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Reducing infection in our hospitals

Reducing infection in our hospitals

This is an update on a story in our Quality Account for 2013/2014 about embedding consistent hand hygiene practice as a means to reduce the incidence of hospital acquired infections and multi-drug resistant bacterial infections [view more about our hand hygiene programme].

What are we trying to achieve?

Our goals are to reduce the incidences of:

  1. hospital acquired infections by ensuring consistent compliance to hand hygiene best practice
  2. hospital acquired infection staph. aureus bacteraemia[1] (SAB)
  3. hospital acquired blood stream infections (HABSI) and healthcare associated blood stream infections (HCA – BSI) e.g. staph. aureus
  4. central line associated bacteraemia (CLAB)
  5. orthopaedic surgical site infections (SSI) – (Knee and Hip Arthroplasty[2])

Why do we need to reduce infection and colonisation rates?

Healthcare associated infections (HCAI) affect 5-15% of hospitalised patients and 9-37% of those admitted to intensive care units (ICUs), and contributes to death in at least 2.7% of cases. HCAIs also result in prolonged hospital stay, long-term disability, increased resistance to antibiotics, massive additional financial burden, and high costs for patients and their families.

There is substantial evidence that hand hygiene reduces the incidence of HCAI and the incidence of multidrug-resistant bacteria[3]. Performing hand hygiene correctly at each of the five moments [WHO five moments of hand hygiene] reduces the risk that infectious organisms will be spread between patients from the hands of healthcare workers.

Hand Hygiene is an important indicator of safety and quality of care delivered in our hospitals. It is one of the Health Quality and Safety Commission’s national quality and safety markers.

  1. Bacteremia is an invasion of the bloodstream by bacteria leading to a blood stream infection
  2. Arthroplasty is surgery to relieve pain and restore range of motion by realigning or reconstructing a joint
  3. World Health Organisation (WHO) guidelines on hand hygiene in health care, 2009


How are we doing?

Hand hygiene

Hand Hygiene New Zealand (HHNZ) is a national priority quality improvement initiative led by Health Quality and Safety Commission (HQSC), aiming to improve hand hygiene practice in New Zealand hospitals. This initiative commenced in early 2012 with quarterly 'Gold Audits' performed by trained auditors. The audit measures how many times staff comply with the World Health Organisation’s "5 moments of hand hygiene".

Waitemata DHB was one of the first nine DHBs to participate in the National “Gold Audits” which commenced in March 2012. All 20 DHBs now participate.

The initial national target in March 2012 was set at 70% compliance to the overall hand hygiene moments; this has recently been increased to 80%. As shown in the graph below Waitemata DHB has made steady improvement and continues to meet or exceed the National target and the National average.

Hand Hygiene Compliance Rate

Since March 2012 the quarterly national hand hygiene audit (Gold Audit) has been undertaken in a select few clinical areas across our DHB; from July 2015 all clinical areas will contribute data to the national hand hygiene compliance audit. This will provide the impetus for all clinical areas to be focussed on improving their compliance to good hand hygiene practice.

Staph. aureus bacteraemia (SAB) infections

The rate of Staph. aureus bacteraemia (SAB) infections attributed to healthcare is the national outcome measure for hand hygiene compliance. The SAB rate is based on HHNZ‘s definition to maintain consistency in DHB reporting.

This is a ‘days between’ control chart and, therefore, the clustering of data points below the mean (Ẋ) represents events occurring close in time or an increased relative frequency of events.

Staph. aureus blood stream infections

The length of time between infections is increasing which may reflect improved compliance with to hand hygiene practices.

Waitemata DHB’s SAB rate (quarterly rate of 0.03-0.06 per 1000 bed days) is consistently well below the national average (1.2-1.3 per 1000 bed days) with approximately one SAB per month. There were a total of 16 S.aureus bacteraemia infections identified in 2014.

The below graph shows that the rate of Staph. aureus infections at Waitemata DHB (red line) in comparison to the National average (orange line).

Staph.aureus infection rates - Waitemata DHB vs National average

Hospital Acquired Blood Stream Infections (HABSI)

HABSI is defined as a bloodstream infection attributable to hospital where acute or rehabilitation care is provided, if the infection was not incubating (present) on admission. Typically bacteraemia (infection in the blood) is diagnosed after 48 hours of admission, on readmission, related to a device (catheter, intravenous line (IVL)) or within 30 days of a procedure (if no alternative source is identified) is categorised as HABSI.

In 2014 there were 79 hospital acquired (HABSI) and 22 healthcare associated (HCA-BSI) bacteraemias; this is a rate of 0.22/1,000 occupied beds days (OBD) which equates to 6-7 HABSIs per month. The overall average rate for 2010 - 2015 is 0.24/1,000 OBD.

Waitemata DHBs mean rates of HABSI / 1, 000 OBD have remained stable and lower than reported in 2013/2014.

Overview of HABSI rate/1,000 OBD for the past five years:


















Hospital acquired blood stream infections

The below table demonstrates the sources of our HABSI:

HABSI Source



Jan - Jun 2015

Vascular catheter (CLAB / IVL)

(5 CLAB)

(10 CLAB)

(3 CLAB)

Catheter associated urinary tract infection (CAUTI)




Post procedure or surgery




Other (mostly urinary tract infections (UTIs))




Unknown source




Central Line Associated Bacteraemia (CLAB)

Patients with a central venous line are at risk of a blood stream infection (CLAB). Patients with a CLAB experience more complications, increased length of stay, and increased mortality (death); and each case costs approximately $20,000 - $54,000.

All incidences of CLAB are investigated by our Infection, Prevention and Control team to understand:

  • why the infection occurred
  • if we could have prevented the infection
  • review current processes and procedures to ensure this does not recur and whether further training for clinicians is required

CLAB infections are largely preventable using a standardised procedure for insertion and maintaining lines (referred to as “insertion and maintenance bundles of care”).

North Shore Hospital’s Intensive Care Unit (ICU) compliance with standard procedure for insertion and maintenance of central lines and rates of CLAB are reported to the Health Quality and Safety Commission (HQSC) as our DHB and National HQSC Quality and Safety markers.

Our rate of CLAB/1,000 line days was 0.65  for June 2015 (target = <1 per 1000 line days).

Central line associated bacteraemias (CLAB)

The following clinical areas have been ‘CLAB Free Days’ (0 infections) (as at 1st August 2015):

Clinical Area


Clinical Area




Ward 10


Ward 2


Ward 11


Ward 3


Ward 14


Ward 4


Ward 15


Ward 5




Ward 6




Ward 7




Ward 8




Ward 9




The compliance to the insertion and maintenance bundles for the central lines is measured in percentages; the DHB and National target is compliance >90%. Waitemata DHB’s ICU has consistently meeting or exceeding this target with the insertion bundles since November 2013; the maintenance bundles have consistently met or exceeded the >90% target from December 2014.

The CLAB “bundles” were progressively rolled out to all medical, surgical, rehabilitation wards and theatres in 2014. Insertion of central lines is primarily undertaken in ICU, theatres, renal services and radiology so compliance overall is either meeting or exceeding the >90% target.

The maintenance bundle compliance is audited on the medical, surgical and rehabilitation wards as these areas are likely to be undertaken maintenance of the central lines as well as ICU.

The graph below shows the overall insertion and maintenance bundle compliance rates:

CLAB insertion and maintenance compliance rates

Orthopaedic Surgical Site Infections (SSI) Surveillance (Knee & Arthroplasty)

Waitemata DHB became involved in the National SSI programme run by the Health Quality and Safety Commission (HQSC) in March 2013. As shown in the table Waitemata DHB has demonstrated a significant improvement in relation to the incidence of post orthopaedic knee and hip procedure infections.

SSI Rate / 100 procedures*

Waitemata DHB


Oct - Dec 2013

1.2 (3/254)


Jan - Mar 2014

0.7 (2/277)


Apr - Jun 2014

1.2 (4/327)


Jul - Sep 2014

1.9 (6/324)


Oct - Dec 2014

1.5 (5/330)


Jan - Mar 2015

0.7 (2/283)


* In scope procedures are total hip and knee primary or revision arthroplasties

The HQSC uses 90-day outcome measures for surgical site infection and, therefore, the data reports run one quarter behind other Quality and Safety Markers. The rate of Surgical Site Infections (hips and knees) for Jan-Mar 2015 was 0.7% (i.e. 2 infections out of 283 procedures).

The overall national cumulative SSI rate for Mar 2013 – Dec 2014 was 1.3% (Confidence Interval (CI) 1.1-1.3), with 202 SSIs from 15,821 procedures. Waitemata DHB’s cumulative rate was 1.4% (CI 0.9 – 2.0) with 26 SSIs from 1888 procedures.

The additional quality safety markers for SSI are:

  • 100% of primary hip and knee replacement patients will receive prophylactic (preventative) antibiotics 0 - 60 minutes before incision of the skin
  • 95% of hip and knee replacement patients are to receive 2gms or more of Cefazolin (antibiotics)
  • 100% of primary hip and knee replacement patients having appropriate skin anti-sepsis in surgery using alcohol/chlorhexidine or alcohol/povidine iodine

View more about our Health Quality and Safety Markers

Where to from here?

We will continue to monitor and track our infection rates and identify further areas for improvement, and continue our participation with regional and national programmes for Infection Control and Prevention.

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