Infection Prevention and Control Annual Report 2015/16

Transcription

1 Infection Prevention and Control Annual Report 2015/16 Amanda Hemsley, Senior Nurse Advisor for Infection Prevention and Control Report Period: April 2015 March 2016 Report Date: June 2016 Infection Prevention and Control Annual Report 2015/16 1 of 39

2 Contents Page Abbreviations 3 Executive Summary Introduction Infection Prevention and Control Arrangements Infection Prevention and Control Team 2.2 LPT Infection Prevention and Control Committee 3.0 Annual Programme 2014/ Monitoring Arrangements MRSA 4.2 Clostridium difficile 4.3 Mortality data for Clostridium difficile 4.4 HCAI risks identified on the risk register 5.0 Prevention and Reduction Strategies 5.1 Post Infection Review 5.2 Increased incidence of Infection Code of Practice for the Prevention and Control of Health Care 11 Associated Infection (The health Act 2008) 6.1 Safer sharps 6.2 Sharps incident data 6.3 Flu vaccination 7.0 Patient and Public Involvement Antimicrobial Prescribing Decontamination Patient Led Assessment of the Care Environment (PLACE) Policies, Procedures and Guidelines Audit Training and Education HCAI Assessment for Commissioning Services Conclusion 16 Appendices Appendix 1: Summary of key findings for internal Root Cause Analysis on reported cases of Clostridium difficile within LPT 2015/16 Appendix 2: 30 day mortality rate for CDI Appendix 3: Annual report overview report Appendix 4: Norovirus Activity Report 2015/16 Appendix 5: PLACE results 2015 Appendix 6: Policy review timetable Infection Prevention and Control Annual Report 2015/16 2 of 39

3 Abbreviations CCG C-Diff CDI CQC CQUIN DIPaC ELRCCG EMSHA HAI IPC IPS LPT MRSA MSSA NHSLA NHSI NPSA NSC PHE PIR PLACE QAC QS RCA RCN SI TDA UHL Clinical Commissioning Group Clostridium difficile Clostridium difficile Infection Care Quality Commission Commissioning for Quality and Innovation Director of Infection Prevention and Control East Leicestershire and Rutland Clinical Commissioning Group East Midlands Strategic Health Authority Healthcare Associated Infection Infection Prevention & Control Infection Prevention Society Leicestershire Partnership Trust Meticillin Resistant Staphylococcus aureas Meticillin Sensitive Staphylococcus aureas National Health Service Litigation Authority National Health Service Improvement National Patient Safety Agency National Specification for Cleanliness Public Health England Post Infection Review Patient Led Assessment of the Care Environment Quality Assurance Committee Quality Schedule Root cause analysis Royal College of Nursing Serious Incidents Trust Development Authority University Hospitals of Leicester Infection Prevention and Control Annual Report 2015/16 3 of 39

4 Executive Summary This report covers the period from 1 April 2015 to 31 March The following bullet points summarise the key areas: Leicestershire Partnership Trust has a fully functioning Infection Prevention and Control Committee with Terms of Reference that ensure representation is achieved from all divisions within the organisation. There were 0 cases of MRSA bacteraemia attributed to LPT against the National Target of 0 cases. There were 13 reportable cases of Clostridium difficile infection against an organisational trajectory of 7. There was 1 case where Clostridium difficile was identified on the death certificate as a contributory factor to the patient s death. Serious incident reviews were carried out for all of these patients and reported through the IPC committee and the governance committees for the clinical services. There were 2 potential cases of Clostridium difficile due to cross contamination of infection within LPT. A full thematic review of the 13 serious incident review cases was carried out and is included within this report. The Quality Assurance Committee was informed through exception reporting. There were 3827 substantive post holders required to undertake level 2 infection control training. The target for compliance with this training is 85%. Compliance rates were 92.5%. Over the last 12 months compliance rates have increased each month. As of Mar 2016, 3969 substantive post holders are required to complete hand hygiene training; 97.4% of post holders are recorded as compliant. Evaluations of e-learning have been very positive and the move to this training medium has resulted in achieving consistent high compliance rates. There were 636 bank post holders required to undertake level 2 infection control training. Compliance in June 2015 was at 38.9%. By March 2016 the compliance rate has increased to 71.5%. This demonstrates a significant improvement, although it remains below the target of 85%. Hand hygiene for bank post holders was recorded at over 85% for 4 months until the end of March Learning and Development Service hold regular meetings with the Centralised Staffing Solutions team to formulate actions, and review success of actions, to address training compliance. Representatives from Learning and Development continue to attend directorate groups and proactively advocate compliance for all mandatory subjects. Where compliance rates fall below the required 85% rate of compliance, services are supported to take the necessary actions to correct this. Infection Prevention and Control Annual Report 2015/16 4 of 39

5 From April 2015 to the end of March 2016 there were 8 known Norovirus incidents within Leicestershire Partnership Trust; an increase of 2 compared to the previous year. In 2015/16 there were 6 reported increased incidences of diarrhoea and/or vomiting where no organism was identified or samples were not obtained. There were a total number of 35 beds closed across the organisation that were closed to admissions, with an approximation of 167 bed days lost. In total 125 patients and 28 staff members were recorded to be affected with diarrhoea and/or vomiting. The patient numbers are comparative to the previous year with approximately 44% reduction of staff affected. There were no wards closed as a result of diarrhoea and/or vomiting. LPT continued to provide evidence of compliance with the Health and Social Care Act 2008 (hygiene code) populating the self-assessment tool developed by the commissioning bodies as part of the quality schedule. Bi-monthly meetings between the Senior Nurse Advisor for Infection Prevention and Control (LPT) and the Head of Infection Prevention and Control (ELRCCG) continued as part of the compliance with the HCAI related Quality Schedule objectives. These are monitored by NHS Leicester City and Leicestershire County and Rutland at the monthly Integrated Quality Performance Review Group meetings (IQPR). A programme of HCAI audit activity was completed. The programme of IPC requirements continued to be actioned and monitored. An assurance folder was relaunched for all areas in January 2016 to support fulfilment of the CQC requirements for Outcome 8 in relation to hand hygiene compliance through audit, cleaning and decontamination schedules and the provision of a link champion programme. The uptake of the flu vaccine overall for LPT was 47% a decrease of under 5% on the previous year. A visit and systems review was carried out in March 2015 by the Head of Infection Prevention and Control for the TDA; now NHSI. Recommendations for improvement were made, which have been incorporated and met in line with the trusts IPC action plans and annual work plan for IPC. Infection Prevention and Control Annual Report 2015/16 5 of 39

6 1. Introduction The effective prevention and control of healthcare associated infection is a prerequisite for delivering safe patient care in Leicestershire Partnership NHS Trust (LPT). This annual report summarises the progress made in the prevention and control of infection in 2015/16. This report is demonstrates that LPT complies with the duties set out in the Health and Social Care Act (2008), requiring healthcare organisations to publish details about their progress in implementing programmes for Infection Prevention and Control. This report provides evidence that LPT meets the duties of the Hygiene Code, the NHS Litigation Authority (NHSLA) and the Care Quality Commission outcomes. The work of the Infection Prevention and Control Team, supported by the Chief Nurse/Deputy Chief Executive and the Head of Professional Practice and Education, ensures LPT minimise the risk of healthcare acquired infection to patients in accordance with and taking into account of: NICE (2012) Infection: Prevention and Control of healthcare associated infections in primary and community care. CQC (2010) Essential standards of Quality and Safety Outcome 8 cleanliness and Infection Control. Clostridium difficile infection: How to deal with the problem (HPA & DH 2009) Board to Ward (DH 2008). The Health Act (2008) Code of Practice for the Prevention and Control of Health Care Associated Infection (DH 2006). DH (2008) Clean, Safe care: Reducing infections and saving lives. DH (2007) Saving lives reducing infection, delivering clean and safe care. DH (2004)Revised guidance on contracting for cleaning. DH (2003)Winning Ways During 2015 / 2016, and in common with many other organisations, the requirement for infection prevention and control support, advice, interventions, education, training, audits and reports of progress and performance increased. The amount of advice and support required during this period was particularly high and reflects the greater awareness and engagement of staff groups. The extensive reporting requirement, verbal and written continues and includes reporting to: NHSLA CQC Hygiene Code IQPR Regarding the following areas: MRSA and Clostridium difficile reporting Infection Prevention and Control Annual Report 2015/16 6 of 39

7 MRSA Post Infection Review (PIR) and Clostridium difficile Root Cause Analysis (RCA) investigations 2. Infection Prevention and Control Arrangements Infection Prevention and Control services are a centralised team working to support all services across the organisation within the three directorates. 2.1 Infection Prevention and Control Team The infection prevention and control team comprised of: Band 8a x 1.0 wte Band 7 x 1.0 wte Band 6 x 3.4 wte total wte = 5.4 infection prevention and control nurses Supported by 0.5 wte admin The Senior Nurse Advisor for infection prevention and control is managed by the Head of Professional Practice and Education. The IPC team are line managed by the Senior Nurse Advisor, Infection Prevention and Control. The IPC team are accountable to the Chief Nurse/Deputy Chief Executive. The Infection Prevention and Control team is responsible for: Providing advice on all aspects of infection prevention and control. Managing increased incidences and outbreaks of infection. Surveillance with regard to incidence of MRSA and Clostridium difficile. Improving infection prevention and control capability and capacity in service areas. Supporting and advising divisions on their responsibilities in relation to local and national IPC requirements. Developing and facilitating programmes of education. Operating and delivering an Infection Control Champions Programme. Undertaking audit processes and associated report writing. Formulating and writing policies and procedures. Interpreting and implementing national guidance at a local level. Involvement with new service development and other projects. Reviewing and advising on building works and facilities. The infection prevention and control team meet fortnightly with the Senior Nurse Advisor for IPC to review infection control issues and any concerns. A co-ordinated annual programme of work was agreed, disseminated and reviewed bi-monthly at the infection prevention and control committee. The Quality Assurance Committee (QAC) received bi-monthly updates and quarterly reports were provided to the Trust Board. Exception reporting to the relevant committees was carried out as required. LPT and the Infection Prevention and Control team have continued to support the role of the IPC link champion and have maintained links with these staff members who are employed within the Community Health Service (CHS), Families, Young Infection Prevention and Control Annual Report 2015/16 7 of 39

8 People and Children (FYPC), Adult Mental Health and Learning Disability (AMH and LD) directorates. The role of the link champion was reviewed and updated in January 2016 resulting in defined responsibilities. The re-launch of the assurance folder which holds evidence and assurance for the IPC agenda was undertaken at this time. The Consultant for Public Health based within the Public Health England, East Midlands Health Protection team continues to support the IPC team. University Hospitals of Leicester NHS Trust (UHL) employs a Consultant Microbiologist with specific responsibility for supporting primary care organisations in Leicester, Leicestershire and Rutland. Microbiological support for LPT has been provided by UHL. The Consultant Microbiologist is a member of the LPT Infection Prevention and Control committee, and advises on policy development and content. Infection prevention and control is incorporated into staff job descriptions as agreed by the Director for Human Resources and is included in staffs personal development plans (PDP s). 2.2 LPT Infection Prevention and Control committee The Infection Prevention and Control committee is chaired by the Chief Nurse/Deputy Chief Executive and reports directly to the LPT Quality Assurance Committee, which reports to the Trust Board. The committee meets six times per year; bimonthly. The minutes are available on the Infection Prevention and Control intranet page via LPT website. The Infection Prevention and Control committee provides strategic development of infection control activities on behalf of LPT Trust Board. A lead nurse for each directorate has provided a highlight report to the committee for assurance and escalation from the directorates. 3. Annual Programme 2015/16 The annual work programme for 2015/16 was completed over the twelve month period. Infection Control Surveillance data was presented monthly to the Integrated Quality Performance Review. The cleanliness of the environment has been assessed externally and locally. The process of audit and assessment as part of the assurance folder requirements was progressed across directorates from January The lead nurse highlight report for each directorate has been developed to provide assurance of compliance with hand hygiene, cleaning and decontamination processes, champion networks and top ten markers for good practice. The cleanliness of the environment is assessed under the remit of Patient Led Assessments of the Care Environment (PLACE), with members of the Infection Prevention and Control team attending the visits as part of the assessment team. Infection Prevention and Control Annual Report 2015/16 8 of 39

9 4. Monitoring Arrangements The East Leicestershire and Rutland Clinical Commissioning Group set targets for the management of Clostridium difficile and Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemias. The trajectory for Clostridium difficile was set at 7 cases and Methicillin Resistant Staphylococcus aureas (MRSA) was set at 0 cases in line with the national requirements. LPT completed monthly provider performance monitoring returns; regular reports to the commissioner led Contract Quality Review Group were presented as per the quality schedule. 4.1 MRSA MRSA screening was reported monthly at the Integrated Quality Performance Review Group and is discussed at the Quality Assurance Committee (QAC) and the Trust Board. There were 0 cases of community acquired MRSA which resulted in a bacteraemia that were attributed to LPT. There were two cases of MRSA bacteraemia that involved an element of care delivery from staff working within LPT. Actions were identified to support the improvement of care for these patients but were not deemed to be a contributing factor to the development of the bacteraemia. 4.2 Clostridium difficile Clostridium difficile is reported monthly at the Integrated Quality Performance Review Group and bi-monthly to the LPT Infection Prevention and Control Committee, and by exception to the Quality Assurance Committee and Trust Board. The trajectory for 2015/2016 for Clostridium difficile, EIA positive cases was set at 7 with a total figure of 13 EIA positive toxin results. One of the patients was concluded to have been tested twice (both times EIA positive) on the request of the Advanced Nurse Practitioner and Specialist Nurse for CDI as the patient remained symptomatic; therefore 12 patients were affected with a total of 13 EIA positive toxin results. All patients were identified to be over the age of 65 and 3 of the patients had extensive co-morbidities. On review of the patients identified, 10 out of the 12 (83%) patients were admitted from a ward at University Hospitals of Leicester, 9 (75%) had received or were currently receiving antibiotics for a documented infection. Five patients (41%) had received proton pump inhibitors, all of which were reviewed and either discontinued or continued for a known medical reason. No patients had a previous history of CDT diagnosis. A number of lessons for learning were identified during the root cause analysis reviews with the themes identified in the appendices. Actions have been taken to address these issues. Infection Prevention and Control Annual Report 2015/16 9 of 39

10 Data reporting Figures for 2015/16 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Clostridium difficile CDI Trajectory set by commissioning MRSA Table Mortality data for CDI Of the13 EIA toxin positive Clostridium difficile tests reported, for 12 patients whilst inpatients within LPT, 5 patients have passed away; 2 of which were within 30 days of being diagnosed with CDI. This equates to 15% of patients who were tested positive for EIA toxin CDT. Where CDI was indicated on the death certificate a serious incident review was carried out to ascertain where lapses in care may be a contributory factor. 4.4 HCAI risks identified on the risk register Risks around HCAI are managed in line with the trust risk management arrangements and are escalated accordingly. Risks are identified and reviewed at the LPT infection prevention and control committee. 5. Prevention and Reduction Strategies 5.1 Post Infection Reviews There were two cases of MRSA bacteraemia that required a post infection review, where care had been provided by staff working for LPT. No cases were attributed to LPT. The root cause analysis of the bacteraemias indicated a number of specific and general contributory factors and lessons for learning have been shared with the appropriate teams. 5.2 Increased incidence of infection During the period of 2015/16 the organisation experienced a number of increased incidences of vomiting and/or diarrhoea. As part of our programme to prevent the outbreak of clostridium difficile infection we ensured that all cases of reported diarrhoea were reviewed by an Infection Prevention and Control Nurse: and if required advice sought from the consultant microbiologist. This supports the prevention and control of any potential or real increased incidences of infection developing into an outbreak, whilst supporting the management of the disease processes to prevent reoccurrence of infection for the patient. Infection Prevention and Control Annual Report 2015/16 10 of 39

11 From April 2015 to the end of March 2016 there were 8 known Norovirus incidents within LPT, which was 2 more compared to the previous year. In 2015/16 there were 6 reported increased incidences of diarrhoea and/or vomiting where no organism was identified or samples were not obtained. There were a total number of 35 beds closed across the organisation which were closed to admissions due to Norovirus incidents, with an approximation of 167 bed days lost to admissions. In total the number of recorded patients affected with diarrhoea and/or vomiting was 125 with a total of 28 staff members affected. No wards were closures as a result of diarrhoea and/or vomiting. The current system ensures that the DIPaC, PHE, Microbiologist and East Midlands Ambulance Service Trust are part of the cascade system when informing areas in the organisation of an increased incident. A full summary report forms part of the appendices to this report. 6. Code of Practice for the Prevention and Control of Health Care Associated Infections (The Health Act 2008) LPT s position against The Code of Practice (The Hygiene Code) was monitored and assessed on a monthly basis using the HCAI assessment tool provided by the East Leicestershire Commissioning Group. Each directorate has been assessed against the CQC requirements for Outcome 8 and any remedial actions were monitored through the directorate Infection Prevention and Control groups. LPT are provider services for healthcare in three prisons; Leicester prison detaining adult male, Gartree detaining adult males serving life sentences, and Glen Parva detaining adult young offenders. They all have an established Infection Prevention and Control champion in each prison who attends the champion days quarterly. An Infection Prevention and Control Nurse was allocated responsibility for the prisons; the nurse has developed an excellent rapport with the prison staff and has been involved in appropriate decisions regarding infection control. Hand hygiene training and audits were maintained throughout 2015/2016. A visit from the Head of Infection Prevention and Control from the Trust Authority Development visited LPT and a number of clinical areas and attended the Infection Prevention and Control Committee. As part of this visit a written report was received with a number of recommendations. An action plan was developed to address the issues raised and feedback has followed this visit. 6.1 Safer Sharps Leicestershire Partnership NHS Trust established a Safer Sharps Group, chaired by the Head of Health and Safety Compliance. This group reports to the Health & Safety Committee and the Infection Prevention Control Committee. It has agreed terms of reference and governance arrangements. Infection Prevention and Control Annual Report 2015/16 11 of 39

12 The purpose of this group is to provide assurance that safer sharps are effectively monitored and managed; promote the implementation of the safer sharps requirements and to eliminate avoidable risk of harm or injury arising out of work activities that involve the use of sharps to both patients and staff. Many types of safer sharps have been introduced into the organisation using a pilot based approached for the devices, which has been accompanied by training and learning opportunities from the manufactures. Work continues on the full adoption of safer sharps devices (where available) for 2016/ Sharps incident data Needlestick and sharps injuries carry the risk of infection and are an occupational hazard for all healthcare professionals involved in clinical care. A quarterly report was presented at the Infection Prevention and Control Committee regarding the data aligned to incidents that involved sharps. The purpose of the report was to inform and assure the Infection Prevention and Control Committee that mechanisms are in place to review, identify themes and trends, share lessons from actions, and monitor progress and performance in terms of sharps incidents across directorates. The following chart shows an overview of the number of incidents reported that involved sharps or associated devices for 2015/ Incidents associated with sharps Devices that are 'dirty' insulin delivery/needle disposal Q1 Q2 Q3 Q4 6.3 Flu Vaccination 2011/ / / / /16 Totals Infection Prevention and Control Annual Report 2015/16 12 of 39

13 The overall rate of vaccination was lower than last year. This equates to 47% of all frontline staff, which was a 5% decrease based on the previous year. This year saw the training and implementation of peer flu vaccinators from within LPT s own registered nursing staff. This proved to be a popular initiative with future plans to develop on this process for forthcoming flu seasons. 7. Patient and Public Involvement Recognising that healthcare associated infection is a key concern of patients and the general public, LPT has sought to raise awareness of how this issue is addressed and to highlight the public s role in reducing infections. There has been a set target that 50% of the assessment team for PLACE is made up of patient representatives, with the visits being rescheduled if this is not achieved. The PLACE assessments were completed. LPT has an established website with dedicated pages regarding health and wellbeing providing information to the public. Infection prevention and control activity has been reported quarterly at the public part of the LPT Board meetings. Board papers are available on the LPT internet site. 8. Antimicrobial Prescribing Antimicrobial prescribing has formed part of the root cause analysis recommendations where appropriate and sits within the audit programme for medicines management. Prescribing of antibiotics for patients with a positive toxin result for Clostridium difficile were reviewed as part of the root cause analysis, lessons learnt regarding prescribing issues were fed back. Antimicrobial stewardship, provided by a Lead Pharmacist, has been incorporated into the Infection Prevention and Control Committee agenda with oversight of the five year strategy. LPT are working towards compliance with the NICE clinical guidance on antimicrobial stewardship (NG15). Integral to this will be the antimicrobial prescribing audit, which in 2016/17; will be approached in a different way. The audit will continue to look at what was prescribed and adherence to the formulary. However, additional information will be gathered by looking at documentation in patient s notes to justify the rationale, check the diagnosis/impression, if an antimicrobial review took place within hours of prescribing and a plan formulated (start SMART then FOCUS approach). The IPC will receive regular reports of antimicrobial usage based on bed days. Work is under way to produce a short module to educate staff on this 9. Decontamination The healthcare environment demands that all instruments used on patients are safe for use. In order to achieve this, surgical instruments and other similar items may be either disposable or re-useable. If instruments are re-usable they require Infection Prevention and Control Annual Report 2015/16 13 of 39

14 appropriate reprocessing between patients via a defined process of decontamination. Equipment must be cleaned and decontaminated in a managed way that reduces the risk of injury or infection. Environmental work continues to be developed in line with the requirements for the provision of Podiatry services, with the development of an options appraisal to support the processes required to ensure the service meets the national requirements for decontamination in regard to this service. 9.1 Podiatry Leicester Partnership Trust (LPT) Podiatry Services reviewed their estates strategy, in particular their approach to the decontamination process of the instruments. In 2015 / 16 the podiatry service operated across 36 sites in the Leicester area, and used a variety of decontamination processes. A project team was assembled to assess the existing procedures and to recommend a way forward. An assessment of the existing facilities and resources was undertaken and recommendations have been taken forward as part of an overview group. There is an expectation that future service changes will meet the decontamination strategy requirements. 10. Patient Led Assessment of the Care Environment (PLACE) 2015 Following the outsourcing of facilities management services in 2013 the Estates and Facilities Management Collaborative (EFMC) managed the external contract on behalf of the Trust. The Head of Performance from EFMC attends the Infection Prevention and Control committee and has provided quarterly assurance reports relating to the monthly cleaning scores, which is based on the National Specification for Cleanliness in the NHS (2007). The Trust had an annual thorough clean programme of all in patient sites and a quarterly window cleaning programme through the external contractor. The progress of the cleaning programme was reported through the Infection Prevention Control Committee. There was a cleaning forum which included representatives from infection prevention, nursing, EFMC and Interserve. The EFMC organise, plan and implement the Patient Led Assessment of the Care Environment (PLACE) programme on behalf of LPT. The Head of Performance from EFMC met with patient representatives from previous years, including current trust shadow governors, Healthwatch representatives and other volunteers who were keen to continue the programme. A briefing session was held in February to review changes to the assessment documentation following a review by HSCIC and NHS England. LPT s PLACE assessments for 2015 were completed within the required timescale and data submitted to the Health and Social Care Information Centre (HSCIC) to meet the required deadline. The assessments were carried out in all in patient sites with 10 or more beds and results forms evidence for the following regulated CQC Outcomes: Outcome 8 (Regulation 12) Cleanliness and Infection Control. Outcome 10 (Regulation15) Safety and Suitability of Premises. Infection Prevention and Control Annual Report 2015/16 14 of 39

15 Outcome 5 (Regulation 14) Meeting Nutritional Needs. The PLACE scores for 2015 show a decline in some figures and areas; appropriate actions have been put in place to address the shortfalls. 11. Policies, Procedures and Guidelines There continues to be a range of policies within the remit of infection prevention and control for staff to follow, in line with the requirements of the Health and Social Care Act The policies have all been updated when new and relevant information became available. Policies are on a timetable for review as a matter of process (Appendix 6) 12. Audit The Infection Prevention and Control team undertook a number of audits for all of the directorates within LPT. These audit form part of the Leicestershire Partnership NHS trust Infection Prevention and Control annual programme of audit for 2015/2016 and encompass; Hand hygiene, Cleaning of equipment and the Top ten markers for practice improvement. These audits are reviewed by the matrons and followed up with actions and training for any reduction in compliance. 13. Training and Education All staff receives Infection Prevention and Control level 1 and hand hygiene training at induction and on a 3 yearly basis as part of their core mandatory training. Clinical staff with patient contact receives infection prevention and control level 2 and hand hygiene on a two yearly basis. The following figures identify LPTs compliance by 31 March The training figures show a slight increase in hand hygiene. The target for compliance with Infection Prevention and Control training was 85%. In June 2015 compliance rates were 78.2%, this is below Trust target. Over the last 12 months compliance rates have increased each month. As of March 2016, 92.5% of this staff group were compliant with this training. As of June 2016, 3827 substantive post holders are required to complete hand hygiene training and 97.4% of post holders are recorded as compliant. Evaluations of e-learning have been very positive and the move to this training medium is the probable cause of the consistently high compliance rates. Infection Prevention and Control Annual Report 2015/16 15 of 39

16 Overall compliance (31/03/2016) Change in compliance from 12 months (01/04/ /03/2016) Hand Hygiene (2 year update) Infection Prevention and Control Level 1 (3 year update) Infection Prevention and Control Level 1 (2 year update) 97.4% +3.9% 95.8% +3.1% 92.5% +23.0% 14. HCAI Assessment for Commissioning Services 2016/17 The healthcare associated infections assessment programme developed by the East Leicestershire Clinical Commissioning Group will continue to form the basis of the organisations assurance requirements in line with the CQC and the health and social care act. The annual programme for this coming year supports the request from the commissioning bodies regarding surveillance for MSSA, ESBL s and multi drug resistant organisms. 15. Conclusion The infection prevention and control activity in LPT in 2015/16 has continued to build on the framework and governance structures for the management of healthcare associated infection to further embed initiatives to reduce the risk of health care associated infection in LPT, improve patient safety and work with the community at large to improve public confidence. Lessons learnt will be built on as part of the Infection Prevention and Control Strategy for 2016/17. LPT continues to promote high standards of practice in all areas and continues to work on areas of partial compliance in line with the divisional leads. Thanks are extended to all colleagues who have assisted in delivering the programme for infection prevention and control during 2015/16, in particular the service leads for IPC, the lead nurses and the link champions for IPC who have attended meetings and supported the IPC agenda across the organisation. 16. References Department of Health (2014) Implementation of modified admission MRSA screening guidance for NHS Infection Prevention and Control Annual Report 2015/16 16 of 39

17 Department of Health (2013) UK five year Antimicrobial Resistance Strategy 2013 to Department of Health (2008) The Health and Social Care Act 2008, Code of Practice on the prevention and control of infections related guidance. Department of Health (2003) Winning ways: working together to reduce healthcare associated infection in England. Report from the Chief Medical Officer. London National Institute for Health Care Excellence (2012) Infection: prevention and control of healthcare-associated infections in primary and community care. London. Norovirus Working Party: Guidelines for the management of norovirus outbreaks in acute and community health and social care settings (2012) Public Health England. Start Smart Then Focus Antimicrobial Stewardship Toolkit for English Hospitals. (March 2015) Infection Prevention and Control Annual Report 2015/16 17 of 39

18 Appendix 1 Infection Prevention and Control Summary of Key Findings for Internal Root Cause Analysis on reported cases of Clostridium difficile within LPT for Clostridium difficile infection (CDI) is defined by the presence of symptoms (usually diarrhoea) and either a stool test positive for C. difficile toxins or toxigenic C. difficile, Trajectories for CDI for LPT had been set at 7 for the year 2015/16, and as part of the on-going commitment to support a zero tolerance to this infection an internal root cause analysis is carried out for each CDI that is attributed to LPT. The content of this report covers those CDI s that are deemed as reportable (i.e. toxin positive). Each report is shared with the relevant commissioning groups for review and feedback. For 2015/16 LPT had 13 reportable cases of CDI out of a trajectory of 7. The internal RCA reports have been tabled at the identified meetings (locality IPC groups) and divisional SI groups as appropriate. Case 1- Coalville Hospital Ward 2 Admitted to the ward from LRI 09/04/15 Date commenced diarrhoea 17/04/15 Sample sent 17/04/15 Positive result 18/04/15 Potential Contributory Factors 1. Patient admitted from UHL 2. No previous history of CDI 3. No Protein Pump Inhibitors prescribed 4. Previous antibiotic history (including Co-amoxiclav which finished a couple of days prior to diarrhoea commencing 5. Appropriate IPC precautions followed 6. CDT core care plan in situ 7. Symptomatic patient on the ward (at UHL) although no contact at the time with this patient. Issues identified for further learning Documentation on commencement of SIPs not clear Sample sent at the weekend and the result not obtained until the Monday morning (ward staff to follow up samples) Patient review not clear that CDT was initially considered Patient Outcome Patient discharged 23/05/15 Patient died 05/06/15 (47 days post result)

19 Case 2 Fielding Palmer Admitted to the ward from LRI 03/04/15 Date commenced diarrhoea between 14/04/15 and 21/04/15 Sample sent 21/04/15 Positive result 22/04/15 Potential Contributory Factors 1. Previous antibiotic history. 2. No recent history of CDI on ILab 3. PPI s prescribed which were discontinued on the 28/04/15 by the ANP 4. Symptomatic patient on the ward at LRI at the same time, but no contact noted between the two patients. Issues identified for further learning Source isolation precautions not considered at the initial stages that diarrhoea had occurred Hand hygiene audits not completed for the months of March and April 15. Patient Outcome Patient discharged 08/05/15 Patient died 02/09/15 (135 days post result) Case 3 Fielding Palmer Admitted to the ward from home 01/04/15 Date commenced diarrhoea 01/05/15 Sample sent 01/05/15 Positive result 02/05/15 Potential Contributory factors 1. No previous known history of CDI 2. Patient on the ward with CDI 3. Previous recent antibiotic history 4. Appropriate IPC precautions followed, once infection considered. 5. CDT core care plan in situ Issues identified for further learning 1. Infection prevention and control were not informed when source isolation precautions were commenced. 2. Potential cross contamination from patient 2 (above). Serious incident review carried out. Patient Outcome Patient discharged 11/05/15

20 Case 4 Fielding Palmer Patient admitted from home 07/07/15 Date commenced diarrhoea overnight 18/07/15-19/07/15 Sample sent 19/07/15 Positive result 20/07/15 Potential Contributory Factors 1. Recent antibiotic history for urinary tract infection 2. No Protein pump inhibitor prescribed. 3. No other patients on the ward with known or suspected CDI at same time Issues identified for further learning 1. No urine sample obtained to confirm UTI prior to admission 2. Hand hygiene and top 10 marker scores had not been completed for July Patient Outcome Patient transferred to LRI on 19/07/15 Patient died 01/08/15 Case 5 East Ward, Hinckley and Bosworth Hospital Patient admitted from UHL 23/07/15 Date commenced diarrhoea 29/07/15 Sample sent 29/07/15 Positive result 29/07/15 Potential Contributory Factors 1. No previous history of CDI 2. Previous recent antibiotic history. Antibiotics prescribed according to antimicrobial guidance 3. No protein pump inhibitors prescribed 4. No other patients on the ward with known or suspected CDI at the same time. 5. Patient resided in a care facility Issues identified for further learning Patients normal bowel function not noted Patient Outcome Patient discharged to UHL 29/07/15 Case 6 North Ward, Hinckley and Bosworth Hospital Patient admitted from LGH 28/10/15 Diarrhoea commenced 19/11/15 Sample sent 19/11/15 Positive result received 20/11/15 Potential Contributory Factors 1. No known previous history of CDI 2. Previous antibiotic history

21 3. Protein pump inhibitors prescribed and administered. No other patients on the ward with known or suspected CDI at the same time 4. Other patients experienced diarrhoea at the same time this patient became symptomatic. Issues identified for further learning There is no documentation of the patient s normal bowels, or documentation to state that is was not possible to obtain this information. There is no documentation to acknowledge that the patient had loose stools between 31/11/15 and 02/11/15. Retrospectively staff have informed that they thought it was due to the laxatives prescribed and administered. However the patient was also on antibiotics at this time and this has not been acknowledged. There is no documentation to support that the medical team were aware of the loose stools, although retrospectively I have been informed that would have happened as routine. The patient was receiving aperients; however there is no documentation of the patient s normal bowels. There is no evidence of an incident form being completed with regards to the patient missing 2 doses of co-amoxiclav. The top 10 marker audits show that the cleaning schedules are not fully completed.. Patient Outcome Patient discharged to UHL on 21/11/15 (as unwell) Case 7 Clarendon ward Patient admitted from LGH 29/10/15 Diarrhoea commenced 23/11/15 Sample sent 23/11/15 Positive result 26/11/15 Potential Contributory Factors 1. No known previous history of CDI 2. Previous antibiotic history. Appropriate prescribing 3. Protein pump inhibitors prescribed and administered for known medical history. Issues Identified for further learning The importance of documenting the date and time of source isolation precautions. The importance of documenting a patient s normal stool type and pattern. The importance in sending samples immediately, there was a 9 day delay in sending a sample from the commencement of loose stools. Inconsistencies evident in the documentation of stools. The use of the nerve centre and manual notes leads to confusion when handing over information to other staff and IPC. The need to improve the cleaning schedules so that they are up to date with the latest ward layout, all rooms to be clearly identified. The severity of the CDI infection was not identified as Mild, Moderate, Severe or Life-threatening. The importance of maintaining accurate documentation in patient records.

22 Patient Outcome Patient discharged home 05/01/16 Case 8 Clarendon Ward Patient admitted from LRI 10/11/15 (prev. LGH) Diarrhoea commenced 12/11/15 Sample sent 15/11/15 Positive result 18/11/15 Potential Contributory Factors 1. Previous antibiotic history 2. No other patients on the ward with known or suspected CDI at the same time. Issues Identified for further learning The importance of documenting the date and time of source isolation precautions. The importance of documenting a patient s normal stool type and pattern. There was a 3 day delay in sending a sample from the commencement of loose stools. Inconsistencies evident in the documentation of stools. The use of the nerve centre and manual notes leads to confusion when handing over information to other staff and IPC. The need to improve the cleaning schedules so that they are up to date with the latest ward layout, all rooms to be clearly identified. The severity of the CDI infection was not identified as Mild, Moderate, Severe or Life-threatening. Incident reports must be initiated if staffing levels fall below local agreed standards Patient Outcome Patient discharged home 26/11/15. Case 9 Clarendon Ward Patient admitted from UHL 04/11/15 Diarrhoea commenced 12/11/15 Negative sample 24/11/15 Positive result 04/12/15 Potential Contributory Factors 1. Other patients on the ward with known or suspected CDI at the same time. 2. Extensive medical history and antibiotic treatments Issues Identified for further learning Potential cross contamination Serious incident review undertaken Patient Outcome Patient died 14/12/15

23 Case 10 Swithland ward, Loughborough Hospital Patient admitted from LGH17/12/15 Diarrhoea commenced 05/01/16 Sample sent 05/01/16 Positive result 05/01/16 Potential Contributory Factors 1. Extensive medical history and antibiotic treatments Issues Identified for further learning Documentation of normal bowel not recorded. Documentation of time patient went into SIP s. Delay in administering Metronidazole 400mg. Documented in the medical notes on the 06/01/16 C.diff suspected start Metronidazole, within the pathway it states that Non severe CDI or clinical suspicion/lab results not available/no septic initiate Metronidazole oral 400mg TDS for 10 days. Error in drug prescribing when CDT confirmed, wrong drug prescribed leading to a further 21hr delay. Patient Outcome Patient discharged 15/01/15 Case 11 and 13 Beechwood ward, Evington centre Patient admitted from LRI 13/02/16 Diarrhoea commenced 17/02/16 1 st positive result 18/02/15 2 nd positive result 27/03/15 Potential Contributory Factors 1. History of antibiotic treatments including Co-amoxiclav 2. Patient has lapses in condition (reason for retest) Issues Identified for further learning None identified Patient Outcome Patient discharged 18/04/16 Case 12 Dalgleish ward, Melton Mowbray Hospital Patient admitted from LRI 19/02/15 (for palliative care) Diarrhoea commenced since admission Positive result 28/02/16 Potential Contributory Factors 1. Extensive medical history and antibiotic treatments Issues Identified for further learning None

24 Patient Outcome Patient died 09/04/16 (CDI not on death certificate) Summary In total 12 patients was tested toxin positive for CDI with one patient having two positive results. This brings the total trajectory for 2015/16 to 13. All patients received treatment in line with the CDT pathway. All of the patients were over the age of 65 and 3 of the patients had extensive co-morbidities. On review of the patients identified, 10 out of the 12 (83%) patients were admitted from a ward at University Hospitals of Leicester, 9 (75%) had received or were currently receiving antibiotics for a documented infection. 5 of these patients (41%) had received Proton pump inhibitors, all of which were reviewed and either discontinued or continued for a known medical reason. 0 patients had a previous history of CDT diagnosis. A number of lessons for learning were identified during the root cause analysis reviews with the themes identified below. Actions that have been taken to address these issues and continue to be; are also listed below. Lessons for Learning Documentation including normal bowel movements need to be addressed Timely source isolation precautions required in line with faecal sampling Consideration of infection when diarrhea/loose stool of unknown origin identified. Hand hygiene audits to be in date Top ten markers to be in date Cleaning issues to be addressed Actions undertaken to date Face to face training by the IPC team to ward staff Development of posters and leaflets to address issues identified Clinical supervision within teams around this subject Re-launch of assurance folder and support around audits Development of clostridium recovery plan Monthly matron walkrounds with the IPC team Actions and processes will continue to be addressed with themes and processes monitored via the IPC team and reported into the IPC committee.

25 Appendix 2 Clostridium difficile Case reviews regarding 30 day mortality Leicestershire Partnership Trust continues to work hard to tackle healthcare-associated infections and support the reduction of these incidences. With regards to the management of Clostridium difficile (EIA toxin positive) the guidance: Clostridium difficile infection: How to deal with the problem, 2007; identifies in section 10.3 Published data suggest 30 day allcause mortality of C. difficile to be 21% (Morgan et al., 2008) and secondary care trusts should maintain comparative data on this. Assessment of criteria for attributing death to CDI is urgently needed states trusts should consider urgent medical action manage cases if their audited 30-day mortality rate approaches 20%. The following information identifies the patients who were diagnosed with toxin positive CDI whilst an inpatient within LPT. There were a total of 13 EIA toxin positive Clostridium difficile tests reported, which equated to 12 patients. One patient had a retest after remaining symptomatic. Of the 12 patients, 5 patients have died, 2 of which were within 30 days of being diagnosed with CDI. This equates to 15% of patients who were tested positive for EIA toxin CDT. Where CDI was indicated on the death certificate a Serious Incident review was carried out to ascertain where lapses in care may be a contributory factor. Patient 1 Admitted 09//5/15 Positive sample 17/05/15 Discharged 23/05/15 Died 05/06/15 (47 days post result) Attributed to lapse: No Patient 2 Admitted 03/04/15 Positive sample 21/04/15 Discharged 08/05/15 Died 02/09/15 (135 days post result) Attributed to lapse: No Patient 3 Admitted 01/04/15 Positive sample 05/05/15 Discharged 11/05/15 Discharge complete Attributed to lapse: Yes Patient 4 Admitted 17/07/15 Positive sample 19/07/15 Discharged 19/07/15 (to UHL as unwell) Died 01/08/15 (13 days post result) Attributed to lapse: No

26 Patient 5 Admitted 23/07/15 Positive sample 29/07/15 Discharged 29/07/15 Discharge complete Attributed to lapse: No Patient 6 Admitted 28/10/15 Positive sample 19/11/15 Discharged 21/11/15 (to UHL as unwell) Discharge complete Attributed to lapse: No Patient 7 Admitted 29/10/15 Positive sample 26/11/15 Discharged 05/01/16 Discharge complete Attributed to lapse: Yes Patient 8 Admitted 10/11/15 Positive sample 15/11/15 Discharged 26/11/15 Discharge complete Attributed to lapse: Yes Patient 9 Admitted 04/11/15 Negative sample 24/11/15 Positive sample 04/12/15 Died 14/12/15 (10 days post result) Attributed to lapse: Yes Patient 10 Admitted 17/12/15 Positive sample 05/01/16 Discharged 15/01/16 Discharge complete Attributed to lapse: No Patient 11 Admitted 13/02/16 Positive sample 18/02/16 Discharged still an inpatient Attributed to lapse: No

27 Patient 12 Admitted 19/02/16 Positive sample 28/02/16 Died 09/04/16 41 days post result) Attributed to lapse: No Patient 13 (Re-test of patient 11) Admitted 13/02/16 Positive sample 27/03/16 Discharged still an inpatient Attributed to lapse: No Amanda Hemsley Senior Nurse Advisor Infection Prevention and Control 22 April2016

28 Appendix 3 Infection Prevention and Control Committee ANNUAL REPORT Year 2015/16 Chair of Committee: Adrian Childs - Chief Nurse, Deputy Chief Executive Deputy Chair: Diane Postle Head of Professional Practice and Education Section A Fulfilling Terms of Reference, 1. Review of Terms of Reference (ToR) All duties of the Infection Prevention and Control Committee as listed in the ToR have been covered through the work plan and agendas during the year. The current membership is deemed to be correct and sufficient to enable carrying out of all duties. All of the Groups or functions that report to the Committee have been identified, their ToR is regularly reviewed, and the reporting of this process is via the Highlight report from the Divisions. These Groups are: Group Community Health Services Infection Prevention and Control Group Families, Young People and Children s Infection Prevention and Control Group Adult Mental Health & Learning Disabilities Infection Prevention and Control Group Terms of Reference reviewed Robust communication with IPC committee Yes Yes Yes IPC committee covered its areas of responsibility for assurance on delivery of the Trust s Strategic Objectives pertaining to continuously improve quality and safety, with services shaped from user experience, audit and research. The ToR of the IPC committee are considered adequate for purpose, to ensure coverage of CQC Outcome 8 (Regulation 12) Cleanliness and Infection Control. The Current Terms of Reference will be reviewed at the committee in March 2016 and agreed at the committee in May They will be reviewed in March 2017.