CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Report of: Gill Heaton, Chief Nurse and Director of Infection Prevention and Control (DIPC) Paper prepared by: Julie Cawthorne, Consultant Nurse, Infection Prevention and Control (IPC) Date of paper: April 2015 Subject: Annual Infection Prevention and Control Report 2014/15 Indicate which by Information to note Purpose of Report: Support Resolution Approval Consideration of Risk against Key Priorities: (Impact of report on key priorities and risks to give assurance to the Board that its decisions are effectively delivering the Trust s strategy in a risk aware manner) 1. Patient Safety 2. Patient experience 3. Productivity and Efficiency Recommendations: The Board of Directors are asked to receive this report for April 2014 to March 2015 and approve for publication. Contact: Julie Cawthorne, Consultant Nurse IPC 0161 276 4042 1 P age

Report of: Paper prepared by: Date of paper: April 2015 Director of Infection Prevention and Control (DIPC) Consultant Nurse, Infection Prevention and Control Subject: Annual Infection Prevention and Control Report 2014/15 Purpose of paper: 1. Introduction To inform the Board of the Infection Prevention and Control performance for the year 2014/15 The Board are asked to receive the Infection Prevention and Control Annual Report for 2014/15. 2. Executive Summary 2.1 The Trust has a consistent and proven track record with regard to the Infection Prevention and Control especially with regard to performance against the Healthcare Acquired Infections (HCAI) objectives. We consider it unacceptable for a patient to acquire an avoidable HCAI while receiving care in any of our healthcare settings; our priority is always to keep patients safe in our care. 2.2 During 2014/2015 we have faced a major challenge in managing and reducing the incidence of Carbapenemase Producing Enterobacteriaceae (CPE). We have taken advice from international experts and liaised with national and local Public Health England (PHE) teams to address the situation and are pleased to report that; the evidence from our enhanced screening programme combined with the use of cohort/isolation facilities would suggest that we have made progress towards more effective management and control of the situation. 2.3 Although the management and control of CPE has been challenging, we have consistently maintained our excellent track record with regard to the HCAI performance objectives. Since the objective for Meticillin Resistance Staphylococcus aureus (MRSA) bacteraemia was first introduced in 2005/6 we have achieved an 89% reduction in the number of attributable incidents of MRSA bacteraemia. The objective for Clostridium difficile infection (CDI) was introduced in 2007/8, since then we have achieved a 73% reduction in the number of incidents of CDI. This year we reported 75 incidents of attributable CDI, a reduction of 3.8% from last year s position. There were seven incidents of MRSA bacteraemia attributed to the Trust of which five were determined to be avoidable. 2.4 2014 saw the largest global epidemic of Ebola Virus Disease (EVD) in history. PHE recommended that all hospitals with acute receiving units should be prepared for EVD in travellers and returning healthcare workers from high-risk areas. The Infection Prevention Control (IPC) Team facilitated preparations to manage suspected cases of EVD across the Trust in five high risk receiving units. 2.5 There were 13 occasions when wards were closed or partially closed due to outbreaks of diarrhoea and vomiting during 2014/2015 resulting in a total of 1,089 bed days lost. In comparison there were 10 outbreaks of CPE resulting in full or partial ward closures, with a total of 3,263 bed days lost. This is the first time that the Trust has reported CPE as a major cause of ward closures in the Annual Report. 1 P age

3. Key Achievements and Challenges 3.1 In October Dr Mitchell Schwaber, Director of National Centre for Infection Control of the Israel Ministry of Health, visited the Trust to share with us the practices implemented to manage CPE across Israel, where they have had a national multicentre outbreak of CPE. It was encouraging to discover that many of the interventions which proved successful in Israel were already being implemented at CMFT. 3.2 Between September and November 2014 a Point Prevalence Survey (PPS) was undertaken across Manchester Royal Infirmary and Royal Manchester Children s Hospital. The aim of the PPS was to establish a baseline of previously unidentified patients in the Trust who are colonised with CPE. 926 in-patients were included in the screen of which 35 (3.8%) were identified as positive. Of the 35 positive new cases, 28 were the same type of CPE associated with the outbreaks at CMFT. Seven cases (25%) were of different types of CPE that have not been associated with the CMFT outbreak, but may be regarded as an important, although incidental finding. 3.3 The Trust was actively involved with the national and regional incident management teams for CPE and progress on the management of CPE at CMFT was reported locally and nationally. There is evidence of an increasing incidence of CPE being reported, particularly from across the Greater Manchester area. Other local trusts are seeking support to develop their action plans based on the model used here at CMFT. 3.4 The knowledge and experience of the Trust Infection Prevention and Control Team in the management and control of CPE was shared at a number of National conferences through presentations and scientific posters. 3.5 In October 2014, a Trust-wide EVD Action Group was established led by the IPC Team, to monitor Trust preparations for Ebola, with representation from clinical areas and appropriate Trust specialist advisors. This was an extensive undertaking across the Trust and a Matron from Surgery who has previous IPC experience was seconded to the IPC Team for a period of 2 months from October to December 2014 to support the preparations. 3.6 The annual Patient Led Assessments of the Care Environment (PLACE Assessments) were carried out between 28th February 2014 and 6th May 2014. Across the Central and Trafford sites the assessors visited 25 wards, nine outpatient departments, seven emergency departments, four organisational departments, one mental health and two external areas, and carried out nine food assessments. Scores ranged from 83.7% to 97.5%. 3.7 The Trust began surveillance of paediatric spinal surgery in the Children s Hospital in October 2013. Public Health England identified the Trust was a high outlier for this type of infection in January 2015. A review of the clinical practice and a case note review of the Surgical Site Infections (SSI) were undertaken in February 2015. The findings were discussed with the clinicians. As a direct result, practice has changed. Surgeons have implemented the use of alternative implants that reduce the need for subsequent invasive surgical procedures. This has proven to be beneficial to the individual patient and also released time in the operating theatre schedule for other surgical procedures. 2 P age

3.8 CMFT have met the target for vaccinating front line staff with a coverage score of 75.2% for the Trust. The programme was co-ordinated and developed by a multidisciplinary planning group consisting of members from the IPC Team, Occupational Health, Pharmacy, Communications, and Senior Nurses from all parts of the organisation. 3.9 Environmental decontamination with Hydrogen Peroxide Vapour (HPV) was used in several ward areas during the year through an ad hoc managed service. The advantage of using HPV is that it kills more micro-organisms and is more consistent than manual cleaning alone. Further to the success of using HPV the IPC and Facilities Teams have procured three machines to be used on site across the Adult Divisions and are working with Hygiene Solutions to establish a programme of decontamination. This has reduced the cost and ensured we had quick access to the HPV decontamination service. 3.10 The Infection Prevention and Control Team led a project to improve the surveillance of Catheter Associated Urinary Tract Infection (CAUTI). Enhanced CAUTI Surveillance at CMFT began in August 2014. A database was created and administered by the IPC team which is regularly updated by Divisional Assessors. This process has greatly improved the Trust s ability to identify and validate incidents of CAUTI. 3.11 An innovative opportunity arose for the Trust to collaborate with a commercial company, who have developed a process to continually measure hand hygiene compliance in clinical areas using an electronic monitoring system. Preliminary work was completed and the next stage of the study commences in April 2015. 3.12 There is national evidence to support the use of Peripherally Inserted Central Catheters (PICCs) for medium term (6 weeks to 6 months) intravascular access, particularly in adults and children requiring antimicrobial treatment, chemotherapy and parenteral nutrition. The benefits of extending the use of PICC lines for patients at CMFT include; less risk of infection and the ability to provide intravenous therapy for antimicrobial treatment in the community setting. Until recently service provision was limited to patients in Gastroenterology and Haematology however; plans are in progress, to extend the use of PICC lines across the Trust through provision of a central service for line insertion, supported by appropriate policy, training and equipment. 3.13 In addition to mandatory training, the Infection Prevention and Control Team delivered training to a broad range of staff including Medical Students, Consultants, Nurses, Domestics and Allied Healthcare Professionals on a variety of prevention of infection topics. In conjunction with Human Resources (HR) the IPC team were also able to provide training for cadets and those undertaking healthcare apprenticeships. In total, 198 training sessions were delivered by the IPC Team to 2103 members of staff. 3.14 The IPC audit programme included: compliance against usage of the Infectious Diarrhoea Integrated Care Pathway (ICP) and Meticillin resistant Staphylococcus aureus ICP. As previous audits illustrated, the severity markers are the most poorly documented on the Infectious Diarrhoea ICP this is partly due to the complexity of having both electronic and paper records. 3 P age

Compliance in the documentation of screening results from Meticillin resistant Staphylococcus aureus ICP has risen by 12% to 37% therefore this will remain a focus for further improvement. The prescribing of decolonisation treatment achieved 76% compliance. All audit results were distributed to the Heads of Nursing in each Division with a request to develop and implement action plans which form the basis of Divisional work programmes for 2015/2016. 3.15 In order to provide assurance that due process is being followed in determining the reported figures of hospital acquired infections as a result of lapse of care, an internal audit of our reporting processes was undertaken by the Mersey Internal Audit Agency in March of 2015. The draft report indicated a significant level of assurance. 3.16 Whilst there is no national UK standard for blood culture contamination rates, the consensus is that rates should be below 3%, aiming for zero. Good compliance with the protocol for taking blood cultures minimises contamination rates. This year the average rate of all peripheral blood culture contamination was 2.2% compared to a rate of 11.5% in 2005/2006. 4. Recommendations 4.1 The Board of Directors are asked to receive the Annual Report, note the work of the Infection Prevention and Control Team and Trust staff in the management, control and prevention of infection and agree to the publication of the report on the Trust website. Julie Cawthorne Consultant Nurse IPC Central Manchester University Hospitals NHS Foundation Trust April 2015 4 P age

INFECTION PREVENTION and CONTROL ANNUAL REPORT 2014 / 2015 Author: Julie Cawthorne Consultant Nurse, Infection Prevention and Control 5 P age

CONTENTS PAGE Executive Summary 1 Infection Prevention & Control Arrangements 7 Budget Allocation to Infection Prevention & Control Activities 9 Surveillance of Healthcare Associated Infections 9 The Management of Carbapenemase Producing Enterobacteriaceae (CPE) Preparations to Receive a Patient with Suspected Ebola Virus Disease (EVD) 22 Maintaining a Clean Environment 22 Developments in Clinical Practice 25 Training and Education 26 Audit 29 Conclusion 37 Recommendations 38 APPENDICES 1a: Infection Prevention & Control/Tissue Viability Nursing Structure 39 1b: Framework for IPC committee/group structure 40 2: Infection Prevention & Control Committee Terms of Reference 41 3: IPC Annual Plan 2014-2015 43 6 P age

1. Infection prevention and control arrangements 1.1 The Director of Infection Prevention and Control (DIPC) Mrs Gill Heaton, Chief Nurse, was designated to this post in 2006. The Infection Control Committee reported to the Trust Clinical Effectiveness Committee and directly to the Board through the DIPC. 1.2 The Infection Prevention and Control (IPC) Team From April 2012 the Infection Prevention and Control and Tissue Viability (TV) nursing teams were integrated under one management structure within the Division of Clinical and Scientific Services Division. An organisational chart demonstrating the full structure of the integrated IPC/TV nursing team can be found in Appendix 1. The members of the IPC team can be found below (whole-time equivalent (WTE) unless otherwise stated). Dr Andrew Dodgson Infection Prevention & Control Doctor (IPCD). Mrs Julie Cawthorne, Consultant Nurse, Infection Prevention & Control. Miss Janice Streets, Matron, Infection Prevention & Control. 1.3 Senior IPC Nurse Specialists 1.4 In Addition Mrs Michelle Worsley, IPC/TV Nurse Specialist. (Promotion to Matron in Surgery from October 2014) Mrs Jane Doyle, IPC/TV Nurse Specialist (left for promotion in another organisation January 2015) Mrs Susan Jones, (0.8 WTE) IPC/TV Nurse Specialist. Mrs Karen Mathieson, IPC/TV Nurse Specialist (promoted from junior to senior specialist nurse, October 2014) Mrs Julie Parker, IPC/TV Nurse Specialist (joined the Trust in January 2015). The senior specialist nursing team were supported by a team of junior specialist nurses, who rotated between Infection Prevention and Control and Tissue Viability every six months. 1.5 Administration Support for Infection Prevention and Control Services Team Dr Ryan George, Healthcare Associated Infection (HCAI) Surveillance Officer Mr John Grimshaw, HCAI Support Officer (0.75 WTE) Ms. Debbie Dunning, Personal Assistant and Team Secretary (until December 2014) The team provided 24 hour advice and support on IPC issues to the staff and patients of the Trust including an out of hours telephone on-call service by the IPC nursing team. 1.6 The Trust Infection Control Committee (ICC) The Infection Control Committee (ICC) had corporate responsibility for overseeing the implementation of infection prevention and control activities across the Trust. In order to provide more emphasis on addressing our key organisational goals the terms of reference including the membership of the Trust ICC was reviewed and refreshed in April 2014. 7 P age

The ICC met six times during the year and was chaired by the DIPC. A key change to the membership was that each clinical division was asked to provide a clinical lead for IPC, to drive the infection prevention and control agenda and had the authority to influence practice within their division. The Terms of Reference for the ICC for April 2014 March 2015 can be found in Appendix 2. 1.7 Framework for Infection Prevention and Control (IPC) The Trust Strategy for IPC defined the structure and activities of IPC within the Trust. It was reviewed and ratified by the Trust ICC in January 2015. 1.8 IPC Annual Plan April 2014 March 2015 We achieved compliance with 82.5% of the objectives in the IPC Annual Plan for 2014/15, (please see Appendix 3). The highest area of non compliance was updating of policies. This was due to the need to concentrate resources on reducing the incidence of CPE. Action has been taken to ensure that all outstanding policies will be ratified at the Infection Control Committee meeting in May 2015. 1.9 Reporting Structure The Infection Control Committee reported to the Trust Clinical Effectiveness Committee and directly to the Board through the DIPC. 1.10 Infection Prevention and Control Structure within the Divisions Clinical Divisions addressed Infection Prevention and Control issues at a local level either as a standing item on the Divisional Clinical Governance meeting or through a separate Divisional Infection Prevention and Control Committee/Group. 1.11 The Infection Prevention and Control Weekly Review Meetings Following the establishment of the CPE Incident Management Team meetings on alternate Wednesdays, (see Section Five), the weekly performance review meetings were streamlined by the DIPC in September 2014. It was agreed that the following cases were presented at the corporate meetings; An incident of Clostridium difficile infection where a ward had entered into a period of increased incidence. An incident of Clostridium difficile infection where the division had established it was due to a lapse in care. An incident of carbapenemase producing Enterobacteriaceae or Meticillin resistant Staphylococcus aureus bacteraemia. All other incidents of infection were reviewed at the performance management meetings held within the divisions. 1.12 External Audit of Process for Reporting Incidents of Clostridium difficile Infection In order to provide assurance that due process is being followed in determining the reported figures of hospital acquired infections as a result of lapse of care, an internal audit of our reporting processes was undertaken by the Mersey Internal Audit Agency in March of 2015. The draft report indicated a significant level of assurance. 8 P age

1.13 External Review of the Incidence of Carbapenemaese Producing Enterobacteriaceae (CPE) The Trust liaised with Public Health England at a local and national level with regard to the on-going issues associated with CPE. In July 2014 senior representatives from the Regional Public Health England met with the DIPC, Medical Director, Director of Nursing (Adults) and senior members of the IPC Team. The discussion focussed on the concern at a national level in regards to the incidence of CPE within the Trust. It was agreed that the situation at CMFT was not deteriorating but that as the existing control measures were not reversing the trend, it was suggested that more stringent measures should be considered. The DIPC confirmed the immediate implementation of a local Incident team and revised management plan A summary of the Trust s actions and subsequent outcomes to control and reduce the incidence of CPE can be found in Section Five of this report. 2. Budget allocation to infection prevention and control 2.1 Funding for Infection Prevention & Control Services The IPC/TV nursing team provided a trust wide service and funding was provided within the Division of Clinical and Scientific Services. 2.2 Microbiology Laboratory Services Funding for Microbiology services, (including screening for CPE and outbreaks of infection), was covered by the Service Level Agreement between the Trust and Public Health England. Financial support for outbreaks of infection (excluding laboratory costs), were sourced locally by the divisions. 2.3 Electronic Surveillance System Recurrent funding for ICNet (electronic Infection Prevention & Control surveillance database) was met from the Division of Clinical and Scientific Support. The systems for the Central site and Trafford site were merged in April 2014 to stream-line reporting across the Trust. Furthermore, as a result the Trust made an approximate cost saving of 5,000. 3. Surveillance of Healthcare Associated Infections (HCAI) 3.1 HCAI Performance Targets The Trust has had a proven track record with regard to performance against the HCAI objectives and we consider it unacceptable for a patient to acquire an avoidable HCAI while receiving care in our healthcare setting. The Trust progress in reducing the incidents of HCAI from 2007/8 2014/15 is demonstrated below in Fig. 1. 9 P age

Fig 1: Attributable MRSA bacteraemia and C. difficile infections (2007/8-2014/15) *In April 2012 CMFT and Trafford Healthcare Trust merged, data from this point includes cases from the combined organisation. ** Of the 78 cases of CDI infection detailed in 2013/2014, only 54 were determined as clinically significant and thus reportable to PHE. 3.2 Since the objective for MRSA bacteraemia was first introduced in 2005/6 we have achieved an 89% reduction (from 54 to 6) in the number of incidents of attributable 1 MRSA bacteraemia. 3.3 The objective for Clostridium difficile infection was introduced in 2007/8, from when we have achieved a 73% reduction in the number of attributable incidents of Clostridium difficile infection (from 274 to 75). Changes to the reporting strategy during the 2013/2014 reporting year resulted in only clinically-significant cases being reported. However, from April 2014 national guidance advised that all laboratory confirmed cases of CDI must be reported. When all CMFT attributable cases are considered, our current position actually represents a yearon-year reduction of 3.8%. 3.4 The objectives for the year ending March 2015 were; zero incidents of avoidable MRSA bacteraemia and no more than 66 incidents of Clostridium difficile infection where a lapse in care was demonstrated. Meticillin Resistant Staphylococcus aureus (MRSA) Bacteraemia 3.5 The Trust is extremely disappointed to report that there were a total of seven incidents of MRSA bacteraemia apportioned to the Trust this year. Each incident of MRSA bacteraemia was investigated by a multi-disciplinary team using a Root Cause Analysis (RCA) tool and presented to the DIPC at a dedicated meeting. The findings were reviewed and discussed and designated as either avoidable or unavoidable. In total, five of the attributable incidents were agreed to be avoidable. Following each review, detailed action plans were devised and implemented in the relevant areas as appropriate. 1 Attributable is the term used when an infection is considered to have been acquired at the Trust 10 P age

3.6 Reporting of Meticillin Sensitive Staphylococcus aureus (MSSA) and Escherichia coli Bacteraemias Mandatory reporting of all MSSA bacteraemia commenced in January 2011. The Trust reported a total of 117 MSSA bacteraemia to PHE, 53 (45.3%) of these were apportioned to CMFT (i.e. occurred 48 hours or more after admission). E. coli bacteraemia reporting began in June 2011. There were 271 incidents reported to PHE. There is no requirement to identify those attributable to the Trust. However; as an indicator, 125 (46%) cases were identified from specimens collected on or after the third day of admission (specimens taken 48 hours post-admission are used as an indicator for hospital-acquired infection). To date no national target has been set for reducing the incidence of MSSA or E. coli bacteraemia. Clostridium difficile Infection (CDI) 3.7 Mandatory Reporting of CDI The Trust agreed an objective of 66 attributable CDI cases in all patients over the age of two for the year 2014/15. The actual number of attributable incidents reported to Public Health England (PHE) was 75. The distribution of these cases can be seen in Fig. 2 below. The cases of CDI that were attributable are those which occurred on or after day three of admission, where day of admission is day one. Fig 2: Cumulative CDI cases (2014/2015) 3.8 Each case of CDI was systematically reviewed by the IPC team in conjunction with the clinical team. The Trust IPC Team collaborated with the IPC leads at the local CCG to adapt a tool based on national guidance. This tool was used to investigate and determine whether a particular CDI was associated with a lapse in care. 11 P age

The types of issues which resulted in the infection being considered to be associated with a lapse in care were any case where there was evidence of transmission of C. difficile in hospital, where there were breakdowns in cleaning or hand hygiene, or where there were problems identified with choice, duration, or documentation of antibiotic prescribing. 3.9 Following internal and peer review, eight of the 75 attributable cases were considered to demonstrate a lapse in care (five cases from March 2015 are pending review). Only cases determined as demonstrating a lapse in care were counted against the trajectory, in line with national guidance. Vancomycin Resistant Enterococci (VRE) 3.10 The Trust reported all incidents of VRE bacteraemia to PHE. The total number of incidents for the 2014/2015 reporting year date is 11 (see Fig.3). The majority of these incidents occurred on the Paediatric Oncology Unit and the Adult Critical Care Unit. The IPC Team have worked closely with both of these areas to investigate each incident and advised on additional control measures where appropriate. Fig 3: Cumulative VRE Bacteraemia Incidents (2014/2015) Surgical Site Infection (SSI) National Surveillance Scheme 3.11 The Trust participates in mandatory Orthopaedic and voluntary Coronary Artery Bypass Graft (CABG) and paediatric spinal surgery reporting of SSI to PHE using nationally agreed protocols including out-patient follow-up and post discharge questionnaires. 3.12 Orthopaedic Surgical Site Infection (SSI) Rates The Trust is required to submit a minimum of one quarter of data per year to comply with mandatory reporting for orthopaedic implant surgery. Data is submitted for both hip and knee replacement surgery, both on the Central and Trafford site. 3.13 Knee Replacement SSI Rates The results from knee replacement procedures performed at MRI and Trafford General Hospital (TGH) can be found in Fig. 4A and Fig. 4B below. The previous 3 periods for which data is available are included for comparison. 12 P age

The most recent national SSI rate for knee replacement surgery is 1.7% (based on 244,820 national procedures over the previous 5 years). Fig 4a: Trends in MRI SSI rates for knee replacement surgery from 2012-2014 Year and Period No. Operations All SSI* 2012 Q2 30 13.3% 2013 Q1 26 11.5% 2013 Q2 32 6.3% 2014 Q2 9 11.1% *All SSI = Inpatient & readmission, post-discharge confirmed and patient reported This year the surveillance period for MRI was quarter two. One patient which equated to 11.1% developed a wound infection, (patient reported, post discharge), and did not require re-admission. This is higher than the national average (1.7%), however the sample size (9 patients) was too small to be clinically significant. Fig 4b: Trends in TGH SSI rates for knee replacement surgery from 2013-2014 Year and Period No. Operations All SSI* 2013 Q4 64 0.0% 2014 Q1 90 0.0% 2014 Q2 102 1.0% 2014 Q3 92 1.1% *All SSI = Inpatient & readmission, post-discharge confirmed and patient reported The results for TGH are from three quarter periods. Out of a total of 284 knee replacement procedures, two patients (1.1%) developed a wound infection; one of these was determined to be a superficial infection and the other was an organ space infection. This rate of infection is below the national average (1.7%). 3.14 Hip Replacement SSI Rates The results from hip replacement procedures performed at MRI and Trafford General Hospital can be found in Fig. 5A and Fig. 5B below. The previous 3 periods for which data are available are included for comparison. The most recent national SSI rate for hip replacement surgery is 1.2% (based on 233,010 national procedures over the previous 5 years). Fig 5a: Trends in MRI SSI rates for hip replacement surgery from 2013-2014 Year and Period No. Operations All SSI* 2013 Q1 46 4.3% 2013 Q2 25 4.0% 2014 Q2 12 8.3% * All SSI = Inpatient & readmission, post-discharge confirmed and patient reported 13 P age

This year there were a total of 12 patients in quarter two who underwent hip replacement surgery at MRI. One of these patients developed a deep incision wound infection and required additional in-patient care. Fig 5b: Trends in TGH SSI rates for hip replacement surgery from 2013 2014 Year and Period No. Operations All SSI* 2013 Q4 36 0% 2014 Q1 57 0% 2014 Q2 67 0% 2014 Q3 43 0% * All SSI = Inpatient & readmission, post-discharge confirmed and patient reported The results for TGH are for the previous four quarter periods. Out of a total of 203 hip replacement procedures performed no surgical site infections were identified. 3.15 Paediatric Spinal Surgical Site Infection Rates The Trust began surveillance of paediatric spinal surgery in the Children s Hospital in October 2013. Fig 6: Trends in SSI rates for paediatric spinal surgery 2013-2014 Year and Period No. Operations All SSI* 2013 Q4 24 4.2% (1 superficial infection) 2014 Q1 19 5.2% (1 superficial infection) 2014 Q2 21 9.5% (2 superficial infection) 2014 Q3 22 9.1% (2 superficial infection) * All SSI = Inpatient & readmission, post-discharge confirmed and patient reported Data submitted to PHE can be found in Fig. 6 below. The most recent CMFT SSI rate for spinal surgery is 9.1%. The national rate of SSI in this category of surgery for the previous five years is 1.8% (based on 40,972 national procedures). Consideration should be given to the limited sample size of the number of procedures performed at the Children s Hospital. Public Health England identified the Trust as a high outlier for this type of infection in January 2015. A review of the clinical practice and a case note review of the Surgical Site Infections (SSI) was undertaken in February 2015. The findings were discussed with the clinicians. As a result practice has changed. Surgeons have implemented the use of alternative implants that reduce the need for subsequent invasive surgical procedures. This is beneficial to the individual patient and also releases time in the operating theatre schedule for other surgical procedures. Further audits are planned following the changes in practice. 3.16 Coronary Artery Bypass (CABG) Surgery SSI Manchester Heart Centre (MHC) The Trust has participated in voluntary CABG SSI from 2011. The results from the last four quarters submitted to PHE can be found in Fig.7. 14 P age

Fig 7: SSI rates for CABG 2014-2015 Year and Period No. Operations All SSI* 2013 Q1 103 10.7% 2013 Q4 119 5.9% 2014 Q1 97 6.2% 2014 Q2 104 5.8% * All SSI = Inpatient & readmission, post-discharge confirmed and patient reported Following an increase in wound infection rate to a high of 10.7% in the first quarter of 2013, a review of pre-operative, peri-operative and post-operative skin and wound care took place with practice evaluated against NICE Guideline 74: Surgical Wound Infections. MHC was found to be compliant with the guideline. In the subsequent quarters the rate has been reduced to 5.8%. Of these six incidents three patients required further in-patient care and three patients were followed up in the community. 3.17 Influenza Vaccination for Staff CMFT have met the target for vaccinating front line staff with a coverage score of 75.2% for the Trust. The programme was co-ordinated and developed by a multi-disciplinary planning group consisting of members from the Infection Prevention and Control Team, Occupational Health, Pharmacy, Communications, and Senior Nurses from all parts of the organisation 3.18 Outbreaks of Infection Diarrhoea and Vomiting, MRSA and CPE There were 13 occasions when wards were closed or partially closed due to outbreaks of diarrhoea and vomiting during 2014/2015. In addition there was one outbreak of MRSA and 10 outbreaks of CPE resulting in full or partial ward closures. There were 4688 lost bed days in total for 2014/2015. (See Fig.8A-C) Fig 8a: Ward Closures due to Diarrhoea and Vomiting (April 2014 - March 2015) Division Ward Total No. of Beds Closed Date of closure No. of Days Closed No. of Patients Affected Number of Staff Affected Number of Bed Days Lost Trafford Ward 15 18 05/04/2014 2 6 5 36 Trafford Ward T06 32 16/04/2014 6 12 1 192 Spec med AM4 28 30/04/2014 2 1 0 56 Spec med AM3 28 30/04/2014 8 12 1 224 Spec med AM4 4 14/05/2014 5 3 0 20 Trafford Ward T06 4 16/05/2014 3 3 0 12 DMACS Ward 45 8 06/06/2014 3 5 0 24 Surgery Ward 7 10 15/06/2014 3 5 0 30 Spec Med CSITU 6 19/07/2014 2 5 0 12 DMACS Debdale 14 30/10/2014 4 4 0 56 DMACS OMU 19 04/11/2014 7 19 1 133 Spec med Ward 3 18 03/12/2014 7 10 0 126 Spec med Ward 4 28 04/12/2014 6 10 4 168 Total 1089 15 P age

Fig 8b: Ward Closures due to MRSA (April 2014 - March 2015) Total No. No. of No. of Number Number Date of Division Ward of Beds Days Patients of Staff of Bed closure Closed Closed Affected Affected Days Lost Surgery 8 28 16/06/2014 12 8 0 336 Total 336 Between 23rd April and 10 th June 2014 six patients acquired MRSA whilst in-patients on Ward 8. In addition there were two other patients within the division who had links to Ward 8 and a similar history of MRSA. Seven specimens had the same antibiotic biogram with mupirocin resistance noted, (this implied that cross infection may have occurred). The ward was closed to admissions on Monday 16 th June 2014, and control measures instigated. The progress of the outbreak was closely monitored and the ward re-opened on Saturday 28 th June 2014 as no new cases had been identified from two consecutive MRSA screens. Fig 8c: Ward Closures due to CPE (April 2014 - March 2015) Division Ward Total No. of Beds Closed Date of closure No. of Days Closed No. of Patient s Affecte d Number of Staff Affected Number of Bed Days Lost DMACS 14 20 23/07/2014 13 16 0 260 Trafford 4 31 31/07/2014 3 2 0 93 Trafford 15 18 31/07/2014 27 7 0 486 Trafford 16 18 04/08/2014 10 1 0 180 Spec med 44 22 09/10/2014 18 13 0 396 Spec med Ward 3 28 06/01/2015 12 9 0 336 Spec med Ward 4 28 06/01/2015 17 9 0 476 DMACS AM2 28 16/01/2015 5 5 0 140 Spec Med Ward AM4 28 26/02/2015 15 7 0 420 Spec Med Ward 3 28 11/03/2015 17 9 0 476 Total 3263 As part of the action plan to reduce the incidence of CPE within the Trust, it was necessary to close wards to prevent on-going transmission. This is the first time that the Trust has reported CPE as a major cause of ward closures in the Annual Report. Please see Section Five for further information about the management of carbapenemase producing Enterobacteriaceae. 16 P age

3.19 Enhanced Catheter Associated Urinary Tract Infection (CAUTI) Surveillance at CMFT The need to strengthen the process for monitoring the incidence of Catheter Associated Urinary Tract Infection (CAUTI) was identified in August 2014. The Infection Prevention and Control Team led a project to improve the surveillance of CAUTI. Definitions and criteria were agreed based on those recommended by the Scottish Surveillance of Healthcare Associated Infection Programme. Enhanced CAUTI Surveillance at CMFT began on Monday 4th August 2014. A database was created and administered by the IPC team which is regularly updated by Divisional Assessors. When a CAUTI is identified, a Root Cause Analysis (RCA) is forwarded to the relevant team for completion. Outcomes from the investigations and figures are presented at local Harm Free Care meetings within the divisions. Fig. 9 and 10 below show the number and distribution of validated CAUTI s across the Trust. This data has established a more robust baseline for us to measure our progress in reducing the number of avoidable CAUTI. We are also working towards providing additional data for benchmarking. Fig 9: Outcome of positive CSU/MSU investigations (August 2014 March 2015) Investigation Outcome Number Not a CAUTI 967 (93%) CAUTI 73 (7%) Total 1040 Fig 10: Distribution of confirmed CAUTI by division (August 2014 March 2015) 17 P age

4. The management of Carbapenemase Producing Enterobacteriaceae (CPE) 4.1 Background A number of UK NHS Trusts have experienced problems with CPE, however CMFT has identified the greatest number of cases in any Trust to date. Following a review by representatives from regional Public Health England in July 2014, the Trust adopted a model planned to reduce the incidence and transmission of CPE using four key components; Enhanced screening for CPE to ensure the identification of all carriers. Increasing the capacity to isolate known carriers (cohort wards). Ensuring staff are held accountable for maintaining the principles of good infection prevention in their clinical practice. Performance review. An Incident Management Team (IMT) was convened by the DIPC. The purpose of the IMT was to co-ordinate the implementation of the action plan trust-wide and to monitor and report progress. Divisions provided senior management team representatives who could lead and drive the local agenda to attend the Incident Management Team meetings. 4.2 Enhanced Screening In order to control spread of CPE it is essential that all carriers are identified as early as possible. The IPC team developed a policy for enhanced patient screening based on national guidance which suggests admission screening of all patients with a history of admission to a healthcare facility with high levels of CPE in the previous 12 months. This equated to all readmissions to CMFT during a 12 month period. Information management systems were developed to identify patients matching this criterion, and laboratory capacity was increased to allow all such patients to be screened. 4.3 Between September and November, a CPE Point Prevalence Survey (PPS) was undertaken across the Manchester Royal Infirmary, Trafford Hospital and Royal Manchester Children s Hospital. 4.4 The aim of the PPS was to establish a baseline of previously unidentified patients in the Trust who are colonised with CPE. 926 in-patients were included in the screen of which 35 (3.8%) were positive. Of the 35 positive new cases 28 were the same type of CPE associated with the outbreaks at CMFT. Seven cases were of different types of CPE that have not been associated with spread in CMFT, and may be regarded as an important but incidental finding. 4.5 A commercial rapid test, with a turnaround time of four hours was implemented for unplanned patient admissions to facilitate appropriate patient management and reduce the risk of transmission of CPE. In addition the Trust developed and implemented an in-house method for testing specimens for CPE (from December 2014). This new test is more sensitive and has a turnaround time of 24 hours, compared to up to 3 days for the previously used culture method. 4.6 Enhanced screening enabled a more robust process for monitoring new and existing inpatients who have CPE. This has led to close scrutiny of wards with a high incidence of CPE and a more focused approach in these areas. Results indicate that this approach has been successful in reducing transmission in vulnerable patient groups such as Haematology/Oncology adult patients. 18 P age

4.7 Over the last 12 months the number of CPE screens processed per month have increased from approximately 1,650 (April, 2014) to over 6,000 (January, 2015 see Fig. 11). The number of positive screens increased in line with the number of screens processed. Fig 11: Total number of CPE screens processed and number of positive CPE screens. Despite an increased number of screens being processed, the number of positive results has fallen. This indicates that we are successfully identifying those patients who have been an inpatient in CMFT who were previously unknown to be CPE positive (see Fig. 12). Fig 12: Proportion of positive CPE screens 19 P age

4.8 Increased Isolation Capacity The type of CPE most commonly seen at CMFT (called Klebsiella pneumoniae carbapenemase, (KPC) was first described in 1996. Since then it has been disseminated across the Eastern Seaboard in the United States and spread to Greece, Italy and Israel. Israel has a national programme aimed at reducing transmission. In October Dr Mitchell Schwaber, Director of National Centre for Infection Control of the Israel Ministry of Health, visited the Trust to share with us the practices implemented across Israel to manage CPE. From his experience he emphasised we should not underestimate how easily this organism can spread and therefore we should, where possible, seek to contain the problem based on the concept of total isolation. This included dedicated cohort wards 2 as well as dedicated staff and patient equipment for the care of infected/colonised patients. 4.9 From August 2014 the majority of patients who were positive with the KPC strain of CPE were cared for in the isolation/cohort wards (14 and 15), from the divisions of Surgery and Medicine and Community unless they required specialist care in which case they were cared for in side rooms on the wards. 4.10 Patients who had a different type of CPE, for example NDM (New Delhi Metallo-betalactamase) and VIM (Verona Integrin-encoded Metallo-beta-lactamase), which are not associated with the outbreaks at CMFT, were cohort nursed 3 separately from the patients on the isolation wards to avoid cross contamination with more than one type of CPE. 4.11 The Trust expanded to three isolation/cohort wards to cope with increasing demand. Following a risk assessment Ward 27 was able to be closed during the week-ending the 15 th March 2015. 4.12 Fig.13 below demonstrates the total numbers of CPE positive inpatients across the three divisions in the Manchester Royal Infirmary. The data shows a downward trend particularly in the number of patients in the divisions of Medicine and Community and Surgery. This would indicate that isolation of patients in a separate facility does reduce the risk of spread of CPE. Fig 13: CPE positive inpatient burden 2 A cohort ward is an isolation ward for patients who are known to be infected with CPE 3 Cohort nursed describes the practice of a group of patients on a ward being nursed by a group of nurses who only care for this patient group during a shift 20 P age

4.13 Environmental Screening Environmental screening was undertaken across wards where there had been persistent onward transmission of CPE despite control measures. 4.14 Key findings from the environmental screens indicated that CPE was isolated in moist environments (the natural niche for these types of organisms). Most frequently organisms were isolated from internal wastewater drainage of hand wash basins. This resulted in the deep clean and replacement of affected sink traps. 4.15 Clinical Practice To provide additional support to the divisions to maintain high standards of clinical practice the following actions were implemented; Miss Amanda Pagett, Matron in the Royal Eye Hospital, (former IPC Nurse), returned to the IPC team from October December 2014 in order to co-ordinate the implementation of the action plan. Additional items of patient shared equipment, (including cleaning equipment) were purchased. The Policy for the management of patients with CPE was updated. In addition to identifying high risk patients on electronic admission systems the IPC team collaborated with the Clinical Informatics Team to identify in-patients who were CPE positive. This was essential in order to effectively manage these patients using the BEDMAN system. A bespoke web-page was created on the Trust IPC Intranet as a resource for our staff. This includes policies and guidance as well as frequently asked questions. 4.16 Performance review The role of the incident management team (IMT) was to support the implementation of the action plan across the hospitals. The plan has now become embedded across the Trust and the focus of management has been transformed from supporting the implementation of change to monitoring and managing the results. 4.17 Weekly performance data was produced regarding the number of high risk patients admitted, stating how many were screened and how many patients acquired CPE during their current admission. This information was reviewed by the senior divisional management teams at a fortnightly meeting with the DIPC, Director of Performance, Director of Nursing for Adults and senior members of the Infection Prevention and Control Team. The divisional teams were asked to account for any omissions to the screening of high risk patients and any new acquisitions of CPE amongst their in-patient population. 4.18 CPE at CMFT The external perspective It has been difficult to evaluate the progress of the management of CPE against other Trusts due to the unique situation at CMFT. 4.19 The Trust was actively involved with the national and regional incident management teams for CPE and progress on the management of CPE at CMFT was fed back at both these levels. There is evidence of an increasing incidence of CPE being reported, particularly from across the Greater Manchester area. Other local trusts are seeking support to develop their action plans based on the model used here at CMFT. 21 P age

4.20 The Infection Prevention and Control (IPC) Team have presented posters and papers at national and international conferences which have generated positive interest and debate. 5. Preparations to Receive a Patient with Suspected Ebola Virus Disease (EVD) 5.1 Background The 2014 Ebola epidemic was the largest in history, affecting multiple countries in West Africa, with widespread sustained transmission in Guinea, Liberia and Sierra Leone. Through the summer and autumn of 2014, PHE recommended that all hospitals with acute receiving units should be prepared for EVD in travellers and returning healthcare workers from highrisk areas. 5.2 In October 2014, a Trust-wide EVD Action Group was established led by the IPC team to monitor Trust preparations for Ebola with representation from clinical areas and appropriate Trust specialist advisors. Mrs Michelle Worsley, Matron in the Division of Surgery returned to the IPC team between October and December 2014 to provide additional support to facilitate the implementation of Trust preparations. 5.3 Trust and therefore education and resources were concentrated in these areas: Adult Emergency Department Paediatric Emergency Department Royal Eye Hospital Saint Mary s Hospital Trafford Urgent Care Centre 5.4 Each area had a designated lead responsible for co-ordinating local preparations. A summary of the key operational preparations undertaken in each of these areas is listed below; Reception staff in the Receiving Units were trained to ask appropriate questions of patients who presented at reception and take appropriate action. An appropriate area was identified in each Receiving Unit for isolation of suspected EVD case (this included identification of areas for putting on/removing PPE). Bespoke Personal Protective Equipment (PPE), was made available in all Receiving Units Staff members were trained in the sequence for putting on and removing PPE. 5.5 This was supported by the IPC team who provided; A major review of the Viral Haemorrhagic Fever (VHF) policy which was ratified by the Trust Infection Control Committee in January 2015. A dedicated EVD web-page which was set up on the Infection Prevention and Control intranet and included all relevant information such as a set of frequently asked questions for staff. 6. Maintaining a clean environment 6.1 Decontamination services Sterilisation of re-useable surgical devices was undertaken centrally on site in the Decontamination Services Department. The Department is accredited to Directive 93/82/EEC annexe 5 and ISO 13485:2003. 22 P age

Decontamination of flexible endoscopes was undertaken in satellite units in the associated clinical areas. This service is currently undergoing implementation of the standard procedures leading to EN ISO 13485 accreditation. 6.2 Trust Decontamination Group The Compliance Manager for Estates is the designated Decontamination Lead for the Trust. The Trust also has an appointed Authorised Engineer for Decontamination (AED). The Decontamination Committee met every quarter. 6.3 Decontamination of Endoscopes All flexible endoscopes were decontaminated using the Automatic Endoscope Repressors (AER) around the site. There is currently an approved Business Case scheme in progress to improve the environmental facilities associated with the AER`s to bring these up to higher standard in accordance with the CPFF 106 NHS Guidance document. 6.4 Rinse Water Testing The rinse water from the AER`s was tested weekly by a UKAS accredited laboratory. The results were reviewed by the Trust Decontamination Lead and appropriate action taken as required. 6.5 Validation of Automated Washer Disinfectors (AER s) It is a national requirement to have all AER s validated. Lancer continued to service the units in accordance with the testing standards. All units were fully compliant and the annual validation was signed off by the Authorised Engineer for Decontamination. 6.6 Management of water quality The Strategic Water Management Group reported to the Trust Infection Control Committee, the Water Committee met monthly to review the Trust s compliance associated with the national regulations; L8 and HTM 04. Dr Tom Makin, Consultant Microbiologist has continued to act as the Trusts External Consultant and Water Advisor. Dr Makin is an expert in the field and also provides technical advice to the HSE and the Department of Health. 6.7 Management of Risk for Legionella Water sampling for Legionella continued to be undertaken in accordance with L8 and HTM 04, due to the complex nature of the site the Trust agreed to undertake sampling on a monthly frequency to provide better assurance. All new building projects were required to provide additional testing if there is modification / connection to the existing water system. 6.8 Management of Pseudomonas aeruginosa from water outlets in high risk clinical areas The list of Augmented Care Units was constantly reviewed and is managed by the Water Quality Group. Sampling for Pseudomonas continued in accordance with the Addendum to HTM 04, the results are reviewed by the Water Quality Group. An agreed action plan was developed as part of the requirements of the HTM 04. 23 P age

Cleaning services 6.9 Contracting Arrangements The Trust cleaning services were provided by both internal and external contractors/teams. Sodexo Healthcare was the main contractor for the provision of cleaning services across the main island site including the Old St Marys building. The Trafford Division and Intermediate Care Units were managed by in-house teams. 6.10 Monitoring Arrangement As part of the contract Sodexo were required to self-monitor the performance of cleaning services against key performance indicators. These were reported to the Trust on a monthly basis for analysis and challenged where appropriate by the Facilities Monitoring Team. The services at Trafford Division and the Intermediate Care Homes were managed and monitored through internal in-house arrangements with the service managers and local users. In addition, the standards of cleanliness were monitored and reported for all sites through the monthly Quality of Care Rounds, the Ward Accreditation Process and the Patient Experience Tracker. These results informed areas of best practice and areas where additional focus was required. 6.11 The Role of the Infection Prevention and Control Team The IPC Team worked in conjunction with the Trust Monitoring Teams, Clinical Divisions, Sodexo and internal providers to ensure cleaning standards were met across the Trust. 6.12 Cleaning Schedules Cleaning schedules were publicly displayed in all clinical areas and processes were in place to report and escalate cleaning problems. These included: the Trust Key Contacts process which provided users with information on what services should be delivered and how to escalate non-compliance; and the cleaning matters process which required clinical and cleaning staff to record the completion of tasks and log additional or amended requirements. 6.13 Patient Led Assessment of the Care Environment (PLACE) The annual Patient Led Assessments of the Care Environment (PLACE Assessments) were carried out between 28 th February 2014 and 6 th May 2014 across the Central and Trafford sites. The assessors visited 25 wards, nine outpatient departments, seven emergency departments, four organisational departments, one mental health and two external areas, and carried out nine food assessments. The scores for each of the four assessment categories are shown in Fig. 14: Fig 14: PLACE Assessments Category Central Site Trafford Site Cleanliness 97.46% 97.03% Condition, Appearance and Maintenance 95.33% 91.95% Privacy, Dignity and Wellbeing 91.90% 83.64% Food and Hydration 90.05% 83.73% 24 P age

6.14 IPC Training for Domestic Staff All new employees attended a generic Sodexo induction which included the principles of IPC. As in previous years this was supported by additional bespoke training specific for domestic staff. The number of staff who received training this year was 372, (compared to last year when 334 staff received the training). This year suppliers of temporary staff to Sodexo were included in the programme. The Sodexo Education Lead and Trust IPC team worked in collaboration to provide bespoke training sessions for all Sodexo Managers. 6.15 Decontamination of the Environment with Hydrogen Peroxide Vapour (HPV) Environmental decontamination with Hydrogen Peroxide Vapour (HPV) was used in several ward areas this year through an ad hoc managed service. The advantage of using HPV is that it kills more micro-organisms and is more consistent than manual cleaning alone. Further to the success of using HPV the IPC and Facilities Teams have procured three machines to be used on site across the Adult Divisions and are working with Hygiene Solutions to establish a programme of decontamination and a process for reactive requests. 7. Developments in clinical practice 7.1 Evaluation of a Hand Hygiene Monitoring System Hand hygiene is a fundamental component of infection prevention and control. Monitoring of hand hygiene practice is undertaken regularly in all clinical areas in accordance with national guidance. Issues with the routinely used methodology include: subjectivity (as reliance is on observation by an individual), inability to observe practice behind drawn curtains or in side rooms, the Hawthorne effect (if subjects realise they are being observed), the fact that audits cover a very short period (e.g. 20mins per month), and that audits are rarely conducted out of the hours of 9am-5pm. A commercial company (Veraz Ltd) have developed a process to objectively measure hand hygiene compliance in clinical areas on an on-going basis using an electronic monitoring system. This system has been used in a small scale study in another Trust and last summer the Trust IPC team were approached to undertake a larger study at CMFT. 7.2 Progress to Date A protocol has been developed by the IPC Team and Veraz. Patient and staff information leaflets have been designed. Preparations have been made with the senior Divisional team in the Division of Surgery (where the study is being undertaken) the consultant staff and senior nurses. The hospital was scoped by Veraz and the installation of equipment has been agreed between Veraz and Sodexo. The contract for the study has been agreed between the CMFT Research and Innovation team and Veraz. A Project Nurse (employed by CMFT, funded by Veraz) was identified. Preliminary observational data of 5,000 hand hygiene opportunities was completed. Application for ethical review completed and submitted. 25 P age

Pending approval of the ethics application, the next stage of the study will begin in April 2015. 7.3 Developing an Extended Service for Peripherally Inserted Central Catheters The CMFT IPC Team participated in the fourth English National Point Prevalence Survey on Healthcare associated Infections (HCAI s) and Antimicrobial Use in 2011. Results indicated that CVC usage within CMFT was higher (17% - n = 832) than the national average (5.1%). Since then the need for Central Venous Catheters (CVCs) has increased as patients receive more complex therapies in both in-patient and out-patient settings. 7.4 There is national evidence to support the use of peripherally inserted central catheters (PICCs) for medium term (6 weeks to 6 months) intravascular access, particularly in adults and children requiring antimicrobial treatment, chemotherapy and parenteral nutrition. The benefits of extending the use of PICC lines for patients at CMFT include; less risk of infection and the ability to provide intravenous therapy for antimicrobial treatment in the community setting. 7.5 Until recently service provision was limited to patients in Gastroenterology and Haematology. There are plans in progress, co-ordinated by the Deputy Director of Nursing for Practice Development and the IPC Team to extend the use of PICC lines across the Trust through the provision of a central service for line insertion. This is being supported by appropriate policy, training, and equipment. 7.6 Summary of Progress to Date A policy for the management of a patient with an intravascular device was ratified by the Trust Infection Control Committee in January 2015. To ensure that the safest evidence based clinical practice is always undertaken, standard operating procedures have been written which are in line with the current services in Gastroenterology and Haematology. Staff in the Department of Radiology have been trained to insert PICC lines and have established a service for two additional sessions per week. A programme of education, technical proficiency and competency assessment has been developed to ensure that all clinical staff (Medical, Nursing and Allied Health Professionals) involved in the insertion, monitoring, use and removal of PICC lines are competent and practice safely. This will be monitored through the Oracle Learning Management (OLM) System. The Procurement Team have been involved to ensure that appropriate decisions are made on the selection of a preferred supplier to provide standardised devices across the Trust. 8. Training and education Training and education programmes were updated or developed by the IPC Team to reflect changes in national policies, local need and requirements of the services. 8.1 Induction and Mandatory Training The IPC Team delivered training on the key principles of Infection Prevention and Control at all the Trust corporate induction and clinical mandatory training days. In addition each clinical division held a local induction attended by a member of the IPC Team. 26 P age

Following a corporate scoping exercise a new induction programme for all Nursing and Midwifery staff commenced in October 2014 which replaced local divisional induction training. The IPC Team updated the programmes for corporate and clinical mandatory training; both face to face and on-line training. The IPC Team contributed to the development of other training programmes including those for medical students and for venepuncture and cannulation. 8.2 Infection Prevention and Control Training for Clinical Staff The IPC team continued to deliver the theoretical component in Aseptic Non Touch Technique (ANTT) training for all medical staff new to the organisation. The managing and recording of attendance and mandatory competency assessment was the responsibility of each division. Between April 2014 and March 2015 the IPC nurses provided 61 sessions attended by 579 medical staff, (see Fig. 15). The team have continued to support sessions for Medical Students on placement in the Trust. This included key principles of Infection Prevention and Control and theoretical training in ANTT. In total 436 Medical Students have attended the sessions (see Fig 15). In conjunction with staff from the divisions, the IPC Team also supported ANTT competency assessments. 8.3 Bespoke Training Bespoke sessions were conducted as requested or when a specific issue was identified within an area/department. These included sessions for all staff groups across all divisions and the PFI partners. As part of the daily workload the IPCT provided unscheduled one to one updates during routine ward/department visits. During this year the IPC team have continued to provide bespoke education sessions specifically on the infection prevention and control measures for CPE. This year the team provided 55 sessions on CPE compared to 30 last year, (see Fig. 15). Other topics have included sessions on Hand Hygiene, MRSA, CDI and use of Personal Protective Equipment (PPE). 8.4 Additional Training Sessions In conjunction with Human Resources (HR) the IPC team have continued to support bespoke training for hospital volunteers, Cadet Nurses, and persons on work experience programmes. As in previous years we have continued to support the Trust s annual young people s open day event with a display stand and practical sessions on hand hygiene. 8.5 Student Placements Within the last year the Trust welcomed student nurses on spoke placements to spend dedicated time with the IPC nurses. Feedback was positive and the placement supported the students to achieve a number of key practice elements related to Infection Prevention and Control. Staff from other agencies such as Public Health England (PHE) and other NHS Trusts spent time shadowing team members. 27 P age

8.6 Miscellaneous Training The IPC Team supported national initiatives to raise awareness and engage staff, patients and visitors. This included the World Health Organisations Save Lives: Clean Your Hands Campaign in May 2014 and Infection Prevention Control awareness week in October 2014. The IPCT displayed stands in each atrium and provided a rolling road show where the team visited all wards and departments to engage with staff and patients. Both events were successful with positive feedback from staff and visitors. 8.7 IPC Team Training Education and updates for the Infection Prevention and Control Nurses was provided internally and externally. The Trust supported two members of staff to undertake the Principles of Infection Control and the Management of an Infection Prevention and Control Service modules at Manchester University (IPC Team members were also guest lecturers on both of these modules). 8.8 Fit Test Training for FFP3 Respirator Masks The divisions are responsible for maintaining a register of staff that are fit tested to wear FFP3 masks and to ensure that staff are periodically re-fit tested. This year an external company supported the Trust IPC Team to provide FFP3 respirator mask fit test training and Train the Trainer fit testing sessions in which staff from across all divisions attended. 8.9 Soft Facilities Management (FM) Services All new Facilities Management employees attended the corporate Trust induction and on the second day attended the Sodexo in-house mandatory induction programme. This includes a session on the principles of infection prevention and control. Figures provided by the Sodexo Training Department demonstrate that 682 staff working in Soft FM services attended an IPC refresher training session. These included Blue Arrow Agency employees as well as Sodexo staff from all groups (Domestics, Porters, Waste Operatives, Receipt and Distribution, Telecoms and Retail) attended, (see Fig. 15). 8.10 Hard FM Services The Health, Safety and Risk Adviser (IPC) lead for Hard FM services and the IPC Team worked in collaboration to provide a bespoke training session for all Sodexo Hard FM Managers. 28 P age

Fig 15: Teaching sessions conducted by IPCT (April 2014 to March 2015) Teaching Sessions Number of training sessions Total Number of Staff Attended CPE 55 541 Clinical Staff- General IPC 31 266 Medical Students- General IPC and ANTT 20 436 Sodexo Staff- General IPC 7 38 Fit Test Training for FFP3 masks 7 58 Hand Hygiene 17 185 ANTT Nursing Staff 23 199 ANTT Medical Staff 38 380 Total 198 2103 * Figures do not include trust induction or mandatory training 9. Audit All NHS organisations are required to audit key policies and procedures for infection prevention and control to provide assurance that practice is effective in the prevention of Health Care Associated Infections (HCAI s) in accordance with the Health and Social Care Act (revised 2012). Please find below the key to the red, amber, green level of compliance. These indicators are used for the Hand Hygiene audit, the Infectious Diarrhoea ICP audit and the MRSA ICP audit. Key: Compliance 95% Compliance 75% - 94% Compliance 74% 9.1 Hand Hygiene Opportunities Compliance Audit This audit was undertaken to establish compliance in undertaking hand hygiene across all clinical areas within the Trust. This audit measured compliance amongst different staff disciplines, measuring against the 6 Golden Moments of hand hygiene. These are defined as; entry to clinical area, exit from clinical area, entry to side-room/bay, exit from side-room/bay, before patient contact, after patient contact. 29 P age

Fig 16: Comparison of Trust-wide Hand Hygiene Compliance Rates by Division; November 2013, February 2014 and July 2014 Division Compliance (%) 2013 (previous) Compliance (%) Feb 2014 (re-audit) Compliance (%) July 2014 (re-audit) Change CSS 89% (47/53) 88% (61/69) 78% (60/77) Dental 89% (91/102) 93% (89/96) 84% (113/135) Medicine & Community 86% (80/93) 87% (165/190) 84% (121/144) Manchester Royal Eye Hospital Royal Manchester Children s Hospital 45% (51/113) 63% (97/153) 71% (98/139) 71% (170/240) 70% (218/310) 74% (226/304) St Marys Hospital 70% (164/235) 86% (308/357) 84% (303/359) Specialist Medicine 81% (200/246) 86% (132/154) 84% (129/153) Surgery 38% (50/131) 60% (115/192) 80% (198/248) Trafford 62% (197/318) 80% (272/339) 92% (249/271) TRUSTWIDE 66% (1050/1599) 78% (1457/1860) 82% (1497/1830) The audit was undertaken by each Division in June/July 2014, following which action plans were developed and implemented. Compliance increased from 78% in February 2014 to 82% in July 2014, (see Fig 16). Divisions developed action plans following this audit and monitored the implementation through their local IPC meetings. The IPC team are in the process of replacing alcohol gel dispensers across the Trust. This will include identified hand hygiene stations at the entrance to all wards and departments. 9.2 Audit of Compliance of the use of the Infectious Diarrhoea Integrated Care Pathway (ICP). The ICP measured documented evidence that patients with Clostridium difficile infection across the Trust were managed according to the Trust policy for Clostridium difficile infection, (ref OC2-2472 CDI). The audit measured compliance against each element within the ICP. From 1 st January to 28 th February 2015 the IPC Team visited patients that were identified as having active infection and collected data from the patients ICP documents. A total of 32 forms were audited across the following Divisions: Medicine (acute), Specialist Medicine, Surgery and Trafford. Divisions omitted from the audit did not have positive patients at the time of data collection. A summary of trust-wide results is illustrated in Fig. 17 which also compares the results of the latest audit to the previous one carried out in December 2013. 30 P age

Fig 17: Infectious Diarrhoea ICP Audit Results. Standard Compliance (%) Dec 2013 Compliance (%) Jan/Feb 2015 Changes 1. Standard one Was the Infectious diarrhoea ICP in place? 2. Standard two Has the patients stool pattern been recorded? 3. Standard three Has the patient been isolated until 48 hours following the last Episode of diarrhoea? 4. Standard four Have the nursing severity markers been completed? 5. Standard five Have the medical severity markers been completed? 6. Standard six Has the patient information leaflet been given? 7. Standard seven Was the orange C difficile sticker in patients notes? 8. Standard eight Were patients/relatives advised of hand hygiene with soap and water? 9. Standard nine Has the fluid balance chart been commenced and completed? 10. Standard ten Was the daily cleaning form in place? 11. Standard eleven Was treatment commenced within 24 hours of the positive result? 93% (26/28) 93% (27/29) 89% (25/28) 93% (28/30) 92% (24/26) 96% (27/29) 29% (8/28) 41% (12/29) 4% (1/28) 21% (6/29) 100% (16/16) 100% (10/10) 100% (15/15) 100% (10/10) 93% (26/28) 100% (25/25) 82% (23/27) 93% (26/28) 93% (26/28) 95% (18/19) 95% (21/22) 79% (22/28) The results of this audit highlighted that 9 out of 11 standards demonstrate compliance of 79% or higher. As previous audits illustrated, the severity markers are the most poorly documented on the ICP this is partly due to the complexity of having both electronic and paper records. These documents are completed by medical and nursing teams and this audit shows improvements from the previous audit by both groups of staff. Medical compliance has increased from 4% to 21% and Nursing from 29% to 41%. This is a more encouraging result. There still remains scope for further improvements to ensure the required compliance in the future as these are an essential tool in monitoring their severity of the patient s disease and ensuring the appropriateness of treatment. The audit has been distributed to the Heads of Nursing and each Division with a request to develop and implement action plans in response to the results. 31 P age

9.3 Audit of Compliance in the use of the Meticillin resistant Staphylococcus aureus (MRSA) ICP The Trust standard is that all MRSA positive patients should receive decolonisation in accordance with Trust MRSA Screening and Decolonisation Policy (version 3:1, ref ICP11). The ICP provides documented evidence that MRSA positive patients within the Trust are managed according to Trust policy. The ICP is divided into sections. All in-patients who were currently or previously MRSA positive were visited by the IPC team during the month of June 2014. Patients were included within the audit once they had been within the Trust for a minimum of 48 hours. A total of 84 ICPs were audited. This year the audit tool was updated and four additional standards were included. The key findings are illustrated in Fig. 18 which also includes a comparison from previous audits in June 2013, February 2014. Fig 18: Comparison of MRSA ICP Audit results June 2013, January 2014 and September- December 2014 Question Trustwide Compliance June 2013 Trustwide Compliance Jan/Feb 2014 Trustwide Compliance Sept-Dec 2014 Change Is the patient isolated? 72% 72% 87% Patient screened as per Trust policy? 71% 92% 88% ICP commenced within 12 hours of admission? 79% 79% 82% All initial actions signed and dated? 54% 57% 77% All screening results documented correctly? 29% 25% 37% Correct decolonisation therapy prescribed? 69% 72% 76% Octenisan given daily? 53% 67% 85% Nasal treatment given? 68% 48% 84% Patient information leaflet given? 86% 95% 94% ICP in place? 88% N/A Is isolation sign on door? 95% N/A Is daily cleaning chart completed? 84% N/A Are VIP (bd) or MRVICTOR (daily) scores completed? 86% N/A Overall the audit showed improvements in seven standards from the previous audit in January /February 2014. Compliance in the documentation of screening results has risen by 12% but still lies at only 37% which remains a concern. The prescribing of decolonisation therapy, although improved is still only 76% compliance. 32 P age

Whilst there is still room for improvement, the results from this audit indicate an overall improvement on the performance from previous years. The report was distributed to all Heads of Nursing and Clinical Heads of Division. Individual areas were asked to develop tailored action plans and determine dates for completion. Trust-wide Audit of Antibiotic Therapy 9.4 Start Smart and Focus Audit 2014 The Trust was audited in September 2014 to assess compliance with the principles of the Start Smart and Focus approach to antimicrobial stewardship. This reviewed the appropriateness of antimicrobial therapies prescribed for greater than 48 hours. Data was collected by Clinical Pharmacists on in-patient wards at the Central and Trafford hospital sites. 77 patients across all eight divisions of the hospital were reviewed. A total of 109 antibiotic agents were prescribed for these patients. These results were disseminated to the divisions for action (See Fig. 5 for results). Fig 19: Trust-wide Compliance with Standards of Antibiotic Prescribing No Standard Target 1. 2. 3. 4. 5. At the time of initiating antibiotic therapy clinical evidence of infection should be present and documented in the medical notes All patients on antibiotic therapy for treatment of infection should have a clinical review documented in the medical notes All patients on antibiotic therapy for treatment of infection should be reviewed within 48 hours. Where culture results are available these should be checked and antimicrobial therapy reviewed accordingly (within 24 hours of the result being available) Where patients meet the Trust IV to oral switch criteria patients should be switched to oral therapy 9.5 Antibiotic Prevalence Audit Compliance 2013 Compliance 2014 95% 94% 88% 95% 83% 85% 95% 53% 52% 95% 89% 87% 95% 79% 75% Compliance with the Trust wide antibiotic guidelines has been audited annually since 2006. This year the audit was carried out in March 2015. Central Site and Trafford Division were audited separately. Antibiotic prescribing was assessed against the Adult Anti-infective Guidelines (version VIII 2013) for adult patients and the Antibiotic Prescribing Guidelines for Paediatric and Neonatal Patients Version VI (2013) for all paediatric patients. See Fig 20 below for provisional results for Central Site (some small changes expected once final ward data analysed and collated). Once completed results will be disseminated to the divisions for action. 33 P age

Fig 20: Antibiotic Prevalence Audit - Central Site Audit Results (provisional) 2015 No Standard Target 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Antibiotics prescribed only if infection present (or for surgical prophylaxis) as outlined in the guidelines The choice of empiric antibiotic therapy should be in accordance with the Trust Anti-infective guidelines unless specific clinical factors prevent this. Allergy status should be documented on all medication charts and prescriptions in accordance with the Trust Medicine s Policy The indication for antibiotic therapy should be documented in the medical notes The indication for antibiotic therapy should be documented on the medication chart Doses and dose frequency should be appropriate for age, weight, renal and hepatic function All prescriptions should have the review date or intended duration documented in the medical notes (exceptions ITU, BMTU, ward 44) All prescriptions should have the review date or intended duration prescribed on the prescription chart (exceptions ITU, BMTU, ward 44) IV antibiotics should only be continued beyond 48 hours if clinically justified due to clinical status of the patient or no suitable oral switch Antibiotic therapy should not be extended beyond the recommended duration in the guidance without clear clinical justification 9.6 Surgical Antibiotic Prophylaxis Audit 95% 95% 95% 95% 75% 95% 75% 75% 95% 95% Compliance 2013/14 99% (397/399) 94% (375/398) 99% (367/370) 92% (341/370) 61% (224/370) 98% (475/487) 55% (215/390) 47% (182/389) 97% (262/270) 96% (385/399) Compliance 2014/15 97% (304/312) 96% (299/312) 99% (308/312) 90% (281/312) 64% (199/312) 99% (309/312) 54% (170/312) 48% (150/312) 94% (88/94) 99% (308/312) The annual audit of antibiotic surgical prophylaxis was performed in April 2014 within the Surgical Division (Central Site) and the Surgical Directorate (Trafford). This audit was performed over a one week period and included 110 surgical procedures and measured against local prescribing guidelines. These results were disseminated to the divisions for action (See Fig. 21 for results) Fig 21: Surgical Antibiotic Prophylaxis Audit Results No. Standard Target 1. 2. 3. Antibiotic prophylaxis should be administered in accordance with the guidelines (unless contraindications exist to the recommended regime) The choice of antibiotic prophylaxis should be in line with the Trust guidelines (unless contraindications exist - includes prophylaxis not given but indicated and prophylaxis administered where not recommended) The timing of the first intravenous antibiotic dose should be given at or within 1 hour before skin incision, unless otherwise stated in the guidelines. 95% 74% 95% 95% 83% Compliance 2013 New standard Compliance 2014 86% (90/105) 93% (98/105) 97% (63/65) 34 P age

4. 5. 6. 7. 8. Antibiotic surgical prophylaxis should be administered in accordance with the guidelines for penicillin allergic patients undergoing procedures requiring prophylaxis Antibiotics used in procedures lasting longer than 3 hours will require a second dose to be given as per guidelines A second dose of antibiotic is required for procedures involving >1.5L blood loss (excluding gentamicin) For procedures that require antibiotic prophylaxis patients with previous MRSA skin colonisation should receive a glycopeptide even if they have been treated with topical de-colonisation therapy. Microbiology advice should be sought for all patients undergoing surgery who are CPE colonised. 95% 100% 95% 95% 95% 95% NA 82% (9/11) NA 0% (0/1) NA 0% (0/1) NA 100% (1/1) 83% (5/6) No patient received penicillin 9. 7 Audit of Compliance with Sharps Policy An audit measuring compliance with CMFT sharps policy was undertaken by Frontier Medical in October 2014. A total of 70 clinical areas were audited across all divisions. The audit measured compliance across three broad areas of sharps management including; equipment, practice and awareness. It included checking sharps containers, observing practice in relation to sharps and questioning staff. The results were disseminated to divisions to be actioned and can be found below in Fig. 22. Fig 22: Audit of Compliance with Trust Sharps Policy 35 P age

9.8 Blood Culture Contamination Audit The following charts (Fig. 23A and 23B) represent CMFT peripheral blood culture contamination trends. There is no national UK standard for contamination rates, but rates should be below 3%, aiming for zero. The mean blood culture contamination indicators for both adult (>16 yrs) and child (<16 yrs) peripheral blood cultures for 2014/2015 are 2.2% and 2.1%, respectively. Fig 23a: Peripheral Blood Culture Contamination Rates (Age >16 yrs) Fig 23b: Peripheral Blood Culture Contamination Rates (Age >16 yrs) 9.9 Audit of Hand Hygiene Practice and Aseptic Non-Touch Technique (ANTT) Monthly Quality Care Rounds (QCR) were undertaken by all divisions across the Trust. Included in the QCR were questions measuring standards of both Hand Hygiene Practice and ANTT. In the event that wards experienced an increased incidence in infection, the frequency of audits being undertaken was increased. Actions were addressed locally at the time of the audit. Community based services undertook separate audits from which local action plans were developed and implemented as required. These are reviewed at the Essential Steps community meetings in conjunction with the IPC team. See Fig. 24 and 25 trust-wide results (indicated by the blue line) and trend (indicated by the red dashed line). 36 P age

Fig 24: QCR Hand Hygiene Audit Results Trust 100% 95% 90% 85% 80% 75% 2013/04 2013/05 2013/06 2013/07 2013/08 2013/09 2013/10 2013/11 2013/12 2014/01 2014/02 2014/03 Fig 25: QCR ANTT Audit Results Trust 100% 95% 90% 85% 80% 75% 2013/04 2013/05 2013/06 2013/07 2013/08 2013/09 2013/10 2013/11 2013/12 2014/01 2014/02 2014/03 10. Conclusion The content of this report demonstrates the broad spectrum of activity associated with Infection Prevention and Control across the Trust. The outcomes of the practice and process described are evidence of the hard work and commitment of staff working across the organisation. The major challenge and focus this year has been the management and control of CPE. Results from interventions such as enhanced screening and cohort/isolation of patients, give cause for cautious optimism that we are progressing in the right direction. Despite the focus and challenge of CPE the Trust has maintained and improved performance against the HCAI objectives for MRSA Bacteraemia and CDI. In addition continuous analysis of the available data has resulted in the development of clinical practice. This is evidenced by the enhanced PICC line service and preparing to pilot innovative new technology to improve hand hygiene compliance. 37 P age

11. Recommendations The Board of Directors are asked to receive the Annual Report, note the work of the Infection Prevention and Control Team and Trust staff in the management, control and prevention of infection and agree to the publication of the report on the Trust website. Julie Cawthorne Consultant Nurse IPC April 2015 38 P age

Appendix 1a: Infection Prevention & Control/Tissue Viability Nursing Structure 2014-2015 Agenda Item 9.5 39 P age

Professional Lead Divisional Director Surveillance Officer 6 Consultant Nurse/Manager Admin Support 4 Admin Support (0.75) WTE 3 Matron 8A TVN Specialist Nurse 7 TVN Specialist Nurse 7 IPC Specialist Nurse (0.8 WTE) 7 IPC Specialist Nurse 7 IPC Specialist Nurse 7 IPC Specialist Nurse 7 IPC/TV Practitioner (0.6 WTE) 6 IPC/TV Practitioner 6 IPC/TV Practitioner 6 IPC/TV Practitioner 6 IPC/TV Practitioner 6 IPC/TV Practitioner 6 IPC/TV Practitioner 6 IPC/TV Practitioner 6 IPC/TV Practitioner 6 40 P age

Appendix 1b: Framework for IPC Committee / Group Structure Agenda Item 9.5 Trust Board Clinical Effectiveness Committee Trust Infection Control Committee (ICC) Trust Infection Prevention and Control Expert Group Divisional IPC Groups Antibiotic Subgroup Decomtamination Group Strategic Water Group 41 P age

Appendix 2 INFECTION CONTROL COMMITTEE TERMS OF REFERENCE 1. CONSTITUTION The Infection Control Committee is a sub-committee of the Clinical Effectiveness Committee. The Infection Control Committee is chaired by the Director of Infection Prevention and Control who is the Chief Nurse/Director of Patient Services. 2. CORE MEMBERSHIP Director of Infection Prevention and Control/Director of Patient Services/Chief Nurse (Chair) Director of Nursing (Adults) Consultant Microbiologist/Infection Control Doctor Consultant Nurse, Infection Prevention and Control (IPC) Associate Director of Clinical Effectiveness Head of Clinical Audit Consultant in Communicable Disease Control (PHE) PCT Infection Control Lead Antimicrobial Pharmacist Clinical Leads from Divisions CSS Representative Acute Medicine and Community Division representative Specialist Medicine Division representative Surgery Division representative Children s Hospital representative Eye/Dental Division representative Saint Mary s Division representative Trafford Hospitals Representative A quorum shall be eight members including the Director of Infection Prevention and Control (or a nominated deputy) and the Infection Control Doctor and Consultant Nurse, Infection Prevention and Control (or nominated deputies). 3. ATTENDANCE AT MEETINGS The Infection Control Committee may require from time to time, the attendance of any Trust employee (or agent of the Trust) to attend the committee at the request of the Chair. 4. FREQUENCY OF MEETINGS The Infection Control Committee will meet every two months (six times a year). 5. OVERVIEW The Infection Control Committee develops and monitors the core Infection prevention and control strategic objectives. The core objectives are agreed by the Trust Board and are based on CMFT organizational priorities. The Trust ICC will oversee and monitor the operational IPC programme through the Trust Expert Group. The Infection Control Committee is authorised to formulate recommendations for Infection Prevention and Control within the Trust and to convey these to the Trust Board. 42 P age