Infection Prevention Control Committee. Annual Report. April 2016 to March Working together to break the chain of infection

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1 Infection Prevention Control Committee Annual Report April 2016 to March 2017 Working together to break the chain of infection

2 1. Executive Summary Biofire Using funds released from internal cost saving the Trust microbiology laboratory know how has a Biofire film array syndromic diagnostics platform that is allowing an improved diagnostic capability and patient bed flow. It has also enabled improved antimicrobial/antiviral stewardship, rapid diagnosis of meningitis and respiratory virus infection, improved diagnostic pathway to increase the sensitivity and specificity of investigations early in the clinical course, improved diagnostic certainty of viral respiratory infections and meningitis and increased microbiology diagnostic capabilities. It has also increased the in-house microbiology laboratory repertoire, reducing the need for referral of tests off site with the associated costs and turnaround times. CPE We continue to screen patients for CPE in line with national policy. We have identified positive patients with and without known risk factors. It is important that we continue to screen and isolate these patients. Evidence from around the country indicates that the incidence of CPE continues to increase. Candida Auris Outbreaks of antibiotic resistant fungal infection has been reported in three hospitals within the UK during 2016/ This is proving to be very difficult to remove from the environment despite infection control measures including enhanced cleaning and disinfection with Hydrogen Peroxide Vapour. Guidance from PHE has been to instigate enhanced screening of all Candida albicans species isolated from patients within augmented care settings. No positive samples for this fungus have been identified at the Trust. Clostridium Difficile (CDI) The Trust reported 22 cases of Clostridium difficile against a trajectory of 14 this year. 5 of these cases were agreed as not associated with lapses in care by the Post Infection Review group. The number of trajectory cases for 2017/ 18 remains at 14. Norovirus Outbreaks of this viral illness have been identified at the Trust during this year in line with seasonal reporting. Individual cases have also been reported in very small numbers. 2

3 2. Purpose of the report To provide assurance to the Board of Directors, our patients, staff and the public on compliance with the Health and Social Care Act 2010: Code of Practice for the NHS on Prevention and Control of Healthcare Associated Infections and related recommendations (the hygiene code) including NICE guidance. Good Infection Prevention and Control (IPC) is essential to ensure that people who use the Trust services receive safe and effective care. Our aim is to ensure that IPC is embedded in part of everyday practice and be applied consistently by everyone. The publication of this report is a requirement to demonstrate good governance and public accountability. It should provide assurance about our systems and processes in relation to infection prevention and control. There are 10 criteria set out by the Health and Social Care Act which are used to judge how we comply with its requirements for cleanliness and infection control. This is reflected in the Care Quality Commission fundamental standards outcome 8 detailed in the annual work plan which is monitored by the Trust s Infection Prevention and Control Committee. This report summarises our progress against the 10 criteria, our business plan and any related National Institute for Health and Care Excellence (NICE) guidance. Paul Bolton Lead Infection Control Nurse Paula Shobbrook Director of Nursing and Midwifery/ Director of Infection Prevention and Control Layth Alsaffar Consultant Medical Microbiologist/ Infection Control Doctor 3

4 Criterion 1 Systems to manage and monitor the prevention and control of infection. Governance Arrangements. The Board of Directors has a collective responsibility for keeping the risk of infection to a minimum. The Board discharges this responsibility in the following ways: The Director of Nursing and Midwifery/Deputy Chief Executive is the designated Director with responsibility for Infection Prevention and Control (DIPC). The Board of Directors statement of commitment and IPCC Terms of Reference are on the infection control intranet and Trust internet sites. Infection Prevention and Control Team (IPC) Structure Director for IPC Doctor for IPC Senior Nurse for IPC Consultant Microbiologists IPC Nurses The Director for Infection Prevention and Control at this Hospital is also the Director of Nursing and Midwifery/Deputy Chief Executive, Paula Shobbrook. The Trust has a Doctor for Infection Prevention and Control, Layth Alsaffar, supported by two microbiologists as well as a Lead Infection Control Nurse supported by three IPC Nurses. Two members of administrative staff support the whole IPC team and the Microbiology laboratory. The Trust enjoys strong external links with Local Authority Public Health teams, Public Health England South West, NHS England, the local Trusts, Dorset CCG and West Hampshire CCG and meets regularly with them to discuss IPC targets, lapses in care and resultant learning. 4

5 Within the Trust the Infection Control Team rely heavily on the skills and knowledge of IPC resource staff. These staff members include nurses and varied allied health professionals ensuring that all areas are able to share and cascade learning to the staff in their area in a way that is tailored to their needs. They are responsible for carrying out various audits including the monthly Hand Hygiene and IPS Saving Lives audit and supporting the Ward Sisters in delivering action plans based on their findings. The IPC team support the IPC resource staff to deliver messages around new guidance and current communicable disease epidemiology to their wards. Out of hours IPC advice and guidance implementation on the wards and departments is delivered by the Clinical Site Team (CST) with the Senior Nurse for Infection Control providing remote advice over the telephone/ through when required. There is currently no official on call rota in place for IPC, as a trust we train our CST and the resource staff to help ensure that IPC guidance and support is available 24/7. IPC roles. The IPC team have benefited from the changes that took place last year. The skill mix for the IPC team is: 2.0 WTE Band 6, 1.0 WTE Band 7 and 1.0 Band 8 plus a 1.0 WTE data administrator. The change in the way that IPC advice is delivered across the Trust has enabled our staff resource to match demand. Being on site for longer has meant that IPC issues within the Trust are able to be highlighted earlier in the day and closed more quickly than was previously possible. The Infection Prevention and Control team have started to work on wards and departments spending time working alongside staff. This has allowed us to share good practice from ward to ward, highlight and address challenges within environments that prevented effective IPC to be delivered and gain a greater insight into day to activities on a ward that impact upon IPC. There is no guidance set down by the NHS or Government on what a team should consist of or how many should be in a team per NHS bed. Focus should instead be on quality of service, multimodal working with other disciplines and good links into all departments. Work being developed by the Infection Prevention Society on credentialing for IPC Nurses will help us to analyse our team and work when this is in place later in The Doctor for Infection Control covers a clinical rota so is available at all times to support the team. Ward rounds are carried out to review complex cases with the IPC team. The Infection Control Doctor links closely with the Trust Antibiotic Pharmacist in reviewing patients on specific antibiotics and carrying out audits to ensure that the Trust antibiotic policy is followed. 5

6 IPC and Information Technology In order to address current gaps in our ability to carry out epidemiological analysis of our follow up of our patients we have been looking at IT developments to help address requirements under NICE guidance. After a failed bid to the Nursing Technology fund for ICNet we are now working closely with the IT department to create our own system within RBCH. This is in the testing stage. Currently we are unable to track and trace patients and their contacts as they move throughout the Trust receiving care in the various departments. We have a good understanding of where a patient is and can use current systems in the Trust to ascertain locations at given points in time but a system does not currently exist that can link this to infectious diseases. In order to truly understand the impact on the Trust of C. difficile, MRSA or other Multi Antibiotic Resistant Organisms this facility is key. To date we have developed a system that flags all the patients on Ecamis and the Bed Management System with an IPC Yellow flag. All ward electronic boards demonstrate if a patient on the ward has a yellow flag. We are currently using a spread sheet that automatically reports all new and current admissions to the Trust with a yellow flag We are using this to ensure that the isolation policy is followed and appropriate screens are carried out as and when necessary. Through the use of this tool we have been able to identify that approximately 50% of the Trusts side rooms are being used for IPC reasons, this is outside of any outbreak or rise in communicable disease within the community. The next steps are to use this information to collate data on the number of communicable diseases within wards over a period of time and map this against patient movement across the wards. 6

7 Infection Prevention and Control Committee (IPCC) The IPCC meets quarterly and provides a monthly report to the Board of Directors on mandatory IPC reporting. The following structure is in place to support information flows: Trust Board of Directors IPCC Heathcare Assurance Committee PMG Care Group and Directorate Heads of Nursing Risk and Governance Group meetings Wards and departments Resource staff meetings Risk and Cleaning Group This year, to improve information sharing and reduce unnecessary time in meetings a 3 month trial was held without holding the Infection Control Directorate Lead (ICDL) meetings. This has enabled the IPC team and Directorate Matrons to focus their effort on the resource meetings. As a result information that was previously cascaded down from the ICDL meetings is now directly discussed with resource staff greatly improving the flow of communication. This has been a positive change and is likely to remain in place. In addition to these structures of reporting and information sharing, weekly s are sent out to all Senior Nurses and General Managers indicating current status against targets for alert organisms such as MRSA and C. Difficile. This information is also sent to the Performance Management Group (PMG) with key learning obtained from investigation into any associated IPC adverse incidents included to add context to the data. Patient-led Assessments of the Care Environment - PLACE Patient-led self-assessments of the care environment (PLACE) were completed in April The cleanliness score element at RBH increased in to 96% (up 1.6%), but fell at Christchurch to 96.5% (down 2.9%). RBCH scores remain within 2% of the national average score which increased by 0.5% to 98.1% in year. Cleanliness assessments were undertaken in 23 wards and departments. Cleaning faults were rectified after the assessments and housekeeping department action reports have been closed. Individual PLACE ward/department cleanliness scores ranged between 79.27% & 100%. A programme of mini PLACE audits involving Trust Governors, was organised throughout , to help improve the year round focus on PLACE issues and action plans. 7

8 There is a direct link between the cleanliness of a Hospital and maintaining low numbers of Healthcare Associated infections (HAI s). Whilst many other factors contribute to low HAI s, environmental cleaning and the ability of staff to effectively clean an area are key in our ability to provide clean and appealing area for patients to be looked after in. The housekeeping service received an additional 60k p.a. funding in 2015/16, to allow extra cleaning of public toilets across the RBH site. Housekeeping benchmark information for 2015/16 (National Estates Return Information Collection (ERIC)) shows RBCH are in the lower quartile of Trusts for cleaning cost. Cost and quality of service will continue to be monitored. Policies and Procedures IPC polices are reviewed on a regular basis in line with the action plan and submitted to the Practice Development Group for review and then the IPCC for sign off. Several policies have been through this route this year including the hand hygiene policy, surveillance policy, protective isolation policy and the cleaning of medical devices policy. CDI trajectories. The trajectory objectives have been calculated by NHS England on the basis of requiring continuous improvement from all trusts and CCGs, but also reflect a need for organisations with higher rates of infections to do more than those organisations with lower rates. How does this impact upon the patient? Cases of CDI detected whilst an inpatient at this hospital are routinely investigated by the IPC team. Cases occurring within 3 days of admission to the Trust are categorised as community acquired, those occurring after this time period are subjected to further follow up. No cases occurring after 3 days of admission to the Trust were found to have been caused by inappropriate medication or lapses in care. However a number of cases followed up did identify lapses in care that could contribute to further cases, delays in isolation for example. These lapses have formed the basis of a number of Directorate reports and have driven teaching sessions in all clinical areas. The cases identified as occurring after 3 days of admission associated with a lapse in care, are presented to the Clinical Commissioning Group and form part of the Trust trajectory cases. It is reassuring that thorough analysis and ribotyping of our cases this year has not been able to identify any patient to patient transmission of CDI. It is estimated that 3% of the population are colonised with CDI, these patients are at greater risk of developing a severe infection with CDI, particularly if given antibiotics. Within the Trust and community antibiotic use is audited on a continuing basis. Current findings 8

9 indicate that 92.6% of inpatients on antibiotics are either compliant with national guidelines or have been approved by a microbiologist, in 4% of cases there was no guidance to follow. Our trajectory figure for this year has not changed. Norovirus Figure 1 Norovirus outbreak data Ward Closures Bay Closures Patient Cases Staff Cases Lost Bed Days / 2017 The number of ward closures and patient cases have remained low in the past 5 years. This matches with the numbers of cases reported at a local and national level. There are many reasons for this drop in numbers since 2012 however the actions carried out by staff in promptly isolating and sampling patients who present with signs of viral gastroenteritis must be praised. 9

10 Criterion 2 Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections Decontamination of medical devices The Trust policy is to ensure that all devices are cleaned, contaminated and labelled as such after each patient use. Audits are carried out on a monthly basis to ensure this takes place and each ward has a list of all the medical devices in their area. This list is used to drive the weekly cleaning for nursing staff ensuring that low use equipment is clean and ready for use. This evidence can reassure patients that all equipment used is clean and free from potentially harmful pathogens. A new policy has been developed this year and was successfully presented to the Practice Development Group. The policy will change the methods which equipment on their ward is recorded putting more of the focus on regular cleaning and appropriate methods than ensuring each piece of equipment is listed. Supply and provision of linen and laundry Clean comfortable linen plays an integral part in patient care. The current supplier has a state of the art system to ensure clean, good quality linen The Trust changed their linen supplier to Berensden in The changeover from the previous supplier to the new supplier was expertly managed by Steve Curtis and the Commercial Services team with minimal impact upon the Trust. Throughout this year regular meetings have held with stakeholders and linen suppliers, minimal issues have been reported with the supply, cleaning and removal of linen to the Trust. Policies on the environment The Trust has a number of policies in place in relation to cleaning services, building and refurbishment, waste management, infected linen, planned preventative maintenance, pest control, drinkable and non-drinkable water and legionella. IPC staff regularly attend Estates meetings in particular those related to water services, planning of new buildings and modification of current structures. The Trust is constantly looking at ways to reduce its impact upon the environment whilst continuing to provide excellent healthcare. This year the IPC team have worked closely with the Estates team and ward leaders to reduce the unnecessary 10

11 placement of household waste into clinical waste bins, this will reduce the impact the Trust has on the environment and saving money for departments at the same time. Cleaning service Housekeeping audits are carried out on a routine and regular basis across the Trust. Internal audit results on average have been above 96% across the Trust. External audits are in line with these findings. Action plans are created by the Housekeeping team and reviewed at monthly intervals with the IPC team. Cleanliness of wards and departments is key to preventing occurrence of HCAI s. Audit results demonstrate the high standards we are striving to achieve at RBCH. IPC staff have excellent links with the Housekeeping team and work closely to reduce the various challenges presented to the teams. Audit scores Regular fortnightly walkabout audits are carried out in all wards and departments within the Trust as well as services commissioned by the Trust. These are led by IPC staff in conjunction with representation from senior nursing staff, the board of governors, housekeeping and estates. Governor involvement in these walkabout reviews brings the patient perspective to our inspections and adds a level of insight the team benefit from. The overall score for the walkabout audit for this calendar year is 88%. Key issues that have arisen during these audits are storage and cleaning of equipment, low level dust and care of intravenous cannula. These issues have been discussed at key meetings to raise awareness. Actions plans have been created and are in place at ward level to address these. Care Quality Commission (CQC) The latest CQC inspection highlighted some areas where equipment cleaning had not been documented or not yet taken place. Each area should have its own list of equipment that is cleaned on a regular basis, either as part of a routine clean or after each use. Labels are used to record the clean with dates and who cleaned the equipment documented. An updated policy on the decontamination of medical devices has been approved at the Practice Development Group that will help staff address some of the issues raised within the report. 11

12 Criterion 3 Provide suitable accurate information on infections to service users and their visitors. The Trust makes information available on the RBCH internet site relating to MRSA screening, C. Difficile and other infectious diseases as well as outbreaks as they arise. IPC audit results and other markers of good infection control are displayed on every ward and form part of the Ward score cards. The IPC team work closely with the Communications team to ensure consistent and far reaching communications. We are aware that many of our patients may not have access to IT and many prefer fact to face communications. So we spend a great deal of our time offering direct advice to patients and their relatives on various factors related to their diagnosis. A quality improvement project is currently reviewing patient information in relation to isolation and multi drug resistant organisms. All ward closure information is displayed on the Trust s website, the intranet and on display boards at the entrances to the main hospital and the Emergency Department. Social media updates on these issues are led by the communication team. Key reports and documents are also held on the Trust internet webpage for all patients to see. The annual open day for staff and patient held in 2016 was a great opportunity for staff and members of the public to discuss any questions they had around infection prevention and control. The Lead IPC Nurse for the Trust gave a talk in the main tent on infection control within the home which was well received. 12

13 Criterion 4 Provide suitable accurate information on infections to any person concerned with providing further information support nursing/ medical care in a timely information. The IPC team are available 07:00 to 17:00 Monday to Friday. Reports of infectious pathogens are reported to the IPC team if they are presumptive or as soon as they are confirmed by the microbiology laboratory. The team visit each ward in person to ensure that staff and the patient are aware of the result and its implications. Written information is given to the patient and follow up visits arranged as necessary. Clear instructions are left within the patients notes on any requirements to isolate, wear protective equipment and whether or not treatment and further sampling is required. Out of Hours (OOH) arrangements OOH Infection Control advice is addressed firstly by the Clinical Site team. Any issues related to infection control that are urgent and cannot be addressed by the team or the on call microbiologist are passed on to the Lead Infection control nurse. This is supported over the weekend by the on call Matron and Manager. Issues related to microbiology results, sampling and interpretation of results are addressed by the on call microbiologist. 13

14 Criterion 5. Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people. Cases of infectious disease are reported to the IPC team on a daily basis either as they are identified by the microbiology laboratory or by clinical suspicion on admission/ transfer. Advice is given over the telephone to patients on actions to take following results and information leaflets plus letters are sent out. We also ensure regular communications with GP s, other hospitals and colleagues in the community to ensure that all those involved in the healthcare of the patient are made aware of any new or existing diagnoses. The IPC team have worked closely with the informatics department to create a live spread sheet that identifies all patients admitted with a potentially contagious infection/ colonisation. This tool reports on all admitted patients and alerts the IPC team if the patient is moved from one ward to the next. This has enabled the IPC team to ensure isolation, prompt and regular screening takes place and that the patient and their medical team are aware of the diagnosis. The tool has been live for the past 12 months and has become an invaluable tool to the IPC team and ward staff. The information that this tool creates has meant that patients with resistant organisms or highly transmissible infections are being identified more promptly than was previously possible. The impact of this has meant that terminal cleans, required following a discharge or transfer of a patient with a resistant organism or potentially infectious pathogen have increased by over 30%. IPC staff visit wards to discuss results and give practical or technical advice to the multidisciplinary team. Audits are carried out to ensure that the appropriate steps have been taken following diagnosis of an infectious disease. The Consultant Microbiologists carry out regular ward rounds visiting patients and providing advice on managing clinical symptoms and medical treatment. Joint visits by the IPC team and the Consultant staff often take place in particular when dealing managing complex cases. Alert organisms, such as MRSA and C. Difficile, are reported on a monthly basis via to all Departments and discussed at each infection Control Directorate meeting for the resource staff. Learning points from these cases are presented and discussed at the same meeting with an overview report given to the IPCC meeting by the appropriate Head of Nursing every 3 months. Healthcare acquired infections are reported to the Trust Performance Management Group every week alongside the learning points from Root Cause Analysis (RCA) investigations into IPC incidents. 14

15 Currently we are partially non-compliant with NICE Infection Control Guidance as there are no electronic epidemiological tools within the Trust. This means we are unable to assure the Board that all cases of infectious disease are monitored at a Trust wide level in a robust manner and that there is no ward to ward transmission of resistant strains of bacteria. This is mitigated by good communication within the infection control team, microbiology staff and lab staff to ensure that we keep an overall awareness of trends in results and observational findings. Excel files and access databases are used for all patient results but these depend upon human interaction to identify and report trends. The IPC lead nurse is working with the informatics team on a number of tools that will help to meet the requirements the NICE Infection Control Guidance. One tool under development will allow quick analysis of the number of patients with resistant organisms on a ward at any time with a lookback function to aid epidemiology. The other tool will automatically flag any patients with similar results on the same ward in a given time period. Outbreaks and occurrence of unusual infections are reported to Public Health England (PHE) and local healthcare providers/ commissioners on a routine basis. Current epidemiology is discussed on a monthly basis with Infection Control leads from Acute and Community providers alongside representative from the CCG and PHE. Influenza Patients admitted with influenza like illness are now screened using PCR swabs. This is a test that looks for the genetic material of influenza and is capable of returning a result within a very short space of time. This year, in line with reporting across the South West the Trust has seen a high number of influenza cases including one ward closing due an outbreak. We predominantly saw influenza A cases at the Trust this season Influenza A Influenza B Figure 2 Positive influenza samples April '15 to March '17 15

16 Number of patients The Biofire system in the laboratory department has revolutionised our ability to give prompt results and guidance to patients thought to have influenza. Not only has this dramatically improved our ability to scale down isolation precautions promptly but also ensure patients with the infection are treated and isolated much sooner than was previously possible. E. coli Infections due to E. coli will be a target for the NHS Healthcare providers and commissioners to reduce from 2017/2018 onwards. Currently we review each case identified after 48 hours of being an inpatient. If the IPC team identify any cause for concern or lapses in care a RCA is requested. Most of the patients we identify with infections due to this bacteria are unwell due to a natural progression of their diseases or illness. However, a stronger focus on catheter care and prompt removal will be carried out over the next 18 months to help reduce infections that may have been related to catheter care E. coli bacteraemia's Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-16 May- Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov- Dec-16 Jan-17 Feb-17 Mar E Coli HAI Ecoli Figure 3 E. coli bacteraemia s Health and Community acquired HCAI Benchmarking - E. coli benchmarking Rates for E. coli bacteraemia s per 100,000 bed days are not calculated by PHE as apportioning is not currently applied. During April and July of 2016 an increase in E. coli bacteraemia s was identified. These were taken from patients within 48 hours of admission indicating that these 16

17 patient s had the infection on admission, known as community associated infections (CA) This rise was greater than 2 standard deviations above the norm, indicating that this was not due to any natural fluctuations. Investigation s carried out by the Trust in conjunction with Public Health England and Dorset Clinical Commissioning Group did not identify any geographical links or common factors between the patients. The number of identified infections fell back to normal levels during August and continued at this level for the rest of this year. A Healthcare associated infection (HAI) is one that is identified after on the third day of admission where the admission day is day 1. Each case of HAI is reviewed by the Infection Control team. If any gaps in practice are identified that may have contributed to the infection an RCA is requested. 60 HAI E. coli bacteraemia s were identified last year, of those case 4 were associated with a root cause analysis (RCA) as it was identified that gaps in practice may have contributed to the infection occurring. The findings from theses RCA s are included below; Delay in TWOC no clinical review of urinary catheter (LERN ) Delay in TWOC (LERN ) Incomplete documentation of catheter care (LERN ) & (LERN ) Each of these RCA s has their own individual action plan led by the Ward sister in conjunction with the infection control team. Ensuring appropriate use of catheters and encouraging the prompt removal and review if they are necessary is generally understood to be contributory factors in reducing E. coli bacteraemia s. As part of the work to reduce gram negative bacteraemia s set out by NHS Improvement this will be one of the focus areas for infection control and the Trust from April 2017 onwards. ESBL (Extended spectrum beta lactamases) Organisms that are resistant to antibiotics are one of the major challenges to the Trust. ESBL is an enzyme that enables resistance in bacteria to certain classes of antibiotic. These bacteria are found in the gastrointestinal tract and often are the cause of urinary tract and blood stream infections. All patients with current or previous diagnosis are nursed under isolation precautions. As a Trust we identify approximately one new case of this each month which adds to the growing number of patients with resistance in our community. 17

18 Rate per 100,000 population (per 100,00 0 occupied bed days for trusts) April May June July August September October November December January February March CDI (Clostridium difficile) This year we identified 22 HA cases of Clostridium Difficile. Each case was reviewed following NHS England s post infection review process. Of these cases 17 were associated with lapses in care. Each lapse in care is reviewed on the ward and presented to all those involved in patient care on the ward to encourage discussion and learning. The increase in cases over the course of the year has led to the development of a QI project aimed at reducing delays in isolation and sampling of patients with loose stools. Benchmarking CDI The Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust PHEC (acute trust rate) ENGLAND (acute trust rate) Month Figure 4 C. difficile rate per 100,000 bed days All data taken from Public Health England Field Epidemiology Services correct as of May Clostridium difficile rates have largely followed national and regional trends except for a peak in cases during July. Peaks such as these are often seen following seasonal increases in respiratory infections and the resultant increase in antibiotic 18

19 Number of patients usage. Each case is thoroughly followed up by the IC team and no common factors were found to link these cases. A separate report has been published on clostridium difficile for this year s cases which has been presented to the Infection Prevention and Control Committee. MSSA (Meticillin sensitive Staphylococcus aureas) Staphylococcus aureas is a bacteria that is found on the skin of most normally healthy individuals. It is a bacteria that is sensitive to methicillin, an antibiotic used to treat infection caused by the bacteria. Infections caused by this bacteria are often related to surgery, open wounds or breaks in the skin either caused by healthcare (surgery or invasive lines) or those present due to illness (cellulitis). Most of the patients we identify with infections due to this bacteria are unwell due to a natural progression of their diseases or illness. However each case is investigated by the IPC team and if any lapses in care are identified an RCA is requested. This year we requested 2 RCA s in relation to MSSA infections. A common trend found in these investigations is care of invasive devices that do not meet the standard set out in Trust policy. It is unclear however if these directly contributed to the infection MSSA bacteraemias Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-16 May- Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov- Dec-16 Jan-17 Feb-17 Mar MSSA HAI MSSA Figure 5 Healthcare and community acquired MSSA bacteraemia 19

20 Rate per 100,000 population (per 100,00 0 occupied bed days for trusts) April May June July August September October November December January February March HCAI Benchmarking - MSSA The Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust PHEC (acute trust rate) ENGLAND (acute trust rate) Month Figure 6 Rate of MSSA bacteraemia s per 100,000 bed days 2016 to 2017 All data taken from Public Health England Field Epidemiology Services correct as of May Our rate of infections for MSSA blood stream infections shows increases in the number of infections reported during May, October and March. Generally we report very low numbers of HA infections, for example the rise from April to May is an increase from 1 to 4 confirmed HA infections. Each case is investigated by the team to identify any gaps in practice that may have contributed to the infection being acquired. Common findings from these investigations were inspection of cannula site not being carried out regularly; patients with poor skin integrity or wounds but these could not be directly attributed to the infection. 3 RCA s were requested following initial investigation as these cases were felt to require further follow up. 20

21 Compliance issues identified in infection control audits with accessing central lines and other venous access devices plus non-compliance with hand hygiene policy ( ) Visual inspection of phlebitis (VIP) assessment not completed on a regular basis ( ) and ( ) Each of these RCA s were associated with an action plan. Incidents in these areas have not reoccurred and audits have demonstrated a sustained improvement in some areas. Regular completion of VIP scores scores for patients is regularly audited across the Trust. Different methods of improving compliance have been implemented across the Trust but a sustained improvement has not been demonstrated. MRSA (Meticilin resistant Staphylococcal aureas) All patients admitted to high risk wards or for high risk procedures are screened for MRSA. Across the Trust we screen over 90% of patients against the MRSA policy. Challenges in meetings this policy are often uncovered when we are under extreme bed pressures and patient movement is often found to be the cause. In order to ensure prompt transfers and identification of MRSA +ve patients waiting to be admitted to high risk wards PCR screening has been implemented. Due to the high volume of tests required this is an increasing cost to the Trust, an amendment to the policy to screen all patients admissions to SAU using the traditional culture method has been introduced to attempt to reduce this cost without impacting upon patient safety. Antibiotic usage Antibiotic stewardship remains very well managed at RBCH. PHE shows the Trust to be in the lowest quintile of antibiotic usage in England measured in Defined Daily Doses per 1000 admissions. This is in terms of total usage and usage of the broad spectrum agents Tazocin and Carbepenems. This is the dataset submitted by Trusts to comply with the national stewardship CQUIN. Internal audit of 326 patients in 2016 across all the inpatient wards showed the following: Antibiotic prescribed in compliance with Trust guidelines or with appropriate approval (E.g. recommended by microbiologist for example) 92.6% Worth noting that in 4% of cases there were no guidelines to follow as well. Indication for prescribing documented 99.7% Total course length given considered appropriate 97% Evidence of review within 72 hours of prescribing 97.5% 21

22 The South West regional point prevalence audit showed the following: (197 pts) Antibiotic prescribed in compliance with Trust guidelines or with appropriate approval (E.g. recommended by microbiologist for example) 93% Indication for prescribing documented 96.2% Course length stated at time of prescribing 64.2% 22

23 Criterion 6 Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection. It is the aim of the IPC team to make Infection Prevention and Control second nature to all staff. We have been able to ensure that all staff joining the Trust view the RBCH Infection Control video and have the opportunity to ask questions directly to the team. We are keen to ensure that all levels of staff access this training. At the Board of Directors public meeting, a statement of commitment with the Infection Prevention and Control Committee is signed in public, this is published on the Trust website. Once staff are in the clinical environment they then have access to all our training materials and policies via the intranet. Each department has one or more Infection Control Resource staff. It is their role to ensure that IPC is audited regularly and that all staff have access to the latest information and advice. Each ward and department does this differently but many have Infection Control boards and folders with information that is regularly updated. The IPC team enjoys strong links with these staff members and rely upon them to report back issues with new ways of working and raise IPC concerns directly with the team. Specific IPC sessions are delivered on wards and in departments. In addition to this a the team also sends out monthly topics with tips for good and to the Infection Control Resource staff for them to disseminate via teaching sessions, posters and the ever popular learning on the loo. More in depth training sessions have been delivered to via the Cavendish Care training for Health Care Assistants and Preceptorship Nurses. This has been scenario based training getting the new staff to understand the importance of IPC and how they can make a key difference. Every year the IPC team deliver an away day for all the resource staff to attend. This year we had guest speakers from within and external to the Trust including representatives from Salisbury Hospital microbiology department and the Trust Older Persons Medicine Team. This year the event was based at RBCH as more cost effective and accessible for staff. The day was split into two parts, the first focussed on education and awareness raising with the second half being more scenario and workshop based. Overall these were well reviewed. In 2017 the Trust will move away from having a day to joining work with the International Infection Prevention Week. We hope that this will allow us to engage with staff from all areas and provide advice and education that is focussed on the type of work they carry out. 23

24 Criterion 7 Provide or secure adequate isolation facilities. The Trust has 550 beds and 100 side rooms including 5 wards with an ICEpod each. Current evidence indicates that on an average day 60% of the side rooms within the Trust are used for patients carrying infectious bacteria. With the rising threat from resistant bacteria and new and emerging infections it is essential that we continue to look at new areas to isolate patients and novel methods to decontaminate areas after the patient leaves the hospital. These methods are coming to market and will be investigated in due course. Management of side room usage is a complex process. The IPC team work closely with ward staff and the clinical site team to ensure that these are appropriately used. The scoring system for side room allocation has been updated by the IPC team and is now in use across the Trust. This number based risk assessment has been well received. Isolation of infectious patients within the Trust is a constant challenge. As new and emerging diseases are identified and the threat of multi resistant organisms (in particular CPO and Candida Auris) we need to ensure within that Trust has enough side rooms to deal with future threats. At each new build the Trust takes on IPC staff are involved at the earliest stages with the Estates team and are able to work closely with them to ensure that adequate isolation and IPC facilities are built in to any new designs. This year the Trust has seen a number of side rooms removed from clinical access in order to facilitate the development of the PPU, closure of Ward 21 and Ward 9. During outbreaks and increases in the incidence of communicable disease in the community this does place pressure on the Trust when trying to isolate in patients with current or recent infections. On a number of occasions the private patient rooms have had to be used to enable isolation. An ambition would be for an increase in the number of side rooms to improve our ability to promptly isolate patients; however this is constrained by the current environment and build of the hospital. 24

25 Criterion 8 Secure adequate access to laboratory support as appropriate. The Infection Control team enjoy a very good working relationship with all staff within the laboratory at the Trust. Whilst we are not part of the Pathology structure we have ensured that the working relationships continue by ensuring attendance at laboratory meetings and having face to face meetings on a daily basis when requesting tests and discussing results. Strong links are also held with Consultant Microbiologists and the Infection Control Teams at neighbouring Acute Trusts. Out of hours the infection control team have access to laboratory staff as well as the on call microbiologist. The microbiology laboratory at RBCH is complaint with all standards associated with CPA accreditation. 25

26 Criterion 9 Have and adhere to policies, designed for the individual s care and provider organisations that will help to prevent and control infections. Trust has a number of IPC related policies all of which are available to staff on the intranet within a specific IPC section which has recently been updated to make it easier to use Links to other policies are also shared within the IPC intranet pages including those used by Poole General Hospital and wider national guidance from Public Health England. 26

27 Criterion 10 Ensure, so far as is reasonably practicable, that care workers are free of and are protected from exposure to infections that can be caught at work and that all staff are suitably educated in the prevention and control of infection associated with the provision of health and social care. Working within the healthcare environment can mean that you are confronted with potentially infectious diseases. To protect staff a multitude of factors are employed to ensure their safety. All staff employed within the Trust go through an Occupational Health screen to ensure that they are up to date with appropriate vaccines. Any staff member who due to health circumstances become vulnerable to infection are given advice by OH in conjunction with the IPC team to ensure their risk of illness as a result of exposure are reduced to a reasonably practical level. Guidance on infectious diseases and actions for staff to take is available on the intranet and directly from the IPC team. Stocks of personal protective equipment (PPE) are available in all departments relevant to the type of activities carried out in that area. Standard precautions are always recommended but sometimes extra precautions are required for example respiratory illnesses such as Middle East Respiratory Syndrome (MERS) require staff to wear FFP3 masks when carrying out care for the patient. These masks require specific training to wear and are each member of staff deemed at potential risk of exposure to a patient with this should be tested to ensure they are wearing the correct mask for their face. FIT testing records are maintained for departments and wards across the Trust. Staff compliance with PPE is part of regular IPC audit as well as hand hygiene. These build into the wards Safety Thermometer figures which are used as part of the information boards on each ward. Training plays a key part in preparing staff to protect themselves, the patient and respond to organisms with the potential to cause and spread infections. The infection control team deliver regular sessions at induction and at other times in wards and departments on various topics. These are either follow a seasonal pattern (influenza training before influenza season, Norovirus preparation before the winter etc) or by staff requests based on current news items of concern. Training sessions on bacteria and viruses will usually cover epidemiology, personal protective equipment, treatment, signs and symptoms and key points for infection control. However many other topics are covered by the IPC team including how to isolate a patient, how to carry out deep cleans following outbreaks, management of the patient with CDI and how to remove and put on PPE. 27

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