Infection Prevention Annual Report

Transcription

1 ovirus Cdiff MRSA Norovirus irus R Infection Prevention virus RS Annual Report us

2 Contents page Welcome (Cheryl Etches) 1 Introduction 2 Team Structure 4 Reporting structure 7 Budget 11 Performance 12 Audit programme 25 Policy review 28 Research & Development 29 National Conference 30 Serious Incidents & Outbreaks 31 Community outbreaks 40 Hotel Services 41 Estates, Projects & Facilities 45 Education Summary 47 Surgical Site Infection Surveillance Team 51 Intravenous Resource Team 52 Antimicrobial Stewardship 55 Decontamination 60 Primary Care 62 PREVENT 66 Innovation and the future (Dr Mike Cooper) 68 Glossary 69 Click on the subject or section you wish to view, click the symbol to return to this contents page.

3 Welcome Welcome to the interactive Infection Prevention & Control Annual Report for 2015/16 Cheryl Etches - Chief Nursing Officer How to use this document. This is an interactive document that contains a collection of images and videos. To go to the next page click next in the bottom right corner of the page. To move to the previous page click back at the bottom left corner. If you know which section you want to visit you can click on the page link in the Contents section. If you want to go directly to the contents page click the of each page. symbol at the bottom

4 Introduction Despite the ever increasing pressures on the healthcare system, both locally and nationally, The Royal Wolverhampton NHS Trust s (RWT) focus on infection prevention has continued to pay dividends in terms of the assurance we are able to give patients over the safety of our services. This is only made possible through the support the Infection Prevention Team (IPT) receives across the organisation and city from directors, managers, clinicians and other staff at all levels and in all areas. Despite being primarily hospital based, the IPT successfully works across all healthcare agencies and facilities within the city of Wolverhampton and in Cannock Chase Hospital, trying to ensure consistent standards and offering expert advice and support when needed to manage incidents, outbreaks and other problems. An important aspect of the work undertaken is predicting when problems might arise and putting actions in place to minimise disruption to services and harm to patients before this occurs. For the first time in over two decades there was not a single MRSA bacteraemia across the city during the entire year. While it must be appreciated that healthcare associated infections are due to a far wider range of pathogens than just MRSA, this is a massive improvement from ten years ago when one of these infections was diagnosed, on average, almost every three days in Wolverhampton. We also had the lowest number of bacteraemia caused by the more sensitive strains of Staph. aureus (MSSA) attributable to RWT than for any year since we started to collect this data, more than ten years ago. Another success has been the lowest number of bacteraemia due to medical devices in hospital in-patients (referred to locally as device-related hospital acquired bacteraemia or DRHABs) since we started to collect this data. This has largely been achieved through the work of the Intravenous Resource Team, established as part of the IPT, to educate on and audit intravenous lines and optimise intravenous access across RWT. This team has become such an integral part of the organisation that funding was granted to enable it s expansion to cover weekends and extended week-day working hours. While the work of this team must continue, there has to now be an increased focus on the second commonest cause of DRHABs, and the commonest cause of community-acquired device related bacteraemia, urinary catheters; the Continence Team is working on reducing the unnecessary use of these devices and the harm that can arise from them.

5 Unfortunately our poor performance against the Clostridium difficile targets continued as it had in the latter part of the previous year. RWT finished the year well above its nationally set objective for toxin positive cases and also breached its internal target, with more cases than in any year since enhanced testing using PCR was introduced. While the reason for this increase can t be established with any certainty, an improvement was seen following a deepclean programme that involved the full decant of wards. This involved a huge effort by staff and managers throughout the organisation, and was only made possible by the dedication of the Domestic and Estates staff. The environment is known to be a significant factor in the acquisition of C. difficile, especially in the hospital setting, but there are undoubtedly multifactorial causes behind the high numbers. All C. difficile patients are closely followed by the IPT while in hospital and all the Wolverhampton CCG C. difficile patients are followed-up post-discharge to ensure any relapse or recurrence of symptoms is managed optimally. Human probiotic infusions are now being used locally with some success to treat patients who have had multiple recurrences of infections or whose disease is refractory to conventional therapies. The number of MRSA acquisitions in RWT was identical to last year, but the pattern across the year was one of improvement, rather than deterioration as seen in the previous year. The Surgical Site Infection Surveillance Team collects data and undertakes in-hospital and post-discharge follow-up of all patients who have had procedures that required skin incision. Surgeons get to view their own data and the anonymised data of their colleagues plus cumulative and summative data. This has produced a substantial and sustained reduction in the number and rate of surgical site infections. One of the principle reasons RWT has been so successful over recent years in the prevention of healthcare associated infections is the recognition and acceptance by all staff in all roles that they are responsible for ensuring the safety of patients in their care. The Infection Prevention Team acknowledge that the prevention of infection is impossible without this commitment from all staff within RWT and the other organisations involved in the provision of health and social care in the City, and they remain grateful that they get the full support of this body of staff. Dr Cooper would like to thank Cheryl Etches, Vanessa Whatley, Jodie Winfield, Matt Reid, and all other members of the Infection Prevention Team who have helped in compiling this Annual Report.

6 Infection Prevention Team Structure /16

7 Infection Prevention Team The Infection Prevention Team (IPT) comprises the following individuals: Sessional Commitment to Infection Prevention: Name Title Sessional Commitment to Infection Prevention Dr M A Cooper Consultant Microbiologist, Director of Infection Prevention and Control, Royal Wolverhampton NHS Trust 6 PAs Dr D K Dobie Consultant Microbiologist, Head of Microbiology Department, Infection Control Doctor Wolverhampton Service specification - Primary care 2.5 PAs Dr H E Jones Consultant Microbiologist, Clinical Director of Pathology 0.5 PAs Dr J Macve Consultant Microbiologist, Antimicrobial Stewardship lead 0.5 PAs Full Time Commitment to Infection Prevention: Mrs V Whatley Head of Nursing Corporate Support Services (including Infection Prevention) 0.8WTE Mrs J Winfield Nurse Manager Infection Prevention (Operational lead) 1.0WTE Mr M Reid Nurse Manager Infection Prevention (R&D lead) 1.0WTE Mrs K Corbett Senior Infection Prevention Nurse 1.0WTE Mrs C Hayward Senior Infection Prevention Nurse 1.0WTE Mrs S Harper Senior Infection Prevention Nurse 1.0WTE (Reduced to 0.6WTE 17/8/15) Mrs H Guttridge Senior Infection Prevention Nurse 0.9WTE Mrs T Jones Infection Prevention Nurse 1.0WTE Mrs D Dain (from Infection Prevention Nurse 0.8WTE 17/8/15) Mrs E Spooner Infection Prevention Nurse 0.6WTE (from 10/8/15) Mrs J Freeman Infection Prevention Practitioner 1.0WTE Mrs S Wyllie Infection Prevention Audit & Surveillance Practitioner 1.0WTE Mrs N Bate (until 22/5/15) Infection Prevention Nurse 0.5WTE

8 Infection Prevention Miss S Wrigley Infection Prevention Nurse 0.6WTE (from 11/1/16) Mr M Beddow Projects Manager Community Projects 1.0WTE Mrs P Fern Infection Prevention Nurse (secondment) 1.0WTE Ms K Doleman HCA - Community Projects Team 1.0WTE Ms H Sims HCA - Community Projects Team 1.0WTE Mr J Parr Data Analyst 1.0WTE (until 1/5/15) Mr L Olayanju Data Analyst 1.0WTE (between 15/6/15 31/3/16) Mrs P Kang Antibiotic Pharmacist 0.4WTE Mrs P Wright Group Secretary 1.0WTE Mrs H Couchman Clerical Officer 0.5WTE (until 24/4/15) Mrs W Lewis Clerical Officer 0.5WTE (from 1/9/15) Mrs D Parmar-Patel Intravenous Resource Team Administration 0.7WTE Ms E Woods Surgical Site Infection Surveillance Team Administration 1.0WTE Mrs S Rowlands Intravenous Resource Team Leader 1.0WTE Mr D Golding Clinical Nurse Specialist Intravenous Resource Team 1.0WTE Mrs L Brand Clinical Nurse Specialist Intravenous Resource Team 0.8WTE Mr P Dunkley (from Clinical Nurse Specialist Intravenous Resource Team 1.0WTE 29/2/16) Ms J Shemwell Clinical Nurse Specialist Intravenous Resource Team 1.0WTE (from 15/2/16) Mr C Brown HCA - Intravenous Resource Team 1.0WTE Ms J Weaver HCA - Intravenous Resource Team 1.0WTE Ms R Edwards HCA - Intravenous Resource Team 1.0WTE Ms D Newman Surgical Site Infection Surveillance Nurse 1.0WTE Ms L Vincent HCA - Surgical Site Infection Surveillance Team 1.0WTE Ms A Seniaray HCA - Surgical Site Infection Surveillance Team 1.0WTE

9 Infection Prevention Reporting Structure Infection Prevention and Control Group (IPCG) The IPCG meets monthly dates of meeting during 2015/16 were: 24th April th May th June th July th August th September th October th November th December th January th February th March 2016 Membership comprises of: Medical Director (Chair), Chief Nurse (Deputy Chair), Chief Executive, Director of Infection Prevention & Control, Head of Nursing for Corporate Support Services (including Infection Prevention), Consultant in Public Health for Wolverhampton City Council, General Practitioner for Wolverhampton City CCG, Representative for Wolverhampton City CCG (lead Commissioners), Representative for NHS South East Staffs, Seisdon & Peninsula CCG, Representative for NHS Cannock Chase CCG, Divisional Medical Director Division 1, Divisional Medical Director Division 2, Director of Pharmacy, Head of Hotel Services, Estates and Facilities Manager/Legionella Lead, Occupational Health and Wellbeing Service Manager (Quarterly attendance), Decontamination Lead (Quarterly attendance), Non-Executive Director, Royal Wolverhampton NHS Trust Governor, Matron Representative, Public Health England representative. Deputies are allowed only if previously agreed with the Chair. The Chief Nurse has weekly 2-to-1 meetings with the DIPC and the Head of Nursing for Corporate Support Services (including Infection Prevention).

10 Infection Prevention Reporting Structure Head of Nursing for Corporate Support Services (including Infection Prevention) sits on the Trusts Senior Nurses Leadership Forum, Directorate Governance Group and Environment Group. She uses these forums to feedback additional information to the wards and departments, and receives information to inform the priorities and actions of the Infection Prevention Team. Infection Prevention reports quarterly to the CCG as part of a quarterly scrutiny meeting to update on progress and provide assurance on commissioned services, to include jointly funded projects with Public Health. Members of the Infection Prevention Team sit on the following Committees /Groups within the Trust: Trust Management Committee, Health and Safety Steering Group, Water Safety Group, Medical Devices Group, Decontamination Group, Environment Group, Clinical Audit and Effectiveness Group, Waste Management Executive Group, Emergency Planning Committee, the Induction and Mandatory Training Group, Antimicrobial Stewardship Group. The Infection Prevention Team also attends Matron Group Meetings monthly and presents a report. Senior IPN s undertake monthly clinical walkabouts with their respective Matrons for each clinical area. They also meet with the Occupation Health Nurses and TB Nurses on an ad-hoc basis when required to deal with incidents. Members of the Team attend relevant meetings of groups dealing with developments, procurement and commissioning when appropriate. A Consultant Microbiologist sits on the Medicines Management Committee. The Microbiologists continue to work with the Antibiotic Pharmacist in monitoring, auditing and education on the use of antimicrobials, and an Antimicrobial Stewardship Committee meets regularly. The Ward Pharmacists monitor antimicrobial use around the hospital. There is a part-time Antibiotic Pharmacist who works in Primary Care supporting General Practitioners. Groups external to the Trust represented by the IP Team are: Wolverhampton Nuffield Hospital Infection Control Committee, West Midlands Infection Prevention Forum, Midlands TB Group, Regional Influenza Planning Group and the Infection Prevention Society.

11 The Infection Prevention Team meets formally every week to discuss a range of topics to include; Governance, assessing progress against the annual programme of work, performance targets, discussion and resolution of problems, review surveillance data and ensure necessary information, including feedback from groups, committees and meetings attended, is disseminated appropriately to the wider team. Reports to the Trust Board At every Trust Board the Chief Operating Officer gives the Operational Performance Report for the organisation, which includes the most recent infection prevention performance data. The minutes of all IPCG meetings are distributed with the papers for Trust Board meetings. All members of the Trust Board, therefore, have full access to all information concerning the Trust s performance against the external and internal infection prevention targets and other infection related issues. In addition, a Non-Executive Director sits on the IPCG and is therefore able to inform the other Non-Executive Directors and the rest of the Trust Board on a timely basis of trends and details of Infection Prevention issues. The DIPC delivers a report to the Patient Safety Improvement Group twice yearly.

12 Infection Prevention Reporting arrangements - RWT Trust Committee Structure

13 Budget Infection Prevention and Control Budget 2015/16 The funding for the Infection Prevention Team in Wolverhampton provided by RWT in 2015/16 consisted of a combination of RWT, Public Health and CCG funding. These budgets were managed separately to ensure the effective use of funds. A service continued to the CCG providing advice, quality assurance and education to independent contractors in Wolverhampton including contracted GPs and dentists and care homes, the funding for which is now detailed in a service specification available from April 16. For this 120,876 is allocated to support staffing costs. A service specification with Public Health provide a modified sustainability plan to the previous Raising Quality and Improving Safety Project and part funding for the nursing home HCAI prevalence project and the provision of outbreak management and education to very sheltered housing. A recurring CIP of 8, was taken from the Infection Prevention budget this year with related services picking up this year s additional saving recurrently. Infection Prevention (including provision to Wolverhampton CCG and surgical site infection surveillance) Pay Non-pay 586,205 51,886 Community Projects 153,762 39,238 Total 739,967 91,124 The end of year position was 41,031 underspent largely due to a delayed project start date.

14 Performance A. Meticillin Resistant Staph. aureus (MRSA) Bacteraemia The targets for the acute Trust and Wolverhampton CCG for MRSA bacteraemia were zero. There were no MRSA bacteraemia attributed to RWT during On 31st March 2016 it was 410 days since the last MRSA bacteraemia in Wolverhampton. Graph 1 MRSA Bacteraemia Numbers in Wolverhampton

15 Performance B. Meticillin Sensitive Staph. aureus (MSSA) Bacteraemia National mandatory surveillance of MSSA bacteraemia began in January 2011, but locally we have undertaken surveillance of these infections for over ten years, with this information used as a Key Performance Indicator (KPI) across the organisation. Graph 1 shows the annual total number of MSSA bacteraemia diagnosed in Wolverhampton since , split according to whether these infections were attributable to RWT or not using our in-house definition of attribution (which includes patients who have been recently discharged from our hospital, or are regular or day-case attenders). Although there was a slight increase in the total number compared with the previous year, it can be seen we had the lowest number of RWT-attributable cases since we began to collect this data. Despite this, we did miss our internal target of 24 cases, with 25 (against the external definition of attribution there were 15 RWT-attributable MSSA bacteraemia). A Root Cause Analysis is carried out on all RWT-attributable MSSA bacteraemia. These revealed: eight were related to IV lines; seven were due to primary skin or soft tissue infections; three were secondary to urinary tract infections (none in catheterised patients), two were secondary to surgical site infections; two were due to hospital acquired pneumonia (none in ventilated patients); and the remaining three were bone and joint, endocarditis or of unknown source. Of note, three of these infections (one each of the skin and soft tissue infections and surgical site infections, plus the bone infection) were almost certainly present when the patient was admitted, but the blood culture was not taken until more than 48 hours following admission. The surgery for this particular surgical site infection case was carried out in another hospital.

16 Performance B.Meticillin Sensitive Staph. aureus (MSSA) Continued Graph 2 MSSA Bacteraemia Numbers in Wolverhampton

17 Performance C. MRSA Acquisitions Universal admission screening for MRSA has enabled us to monitor the acquisition of MRSA in RWT and use this as another KPI for the organisation. Graph 3 shows the number of MRSA acquisitions across RWT (including West Park Hospital from April 2008 and Cannock Chase Hospital from November 2014) over the past eight years. The performance this year was disappointing, with a total identical to that of the previous year. It can be seen, however, that the performance improved from November 2015 onwards, and every effort will be made to ensure that this improvement continues into Graph 3 Cumulative RWT MRSA Acquisitions from April 2008

18 Performance D. Glycopeptide Resistant Enterococci (GRE) Bacteraemia During the year there were eight GRE bacteraemia. This compares with between two and eight cases per year during each of the preceding eight years. There were two linked cases on the Clinical Haematology Unit that were part of a cluster of infections from around the end of and beginning of Several incident meetings were held and an action plan put in place to reduce the likelihood of any further cases arising. There have been no further cases of that particular strain since April 2015 and no cases linked to this ward since July Altogether there were three cases on the Clinical Haematology Unit during the year, four (unlinked) cases across four different surgical wards and the remaining case was from a patient on the Critical Care Unit.

19 Performance E. Clostridium difficile Objectives for the number of C. difficile infections for acute Trusts and CCGs were set for the year by the DH based on nationally set target rates and the performance of each Trust and CCG for the period October 2013 to September This gave RWT a target of 35 and Wolverhampton CCG a target of 71 cases. Unfortunately, the poor performance seen in the latter part of continued into and RWT finished the year 38 cases over target. Wolverhampton CCG exceeded its target by 15 cases. Graph 4 shows the cumulative monthly performance against target for RWT and Wolverhampton CCG. Graph 4 C. difficile Toxin Positives and External Targets

20 Negotiation is allowed with the commissioners of acute services to determine if any of the cases could be determined to have been unavoidable. A 10,000 fine is incurred for every avoidable case above the target. Of the 73 cases attributed to RWT, only 24 were judged to have been avoidable using the agreed (national) definition of this measure. Locally we have another definition of avoidability that includes a 95% or greater compliance with infection prevention and antimicrobial prescribing mandatory training, which are not included in the national model for this definition. Using our local definition, only 10 cases were determined to have been unavoidable. The objectives are based on DH s definitions of attribution of infections, which does not take into account recent discharge from hospital and only records those cases that give a C. difficile toxin positive result. Internally, we set another target that, in addition to counting the cases included in the DH definition, also includes cases against RWT if infection is diagnosed within six weeks of discharge, unless the patient had been housed in another healthcare institution since discharge. This internal definition of infection includes all cases diagnosed with a positive C. difficile PCR or toxin result. The PCR test is a measure of colonisation with strains of C. difficile capable of causing disease and allows us to better monitor the spread of C. difficile. It enables us to take appropriate barrier precautions with such patients to prevent spread or contamination of the environment, and to pre-emptively treat such patients if they develop symptoms. The number of cases diagnosed against the internal definition of attribution increased slightly in comparison with the totals for the past four years. If there are possible linked cases on a ward or clinical area, the isolates are sent for ribotyping to determine if the same strain of C. difficile has spread. During over 55% of all positive samples were sent for typing, compared with less than 40% in and less than 20% the previous year. Usually several different strains are reported for each apparent cluster, which gives assurance that no transmission has occurred on the ward. During the year, however, several wards did have more than one case with the same ribotype, although it must be noted that not all of these cases were toxin positive, they often occurred more than 28-days apart and many were diagnosed after discharge from the ward, so were only picked up because we undertake extended surveillance. Sub-type testing is carried out on these apparent clusters, and those on Deanesly and A5 in May, the Clinical Haematology Unit between May and August, ASU in July and August, Deanesly between August and September, the Clinical Haematology Unit and C25 in November plus A14 in November and December indicate spread between patients on those wards. Each of these clusters involved just two patients with the exception of the cluster of ribotype 011 which went on from May until August 2015 and involved nine patients. Deep cleans, including hydrogen peroxide environmental decontamination, are carried out on all wards where apparent spread has occurred, while audits of the environment, practices on the ward and antimicrobial use are also undertaken.

21 Performance F. Extended Spectrum β-lactamase Producers (ESBLs) Graph 5 shows the number of new patients found to be colonised or infected with ESBL-producing organisms diagnosed in our laboratory. The number diagnosed while in-patients in RWT (blue bars) remains far lower than the number of cases found in the community (red bars). The total is slightly lower for compared with the previous year; this may be because during the GPs in Cannock began sending samples to the Wolverhampton laboratory, so a large number of previously known positive patients from outside Wolverhampton were recorded as having newly acquired the organism. Graph 5 New ESBL-Producers in Wolverhampton

22 Performance G. Hospital Acquired Bacteraemia (HABs) and Device- Related Hospital Acquired Bacteraemias (DRHABs) Hospital Acquired Bacteraemia (HABs) and Device-Related Hospital Acquired Bacteraemia (DRHABs) are used as another KPI for the Trust. All positive blood cultures are designated as being either significant or a contaminant by a Consultant Microbiologist, and the source of all significant positive blood cultures is determined. If the source is an implanted medical device and the patient has been in hospital for more than 48 hours when the blood culture was taken, or is within two weeks of discharge, or is a regular day-case attender, then it is designated as a DRHAB. Graph 6 shows how the Trust s performance has improved over the seven years this data has been collected. The DRHAB target for this year was 60 and there were actually 53 DRHABs, which is the lowest total we ve ever achieved. No target is set for HABs, but the graph does show how almost all of the decrease in HABS is accounted for by the reduction in DRHABs. Graph 6 Annual Totals Hospital Acquired Bacteraemia (HABs) and Device-Related Hospital Acquired Bacteraemia (DRHABs)

23 Performance Table 1 shows the blood culture data, with sources of DRHABs over the course of the year and data from the previous year and the first year this data was collected, for comparison: Table Blood Cultures taken 10,943 15,092 15,640 Blood Culture positives 1,113 1,014 1,019 Blood Culture significant Blood Culture contaminants Hospital Acquired Bacteraemia (HABs) Device-Related HABs: Lines Urinary Catheters VAP ?VAP/?Line Nephrostomy Pacemaker PEG Other 4 0 0

24 Performance It can be seen how much the number of line-associated infections has decreased over the years; this is a reflection of the influence and work of the IV Team. Table 2, shows the wards to which these infections have been attributed. The Haematology and Oncology service, Neonatal and Critical Care Units have maintained their low totals while the Renal Unit has had a considerable reduction in number compared with last year. Only the Surgical wards have had an increase in numbers by more than two cases. Table 2 Ward / Area Clinical Haematology Unit Durnall / Chemotherapy Deanesly Oncology Ward Neonatal Unit Renal Dialysis Unit (including satellite units) Critical Care Unit Cardiac (excluding Critical Care Unit) Surgical Wards Medical Wards West Park and Cannock Chase Hospitals Other wards

25 Performance H. Escherichia coli Bacteraemia Mandatory surveillance of E. coli bacteraemia started in June The intention is to allow assessments to be made nationally on the possible reasons for the increasing number of cases seen over recent years. Locally we have robust data on E. coli bacteraemias for the past six years. Graph 7 shows the breakdown of these infections according to whether they are attributable to RWT (HABs) or not using our internal definition of attribution, which attributes far more cases to the acute Trust than the official, external definition of attribution. These RWT-attributable cases are further broken down to show those that are due to medical devices (DRHABs), which are the only cases that may be potentially avoidable. It can be seen that, while the total number of E. coli bacteraemia are increasing year on year, the proportion of these that are attributable to RWT remains small. This year over seventy percent of cases were not attributable to RWT. Device-related RWT-attributable E. coli bacteremia accounted for 3.65% of the overall total. Graph 7 Breakdown of E. coli Bacteraemia in RWT

26 Performance Carbapenemase-Producing Enterobacteriaceae (CPEs) The carbapenem group of antibiotics are regarded as the antibiotic of last resort in many situations in which they are used. Organisms that produce enzymes (the common enzymes being NDM, KPC, and OXA-48) that destroy these antibiotics are increasing in Wolverhampton, as Table 3 shows. Table 3 NDM OXA-48 KPC Others Total * 12 *2 patients had an identical strain of Acinetobacter baumanii that produced OXA-23-like and OXA-51-like carbapenemases. RWT has adopted a very strict policy for the control of these organisms, based on national guidelines and the experiences of a hospital in the north of England that has had many more isolates than we have had here so far.

27 Audit Programme The Infection Prevention Team have a comprehensive citywide audit programme for assurance purposes that has been successfully delivered during 2015/16. The programme incorporates the acute Trust whereby clinical areas are classed as high, medium or low risk dependant upon activity performed, mini PEAT environmental audits which are undertaken collaboratively with Hotel Services and Estates, and the introduction of monthly environmental audits following on from an external Trust Development Authority visit. These monthly audits are undertaken by the ward / department and once each quarter they are completed by the Infection Prevention Team. General Practice, NHS contracted Dentists, Care homes and Policy audits are also included as part of the annual audit programme. The audit tools utilised are specific to each area. A modified Infection Prevention Society (IPS) audit tool is used for audits in the acute setting. Infection Prevention guidance for General Practice is a locally devised environmental specification for GPs and includes an audit tool which can be used by the Infection Prevention Team to undertake the audit but also allows for the practice to undertake self audits. HTM Decontamination in Primary Care Dental Practices is used for the contracted dentists and this is a national specification. Care homes are audited against a locally devised tool that reflects national guidance and the Health and Social Care Act (2012). Any deficits identified during the audit are verbally relayed to the person identified in charge at that time. A written report and action plan is always provided to the clinical area. A 30-day time frame is given to complete and return the action plan to Infection Prevention as assurance that any highlighted issues have been addressed. Any concerns or risks are discussed at Infection Prevention Governance meetings on a monthly basis for acknowledgement and to plan an escalation / improvement process.

28 Commode Audit A commode audit was undertaken by the Infection Prevention Team on 1st December 2015, including inpatient areas in New Cross, Cannock Chase and West Park Hospitals. The cleanliness and integrity of the commodes were assessed alongside availability of correct products for decontamination of the commodes. Areas received verbal and written feedback and are responsible for monitoring compliance on a daily basis. An overall increase in compliance was seen following this audit in comparison to the data for the previous audit undertaken during 2014/15. The scores for each Division were recorded as; Division 1-87% Division 2 81%. The overall Trust compliance score for this year was 83% which is an increase on last years performance of 67%. This information has been formally communicated to the Infection Prevention and Control Group and the Matrons Group for remedial actions. Sharps Audit A sharps audit was completed in December 2015 by the Trusts sharps provider. The overall compliance rate for sharps practice across the Health Economy was 99.4%. Overall compliance rates for each site was: New Cross Hospital 99.3%, West Park Hospital 100%, Community Services 100% and Cannock Chase Hospital 99.3%. Person Protective Equipment (PPE) Audit A Trust-wide audit was undertaken to establish compliance with Personal Protective Equipment (PPE) as outlined in the Trust s Standard Precautions Policy IP12 utilising the Infection Prevention Society audit tool questions. The overall compliance rate was 94% (an increase on last year s score of 93%), with Division 1 scoring 92% and Division 2 scoring 95%. This information has been formally communicated to the Infection Prevention and Control Group and the Matrons Group for remedial actions. Linen Policy Audit IP05 was audited in December 2015 utilising the Infection Prevention Society audit questions. Overall compliance scores were 96%, with Division 1 scoring 97% and Division 2 scoring 95%. This was an increase in the score from 2014/15 of 93%. This information has been formally communicated to the Infection Prevention and Control Group and the Matron Group for remedial actions.

29 Isolation Audit Royal Wolverhampton NHS Trust is committed to minimising the risk and preventing the spread of microorganisms among patients, staff and visitors by the use of isolation. This audit was undertaken to demonstrate compliance with the isolation of patients who required it. Overall compliance scores were 96%, with Division 1 scoring 98% and Division 2 scoring 95%. This information has been formally communicated to the Infection Prevention and Control Group and the Matron Group for remedial actions. Antibiotic Prescribing Audit Antibiotic prescribing audits have been introduced within the Trust with junior medical staff playing a key role. Data is collected monthly and inputted monthly into Synbiotix, an electronic system. This data is presented to the Infection Prevention and Control Group (IPCG) on a monthly basis. Hand Hygiene Audits Hand Hygiene practice is based on the World Health Organisation s (WHO) 5 Moments for Hand Hygiene. The message is to decontaminate hands properly and prevent the spread of potentially pathogenic organisms. The poster identifies 5 moments when hand hygiene must be carried out. Hand Hygiene is a mandatory requirement for all Trust Staff. Hand Hygiene audit data is collected monthly and inputted monthly into Synbiotix, an electronic system. This data is presented to the Infection Prevention and Control Group (IPCG) on a monthly basis. The Infection Prevention Team also spot-check hand hygiene compliance when visiting clinical areas.

30 Policy Review All Infection Prevention policies and leaflets that were due for review during 2015/16 were updated to reflect current evidence based best practice. Current policies were also amended when relevant new guidance was published to ensure they remained contemporary and that compliance could be monitored. Policies reviewed during 2015/16 (which reflected a large proportion of the team s workload) included: Number of Policy Policy Title Date reviewed IP01 Hand Hygiene June 2015 IP02 Preventing Infection in the Built Environment - New Policy July 2015 IP03 Antibiotic Resistant Organisms November 2015 IP04 Transportation of instruments, equipment and specimens January 2015 IP05 Linen January 2015 IP06 Clostridium difficile January 2015 IP07 Viral Haemorrhagic Fever October 2015 IP09 Glove Policy September 2015 IP10 Isolation July 2015 IP11 Management of Parasites January 2016 IP13 Outbreaks January 2016 IP16 Blood Cultures June 2015 IP19 Blood and Bodily fluid management September 2015 IP20 Urinary Catheter February 2016

31 Research & Development Two abstracts were submitted and accepted for the Infection Prevention Society conference in Liverpool in September One was described the Chronic Wound project from a previous year and the other related to UV-C light room decontamination technology. This study involved microbiological sampling in single rooms that required a red or amber rated clean and the decontaminating effect of the UV-C units assessed. It is planned that this pilot work will facilitate a larger study with a plan for external collaboration. The team continues to explore research funding routes and has submitted applications where appropriate. The team is involved with an antimicrobial resistance (AMR) research network as part of a grant awarded to Loughborough University. The grant will allow scientists to interact with clinical and industry partners, facilitated through hosting of a series of workshops, lectures and networking events to share knowledge and bring together experts to address the AMR challenge. The team are involved with exploring collaborative research opportunities to help tackle the issue of AMR, with study applications being submitted. One of the team was invited to speak at an international infection prevention congress in Geneva to discuss the use of innovative technologies to monitor hand hygiene compliance. A novel cleaning product which has shown encouraging results in reductions of Clostridium difficile in Europe was presented at the same conference; this has since formed a product evaluation over 10 wards at the Trust. The data generated is currently being analysed and will be reported through the appropriate forums. Other studies are being planned with both external academic partners and internal clinical partners.

32 National Conference In June 2015 a member of the Infection Prevention Team was successful in her submission to deliver a poster presentation at the Infection Prevention Society national conference in Liverpool in September The topic was mucormycosis. This was chosen as it was an unusual incident that had occurred in the Trust the previous year and had resulted in learning opportunities and improvements made across the organisation to reduce the risk of future occurrence. The poster was well received and is currently being written up for national publication.

33 Serious Incidents & Outbreaks The Trust has an Outbreak/Serious Incidents (SI) Policy and serious incidents are reported and managed in line with this policy. Outbreaks/Incidents are managed by Post Incident Reviews (PIR) held within seven working days wherever practicable and chaired by an Executive Director supported by key healthcare professionals. A 48 hour report is completed by the Infection Prevention Team to outline the suspected outbreak or incident and this is submitted to the area concerned and the Commissioners. If the subsequent PIR investigation and sampling confirms that it is an SI a 30-day report is compiled, agreed with Directorates and submitted to the Commissioners. If typing results indicate that it is not an outbreak and other ward indicators are assessed to be at the required infection prevention standards, then a request to downgrade the SI can be made to the Commissioners. Frequent meetings are held to manage and monitor the outbreak/incident to discuss individual cases and arrange appropriate sampling or screening, support patient experience and care, inform, arrange appropriate decontamination of the affected areas and reduce the risk of spread to other areas whilst maintaining the operational function of the hospital and patient flow. Different outbreaks/incidents demand different responses but are managed with precision and collaborative working between the multi-disciplinary teams across the Health Economy. This joint approach to infection prevention has proved to be successful in preventing admissions into the acute hospital with outbreaks in community care homes and very sheltered accommodation managed locally by the Infection Prevention Team. Norovirus or Suspected Norovirus Norovirus is a self-limiting diarrhoea and vomiting bug that usually lasts hours and is usually more prevalent in the winter months. Nationally the norovirus surveillance intelligence data showed a decreased number of laboratory reports than the previous year. Cumulative reports this season in the West Midlands (up to week ending 10 April 2016) are 22% lower than the number of reports in a similar period of the 2014/15 season (377 vs. 293 reports). Nationally, for the same period, the cumulative number of laboratory reports of norovirus this season is 36% lower than the average number for the same period in the five seasons from 2010/11 to 2014/15.

34 There were a total of 22 outbreaks of norovirus or suspected norovirus, the majority of which involved one or two bays within a ward, 9/22 were laboratory confirmed norovirus. The longest outbreak at RWT was 23 days (range 2-23 days). In total during the 22 outbreaks, 119 patients, eight staff and one visitor were affected. The number of bed days lost was calculated as 55. The number of staff reporting symptoms of diarrhoea and/or vomiting across the whole organisation was less this year (2015/16) compared to 2014/15 (942 vs 1235). Signage was in place at key entrances and the Infection Prevention Nurses were on call at weekends and bank holiday to support staff while on site testing helped with prompt identification of the virus. Clostridium difficile All patients identified with Clostridium difficile are reviewed on a weekly ward round with a Microbiologist and a member of the Infection Prevention Team. Increased incidence of Clostridium difficile are managed and monitored in line with IP06 Policy. An increase in incidence within a twenty eight day period triggers a Post Incident Review (PIR) or a Serious Incident (SI) depending on the circumstances. Any actions from the review meetings are implemented at ward level. There were 15 SIs reported in 2015/16. Following investigation and further testing, four of the incidents had no evidence of cross infection and had different strains of the organism detected. Five of the incidents were escalated to SI as the typing indicated the same strain of the organism. Robust actions were identified following each PIR to include Environmental cleaning using Hydrogen Peroxide Vapour (HPV) and hand hygiene assessments for all staff in those areas. A Trust wide Clostridium difficile action plan was devised and implemented involving all members of the multi-disciplinary team. This was finalised and completed by year end. Carbapenemase- Producing Enterobacteriaceae (CPE) Enterobacteriaceae are a large family of bacteria that usually live harmlessly in the gut of all humans and animals. These organisms are also some of the most common causes of urinary tract, intra-abdominal and bloodstream infections. They include species such as Escherichia coli, Klebsiella spp. and Enterobacter spp. The carbapenems are a family of antibiotics that are usually reserved for serious infections caused by drug-resistant Gram-negative bacteria (including Enterobacteriaceae). The carbapenems used in RWT are meropenem and ertapenem. There are often regarded as the antibiotics of

35 last resort, as organisms resistant to this class of antibiotics are often resistant to most other antibiotics. Carbapenemases are enzymes that destroy carbapenem antibiotics, conferring resistance. There are several different types of carbapenemases, of which KPC, OXA-48, NDM and VIM enzymes are currently the most common. In the UK over the last five years, there has been a rapid increase in the incidence of infection and colonisation by multi-drug resistant carbapenemase-producing organisms. A number of clusters and outbreaks have been reported in England, some of which have been contained, providing evidence that, when appropriate control measures are implemented, these clusters and outbreaks can be managed effectively. There have been eleven identified cases admitted to the Trust in 2015/16. Of these, seven were reported as incidents and investigated. Following on from the detection of the CPE, contact screening was undertaken, which provides evidence that appropriate control measures were implemented and managed effectively, with a total of 204 contacts being screened. One incident indicates likely cross infection, with a second patient identified with the same organism following contact screening, and was raised as an SI. An incident meeting was held and an action plan produced. With an increase in the cases seen over the year the Infection Prevention Team have liaised with another NHS Trust and developed a more robust strategy for the early detection and isolation of known positive and high risk patients. Standard operating procedures have been developed and an automated surveillance system is used to alert the team to readmission of both known positive patients and previous contacts. The new standard operating procedures have been taken to divisional governance meetings to ensure the information is disseminated Trust wide. A review of the admission documentation to look at the high risk categories is on-going. Mycobacterium chimaera Mycobacterium chimaera was identified in June 2015, in a patient who had received valve replacement surgery in October MHRA and PHE briefing notes in April 2015 alerted to the risk associated with cardiopulmonary heater cooler units and a risk assessment was completed. Multiple incident meetings were held and additional measures were discussed with an action plan formulated. Incident meetings were held until the action plan was completed and closed. Confirmation that three of the four machines that were in use were found to be contaminated with Mycobacterium spp. via water sampling. New machines have since been ordered.

36 Influenza There were clusters of patients with Influenza on two wards in January and February. Affected bays were closed to admissions at the time. Eleven patients were affected on one ward and six patients on the second. All affected patients and contacts were commenced on Tamiflu if their condition allowed, for treatment or prophylaxis. Infection prevention precautions were instigated immediately with dedicated staff, reduced visiting and increased cleaning. A post incident report was produced and lessons learnt identified. Protocols have been written to ensure that patients admitted with suspected viral illnesses, via the Emergency Portals, are admitted immediately into side rooms to reduce the risk of intra-hospital transmission. Serratia marcescens Three cases of Serratia marcescens were identified on one ward in November. One case was proven to be an unrelated strain through typing. Infection Prevention precautions were instigated at the time including increased cleaning. Incident meetings were held, a post incident report was produced and lessons learnt identified. Vancomycin Resistant Enterobacteria (VRE) Four cases of VRE was identified on one ward in April There was evidence of cross infection but the definitive cause was unclear. Nurse contact, patient contact or environment were all identified as potential factors in transmission. Infection prevention precautions were instigated and the ward area received a deep clean. Antibiotic prescribing and the use of vancomycin within this speciality was reviewed and altered accordingly. MRSA acquisition Two wards were were found to have had clusters of MRSA acquisitions within a 28 day period. The first ward had three cases and the second four cases. Infection prevention precautions were instigated and further education was provided to the clinical staff. Observational audits were undertaken to identify good practice and concerns these were identified to be environmental issues, the challenging patient group and decontamination processes. These issues were all addressed and no further incidents on those wards have occurred.

37 Serious Incidents and outbreaks Date Reported Serious Incident Number Description of incident Investigation level /12939 VRE Post Incident Review (PIR), 48 hour report and 30 day report completed / cases of Clostridium Post Incident Review (PIR), difficile on one ward 48 hour report and 30 day within a 28 day period report completed /16243 Norovirus identified on 4 wards / cases of Clostridium difficile on one ward within a 28 day period / cases of Clostridium difficile on one ward within a 28 day period Outbreak Management plan implemented and PIR investigation completed. Root Cause Analysis completed and presented to Division 1 & 2 Governance, Infection Prevention and Control Group meeting and Commissioners Post Incident Review (PIR), 48 hour report Post Incident Review (PIR), 48 hour report Outcomes Review of use of Vancomycin and IP education for clinical staff Further laboratory testing confirmed that the cases were not linked. Key Points: Reported promptly Outbreak contained Short duration. Good outbreak education and management at ward level Further laboratory testing confirmed that the cases were not linked. SI downgraded by Commissioners Further laboratory testing confirmed that the cases were not linked. SI downgraded by Commissioners

38 Date Reported Serious Incident Number Description of incident / cases of Clostridium difficile on one ward within a 28 day period / cases of Clostridium difficile on one ward within a 28 day period / cases of Clostridium difficile on one ward within a 28 day period /23205 Mycobacterium chimaera / cases of Clostridium difficile on one ward within a 28 day period / cases of Clostridium difficile on one ward within a 28 day period Investigation level Post Incident Review (PIR), 48 hour report and 30 day report completed Post Incident Review (PIR), 48 hour report and 30 day report completed Post Incident Review (PIR), 48 hour report and 30 day report completed Post Incident Review (PIR), 48 hour report and 30 day report completed Post Incident Review (PIR), 48 hour report and 30 day report completed Post Incident Review (PIR), 48 hour report and 30 day report completed Outcomes Further laboratory testing confirmed that the cases were linked. Further laboratory testing confirmed that the cases were linked. Further laboratory testing confirmed that the cases were linked. Machines received further testing, enhanced decontamination processes and new machines were purchased Further laboratory testing confirmed that the cases were linked. Trust wide Clostridium difficile action plan produced involving all members of multi-disciplinary team Further laboratory testing confirmed that the cases were linked. Continue to work through the Clostridium difficile action plan

39 Date Reported Serious Incident Number Description of incident /33177 Multi-resistant organism - Carbapenemase Producing Enterobacteriaceae (CPE) / cases of MRSA acquisition on one ward within 7 day period / cases of Clostridium difficile on one ward within a 28 day period / cases of Clostridium difficile on one ward within a 28 day period / cases of Serratia marcescens on one ward / cases of MRSA acquisition on one ward within 28 day period Investigation level Post Incident Review (PIR), 48 hour report and 30 day report completed Post Incident Review (PIR), 48 hour report and 30 day report completed Post Incident Review (PIR), 48 hour report Post Incident Review (PIR), 48 hour report and 30 day report completed Post Incident Review (PIR), 48 hour and 30 day report completed Post Incident Review (PIR), 48 hour and 30 day report completed Outcomes Screening took place of all contacts of index patient and one further isolate was identified Further education of decontamination process of equipment and cleaning schedules Further laboratory testing confirmed that the cases were not linked. SI downgraded by Commissioners Further laboratory testing confirmed that the cases were linked. Continue to work through the Clostridium difficile action plan Increased education on IP precautions and increased environmental cleaning

40 Date Reported Serious Incident Number Description of incident / cases of Clostridium difficile on one ward within 28 days / cases of Influenza identified on one ward /2289 Norovirus identified on two wards / cases of Influenza identified on one ward / cases of Clostridium difficile on one ward within 28 days Investigation level Post Incident Review (PIR), 48 hour and 30 day report completed Post Incident Review (PIR), 48 hour and 30 day report completed Outbreak Management plan implemented and PIR investigation completed. Root Cause Analysis completed and presented to Division 1 & 2 Governance, Infection Prevention and Control Group meeting and Commissioners Post Incident Review (PIR), 48 hour and 30 day report completed Post Incident Review (PIR), 48 hour completed and 30 day report in progress Outcomes Further laboratory testing confirmed that the cases were linked. Continue to work through the Clostridium difficile action plan Key Points: Reported promptly Outbreak contained Short duration. Good outbreak education and management at ward level Further laboratory testing confirmed that the cases were linked. Continue to work through the Clostridium difficile action plan

41 Date Reported Serious Incident Number Description of incident /6965 Norovirus identified on one ward / cases of Clostridium difficile on one ward within 28 days / cases of Clostridium difficile on one ward within 28 days /8819 Norovirus identified on one ward Investigation level Outbreak Management plan implemented and PIR investigation in progress Root Cause Analysis in progress Post Incident Review (PIR), 48 hour and 30 day report in progress Post Incident Review (PIR), 48 hour and 30 day report in progress Outbreak Management plan implemented and PIR investigation in progress Outcomes Key Points: Reported promptly Outbreak contained Short duration. Good outbreak education and management at ward level Awaiting confirmation of further laboratory testing Further laboratory testing confirmed that the cases were not linked. SI downgraded by Commissioners Key Points: Reported promptly Outbreak contained Short duration. Good outbreak education and management at ward level

42 Community Outbreaks During the year the Infection Prevention Project team has assisted with the management of 14 outbreaks of diarrhoea and vomiting in Wolverhampton care homes. Seven were confirmed as Norovirus positive through laboratory testing of stool samples. Outbreak management training included 11 formal training sessions for the staff of care homes and very sheltered accommodation facilities. The training is aimed at senior care staff and includes: recognition of an outbreak, infection prevention precautions to be implemented to reduce the transmission of infection, the importance of hand hygiene with soap and water, the requirement to submit stool samples from symptomatic residents/staff and enhanced cleaning practices. Care homes are required to discuss all potential outbreaks with the Infection Prevention Team (IPT). Once an outbreak is confirmed the care home get an initial visit from the IPT to ensure optimal outbreak management information and advice is provided and then is monitored daily and advice on appropriate actions are given. An update to all other agencies involved with the care home is sent out daily until the outbreak is concluded when all residents and staff are 72 hours symptom free. The graph below shows the numbers of care home residents and staff symptomatic or at risk per month: Three care homes have reported scabies outbreaks with two or more symptomatic residents or staff diagnosed by the GP s. Following Infection Prevention advice and support each care home undertook mass treatments of residents, staff and contacts. Logistically this requires a short delay while the care home obtains all the treatments required and extra staff are organised to help apply the treatments to all residents. Whenever possible all first treatments for residents, staff and contacts are co-ordinated for the same day. Then only the symptomatic residents and staff receive a second treatment seven days later. The staff are then advised to monitor the response to treatment for six weeks to ensure the effectiveness of treatment.

43 Hotel Services Management Arrangements The Trust s Housekeeping Services are managed in-house. The Housekeeping Services are split into 3 sections for the different sites covered; New Cross Hospital and West Park Hospital, Cannock Chase Hospital and Community Premises. The table below details who is responsible for which area. Area Manager Deputy New Cross Hospital and West Park Jenny Hickman Tina Tipton-NX Julie Burgess-WP Cannock Chase Hospital Janet Walker Amy Hill Community Premises Brendan Houston Julie Burgess Lesley Austin The management structure for each of the three areas is supported by a well-trained team of Day and Evening Supervisors.

44 Hotel Services The Community premises include the following sites:- Alfred Squire, Ashmore Park, Bilston HC, Bilston Urban Village, Bushbury Heath Town, Castlecroft Medical Centre, Gem Centre, Woodcross HC, Whitmore Reans HC, Pendeford HC, Tettenhall Wood HC, Maltings, Primrose Lane HC, Showell Park, Snow Hill, Mayfields, Phoenix Centre, Warstones, Oxley and Penn Fields. The Housekeeping Services Managers and Head of Hotel Services meet monthly with the Head of Nursing for Infection Prevention at the Environment Group. This meeting is chaired by the Head of Hotel Services, who presents a report from the Environment Group to the IPCG monthly. Training During the year priority has been given to ensure that all Hotel Services staff complete their annual mandatory hand hygiene and IP Level 1 training. Monitoring Technical Monitoring has been reviewed and now forms its own Monitoring Team. The majority of monitoring is conducted by the Hotel Services Monitoring Officer and the Domestic Supervisors in accordance with the National Specification for Cleanliness in the NHS: a framework for setting and measuring performance outcomes (DH April 2007). This document has a risk specification for areas within hospitals, and this informs the frequency of the audit:- Very High Risk areas are audited fortnightly High Risk areas are audited monthly Significant Risk Areas are audited quarterly Low Risk Areas are audited every 6 months In the main, the audits are carried out electronically, using a bespoke monitoring system.

45 Budget Allocation The pay budget for the whole of Housekeeping Services for the year 2015/16 was 6,254,327; the non-pay budget was 872,355. Clinical Responsibility / Access The Domestic Staff play a pivotal role in ensuring the hospital is a safe environment for patients, visitors and staff. The Domestic Services Department is very receptive to clinical need and responds to emergency and urgent situations rapidly and fully whenever possible, 24 hours a day. Deep Clean In October 2008, the Domestic Services Department introduced an in-house Deep Clean Team. They are required to deep clean all areas at least annually as follows:- Very High Risk Areas October to December A & E Department, Neonatal Unit, Delivery Suite, Renal Unit. Integrated Critical Care Unit, Beynon Centre, & Endoscopy, Emergency Assessment Unit, Clinical Haematology Unit. High Risk Areas April to September All Wards, Fracture Clinic, Diabetic Clinic, Cath Lab, Stroke Unit. To support the Deep Clean Programme, the Housekeeping Department also operates its own in-house HPV system (Hydrogen Peroxide Vapour). This is used, in both the Annual Scheduled programme and also used throughout the year, to support the eradication of Norovirus and Clostridium difficile. With a dedicated decant ward this has been a very successful programme this year.

46 Bed Cleaning Service In January 2014 the Housekeeping Department received Winter Pressure funding to implement a rapid response bed cleaning service. Upon patient discharge/move, a Housekeeper is immediately dispatched to a ward to clean all patient area equipment. The Bed Cleaning Service operates between 1200 hours and 2000 hours, and is delivering approximately 2,600 bed cleans a month. Since 10th March 2014 the response has been automated utilising the Teletracking System, and since 2nd March 2015 we can identify which beds have been cleaned. This service has been both successful and extremely wellreceived by Clinical teams. Initially funded for one year; in April 2015 recurrent funding for the service was agreed. Benefits Release of nursing time at ward level to improve patient care. Current data equates this to approximately 9 to 12 hours per day saved (based upon a 7 minute clean by ward staff). The bed, area and all equipment is cleaned thoroughly after each patient. Housekeeping staff are paid at Band 1. Feedback regarding the service has been excellent. Cleaning Strategy The strategy includes cleaning plans for RWT, Cannock Chase Hospital, West Park Hospital and all Community premises. Environment Audits The audit tool used for the Trust s Environmental audits has been revised to reflect the audit used by the Trust Development Authority. The Environment Audits of inpatient areas are conducted on a monthly basis by the Clinical Team and annually they are accompanied by IP, Estates and Hotel Service Managers. The audits are reviewed by the Clinical Leads, Infection Prevention and Hotel Services at the monthly Environment Group.

47 Estates, Projects and Facilities 2015 has been an exciting year for the Trust in terms of growth, new buildings, the development of new areas and refurbishment of existing areas. The past year has seen a strengthened collaborative working approach between Estates, Capital Projects, Hotel Services and Infection Prevention which has encouraged more integrated working relationships and improved outcomes. An Infection Prevention risk assessment is undertaken prior to commencement of Estates works, which ensures patient safety is paramount. This collaborative working demonstrates compliance with NICE Quality Standard 113, statement 4, and Health Building Note Infection Control in the Built Environment, which dictates that hospitals involve Infection Prevention and Control Teams in the building, refurbishment and maintenance of hospital facilities. The Trust has also implemented a more robust deep clean process for all clinical areas, involving using a decant facility to allow a thorough clean and decontamination using Hydrogen Peroxide Vapour (HPV).

48 This is primarily led by the Hotel Services Team, but again with a collaborative approach involving Infection Prevention and Estates. As part of the maintenance strategy, clinical areas also received Estates maintenance, repair works and redecoration as part of the deep clean schedule this year. Trust projects this year have included; the completion and opening of the Urgent and Emergency Care Centre, The development of the Eastside Café, new build of a Linac Centre, the creation of a Cystic Fibrosis outpatients department, refurbishment of delivery rooms, clean areas in Paediatrics, Medical Physics and the redesign of the clean utility areas on the Surgical Assessment Unit (SAU) on the New Cross site. At Cannock Chase Hospital we have opened a new purpose built Rheumatology/ Oncology unit The Davy Unit, the refurbishment of the previous catering department to a new modern catering area and two new ultra-clean operating theatres. Work is due for completion early April on a further enhanced recovery area on Hilton Main.

49 Education Summary Medical In addition to taking part in Trust and several Directorate induction and mandatory training events, the following formal post-graduate teaching has been given to RWT medical staff by the Medical Microbiologists: infection prevention; infectious diseases, including infections in the immunocompromised host; viral infections; antibiotics and antimicrobial prescribing and sepsis. The microbiologists also delivered a Grand Round in Antimicrobial Stewardship and the dangers of multi-resistant organisms to coincide with European Antibiotic Awareness Day. The following sessions have been delivered to Primary Care doctors in Wolverhampton and/or Cannock CCGs: C. difficile, antimicrobial prescribing, urinary tract infections and the investigation of sexually transmitted infections. Other teaching has included sessions for nursing staff on Carbapenemase Producing Enterobacteriaceae (CPE), antibiotics, new and emerging infections, Pharmacists on hepatitis and a wide variety of topics on the Biomedical Sciences MSc course at Wolverhampton University. Primary Care A training and recognition event was hosted for 85 GPs, Practice nurses and their staff by the Infection Prevention Team. The programme content was designed to support the implementation of the Health and Social Care Act (2010), and assist teams with the development of risk management approaches with regard to Health and Safety. The remainder of the programme included how to ensure GP premises provide a safe clean environment and also reviewed the standards for premises suitability for undertaking minor surgery. The Community Projects team maintained its links network with care homes across the city and very sheltered accommodation. The training sessions involved quarterly link nurse meetings, outbreak management training sessions over the winter period and supporting the CCG Care Home Managers Development Programme and West Midlands Care Home Managers Forum.

50 Education Summary Secondary Care A recurring annual programme for education is presented in order to inform and sustain Trust employee s knowledge of the importance of Infection Prevention (IP). Topics include; IP policy, standard infection prevention principles, Trust performance and provides information for emerging challenges. Induction to the organisation is supported monthly and for all new starters with additional support for overseas staff joining the organisation. A link practitioner programme meets during the year to share new initiatives and engage teams in development of infection prevention improvement and awareness of their responsibilities. Additional opportunities are taken to support education in clinical settings as they arise during outbreaks or following incidents of infection by dissemination of learning following audit and root cause analysis. Nursing Students Student nurses receive infection prevention education at the outset of clinical placements to inform them of the standards expected during care delivery whilst in RWT. Early engagement with students for key IP principles is important for their future career in healthcare. With this in mind for 2015/2016 all student nurses in year 2 are experiencing a short placement of two days with an experienced IPN. The objective is to provide a clear insight into the importance of infection prevention in their practice. The placement offers an alternative clinical perspective for the students working with a specialist practitioner, to highlight the impact clinical elements can have upon outcomes for patients. The IPT are core members of Clinical Practice Development Groups and the Trust Induction and Mandatory Training Group (IMTG) for Infection Prevention.

51 Education Summary Infection Prevention Team educational achievements Leanne Brand is a Clinical Nurse Specialist within the Intravenous Resource Team and won a 2015 Academy Award for her Positive Approach to Learning. This was in recognition of the positive approach Leanne had to the MLD & AEI programmes as well as her outstanding contributions to the programme through her open and honest approach to self-development. Rachel Edwards is a Healthcare Assistant within the Intravenous Resource Team and won a 2015 Academy Award for being an Excellent Advocate for Further Higher Education Having completed Health & Social Care level 3 and individual QCF units Rachael went on to commence her Health & Social Care Foundation Degree, which she is undertaking in her own time.

52 Education Summary Infection Prevention Team educational achievements Colin Brown is a Healthcare Assistant within the Intravenous Resource Team and won a 2014 Academy Award. Colin is the first HCA in the Trust to complete the Level 3 QCF unit Performing Intravenous Cannulation through Work Based Learning. He was committed enthusiastic and his work was of a high standard. He successfully achieved a national unit of accreditation with an awarding body, setting the standard thus encouraging other HCAs to follow his lead.

53 Surgical Site Infection Team (SSIS) The SSIS Team consists of: Band 7 IPN with responsibility to operationally manage the team 1.0 WTE Band 6 SSIS Nurse 2.5 WTE Band 3 SSIS Co-ordinators 1.0 WTE Band 2 administrative support The service currently follows up all patients following surgery at 30 days post operatively. All patients who have had surgery where an implant has been required are also followed up at 3, 6 and 12 months postoperatively. Surgical Site Infection Rate The Trust has been successfully collecting and reporting on data around SSIS since The Trust has a standardised approach to SSI data collection across our inpatient facilities and we currently undertake data collection for all knife to skin procedures 365 days a year. Most of our elective orthopaedic surgery, both major and day case is now undertaken at Cannock Chase Hospital; this expansion has seen the development of 2 new ultra-clean theatres allowing us to perform surgery across 7 theatres.

54 Intravenous Resource Team The IV Therapy Resource Team has been in place since August 2012 and has recently expanded following a successful business case to consist of 1.0WTE Band 7 Lead, 3.8WTE Band 6 Clinical Nurse Specialists (CNS s), 3.8WTE Band 3 HCA s and 0.6WTE clerical support. The Team continues to have the same three main deliverables long intravenous (IV) line insertion, facilitation of an Outpatient Parenteral Antimicrobial Therapy (OPAT) service and to lead in the reduction of Device Related Hospital Acquired Bacteraemias (DRHAB s) across the Trust. With the expansion of staff numbers, the team is to offer a seven day service from the spring of Long line insertion Over the past 12 months the team has inserted 2474 lines (as illustrated). This has enabled the provision of vascular access to complicated and frail patients as well as those needing long line insertions for long term IV antibiotics, chemotherapy and parenteral nutrition. The chart below displays indication for insertion. The two newest CNS recruits are currently being inducted and trained in the practical aspects of long line insertion, in order that they can support the service independently with the introduction of weekend cover. They will also enable increased support to West Park and Cannock Chase Hospital.

55 Outpatients Parenteral Antibiotic Therapy (OPAT) Service Patients identified by clinical teams across the Trust as being potentially able to be discharged into the community on intravenous antibiotics are assessed by the Team for suitability. The service works with a large number of community teams to achieve this, which enables patients to return home sooner and, on occasion, even to their work environment. Patients are monitored and reviewed at a weekly multidisciplinary team meeting virtual ward round, to ensure that their care remains properly governed regarding dose and duration of therapy. The number of patients discharged under this service has increased year by year as the graph below demonstrates. Over the coming year the service is focusing on Wolverhampton patients attending a daily clinic to receive their medication, as opposed to home based visits. This will further increase the efficiency and capacity of the service.

56 Device Related Hospital Acquired Bacteraemias (DRHAB s) The reduction in the incidence of DRHAB S is primarily important for patient safety, but also leads to reductions in the financial and service provision costs associated with their occurrence. Daily auditing continues and nursing clinical practices have been updated for those procedures with high infection risks, for example urinary catheter management and parenteral nutrition administration. Nurse education continues surrounding their insertion and maintenance. Over the past year there has been a total of 53 DRHAB s, the current low record - a huge reduction from the initial annual measurement of 140.

57 Antimicrobial Stewardship In November 2015, the Infection Prevention Team spearheaded a campaign for World Antibiotic Awareness Week. This took place from the 16th to 22nd November 2015 and covered the Royal Wolverhampton NHS Trust to include Cannock Hospital, West Park Hospital and the Phoenix Centre. The aim of the campaign was to raise awareness and promote the appropriate use of antibiotics and increase awareness and understanding of antibiotic resistance by engaging staff and the public. This was spilt into 3 clear messages which would target both the general public and staff members. These messages included antibiotic guardianship, antibiotic resistance and the launch of the Microbiology app for prescribers. The Campaign was organised by the Infection Prevention Team with the help of a Consultant Microbiologist and the Antimicrobial Pharmacist. The engagement of staff across the Trust was inspiring and enthusiasm to take the information back to their clinical areas was encouraging. Promotional strategies utilised included pop up stands in several areas across the Trust, with live pledging for guardianship, a visit and photo session with Dr Hans Clean, leaflets, gifts, pics on sticks, T-shirts with the guardianship logo, quiz, leaflets, videos were played on the totem poles, colouring in and balloons for the children. All activities were communicated through the Trusts twitter account and regular updates were placed on the desk tops, this received great feedback throughout the Trust and reinforced the message across all areas.

58 Antimicrobial Stewardship Antimicrobial Stewardship Group The Antimicrobial Stewardship Group (ASG) has expanded to include pharmacy representatives from both Primary Care and Public Health, to promote collaboration towards stewardship goals across the local healthcare economy. The group continues to meet every 2 months; there are regular reviews of antibiotic prescribing data, datix incidents relating to antimicrobials, audit findings and horizon scanning for new antimicrobials. RWT Antimicrobial Guidelines The Trust antimicrobial guidelines (adult and paediatric) are now available on the Microguide app which can be downloaded to mobile devices, so that prescribers have easy, immediate access to guidelines when prescribing. Within 5 months of the app being available, the guidelines were downloaded 441 times. The new format allows rapid update of guidelines and dissemination of changes to users.

59 Antimicrobial Stewardship Audit The Synbiotix audit system used for infection prevention audits has been adapted so that prescribers on each ward can audit the quality of antimicrobial prescribing on that ward. Despite communications by the Medical Director uptake of this audit has been variable across the trust, with some wards auditing monthly and other wards failing to submit an audit to date. Antimicrobial prescribing training at Induction Antimicrobial prescribing now has a dedicated slot within the induction programme; a package has been developed and is being delivered monthly at induction by the Consultant Microbiologists. ANTIBIOTIC RESISTANCE Antibiotic resistance happens when bacteria change and become resistant to the antibiotics used to treat the infections they cause. This is compromising our ability to treat infectious diseases and undermining many advances in medicine. We must handle antibiotics with care so they remain effective for as long as possible. WHAT HEALTH WORKERS CAN DO Prevent infections by ensuring your ü... ü... ü... ü... ü hands, instruments and environment are clean Keep your patients vaccinations up to date If you think a patient might need antibiotics, where possible, test to confirm and find out which one Only prescribe and dispense antibiotics when they are truly needed Prescribe and dispense the right antibiotic at the right dose for the right duration #AntibioticResistance

60 Antimicrobial Stewardship European Antibiotic Awareness Day The Infection Prevention Team provided significant support to ASG members in planning and implementing a week of information sharing and events to mark the November 2015 European antibiotic awareness day (EAAD). Events included: Ward walkarounds at all 3 Trust inpatient sites by team members wearing promotional T-shirts and providing written information on antibiotic resistance and the need to reduce inappropriate use; desktops that included reminders on the importance of documentation and risks of antibiotic overuse; and a stand at Greggs to engage staff and public, with the help of Dr Hans Clean. Following on from this a working group of ASG members including IP staff and representatives from public health and primary care has been set up to plan a co-ordinated event for EAAD in 2016, with a view to promoting a consistent message across the health economy and reducing costs by improving resource management. Following on from this a working group of ASG members including IP staff and representatives from public health and primary care has been set up to plan a co-ordinated event for EAAD in 2016, with a view to promoting a consistent message across the health economy and reducing costs by improving resource management.

61 Antimicrobial Stewardship Antibiotic use Antibiotic use across the trust continues to rise annually, with annual increases in use of broad-spectrum agents such as piperacillin-tazobactam and meropenem. Many factors are likely to be influencing this increase such as an aging population with rising co-morbidities, and efforts to improve sepsis outcomes by early treatment of patients with antimicrobial. Nationally the spectre of antimicrobial resistance means that there is a drive to reduce antimicrobial prescribing, including a national CQUIN for 2016/17 that demands reduction of total antimicrobial prescribing and prescribing of broad-spectrum agents. In June 2015 RWT submitted antibiotic usage data for the period April 2013-April 2014 to Public Health England. Total antibiotic usage data (defined daily dose per 100 admissions) was 419.7, only slightly less than the national average for England of Use of piperacillin-tazobactam in RWT was significantly higher than the national average (24.9 vs 12.7) as was carbapenem use (18.3 vs 10.0). These figures represent a challenge to RWT with regards to reduction of broad-spectrum antibiotic use to reduce the risk of antibiotic resistance.

62 Decontamination Structure The Trust has a new Decontamination Lead, who has responsibility for ensuring that a decontamination programme is implemented across New Cross Hospital, Cannock Chase Hospital and Community elements which take account of relevant national guidelines. As part of this role the lead has visited Decontamination areas across the Trust and more recently the Endoscopy Suite at Cannock Chase Hospital to gain assurance that appropriate decontamination procedures are in place since it becoming fully operational. The Endoscopy Suite at Cannock has been recognised externally as a fantastic facility and the service are now supporting other Provider units outside of Wolverhampton. The Trust has an established core group of individuals, including an authorised person (Decontamination) (AP (D) & Authorising Engineer (Decontamination) (AE (D) who continues to meet bi-monthly, who have key roles in ensuring that decontamination principles and practices are adhered to in line with the Choice Frameworks for Practice and Policy (shortly to be superseded HTM & 01-06). Incidents The Trust has had an ongoing issue with ripped and damaged wraps resulting in instruments/scopes not being used or having to be re-decontaminated. A series of trials have been undertaken in relation to the durability and finding a stronger and more tear resistant system. This has now been resolved with the introduction of using a 3 layer system. There has been a cardiopulmonary bypass machine water issue. As a result of this, the cardiothoracic theatre staff have undertaken extra cleaning and decontamination of the cardiopulmonary bypass machines to reduce the risk of contamination of the patient during surgery. The Trust is one of a number of centres that have identified Mycobacterium chimaera in the water - that is the reservoir for the heater cooler unit. This is a national issue and we have been involved with national teleconferences on the issue.

63 Performance - Total nonconformities from April January 2016 The main area of concern was ripped/damaged wraps, this is now showing a reduction since the introduction of the 3 layer system, with an expectation from February 2016, this will have dropped even further. Audit Annual Decontamination Audit In line with the current decontamination standards the annual audit has been checked by the AE (D) in December The Audit showed that the Trust to be compliant and with no concerns being highlighted. SYNERGY (Sterilising Service) The Trust continues to work with Synergy our Sterilising Service showing a continual reduction in the number of non-conformity reports, along with helping to resolve the ongoing issue with ripped and damaged wraps. Synergy has been working with key areas across the Trust in the roll out of their online access system called Synergytrak Portal. This gives users instant and direct access to the track and trace system used in Central Sterile Supply Department (CSSD), where they can search by item name and see where in the decontamination cycle the item(s) is, saving time phoning or visiting if items are not ready, or lets users know the items have already been dispatched.

64 Primary Care Report General Practice and NHS contracted dentists A Service Specification is in place between Wolverhampton City Clinical Commissioning Group (WCCCG) and Infection Prevention to deliver a comprehensive service to Primary Care contractors, which includes General Practice and NHS dentists. This service specification has been in place since 2011 and includes a variety of components which each contribute to providing the necessary assurance for both WCCCG and Infection Prevention, and includes: Audit Programme for General Practice and Dentists, with a detailed report and action plan and a 30 day time frame for return of the completed action plan. A General Practice audit tool which was reviewed and made more robust in 2014 and consists of a General Audit, a Minor Surgery Room Audit and a Practice Nurse Room Audit. Education and Training - A General Practitioner Recognition and Training Event took place in September 2015 with excellent attendance and positive feedback. Practices received certificates based on the 2014/2015 audit scores they achieved.

65 Summary of 2015/16 activity 51/61 practices across the City performs some elements of minor surgery. Forty one practices reached compliance scores of 90% or above for their Minor Surgery room standard. Overall scores have increased from the previous year s audit data. Support is being given to practices to meet the new specifications and Three support visits have been carried out throughout the year either in response to individual concerns or refurbishment plans. One practice was excluded from the programme due to major refurbishment work being undertaken but was visited to check on progression and infection prevention compliance. Thirty one Dental practices were requested to self-audit using a tool based on the Health Technical Memorandum audit. Those practices which required support or preferred the Infection Prevention team to carry out the audit were visited. Spot checks and support visits were carried out on Practices with low self-audit scores or requested by the Infection Prevention Team to carry out their audit. Two practices were audited and three Dental practices were supported with refurbishment or new build plans. The Infection Prevention service specification has been renewed for 2016/17 by Wolverhampton City Clinical Commissioning Group due to the continued success of the collaborative health economy approach to Infection Prevention.

66 GP Recognition Event Wolverhampton Clinical Commissioning Group Certificate of Recognition 10 th September 2015 This certificate is awarded to Name of practice Wolverhampton Clinical Commissioning Group Infection Prevention Training and Recognition Event for General Practice staff, including Practice Managers, clinical and non-clinical nursing staff For gaining the following awards: General Audit - Gold Minor surgery room - Silver Practice nurse room - Bronze When audited in 2014/2015 against the Infection Prevention Guidance for General Practice (Including Minor Surgical procedures undertaken in Primary Care (LES/DES) Manjeet Garcha Executive Director of Quality and Nursing Wolverhampton City Clinical Commissioning Group GP Dental Hospital Care Homes Product Evaluation Research Consultancy Infection prevention in partnership Donald Dobie Consultant Microbiologist Mi V0.1 Date: Thursday 10th September 2015 Time: pm Venue: Linden House, 211 Tettenhall Road, Wolverhampton, WV6 ODD. Certificates will be sent electronically after the event. CPD accreditation. Contact details: If you would like further information regarding this event, or wish to book please complete the booking form and return to: juliafreeman@nhs.net Sponsered by: For more information contact: Julia Freeman, Infection Prevention Practitioner, Royal Wolverhampton NHS Trust juliafreeman@nhs.net Tel: Mi V0.3

67 GP Recognition Event A General Practitioner Recognition and Training Event took place in September 2015 with excellent attendance and positive feedback. Gold % Silver % Bronze % The table below identifies the number of gold, silver and bronze awards awarded to General Practice at the recognition event on 10th September 2015: Audit Type Gold % Silver 91-96% Bronze 85-90% Not achieved minimum audit score to achieve General audit Minor Surgery audit Nurses room audit

68 PREVENT The Infection Prevention Team has continued the work across the health economy to reduce the MRSA carriage and support patients through the two week treatment for Clostridium difficile. Patients found to be MRSA positive from screens and samples taken whilst admitted to a Wolverhampton hospitals are followed up in the community to ensure decolonisation/treatment and rescreening is completed. Rescreening demonstrates that the success rate for decolonisation remains around 80%. Clostridium difficile infections sampled in the community are identified and appropriate treatment commenced at the earliest opportunity. Telephone contact is then maintained with the patient for a period to ensure the patient completes the treatment course and any reoccurrence of symptoms is treated without delay, which aims to improve the patient experience and outcomes. PREVENT Charter The project continues to support care homes through the Wolverhampton PREVENT Model, a triad of targeted MRSA screening, education training and auditing of key standards. Care Home MRSA screening has been targeted to include those homes with known longstanding or residents newly diagnosed. A total of 319 residents have been screened and only 5 new cases were found. All 5 residents accepted treatment and were rescreened and successfully decolonised. The seventh year of the PREVENT recognition awards has been completed. The care home audit tool is based upon the Health and Social Care Act (2015) and has incorporated some questions and elements of the Infection Prevention Society s care home audit tool. Infection Prevention has undertaken a full audit in all care homes this year following 2 years of care home self-auditing. Care homes with poor audit results have received revisits to ensure progress has been made.