Infection Prevention and Control Annual Report 1 st April st March 2014

Transcription

1 Infection Prevention and Control Annual Report 1 st April st March 2014 Produced by: The Director of Infection Prevention and Control Written by: Lead Nurse Infection Prevention & Control Reviewing the period: April March 2014 Approved by Infection Control Committee: July 2014 Received by Trust Board: July 2014

2 Table of Contents Section: Page: 1 Introduction 4 2 Infection Control Roles and Governance Structures Within the Trust 2.1 Corporate Responsibility 2.2 Infection Prevention and Control team and Members 2.3 Infection Control Committee 2.4 Internal Reporting Arrangements 2.5 Reports to the Executive Team and Trust Board 2.6 Risk Register Infection Control Resources Within the Trust 6 4 Infection Control in 2014/15: The Local Picture 4.1 Aseptic Non Touch Technique 4.2 Infection Prevention and Control Strategy Mandatory Surveillance During 2014/ Mandatory reporting Meticillin Resistant Staphylococcus aureus (MRSA) Meticillin Sensitive Staphylococcus aureus (MSSA) Surveillance of Clostridium difficile toxins Escherichia coli bacteraemia Surveillance Glycopeptide Resistant Enterococcal (GRE) bacteraemia 5.2 Other Resistant Bacteria 5.3 Surgical Site Infection Orthopaedic Caesarean Section The Infection Control Team: Other Core Activity During 2014/ Education and Training 6.2 Supporting and Working with Infection Control Link Staff 6.3 Implementation of the European Directive on Safer Sharps 6.4 Audit and Monitoring 6.5 Working with the Patients and Public 6.6 Working to Ensure Optimum Hospital Hygiene Cleaning and Catering Services 6.7 Sterile Services 6.8 Redesigning Environments and New Builds Endoscopy Infection Control Policy and Procedures Within the Trust 19 8 Outbreaks and Incidents at the Trust in 2014/ Pandemic Influenza 8.2 Gastroenteritis / Norovirus 8.3 Needlestick incidents and Prevention of Needlestick injuries 8.4 Legionella and Water Quality Monitoring Management of Antibiotics Prescribing at the Trust in 2014/ Safety and Quality in Infection Control: Statutory Duties 10.1 Care Quality Commission

3 11 Measures of Infection Prevention and Control: Shaping Practice to Improve Performance Looking Forward to 2014/ Conclusion Acronyms Appendix A : IP&C Policies Appendix B: IP&C Strategy Metrics 28-3

4 1 Introduction to the Report This is the annual report from the Director of Infection Prevention and Control (DIPC) providing information on infection prevention and control activity across the organisation. The purpose of this report is to provide detail to our patients, public, staff, Trust Board, Commissioners and Monitor on the infection control agenda for the previous year. This report covers the period from 1 st April st March 2014 and provides performance against national targets for: Meticillin Resistant Staphylococcus Aureus (MRSA) bacteraemia figures, Clostridium difficile Toxin (CDT) rates, Healthcare associated infections Other key activities and audit for the year. Infection prevention and control remains a key patient safety and quality focus for the organisation. This year was the first year NHS England set all MRSA bloodstream infections targets as nil, as they continue to pursue a zero tolerance approach to Health Care Associated Infections (HCAI). A zero target for MRSA, coupled with a significant reduction in the Clostridium difficile threshold, proved very challenging for the Trust at a time when there is greater scrutiny and challenge for reducing HCAI. Whilst the Trust did not achieve the MRSA bloodstream infection target, performance was sustained with only 1 case reported. Key achievements for 2013/14 include:. Clostridium difficile infections were reduced by 48% reporting only 12 cases from a threshold of 14 No ward closures due to confirmed/suspected Norovirus through the winter period, an achievement never seen before. 2 Infection Control Roles and Governance Structures Within the Trust 2.1 Corporate Responsibility The Hillingdon Hospitals NHS Foundation Trust maintains a full compliment of staff for infection prevention and control as required under the Health and Social Care Act. The Director Infection Prevention and Control (DIPC) is both an Executive member of the board and also the Director of Nursing and Patient Experience. The Trust has two Consultant Microbiologists, one of whom holds the position of infection control doctor and they continue to provide specialist advice and microbiology support on a 24hour basis. The specialist nursing team and antimicrobial pharmacist are available during office hours Monday to Friday. 2.2 Infection Prevention and Control (IPC) Team and Members In May 2013 the Trust appointed a new Director of Nursing and Patient Experience and as a result a new DIPC. Whilst this new appointment did not affect the specialist nursing team, it did bring to the organisation an experienced DIPC and returned the - 4

5 team to full strength with the return of the Deputy DIPC and Deputy Director of Nursing. Infection control team members consist of: 2.3 The Infection Control Committee The Infection Control Committee (ICC) report an overview of the infection control agenda and progress throughout the year to the Quality and Risk Committee (QRC). ICC is a key forum for the development and performance management of the infection control agenda across the organisation. The Committee meets bi monthly and is chaired by the DIPC with key representation from across the organisation. Membership includes the ICT, a number of senior management and senior nurses, the Occupational Health Department, clinical governance staff, Pharmacy, Estates and Facilities staff and external bodies such as the local Public Health England (PHE) Health Protection Unit and Hillingdon Community Health (HCH). A change in the NHS and consequently the community with the establishment of Clinical Commissioning Groups (CCGs) has seen the Infection Control Committee for HCH no longer exist. Whilst the Infection Control Nurses from HCH attend the Trusts ICC it is challenging to collaboratively drive forward the IP&C agenda across the health economy when there is no current ICC in the CCG. 2.4 Internal Reporting Arrangements New to 2013/14 is a Patient Safety and Quality Report submitted quarterly. This report includes key information on the Trusts quality and safety priorities reflecting the new Clinical Quality Strategy. Infection control includes performance against National objectives as well as progress on local trust initiatives and has been well received across the organisation. Infection Prevention and Control (IP&C) is also discussed monthly via divisional dashboards at the Divisional Reviews with the Executive Team. These divisional dashboards include HCAI data, overall IP&C performance and compliance to antimicrobial prescribing. - 5

6 2.5 Reports to the Executive Team and Trust Board The Infection Control Team provide a range of measures to The Board monthly which include cleaning scores, infection control audit results, compliance to restricted antimicrobial prescribing, MRSA screening and other initiatives. IP&C performance is also commented on in the monthly performance report so that direct feedback on post infection reviews or root cause analysis is provided to the board and any necessary actions. 2.6 Risk Register The Trust includes the risk of HCAI on the corporate risk register. The risk is updated and reviewed every 2 months at ICC, in order to reflect current priorities and activities; and is presented to QRC for discussion and scrutiny. 3 Infection Control Resources Within the Trust The ICT continues to have a budget that is predominately staff pay. The team does however continue to work closely with the procurement department to ensure the trust purchases quality products, that are fit for purpose and deliver value for money. In 2013 the ICT developed a business case to upgrade the current IT system ICNet to the newer version NG. As part of this process the ICT bid in round one of the Nursing Technology Fund (2013/14) to support this initiative. Whilst this was not successful the organisation is planning to bid in the second round in the Spring Infection Control in 2014/15: The Local Picture Some of the key activities over the past 12 months are outlined below: 4.1 Aseptic Non Touch Technique (ANTT) ANTT is now an established technique across the Trust and remains key in reducing intravenous (IV) related blood stream infections. Annual reassessments are undertaken in each division, supported by the ICT. Across the organisation ANTT was above 95% by the end of the year. The performance by division is demonstrated in the chart below: Divisional ANTT 2014 Competencies 100% 98% 99% 100% 95% 90% 85% 91% Medicine Surgery W&C CSS Medicine Surgery W&C CSS - 6

7 4.2 Infection Prevention and Control Strategy In the third and final year of the IP&C strategy the Trust successfully achieved a number of measures (refer Appendix B) Those not achieved fully have been included in the annual HCAI action plan and will form the basis of the new trust IP&C 3 year strategy, these included: C section surveillance Further improvement in Antimicrobial prescribing and stewardship 5 The Infection Control Team: Mandatory Surveillance During 2013/ Mandatory Reporting The Trust reports the following mandatory HCAI statistics to both the Trust Board and Public Health England (PHE) on a monthly basis. Meticillin Resistant Staphylococcus aureus (MRSA) bacteraemia Clostridium difficile infection Meticillin Sensitive Staphylococcus aureus (MSSA) bacteraemia Escherichia coli (E coli) bacteraemia The Trust follows guidance for HCAI associated deaths. Where MRSA or C.diff is included as a part 1A, 1B or 1C on a death certificate it is entered onto the Strategic Executive Information System (STEIS). Inclusion criteria in this data set are any incidents of C diff on the same ward if two or more cases were reported in one week or three in a month. A Root Cause Analysis (RCA) is undertaken on such cases and they are presented to ICC for monitoring and scrutiny of any arising actions. In 2013/14 there were 3 cases reported under this guidance as detailed below: Reason for STEIS report Number of cases MRSA on death certificate 2 C diff on death certificate 1 Two cases C diff on 1 ward in a week 0 Included in the above data is an MRSA case which was attributed to the CCG and died shortly after admission and the MRSA case which was attributed to the organisation sadly died. All of the above cases had root cause analysis (RCAs) - 7

8 5.1.1 Meticillin Resistant Staphylococcus aureus (MRSA) With the new NHS landscape and emergence of CCGs also came a change to the MRSA bloodstream infection objectives and methods of attributing cases to organisations. Any Trust reporting a positive MRSA blood stream infection will be expected to complete a Post Infection Review (PIR). The organisation for leading the case is responsible for completing a PIR within 1 week of the date of assignment (acute providers will be assigned the PIR for samples taken after the 1 st two days of admission and the CCG for those admitted septic.) The outcome of the PIR should establish the organisation to which the bacteraemia should be finally assigned. The final assignment will identify the organisation best placed to ensure that any lessons learned are acted upon. It was envisioned that with this new system there would be greater partnership working across the health economy. The variety of MRSA objectives was abolished for 2013/14 with a zero tolerance approach to MRSA bloodstream infections, therefore all organisations has a target of zero for the year. The following graph illustrates the MRSA bacteraemia reported by month for 2013/14; including those attributed to the CCG. The Trust reported one MRSA bacteraemia in May this was a complex case with the patient having multiple hospital admissions including treatment in a specialist unit at another acute Trust. The root cause analysis included both acute trusts and there was learning identified for both organisations, however under the current system cases could only be attributed to either the acute trust taking the specimen or the CCG. This case was therefore attributed to The Hillingdon Hospitals NHS Foundation Trust. Of the four cases attributed to the CCG three of these underwent an arbitration process. This involved the ICT from both the acute trust and CCG and Public Health England and this was facilitated by the Director of Public Health. The process looked at the PIR and evidence from both organisations to demonstrate that policies were followed and that patient safety was maintained and quality care delivered. After the review, cases were attributed to either the CCG or Trust by the Director of Public Health. In all three cases the Trust was able to demonstrate robust documentation and all were attributed to the CCG. - 8

9 MRSA bloodstream infections since 2003 Whilst the Trust was disappointed to not achieve the national target it did meet those set by Monitor and sustained performance. The Monitor framework states Where an NHS Foundation Trust has an annual MRSA objective of six cases or fewer (the de minimis limit) and has reported six cases or fewer in the year to date, the MRSA objective will not apply for the purposes of Monitor s Compliance Framework. MRSA screening remains an important part of the patient pathway and certainly provided evidence for the PIRs. Currently the Trust can only provide MRSA screening data based on the number of admissions, either emergency or elective against screening requests via our laboratory system Sunquest. In order to get an accurate picture of MRSA screening which is able to provide patient specific data the Trust would need to invest in the upgrade to the ICNet system as this would then be available at the touch of a button. MRSA screening for 2013/14 is detailed below: Group Activity Type YTD Pathology MRSA Screenings PAS Admissions Elective Screening Rate % 97.7% Pathology MRSA Screenings PAS Admissions Emergency Screening Rate % 92.8% Meticillin Sensitive Staphylococcus aureus (MSSA) The Department of Health have applied the same data definition previously attributing cases as per MRSA bacteraemia. There is currently no PIR process for these cases or national target so they are assigned by time from admission to specimen being taken. - 9

10 5.1.3 Surveillance of Clostridium difficile toxins The annual objective for C. difficile was significantly reduced from the previous year s number to just 14. This was a significant challenge for the organisation having finished 3 years with between cases. A case attributed to the acute organisation is defined as a case where the sample was taken on the fourth day or later of an admission to that trust (where the day of admission is day one). Following the previous year s root cause analysis the Trust was aware that a proportion of the positive cases were associated with inappropriate sampling. In order to improve clinical practice and provide more accurate information for teams on bowel management the ICT developed a new Bristol stool chart with the multidisciplinary team. This was successfully passed through the clinical records committee and is now used in clinical practice. 2013/14 demonstrated a significant reduction on previous year s numbers reporting 12 cases which was a 48% reduction. This met both national and monitor targets for the year. C diff cases for 2013/14 The chart below details the number of cases per month Escherichia coli (E coli) bacteraemia E. coli is a species of bacteria commonly found in the intestines of humans and animals. There are many different types of E. coli, and while some live in the intestine quite harmlessly, others may cause disease. - 10

11 There is no objective or target associated with this bacteramia and it is not included in London performance data. However E coli bacteraemia contribute to a high number of blood stream infections and the significant effect on both the patient and burden on the health economy should not be underestimanted. In total there were 149 E coli blood stream infections for 2013/14 with the siginifcant number of patients admitted with septicaemia. By using the same data definitions as MRSA and MSSA attributed cases, the Trust has reported the following cases as represented in the following graph Surveillance of Glycopeptide Resistant Enterococcal (GRE) Bacteraemia GRE are resistant to glycopeptides (antibiotics such as vancomycin) and have been nationally reported since During 2013/14 the Trust reported no cases, with the last reported case being in Although the incidence remains low the ICT will continue to monitor and report cases. 5.2 Other Resistant Bacteria Carbapenemase-producing Enterobacteriaeae The Trust has received both a letter from Public Health England and a Patient Safety Alert in relation to carbapenemase-producing Enterobacteriaceae and other carbapenem-resistant organisms. Enterobacteriaceae are a large family of bacteria that usually live harmlessly in the gut of all humans and animals, but, in the wrong place, can cause serious infections. Worldwide, a small but increasing number of strains of enterobacteriaceae have become resistant to carbapenem antibiotics, which have been defined by WHO as critically important antibiotics. Increasing trends in sporadic infections, clusters and outbreaks of carbapenemase-producing Enterobacteriaceae (CPE) have been observed in a number of NHS trusts in England. There is a high risk of this problem becoming more widespread unless early and decisive action is taken by Trusts as these bacteria represent a significant challenge in terms of prevention, treatment and control. In the UK, we have a window of opportunity to prevent widespread problems caused by these organisms. Whilst we are seeing increasing numbers of carbapenemaseproducing Enterobacteriaceae, we have not yet reached the escalated situation seen in other countries. New guidance on the management and detection of these resistant organisms has been produced and the Infection Prevention and Control Team are reviewing current - 11

12 policies and practice to ensure we meet these new recommendations. Crucial to these new guidelines is the ability to isolate a higher number of patients within the organisation. This is clearly a challenge for all trusts as isolation facilities are at a premium, and often risk based. If we are to fully implement the new guidance then in 2014 the ICT with the Trust will have to review the isolation facilities across the organisation and provide recommendations on how isolation facilities can be both improved and increased in number. 5.3 Surgical Site Infection Orthopaedic Surveillance of orthopaedic surgical site infection (SSI) is undertaken for both total hip replacements and repair of fractured neck of femur only. Whilst this meets our mandatory requirements for SSI the Trust would ideally like to extend this surveillance over additional surgical techniques. In the July - September 2013 submission period for total hip replacements and neck of femur the Trust saw an unusual peak in the number of surgical site infections. For this quarter the combined rates were 2% for hip replacement and 4.4% for repair neck of femur, with National data for hip replacement at 1.2% and neck of femur 1.7%. This resulted in the Trust being identified as an outlier by PHE, as we are outside national rates. In actual cases this represented four infections for neck of femur in one data collection period which triggered the orthopaedic and infection control team to review the cases. The increased incidence of cases was discussed at the divisional audit day and ICC in both January and March. Whilst initial investigation did not identify any immediate themes such as the same surgeon a more detailed case review was undertaken by the orthopaedic team. The Trust held a meeting with the wider multidisciplinary team focusing on surgical site infection, the report on the cases and to identify any further actions. In order to monitor the effectiveness of any change in practice the meeting agreed to currently take forward work on: Culture and behaviour within the theatre environment (including wearing of scrubs outside theatre areas) Maintenance of Normothermia- including pre, intra and post operative rewarming Skin decolonisation / washes prior to surgery Dressing changes on non orthopaedic specialist wards. Since 2013 the Trust has been reviewing the operating theatre environment and has a planned programme of works which includes re-commissioning of the theatres. Work on one orthopaedic theatre has been completed and the second orthopaedic theatre has planned maintenance in May 2014, with the remaining theatres to follow. Water testing for Pseudomonas aeruginosa was commenced in October 2013, as this is national guidance for critical care areas where patients are either immunocompromised or whose defences may have been breached ie: surgery. This will be undertaken as per guidance every 6 months. The Trust did identify taps which were positive and remedial work with re-testing was undertaken. - 12

13 It should be noted that we did not report any SSIs in neck of femur for the following two periods of surveillance but the increase in cases for July-September has clearly affected the combined 4 month data. There is only a small number of total hip replacements carried out at the Hillingdon site. The majority of cases, as they are elective are undertaken at Mount Vernon however patients with a Body Mass Index (BMI) over 40, ASA* 3 or 4 or require ITU admission are done at the Hillingdon site. The one reported case for July-September was very complex with a number of co-morbidities and high risk factors. PHE have responded to a recent communication from the Trust that they would note that only high risk cases are done at the Hillingdon site. (*The ASA score is a subjective assessment of a patient's overall health that is based on five classes (I to 5). 1 is patient has severe systemic disease that is not incapacitating to 5 Patient has incapacitating disease that is a constant threat to life.) The Trust is taking seriously this increased incidence and in collaboration with the Infection Control Team, there is a current business case to upgrade ICNet to the NG version and include the SSI module. This upgrade would enable real time monitoring and greater ownership by the clinicians involved. Our strategy, risk register and HCAI action plan all identify the need to expand SSI surveillance and for surgeons to have the ability to analyse and own their own data in order to understand patient outcomes and drive safer, quality care. Work on reducing surgical site infection is a priority for 2014/15. Surgical site infections are estimated to account for 15 per cent of all hospitalacquired infections and affect around 5 per cent of all patients undergoing a surgical procedure. (PHE 2012) Monitoring of surgical site infections is complicated; while many occur during hospitalisation, the majority manifest only after discharge, a phenomenon that has increased as hospitals have sought to reduce the length of inpatient stays. In these instances, the infection is often managed in primary care and is only recognised by the host institution if the patient is readmitted and these cases are typically not captured in monitoring/surveillance studies due to the manual nature limiting scope of surveillance. SSI data for 2013/14 is reflected in the table below Trust Procedure Number of Number of % SSI National data Site cases cases with SSI MVH Total hip % 1.2% replacement THH Neck of femur % 1.7% fracture THH Total hip replacement % 1.2% Caesarean section Recent studies have shown that C-section infection could be as high as 9.6% nationally in recent studies. The ICT have been working closely with the women and children s division in order to establish a C-section surveillance system as currently - 13

14 the Trust does not have robust knowledge of current infection rates. With birth rates increasing and patient choice we need to be able to monitor rates in order to drive reductions, therefore encouraging more patients to choose the organisation. A data collection sheet has been agreed with the division but there remain challenges around receipt of completed data. A recent change in something as simple as the colour of the data collection form has seen a significant increase in the number of returns to the ICT office. In quarter 1 of 2014 it is anticipated that the Trust will have some robust data to analyse. 6 The Infection Control Team: Other Core Activity during 2013/14 The ICT remains focussed on patient safety, reductions in HCAI and that no person is harmed by a preventable infection. The team appreciate the focus and commitment from the members of staff across the organisation, including the Trust Board in ensuring they deliver safe quality care in a clean and suitable environment. 6.1 Education and Training The ICT continue to deliver IP&C training to all members of staff across the organisation; this training varies from regular formal sessions to individual bespoke delivery at a ward or department level saw a completely new approach for statutory and mandatory training across the organisation. Instrumental to these changes was the move to ensure that the organisation followed the core skills training framework outcomes for subject matters and included in this were refresher periods. The ICT had undertaken a risk based approach in previous years, establishing 3 levels of training. This new system has clinical and non-clinical staff only with refresher periods moving from every 2-3 years for clinical staff to annual and for non- clinical staff from once to every 3 years. The ICT worked closely with the STaM training advisory group as subject matter experts (SME) in IP&C. Concern was raised by the ICT at the time that current training, which was over 80% across the organisation, would drop significantly and measures would need to be in place to deliver extra-ordinary sessions. The Trust announced in January the new move for STaM training with details of the new fresher periods. An amnesty period from February to March was announced with a significant amount of additional sessions provided by SMEs. Linked to this transition was the movement of the current reporting for STaM to a new system as well as linking training records to ESR. Up to January 2014 the Trust was over 80% compliant in all levels of IP&C training. Data for January and February was not reported due to the amnesty, additional staff trained during this period is detailed below: Training Number of Staff attended Non-clinical 76 Clinical

15 6.2 Supporting and Working with Infection Control Link Staff Link nurses from wards and departments have a pivotal role as the member of the team in order to drive forward the IP&C agenda. Each clinical area has a named link nurse and in some departments and wards there are two members of staff who support each other in this role. The ICT held one link nurse study day in 2013 with representation from a number of specialist staff. A key item on this agenda was work around waste management. The Trust had just introduced new waste streams and it was essential that staff were clear on the use of the new offensive and alternative waste streams including new hard burn bins. 6.3 Implementation of the European Directive on Safer Sharps July 2013 saw the introduction of new safety engineered devices and a week of raised awareness on sharps, reporting and reducing risk. Educational stands were held in both the main entrance and staff canteen, where representatives from the new companies demonstrated their new products and were supported by the ICT, Health and Safety Team and Occupational Health. The new products had a staged roll out supervised by the procurement team and supported with ward/departmental training by the company representatives. The introduction of the new devices went smoothly as these products had been trialled in key clinical areas prior to final approval. Further work continued throughout the rest of the year with attention on risk assessments for those devices where safety engineered products are not availanble or practical. 6.4 Audit & Monitoring The Trust and ICT currently use the Meridian (Optimum) system to support audit and monitoring across the organisation. This system which is principally used for patient experience data, is also used for some IP&C audits but cannot be used for all measures due to limitations in the system. Currently the system is used for hand hygiene, VIP, Bare Below Elbows by the ward staff and for linen and isolation by the ICT. The Meridian system is due for contract review at the end of the year and the ICT is working closely with the audit department to ensure that the system is suitable for all of its users and provides appropriate data and reports for the organisation. The current audits & monitoring for IP&C in 2013/14 are detailed below: Compliance with Hand Hygiene policy (monthly) Compliance with Bare Below Elbows policy (monthly) Compliance with Isolation policy (annually) Compliance with Restricted Antibiotic Prescribing policy (quarterly) Compliance with Linen policy (annually) High Impact Intervention 1 Central Venous Catheter care (monthly) High Impact intervention 2 Peripheral Line Care (monthly) High Impact Intervention 4 Preventing Surgical site infection (bi annually) - 15

16 High Impact Intervention 5 Ventilator Care (monthly) High Impact Intervention 6 Urinary catheter care (monthly) High Impact Intervention 7 Clostridium difficile care bundle (monthly) High Impact Intervention 8 Cleaning and decontamination of clinical equipment (bi-weekly) 6.5 Working with the Patients and Public The Fighting Infection Together (FIT) is a public group that was established a number of years ago. This longstanding group is one of a kind with people passionate about infection prevention and the Trust as a whole. They provide a valuable interface, with a critical eye between the public, staff and the ICT. In addition to the support on infection control stands, producing and reading IP&C leaflets and general awareness raising, they provided significant support in the Trusts new hand hygiene products. In November 2013 after trials of new products the ICT with the FIT group and procurement department approved the move from our previous supply to our new supply Deb-cutan. This new product provided both a foam sanitiser and soap that was gentle to hands as well as outstanding product support with posters and our new bus stop signs. The new hand hygiene signage is clear, concise and eye catching with sanitiser signs in red throughout the organisation. New sanitiser signs in the main entrance 2013: 6.6 Working to Ensure Optimum Hospital Hygiene The Trust has undertaken a significant investment in order to ensure that we provide a clean, safe, suitable environment for our patients, staff, visitors and the organisation Cleaning & Catering services PLACE The new PLACE process has replaced the long standing PEAT (Patient Environment Access Team) process in It has been introduced to both revitalise the assessment of the patient environment process but also, more importantly, to ensure that there is a greater focus on patient involvement in the process. PLACE covers broadly the same areas as PEAT namely privacy and dignity, wellbeing, food, cleanliness and general maintenance of buildings and facilities. It focuses entirely on the care environment and does not stray into clinical care - 16

17 provision or staff behaviours. It extends only to areas accessible to patients and the public (for example, wards, departments and common areas) and does not include staff areas, operating theatres, main kitchens or laboratories. In the past, all NHS providers have undertaken PEAT inspections and in the same way, PLACE will continue to provide an invaluable resource in assessing the care environment. This will directly support the provision of a high quality service to patients. The key feature of PLACE is the central role of patients in carrying out the assessments. At least 50 per cent of the team must be patients, and local Healthwatch must be offered the opportunity to be involved. Recruiting and training patient assessors is carried out locally and there is criteria outlining who is eligible and who is not available to become a patient assessor. The PLACE assessments took place at Hillingdon and Mount Vernon in April 2013 and involved patient and staff assessors including representatives from Facilities, Infection Control, Nursing and Estates. The four days of assessments covered wards, Minor Injuries Unit, Accident and Emergency, outpatients, internal pubic areas and grounds and buildings and generated almost 400 pages of assessment score sheets. The assessment scores covered the key areas of hygiene and cleanliness; condition, maintenance and appearance; privacy, dignity and wellbeing; and food and hydration. The results were published nationally in September 2013 with the Trust disappointed to be below national average for cleanliness; privacy, dignity and wellbeing; and condition and appearance at the Hillingdon site. Mount Vernon was above the national average in all of the key domains. On the plus side the Trust s food and hydration scores were above the national average. In 2013 the results were used to develop an Improvement Plan, which focused on the recurrent themes across the organisation that led to possible failure to meet the required standard or a qualified pass. This has resulted in a considerable amount of work that led to reception changes, new signage, new patient and waiting area chairs, new patient wheelchairs, an increased focus on cleanliness and hygiene and maintenance improvements. Domain/Score Hillingdon % Score Mount Vernon % Score - 17 HH/MVH % Combined Score National Average % Score Cleanliness Privacy, dignity & wellbeing Condition, appearance and maintenance Food & Hydration

18 Cleaning & Catering In August 2013 all cleaning and housekeeping rosters were reviewed and changed to ensure that they better met the size and infection control risk of an area, the work taking place there and the throughput. This led to many clinical areas receiving increased cleaning inputs and achieved savings through better productivity and utilisation of staff. The team engaged an external cleaning consultant to work with the team on cleaning processes, equipment and training. Working with infection control and nursing, for example, the cleaning team changed the processes and structure for cleaning outpatient areas to improve the standards. There were considerable catering service developments for both patient dining and retail services during the year with a new patient and retail kitchen being installed and new patient menus being introduced as well as a new HACCP manual developed to underpin food handling and safety. An internal audit was undertaken by TIAA to determine whether management had implemented adequate and effective operational and management controls over the Catering and Cleaning function. The audit included focus on: Policy and procedures to ensure the Trust s catering and cleaning services meet all applicable regulations and standards for NHS catering and cleaning services (Trust has identified standards and regulations for compliance; policies and procedure are in place; training is provided; cleaning arrangements are in place). And that Trust s catering and cleaning service complies with the requirements of CQC related standards (arrangements/action plans in place to ensure compliance). Overall the audit provided substantial assurance against the objectives. Linen The London procurement program with facilities led the work to tender the linen and sterile theatre packs contract in The infection control team played a crucial role in the tender assessment process participating in the tender assessment group to review the quality of linen and cleaning processes. Unfortunately the process in late 2013 needed to be repeated, from a contractual point of view, and this will take place in April and May Sterile Services The sterile services contract with IHSS continues to provide a good service to the organisation and is closely monitored by the facilities team in partnership with clinical services. Performance remains high on equipment turnaround times, which is encouraging as 2013 saw a number of additional trusts utilising the company and it is essential that standards are maintained. 6.8 Redesigning Environments and New Builds The ICT continue to work closely with the project team to ensure that the new designs and builds are fit for purpose, meet the Health Technical Guidance and provide a safe, clean environment. The new plans for 2013 included: - 18

19 Redesign and upgrade of the delivery suites in maternity New kitchen and catering facilities Beaconsfield East dementia ward refurbishment Redesign and commissioning of the urgent care centre Re commissioning of orthopaedic theatre 1, including duct cleaning, recommissioning of the specialist airflow system and purchase of specialist ventilation for the prep room Endoscopy The Trust successfully redesigned and opened a new endoscopy unit at Mount Vernon. This new unit provides a spacious dedicated endoscopy unit with associated decontamination facilities. This new unit is the culmination of a number of years work to ensure the organisation s decontamination facilities meet Department of Health guidelines and provide a suitable environment for both patients and staff. The Hillingdon Hospital Endoscopy Unit will be completed as part of the new emergency admission unit on the ground floor in 2014/15. 7 Infection Control Policy and Procedure Within the Trust Infection Prevention and Control Policies are reviewed every three years or in light of new best practice or guidance. There are 28 policies found under the Policy Management Information System (PMiS) for infection control, which can be found in Appendix A. All policies now follow the Trust permitted format and are approved at the Infection Control Committee then ratified at the Clinical Governance Committee. 8 Outbreaks and Incidents at the Trust in 2013/ Pandemic Influenza The Pandemic Influenza Operational Policy is reviewed annually in preparation for the winter season by the ICT and links with the Trusts winter preparations and planning. This operational policy remains a flexible document that not only enables the Trust to react to a potential new pandemic but is also to respond to an increase in demand due to seasonal influenza activity or other possible increases in capacity due to either a Severe Acute Respiratory Syndrome (SARS) or the newer Middle East Respiratory Syndrome (MERS-CoV). An increase in influenza activity was not evident over the winter period, with relatively few confirmed flu patients admitted to the organisation. The Trust did however have a few suspected MERS-CoV patients admitted to the organisation in November This new respiratory syndrome is associated with travellers and residents from the Middle East. This year it was evident that with the high numbers of travellers returning from Hajj, the Trust could see potential admissions with suspected influenza or MERS-CoV. 8.2 Gastroenteritis/Norovirus Norovirus is always a particular challenge for organisations especially over the busy winter period. This virus is spread easily from one person to another and is highly infectious in nature. Whilst Norovirus activity remained high in the community setting - 19

20 and other organisations had wards closed for the first time in years the Trust did not close one ward or bay over winter due to confirmed/suspected Norovirus. Seasonal activity was lower in comparison to previous years as can be seen in the following chart from PHE. However the Trust still admitted cases with diarrhoea and vomiting and successfully managed them in side rooms without impact on the organisation. Possible contributing factors to the success of this year s management were: Recent change of Hand Hygiene product and awareness leading to greater compliance New pull up banners in the main entrances highlighting Norovirus A&E undertook a risk assessment for inpatients to identify those patients currently not symptomatic but had been in household/ contact with relative with known diarrhoea and vomiting, these patients were isolated as a precaution. 8.3 Needlestick Incidents and Prevention of Needlestick Injuries Occupational Health received 76 reports of needle stick injury for 2013/14, which is three more than the previous year. It was noted that there was a significant rise in reported needlestick injuries in July with 16 cases, compared with the usual 4-8 per month. This rise coincided with the month where the Trust had sharps awareness week and is possibly due to the promotion of reporting. Certainly towards the end of the year injuries from intravenous cannulae has significantly dropped due to the introduction of the safety engineered device. 8.4 Legionella & Water Quality Monitoring Legionella bacteria, which cause legionellosis, is an uncommon form of pneumonia and the majority of cases are reported as single (isolated) cases but outbreaks can and have occurred. Our duties, as an organisation, are provided in the approved Code of Practice and guidance Legionnaires' disease: The control of legionella bacteria in water systems (L8). This contains practical guidance on how to manage and control the risks in your system. Control and prevention of the disease is through treatment of the source of the infection, i.e. by treating the contaminated water systems, and good design and maintenance to prevent growth in the first place. The Trust continues to take this responsibility very seriously and is aware of the risks inherent in a multi building site with a number of older facilities. The Trust has a - 20

21 Water Quality group which meets regularly throughout the year monitoring Trust performance for both Legionella and Pseudomonas. In February 2014 the Trust tested a number of outlets as part of re-commissioning of units back into general use following work or upgrades. A number of these outlets had positive counts and as a result were chlorinated and a revised system put in place to ensure that outlets under construction are tested and flushed just prior to handover. Testing for Pseudomonas aeruginosa P. aeruginosa is a Gram-negative bacterium, commonly found in wet or moist environments. It is commonly associated with disease in humans with the potential to cause infections in almost any organ or tissue, especially in patients compromised by underlying disease, age or immune deficiency or whose defences have been breached (for example, via a surgical site, tracheostomy or indwelling medical device such as a vascular catheter). In most cases, colonisation will precede infection. Some colonised patients will remain well but can act as sources for colonisation and infection of other patients. Its significance as a pathogen is exacerbated by its resistance to antibiotics, virulence factors and its ability to adapt to a wide range of environments. Contaminated water in a hospital setting can transmit P. aeruginosa to patients through the following ways: direct contact with the water through: ingesting bathing contact with mucous membranes or surgical site, or through splashing from water outlets or basins (where the flow from the outlet causes splashback from the surface); inhalation of aerosols from respiratory equipment, devices that produce an aerosol or open suctioning of wound irrigations; medical devices/equipment rinsed with contaminated water; indirect contact via healthcare workers hands following washing hands in contaminated water, from surfaces contaminated with water or from contaminated equipment such as reusable wash-bowls. The Trust has identified areas across the organisation for testing of P. aeruginosa and include ITU, NNU, Bevan and Theatres. In September 2013 the theatre complex at Hillingdon was tested for P. aeruginosa and some water outlets came back positive. As per guidance these outlets are taken out of use, remedial work is undertaken and then retesting of the water supply is undertaken. Only after a number of tests can the outlet be placed back in use. Unfortunately during routine testing for theatres one of the positive outlets was incorrectly labelled. This led to an incident of concern being raised and investigated by the Trust to ensure that patients and staff were protected. All testing was undertaken as per guidance with retesting in order to ensure results of <1 cfu/100ml. No patients in the two weeks following the incident isolated Pseudomonas species. The direct cause of the incident was attributed to human error exacerbated by a number of additional factors detailed in the report. In order to prevent a similar incident occurring the report recommended a number of actions which were - 21

22 contained in a Pseudomonas action plan, a new Standard Operating Procedure and signage was put into effect immediately. 9 Management of Antibiotic Prescribing at the Trust in 2013/14 The scale of the threat of Anti-Microbial Resistance (AMR) and the case for action was set out in the Annual Report of the Chief Medical Officer published in March The UK Five Year Antimicrobial Resistance Strategy set out actions to address the key challenges to AMR. The overarching goal of the strategy is to slow the development and spread of AMR. It focuses activities around three strategic aims; improve the knowledge and understanding of AMR, conserve and steward the effectiveness of existing treatments, stimulate the development of new antibiotics, diagnostics and novel therapies. Antimicrobial prescribing & stewardship (APS) competencies have been developed by The Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) and PHE; the goal is to improve the quality of antimicrobial treatment and stewardship and so reduce the risk of inadequate, inappropriate and ill effect of treatment. The aim is to improve the safety and quality of patient care, as well as contributing significantly to the reduction in the emergence and spread of antimicrobial resistance This year the Trust Antimicrobial Stewardship Group (ASG) started looking at Datix incidents related to antimicrobials, it continues to monitor spending on antimicrobials as well as Defined Daily Dosing (DDD)/1000 bed day report on selected restricted antibiotics. Ward pharmacists continue to report restricted antibiotic use to the antibiotic pharmacist, these are all reviewed by both the antibiotic pharmacist and the consultant microbiologists with the average number of reported prescriptions as 184/month The annual surgical prophylaxis audit which was completed in February 2014, showed that 78% of patients were given antibiotics as recommended in Surgical Prophylaxis Guideline. When looking at the timing of administration, in 88% of cases the correct surgical prophylaxis antibiotic was given at the correct time, this is an improvement from the 2012 audit. The Start Smart then Focus guidance and its subsequent action plan continue to be developed. The audit programme for antibiotic compliance has recently changed from monthly to quarterly. The frequency has been changed in collaboration with the clinical audit department and ensures that with the new quarterly data an action plan from divisions will be required to address low compliance. A recent meeting with the ADOs, NSMs and CDs strengthened the focus on antimicrobial prescribing with a commitment from specialties to undertake their own audits using a Trust template. This will provide data specific to the specialty in order to drive performance. The Trust Continues to take part in the European Antimicrobial Awareness day on 18 th November of each year - 22

23 10 Safety and Quality In Infection Control: Statutory Duties & External Visits The Trust has an established assurance framework for IP&C as the safety of patients and staff, and quality care is a key consideration for all organisations. The Health and Social Care Act 2008 clearly reflects our duties and provides a collection of systems, processes and procedures in order to define the risks to achieve high quality care Care Quality Commission The Trust was inspected by the CQC over a number of days from 4 th -7 th October For Cleanliness and Infection Control the regulated outcome stipulates that; People should be cared for in a clean environment and protected from the risk of infection. The outcome of the inspection was reported by the CQC as the following: Whilst the trust had many positive infection control indicators and audits showed a low level of infection, we found a number of instances where the risks of the spread of infection were increased. We have judged that this has a minor impact on people who use the service, and have told the provider to take action. The provider was not meeting this standard The Trust was disappointed with the decision by the CQC which was based on: Isolation doors not shut on all occasions The use of a cordless phone-on one of the wards Lack of knowledge amongst clinical staff on curtain changes Cleaning of equipment Damaged flooring/ condition of the building As a result the Infection Control Team revised the current audit programme within the organisation following the inspection. A new quick question assessment (QQA) tool was devised using elements from the inspection such as correct use of personal protective equipment, isolation standards and inspection of equipment in the clinical area. This was then assessed twice a month and findings reported at both divisional and Board level. The Trust will continue to audit mattresses annually as well as adhoc inspections by staff to ensure damaged items are replaced. The Estates and Facilities team have a robust programme of audit for cleaning of the Trust and the supervising staff have all been given details of areas in which to pay particular attention ie: high level dusting. There is an existing PLACE improvement group which includes any Estates issues that require rectification eg: damage to floors, and this has already been identified and a report produced. There are a number of financial implications for the organisation in particular the maintenance of the Estate and repairs to the existing floors. A full report with costing on such repairs has been produced since the inspection. - 23