 2.7 (Benchmark 8.5%)
Sternal SSI Rate = 2.2% (Benchmark 5.6%)
Donor SSI Rate = 0.4% (Benchmark 2.2%)
Overall SSI Rate
in 2011= 3.9%
12.00%
1 Suture knot
10.00%
10.00%
SSI as a %
8.00%
6.00%
6.00%
Superficial
SSI rate
4.00%
3.00%
2.40%
2.20%
2.70%
3.00%
2.50%
2%
2.00%
1 Donor
1 Donor
0.00%
0.00%
0.00%
0.00%
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Table 15 the Superficial SSI rate in 2012
16
Surgical Site Infection (SSI) rates for Cardiac Surgery from 2009- 2012 in Blackrock Clinic
7.00%
5.90%
6.00%
SSI rate
5.00%
4.70%
3.90%
4.00%
SSI rate
2.90%
3.00%
2.00%
1.00%
0.00%
*2009
*2010
*2011
*2012
Table 16 The SSI trend since 2009
ORTHOPAEDIC SURGERY SSI SURVEILLANCE
The orthopaedic surgery SSI’s are broken down into categories i.e. superficial, deep and
organ space SSI. There is a monthly Orthopaedic surgery team meeting on Abraham Colles
Unit. At these meetings each patient is discussed and wound infections are categorised.
Overall Hip Superfical Surgical site infection (SSI) rate 2012 is 0.3%
Benchmark is 2.09%
(2011 SSI rate was 1.67%)
4.00%
1.2
3.80%
3.50%
1
1
3.00%
2.00%
0.6
1.50%
No. pts with SSI
SSI rate as a %
0.8
2.50%
SSI rate
No. pts with SSI
0.4
1.00%
0.2
0.50%
0.00%
0.00%
0
Jan
0.00%
0
Feb
0.00%
0
Mar
0.00%
0
Apr
0.00%
0
May
0.00%
0
Jun
0.00%
0
Jul
0.00%
0
Aug
0.00%
0
Sep
0%
Oct
0
Nov
0.00%
0
Dec
0
17
Overall Knee Surgical site infections (SSI) rate 2012 is 0%
Benchmark is 0.9%
(2011 SSI rate was 0.4%)
1
90.00%
0.9
80.00%
0.8
70.00%
0.7
60.00%
0.6
50.00%
0.5
40.00%
0.4
30.00%
0.3
20.00%
0.2
10.00%
0.00%
No. pts with SSI
SSI as a %
100.00%
SSI rate
No. pts with SSI
0.1
0.00%
0
Jan
0.00%
0
Feb
0.00%
0
Mar
0.00%
0
Apr
0.00%
0
May
0.00%
0
Jun
0.00%
0
Jul
0.00%
0
Aug
0.00%
0
Sep
0.00%
0
Oct
0%
0
Nov
0.00%
0
Dec
0
Table 17 the infection rates for hip and knee surgery in 2012
Hip Surgical Site Infection rate from 2009- 2012
3.00%
2.60%
2.50%
2.00%
1.67%
1.50%
1.50%
SSI Rate
1.00%
0.50%
0.30%
0.00%
*2009
*2010
*2011
*2012
18
Knee Surgical Site Infection Rate from 2009- 2012
1.40%
1.20%
1.20%
1.00%
0.80%
SSI Rate
0.60%
0.40%
0.40%
0.40%
0.20%
0.00%
0.00%
*2009
*2010
*2011
*2012
Table 18 The SSI trends since from 2009 to 2012 in Hip and Knee surgery
OUTBREAK OF INFECTION
There were no reported outbreaks of infection in 2012 in Blackrock Clinic.
PROJECT DEVELOPMENT
Blackrock Clinic commenced a major development project in 2008. During 2012 the IC&P
Nurse Specialist and Consultant Microbiologist remained actively involved throughout the
ongoing construction outside and within the hospital, both in advising on the provision and
design of facilities within a variety of projects. The IP&C Nurse Specialist closely monitored
activity during each phase of the project.
Risk assessments of works were carried out and are available on Q Pulse. Dust checks were
carried out by the accommodation supervisors. Any increase in dust levels was immediately
reported to the construction manager and work was stopped until the problem was
investigated and resolved. In these cases, air sampling was carried out using fungal media.
HEPA filtration was implemented in high risk patient areas throughout the hospital as a
preventative measure. There were no cases of hospital acquired invasive aspergillosis or
Legionella in 2012.
19
ENVIRONMENTAL HYGIENE
The IP&C Nurse Specialist continues to attend the Hygiene Committee that meets on a
weekly basis within clinical areas. Clinical managers or staff in charge are invited to attend
and discuss various hygiene topics within their area. A visual inspection of the area is also
carried out and findings are reported to each manager. All clinical managers receive minutes
of these meetings. There is a patient information leaflet supplied in all bedrooms to provide
patients with information on how their room is cleaned. An audit tool was introduced in
2012. This facilitated a team approach to audits carried out in clinical areas.
AUDIT RESULTS AVERAGE 2012
97.00
95.94
96.00
95.36
94.94
95.00
94.61 94.81
94.00
93.18
93.03
92.71
93.00 92.62
92.60
91.96
91.50
92.00
91.00
94.72
94.54
90.11
90.02
90.23
90.00
89.00
88.00
ol
o
r M gy
5t
ed
h
Fl
i
oo cin
e
rT
G
he
ro
at
un
re
dT
he
at
re
P
hy
si
o
C
Fr
SS
on
tC D
or
rid
or
N
5t
h
uc
l
ea
O
nc
og
y
y
io
l
ar
d
C
U
ol
og
IC
ad
i
R
D
ng
io
A
ov
ec
or
R
4t
h
Fl
o
E
er
y
or
Fl
o
or
r
Fl
o
3r
d
Fl
oo
d
2n
1s
tF
lo
o
r
87.00
Table 19 The average hygiene audit score in 2012
VACCINATION PROGRAMME
Blackrock Clinic encourages all staff to avail of the influenza vaccination annually, to reduce
the risk of transmission to vulnerable patients.
A Hepatitis B vaccination programme is provided for all clinical and accommodation staff
prior to employment. Personal protective clothing is supplied to all clinical areas to reduce
the risk of exposure to body fluid. Staff also have access to an occupational health facility
where they can seek advice and treatment, where necessary.
20
ANTIMICROBIAL THERAPY
INTRODUCTION
In May 2012, 50 acute Irish hospitals (42 public and 8 private) participated in the voluntary
European Centre for Disease Prevention and Control (ECDC) point prevalence survey (PPS)
of hospital acquired infections (HAI) and antimicrobial use (AMU). The survey was
coordinated in Ireland by the Health Protection Surveillance Centre (HPSC), the national
centre for the surveillance of infections in Ireland. The breakdown of participating hospitals
by type included: 15 primary/general, 10 secondary/regional, 6 tertiary, 11 specialist public, 1
specialist private and 7 other private hospitals.
Although the Blackrock Clinic did not participate in the PPS the Pharmacy Department
conducted a similar point prevalence audit on the 1st of November which has been completed
for the previous three years. These results provide us with a snapshot of number of patients
who were prescribed antimicrobials in the Clinic on that day.
We aim to conduct a PPS for 2013 this coming autumn. This year we intend to collect data
regarding compliance with the Antimicrobial Guidelines and involvement of Microbiology,
where necessary, in choosing appropriate treatment.
ANTIMICROBIAL USE PREVALENCE
Percentage of Inpatients on Antimicrobials
45.00%
40.00%
percentage
35.00%
30.00%
25.00%
On Abc
20.00%
Treatment
Prophylaxis
15.00%
10.00%
5.00%
0.00%
2012 N=108 2011 N=110
2010 N =81
2009 N=83
On Abc
38.90%
36.4%
31%
39%
Treatment
29.60%
26.4%
18.5%
30%
9.30%
10.0%
13%
9%
Prophylaxis
number of patients
Table 20 NPPS 2012 antimicrobial use prevalence = 34% 1
21
Top Antimicrobials Prescribed - Treatment and Prophylaxis
Coamoxiclav
Ciprofloxacin
Flucloxacillin
Cefuroxime
Rifampicin
2012
Penicillin
2011
Clarithromycin
2010
Trimethoprim
2009
Piperacillin
Metronidazole
Clindamycin
Fluconazole
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
Table 21 The top antimicrobials prescribed were Co-amoxicillin (15%), Ciprofloxacin (14%),
Flucloxacillin (12%) and Cefuroxime (10%), followed by Rifampicin, Penicillin,
Clarithromycin and Piperacillin/Tazobactam (all approximately 5%).
Top Antimicrobials Prescribed 2012 -
Treatment Only
18.00%
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
C
C
ip
ro
f
lo
oa xac
in
m
Fl oxic
uc
l
l o av
xa
R cill
i
i
C fam n
la
p
rit
i
hr cin
om
y
Pe cin
n
Pi icil
pe lin
r
C acil
ef
l
ur in
C oxi
m
lin
da e
m
Fl
uc yci
n
M on a
et
z
ro
ol
e
ni
da
D
z
ap
o
to le
m
Le
vo ycin
flo
x
Li
m aci
n
e
Tr cyc
im
l
et i ne
ho
Va
p
nc rim
om
yc
in
0.00%
22
Indication
35.00%
30.00%
25.00%
20.00%
2012
2011
15.00%
10.00%
5.00%
BJ
EN
T
UN
Pr
op D
h
U
TI
G
I
BA
C
SI
R
S
RE
SP
G
U
M
O
TH
UT
I
pr Pn
op eu
h
M
Pr ED
op
pr h C
op T
h
SB
O J
B
pr
G
op Y
h
EN
T
ND
SS
T
0.00%
BAC
Bacteraemia
BJ
Septic arthritis, osteomyelitis
ENT
Ear, nose, throat, larynx
GI
Gastrointestinal
GUM
Prostitis, epididymo-orchitis
ND
Not documented, no indication given
OBGY
Obstetric, gynaecological
OTH
Other
Pneu
Pneumonia
Proph CT
Cardio-thoracic prophylaxis
Proph ENT
Ear, nose, throat prophylaxis
Proph MED
Medical Prophylaxis
Proph SBJ
Orthopaedic/Plastic prophylaxis
Proph UTI
Urological Prophylaxis
RESP
Respiratory (non-pneumonia)
SIRS
Systemic with no clear anatomic site
SST
Cellulites, wound, deep soft tissue
UND
Undefined site and no systemic inflammation
UTI
Urinary (lower and upper)
Table 22 Top Antimicrobials used at the time of the point prevalence
23
There was a documented indication for the antimicrobial prescription in 79% (NPPS 83% 1).
The indication for prescription was for treatment of infection in 71% of cases (NPPS 78% 1),
surgical antimicrobial prophylaxis in 15% of cases (NPPS 11% 1) and medical prophylaxis in
6% of cases (NPPS 8% 1).
The most common infection sites for which antimicrobials were prescribed on the day of the
study included; skin/soft tissue (29%), urinary tract infections (10%), Pneumonia (8.6%).
These were followed by medical, cardio-thoracic and orthopaedic prophylaxis (all
approximately 5%).
Percentage of Patients on Parenteral
Antimicrobials
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
2012
2011
2010
2009
Table 23 NPPS 2012: 63% on parenterals 1
The parenteral (i.e., intravenous) route accounted for most prescribed antimicrobials (63%) in
the NPPS 1. In contrast less than half of patients were on IV antimicrobials on the day of our
study, although this figure was higher the previous year.
24
Allergy Status Completed
yes
2%
no
98%
Percentage of Penicillin Allergic Patients
allergic
8.60%
not allergic
91.40%
Reason for Treatment in Notes
no
yes
31%
69%
25
Duration of Treatment Recorded
yes
no
32.70%
67.30%
Culture Pre-Therapy
no
yes
31%
69%
REFERENCE LIST
1. Health Protection Surveillance Centre, Point Prevalence Survey Hospital Acquired
Infections & Antimicrobial Use in European Acute Care Hospitals: May 2012 – Republic of
Ireland National Report: November 2012. Foley, M et al. Last accessed 22nd April 2013.
Available at: http://www.hpsc.ie
26
We would like to thank all the staff in Blackrock Clinic for their help in reducing infection
throughout 2012. We would also like to thank the Infection Prevention and Control
Committee for their support and advice throughout 2012.
27