Infection prevention and control Annual Report 2016/17 National Infection Prevention and Control Strategic Management Team Dee Sissons Executive Director of Nursing, Marie Curie Director, Infection Prevention and Control, Marie Curie Jo Shackleton Senior Nurse, Infection Prevention and Control, Marie Curie Dr Adrian Tookman Medical Director, Marie Curie Hospice, Hampstead Clinical Lead, Infection Prevention and Control, Marie Curie
Executive Summary The Marie Curie Infection Prevention and Control Annual Report covers the period from 1 April 2016 to 31 March 2017. We provide care to people with a terminal illness and their families, often at a very difficult time in their lives, so we have a particular duty to assure our patients and their families that the care they receive is provided in a clean and safe environment. Reducing, preventing and managing infections therefore remains a priority for Marie Curie. This report details the significant progress made in the last year around the reporting, surveillance and management of healthcare associated infections and infection prevention and control. In the last year we have: Improved the quality monitoring and surveillance of all infections. A standard operating procedure has been developed and embedded, and IPC reporting categories have been expanded, which will further improve the quality of reporting. Quality monitoring and surveillance allows us to demonstrate improved awareness and consistency of practice. Continued the development of Link Nurses and the roll out of the framework. The nurses meet regularly as a group to identify and implement improvements across our services, and check on practices such as hygiene. They are also able to share key guidance with other staff, and promote an environment of support. The Link Nurse role also provides nurses with an excellent opportunity for continuing professional development. Implemented and embedded local audit programmes for personal protective equipment and hand hygiene. Personal protective equipment and good hand hygiene are cornerstones of infection prevention and control, and as part of the local audit programmes, areas of good practice were highlighted and quality improvement action plans were developed to ensure improvement where needed. The Infection Prevention and Control Committee and key stakeholders continue to maintain and improve on the application and development of infection prevention and control standards. However, the successes over the last year have only been possible thanks to the commitment and dedication demonstrated at all levels within the organisation. 2
To continue building on these successes, there are four key priorities for 2017/18: 1 Ensure we have systems in place to manage and monitor the prevention and control of infection for people with a terminal illness in our care, their families and our staff. 2 Develop and provide suitable, accurate information on infections, and infection prevention and control for our service users, their families, our staff and any person concerned with providing further support or nursing/medical care to our patients. 3 Ensure that our staff are fully equipped with the knowledge and skills they require to identify, manage and reduce the risk of infection. 4 Work with internal and external partners to provide and maintain a clean and safe environment that facilitates the prevention and control of infections in managed premises, with particular attention to water safety and policy. We are proud of the work we have done and the progress that has been made in the last year. We remain committed to actively supporting infection prevention and control and best practice, for the continued safety and wellbeing of our patients, their families and our staff. Abbreviations CDI Clostridium Difficile infection CPE Carbapenemase-producing Enterobacteriaceae CRE Carbapenem-resistant Enterobacteriaceae CQC Care Quality Commission DIPC Director, Infection Prevention and Control ESBL Extended-spectrum beta-lactamases HCAI Healthcare associated infection HIS Healthcare Improvement Scotland HIW Healthcare Inspectorate Wales IPC Infection Prevention and Control IPCC Infection Prevention and Control Committee MSSA Meticillin-sensitive Staphylococcus Aureus MRSA Meticillin-resistant Staphylococcus Aureus PIR Post-infection review PPE Personal Protective Equipment RQIA Regulation and Quality Improvement Authority SLA Service Level Agreement SNIPC Senior Nurse, Infection Prevention and Control SOP Standard Operating Procedure 3
1 Foreword This is the third Marie Curie Infection Prevention and Control (IPC) Annual Report and covers the period from 1 April 2016 to 31 March 2017. It demonstrates the significant amount of progress around the reporting, surveillance and management of healthcare associated infections (HCAI) and IPC. Since the last report, the IPC governance arrangements have been further strengthened and, in line with national best practice, we have successfully embedded multiprofessional post-infection reviews (PIR). This annual report seeks to assure that progress has been made against the IPC assurance framework. The work plan is considered as the IPC assurance framework and ensures sustained improvements in IPC and a reduction in healthcare associated infections. We will continue to devolve responsibility for IPC to local clinical teams during 2017/18 through strengthening the role of the IPC Link Nurses and IPC champions and ensuring the Divisional Quality Boards are engaged with local IPC issues. Like other organisations we are seeing an increase in the numbers of patients with HCAIs. We have reviewed the information given to our teams by developing and embedding an IPC manual, which provides a wide range of Standard Operating Procedures (SOP) that support staff to give the right care irrespective of the type of infection. Reducing, preventing and managing infections remains important. We have identified three key priorities that are reflected in our 2017/18 work plan. They are: Ensure we continue to manage Clostridium Difficile Develop IPC information for patients and families, specific to end of life care Continue to carry out postinfection reviews. My thanks to the Senior Nurse, Infection Prevention and Control (SNIPC), for continuing her hard work with passion and enthusiasm, and the clinical teams who have demonstrated support and commitment to the HCAI reduction plan. I would particularly like to thank: The IPC Link Nurses and IPC champions Dr Adrian Tookman, Clinical Lead Anne Cleary, Deputy Director of Nursing The Quality Assurance team. Special thanks to Susan Marmito, Information Lead, for her support in compiling this report. Dee Sissons Executive Director of Nursing 4
2 Introduction High standards of IPC across the organisation are crucial. The national IPC strategic management team continues to work hard to deliver the annual plan in our attempts to prevent all avoidable infections and to reduce the risk of resistant organisms across all our provider services. We are supported in this by Marie Curie-established IPC Link Nurses and IPC colleagues from NHS Trusts and local authority public health teams, who support teams within Marie Curie hospices and the Marie Curie Nursing Service. The team use the following values in all areas of their daily work: Communication we encourage communication with our staff by being available, having Link Nurses, providing expert advice and attending key meetings Evidence-based care we are committed to providing evidencebased care Safety we have the courage to challenge any behaviour that puts our service users, carers, visitors or staff at risk in our commitment to preventing any avoidable infection Service we are dedicated to maintaining the competence required for preventative IPC practice Respect and compassion we are respectful and compassionate in all our contact with patients, carers and colleagues Teamwork cooperation among clinicians is a priority. Health professionals actively collaborate and communicate to ensure an appropriate exchange of information and co-ordination of care. Notable achievements in 2016/17 include: No preventable Meticillin-resistant Staphylococcus Aureus (MRSA) Bacteraemia infections within our provider services No preventable Clostridium Difficile Infections (CDI) within our provider services Collaboration with Public Health England on producing guidance on Carbapenemase-producing Enterobacteriaceae (CPE) No identified cross infection cases in service users or staff (excluding small round-structured virus periods of increase incidence). During 2016/17 the IPC Committee has met quarterly and continues to be assured that IPC has been embedded into both clinical and operational service. Ben Gold/Marie Curie 5
3 Governance arrangements 3.1 IPC governance arrangements The key roles relating to IPC were fulfilled throughout 2016/17. Clinical Governance Trustees Committee Director of Nursing Clinical Governance Executive Committee Infection Prevention and Control Committee (IPCC) Divisional Clinical Quality Boards Chaired by Medical Directors 3.2 Frequency and nature of reporting In addition to delivering the annual report, the Director, Infection Prevention and Control (DIPC) delivers a quarterly report on IPC as part of their Director of Nursing report. This report highlights areas of practice and development, and provides assurance for Trustees in relation to all regulators standards. 3.3 Regulatory compliance England The Care Quality Commission (CQC) inspection during 2016 did not highlight any IPC gaps. The CQC assesses IPC standards against the new 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 (Department of Health, 2015). This contains the 10 criteria that healthcare providers are assessed against. 6
Wales Healthcare Inspectorate Wales (HIW) inspects Marie Curie services in Wales. No inspections took place during 2016 in the Marie Curie Hospice, Cardiff and Scotland In 2016/17 the Healthcare Improvement Scotland (HIS) inspection highlighted concerns regarding the removal of used personal protective clothing and thermal disinfection of laundry. These issues have been managed locally through the Divisional Quality and Safety Board. Northern Ireland The Regulation and Quality Improvement Authority (RQIA) inspection during 2016/17 did not highlight any IPC gaps. The RQIA assesses IPC standards against the Independent Health Care Regulations (NI) 2005, the Regulation and the Vale. HIW assesses IPC standards against the Care Standards Act 2000 and national minimum standards. HIS assesses IPC standards against the National Health Service (Scotland) Act 1978, Health Improvement Scotland Regulations 2011 (quality statement 2.4 for IPC) and National Care Standards Scotland (standard 7 for IPC), which contains the criteria that healthcare providers are assessed against. Improvement Authority Regulations (NI) 2011 and the Department of Health, Social Services and Public Safety Minimum Care Standards 2014, which contains the criteria that healthcare providers are assessed against. 3.4 Infection Prevention and Control Committee The IPCC reports directly to the Clinical Governance Executive Committee and is chaired by the DIPC. Meetings take place four times a year and all nations and services are represented. All IPC incidents and outbreaks are routinely reported to the IPCC and the Trustees receive a quarterly report. 3.5 Arrangements for IPC services The charity s Chief Executive holds ultimate responsibility for providing effective IPC arrangements across the organisation. This duty of care is delegated to the Executive Director of Nursing, who is also the Director, Infection Prevention and Control. 7
3.6 Infection Prevention and Control strategic management team Marie Curie does not have a dedicated operational IPC team. The DIPC, Senior Nurse for Infection Prevention and Control (SNIPC) and Clinical Medical Director provide strategic national leadership and specialist subject expertise. The Clinical Medical Director is responsible for leading on clinical IPC matters and providing clinical IPC advice and support to the DIPC, SNIPC and Medical Directors. The SNIPC provides strategic leadership and specialist expertise, advice and support across the organisation in clinical and nonclinical settings, and supports the IPC Link Nurse network. The Registered Manager is locally responsible for IPC and further specialist support is available for hospices through local service level agreements, microbiologists and IPC specialists. Both hospices and the Marie Curie nursing service are also provided with support from local authority Public Health teams. Hospice Pharmacists work with Medical Directors to ensure antimicrobial prescribing is in line with national and local guidelines. I have been the IPC Link Nurse at the hospice since May 2016. I work closely with our community IPC team who are always willing to guide and provide advice. At the hospice, I ve set up a multi-disciplinary IPC team and we meet quarterly to discuss any issues raised at the hospice and how to move forward. I also work with our champions on the ward, who assist with IPC concerns. I complete audits and teach IPC to staff and volunteers at the hospice. I attend the Link Network meetings, which I find invaluable. I m able to bring questions raised at the hospice via meetings, audits and staff. I find this a really good way of receiving like-minded support and help. We have teaching sessions at the meeting, which are also invaluable, and we participate in case studies, discussing incidents that have happened in our areas. It s a good source of networking. Shirley Williams, IPC Link Nurse, Marie Curie Hospice, Liverpool 8
Ben Gold/Marie Curie 3.7 IPC Link Nurses Following the establishment of the IPC Link Nurse network in 2015/16, in partnership with the Royal College of Nursing, the Link Nurses meet quarterly. This provides an excellent opportunity to cascade and disseminate key IPC guidance to staff. An education element is also incorporated to promote continuing professional development. Twenty nurses have been designated as IPC Link Nurses across the organisation and IPC champions have been embedded in all our provider services. 3.8 Local IPC groups All IPC incidents are managed locally and reported and monitored through the Divisional Quality and Safety Board. Within hospices and the Marie Curie Nursing Service, Lead Nurses and Clinical Nurse managers, along with the IPC Link Nurses, are supported by both the SNIPC and SLA IPC specialists to deliver the IPC agenda locally. 9
4 Training and continuing professional development 4.1 Statutory and mandatory training Online IPC training is mandatory across the charity. In adherence with the new Mandatory Training Compliance Policy (2016), IPC needs to be completed biannually, except in Northern Ireland where the regulations require annual updates. Since December 2016, compliance has remained above 90% across both hospices and community teams. Compliance with training is monitored locally and regular reports are received by the IPCC, Clinical Governance Executive Committee and the Clinical Governance Trustees Committee (see 3.1, IPC governance arrangements). Clinical mandatory training compliance 100 98 96 94 Hospice Community Overall % compliance 92 90 88 86 84 82 80 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr While online training provides the mandatory training for IPC, local areas also undertake further education to update staff. The topics include hand hygiene, personal protective equipment (PPE), sharps, audit, waste management and practical demonstrations with light boxes. These sessions are provided by IPC Link Nurses and are specific to the hospice within which they are working, informed by incidents, near misses and staff. The Marie Curie Nursing Service did not undertake any further IPC training other than mandatory training. Hand hygiene is discussed and demonstrated during clinical skills assessments. 10
4.2 Continuing professional development of the IPC team As well as completing organisational training requirements, the DIPC and SNIPC attended relevant local and national workshops and conferences, including national and regional Infection Prevention Society conferences. The SNIPC spoke at the 2016 Healthcare Infection Society biannual conference in Edinburgh. 5 Operational approach 5.1 Refurbishments and new builds The SNIPC provides advice and support during refurbishments and new builds across Marie Curie, including advice to ensure compliance with national guidance. The SNIPC has continued to work in partnership with SLA IPC specialists, and with colleagues from the estates and facilities departments, to support the refurbishment of the laundry in the Marie Curie Hospice, Edinburgh. 5.2 Hand decontamination Marie Curie continues to actively promote hand hygiene, at all opportunities. Ben Gold/Marie Curie Staff at the Marie Curie Hospice, Bradford have been working closely with colleagues from the facilities department, along with representatives from Deb Group Ltd, to complete site surveys in response to introducing a new soap, alcohol hand foam and moisturiser. The aim of this is to ensure compliance with Marie Curie hand hygiene SOP and evidence-based practice. 11
6 IPC standards reviews 6.1 IPC audits Ben Gold/Marie Curie Hospice IPC Link Nurses carried out snapshot observational audits on hand hygiene practice, availability of hand hygiene resources at the point of care, and the correct wearing of Personal Protective Equipment (PPE) at the point of care. Individual hospice Link Nurses reported results back to the Lead Nurse and through the local governance arrangements for IPC. Areas of good practice were highlighted, and quality improvement action plans have been developed to ensure improvement where needed. The IPC Link Nurses for the Marie Curie Nursing Service acted as facilitators to help staff carry out self-audits in all regions, with the appropriate follow up and support. Results were reported back locally within IPC governance arrangements. Areas of good practice were highlighted and appropriate actions regarding areas of concern were actioned and documented. Further hand hygiene and PPE audits will be undertaken locally during 2017/18. Hand hygiene observational audit Hospices Hospices audited Audits submitted Compliance achieved 7 81 92% Marie Curie Nursing Service Regions audited Audits submitted Compliance achieved 11 600 99% 12
Hand hygiene resources at the point of care audit Hospices Hospices audited Audits submitted Compliance achieved 6 18 91% Marie Curie Nursing Service Regions audited Audits submitted Compliance achieved 11 522 87% Correct wearing of PPE at the point of care Hospices Hospices audited Audits submitted Compliance achieved 6 44 87% Marie Curie Nursing Service Regions audited Audits submitted Compliance achieved 11 434 95% PPE resources at the point of care Hospices Hospices audited Audits submitted Compliance achieved 6 24 86% Marie Curie Nursing Service Regions audited Audits submitted Compliance achieved 11 453 62% 13
7 Surveillance 7.1 Healthcare associated infections There is no mandatory requirement for Marie Curie to undertake surveillance of HCAIs. However, in line with best practice and Marie Curie policy, we continue to monitor the acquisition of Meticillin-sensitive Staphylococcus Aureus (MSSA), MRSA and E. coli bloodstream infections and toxigenic Clostridium Difficile infection (CDI). The local clinical teams are responsible for collecting and reporting the data via Sentinel, the complaints and incidents logging and monitoring tool used by Marie Curie. All reported acquisitions are reviewed by the SNIPC and, where appropriate, a postinfection review is undertaken. Hospices The table below shows reported infections (including known on admission, previous positive and suspected infections). For data of all IPC reported incidents, see Appendix 1. 2016/17 Hospices Clostridium Difficile Toxin (CDT) 10 E. coli Bacteraemia 3 Gram Negative Multi-Drug Resistant Organism including CRE/CPE 1 MRSA Bacteraemia 0 MRSA (other than Bacteraemia) 6 MSSA Bacteraemia 0 Other Bacteraemia 1 Total 21 On investigation of these reported infections it was found that there were no cases of MSSA, E. coli or MRSA blood stream infections in our in-patient service during 2016/17. Of the 10 reports of CDT, seven were either found to be not positive or on admission. Three patients were diagnosed with CDI in our in-patient services. Post-infection reviews were carried out for all three cases and all were attributable to Marie Curie (acquired in our care more than 72 hours post-admission). However, the post-infection reviews determined there were no lapses in care and all three cases were unavoidable. One case triggered a further clinical review. 14
Marie Curie Nursing Service In the nursing service, we note known infections and conditions to advise our staff on appropriate actions to take when caring for these patients. We recorded 23 incidences of infection in the nursing service. Ben Gold/Marie Curie 7.2 Outbreaks/period of increased incidence in in-patient areas Only one period of increased incidence was reported in the Marie Curie Hospice, Newcastle of a suspected small round-structured virus causing symptoms of diarrhoea and vomiting. There was one patient with symptoms, two staff were off sick with similar symptoms and three relatives (who had visited in the previous 48 hours) were showing symptoms. In line with IPC SOP for management of a period of increased incidence, the DIPC was contacted and appropriate action was taken at the time. This included the closure of the ward for one day, with the ward opened following a postoutbreak clean by facilities staff. No causative agent was identified. 8 Influenza immunisation activity Marie Curie has multiple modes of delivering the Marie Curie model for influenza vaccine, including partnerships with local Clinical Commissioning Groups to pay for vaccinations that members of staff administer to other staff, and offering free vaccine vouchers to encourage frontline staff to receive a vaccine. Marie Curie does not have an accurate system to identify the number of staff who received the vaccine. In 2016/17, a pilot scheme has been planned in partnership with the local NHS provider to offer staff at the Marie Curie Hospice, Cardiff and the Vale immunisation, to increase uptake of influenza and other vaccines. Ben Gold/Marie Curie 15
9 Patient and carer experience 9.1 Patient feedback This information was taken from 1,333 surveys and three complaints during the reporting period. Patients completed 53% of surveys; family members and carers completed the remainder. Respondents were given the opportunity to provide free text comments in response to the question on the cleanliness of the hospice. Two hundred and twenty people left a comment in response to this question. These comments can be broken down in to the following themes: Comparison with other providers 4% Hardworking cleaners 4% Clean/spotless/ immaculate 46% Negative comments and suggestions 8% Personal qualities of cleaners 8% General positive description 22% Frequency/amount of cleaning 9% There were 14 comments that can be categorised as negative, or suggestions for improvement. One hundred and one comments said that the hospice was very clean, respondents frequently describing the hospice as spotless or immaculate. People also used a range of positive adjectives to describe the cleanliness of the hospice. Respondents also commented on how hardworking the cleaners are, describing them as thorough and paying attention to detail. Some respondents talked about the personal qualities of the cleaners. 16
Ben Gold/Marie Curie I asked a cleaner to do my Dad s room early yesterday morning before everyone came it was absolutely no trouble to her and I know she stopped what she was doing to do what I asked. Nothing is too much trouble I am so grateful and thankful for everything. It meant so much that she did it straight away. Respondent, whose father was cared for at the Marie Curie Hospice, Bradford 10 Antimicrobial resistance strategy The numbers of patients who are resistant to antibiotics has increased over the last 40 years and the inappropriate use of antimicrobials has been identified as a key contributor. The consequences of antimicrobial resistance include increased treatment failure for common infections and decreased treatment options where antibiotics are vital. Antimicrobial stewardship is crucial in combating this and is an important element of the Department of Health s Five-Year Antimicrobial Resistance Strategy 2013 18. All hospices follow local NHS antibiotic guidelines. The Hospice Manager is responsible for antimicrobial stewardship and the Medical Director and Pharmacist promote and monitor the prudent use of antimicrobials by: optimising therapy for individual patients preventing overuse and misuse minimising the development of resistance at patient and community levels. Both the Marie Curie Hospice, West Midlands and Marie Curie Hospice, Liverpool have implemented antimicrobial stewardship groups and audits. 17
11 Estates department contribution to the IPC work programme 11.1 Legionella compliance with legislation The control of legionella is covered by the legal requirements of the Health and Safety at Work Act 1974, concerning risks from exposure to legionella and guidance on compliance with the relevant parts of the Management of Health and Safety at Work Regulations 1999. Legionella is managed and controlled by the hospice estates facilities department, following Marie Curie policy. All continue to employ the services of contractors, who provide professional legionella services and undertake legionella risk assessments on Marie Curie properties. Written site-specific schemes of control for all in-patient premises, which reflect the initial risk assessment, are in place. The estates and facilities team continually undertook legionella tests throughout the Marie Curie estate in 2016/17, which included temperature tests. 11.2 Pseudomonas compliance with legislation Pseudomonas infections are diseases caused by a bacterium that is found widely in the environment, such as in soil, water and plants. They usually do not cause infections in healthy people. If an infection does occur in a healthy person, it is generally mild. Marie Curie introduced pseudomonas testing during 2016/17. The bacterium was isolated in water sources in seven of our nine hospices. All hospices were supported by an external expert and, where appropriate, local IPC teams and the SNIPC. Remedial actions were immediately put into place and all seven hospices have since been retested. No pseudomonas infections have been recorded or related to those affected areas. 11.3 Cleaning services Operational cleaning services are currently led by Hospice Managers and facilities leads in all in-patient facilities, who are responsible for implementing Marie Curie s cleaning policy. Facilities teams in each location report through a structure of supervisory staff members, who are responsible for the co-ordination of services and monitoring of standards in all 18
in-patient areas. This is in line with national standards of cleanliness. Facilities services are predominantly provided in-house. This helps ensure that services provided by the Facilities Management teams are linked to the needs of clinical services. The Marie Curie Hospice, West Midlands is the only location where cleaning services are outsourced and are provided by Mitie. The contract is due to expire in November 2017. The specification is currently being reviewed and will go out to tender in June 2018. 11.4 Monitoring arrangements for cleaning service To monitor compliance to cleaning standards, Marie Curie operates a monitoring system that covers all 49 elements set out in the National Standards of Cleanliness 2007 Approved Code of Practice. Paper audits are completed for all Marie Curie in-patient areas, and written and verbal updates are provided via the IPCC. (See Appendix 2: Hospice technical cleaning audit scores.) An electronic monitoring system is being trialled at the Marie Curie Hospice, Liverpool, to carry out monitoring in a more effective and timely manner. If successful, this will be rolled out to all hospices. The system will also provide better management information, helping identify failure trends and training requirements and improve reporting processes. Monitoring cleanliness is also supported by lead nurses, to undertake a joined-up approach and address any issues patients or clinicians have with facilities services, including the environment. This is actioned by the relevant departments. See Appendix 2 for details of the target scores for each risk category, and the achieved cleaning scores for each hospice for 2016/17. Ben Gold/Marie Curie 19
12 IPC work programme Marie Curie s IPC work programme details our work around continued reporting, surveillance and management of healthcare associated infections, and IPC. The programme is approved by the Trustees and reviewed at each committee meeting. Areas of concern are highlighted and escalated where required. 12.1 Progress against work plan Ben Gold/Marie Curie The IPC Assurance Framework was developed in 2015/16 to provide assurance to Trustees, Regulators, Commissioners and others that prevention and control of infection risks were being identified and managed effectively, and to ensure compliance with all regulatory requirements and standards (see section 3.2, regulatory compliance). The IPC Assurance Framework annual work plan was considered as Marie Curie s healthcare associated infection reduction plan. The plans were monitored by the IPCC. Successes in 2016/17 include: Improving the quality monitoring and surveillance of all infections. A standard operating procedure has been developed and embedded. The IPC reporting categories have been expanded, which will improve the quality of reporting Continuing the development of Link Nurses and the roll out of the framework Implementing and embedding local audit programmes personal protective equipment and hand hygiene. The IPC Assurance Framework will continue to be available and reviewed and updated as required according to regulatory changes. 20
12.2 Programme of policy review After introducing the IPC manual in 2015/16, which is accessible to all staff on the intranet, the SNIPC has continued to develop standard operating procedure in line with the policy review programme, which forms part of the IPCC work plan. The focus for 2017/18 is to implement further specific standard operating procedures to support staff in dealing with specific multi-drug resistant organisms and conditions (eg Carbapenem-resistant Enterobacteriaceae). Using the standard operating procedure for the management of Clostridium Difficile infection gave a clear, structured pathway to managing the infections. It is informative and follows a process to equip you with a clear direction of care management, which includes information for many of the questions staff frequently ask (eg How to manage visitors? What to do with cutlery? Can a patient be transferred?). The root cause analysis tool within the standard operating procedure has been of great use and gave ownership within the multi-disciplinary team. Part 1 directs the user to the immediate action that is required. Part 2 then goes on to the in-depth investigation and includes not only the patients journey but environment and audit process to reflect on and learn from when evaluating infection control practice. Shared learning was particularly constructive and the format of this standard operating procedure guides the team through the pathway, which in turn leads to quality and improvement within the hospice. We have found this very useful and a lot of change in practice has emerged, along with training needs of our staff. Angela Alsop, Lead Nurse, West Midlands 21
13 Priorities for 2017/18 The priorities for 2017/18, listed below, have been developed into the IPC work plan. Key priorities for 2017/18 are to: ensure we have systems in place to manage and monitor the prevention and control of infection for people with a terminal illness in our care, their families and our staff develop and provide suitable, accurate information on infections, and infection prevention and control for our service users, their families, our staff and any person concerned with providing further support or nursing/medical care to our patients ensure that our staff are fully equipped with the knowledge and skills they require to identify, manage and reduce the risk of infection work with internal and external partners to provide and maintain a clean and safe environment that facilitates the prevention and control of infections in managed premises, with particular attention to water safety and policy. 13.1 Future quality and improvement plans Quality and improvement plans include: continuing to have a zero-tolerance infection prevention and control attitude towards people acquiring a healthcare associated infection continuing to provide a framework for assurance including audit, mandatory and induction training continuing to sustain the role of the IPC Link Nurses by developing a resource and competency booklet to help develop professional knowledge and competencies continuing to promote and enhance best practice throughout Marie Curie continuing to make water safety and hygiene a priority developing an IPC web page, with the help of the communications team. 22
14 Conclusion Infection prevention and control remains a priority for Marie Curie. The IPCC and key stakeholders continue to maintain and improve on the application and development of IPC standards. Marie Curie is committed to working towards excellence in IPC practice as a best practice provider, considering our contractual obligation to our external commissioners. Infection prevention and control is the responsibility of all staff. The successes over the last year have been possible due not only to the commitment of the SNIPC but also to the commitment demonstrated at all levels within the organisation. 23
Appendix 1 IPC reported incidents 2016/17 National 2016/17 Hospices Marie Curie Nursing Service Clostridium Difficile Antigen (CDA) 0 0 Clostridium Difficile Toxin (CDT) 10 7 E. coli Bacteraemia 3 0 Gram Negative Multi-Drug Resistant Organism including CRE/CPE 1 1 MRSA Bacteraemia 0 0 MRSA (other than Bacteraemia) 6 1 MSSA Bacteraemia 0 0 Multi-Drug Resistant Organisms (eg ESBL) 0 1 Norovirus 0 0 Other Bacteraemia 1 0 Vancomycin Resistant Enterococci (VRE) 0 0 Other 28 7 Infection control policy not followed 11 6 Totals 60 23 NB. There were previously limited options for IPC categories in Sentinel, the complaints and incidents logging and monitoring tool used by Marie Curie. The Other category incorporated a number of IPC-related options, such as Vancomycin Resistant Enterococci, as separate categories for these incidents did not exist. Changes were made to Sentinel in early 2017 to improve recording and monitoring of incidents, including creating new, separate categories for IPC. Records have not been retrospectively updated. 24
Local Hospices Belfast Bradford Cardiff and the Vale Edinburgh Glasgow Hampstead Liverpool Newcastle West Midlands Clostridium Difficile Antigen (CDA) 0 0 0 0 0 0 0 0 0 Clostridium Difficile Toxin (CDT) 0 0 2 2 0 0 1 0 5 E. coli 1 0 0 2 0 0 0 0 0 Gram Negative Multi-Drug Resistant Organism including CRE/CPE 0 0 0 0 0 0 1 0 0 MRSA Bacteraemia 0 0 0 0 0 0 0 0 0 MRSA (other than Bacteraemia) 0 2 3 0 0 0 0 1 0 MSSA Bacteraemia 0 0 0 0 0 0 0 0 0 Multi-Drug Resistant Organisms (eg ESBL) 0 0 0 0 0 0 0 0 0 Norovirus 0 0 0 0 0 0 0 0 0 Other Bacteraemia 0 0 0 1 0 0 0 0 0 Vancomycin Resistant Enterococci 0 0 0 0 0 0 0 0 0 Other 3 2 1 13 1 1 3 2 2 Infection control policy not followed 0 0 0 0 10 2 0 0 0 Totals 4 4 6 18 11 3 5 3 7 Edinburgh reported a total of 13 incidences in the Other category on Sentinel. Their policy during this time was to report all patients requiring transmissionbased IPC precautions, including those patients admitted with a known organism. Changes were made to Sentinel in early 2017 to improve recording and monitoring of incidents, with a more focused approach to reporting IPC incidences. 25
Local Marie Curie Nursing Service Central Eastern London and South East North East North West Northern Ireland Scotland North Scotland South South West Wales Clostridium Difficile Antigen (CDA) Clostridium Difficile Toxin (CDT) 0 0 0 0 0 0 0 0 0 0 1 0 0 4 2 0 0 0 0 0 E. coli 0 0 0 0 0 0 0 0 0 0 Gram Negative Multi- Drug Resistant Organism including CRE/CPE 0 0 0 0 1 0 0 0 0 0 MRSA Bacteraemia 0 0 0 0 0 0 0 0 0 0 MRSA (other than Bacteraemia) 0 0 0 0 1 0 0 0 0 0 MSSA Bacteraemia 0 0 0 0 0 0 0 0 0 0 Multi-Drug Resistant Organisms (eg ESBL) 0 0 0 1 0 0 0 0 0 0 Norovirus 0 0 0 0 0 0 0 0 0 0 Other Bacteraemia 0 0 0 0 0 0 0 0 0 0 Vancomycin Resistant Enterococci 0 0 0 0 0 0 0 0 0 0 Other 1 0 0 3 2 0 0 0 1 0 Infection control policy not followed 0 0 0 5 0 0 0 0 1 0 Totals 2 0 0 13 6 0 0 0 2 0 26
Appendix 2 Hospice technical cleaning audit scores All areas are assigned one of four risk categories, according to their functionality. As each functional area represents a different degree of risk, each requires different frequencies of cleaning, which have been developed locally, and different frequencies of auditing. All rooms are audited using the 49-element audit tool. This is a rolling audit programme and the timing of the audits are affected by the capacity and workload of individual units. The introduction of an electronic monitoring system and an increased number of auditors will improve the process and therefore we expect all future audits to be completed. Category Area Frequency of audit Very High Risk Marie Curie does not have any areas in this category N/A High Risk All wards Monthly Significant Risk Clinical departments Every three months Low Risk Non-clinical areas Every six months 27
Hospice technical audit cleaning scores High Risk Areas Target score: 95% West Midlands Newcastle Liverpool High Risk Areas (wards) Edinburgh Hampstead Belfast Cardiff Bradford Glasgow Apr 96.69% 98.00% 100.00% 97.00% 97.00% 97.00% 98.95% 98.00% May 98.68% 99.00% 100.00% 96.00% 96.00% 98.00% 98.34% 99.00% 99.00% Jun 97.18% 99.00% 100.00% 91.00% 97.00% 98.00% 84.00% 97.00% 98.00% Jul 99.99% 99.00% 100.00% 98.00% 97.00% 100.00% 97.00% 98.00% 98.05% Aug 99.65% 98.00% 100.00% 97.50% 96.00% 98.00% 97.00% 96.50% 98.05% Sep 99.89% 99.00% 100.00% 97.00% 97.00% 99.00% 98.00% 98.25% Oct 97.71% 97.00% 100.00% 97.50% 98.00% 99.00% 97.23% 97.33% Nov 97.17% 100.00% 100.00% 97.00% 98.00% 99.00% 97.00% 97.00% 98.00% Dec 98.16% 98.00% 95.00% 97.00% 99.00% 96.81% 97.00% 97.66% Jan 97.99% 95.00% 97.00% 98.00% 97.00% 96.34% 98.00% Feb 98.99% 99.00% 100.00% 96.00% 98.00% 99.00% 96.34% 98.00% 97.00% Mar 98.79% 99.00% 99.75% 97.50% 96.00% 98.50% 98.00% 97.00% Significant Risk Areas Target score: 85% West Midlands Newcastle Significant Risk Areas (clinical departments) every three months Liverpool Edinburgh Hampstead Belfast Cardiff Bradford Glasgow Apr 99.15% 93.00% 98.00% 97.00% 99.62% 99.00% May 94.66% 99.00% 100.00% 99.87% 99.00% 99.00% Jun 95.05% 99.00% 98.00% 98.00% 99.00% Jul 98.24% 100.00% 100.00% 93.00% 98.00% Aug 99.50% 94.00% 100.00% 99.00% 97.89% 95.00% Sep 99.63% 99.00% 98.00% Oct 94.75% 100.00% 98.00% 99.00% 96.89% Nov 94.75% 96.00% 98.00% 96.90% 95.33% Dec 95.00% 99.00% 98.00% 99.00% 95.59% Jan 94.50% 91.00% 99.00% Feb 96.33% 100.00% 98.00% 91.00% 100.00% 94.00% Mar 97.18% 98.00% 98.34% 99.00% 98.00% 28
Low Risk Areas Target score: 75% West Midlands Newcastle Low Risk Areas (non-clinical areas) every six months Liverpool Edinburgh Hampstead Belfast Cardiff Bradford Glasgow Apr 99.78% 98.00% 97.00% 98.00% 99.85% 100.00% May 98.39% 86.00% 95.00% 92.00% 99.61% 98.00% 99.00% Jun 98.78% 91.00% 97.00% 99.00% Jul 99.36% 91.00% 96.00% 98.00% 96.00% 86.00% 95.33% Aug 99.99% 97.00% 98.00% 97.00% 98.00% 99.64% 97.00% Sep 99.65% 93.00% 96.00% 98.00% 100.00% Oct 92.38% 99.00% 95.47% 94.33% Nov 92.71% 96.00% 99.00% 96.60% 97.00% Dec 99.00% 97.50% 97.00% 99.00% 94.73% 98.00% Jan 96.33% 99.00% 95.00% Feb 95.86% 97.00% 85.00% 98.00% Mar 96.15% 97.00% 100.00% 96.00% 89.00% 29
Appendix 3 Marie Curie Infection Prevention and Control (IPC) Annual Work Plan 2017-18 This should be considered as our Health Care Associated Infection (HCAI) reduction programme. The core activities of the Infection Prevention and Control programme remain focused on ensuring continuing compliance with regulatory requirements and removing the risk of infection. Progress against the Programme will be monitored by the Infection Prevention and Control Committee (IPCC) and the Clinical Governance Executive Committee (CGEC). No Key Priorities for 2017-18 Responsible Contribution to the Quality Assurance Strategy Outcomes 1 Ensure we have systems in place to manage and monitor the prevention and control of infection for people with a terminal illness in our care, their families and our staff. 2 Develop and provide suitable, accurate information on infections, and infection prevention and control for our service users, their families, our staff and any person concerned with providing further support or nursing/medical care to our patients. 3 Ensure that our staff are fully equipped with the knowledge and skills they require to identify, manage and reduce the risk of infection. 4 Work with internal and external partners to provide and maintain a clean and safe environment that facilitates the prevention and control of infections in managed premises, with particular attention to water safety and policy. Director of Infection Prevention and Control (DIPC) DIPC DIPC DIPC Healthcare is safe for every person every time Healthcare is safe for every person every time Healthcare is safe for every person every time Healthcare is safe for every person every time 30
Implementation Plan 2017-18 Key Priority 1 Action(s) required Lead Date/ intervals Assurance evidence Ensure we have systems in place to manage and monitor the prevention and control of infection for people with a terminal illness in our care, their families and our staff. Infection risk assessment to be undertaken on referral and admission All IPC incidents are reported on Sentinel Provide HCAI statistics on Staphylococcus bacteraemia, E.coli, Klebsiella and pseudomonas aeruginosa bacteraemia and Clostridium Difficile Toxin (CDT) positive cases for the attention of operational teams, Executive Directors and the Council of Trustees Lead Nurse/ Medical Director Lead Nurse/ Medical Director DIPC Senior Nurse, Infection Prevention and Control (SNIPC) Ongoing Ongoing Quarterly Patient assessment documentation Sentinel/local microbiology systems IPCC quarterly reports and minutes Quality and patient safety reports Annual report for IPC Carry out post infection review (PIR) on those infections acquired post-48hrs after admission. Ensure any learning outcomes are shared via the IPCC with wider circulation as required Deputy Director of Nursing DIPC SNIPC Ongoing Post infection review documentation Clinical Lead Review Marie Curie Assurance Framework as required DIPC SNIPC Quarterly IPCC quarterly reports and minutes Provide assurance through agreed IPC audit programme that staff are compliant with key IPC prevention strategies DIPC SNIPC Hospice Managers/ Lead Nurse As required All cleaning audits reported quarterly to IPCC Local quality board minutes Key Priority 2 Action(s) required Lead Date/ intervals Assurance evidence Develop and provide suitable, accurate information on infections, and infection prevention and control for our service users, their families, our staff and any person concerned with providing further support or nursing/ medical care to our patients. Review patient information leaflets including: Hand hygiene Clostridium Difficile Norovirus Reducing the risk of infection Develop the intranet pages to hold all resources and information on IPC and agree a process for updating regularly SNIPC IPC Link Nurses DIPC SNIPC December 2017 February 2018 Leaflets are available in hard copy and on the intranet page Intranet pages are available 31
Key Priority 3 Action(s) required Lead Date/ intervals Assurance evidence Ensure that our staff are fully equipped with the knowledge and skills they require to identify, manage and reduce the risk of infection. Review and update policies and Standard Operating Procedures (SOPs); ensure that they are uploaded to the intranet All staff receive appropriate IPC education at the time of induction. Updates are in line with Statutory and Mandatory training policy DIPC SNIPC Head of Practice Development Ongoing Quarterly SOPs available on the intranet Quarterly training reports to CGEC Link Nurses have access to four training and development events per annum Hospice Manager Ongoing Regional Manager Lead Nurses Key Priority 4 Action(s) required Lead Date/ intervals Assurance evidence Work with internal and external partners to provide and maintain a clean and safe environment that facilitates the prevention and control of infections in managed premises, with particular attention to water safety and policy. Monitoring of water safety plans through IPCC and Health and Safety Group Continue surveillance of organisms as per water hygiene policy Director of Corporate Affairs DIPC Health and Safety Manager Quarterly Ongoing Health and safety minutes Sentinel/local testing results Water hygiene policy Sentinel IPCC quarterly reports IPCC minutes Director of Nursing reports IPC Annual Report Share any learning across all hospices Hospice Managers Ongoing 32
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For further information contact Dee Sissons Executive Director of Nursing dee.sissons@mariecurie.org.uk Cover photo: Ben Gold/Marie Curie Thank you to everyone who supports us and makes our work possible. To find out how we can help or to make a donation, visit mariecurie.org.uk mariecurieuk Charity reg no. 207994 (England & Wales), SC038731 (Scotland) C072