Update on the Prevention and Control of Healthcare Associated Infections in the Betsi Cadwaladr University Health Board

Betsi Cadwaladr University Health Board Health Board Meeting Date: 23 rd January 2014 Item 14/007 Subject: Update on the Prevention and Control of Healthcare Associated Infections in the Betsi Cadwaladr University Health Board Summary or Issues of Significance The Health Board remains determined to do everything possible to reduce infections to the minimum. This paper provides the Board with: An update on progress with infection prevention, including progress in reducing Clostridium difficile infection, the prevention of MRSA, and the actions in place to strengthen Norovirus control measures. A detailed briefing on the work programme to improve antimicrobial prescribing across BCUHB, and the actions necessary to achieve required outcomes. A briefing on the new Welsh Government healthcareassociated infection reduction targets. Strategic Theme / Priority / Values / Francis Report recommendations addressed by this paper Making it safe / better / sound / work / happen? Making it safe Making it better Making it sound Making it happen Relevant legislation or Standard for Health Services: Evidence base or other relevant information to inform decision (e.g risk assessment, consultation with others) This section is mandatory due to legal requirements Healthcare Standard 13 This paper is based upon the expert external review by Professor Duerden (1), which also takes account of the review and report by Public Health Wales (2) into the outbreak of Clostridium difficile infection at Ysbyty Glan Clwyd in early 2013. The Board and its Committees may reject papers/proposals that do not appear to satisfy the equality duty. See http://howis.wales.nhs.uk/sitesplus/861/page/47193

Equality Impact Assessment (EqIA) 1. Has EqIA screening been undertaken? No 2. Has a full EqIA been undertaken? No 3.Please state how this paper supports the Strategic Equality Plan Objectives: http://howis.wales.nhs.uk/sitesplus/documents/861/sep_0412_e.pdf 4.Please include a justification if no EqIA has been carried out: Recommendations: (e.g for Board approval or for noting) The Health Board is asked to: 1. Note Clostridium difficile infection rates, and the continued progress that is being made to achieve the recommendations in the Duerden report. 2. Note the number of deaths reported since September 2013 in patients who have had Clostridium difficile infection, consider the issues identified via the RCA process, and note the progress made in investigating the mortality issue highlighted previously at WMH. 3. Consider the monthly infection rates reported for MRSA bacteraemia and MSSA bacteraemia, noting the increase in MRSA bacteraemia, the gaps identified in MRSA policy and control, and the significant programme of work being put into place to address this. 4. Review the information provided on antimicrobial prescribing, including the key actions required by CPGs. 5. Note the national reduction targets set for MRSA bacteraemia and Clostridium difficile infection, to be achieved by March 2015. 6. Highlight any issues where further information or assurance is required at this time by the Board. Author(s) Presented by Mrs T Cooper, Assistant Director of Nursing - Infection Prevention & Mr B Owen, Clinical Director of Pharmacy Medicines Management (Interim Lead Antimicrobial Pharmacist) Mrs A Hopkins, Executive Director of Nursing & Midwifery Date of report 07 th January 2014 Date of meeting 23 rd January 2014 Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

Betsi Cadwaladr University Health Board Health Board paper Date: 23 rd January 2014 Subject: Update on the Prevention and Control of Healthcare Associated Infections in the Betsi Cadwaladr University Health Board Summary Introduction: BCUHB is committed to reducing preventable infections to the absolute minimum. We will do this by achieving excellent standards of infection prevention practice. This is the right thing to do for our population, and is the standard of care our staff want to deliver. This paper provides the Board with: An overview of progress on infection prevention, including progress in reducing Clostridium difficile infection (CDI). A briefing on the work programme to improve antimicrobial prescribing across BCUHB, and the actions necessary to achieve required outcomes. Information on new national targets for infection reduction. Increasing The Pace of Improvement: Focus on Key Practice Standards The Health Board is committed to increasing the pace of improvement and the speed of reduction of healthcare-associated infection (HCAI). Learning from the HCAI reduction programme in England shows that focus on a number of key practice standards is essential to achieve this. In early December, BCUHB issued 10 key standards for the reduction of both Clostridium difficile infection and MRSA. These standards are being implemented in all wards and departments, and have been included in the written objectives for CPGs. These key standards include clear expectation of the minimum practice standards to be achieved, and cover hand hygiene, cleanliness, training compliance and care bundle compliance. Work is in progress to ensure the care metrics system can be used for routine monitoring of compliance with the key standards. Monitoring will be via CPG governance arrangements, and Local Infection Prevention & Control Groups. Dashboard reporting of these standards to the Strategic Infection Prevention Group and Quality & Safety Committee is also being developed. The currently available summary data on these key standards is presented here: Key Standard BCUHB Compliance 1. Hand Hygiene compliance 96.17% 2. Commode audit compliance 95.66% 3. Isolation audit compliance To be collated via care metrics Page 1

4. PVC care bundle compliance 80.59% 5. Urinary catheter care bundle 90.82% 6. Bare below the elbows To be collated via care metrics 7. Cleanliness: domestic 94% 8. Cleanliness: nursing 89% 9. Cleanliness: risk assessment of estates issues 10. IPC Mandatory Training 33% This is a new requirement, and summary monitoring is being worked on at present Cleanliness Achieving a clean, safe environment is essential to inspire confidence in our patients and visitors, and to assist in the prevention of infection. Review of standards has confirmed that BCUHB can do more to consistently meet minimum national cleaning standards. A major programme has commenced to address the issues identified, including standardisation of products and methods based on evidence of effectiveness, review of cleaning frequencies and cleaning responsibilities, action to routinely achieve minimum national standards, and implementation of a robust monitoring framework and reporting of standards. As an initial step, routine cleaning using Actichlor plus has been implemented. This is a detergent-chlorine product, and published evidence shows it can help in reducing the number of cases of Clostridium difficile infection, and also help with Norovirus control. Cleanliness has been included in the 10 key standards, to ensure focus on this issue at clinical level. This programme is being led by the Operational Estates Department and an action plan is currently in development. The Strategic Healthcare Cleanliness Group will drive forward the action plan, and ensure sufficient pace is injected to deliver the improvements needed. More detailed information on the cleanliness work programme, and cleanliness standards will be provided in the next report to Board. MRSA Prevention Actions Welsh Government guidance requires that there should be routine MRSA screening prior to or on admission for all renal, cardiothoracic, vascular, intensive care and orthopaedic patients as a minimum. In addition, screening should be in place for other patients based upon a clinical risk assessment. Currently BCUHB does not consistently screen all of these groups. A significant programme of work on MRSA prevention is commencing, which will include: Development and implementation of an MRSA policy, to take account of all areas of BCUHB Page 2

Review to confirm the number of patients who will require screening to fully comply with Welsh Government policy Confirmation the laboratory system can handle the volume of screening specimens that will be required for full compliance with Welsh Government guidance Agreement with Pharmacy on the prescription and supply of decolonisation products (products used to eradicate carriage of MRSA) Acceptance that implementation of this programme will result in costpressures re: screening costs and decolonisation costs A major programme of education to support policy implementation, as this will require a significant change in clinical practice across all areas of BCUHB Audit and monitoring once the programme rolls out, to ensure it becomes embedded, and to identify areas where additional support and education is required. Given the scale of the work required, this will take time to fully implement. As a first step, work will be progressed with adult critical care units, in order to ensure best-practice measures are in place for this group of patients. Work on policy development has also commenced. Norovirus Control BCUHB continues to see outbreaks of Norovirus, most notably at WMH. Initial review of Norovirus control has been performed. This has identified that the rigour with which outbreak control measures are implemented could be improved. An action plan is in place to address this, which includes strengthening the BCU policy, additional focus on cleaning, and greater discipline in the implementation of contact precautions on outbreak wards. The initial impact appears to be positive, with no diarrhoea and vomiting outbreaks reported across the Health Board for the past 2 weeks (as at 9 th January 2013). Progress With Recommendations In The Duerden Report (1): Since the last meeting of the Board, progress has been made on a range of issues, including: Management (p16) The job description, person specification and job plan for the Lead Infection Prevention & Control Doctor has been approved by the Royal College of Pathologists, and the advert is now live on NHS jobs. The interview date is set for 24 th January 2014. Review of the interim arrangement for the Lead Antimicrobial Pharmacist has commenced, in order to determine the most suitable long-term model for BCUHB. Role of Site Management and Clinical Programme Groups (p17) CPGs have been issued with a set of clear and consistent objectives to ensure a focus on quality improvement, which include the 10 key standards for Clostridium difficile and MRSA reduction. Page 3

Staffing and Function of Local ICTs (p18) The Executive Team has approved the preferred option for the restructure of the Infection Prevention Team. Work to implement this structure has commenced. In the interim, additional temporary recruitment has been progressed for a period of 6 months to support the nursing team. PHW is also supporting BCUHB by seconding of one of their experienced Infection Prevention Nurses to support the team. Antimicrobial Stewardship (p18) The Board-wide launch of the Secondary Care Antimicrobial Prescribing Policy for adults took place on European Antibiotic Awareness day, 18 th November 2013. The Primary Care Antimicrobial Policy is to be ratified by March 2014. For the four months ending Oct 2013, there was a 6.53% reduction in antibiotic prescribed items in primary care compared to the same four months in 2012. A national and regional campaign is planned from April 2014 to raise awareness of the harm caused by unnecessary antibiotic usage. The Antimicrobial Audit and Improvement tool has been ratified by the Strategic Infection Prevention Group and is being rolled out within CPGs. This will provide monthly monitoring of compliance. Death Certification (p20) The 2 nd workshop to further develop and strengthen the Clostridium difficile infection care pathway has been held. The existing care pathway remains in use, with compliance monitored weekly, and reviewed at local site-based Infection Prevention & Control Meetings. Root Cause Analysis (p21) RCA is in place for all Clostridium difficile-related deaths, and for severe cases at YG and WMH sites. The next step is to roll this out to severe cases at YGC. A robust system to ensure action plans are completed is being implemented. A monthly HCAI Lessons Learned summary is being implemented from January 2014 to ensure shared learning across BCUHB Policy and Practice Final amendments are being made to the draft policy review programme, to ensure it includes all policies listed in the newly-launched Code of Practice. Communications The BCU communications team have met with the Assistant Director of Nursing, to agree in principle a plan for a wide-ranging communications campaign on infection prevention and control, aimed at staff, patients and the public. It is proposed to involve a variety of groups who represent patients and the public in this work. Page 4

Antimicrobial Stewardship BCU has been identified as an outlier for antibiotic prescribing in comparison with the rest of Wales. There is also considerable variation in prescribing across different geographical areas within our Health Board. This report seeks to provide an update of the current position and recommendations for further actions to ensure standardised antibiotic prescribing across the Health Board. There is considerable historic variation in volume of antibiotic prescribing in primary care across BCU, with Denbighshire, Gwynedd and Ynys Mon all having considerably higher prescribing rates than the rest of Wales. As with the secondary care data this could be due to more patients with infection or indicate over-diagnosis and treatment. However, for the four months ending October 2013, there was a 6.53% reduction in prescribed items and 8.63% reduction in spend on antimicrobials compared to the same four months in 2012. Gwynedd and Anglesey observed a 50% reduction in the use of Cephalosporin, Quinolone and Coamoxiclav prescribing during the same time period. These are the antibiotics which have specific concern with Clostridium difficile infection and the areas are now comparable to other North Wales counties. An all-wales survey of antimicrobial prescribing practices is performed annually, and BCUHB routinely participates. Results of the 2013 survey which took place in November are not yet available, and will be reported to Board once they are received. Key results from the 2012 survey are summarised below, and support the need for the programme of work to improve antimicrobial stewardship in secondary care. Secondary care total antibiotic usage 2012 There is almost a two-fold variation in total antibiotic prescribing from hospital K (Ysbyty Gwynedd) and hospital H (Wrexham Maelor). Ysbyty Glan Clwyd is hospital L. High usage of antibiotics without significant variations in case mix can imply a larger proportion of that usage might be unnecessary, exposing patients to unnecessary risk, including the development of health care associated infections. Page 5

Secondary care antibiotic prescribing rates 2010-2012 45 40 Antibacterial prescribing rates 35 30 25 20 15 10 5 0 K H J A L P F C N M E D S B R G T 2012 44 38 38 34 36 33 34 32 32 31 32 27 27 26 26 19 17 2011 44 37 42 38 32 29 33 34 30 31 28 34 24 29 29 27 26 2010 39 33 37 36 28 34 32 27 30 33 37 32 24 26 28 22 22 The three acute sites within BCUHB sit at the higher end of percentage prescribing rates compared to the rest of Wales, with each site having a rising rate. A higher prescribing rate could be due to more patients with infection on the day of the study or be an indicator of over-diagnosis of infection or prolonged courses of therapy such that patients are exposed to unnecessary drug. Antimicrobial Pharmacist Ward Round Data Measurement The Antimicrobial Pharmacists perform regular ward rounds to review antimicrobial prescribing. Response to feedback, particularly when provided on an individual consultant level, has been largely positive and data has been used to support the revalidation and appraisal process for consultants and their teams. Globally, the data suggest similar issues with antimicrobial prescribing and review processes to those highlighted in the All Wales reports. Progress and Recommendations A major cultural shift with regards to the prescribing and review processes for antibiotics is ongoing within the Health Board. The Hospital Antimicrobial Prescribing Policy sets out expectations and standards for CPGs and provides a tool for measurement of compliance with the support of Clinical Audit. A business case is being submitted to Welsh Government in time for the 2014/15 Modernising Pharmacy Capital Programme, to replace and modernise the pharmacy IT system and roll out electronic prescribing. This will antimicrobial e-prescribing and monitoring. directly support Page 6

Consultant antimicrobial champions are to be identified in each CPG for each site. Primary Care antimicrobial guidelines are at the final stages of approval. A plan is being developed for a high-profile launch campaign for these guidelines, similar to that recently staged across our hospitals, to ensure the use of the new guidelines in primary care. Action is being taken to ensure antimicrobial prescribing is a core feature in the 2014/15 GP Prescribing Incentive Scheme & Local Enhanced Service. BCUHB is working with Welsh Government to establish a national and regional campaign from April 2014 to raise public awareness of the harm associated with unnecessary antibiotics. Impact of Actions To Date: Clostridium difficile Infection The number of new cases of Clostridium difficile infection across the Health Board continues to show an overall reduction trend, and the rise in numbers in September-October has been halted. A total of 34 cases were reported across all primary and secondary care NHS locations within the Health Board in December 2013. The charts below are provided by the Welsh Healthcare Associated Infection Programme. The total number of patients positive for Clostridium difficile across all primary and secondary care NHS locations within the Health Board is reported, with the rate calculated by using all admissions to Health Board inpatient facilities as a denominator. Monthly Numbers of Clostridium difficile (aged 2 and over) in BCUHB Number of Clostridium difficile (aged 2 and over) 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Monthly numbers of Clostridium difficile (aged 2 and over) diagnosed in Betsi Cadwaladr University Health Board, for the period Apr 10 to Dec 13 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Number of Clostridium difficile (aged 2 and over) Mth/Yr Trend Page 7

Monthly Rates of Clostridium difficile (aged 2 and over) in BCUHB, per 1000 Hospital Admissions Clostridium difficile (aged 2 and over)/1,000 admissions 12.0 10.0 8.0 6.0 4.0 2.0 0.0 Monthly rates of Clostridium difficile (aged 2 and over) diagnosed in Betsi Cadwaladr University Health Board per 1,000 hospital admissions, for the period Apr 10 to Dec 13 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Mth/Yr Clostridium difficile (aged 2 and over)/1,000 hospital admssions Trend In line with the decrease in case numbers, the rate within BCUHB has dropped to 4.39 cases per 1000 hospital admissions in December 2013. The published all-wales rate for October is 3.00 cases per 1000 hospital admissions, meaning BCUHB remains as a high outlier for this infection. Clostridium difficile by Site This data is reported as the number of patients positive from within each acute hospital, and rates are obtained by using the number of acute admissions to the same hospital as a denominator. Note that site-based data does not take account of patients who are positive in other locations outside the acute sites. YGC: Monthly Numbers of Clostridium difficile (aged 2 and over Number of Clostridium difficile (aged 2 and over) 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Monthly numbers of Clostridium difficile (aged 2 and over) diagnosed in Glan Clwyd General Hospital, for the period Apr 10 to Dec 13 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Mth/Yr Number of Clostridium difficile (aged 2 and over) Trend YG: Monthly Numbers of Clostridium difficile (aged 2 and over) Number of Clostridium difficile (aged 2 and over) 25.0 20.0 15.0 10.0 5.0 0.0 Monthly numbers of Clostridium difficile (aged 2 and over) diagnosed in Ysbyty Gwynedd, for the period Apr 10 to Dec 13 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Mth/Yr Number of Clostridium difficile (aged 2 and over) Trend Page 8

WMH: Monthly Numbers of Clostridium difficile (aged 2 and over) Number of Clostridium difficile (aged 2 and over) 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Monthly numbers of Clostridium difficile (aged 2 and over) diagnosed in Wrexham Maelor Hospital, for the period Apr 10 to Dec 13 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Number of Clostridium difficile (aged 2 and over) Mth/Yr Trend Comparison of acute site numbers and rates in December 2013: Site Number of Cases Rate per 1000 hospital admissions WMH 7 3.08 YGC 8 3.26 YG 7 3.05 Not from acute sites 12 No rate calculated Deaths related to Clostridium difficile The number of deaths in patients who have Clostridium difficile infection continues to be very closely monitored. Deaths with CDI Listed on Death Certificate Apr May June July Aug Sept Oct Nov Dec YG/West 2 0 0 0 1 2 2 3 1 YGC/Central 4 0 0 0 0 2 1 0 1 WMH/East 1 1 0 0 0 0 0 0 1 Total Deaths 7 1 0 0 1 4 3 3 3 The number of patients with Clostridium difficile infection listed on part 1 of the death certificate (indicating a direct cause of death) was 11, and the number listed on part 2 (indicating it was a contributory factor) was 11. Root cause analysis on the care of these patients has identified a number of issues, including: Some delays in isolating patients with symptoms, or poor compliance with isolation practices The need to send repeat specimens if patients have a negative sample but diarrhoea continues in the absence of alternative diagnosis Cleanliness standards in some areas, and some staff unclear about who is responsible for cleaning certain items Patients previously positive for Clostridium difficile and re-admitted with symptoms; treatment not in line with guidelines for recurrence The process for receiving information and patient history on repatriation of patients from a specialty centre is under review, to ensure significant infection-related information is clearly communicated Page 9

Each RCA has an action plan developed, and an assurance process to confirm these are robustly implemented with all actions being completed is currently being put into place. An HCAI Lessons Learned Summary is being implemented, with effect from January 2014, to ensure that the lessons identified from RCAs are disseminated widely on a monthly basis. Report from Public Health Wales on Clostridium difficile Across BCUHB At the last meeting of the Board, the findings from the further report by Public Health Wales into the epidemiology of Clostridium difficile infection across BCUHB was discussed. The finding of concern was that in WMH, the proportion of total deaths and deaths within 30 days of Clostridium difficile infection was almost twice as high as in the other two hospitals. The action plan drawn up to investigate this finding has been progressed by the investigation team, which includes representation from PHW. To date the following has been confirmed: Audit data shows that there is no major issue with the sending of specimens for testing. This excludes lack of specimens as a cause. Detailed laboratory analysis (ribotyping) of the first 20 cases does not show the presence of an aggressive ribotype, or evidence of widespread cross-infection. This appears to exclude the presence of a specific Clostridium difficile ribotype as the cause. Ribotyping of the remaining cases is being carried out at present. Casenote review has been completed, and the report is awaited from PHW. Laboratory cross-checking of test results between the laboratories at WMH and YGC has been completed, and there is concordance between laboratories on the results. This excludes laboratory procedures as a possible cause. The second meeting of the investigation team identified some additional investigative actions based on the preliminary findings, and these are now being put into place. Routine quarterly analysis of 30-day all-cause mortality for patients who have Clostridium difficile infection has been agreed with PHW, and this is next due in January 2014, for the period to the end December 2013. Update on Other Healthcare-Associated Infections: Bloodstream infections caused by Meticillin-resistant Staphylococcus aureus (MRSA), and Meticillin-sensitive Staphylococcus aureus (MSSA) are also monitored as part of the national programme in Wales. The charts below are provided by the Welsh Healthcare Associated Infection Programme. For BCUHB data, the total number of patients positive across all primary and secondary care NHS locations within the Health Board is reported, with the Page 10

rate calculated by using all admissions to Health Board in-patient facilities as a denominator. MRSA Bacteraemia Monthly Rates of MRSA Bacteraemia in BCUHB, per 1000 Hospital Admissions MRSA bacteraemia/1,000 admissions 2.0 1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 Monthly rates of MRSA bacteraemia diagnosed in Betsi Cadwaladr University Health Board per 1,000 hospital admissions, for the period Apr 10 to Dec 13 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 MRSA bacteraemia/1,000 hospital admssions Mth/Yr Trend MRSA Bacteraemia: Comparison of BCUHB to All-Wales Data 2013 Q3 Number of Cases Rate per 1000 hospital admissions BCUHB All-Wales BCUHB All-Wales October 4 15 0.50 0.39 November 7 17 1.09 0.52 December 6 19 0.77 0.53 MRSA Bacteraemia by Site This data is reported as the number of patients positive from within each acute hospital, and rates are obtained by using the number of acute admissions to the same hospital as a denominator. Note that site-based data does not take account of patients who are positive in other locations outside the acute sites. MRSA: Comparison of Numbers and Rates in December 2013: Site Number of Cases Rate per 1000 hospital admissions WMH 0 0.00 YGC 3 1.22 YG 3 1.31 Not from acute sites 0 Rate is not calculated BCUHB remains a high outlier in Wales for MRSA bacteraemia. The actions that are being put into place regarding policy, screening, and other preventative actions will be fundamental in addressing this. Page 11

MSSA Bacteraemia For BCUHB data, the total number of patients positive across all primary and secondary care NHS locations within the Health Board is reported, with the rate calculated by using all admissions to Health Board in-patient facilities as a denominator. Monthly Rates of MSSA Bacteraemia in BCUHB, per 1000 Hospital Admissions MSSA bacteraemia/1,000 admissions 2.5 2.0 1.5 1.0 0.5 0.0 Monthly rates of MSSA bacteraemia diagnosed in Betsi Cadwaladr University Health Board per 1,000 hospital admissions, for the period Apr 10 to Dec 13 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 MSSA bacteraemia/1,000 hospital admssions Mth/Yr Trend MSSA Bacteraemia: Comparison of BCUHB to All-Wales Data 2013 Q3 Number of Cases Rate per 1000 hospital admissions BCUHB All-Wales BCUHB All-Wales October 9 70 1.13 1.82 November 7 64 1.09 1.96 December 8 67 1.03 1.86 MSSA Bacteraemia by Site This data is reported as the number of patients positive from within each acute hospital, and rates are obtained by using the number of acute admissions to the same hospital as a denominator. Note that site-based data does not take account of patients who are positive in other locations outside the acute sites. MSSA: Comparison of Numbers and Rates in December 2013: Site Number of Cases Rate per 1000 hospital admissions WMH 6 2.64 YGC 1 0.41 YG 1 0.44 Not from acute sites 0 Rate not calculated This data shows that overall BCUHB compares well with the all-wales rate for MSSA bacteraemia, providing an indicator of safe care. However, there continues to be variability between and within sites month-on-month which Page 12

requires continued monitoring. Initial review of the cases reported at WMH indicates that a number of them were probably acquired in the community, and further investigation is in progress in relation to these cases. New National Targets for HCAI reduction The Executive Team and specialist leads attended an HCAI event run by Welsh Government in December 2013. A number of initiatives were announced at this event including new national targets and a large-scale change initiative. Large-scale change programme Welsh government are advocating adoption of a large-scale change methodology for health-economy wide action to reduce HCAI. This model has been used successfully elsewhere, and BCUHB is keen to progress this approach. Initial discussions have been held with experts who may be able to support BCUHB progress this. National Targets for HCAI Reduction All Health Boards have been issued with new targets for reduction of Clostridium difficile infection and MRSA bacteraemia. For BCUHB this means that by March 2015, there must be no more than: 18 cases of Clostridium difficile infection per month (216 per year) 1.5 cases of MRSA bacteraemia per month (18 per year) Reduction trajectories are currently being finalised to ensure close monitoring of progress towards those targets. These will also be calculated by site so that it is clear what performance is expected at local level within BCUHB. Next Steps: The improvement action plan will continue to be progressed, with specific emphasis on: Achievement of the 10 key standards will continue to be driven forward as a priority in clinical areas. Learning from the improved RCA process that is in place will start to be shared across BCUHB, and action plans will be monitored to provide assurance that everything has been done. The work programme to drive up standards of cleanliness will continue, and more detailed performance information will be included in the next report to Board. The major focus on antimicrobial prescribing will continue, including progression of the actions identified in this paper, and an update will be included in the next report to Board. Page 13

Trajectories for the new national targets will be finalised and implemented, with monthly monitoring put into place. The opportunity to implement a large-scale change programme across the area of BCUHB will be actively progressed. The improvement action plan will continue to be monitored monthly to ensure sufficient progress is being made against all areas of work. Any lack of progress is escalated rapidly to the Director of Nursing and Midwifery and Medical Director for executive level action. Focus throughout BCUHB will remain on infection prevention and control, to ensure patients are protected from avoidable harm and receive safe care. References: 1. Review of Governance Arrangements, Structures and Systems for the Prevention and Control of Healthcare-Associated Infections in the Betsi Cadwaladr University Health Board. Professor B. Duerden. August 2013 Page 14