Approval Discussion Information Assurance

Transcription

1 Report Title: Executive/NED Lead: Report author(s): Previously considered by: Board of Directors 27 February 2018 Annual Infection Prevention and Control Report Catherine Morgan - Director of Nursing Dr R A Elston Consultant Microbiologist Director of Infection Prevention and Control CHUFT Hospital Infection Control Committee Approval Discussion Information Assurance Executive summary Annual report of Director of Infection Prevention and Control using the template as supported by the Health and Social Care Act Action Required of the Board of Directors To approve Link to Strategic Objectives (SO) SO1 SO2 SO3 Acting in the best interests of every patient every day Supporting our Workforce to look after every patient, every day Achieving financial sustainability and organisational resilience Risk Implications for the Trust (including any clinical and financial consequences) Trust Risk Appetite To deliver care in the right place at the right time in line with national best practice To ensure a positive patient experience at every contact by providing safe, effective, kind and compassionate care To achieve sustainable quality improvements in the delivery of care To deliver a positive patient-centred culture of great care for patients To engage, support and develop staff to achieve their potential To train and support all staff to take personal responsibility and accountability for their actions and the actions of others to drive organisational success To develop constructive relationships with partner organisations to deliver sustainable and effective care for patients To deliver consistently and sustainably against national and local priorities To maximise value for money in delivering healthcare in our locality Choose an item. Please tick Legal and regulatory implications (including links to CQC outcomes, Monitor, inspections, audits, etc) Financial Implications Compliance with Health & Social Care Act 2008 (2015) Hygiene Code Equality and Diversity Click here to enter text

2 DIRECTOR OF INFECTION PREVENTION AND CONTROL ANNUAL REPORT APRIL MARCH 2017 Page 2 of 37

3 CONTENTS 1. Executive summary 3 Overview of Infection Prevention and Control activities in the Trust 1.1 Key achievements On-going work 4 2. Description of Infection Prevention and Control Infection Prevention and Control Team Arrangements Infection Prevention and Control Team Activities Infection Prevention and Control Enquiries Hospital Infection Control Committee Organisational structure and reporting line to the Trust Board 9 3. DIPC reports to the Trust Board Summary Number and Frequency Outbreak Reports Carbapenem-resistant Organisms (CRO) Estates and Planning Water Safety Management Budget Allocation to Infection Prevention and Control Activities Annual Budget Project Allocation Training requirements for the Team in the coming year Training requirements within IP&C Team Personal Development Plans HCAI Statistics Clostridium difficile Staphylococcus aureus MRSA bacteraemia Meticillin Sensitive Staphylococcus Aureus (MSSA) Carbapenemase Resistant Organisms (CROs) Escherichia coli (E coli) blood stream infections ICNet Surveillance System Surgical Site Infection Surveillance (SSIs) th UK and European Healthcare Associate Infection and Antimicrobial 20 Study 5.10 CHUFT Blood Culture Contamination Rates Jan Mar Hand Hygiene Cleaning Services Management arrangements Cleaning Schedules Monitoring arrangements NPSA Audit Results IP&C Decontamination Audit 27 Audit programme and outcomes Targets and Outcomes 28 Policies updated in 2016/ Antibiotic Team Report Training Activities 32 Induction for all staff 32 E-learning 32 Link Nurses 32 General 32 Page 3 of 37

4 13. Infection Prevention and Control Programme for 2017/ EXECUTIVE SUMMARY Overview of Infection Prevention and Control Activities in the Trust This has been another challenging year for Colchester Hospital University Foundation NHS Trust (the Trust) as it continued to operate under Special Measures. This was compounded by staffing difficulties in clinical areas and problems in maintaining the flow of emergency patients through the hospital. Overall I can report that the incidence of Health Care Acquired Infections (HCAI) remained low; the Trust had fewer cases of Clostridium difficile (C.difficile) than expected in its nationally set objective. The main focus of infection prevention and control activity was to continue the good work already established in maintaining the low levels of Clostridium difficile and MRSA colonisation acquired within the hospitals of the Trust in the face of staffing issues throughout the hospital and within the Infection Prevention and Control team. We continued to use the Saving Lives High Impact Interventions and Hand Hygiene rates to monitor good infection prevention practice. These results were reported monthly to the board through a board sub-committee. The results are also discussed at local divisional governance groups and the Hospital Infection Control Committee. The Antibiotic Management Team continued to review antibiotic guidelines and audit their use. European Antibiotic Awareness Day (18 November) the team ran a travelling educational stall through the main hospital site visiting most of the wards. The team were successful in achieving part of the antimicrobial prescribing CQUIN s offered to trusts in this financial year (100% of antimicrobial prescriptions reviewed at 72 hours). The guidance around the reporting and performance management of Clostridium difficile cases changed for this year. The total number of cases continued to be reported and only those in which there were breaches in policy were subject to performance management terms. Our objective for the latter group was 18 cases. As in previous years all cases were followed up with an internal investigation and discussion at the North Essex HCAI Scrutiny Panel. Part of this process included a judgement as to whether any of the cases could have been managed better and thus possibly prevented; were there breaches of policy or not? There were 35 cases of hospital attributed Clostridium difficile disease; only nine of these were associated with one or more breaches of major policy, the other 26 cases received care with no breaches in policy. Of the nine cases five were associated with a period of poor environmental cleaning on one ward, an issue that was addressed through the remainder of the year. There were two cases of MRSA bacteraemia attributable to the hospital during the year. Both were discussed with commissioning colleagues at a Post Infection Review. In one case there were minor suggestions as to how better care could have been provided but there were no breaches of major policy. The other was considered to be a consequence of contamination of blood cultures taken on admission to hospital. The Trust participated in the 5 th Health Care Associated Infection Point Prevalence Study, a national study co-ordinated by the DH and Hospital Infection Society. Preliminary results show that overall 7% of patients in hospital in the UK had a healthcare associated infection. For Trust patients, this figure was 4.85%. Page 4 of 37

5 The Infection Prevention and Control Team (IP&CT) held another successful annual conference for local healthcare staff (doctors, nurses, healthcare scientists) with 68 delegates attending. 1.1 Key achievements Performance generally low levels of C difficile Governance evidence that Saving Lives and Hand Hygiene data is discussed and acted upon at divisional and departmental level. Infection Prevention and Control policies and guidelines - Updated CRO (Carbapenemase Resistant Organisms) policy all other standard IP&C policies current Integrated computerised surveillance system system has been introduced to generate clinical reports Annual Mandatory updates for all staff the uptake continues to increase year on year 91.3% as at March National Studies- participated in the 5 th HCAI Prevalence Study October On-going work To continue the trend of minimal number of patients with MRSA and Clostridium difficile. To introduce improved management of peripheral IV devices. To reduce the number of urinary catheterisations in the Trust To continue to participate in the development of the catheter passport To collect and continue to report data on bacteraemia caused by a sensitive ordinary Staph aureus (MSSA) and Escherichia coli to PHE Klebsiella spp. and Pseudomonas aeruginosa to the HCAI Data Capture System (DCS) since April This is to support the government initiative to reduce Gram-negative bloodstream infections by 50% by financial year 2020/21. Governance to continue to embed IP&C throughout the organisation working closely with Clinical Leads Mandatory bi-annual updates for all Trust Staff Dr Tony Elston Director of Infection Prevention and Control/- Consultant Microbiologist and Infection Control Doctor Page 5 of 37

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7 2. DESCRIPTION OF INFECTION PREVENTION AND CONTROL 2.1 Team Arrangements Dr Tony Elston Consultant Microbiologist/Director of Infection Prevention and Control (DIPC) Dr Sima Jalili Consultant Microbiologist Dr Gillian Urwin Consultant Microbiologist Heather Dakin Head of Infection Prevention and Control Vicky Bywater Senior Infection Prevention and Control Nurse Allison Munson Infection Prevention and Control Audit/Surveillance Nurse Nikki Harding Infection Prevention and Control Audit Ralph Nation Data Manager Sue Fordham Antimicrobial Team Secretary Angela Heard Infection Prevention and Control Team Secretary Page 7 of 37

8 2.2 Infection Prevention and Control Team Activities Members of the team are involved in the following committees/meetings: Infection Control Team Meeting Hospital Infection Control Committee Medicine Management Committee Clinical Product Review Group Matron and Ward Sisters Meetings Risk Management Committee Senior Management Advisory Group Service review meetings for facilities management Clinical Executive Board Intravenous Management Group Trust Clinical Governance Committee Sharps Safety Working Group PLACE inspection team/annual and monthly PLACE Operational Steering Group Meeting Quality and Patient Safety Committee Capital Planning Update Monthly Meeting Water Safety Group Decontamination Group The Director of Infection Prevention and Control attends and reports to the following: Trust Clinical Governance Committee, Trust Board, Quality and Patient Safety Assurance Committee. There is an active North East Essex HCAI Operational Group: The group includes representatives from ACE, SEPT, PROVIDE, CHUFT, PHE - Essex and Essex County Council Social Services. The remit is to review progress in HCAI prevention in each of the organisations and to monitor progress against a joint action plan. Page 8 of 37

9 2.3 Infection Prevention and Control Team Enquiries The number of enquiries to the IP&C team captured continues to increase year on year, some of these enquiries may be dealt with quickly whilst others can lead to a major piece of project work. The three main themes remain consistent MRSA, D&V and infectious diseases. The C. difficile enquiries were separated out from the diarrhea and vomiting category as there appears to be a significant increase in enquiries relating to this topic. This may well be related to the increased teaching relating to this subject as the Trust overall has seen a reduction in cases in 2016/17. However, testing in terms of C. difficile carriage without disease has increased as has awareness of C. difficile disease in the Trust. What must be remembered is that the data does not capture all of the enquiries and work generated within the Team; however, it does assist in focusing where and what is required to plan for teaching and support for the coming year. Page 9 of 37

10 2.4 Hospital Infection Control Committee Out of five meetings held, attendance is given as follows: ( indicates attendance) MEETING DATES NAME TITLE 24/05/16 21/09/16 22/11/16 07/02/17 14/03/17 Elston, Dr Tony Consultant Microbiologist Meeting Chairman Cancelled Bazzali, Jane Public Health England (PHE) Apologies Apologies Cancelled Apologies Boyle, Sheila Head of Health and Wellbeing Julie Harris Cancelled Apologies Cook, Terry Estates Project Manager Cancelled Dakin, Heather Senior Infection Control Nurse Cancelled Holman, Chris Antimicrobial Pharmacist Not in post Howlett, Chris Director of Estates and Facilities Apologies Cancelled Jackson, Shaun Estates Operational Manager Not in post Cancelled Jalili, Sima Consultant Microbiologist Apologies Cancelled Apologies Morgan, Catherine Director of Nursing Giles Thorpe Apologies Barbara Stuttle Cancelled Apologies Barbara Stuttle Needle, Richard Chief Pharmacist Apologies Apologies Cancelled Notley, Lou ADoN Medicine Cancelled Sparrow, Fiona Head of Facilities Cancelled Swanson, John TBC Thorpe, David Infection Prevention and Control Nurse Specialist Womens, Children s and Midwifery Services ADoN Surgery and Cancer Services Apologies Annual Leave Cancelled Apologies Apologies Jennifer Collins Jennifer Collins Cancelled Jennifer Collins Cancelled Apologies Tonkin, Jo ADoN Medicine and Urgent Care Not in post Cancelled Urwin, Dr Gillian Walker, Howard Divisional Director for C&CSS, Consultant Microbiologist Ipswich Hospital Paula Lightfoot Paula Lightfoot Apologies Cancelled Apologies Apologies John McManus change of represent ative Cancelled Daniel Imoh Wheatcroft, Barry Patient Governor Cancelled Heard, Angela Team Secretary, Infection Prevention and Control Minute Taker Not in post Daniel Imoh Page 10 of 37

11 2.5 Organisational structure and reporting line to the Trust Board Page 11 of 37

12 3. DIPC REPORTS TO THE TRUST BOARD SUMMARY The DIPC reported monthly to the Quality and Patient Safety Assurance Committee, which itself reports monthly to the Trust board 3.1 Number and Frequency Monthly 3.2 Outbreak Reports Norovirus Date 07/12/ /12/ /12/ /12/ /12/ /12/ /12/ /12/ /12/ /12/ /12/ /12/ /12/ /12/2016 Ward Number of bays, ward closed Number of days ward affected Cases confirmed by PCR Layer Marney One bay 2 No Tiptree One bay 5 No Aldham Two bays One bay closed 5 days, one bay closed 9 days Yes Stroke on Birch One bay 2 No Layer Marney One bay 4 No Aldham One bay 2 N/A Aldham One bay 9 N/A Actions taken Wards visited daily by Infection Prevention and Control Nurse and daily management plan agreed with local team and Trust site team Decision to close bay or Ward agreed by Infection Prevention and Control team Increased and enhanced environmental and equipment cleaning is put into place Cohort nursing/care managed as required 28 training sessions in September December 2016 were provided where 194 attended to update on general infection prevention and control standards with an emphasis on Isolation and outbreak management, following the closure of the isolation ward. Page 12 of 37

13 3.3 Carbapenem-resistant Organisms (CRO) increased incidence in a Surgical Ward There was an index case which was not identified as a risk for CRO upon admission having had treatment in a London Hospital. This led to the patient not being isolated and two subsequent patients whom were in the same bay being identified with the same organism. Whilst this has not led to infections in these patients there was a potential for this to happen. Actions taken Ward was decanted and a deep clean performed Trust admission document to highlight the need for appropriate questioning at the time of admission Trust CRO policy updated Appropriate patient contacts were screened in compliance with national guidance. Increased education including but not exclusive to mandatory IP&C E learning training updated and CRO information included; screensavers All IP&C training sessions include CRO updates including E-learning 3.4 Estates and Planning The IP&C team have continued to support and provide advice building projects, and schemes to develop or create facilities and services, including three full ward refurbishments during the year. Collaborative work with the Estates and Facilities Division continues to improve monitoring and reporting on cleaning standards and maintenance and monitoring of the estate. 3.5 Water Safety Management During 2016/17 the Water Safety Committee met on a monthly basis and continued to make progress in improvements and maintenance of water management and quality. The Authorising Engineer from the Water Hygiene Centre now sits on the Trust Water Safety Committee to support expert guidance. Following the update in Health Technical Memorandum (HTM) requirements the Water Safety Group meet monthly and the Water Safety Committee meet quarterly since January The monitoring and management of Pseudomonas aeruginosa is achieved by six monthly sampling and testing in augmented care areas. The Water Safety Group sits monthly and all results and actions are discussed together with future plans as necessary. Colour coding system for showerhead replacement management has been instituted whereby on a quarterly basis the showerheads and hoses are replaced with a different colour. This allows for easy visual checks. Clearwater Technologies was appointed as the main water management contractor in May HTM water safety management compliance is monitored via the Clearwater Portal. The Trust has a well - structured legionella risk assessment and sampling programme in place. The electronic monitoring reports go directly to Estates to action and other members of the Water Safety Group are involved in the monitoring and support of the actions. Any Page 13 of 37

14 non-mitigated issues are escalated to the Water Safety Committee. Page 14 of 37

15 4.0 BUDGET ALLOCATION TO INFECTION PREVENTION AND CONTROL ACTIVITIES Staff Month 1 Month 12 Budgeted Actual Budgeted Actual Consultant Nursing Band 8a A&C Band * staffing allocation shown as whole time equivalents (wte) 4.1 Annual Budget There was an under-spend at year end of 33,000. The under-spend was primarily due to two long term staff sickness episodes and vacancy factor. However, there was an opportunity to look at skill mix and create an Infection Control Practitioner position at a band 3 this post is to be recruited into. 4.2 Project Allocation (monies were spent as below) Colour coded showerhead project to pump prime a system to ensure timely cleaning and replacement of showerheads to reduce legionella and pseudomonas infection risks. This visual way of inspecting is also aimed to support best practice and reduce maintenance. 4.3 Training requirements for the Team in the coming year 2017/2018 Depending upon the ability to recruit to Nurse posts will determine the need for the training requirements over and above mandatory training. 4.4 Training requirements within IP&C Team Personal Development Plans Due to staff shortages and changes IP&C training requirements will be reviewed when posts and team structures are refreshed in light of recruitment. Page 15 of 37

16 UNIVERSITY HOSPITALS WYE VALLEY NHS TRUST MID ESSEX HOSPITAL SERVICES NHS UNIVERSITY HOSPITALS OF NORTH NOTTINGHAM UNIVERSITY HEART OF ENGLAND NHS NORTH WEST ANGLIA NHS WEST SUFFOLK NHS FOUNDATION COLCHESTER HOSPITAL UNIVERSITY THE QUEEN ELIZABETH HOSPITAL, WORCESTERSHIRE ACUTE THE ROYAL WOLVERHAMPTON IPSWICH HOSPITAL NHS TRUST DERBY TEACHING HOSPITALS NHS CAMBRIDGE UNIVERSITY BASILDON AND THURROCK JAMES PAGET UNIVERSITY THE DUDLEY GROUP NHS THE ROYAL ORTHOPAEDIC NORFOLK AND NORWICH UNITED LINCOLNSHIRE HOSPITALS WALSALL HEALTHCARE NHS TRUST SOUTHEND UNIVERSITY HOSPITAL UNIVERSITY HOSPITALS OF THE PRINCESS ALEXANDRA SHERWOOD FOREST HOSPITALS KETTERING GENERAL HOSPITAL EAST AND NORTH HERTFORDSHIRE SANDWELL AND WEST NORTHAMPTON GENERAL WEST HERTFORDSHIRE HOSPITALS SOUTH WARWICKSHIRE NHS SHREWSBURY AND TELFORD BURTON HOSPITALS NHS BEDFORD HOSPITAL NHS TRUST UNIVERSITY HOSPITALS COVENTRY MILTON KEYNES UNIVERSITY CHESTERFIELD ROYAL HOSPITAL LUTON AND DUNSTABLE GEORGE ELIOT HOSPITAL NHS TRUST BIRMINGHAM WOMEN'S AND PAPWORTH HOSPITAL NHS THE ROBERT JONES AND AGNES 5.0 HEALTH CARE ASSOCIATED INFECTION STATISTICS 2016/ Clostridium difficile Clostridium difficile infection (CDI) remains an unpleasant, and potentially severe or fatal infection which occurs mainly in the elderly or other vulnerable groups especially those who have been exposed to antibiotic treatments. The Trust has made great strides in reducing the number of people affected by CDI, however, the rate of improvement has slowed over recent years and it is recognised that some infections are a consequence of factors outside of the control of the NHS organisation that detected the infection. (NHS England 2016/17). Each case identified in the Trust is subject to post infection review. If all care and treatment is managed within nationally and locally recognised policy, the Clinical Commissioning Group (CCG) scrutiny panel may agree that it is deemed as non trajectory. (2015/16 onwards) 26 of the 35 C. difficile cases for Colchester have been agreed as non- trajectory 2016/17 following panel review and sign off by CCG. Comparison of rates of Clostridium difficile of Colchester Hospital with other acute hospitals in the East of England 2016/17 30 C.diff 16/17 - EOE Trusts KH03 occupied overnight beds Value Median Page 16 of 37

17 Year Number of cases of Clostridium difficile apportioned to Colchester Hospital Target No more than 2014/15 32 cases 20 cases 2015/16 24 cases 14 non - trajectory 18 cases 2016/17 35 cases - 26 non-trajectory 18 cases There had been an increased incidence in cases with three cases linked on the Stroke Unit December 2015 March An investigation took place with a comprehensive action plan drawn up and implemented which included two deep cleaning episodes for this area a few months apart with some environmental refurbishment taking place. Targeted education and intensive support from the infection prevention and control team. Patients identified as carriers are monitored closely and managed in much the same way as patients with CDI. Work continues through scrutiny panel reviews with Clinical Commissioning Group to identify areas which may impact on further reduction of cases. Including looking at antimicrobial prescribing in the local health care economy. The incidence of cases of Clostridium difficile is higher in Medicine and Care of the Elderly Wards; seven of the eight Wards have had a significant investment in refurbishments in the past three years with a plan for the final COTE Ward to be refurbished in the coming financial year. This supports the appropriate positioning of patients in an environment which allows for better isolation with an ability to clean effectively. Continue to investigate and invest in new cleaning technologies to support best practice and efficiency including the use of hydrogen peroxide vapour (HPV) fogging, micro-fibre for example Page 17 of 37

18 5.2 Staphylococcus aureus Staphylococcus aureus (S. aureus) is a bacterium that commonly colonises human skin and mucosa without causing any problems. It can also cause disease, particularly if there is an opportunity for the bacteria to enter the body, for example through broken skin or a medical procedure. Most strains of S. aureus are sensitive to the more commonly used antibiotics, and infections can be effectively treated. Some S. aureus bacteria are more resistant. Those resistant to the antibiotic meticillin are termed meticillin resistant Staphylococcus aureus (MRSA) and often require different types of antibiotic to treat them. Those that are sensitive to meticillin are termed meticillin susceptible Staphylococcus aureus (MSSA). MRSA and MSSA only differ in their degree of antibiotic resistance: other than that there is no real difference between them. (PHE 2017) 5.3 MRSA bacteraemia Achieve Trust Target of zero for MRSA cases in 2016/17 Year Number of cases of MRSA Target bacteraemia cases apportioned to Colchester Hospital 2014/ / /17 2 (1 of which was a contaminant) 0 All Acute Trusts have participated in PHE mandatory enhanced surveillance of MRSA bacteraemia since October Comparison of rates of MRSA Bacteraemia of Colchester Hospital with other acute hospitals in the East of England 2016/17 Page 18 of 37

19 NOTTINGHAM UNIVERSITY UNIVERSITY HOSPITALS PAPWORTH HOSPITAL NHS CHESTERFIELD ROYAL HOSPITAL SHREWSBURY AND TELFORD JAMES PAGET UNIVERSITY UNIVERSITY HOSPITALS OF NORTH SOUTHEND UNIVERSITY HOSPITAL DERBY TEACHING HOSPITALS NHS HEART OF ENGLAND NHS MILTON KEYNES UNIVERSITY NORTH WEST ANGLIA NHS THE ROYAL WOLVERHAMPTON WYE VALLEY NHS TRUST WEST HERTFORDSHIRE HOSPITALS WALSALL HEALTHCARE NHS TRUST MID ESSEX HOSPITAL SERVICES EAST AND NORTH HERTFORDSHIRE BIRMINGHAM WOMEN'S AND UNIVERSITY HOSPITALS COVENTRY CAMBRIDGE UNIVERSITY SHERWOOD FOREST HOSPITALS SANDWELL AND WEST IPSWICH HOSPITAL NHS TRUST COLCHESTER HOSPITAL LUTON AND DUNSTABLE NORTHAMPTON GENERAL THE QUEEN ELIZABETH HOSPITAL, UNIVERSITY HOSPITALS OF BASILDON AND THURROCK THE DUDLEY GROUP NHS NORFOLK AND NORWICH BEDFORD HOSPITAL NHS TRUST BURTON HOSPITALS NHS WORCESTERSHIRE ACUTE WEST SUFFOLK NHS FOUNDATION THE PRINCESS ALEXANDRA SOUTH WARWICKSHIRE NHS UNITED LINCOLNSHIRE HOSPITALS KETTERING GENERAL HOSPITAL GEORGE ELIOT HOSPITAL NHS TRUST THE ROBERT JONES AND AGNES THE ROYAL ORTHOPAEDIC MRSA bacteraemia cases apportioned to CHUFT 2016/17 and the learning from these cases The root cause of the MRSA bacteraemia case in 2016/17, related to peripheral intravenous line management. There has been further training locally and across the Trust relating to intravenous line management, the policy was updated and promoted. There was a Grand Round and at the Infection Control conference in November the affected patient attended discussing the impact the infection had for them, which was extremely powerful in supporting improvement in practice. There was a blood sample which was a contaminant and was not an infection in a patient. However, the opportunity was taken to review the blood culture taking procedure with new packs introduced to reduce the risk of contamination of samples. There were two cases of MRSA bacteraemia in 2016/17 apportioned to the Trust there was a case in April 2016 and a case identified in August The case in April 2016 was deemed to be related to a peripheral intravenous access device this was treated as a Serious Incident and investigated and learning shared across the Trust. The case identified in August 2016 was identified as a contaminant which indicated that there was no infection noted. Enhanced training related to blood culture sampling was put in place and information shared. Quarterly blood culture contamination data is shared across the Trust, the national average of blood culture contamination realises 3-5% and the Trust data is comparable. See section Meticillin Sensitive Staphylococcus Aureus (MSSA) bacteraemia MSSA 16/17 - EOE Trusts KH03 occupied overnight beds Value Median 7.33 Page 19 of 37

20 Mandatory reporting of MSSA bacteraemia has been in place since January 2011 for NHS acute trusts; patient-level data of any MRSA and MSSA bacteraemias are reported monthly to PHE. Independent sector (IS) healthcare organisations providing regulated activities also undertake surveillance of MRSA and MSSA bacteraemia. There were at total of 14 cases which would be apportioned to the Trust and 71 cases for community onset in the year 2016/17. There is no national target, for each MSSA bacteraemia a local RCA is completed there were no themes drawn from these cases, individual cases highlighted peripheral line management could have been better in terms of documentation and insertion technique, contamination at the time of blood culture sampling, Local departmental education and Trust wide learning shared. 5.5 Carbapenemase Resistant Organisms (CRO s) Carbapenemase-producing Enterobacteriaceae (sometimes abbreviated to CPE) are a type of bacteria which has become resistant to carbapenems, a group of powerful antibiotics. This resistance is helped by enzymes called carbapenemases, which are made by some strains of the bacteria and allows them to destroy carbapenem antibiotics. This means the bacteria can cause infections that are resistant to carbapenem antibiotics and many other antibiotics. Carbapenem antibiotics successfully treat certain complicated infections when other antibiotics have failed. The spread of these resistant bacteria can cause problems to vulnerable patients in hospitals or other settings because there are so few antibiotics available to treat the infections they cause. In line with national guidance from PHE Carbapenemase Resistant Organism toolkit, this helped to manage the CRO outbreak as described in section 3.3 of this report. It also helped to inform and update local policies to incorporate all mechanisms by which Carbapenemase resistance is shared between organisms. 5.6 Escherichia coli (E coli) blood stream infections Page 20 of 37

21 In November 2016, the Secretary of State for Health, Jeremy Hunt announced Government plans to halve the number of gram-negative bloodstream infections by E coli infections represent 65% of these gram-negative infections. As approximately threequarters of E. coli BSIs occur before people are admitted to hospital, reduction requires a whole health economy approach. E coli bacteraemia total cases for North East Essex CCG 2016/17 Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Total Hospital Community NB: where an infection develops after 48 hours in hospital the case according to national guidelines is considered to be apportioned to the hospital in which the patient is an inpatient. If the infection develops prior to or within the first 48 hours of admission the case is apportioned to the Community. Locally, it is recognised that a significant proportion of E coli bacteraemia occur in the elderly population in the community setting who then present to our hospital. In the past year North East, Mid and West Essex IP&C teams worked together with colleagues in the Clinical Commissioning Group and Essex County Council in order to deliver train the trainer sessions for Nursing and Residential Homes in order to increase awareness in relation to urinary catheter management, hygiene and hydration. It was hoped that this important education would support a reduction in the incidence of E coli bacteraemia in the local population. 5.7 ICNet Surveillance System ICNet surveillance system was introduced to the Trust in 2007 and provides the Infection Prevention and control team and the Trust with tools to support the effective monitoring and management of HCAI s. The system will require an upgrade in the next 12 months as the system will not be able to continue to be supported in its current version. The system provides 3 times a day imports of relevant microbiological results to all for the timely review of patients and appropriate interventions to be managed. The system is starting to show value in supporting data production for antimicrobial resistance and stewardship reporting for CQUIN. The system supports the data required for reporting to relevant internal and external agencies. The continued investment in ICNet with the Link with Patient administration System Medway going forward in the Transforming Pathology Partnership must not be lost and the value of this system for reporting and case management cannot be underestimated. Page 21 of 37

22 5.8 Surgical Site Infection Surveillance (SSIs) 2016/17 Large Bowel April June 2016 July- Sept 2016 Oct- Dec 2016 Small Bowel Vascular N/A 2/44 4.5% 1/103 1% 4/75 1/96 5.3% 1% N/A N/A 2/ % Abdominal Total Hip Hysterectom y N/A 0/111 0% N/A 0/112 0% Knee Replace ment 0/119 0% 1/ % N/A 0/139 0/143 0/25 Repair of Neck of Femur 1/ % 1/ % Jan-March 2017 N/A 1/ % 1/ % N/A 1/ % 0/136 2/ % National average 11.8% 8.5% 4.8% 4.4% 1.1% 1.5% 1.4% NB: The national programme for surgical site surveillance suggests that at least 50 cases need to be surveyed in a three-month period in order to obtain good quality figures which are statistically significant. NB: all participating hospitals % per period in brackets in bold. The mandatory requirement is for each Trust to complete surveillance in one module of orthopedic surgery for one quarter per financial year. The Trust has always been keen to be able to benchmark in more areas of surgery and plans to continue this in the coming year. This provides national data that can be used as a benchmark allowing individual hospitals to compare their rates of SSI with collective data from all hospitals participating in the service. All of the SSI categories reported for 2016/17 continue to compare favorably with the National benchmarking th UK and European Healthcare Associated Infection (HCAI) and Antimicrobial study The Trust participated in the 5 th UK and European Healthcare Associated Infection (HCAI) and Antimicrobial study which was completed during October The Trust has taken part in the four previous studies and has been able to utilize the local and comparative data to progress best practice. The complete comparative data for this study will be available in its entirety later in However, we are able to report the findings as below with more detailed analysis to follow. Health Care Associated Antimicrobial Usage Infection Prevalence CHUFT 4.85% 4.8% 36% 31.9% All participating Hospitals 7% 6% 38% 35% Page 22 of 37

23 5.10 CHUFT Blood culture contamination rates Jan March 2017 Jan March 2017 A&E CHUFT minus CHUFT Overall National A&E 87/ % 45/ % 132/ % Range 3-5% NB: it is not uncommon to find highest level of blood culture contamination rates in Emergency Departments (A&E) Blood culture contamination can be reflective of poor collection practice and can be a waste of limited resources. Whilst CHUFT and in particular the A&E department were within the higher level of the national range the work undertaken in terms of new blood culture. 6. HAND HYGIENE 99.00% Hand Hygiene monthly percentages 2016/ % 98.00% 97.50% 97.00% 96.50% 96.00% 95.50% 95.00% Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Hand hygiene compliance observations continue to be reported monthly from each clinical area averaging a score 95%+ each month overall. Where there are areas of reduced compliance education and increased awareness sessions are put in place. Periodic PEER review audits are undertaken to continue to promote awareness. 7. CLEANING SERVICES (FACILITIES) 7.1 Management Arrangements The Housekeeping service is an In-house service which is managed by the Facilities Department along with other non-clinical support services. It falls directly within the remit of the Patient Environment Manager who manages it on a day to day basis through the Hotel Services Management and Supervisory Team in order that there is around the clock supervisory cover for the cleaning staff on duty. These arrangements enable cleaning requests to be carried out with the minimum of delay. Page 23 of 37

24 7.2 Cleaning Schedules Cleaning schedules are available in all patient areas and updated as required to meet individual service needs with the Ward Sister/Department Manager. 7.3 Monitoring Arrangements All wards and departments are audited and monitored against the National Specifications for Cleanliness (2007) using 55 Elements approved by the Lead Infection and Prevention Control Nurse, which includes the 49 detailed in the Specifications documentation. The audits are generally carried out by a Matron or Ward Sister/Department Manager in conjunction with a member of the Housekeeping Management Team who is experienced in the NPSA Audit process. The results of the audits are reported at both the Estates and Facilities Senior Management Team and the Hospital Infection Control Committee. 7.4 NPSA Audit Results The charts below detail the overall NPSA audit scores over the past year as well as the scores achieved by the three specialties, i.e. Housekeeping (Cleaning), Nursing and Estates over the year. The target average score for the whole Trust is 90% and takes into account the number of wards/departments etc. in each of the Very High Risk, High Risk and Significant Risk areas where the target scores are 98%, 95% and 85% respectively. Trust Average NPSA Score for 2016/17 NB. The average score for the year has risen by 0.6% from 96.0% in 2015/16 to 96.6% in 2016/17 Page 24 of 37

25 The NPSA Scores by Cleaning Specialty This chart details that the scores achieved by Nurse cleaning have become a little more consistent over the last year. The scores achieved by Housekeeping fluctuated more than they did during 2015/16. The main issues for Housekeeping related to staff attendance in August and September 2016 and difficulties achieving the target score in the Emergency departments. This was because those areas were exceptionally busy and it can be noted that the scores achieved by the other specialties were also problematic over the year. 7.5 IP&C Training for Housekeeping staff All Housekeeping staff receive Infection Control training as part of their mandatory training. They also receive on the job training which supports and underpins the Infection Prevention and Control Training and covers topics such as the use of colour coded mops, and cleaning from clean to dirty, to prevent cross contamination and infection. 7.6 Deep Cleaning The Trust continues to support the process of environmental decontamination with hydrogen peroxide vapour (HPV) which is used as standard practice for deep cleaning as per the Trust policy and as directed by the Nursing or Infection Control Team and where upgrades or refurbishments take place. There is an arrangement with each clinical department to release a room and undertake deep cleaning of ward based equipment on a monthly basis. 7.7 Innovation 2016 saw the approval of the Business Case to introduce micro-fibre equipment into the Trust in 2017 as well as a long awaited upgrade of the mop laundry which once completed will see the Trust use OTEX technology to wash the mops and cloths rather than thermal disinfection. Page 25 of 37

26 7.8 Patient Led Assessment of the Care Environment (PLACE) The Trust continues to perform well with regards to patient perception of the cleanliness of the environment, and the results of the 2016 assessments are detailed in the table below. The results of 2017 assessments which were carried out in April will not be officially available until August 2017, but early indications are that the score for cleanliness will remain very similar to National Average Colchester General 2016 Colchester General 2015 Cleanliness 98.10% 99.43% 99.13% Food and Hydration 88.2% 88.82% 90.61% Privacy, Dignity and Wellbeing Condition, Appearance, Maintenance 84.2% 89.16% 89.33% 93.4% 93.8% 93.00% Dementia 75.3% % Accessibility 78.8% 71.58% 99.13% NB. Figures in green detail where the Trust scored higher than the national average and figures in red detail where the Trust scored lower than the national average. The Trust also holds six PLACE lite inspections throughout the year, and quarterly PLACE steering Group meetings to review and update the action plan. 8. DECONTAMINATION Medical Devices that are able to withstand the preferred high temperature decontamination processes are returned for re-processing in the onsite Sterile Services Unit (SSU). The departments activities are regulated by the external annual auditing undertaken by British Standards Institute (BSI) a Notified Body on behalf of the MHRA to the requirements of EN ISO 13485: 2012 and Annex V 93/42/EEC. SSU continues to meet these requirements with no required corrective actions through either major or minor non-conformance. The next audit will be undertaken by BSI in July The new standard of EN ISO 13485: 2016 has now been released and the Trust will seek compliance to the new standard in January The current project to replace the Flexible Endoscope Washer Disinfectors due to end of life of product will see a centralisation of service serving for both Elmstead Endoscopy and Main Theatre. New facilities are being built to replace the existing facility currently at Essex County Hospital. Both the new builds will be compliant to the requirements and national standards of the new Hospital Technical Memorandum for Flexible Endoscopes and the Joint Advisory Group (for Gastrointestinal Surgery) JAG providing reassurance of best practice. After a tender evaluation exercise undertaken by a multi-disciplinary team and with expert guidance from Eric Miller, Trust Authorising Engineer for Decontamination (AE (D), Cantel Medical were the chosen providers of the EWDs in common with the current facility at Ipswich Hospital NHS Trust. Commencement of service from the new builds is expected in early autumn of Page 26 of 37

27 The Trust Decontamination Committee has been reformed, and is chaired by Tony Elston, Trust Director of Infection Prevention and Control (DIPC). The committee will provide a forum to discuss the decontamination of both reusable medical devices and the environment to ensure that best practice prevails wherever possible; National Standards and Guidance are implemented providing re-assurance to both practitioners and patients alike. The new HTM 01-01: Management and Decontamination of Surgical Instruments (Medical Devices) used in Acute Care released by the Department of Health (DH) has several key recommendations in relation to the requirement to improve and measure protein detection upon instruments and to undertake mandatory daily testing of Washer Disinfectors in the efficacy of protein removal. The recommendations are being taken forward through this Committee. Similarly, the new HTM highlights the need to improve the recording and trending of Total Viable Counts (TVC) for final rinse water of EWDs this will provide reassurance to users that flexible endoscopes are being decontaminated to national standards. The Trust Decontamination Policy has been reviewed and revised to reflect the new standards and best practice. 9. AUDIT Annual Ward/Departmental Infection Prevention and Control Audits Year HH SP SHA UC UCI PVD PVDI CVC CVC IP OTA EF ME GE Total 2014/15 77% 77% 90% 83% 96% 82% 97% 89% 100% 89% 100% 83% 81% 73% 87% 2015/16 92% 84% 100% 88% 96% 87% 92% 95% 96% 95% 99% 91% 87% 75% 91% 2016/17 91% 87% 100% 92% 98% 86% 95% 95% 100% 96% 100% 96% 88% 77% 87% Page 27 of 37

28 The annual infection prevention and control audit is completed in all clinical areas (58) on an annual basis by the IP&C team and the results have remained relatively consistent over the years. It is a good opportunity to support clinical teams in highlighting best practice and practices which could be improved upon. These audits provide evidence in order to support ward refurbishment risk assessments for instance. The Trust monthly hand hygiene observational audits have demonstrated an increase in compliance consistently above 95% and regularly 97%. There are between 3700 and 4500 observations documented per month. There is regular peer review to monitor results and support education at a local level in order to maintain awareness for best practice. Hand hygiene is seen as an integral part to patient safety within the Trust. Periodic hand hygiene awareness roadshows are supported by the Infection Control team. 10. TARGETS AND OUTCOMES Page 28 of 37

29 Plan for Key points Compliance with Hygiene To review action plan against the code on a regular basis Code (2008 updated 2015) Saving Lives audits Continue to support clinical teams in the education and use of the tools ICT data manager continues to work with local teams to tailor reports to department To target three High Impact Interventions Appropriate use of urinary catheters Appropriate use of Isolation Facilities for HCAI Effective use of risk assessments for HCAI Promote Peer review of audits to promote learning across divisions Annual IC audits Continue with annual rolling programme of Infection control audits with timely feedback to clinical teams Facilitate the MRSA screening project To continue to assist divisions in achieving compliance with MRSA emergency admission screening procedure To support a robust system is in place to assure compliance with the target To support the feedback of data to support this work Facilities /Estates Project review To work with Trust Facilities management team to look at current specifications and which require Infection Control advice support through NPSA auditing Work with Projects team to manage IP&C from feasibility/design, build and handover Promote e-learning Continue updating programmed annually programmed and audit To audit uptake and report to HICC bi monthly uptake Mandatory annual updates for IC & antimicrobial To continue to support the Trust programme at induction and Mandatory update sessions update annually management for all staff Programme available in e-learning format for induction Update IC policies Ongoing programme IC manual update Ongoing updating on web based Manual ICNet surveillance system To continually evaluate effectiveness of the system The system requires upgrading at a financial cost look at joint link in with Ipswich hospital Continue with Surgical site surveillance Continue with agreed rolling programme of modules in addition to the mandatory modules Promote the adoption within the Trust of Surveillance in areas such as C sections as the new modules become available Infection Control Link System Continue to develop the link role into other healthcare disciplines To further develop the role of the Link role to enhance local infection control Induction Surveillance E coli bacteraemia RCA and reporting MSSA bacteraemia RCA and reporting MRSA bacteraemia RCA and reporting Psuedomonas bacteraemia reporting Klebsiella bacteraemia reporting C diff RCA and reporting CRO reporting and RCA Alert Organism reporting and Management Page 29 of 37

30 10.1 Policies Updated this year Document No: Document Title Expiry Date O84 Prevention of Infection in Patients with an Absent or Dysfunctional Spleen Guidelines Apr Hand Hygiene Procedure Feb Infection Control Procedure Dec CreutzfeldtJacob Disease (CJD) Procedure for the Management of Related Disorders in Hospital Sep-17 PP(16)181 Control of Outbreaks of Infection in the Hospital Setting Procedure Apr-18 PP(16)361 Isolation Procedure Sep-18 PP(17)371 Viral Haemorrhagic Fever (VHF) Procedure Feb-19 PP(17)343 Hydrogen Peroxide Vapour (HPV) Decontamination Procedure Feb-19 PP(16)245 Clostridium difficile and Unexplained Diarrhoea Procedure Mar-19 PP(16)360 PP(16)246 Procedure for the Management of Extended Spectrum Beta- Lactamase (ESBL) Producing Organisms and AmpC Producing Organisms and Prevention of Spread Management of Chickenpox and Shingles Procedure, Including Immunisation for Healthcare Workers (Replaces 81 and 155) Mar-19 Mar-19 PP(16)407 Policy and Procedure for the management of Carbapenamaese producing Entrobacteriaciae Mar-19 PP(16)112 Methicillin-Resistant Staphylococcus Aureus (MRSA) Procedure May-19 PP(16)410 Visiting Pets Procedure (extension requested to allow for volunteer leader input - new post) Jul-19 PP(16)80 Tuberculosis (TB) Management Procedure Sep-19 PP(16)378 Vascular Access Devices (Peripheral and Central): Insertion, Management and Removal Procedure Dec-19 Page 30 of 37

31 11. ANTIBIOTIC MANAGEMENT TEAM REPORT 2016/17 The Antimicrobial Management Team (AMT) meets every two months to plan and monitor the Antimicrobial Stewardship (AMS) strategy within the Trust. There have been a number of staffing changes over the past year: An Antibiotic Stewardship Pharmacist has been recruited (0.5 WTE spent on AMS activity) The previous AMS pharmacy technician left the Trust and a replacement pharmacy technician has been recruited. This is not a like for like replacement as the new pharmacy technician spends 0.5 WTE on AMS activity, with the rest of their time spent on clinical pharmacy activity The lead consultant microbiologist for AMS has now started a six-month secondment to Ipswich Hospital NHS Trust. As this consultant was the chair of the AMT, this role has moved to the Antibiotic Stewardship Pharmacist on an interim basis. Backfill for this post is being paid for by Ipswich Hospital NHS Trust and a locum consultant microbiologist has been employed Due to the staffing changes, the meetings have been reduced to two-monthly from sixweekly in order to give members of the team sufficient time to complete actions assigned to them. Monthly trends on Datix (Trust electronic incident reporting system) are monitored as a regular agenda item by AMT. From identifying trends in incidents or near misses education can be enhanced and systems can be implemented to minimise the risks in the future, for example, as a result of the monitoring small laminated cards continue to be updated and available for all clinical staff detailing the antibiotics to be avoided or used with caution in patients with a confirmed penicillin allergy. Results of these actions are fed into the Medication Safety Committee for further monitoring. Existing guidelines continue to be reviewed and new guidance produced working with the relevant lead clinicians. Enhancements to the team s intranet pages have resulted in improved access to the guidance and the ability to access the most frequently used guidance in a timely manner. For example, the layout of the guidelines page has been changed to allow the information to be found more easily and the format has been changed to PDFs to allow a faster document download. The team continue to liaise and build close links with other Trusts within the East of England to ensure that guidance is in line with other Hospitals within the region and follows best practice. In particular, the AMT has started some early joint working with the AMT at Ipswich Hospital NHS Trust. A joint audit is being carried out and joint attendance at team meetings has started. Regular monitoring through audit continues. A rolling programme of audit, looking at antibiotic prophylaxis during surgery, has been expanded and the following surgical specialities are monitored: Vascular Gastrointestinal Urology Orthopaedics Breast Gynaecology Caesarean sections Pacemaker Interventional Radiology Page 31 of 37