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Press release: Young patients set to celebrate 'everyday heroes' during fun-filled week

Description: Young patients at Southampton Children's Hospital are set to celebrate their 'everyday heroes' during a fun-filled week of activities from
Url: /AboutTheTrust/Newsandpublications/Latestnews/2018/October-2018/Press-release-Young-patients-set-to-celebrate-'everyday-heroes'-during-fun-filled-week.aspx

Young hospital patients set for fun-filled superhero week

Description: Young patients are set to receive some visitors with a difference this week when a team of superheroes swoop onto the
Url: /AboutTheTrust/Newsandpublications/Latestnews/2017/October-2017/Young-hospital-patients-set-for-fun-filled-superhero-week.aspx

Papers Trust Board - 29 November 2022

Description: Date Time Location Chair Agenda Trust Board – Open Session 29/11/2022 9:00 - 13:20 Conference Room, Heartbeat/Microsoft Teams
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2022-Trust-documents/Papers-Trust-Board-29-November-2022.pdf

Finance and Performance Reports 2022-23 Month 2 May 2022

Description: Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author: Date: Purpose Issue to be address
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2022-Trust-documents/Finance-and-Performance-Reports-2022-23-Month-2-May-2022.pdf

Papers-CoG 26.04.2023

Description: Agenda attachments 1 CoG Agenda - 26.04.2023.docx Date Time Location Chair Agenda Council of Governors 26/04/2023 14
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Governors/Papers-CoG-26.04.2023.pdf

Finance and Performance Reports 2021-22 month 4 July 2021

Description: Report to the Trust Board of Directors Title: Agenda item: Sponsor: Author: Date: Purpose Issue to be addressed: Finance Report 2021-22 Month 4 11.3 Ian Howard – Interim Chief Financial Officer Philip Bunting – Interim Deputy Director of Finance 26 August 2021 Assurance Approval or reassurance Ratification Information X The finance report provides a monthly summary of the key financial information for the Trust. Response to the issue: The Trust continues to report an on plan financial position of breakeven. In month £1.3m of non-recurrent benefits have however helped support breakeven achievement with ERF income significantly lower than expected. Elective Recovery Framework (ERF): • Elective Recovery Framework achievement of £0.35m is estimated in month, based on activity of circa 97% of pre-Covid levels of activity for Elective and Outpatients. This compares to a baseline expectation of 95%. (M3 achievement of 94% vs. 80% baseline target). Although this has marginally improved from June this is significantly lower than the anticipated forecast of £3m achievement (108%). The drivers behind this are as follows: o Increased levels of annual leave and staff isolating. Rates of self-isolation increased from 0.5% of workforce in April to June to 2.5% of workforce in July. This has had a significant impact on the availability of staffing and therefore activity. o Continued non-elective pressure (spells increasing 3% from M3 and reaching 99% of production plan levels) and ED activity (also 3% increase from M3). Operational bed pressures are particularly acute within critical care. o Increasing numbers of Covid-19 patients on wards which ended July with 48 Covid positive inpatients reported. This number remains above 40 in mid-August having started July at below 10 patients. • ERF achievement is below the 110% target for elective and outpatient activity by July as per the accelerator programme ambitions. M4 Forecast Review: • We undertake a quarterly review of the Trust forecast position. • Operational pressures in July and August have significantly dampened the trusts ERF forecast for H1 which has been revised down by £6.6m from £23.8m to £17.2m as a result. This poses a significant risk to financial performance over the remainder of H1 however the trust remains in a strong position to Page 1 of 17 manage this risk making an underlying margin on ERF in Q1. • Overall, given the stability of the year-to-date position and balance sheet, the Trust are in a strong position to manage the risks of quarter 2 and achieve a break-even plan position for H1. • The forecast for H2 will be reviewed as part of the H2 planning process. Capital: • CDEL reported spend is £1.5m behind plan YTD with spend in month £1.3m below plan. The trust remains confident however that the annual CDEL allocation of £49.8m will be spent in full. ICS finance position: • All organisations at month 3 were reporting a break-even position. A verbal update will be provided to the Committee on the underlying position within the ICS. An ICS finance report will be made available to the Committee but is not ready for UHS paper deadlines. Other financial issues: • The finance team continue to undertake investigations with Pharmacy regarding use of drugs that are included within block contracts. The value has reduced from previous months but is still £2m ahead of plan YTD. • Specialist commissioning have started informal consultation around the transfer of a proportion of activity to ICS level which will be funded on a population needs basis. The exact quantum of activity, funding envelope and scope of services is currently undecided. This is likely to be in shadow format in 22/23 and then permanently embedded in 23/24. UHS intends to work closely with NHS England and the provider network throughout the consultation period. Implications: (Clinical, Organisational, Governance, Legal?) • Financial implications of availability of funding to cover growth, cost pressures and new activity. • Organisational implications of remaining within statutory duties. Risks: (Top 3) of carrying out the change / or not: • Financial risk mainly linked to the uncertainty of H2 21/22 funding arrangements and ability to support long term decision making. • Cash risk linked to volatility above • Inability to maximise CDEL (which cannot be carried forward) if mitigations are not put into place Summary: Conclusion Trust Board is asked to note this report. and/or recommendation Page 2 of 17 2021/22 Finance Report - Month 4 Report to: Board of Directors and Finance & Investment Committee July 2021 Title: Finance Report for Period ending 31/07/2021 Author: Philip Bunting, Interim Deputy Director of Finance Sponsoring Ian Howard, Interim Chief Director: Financial Officer Purpose: Standing Item The Board is asked to note the report Executive Summary: In Month and Year to date Highlights: 1. In July 2021, the Trust reported a breakeven position as planned. 2. Elective Recovery Framework (ERF) income is estimated at £0.35m for July; however this has not yet been confirmed and is dependent on wider system achievement and NHSI validation. This was down from £3.1m the previous month and reflects the revised activity achievement target of 95% now in place for Q2. Significant operational pressures have also dampened ERF achievement and forecast. 3. In month, £3.6m (£2.5m pay and £1.1m non pay) was incurred on additional expenditure relating to Covid-19. This was £0.6m lower than in June mainly due to lower Covid vaccination costs (down £0.5m). Within the trusts block funding is a non-recurrent fixed element for Covid costs which will continue throughout H1. Covid inpatient volumes increased in month to 48 diverting resources away from elective. 4. The main underlying themes seen in M4 were : – Elective activity in July represents 94% of planned income levels, up slightly from 93% in June. – Non Elective activity levels in July was at 99% of planned levels, down from 103% in June. A&E attendances continue to be high, back to pre-Covid levels. – Outpatient activity in July was at 107% of planned levels, down slightly from 108% in June. – Drugs and devices expenditure was high in month with £4.6m over performance reported on pass through items, higher than the £2.2m over performance in M3. This is mirrored by additional income. – Trust underlying performance deteriorated slightly although remains at close to breakeven levels after adjusting for one off items. 1 Page 3 of 17 2021/22 Finance Report - Month 4 Finance: I&E Summary The financial position for M4 was breakeven as per plan. This position does however include £1.3m in non recurrent income. The Saliva testing finances are significantly distorting variances within income and expenditure categories as testing activity is not yet fully mobilised. Pay costs are £1.7m below plan in month and now £9.5m behind plan YTD. In addition to Saliva testing this is further driven by elective recovery costs that have not increased pay to the originally anticipated level. This is however offset by reduced ERF income. Agency costs spiked in month due partly to increased staff sickness due to covid self isolation notifications dramatically increasing. Block drugs costs were £0.2m above plan in M4 and remain under investigation as this remains an in year pressure having previously been pass through costs. Energy cost increases and overseas recruitment expenditure are the key areas of overspend within ‘other non pay’. NHS Income: Clinical Pass-through Drugs & Devices Other income Other Income excl. PSF Top Up Income Total income Costs Pay-Substantive Pay-Bank Pay-Agency Drugs Pass-through Drugs & Devices Clinical supplies Other non pay Total expenditure EBITDA EBITDA % Depreciation / Non Operating Expenditure Surplus / (Deficit) Less Donated income Add Back Donated depreciation Net Surplus / (Deficit) 2 Page 4 of 17 Current Month Cumulative H1 Plan Plan Actual Variance Plan Actual Variance Plan Forecast Variance £m £m £m £m £m £m £m £m £m 69.1 65.4 3.8 275.1 266.4 8.6 412.8 406.4 6.4 8.5 13.1 (4.6) 33.9 44.0 (10.1) 50.9 61.6 (10.7) 15.2 13.2 2.0 60.6 52.1 8.6 90.9 77.8 13.1 0.8 1.1 (0.3) 3.1 4.6 (1.4) 4.7 6.9 (2.2) 93.6 92.7 0.8 372.8 367.1 5.7 561.4 552.7 6.7 46.9 45.4 (1.6) 187.7 180.9 (6.8) 281.5 273.0 (8.5) 4.0 3.5 (0.4) 15.8 14.0 (1.9) 23.7 21.8 (1.9) 1.2 1.6 0.3 5.0 4.2 (0.8) 7.5 5.2 (2.3) 4.3 4.5 0.2 17.4 19.4 2.0 26.0 30.4 4.4 8.5 13.1 4.6 33.9 44.0 10.1 50.9 61.6 10.7 11.2 6.4 (4.8) 43.2 31.9 (11.3) 65.1 51.9 (13.2) 14.2 15.2 0.9 56.9 60.6 3.7 85.4 90.9 5.5 90.4 89.7 (0.7) 360.0 354.9 (5.0) 542.2 534.9 (5.3) 3.2 3.0 0.2 12.8 12.1 0.7 19.2 17.8 1.4 3.4% 3.3% 0.1% 3.4% 3.3% 0.1% 3.4% 3.2% 0.2% 3.2 3.1 (0.1) 12.9 12.4 (0.4) 19.3 18.6 (0.6) (0.0) (0.1) 0.1 (0.0) (0.3) 0.2 (0.1) (0.8) 0.8 0.1 0.0 0.1 0.4 0.0 0.3 0.5 0.0 0.5 0.1 0.1 0.0 0.4 0.6 0.2 0.6 0.9 0.3 (0.0) 0.0 (0.0) (0.0) 0.3 (0.3) (0.0) 0.0 (0.0) 2021/22 Finance Report - Month 4 Monthly Underlying Position The graph shows the underlying position for the Trust from 2019/20 to present. This position is however heavily linked to the numbers of Covid positive patients the Trust is managing. We are now operating at a position where we would be earning marginally more under PbR than the current block. However, we are also earning ERF, which would not be payable under PbR for activity below 100% of contract. After adjusting the income position to be reflective of what would prevail under PbR it is clear that the underlying position is close to breakeven and has been throughout Q1. This has slightly deteriorated in July as staffing pressures together with non elective and covid pressures have suppressed elective activity and PbR equivalent income. 5.00 - -5.00 -10.00 -15.00 -20.00 -25.00 -30.00 With future funding arrangements unclear due to non recurrent ERF and additional Covid-19 funding, we exercise caution over the Trust’s underlying position going forwards. Monthly Underlying Position 2020/21 & 2021/22 Budget 2019/20 Underlying Actuals 2020/21 & 2021/22 Underlying Actuals 3 Page 5 of 17 2021/22 Finance Report - Month 4 Clinical Income Clinical income for the month of July was £0.9m favourable to plan and including Non NHS income was £0.7m favourable to plan. Most of the Trust's income remains fixed with confirmed block contract funding in place for at least the first half of the financial year. July has seen a small increase in activity from June. Plans for 21/22 have been phased to account for the variation in calendar and working days in relevant POD Groups. Elective income increased to 94% of planned levels although this follows a dip in June having been over 100% in May. Overall non elective activity increased but against the working day adjusted plan reduced to 99% of planned level. A&E attendances continue to be high, back to pre-Covid levels having shown a downward trend for much of the previous financial year. Outpatient income remains strong at over 100% of planned levels although not as high against plan as in May. The graphs overleaf show trends over the last 16 months and the impact of Covid-19 as well as the recovery to pre Covid levels of activity in many areas. (Fav Variance) / Adv Variance POD GROUP NHS Clinical Income Elective Inpatients Non-Elective Inpatients Outpatients Other Activity Blocks & Financial Adjustments Other Exclusions Pass-through Exclusions Subtotal NHS Clinical Income Additional funding Covid block adjustments Total NHS Clinical Income Non NHS Clinical Income Private Patients CRU Overseas Chargeable Patients Total Non NHS Clinical Income In Month In Month Plan £000s Estimate £000s In Month Variance £000s 2021/22 YTD Plan £000s YTD Estimate £000s YTD Variance £000s £13,159 £19,474 £7,718 £11,864 £5,590 £8,003 £8,485 £74,292 £5,848 (£2,535) £77,605 £12,413 £20,140 £8,249 £11,571 £1,872 £5,648 £13,100 £72,993 £5,848 (£368) £78,473 £745 (£666) (£531) £294 £3,718 £2,355 (£4,616) £1,299 £0 (£2,167) (£868) £49,645 £76,638 £29,119 £46,239 £20,449 £31,543 £33,938 £287,571 £23,392 (£1,952) £309,011 £47,675 £78,250 £32,081 £45,770 £8,530 £31,105 £44,025 £287,438 £23,392 (£368) £310,462 £1,969 (£1,612) (£2,962) £469 £11,919 £438 (£10,087) £133 £0 (£1,584) (£1,450) £368 £235 £134 £208 £186 £23 £66 £64 £2 £643 £484 £158 £1,504 £833 £264 £2,601 £2,023 £683 £158 £2,864 (£519) £150 £106 (£263) 2019/20 YTD Actuals £000s £47,966 £71,796 £28,339 £42,701 £1,475 £1,260 £38,725 £232,262 £232,262 £1,394 £840 £651 £2,885 Grand Total £78,248 £78,958 (£710) £311,612 £313,325 (£1,713) £235,147 Income (£m) NHS Clinical Income £100 £80 £60 £40 £20 £0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Income Actual - Income 4 Page 6 of 17 2021/22 Finance Report - Month 4 Clinical Income Activity ('000) Income (£m) Elective spells £16 8 £14 7 £12 2% 6 £10 5 £8 4 £6 3 £4 2 £2 1 £0 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Activity Actual - Activity Plan - Income Actual - Income Activity ('000) Income (£m) Non elective spells £25 7 £20 3% 6 5 £15 4 £10 3 2 £5 1 £0 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Activity Actual - Activity Plan - Income Actual - Income Outpatients £10 70 £8 -1% 60 50 £6 40 £4 30 20 £2 10 £0 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Activity Actual - Activity Plan - Income Actual - Income Activity ('000) Income (£m) A&E £3 14 £2 3% 12 10 £2 8 £1 6 4 £1 2 £0 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Activity Actual - Activity Plan - Income Actual - Income 5 Page 7 of 17 Activity ('000) Income (£m) 2021/22 Finance Report - Month 4 Clinical Income Activity ('000) Income (£m) Adult critical care £6 4 £5 3 £4 2% £3 2 £2 1 £1 £0 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Activity Actual - Activity Plan - Income Actual - Income Activity ('000) Income (£m) Neonatal & paediatric critical care £3 3 £3 5% £2 2 £2 £1 1 £1 £0 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Activity Actual - Activity Plan - Income Actual - Income Tariff excluded drugs £14 1 £12 -8% £10 £8 £6 £4 £2 £0 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Activity Actual - Activity Plan - Income Actual - Income Activity ('000) Income (£m) Tariff excluded devices £3 2 £3 -14% £2 £2 1 £1 £1 £0 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 2020/21 2021/22 Plan - Activity Actual - Activity Plan - Income Actual - Income 6 Page 8 of 17 Activity ('000) Income (£m) 2021/22 Finance Report - Month 4 Income and Activity The tables shown illustrate by division and care group the % of the activity and income plan being achieved across the first month of 2021/22 for Elective, Non Elective and Outpatient Activity. The plan for 2021/22 has been phased to reflect working day differences for Elective and Outpatient and calendar days for Non Elective. Elective activity in July represents 94% of planned income levels, up slightly from 93% in June. Recovery planning is targeting improvement in all areas but will be governed by clinical priority. Non Elective activity levels in July was at 99% of planned levels, down from 103% in June. It should be noted that non elective spells actually increased 3% month on month but due to July being a day longer the % of production plan delivered actually reduced slightly. Page 79 of 17 2021/22 Finance Report - Month 4 Income and Activity Outpatient activity in July was at 107% of planned levels, down slightly from 108% in June. Page 180 of 17 2021/22 Finance Report - Month 4 Elective Recovery Fund 21/22 The Elective Recovery Fund has been launched as part of the 21/22 planning guidance as a mechanism for distributing £1bn of national recovery funds for Elective and Outpatient activity. Providers are targeted with achieving threshold equivalent PbR income levels set at a % of pre-Covid income levels (Price x Activity). The graph shows both the trends through 20/21 and estimated performance for July. This indicates performance of 97% of baseline activity which is 2% over the revised target threshold of 95% in July. This would yield an estimate of £0.35m additional income if paid at tariff. It should be noted that this is an early estimate of this data and has dependencies on the performance of others from within the ICS. The 20% premium has already been agreed with ICS partners will be centrally pooled rather than allocated directly to providers. Elective Recovery Framework Performance 20-21-22 % 120% 100% Actual Activity 80% (OP & EL) 70% Threshold 60% (April-21) 85% Threshold 40% 20% 0% Month Apr-21 May-21 Jun-21 Jul-21 YTD Total ERF Achievement - Elective/Daycase/Outpatients (£'000) Baseline Actuals Variance % £ 18,770 £ 18,575 -£ 195 99% £ 18,276 £ 19,673 £ 1,398 108% £ 21,464 £ 20,274 -£ 1,189 94% £ 20,780 £ 20,091 -£ 688 97% £ 37,046 £ 38,249 £ 1,203 103% ERF Top-up 100% Top Up 20% Top Up Total £ 5,436 £ 524 £ 5,960 £ 5,967 £ 828 £ 6,794 £ 3,104 £ 406 £ 3,510 £ 351 £ -£ 351 £ 14,506 £ 1,758 £ 16,264 9 Page 11 of 17 2021/22 Finance Report - Month 4 ICS Elective Recovery Fund 21/22 ICS current estimated performance and forecast is shown for the four main Providers for the Elective Recovery Framework (ERF). April – July numbers are all currently based on local assessment and awaiting national finalisation. It should be noted that the Q2 forecast reflects the recent increase to the baseline for Q2 moving from 85% to 95% hence the trajectory indicating below plan performance for these months. At M4 the ICS has collectively reported £38.9m in ERF income vs an original (unadjusted) plan of £35.1m. The H1 forecast is now £46.3m dropping from £55.3m last month, this is against an original (unadjusted) plan of £50.4m. This includes circa £3.4m estimated impact of accelerator programmes on ERF income. 16000 14000 12000 10000 8000 6000 4000 2000 ICS ERF - All Organisations Plan vs Estimates(M1-4) vs Forecast (M5-6) 0 Apr May Jun Jul Aug Sep Plan Estimates/Forecast 10 Page 12 of 17 2021/22 Finance Report - Month 4 Substantive Pay Costs Total pay expenditure in July was £50.5m. This was higher than in June (up by £0.9m). The main increase was nursing agency staff (£0.7m) due mainly to staff sickness backfill and increased staffing requirements due to non elective pressures and covid. There was also a small increase in substantive medical staff costs. Pay costs remain in excess of that seen last year prior to the second covid wave as the organisation continues to drive recovery. Substantive recruitment has been challenging however with workforce numbers remaining broadly flat since April 21. These will be monitored closely going forward as costs are expected to increase as new theatre capacity comes on board this summer, in addition to investment in recovery plans and accelerator programme initiatives which are fully funded. £m £m £m 53.0 51.0 49.0 47.0 45.0 43.0 41.0 39.0 37.0 35.0 Total Pay Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 Apr-21 May-21 Jun-21 Jul-21 18.0 Substantive Pay 16.0 14.0 12.0 10.0 Covid Agency Bank Substantive Plan Total Medical Nursing Other 48.0 Substantive Pay 46.0 44.0 42.0 40.0 Start Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Substantive Plan 21/22 Substantive Actual 21/22 Substantive Actual 20/21 11 Page 13 of 17 2021/22 Finance Report - Month 4 Temporary Staff Costs Agency spend has increased sharply month on month by £0.7m. All staff groups increased spend but the majority was in nursing (£0.5m) which was driven by increased short notice sickness (covid self isolation) plus bed pressures due to non elective and covid forcing ward costs higher. Expenditure on bank staff has fallen slightly month on month (£0.2m) with the largest fall in nursing. The plan adjustment within the bank graph relates to staffing requirements to deliver elective recovery that were forecast to increase the need for bank staffing. 1,700,000 1,600,000 1,500,000 1,400,000 1,300,000 1,200,000 1,100,000 1,000,000 900,000 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 5,000,000 4,500,000 4,000,000 3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 2021/22 Agency Total Spend 2021/22 Bank Total Spend Page1142of 17 Total Agency Nursing Medics Scient & Tech Admin & Estates NHSI Plan Nursing Medics Scient & Tech Admin & Estates Total Bank 2021/22 Finance Report - Month 4 Cash The cash balance decreased slightly in July to £117.3m. This continues the marginal downward trend as cash reserves are used to deliver capital expansions. There are no foreseen material movements forecast now the cash regime has adjusted back to pre-covid levels with block income paid in the month for which it is due. We may however see some in-month volatility as we move to a more “normal” period and the working capital position stabilises. A gradual reduction is expected over the next two years as capital expenditure plans exceed depreciation. 180.0 160.0 140.0 120.0 100.0 80.0 60.0 40.0 20.0 - Cash Position Actual Minimum Cash Holding 13 Page 15 of 17 2021/22 Finance Report - Month 4 Capital Expenditure Expenditure on internally funded capital schemes YTD is £14.6m against budget of £16,2m. Total expenditure including externally funded schemes is £16m against budget of £17,4m, £1.4m behind plan. Significant expenditure in M4 included the vertical extension theatres scheme, which is nearing completion, the ED expansion scheme, where phase 1b of the works has commenced and the Ophthalmology Outpatients scheme where significant expenditure was incurred this month. The Trust continues to forecast to spend all of the Capital Departmental Expenditure Limit (CDEL) funding. The forecast shows expenditure of £2.46m over plan based on the expectation of receiving £2m of external funding for community diagnostic hubs and an allowable overspend of £0.46m on medical equipment as part of the accelerator funding scheme . Forecast variances on individual schemes include the vertical extension theatres scheme (-£1m), the ED expansion scheme where unforeseen generator and VAT costs were incurred (+£0.7m), IISS leases (£2.5m slippage) and equipment leases, where additional leases have been authorised. (Fav Variance) / Adv Variance Month Year to Date Full Year (Forecast) Plan Actual Var Plan Actual Var Plan Actual Var Scheme £000's £000's £000's £000's £000's £000's £000's £000's £000's Fit out of E level. Vertical Extension - Theatres 2,460 1,056 1,404 9,463 7,174 2,289 11,941 10,950 991 Strategic Maintenance 258 242 16 1,032 1,087 (55) 6,183 6,183 0 ED Expansion and Refurbishment 827 428 399 2,908 1,642 1,266 5,791 6,489 (698) Wards 0 17 (17) 0 17 (17) 4,000 4,000 0 Ophthalmology OPD 737 718 19 787 937 (150) 3,303 3,098 205 Maternity Induction Suite 0 0 0 0 (0) 0 2,000 2,000 0 NICU Pendants 0 0 (0) 0 0 (0) 896 355 541 Oncology Ward 0 2 (2) 861 430 431 861 751 110 Decorative / Environment Improvements 21 0 21 84 0 84 500 500 0 Side Rooms 0 5 (5) 490 517 (27) 490 537 (47) Information Technology Programme 250 137 113 1,000 810 190 5,000 5,000 0 Other Projects 175 374 (199) 1,208 1,073 135 3,060 2,803 257 Pathology Digitisation 59 5 54 236 22 214 1,171 1,171 0 Medical Equipment 42 64 (22) 168 476 (308) 1,000 2,016 (1,016) Accelerator Funded Equipment 0 0 0 0 0 0 0 460 (460) Slippage (516) 0 (516) (2,464) 0 (2,464) (5,035) (3,143) (1,892) Total Trust Funded Capital excl Finance Leases 4,313 3,049 1,264 15,773 14,185 1,588 41,161 43,170 (2,009) Finance Leases - IISS 0 0 0 0 32 (32) 5,230 2,765 2,465 Finance Leases - MEP 92 0 92 368 179 189 2,200 1,183 1,017 Finance Leases - Other Equipment 75 104 (29) 300 159 141 1,500 3,083 (1,583) Finance Leases - Opthalmology OPD 0 0 0 0 0 0 1,166 1,166 0 Finance Leases - Divisonal Equipment 25 (25) 50 75 82 (7) 475 500 (25) Donated Income (88) (32) (56) (352) (49) (303) (1,921) (1,596) (325) Total Trust Funded Capital Expenditure 4,417 3,096 1,321 16,164 14,588 1,576 49,811 50,271 (460) Fit out of E level. Vertical Extension - Theatres 140 140 0 538 538 0 700 700 0 Maternity Care System (Wave 3 STP) 96 243 (147) 384 753 (369) 1,917 1,776 141 Digital Outpatients (Wave 3 STP) 41 47 (6) 164 72 92 814 955 (141) LIMS Digital Enhancement 38 (0) 38 152 (0) 152 455 455 0 Community Diagnostic Hub 0 0 0 0 0 0 0 2,000 (2,000) Total CDEL Expenditure 4,732 3,526 1,206 17,402 15,950 1,452 53,697 56,157 (2,460) Page 16 of1147 2021/22 Finance Report - Month 4 Statement of Financial Position The July statement of financial position illustrates net assets of £443.6m which has decreased £7.6m compared to June 2021. This is however within the bounds of normal month on month volatility. The downward movement on inventories is driven by a reduction in Pharmacy stock (£2m). The Payables reduction of £5.3m was primarily due to the clearing of aged trade payables and also a reduction in capital creditors. Payables is becoming a greater focus area for the NHS and an improvement plan is being developed to help tackle this down to Better Payment Practice Code (BPPC) compliant levels. The Receivables increase of £4.6m was due to Chilworth invoicing. Statement of Financial Position Fixed Assets Inventories Receivables Cash Payables Current Loan Current PFI and Leases Net Assets Non Current Liabilities Non Current Loan Non Current PFI and Leases Total Assets Employed Public Dividend Capital Retained Earnings Revaluation Reserve Other Reserves Total Taxpayers' Equity 15 Page 17 of 17 2020/21 YE Actuals £m 415.4 14.7 71.3 129.0 (171.5) (2.8) (9.0) 447.1 (18.3) (8.5) (36.3) 384.0 246.0 114.0 24.0 0.0 384.0 (Fav Variance) / Adv Variance M3 Act £m 425.6 15.9 77.9 123.6 (180.2) (2.7) (8.8) 451.3 (17.5) (7.8) (34.7) 391.3 246.0 121.3 24.0 0.0 391.3 2021/22 M4 Act £m 426.9 13.8 82.5 117.3 (185.5) (2.7) (8.6) 443.6 (18.1) (7.5) (34.3) 383.7 246.0 113.7 24.0 0.0 383.7 MoM Movement £m 1.3 (2.0) 4.6 (6.4) (5.3) 0.0 0.2 (7.6) (0.6) 0.3 0.4 (7.6) 0.0 (7.6) 0.0 0.0 (7.6) Report to the Trust Board of Directors Title: Agenda item: Sponsor: Date: Purpose Integrated Performance Report 2021/22 Month 4 11.2 Chief Executive 26 August 2021 Assurance Approval or reassurance Y Ratification Information Issue to be addressed: The report aims to provide assurance: • Regarding the successful implementation of our strategy • That the care we provide is safe, caring, effective, responsive, and well led Response to the issue: The Integrated Performance Report reflects the current operating environment and is aligned with our strategy. Implications: This report covers a broad range of trust services and activities. It is (Clinical, Organisational, intended to assist the Board in assuring that the Trust meets regulatory Governance, Legal?) requirements and corporate objectives. Risks: (Top 3) of carrying out the change / or not: Summary: Conclusion and/or recommendation This report is provided for the purpose of assurance. This report is provided for the purpose of assurance. Page 1 of 29 Integrated KPI Board Report covering up to July 2021 Sponsor - Andrew Asquith, Director of Planning, Performance and Productivity, andrew.asquith@uhs.nhs.uk Page 2 of 29 Chart Type Cumulative Column Example Cumulative Column Year on Year Line Benchmarked Line & bar Benchmarked Control Chart 100% 0% 49.0% Variance from Target Report Guide Explanation A cumulative column chart is used to represent a total count of the variable and shows how the total count increases over time. This example shows quarterly updates. A cumulative year on year column chart is used to represent a total count of the variable throughout the year. The variable value is reset to zero at the start of the year because the target for the metric is yearly. The line benchmarked chart shows our performance compared to the average performance of a peer group. The number at the bottom of the chart shows where we are ranked in the group (1 would mean ranked 1st that month). 72.09% The line shows our performance and the bar underneath represents the range of 0.72 performance of benchmarked trusts (bottom = lowest performance, top = highest performance) A control chart shows movement of a variable in relation to its control limits (the 3 lines = Upper control limit, Mean and Lower control limit). When the value shows special variation (not expected) then it is highlighted green (leading to a good outcome) or red (leading to a bad outcome). Values are considered to show special variation if they -Go outside control limits -Have 6 points in a row above or below the mean, -Trend for 6 points, -Have 2 out of 3 points past 2/3 of the control limit, -Show a significant movement (greater than the average moving range). Variance from target charts are used to show how far away a variable is from its target each month. Green bars represent the value the metric is achieving better than target and the red bars represent the distance a metric is away from achieving its target. 2 Page 3 of 29 Report to Trust Board in August 2021 Introduction The Integrated Performance Report is presented to the Trust Board each month. The report aims to provide assurance: • Regarding the successful implementation of our strategy • That the care we provide is safe, caring, effective, responsive, and well led The content of the report includes the following: • The ‘Spotlight’ section, to enable more detailed consideration of any topics that are of particular interest or concern. The selection of topics is informed by a rolling schedule, performance concerns, and requests from the Board • An ‘NHS Constitution Standards’ section, summarising the standards and performance in relation to service waiting times • An ‘Appendix’, with indicators presented monthly, aligned with the five themes within our strategy This month, several of the new indicators have commenced reporting and further development is also taking place. Our indicators and this report structure will continue to be regularly reviewed, and feedback would be welcome. 3 Page 4 of 29 Report to Trust Board in August 2021 Summary This month the ‘Spotlight’ section features: 1. Clostridium Difficile Infection (C. diff) There have been 25 infections compared to a ‘target’ limit of 20 year to date, whilst in 2020/21 there were 63 infections compared to a limit of 64. UHS performance remains good compared to peer hospitals. The spotlight discusses variability in infection rates, the link to antibiotic prescribing, and actions being taken to further reduce the number of C. diff infections. 2. Diagnostic waiting time target Diagnostic waiting times have experienced major impacts during the pandemic, and 17% of patients are currently waiting longer than the national 6-week target. Trends at UHS are similar to those at peer hospitals. The spotlight discusses current performance and forecast recovery timescales for different test types, alongside strategic issues, and opportunities for diagnostics. Highlights to note in the appendix containing indicators by strategic theme include: • A further decline in Emergency Department performance to 78.4% and an increase in attendances to a new maximum • An increase to 129 inpatients who had been medically optimised for discharge but were waiting for care at home / in the community • Staff sick absence remains close to target (although COVID-19 absence including isolation of COVID-19 ‘contacts’ reached a peak of 2.5% during July) • Excellent research performance across a range of measures. 4 Page 5 of 29 Report to Trust Board in August 2021 Spotlight Spotlight Subject - Clostridium Difficile Infection (C. diff) C. diff infections are caused by an imbalance of gut microbiota. The person must have been exposed to C. diff spores either from food or from acquisition from the healthcare environment. The toxigenic C. diff spores reside in the large intestine for months to years. In the case of exposure to a broad-spectrum antibiotic, or cancer chemotherapy, the toxigenic spores start to produce toxins causing clinical disease manifesting with diarrhoea. In 2020/21 UHS reported 63 infections compared to a limit of 64. In 2021/22 to date, the monthly limits have been exceeded. The graph below shows the most recent 12 month period in blue, and prior 12 months in yellow. UHS ranks 3rd out of 16 self-selected peer acute trusts, with a rate of 16.2 cases/ 100,000 bed days. Reporting criteria are standardised across trusts. 5 Page 6 of 29 Report to Trust Board in August 2021 In 2021/22 there were 19 Community Onset – Hospital Attributable (COHA), 44 Hospital Onset – Hospital Attributable (HOHA) cases. The total number of infections has varied significantly in the past 18 months. The reasons for peaks are unclear but a possible reason might relate to the pandemic, C. diff infections appear to have peaked three months after both the first and second waves. Spotlight It is likely that C. diff rates relate to rates of antibiotic use, possibly in the community as well as hospital; hospital antibiotic usage has been at higher levels during COVID-19 peaks. Underlying trends are of stable / reducing antibiotic use, and the use of ‘broad-spectrum’ antibiotics is particularly closely managed. The average length of an antibiotic course at UHS has also reduced from 7.5 days in 2018/19 to 6.7 in 2020/21. 6 Page 7 of 29 Report to Trust Board in August 2021 Spotlight A wide range of other potential influences upon C. diff infection have been examined including: Infection control – most cases are not part of a cluster or outbreak Infection control – infections in chemotherapy patients appear to relate to their treatment, not an association between the patients themselves or the care environment Cleaning – Audited and generally found to be of a high standard; some opportunities for improvement identified with those items that are to be cleaned by clinical staff Hand hygiene – Improved during the pandemic, and is audited, though a minority of areas still require improvements Physical environment – UHS has relatively few individual rooms, which risks delay in isolation in patients with symptoms which might indicate an infection i.e. loose stools A range of measures are in place, and further actions have been taken, which are expected to impact upon C. diff infection rates and maintain them within acceptable levels: All inpatient cases are reviewed by the infection prevention team to ensure all elements of the care bundle were followed. All hospital acquired cases are reviewed by a Consultant microbiologist/Infection control doctor. The Antimicrobial Review Group reviews cases for appropriate antibiotic use and duration. An updated C. diff policy was approved in July, including changes to the required prevention, treatment and infection control measures. The care plan documentation was expanded. Additional individual rooms have been built in 2020 and 2021, within adult and paediatric wards, and the new Cancer Care ward (C2). This need will remain an important focus for the Trust. Improvements in the turnaround time for stool samples has helped to achieve appropriate isolation of infected patients / closure of bays, whilst making effective use of available bed capacity. Further innovation in point of care testing and rapid laboratory testing are expected to deliver additional improvement in 2021/22. Investment in equipment, and 24/7 operation of the microbiology laboratory, have significantly improved the turnaround time for blood cultures for patients with bacteraemia, and enabled earlier implementation of more specific antibiotics which are less likely to promote C. diff infection. The ongoing review of anti-microbial guidelines and high-risk broad-spectrum antibiotics had been disrupted by the pandemic, and by the resource requirements of the COVID-19 vaccination programme. This is expected to be addressed during the remainder of 2021/22. 7 Page 8 of 29 Report to Trust Board in August 2021 Spotlight Spotlight Subject - Diagnostic waiting time target The national target is that at least 99% of the patients waiting for an elective diagnostic test will have waited less than 6 weeks / no more than 1% will have waited more than 6 weeks. 15 different tests are reported at the end of each month, although Trust performance is normally assessed for the group of tests as a total. UHS is not currently achieving the target, largely due to the impact of COVID-19. During the pandemic, diagnostic services have experienced postponement of nonurgent patients, staff shortages, and reduced productivity due to enhanced infection control measures. Performance is gradually improving, although 17% patients currently waiting have still waited more than 6 weeks. UHS performance is typical of the NHS, UHS is currently 7th best amongst a peer group of large teaching hospitals. As referral volumes recovered following a steep drop when the pandemic started (referrals come from both primary and secondary care clinicians, dependent upon the test), the total number of patients on the waiting list increased beyond pre-pandemic levels (Feb 2020 = 7907), but this is currently relatively stable. 8 Page 9 of 29 Report to Trust Board in August 2021 Spotlight Diagnostic activity levels, as a whole, have recovered and are now above pre-pandemic levels. 20000 15000 10000 5000 0 Diagnostic activity per month The following table show the position at end July, ordered by the number of patients waiting over 6 weeks. There are significant differences between the size and duration of the waiting lists for each of the tests. Tests also require different professions and equipment to perform them (although there are some resources in common e.g. Radiographers and Radiologists shared between MRI and CT, Endoscopy rooms shared between Colonoscopy, Gastroscopy and Flexible Sigmoidoscopy). Diagnostic Area NEUROPHYSIOLOGY - PERIPHERAL NEUROPHYSIOLOGY MAGNETIC RESONANCE IMAGING NON-OBSTETRIC ULTRASOUND GASTROSCOPY CARDIOLOGY - ECHOCARDIOGRAPHY CYSTOSCOPY COLONOSCOPY RESPIRATORY PHYSIOLOGY - SLEEP STUDIES FLEXI SIGMOIDOSCOPY COMPUTED TOMOGRAPHY URODYNAMICS - PRESSURES & FLOWS DEXA SCAN CARDIOLOGY - ELECTROPHYSIOLOGY AUDIOLOGY - AUDIOLOGY ASSESSMENTS BARIUM ENEMA Breach 6 Week Target Within 6 Week Target Grand Total % achieved within 6 weeks 499 629 1128 55.76 425 1583 2008 78.83 175 2779 2954 94.08 150 233 383 60.84 84 370 454 81.5 69 145 214 67.76 44 292 336 86.9 40 89 129 68.99 22 90 112 80.36 18 937 955 98.12 13 27 40 67.5 9 311 320 97.19 9 4 13 30.77 1 110 111 99.1 1 65 66 98.48 9 Page 10 of 29 Report to Trust Board in August 2021 Spotlight All services are forecasting recovery of their pre-pandemic performance by the end of October 2021, with the exception of Neurophysiology and Magnetic Resonance Imaging (MRI). Neurophysiology waiting times were substantially impacted by a two month cessation of most investigations at the start of the pandemic in order to reduce the risk of COVID-19 transmission, and also by subsequent staff shortages - due to vacancies and role changes to protect staff at high risk from COVID-19, and reductions in productivity in outpatients as a result of additional infection control measures. The service is now fully staffed, but capacity to increase activity is constrained by physical space, ability to recruit further, and limited capacity amongst staff to undertake further overtime / additional sessions. Further opportunities to improve productivity, and test new working practices, continue to be investigated. MRI waiting times are at risk because our scanners are already operated for extended hours each day, both Radiographers and Radiologists are difficult to recruit in sufficient numbers, and capacity is currently being supported by scanner time contracted from Independent Sector suppliers which is not secure in the long term. A business case is being prepared which will propose an option to replace existing older scanners without the loss of capacity that would normally be experienced during decommissioning / commissioning, and to upgrade an existing scanner to extend its life and increase the number of UHS operated scanners by one. Strategic issues and opportunities related to diagnostic services include: Community Diagnostic Hub (CDH) - The NHS Long Term Plan recognised a need for radical investment and reform, and an Independent Review of Diagnostic Services* in Oct 2020 recommended ‘Community Diagnostic Hubs’ be established away from Acute Hospital Sites. UHS is currently part of a collaborative bid which, if successful, would provide an additional NHS CT scanner and Ultrasound room in Southampton. Further NHS CDH investment is likely, and UHS will consider this as part of the Estate Strategy. Growth in Demand – Significant (national) growth rates include CT (6.8%), MRI (5.6%), Colonoscopy (5.3%) and Flexible Sigmoidoscopy (8.4%). Diagnostic activity rates are also often significantly below international comparators. Further growth in demand should be anticipated and planned for, for example recommendations* that CT scanning capacity should be increased by 100% within 5 years, and that at least 200 new endoscopy rooms are required in NHS trusts. Capacity Expansion and Innovation – is supporting the current recovery. For example, national funding supported construction of an additional UHS endoscopy room which opened in April, and the purchase of equipment which enables ‘sleep studies’ to be performed in greater volumes and in a patient’s home rather than in the hospital. * https://www.england.nhs.uk/wp-content/uploads/2020/11/diagnostics-recovery-and-renewal-independent-review-of-diagnostic-services-for-nhs-england2.pdf 10 Page 11 of 29 Report to Trust Board in August 2021 NHS Constitution Standards for Access to services within waiting times The NHS Constitution* and the Handbook to the NHS Constitution** together set out a range of rights to which people are entitled, and pledges that the NHS is committed to achieve, including: The right to access certain services commissioned by NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer you a range of suitable alternative providers if this is not possible o Start your consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions o Be seen by a cancer specialist within a maximum of 2 weeks from GP referral for urgent referrals where cancer is suspected The NHS pledges to provide convenient, easy access to services within the waiting times set out in the Handbook to the NHS Constitution o All patients should receive high-quality care without any unnecessary delay o Patients can expect to be treated at the right time and according to their clinical priority. Patients with urgent conditions, such as cancer, will be able to be seen and receive treatment more quickly The handbook lists 11 of the government pledges on waiting times that are relevant to UHS services, such pledges are monitored within the organisation and by NHS commissioners and regulators. Performance against the NHS rights, and a range of the pledges, is summarised below. Further information is available within the Appendix to this report. * https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england ** https://www.gov.uk/government/publications/supplements-to-the-nhs-constitution-for-england/the-handbook-to-the-nhs-constitution-for-england 11 Page 12 of 29 Report to Trust Board in August 2021 NHS Constitution Standards for Access to services within waiting times Monthly May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul target YTD % Patients on an open 18 week 100% 72.1% UT28-N pathway teaching (within 18 weeks ) with hospital min-max range and 49.0% ≥92% rank (of 20) 14 7 6 7 7 10 10 10 9 9 8 7 8 8 30% 100% 96.3% % Patients following a GP referral for - suspected cancer seen by a specialist within 2 weeks 83.8% ≥93% 80% Cancer waiting times 62 day standard - Urgent referral to first definitive 100% 87.8% UT34-N treatment (Latest data held by UHS) ≥85% - with teaching hospital min-max range 73.5% 4 3 1 1 1 9 10 9 3 4 2 1 4 6 and rank (of 20) 30% Patients spending less than 4hrs in ED - 93% 94.1% SGH Main ED (Type 1 and UCH) UT25-N Major Trauma Centres (Type 1) 85% 77% 78.4% ≥95% - Rank of 8-> 5 3 3 4 2 2 1 1 1 2 3 3 3 3 703.28% % of Patients waiting over 6 weeks for 80% 35.4% UT33-N diagnostics with teaching hospital min- 16.9% ≤1% - max range and rank (of 20) 7 7 9 13 14 14 11 12 9 10 10 10 9 7 0% 12 Page 13 of 29 Report to Trust Board in August 2021 Outstanding Patient Outcomes, Safety and Experience Outcomes UT1-N HSMR - UHS HSMR - SGH UT2 HSMR - Crude Mortality Rate May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul 83 77 3.1% 78.3 77.9 2.9% 2.6% 800 597 UT3 Emergency readmissions within 30 days of discharge from hospital 627 200 Monthly target ≤100 - - UT4-L Cumulative Specialities with Outcome Measures Developed 54 56 56 57 61 +1 260 285 305 332 396 100% UT5 Developed Outcomes RAG ratings 81% 75% 79% 77% 76% 80% - 50% Appendix YTD YTD target 13 Page 14 of 29 Report to Trust Board in August 2021 Outstanding Patient Outcomes, Safety and Experience Safety May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Cumulative Clostridium difficile UT6-N This year vs. last year 2732 3039 3543 4250 4852 5455 6057 7063 57 1116 1521 1825 35 Healthcare-acquired COVID infection: UT7 COVID-positive sample taken > 14days 39 after admission (validated) 0 12 1 0 0 0 8 0 10 2 5 0 0 0 3 Probable hospital-associated COVID 80 UT8 infection: COVID-positive sample taken > 7 days and 70.28% 533422111233333 05:00 UT26 Average (Mean) time in Dept - nonadmitted patients 02:14 03:06 - 01:00 05:00 03:17 UT27 Average (Mean) time in Dept - admitted patients 04:13 - 01:00 100% % Patients on an open 18 week pathway 72.1% UT28-N (within 18 weeks ) with teaching 49.0% ≥92% hospital min-max range and rank (of 20) 14 7 6 7 7 10 10 10 9 9 8 7 8 8 30% 42,500 Total number of patients on a waiting 42149 UT29 list (18 week referral to treatment 33401 - pathway) 30,000 21,000 Patients on an open 18 week pathway UT30 (waiting 52 weeks+ ) with teaching 951 2309 - hospital min-max range and rank (of 20) 0 13 11 11 11 10 9 6 6 6 5 4 4 4 6 Appendix YTD YTD target - - - - - - - - - - 17 Page 18 of 29 Report to Trust Board in August 2021 Outstanding Patient Outcomes, Safety and Experience May Jun 1000 UT31 Patients on an open 18 week pathway (waiting 78 weeks+ ) 0 11,000 UT32 Patients waiting for diagnostics Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul 799 7 7875 9223 Monthly target - - 4,000 80% % of Patients waiting over 6 weeks for UT33-N diagnostics with teaching hospital min- max range and rank (of 20) 7 0% Cancer waiting times 62 day standard - Urgent referral to first definitive 100% UT34-N treatment (Latest data held by UHS) with teaching hospital min-max range 4 and rank (of 20) 30% 100% 31 day cancer wait performance - UT35-N decision to treat to first definitive treatment (Latest data held by UHS) 80% 100% 31 day cancer wait performance - UT36-N Subsequent Treatments of Cancer (Latest data held by UHS) 80% 35.4% 7 9 13 14 14 11 12 9 87.8% 3 1 1 1 9 10 9 3 97.6% 98.6% 10 10 10 9 16.9% 7 73.5% 4 2 1 4 6 96.0% 96.2% ≤1% ≥85% ≥96% ≥95.2% Appendix YTD YTD target - - - - - - - - - - 18 Page 19 of 29 Report to Trust Board in August 2021 Pioneering Research and Innovation PN1-L Comparative CRN Recruitment Performance - non-weighted May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul 2 5 9 10 10 9 Monthly target Top 10 PN2-L Comparative CRN Recruitment Performance - weighted 2 2 5 3 7 8 Top 5 PN3-L Comparative CRN Recruitment contract commercial 7 13 17 PN4-L Achievement compared to R+D Income 160% Baseline Monthly income increase % YTD income increase % -50% 2 12 11 Top 10 46.0% 152.0% 55.0% -22.0% 45.0% ≥5% Appendix YTD YTD target 19 Page 20 of 29 Report to Trust Board in August 2021 World Class People Appendix Workforce Capacity May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Monthly target 14% Substantive Staff - Turnover WR1-L -R12M turnover % -Leavers in month (FTE) 10% 12.6% 80 200 12.7% R12M 100 =92.0% 84.5% > =76% 20 Page 21 of 29 Report to Trust Board in August 2021 World Class People Staff survey engagement score WR8-L National NHS Staff Survey May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul 8 7.3 0 WR8-L - Maximum score = 10, Average of “Acute and Acute&Community”, group is 7 Compassion and Inclusion 11% WR9-L % of Band 7+ staff who are Black and Minority Ethnic 9.21% 7% WR10 14% % of Band 7+ Staff who have declared a disability or long term health condition 13.7% WR11 12% Pulse survey % of staff recommend UHS as a place to work- White British staff compared with all other ethnic groups combined Data available from August 2021 - new monthly staff survey 10.19% 13.5% WR12 Pulse survey % of staff recommend UHS as a place to work- Disabled compared with non disabled / prefer not to answer Data available from August 2021 - new monthly staff survey WR13 Pulse survey % of staff recommend UHS as a place to work- Sexuality = Heterosexual compared with all other groups combined Data available from August 2021 - new monthly staff survey Appendix Monthly target YTD YTD target 15% by 2023 - 21 Page 22 of 29 Report to Trust Board in August 2021 Integrated Networks and Collaboration Local Integration Number of inpatients that were NT1 medically optimised for discharge (monthly average) May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Monthly target 150 129 92 ≤80 50 Emergency Department NT2 activity - type 1 This year vs. last year Percentage of virtual appointments as a NT3 proportion of outpatient consultations This year vs. last year 15,000 9,482 9,077 5,000 70.00% 44.40% 15.6% 0.00% 11,722 - 8,456 51.5% - 28.1% Appendix YTD YTD target - - - - - - 22 Page 23 of
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STHW841-V1-Biomerieux-Blood-culture-guidance

Description: BLOOD CULTURE A key investigation for diagnosis of bloodstream infections OUR SPECIAL THANKS GO TO Dr Susan M. Novak-Weekley Ph.D. D(ABMM), S(M)ASCP Vice-President, Medical Affairs, Qvella, Carlsbad, CA, USA Wm. Michael Dunne, Jr. Ph.D. D(ABMM), F(AAM, CCM, IDSA, PIDJ) Senior Fellow, Clinical Microbiology, Data Analytics Group, bioMérieux, Inc., Durham, NC, USA Adjunct Professor of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA Adjunct Professor of Pediatrics, Duke University School of Medicine, Durham, NC, USA for their helpful advice and comprehensive review of this booklet. INTRODUCTION “…the laboratory detection of bacteremia and fungemia remains one of the most important functions of clinical microbiology laboratories... A positive blood culture establishes or confirms that there is an infectious etiology of the patient’s illness. Moreover, it provides the etiologic agent and allows antibiotic susceptibility testing for optimization of therapy.”1 The laboratory detection of bacteremia and fungemia using blood cultures is one of the most simple and commonly used investigations to establish the etiology of bloodstream infections. Rapid, accurate identification of the bacteria or fungi causing bloodstream infections provides vital clinical information required to diagnose and treat sepsis. Sepsis is a complex inflammatory process that is largely underrecognized as a major cause of morbidity and mortality worldwide. There are an estimated 19 million cases worldwide each year,2 meaning that sepsis causes 1 death every 3-4 seconds.3 Early diagnosis and appropriate treatment make a critical difference when it comes to improving sepsis patient outcomes. Chances of survival go down drastically the longer initiation of treatment is delayed. If a patient receives antimicrobial therapy within the first hour of diagnosis, chances of survival are close to 80%; this is reduced by 7.6% for every hour after. Yet, if a patient initially receives inappropriate antimicrobial treatment, they are five times less likely to survive.4 This booklet aims to: a nswer key questions commonly asked in relation to blood culture p rovide practical recommendations for routine blood culture procedures o ffer an illustrated step-by-step guide to best blood culture collection practices. This booklet is intended to be a useful reference tool for physicians, nurses, phlebotomists, laboratory personnel and all other healthcare professionals involved in the blood culture process. DEFINITIONS Bacteremia: the presence of bacteria in the blood. It may be transient, intermittent or continuous. Blood culture: blood specimen submitted for culture of microorganisms. It enables the recovery of potential pathogens from patients suspected of having bacteremia or fungemia. Blood culture series: a group of temporally related blood cultures that are collected to determine whether a patient has bacteremia or fungemia. Blood culture set: the combination of blood culture bottles (one aerobic and one anaerobic) into which a single blood collection is inoculated. Bloodstream Infection (BSI): an infection associated with bacteremia or fungemia. Contaminant: a microorganism isolated from a blood culture that was introduced during specimen collection or processing and is not considered responsible for BSI (i.e., the isolates were not present in the patient’s blood when the blood was sampled for culture). Contamination: presence of microorganisms in the bottle that entered during sampling but were not actually circulating in the patient’s bloodstream. Fungemia: the presence of fungi in the blood. Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection.5 Septicemia: clinical syndrome characterized by fever, chills, malaise, tachycardia, etc. when circulating bacteria multiply at a rate that exceeds removal by phagocytosis.6 Septic episode: an episode of sepsis or septic shock for which a blood culture or blood culture series is drawn. Septic shock: a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality.5 Source: Wayne, P.A. Principles and procedures for Blood Cultures; Approved Guideline, CLSI document M47-A. Clinical and Laboratory Standards Institute (CLSI); 2007 unless otherwise specified. 2 TABLE OF CONTENTS 1 BLOOD CULTURE ESSENTIALS p. 2 1 What is a blood culture? p. 4 2 Why are blood cultures important? p. 4 3 When should a blood culture be performed? p. 5 4 What volume of blood should be collected? p. 6 5 How many blood culture sets should be collected? p. 8 6 Which media to use? p. 10 7 Timing of blood cultures p. 11 8 How to collect blood cultures p. 12 9 How many days of incubation are recommended? p. 14 10 Is it a contaminant or a true pathogen? p. 15 2 SPECIAL TOPIC : INFECTIVE ENDOCARDITIS p. 18 3 PROCESSING POSITIVE BLOOD CULTURES p. 20 4 INTERPRETATION OF RESULTS p. 22 5 BLOOD CULTURE/ SEPSIS GUIDELINES p. 24 REFERENCES p. 26 RECOMMENDATIONS FOR BLOOD CULTURE COLLECTION p. 30 3 1 BLOOD CULTURE ESSENTIALS 1 What is a blood culture? A blood culture is a laboratory test in which blood, taken from the patient, is inoculated into bottles containing culture media to determine whether infection-causing microorganisms (bacteria or fungi) are present in the patient’s bloodstream. v B lood cultures are intended to: Confirm the presence of microorganisms in the bloodstream Identify the microbial etiology of the bloodstream infection 3 MAIN AIMS OF BLOOD CULTURE*: Help determine the source of • Confirm infectious etiology infection (e.g., endocarditis) • Identify the etiological agent P rovide an organism for • Guide antimicrobial susceptibility testing and optimization therapy of antimicrobial therapy * Adapted from ESCMID (European Society of Clinical Microbiology and Infectious Diseases) guidelines, 2012.7 2 Why are blood cultures important? Blood culture is the most widely used diagnostic tool for the detection of bacteremia and fungemia. It is the most important way to diagnose the etiology of bloodstream infections and sepsis and has major implications for the treatment of those patients. A positive blood culture either establishes or confirms that there is an infectious etiology for the patient’s illness.3 A positive blood culture also provides the etiologic agent for antimicrobial susceptibility testing, enabling optimization of antibiotic therapy.3 Sepsis is one of the most significant challenges in critical care, and early diagnosis is one of the most decisive factors in determining patient outcome. Early identification of pathogens in the blood can be a crucial step in assuring appropriate therapy, and beginning 4 BLOOD CULTURE ESSENTIALS effective antibiotic therapy as early as possible can have a significant impact on the outcome of the disease.8, 9 v P roviding adequate antibiotic therapy within the first 24-48 hours leads to:10-14 Decreased infection-related mortality (20-30%) Earlier recovery and shorter length of hospital stay Less risk of adverse effects Reduced risk of antimicrobial resistance Cost reduction (length of stay, therapy, diagnostic testing) Figure 1: Fast effective antimicrobial therapy increases survival chances Adapted from Kumar A, et al. Crit Care Med. 2006;34(6):1589-96.15 Total patients (%) Patient survival rate (%) 100 Patients with e ective antibiotic therapy 80 60 40 20 0 0 hours 1 2 3 4 5 6 9 12 24 36 Time to antibiotics 3 When should a blood culture be performed? Blood cultures should always be requested when a bloodstream infection or sepsis is suspected. v C linical symptoms in a patient which may lead to a suspicion of a bloodstream infection are: undetermined fever (≥38°C) or hypothermia (≤36°C) shock, chills, rigors s evere local infections (meningitis, endocarditis, pneumonia, pyelonephritis, intra-abdominal suppuration…). abnormally raised heart rate low or raised blood pressure raised respiratory rate 5 BLOOD CULTURE ESSENTIALS v B lood cultures should be collected: as soon as possible after the onset of clinical symptoms; ideally, prior to the administration of antimicrobial therapy.16 If the patient is already on antimicrobial therapy, recovery of microorganisms may be increased by collecting the blood sample immediately before administering the next dose and by inoculating the blood into bottles containing specialized antimicrobial neutralization media. 4 W hat volume of blood should be collected? The optimal recovery of bacteria and fungi from blood depends on culturing an adequate volume of blood. The collection of a sufficient quantity of blood improves the detection of pathogenic bacteria or fungi present in low quantities. This is essential when an endovascular infection (such as endocarditis) is suspected. The volume of blood that is obtained for each blood culture set is the most significant variable in recovering microorganisms from patients with bloodstream infections.17, 18 Blood culture bottles are designed to accommodate the recommended bloodto-broth ratio (1:5 to 1:10) with optimal blood volume. Commercial continuously monitoring blood culture systems may use a smaller blood-to-broth ratio ( 200 4 2 6 12.8-36.3 28-80 > 800 10 10 20 > 36.3 > 80 > 2,200 20-30 20-30 40-60 % of patient’s total blood volume 4 4 3 2.5 1.8-2.7 7 BLOOD CULTURE ESSENTIALS 5 H ow many blood culture sets should be collected? Since bacteria and fungi may not be constantly present in the bloodstream, the sensitivity of a single blood culture set is limited. Using continuous-monitoring blood culture systems, a study investigated the cumulative sensitivity of blood cultures obtained sequentially over a 24-hour time period. It was observed that the cumulative yield of pathogens from three blood culture sets (2 bottles per set), with a blood volume of 20 ml in each set (10 ml per bottle), was 73.1% with the first set, 89.7% with the first two sets and 98.3% with the first three sets. However, to achieve a detection rate of > 99% of bloodstream infections, as many as four blood culture sets may be needed.22 Figure 2: Cumulative sensitivity of blood culture sets22 Adapted from Lee A, Mirrett S, Reller LB, Weinstein MP. Detection of Bloodstream Infections in Adults: How Many Blood Cultures Are Needed? J Clin Microbiol 2007;45:3546-3548. Detection sensitivity 100% 90% 89.7% 98.3% 80% 73.1% 70% 20 ml 40 ml 60 ml A single blood culture bottle or set should never be drawn from adult patients, since this practice will result in an inadequate volume of blood cultured and a substantial number of bacteremias may be missed.3, 22 8 BLOOD CULTURE ESSENTIALS A contaminant will usually be present in only one bottle of a set of blood culture bottles, in contrast to a true bloodstream infection, in which multiple blood culture bottles/sets will be positive. Therefore, guidelines recommend to collect 2, or preferably 3, blood culture sets for each septic episode.3, 7, 16 If 2 to 3 sets are taken and cultures are still negative after 24-48 hours incubation, and the patient is still potentially septic, 2 to 3 additional cultures may be collected, as indicated in the following diagram.16 Figure 3: Recommended number of blood culture sets Adapted from Baron EJ, Cumitech 1C, Blood Cultures IV. Coordinating ed., E.J. Baron. ASM Press, Washington, D.C. 2005 Collect 2 to 3 sets of bottles (aerobic + anaerobic) for each septic episode If culture is negative after 24-48 h incubation and patient is still potentially septic without an identified source Collect 2 to 3 additional sets of bottles (aerobic + anaerobic) If culture is negative after 24 h incubation Repeat protocol Prolong if necessary incubation Investigate non-microbial etiology 9 BLOOD CULTURE ESSENTIALS 6 W hich media to use? Microorganisms causing bloodstream infections are highly varied (aerobes, anaerobes, fungi, fastidious microorganisms…) and, in addition to nutrient elements, may require specific growth factors and/or a special atmosphere. In cases where the patient is receiving antimicrobial therapy, specialized media with antibiotic neutralization capabilities should be used. Antibiotic neutralization media have been shown to increase recovery and provide faster time to detection versus standard media.23-26 It is recommended that each adult routine blood culture set include paired aerobic and anaerobic blood culture bottles. The blood drawn should be divided equally between the aerobic and anaerobic bottles. If an anaerobic bottle is not used, it should always be replaced by an additional aerobic bottle to ensure that a sufficient volume of blood is cultured.27 v A blood culture medium must be: sensitive enough to recover: - a broad range of clinically relevant microorganisms, even the most fastidious (Neisseria, Haemophilus…) - microorganisms releasing small amounts of CO2 (Brucella, Acinetobacter…) versatile: able to provide a result for all types of sample collection (adults, infants, patients receiving antibiotic therapy, sterile body fluids…) v Which bottle should be inoculated first? If using a winged blood collection set, then the aerobic bottle should be filled first to prevent transfer of air in the device into the anaerobic bottle. If using a needle and syringe, inoculate the anaerobic bottle first to avoid entry of air. If the amount of blood drawn is less than the recommended volume*, then approximately 10 ml of blood should be inoculated into the aerobic bottle first, since most cases of bacteremia are caused by aerobic and facultative bacteria. In addition, pathogenic yeasts and strict aerobes (e.g., Pseudomonas) are recovered almost exclusively from aerobic bottles. Any remaining blood should then be inoculated into the anaerobic bottle.8 * For recommended volumes, see page 6 “What volume of blood should be collected? 10 BLOOD CULTURE ESSENTIALS 7 T iming of blood cultures Studies have shown that the time interval between collecting two blood culture samples is not considered to be a critical factor as the diagnostic yield remains the same.7 Guidelines recommend that the first two/three sets (2 bottles/set) of blood culture be obtained either at one time or over a brief time period (e.g., within 1 hour) from multiple venipuncture sites.1,16 Drawing blood at spaced intervals, such as 1 to 2 hours apart, is only recommended to monitor continuous bacteremia/fungemia in patients with suspected infective endocarditis or other endovascular (i.e., catheterrelated) infections.16 Two to three additional blood culture sets can be performed if the first 2-3 blood cultures are negative after 24-48 hours incubation in cases of severe infection or in order to increase detection sensitivity (in cases of pyelonephritis for example). This also depends on the microorganisms involved: while sensitivity is relatively good for organisms like Escherichia coli or Staphylococcus aureus, it is lower for Pseudomonas aeruginosa, streptococci or fungi.28 8 H ow to collect blood cultures Sample collection is a crucial step in the blood culture process. Standard precautions must be taken, and strict aseptic conditions observed throughout the procedure. Compliance with blood culture collection recommendations can significantly improve the quality and clinical value of blood culture investigations and reduce the incidence of sample contamination and “false-positive” readings. A properly collected sample, that is free of contaminants, is key to providing accurate and reliable blood culture results. It is recommended that blood cultures should be collected only by members of staff (medical, nursing, phlebotomist or technician) who have been fully trained and whose competence in blood culture collection has been assessed.29 11 BLOOD CULTURE ESSENTIALS 10 Key Steps to Good Sample Collection: For an illustrated step-by-step, see page 30. 1 Prior to use, examine the bottles for evidence of damage, deterioration or contamination. Do not use a bottle containing media which exhibits turbidity or excess gas pressure, as these are signs of possible contamination. 2 Check the expiry date printed on each bottle. Discard bottles that have expired. 3 S trictly follow the collection protocol in use in the healthcare setting, including standard precautions for handling blood at the bedside. 4 Blood culture bottles should be clearly and correctly labelled, including patient identification, date and collection time, puncture site (venipuncture or intravascular device). 5 E ach blood culture set should include an aerobic and an anaerobic bottle. 6 Blood for culture should be drawn from veins, not arteries.30 7 It is recommended to avoid drawing blood from a venous or arterial catheter, since these devices are often associated with higher contamination rates.31 12 BLOOD CULTURE ESSENTIALS 8 Carefully disinfect the skin prior to collection of the sample using an appropriate disinfectant, such as chlorhexidine in 70% isopropyl alcohol or tincture of iodine in swab or applicator form.1 9 Transport the inoculated bottles and the completed blood culture request to the clinical microbiology laboratory as quickly as possible, preferably within 2 hours per CLSI.1 Any delay in testing the inoculated bottles may potentially lead to an increased risk of false negative results. If delays are expected, it is important to refer to the manufacturer’s Instructions for Use (IFU) for guidance. As an example for guidance regarding delays, the ESCMID guidelines recommend that blood culture bottles for testing in continuous monitoring systems should be stored temporarily at room temperature, whereas bottles for manual testing should be incubated as soon as possible.32Again, refer to the manufacturer’s IFU for guidance. The use of vacuum tube transport systems can facilitate the rapid transmission of bottles to the microbiology laboratory. However these systems should be used with caution if using glass bottles.33 10 All blood cultures should be documented in the patient’s notes, including date, time, collection site and indications. 13 BLOOD CULTURE ESSENTIALS 9 H ow many days of incubation are recommended? The current recommendation, and standard incubation period, for routine blood cultures performed by continuous-monitoring blood systems is five days.34 However, published data suggest that three days may be adequate to recover over 97% of clinically significant microorganisms. A study by Bourbeau, et al. (JCM, 2005) showed the number of significant microorganisms isolated per day for 35,500 consecutive blood cultures collected over 30 months, of which 2,609 were clinically significant isolates and 1,097 were contaminants.35 Figure 4: Clinically significant isolates per day35 Adapted from Bourbeau PP, Foltzer M. Routine incubation of BACT/ALERT* FA and FN blood culture bottles for mo10re0t%han 3 days may not be necessary. J Clin Microbiol. 2005;43:2506-2509. 80% 74.1% 60% 40% 19.7% 20% 3.6% 1.7% 0.9% 0% Day 1 Day 2 Day 3 Day 4 Day 5 These results demonstrate that 97.4% of clinically significant isolates were recovered within the first 3 days of incubation and 93.8% within 2 days of incubation. v Incubation of Fastidious Microorganisms Another study by Cockerill, et al. (CID, 2004) demonstrated that, when using a continuous-monitoring blood culture system, 99.5% of non-endocarditis bloodstream infections and 100% of endocarditis episodes were detected within 5 days of incubation.19 This data suggests that extended incubation periods previously recommended for detection of the fastidious microorganisms* that sometimes cause endocarditis, are no longer necessary when using continuous-monitoring blood culture systems.16 * including Brucella, Capnocytophaga and Campylobacter spp., and the HACEK group (Haemophilus (except H. influenzae) species, Aggregatibacter (previously Actinobacillus) species, Cardiobacterium hominis, Eikenella corrodens and Kingella species)36 14 BLOOD CULTURE ESSENTIALS 10 I s it a contaminant or a true pathogen? Contamination of blood cultures during the collection process can produce a significant level of false-positive results, which can have a negative impact on patient outcome. A false positive is defined as growth of bacteria in the blood culture bottle that were not present in the patient’s bloodstream, and were most likely introduced during sample collection. Contamination can come from a number of sources: the patient’s skin, the equipment used to take the sample, the hands of the person taking the blood sample, or the environment. Collecting a contaminant-free blood sample is critical to providing a blood culture result that has clinical value. Certain microorganisms such as coagulase-negative staphylococci, viridansgroup streptococci, Bacillus spp, Propionibacterium spp., diphtheroids, Micrococcus spp. rarely cause severe bacterial infections or bloodstream infections. These are common skin contaminants, and a though they are capable of causing serious infection in the appropriate setting, their detection in a single blood culture set can reasonably be identified as a possible contaminant without clinical significance. However, it is important to consider that coagulase-negative staphylococci are the primary cause of both catheterand prosthetic device-associated infections and may be clinically significant in up to 20% of cases.37 The most difficult interpretation problem for the physician is whether the organism recovered from a blood culture is a true pathogen causing bloodstream infection, or a contaminant. If it is a contaminant, the patient may be treated unnecessarily with antibiotics, leading to additional patient risks. Interpretation of true pathogen versus contaminant should be based on whether the blood has been collected with a venipuncture or an intra-vascular device, and multiplicity of isolation of the same species. This illustrates the crucial nature of having collection site information included with the blood culture request sent to the laboratory. 15 BLOOD CULTURE ESSENTIALS In contrast to patients with infective endocarditis or other true positive bloodstream infections, patients whose blood cultures grow contaminants usually have only a single blood culture that is positive. This information is of great practical value for physicians, and underlines the importance of taking two to three blood culture sets from different anatomical sites.16 Contamination rates can be most effectively reduced by strict compliance with hand hygiene rules and best practices for blood collection, particularly during the stages of skin antisepsis, venipuncture and sample transfer to blood culture bottles. However, even when the best blood collection protocols are used, it may not be possible to reduce the contamination rate below 2%.38 The American Society for Microbiology and CLSI recommend targeting contamination rates not exceeding 3% of the total of collected sets.1, 16 v Impact of contamination rates A contaminated blood culture can result in unnecessary antibiotic therapy, increased length of hospitalization and higher costs. It has been found that each false positive result can lead to: Increased length of stay - on average 1 day.39 39% increase in intravenous antibiotic charges.39 $5,000 to $8,720 additional charges.40, 41 20% increase in laboratory charges.39 3 days longer on antibiotics.39 16 BLOOD CULTURE ESSENTIALS Figure 5: E xample of a laboratory-based algorithm to determine blood culture contamination42 Adapted from Richter SS, Beekman SE, Croco JL, Diekema DJ, et al. Minimizing the workup of blood culture contaminants: implementation and evaluation of a laboratory-based algorithm. J Clin Microbiol. 2002;40:2437-2444. Potential contaminant* isolated from blood culture Additional draws +/48 hours? NO YES Positive with same organism? NO YES Evaluation by qualified personnel Probable contaminant; AST** not performed unless requested Viridans group streptococci? NO YES Evaluation by qualified personnel Pathogen; set up AST† * Microorganisms such as coagulase-negative staphylococci, Streptococcus viridans, Bacillus spp, Propionibacterium spp., diphtheroids, Micrococcus spp. † AST: Antimicrobial Susceptibility Testing 17 2 SPECIAL TOPIC: INFECTIVE ENDOCARDITIS Blood culture is essential in the diagnosis of infective endocarditis (infection of the heart valves). In this elusive disease, blood cultures may need to be taken repeatedly during febrile episodes, when bacteria are shed from the heart valves into the bloodstream. For patients with infective endocarditis, positive blood cultures will be obtained in greater than 90% of cases, if optimal culture conditions are respected.43 v Acute Infective Endocarditis This is a fulminant illness progressing rapidly over days to weeks, which may be caused by highly virulent pathogens, such as Staphylococcus aureus. When suspected, the severity of this disease requires blood cultures to be drawn immediately to avoid unnecessary delays in treatment. Multiple blood culture sets should be drawn during a 30-minute period prior to administration of empiric antimicrobial therapy.44 v Subacute Infective Endocarditis If sub-acute infection is suspected, there is usually not an urgent need to initiate empiric therapy. It is more important to attempt to establish the microbiological diagnosis. Multiple blood culture sets should be obtained prior to initiation of antimicrobial therapy, with sets spaced 30 minutes to one hour apart. This may help document a continuous bacteremia, and could be of additional clinical value.3 v Fungal Infective Endocarditis Once a rare occurrence, the incidence of fungal endocarditis is increasing considerably.45 Candida species are the most common fungal pathogens involved in infective endocarditis.46 If optimum collection conditions are observed, the yield for positive blood cultures in fungal endocarditis for Candida spp. is 83 to 95%.47 18 SPECIAL TOPIC: INFECTIVE ENDOCARDITIS v How many cultures? In order to distinguish between contamination and true bacteremia, a total of three to five blood culture sets should be sufficient. Initially, two to three blood culture sets should be obtained from patients with suspected infective endocarditis. If the first 2-3 sets are negative after 24-48 hours, collect two to three more sets of cultures.3 Often patients with suspected infective endocarditis have been put on antibiotics prior to blood collection. This is the most common reason for “culture-negative” infective endocarditis. It is therefore important to use a blood culture medium that has antimicrobial neutralization capacity in order to sustain microbial growth in the presence of antibiotics (see page 10 “Which media to use?”).48,49 However, “culture-negative” endocarditis may also be due to fastidious microorganisms, such as Aspergillus spp., Brucella spp., Coxiella burnetii, Chlamydia spp. and HACEK* microorganisms. S ince current continuous-monitoring blood culture systems can recover all HACEK and other fastidious organisms within a 5-day period, extending incubation beyond this period is no longer considered to be necessary. However, if all blood culture bottles are negative after 5 days, and infectious endocarditis is still suspected, all bottles should be subcultured to chocolate agar.50 19 3 PROCESSING POSITIVE BLOOD CULTURES Today, continuously-monitored blood culture systems provide the optimum solution for blood sample processing. Generally accepted incubation periods can vary from 5-7 days, with 5 days being most popular.27 The study discussed in Figure 4 shows that 98% of all positive specimens were detected within the first 3 days (see page 14).35 Patients who progress to septic shock have a 7.6% increase in mortality every hour while not on appropriate therapy.15 Following an instrument-flagged positive event, the bottle is removed from the system and a Gram stain and subculture is performed. If the sample is Gram stain positive, the morphology of the organism should be reported immediately to the physician. Subcultures or rapid techniques (e.g., molecular diagnostics) should be initiated immediately in order to provide further organism identification and antibiotic susceptibility testing should be performed as soon as possible. If a sample is Gram stain negative, no report is made to the clinician unless there is growth on subculture. A positive blood culture is a critical result and must be reported as soon as available, due to the immediate impact on patient care decisions. When reports are delivered rapidly, studies have shown broadly improved outcomes and efficiencies in patient management.51, 52 A study by Barenfanger, et al. (Am J Clin Pathol. 2008) validated that Gram stains of positive blood cultures are a very important factor influencing appropriate therapy and patient outcomes. The study documented a statistically significant increase in the mortality rate for patients who had blood cultures processed after a delay (i.e., Gram stain performed ≥1 hour after being detected as positive; P= 0.0389). The timely removal and reporting of Gram stain results have a positive impact on patient care and this study supports the need for 24/7 coverage of blood culture instruments.53 20 PROCESSING POSITIVE BLOOD CULTURES Recent technological advances such as MALDI-TOF (Matrix-Assisted Laser Desorption Ionization Time of Flight) provide the ability to rapidly deliver definitive organism identification. Molecular diagnostics can identify the most common pathogens in positive blood cultures as well as specific antibiotic resistance genes associated with bloodstream infections. Rapid identification allows physicians to prescribe more targeted and effective antimicrobial therapy earlier to positively influence outcomes.54-56 Additionally, antibiotic susceptibility testing techniques should be performed on positive blood cultures to provide the clinician with a complete result. Appropriate use of antibiotics is crucial in cases of bloodstream infections and sepsis. Accurately determining the antimicrobial resistance profile of the causative pathogen in order to select the most effective antibiotic therapy can have a significant impact on patient outcomes. When processed correctly, blood cultures provide clinically relevant information that can help improve patient outcomes, decrease length of hospital stay and reduce use of antibiotics. 21 4 INTERPRETATION OF RESULTS The microbiology laboratory can provide useful information to clinicians to help them determine whether a blood culture sample is a true positive or a false positive (contaminant). For example, the identity of the micro- organism isolated can help determine if the culture is contaminated, and the number of Figure 6: Example of interpretation algorithm for blood culture results 1 More than one positive bottle monomicrobial culture + clinical symptoms (e.g., endocarditis, meningitis, pneumonia…) polymicrobial culture (from the appropriate clinical setting (e.g., transplants, intraabdominal infection, immunocompromized patient…) bloodstream infection probable bloodstream infection 3 Negative blood cultures but clinical symptoms 22 INTERPRETATION OF RESULTS cultures positive with the same organism can help predict true infections.57 Time to positivity is also a factor used to determine potential contamination as contaminants usually have a delayed (longer) time-to-detection due to a lower overall bio-load. Laboratories should consult with their medical director to create an algorithm which helps determine whether or not an isolated organism is a contaminant vs. an infective agent. Models, such as the algorithm below, can give guidance only on the interpretation of blood culture results.42, 57, 58 These guidelines should be used in conjunction with clinical guidelines e.g., patient’s full blood count, presence of catheters, radiological findings, etc. 2 Only one positive bottle if pathogenic organism: Listeria, S. aureus, Brucella, Haemophilus, Enterobacteriaceae, … if normal skin flora: Propionibacterium, corynebacterium, Bacillus, coagulase-negative staphylococci if viridans streptococci or coagulase-negative staphylococci and consistent with clinical setting (e.g., indwelling catheter, prosthetic heart valve, immunocompromized patient) probable bloodstream infection probable contamination probable bloodstream infection Repeat blood samples Consider non-infectious etiology Investigate viral etiology or non-culturable microorganism 23 5 BLOOD CULTURE/SEPSIS GUIDELINES v International Guidelines WHO guidelines on drawing blood: best practices in Phlebotomy. World Health Organization 2010. http://whqlibdoc.who.int/publications/2010/9789241599221_eng.pdf Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Dellinger RP., et al. Crit Care Med. 2013;41:580-637. http://www.survivingsepsis.org/guidelines/Pages/default.aspx The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Singer M., et al. JAMA. 2016;315(8):801-810. http://jama.jamanetwork.com/article.aspx?articleid=2492881 v National Guidelines COUNTRY/ REGION GUIDELINES Australia Clinical Excellence Commission. SEPSIS KILLS Adult Blood Culture Guideline Updated September 2016. SHPN (CEC) 160406. http://www.cec.health.nsw.gov.au/__data/assets/pdf_ file/0005/259412/adult-blood-culture-guideline-updated-sept2016.pdf Brazil Elmor de Araujo MR, Hemocultura: recomendações de coleta, processamento e interpretação dos resultados, J Infect Control 2012; 1: 08-19 http://www.iqg.com.br/pbsp/img_up/01355393320.pdf Europe European Society for Clinical Microbiology and Infectious Diseases, European Manual for Clinical Microbiology, 1st Edition, 2012. https://www.escmid.org/escmid_publications/manual_of_microbiology/ 24 BLOOD CULTURE/SEPSIS GUIDELINES COUNTRY/ REGION France GUIDELINES REMIC 2015. Automatisation des cultures microbiennes : quel cahier des charges ? Chapitre 11 http://www.sfm-microbiologie.org/ Germany Reinhart K, Brunkhorst FM, Bone HG, Bardutzky J, et al., Prevention, diagnosis, therapy and follow-up care of sepsis: 1st revision of S-2k guidelines of the German Sepsis Society (Deutsche Sepsis-Gesellschaft e.V. (DSG)) and the German Interdisciplinary Association of Intensive Care and Emergency Medicine (DIVI). German Medical Science, 2010, Vol. 8: 1-86 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899863/pdf/ GMS-08-14.pdf South Africa Guideline for the optimal use of blood cultures. SAMJ 2010; Vol. 100, No. 12: 839-843 SAMJ https://www.fidssa.co.za/Content/Documents/Guideline_for_the_optimal_use_of_blood_cultures.pdf UK UK Standards for Microbiology Investigations. Investigation of Blood Cultures (for Organisms other than Mycobacte- rium species). Bacteriology | B 37 | Issue no: 8 | Issue date: 04.11.14 | Page: 1 of 51. Issued by the Standards Unit, Health Protection Agency, PHE. https://assets.publishing.service.gov.uk/government/uploads/sys- tem/uploads/attachment_data/file/372070/B_37i8.pdf Taking blood cultures - a summary of best practice: Saving lives reducing infection, delivering clean and safe care. 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The clinical significance of positive blood cultures in the 1990s; a prospective comprehensive evaluation of the microbiology, epidemiology, and outcome of bacteremia and fungemia in adults. Clin Infect Dis. 1997;24:584-602. 29. U K Department of Health: Taking Blood Cultures – A summary of best practice. 2007 30. W einstein MP. Current blood culture methods and systems: clinical concepts, technology, and interpretation of results. Clin Infect Dis. 1996;23:40-46. 31. E verts RJ, Vinson EN, Aholla PO, Reller LB. Contamination of catheter-drawn blood cultures. J Clin Microbiol. 2001;39:3393-3394. 32. Cornaglia G, Courcol R, Hermann JL, Kahlmeter G. European Manual of Microbiology. ESCMID-SFM 2012. 33. K irm TJ, Weinstein MP. Update on blood cultures: how to obtain, process, report, and interpret. Clin Microbiol Infect. 2013;19(6):513-520. 34. W ilson ML, Mirrett S, Reller LB, Weinstein MP, Reimer LG. Recovery of clinically important microorganisms from the BACT/ALERT blood culture system does not require testing for 7 days. Diagn Microbiol Infect Dis. 1993;16:31-34. 35. Bourbeau PP, Foltzer M. Routine Incubation of BACT/ALERT FA and FN blood culture for more than 3 days may not be necessary. J Clin Microbiol. 2005;43:2506-2509. 36. S chlossberg D, ed. Clinical Infectious Disease. Cambridge University Press, 2015. 37. Hall KK, Lyman JA. Updated Review of Blood Culture Contamination. Clin Microbiol Rev. 2006,19(4):788. 38. D unne Jr. WM, Nolte FS, Wilson ML. Cumitech 1B, Blood Cultures III. coordinating ed. Hindler JA. ASM Press. Washington, D.C. 1997. 39. Hall KK, Lyman JA. Updated review of blood culture contamination. Clinical Microbiology Reviews. 2006;19:788-802. 40. Bamber AI, Cunniffe JG, Nayar D, Ganguly R, Falconer E. The effectiveness of introducing blood culture collection packs to reduce contamination. Br J Biomed Sci. 2009;66(1):1-9. 41. Gander RM, Byrd L, DeCrescenzo, Hirany S, Bowen M, Baughman J. Impact of Blood Cultures Drawn by Phlebotomy on Contamination Rates and Health Care Costs in a Hospital Emergency Department. J Clin Microbiol. 2009;47:1021-1024. 42. Richter SS, Beekman SE, Croco DJ, et al. Minimizing the workup of blood culture contaminants: implementation and evaluation of a laboratory-based algorithm. J Clin Microbiol. 2002;40:2437-2444. 43.T owns ML, Reller LB. Diagnostic methods: current best practices and guidelines for isolation of bacteria and fungi in infective endocarditis. Infect Dis Clin N Am. 2002;16:363-376. 44. Osborn TM, Nguyen HB, Rivers EP. Emergency medicine and the surviving sepsis campaign: an international approach to managing severe sepsis and septic shock. Ann Emerg Med. 2005;46:228-231. 45. R ubenstein E, Lang R. Fungal endocarditis. Eur Heart J. 1995:16(Suppl B):84-89. 46. E llis ME,Al-Abdely H, Sandridge A, Greer W,Ventura W. Fungal endocarditis: evidence in the world literature, 1965-1995. Clin Infect Dis. 2001; 32:50-62. 28 REFERENCES 47. M cLeod R., Remington JS. Fungal endocarditis. In: Rahimtoola SH et al., eds. Infective Endocarditis. New York, NY: Gune & Stratton.1978:211-290 48. Z iegler R, Johnscher I, Martus P, Lenhardt D, Just HM. Controlled Clinical Laboratory Comparison of Two Supplemented Aerobic and Anaerobic Media Used in Automated Blood Culture Systems to Detect Bloodstream Infections. J Clin Microbiol. 1998;36:657-661. 49. Pohlman JK, Kirkley BA, Easley KA, Basille BA, Washington JA. Controlled Clinical Evaluation of BACTEC Plus Aerobic/F and BACT/ALERT Aerobic FAN Bottles for Detection of Bloodstream Infections. J Clin Microbiol. 1995;33:2856-2858. 50. B aron EJ, Scott JD,Tompkins LS. Prolonged incubation and extensive subculturing do not increase recovery of clinically significant microorganisms from standard automated blood cultures. Clin Infect Dis. 2005;41:1677-1680. 51. Beekmann SE, Diekema DJ, Chapin KC, Doern GV. Effects of rapid detection of bloodstream infections on length of hospitalization and hospital charges. J Clin Microbiol. 2003;41:3119-3125. 52. Munson EL, Diekema DJ, Beekmann SE, Chapin KC, Doern GV. Detection and treatment of bloodstream infection: laboratory reporting and antimicrobial management. J Clin Microbiol. 2003;41:495-497. 53. B arenfanger J, Graham DR, Kolluri L, et al. Decreased Mortality Associated With Prompt Gram Staining of Blood Cultures. Am J Clin Pathol. 2008;130:870-876. 54. Timbrook T, Boger MS, Steed LL, Hurst JM. Unanticipated Multiplex PCR Identification of Polymicrobial Blood Culture Resulting in Earlier Isolation, Susceptibilities, and Optimization of Clinical Care. J Clin Microbiol. 2015;53(7):2371-2373. 55. Bauer KA, West JE, Balada-Llasat JM, Pancholi P, Stevenson KB, Goff DA. An Antimicrobial Stewardship Program’s Impact with Rapid Polymerase Chain Reaction Methicillin-Resistant Staphylococcus aureus/S. aureus Blood Culture Test in Patients with S. aureus Bacteremia. Clin Infect Dis. 2010;51(9):1074-1080. 56. Dierkes C, Ehrenstein B, Siebig S, Linde HJ, Reischl U, Salzberger B. Clinical impact of a commercially available multiplex PCR system for rapid detection of pathogens in patients with presumed sepsis. BMC Infect Dis. 2009; 9(1):126 57. Weinstein MP. Blood Culture Contamination: Persisting Problems and Partial Progress. J Clin Microbiol. 2003;41:2275-2278. 58. Weinstein MP, Towns ML Quartey SM, et al. The clinical significance of positive blood cultures in the 1990s: a prospective comprehensive evaluation of the microbiology, epidemiology and outcome of bacteremia and fungemia in adults. Clin Infect Dis. 1997;24:584-602. 59. Ernst DJ. Applied Phlebotomy. Dennis J. Ernst (MT(ASCP)). Lippincott Williams & Wilkins, 2005. 60. Lieseke CL, Zeibig EA. Essentials of Medical Laboratory Practice. F.A. Davis, 2012. 61. Q amruddin A, Khanna N, Orr D. Peripheral blood culture contamination in adults and venipuncture technique: prospective cohort study. J Clin Pathol. 2008;61:509513. 29 RECOMMENDATIONS FOR BLOOD CULTURE COLLECTION A) USING WINGED BLOOD COLLECTION SET (preferred method of collection)59-61 1 PREPARE BLOOD COLLECTION KIT Confirm the patient’s identity and gather all required materials before beginning the collection process. Do not use blood culture bottles beyond their expiration date, or bottles which show signs of damage, deterioration or contamination. It is recommended to identify the Fill-to Mark or mark the target fill level on the blood culture bottle label about 10 ml above the media level. 2 PREPARE BOTTLES FOR INOCULATION Wash hands with soap and water then dry, or apply an alcohol hand rub or another recognized effective hand rub solution. Remove the plastic “flip-cap” from the blood culture bottles and disinfect the septum using an appropriate and recognized effective disinfectant, such as chlorhexidine in 70% isopropyl alcohol, 70% isopropyl alcohol, or tincture of iodine in swab or applicator form. Use a fresh swab/applicator for each bottle. Allow bottle tops to dry in order to fully disinfect. 30 3 PREPARE VENIPUNCTURE SITE If skin is visibly soiled, clean with soap and water. Apply a disposable tourniquet and palpate for a vein. Apply clean examination gloves (sterile gloves are not necessary). Cleanse the skin using an appropriate disinfectant, such as chlorhexidine in 70% isopropyl alcohol or tincture of iodine in swab or applicator form. The venipuncture site is not fully clean until the disinfectant has fully evaporated. 6 OTHER BLOOD TESTS If blood is being collected for other tests, an insert placed into the adapter cap may be required. The insert is used to guide blood collection tubes onto the needle. If other blood tests are requested, always collect the blood culture first. 4 VENIPUNCTURE Attach a winged blood collection set to a collection adapter cap.* To prevent contaminating the puncture site, do not re-palpate the prepared vein before inserting the needle. Insert the needle into the prepared vein. 5 CULTURE BOTTLE INOCULATION Place the adapter cap over the aerobic bottle and press straight down to pierce the septum. Hold the bottle upright, below the level of the draw site, and add up to 10 ml of blood per adult bottle and up to 4 ml per pediatric bottle.† Ensure the bottle is correctly filled to the Fill-to Mark or target fill level. Once the aerobic bottle has been inoculated, repeat the procedure for the anaerobic bottle. 7 FINISH THE PROCEDURE Discard the winged collection set into a sharps container and cover the puncture site with an appropriate dressing. Remove gloves and wash hands before recording the procedure, including indication for culture, date, time, site of venipuncture, and any complications. Ensure additional labels are placed in the space provided on the bottle label and do not cover the bottle barcodes, and that the tear-off barcode labels are not removed. If additional labels contain a barcode, they should be positioned in the same manner as the bottle barcode. Inoculated bottl
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Radiotherapy to the prostate or prostate bed - patient information

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Preparation for radiotherapy treatment to the male pelvis - patient information

Description: This factsheet explains the preparation needed before having radiotherapy to the male pelvis.
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Preparation for radiotherapy treatment to the female pelvis - patient information

Description: This factsheet explains the preparation needed before having radiotherapy to the female pelvis.
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