CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

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1 CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Agenda Item 9.1 Report of: Paper prepared by: Cheryl Lenney - Chief Nurse Consultant Nurse Infection Prevention and Control Julie Cawthorne Dr Andrew Dodgson, Infection Control Doctor Date of paper: June 2015 Subject: To update the Board on the management and control of Carbapenemase-Producing Enterobacteriaceae (CPE) and provide a brief overview and background to a proposed study into the Transmission of CPE Indicate which by Purpose of Report: Information to note Support Resolution Approval (Impact of report on key priorities and risks to give assurance to the Board that its decisions are effectively delivering the Trust s strategy in a risk aware manner) Consideration of Risk against Key Priorities 1. Patient Safety 2. Patient experience 3. Productivity and Efficiency Recommendations Contact To receive the report, note progress and support proposals for a research study with Public Health England (PHE) Dr Andrew Dodgson (consultant Microbiologist and Infection control doctor)

2 1. Introduction 1.1 The Board of Directors received a report in January 2015 setting out the actions taken and the controls in place to manage and control the transmission of Carbapenemase-Producing Enterobacteriaceae (CPE) within the Trust 1.2 Nationally since there have been outbreaks of a Multi-drug resistant organism (CPE) in several hospitals across England. The number of cases has been rising steadily, from 23 in 2008 to 1048 in 2013, and over 1600 in Much of this increase is due to a number of outbreaks in Greater Manchester 1.3 The first case of CPE was identified in this Trust in Over the past five years we have undertaken extensive measures to control the spread of CPE, educating staff and understanding the emerging problem. Over the last 12 months, as part of an augmented plan of action we have implemented an enhanced screening programme for patients, increased isolation facilities and undertaken environmental work. 1.4 This paper provides an update on progress, using the model set out in the previous paper under four key components of Identification, Isolation, Infection control Measures and Information and describes a proposed joint research study with this Trust, Public Health England, NHS England (NHSE) and University Hospitals South Manchester NHS Foundation Trust (UHSM) 2. Identification 2.1 An enhanced screening policy has been implemented, as previously described based on national guidelines. Since April 2014 the microbiology laboratory has increased the number of CPE screens processed per month from approximately 1, 600 to over 6,000 (see Fig.1). Fig. 1 Total number of CPE screens processed and number of positive CPE screens 2.2 The Infection Prevention and Control Team are working with Clinical Informatics to improve the identification of high risk patients who require screening using the BEDMAN system and enable timely intervention and clinical management. 2

3 2.3 From January until June 2015, there were four outbreaks of CPE which were successfully managed using a range of interventions including isolation, deep cleaning, strict infection control practice and decontamination of the environment with hydrogen peroxide vapour. Environmental causes were considered a significant contributory factor. 3. Isolation 3.1 The majority of patients who are positive with the Klebsiella pneumonia Carbapenemase (KPC strain) of CPE are cared for in the isolation/cohort wards (14, 15 and 37), unless they require specialist care in which case they are cared for in side rooms on the wards. 3.2 Patients who have a different type of CPE such as New Delhi Metallo-beta-lactamase (NDM) and Verona Integrin-encoded Metallo-beta-lactamase (VIM), which are not associated with the outbreaks at CMFT, continue to be cohort nursed separately from the patients on the isolation wards to avoid cross contamination with more than one type of CPE. 3.3 The Trust was able to close an isolation ward earlier in the year following a reduction in the number of cases. There are currently three isolation/cohort wards as ward 37 was established in response to the outbreaks experienced within the Division of Specialist Medicine. Occupancy peaked at the beginning of June (with 23 patients).this number has fallen steadily since then. 3.4 A review will take place with the divisions and the infection control team (ICT) to establish the need and scope for CPE cohort wards across the MRI. Dependent on the analysis of the actual numbers there is a potential option to safely reduce the number of isolation wards. 3.5 The CPE in-patient burden can be seen in Fig 2 below. This demonstrates the total numbers of CPE positive inpatients across the three divisions in the Manchester Royal Infirmary and the Children s Division. Fig. 2 CPE In-patient Burden 3

4 3.6 The data shows a downward trend in the number of patients in the divisions of Medicine and Community however; there was an increase in the numbers of positive patients in the Division of Specialist Medicine, from April June 2015 due to an outbreak in the Manchester Heart Centre (MHC) during this period. 3.7 In responding to the CPE issue there is evidence to suggest that we are successfully managing the situation and reducing the risk of cross transmission and further consideration will be given to future management strategies as the CPE in-patient burden reduces. 4. Infection Prevention and Control Measures 4.1 Across the world there are a number of studies that are being shared and starting to be published that show evidence of environmental factors as well as transmission through patient-to-patient contact. 4.2 Environmental screening was undertaken across wards where there had been persistent onward transmission of CPE despite control measures. 4.3 Key findings from the environmental screens indicated that CPE was isolated in moist environments (the natural niche for these types of organisms). Most frequently organisms were isolated from internal wastewater drainage of hand wash basins. This resulted in the deep clean and replacement of affected sink traps and cleaning of taps. Re-screens of these areas indicated that the actions taken were successful. 5. Information 5.1 Data is produced regarding the number of high risk patients admitted, how many were screened and how many patients acquired CPE during their current admission. This information is reviewed with the divisional leadership teams and the ICT at a fortnightly meeting chaired by the DIPC. 5.2 The review meetings have demonstrated an overall improvement in the identification and screening of high risk patients. 5.3 In addition to the improved information to improve the operational day to day identification, management and control of CPE the Trust is working with PHE to develop our understanding of this organism. 5.4 Across the world there are a number of studies that are being shared and starting to be published that show evidence of environmental factors in the transmission of CPE as well as transmission through patient-to-patient contact. Preliminary work suggests that environmental sources may be a contributory factor in Manchester. 5.5 A proposal for a joint research study into the Transmission of CPE from patient to patient and the environment is under development. The proposed project would be to work with PHE and the National Institute for Health research (NIHR) Health Protection Research Unit at Oxford University together with UHSM and NHS England to undertake a more detailed study to assess the extent of the environmental factors contributing to acquisition of CPE in Manchester. 4

5 5.6 It is intended that all costs incurred by the Trust as a result of participation in the study will be reimbursed by funding from the Health Protection Research Unit at Oxford University and PHE. 5.7 The study will involve sharing the isolates from our patients and some isolates that would be looked for in the environment on the wards. These would then be fully sequenced and analysed using cutting edge science to provide a genetic picture of potential sources and transmission within the hospital. 5.8 This research will hopefully lead to a high impact publication and a better understanding of the routes of transmission of this bacterium. This may well inform national and international practice and improve patient safety. 6. Conclusion 6.1 The Trust continues to take the management and prevention of the transmission of CPE extremely seriously and is working with stakeholders across the health economy not only to reduce transmission but also to inform the body of knowledge nationally on the problem. 6.2 The Trust recognises the implications of the continued transmission as a patient safety issue and has made significant progress to enhance screening and isolation policies. We also continue to develop practice, systems and process to reduce the risk of transmission. 6.3 The prevention and management of CPE is on the Trust risk register and performance and outcomes are monitored through the Infection Control Committee. 6.4 The Chief Nurse/DIPC will continue to provide regular updates to the Board of Directors on the prevention and management of CPE. 6.5 The Board of Directors are asked to receive this briefing and approve and support the progress of this research study. 5