Annual Infection Prevention and Control Report Produced by Colette Thomas Lead Nurse Infection Prevention and Control Page 1

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1 Infection Prevention And Control Annual Report Presented by: Written and Compiled by: Contributors: Executive Lead: Director of Infection Prevention and Control Lead Nurse, Infection Prevention and Control Hotel Services Manager Infection Prevention and Control Team Antimicrobial Pharmacist Consultant Microbiologist-Infection Control Doctor Director of Nursing and Patient Services/Director of Infection Prevention and Control Page 1

2 Contents EXECUTIVE SUMMARY...4 INFECTION CONTROL ARRANGEMENTS...6 INFECTION PREVENTION AND CONTROL TEAM...7 HOSPITAL INFECTION PREVENTION CONTROL COMMITTEE (HIPCC)...8 RESULTS OF MANDATORY REPORTING...9 STAPHYLOCOCCUS AUREUS... 9 METICILLIN SENSITIVE STAPHYLOCOCCUS AUREUS BACTERAEMIA... 9 METICILLIN RESISTANT STAPHYLOCOCCUS AUREUS BACTERAEMIA ESCHERICHIA COLI BACTERAEMIA CLOSTRIDIUM DIFFICILE Deaths attributable to Clostridium difficile TIME TO ISOLATE SURGICAL SITE INFECTION ORTHOPAEDIC SURGICAL SITE INFECTION MRSA SCREENING MRSA SCREENING OF EMERGENCY ADMISSIONS MRSA SCREENING OF ELECTIVE ADMISSIONS CATHETERS AND URINARY TRACT INFECTION POINT PREVALENCE MONITORING OUTBREAK AND INCIDENT REPORTS CARBAPENEMASE PRODUCING ENTEROBACTERIACEAE (CPE) NOROVIRUS OUTBREAKS VIRAL HAEMORRHAGIC FEVER (VHF) HAND HYGIENE ASEPTIC CLINICAL PROTOCOLS CARE OF CENTRAL VENOUS CATHETERS FOR ADMINISTRATION OF PARENTAL NUTRITION DECONTAMINATION INCIDENTS RELATING TO DECONTAMINATION MONITORING SAFETY OF THE WATER LEGIONELLA PNEUMOPHILIA PSEUDOMONAS AERUGINOSA CLEANING SERVICES MANAGEMENT ARRANGEMENTS ENVIRONMENT AND CLEANLINESS GROUP BUDGET ALLOCATION TRAINING MONITORING ARRANGEMENTS PLACE 2014 RESULTS ENVIRONMENTAL AUDITS WITH IPC TEAM ISSUES TO RESOLVE IN ANTIMICROBIAL STEWARDSHIP Page 2

3 POINT PREVALENCE AUDIT (DECEMBER 2014) SURGICAL PROPHYLAXIS AUDIT (OCTOBER 2014) IV TO ORAL SWITCH OF ANTIMICROBIALS AUDIT (FEBRUARY 2015) TRAINING ACTIVITIES POLICIES AND GUIDELINES CONCLUSION REFERENCES APPENDIX ANNUAL PROGRAMME FOR 2015/ APPENDIX AUDIT PROGRAMME 2015/ APPENDIX SURVEILLANCE PROGRAMME Page 3

4 Executive Summary The purpose of this report is to inform and provide assurance to the Trust Board, Bedfordshire Clinical Commissioning Group, patients, public and staff. It provides an overview of the key work at Bedford Hospital NHS Trust with regard to infection prevention and control for the reporting period 1 April 2014 to 31 March 2015, and demonstrates the progress made against performance targets and the compliance with the Health and Social Care Act 2008 (Reviewed 2010): Code of Practice for the NHS on the prevention and control of healthcare related guidance. The Trust continues to regard patient safety in relation to the prevention of Health Care Associated Infections (HCAI) as a key priority for the organisation. Key Achievements Bedford Hospital NHS Trust has continued to reduce MRSA blood infections (bacteraemias) and Clostridium difficile (C.difficile) infections to their lowest level since mandatory reporting began. The hospital recognises however that any avoidable infection is one too many and pledges to continue to work towards reducing infection in hospital. Robust post infection reviews (PIR) have been undertaken to ensure learning in relation to reported cases of both MRSA bacteraemia and Clostridium difficile infections and as a result: 1 MRSA bacteraemia case was identified as attributable to Bedford Hospital NHS Trust following post infection review (PIR) for the period 2014/15 against a trajectory of Clostridium difficile cases were identified during the period 2014/15 against a trajectory of 18; this is a testament to the continued vigilance around antibiotic stewardship, early assessment and reporting of change of patient bowel habit and appropriate isolation of symptomatic patients. The Trust set a patient safety objective to achieve a time to isolate compliance rate of 80% for 2014/15 for any patients with potentially infectious diarrhoeal symptoms. Data collection began in July There has been month-on-month improvement overall and the hospital finished the year on an average of 80%. In addition to mandatory surveillance of MRSA Bacteraemia and C.difficile, Bedford Hospital NHS Trust undertakes mandatory surveillance and reporting for all E.coli and MSSA bacteraemias. Mandatory Orthopaedic and Voluntary Surgical Site Infection Surveillance (SSIS) is undertaken using the Surgical Site Infection Surveillance Service of Public Health England (PHE). This allows Bedford Hospital to make comparisons with other participating trusts. As in previous years viral gastro-enteritis outbreaks caused by Norovirus continue to place a considerable burden on the organisation. The organisation experienced an outbreak during the months of February to March 2015 that affected 6 wards. The outbreaks were managed by undertaking daily multi-disciplinary outbreak meetings and full organisational engagement to minimise the impact of the outbreaks in the hospital. Page 4

5 Interventions to achieve the low rates of infection are described within this report including environmental cleanliness, antimicrobial stewardship and hand hygiene. Relevant to the reduction of most types of infection is good hand hygiene. The on-going hand hygiene programme in this organisation continues to maintain high rates of hand hygiene compliance. Page 5

6 Infection Control Arrangements Trust Board Chief Executive Quality and Clinical Risk Committee Quality Board Hospital Infection Prevention and Control Committee Environmental Cleanliness Group Decontamination Committee Water Quality Management Committee Antimicrobial Stewardship Group (From February 2015) Page 6

7 Infection Prevention and Control Team Director of Infection Prevention and Control (No defined hours) Consultant Microbiologist/Infection Control Doctor Lead Nurse Infection Prevention and Control (WTE 1.0) Antimicrobial Pharmacist (WTE 0.3) Service Administrator (WTE 1.0) Senior Nurse Infection Prevention and Control (WTE 1.0) vacant from February 2015 Invasive Devices Nurse (WTE 0.6) Infection Prevention and Control Practitioner (WTE 1.0) vacant Oct Sept 2014 At Bedford Hospital NHS Trust, the IPC agenda is led by the DIPC and her team. The Medical Director, Director of Nursing (who is also the DIPC), Clinical Business Units Leads and Matrons all have key roles in ensuring high standards of clinical care are delivered to patients. During this year the IPCT worked closely with the Microbiology Department, Clinical Business Unit Managers, Estates Department, Bed Management Team, Support Services Managers, Learning and Education Department, Occupational Health Department, Bedfordshire Clinical Commissioning Lead Nurse for Infection Prevention and Control, Local Health Protection Committee and Public Health England staff. Page 7

8 The IPC nursing team provided a rotational weekend rota for weekend review of patients with diarrhoea and outbreak management. This service was informal on the understanding that hours worked could be taken under time of in lieu. Due to nursing shortages time off in lieu could not be honoured consistently and therefore the out of hours service will be paid during 2015/16. Infection Prevention and Control Annual Programme An annual programme of planned worked is prepared by the Infection Prevention and Control Team. The plan is mapped to the duties of the Code of Practice. Progress against the annual plan is monitored by the HIPCC. The plan for can be found at Appendix A. Infection Prevention and Control Budget The budget allocation for 2014/15 covered the salaries of the nurses and administrator, as well as a small stationery budget. Hospital Infection Prevention Control Committee (HIPCC) The HIPCC is the forum developing and delivering the Trust s Infection Control Strategy. The committee ensures that effective systems exist to prevent infection and where it occurs to minimise its impact on patients, staff and the organisation. The committee operates within national guidance on Infection Prevention and Control and the Health and Social Act 2008: Code of practice for the prevention and control of healthcare associated infection and related guidance (revised 2010). The Committee is chaired by the Director of Infection Prevention and Control (DIPC) or her deputy. The frequency of the quarterly meetings has been increased to monthly meetings to meet the demands of the ever increasing work programme. The change came into effect from November The Committee reports to the Chief Executive and the Board through the Quality Board and Quality and Clinical Risk Committee. The Director of Infection Prevention and Control will report matters of urgency directly to the Chief Executive, EMC or Trust Board. HIPCC membership: All Matrons or their deputies Antimicrobial Pharmacist Bedfordshire Clinical Commissioning representative Clinical Risk Manager Consultant in Communicable Disease Control (CCDC) Consultant Medical Microbiologist (Infection Prevention and Control Doctor) Director of Infection Prevention and Control/ Director of Nursing (Chair) Director/deputy from Estates Department Hotel Services Manager Infection Prevention and Control Nurses Medical Director Patient Representatives Senior clinical representative from each of the Medical, Surgical/Anaesthetic, Speciality medicine and Women & Children business units. Senior Occupational Health Nurse OR the Occupational Health Physician Other staff may be invited to attend as required Page 8

9 Results of mandatory reporting The Infection Prevention and Control Team reports the following Healthcare-Associated Infections (HCAI) monthly to Public Health England (PHE) Meticillin resistant Staphylococcus aureus (MRSA) bacteraemia Clostridium difficile infection ( C.difficile) Glycopeptide resistant Enterococcal Bacteraemia Meticillin sensitive Staphylococcus aureus (MSSA) bacteraemia Escherichia coli (E.coli) bacteraemia Staphylococcus aureus Staphylococcus aureus is a bacterium commonly found colonising humans. Although many people carry this organism harmlessly, it is capable of causing a wide range of infections, from minor boils to serious wound infections, food poisoning and toxic shock syndrome. In hospitals, it can cause surgical wound infections, and blood stream infections. When Staphylococcal aureus is found in the blood stream, it is referred to as a Staphylococcal aureus bacteraemia. Meticillin sensitive Staphylococcus aureus bacteraemia Due to the relatively low national rate of decline in MSSA compared to that of MRSA bacteraemia reports, mandatory reporting of MSSA bacteraemia was introduced in January No national or local reduction targets have been set for MSSA bacteraemia. The advanced data set now collected nationally allows distinction to be made between bacteraemias that are attributable to the acute trust or to a community provider. It also identifies the care details and risk factor information that enables improvement to be focussed. For each case identified in hospital a full post infection review (PIR) is undertaken in order to identify any lapses in care and key learnings associated with each case. 2 cases of MSSA bacteraemia were identified as trust-apportioned during 2014/15. These are shown in table one. Page 9

10 4 MSSA Bacteraemia 2014/ Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Acute Trust Apportioned Non Acute Trust Apportioned Table One: MSSA Bacteraemia 2014/15 showing Trust apportioned cases Meticillin resistant Staphylococcus aureus bacteraemia Reporting of MRSA bacteraemia by NHS Trusts has been mandatory in England since April 2001 (Health Protection Agency, 2012). These include all isolates, whether true infections or contaminated blood cultures; hospital acquired or community acquired infections In April 2013, the NHS England issued Guidance on the reporting and monitoring arrangements and post infection review process for MRSA bloodstream infections from April The post infection review (PIR) process is used as a learning tool to identify the causes of the MRSA blood stream infection (BSI) and to review whether or not the blood stream infection was avoidable and to take appropriate action if it was. This is an enhancement of the root cause analysis (RCA) process introduced in 2007 that used the NPSA RCA tool by adopting a whole system approach that fosters strong partnership working by all organisations involved in the patient s care pathway. The MRSA bacteraemia objective for 2014/15 was to have no more than 0 cases. There has been 1 trust apportioned MRSA bacteraemia this year. This resulted in the Trust being above the annual trajectory of zero. A MRSA Bacteraemia was identified in April 2014 on admission to the A+E department. A PIR process has been undertaken for the single preventable MRSA bacteraemia in the Trust; supported by the BCCG. Learning points from the PIR helped in identifying actions that would prevent similar cases recurring in the future. Page 10

11 Hospital-apportioned MRSA Bacteraemia /6 2006/7 2007/8 2008/9 2009/ / / / / /15 Table Two: Acute Trust- apportioned MRSA bacteraemia inc. Escherichia coli bacteraemia Escherichia coli, commonly known as E. coli, is found in the human gut and is part of the normal microflora. The most common infection caused by E. coli is infection of the urinary tract and overspill through the primary site to the blood stream infection (E. coli bacteraemia). E. coli bacteraemia can also result from infections in other sites such as bile duct and abdominal infections. Antibiotic resistance has increased in recent years with some E. coli able to produce enzymes that makes it resistant to several antibiotics. In June 2011, surveillance of E. coli bacteraemia became mandatory. There is no current target associated with this surveillance. The aim of the surveillance is to allow more accurate determination of possible interventions to prevent avoidable bacteraemias. Surveillance has shown that 92% of E.coli bacteraemias identified at Bedford Hospital NHS Trust are community acquired rather than hospital acquired. Page 11

12 Escherichia coli Bacteraemia 2014/15 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Non Acute Trust Apportioned Acute Trust Apportioned Table Three: Escherichia coli Bacteraemia 2014/15 Clostridium difficile Clostridium difficile is a gut bacterium that releases a toxin. Clostridium difficile infection (CDI) is the predominant cause of antibiotic-associated diarrhoea among hospitalised patients, and is of great importance as a healthcare associated infection. Acquisition of C.difficile may manifest as asymptomatic colonisation of the intestine, or as an infection ranging in severity from mild diarrhoea through to severe disease in the forms of pseudomembranous colitis and toxic mega colon, both of which can lead to death. The risk of infection is higher in the healthcare setting due to a combination of risk factors including a predominantly elderly population, antibiotic use, and the possibility of cross-infection. Since 2004 it has been a mandatory requirement to report all CDI in NHS acute trusts in patients aged 65 years and over. In April 2007 enhanced surveillance for CDI was introduced and it became mandatory to report all CDI in patients aged 2 years and older (Health Protection Agency, 2012). Diarrhoeal stool specimens that are submitted to the microbiology laboratory are examined for the presence of C. difficile toxin in accordance with the Department of Health updated guidance on diagnosis and reporting which was published in March 2012 (Department of Health, 2012). This guidance requires that the appropriate samples are tested using a two stage test which includes a glutamate dehydrogenase (GDH) enzyme immunoassay (EIA) and a sensitive toxin EIA. Samples that are both GDH and toxin positive must be included in mandatory reporting. National targets are set and our performance against this target for 2014/15 was very favourable. The Trust is pleased to report achievement of a below target of 14 cases against a ceiling of 18, continuing the year-on-year reduction since 2007/8. Page 12

13 Hospital-apportioned Clostridium difficile / / / / / / / /15 Table Four: Acute Trust- apportioned Clostridium difficile inc. Reducing Clostridium difficile remains a priority for Bedford Hospital NHS Trust in 2014/15. Actions to improve the Trust position forms part of the infection prevention and control annual programme of work for 2014/15 and specifically focuses on introducing and embedding the national five-year antimicrobial strategy, and improving time to isolate (for all patients with CDI). Each case identified in hospital is investigated and the precipitating factors examined. The Trust compares favourably in the PHE comparisons rate per bed days of acute trusts located within South Midlands and Hertfordshire area with a rate of against the overall rate of for the period of 2014/15. Deaths attributable to Clostridium difficile 0 patients died within 30 days of C.diff diagnosis during 2014/15. Page 13

14 Glycopeptide Resistant Enterococcal Bacteraemia (GRE) Enterococci are normally found in the gut. Enterococci can occasionally cause serious infections such as endocarditis. In immunocompromised patients, especially those with intravascular lines, enterococci may cause a bacteraemia. Glycopeptide resistant enterococci are resistant to glycopeptide antibiotics such as vancomycin and teicoplanin. Any cases are reported to the Health Protection Agency. The numbers of cases are low and sporadic. 0 GRE bacteraemia was reported for the year 2014/15. Time to Isolate Any patient suspected or known to be colonised or infected with an infectious agent that may pose a risk to others must be isolated in line with the isolation policy. Due to the use of isolation facilities for needs other than suspected/infectious patients it is recognised that the use of isolation rooms need to be prioritised. The Trust has set a local standard/patient safety objective to achieve time to isolate for patients with suspected infectious diarrhoea and/or vomiting, within 2 hours. The minimum compliance has been set at 80% for 2014/2015. Data collection began in July The monthly results for 2014/15 are shown in Table Percentage Compliance with Isolation Achieved within 2 Hours of Request 2014/ The hospital finished the year on 80%. Table Five: Time to Isolate Compliance April March 2015 Page 14

15 Surgical Site Infection Infections of the surgical site account for approximately 16% of all hospital acquired infections (HAI), and are estimated to double the length of post-operative stay in hospital and significantly increase the cost of care. The aim of SSISS is to enhance the quality of patient care by encouraging hospitals to use data obtained from surveillance to compare their rates of SSI over time and against a benchmark rate, and to use this information to review and guide clinical practice (PHE 2013) Bedford Hospital NHS Trust has participated in the Public Health England (PHE) Surgical Site Surveillance Service for more than 10 years using a systematic method of identifying surgical site infections during the inpatient stay and on readmission with the objective to produce data to inform preventative strategies within healthcare. In addition to surveillance of inpatients, data collection included post discharge surveillance using out-patient clinic feedback and patient feedback via post discharge questionnaire (PDQ). The PHE recommend that hospitals aim for at least 70% of completed PDQ to give a reasonable estimate of the true infection rate. Orthopaedic Surgical Site Infection It is a mandatory requirement to conduct surveillance of orthopaedic surgical site infections, using the Surgical Site Infection Surveillance Service of Public Health England. The data set collected is forwarded to the service for analysis and reporting. This system is controlled and validated to allow comparison between trusts in England and Wales. The IPCT undertook the 3 month mandatory surveillance requirement for the period April-June Voluntary orthopaedic surveillance has been undertaken during the period of October 2014 to March 2015 to provide continuous surveillance (including post discharge questionnaire (PDQ) in order to obtain a more accurate rate. The following mandatory orthopaedic category surveillance has been undertaken for the period of 2014/15 Hip Replacement Knee replacement Voluntary surveillance for the period of 2014/15 Reduction of long bone fracture (Oct 2014-March 2015) Repair neck of femur (Oct 2014-March 2015) Hip replacement surgical site infection surveillance April-June 2014 Number of patients monitored PDQ % Total patients with SSI % National Average SSI %with PDQ over previous 5 year period % 2.3% 1.4% An above national average percentage of 2.3% was noted against a national average of 1.4% for this period, however an improvement was noted from the previous 4 periods which was 2.9%. Page 15

16 2.3 % of these infections were patient reported. With regard to patient reported infections, these patients did not present to any healthcare facility and so these are likely to be superficial or local inflammations. Knee replacement surgical site infection surveillance April-June 2014 Number of patients monitored PDQ % Total patients with SSI % National Average SSI %with PDQ over previous 5 year period % 2.7% 2.3% An above national average was noted of 2.7% against the national average of 2.3%. 1.3% of these infections were patient reported. 1.3% infection confirmed post discharge. Reduction of long bone fracture surgical site infection surveillance Bedford Hospital NHS Trust National Period Number of Average Total patients patients PDQ % SSI %with PDQ with SSI % monitored over previous 5 year period Oct-Dec % 0% 1.5% Jan-Mar % 0% 1.5% An above national average percentage of 78.9% PDQ surveillance noted for the period of Oct- Dec 2014 against the national average of 53.9% for this period. The results identified an infection rate of 0% which compares favourably against an aggregated rate for all participating hospital over the last 5 years of 1.5%. Repair neck of femur surgical site infection surveillance Bedford Hospital NHS Trust Period Number of patients monitored PDQ % Total patients with SSI % National Average SSI % with PDQ over previous 5 year period Oct-Dec % 0% 1.5% Jan-Mar % 0% 1.5% An above national average percentage 76.2% PDQ surveillance noted for the period of Oct-Dec 2014 against the national average of 53.9% for this period, and an above national average percentage 61.9% PDQ surveillance noted for the period of Jan-March However a drop in percentage noted from the previous reporting period of 76.2%, this is due to the increase number of patients during this period that did not have the mental capacity or relatives who could support the completion of the PDQ. Page 16

17 MRSA Screening The Department of Health (DOH) published new MRSA screening guidance for NHS Trusts in August This guidance recommends a move to a more focused screening programme and the guidelines are to be adopted in line with local risk assessment. At the time of the publication of these guidelines the initial local risk assessment determined screening to remain within the previous guidelines set out by the DOH in December The DIPC has commissioned a project to explore the process required for implementation of the most current guidance for MRSA screening, which recommends screening of high risk patients only. Progress with this project will be included in the next annual report. Screening rates are monitored monthly and results reported to the monthly HIPCC. MRSA Screening of Emergency Admissions All NHS Trusts are required to screen all emergency hospital admissions as from December The proportion of patients screened by the end of the year was 84.77%. This is above the screening identified in a national survey in 2012, commissioned by the DOH, where it was identified that 61% of emergency admissions were screened in participating hospitals. MRSA Screening of Elective Admissions The rationale for screening elective patients is to identify MRSA carriers and therefore enables the application of topical decolonisation/suppression treatment either prior to admission or on admission it further enables the use and choice of an appropriate systemic antimicrobial prophylaxis at the time of the procedure if required. The proportion of patients screened by the end of the year was 95.55%. The national survey mentioned above identified that only 81% of elective admissions were screened. Catheters and Urinary Tract Infection Point Prevalence Monitoring The NHS Safety Thermometer is an improvement tool for measuring, monitoring and analysing patient harms and harm free care. One of the elements of the data collected relates to urinary catheters and urinary tract infection (UTI) and allows the Trust to monitor the point prevalence rate of catheter associated urinary tract infections (CAUTI). Data is collected on one day a month on every in-patient in an NHS provided ward nationally; thus far the data fluctuates between 0-3 patients per month. Retrospective thematic review is undertaken at the end of every financial year. The Safety Thermometer is not a tool for comparison between trusts, but it allows bench marking against other local and similar Trusts. The Trust continues to report low numbers of possible harms which relate to urinary catheters. Bedford Hospital NHS Trust report a lower than average in comparison to other local and similar Trusts Page 17

18 The presence of a urinary catheter and a UTI does not necessary mean that harm has been caused within the Trust. Many patients have a urinary catheter inserted due to a UTI causing retention and this is the correct clinical treatment. The safety thermometer point prevalence tool identifies patients and from here we review all those identified to gain a full picture. Of the 17 patients highlighted by the safety thermometer, 7 patients were identified as likely to have developed a CAUTI during their admission to hospital. The factors reviewed (known risk factors for CAUTI) for the 7 patients included: length of time the urinary catheter remains in situ multiple catheterisations non-compliance with guidelines. Of these patients the average age was 79 years, the most common reasons for urinary catheter insertion was for retention (probably due to UTI) or to monitor fluid balance due to poor medical condition. Length of time the catheter was in situ ranged from 1-39 days. Organism s causing the UTI were E coli, ESBL E.coli and 1 case with Vancomycin resistant enterococci (VRE). Of the 7 patients who had a probable CAUTI, 4 had an underlying condition that predisposed them to UTI before the urinary catheter was inserted, 1 patient was confused and pulled out their urinary catheter this caused trauma and an increased risk of infection. The Trusts continues to promote best practice through guidelines, high impact intervention (HII) monitoring, collaborative working with the CCG and a programme developed alongside the Oxford Academic Health Science Network. Themes are reported to HIPCC and Matrons meetings and individual wards in order to improve patient safety and outcome Safety Thermometer 2014/15 Catheters and New UTIs Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Actual 1 0 Table Six: Safety Thermometer 2014/15 Catheters and New UTIs Page 18

19 Outbreak and Incident reports Every year the infection prevention and control team (IPCT) recognize and respond to many incidents and potential outbreaks, some of these are real but many turn out to be random clusters of disease or patients with suspected infectious symptoms not caused by cross infection. The IPCT have to be alert of all potential outbreaks and incidents and investigate them accordingly. Early assessments are key to detecting and taking action on incidents and outbreaks to minimise adverse outcomes. Every year the infection prevention and control team recognize and respond to many incidents and potential outbreaks. Some are real but others turn out to be chance clusters not caused by cross infections. The infection prevention and control team has to be alert to all potential outbreaks and investigate them accordingly. The Trust reports outbreaks of infection as serious incidents. These include incidents where there has been a near miss, or a failure of infection prevention and control which can have an impact on the running of the hospital, or where there has been a severe impact on the patient s outcome. Noteworthy outbreaks: CPE outbreak Norovirus outbreak Carbapenemase producing Enterobacteriaceae (CPE) The emergence of CPE is a major public health concern, with a rapid increase in cases worldwide. Although still rare in the United Kingdom, these organisms are endemic in other areas of the world and there is a risk of introduction to the UK, and subsequent person-to-person spread in health care settings. Carbapenemases (CPE) are enzymes produced by some gram negative bacteria which confer resistance to Carbapenems e.g. Meropenem. They are more common in the Mediterranean region (E.g. Italy, Malta, Greece, Cyprus, Turkey, Israel and Egypt.), Asia (including the Indian subcontinent), Japan and the United States of America (USA). There have however been outbreaks in the UK as a result of introduction of these organisms, and their subsequent person to person spread within high risk settings such as Intensive Care Units. Carbapenemases are a group of clinically important β-lactamases that efficiently hydrolyse most β-lactams including the Carbapenems, have emerged and spread among the Enterobacteriaceae family of bacteria worldwide. Carbapenems are currently the only class of β- lactam antibiotics reliably active against Enterobacteriaceae with ESBL or AmpC activity. Following the December 2013 launch of the Public Health England toolkit on the management of carbapenemase-producing Enterobacteriaceae (CPE), the Infection Control Team (IPCT) at Bedford Hospital NHS Trust initiated a program of work to launch the toolkit at the Trust. During April 2014, two clinical isolates of multi-drug resistant Escherichia coli were identified from two patients on the same ward. One patient had recently received medical treatment abroad. After screening the remaining ward patients, one further colonized patient was identified. An Page 19

20 outbreak was therefore formally declared. The ward was closed to new admissions and transfers and enhanced cleaning commenced. The three clinical isolates were found to be epidemiologically linked. The BCCG, TDA and Public Health England were actively involved in all outbreak meetings. The CPE outbreak catalyzed the rapid implementation of the PHE toolkit. The IPCT engaged key stakeholders to ensure implementation of the toolkit was expedited. Following discharge of the cases, the outbreak was officially declared over on 17 April Norovirus Outbreaks Norovirus causes outbreaks of diarrhoea and/or vomiting. It is extremely infectious and spreads easily in any semi-closed settings such as hospital, schools, hotels and cruise ships. Typically norovirus outbreaks are associated with the winter months. Norovirus infections do not only affect patients but also staff and visitors. An increase in cases identified in the hospital is usually preceded with increased norovirus activity in the community. An outbreak is defined as two or more patients presenting with the same symptoms of a communicable disorder connected by place and time. The hospital experienced an outbreak of viral gastroenteritis across a number of the adult wards during February 2015 and March Details as follows: Duration of outbreak (days) 32 Number of staff affected 33 Number of patients affected 106 Number of visitors affected 8 Total number of days wards closed (aggregated) 85 Bed days lost 224 Contributors to the outbreak include: Background community activity of norovirus High hospital activity Challenges in isolating suspected cases promptly due to high bed occupancy The outbreak was quickly identified and reported to the IPCT due to prompt reporting by ward nurses which resulted in the timely movement of admissions and transfers to and out of the affected wards. There was evidence of effective team-working between the different hospital disciplines involved such as the site and operational management teams with the matrons, hotel services and corporate nursing team. There was also effective engagement with the Clinical Commissioning Group, with good communication between the various parties involved. Daily outbreak meetings were attended by internal and external stakeholders including BCCG. Following this there were daily reports distributed by to all users, giving a status update. The infection prevention and control team continued to review the outbreak out of hours. Page 20

21 The causative organism was confirmed as Norovirus for the outbreak. Viral Haemorrhagic Fever (VHF) Response to the outbreak of Ebola Virus Disease (EVD) The UN has declared the outbreak of the Ebola virus an international public health emergency. Ebola is spread through direct contact with blood and body fluids from infected people. The incubation period ranges from 2 to 21 days. It remains unlikely but not impossible that travellers infected in one of the affected countries could arrive in the UK while incubating the disease and develop symptoms after their return. Although the likelihood of imported cases is very low, healthcare staff in the UK needs to remain vigilant. All Acute Trusts received clear Public Health England (PHE) guidance on identifying and managing patients who require assessment for Ebola virus disease. The Emergency Department decontamination/isolation room has been completed and is being used for training purposes, as well as additional capacity. Members of staff from Emergency Department and Maternity Unit attended PHE Personal Protective Equipment training in December 2014 and are tasked with training appropriate staff. The Resilience Committee oversees the action plan VHF. At present the IPCT is working with the relevant departments and the learning and education team to add specialist PPE training to WIRED, in order to monitor compliance proportionally. Hand Hygiene Promotion of effective hand hygiene remains a priority at the Trust in ensuring patient safety and experience. There continues to be a need for all staff to be continually vigilant and the IPCT are continuing to provide training sessions for all health care professionals to improve awareness for compliance of my 5 moments of hand hygiene. Observational audits with feedback on performance are undertaken on a monthly basis. The audit is undertaken in this way to help gain the most accurate picture of compliance. Page 21

22 Over the year hand hygiene compliance has been good, a significant dip in compliance occurred through August-October 2014 but improvement has been observed with the overall compliance for the whole hospital following this. Where there is non-compliance this is addressed at the time with the relevant staff. For those areas that are achieving less than 90% compliance the IPCT will notify the ward manager and matron to action. The IPCT will provide education and training for hand hygiene training in the area. A monthly summary of compliance is disseminated to respective Clinical Business Units (CBU) and is part of the key performance indicators in the monthly IPC dashboard which is discussed and actioned at the monthly HIPCC meetings Doctors Hand Hygiene Compliance 2014/ Doctors Target Compliance Page 22

23 Table Seven: Doctors Hand Hygiene Compliance 2014/ Nurses Hand Hygiene Compliance 2014/ Nurses Target Compliance Table Eight: Nurses Hand Hygiene Compliance 2014/ Other Professional Groups Hand Hygiene Compliance 2014/ Other Target Compliance Table Nine: Other Professional Groups Hand Hygiene Compliance 2014/15 Page 23

24 Promotion of effective hand hygiene remains a priority in 2015/16. Aseptic clinical protocols The principals of asepsis are included on the Trust induction programme for new staff. Clean and aseptic technique principles are also provided as part of nursing education, with assessment competency made in relation to intravascular drug administration, intravascular cannulation and venepuncture. Particular emphasis continues to be placed on aseptic procedures when inserting and managing the ongoing care of peripheral and central venous catheters. The trust has standardised to ANTT (Aseptic Non-Touch Technique) and the training video and workbook are available on the intranet. These are embedded into the IV study day and update sessions for non-medical staff. Peripherally Inserted Central Catheters (PICCs) PICCs are used for lengthy intravenous treatments, when otherwise patient would have multiple peripheral vascular devices, reducing pain and discomfort and when cared for following evidence based guidelines, reduce the risk of infections PICC insertion is undertaken by an anaesthetist or an appropriately trained and competent nurse (for example in the Primrose unit). Insertion is always undertaken to a high standard using maximal barrier precautions and aseptic technique. Ongoing care of the line is managed by the ward staff and this is supported by the vascular access nurse and invasive devices nurse. Patents are often discharged home for antimicrobial therapy and in some instance other intravenous therapy with PICC lines in situ. Care and maintenance of the PICC line is taken over by Hospital@Home or Community services. The consultant and Trust remain with overall responsibility for the device, review and timely removal as appropriate. Care of Central Venous Catheters for Administration of Parental Nutrition Central venous catheters are used for the administration of nutrition directly into the blood stream of patients who are unable to absorb adequate nourishment in the normal manner within the gut. Parental nutrition is associated with a very high risk of infections. Cohorting patients receiving parenteral nutrition on wards where the staff have received training and who are competent is critical to maintaining low levels of infection. The invasive Devices Nurse and Vascular Access Nurse work collaboratively with the PN team and nutrition nurse to support ward staff and monitor patients as necessary to ensure a high standard of CVC care and documentation. Decontamination The Decontamination Committee is responsible for monitoring decontamination arrangements and compliance overall, and reports to the HIPCC. The Committee is chaired by the Trust s Page 24

25 Decontamination Lead, who is the head of estates department. The committee meets 4 times a year. The hospitals accredited sterilisation and decontamination unit, which reprocesses surgical and other invasive devices reusable instruments, are externally audited twice a year by a notified body. The unit have an internal monthly audit plan to ensure the unit remains compliant. Decontamination of lower risk patient equipment (i.e. non-invasive equipment such as commodes, infusions, pumps, beds) are audited using the quality improvement tools environmental audit tool published by the Infection Prevention Society (IPS) in 2011 and audits are undertaken during times of increased incident rate of infection/outbreak in an area to provide assurance. Incidents relating to Decontamination Theatre set-annual sterility assurance failure In January 2015 the infection prevention and control team were informed of a rigid container instrumentation set which had failed its annual sterility assurance test. This set was sterilised and stored for 1 year in the Sterile Services Department (SSD) data room before it underwent its annual sterility assurance test. A year ago a similar incident occurred. A comprehensive external audit identified that the rigid containers used for the surgical instruments at the Trust have exceeded the manufactures recommended lifespan and were no longer fit for purpose. Funding has been provided to replace all of the rigid containers for surgical instruments at the Trust. Delivery and implementation of these containers will be at the end of July No patients have come to harm. Monitoring safety of the water Hospitals have particular risks associated with the movement and storage of water once it has entered the complex internal plumbing. Thus water can be a source of infection for vulnerable patients and staff. Legionella is recognised as a major risk, and much effort is directed to maintain the water supply to minimise the risk from Legionella. However other organisms may be harboured in the water system which can be a threat to immunocompromised patients, for example Pseudomonas aeruginosa. Following an incident of Pseudomonas aeruginosa infection in a neonatal unit in Northern Ireland 2011, the Department of Health issued preliminary guidelines in February 2012 on minimising the risk of Pseudomonas aeruginosa, especially to vulnerable patients in the intensive care units and neonatal units. In response, Bedford Hospital NHS Trust Legionella Committee was reconfigured as the Water Quality Management Group and its remit expanded to include all waterborne infective threats. An addendum to Health Technical Memorandum covering Pseudomonas aeruginosa was released March Legionella pneumophilia This bacterium can cause Legionnaires disease, it is a bacterium that lives in water and can infect the water systems in buildings such as hotels, offices and hospitals. Human infection is caused by inhaling water droplets contaminated with the bacteria. Droplets are formed normally Page 25

26 when devices such as taps and showers are operated. Typically those most at risk of the infection are either immunocompromised or are people over 50 who smoke. Hospital water supplies are monitored for legionella risk, and this is minimised by ensuring that hot and cold water systems are maintained at the correct temperatures and that no stagnation occurs in the water distribution system. Control measures included, where possible modifying pipe work and mains supply and the introduction of chlorine dioxide dosing treatment into the water supply. Further control to provide assurance and monitoring that no stagnation occurs, weekly flushing return sheets are submitted to the Estates Department and compliance is monitored via the IPC dashboard and is reported monthly to the HIPCC to provide assurance. No hospital acquired cases in patients or staff have ever been detected at the Trust. Pseudomonas aeruginosa Pseudomonas aeruginosa is a common environmental organism, it is commonly found in some patients, especially those with chronic chest disease. Contaminated water in a health care setting can transmit Pseudomonas aeruginosa to patients in the following ways: Direct contact with the water for example through bathing/showering. Inhalation of aerosols Medical equipment and devices rinsed with the contaminated water Indirect contact from contaminated surfaces via health care workers hands Guidance on minimising the risk for Pseudomonas aeruginosa was issued to the augmented care units, mainly on practices around the use of clinical hand wash basins and other sinks. A trust risk assessment for augmented care areas was carried out and control measures implemented, a programme of tap replacement was commenced in order to be compliant with the Health Technical Memorandum guidelines (HTM 04-01) before the water testing programme was due to commence end of January Pseudomonas aeruginosa is now routinely monitored in hospital water supplies to designated areas every six months or more frequent for those systems that are found to have positive results. These designated areas Meadowbank Neonatal Unit, Critical Care Complex and Primrose Oncology Unit. Continuous microbiological surveillance is also conducted in these areas to detect Pseudomonas aeruginosa infections in patients likely to have been acquired during admission to the units. The Critical Care Complex continues to yield positive results from various outlets since testing commenced in January The IPCT are working closely with the Estates Department in partnership with the contracted external expert advisor in monitoring and managing the situation. Expert advice is being sought from Public Health England to find a possible solution relating to the ongoing problem of positive results from outlets from the above augmented care unit. Cleaning Services Management arrangements Cleaning services are 'in-house' and are part of Operational Support Services. The standard and frequency of cleaning is broadly in accordance with the NPSA '49 steps' as detailed in their National Specification for Cleanliness in the NHS (2007). Page 26

27 The department also provides several other services to improve environmental cleanliness as follows: Special Cleans team for terminal cleans of wards, bays, bed-spaces and side rooms after occupation by patients with known infections. This team also clean pressure mattresses and pumps thus facilitating a quicker turnaround of this equipment than if it had to be sent away for cleaning. The Domestic Services Department employs a Clinical Equipment Cleaning Team to help ward nursing staff by releasing their time for direct patient care. Items such as blood pressure monitors, scales and drip stands are cleaned on a regular basis using a sporicidal cleaning solution. Additional late evening bed space cleaning (funded from Winter Pressure monies) to facilitate patient flow following discharges. This was a temporary service during the winter months but worked well so is likely to be required again for Environment and Cleanliness Group This group meets fortnightly, is chaired by the Director of Operational Support Services and has representation from the Matrons, Maintenance, Estates, Infection Prevention and Control, Portering, Catering and Domestic Services. There is an open invitation to members of the Patient Council to attend. The Environment and Cleanliness group addresses non -clinical issues that can enhance or detract from patient perception and experiences. Topics such as cleaning, monitoring standards, service and building changes, PLACE results, waste management, equipment storage plus new innovations all feature on the ECG agendas. Upward reporting is to the HIPCC (Hospital Infection and Prevention Control Committee). Budget allocation Cost element Pay 2,372,776 Non-pay e.g. training, cleaning materials, disposables, waste bags etc 293,229 Training All 133 domestic staff receives basic infection control training from the Infection Prevention and Control Team. Topics covered include the use of protective clothing, the correct waste disposal bags to use, safe handling of sharps boxes, the application of the NHS colour code for mops, gloves, cloths etc. according to areas being cleaned and key hand washing circumstances. Staff also have training in the correct use and storage of cleaning products. Monitoring arrangements Cleaning standards are monitored by the Domestic Services department against the NPSA 49 Steps. Wards and areas are assessed in accordance with the NHS National Standards of Cleanliness (2007). Individual areas are monitored for cleanliness in as many of the 49 Steps as are present e.g. toilets, high surfaces, internal glass, bed frames and chairs. The percentage score for each area monitored indicates how many of the 49 Steps present were of a satisfactory standard of cleanliness. In July 2014 matrons started participating in the regular monitoring of cleaning standards in their areas of responsibility. The graph below shows the performance against these standards over the year : Page 27

28 Domestic Services Department Cleaning Monitoring Scores %Compliance with NPSA '49 steps' Achieved Target In January 2013, the annual PEAT assessment was succeeded by PLACE (Patient Led Assessment of the Care Environment). As the name suggests, this new assessment increases patient and public involvement in reviewing non-clinical services. Each PLACE visit will generate a score in the four separate domains of cleanliness, food, privacy and dignity, and general maintenance/décor. The results must be published locally, with an accompanying action plan that sets out how the organisation expects to improve their services before the next assessment. Reports will be made to the HIPCC through the Environment and Cleanliness Group. The PLACE 2014 assessment for Bedford Hospital was completed on 22 nd May 2014 and results from this assessment are very positive. PLACE 2014 Results These results were received from the HSCIC (NHS Health and Social Care Information Centre) and are confirmed as: Cleanliness Food and Hydration Privacy, Dignity and Well-being Condition, Appearance and Maintenance of Premises 98.68% 90.11% 83.95% 92.47% Environmental Audits with IPC Team The audit assesses both environmental and patient equipment hygiene and overall shows high standards of cleanliness. Where any problems are identified these are highlighted immediately Page 28

29 for rectification by either the domestic supervisor, ward manager and ward matron or the estates department. These continue in accordance with the weekly schedule issued by the Environment and Cleanliness Group. A member of the Maintenance Department attends to note repairs and maintenance issues and Domestic Department staff log any cleaning requirements. Work on a new audit tool began in March 2015 with the specific aims to use a recognised IPS (Infection Prevention Society) quality improvement tool and to be able to RAG rate the results to prioritise further action. The audit tool is scheduled to be introduced in June Norovirus Outbreak: to The outbreak required an additional 686 hours cleaning time form the Domestic Department. This included daily enhanced cleaning and the amount of time to carry out terminal cleans so wards/bed spaces /side rooms could re-open and admit patients. The cost of cleaning during the outbreak (labour and materials) was 8,704. Issues to resolve in The Domestic Services Department continues to monitor the standard of cleaning against the NPSA 49 steps. This includes all the items the domestic staff clean in clinical and public areas of the hospital. The trust should review the resource allocated to monitor the cleaning service and provide comprehensive reports Ensure an allocation from any winter pressure money issued to the Trust is made available to facilitate bed space cleaning during evening hours. Antimicrobial Stewardship Antimicrobial resistance is a global public health issue driven by the overuse of antimicrobials and inappropriate prescribing. The increase in resistance is making antimicrobial agents less effective and contributing to infections that are hard to treat. The number of infections due to multi-drug resistant organisms is growing; however, the number of new antibiotics in the pipeline is extremely limited. The scale of the threat of antimicrobial resistance (AMR) and the case for action was set out in the Annual Report of the Chief Medical Officer, 2011, published in March The UK Five Year Antimicrobial Resistance Strategy 2013 to 2018 sets out actions to address the key challenges to AMR : 1. improve the knowledge and understanding of AMR 2. conserve and steward the effectiveness of existing treatments 3. stimulate the development of new antibiotics, diagnostics and novel therapies Page 29

30 Public Health England published in March 2015 updated guidance on antimicrobial stewardship in secondary care. The aim of the toolkit is to provide an evidence-based outline for antimicrobial stewardship (AMS) in the secondary healthcare setting. The toolkit will help healthcare providers assess whether they meet Criterion 9 of the Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance. A strong and robust antimicrobial stewardship programme is seen as a key component in the reduction of some health care associated infections (HCAIs) in support of patient safety. A Start Smart-then Focus approach is recommended for all antibiotic prescriptions in secondary care and is outlined in the algorithm below: Current guidance and the published evidence recommends an antimicrobial stewardship programme should include the following: 1. An assessment of the Trust s antimicrobial stewardship activities 2. An antimicrobial stewardship management committee Page 30

31 3. A ward-focused antimicrobial team 4. Evidence-based antimicrobial prescribing guidelines 5. Quality assurance measures/audits and feedback 6. Education and Training Like any change and improvement activity, especially those linked to patient safety, the success of an antimicrobial stewardship program is dependent on the support of hospital management and senior clinical staff. It is no longer the responsibility of specialists alone to champion the stewardship efforts within an organisation. Ultimately the Trust Board, managers and staff are all responsible for establishing, maintaining and supporting a co-ordinated approach to antimicrobial stewardship. The infection prevention and control team and antimicrobial pharmacist have reviewed current antimicrobial stewardship within Bedford Hospital NHS Trust. A summary of the areas reviewed is given below: Antimicrobial Stewardship Group The Trust s antimicrobial stewardship group was re-formed in February 2015 and is chaired by the Medical Director and will be monitoring the Trust s progress with compliance with the Start Smart then Focus guidelines, as well as the audit results presented below. Antimicrobial Ward Team Weekly multi-disciplinary ward rounds are undertaken when necessary for all patients found to be C. Difficile positive. A wider antimicrobial ward team presence would require an increase in the available microbiology consultants time. Antimicrobial Prescribing Guidelines The antimicrobial prescribing guidelines are currently being reviewed and updated. A hospital charitable funds bid for a mobile phone application to allow prescribers immediate access to local guidelines has been successful. It is hoped that the app will be available for the new intake of junior doctors in August to support safe antimicrobial prescribing and improve antimicrobial stewardship. Antimicrobial Audits Point Prevalence Audit (December 2014) An audit of all adult prescription charts for antimicrobials across the Trust was carried out by the infection prevention and control team and antibiotic pharmacist on the 9 th -12 th December The purpose of the annual audit is to compare current antimicrobial prescribing practices with the Department of Health recommendations Start Smart - Then Focus. The audit is a point prevalence audit surveying all prescriptions for antimicrobials across the Trust and is a repeat of previous year s audits. The audit is a point prevalence audit and all patients on antibiotics were recorded and the prescribed antimicrobial and documented indication were noted. The table below outlines the basic findings of this audit. Page 31

32 No of patients surveyed 337 % of patients on antimicrobials 45% % of antimicrobials prescribed-iv 60% Appropriate choice on antimicrobial prescribed 93% Stop/review date documented on drug chart 40% 1. Allergy status was documented in 99% of patients. 38% of patients were documented as having a drug allergy. 2. Co-amoxiclav is the most frequently prescribed antimicrobial; there is increasing use of the very broad spectrum antimicrobials such as Piperacillin/Tazobactam and Meropenem demonstrated in this audit and from pharmacy usage data. 3. The most common indication for antimicrobial prescription is Respiratory Tract Infection 4. 90% of notes had a clear indication documented for the antimicrobial. 4 prescriptions had the indication documented on the prescription % of relevant notes had a statement showing review of intravenous antimicrobials after hours 6. An antimicrobial course length was specified on 40% of prescriptions. 80% of oral antimicrobial prescriptions had a stop date and 12% of IV prescriptions had a stop date. Surgical Prophylaxis Audit (October 2014) A snapshot audit of 26 patients who had undergone elective and emergency surgery found: 85% of patients had prophylactic antibiotics prescribed as per the antimicrobial guideline. 92% of patients should have had prophylactic antibiotics prescribed as per the antimicrobial guideline i.e. 2 patients were not prescribed antibiotics when they should have been. 29% of patients had the appropriate antibiotic(s) prescribed as per the antimicrobial guideline. 32% of patients had the antibiotics documented as being administered with 30 minutes of surgery. IV to oral switch of antimicrobials audit (February 2015) An audit took place of 24 patients newly started on intravenous antimicrobials on both medical and surgical wards. The audit aimed to assess compliance with the early intravenous to oral switching of antimicrobials recommended by the Department of Health. Standard Achieved Target Antibiotics are switched from IV to oral at 48 7/14 (50%) 100% hours if clinically appropriate Evidence of review of intravenous antibiotics in 18/24 (75%) 100% the medical notes at 48 hours An ongoing plan for antimicrobial treatment is documented in the medical notes after initial 48 hours of treatment 11/24 (46%) 100% Page 32

33 Electronic Prescribing and Medicines Administration (epma) The rollout of epma across the Trust was completed in March To help improve antimicrobial stewardship the following rules have been built into the prescribing system: Mandatory indications for all prescribed antimicrobials. A clinical review appears on all intravenous antimicrobial prescriptions after 48 hours to prompt a switch from IV to oral. Training Activities Good infection control practice must be underpinned by a comprehensive programme of education and training. Such a programme is provided for all relevant disciplines of staff on general infection prevention and control, antimicrobial prescribing and aseptic technique. The infection prevention and control team provides a comprehensive induction and mandatory training service, which includes formal and informal opportunities, as well as day-to-day counsel. The hospital s mandatory training requirements are for clinical staff groups (Level 2) to attend update training annually and other non-clinical staff groups (Level 1) every three years. Training data collated by the learning and education department report 75%, attendance rates have improved since last year when a 72% compliance rate was reported. Exceptions staff groups reported on WIRED as being >70% compliant with in-date training 52% of Consultants - Level 2 training 64% Specialty Registrars - Level 2 training 73% Staff Nurses - Level 2 training Page 33

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