Infection Prevention & Control Annual Report 2016/17

Transcription

1 Infection Prevention & Control Annual Report 2016/17 1

2 Contents 2 Page 1.0 Introduction Where to find evidence of compliance with the code of practice 2.0 Structure of the Infection Prevention & Control Team Reporting Framework 2.2 Laboratory services 2.3 Isolation facilities 3.0 Performance MRSA bacteraemia 3.2 MRSA acquisitions 3.3 Clostridium difficile infection 3.4 Escherichia coli bacteraemia 3.5 MSSA bacteraemia 3.6 Vancomycin resistant enterococci (VRE) 3.7 Multi-drug resistant Acinetobacter sp. 3.8 Carbapenemase Producing Enterobacteriaceae (CPE) 3.9 Pseudomonas aeruginosa 3.10 Extended spectrum beta lactamase producers (ESBL) 4.0 Outbreaks and learning from incidents Norovirus 4.2 Seasonal influenza 4.3 Infection prevention and control incidents recorded on Datix 4.4 Serious incidents 4.5 Patient Advice and Liaison Services (PALS) Contacts 5.0 Surgical site infection Audit Antimicrobial stewardship Total antibiotic consumption 7.2 Carbapenem usage 7.3 Piperacillin/tazobactam usage 7.4 Submission of antimicrobial usage data 7.5 Sepsis CQUIN 7.6 Antimicrobial audits 7.7 Antimicrobial sensitivities 7.8 PICS developments 8.0 Education and training Facilities Occupational health Research and development Initiatives Innovation and the future 43

3 1.0 Introduction Infection prevention and control is a top priority for University Hospitals Birmingham NHS Foundation Trust (UHB). Keeping our patients safe from avoidable harm is everyone s responsibility. The Trust has a wide ranging programme of activity that focusses on continual improvement in order to deliver the best in care. This report provides details of the progress made with infection prevention and control from April March /17 has been a challenging year with national objectives for Meticillin Resistant Staphylococcus aureus (MRSA) and Clostridium difficile infection aimed at delivering a zero tolerance approach to avoidable infections. Progress has been made throughout when compared to recent years, primarily due to the decrease in MRSA bacteraemias and other healthcare-associated infection seen within the Trust. During 2016/17, there were a number of staff changes within the Infection Prevention and Control Team including the appointment of a new Lead Doctor and a new Lead Nurse. The Infection Team work in line with national guidance on the prevention of infections in the healthcare setting. Adherence to policies and procedures based on national guidance and the evidence base supports the Trust in continually reducing the risk from avoidable infection for our patients and staff. All the policies and procedures are readily available on the Trusts intranet page for all staff and are regularly kept up to date. A list of policies and procedures can be found in Appendix 1. The Trust is a teaching hospital and tertiary referral centre providing clinical services to over one million patients each year. The Trust has one of the largest co-located critical care units in the world and is a specialist centre for burns, plastic, liver, cardiac surgery and neurosciences; and has a specialist cancer centre. The Trust also has the largest transplant programme in Europe, is the regional major trauma centre and hosts the Royal Centre for Defence Medicine. The Infection Team work closely with external agencies. A strong working relationship is maintained with the local Clinical Commissioning Groups, Public Health England (PHE) and NHS Improvement. The team meet monthly with Birmingham CrossCity Clinical Commissioning Group as the coordinating commissioners for the Trust to primarily discuss C. difficile Post Infection Reviews (PIR). During outbreaks of infections PHE are notified and invited to support outbreaks meetings. NHS Improvement are kept up to date on the Trust s performance. The Trust has an open approach to infection prevention and control; sharing learning and experience. As a result several other Trusts have visited the Infection Team to learn from the experiences the Trust has faced which can often be complex. 1

4 1.1 Where to find evidence of compliance with the code of practice (2015) on infection prevention and control from the Health and Social Care Act 2012 Criterion What the registered provider will need to Location in demonstrate annual report 1 Systems to manage and monitor the prevention and Section 2 and 4 control of infection. These systems use risk assessments and consider the susceptibility of service users and any risks that their environment and other users may pose to them. 2 Provide and maintain a clean and appropriate Section 9 and 12 environment in managed premises that facilitates the prevention and control of infections. 3 Ensure appropriate antimicrobial use to optimise patient Section 7 outcomes and to reduce the risk of adverse events and antimicrobial resistance. 4 Provide suitable accurate information on infections to service users, their visitors and any person concerned Section 6, 8, 11 and 12 with providing further support or nursing/ medical care in a timely fashion. 5 Ensure prompt identification of people who have or are at risk of developing an infection so that they receive Section 3, 4 and 12 timely and appropriate treatment to reduce the risk of transmitting infection to other people. 6 Systems to ensure that all care workers (including contractors and volunteers) are aware of and discharge Section 6, 8 and 12 their responsibilities in the process of preventing and controlling infection. 7 Provide or secure adequate isolation facilities. Section 2 8 Secure adequate access to laboratory support as appropriate. Section 2, 3 and 4 9 Have and adhere to policies, designed for the Section 1; individual s care and provider organisations that will Appendix 1 help to prevent and control infections. 10 Providers have a system in place to manage the occupational health needs and obligations of staff in relation to infection. Section 10 2

5 2.0 Infection Team Structure 2016/17 In January 2017 Consultant Microbiologist Dr Elisabeth Holden was appointed the Lead Doctor for Infection and Craig Bradley was appointed as the Lead Nurse for Infection. In addition, the team has recruited two new Senior Infection Nurses, an Infection Nurse and an administrator for the team. The Executive Chief Nurse is the Director for Infection ; the Infection Team also consists of a Lead Infection Control Doctor, a Lead Nurse, a Clinical Scientist, a Principal Antimicrobial Pharmacist and the team of specialists nurses. The Infection Team structure at the end of the year is shown in Figure 1. Job titles in dark blue are core members of the team. Figure 1 Infection Team Structure on 30 th March 2017 Executive Chief Nurse and DIPC Philip Norman Director of Estates & Facilities Karen Johnson Deputy Chief Nurse Michele Owen Lead Doctor Elisabeth Holden 0.3 WTE Clincial Scientist Decontamination Advisor Lead Nurse Antimicrobial Pharmacist Mark Garvey 1.0 WTE Sara Weston 1.0 WTE Craig Bradley 1.0 WTE Martin Biggs 1.0 WTE Senior Infection Prevention Nurses 4.08 WTE Administration 0.53 WTE Infection Prevention Nurses 2.0 WTE 3

6 2.1 Infection Prevention Reporting Framework The Infection Group met monthly throughout 2016/17 with the exception of August and December. Membership comprises of: Executive Chief Nurse/Director for Infection (Chair) Deputy Chief Nurse (Deputy Chair) Lead Doctor in Infection Lead Nurse for Infection Infection Clinical Scientist Principal Antimicrobial Pharmacist Divisional representative (for all 4 divisions) Director of Facilities and Estates Allied Health Professional representative Lead Nurse for Quality & Clinical Standards Head of Facilities Health and Safety Lead Head of Risk and Compliance Head of Estates (Quarterly attendance) Occupational Health Lead Nurse (Quarterly attendance) Decontamination Advisor (Quarterly attendance) Cross City Clinical Commissioning Group Lead for Infection Prevention and Control Public Health England representative Members of the Infection Team sit on the following Groups within the Trust: Health and Safety Steering Group Water Safety Group Medical Devices Group Decontamination Group Continence Action Group Emergency Planning Committee Antimicrobial Steering Group Preventing Harm Meetings Product Evaluation Group Equipment Standards Group A member of the Infection Team also attends the Divisional Matrons meetings. Senior Infection Nurses undertake regular clinical walkabouts with their Matrons for each clinical area. Members of the Infection Team attend relevant meetings of groups dealing with developments, procurement and commissioning when appropriate. A Consultant Microbiologist sits on the Medicines Management Advisory Group. The Consultant Microbiologists continue to work with the Principal Antimicrobial Pharmacist in monitoring, auditing and providing education on the use of antimicrobials, and an Antimicrobial Steering Group meets regularly. The ward pharmacists monitor antimicrobial use around the hospital. The Infection Team meets formally every week to discuss a range of topics including; governance, assessing progress against the annual 4

7 programme of work, performance targets, discussion and resolution of issues, review of surveillance data and ensure necessary information, including feedback from groups, committees and meetings attended, is disseminated appropriately to the wider team. At every Board of Directors meeting the Chief Nurse as part of the Care Quality Report gives an overview of the most recent infection prevention performance data. All members of the Board of Directors, therefore, have access to information concerning the Trust s performance against the external and internal infection prevention targets and other infection related issues. 2.2 Laboratory services The Infection Team work closely with the clinical microbiology department which provides comprehensive bacteriology, virology, parasitology, and mycology services. The department is UKAS accredited and participates fully in external quality assurance schemes for the full repertoire of tests. The department is based at the Queen Elizabeth Hospital Birmingham and has a satellite laboratory at the Genitourinary Medicine Clinic in Whittall Street, Birmingham. There are 50 scientific, support and clerical staff offering a 24-hour diagnostic and monitoring service for routine and urgent detection of patient infection, e.g. meningitis, hepatitis and MRSA infections caused by bacterial, viral and fungal agents, using specialized automated and manual techniques. The clinical microbiology department provides support to the Infection Team through reporting of results and processing of clinical samples. Out of hours the on duty microbiologist will provide Infection advice for the Trust. 2.3 Isolation facilities There are over 1400 inpatient beds and of these 474 are single rooms, providing facilities to isolate patients with alert organisms. The Trust has 9 rooms with positive pressured lobbies which the Infection Team can utilise to isolate patients with such as Middle East Respiratory coronavirus or pulmonary MDR Tuberculosis. In addition the Trust has two negative pressured single rooms in Critical Care. 3.0 Performance 3.1 MRSA bacteraemia During 2016/17 the objective for Trust apportioned MRSA bloodstream infections was zero. The Trust was disappointed to report 4 avoidable cases. Overall there were 11 MRSA bacteraemias reported, 4 of which were Trust apportioned and 7 non-trust apportioned. Figure 2 shows the annual number of bacteraemias from All cases have been investigated using the Post Infection Review process and have been discussed at the Chief Executive Root Cause Analysis review meetings. Action plans to address learning points have been developed and are being monitored to ensure implementation. To continue with improving MRSA performance the annual infection control action plan developed in conjunction with the Clinical Commissioning Group focused on the following: hand hygiene, screening and decolonisation, clean environment, 5

8 antimicrobial stewardship, invasive devices and investigations such as Post Infection Reviews and root cause analysis reviews. Figure 2. Cumulative annual MRSA bacteraemias from Number of MRSA Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2008/ / / / / / / / /17 There is a zero tolerance approach to MRSA bacteraemias and all cases undergo an urgent Post Infection Review across the relevant health economy to assess whether any learning points can be extracted to prevent a repeat in the future, the process also determines which organisation is best placed to implement those learning points. The process requires a transparent, thorough and timely response. 3.2 MRSA acquisitions Targeted admission screening for MRSA has enabled the Trust to monitor the acquisition of MRSA and use this as another key performance indicator for the organisation. Figure 3 shows the number of MRSA acquisitions across the Trust from The performance for 2016/17 has improved compared with that of 2015/16. Since monitoring MRSA acquisitions within the Trust 2016/17 was the lowest year for MRSA acquisitions this was in part due to the re-introduction of universal MRSA decolonisation therapy introduced within critical care and nurse-led MRSA acquisition ward rounds. Figure 4 shows how the incidence of MRSA bacteraemias and MRSA acquisitions have reduced in relation to the reintroduction of universal MRSA decolonisation in critical care. 6

9 Figure 3. Cumulative attributable MRSA acquisitions since Number of MRSA acquisitions / / / /17 0 Figure 4. Using break-point changes hospital-wide monthly MRSA bacteraemia rates (A) and MRSA acquisition rates (B) per 100,000 bed days between August 2013 and August 2014 (prior to the discontinuation of universal MRSA decolonization therapy to patients in Critical Care), between August 2014 and December 2016 (discontinuation of MRSA decolonization therapy in Critical Care), and between January and June 2016 (reintroduction of universal MRSA decolonization therapy in Critical Care). The break-point model identified 4 probable changes in rate, with the fitted means of the segments either side indicated by horizontal blue bars. The dotted vertical lines in August 14 and December 15 indicate the discontinuation and reintroduction of decolonization therapy, respectively. A Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 7

10 B 3.3 Clostridium difficile infection Objectives for the number of C. difficile infections for Acute Trusts and Clinical Commissioning Groups were set for the year 2016/17 by the Department of Health; based on nationally set target and performance rates of each Trust and Clinical Commissioning Group. The objective for Trust apportioned cases of C. difficile infection for 2016/17 was a rate of 17.3 cases per 100,000 bed days; Trust performance was 92 cases giving an overall rate of 22.7 cases per 100,000 bed days. Figure 5 shows the number of Trust apportioned cases annually NHS England published C. difficile infection objectives for acute Trusts and Clinical Commissioning Groups for 2016/17. NHS England calculated these objectives and suggested Clinical Commissioning Groups consider sanctions for breach of C. difficile infection objectives only where those C. difficile infections were associated with lapses in care. With agreement from the Clinical Commissioning Groups all Trust apportioned cases of C. difficile infection were reviewed against avoidability criteria, using a similar process to that described for MRSA bloodstream infections, and those deemed unavoidable were excluded from consideration of local penalties. Of the 92 Trust apportioned cases, 31 (33%) were deemed to have some potentially avoidable factors, most commonly related to deviations from best practice in timely taking of stool specimens, appropriateness of stool testing, timely isolation of symptomatic patients and appropriate antimicrobial prescribing. For 2017/18 the same Post Infection Review tool developed by this Trust which has been recommended for use across England will be used to review any C. difficile infection case. 8

11 Figure 5. Cumulative annual number of Trust apportioned C. difficile infections from Number of CDI Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2008/ / / / / / / / /17 This year the numbers for C. difficile were above our target. Analysis of all cases and the testing algorithm revealed why the rate was higher this year compared to previous years. The increase can in part be explained by norovirus outbreaks during 2016/17 identifying more C. difficile cases as a result of extra testing, retesting of cases within 28 days of admission when these patients have recurrent disease, testing cases as part of the faecal microbiota transplant service and finally a testing anomaly where the test used to identify toxigenic producing strains of C. difficile had a higher positivity rate compared to previous years increasing from 45% to 57% in 2016/17. When comparing the actual amount of C. difficile cases in 2016/17 based on nucleic acid amplification tests the Trust has actually seen a 5% decrease in the amount of C. difficile cases. Although the burden of C. difficile in the Trust has decreased there is always concern around possible transmission of C. difficile infection in hospital. In order to investigate this, strains have been sent for typing in cases where there were possible clusters in clinical areas, generally increased numbers in particular areas. Figure 6 shows the ribotype results for the Trust in 2016/17. For 2016/17 as in previous years, the picture was one of extremely diverse ribotypes with very little evidence of possible transmission and no particular endemic strains to the organisation. 9

12 Figure 6. Number of different C. difficile ribotypes during 2016/ Number of isolates NC Ribotype for 2016/17 In light of the Trust exceeding its C. difficile target, although this can be explained by the aforementioned reasons, the annual plan has addressed some of the lessons from the Post Infection Reviews of the Trust apportioned cases. This year there has been particular actions around improving time to isolation of patients with diarrhoea to prevent transmission of C. difficile, improving timeliness of C. difficile specimen collection and timely treatment of patients with C. difficile infection. In addition the team undertake nurse-led C. difficile ward rounds improving access to expert review of patients with C. difficile. In line with the national antimicrobial CQUIN the antimicrobial stewardship programme has been reinvigorated with a particular focus on reducing the use of broad spectrum antibiotics. In the next financial year focusing on these actions while addressing the issues of extra testing should see the Trust return to previously reported levels of C. difficile. 3.4 Escherichia coli bacteraemias Mandatory surveillance of E. coli commenced in June The intention is to allow assessments to be made nationally on the possible reasons for the increasing number of cases seen over recent years. With the new bloodstream infections quality premium there will be an enhanced focus on Gram negative bacteraemias specifically reducing E. coli bacteraemias by 10% across the whole health economy. It is well known that many E. coli infections arise from the patient s own normal flora and that there is little evidence at present of the interventions that can be made to reduce the majority of these infections. The Trust has robust data on E. coli bacteraemias for the past 4 years. We have seen a year on year increase in the number of E. coli bacteraemias since implementation of mandatory surveillance. However during 2016/17 there was a slight decrease compared to the last financial year with 88 Trust apportioned and 264 non-trust apportioned cases of E. coli infections. Figure 7 shows the total number of E. coli bacteraemias over the year. Urinary tract infections are the most common source of an E. coli bacteraemia (Figure 8). The NHS Safety Thermometer tool looks for the presence or absence of harms, one of these being urinary tract infections in patients with a urinary catheter. National data from the Safety Thermometer showed in 2015/16 around 24% of 10

13 patients at the Trust had a urinary catheter in situ making us a potential higher user for catheter insertion, literature shows catheterising patients can increase the risk of acquiring urinary tract infections. The Infection Team have used a urinary tract infection Post Infection Review tool during 2016/17 in patients where a new harm has been identified through the Safety Thermometer, with the aim of identifying any lessons to be learnt in this group of patients. This work has been fed into the Continence Action Group leading to practice changes within the Trust resulting in a reduction in the amount of urinary catheters in situ decreasing to 20% in 2016/17. Figure 7. Cumulative total number of Trust apportioned E. coli bacteraemias from Number of E. coli / / / /17 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Figure 8. Source of E. coli bacteraemia infections during the financial year 2016/17 UTI Hepatobiliary GI Respiratory Other Unknown 3.5 Methicillin Sensitive Staphyloccous aureus (MSSA) bacteraemias National mandatory surveillance of MSSA bacteraemia began in January During 2016/17 there were 35 Trust apportioned cases and 73 non-trust apportioned cases; no real change in numbers compared to the previous financial year. Figure 9 shows the annual numbers of MSSA bacteraemias over the past four years. 11

14 Similarly to E. coli bacteraemias, many of these represent infections that cannot be predicted or prevented, however all cases are reviewed to assess whether they were related to the presence of a medical device such as a peripheral or central venous access device or urinary catheter as this may assist in determining any key actions for improvement. Of the 35 Trust apportioned cases: 26% were associated to intravenous lines, 15% were predominantly secondary to skin or soft tissue infections, 3% were due to endocarditis, 3% due to urosepsis, 37% being other sources. Surveillance data shows the majority of Trust apportioned MSSA bacteraemias are related to devices which is not an uncommon picture nationally. In 2016/17 the Infection Team have implemented Post Infection Reviews of Trust apportioned MSSA bacteraemias across the Trust related to invasive devices, with any learning/actions being feedback to the clinical areas changing practice if necessary. This has resulted in a reduction of Trust Apportioned MSSA bacteraemias related to devices from 40% to 26% in 2016/17. Figure 9. Cumulative total number of Trust apportioned MSSA bacteraemias between Number of MSSA / / / /17 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 3.6 Vancomycin Resistant Enterococci (VRE) bacteraemia During 2016/17 there were 21 Trust apportioned and 3 non-trust apportioned cases a slight decrease in the numbers compared to the previous year, the majority occurring in patients who were either inpatients or had recently been inpatients. Figure 10 shows the total number of Trust Apportioned VRE bacteraemias over the past four years, as the Figure shows the number of cases has remained constant. Although numbers of cases remain low there is the potential for possible transmission of VRE in hospital. In order to investigate this, strains have been sent for molecular typing in cases where there were possible clusters. In general the typing data rarely identifies cross transmission; often diverse types with very little evidence of possible transmission are seen (Figure 11). 12

15 Figure 10. Cumulative total number of Trust apportioned VRE between Number of VRE / / / / Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Figure 11. Typing of VRE during 2016/ QUEE13EC-12 QUEE13EC-25 QUEE13EC-28 QUEE13EC-38 QUEE13EC-42 QUEE13EC-44 QUEE13EC-45 Number QUEE13EC-46 QUEE13EC-47 QUEE13EC-48 QUEE13EC-49 QUEE13EC-51 QUEE13EC-52 QUEE13EC-53 QUEE13EC-54 QUEE13EC-55 QUEE13EC-56 QUEE13EC-57 Unique 3.7 Multi-drug Resistant Acinetobacter baumannii (MDR-AB) MDR-AB has been a challenge in healthcare settings for a number of years, and controlling the spread of this highly resistant pathogen is a global problem. Cases are often imported by patients who have received medical treatment abroad. During 2016/17 we saw an increase in cases with 8 MDR-AB reported. Seven cases were related and corresponded to an outbreak which spanned two hospitals including our Trust, with a total of 10 cases in all. The index patient had medical care abroad and was admitted to our Trust highlighting the importance of medical history and travel history. Subsequent transmission was seen to 6 further patients. The need for basic infection control measures including strict attention to decontamination of the environment remains vitally important in the control of this pathogen. 13

16 3.8 Carbapenemase Producing Enterobacteriaceae (CPE) Carbapenems are the antimicrobials of last resort used to treat severe infections caused by multi-drug resistant organisms. Over the last decade, CPEs have emerged worldwide, becoming a public health issue. Increasing incidence of CPEs continues to cause potentially serious and occasionally untreatable infections in healthcare settings. Acquisition of these bacteria is mainly nosocomial, being endemic in some countries around the world. The incidence of CPEs in the UK remains low, and implementation of Public Health England s acute trust toolkit for early detection, management and control of CPE has thus far, kept the emergence of widespread CPEs at bay. During 2016/17 there were 11 cases of CPE identified in patients treated at the Trust compared to 10 cases reported the previous year (Figure 12). These strains were predominantly associated with individuals who had received healthcare abroad; however we also saw increase in CPEs in patients from the local community. Evidence from other countries including the UK has shown the potential spread of these organisms within hospitals affecting local populations. In many cases these strains may have only one, or sometimes no, antibiotics which can be usefully employed for treatment, making this a potential concern to patient management and treatment. Further efforts are needed to prevent transmission with emphasis on the importance of identifying those patients at risk of carrying these strains and screening them for carriage, with colonised cases requiring strict isolation for the duration of their hospital stay. Initiatives to control the spread of CPE include identifying if patients have had healthcare abroad, following the national toolkit for management and control of CPEs and enhanced cleaning of a room or bay of known patients harbouring CPEs. As there are no new antibiotics to be licensed for CPEs we are dependent on adherence to hygienic precautions in health care to prevent the spread of CPEs. We have worked closely with facilities to implement a new cleaning regime in bed spaces occupied with patients harbouring CPEs to minimise onward transmission of these organisms. Figure 12. Cumulative CPE cases since 2013 until present Number / / / / Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 14

17 3.9 Pseudomonas aeruginosa P. aeruginosa is a ubiquitous and important opportunistic pathogen in the healthcare setting, particularly affecting those with impaired host or mucosal immunity. It is found in a wide range of moist, nutrient-limited environments and may colonise hospital and domestic water taps, sinks, drains, toilets, and showers. P. aeruginosa forms biofilms that allow persistence of micro-organisms in water systems for long periods, and this helps to explain why high colonisation rates may be seen in hospital water systems. Nosocomial P. aeruginosa outbreaks have previously been reported in some healthcare settings as associated with hospital water sources. Other potential routes of transmission include cross infection, for example carriage on the hands of healthcare workers, and through contaminated medical equipment. In the UK, the role of water in the transmission of P. aeruginosa in healthcare settings has become an increased area of focus in response to a high-profile outbreak affecting a neonatal critical care unit in Belfast, Northern Ireland. In the Belfast outbreak the source was eventually determined to be wash hand basin taps. National guidance is now in place in England detailing procedures for routine water sampling on augmented care units, with directed interventions such as disinfection and replacement of high-risk plumbing parts required. The national guidelines recommend sampling water outlets in augmented care units on a six-monthly basis and taking remedial action for outlets which are positive for P. aeruginosa. Additional general infection prevention and control precautions for dealing with high-risk outlets within clinical areas and routine surveillance of clinical isolates are recommended. The Trust Water Safety Group has implemented the guidance and monitors water sampling and clinical surveillance data (Figure 13), taking action where any concerns are noted. Figure 13. Cases of P. aeruginosa per month for 2016/17 in augmented care areas Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Number of New Pseudomonas W625 WBU WCCD WCCC WCCB WCCA Water sampling in line with the national addendum has shown 31% of the outlets were positive for P. aeruginosa in 2016, with results ranging from 5.5% to 20.6% in other augmented care areas. These areas include the following wards with severely immunocompromised patients: transplant patients, patients where organ support is necessary including renal dialysis, and patients with breaches in their dermal 15

18 integrity for example burns. Since 2013, there has been a 10% increase in the amount of water outlets being colonized with P. aeruginosa across the Critical Care unit. The clinical surveillance from August 2013 to December 2016 saw P. aeruginosa patient isolate rates ranging from 10 to 30 per 100,000 patient bed days. Typing results of the water isolates and the patient clinical isolates in 2014 revealed 30% of the patient isolates matched the water isolates. To reduce the risk of transmission healthcare institutions need to examine intrinsic, holistic and engineering factors for example: the role of disposal of waste water, the installation of new tap outlets that are redesigned either to prevent contamination or enable decontamination, the cleaning of taps appropriately, and the frequency of water sampling to identify outbreaks. Healthcare workers can also play a role in transmission and need to be educated accordingly. In response to 30% of water outlets being colonised with P. aeruginosa as well as potential patient transmission events, a series of both engineering and holistic interventions were implemented across the Critical Care unit. Initiatives included correct disposal of waste water, replacement of current tap units in critical care, appropriate cleaning of taps outlets and effective remedial work on any taps identified as being colonised. All these initiatives resulted in a reduction in the number of P. aeruginosa patient isolates across the Critical Care unit (Figure 14). Breakpoint model analysis identified three probable changes in the P. aeruginosa patient isolate rates across the entire Critical Care unit (Figure 14). The first breakpoint was a result of introducing PALL point-of-use filters on selected outlets on Critical Care Area B. The second and most dramatic breakpoint was when PALL point-of-use filters were fitted on selected outlets across the whole Critical Care unit and holistic interventions such as a new tap cleaning method and appropriate disposal of patient waste water were implemented. Both types of intervention resulted in a reduction in the rate of P. aeruginosa across the Critical Care unit. The third breakpoint again corresponded to the installation of PALL point-of-use filters across the whole Critical Care unit and holistic interventions. During the third breakpoint, new tap outlets were installed on Critical Care A which may have also contributed to the reduction in patient P. aeruginosa isolate rates, however the holistic interventions and PALL point-of-use filters would still be affecting the results seen. Figure 14. Using breakpoint changes patient P. aeruginosa isolate rates per 100,000 bed days were analysed between August 2013 December 2016 across the entire Critical Care unit. The breakpoint model identified three probable changes in rate (breakpoint dotted lines), with the fitted means of the segments either side indicated by horizontal blue bars. The first breakpoint was a result of introducing PALL end filters on selected outlets on Critical Care Area B, the second breakpoint was coincident with PALL end filters being fitted on selected outlets across the entire Critical Care unit, and the third breakpoint as a response to the holistic infection control interventions and installation of new tap outlets on Critical Care Area A. 16

19 Key: Red arrows, and boxes indicate Infection Control Interventions, dotted line represents breakpoints. Intervention A corresponds to the introduction of PALL filters on selected outlets on Critical Care Area B, intervention B corresponds to the fitting of PALL filters on selected outlets across the entire Critical Care Unit, intervention C corresponds to holistic infection control interventions, intervention D corresponds to the installation of new tap outlets on Critical Care Area A Extended spectrum beta lactamase (ESBL) producers Bacteria that produce enzymes called extended-spectrum beta-lactamases (ESBLs) are resistant to many penicillin and cephalosporin antibiotics and often to other types of antibiotic. The two main bacteria that produce ESBLs are E. coli and Klebsiella species. The ESBLs that E. coli most often produce are called CTX-M enzymes. E. coli with ESBLs may cause urinary tract infections that can sometimes progress to more serious infections such as septicaemia. Resistance can make these infections more difficult to treat. Figure 15 shows the number of patients found to be colonised or infected with ESBL-producing organisms. The vast majority of these patients come into hospital from the community; it is unknown where or how these organisms are arising. Further efforts are needed to prevent transmission with colonised cases requiring isolation if presenting with diarrhoea and strict attention to hand hygiene. 17

20 Figure 15. Cumulative number of new ESBLs identified from 2014 to Number of ESBLs / / / Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 4.0 Outbreaks and learning from incidents The infection prevention and control team have a comprehensive surveillance programme that allows early detection of emerging incidents. The Trust investigates incidents to extract learning points in order to continually improve the quality of our services. 4.1 Norovirus Norovirus is a self-limiting diarrhoea and vomiting bug that usually lasts hours. During 2016/17 nine outbreaks of norovirus were reported by the Trust compared to no outbreaks the year previously. In addition two outbreaks of diarrhoea and vomiting were reported in 2016/17 however the causative agent of these outbreaks was not identified. In recent years outbreaks of norovirus have been occurring towards the end of spring. The Trust needs to remain aware of patients presenting with symptoms typical of norovirus including diarrhoea and vomiting. Key learning from the norovirus outbreaks in 2016/17 including the stopping of patient transfers with symptoms from the Clinical Decision Unit to other wards. In 2017/18 there will be an emphasis on working with the clinical site managers to avoid such occurrences. 4.2 Seasonal Influenza Moderate levels of influenza activity were seen in the UK community in 2016/17, with influenza A(H3N2) the predominant circulating virus for the majority of the season peaking in week 1 of The impact of influenza A(H3N2) was predominantly seen in older adults, with a consistent pattern of outbreaks in care homes noted. In addition, admissions to hospital and Critical Care units particularly amongst older adults were observed, although the impact on general practice was variable. Peak admissions to hospital and Critical Care units were lower than seen last season. Levels of excess all-cause mortality were elevated particularly in the elderly, but were lower than the 2014/15 season in which influenza A(H3N2) also dominated. The UK, as with many Northern Hemisphere countries has reported that the majority of circulating A(H3N2) circulating strains were genetically and antigenically similar to 18

21 the Northern Hemisphere 2016/17 (H3N2)vaccine strain. There were 51 laboratory confirmed cases of influenza A between 1 December 2016 and end of March 2017 at the Trust. This was lower than previous years were the Trust had 71 cases in 2015/16 and 155 cases in 2014/15. Influenza vaccine uptake in 2016/17 in England was higher than the 2015/16 in healthcare workers primarily due to the national CQUIN on staff health and wellbeing. One part of this CQUIN focused healthcare providers achieving a 75% uptake of the Influenza vaccination in front line staff. For the first time the Trust achieved greater than 75% vaccination in front line staff which has resulted in lower number of cases of Influenza A seen within the Trust. The Trust achieved 75% of frontline staff being vaccinated which was considerably higher than previous year s figures 50.17% 2014/15, 35.78% 2015/ Infection prevention and control incidents recorded on Datix Every incident (clinical/ non-clinical) or near miss at the Trust should be reported to the Risk Management Team via the online electronic reporting system Datix. Hospitals use Datix to improve safety for patients, healthcare workers, visitors and contractors. During 2016/17 the Infection Team have continued to report incident reporting through Datix, reporting incidents such as: Serious Incidents Requiring Investigation, Post Infection Reviews and Periods of Increased Incidences of Infections for example. This enables more transparency to infection prevention and control incidents and enables feedback to patients and staff if any lapses in care are identified, via Duty of Candour. In addition staff can report any other infection prevention and control incidents enabling the Infection Prevention and Control Team to identify any areas for improvement. During 2016/17, 266 infection prevention and control incidents were reported through Datix which consisted off: 42% incidents relating to acquisitions of infections, 19% inadequate handover of the infection status of the patient by a clinical area, 19% issues with the cleanliness of the clinical area, 8% issues with patients not being isolated appropriately, 4% with an issue related to the patients peripheral venous cannulae/line, 4% sharps disposal issue, other issues included: inappropriate personal protective equipment usage and inappropriate hand washing technique. All these incidents are formally worked through in the Datix incident reporting system and are feedback quarterly to the Infection Group. 4.4 Serious Incidents (SI) The Trust has a Serious Incidents (SI) Policy with serious incidents being reported and managed in line with this policy. Outbreaks/Incidents are managed by Post Infection Reviews held within seven working days wherever practicable and chaired by the Lead Microbiologist for infection prevention and control supported by key healthcare professionals. All SIs are reported to the coordinating Clinical Commissioning Group with a thirty day report being compiled if required. Frequent meetings are held to manage and monitor the outbreak/incident to discuss individual cases and arrange appropriate infection prevention interventions to reduce the risk of spread to other patients/areas whilst maintaining the operational function of the hospital (Table 1). Different outbreaks/incidents demand different responses but are managed with precision and collaborative working between the multidisciplinary teams across the Trust. 19

22 Table /17 Serious incidents and outbreaks Date reported to Risk STEIS No. Description of Incident Investigation Level Outcome Quarter /17 06/04/ /9360 Norovirus outbreak Daily outbreak meetings No lapses in care identified 29/04/ /11675 MRSA bacteraemia MRSA bloodstream Post Infection Review Completed Trust Apportioned case reviewed at Executive RCA 17/05/ /13427 Norovirus outbreak Daily outbreak meetings No lapses in care identified 02/06/ /14932 MRSA bacteraemia MRSA bloodstream Post Infection Review Completed Third party assigned 02/06/ /14934 MRSA bacteraemia MRSA bloodstream Post Infection Review Completed Third party assigned 10/06/ /15792 Norovirus outbreak Daily outbreak meetings No lapses in care identified 24/06/ /17097 C. difficile Period of Increased Incidence Post Infection Review meeting held No further cases on wards after Infection Control interventions Quarter /17 05/07/ /18022 MRSA Period of Increased Incidence Post Infection Review meeting held No further cases on wards after Infection Control interventions 03/08/ /20660 MRSA bacteraemia MRSA bloodstream Post Infection Review Completed Trust Apportioned case reviewed at Executive RCA 03/08/ /20723 MRSA bacteraemia MRSA bloodstream Post Infection Review Completed Third party assigned 11/08/ /21461 C. difficile death Post Infection Review meeting held No lapses in care identified 11/08/ /21466 C. difficile death Post Infection Review meeting held No lapses in care identified 26/08/ /22904 MRSA bacteraemia MRSA bloodstream Post Infection Review Completed Third party assigned 06/09/ /23603 C. difficile death Post Infection Review meeting held No lapses in care identified 07/09/ /23658 C. difficile death Post Infection Review meeting held No lapses in care identified 20/09/ /24791 MRSA bacteraemia MRSA bloodstream Post Infection Review Completed Third party assigned 07/10/ /26306 MRSA bacteraemia MRSA bloodstream Post Infection Review Completed Trust Apportioned case reviewed at Executive RCA Quarter /17 07/10/ /26321 C. difficile Period of Increased Incidence Post Infection Review meeting held No further cases on wards after Infection Control interventions 31/10/ /28247 TB case TB incident meeting held Incident meeting held appropriate staff and patient letters written 14/11/ /29354 Norovirus outbreak Daily outbreak meetings No lapses in care identified 29/11/ /30839 MRSA bacteraemia MRSA bloodstream Post Infection Review Completed Third party assigned 06/12/ /31452 MRSA Period of Increased Incidence Post Infection Review meeting held No further cases on wards after Infection Control interventions 14/12/ /32372 Norovirus outbreak Daily outbreak meetings No lapses in care identified Quarter /17 05/01/ /377 MRSA bacteraemia MRSA bloodstream Post Infection Review Completed Trust Apportioned case reviewed at Executive RCA 19/01/ /1761 MRSA bacteraemia MRSA bloodstream Post Infection Review Completed Third party assigned 26/01/ /2574 C. difficile death Post Infection Review meeting held Trust Apportioned case reviewed at Executive RCA 26/01/ /2580 C. difficile Period of Increased Incidence Post Infection Review meeting held No further cases on wards after Infection Control interventions 24/01/ /2303 Influenza A outbreak Daily outbreak meetings No lapses in care identified 13/02/ /4144 MDR Acinetobacter baumannii outbreak Post Infection Review meeting held No further cases on ward after Infection Control interventions 13/03/ /6984 C. difficile Period of Increased Incidence Post Infection Review meeting held No further cases on wards after Infection Control interventions 20/03/ /7657 Diarrhoea and vomiting outbreak Daily outbreak meetings No lapses in care identified 31/03/ /8853 Norovirus outbreak Daily outbreak meetings No lapses in care identified 20

23 4.5 Patient Advice and Liaison Services (PALS) Contacts The Trust is committed to working in partnership with patients and staff to help improve patient experience. The PALS is part of this commitment to provide high standards of care and to support patients, carers and the public who use Trust services. During 2016/17 there were sixteen contacts received by the Trust in relation to infection prevention and control issues. Some of the issues included: patients acquiring infection, environmental cleanliness, issues over the personal hygiene of the patient and lack of communication with the family regarding the patients infection status. The reoccurring issue included patients acquiring an infection whilst in hospital. These issues are tackled in the everyday work of the Infection Team, for example the team works with the wards providing education on infections and communicating these to the patients. Acquisitions of infections and periods of increased incidences of infections are reported through Datix incidents and reviewed through a Post Infection Review. 5.0 Surgical Site Infections Surgical site infection is a type of healthcare-associated infection in which a wound infection occurs after an invasive (surgical) procedure. Surgical site infections have been shown to compose up to 20% of all of healthcare associated infections. Around 5% of patients undergoing a surgical procedure develop a surgical site infection. A surgical site infection may range from a spontaneously limited wound discharge within 7 10 days of an operation to a more serious postoperative complication, such as a sternal infection after open heart surgery. Most surgical site infections are caused by contamination of an incision with microorganisms from the patient's own body during surgery. Infection caused by microorganisms from an outside source following surgery is less common. The majority of surgical site infections are preventable. Measures can be taken in the pre-, intra- and postoperative phases of care to reduce risk of infection. Surgical site infections can have a significant effect on quality of life for the patient. They can be associated with increased morbidity and extended hospital stay. In addition, surgical site infections result in increased financial costs to healthcare providers. Advances in surgery and anaesthesia have resulted in patients who are at greater risk of surgical site infections being considered for surgery. In addition, increased numbers of infections are now being seen in the community as patients are allowed home earlier following day case and fast-track surgery. Mandatory surveillance of surgical site infections started in 2004, specifying each Trust should conduct surveillance for at least 1 orthopaedic surgical category for 1 period in a financial year. The categories include: hip replacements, knee replacements, repair of neck of femur and reduction of long bone fracture. The Trust has a Trauma audit team which undertakes the mandatory surveillance, reporting on repair of neck of femur and hip replacement surgical site infections. In 2014/15 the Trust reported 0% surgical site infections in hip replacements and 0.7% surgical site 21

24 infections in repair of neck of femur fractures. This increased in 2015/16 with rates of surgical sites infections of 1.5% and 2.6% in repair of neck of femur fractures and hip replacements respectively. During 2016/17 the Trust reported an increase in hip replacement surgical site infections rates (2.7%); however a decrease in repair of neck of femur fractures was seen with a rate of 0.7%. A programme to deliver snapshot surveillance of infections following various types of surgery with the long term aim of making each specialty able to continuously monitor their own infection rates is a priority. One of the targets in the new financial year will be to identify specialities with increased rates of surgical site surveillance; one means of achieving this could be by the development of electronic surveillance systems. Manual snapshot surveillance in areas may need to be undertaken to validate the electronic systems. In addition compliance audits on National Institute for Health and Care Excellence guidance for reduction in surgical site infections needs to be undertaken. 6.0 Audit The Infection Team have a comprehensive audit programme for assurance purposes that has been successfully delivered during 2016/17. Cleaning hands is one of the most important actions anyone can carry out to prevent infection. Hand hygiene audits are undertaken by the clinical area and are reported every month at the Infection Group. Audits are undertaken weekly by the clinical area if hand hygiene compliance is above 90%, if compliance drops below 90% then daily audits are undertaken. Regular hand hygiene audits are performed by the Infection Team to further validate the results. Saving Lives high-impact interventions are evidence based tools that allow staff to monitor compliance with clinical guidance and provide feedback so that compliance can improve consistently. High impact interventions provide the means to ensure that staff undertake clinical procedures correctly every time they are needed. The high impact interventions include guidance and tools for: central venous catheter care, peripheral venous catheter care, renal dialysis catheter care, prevention of surgical site infection, care for ventilated patients, urinary catheter care and reducing the risk of C. difficile. Saving lives audits are regularly undertaken by clinical areas every month and results are reported monthly at the Infection Group. The Saving Lives tools are now out of date; these have now been updated by a nationally working party. It is the aim of the Infection Team to roll out and implement these tools in the new financial year. New tools will enable more robust data to be collected and match current guidelines for the above outlined clinical procedures. A regular infection control audit of clinical areas is carried out by an Infection Prevention Nurse. The audit consists of: observation of practice, review of care and management of patients with infections, observations on correct use of personal protective equipment, observations of environmental cleanliness and review of patient indwelling devices. The results of the audit are feedback to the clinical area 22

25 and Matron. A sharps audit was completed in February 2017 by the Trusts Sharps provider. The survey endeavoured to: raise sharps awareness, assess practice, discuss problems and advise on compliance to current legislation. The overall compliance for sharps practice was 97.7%. A Trust wide central venous catheter audit was completed in April The survey assesses numerous factors in relation to the catheter and care, for example: type, dressing, skin condition of the patient, evidence of infection etc. The results are due to be feedback to the Infection Team, who will then disseminate these to the Divisions. A rolling programme of monthly independent environmental audits, led by the Estates Team, are in place to monitor the compliance of clinical and non-clinical areas against the national cleaning standards framework. Audit results are made available to areas with robust action plans monitored as part of a quarterly summary report to the Infection Group. The Infection Team are active members in the Patient Led Assessments of the Care Environment (PLACE) inspections. PLACE inspections assess the quality of the patient environment. The assessments see local people go into hospitals as part of teams to assess how the environment supports the patient s privacy and dignity, food, cleanliness and general building maintenance. During 2016/17, the Infection Team took part in these assessment audits, driving improvements in the care environment. During 2016/17 an observational audit of the preparation and the administration of intravenous drugs was undertaken. Intravenous therapy is a complex process usually requiring the preparation of the medicine in the clinical areas before administration to the patient. There have been reports of deaths and harm following medication errors such as wrong drug, dose, diluent, and cross contamination errors with intravenous therapy. There is a growing awareness of the importance of the design and implementation of systems of care on the risk of medication errors. The objective of this audit of intravenous practice was to gage the number of observed medication errors, to gain a better understanding of these risks and the methods used. Each year an annual audit of mattresses is carried out within the Trust. The main aim of the foam mattress audit is to identify equipment that is no longer providing pressure reduction. Although Infection control issues should be identified at regular mattress inspections throughout the year, the audit also provides the opportunity for any unresolved problems to be actioned. In conjunction with tissue viability the Infection Team actively take part in the annual audit. The 2016/17 mattress audit results showed the greatest number of acceptable mattresses when comparing results from the last 10 years. In general a change in culture towards mattresses has been seen across the Trust with engagement and interest from staff helping achieve the results seen this year. Both patients and NHS staff have high expectations for safe, good quality care, delivered in welcoming and clean environments. The Productive Ward programme 23

26 helps the NHS to deliver this ambition. The Productive Ward (sometimes known as the releasing time to care) programme supports staff to identify time wasting activities, duplication and inefficiencies that takes time away from caring for patients. The programme identifies simple changes like protecting meal times, protecting drug rounds and preventing interruptions at staff handovers; these improvements can reduce errors and improve safety. In implementing the Productive Ward programme staff have freed up on average 20-30% of additional time, which can be spent with patients. This has a huge impact on improving the quality of care for patients in a visible and tangible way. In turn this programme has sparked the development of The 15 Steps Challenge, a toolkit to help look at hospital care through the eyes of patients and relatives, helping to hear what good looks like. Towards the end of the financial year the Infection Team in conjunction with the Clinical Decision Unit (CDU) and Governors have implemented the 15 steps challenge into CDU. CDU is one of our busiest areas with constant constraints on the Trust due to bed pressures and activity. There are numerous reports in the literature detailing how front door services are constantly being exposed to various nosocomial infections, such as MRSA and C. difficile, seeding the hospital environment. Undertaking the 15 step challenge will help free up time for a busy department such as CDU and improve infection control practices in that area as a result. 7.0 Antimicrobial Stewardship The Trust adopted the national antimicrobial resistance (AMR) CQUIN for 2016/17. Antimicrobial resistance (AMR) has risen over the last 20 years and inappropriate and overuse of antimicrobials is seen as a key driver for this. Between 2010 and 2013, total antibiotic prescribing in England increased by 6%, which was of the largest increases in recent years. As a result a national CQUIN aimed at reducing antimicrobial consumption was implemented. The main aim was to reduce antimicrobial usage in secondary care back to levels before Martin Biggs, Principal Antimicrobial Pharmacist was assigned operational lead for the CQUIN. The CQUIN was divided into two parts (A and B): Part A - Reduction in antibiotic consumption This looked at total Trust consumption and two very commonly used broad spectrum agents that had seen big increases in usage and resistance rates. Four targets were included in this part: 1. 1% Reduction in Total antibiotic consumption per 1,000 admissions 2. 1% Reduction in carbapenem usage (Meropenem and Ertapenem) per 1,000 admissions 3. 1% reduction in piperacillin/tazobactam (Tazocin) consumption per 1,000 admissions 4. Submit Trust usage data for the following years: 2014/15, 2015/16, 2016/17 24

27 The baseline target used for the reduction was usage data from 2013/14. This had previously been submitted to Public Health England (PHE) in 2014 as part of the national ESPAUR report looking at antibiotic usage for the first time in secondary care. Data was to be reported Quarterly to PHE and to local commissioners. Antibiotic usage was measured as defined daily dosing (DDD). Where one DDD = Assumed average maintenance dose per day for a drug used for its main indication in adults. Below are the Trust AMR CQUIN results for the year. 7.1 Total antibiotic consumption Figure 16 shows the total antimicrobial usage for the Trust over the financial year. Figure 16. Trust total antibiotic usage against target - DDD/1000 admissions. Overall there was an 8% reduction in total antibiotic consumption compared to 2015/16. Against the CQUIN target for 2013/14 the Trust has achieved a 24.1% reduction in usage. This was well above the national target. 7.2 Carbapenem usage (meropenem plus ertapenem) Figure 17 shows the total carbapenem consumption over the financial year. Carbapenem usage consists of a combination of two antibiotics: Meropenem accounting for 98% usage in the organisation and Ertapenem accounting for 2% usage Over the financial year there was a 1.8% reduction in carbapenem consumption compared to 2015/16 levels. Against the CQUIN target for 2013/14 the Trust was not been able to achieve the 1% target reduction. Usage since 2013/14 had increased by 0.8%. This was a very challenging target due to the large increase in usage observed between 2013/14 and 2015/16. Therefore the predicted Trust reduction required at the beginning of the financial year was 9%. As a result the Trust 25

28 did extremely well by focusing on duration of therapy across the Trust to reduce usage and end the year in its current position. A number of reasons have affected the Trust not achieving the carbapenem reduction target: National antibiotic shortages: There have been various antibiotic shortages across the UK as a result of the CQUIN driving changes in practice as well as a natural disaster in China, which affected the production of piperacillin/tazobactam, which was to be used in combination with other agents in key antimicrobial guidelines. Assurance of patient safety. Before any major changes to policy choices and switches assurance that patient safety was not affected by reducing total consumption of antimicrobials was assessed and presented to the quality meeting. Figure 17. Carbapenem usage (meropenem and ertapenem) usage against 1% reduction target DDD/1000 admissions. 7.3 Piperacillin/tazobactam (Tazocin ) usage Figure 18 shows the total piperacillin/tazobactam consumption over the financial year. Overall there was a 10% reduction in piperacillin/tazobactam consumption compared to 2015/16 levels. Against the CQUIN target for 2013/14 the Trust achieved a 19.6% reduction in usage. 26

29 Figure 18. Piperacillin/tazobactam usage against target DDD/1000 admissions. 7.4 Submission of antimicrobial usage data Trust antimicrobial usage data was gathered by the antimicrobial pharmacist and submitted successfully to PHE to be included in the national fingertips reporting tool. Part B - Review of antibiotic prescriptions An additional aim of the CQUIN was to ensure that any patients prescribed antimicrobials were also reviewed within 72 hours of starting therapy to ensure appropriateness of treatment and to encourage de-escalation from the intravenous route to the oral route as part of the national start smart then focus approach. Monthly review audits were undertaken by the Pharmacy ward staff. A total of three patients per clinical ward area were audited with information gathered from the electronic prescribing system (PICS) and the medical notes. This information was then gathered by the Principal antimicrobial pharmacist to generate the Trust CQUIN report and submit data to PHE and commissioners via the online submission tool. Below were the Trust target and results for the year: Table 2. Empirical review ward audits. Quarter CQUIN Target milestones Quarter Achieved based on Average target (Yes/ No) 1 N/A - Baseline audit of 50 cases 86.5% Yes 2 10% 91.1% Yes 3 10% 92.6% Yes 4 80% 94.6% Yes Table 2 shows the documented antimicrobial review decision remained above 90% for the last three quarters. Overall the Trust achieved 90.7% of 27

30 documentation being written in the medical notes / electronic prescribing system. Nationally the Trust was higher than the national average of 88.9% in documentation of the review recorded. In addition as part of the CQUIN the outcome of the antimicrobial review documented in the notes was also gathered and submitted: Figure 19. Documented antimicrobial prescribing decision on drig chart (or clinical notes). The most common decision documented was continue with no review date. Although by Q4 this was at 46.7% this had not changed much over the financial year. What was noted was a large reduction in no review date documented at all and a large increase in continue with a review date seen. Further work targeting the quality of the reviews and to empower prescribers to deescalate intravenous antibiotic prescriptions when appropriate was added to the Trust antimicrobial action plan. 7.5 Sepsis CQUIN In addition to the AMR CQUIN the Trust also agreed to complete the national sepsis CQUIN. Sepsis is a common and potentially life-threatening condition where the body s immune system goes into overdrive in response to an infection, setting off a series of reactions that can lead to widespread inflammation, swelling and blood clotting. Sepsis is recognised as a significant cause of mortality and morbidity in the NHS, with around 44,000 deaths in England attributed to Sepsis annually. Of these some estimates suggest 11,000 could be prevented. At the end of the quarter 2 (June 2016) the Trust appointed Dr Mav Manji (critical care consultant) as clinical lead for the sepsis CQUIN and Martin Biggs in a support role to facilitate the completion of the CQUIN. The Sepsis CQUIN was divided into two main sections: 28

31 Part A Timely identification of sepsis The percentage of patients who met the criteria for sepsis screening and were screened for sepsis Part B Timely administration of treatment and review The percentage of patients who present with severe sepsis, Red Flag Sepsis or septic shock and were administered intravenous antibiotics within the appropriate timeframe and had an empiric review within three days of the prescribing of antibiotics. Below are the Trust results for the year: Table 3. Trust sepsis CQUIN results 2016/17. Screening Treatment within time period and review undertaken within 3 days Emergency admissions Inpatients Result Target Result Target Q Q2 95.3% % - Q3 98.1% > 90% 90.3% > 90% Q4 100% > 90% 96.6% > 90% Q Q2 62.1% % - Q3 43.8% >65% 81.8% >85% Q4 ED = 41.2% AUO = 72% Total = 46.5% >70% 92.3% >90% To facilitate the improvements in managing patients with Sepsis a sepsis group was setup with terms of reference and meets quarterly. An educational subgroup with clinical co-ordinators was also created to tackle staff education and training. Screening of patients was also improved with adoption of the Sepsis Trust screening and action tool which has also be added to the Prescribing Information and Communication System (PICS) help tab for easy access for staff. Unfortunately based on the high target thresholds set by the Clinical Commissioning Groups the Trust failed three elements of the CQUIN over the financial year. Timely administration of treatment was a particular challenge in the emergency department due to capacity issues 7.6 Antimicrobial audits In addition to the audits which form part of the AMR and Sepsis CQUIN s, Faye Kester (pre-registration pharmacist) undertook a Gentamicin audit looking at compliance with the Trust antimicrobial guidelines? The results of this highlighted important improvements required, which the Trust is working towards. 7.7 Antimicrobial sensitivities To help further develop the Trust antimicrobial guidelines Dr Martin Gill (consultant microbiologist) developed a sensitivity database from the Trust telepath data. Using this we have been able to assess if the current Trust guidelines need developing. 29

32 Key areas that have been identified to date are Haematology and urinary tract infections. 7.8 PICS development With the support of the PICS team changes were made over the year to improve antimicrobial prescribing of patients. In patients prescribed an antibiotic an icon was added ( ). This is displayed on the patient record and ward list to highlight to staff which patients are on antibiotic treatment to ensure they are managed correctly. To facilitate staff in the review of antimicrobials a red eye icon ( ) is added 48 hours after the start of the prescription to remind staff to review therapy and to document the outcome of this in the medical notes. Serious infection CQUIN 2017/19 The Trust has adopted the serious infection CQUIN for 2017/19 which is a combination of the Antimicrobial resistance (AMR) CQUIN and the Sepsis CQUIN. The new CQUIN involves four elements. Very similar to those of the previous two CQUIN s (Table 4): Table 4. The serious infection CQUIN summary. Goal reference (National CQUIN) Indicator name Default Default CQUIN CQUIN weighting - weighting Year 1 - year 2 2a Timely identification of patients with sepsis in emergency departments and acute inpatient settings 0.250% 0.250% 2b Timely treatment of sepsis in emergency departments and acute inpatient settings 0.250% 0.250% 2c Antibiotic review 0.250% 0.250% 2d Reduction in antibiotic consumption per 1,000 admissions: 1. Total antibiotic usage per 1,000 admissions 2. Total usage of carbapenem per 1,000 admissions 3. Total usage of piperacillin-tazobactam per 1,000 admissions 0.250% 0.250% 30

33 Percentage reduction in usage will be based on Trust performance for 2016/17: o 1% reduction for those Trusts with 2016 consumption indicators below 2013/14 median value, or o 2% reduction for those Trusts with 2016 consumption indicators above 2013/14 median value Baseline used will be January 2016 till December 2016 Based on performance above the Trust will need the achieve: o 2% reduction in total antibiotic usage o 2% reduction in piperacillin/tazobactam usage o 2% reduction in carbapenem usage 8.0 Training and Education In 2016/17 the Infection Team have continued to deliver a wide variety of education both within the Trust and externally. It is mandatory for every member of staff to receive an annual infection prevention and control update. In 2016/17, 8,085 staff were trained resulting in a compliance rate of 92.71%. This is a slight decrease compared with previous years where the Trust achieved compliance rates of 94.2% (2015/16) and 93% (2014/15). The high training figures have been achieved through Trust Induction and both Trust, local mandatory training sessions and an elearning package. These sessions have been reviewed and updated to ensure they remain relevant with up to date content. During 2016/17, the Infection Team have worked in collaboration with Learning and Development to ensure appropriate role specific training, in addition to rolling out an elearning package. The Infection Team have delivered informal and formal sessions on a variety of subjects and continue to support registered practitioner and doctor induction programmes. The team have tailor made annual infection prevention and control updates for doctors in different specialities and doctors of different grades making this more relevant. The team have also tailored infection prevention and control presentations for international fellows and the new consultant s mandatory training. On top of this the Infection Team have delivered infection control training sessions/updates to numerous specialities and staff groups throughout the Trust, for example teaching and education sessions to: facilities staff, preventing harm meetings, divisional quality meetings, divisional governance meetings, care quality management group, antimicrobial steering group, doctors grand round, divisional monthly update meetings, volunteer sessions, matron meetings and the executive team. Nursing assistants also receive an in depth infection prevention and control training session on their development programme including using the glow box, extra information on C. difficile and MRSA. One of the key strategic aims for the next financial year is engagement with staff and part of this is to reinvigorate doctors training. The specific aim is to engage doctors by delivering infection prevention and control educational programmes that are tailored to meet the needs of the service and this staff group. 31

34 During 2016/17 there has been a big drive towards recognition and management of sepsis due to the national CQUIN. As such a sepsis group has been formed within the Trust to improve the management and recognition of sepsis which the Infection Team are members off. An education sub group was also formed in 2016/17 which the Infection Team are active members off. As a result an educational package on sepsis has been rolled out across the Trust being delivered to all clinical staff (tier 1) and is provided to all newly qualified registered nurses on their preceptorship course. Sepsis education is given at various forums such as: mandatory or divisional training, during basic/advanced life support training and during recognising an acutely sick patient training. In addition the sepsis group has launched a new sepsis tool to be used throughout the Trust; training on how to use the tool has been given at the various forums. Sepsis awareness teaching has also been given at the grand round, the Clinical Nurse Specialist (CNS) forum and delivered to every ward during the sepsis awareness week campaign. The Infection Team have also given education sessions externally teaching on the University of Birmingham s undergraduate nursing programme. The Infection Team have delivered lectures on infection prevention and control, communicable diseases such as Mycobacterium tuberculosis (TB) (Figure 20) and leadership roles within nursing. The Infection Team have also given lectures on the undergraduate and postgraduate Medical Microbiology courses delivered by the University of Birmingham on various nosocomial pathogens. The team have also delivered lectures at International conferences both within the UK and in Europe promoting best practice within infection prevention and control. Figure 20. TB lecture given by the Infection Team to the undergraduate nursing programme at the University of Birmingham on World TB day Education and training will remain a key priority in the new financial year promoting best practice within infection prevention and control. 32

35 9.0 Facilities The ongoing and continuous review of cleaning requirements between Facilities and the Infection Team has resulted in 1,600 areas being misted with H 2 O 2. There were also 8,800 terminal cleans on bed spaces and 19,500 fresh curtain changes. The Trust s independent monitoring team gave an overall rating of 97% for the cleanliness of the hospital in the first two months of this financial year with 96% of patients surveyed over the last 12 months reporting their wards / clinical areas as clean. The Patient-Led Assessment of the Care Environment (PLACE) audit that took place in May 2017 saw 30 patient and staff assessors review the environment in detail; giving an overall score of 99.30% for the hospital environment. This is an increase from the 2016 PLACE score of 98.94%. 10. Occupational Health As part of the Health and Social Care Act 2015 providers are required to have a system in place to manage the occupational health needs and obligations of staff in relation to infection. Briefly during 2016/17 the Occupational Health team has dealt with several issues including skin integrity of staff, respiratory related issues including incidents around Tuberculosis, actively involved in achieving the national CQUIN on staff health and wellbeing specifically focusing on healthcare providers achieving a 75% uptake of the Influenza vaccination in front line staff, dealing with inoculation injuries and immunisation/ blood tests for staff. All new starters when attending Occupational Health for their first appointment have their skin assessed and relevant advice given to them. During 2016/17 55 individuals have either self-referred or been referred to Occupational Health for advice about their hands. Cases of dermatitis since the introduction of Sonic 200 gloves have increased, however the original gloves can now be ordered once the individual has been reviewed in Occupational Health. In relation to dermatitis problems both the Occupational Health Team and Infection Team have held a road show on hand hygiene and hand healthcare. During 2016/17 the Occupational Health team have had a number of respiratory related queries. The majority of cases seen by the Occupational Health team are due to overseas honorary doctors coming from high Tuberculosis endemic areas who require testing and treatment for latent Tuberculosis. There continues to be an international shortage of BCG vaccine, therefore previously unvaccinated staff members are not able to receive this vaccine. They are given advice about using appropriate PPE from the ward manager and infection control. All staff exposures from Tuberculosis are followed up and given appropriate advice. In relation to a number of Tuberculosis incidents last year the Infection Team have set up monthly Tuberculosis exposure incidents to both staff and patients. Membership consists of the Infection Team, the Occupational Health Department, Medical Microbiologist and the Tuberculosis lead for the Trust. Tuberculosis is among the top 10 cases of death worldwide with the UK 33

36 seeing up to 6,000 cases per year. In the Midlands there is a high incidence of Tuberculosis so the Trust sees cases throughout the year. Monthly meetings to discuss cases ensure all exposure incidents are dealt with appropriately in a timely fashion. 2016/17 has been a challenging year for the Occupational Health Team with the national CQUIN on staff health and wellbeing. Part of the CQUIN requires healthcare providers to achieve a 75% uptake of the Influenza vaccination in front line staff. To achieve the CQUIN 4283 staff member were vaccinated, of these 3959 were frontline which meant 76.5% of frontline staff were vaccinated against influenza. The Influenza programme was led by the Executive Chief Nurse and DIPC Mr Philip Norman and Deputy Chief Nurse Mrs Michele Owen and was delivered by Occupational Health supported by Peer Vaccinators. The Infection Prevention and Control Team supported the Occupational Health Team during the Influenza vaccination campaign. In 2016/17 inoculation injuries continue to be at 3-4% of the Trust head count (Figure 22). High risk injuries: consent is sought from the individual to report to H&S and onto RIDDOR. Figure 22. Inoculation and splash injuries by Division 2016/ A B C D Corp Splash Injury Inoculation Injury During 2016/17 the Occupational Health team undertook 8071 Occupational Health immunisations/blood tests (excluding flu), however there is a 19% did not attend rate of all appointments Research and development Research and Development is a key component of an infection prevention and control programme, particularly in a high profile teaching Trust such as UHB. Research can be used to develop science and evidence based practice to further drive infection prevention and control improvement. During 2016/17 the Infection Team has been actively involved in numerous research projects highlighted by 8 peer reviewed journal articles being publishing and several team members giving presentations at international/national conferences and study days 34

37 on its work throughout the year. At the annual international Infection Prevention Society conference in Harrogate the team gave two verbal presentations and presented 2 posters. The team also has members which are part of national infection control societies such as the Infection Prevention Society (IPS) and Healthcare Infection Society (HIS). The Lead Nurse is a director and trustee of IPS and the Associate DIPC is a councillor and trustee of HIS. Roles within these societies have enabled team members to be part of various national groups including working parties and scientific development committees to drive practice change both nationally and internationally. The Infection Team work closely with the Hospital Infection Research Laboratory (HIRL). HIRL established in 1964 at City Hospital and relocated to the Trust in 2008; providing specialised infection advice both international, nationally and locally. This financial year HIRL have provided the following support to the Trust: validation of theatre ventilation on the upgraded theatres, research work on P. aeruginosa in relation to water quality within critical care, mop decontamination reducing the risks of infection, testing alternative cleaning methods with facilities, advising the endoscopy department and endoscopy decontamination. The HIRL laboratory manager sits on the decontamination and water safety group in an advisory capacity, working closely with the decontamination services both within the Trust and externally at BBraun sterilog. HIRL actively participate in research with the Infection Team as highlighted from the recent publications. Selected research publications from the year are detailed below: Bradley CW, Wilkinson MA, Garvey MI. The Effect of Universal Decolonization With Screening in Critical Care to Reduce MRSA Across an Entire Hospital. Infect Control Hosp Epidemiol Garvey MI, Bradley CW, Casey AL. Using a carbapenemase-producing organism polymerase chain reaction to rapidly determine the efficacy of terminal room disinfection. J Hosp Infect Bradley CW, Holden E, Garvey MI. Hand hygiene compliance targets: what are we actually targeting? J Hosp Infect Garvey MI, Bradley CW, Holden KL, Hewins P, Ngui SL, Tedder R, Jumaa P, Smit E. Use of genome sequencing to identify hepatitis C virus transmission in a renal healthcare setting. J Hosp Infect Garvey MI, Pichon B, Bradley CW, Moiemen NS, Oppenheim B, Kearns AM. Improved understanding of an outbreak of meticillin-resistant Staphylococcus aureus in a regional burns centre via whole-genome sequencing. J Hosp Infect Garvey MI, Bradley CW, Jumaa P. The risks of contamination from tap end filters. J Hosp Infect Garvey MI, Bradley CR, Bradley CW. Evaluating the risks of wash hand basin tap disinfection. J Hosp Infect Garvey MI, Bradley CW, Tracey J, Oppenheim B. Continued transmission of Pseudomonas aeruginosa from a wash hand basin tap in a critical care unit. J Hosp Infect

38 Garvey MI, Ashford R, Bradley CW, Bradley CR, Martin TA, Walker J, Jumaa P.J Decontamination of heater-cooler units associated with contamination by atypical mycobacteria. Hosp Infect Garvey MI, Bradley CW, Jumaa P. Environmental decontamination following occupancy of a burns patient with multiple carbapenemaseproducing organisms. J Hosp Infect Other studies are being planned with both external academic partners and internal clinical parties. Research development within the Infection Team at the Trust will continue to flourish in the next financial year. Already in the new financial year the flowing research articles have been accepted for publication: Garvey MI, Bradley CW, Casey AL. Using a Van-A polymerase chain reaction to rapidly determine the environmental contamination following a VRE outbreak. J Hosp Infect Garvey MI, Bradley CW, Wilkinson MAC, Holden E. Can a toxin gene NAAT be used to predict toxin EIA and the severity of Clostridium difficile infection? Lancet Infec Dis 2017 Garvey MI, Philips N, Bradley CW, Holden E. Decontamination of an extracorporeal membrane oxygenator contaminated with Mycobacterium chimaera. Infect Control Hosp Epidemiol 2017 Garvey MI, Bradley CW, Biggs M, Holden E, Walker J, Gill M. Waterborne carbapenem resistant Pseudomonas transmission in a haematology unit? J Hosp Infect, 2017 Garvey MI, Bradley CW, Holden E, Weinbren M. Where to do water testing for Pseudomonas aeruginosa in a healthcare setting? J Hosp Infect, 2017 Halstead FD, Niebel MO, Quick J, Garvey MI, Cumley N, Smith R, Neal T, Roberts P, Hawkey P, Hardy K, Shabir S, Walker J, Loman L, Oppenheim B. Pseudomonas aeruginosa infection in augmented care: detecting transmission from water using whole genome sequencing in an observational study. J Hosp Infect, 2017 Walker J, Moore G, Collins S, Parks S, Garvey MI, Lamagni T, Smith S, Dawkin L, Goldenberg S, Kappeler R, Chand M. A review of the microbiological problems and biofilms associated with Mycobacteria chimaera in heater cooler units used for cardiopulmonary bypass. J Hosp Infect, 2017 Garvey MI, Bradley CW, Wilkinson MA, Bradley CR, Holden E. Engineering waterborne Pseudomonas aeruginosa out of a critical care unit. Int J Hyg and Env Health, 2017 Garvey MI, Bradley CW, Holden KL, Oppenheim BA. Outbreak of clonal complex 22 Panton-Valentine leucocidin positive meticillin resistant Staphylococcus aureus. J Infect Prev Garvey MI, Bradley CW, Walker J. Heater cooler units contaminated with Mycobacterium chimaera a year on? Infect Control Hospi Epidemiol

39 12.0 Infection Initiatives Continuing the work from last year MRSA bacteraemias and acquisitions within the Trust for this financial year have been lower compared to previous years. For this financial year the Infection Team has focused on the following: hand hygiene, increasing the screening compliance internally, education around MRSA screening and decolonisation, MRSA acquisition nurse led ward rounds, antimicrobial stewardship and investigations such as Post Infection Reviews and root cause analysis reviews being feedback throughout the Divisions within the hospital. One of the main initiatives to tackle the increase in MRSA bacteraemias has been the reintroduction of universal MRSA decolonisation in critical care. Isolation and decolonisation are the two main targeted control measures for reducing transmission of MRSA in hospitals. Before 2014 all Critical Care Unit patients at the Trust received universal MRSA decolonisation therapy. In August 2014 the Trust discontinued the use of universal decolonisation due to published reports in the UK detailing the limited usefulness and cost effectiveness of such an intervention. As a result MRSA acquisition and bacteraemia rates significantly increased in the Trust. As a result of the increase the Trust reintroduced universal MRSA decolonisation therapy which has reduced the rate of MRSA acquisitions and bacteraemias throughout the Trust (Figure 4), for this financial year. The Trust has utilised MRSA screening and clinical isolate data to further clarify MRSA acquisitions within the Trust. This has enabled the teams to identify potential transmission links within the Trust, understand the epidemiology of this pathogen and use acquisitions as a predictor for an MRSA bacteraemia. MRSA acquisition data has also been used as an indirect quality for adherence to infection prevention and control practice. Areas where MRSA acquisitions are seen are reviewed by the Infection Team observing practice and formulating action plans if needed. Data is also shared with Divisions and presented at specialty meetings. During this financial year all MRSA acquisitions are reviewed by the Infection Team on nurse led MRSA acquisition ward rounds. Patients which acquire MRSA are at high risk of developing an MRSA bacteraemia; nurse led ward rounds of these patients has been invaluable for the care and management of these high risk patients. Infection Control Nurses are uniquely placed to lead MRSA ward rounds due to their experience and expertise in the management of the infection. The ward rounds provide an opportunity for a holistic nursing assessment including review of the decolonisation therapy for colonised patients, review of the antimicrobial treatment if the patient requires any, review of any invasive devices and skin integrity of patients. In addition patients have rapid access to specialist advice from Microbiology Consultants via the ward round team if they become unwell. Improvement in the outcome of patients has been observed since implementation including an overall reduction in the number of MRSA acquisitions and bacteraemias observed within the Trust. C. difficile infection continues to be a major burden to patients that can also cause 37

40 increased morbidity and mortality. For this financial year the number of Trust apportioned C. difficile infection cases has increased. At the Trust we have strengthened the national Post Infection Review process adding more criteria into the review allowing more detail about the individual cases to be gathered. This has enabled robust action plans to be developed if any lapses in care have been identified. During the last financial year we have continued and improved the nurse led C. difficile ward rounds. Infection Control Nurses are uniquely placed to lead C. difficile ward rounds due to their experience and expertise in the management of the infection. Supported by Gastroenterology and Microbiology; ward rounds include patient assessment and treatment review to optimise the management of C. difficile infection for patients. The ward rounds provide an opportunity for a holistic nursing assessment including nutrition and hydration, skin integrity, bowel management and medicines review and optimisation. Patients are assessed early in the course of disease for faecal microbiota transplant which if indicated is administered by the infection control nurse. Patients have rapid access to specialist advice from gastroenterology and microbiology consultants via the ward round team. Improvement in the outcome of patients has been observed since implementation including an overall reduction in the level of severity, reduced mortality, reduction in recurrence rates and increased uptake of faecal microbiota transplant. Over the last decade, CPEs have spread worldwide, becoming a public health concern. During the last financial year we have seen an increase in the amount of CPEs within the Trust. The interventions at present to control the spread of these organisms consist of screening high risk patients, good infection control practice and environmental cleaning. The Trust has worked closely with the Clinical Commissioning Group, Public Health England and local hospitals in the control and spread of these organisms due to our experience in dealing with patients repatriated from abroad harboring these organisms. The Infection Team have worked closely with facilities and created a new decontamination method which the Trust now use to render a room safe for re-use after these patients have been discharged. This work has been published with other hospitals using this method to clean in a similar way to our Trust. CPEs are a concerning problem with a large increase seen nationally and locally the Trust will have to be aware of this moving into the next financial year. The Infection Team along with the clinical microbiology department will be looking into new ways to screen patients to readily identify carriage. Contamination of hospital surfaces can contribute to the transmission of healthcare associated infections. The best way of reducing healthcare associated infections after hand hygiene is environmental control. The Infection Team have worked closely with Facilities further improving cleaning techniques, making the procedures more robust and easy to follow. During the last financial year the Infection Team have launched a new cleaning traffic light poster for outpatients (Figure 23). Other changes have included changing of the wipes used within the Trust; the Trust has now moved over to using clinell universal wipes. The Infection Team and the HIRL are constantly working with the facilities department to improve the cleaning practices for example trailing new products to decontaminate the environment including UV light. 38

41 Figure 23. New cleaning traffic light poster used within the Trusts outpatient department to make cleaning easier to understand. Surveillance of MSSA bacteraemias has shown a large proportion of infections are line associated. Due to the success of undertaking Post Infection Reviews of MSSA bacteraemias in haematology related to devices and the subsequent reduction in device related infections. MSSA root cause analysis review are now undertaken in all specialities across the Trust on line associated MSSA bacteraemias, enabling any potential lapse in care to be identified and addressed with robust action plans. For 2016/17 the number of MSSA bacteraemias related to invasive devices has decreased to 26% as compared to 2015/16 where 40% were related to invasive devices. Similarly, surveillance of E. coli bacteraemias has shown a large proportion of infections are associated with urinary tract infections with a proportion of these being catheter associated. Any E. coli bacteraemias with the source of infection being a catheter associated urinary tract infection undergo a Post Infection Review to identify learning points. The NHS Safety Thermometer tool looks for the presence or absence of harms, one of these being urinary tract infections in patients with a urinary catheter. Any new urinary catheter harm identified in a patient through the Safety Thermometer also undergoes a Post Infection Review. This work was trialled in Division D with any learning points being addressed by the wards and feedback through the Continence Action Group. Undertaking this work there was a reduction in E. coli bacteraemias related to urinary catheters by 22% and a reduction in urinary catheter harms by 39% during 2016/17. During 2016/17 we have started Post Infection Reviews on all catheter related E. coli bacteraemias and new urinary catheter harms throughout the Trust. In light of the new quality premium to reduce Gram negative bacteraemias across the whole healthcare economy the Infection 39

42 Team will continue to undertake work on reducing E. coli bacteraemias. Key areas to focus on will be antimicrobial stewardship, surgical antimicrobial prophylaxis and urinary catheter care. The infection Prevention and Control Team have started work with the Infection Team at Heartlands hospital on creating a central database of E. coli bacteraemias and sharing the learning on reducing the number of these infections across both hospitals. Cleaning hands is one of the most important actions anyone can carry out to prevent infection. Patient safety organisations in the UK and the World Health Organisation have focused on making hand hygiene routine behaviour in healthcare settings. Hand hygiene forms a major part of the Infection Team s key priorities and every year initiatives are undertaken to further raise awareness of hand hygiene prompting this through education and teaching to all staff within the Trust (Figure 24). Examples of promoting hand hygiene have included partaking in World hand hygiene awareness day with stands in the atrium for the public as well as road shows on clinical areas (Figure 25). At the annual Trusts nursing conference hand hygiene was also promoted throughout the day with a stand in the atrium (Figure 26). Working with the Communications Department, hand hygiene is constantly being promoting to staff and public, via electronic bulletins and in QEHB news. Figure 24. Photographs of the Infection Team and Nursing Students promoting hand hygiene. Figure 25. Photographs of the Infection Team and Nursing Students promoting hand hygiene. 40

43 Figure 26. Infection Team with a stand at the Annual Nursing Conference promoting hand hygiene. The Infection Team are actively involved in the management of water safety within the Trust. Representatives of the team sit on the Water Safety Group and are actively involved in the control of Legionella pneumophilia, P. aeruginosa and other waterborne pathogens. The Water Safety Group are actively involved in numerous research projects to improve the water quality and management within the Trust. The financial year 2016/17 has been challenging in terms of P. aeruginosa and the Trust has taken steps to reduce the risk of transmission by examining intrinsic, holistic and engineering factors. Research is ongoing with planned initiatives to further reduce the number of outlets being colonised with P. aeruginosa across all areas of augmented. Work has influenced recently published national guidance on managing P. aeruginosa in augmented care units. L. pneumophilia continues to be controlled by the PFI and results monitored by the water safety group, during 2016/17 there were no issues with L. pneumophilia and all results were managed in accordance with national policy and local policy. Water microbiology is unpredictable and unknown problems can arise at any time. This was case this year when the Trust was alerted to an international problem where Mycobacterium chimaera infections were identified following cardiac surgery being attributed to the use of heater cooler units (HCUs) which form part of the cardiopulmonary bypass equipment. Cases of endocarditis have been reported worldwide with the causative organism being M. chimaera reflecting the global problem of microbial colonization and the need for effective management of HCUs. The Water Safety Group have actively been involved in dealing with this problem, with the work undertaken by the Trust being published and used worldwide to tackle this problem. The Water Safety Group meets monthly managing such problems feeding into the Infection Group. Mycobacterium tuberculosis (TB) infects one-third of the world s population and is 41

44 the most frequent infectious cause of death worldwide, accounting for 3 million deaths per year. Infection is acquired by inhalation of infectious droplets. Almost all UK TB is acquired through the respiratory route. The Infection Prevention and Control Team have undertaken education work on TB within the Trust focusing on early recognition, diagnosis and infection prevention and control precautions. The team has also participated in World TB day focusing on education and made strong links with regional TB nurses. In addition the Infection Team have created a monthly TB incidence review panel to discuss any new case within the Trust to identify whether staff or patients have been exposed to TB; with action plans being developed if such an occurrence has been identified. Sepsis is a life-threatening condition that that affects an estimated 150,000 people in the UK every year. It occurs when the body s natural response to an infection damages its own tissues and organs. If not recognised early and treated quickly, sepsis can lead to septic shock, organ failure and even death. Approximately 44,000 people die each year in the UK as a result of sepsis more than bowel, breast and prostate cancer combined. It s estimated that a quarter of deaths could be avoided by early detection and timely treatment. In 2016/17 the Trust agreed to complete the national sepsis CQUIN. The Infection Team were heavily involved in the promotion of sepsis, sepsis education as well as launching a new screening and action toolkit to improve awareness of sepsis within the Trust. The sepsis screening and action toolkit is part of the Trust s think sepsis campaign to educate staff on the early-warning signs of sepsis and is just one of a number of ways the sepsis team are improving the sepsis care pathway. To launch the initiative, the Trust held a sepsis awareness week (Figure 27) which was opened by Dr Ron Daniels, chief executive of the UK Sepsis Trust, who has greatly influenced the national and international sepsis agenda and is a clinical adviser on sepsis to NHS England. More than 160 clinical staff attended Dr Daniels thought-provoking lecture on the real-life impact of the condition highlighting the importance of early intervention and treatment. Throughout the week, staff across the Trust got involved in a range of education activities, held information stands and took part in a tastebud-tantalising charity cake sale, raising for the UK Sepsis Trust and QEHB charities, whilst promoting the think sepsis recognise, screen and treat message (Figure 28). Figure 27. Photograph of the launch of the sepsis awareness week at the Trust. 42

45 Figure 28. Photographs of the Infection Team promoting sepsis awareness week. The Infection Team have supported other departments within the Trust for example: Working with the Tissue Viability Team by undertaking the annual foam mattress audit Reviewing the external renal dialysis clinics from an infection prevention and control perspective Having nursing students shadowing the Infection Team during their nursing course The team now undertakes a student nurse Infection prevention and Control education pathway experience Having military staff shadow the team during their infection prevention and control courses Given Infection Control updates at the patient and carers council Team members sit on the Product Evaluation Group being involved in decision making of products for example implementation of the new needle free connectors Have regular medical students undertake projects within the team highlighted by one of the students receiving the best poster prize during their degree This has enabled the team to broaden relationships across the Trust further embedding infection prevention and control practice within the Trust. The team are also working closely with counterparts at Heart of England NHS Foundation Trust on various projects and to learn from one another s practices embedding the learning into our Infection Control practices moving forward 13.0 Innovation and the future Infection is a top priority for the Trust. Keeping our patients safe from avoidable harm is everyone s responsibility. The infection prevention and control team has set out an ambitious but flexible and achievable programme of work over 2017/18, with the aim to keep our patients, staff and public informed of planned activity. Each year the Infection Team undertake a review of the Trust s compliance with the Health and Social Care Act 2008 code of practice on the prevention and control of infections (2015). The teams aim is to provide an infection prevention and control service that supports our clinical teams to deliver the best in 43

46 care. This year s annual plan covers 5 strategic themes (Figure 29). An update on the actions and work plan is provided as part of the regular Board of Directors updates around infection prevention and control. The plan for the Infection Prevention Control Team in 2017/18 provides an operational framework for achieving progress with our strategic themes. The Executive Director responsible is Philip Norman, Executive Chief Nurse and Director of Infection prevention and Control. The Infection Teams plan will ensure: The Trust complies with relevant national guidance and policies specifically the Health and Social Care Act. Incorporates the learning from Post Infection Reviews, complaints and incidents. Ensure audits/reviews are undertaken providing robust assurance around the Trusts quality indicators for infection prevention and control. Antibiotic stewardship is improved through the new reductions in serious infections CQUIN. Engagement, education and training in infection prevention and control being at the forefront in all what we do. To deliver the priorities and plans for 2017/18 the key actions will be (Figure 29): Figure 29. The Infection Teams strategic themes in 2017/18 A hand hygiene programme to reinvigorate compliance across the Trust, reducing the transmission of nosocomial pathogens amongst our patients. Healthcare associated infection reduction plan focusing on the following pathogens: o To implement an MRSA reduction plan and audit compliance on this. o Implement a C. difficile action plan to further reduce the rates of C. difficile infection and audit compliance on this. o Implement a Gram negative bacteraemia reduction plan specifically focused on E. coli related to the quality premium guidance to reduce 44