Ruth McCarthy, Associate Director Clinical Governance/IP&C

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1 Trust Board Meeting: 25 April 28 Title: Executive Summary: Items for discussion: Clinical Governance/Infection Prevention and Control Report - April 28 The Clinical Governance Report April 28 comprises: Clinical Governance Update IP&C update and monthly Infection Prevention and Control (IP&C) Surveillance Data March 28 IP&C surveillance data DOH IP&C follow up visit April 4 th 28 Recommendations/decisions Implementation of actions to further reduce HCAI required: Financial implications: Financial penalties linked to IP&C targets 28/9 Legal implications: Impact upon patients: Impact upon carers: Consultation/Communication: Risk issues: Health Care Commission will assess compliance against The Health Act 28/9 Opportunity for improvements in patient experience Confident within working environment and of patient satisfaction Clinical Quality and Risk Committee Reputational risks associated with patient perceptions/experience reports IP&C performance targets Name of Lead Executive Director: Name of Author: Alf Troughton, Medical Director/DIP&C Ruth McCarthy, Associate Director Clinical Governance/IP&C - 1 -

2 Clinical Governance Report April 28 1 Standards for Better Health (S4BH) The S4BH declaration advising full compliance with no significant lapses will be forwarded to the Healthcare Commission by 3 th April 28. A Clinical Governance work plan has been developed to strengthen assurances and develop practice as agreed by the Board. The plan will be tabled for agreement at the Clinical Governance Committee in June 28. It is proposed that progress of the work plan will inform the Board quarterly. Internal audit are currently assessing compliance with and seeking assurances regarding the process for the S4BH declaration 27/8. A report is anticipated May Serious Untoward Incidents (Appendix 1) One serious incident was reported during March and two have been reported since the beginning of April 28. These incidents were all patients who have acquired MRSA bacteraemia. One infection was acquired prior to admission to hospital (March) and 2 infections were hospital acquired (April). One C.diff mortality was reported during March. This infection was considered to be community acquired and has been investigated by Wiltshire PCT. A summary report will go to CQRC in May. All incidents are monitored and progressed via the CQRC and a summary of each case is attached to this report for information. 3 Clinical Risk and Litigation. NHSLA - The Trust is seeking an informal Level 2 NHSLA assessment during September 28 with an aim to undergo a formal Level 2 assessment during April 29. Action arising from the local assessments been included within the Clinical Governance Work Plan. The Trust has been successful in its application for the pilot assessment against the new Level 3 Maternity Clinical Risk Management Standards 4 PALS/Patient Experience The Head of Patient Experience position has been readvertised and interviews will take place at the beginning of May Infection Prevention and Control The Department of Health (DOH) undertook a second visit on Friday 4 th April 28 to assess progress against their recommendations following their first visit, October 27. The DOH team were pleased with the progress that the Trust has made and steps taken to tackle hospital acquired infections to date and also gave clear direction as to where further work is required to strengthen and sustain practice. A summary report from the DOH has now been received and this will inform the Clinical Risk and Governance Committees prior to the Board. The hospital deep clean has been progressed and will be completed by mid April 28. IP&C Surveillance Report March 28 (Appendix 2). One MRSA bacteraemia was reported during March 28 and this was not a hospital acquired infection. Two hospital acquired MRSA bacteraemias have been reported since the beginning of April 28 and these are currently being investigated (Appendix 1). All investigations and actions are reported to the CQRC

3 The total MRSA bacteraemias reported for 27/8 was 18, 12 of which were hospital acquired. 3 of these were considered to have been contaminated samples. The number of Clostridium difficile infections has continued to reduce. 19 cases were reported during March 28. The cumulative total for 27/8 was 343, 21 below trajectory. The IP&C targets for 28/9 are being finalised. It is anticipated that the MRSA target will be 1 or less for the whole local healthcare community 28/9. The SHA/PCT Clostridium difficile target will be 196 or less hospital acquired infections. Name of Lead Executive Director: Name of Author: Alf Troughton, Medical Director/DIPC Ruth McCarthy, Associate Director of Clinical Governance/IP&C - 3 -

4 Clinical Governance Support Team Serious Untoward Incident Monitoring and Reporting Tool Date IR1 No Risk (SxL) (4x3) (5x2) (5x2) (5x5) Lead Invest igator SZ SO K TBC RC TBC Sharen Pells (PCT) Ext Report Incident SUI (PCT) Outbreak of MRSA colonisation on SCBU (6 babies/3 staff) SUI (PCT); RIDDOR CEMACH 19/3/8 SUI (PCT) 26/3/ TBC TBC TBC SHA PCT TBC TBC SHA / PCT Patient forced open and jumped from window on 2 nd floor of hospital, suffered fractured ankle Maternal Death (34wks) Patient contracted Strep A in community SUI (PCT) Patient fell from 3 rd floor to 1 st floor down stairwell. Apparent attempted suicide SHA MRSA bacteraemia within 48hrs of admission (SwPCT) MRSA bacteraemia hospital acquired (Jupiter) MRSA bacteraemia hospital acquired (Linnet) TBC TBC TBC TBC Community acquired C.diff. C.diff listed as 1a on death certificate Prelim meet RCA complete Final Report complete CQRC/ H&SG Dates (CQRC) Draft (CQRC) APPENDIX 1 Exec lead SUI closed date AT AT TBC TBC TBC TBC SR (draft) (CQRC) Unknown (draft) AT PCT lead TBC TBC TBC AT TBC AT TBC TBC TBC TBC TBC TBC

5 INFECTION PREVENTION & CONTROL MONTHLY SURVEILLANCE - MARCH 28 APPENDIX 2 MRSA Bacteraemia Monthly numbers along with the cumulative number since April 27 and the target trajectory are plotted on Chart 1. Also included is a 12 month rolling total which following a fall, has levelled over the last month. Chart 1 MRSA Bacteraemias with 12 month rolling performance 25 per month Target 12 month rolling Cumulative number Month 27/8 Summary One Bacteraemia was reported during March. This was not hospital acquired. Total of 18 MRSA Bacteraemias. 19 were reported but one has been removed from the trajectory by the SHA. The target of 12 was breached. 7/18 were detected in blood samples taken within 48 hours of admission including one contaminated sample which was deemed hospital acquired. See Chart 2. 12/18 were hospital acquired (>48 hrs) including two further contaminated samples. Chart 2. Chart MRSA Bacteraemias by Month 27-8 Pre and post 48 hours Total <48 hrs >48 hrs Trajectory 2 1 Month 27-8 The most probable sources of entry into the blood stream are peripheral line (3/15), central line (4/15), wound/ulcer (4/15), and the chest (3/15) plus 5/15 with other sources.

6 Clostridium difficile SWINDON AND MARLBOROUGH NHS TRUST APPENDIX 2 Chart 3 shows the number of C.diff infections reported each month. Chart 3 6 C.diff per Month Month 27/8 Following a peak in numbers in July, the trend fell to the end of 27. Following a rise in January, the numbers continued to fall to the end of the year. Summary There were 19 C.diff isolates reported in March 28, the cumulative total to the end of year was 343, against the target of 364 and therefore this was achieved. Chart 4 shows the number of C.diff cases per month along with the cumulative total since April and the target trajectory. Also included is the 12 month rolling total which, following a sustained rise has continued to fall over the last six months. Further analysis is provided in the weekly surveillance reports. Chart 4 Clostridium difficile with 12 month rolling performance Monthly Trajectory 12 month rolling Cumulative Month 27/8

7 Mortalities Chart 5 SWINDON AND MARLBOROUGH NHS TRUST APPENDIX Patient Deaths due to HCAI C.diff MRSA bacteraemia Apr-7 May-7 Jun-7 Jul-7 Aug-7 Sep-7 Oct-7 Nov-7 Dec-7 Jan-8 Feb-8 Mar-8 Month A total of 5 deaths have been recorded on death certificates where Clostridium difficile is given as the cause or contributory factor, one within the Trust in March. One community acquired C.diff mortality was reported during March and this has been investigated by Wiltshire PCT. - 31/5 (62%) were recorded as a cause in Part 1a-c - 19/5 (38%) were recorded as a contributory factor in Part 2 There have been a total of three deaths due to MRSA septicaemia, all recorded in Part 1 of the death certificate. Tina McCready Information Analyst Infection Prevention & Control 1.4.8