Infection Prevention & Control Report to Trust Board 1. Executive Summary Meeting Date 6 th October 2016 The Department of Health for Northern Ireland has now issued the MRSA bacteraemia and C. difficile associated disease (CDAD) reduction targets for 2016/17. The MRSA bacteraemia target is seven, a reduction of two cases or 22.22% on the previous year. The challenging target for CDAD is 48, a reduction of 16 cases or 25% compared to last year. To date there have been two cases of MRSA bacteraemia for 2016/17, both of which have been categorised as community-associated. As of 29 th September 2016, the total number of days since the last Trust hospital-associated MRSA bacteraemia is: Altnagelvin Hospital 393 days (Last recorded case was in Ward 4) South West Acute Hospital (SWAH) 229 days (Last recorded case was in Ward 8) Tyrone County Hospital (TCH) 623 days (Last recorded case was in the Rehab Unit) During August 2016 residents and staff in Seymour Gardens Residential Home, Derry, experienced symptoms of vomiting and diarrhoea. This was confirmed as Norovirus and the home was closed for 10 days. A total of 16 residents and 7 staff were affected. All the necessary infection prevention and control measures were put in place, but as this facility is an EMI speciality residential home, it was difficult to isolate residents effectively and to ascertain if residents were having more symptoms than were being recorded. This home has single rooms but no en-suite facilities, so enhanced cleaning regimes and an additional cleaner were put in place. Following the end of the outbreak there were challenges in the reopening of the home due to difficulties in a responsive terminal clean process. In September 2016 the Infection Prevention and Control Nurses (IPCNs) commenced an MRSA Improvement Programme at both Altnagelvin and the SWAH. This ward-based enhanced support will assist staff to address deficits in the identification, treatment and care of a patient with MRSA. This need was previously identified in audit work completed in late 2015. It is also an opportunity to improve the patient s experience, and thus, the IPCNs will also engage directly with patients to gain their experience and understanding of MRSA. It is anticipated that this work will be completed by January 2017. International Infection Prevention and Control Week will be take place on 16 th 22 nd October 2016. The Trust s Infection Prevention and Control Team (IPCT) will be participating in a range of activities to raise awareness of the role infection prevention plays in improving patient safety with this year s theme Break the Chain of Infection. 2. C. difficile Performance The 2016/17 target for C. difficile ( 2 years) is 48 cases, which equates to a reduction of 25% on the baseline figure of 2015/16 (64 cases). So far this year the Trust has reported 26 cases, with 12 of those being categorised as community-associated. Therefore, reduction is currently off profile, with a decrease of just 18.75% compared to last year. Infection Prevention & Control Report, September 2016 Page 1 of 7
* The value for Sep 16 is subject to change as the report was compiled prior to the end of the month. A breakdown of this year s cases (as of 29 th September 2016) by hospital site and acquisition type is given in the chart below. Key: CAI HAI Community-associated infection Hospital-associated infection Infection Prevention & Control Report, September 2016 Page 2 of 7
C. difficile Care Bundle and C. difficile Care Pathway Audits Evidence based care bundles are effective when all elements of care are performed consistently. Therefore, scores are represented as either pass (100%) or fail (anything less than 100%). There is no differentiation between those achieving a very low score and those achieving 95%. This is done deliberately to highlight the importance of 100% compliance with the bundle as a whole. Infection Prevention & Control Report, September 2016 Page 3 of 7
The C. difficile care bundle and the C. difficile care pathway audit are undertaken by an IPCN twice weekly, whilst the patient remains an inpatient. This should also be supported by daily ward self-audits in relation to the same. During the period August-September 2016, the following wards/ departments were found to be non-compliant with some elements of the C. difficile care bundle and/ or the C. difficile care pathway. Altnagelvin Ward 1 Ward 2 TOU (C. difficile audit, September) Ward 40 Ward 41 AMU The main trend for non-compliance with the C. difficile audits relates to environmental decontamination. There is also inconsistent compliance with other elements, e.g. hand hygiene and isolation/ cohort nursing. 3. Root Cause Analysis (RCA) Quarter 1 (January-March) and quarter 2 (April-June) 2016 findings for outcomes of C. difficile RCAs demonstrate that, of the 21 cases examined, 13 were deemed to have been avoidable. The causes were all mainly related to the need for antibiotics to treat acute or reoccurring infections prescribed in hospital or by GPs. Only a small number of cases, 17% (2/12), in Q2 were found to have been hospital off-guideline or inappropriate prescriptions. However, in Q1 33% (2/6) and in Q2 57% (4/7) of cases were deemed to be GP off-guideline or inappropriate prescriptions. The majority of patients were over 65 years of age and had recent, and sometimes frequent, admissions to hospital. The use of proton pump inhibitors remains a prevalent feature, with use in 67% of cases for both quarters (6/9 and 8/12 respectively). Poor nutritional intake was also a common finding for patients during these quarters. RCAs were carried out for one MRSA bacteraemia and one MSSA bacteraemia during the first two quarters of 2016. The root causes were poor compliance with MRSA screening guidelines and the insertion/ ongoing care of a medical device. Both cases were deemed to be preventable. Infection Prevention & Control Report, September 2016 Page 4 of 7
4. Clinical Incidents Relating to Infection Control 5. Critical Care Device-Associated Infection Surveillance Critical care device-associated infection surveillance commenced in June 2011. There have been no device related infections since April 2014. The Critical Care staff are to be commended for their exemplary performance across all the parameters of this surveillance programme. Ventilator-Associated Pneumonia (VAP) Infection Prevention & Control Report, September 2016 Page 5 of 7
Catheter-Associated Urinary Tract Infection (CAUTI) Infection Prevention & Control Report, September 2016 Page 6 of 7
Central Line Associated Blood Stream Infection (CLABSI) Infection Prevention & Control Report, September 2016 Page 7 of 7