Clostridium difficile related Serious Incidents at ...
Summary report following case reviews for Escherichia.coli Bloodstream Infection
Quarters 2 - 4 (July 2017 - March 2018)
The reporting of all Escherichia coli bloodstream infections (E.coli BSI) has been mandatory since 2011. Nationally counts and rates of infection have been increasing year on year. The Quality Premium 2017-19 targets reflect the ambitions set by Government following the O’Neill Review on Antimicrobial Resistance (May, 2016). These ambitions include a: 50% reduction of healthcare associated Gram negative bloodstream infections by 2020/21 and a 50% reduction of the number of inappropriate antibiotic prescriptions by 2020/21. The gathering of primary care data for all E.coli BSI cases has been mandatory for CCGs since July 2017. Locally the Community Infection Prevention and Control team (CIPC) have been undertaking case reviews on all E. coli BSI as part of the requirements to meet the 2017/18 Quality Premium. All primary care data is entered quarterly onto the Data Capture System. This work commenced July 2017. In order to support the CCGs to achieve their trajectory NHS Improvement developed a resource pack. As the majority of the infections arise in the community the resource pack advocates a health economy approach to reducing E. coli. The actions that NHS Improvement suggest include:
• organisations review their approach to reducing E.coli BSI
• surveillance
• review of cases to determine any common themes that could help to identify areas for action
• develop an improvement plan:
• review progress
Escherichia.coli
Escherichia.coli is a gram negative bacterium commonly found in faeces and the intestine of animals and people, where it forms part of the normal gut flora. Although most types of E. coli live harmlessly in the gut, some types can cause a range of infections including urinary tract and intestinal infection. Bloodstream infections (BSI) may be caused by primary infections spreading to the blood. Rates of E. coli BSI are reported by Public Health England (PHE) per 100,000 populations. The rates are higher in the local area than the national rate and after rising each year we are now starting to see a reduction, this is encouraging; however E. coli infections remain a source of concern for CIPC teams. Increasing antibiotic resistance makes these common infections more difficult to treat in community settings resulting in increased hospital admissions. It would appear from the current and previous year’s data that there is an increase in cases locally over the summer months and this may be linked to dehydration and associated increased incidence of urinary tract infection (UTI), however this theory will require further analysis as causes of E. coli BSI are multifactorial.
Data
|CCG |All E.coli BSI cases attributed to CCG |E-coli BSI CCG Quality Premium |Actual Cases Reported |
| |Jan-Dec 2016 Baseline data set |target 2017-18 |2017-18 |
| | |(10% reduction from baseline) |*Community case( ) |
|Mansfield and Ashfield |201 |181 | |
| | | |192 (149) |
|Newark & Sherwood |135 |122 | 109 (90) |
|CCG |All E.coli BSI cases attributed to CCG |E-coli BSI CCG Quality Premium |Actual Cases Reported |
| |Jan-Dec 2016 Baseline data set |target 2017-18 |2017-18 |
| | |(10% reduction from baseline) |*Community case( ) |
|Nottingham North and East |154 |139 | 131 (90) |
|Nottingham West |91 |82 | 70 (49) |
|Rushcliffe |107 |96 | |
| | | |101 (84) |
|Total |688 |620 | |
| | | |603 |
Table 1: shows E. coli BSI baseline rates reported by Public Health England (PHE), target needed to meet 10% reduction 2017/18 and actual cases reported at year end
|E-Coli Total 2017-18 |
| |
|CCG |Quarter 2 |Quarter 3 |Quarter 4 |Number of E. coli community (pre 48 hr) case |Total number of |
| |2017-18 |2017-18 |2017-18 |reviews |E. coli case reviews |
| |*(community acquired) |*(community acquired) |*(community acquired) | | |
|Mansfield & Ashfield |57 (45) |48 (36) |43 (33) |114 (77%) |148 |
|Newark & Sherwood |31 (23) |28 (26) |27 (23) |72 (84%) |86 |
|Nottingham North & East |32 (22) |33 (26) |35 (26) |74 (74%) |100 |
|Nottingham West |18 (11) |16 (12) |21 (11) |35 (64%) |55 |
|Rushcliffe |29 (22) |18 (16) |18 (15) |53 (82%) |65 |
|Total |167 (123) |143 (116) |144 (108) |348 (77%) |454 |
Table 2: shows the number of E. coli BSI case reviews completed in each CCG.
|Themes |Numbers | |
| |M&A |N&S |
|E.coli BSI Source (DCS) |M&A |N&S |NNE |NW |R |Total CCGS |
|Central Nervous System |0 |0 |1 (1%) |0 |0 |1 |
|Gastrointestinal or Intraabdominal collection |8 (5%) |6 (7%) |9 (9%) |14 (25%) |6 (9%) |43 (9%) |
|(excluding hepatobiliary) | | | | | | |
|E.coli BSI Source (DCS) |M&A |N&S |NNE |NW |R |Total CCGS |
|Hepatobiliary |15 (10%) |18 (21%) |18 (18%) |9 (16%) |9 (14%) |69 (15%) |
|Intravascular device (including Pacemaker/ ICD or CVC)|1 (1%) |0 |2 (2%) |0 |0 |3 (1%) |
|Lower Respiratory Tract pneumonia, bronchiectasis,COPD|9 (6%) |1 (1%) |2 (2%) |1 (2%) |0 |13 (3%) |
|Lower Urinary Tract |76 (51%) |41 (48%) |41 (41%) |13 (24%) |31 (48%) |202 (44%) |
|No underlying focus of infection |14 (9%) |2 (2%) |7 (7%) |7 (13%) |5 (8%) |35 (8%) |
|Skin or Soft Tissue (including ulcers, cellulitis, |0 |2 (2%) |1 (1%) |0 |0 |3 (1%) |
|diabetic foot infections without OM) | | | | | | |
|Unknown |14 (9%) |6 (7%) |11 (11%) |7 (13%) |10 (15%) |49 (11%) |
Upper Urinary Tract (pyelonephritis/ abscess) |8 (5%) |6 (7%) |8 (8%) |4 (7%) |3 (5%) |29 (6%) | |Grand Total |148 |86 |100 |55 |65 |455 | |Table 3: shows the number of E. coli BSI case reviews completed in each CCG by Source.
A thematic review has been completed using the data collated post E.coli BSI case review. In each case the past medical history and recent healthcare interactions were reviewed with particular attention paid to the preceding 28 days before the bloodstream infection, this criteria is set nationally. There were 12 case reviews with learning identified post general review over the year, however it is difficult to determine whether the BSI could have been avoided even with optimal treatment. The themes were the following:
• 6 cases were linked to a positive E-coli urine sample taken in secondary care that was not treated (not all had remained symptomatic).
• 2 palliative patients were admitted, both had urinary tract infections. One received treatment in hospital but there was a missed opportunity to involve the GP earlier as the patient was in a care home and no visit had been requested when they became unwell the day before admission. The second case had a catheter infection that wasn’t treated
• 2 cases were treated with Trimethoprim for a UTI despite previous resistance
• 1 case involved a leaking catheter that wasn’t reviewed by the community nursing team and the patient was admitted with UTI and sepsis
• 1 case involved a patient under the community nurses, they were re-catheterised and it was recorded that there had been debris and the patient had UTI symptoms yet there was no follow up or treatment with antibiotics and the patient was admitted the next day acutely unwell.
• National theme data is similar to local data.
Onset |Cases with reported Primary Focus |Total Cases |Gastrointestinal (not hepatobiliary |Hepatobiliary |Urinary Tract Infection |Respiratory Tract |Others |Unknown | |All reported cases |23,899 |41,237 |6.7% |15.7% |49.0% |5.5% |6.7% |16.4% | |Community onset |19,068 |33,454 |5.1% |16.1% |52% |5.4% |5.6% |16.0% | |Hospital Onset |4,831 |7,783 |13.0% |14.0% |38% |5.8% |11.0% |17.9% | |Table above shows E.coli BSI focus results since data collection started 2017-18 Public Health England
Actions and Challenges
This work is mandatory and all cases require review to meet the Quality Premium requirements 2017/18. There is variation as to how these reviews are completed. Some GP practices have granted access to SystmOne which removes the need for a clinical call back and allows for a robust case review. Other practices have declined access or are on EMIS web and these reviews are completed via a clinical call back. This process relies on detailed documentation and the information provided by the clinicians providing the care. Some information is not well documented including continence and detailed clinical signs when patients are treated for suspected urinary tract infection.
NHS Improvement provide support with central resources and recommendations based on work completed in other areas and best practice, there is a local action plan in place that maps the organisation against these requirements. Across Nottinghamshire we have already implemented many of the suggested recommendations and we are focussing on the wider public messages around hydration and self-care as we are not finding specific areas for improvement from our themes which is a similar finding to other areas of the country and reflects the complexity of this bacterium.
Nationally NHS Improvement report that there has not been the expected reduction in E.coli BSI rates over 2017-18 despite the work that has been completed. Locally we are currently performing well as all CCG areas have seen a reduction in cases with three achieving the 10% reduction, whereas nationally there continues to be an increase in incidence from the 2016 baseline albeit at a slower rate than previously seen. National theme data is similar to local data.
Future Need
The Secretary of State for Health has launched an important ambition to reduce healthcare associated Gram-negative blood stream infections by 50% by March 2021. As data collection increases nationally the aim is to identify gaps in current health and social care provision and to establish which key measures are needed to prevent and reduce further cases. Nationally and locally the risk factor data to date indicates that the most likely source leading to E.coli BSI continues to be urinary tract infection followed by hepatobiliary infection and these are areas that we will continue to review.
The Quality Premium 2018/19 has stretch targets applied, a 10% reduction now attracts 20% of the weighting and two extra milestones of 15% and 20% reductions have been added. It is anticipated that data gathering could be extended to include all Gram-negative BSI this may be introduced in 2019/20.
Summary
The reduction in E. coli BSI cases continues to be a difficult challenge to meet as the data collection both locally and nationally is not conclusively identifying key actions for reduction. Overall NHS Improvement is reporting that the 2017-18 reduction target was not achieved overall. The upward trend is reducing but further improvements are required.
Across Nottinghamshire we have successfully acquired and reported 100% of the data required and we have collectively reviewed this as a whole health economy. The work we have achieved has been recognised by NHS Improvement leads who came to discuss our joint approach, however we are still unable to identify specific factors that will lead to us reducing cases further, this is similar to the national findings to date.
Locally we have a shared action plan in place and we are working well together. We will continue to review cases and drill down to establish if we have actual themes or just an insignificant increase in incidence, we will continue with joint working including support with epidemiological expertise from Public Health England.
The areas we have focused on that may have accounted for some of the success across Nottinghamshire County includes:
• Changed and improved antimicrobial guidelines for use in primary care including prophylaxis
• Hydration campaign that included the ‘what colour is your wee’ postcards and media campaign
• The Dip or Not To Dip project to improve the management of UTI in care homes
Where reviews have yielded areas for improvement, these have predominantly been around the management of blocked catheters and sampling to determine urinary tract infection and treatment and remain in small numbers. A large proportion of patients have not presented to the GP with symptoms before experiencing their BSI, however a proportion of these will count as healthcare associated cases as they were receiving health care which may be unrelated e.g. podiatry, physiotherapy or they live in a care home. A number of cases that were investigated post BSI episode were found to have an underlying undiagnosed malignancy this would be considered to be an associated factor.
Further work is needed to identify any gaps in current UTI management, continence provision and aspects of self and social care that may be linked to E.coli BSI incidence. Pharmacist support will be key to ensuring that prescribing is compliant with local guidelines, particularly when treating for UTI.
In addition locally, we will be, repeating the messages around improving hydration as we enter the summer months and promoting the Dip or Not To Dip Project across care homes.
Newark and Sherwood, Nottingham North and East and Nottingham West CCGs all successfully achieved the required 10% reduction target. Rushcliffe CCG and Mansfield and Ashfield CCG failed to meet the Quality Premium 10% reduction in E.coli BSI cases 2017-18, however both achieved a reduction in cases from baseline of 6% and 4.5% respectively, both areas are noted to have the highest rates of UTI related BSI. This overall performance is an improvement when compared with the national data as there continues to be an increase in reported cases year on year.
The benefits of reducing these infections are improved patient safety and patient experience through reducing infection rates and length of hospital stay. The work to date across Nottinghamshire has resulted in 85 less cases over 2017-18 when compared with the 2016 baseline data.
There are financial savings to be gained from preventing admission and the need for treatment for a blood stream infection. The Community Infection Control Team and the wider Nottinghamshire RCA group are fully committed to this work and will endeavour to improve rates locally.
Sally Bird
Head of Service
Infection Prevention & Control Team
Mansfield & Ashfield CCG
References
The NHS Improvement 'Preventing healthcare associated Gram-negative bloodstream infections: an improvement resource' can be accessed at
NHS England CCGs Quality Premium: 2016/17 Guidance for CCGs
NHS Improvement Technical Guidance Annex B Information on Quality Premium April 2018 under Gateway Reference 07905
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