J. Reilly

From intermittent antibiotic point prevalence surveys to quality improvement: experience in Scottish hospitals

BackgroundIn 2008, the Scottish Antimicrobial Prescribing Group (SAPG) was established to coordinate a national antimicrobial stewardship programme. In 2009 SAPG led participation in a European point prevalence survey (PPS) of hospital antibiotic use. We describe how SAPG used this baseline PPS as the foundation for implementation of measures for improvement in antibiotic prescribing.MethodsIn 2009 data for the baseline PPS were collected in accordance with the European Surveillance of Antimicrobial Consumption [ESAC] protocol. This informed the development of two quality prescribing indicators: compliance with antibiotic policy in acute admission units and duration of surgical prophylaxis. From December 2009 clinicians collected these data on a monthly basis. The prescribing indicators were reviewed and further modified in March 2011. Data for the follow up PPS in September 2011 were collected as part of a national PPS of healthcare associated infection and antimicrobial use developed using ECDC protocols.ResultsIn the baseline PPS data were collected in 22 (56%) acute hospitals. The frequency of recording the reason for treatment in medical notes was similar in Scotland (75.9%) and Europe (75.7%). Compliance with policy (81.0%) was also similar to Europe (82.5%) but duration of surgical prophylaxis <24hr (68.6%), was higher than in Europe (48.1%, OR: 0.41, p<0.001). Following the development and implementation of the prescribing indicators monthly measurement and data feedback in admission units illustrated improvement in indication documented of ≥90% and compliance with antibiotic prescribing policy increasing from 76% to 90%. The initial prescribing indicator in surgical prophylaxis was less successful in providing consistent national data as there was local discretion on which procedures to include. Following a review and a focus on colorectal surgery the mean proportion receiving single dose prophylaxis exceeded the target of 95% and the mean proportion compliant with policy was 83%. In the follow up PPS of 2011 indication documented (86.8%) and policy compliant (82.8%) were higher than in baseline PPS.ConclusionsThe baseline PPS identified priorities for quality improvement. SAPG has demonstrated that implementation of regularly reviewed national prescribing indicators, acceptable to clinicians, implemented through regular systematic measurement can drive improvement in quality of antibiotic use in key clinical areas. However, our data also show that the ESAC PPS method may underestimate the proportion of surgical prophylaxis with duration <24hr.

Results from the second Scottish national prevalence survey: the changing epidemiology of healthcare-associated infection in Scotland

BACKGROUND Healthcare-associated infections (HAIs) are a recognized public health problem worldwide. Point prevalence surveys (PPSs) can be used to measure the burden of all HAI types. AIM To measure the prevalence of HAI and determine any changes in the epidemiology of HAI since the first Scottish national PPS. METHODS A national rolling PPS in National Health Service (NHS) acute, NHS non-acute, NHS paediatric and independent hospitals was carried out during September and October 2011 using the European Centre for Disease Prevention and Control protocol designed for the European PPS. The prevalence of HAI and distribution of HAI types were measured and the results compared with the first Scottish national HAI point prevalence survey of 2005/2006. RESULTS The prevalence of HAI was 4.9%, 2.5%, 6.1% and 1.2% in acute, non-acute, paediatric and independent hospitals respectively. The prevalence of HAI was significantly higher in acute hospitals compared with non-acute hospitals. There were no significant differences between the prevalence in the other hospital types. The prevalence of HAI in acute and non-acute hospitals was lower than the first survey by approximately one-third. The proportion of HAIs that were urinary tract infection, surgical site infection and bloodstream infection was higher and the proportion that were gastrointestinal including Clostridium difficile infection was lower in acute hospitals compared with the previous survey. CONCLUSIONS The epidemiology of HAI has changed in Scotland since the first national survey in 2005/2006, thus infection prevention and control measures require to be refocused in this regard. The lower prevalence and changing epidemiology of HAI in acute and non-acute care suggest that there may be a temporal relationship with the implementation of the national programme of targeted HAI interventions in the intervening period.

Evidence-based infection control planning based on national healthcare-associated infection prevalence data.

This study identifies factors associated with a high prevalence of healthcare-associated infection (HAI) in the Scottish inpatient population, on the basis of the Scotland National HAI Prevalence Survey data set. The multivariate models developed can be used to predict HAI prevalence in specific patient groups to help with planning and policy in infection control.

Integrating intensive care unit (ICU) surveillance into an ICU clinical care electronic system

The intensive care unit (ICU) is the specialty with the highest prevalence of healthcare-associated infection (HCAI) in European hospitals and therefore a priority for surveillance of HCAI. Whereas surveillance is an essential part of an effective infection prevention and control (IPC) programme, all too often it consumes too much clinician and IPC team time, limiting the time available for quality improvement. The case for electronic surveillance is made in the literature from several countries on this basis. These studies indicate that electronic surveillance can improve validity, reduce time spent on surveillance, and provide opportunities for improvement in clinical decision-making and IPC action arising from surveillance. The Scottish ICU HAI surveillance system was established as part of an integrated audit and clinical care system. Investment in this technology infrastructure reduced the burden of data collection and has resulted in a focus on driving improvement in all Scottish ICUs. The experience in Scotland indicates that several critical components are necessary to optimize ICU HCAI surveillance, including: nationally agreed definitions and methods; national investment in information technology infrastructure to make it easier to follow clinical care pathways; leadership of surveillance by intensivists; piloting and validation to ensure confidence in the system; and strategic integration of national and local programmes. These elements have helped improve surveillance data locally, nationally, and at a European level, allowing clinical attention to be focused on the data rather than on the process of data collection.

Staphylococcus aureus bacteremia and peripheral vascular catheters.

To the Editor—We were interested in the article by Trinh et al that reported on the risks of peripheral vascular catheters for Staphylococcus aureus bacteremia (PVC-SAB). We (E.T.C. and J.R.) have also commented on the importance of PVCs as a cause of S. aureus bacteremia (SAB) on the basis of the following data: (1) a national prevalence of PVCs among hospitalized patients of 30.3%; (2) a report that PVCs cause more SABs than are caused by central vascular catheters; (3) reports of PVC care, when audited, being suboptimal; and (4) studies of mortality indicating that PVCs pose a considerable risk. Trinh et al report that PVCs associated with SABs had a longer mean dwell time than did PVCs that were not associated with SABs ( ). Their comparison was based on P ! .001 completed PVC episodes for the group of patients who developed SABs. They compared these times with the PVC dwell times obtained from a group of patients who were identified in a point-prevalence study. However, it is clear that this latter group included PVC episodes that could not have been completed, because the PVCs were still in situ. This would have resulted in the dwell times of the comparator group being underestimated, leading to a likely overestimation of the SAB risk associated with the duration of insertion of PVCs. Although we concur with Trinh et al that patients’ risks of developing SABs increase with an increased duration of PVC insertion, we do not believe that their analysis supports this conclusion. We believe that additional work is still needed to highlight the importance of duration of PVC exposure, to reduce patients’ risks of developing SABs while receiving healthcare interventions. It would also be useful to understand the rationale for variation in PVC prevalence (30.3% in Scotland and 76% reported by Trinh et al). In addition, the use of the PVC point-prevalence data, multiplied by bed occupancy data, to serve as a denominator for incidence density may have also underestimated or overestimated incidence if the PVC use varied during the study period.

An adjusted funnel plot methodology for benchmarking targeted local healthcare associated prevalence surveys

We report the development of a local healthcare associated infection prevalence survey methodology that uses multivariate adjustment and funnel plots to facilitate benchmarking of local survey results against Scottish National HAI Prevalence Survey data. The tool provides robust and consistent results that can be used to inform infection control strategy.