CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

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1 CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Report of: Chief Nurse and Director of Infection Prevention and Control (DIPC) - Cheryl Lenney Paper prepared by: Consultant Nurse, Infection Prevention and Control IPC - Julie Cawthorne Date of paper: April 2017 Subject: Annual Infection Prevention and Control Report 2016/17 Indicate which by Information to note Purpose of Report: Support Resolution Approval Consideration of Risk against Key Priorities: Recommendations: Contact: (Impact of report on key priorities and risks to give assurance to the Board that its decision are effectively delivering the Trusts strategy in a risk aware manner) Patient Safety Patient Experience Product and Efficiency The Board of Directors are asked to receive this report for April 2016 to March 2017 and approve for publication Name: Julie Cawthorne, Consultant Nurse IPC Tel:

2 Introduction The Board of Directors are asked to receive the Infection Prevention and Control Annual Report for 2016/ Executive Summary 1.1 The Trust has a statutory responsibility to be compliant with the Health and Social Care Act 2008 (Department of Health, 2010). A requirement of this Act is for the Board of Directors to receive an annual report from the Director of Infection Prevention and Control. This report details Infection Prevention and Control activity from April 2016 to March 2017, outlining our key achievements and an assessment of performance against national targets for the year. 1.2 The prevention and control of infection is a high priority for the Trust. There is a strong commitment to preventing all Healthcare Acquired Infections (HCAI). Since the objective for meticilin resistant Staphylococcus aureus (MRSA) bacteraemia was first introduced in 2006 the Trust has achieved a 81.4% reduction (from 54 to 10) in the number of incidents of attributable 1 MRSA bacteraemia and a 72.9% reduction in the number of attributable incidents of Clostridium difficile infection (CDI) (from 274 to 74). 1.3 The 2014/15 Annual report 2 set out the Trust s response to the emergence of Carbapenemase Producing Enterobacteriaceae (CPE) which included a specific action plan focused on enhanced screening and isolation of known carriers of CPE. From April 2016 all previously CPE positive patients were re-screened on admission, those who screened CPE not detected 3 were admitted into the general ward population and closely monitored during their in-patient stay. This action was supported by Public Health England (PHE), both at a local and national level. We are pleased to report that we have seen a decrease in the number of new acquisitions from 512 in 2015/16 to 378 in 2016/7(26.1%). This reduction in CPE acquisitions provides the Trust with assurance in determining the change to the screening policy. 1.4 The Trust is at the forefront of developing national as well as local policy for the management and control of patients with CPE and continued to liaise with PHE at a local and national level throughout the year on the Transmission of Carbapenemase resistant Enterobacteriaceae (TRACE) project. This study is investigating the role of the environment in the transmission of CPE. The fieldwork was completed in January Publications from the study will be published and available during 17/18 1 Attributable is the term used when an infection is considered to have been acquired at the Trust 2 CMFT Infection Prevention and Control 3 No longer had detectable levels of CPE on re-screening and therefore did not represent a significant risk of onward transmission of CPE. 2

3 2 Key Achievements and Challenges Agenda Item Following consultation with the Trust Infection Control Committee (ICC) and PHE, a risk based operational/working approach to CPE screening was adopted. Since April 2016 all previously CPE positive patients have been re-screened on admission. Of the 843 admissions, 519 (61.5%) were CPE not detected on admission, of which 55 (10%) were identified as CPE positive during their admission. This may have been due to the sensitivity of the test, making it difficult to detect very low levels of CPE at the initial screen or it may indicate a new acquisition. 2.2 The Trust is pleased to report that between March 2016 and August 2016 the Trust was able to reduce the isolation/cohort bed numbers from four wards (85 beds) to one ward (27 beds) based on a sustained reduction in the number of in-patients with CPE. 2.3 There were a total of ten incidents of MRSA bacteraemia attributed to the Trust during the year. In total, four of the attributable incidents reported by CMFT during 2016/2017 were considered following a detailed investigation, to have been avoidable compared to five cases of avoidable bacteraemia reported the previous year. 2.4 The number of Clostridium difficile infection attributable incidents reported to PHE was 74. All cases were presented and reviewed independently to determine whether they were associated with a lapse in care. 12 of the 74 attributable cases were considered to demonstrate a lapse in care (2 cases from March 2017 are pending review). 2.5 As part of a programme on surgical site infection, data was submitted for both hip and knee replacement surgery. Of a total of 472 knee replacement procedures conducted during the previous four quarters, three patients (0.8%) developed an infection. This rate of infection is below the national average of 1.5%. The most recent PHE SSI rate for hip replacement surgery is 1.1%. The last four periods for which data was submitted shows that out of a total of 369 hip replacement procedures performed at CMFT, two patients developed an infection. The rate of infection is less than 1% and not considered to be statistically significant. 2.6 The Vascular Surgery Department participated in a three month pilot of Surgical Site Infection (SSI) surveillance funded by the Trust IPC/TV team. A report of the findings was presented at the Trust Infection Control Committee (ICC) in March 2017 where it was agreed that a dedicated meeting would be convened early in 2017/18 to agree the next stage in developing the Trust SSI programme. 2.7 In total, there were 2782 bed days lost for 2016/2017 due to wards closed due to infection, (compared to 5331 for 2015/2016). The reduction is attributable in part to the reduced number of outbreaks of CPE. This has provided further assurance that the policy for screening and managing patients with CPE is successful. 2.8 There were 13 instances when wards were closed or partially closed due to outbreaks of diarrhoea and vomiting during 2016/2017 compared to two occasions for 2015/6. This reflects the national epidemiology for Norovirus in the 2016/2017 season. 2.9 Following approval from the Division of Research and Innovation, the Trust IPC Team have collaborated with Glasgow Caledonian University on a qualitative study in regards to staff and patient perceptions of CPE. The focus of the field work to date has been on the experience of staff and will extend to include the patient experience in the next few months. 3

4 2.10 The framework to strengthen the accountability arrangements for infection prevention and control within the Divisions was revised and agreed at the Trust ICC meeting in October This allowed the divisional committees to manage and debate issues more pertinent to their individual specialities. To strengthen this process from January 2017 the Divisions received weekly data on Healthcare Associated Infection in order to review incidents/clusters of alert organisms that occurred on each ward with a view to identifying common themes and a focus for action The Microbiology Laboratory processed an average number of 6,000 CPE screens per month for the year. From November 2016 funding was approved to extend the use of a commercial rapid test to all CPE screens, (previously this test had been available for unplanned patient admissions only). This improved patient flow through the organisation as the test is more sensitive and has a turnaround time of 24 hours, compared to up to three days for the previously used culture method Following the analysis of the results of the Urinary Catheter Care Audit undertaken in July 2016 the policy for Urinary Catheterisation and Catheter Care was reviewed to include an updated integrated care pathway and described competencies for nursing assistants and registered practitioners in order to standardise practice and reduce variations in care The Deprox Hydrogen Peroxide Vapour (HPV) decontamination system (manufactured by Hygiene Solutions) has been employed on an on-call reactive basis at the Trust in response to outbreaks of infection since In July 2016 Hygiene Solutions began a managed service, under a two year contract delivering the facility for the Trust s core and peak usage times. This enabled a timelier and proactive service for the use of HPV as well as bringing significant cost savings to the Trust Installation of an additional new purpose built Satellite Endoscope Decontamination unit in the Children s Hospital has been completed. This new unit has the capacity to re-process 16 endoscopes per hour. The decontamination unit in the Outpatient Department at the Central site has also been upgraded. The unit at Trafford is Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accredited. Work to gain JAG Accreditation for the MRI Endoscopy Suite began in March The annual Patient Led Assessments of the Care Environment (PLACE) Assessments were carried out between 9th and 19th May 2016 across the Central and Trafford sites. The overall scores for each of the five assessment categories were: Cleanliness 97.79%, Condition/Appearance/Maintenance 96.7%, Privacy dignity and Wellbeing 84.42%, Food 88.24% Organisation Food 87.01%, Ward Food 88.96%, Dementia 75.28% and Disability 78.84% 2.16 In addition to mandatory training, the Infection Prevention and Control Team delivered training to a broad range of staff including Medical Students, Consultants, Nurses, and Allied Healthcare Professionals on a variety of prevention of infection topics. The team supported training for the Hospital Volunteers and people on work experience programmes across the Trust The audit findings from the Trust Antibiotic Audit demonstrated assurance of good practice within some areas, but also highlighted areas where significant improvement in antimicrobial stewardship can be made. An action plan was developed and is being implemented and monitored through the Antibiotic Pharmacy Team The hand hygiene audit was undertaken by each division in December The overall level of compliance was 87%. This is a year on year improvement since July Action plans to improve compliance were developed and implemented through the Divisional Infection Prevention and Control meetings. 4

5 2.19 Members of the Trust IPC Team; Dr Andrew Dodgson, Consultant Microbiologist, Infection Control Doctor and Mrs Julie Cawthorne, Consultant Nurse IPC have presented papers on the management and control of CPE at the following conferences during 2016/17: 6 th July 2016 Infection Prevention Society West Midlands Branch Conference -Dr Andrew Dodgson 7 th July 2016 Public Health England London Tackling Antimicrobial Resistance in London Workshop -Dr Andrew Dodgson 13 th September 2016 PHE Annual Conference - Dr Andrew Dodgson 6 th & 7 Th November 2016 Federation of Infection Societies - Dr Andrew Dodgson 8th December 2016 British Society for Antimicrobial Chemotherapy educational workshop - Dr Andrew Dodgson 14 th March 2017 British Society for Antimicrobial Chemotherapy Spring Meeting - Dr Andrew Dodgson June 2016 Carbapenemase producing enterobactriaceae: The Manchester Experience East of England Infection Prevention Society Kingsgate Conference Centre - Mrs Julie Cawthorne October 2016 Queen Elizabeth Hospital (Link Nurse meeting), Kings Lynn - Mrs Julie Cawthorne November 2016 Carbapenemase producing enterobactriaceae: Outbreak Overview Public Health England Conference Park Plaza Hotel, Leeds - Mrs Julie Cawthorne 2.20 Members of the Trust IPC Team; Dr Andrew Dodgson, Consultant Microbiologist, Infection Control Doctor, Mrs Julie Cawthorne, Consultant Nurse IPC and Dr Ryan George, Surveillance Officer have contributed authorship to the following publications in 2016/2017: Rectal swab screening for the detection of carriage of carbapenemase-producing Enterobacteriaceae. Shorten RJ, Ashcroft P, Dodgson A. Journal of Hospital Infection (2016) Oct, 94(2), Active case finding for carbapenemase-producing Enterobacteriaceae in a teaching hospital: prevalence and risk factors for colonization. K. Poole, R. George, V. Decraene, K. Shankar, J. Cawthorne, N. Savage, W. Welfare, A. Dodgson Journal of Hospital Infection, (2016) 94, Issue 2, p Multisite Evaluation of Cepheid Xpert Carba-R Assay for Detection of Carbapenemase-Producing Organisms in Rectal Swabs. Tato M, Ruiz-Garbajosa P, Traczewski M, Dodgson A, McEwan A, Humphries R, Hindler J, Veltman J, Wang H, Cantón R.Journal of Clinical Microbiology (2016) Jul;54(7): The Director of Infection Prevention and Control acknowledges the breadth and depth of work undertaken by the wider IPC Team, members of the Trust ICC as well as the day to day contribution of all our staff and clinical leaders; working together to reduce the incidence of HCAIs. 5

6 INFECTION PREVENTION AND CONTROL ANNUAL REPORT 2016/17 Author: Julie Cawthorne Consultant Nurse Infection Prevention and Control 6

7 Contents Page 1. Executive Summary 2 2. Key achievements and challenges 3 3. Infection Prevention & Control Arrangements & Budget Allocation to Infection Prevention & Control 8 4. Healthcare Associated Infection (HCAI) The Management of Carbapenemase Producing Enterobacteriaceae (CPE) Developments in a Clinical Practice Maintaining a Clean Environment Training and Education Audit Conclusion 32 Appendices 1. Infection Prevention and Control/Tissue Viability Nursing Team structure Infection Control Committee terms of reference Infection Prevention and Control Annual Plan 2016/

8 Section 3: Infection Prevention and Control Arrangements 3.1 The Director of Infection Prevention and Control (DIPC) Mrs Cheryl Lenney, Chief Nurse, was designated to this post in July The Infection Control Committee reported to the Trust Clinical Effectiveness Committee and directly to the Board through the DIPC. 3.2 The Infection Prevention and Control (IPC) Team From April 2012 the Infection Prevention and Control and Tissue Viability (TV) nursing teams were integrated under one management structure within the Division of Clinical and Scientific Services Division. An organisational chart demonstrating the full structure of the integrated IPC/TV nursing team can be found in Appendix 1. The members of the IPC team can be found below (whole-time equivalent (WTE) unless otherwise stated). Dr Andrew Dodgson Infection Prevention & Control Doctor (IPCD). Mrs Julie Cawthorne, Consultant Nurse, Infection Prevention & Control. Dr Kirsty Dodgson, Deputy Infection Prevention & Control Doctor Miss Janice Streets, Matron, Infection Prevention & Control (until June 2016) Mrs Susan Jones, Acting Matron Infection Prevention & Control (0.8 WTE) (from June 2016) 3.3 Senior IPC Nurse Specialists Mrs Karen Mathieson - IPC Nurse Specialist Mrs Melanie Phillips - IPC Nurse Specialist 3.4 Dual Role Specialist Nurses There are 7.6 (WTE) nurse practitioners in the IPC/TV nursing team who undertake a dual practitioner role. 3.5 Antibiotic Pharmacists Ms Kelly Alexander (0.6 WTE) Ms Frances Garraghan (0.6WTE) Ms Catherine Child (0.4 WTE) Mrs Caroline Templeton (0.4 WTE) 3.6 Administration Support for Infection Prevention and Control Services Team Dr Ryan George (PhD) Healthcare Associated Infection (HCAI) Surveillance Officer Mr John Grimshaw, HCAI Support Officer Ms Gemma Shaw, Personal Assistant and Team Secretary 3.7 The IPC team provided 24-hour advice and support on IPC issues to the staff and patients of the Trust including an out of hour s telephone on-call service by the IPC nursing team. 8

9 3.8 The Trust Infection Control Committee (ICC) Agenda Item 9.4 The Trust Infection Control Committee (ICC) had corporate responsibility for overseeing the implementation of infection prevention and control activities across the Trust. The ICC met six times during the year and was chaired by the DIPC. The ICC Terms of Reference can be found in Appendix 2. The Infection Control Committee reported to the Trust Clinical Effectiveness Committee and directly to the Board through the DIPC. 3.9 Framework for Infection Prevention and Control (IPC) The Trust Strategy for IPC defined the structure and activities of IPC within the Trust. It was reviewed and ratified by the Trust ICC in January IPC Annual Plan April 2016-March 2017 We achieved a high level of compliance with the objectives in the IPC Annual Plan for 2016/17, (please see Appendix 3) Infection Prevention and Control Structure within the Divisions The framework to strengthen the accountability arrangements for infection prevention and control within the Divisions was revised and agreed at the Trust Infection Control Committee (ICC) meeting in October This allowed the divisional committees to manage and debate issues are more pertinent to their individual specialities. From January 2017 the Divisions received weekly data on Healthcare Associated Infection in order to review incidents/clusters of alert organisms that occurred on each ward with a view to identifying common themes and a focus for action. This process replaced the need for the divisions to undertake individual case reviews for patients with MRSA/CPE/VRE colonisation. Corporate KPI meetings were held on Wednesday afternoons to review; An incident of Clostridium difficile infection where a ward had entered into a period of increased incidence or an incident of Clostridium difficile infection where the division had established it was due to a lapse in care. An incident of CPE/MRSA/VRE bacteraemia 3.12 External Review of the Incidence of Carbapenemaese Producing Enterobacteriaceae (CPE) Public Health England launched a national level 3 incident into the incidence of CPE in Greater Manchester in November As part of that investigation the CMFT Infection Prevention and Control (IPC) Team worked in collaboration with PHE and the National Institute for Health Research (NIHR) Public Health Research Unit (PHRU) and the national lead for infection control Professor Derrick Crook, based at the University of Oxford, on a project referred to as the Transmission of Carbapenemase resistant Enterobacteriaceae (TRACE) project. This study investigated the role of the environment in transmission of CPE. The fieldwork for the project was completed in January 2017 and a report is expected later this year Funding for Infection Prevention and Control Services The IPC/TV nursing team provided a trust wide service and funding was provided within the Division of Clinical and Scientific Services. 9

10 3.14 Microbiology Laboratory Services Agenda Item 9.4 Funding for Microbiology services, (including screening for CPE and outbreaks of infection) was covered by the service level agreement between the Trust and PHE. Financial support for outbreaks of infection (excluding laboratory costs), were sourced locally by the divisions Electronic Surveillance System Recurrent funding for ICNet (electronic Infection Prevention & Control surveillance database) was met from the Division of Clinical and Scientific Support. Section 4: Healthcare Associated Infection (HCAI) 4.1 HCAI Performance Targets The prevention and control of infection remains a high priority for the Trust. There is a strong commitment to preventing all Healthcare Acquired Infections (HCAI). The Trust s progress in reducing the incidents of HCAI from 2007/8 2016/17 is clearly demonstrated below in Fig. 1. Fig. 1 Attributable MRSA Bacteraemia, and C. difficile Infections (2007/8-2016/17) Since the objective was first introduced in 2006 we have achieved an 81.4% reduction (from 54 to 10) in the number of incidents of attributable MRSA bacteraemia. The objective for Clostridium difficile infection was introduced in 2007/8, from when we have achieved a 72.9% reduction in the number of attributable incidents (from 274 to 74). The objectives for the year ending March 2017 were; zero incidents of avoidable MRSA bacteraemia and no more than 66 incidents of Clostridium difficile infection with a demonstrated a lapse in care. Issues which were considered to demonstrate a lapse of care include evidence of transmission of C. difficile within the hospital, breakdowns in cleaning or hand hygiene, or where issues were identified with the choice, duration, or documentation of antibiotic prescribing (poor antimicrobial stewardship). 10

11 4.2 Meticillin Resistant Staphylococcus aureus (MRSA) Bacteraemia Agenda Item 9.4 There were a total of ten incidents of MRSA bacteraemia attributed to the Trust this year. There was an additional case reported to PHE which has subsequently been identified as a laboratory contaminant. Application has been made to remove this from the Trust objective. From April 2013, a Post Infection Review (PIR) for all MRSA bacteraemia cases has been required as part of the government strategy for achieving a zero tolerance approach. The PIR process for each incident was undertaken by a multi-disciplinary team and presented to the DIPC at a dedicated meeting. The purpose of the PIR was to identify any possible failings in care. The findings were reviewed and each case was designated as either avoidable or unavoidable. In total, four of the attributable incidents reported by CMFT during 2016/2017 were agreed to have been avoidable, compared to five cases of avoidable bacteraemia reported last year. Areas for improvement identified through the PIR were incorporated into an action plan to be implemented and monitored through the Divisional Infection Control Groups. Key themes identified included; delays in MRSA screening and decolonisation therapy, incomplete documentation and failure to identify risk factors. 4.3 Meticillin Sensitive Staphylococcus aureus (MSSA) and Escherichia coli (E. coli) Bacteraemias Mandatory reporting of all MSSA bacteraemia commenced in January The Trust reported a total of 144 MSSA bacteraemia, 54 (37.5%) of these were apportioned to CMFT (i.e. occurred 48 hours or more after admission). E. coli bacteraemia reporting began in June There were 300 incidents reported to PHE. Currently, there is no requirement to identify those attributable to the Trust. However; as an indicator, 122 (40%) cases were determined to be attributable to CMFT, whilst 178 (60%) were attributed to the community. In November 2016 the Health Secretary announced plans to reduce Gram negative bacteraemia by 50%, by A preliminary analysis of E. coli bacteraemias identified at CMFT, reported to the November ICC, identified age/gender, likely source of infection, (for example, chest infection/urinary tract infection) and urinary catheterisation as a risk factor. The peaks of incidence were in children less than 10 year old and in adults greater than 60 years old. The urinary tract was the primary focus of infection in post 48hr cases, followed by hepato-biliary and abdominal sources. This analysis is being extended to incorporate bacteraemias caused by other gram negative organisms which will then direct a targeted intervention strategy. 4.4 Clostridium difficile Infection (CDI) The Trust was set a trajectory to achieve no more than 66 attributable CDI cases in all patients over the age of two for the year 2016/17. The actual number of attributable incidents reported to PHE was 74. The Trusts performance over previous reporting years can be seen in Fig. 2 below. The cases of CDI that were attributable are those which occurred on or after day three of admission, where day of admission is day one. 11

12 Fig. 2 Cumulative CDI cases (2013/ /17) Agenda Item 9.4 Each case of CDI was subject to a detailed review by the IPC team in conjunction with the clinical teams involved in delivering each patient s care. In collaboration with the local Clinical Commissioning Group (CCG) and colleagues from local trust, all cases were presented and reviewed externally to determine whether they were associated with a lapse in care. Following internal and external peer-review, 12 of the 74 attributable cases were considered to demonstrate a lapse in care (2 cases from March 2017 are pending review). Contractual sanctions were only applied to cases determined to be a lapse in care, and at the discretion of the CCG. Opportunities for education and improvement were identified following each investigation. These findings included; incomplete documentation, delays in sending stool specimens and isolating patients and poor antimicrobial stewardship. These issues were addressed locally within the divisions. 4.5 Vancomycin Resistant Enterococci (VRE) The Trust reports all incidents of VRE bacteraemia to PHE. The total number of incidents for the 2016/2017 reporting year to date is five (see Fig.3). 12

13 Fig. 3 Cumulative VRE Bacteraemia Incidents ( ) Agenda Item Orthopaedic Surgical Site Infection (SSI) Rates In accordance with national guidance, the Trust is required to submit a minimum of one quarter of data per year to comply with mandatory reporting for orthopaedic implant surgery. Data was submitted for both hip and knee replacement surgery. The results from knee replacement procedures can be found in Fig. 4 below. The previous three periods for which data is available are included for comparison. The most recent national SSI rate for knee replacement surgery is 1.5 % (based on 285,086 national procedures over the previous five years). Fig. 4 Trends in SSI Rates for Knee Replacement Surgery from Year and Period No. Operations All SSI* 2015 Q % 2015 Q % 2016 Q % 2016 Q % *All SSI = Inpatient & readmission, post-discharge confirmed and patient reported Of a total of 472 knee replacement procedures conducted during the previous four quarters, three patients (0.8%) developed an organ/space infection; two of which required re-admission and one of which was patient reported. This rate of infection is below the national average of 1.5%. The results from hip replacement procedures performed can be found in Fig. 5 below. The previous three periods for which data are available are included for comparison. The most recent national SSI rate for hip replacement surgery is 1.1% (based on 271,611 national procedures over the previous five years). 13

14 Fig. 5 Trends in SSI Rates for Hip Replacement Surgery from Year and Period No. Operations All SSI* 2015 Q2 93 0% 2015 Q % 2016 Q % 2016 Q % * All SSI = Inpatient & readmission, post-discharge confirmed and patient reported The last four periods for which data was submitted shows that out of a total of 369 hip replacement procedures performed, two patients developed organ/space surgical site infections and required readmission. The rate of infection is less than 1% and not considered to be statistically significant. 4.7 Coronary Artery Bypass Graft (CABG) SSI Rates The Trust has participated in voluntary CABG SSI in Manchester Heart Centre (MHC) since The results from the last four quarters submitted to PHE can be found in Fig.6. Fig.6 SSI Rates for CABG Year and Period No. Operations All SSI* 2014 Q % 2015 Q % 2015 Q4 75 4% 2016 Q % * All SSI = Inpatient & readmission, post-discharge confirmed and patient reported Despite being identified as an outlier in Q3 of 2015 (reported in the 2015/2016 IPC Annual Report), subsequent surveillance periods have demonstrated rates returning to below the national average (6.7% based on 30,841 national procedures). The most recently submitted data (Q3 of 2016) identified an SSI of rate of 5.1% due to the identification of three superficial incision and two deep incision infections. 4.8 Progress to Extend the Programme for Surgical Site Infection (SSI) Surveillance The Vascular Surgery Department volunteered to participate in a three month pilot of SSI surveillance funded by the Trust IPC team. The surveillance was based on the established protocols developed through PHE national surveillance programme and included data collection and data analysis. Incidents of deep wound infection were investigated using Root Cause Analysis. The preliminary results identified that 12 (18.5%) of the 65 procedures included in the surveillance developed complications in healing. Of those surgical site infections identified, two (3%) were categorised as deep, and 10 (15.4%) were superficial, nine of which were patient reported (identified via telephone follow up). A report of the findings was presented at the Trust Infection Control Committee in March 2017 where it was agreed that a dedicated meeting would be convened to agree the next stage in developing the Trust SSI programme. 14

15 4.9 Influenza Vaccination for Staff Agenda Item 9.4 Influenza vaccination uptake rates were lower than previous years: 50% of front line staff were vaccinated during the previous flu season. Despite being lower than last year s coverage (72%), this remains higher than the NHS national uptake of 47%. The programme was co-ordinated and developed by a multi-disciplinary planning group lead by the Occupational Health Department. An evaluation of the campaign is planned to determine areas for improvement Outbreaks of Infection Diarrhoea and Vomiting, Influenza, MRSA and CPE In total, there were 2782 lost bed days for 2016/2017 (compared to /2016). The reduction is attributable in part to the reduced number of outbreaks of CPE. This provides assurance that the policy for managing patients with CPE is successful. There was one occasion when a ward was partially closed due to Influenza B (Fig. 7A) and one partial closure due to Group A Streptococcus (Fig. 7B). In addition, there were five ward closures due to CPE (Fig. 7C). There were a number of occasions when wards were closed or partially closed due to outbreaks of diarrhoea and vomiting during 2016/2017 (Fig. 7D). This figure is higher than previously reported by CMFT and reflects the national epidemiology for Norovirus in the 2016/2017 season. Division Fig. 7A Ward Closures due to Influenza (April March 2017) Ward Date of closure No. of Days Closed No. of Patients Affected Number of Staff Affected Surgery Ward 10 11/05/ Total 14 No. of Bed Days Lost Fig. 7B Ward Closures due to Group A Streptococcus (April March 2017) Division Ward Date of closure No. of Days Closed No. of Patients Affected Number of Staff Affected Surgery H&N 28/12/ Total 80 No. of Bed Days Lost 15

16 Fig. 7C Ward Closures due to CPE (April March 2017) Agenda Item 9.4 Division Ward Date closure of No. of Days Closed No. Patients Affected of Number of Staff Affected No. of Bed Days Lost DMAC Ward 45 21/07/ N/A 0 20 DMAC AM 1 08/08/ DMAC Ward 45 12/09/ Trafford Ward 04 17/10/ Trafford Ward 4 TGH 07/01/ Total 1201 Fig. 7D Ward Closures due to Diarrhoea and Vomiting (April March 2017) Division Specialist Medicine Ward Coronary Care Unit Date of closure No. of Days Closed No. of Patients Affected No. of Staff Affected Bed Days Lost 24/08/ SMH Ward 62 22/11/ Specialist Medicine Ward 37 21/12/ Specialist Medicine Ward 04 26/12/ Specialist Medicine Ward 03 08/01/ Trafford Ward 06 10/01/ Surgery ESTU Male 22/01/ Surgery ESTU female 22/01/ Surgery Ward 9 25/01/ DMAC Ward 15 02/02/ DMAC Debdale, Gorton Parks 04/02/ Specialist Medicine ACC 06/02/ DMAC Ward 7 13/02/ Total

17 4.11 Enhanced Catheter Associated Urinary Tract Infection (CAUTI) Surveillance at CMFT All positive catheter specimens of urine are alerted and investigated on a daily basis by the IPC/TV team and Continence Specialist Nurse. Fig. 8 below describes the outcome of these investigations. A root cause analysis was completed for each CAUTI and was presented at divisional harm free care meetings. The Continence Specialist Nurse continued to provide a programme of monthly and ad hoc education sessions related to catheterisation and catheter care. There is an on-going work stream involving IPC/TV and Informatics which seeks to automate the reporting of potential CAUTI and provide denominator data around catheter insertion. Fig. 8 Outcome of Positive CSU/MSU Investigations: April 2016 March 2017 Investigation Outcome CAUTI 157 Not a CAUTI 1757 Grand Total 1914 Fig. 9 Distribution of CAUTI Across the Divisions at CMFT: April 2016 March

18 Section 5: The Management of Carbapenamase Producing Enterobacteriaceae (CPE) 5.1 Enhanced Screening The Microbiology Laboratory continued to process an average number of 6,000 CPE screens per month for this year. From November 2016 funding was approved to extend the use of a commercial rapid test to all CPE screens, (previously this test had been available for unplanned patient admissions only). This improved patient flow through the organisation as the test is more sensitive and has a turnaround time of 24 hours, compared to up to 3 days for the previously used culture method. There was a significant decrease in the number of new cases of CPE from April 2016 March 2017 compared to the previous year (from 512 cases to 378). The increases observed in August and September 2016 were due to outbreaks on Wards AM1 and 45 (see Fig 10 below). Figure 10 CMFT CPE Acquisitions January 2015 to March Changes to the CPE Screening Policy Since the first emergence in 2009 of Klebsiella pneumoniae Carbapenemase (KPC) producing CPE at CMFT, the Trust policy has been to isolate CPE positive patients on the assumption that a patient found to be carrying CPE is likely to remain a carrier on all subsequent admissions and require isolation. This was based on the fact that there are uncertainties regarding the detection and the natural history of CPE carriage. In January 2016 a review of a cohort of patients previously known to be carrying CPE who were re-screened on admission identified that a significant number (65%) no longer had detectable levels of CPE on re-screening and therefore did not represent a significant risk of onward transmission of CPE to other patients. Subsequent to this review and following consultation with the Trust Infection Control Committee and PHE, a risk based operational/working approach to screening was adopted and rolled out across the MRI from 12th April

19 Since April 2016 all previously CPE positive patients have been re-screened on admission, those who screened CPE negative (subsequently referred to as CPE not detected), were admitted into the general ward population following risk assessment and were closely monitored during their admission (i.e. re-screened every 72 hours). See Fig. 11 below for a breakdown of the results. Fig. 11 Results of CPE Screening from April 2016 March 2017 *not re-screened on date of admission due to; test failure, patient discharged before testing, sample rejected (as no visible faecal matter on swab) Data on relevant risk factors was collected by the IPC team on all patients on the pathway during their in-patient stay. An analysis of the data will be undertaken when sufficient data has been collected, which will help to shape future policy at local and national level. 5.3 Reduction in the Capacity of Cohort Wards March to August Evidence from the Trust data demonstrated that the provision of dedicated cohort facilities for patients who are CPE positive was a major contributing factor in reducing the transmission of CPE. However, the provision of cohort wards impacted on patient flow and may have disadvantaged patients as they may not have been treated in an appropriate speciality ward. Between March 2016 and August 2016 the Trust was able to reduce the cohort bed base from four wards (85 beds) to one ward (27 beds) based on a sustained reduction in the number of in-patients with CPE. 5.4 Transmission of Carbapenemase Producing Enterobacteriaceae (TRACE) Project The Trust is at the forefront of developing national as well as local policy for the management and control of patients with CPE and continued to liaise with PHE at a local and national level throughout the year. PHE launched a national level 3 incident into the incidence of CPE in Greater Manchester in November As part of that on-going investigation during 2015/2016 the CMFT IPC Team worked in collaboration with PHE and the National Institute for Health Research (NIHR), Public Health Research Unit (PHRU) and the national Lead for Infection Control Professor Derrick Crook, based at the University of Oxford, on the TRACE project. 19

20 This study investigated the role of the environment in the transmission of CPE and involved taking patient screens and environmental samples for CPE across six wards in the Manchester Royal Infirmary. The field work was completed in January 2017 and a report is expected later this year. 5.5 Factors Affecting the Implementation and Acceptability of Hospital Screening Policies for Antimicrobial Resistant Organisms (including CPE): Following approval from the Division of Research and Innovation the Trust IPC Team have collaborated with Glasgow Caledonian University on a qualitative study in regards to and patient perceptions of CPE. The focus of the field work to date has been on the experience of staff and will extend to include the patient experience in the next few months. 5.6 Publications 2016/17 Members of the Trust IPC Team; Dr Andrew Dodgson, Consultant Microbiologist, Infection Control Doctor, Mrs Julie Cawthorne, Consultant Nurse IPC and Dr Ryan George, Surveillance Officer have contributed authorship to the following publications in 2016/2017: Rectal swab screening for the detection of carriage of carbapenemaseproducing Enterobacteriaceae. Shorten RJ, Ashcroft P, Dodgson A. Journal of Hospital Infection (2016) Oct, 94(2), Active case finding for carbapenemase-producing Enterobacteriaceae in a teaching hospital: prevalence and risk factors for colonization. K. Poole, R. George, V. Decraene, K. Shankar, J. Cawthorne, N. Savage, W. Welfare, A. Dodgson Journal of Hospital Infection, (2016) 94, Issue 2, p Multisite Evaluation of Cepheid Xpert Carba-R Assay for Detection of Carbapenemase-Producing Organisms in Rectal Swabs. Tato M, Ruiz- Garbajosa P, Traczewski M, Dodgson A, McEwan A, Humphries R, Hindler J, Veltman J, Wang H, Cantón R.Journal of Clinical Microbiology (2016) Jul;54(7): Presentations at National Conferences 2016/17 Members of the Trust IPC Team; Dr Andrew Dodgson, Consultant Microbiologist, Infection Control Doctor and Mrs Julie Cawthorne, Consultant Nurse IPC have presented papers on the management and control of CPE at the following conferences: Dr Andrew Dodgson 6th July 2016 Infection Prevention Society West Midlands Branch Conference 7th July 2016 Public Health England London Tackling Antimicrobial Resistance in London Workshop 13th September 2016 PHE Annual Conference 6th & 7Th November 2016 Federation of Infection Societies 8th December 2016 British Society for Antimicrobial Chemotherapy educational workshop 14th March 2017 British Society for Antimicrobial Chemotherapy Spring Meeting 20

21 Mrs Julie Cawthorne June 2016 Carbapenemase producing enterobactriaceae: The Manchester Experience East of England Infection Prevention Society Kingsgate Conference Centre October 2016 Queen Elizabeth Hospital (Link Nurse meeting), Kings Lynn November 2016 Carbapenemase producing enterobactriaceae:outbreak Overview Public Health England Conference Park Plaza Hotel, Leeds Section 6: Developments in Clinical Practice 6.1 Updated Infection Prevention and Control (IPC) Policies The IPC Team in collaboration with colleagues from other specialist services and service users revised/updated four IPC policies. Each Policy was subject to consultation with stakeholders and ratified by the Trust Infection Control Committee (ICC). 6.2 Replacement of Hand Hygiene Gel Dispensers The replacement of all alcohol hand gel dispensers was completed to increase hand hygiene compliance by improving access to facilities trust-wide. 6.3 Urinary Catheter Competencies Following the analysis of the results of the Urinary Catheter Care Audit undertaken in July 2016 the policy for Urinary Catheterisation and Catheter Care was reviewed to include an updated integrated care pathway and described competencies for nursing assistants and registered practitioners in order to standardise practice and reduce variations in care. 6.4 Management of Central Venous Catheters (CVC s) Through the Trust CVC Line Access Group an honorary contract was established to provide a Clinical Nurse Specialist who delivered support and training to extend the roll-out of Peripherally Inserted Central Catheters (PICC s) across the Trust. This included education for staff in Radiology in the insertion of PICC lines and developing a competency framework and training for ward based staff to care for patients with a PICC line. The IPC team collaborated with the Patient Track Team in order to develop electronic monitoring of the insertion, management and timely removal of CVC s (including PICC lines). This was piloted in the Division of Surgery on Wards 8, 9 and 10 from early March 2017 and has been well received by staff. It will be rolled out across the remainder of the Trust in Data from this electronic monitoring system will be used to provide baseline information to measure the incidence of CVC line infection. 21

22 6.5 Review of the Use of Hard Surface Disinfectant Wipes Agenda Item 9.4 This year the IPC team reviewed the use of hard surface disinfectant wipes and are in the progress of changing to a single universal disinfectant wipe which can be used to decontaminate medical devices in a single stage process, (replacing the previous two stage process). The wipes were trialled by users across four wards at the Central site and two at Trafford Hospital. The new wipes were approved for use by Health & Safety and Medical Engineering and Maintenance (MEAM). This change to practice has aligned the Trust with the other Shelford Group Hospitals and provides significant cost savings. 6.6 Decontamination of the Environment with Hydrogen Peroxide Vapour (HPV) The Deprox HPV decontamination system (manufactured by Hygiene Solutions) had been employed on an on-call reactive basis at the Trust in response to outbreaks of infection since 2009 mainly in the Manchester Royal Infirmary. Following collaboration between the Trust and Sodexo in July 2016 Hygiene Solutions began a managed service, under a two year contract delivering the facility for the Trust s core and peak usage times (Monday Friday 10:00 20:00 hours). This enabled a timelier and proactive service for the use of HPV as well as bringing significant cost savings to the Trust. The cost of the service was managed through the Trust Estates and Facilities Directorate and divided according to use between the Divisions across the Trust. The contract was overseen by a Trust led group that met monthly, comprising of the key stake holders including; representatives from the Divisions, Trust Estates and Facilities Team, Sodexo and the IPC team. The IPC team have also worked with Hygiene Solutions to develop the use of Ultra violet technology (UV-C), as an adjunct to cleaning following an outbreak of CPE on Wards AM1 and Decontamination of Hand Wash Basins and Utility Sinks Following on from the investigation into the risk of transmission of CPE from the environment the IPC Team developed new guidance for decontamination of hand wash basins and utility sinks. To ensure compliance posters demonstrating best practice (Fig. 12) have been posted above all sinks and hand wash basins. In addition extensive re-training has been undertaken with Sodexo domestic staff. 22

23 Fig. 12 Guidance for Decontamination of Hand Wash Basins Section 7: Maintaining a Clean Environment 7.1 Decontamination Services Sterilisation of re-useable surgical devices was undertaken centrally on site in the Decontamination Services Department but was outsourced at Trafford Hospital. The Department is accredited to ISO 13485:2003, ISO 13485:2012 and holds ISO Programme to Upgrade the Satellite Endoscopy Decontamination Units The Department of Health replaced the Choice Framework for local Policy and Procedures (CFPP) with a new HTM set (released in July 2016). The implication of these new documents has been taken into consideration alongside the ongoing programme to upgrade the satellite decontamination units. Work progressed to replace all the over life-cycle Automated Endoscope Repressors (AER s), associated Reverse Osmosis (RO) plant and cabinets, and improve the environmental facilities associated with the AERs to bring these to a higher standard. Installation of an additional new purpose built endoscope decontamination unit in the Children s Hospital has been completed. This new unit has the capacity to re-process 16 endoscopes per hour. The decontamination unit in the Outpatient Department at the Central site has also been upgraded. The unit at Trafford is Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accredited. Work to gain JAG Accreditation for the MRI Endoscopy Suite began in March Decontamination of flexible endoscopes was undertaken by the peripatetic decontamination team in satellite units in the associated clinical areas on the Central Site. 23

24 7.3 Trust Decontamination Monitoring Group Agenda Item 9.4 The Interim Compliance Manager was the designated Decontamination Lead for the Trust and Dr J A Kerry was the Authorised Engineer for Decontamination (AED). The Trust Decontamination Monitoring Group is a sub-group of the Trust Infection Control Committee and met every two months. The Contract Review meeting with the Automated Endoscope Re-processor (AER) supplier and service contractor along with their Reverse Osmosis (RO) Plant supplier and service contractor was held quarterly. A number of service quality issues were addressed with the contractor through the year and appropriate remedial action implemented. 7.4 Decontamination of Endoscopes All flexible endoscopes were decontaminated using the AERs around the Trust with the exception of the nasendoscopes at Trafford and Altrincham Ear Nose and Throat (ENT) Outpatient Department (OPD) which were hand washed and decontaminated using the Tristel Wipe methodology (this standard meets the Essential Quality Requirements (EQR) in CFPP 106 NHS Guidance document). All nasendoscopes will be re-processed following each patient use through an AER following the completion of the programme to upgrade the satellite decontamination units. 7.5 Validation of Automated Washer Disinfectors (AER s) It is a national requirement to have all AER s validated. Getinge continued to service the units in accordance with the testing standards. All units were fully compliant and the annual validation was signed off by the Authorised Engineer for Decontamination. 7.6 Rinse Water Testing Two High Level Incidents were raised following two near total failures of rinse water analysis results. The sampling regime for rinse water from the AER`s and RO Plant was amended short term. This included parallel sampling by an independent specialist contractor and analysis using the services of a second accredited laboratory. The results were reviewed by the Trust Decontamination Lead. The outcome of the investigation was that no root cause could be identified. Some minor changes in practice were implemented for both the operational teams and our main AER supplier and contractor; the parallel sampling regime has been kept in place and is currently contracted to the end of May 2017.The Trust updated its processes in relation to rinse water testing. All samples are now compliant with the new HTM Audits of the Trust-wide Satellite Endoscope Decontamination Units Interim audits were undertaken through the year as the current programme of works progressed and formal audits of each unit as they were commissioned were completed. The Working Group (established in the previous year), included relevant Trust experts as well as service representatives. It continued to meet monthly to oversee the implementation of the longer term solutions previously agreed. A sub-group to review the requirements for an electronic Track and Trace system to replace the current paper based solution was commissioned. 7.8 Management of Water Quality The management of Water Quality across the Trust Estate was undertaken in accordance with relevant guidance and legislation (L8 and HTM-04)and reported into the Trust Strategic Water Quality Management Group (renamed to the Trust Water Safety Group (WSG)) in accordance with guidance in the new HTM04. 24

25 7.9 Trust Water Safety Group Agenda Item 9.4 The Interim Compliance Manager is the designated Water Quality Lead for the Trust. The Trust has appointed Dr T Makin as Authorising Engineer for Water (AEW). The Trust WSG reports to the Trust Infection Control Committee. The Group met monthly to review the Trust s compliance associated with the national regulations; L8 and HTM-04. The revised Terms of Reference to reflect these changes was approved by the WSG Management of Risk for Legionella Water sampling for Legionella continued to be undertaken in accordance with L8 and HTM-04. Following a period of robust results the monthly regime was reduced to the mandated periods rather than the monthly sampling as run in previous years. Outlets which failed sampling were placed in to the protocol for cleansing and resampling until they produced a clear result or alternative solutions sought. All building and engineering projects were required to provide additional testing if they included modification or connection to the existing water system including the need to undertake Water Risk Assessments in line with the new HTM Management of Pseudomonas aeruginosa from Water Outlets in High Risk Clinical Areas The list of Augmented Care Units was constantly reviewed and managed by the Trust Strategic Water Quality Management Group (TSWQMG). Sampling for Pseudomonas spp. continued in accordance with the addendum to HTM 04, the results were reviewed by the TSWQMG. An agreed action plan was developed and implemented as part of the requirements of the HTM Individual Site Audits Water Action Plans from the individual site audits from the previous year have been implemented, actions monitored and reported back to the WSG along with sign off by the Trust AEW. Each action plan was reviewed and risk assessed in line with the Trust s Risk Assessment Matrix by the Compliance Team, AEW and appropriate operational staff. A programme of audits is planned once the new Water Policy has been approved by the WSG CLEANING SERVICES: Contracting Arrangements The Trust cleaning services were provided by both internal and external contractors/teams. Sodexo Healthcare was the main contractor for the provision of cleaning services across the Central Campus, including the Old St Mary s building. The Trafford Division and Intermediate Care Units were managed by in-house teams. 25

26 7.14 Monitoring Arrangement Agenda Item 9.4 As part of the contract Sodexo were required to self-monitor the performance of cleaning services against key performance indicators. These were reported to the Trust on a monthly basis for analysis and challenged where appropriate by the Estates and Facilities Team. The services at Trafford Division and the Intermediate Care Homes were managed and monitored through internal in-house arrangements with the service managers and local users. In addition, the standards of cleanliness were monitored and reported for all sites through the monthly Quality of Care Rounds, the Ward Accreditation Process and the Patient Experience Tracker. These results informed areas of best practice and areas where additional focus was required The Role of the Infection Prevention and Control Team The IPC Team worked in conjunction with the Trust Facilities Management (FM) Improvement Team, Clinical Divisions, Sodexo and internal providers to ensure cleaning standards were met across the Trust Cleaning Schedules Cleaning schedules were publicly displayed in all clinical areas and processes were in place to report and escalate cleaning problems. These included: the Trust Key Contacts process which provided users with information on what services should be delivered and how to escalate non-compliance; and, the cleaning matters process which required clinical and cleaning staff to record the completion of tasks and log additional or amended requirements IPC Training for Domestic Staff All new employees attended a generic Sodexo induction which included the principles of IPC 7.18 Patient Led Assessment of the Care Environment (PLACE) The annual Patient Led Assessments of the Care Environment (PLACE Assessments) were carried out at the Central site on 9th and 11th May 2016 and at the Trafford sites on 16th and 19th May The assessors visited a total of 24 wards, nine outpatient departments and seven emergency departments, carried out 11 food assessments, and undertook a review of the external and internal public areas on both sites. The scores for each of the five assessment categories are shown in Fig 13: 26

27 Fig. 13 PLACE Assessments May 2016 Agenda Item 9.4 Category Cleanliness Condition, Appearance and Maintenance Privacy, Dignity and Wellbeing Food* Organisation Food* Ward Food* Dementia Disability 2016 Central Site Trafford CMFT National Overall Average 97.84% 97.45% 97.79% 98.06% -0.24% -1.66% -0.43% 0.49% 96.73% 96.51% 96.70% 93.37% 1.67% 0.77% 1.55% 3.26% 84.42% 84.42% 84.42% 84.16% -3.12% -6.95% -3.62% -1.87% 84.81% 77.75% 83.94% 88.24% n/a n/a n/a n/a 84.04% 81.60% 83.73% 87.01% n/a n/a n/a n/a 84.93% 75.90% 83.82% 88.96% n/a n/a n/a n/a 84.91% 83.05% 84.68% 75.28% 1.56% -2.73% 1.01% 0.77% 86.99% 80.47% 86.19% 78.84% n/a n/a n/a n/a * 2015 Food was reported as a single element but in 2016 this has been subdivided into three separate areas Section 8: Training and Education All training and educational programmes were developed and updated in accordance with changes to national policies and guidance, requirements of the services and local need. 8.1 Induction and Mandatory Training The IPC team delivered face-to-face training on the key principles of infection prevention and control to all new starters on the Trust corporate induction day, and facilitated the induction sessions on Aseptic Non-Touch Technique (ANTT) theory, MRSA, C. difficile infection and CPE for all Nursing and Midwifery staff. The Organisational Development and Training Department monitored all mandatory training attendance and provided reports to the divisions through the online management system. This enabled the Trust to monitor training compliance. The IPC team updated the e-learning package programmes for the corporate and clinical mandatory training. All face to face presentations have been updated. The content of the training was aligned with the National Core Skills Framework. 8.2 Additional Training Programmes The IPC team continued to deliver formal and informal training across the Trust. A summary of the training sessions conducted, excluding induction and mandatory training sessions, can be found in Fig 14 below.. This year the IPC Team worked with the divisions to develop a system of cascade training on the principles of infection prevention and control. The benefit of this innovation was that it has facilitated access to additional training for staff who work night shifts/week-ends and in remote community areas 27

28 Fig. 14 Teaching Sessions Undertaken by the IPC team (April ) Teaching Sessions Number of training sessions Total of number of Staff attended IPC Medical Staff 6 66 Medical Students IPC and ANTT ANTT Medical staff 9 99 ANTT Nursing Staff BSc University of Bolton Students 3 47 International Nurses Clinical Staff General IPC Work experience students Infection Prevention and Control Training for Medical Staff The IPC team delivered the theoretical component of ANTT training for all medical staff new to the organisation. The managing and recording of the competency assessment was the responsibility of each division. In addition the IPC team supported sessions for Medical Students in year one, three and five on placement in the Trust. This consisted of the key principles of IPC and the theoretical training in ANTT. In total between April 2016 and March 2017, 23 sessions were attended by 442 medical staff including trained Doctors and Medical Students. 8.5 International Nurses Following a programme of international nursing recruitment, the IPC team delivered additional sessions to achieve the standards set for registration with the Nursing and Midwifery Council (NMC). 8.6 Bespoke IPC training Bespoke training sessions were undertaken as requested or in response to a specific need identified (for example, following an outbreak of infection), on a ward or department. These sessions included all staff groups including the PFI partners. 8.7 Additional Training Sessions The IPC team supported the IPC training for the Hospital Volunteers and people on work experience programmes across the Trust in conjunction with the Human Resources Department. As in previous years the team has continued to support the Trust annual young people s open day and the Nursing, Midwifery and Operating Department Assistant experience with a display stand and practical sessions on hand hygiene. 28

29 8.8 Raising Awareness Sessions Agenda Item 9.4 The IPC Team raised awareness with staff, patients and visitors of national initiatives in infection prevention and control. This included the World Health Organisation s Save Lives: Clean Your Hands campaign in May 2016 and Infection Prevention Control awareness week in October The IPC team created display stands in each atrium and provided a rolling road show where the team visited all wards and departments to engage with staff and patients. Both events were well received with positive feedback from staff and visitors. 8.9 CMFT Christmas Lecture The annual Clinical Scientist Christmas Lecture for 2016 focussed on Infectious Diseases and Infection Control in Microbiology. Over 400 schoolchildren and teachers from across Greater Manchester were entertained with an interactive outbreak investigation and a UV light experiment to demonstrate the importance of good hand hygiene Student Education During the last year the Trust welcomed nursing students on spoke placements to spend dedicated time with the IPC team. The feedback was positive and enabled the students to gain a valuable insight into the principles of infection prevention and control nursing. The IPC team in conjunction with the Professional Development and Education Team organised a multi professional learning workshop comprising of formal presentations on the topic of CPE and outbreaks of infection. The feedback was very positive. In February, the Trust, in collaboration with the University of Bolton welcomed the second cohort of the non-commissioned BSc (Hons) Adult Programme for Nurse training. The IPC team were invited to devise and deliver the infection prevention and control sessions. 29

30 Section 9: Audit Agenda Item Key to Level of Compliance The levels of compliance and are identified as Red (74% or less), Amber (75 94%) and Green (over 95%). These indicators are used for the Hand Hygiene audit, and the Trust -wide Catheter Care audit. 9.2 Hand Hygiene Compliance Audit This audit was undertaken to establish staff compliance with hand hygiene opportunities across all clinical areas within the Trust. The audit measured compliance amongst staff disciplines against the 6 Golden Moments of hand hygiene. These are defined as; entry to clinical area, exit from clinical area, entry to side-room/bay, exit from side-room/bay, before patient contact and after patient contact. The audit was undertaken by each division in December The overall level of compliance was 87% in December This is a year on year improvement since July 2014 (Fig. 15 below). Action plans to improve compliance were developed and implemented through the Divisional Infection Prevention and Control meetings. Fig. 15 Trust-wide Hand Hygiene Compliance Rates October/November 2013-December 2016 Divisions Trust-wide CSS Dental Compliance July 2014 (%) 82% (1497/1830) 78% (60/70) 84% (113/135) Compliance May 2015 (%) 83% (1204/1455) 94% (61/65) 97% (70/72) Compliance July 2016 (%) 86% (1216/1418) 88% (49/56) 97% (70/72) Compliance Dec 2016 (%) Change 87% (1310/1510) 92% (46/50) 93% (95/102) Medicine 84% (121/144) 79% (166/210) Not Audited 93% (321/345) Eye 71% (68/139) 83% (124/149) 82% (112/136) 89% (93/105) RMCH Not reported 90% (159/177) 88% (198/226) St Mary s 84% (303/539) 84% (150/179) 86% (268/311) 83% (198/226) Specialist Medicine 84% (129/153) 89% (153/172) 95% (176/186) 75% (192/257) Surgery 80% (198/248) 68% (159/233) 66% (175/265) Not Audited Trafford 92% (249/271) 81% (128/158) 96% (207/215) 87% (230/263) 9.3 Trust-wide Audit of Compliance with Urinary Catheter Policy This audit was conducted to evaluate the use of the Integrated Care Pathway (ICP) and to compare results with the same audit undertaken last year. The ICP is based on National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (epic:3). 30

31 A total of 1111 patient s notes were reviewed across six divisions. Royal Eye/Dental Hospitals were excluded as there were no patients identified with a urinary catheter during the period of the audit. Findings identified that documented evidence for catheterisation and catheter care remains variable across the Trust although there have been some improvements (see Fig 16 below). The audit report was disseminated to the Clinical Lead for Infection Control in each division to develop and monitor the implementation of local action plans to improve practice. Additional corporate actions have been previously reported in section 6 of this report Fig. 16 Trust-wide Audit of Compliance with Catheterisation and Catheter Care ICP Overall Overall Standards Total number of patients Total number of catheterised patients 146 (168 audited) % of catheterised patients - 16% 1. Catheterised patients should have a Integrated Care Pathway booklet 94/146 (64%) Change 146/168 (87%) 2. All patients should have the front cover of the ICP completed 3. All patients should have the care pathway section of the ICP completed 4. All patients should have the catheter care bundle section completed with a signature 79/146 (54%) 63/146 (43%) 83/146 (57%) 135/168 (80%) 135/168 (80%) 116/168 (69%) 9.4 Blood Culture Contamination Audit Peripheral blood culture contamination data was collected from 1 st April to 31 st March. There is no national UK standard for contamination rates, but rates should be below 3%, aiming for zero, as suggested by the Clinical and Laboratory Standards Institute 5. The overall contamination rates were frequently below 3% in both patient groups. Please see Figs. 17 and 18 below. This report was circulated to the divisional management teams and used as an indicator for compliance with the ANTT Policy. 31

32 Fig. 17 Peripheral Blood Culture Contamination Rates (>16 yrs) Fig. 18 Peripheral Blood Culture Contamination Rates (<16 yrs) 32

33 9.5 Antibiotic Point Prevalence Audit Agenda Item 9.4 Antibiotic prescribing was assessed against the Adult Anti-Infective Prescribing Guidelines version 10 (October 2016) and the Antibiotic Prescribing Guidelines for Paediatric and Neonatal Patients version 9 (August 2016). Ambiguous prescribing was discussed between Microbiology and Pharmacy and classified by consensus. An antimicrobial agent was defined as any drug falling under chapter 5: Infections in the British National Formulary but for the purposes of this study excluding antiretroviral medication for treating HIV. Other systemic antiviral and antifungal agents were included. Topical preparations were excluded. Long term medical prophylaxis for haematology and renal transplant patients was also excluded. The audit reviewed 339 patients, which totalled 357 indications for antibiotic use and 461 different antibiotics. The findings of the audit as compared to the results from the previous audit can be found in Fig 19 below Fig 19 Results of Antibiotic Point Prevalence Audit Standard Antibiotics should only be prescribed for indications outlined in the guidelines Empiric antibiotic therapy should be in accordance with the Trust Anti-infective guidelines, micro advice or C and S (unless clinically justified). Allergy status should be documented on all medication charts Patients should not be prescribed antibiotics that they have a documented allergy to The indication for antibiotic therapy should be documented in the medical notes Dose and frequency should be appropriate for age, weight, renal and hepatic function All prescriptions should have the review date / duration documented in the medical notes or the prescription chart IV antibiotics should only be continued beyond 48 hours if clinically justified Antibiotic therapy should not be extended without clear clinical justification For patients on antibiotic therapy for >72 hours there should be evidence of a review of therapy and a prescribing decision made and documented. Compliance(%) 2015/16 100% (343/343) Compliance(%) 2016/17 Change 99% (350/351) 95% (326/343) 97% (337/349) 100% (309/309) 99% (337/339) 94% (44/47) 95% (325/344) 92% (45/49) 94% (330/350) 98% (416/427) 97% (433/446) 68% (221/324) 78% (243/310) 92% (141/153) 94% (130/139) 99% (340/344) 98% (342/350) 85% (93/111) 75% (119/158) 33

34 The audit findings demonstrated assurance of good practice within some areas, but also highlighted areas where significant improvement in antimicrobial stewardship can be made. An Action Plan was developed (see figure 20 below). This is being implemented and monitored through the Antibiotic Pharmacy Team. Fig. 20 Action Plan Following Point Prevalence Audit Key Action Action Plan Introduce a standard template for taking allergy history to improve documentation of allergy reaction and timing Amend the medication chart to facilitate improved allergy recording Amend the medication chart to prompt antibiotic review within 72 hours and facilitate recording of the intended action Include antibiotic review and changes to medication chart in medical teaching to ensure effectiveness of the change Introduce a tool to guide investigations required for possible infections to assist prescribers in effective diagnosis and antibiotic review To include details of who performs the antibiotic review in subsequent audits in line with CQUIN data Coordinator for action Antimicrobial stewardship group Timescale August 2017 Kelly Alexander April 2017 Kelly Alexander April 2017 Kelly Alexander April 2017 Kelly Alexander / Louise Sweeney April 2017 Kelly Alexander November 2017 Section 10: Conclusion 10.1 The content of this report establishes the broad spectrum of activity associated with Infection Prevention and Control across the Trust. The outcomes of the practice and process described are evidence of the hard work and commitment of staff working across the organisation One of the major challenges this year has been balancing the risks associated with the management and control of CPE. The evidence demonstrates that there has been a reduction in the rate of new CPE acquisitions amongst patients and we have been able to reduce the number of cohort/isolation beds Despite the enormous challenge presented by CPE, we have maintained a low level of avoidable incidents of MRSA bacteraemia: these results indicate that we may have arrived at an irreducible minimum. However, this does not mean that we are complacent as the content of this report reflects our enthusiasm for striving to develop new and innovative means of improving patient care The Board of Directors are asked to receive this report for April 2016 to March 2017 and approve for publication. Julie Cawthorne Consultant Nurse IPC April

35 Appendix 1 Infection Prevention and Control Team Structure March 2017 Chief Nurse and Director of IPC Professional Lead Director of Nursing Divisional Director Infection Control Doctor Consultant Nurse & Head of IPC/TV Nursing Services Antibiotic Pharmacists Deputy Infection Control Doctor TV Advanced Nurse Practitioner Matron Surveillance Officer TVN Specialist Nurse Continence Nurse Specialist 2 x IPC Specialist Nurse PA/Secretary Support Data Manager IPC/TV Practitioners Healthcare Assistants Abbreviations Key IPC =Infection Prevention and Control TV = Tissue Viability AB = Antibiotic 35

36 Appendix 2 INFECTION CONTROL COMMITTEE TERMS OF REFERENCE 1. CONSTITUTION The Infection Control Committee is a sub-committee of the Clinical Effectiveness Committee. The Infection Control Committee is chaired by the Director of Infection Prevention and Control who is the Chief Nurse. 2. CORE MEMBERSHIP Director of Infection Prevention and Control Chief Nurse (Chair) Director of Nursing Consultant Microbiologist/Infection Control Doctor Consultant Nurse, Infection Prevention and Control (IPC) Head of Clinical Audit Consultant in Communicable Disease Control (PHE) PCT Infection Control Lead Antimicrobial Pharmacist Director of Estates and Facilities CLINICAL LEADS FROM DIVISION CSS Representative Acute Medicine and Community Division representative Specialist Medicine Division representative Surgery Division representative Children s Hospital representative Eye/Dental Division representative Saint Mary s Division representative Trafford Hospitals Representative A quorum shall be eight members including the Director of Infection Prevention and Control (or a nominated deputy) and the Infection Control Doctor and Consultant Nurse, Infection Prevention and Control (or nominated deputies). 3. ATTENDANCE AT MEETINGS The Infection Control Committee may require from time to time, the attendance of any Trust employee (or agent of the Trust) to attend the committee at the request of the Chair. 4. FREQUENCY OF MEETINGS The Infection Control Committee will meet every two months (six times a year). 5. OVERVIEW The Infection Control Committee develops and monitors the core Infection prevention and control strategic objectives. The core objectives are agreed by the Trust Board and are based on CMFT organizational priorities. The Trust ICC will oversee and monitor the operational IPC programme. 36

37 The Infection Control Committee is authorised to formulate recommendations for Infection Prevention and Control within the Trust and to convey these to the Trust Board. 6. SCOPE AND DUTIES To ensure the infection control strategic objectives are defined and progressed throughout the Trust. At a corporate level this will be through the IPC Team and at a local level by the divisional representative. To provide advice and support on the implementation of the strategic objectives and make recommendations for action. To receive reports from the Infection, Prevention and Control teams on progress of the Trust s operational IPC annual plan and any serious or untoward incidents related to IPC. To receive reports from the Divisional representatives on progress of Infection prevention and control divisional action plans. To receive the DIPC s Annual Infection Control Board Report. To draw the attention of the Chief Executive, through to the Director of Infection Prevention and Control to any serious problems or hazards relating to infection prevention and control. To describe, review and monitor the principle and significant risks related to infection control on behalf of the Trust and present these with the plan of controls to the Trust Significant Risk Review Group and Risk Advisory Committee at least annually. Members will disseminate relevant information to their clinical areas. 7. AUTHORITY The Infection Control Committee is empowered to examine and investigate any activity within the Trust pursuant to the above scope and duties. 8. REPORTING The Infection Control Committee reports to the Clinical Effectiveness Committee 9. REVIEW These Terms of Reference will be reviewed before April KEY PERFORMANCE INDICATORS Attendance of the Infection Control Committee will be monitored on an on-going basis and reported for information at each meeting. Members are expected to attend (or send a nominated, named Deputy) to a minimum of four out of six meeting per year. Minutes and reports of the Infection Control Committee Care Quality Commission annual assessment of compliance against the Health and Social Care Act (2008) Terms of Reference for Infection Control Committee reviewed annually 37

38 Framework for IPC Committee / Group Structure 38