Infection Prevention & Control. Annual Report

Infection Prevention & Control Annual Report 2013-2014 1

Report To Meeting Date Risk and Quality Committee July 2014 Title of Report Infection Prevention and Control Annual Report 2013/14 Action Sought For Approval Estimated time 30 minutes Executive summary This report from the Director of Infection Prevention and Control (DIPC) is the annual report to the Trust Board on healthcare associated infections and the progress of the annual plan. The report highlights the continued excellent performance for infection prevention and control within the Trust. The Trust has met the Clostridium difficile target set by the CCG. The Trust currently has the lowest levels of Clostridium difficile associated disease (CDAD) in the region and is in the upper decile nationally of comparator organisations. The Trust also achieved the lowest number of cases of MRSA bacteraemia in the past decade moving from 86 cases 2002/03 to 2 cases reported in 2013/14 and only 1 of these cases was avoidable. Devolution of accountability for IP&C to local clinical teams continued during 2013/14 through strengthening of the role of IC link practitioners and IC leads for all trust divisions, and through regular reporting by the IC leads to the Trust Infection Prevention and Control Committee and presentations by consultant IC Leads to their respective divisional rolling half days. The trust has declared compliance with the Hygiene Code and is unconditionally registered with the CQC. Presenting Director - A Thompson, Director of Nursing and Patient Experience & Director for Infection Prevention and Control Authors - F M Awadel-Kariem, Infection Control Doctor/Lead Consultant Microbiologist - H O Connor, Nurse Consultant/Assistant Director for Infection Prevention and Control Acknowledgement The authors would like to acknowledge the contribution of colleagues to this report CQC Outcomes supported by this report 8 Cleanliness and infection control Equality impact assessment No adverse impact 2

CONTENTS Section Page 1 Introduction 4 2 Compliance with the Health and Social Care Act 2008 5 3 Criterion 1: a - Systems to manage the prevention and control of infection 5 4 Criterion 1: b - Monitoring the prevention and control of infection 8 5 Criterion 2: Clean and appropriate environment 19 6 Criterion 3&4 : Information on infections to service users and their visitors & Information on infections to other providers 21 7 Criterion 5: Identification and prompt management of infection 21 8 Criterion 6: Involvement of all staff 22 9 Criterion 7: Isolation facilities 22 10 Criterion 8: Laboratory support 23 11 Criterion 9: Policies 23 12 Criterion 10: Health care workers: Infection Status, Protection from Infection & Education in infection prevention & control 24 13 CQC visits 24 14 Trust Development Authority visits 24 15 CCG visits 25 16 Independent External Reviews 25 17 Conclusion 26 Appendix I Infection Control Policies 27 Appendix II Action Plan following investigation into Clostridium difficile Management at East & North Hertfordshire NHS Trust 30 Appendix III Annual Plan 2014/15 32 3

1. Introduction The Trust Board recognises and agrees their collective responsibility for minimising the risks of infection and has agreed the general means by which it prevents and controls these risks. The responsibility for infection prevention and control is designated to the Director of Infection Prevention & Control (DIPC) supported by the Lead Infection Control Doctor and Nurse Consultant/Assistant DIPC. The Infection Prevention & Control (IPC) Annual Report, together with the monthly Risk and Quality Committee IPC Report, Annual IP&C Plan and IPC Assurance Framework are the means by which the Trust Board assures itself that prevention and control of infection risks are being managed effectively and that the Trust remains registered with the Care Quality Commission (CQC) without conditions. In addition, the Annual Report seeks to assure the Trust Board that progress has been made against the 2013/14 Annual Plan, to reduce healthcare associated infections (HCAIs) and sustain improvements in infection prevention and control practices for 2014/15. It demonstrates that priorities identified in the Annual Plan last year have been addressed by employing a robust programme of work that enabled some notable successes on which to build. These improvements have been achieved despite major reconfiguration as part of the Our Changing Hospital programme. Achieving the target for Clostridium difficile for the third consecutive year, following the dramatic reduction of our year end target ceiling from 65 cases in 2010/11 to only 14 cases for 2013/14. Achieving a single preventable MRSA bacteraemia against the very demanding MRSA bacteraemia target of 0 preventable cases. Improving prescribers compliance with the Trust-wide reduction in the use of antibiotics that are known to precipitate Clostridium difficile, MRSA bacteraemia, Carbapenemase Resistant Enterobacteriaceae and other HCAIs. Improving prescribers compliance with antimicrobial prophylaxis for trauma and surgical cases. Addressing the new threat of Pseudomonas aeruginosa in the water supply of augmented care units and the threat of other water-borne pathogens by creating a Water Safety Group. Trust wide improvement with decontamination of equipment at ward and clinic level Achieving 100% compliance with elective MRSA screening 4

Challenges that remain include: efforts to further improve the turn around of action plans relating to audits of the clinical area thereby closing the loop on issues identified; improving MRSA screening for patients admitted as an emergency maintaining the Annual Deep Clean programme. Whilst progress has been made in the past year, the reduction of surgical site infection rates in Trauma and Orthopaedic surgery remains a priority for improvement in patients outcomes. The provision of this report fulfils the legal requirements of sections 1.1 and 1.3 of the Health and Social Care Act 2008: Code of Practice for Health and Adult Social Care on the Prevention and Control of Infections and Related Guidance. The information provided in this report should be released to the public following the Trust Board s approval. 2. Compliance with the Health and Social Care Act 2010 The CQC has used the Code of Practice as a key feature of registration. Failure to observe the Code may either result in an improvement notice being issued to the Trust by the CQC following an inspection, or in it being reported for significant failings and placed on special measures. All NHS organisations must be able to demonstrate that they are compliant with the Code. The Trust continues to be registered with the CQC, without conditions. 3. Compliance with Criterion 1: a - Systems to manage and monitor the prevention and control of infection IPC is the responsibility of everyone in the organisation. arrangements are detailed below: Key roles and 3.1 IPC Structure: The Chief Executive Officer has overall responsibility for the control of infection within East and North Hertfordshire NHS Trust. 3.2 Senior IPC Management Team: The senior IPC management team includes the DIPC, the Assistant DIPC () and the Infection Control Doctor (ICD) and meets every two weeks to discuss activity and issues. 3.2.1 The DIPC 5

The DIPC is the Executive Lead for the IPC service, and oversees the implementation of the IPC plan through her role as Chair of the Trust Infection Prevention and Control Committee (TIPCC). The DIPC approves the Annual IPC report and releases it publicly. She reports directly to the Chief Executive and the Trust Board on IPC matters. The DIPC has the authority to challenge inappropriate practice. 3.2.2 The Assistant DIPC The is a Consultant Nurse reporting directly to the DIPC and working with the ICD. The role includes: - Supports the DIPC - Manages and chairs the Divisional IP&C Committees which meet monthly reporting to the TIPCC and Divisional Boards. - Chairs the Joint IP&C monthly meeting of Consultant Microbiologists, Nursing Team and Antimicrobial Pharmacists - Leads the Trust Decontamination service - Manages the IP&C & Deep clean programme - Responsible for the delivery of IPC training for all trust staff with the exception of the doctors. - Ensures that all policies and guidelines related to infection prevention are valid and implemented across the service - Manages infection control nurse s service level agreements with 3 external hospices and Hertfordshire Partnership Trust - Leads the deep cleaning programme - Produces together with the DIPC and the ICD, the IPC Strategy, Annual Plan, Assurance Framework and Annual IPC Report. 3.2.3 The Infection Control Doctor The ICD is the Clinical Lead for the IPC service. The role includes: - Supports the DIPC - Oversees local IPC policies and their implementation by ensuring that adequate laboratory support is in place - Chairs the Water Safety Group (which replaces the Pseudomonas Risk Assessment Group and the Legionella Steering Group). - Supervises IPC education for doctors and delivers the mandatory training lecture for consultants. - Provides expert clinical advice on infection management. - Manages an infection control doctor service level agreement with the Hertfordshire Community NHS Trust. - Produces, together with the assistant DIPC, the annual IPC report. - Has the authority to challenge inappropriate practice including inappropriate antibiotic prescribing decisions. The ICD reports to the DIPC on IPC matters. 6

3.3 The Infection Control Nursing Team: In 2013-2014 the team consisted of: 1.0 WTE Nurse Consultant /Assistant DIPC (Band 8C) 1.0 WTE Lead Nurse (April December 2013) (Band 8A) 2.4 WTE Clinical Nurse Specialists Infection Control (Band 7) (1.0 WTE on maternity leave 2013 through to 2015) 2.0 WTE Infection Control Nurse (Band 6) 0.4 WTE Admin Support (Band 3) 1.0 WTE Surgical Site Surveillance Nurse (Band 6) 3.4 The Consultant Microbiologists In addition to the Infection Control Doctor, the Trust employs two consultant medical microbiologists (CMMs). All three CMMs play an active role in infection prevention. There is cover 24 hours a day, 7 days a week provided by a CMM for clinical microbiology/infection prevention. One consultant microbiologist has been designated Deputy ICD, and this post holder represents the ICD in the Flu Preparedness Committee and provides clinical leadership for the Trust SSI management programme. 3.5 The Antimicrobial Pharmacists The Trust employs 1.2 WTE Antimicrobial Pharmacists who work closely with the Deputy ICD and other members of the infection prevention & control team. There is robust management of antimicrobial stewardship throughout the Trust. One antimicrobial pharmacist is the secretary of the Trust Antimicrobial Forum (TAF), a subcommittee of the New Drugs and Formulary Committee. The TAF is responsible for writing and disseminating Trust specific antimicrobial guidelines. These guidelines are ratified by the Therapeutics Policy Committee. The role of the antimicrobial pharmacists includes: - attending and contributing towards the Trust Infection Prevention & Control Committee meetings and the Joint Infection Prevention & Control Committee meetings (with the infection control team) - supporting antimicrobial stewardship initiatives by working closely with the ICD and the CMMs - joining and contributing toward the Antimicrobial Ward Rounds with the CMMs - carrying out audits in line with national guidance. - providing training regarding antimicrobial stewardship to clinical staff within the Trust. 7

3.6 The Trust Infection Prevention & Control Committee (TIPCC) The Committee is chaired by the DIPC. Its membership includes, in addition to the Medical Consultant leads from all specialities, Consultant for Communicable Disease Control, occupational health representative, clinical governance officer, head of estates and facilities, education leads, matrons and the antimicrobial pharmacists. The terms of reference and membership were reviewed in 2014. The TIPCC meets 11 times a year and reports to the Trust Board via the Risk and Quality Committee. 3.6.1 Medical Consultant Infection Prevention Leads Each speciality has a designated lead that forms the link within their division and the Trust Infection Prevention Committee. Their role includes a bimonthly report on local infection prevention issues, taking back information to their divisions and working with the divisional matrons on new clinical initiatives and the resolution of local issues supported by the at monthly divisional meetings. 3.7 The Annual Plan An annual plan is prepared by the in conjunction with the Infection prevention team and agreed at TIPCC prior to approval by the Board. The plan of work is mapped to the duties of the Code of Practice. Progress against the annual plan is monitored by the TIPCC and reported to the RAQC quarterly. The plan for 2014-2015 can be found at Appendix A. 4 Compliance with Criterion 1: b - Monitoring the prevention and control of infection 4.1 Mandatory Surveillance: Mandatory surveillance comprises of MRSA, MSSA, Escherichia coli (E.coli), cases of Clostridium difficile infection and surgical site infection in fracture neck of femur, total hip and knee replacement surgery. Mandatory surveillance of bacteraemia caused by Vancomycin Resistant Enterococci bacteraemias (VRE), also known as Glycopeptides Resistant Enterococci (GRE), was introduced in 2003. The Department of Health advised that from 1st April 2013, GRE bacteraemias would no longer be the subject of mandatory surveillance. 4.1.1 MRSA blood stream infections (BSI) Isolates of MRSA (Meticillin Resistant Staphylococcus Aureus) from blood cultures have been reported since 2002; enhanced reporting using the Health Protection Agency (HPA) MRSA Data Capture System began in 2006. The HPA is now known as Public Health England. 8

National and local MRSA bacteraemia figures may be seen at: http://www.hpa.org.uk/infections/topics_az/staphylo/default.htm The table below shows the performance of the Trust since the introduction of Mandatory Surveillance in 2002. Red font indicates MRSA blood stream infections (BSI) numbers exceeding yearly targets. Year 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13 13/14 Trust total 86 56 50 58 53 33 18 10 5 3 2 1 (2)* Target n/a n/a n/a 39 31 22 21 15 3 3 3 0 * 2 cases reported (1 avoidable, 1 unavoidable). The Trust target for 2013/14 was set at 0 preventable MRSA Blood Stream Infections (BSI). We had two cases with only one deemed as preventable (i.e. trust policies and procedures were not followed fully which might have contributed to the MRSA BSI). In April 2013, the NHS Commissioning Board issued Guidance on the reporting and monitoring arrangements and post infection review process for MRSA bloodstream infections from April 2013. The post infection review (PIR) process is used as a learning tool to identify the causes of the MRSA BSI and to review whether or not the blood stream infection was avoidable and to take appropriate action if it was. This is an enhancement of the root cause analysis (RCA) process introduced in 2007 that used the NPSA RCA tool by adopting a whole system approach that fosters strong partnership working by all organisations involved in the patient s care pathway. A PIR process has been undertaken for the single preventable MRSA BSI in the Trust; supported by the CCG (a PIR was not indicated for the unpreventable MRSA BSI case). Learning points from the PIR helped in identifying actions that would prevent similar cases recurring in the future. Following an extensive training initiative during the past two years the trust has made a significant improvement in avoiding contaminated samples of blood leading to false positive results. 4.1.2 Clostridium difficile-associated disease (CDAD) Clostridium difficile is a type of bacterium found in the gut that can cause diarrhoea in certain circumstances. It can cause a spectrum of symptoms from mild antibiotic-associated disease to severe colitis. The bacterium is found without ill effects in a percentage of the population such as neonates (hence we do not test patients <2 years of age) and the elderly, where up to 50% in some studies are colonized without ill effects. As the current testing technologies only detect the presence of the bacterium, the DH has produced a number of guidelines advising laboratories on how and when to test and which groups of patients should not be tested routinely. New episodes of laboratory confirmed Clostridium difficile toxin positive samples are reported. A new way of counting CDAD numbers was introduced from April 2008 in an attempt to define hospital-acquired versus community 9

acquired cases. This has resulted in improved working across the whole health economy in relation to target organisms. The incidence of C.difficile infection has reduced nationally year on year for the past three years. National and local results can also be seen at: http://www.hpa.org.uk/topics/infectiousdiseases/infectionsaz/clostridiumdifficile/ The table below shows the performance of the Trust since the introduction of Mandatory Surveillance in 2004. Red font indicates CDAD numbers exceeding yearly targets. Year 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13 13/14 Total 474 487 594 457 108 81 56 12 13 14 Target n/a n/a n/a 414 183 90 63 65 14 14 In July 2013, it was realised that 8 cases of Clostridium difficile were reported since the beginning of April against a year end target ceiling of 14, indicating that the Trust was over trajectory. Furthermore, 3 of the cases occurred in patients in one elderly-care ward. Two patients were positive for Clostridium difficile of the same ribotype (RT 005). External advice from PHE and from the CCG was sought in investigating these two cases. An incident management team was set up, chaired by the DIPC. A number of meetings were convened and a detailed action plan was implemented. The outbreak was declared over when no additional cases were observed following the implementation of a robust action plan. Two cases of Clostridium difficile (one was health-care associated while the second was community-acquired) were identified and reported to the Mandatory Surveillance System, as requested by the DH, on the basis of positive endoscopy demonstrating the presence of pseudomembranous colitis (PMC). However, upon histological examination of biopsies taken during endoscopy, no evidence of PMC was seen by the histopathologists and the diagnosis of PMC was not supported. These two cases were later withdrawn from the database and the patients informed that they did not have CDAD. As a result of this the Trust will only report cases following positive histopathology. In addition to the improvements in the patients outcomes and experience there are significant financial savings associated with reducing healthcare associated Clostridium difficile. The cost of a single case of CDAD to the hospital has been estimated to be 5,846-7,297. The reduction in CDAD numbers between 2006/7 and 2013/14 represents a cost to the health economy of 3.9M in 2006/07 compared to 76,000 last year. The mandatory surveillance numbers for this year have been excellent, continuing the positive trend of the last three years and giving the Trust the lead position within the East of England. The Trust is in the upper decile compared to all acute DGH s in England, excluding specialist organisations. 10

Monthly rate of Clostridium difficile cases per 100,000 occupied bed days (acute trust apportioned cases only) Trust Acute Trust 2013 2014 Total Code Name April May June July August September October November December January February March Total RC1 Bedford Hospital 0.00 0.00 0.00 70.71 0.00 20.88 0.00 10.44 0.00 10.10 0.00 0.00 11.26 RWH East & North Hertfordshire 4.92 9.52 19.68 4.76 9.52 4.92 4.76 4.92 0.00 0.00 10.55 0.00 6.27 RNQ Kettering General Hospital 6.40 24.76 12.79 6.19 12.38 19.19 18.57 12.79 6.19 6.19 13.71 0.00 12.54 RC9 Luton & Dunstable Hospital 6.18 5.98 18.54 5.98 5.98 18.54 5.98 24.71 5.98 5.98 6.62 5.98 10.30 RD8 Milton Keynes Hospital 0.00 16.82 0.00 16.82 8.41 17.38 33.64 26.07 84.11 25.23 27.94 33.64 23.01 RNS Northampton General Hospital 36.35 10.05 20.77 5.03 15.08 5.19 10.05 15.58 0.00 0.00 5.56 10.05 11.71 RWG West Hertfordshire Hospitals 12.79 24.76 12.79 12.38 12.38 19.19 12.38 31.99 0.00 12.38 0.00 24.76 15.05 SMHXXX South Midlands and Hertfordshire 11.10 13.43 13.87 13.43 9.85 13.87 11.64 17.57 10.74 7.16 8.92 9.85 12.24 11

4.1.3 Other Mandatory Surveillance organisms We also report on bacteraemias caused by Meticillin Sensitive Staph Aureus (MSSA), Vancomycin-resistant enterococci (VRE) and E. coli. The table below shows the numbers of these bacteraemias from 2011/12. Bacteraemia MSSA VRE E coli 2011/12 18 7 30 2012/13 15 4 43 2013/14 9 9 53 MSSA bacteraemia The number of MSSA BSI continued to come down. It is very likely that measures introduced to reduce MRSA BSI (including changes to how blood cultures are collected and the avoidance of contamination) may have played an important role in the observed reduction in MSSA BSI numbers. Vancomycin Resistant Enterococci (VRE) bacteraemia: VRE, also known as glycopeptides resistant enterococci (GRE), are low pathogenicity bacteria that are inherently resistant to many antibiotics and can acquire resistance to effective antibiotics such as vancomycin. VRE infections are difficult to treat and in certain groups (where they can cause opportunistic infections, such as in transplant patients, patients in the ITU and renal patients with indwelling devices) can present a challenge. Following the observation of an increase in VRE bacteraemias in the renal unit in 2011/12 (see Table 1), the Infection Control Lead for the renal unit worked with the ICD to review the bacteraemia cases. At that stage, it was concluded that these bacteraemias were not linked. Some had originated at other organisations. Recommendations were made. Table 1 2009-10 2010-11 2011-12 2012-13 2013-4 Total VRE bacteraemias 1 3 7 4 6 Renal unit VRE bacteraemias 1 0 4 0 3 The ICD continued to monitor the occurrence of VRE bacteraemia at the unit and noted that the measures introduced by the unit seemed to work as no further VRE bacteraemias were seen in 2012/13. However, there has been a simultaneous increase in the number of clinical samples with VRE both in the hospital and in the renal unit in the same year (see Table 2). The consultant microbiologist leading on renal microbiology investigated this increase and liaised with the renal unit to assess whether any change in practice had occurred. Clinical isolates were sent to the reference laboratory for typing. A number of new strains were identified. A comprehensive action plan (that included: snap shot screening for gut colonisation, deep cleaning of the ward 12

environment, enhanced cleaning using hypochlorite and antimicrobial stewardship) was developed to address this increase in VRE in the renal unit in 2013/14. Table 2 2009-10 2010-11 2011-12 2012-13 2013-14 Hospital Renal (%) Hospital Renal Hospital Renal Hospital Renal Hospital Renal Fluid 0 0 1 1 0 0 3 2 3 2 MSU 8 1 3 2 9 6 40 21 47 22 CSU/U 3 0 8 1 9 2 28 14 40 5 Line tips 3 2 0 0 4 2 3 2 2 2 Other* 4 1 2 2 14 1 11 3 42 7 Total 18 4 (22) 14 6 (43) 36 11 (31) 85 42 (49) 134 38 (28) In May 2013, two renal patients associated in time and place were diagnosed with a VRE blood stream infection. Therefore an outbreak was declared. Molecular studies demonstrated that the two isolates were closely related but not identical. The Trust approach to managing the increased prevalence of VRE was supported by the Consultant for Communicable Diseases at the local PHE Unit. Advice was also sought from national experts who agreed that the approach adopted by the Trust in controlling VRE was correct and that there is no dominant outbreak strain(s) in the Trust. While the total number of VRE isolates from the whole Trust has crept up year on year, the percentage of isolates from the Renal Unit has actually reduced in the last year (from 49% of all VRE isolations in the Trust in 2012/13 to only 28% in 2013/14). The absolute number of clinically significant isolates has also reduced. These reductions coupled with the reduction of VRE BSIs from the Renal Unit provided added evidence that the measured approach adopted by the Trust in managing the observed increase (in VRE colonisation as well as clinical infections) was correct. This approach ensured that the safety of patients is at the centre of our practice and control has been achieved with measured and prudent use of resources. E coli bacteraemia The reasons for the year on year increase in E coli BSI numbers are not fully understood. The increase is mirrored in national figures. The Trust has contributed to the enhanced E. coli bacteraemia surveillance programme that ran from November 2012-February 2013. The study concluded that there is a strong association of urinary catheters with genitourinary related bacteraemias which suggested that improved primary and acute care of such patients would reduce E. coli bacteraemia incidence. An action plan to bring about a reduction of the number of catheter-associated urinary tract infections (CAUTI) (and the number of unnecessary urinary catheterisation) has been introduced. It includes training, improved urinary catheter packs and the investment of 250,000 to purchase additional bladder scanners to reduce unnecessary catheterisation 4.1.4 MRSA admission screening 13

All emergency and elective patients are screened for MRSA carriage in accordance with DH guidelines. Screening of all admissions became mandatory in March 2011. The table below shows the numbers of MRSA screens for 2013/14. MRSA Screens Elective Emergency Total 15,471 30,308 Positive 88 339 Percentage 0.6% 1.1% The Trust has achieved 100% compliance for Elective screening. Emergency screening has proved more challenging with an improvement during the year to achieve 90.94% compliance. Challenges have been posed by the increase in activity within the Emergency Department (ED) which has seen an annual increase in patients admitted to the hospital via the ED of 3.6% on the previous year (1,150 patients). Progress is constantly reviewed with refreshed initiatives. 4.2 Incidents related to infections (including outbreaks): 4.2.1 Norovirus Outbreaks: Norovirus is a highly contagious pathogen responsible for outbreaks in the community (e.g., schools, cruise ships, residential homes, etc.). Norovirus outbreaks occurring in hospitals are normally acquired as a result of increased activity in the community and the admission of a symptomatic patient from the community. Nationally, Norovirus activity has been low in 2013/14. PHE observed that reports of outbreaks of diarrhoea and vomiting in hospitals continue to be reported but at lower levels than in previous years. (PHE Graph) 14

During the past two years the Trust has seen a reduction in the number of Norovirus outbreaks. We had 6 confirmed outbreaks (with two additional outbreaks with no laboratory confirmation) for the 2013/14 season, compared to 9 for the 2012/13 season and 15 in 2011/12. It is believed that the deep clean programme and public awareness which includes public pop up banners stating periods of high activity in the community and advising the public not to visit unless essential, a telephone message via switchboard at time of outbreaks and public notice board displays in main hospital corridors may have played a role in this reduction. Table of the Trust laboratory confirmed Norovirus outbreaks 2013-14 Ward Patients affected Staff affected Outbreak dates Laboratory confirmed (positives/total submitted) SSU 10 4 May 2013 3:8 MAU 13 0 May 2013 1:4 Barley 8 2 May 2013 3:3 Pirton 13 6 May 2013 5:6 9BS 5 1 May 2013 2:2 SSU 7 6 December 2013 1:4 Furthermore, the PHE regional unit has provided the Trust (and other local healthcare providers) with bi-weekly updates on outbreaks in residential and nursing homes which are routinely circulated to all wards and the Emergency Department thus staff could identify in advance patients attending ED who may be symptomatic with Norovirus. In addition, regular reports of the number of positive samples from our region were monitored and email alerts were issued when a significant increase in the number of positive samples was observed. These alerts helped to inform staff of local Norovirus activity and, in turn, maintain awareness and vigilance in looking out for patients presenting with diarrhoea and vomiting on admission leading to prompt isolation as required. 4.2.2 Influenza: Looking at the national and regional pictures, data from Health Protection England shows that influenza activity has been low over the last three years. This is reflected in our local data from East and North Hertfordshire NHS Trust as presented in the table below which compares rates for the 2013/14 season with previous years: 2010/11 2011/12 2012/13 2013/14 Influenza A (H1 Swine) 24 0 1 1 Influenza A (H1 Seasonal) 0 0 0 0 Influenza A (H3 Seasonal) 1 0 3 0 Influenza B 7 2 1 0 Flu virus not isolated 57 38 51 42 Total requests 89 40 56 43 15

Despite maintaining a high degree of vigilance and an active testing strategy there have been relatively few cases of flu at East and North Hertfordshire NHS Trust. No seasonal influenza of strain type A (H3) or influenza type B were detected and there has been only a single case of Swine Influenza A (H1N1) detected. 4.2.3 Carbapenem-resistant bacteria: Carbapenems (such as Meropenem) are a powerful group of broad-spectrum antibiotics which are often the last effective defense against multi-resistant bacteria. Infections with Carbapenem-resistant enterobacteria are an emerging threat. It is seen mainly in the Indian subcontinent but has also been reported in the Mid-East, North Africa, Europe and the USA. In this country, less than 100 cases have been identified by the Health Protection Agency (now PHE) with bacteria that are Carbapenem-resistant. Many have been associated with patients who have received prior treatment abroad, in India or Pakistan, but there are reports of a few incidents of cross infection in the UK. In December 2013, PHE issued the Acute trust toolkit for the early detection, management and control of Carbapenemase-Producing Enterobacteriaceae (CPE). The toolkit requires that the Trust should have a dedicated preprepared plan to prevent the spread of CPE. The toolkit required that certain measures relating to screening, identifying, isolating and managing suspected or confirmed cases are in place by the end of June 2014. The Trust is fully compliant with the toolkit. 4.2.4 Surgical site infection It is a mandatory requirement to conduct surveillance of orthopaedic surgical site infections using the Surgical Site Infection Surveillance Service of Public Health England. The minimum requirement is for a 3 month module of surveillance of one of the Orthopaedic options: Open reduction of long bone fracture Total Hip Replacement (THR) Total Knee Replacement (TKR) Repair Neck of Femur Fracture (RNoF) In 2011/12 the trust received notification from the Surgical Site Surveillance Unit that the current SSI rates were above the national average as reported in the annual report last year. In response to this, Root Cause Analysis meetings were initiated to examine all cases of surgical site infection following orthopaedic surgery. Cases were systematically examined by the multidisciplinary team. This has resulted in a robust action plan which ran throughout the year. A second stage plan commenced in January 2013 for the calendar year. The focus was initially nursing activity on the ward which included reassessment of all nursing staff in aseptic technique, focus on the timing of dressing removal by clinicians, antimicrobial prophylaxis by 16

anaesthetists, intra-operative and post operative normothermia management and improved documentation. Surveillance data was submitted in all three categories for quarters 2, 3 & 4 of 2013. Whilst a slight improvement was seen, the total annual rate of infection remained above the national average. It is hoped that with the continued implementation of the third stage plan, a continued decrease will be seen over the coming year. Active surveillance will continue. Progress is reflected in the graphs below. 17

SSI Incidence 2012-13 12.00% 10.00% 8.00% I n c i d e n c e 6.00% 4.00% April-Dec 2012 Jan-Sept 2013 2.00% 0.00% Hip prothesis Knee prosthesis RNoF Operation 18

5 Criterion 2: Clean and appropriate environment 5.1 Environmental Cleaning 5.1.1 Cleaning Services The majority of services are managed by an external company G4S for Lister, QEII and Hertford County hospitals. Since January 2014, services at Mount Vernon Cancer Centre are provided in house by the Hillingdon Hospital Foundation Trust. The cleaning services in the satellite renal dialysis units were managed through SLAs with the respective Trusts that they are located in. The Bedford Unit is managed by an external company named Cleaning Matters. 5.1.2 Deep Clean Programme The Trust continues with the Annual Deep Clean Programme commenced in 2008. This programme is managed by the Assistant DIPC on behalf of the IPC Team and aims to cover all in patient wards. This year the programme extended to outpatient departments on three sites as bed pressures were challenging and access to all wards was not possible. We continue to use steam cleaners and chlorine releasing disinfectants. Following cleaning and disinfection all areas are fogged with hydrogen peroxide to provide high level disinfection. 5.1.3 Monitoring arrangements Dedicated monitoring officers undertake and record technical monitoring on a weekly basis as required by the National Specification. The monitoring of waste streams is also included in their audits. Additional focused monitoring takes place in liaison with the IPC team. Ward Sisters/Charge Nurses, Matrons and Divisional Nurses undertake the biweekly cleaning/environmental audit in their clinical areas. Failure to achieve 95% compliance with the cleaning audit results in a written action plan which is followed up by the Assistant DIPC and discussed at monthly Divisional IPC meetings. The Trust Facilities Manager and Assistant DIPC meet monthly with the contract Manager for the G4S contactor with the external G4S Manager to discuss monitoring standards and the impact of the Our changing hospital programme and Deep Clean programme. 5.2 Environmental Monitoring 5.2.1 Water Safety Group East and North Hertfordshire NHS Trust accept its responsibility under the Health and Safety at Work Act 1974 and the Control of Substances Hazardous to Health Regulation 2002 (as amended), to take all reasonable 19

precautions to prevent or control the harmful effects of contaminated water to residents, patients, visitors, staff and other persons working at or using its premises. During March 2013 the Department of Health issued an Addendum to the current HTM 04-01 Pseudomonas aeruginosa advice for augmented care units. Following this advice the Legionella Steering Group Committee & the Pseudomonas Risk Assessment & Management (PRAM) Group were amalgamated to create a Water Safety Group (WSG). The WSG meets quarterly, chaired by the ICD and is attended by representatives from Estates, Infection Prevention and Control (IPC), Capital Projects, External Water Safety Consultants (Hydrop) and Pharmacy (QC). The WSG Policy & Plan documents are reviewed by the WSG and ratified by the TIPCC. The Trust s appointed Water Safety Consultants undertake two yearly water risk assessments advising and identifying any control measures that need to be established. The WSG is supported by the Quality Control (QC) Department. The QC team is responsible for testing water samples for total viable counts (TVC) and for Pseudomonas aeroginosa. These tests are carried out at Trust sites, including renal satellite units. The QC team also reports on rinse water samples from the Endoscopy Washer disinfectors. When higher than desirable counts have been obtained the QC team alerted the WSG and contributed to the development of remedial actions and follow-up sampling. On 8/10/2013, the Harlow Renal Dialysis Unit staffs were informed that water samples taken from the unit were positive for Legionella species. The Harlow RDU was opened to patients in April 2013. The unit is based at the Princess Alexandra Hospital site in Harlow. It was built and managed by a private partner (Diaverum UK) and is run by the renal team of the Trust. An action plan (that included fitting filters to positive outlets) was developed and implemented. Clinical review of all patients attending the RDU revealed no cases of Legionnaire s disease. Two joint meetings between officers from the two trusts were held onsite, supported by local and national public health experts. The Risk Assessment (RA) investigation, carried out by Hydrop (the Trust external consultants), revealed that the softened hot water supply to the unit might have been at suboptimal temperatures before the incident (which might have provided optimal condition for the Legionella bacteria to grow). Subsequent increase of the system s temperature might have resulted in releasing debris into the water supply. Build-up of debris at the outlets (for example on the strainers) provided nutrients for the growth of the Legionella bacteria at the outlets which meant that water samples taken from affected outlets were positive for Legionella even after local disinfection treatment of the outlets. Following the RA, all strainers were removed and cleaned and the system chlorinated. A new strict flushing regime was introduced with recording of the data on a new detailed form. 20

The Legionella isolated from the water samples was identified as L anisa, an environmental species not capable of causing legionnaire s disease but it can act as an indicator of the failure of the Legionella Control Measures in the system. This incident has been managed in an open and collaborative manner between the two trusts. As a result of this collaboration, new measures were introduced (such as the modified flushing forms, the temperature monitoring protocol, and the establishment of clear lines of communication between the Water Safety Groups in both Trusts). These measures will ensure that the chance of similar incidences happening in the future is greatly reduced. 6. Criterion 3 & 4: Information on infections to service users and their visitors & information on infections to other providers In addition to the public pop banners used to inform the public of increased incidence of the winter vomiting bug Norovirus and a separate banner for notification of an actual outbreak the Trust continues to use the switchboard as a mechanism for informing the public of infection outbreaks, should they occur. A pre-recorded message is used at time of outbreaks and removed once they are over. Infection Prevention & Control information leaflets are available on the Trust website for the patients and public to access. Printed copies are available for patients identified with infections at ward level. Washable information labels have been placed on all in-patient lockers and dialysis trolleys informing the public of the importance of hand hygiene whilst in the hospitals and drop down signage has been mounted from the ceilings in long corridors informing the public of gel dispensers at the entrances to departments and asking for their cooperation in using the gel dispensers. 7. Criterion 5: Identification and prompt management of infection The ICD and the consultant microbiologists provide advice on the prompt diagnosis and treatment of infections, including the appropriate use of antibiotics. Close working relationship are also in place to facilitate the reporting of infections of public health significance to the local Public Health England (PHE) Unit. In addition, the ICD works closely with PHE in the management of infection-related serious incidents in the hospital, such as Norovirus outbreaks and open TB cases. The IPCNs also liaise with their Public Health nursing colleagues in respect of infection control incidents such as TB cases and gastrointestinal outbreaks. During 2013/14, the ICD contributed to a number of PHE surveillance programmes, including Carbapenemase-Producing Enterobacteriaceae enhanced surveillance and surveillance of Influenza-related ITU-admissions. During the last year the Antimicrobial Stewardship agenda has continued to promote the Trust s ongoing commitment in ensuring the evidence-based prudent use of antibiotics. The following approaches are employed: 21

1. Policies and guidelines on the use of antibiotics in adults, children and neonates and on the use of antifungal agents are available to all Trust s prescribers on the Knowledge Centre. These policies and guidelines have been reviewed and/or updated during this last year. 2. Clinical audit has enabled adherence to various aspect of Trusts policies and guidelines to be assessed. These audits include an annual point prevalence audit, which is concerned with the extent of prescribing in the Trust and a stop policy audit which is concerned with the adherence to the antimicrobial stop policy. 3. There is a rolling programme of education and training for clinical staff to ensure that the antimicrobial stewardship agenda is embedded in everyday clinical practice in the Trust. 4. The introduction of an antibiotic app for all prescribers in the Trust to download onto smart phones and tablets. 8. Criterion 6: Involvement of all staff The IPCT works closely with all Trust staff to implement good practice and reduce HCAIs. The IPCT is an integral part of Trust induction for all new staff, with presentations on both Infection Prevention and Antimicrobial Stewardship. IPC updates are included in the statutory training programme. In addition, a number of educational activities have been developed: o Monthly mail shots to all clinicians discussing topical IPC related issues in the Trust (until July 2013). o A report by the ICD is now an integral part of the Learning Points issued monthly to all Clinical Directors for discussion at the specialities monthly meetings. o The IPC team has presented information on screen savers displayed on Trust wide computers at varying intervals throughout 2013/14, highlighting key IPC issues. For example one screen saver was dedicated to Clostridium difficile while another was dedicated to the High Risk alerts in Pathology Test Requesting o system. The IPCNs have developed a monthly mail shot to all staff called Quick Pics which highlights news and hot topics relating to infection prevention & control.. 9. Criterion 7: Isolation facilities The Trust has a dedicated isolation ward with 14 beds (3X 4 bedded bays with doors and 2 side rooms). The number of side rooms available across the Trust is approximately 50 (some with en-suite facilities). This number has varied with the reconfiguration of the wards. It is important to note that in the maternity unit all rooms are single rooms (with en-suite facilities). During 2013/14, the use of the isolation ward has proved challenging due to the reduced number of patients requiring isolation for Clostridium difficile. The 22

bays are therefore used flexibly to admit other patients requiring isolation for other infections and general medical patients. Some cases required specialist care and were nursed in isolation in the Renal and the Criitical Care Units. The isolation ward is deemed essential to maintaining the low numbers of infection across the trust involving a range of microorganisms and their accompanying clinical infections and the Trust is committed to maintaining this facility. 10. Criterion 8: Laboratory support Since 2006 the Microbiology Department has undergone a process of evolution which has led to the restructuring of the workflows within the department and the introduction of automation to the department. The cumulative effect of this has been to increase productivity by 160% with a 17% decrease in staff numbers. The in house cost per test has similarly reduced from 9.26 in 2006 to 6.63 in 2012. The Trust normally employs 3 substantive consultant microbiologists but since September 2013 the Microbiology service has been delivered by two consultants with support from one locum consultant. This is due to the sad loss of one of the consultants in a tragic road traffic accident. This has meant that some of the services led by the consultants were affected. This included less support for the SSI programme and for the Influenza preparedness subcommittee; two tasks that were carried out by the late Deputy ICD. A third substantive consultant has now been recruited. Despite the disruption to consultant staff, coupled with the transfer of the Pathology service to TPP, the department has maintained and developed the microbiology service. The Laboratory is fully accredited by Clinical Pathology Accreditation. Furthermore, the laboratory was able to handle a number of requests for changes in practice in 2013/14 from the infection control service (e.g., to support added screening for VRE in the Renal Unit). 11. Criterion 9: Policies All policies required for compliance with the Hygiene Code are in place and audited through the Annual Plan (see Appendix 1). The results of audits are shared and discussed at Divisional level and any remedial actions required are addressed through a written plan of action which is followed up and signed off when completed through the divisional meetings by the. Support is given to the clinical areas to adhere to policies by the IPCT. The IPC policies are written by the IPC team members with support from other trust staff with expertise in the relevant areas. Some policies are written by other teams in the trust with relevant experience with approval of the IPC team. These policies are all listed under the IPC policies and guidelines on the Knowledge Centre (KC). 23

12. Criterion 10: Health care workers: Infection Status, protection from infection & education in infection prevention & control In 2013/14, the Occupational Health Department has worked closely with the IPC team to ensure that staff are protected against infection. The department has been fully involved in IPC related incidents that affect staff health, such as Norovirus outbreaks, needle-stick injuries and staff exposure to rash illness in patients including chicken pox, and skin integrity in relation to use of hand hygiene products. The department has also been responsible for the flu immunisation programme and ran an annual campaign with the training and utilization of flu champions around the Trust to vaccinate in the work place as well as scheduled clinics in Occupational Health. It involved significant promotion with information disseminated through a number of sources. Senior team members were surveyed and volunteers (flu champions) were requested to help promote the flu campaign. The uptake of the vaccine by frontline staff has increased on last years figures from 35.7% to 52.0%. Staff group Number of frontline staff in Trust % vaccinated end of 2012/13 Campaign % vaccinated 10 th February 2014 Dr 692 33% 47.3% Nurse, Midwives, 1680 33.6% 44.9% Health visitors Allied Healthcare 585 21.6 34.7% professionals Support staff 1020 48.5% 76.7% Total 3977 35.7% 52.0% The OH team are continuing with the skin surveillance programme and are developing a robust reporting plan for the immunisation status of staff against communicable diseases. 13. CQC visits There have been no CQC visits to the Trust specifically in relation to infection prevention in 2013/14. The improved performance in all IPC issues over the past year and the future maintenance of this high standard will ensure that the Trust continues to be compliant with the Health and Social Care Act 2008: Code of Practice (Hygiene Code), and is fully accredited by the CQC. 14. Trust Development Authority visits The NHS Trust Development Authority (TDA) was formed in 2013 and is responsible for providing leadership and support to the non-foundation Trust sector of NHS providers. The key functions of the TDA include monitoring performance and providing support, this includes clinical quality, governance and risk. 24

The TDA visited the Lister and QEII hospitals on 23/24 th September 2013 to review how the trust managed cases of Clostridium difficile in particular. The outcome of the visit was very positive, the Trust was found to be compliant with the Hygiene Code with no concerns. Dr Debra Adams, Head of Infection Prevention and Control (Midlands and East) at the TDA, stated that she was very pleased and commented on how the staff were professional and were able to discuss how the healthcare associated infection (HCAI) strategy affected their practice. Every staff member approached was proud to work in the organisation. The Trust demonstrates good clinical involvement and effective HCAI communication strategies throughout the Trust. 15. CCG visits The CCG have made a number of regular visits to the Trust throughout the year working collaboratively with the Trust IPCT and their own IPC nursing lead. The Trust partakes in a Whole Health Economy meeting and working group to reduce Clostridium difficile numbers particularly in the community. The CCG IPC Lead is also a member of the Trust Infection Prevention & Control Committee. 16. Independent External Reviews In 2013/14, the Trust was notified of a whistleblowing concern raised with the DH in relation to the Clostridium difficile testing policy. An external microbiology consultant and infection control doctor in collaboration with the Head of Infection Control at the East & North Herts and the Herts Valleys Clinical Commissioning Groups undertook a comprehensive review of the Trust policies and procedures, including implementation at the ward level by Trust staff. The Trust policy was found to be fully compliant with national guidance. A small number of recommendations were made which included: 1. Documentation of the reasons for a decision not to carry out C difficile testing on a patient should be readily available to all relevant staff involved in the care of a patient. This includes documentation in the main patient medical record. 2. The Trust should consider how messages for staff in relation to the rationale for differences in approach to testing before and after 72 hours from admission can be delivered and also incorporated into policies. 3. The Trust should consider processes for providing assurance that the national requirement to isolate patients with diarrhoea within 2 hours is complied with. 4. The audit of patients who had had C. difficile testing declined should be repeated, with identification of outcomes for patients assessed as not fulfilling the criteria for C difficile testing, including any delays in diagnosis or treatment. Data showing what proportion of samples rejected for C difficile testing are community samples, samples taken from inpatients in the first 72 hours of 25