Infection Prevention and Control Annual Report 2016/17 Patients and their safety remain at the very heart of NUH. Preventing, controlling and treating infection is a key part of our endeavour. Some infections, e.g. MRSA bacteraemia and Clostridium difficile (C. difficile) can be associated with healthcare, and some cases of such healthcare-associated infections (HCAI) are preventable. This report provides assurance that we track and manage down the likelihood and severity of infections associated with our operations, treatments and care. 1. Surveillance of Infections Infection rates are continuously monitored by the Infection Prevention and Control Team (IPCT), and mandatory infections are reported to the Department of Health. This section focuses on specific alert organisms, and infections that are NUH-attributable. Bloodstream Infections (Bacteraemias) In 2016/17 there were 1046 bacteraemias (1.75 per 1000 occupied bed days), (Figure 1). This is higher than 2015/16. The number of bacteraemias associated with devices is also higher than last year, although the proportion is similar. Further analysis and ongoing close monitoring is being undertaken, with no single factor presently identified. Monitoring is via the quarterly Infection Prevention and Control Committee (IPCC). Figure 1: NUH-Attributable Bacteraemia Rates 2003 2017 MRSA Bacteraemias We aim to prevent MRSA bacteraemias through zero tolerance of non-compliance with relevant best practices. The national target for all healthcare providers for 2016/17 was zero cases. We had five cases (figure 2). Each case was investigated; 1 was deemed unavoidable, 2 avoidable and 2 identified as contaminant/third party. IPC Annual Report July 2017 Final Draft Page 1 of 8
Figure 2: NUH Attributable MRSA Bacteraemia Infection Rates 2003 2017 Clostridium difficile Performance The objective for NUH was 91 cases. There were 93 NUH-attributable C. difficile infections. Figure 3: NUH Attributable C. difficile Infection Rates 2003 2017 Peer Trust Benchmarking NUH collates benchmarking data from published MRSA bacteraemia and C. difficile infection information for 2016/17 and 2015/16 HES bed-days. IPC Annual Report July 2017 Final Draft Page 2 of 8
Our MRSA bacteraemia rate (0.9 per 100,000 bed days) and C. difficile rate (1.8 per 10,000 bed days) are compared to those of peers in Figure 4. Figure 4: Benchmarking MRSA and C. difficile 2016/17 Carbapenem-resistant Enterobacteriaceae (CRE) Carbapenem-resistant Enterobacteriaceae (CRE) can be identified as a group of organisms that are essentially resistant to all mainline antibiotic therapy. Following the release of national guidance in 2014, NUH was one of the first hospitals to put in place robust systems and a policy to screen and identify potential patients with these organisms. The number of cases in our region remains low, although an increase in the number of colonised patients (predominantly travel related) admitted to our hospitals is increasing year on year. In December 2016, there was the first NUH outbreak of Carbapenemase-producing Enterobacteriaceae (CPE). This is described in section 2. Patient Safety Work Significant patient safety infection related work led and managed by other groups, e.g. sepsis has progressed well. 2. Outbreaks of Infection An outbreak of infection is defined as an episode of infection where there is spread of sufficient seriousness to demand immediate action. Table 1: Outbreaks of Infection 2016/17 Organism Outbreaks Patients Staff Closed Bed Days Suspected/confirmed norovirus 25 318 121 1009 Group A Streptococcus (GAS) 3 13 5 307 Clostridium difficile 2 5 0 0 Pneumocystis jirovecii 1 22 0 0 IPC Annual Report July 2017 Final Draft Page 3 of 8
Influenza A 1 9 3 0 Carbapenemase-producing Enterobacteriaceae (CPE) 1 2 0 510 Total 2016/17 33 369 129 1826 Previous years comparison Total 2015/16 29 345 76 798 Total 2014/15 54 732 165 1390 Total 2013/14 24 300 64 779 Total 2012/13 33 424 85 924 Total 2011/12 50 731 161 1395 Total 2010/11 29 322 58 860 Total 2009/10 53 673 174 1517 The IPCT also reviewed clusters of patients with symptoms of diarrhoea and vomiting on 41 wards, determined to be due to non-infectious clinical causes. Outbreaks of Group A Streptococcus (GAS) Group A Streptococcus can cause infections of the throat and skin. These may vary from very mild conditions to severe, life-threatening diseases. Spread is usually via person to person contact or environmental contamination. Total ward and equipment enhanced cleaning was deployed, using manual disinfection methods and hydrogen peroxide decontamination. Outbreaks of Clostridium difficile 2 wards were affected by an outbreak of C. difficile and were thoroughly decontaminated to prevent further transmission. Outbreak of Pneumocystis (PCP) jirovecii Pneumocystis jirovecii can cause severe pneumonia in immunocompromised patients. A case-control study identified the main risk factor was attending clinic at the same time as another patient who subsequently developed PCP. Prophylaxis was offered to susceptible oncology patients, along with the wearing of a face mask whilst attending clinic. Carbapenemase-producing Enterobacteriaceae (CPE) In December 2016, 2 patients on one ward were identified with CPE highlighting the first recorded case of transmission in Nottingham. The ward was closed to facilitate the implementation of enhanced infection prevention and control measures and a thorough investigation of the cause. The detailed investigation concluded the index case was probably acquired and imported from another hospital and cross infection occurred to a further patient. Enhanced cleaning and sampling of all patient contacts and the environment was undertaken. No further cases have been identified. Isolation of patients with Clostridium difficile and MRSA This continues to be a high priority, to prevent cross-infection and minimise environmental contamination. Isolation non-compliance continues generally to be for a clinical safety reason (e.g. falls risk). Prompt escalation to senior Divisional colleagues in conjunction with IPCT advice and support ensured good overall compliance with the prompt isolation of such patients by instigating measures, (e.g. one to one care) to prevent and reduce the risk of cross infection. Influenza Vaccination In 2016/17, 66% of eligible staff received influenza vaccination, against a national target to achieve 75%. This compares to 42.87% in 2015/16. IPC Annual Report July 2017 Final Draft Page 4 of 8
3. Decontamination The Trust has continued to invest in a rolling replacement programme for essential decontamination equipment, including the installation of a new flexible endoscope washer disinfector in Urology Outpatients, two thermal instrument washer disinfectors and two sterilisers (autoclaves) in Sterile Services. Since August 2016, 3 new cardiopulmonary by-pass heater coolers were purchased for the Cardiac Theatres. To date, these units have tested negative for the Mycobacterium chimaera strain which has been associated with an international outbreak of prosthetic valve endocarditis. Staff continue to decontaminate and manage the use of these devices, in accordance with the manufacturer s instructions, along with recommendations from Public Health England and NHS England. Sterile Services has retained accreditation to the International Standard (ISO) 13485(2016) which demands robust quality management systems for decontamination processes (surgical instruments and other invasive medical devices). The IPCT continues to support a detailed programme of audit relating to high level disinfection of flexible endoscopes and invasive ultrasound probes. From 2017 this included a new semi-automated decontamination system to provide improved standardisation and documentation relating to high level disinfection of transvaginal and trans-rectal ultrasound probes. 4. Antimicrobial Prescribing In the last 40 years, antimicrobial resistance (AMR) has significantly risen and inappropriate use of antimicrobials is a key driver. The number of new classes of antimicrobials coming to the market has reduced with no new class of agent introduced in to clinical practice for thirty years. The response at a national level includes the new criterion 3 in the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance, NICE guidelines, the Antimicrobial Stewardship (AS) Toolkit and Start Smart then Focus guidance. In 2016/7, there was a new National CQUIN on antimicrobial resistance that aimed to reduce both total and inappropriate antibiotic usage in hospitals. Summary of activity and achievements include: Emphasis on a safe and sustainable organisation-wide approach for appropriate antibiotic use, integrating CQUIN-focus with a wider programme of improvement activities to promote behavioural change Partnership with the Sepsis team to convey the key messages of timely recognition and treatment of high risk of death red sepsis in conjunction with making a clinical and microbiological diagnosis of bacterial infection to allow appropriate use of antimicrobials (including duration and 72 hour prescription review) Establishing baseline and quarterly performance data for antibiotic review and consumption in the absence of Trust-wide e prescribing Organisation-wide engagement and activity to achieve 80% of the CQUIN targets (with the associated income of approximately 800,000) with an understanding of local factors (e.g. Oncology PCP outbreak) contributing to the failure to achieve the reduction in total consumption Appointment of a CQUIN Project Nurse and allocation of daily Consultant Microbiologist time to Stewardship activity as well as securing Trust provision of significant additional resource (including Consultant Microbiologist PAs and WTE Lead Pharmacist) for ongoing activity for the 2017/19 combined AMR/Sepsis reducing the impact of serious infection CQUIN Performance of annual point prevalence and co-ordination of specialty-led antibiotic audits IPC Annual Report July 2017 Final Draft Page 5 of 8
Leading the NUH support for World Antimicrobial Awareness Week, 14th-20th November 2016. Activities included daily mailshots, patient engagement stands and ward-based huddles The bi-monthly Antimicrobial Guidelines Committee has continued to develop and update guidelines in line with best-practice, and encourage the appropriate use of antimicrobial agents. Guidelines continue to be uploaded on to the antibiotic intranet site and the smartphone app in a user friendly format. Antibiotic Audits Through 2016/17 the Antimicrobial Pharmacists made an average of 101 interventions (including improving documentation of indications and durations) for every 100 patients reviewed. Monthly posters were used to feedback learning points from common interventions to the prescribers. As part of C. difficile initatives an antimicrobial audit with intervention and feedback is undertaken (32 audits completed for review and appropriate action by clinical teams). Furthermore, specialtyled, trust-wide antibiotic stewardship audits (614 patients across 28 specialties) were facilitated with a local action plan to improve antibiotic usage and patient care. 5. Estates and Facilities Management (EFM) Estates & Facilities During 2016/17 external scrutiny visits demonstrated standards of cleanliness were not to the required standards. Moreover, there continues to be an increased academic recognition of the contribution and role of the environment and near patient surfaces in the transmission of HCAI. Trust-wide improvements were identified, managed and monitored. EFM and IPCT colleagues have continued to work closely to support clinical areas where concerns surrounding cleanliness have been highlighted. From April 2017 EFM returned to an in-house service provision following an unsuccessful period of outsourcing. This will require a period of transition and review to ensure the needs of the patients, staff and organisation are adequately met. Mini Deep Clean Hydrogen Peroxide and Sodium Hypochlorite Programme for High Priority Clostridium difficile Wards and Mini-Decant Programme From May to November 2016, 5 wards with a higher risk of C.difficile at the QMC Campus were decanted. This was to enable the vacated ward to receive an enhanced clean followed by hydrogen peroxide decontamination of the environment and equipment. The works also incorporated redecoration and the undertaking of some minor new works and repairs. On the City Campus it has not been possible to proceed with decant cleans as a ward requiring longer term occupancy has been allocated this facility. The Mini Deep Clean Hydrogen Peroxide and Sodium Hypochlorite Programme (at both Campuses) ran concurrently with the decant programme. The delivery of both was monitored by the Infection Control Operational Group (ICOG). Patient-Led Assessments of the Care Environment (PLACE) Assessments PLACE assessments were carried out in March and April 2016, along with a further self-assessment (PLACE-Lite) in November 2016 to assess progress. In both instances patient representatives joined multi-disciplinary teams to judge wards against 150 standards covering cleanliness, the environment, food and hydration, and privacy and dignity. It is recognised there are some areas of the clinical environment which continue to require improvement. IPC Annual Report July 2017 Final Draft Page 6 of 8
6. Programme of Audit Audit is an essential tool to monitor and improve infection prevention and control. A wellestablished programme of audit continues to provide assurance that a high standard of infection prevention and control practice is consistently maintained throughout the Trust. A wide range of audits are undertaken by the IPCT, with participation by Infection Control Link Professionals (ICLPs) and external providers. The programme includes: Quarterly Clinical Audit Programme: organisation-wide, covering a wide range of infection prevention and control clinical practices and environmental standards with common themes presented to ICOG. In August 2016, a revised theatre tool was appraised and re-launched. Audits overall described high adherence to good practice in invasive device management, and the care of patients requiring infection control special precautions Audit of Hand Hygiene: undertaken bi-monthly utilising the 5 moments of care tool (target 95%). There remains a commitment across the organisation to achieving and sustaining high standards of hand hygiene. During the last year, 1 month fell below the target (94%). The overall mean was 96% (range 94%-99%) Audit of Sharps Containers: carried out throughout 2016 concentrating on areas with high sharps container usage, (all clinical areas are audited at least once a year). Results confirmed high adherence to safe sharps related practices Audit of Meticillin Resistant Staphylococcus aureus (MRSA) Screening in Adult Patients with Prolonged Hospital Stays: adult patients whose stay exceeds 3 weeks were screened for MRSA on day 21 and weekly thereafter. 83% (240/289) of eligible patients had 3-week screens (the same as previous year). The MRSA pick up rate was found to be 2% (6/289) compared to 1% in the 2015 audit Audit of Sluice and Macerators: to ensure sluice room infection prevention and control standards continue to be consistently met. The audit has shown continued high compliance with regard to accessibility, hand washing facilities and general cleanliness of all sluice rooms. The main recommendations necessitating action were to ensure all equipment such as macerators, commodes and waste bins were in a good state of repair. 7. Education The IPCT continues to deliver a wide range of educational topics to reflect local and national infection prevention and control initiatives. The sessions consistently receive positive evaluation. Contribution to the Trust corporate induction continues and mandatory training e-learning sessions have been devised. The number of attendees at planned infection prevention and control education sessions was affected by the Trust-wide suspension of non-mandatory education (November 2016). The amount of additional training in 2016 however increased to 83 hours delivered to over 2100 staff. This is an increase from 35 hours training to 987 staff in 2015. The IPCT has supported 37 Student Nurse Placements with positive evaluation and feedback. The ICLP network consists of proactive clinical colleagues who support and develop infection prevention and control practice, audit, and education in all clinical environments. IPC Annual Report July 2017 Final Draft Page 7 of 8
8. Patient Public Involvement ( PPI) A member of the IPCT has represented Integrated Governance on the PPI Steering Group, along with attendance at the Patient Safety Reference Group. Infection prevention and control patient leaflets are available on the NUH public website as part of the NUH electronic patient safety set produced over 2016. 9. The Way Forward The following 2017/18 Infection Prevention and Control Key Objectives have been agreed by the IPCC and this forum will also oversee the progress and performance monitoring: Number Objective 1 Review and further strengthen infection prevention and control Governance arrangements 2 Continuous improvement of the surveillance of healthcare associated infections and performance 3 Establish and sustain (new and improved) standards of cleanliness through partnership working with Estates and Facilities Management and Patient Partnership Groups 4 Review and plan the replacement of hydrogen peroxide decontamination machines. Explore the feasibility of extending the current service and re-establishing the deep clean programme to facilitate organisation-wide total room decontamination 5 Complete an organisation-wide survey of the ventilation in single room accommodation. Develop a plan to undertake remedial action that will ensure the provision of adequate ventilation to prevent and reduce the risk of transmissible infections 6 Progress decontamination and water safety requirements as sub-groups of the Infection Prevention and Control Committee to ensure patient safety requirements 7 Establish Governance arrangements for appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance 8 Develop Divisional self-assessment and gap analysis of The Health and Social Care Act 2008. Code of Practice on the prevention and control of infection and related guidance, to gain assurance the required infection prevention and control arrangements and initiatives are in place and compliance is monitored 10. Conclusion NUH remains committed to preventing and reducing the harms from HCAI by the development and implementation of a wide range of infection prevention and control strategies and initiatives. The IPCT is the fulcrum for much of this endeavour, though the successes through 2016/17 are a testament to the dedication and commitment of the very many staff across the Trust determined to make a difference. IPC Annual Report July 2017 Final Draft Page 8 of 8