DIRECTOR OF INFECTION PREVENTION AND CONTROL ANNUAL REPORT

DIRECTOR OF INFECTION PREVENTION AND CONTROL ANNUAL REPORT 2011-12 Judy Hillier Director of Nursing & Quality Director of Infection Prevention & Control Ann Bishop Specialist Infection Practitioner Infection Prevention and Control Team Lead

Section INDEX 1.0 Introduction 4 2.0 The Infection Prevention and Control Service 4 3.0 Review of Infection Prevention and Control Objectives and the Annual Programme 4.0 Surveillance 5 Page 5.0 MRSA Screening 13 6.0 MRSA Patient Held Records (PHR) 14 7.0 Audit 14 8.0 Hand Hygiene Observational Audits 15 9.0 Patient Environmental Action Team (PEAT) 16 10.0 Observations of Practice High Impact Interventions (HII) 16 11.0 Asepsis Training and Podiatry 18 12.0 Sharps 18 13.0 Education and Training 19 14.0 IPC Link Advisors 19 15.0 Policies 20 16.0 Conclusion 20 Appendix 1 C.difficile Draft Care Pathway 21 Appendix 2 Legionella Report 23 Appendix 3 MRSA Screening Report 28 Appendix 4 Hand Hygiene Observational Tool 36 Appendix 5 CVC PICC Line Care Bundle 38 Appendix 6 Enteral Feeding Care Bundle 42 Appendix 7 Safer Sharps 44 5

EXECUTIVE SUMMARY This report is based on the review of the Infection Prevention and Control Service and the achievements of the provider arm objectives set out in the annual programme for 2011-12. The objectives are based on achieving compliance with the relevant Standards for Better Health Care Associated Infections (revised 2008), NHS Litigation Authority standards and other Department of Health and Strategic Health Authority Drivers. Reduction in Healthcare Associated Infections (HCAI) remains a priority for the NHS and was reiterated by the White Paper Equity and Excellence: liberating the NHS (DH July 2010). It has been recognised that some infections cannot be prevented so the ultimate aim is for zero preventable infections. NHS providers and commissioners should ensure that their HCAI reduction plans are delivered at least to the level of performance set out by HCAI indicators. MRSA remains a significant patient safety issue and along with other HCAI it can cause illness, pain, disability and sometimes death. This, therefore, is a key issue for public confidence within the NHS and reducing HCAI will foremost ensure improved patient outcomes as well as cost savings for the NHS. April 2011 saw the beginning of Solent NHS Trust as a stand alone organisation and the organisation is committed to eliminating all avoidable healthcare associated infections. This report aims to highlight the measures that have been taken to reduce HCAI in Solent NHS Trust during 2011-12. The Director of Infection Prevention and Control (DIPC) has the executive responsibility for ensuring the implementation of strategies to prevent avoidable HCAI at all levels within Solent NHS Trust. The DIPC reports directly to the Chief Executive of the Board and not through any other officer. Director of Infection Prevention and 3 of 47

1.0 INTRODUCTION Reducing HCAI remained a priority within the NHS Operational Framework 2011-12 and Solent NHS Trust is committed to eliminating avoidable HCAI. Achieving this vision requires planning and a systematic approach. The Infection Prevention and Control Team (IPCT) led the annual programme for the provider arm and worked collaboratively to ensure this priority was realised within Solent NHS Trust. Although the IPCT have a pivotal role in supporting Solent NHS Trust to achieving its aims, the Trust acknowledges that every member of staff needs to be involved in the process. Clarity is required on both individual and service/care delivery unit accountability and responsibility therefore making infection prevention and control everyone s concern. Key standards and drivers emphasised the need for all staff to be involved in infection control and that HCAI initiatives are not solely the responsibility of the IPCT. This report will focus on the associated activities and outcomes of the annual programme by using the key objectives and performance indicators. 2.0 THE INFECTION PREVENTION AND CONTROL SERVICE The IPCT provides a service to all areas of the provider arm of Solent NHS Trust. They do this by providing expert knowledge and guidance so that each member of staff is empowered to carry out their role in such a way that the risks of HCAI are minimised. May 2011 saw the departure of the IPCT Lead Nurse and this position has not been filled. The team currently consists of: 2 x WTE band 7 specialist infection practitioners 1 x 0.6 band 7 specialist infection practitioner 1 x WTE band 6 infection practitioner 1 x 0.8 band 4 administration co-ordinator It needs to be noted that a Service Specification is in place with Portsmouth City to provide two and a half days a week of an enhanced infection control service to GP practices across the city. The two and a half days is provided from the above staffing. It aims to assist with the following outcomes: Reduction in Primary Care Organisation (PCO) rates of targeted HCAI Develop and embed GP practice based infection control Link Advisors Provision of data to NHS Portsmouth Commissioners on a quarterly basis Root cause analysis for any Meticillin Resistant Staphylococcus Aureus (MRSA) bacteraemia or CDI death mentioned on part one of a death certificate Support and advice to GP practices A total of 158 infection cases during 2011-12, predominantly complex MRSA were identified through the service specification. Actions and advice were provided in a timely way therefore helping to avoid serious infection or septicaemia developing within this vulnerable group. Director of Infection Prevention and 4 of 47

3.0 REVIEW OF INFECTION PREVENTION AND CONTROL OBJECTIVES AND THE ANNUAL PROGRAMME The Annual Infection Prevention and Control Programme for 2011-12 outlined key objectives, activities and priorities for Solent NHS Trust. This programme supported the Policy for Infection Control Framework. The purpose of the programme was to identify all key work streams required to ensure that the organisation minimised the risk of HCAI. The objectives for the annual programme were based on achieving compliance with national standards and guidance. The main drivers being the Health and Social Care Act (2008) Code of Practice for the Prevention and Control of Healthcare Associated Infections (revised 2009), NHS Litigation Authority Standards and the relevant Standards for Better Health. The purpose of the programme was to help identify all key work streams required to ensure all appropriate actions were applied where necessary, provide a structure for the IPCT and ensure limited resources are applied appropriately to achieve maximum impact. 4.0 SURVEILLANCE The main objective of on-going surveillance is to identify trends and hotspots and ensure early interventions are applied to provide assurance that all aspects of care are being carried out in the safest way possible with regards to infection prevention and control. In addition to this, preventing outbreaks depends upon prompt recognition of two or more infections with alert organisms and putting into place special control measures to reduce onward transmission of the organism. The IPCT receives results of alert organisms on a daily basis from two microbiological laboratories so it needs to be noted that there are variations in reporting mechanisms between Portsmouth and Southampton Cities. For 2011-12 targets for the reduction of MRSA bacteraemia and CDI cases were set across the health economy in the form of Primary Care Organisation (PCO) targets. Solent NHS Trust did not have set targets for 2011-12 but fed into the PCO targets for Portsmouth and Southampton Cities. The PCO targets for 2011-12 were set at: MRSA Bacteraemia CDI Portsmouth City 6 Portsmouth City 50 Southampton City 4 Southampton City 71 The year end results are illustrated below MRSA Bacteraemia CDI Portsmouth City 0 Portsmouth City 55 Southampton City 6 Southampton City 32 Director of Infection Prevention and 5 of 47

Solent NHS Trust contributed the following to the above targets MRSA Bacteraemia CDI 2 3 In the absence of having our own reduction targets during 2011-12 internal surveillance was upheld and reported quarterly to the Infection Prevention and Control Committee. The graph below illustrates comparative data within Solent NHS Trust between 2010-11 (then Solent Healthcare) and 2011-12. Alert Organisms Solent NHS Trust 16 14 12 10 8 6 4 2 0 MRSA colonisation/infection Admission MRSA colonisation/infection identified MRSA Bacteramia C. difficile toxin positive < 3 days 2010-11 2011-12 MRSA Pre 48 hour bacteraemia cases 2011-12 An MRSA bacteraemia is defined as a positive blood culture test for MRSA. Reports of MRSA cases must include all positive MRSA blood cultures detected in laboratories, whether clinically significant or not, whether treated or not, whether acquired within the Trust or elsewhere. Positive results on the same patient more than 14 days apart should be reported as separate episodes, irrespective of the number of specimens taken in the intervening period, or where they were taken (HPA 2010). Appropriate objective figures for 2011-12 were calculated centrally for each PCO and acute Trust based on their performance in the twelve months October 2009 to September 2010. For the best performers no central objectives were set but these organisations negotiated local objectives in order that at least their performance was maintained. MRSA bacteraemia cases are categorised as either pre or post 48 hours relating to the timescale of when the infection is diagnosed in relation to admission. If less than 48 hours it will be assumed that the infection was acquired within the community. Every pre 48 hour MRSA bacteraemia case that is linked with Solent NHS Trust services Director of Infection Prevention and 6 of 47

received a full Root Cause Analysis (RCA) investigation and actions were developed for learning in line with DH guidance. The first MRSA pre 48 hour bacteraemia case occurred in August 2011. The following is a brief summary of events: Patient admitted to the Southampton Independent NHS Treatment Centre for a right total knee replacement. Surgery was uneventful and the patient was discharged home on day six. Community nursing services continued care of wound as some gaping to distal end and some oozing had been noted prior to discharge. Patient was readmitted approximately six weeks later with a diagnosis of knee infection that required washout and debridement the following day. Further washout and debridement was required prior to first stage revision. Patient then transferred to a Solent NHS Trust rehabilitation ward for a period of rehabilitation prior to becoming increasingly unwell and finally requiring urgent transfer to University Hospital Southampton (UHS) with symptoms of septicaemia. The severity of this infection required the patient to undergo an above knee amputation. A full RCA was completed and the incident reported via the Serious Incident Requiring Investigation (SIRI) process. Each service that was involved with this case produced an action plan. The second pre 48 hour MRSA bacteraemia related to a patient admitted to a local authority residence in Southampton for a period of rehabilitation. Solent NHS Trust funds some of the rehabilitation beds at the Southampton City Council premises so the case was attributed to this organisation for full SIRI investigation. This was a complex case and unfortunately the patient died from a necrotising pneumonia caused by a relatively unusual PVL producing strain of MRSA which is generally transmitted within the community and is endemic in Europe. The transmission epidemiology differs from MRSA strains that are generally associated with hospitals, in that it often colonises younger people without underlying medical conditions. It tends to cause skin infections in about 50% of those colonised and can cause devastating infection in some individuals. Transmission in hospitals or other healthcare settings can occur, usually involving a healthcare worker with unrecognised skin infection. This was a particularly complex case due to the rare nature of the PVL MRSA. The subsequent investigation involved the screening of over 100 healthcare workers that had come into contact with this patient. Prior to being admitted to Brownhill House the patient had spent two weeks at UHS for control of back pain and improvement of mobility. Therefore UHS contributed to the RCA, called their own investigation and screened many staff for MRSA. Clostridium Difficile Infection (CDI) Infection due to C.difficile is defined when a patient shows clinical symptoms of CDI infection and has a positive laboratory test according to the laboratory s diagnostic algorithm and is over two years of age (HPA 2010). Positive results on the same patient more than 28 days apart should be reported as separate episodes, irrespective of the number of specimens taken in the intervening period, or where they were taken. Similar to MRSA, appropriate objective figures for 2010-11 were calculated centrally for each PCO based on performance figures from the twelve months October 2009 to September 2010. The PCOs are accountable for all cases of CDI occurring in their populations. Cases are attributed to responsible PCOs via the NHS Connecting for Director of Infection Prevention and 7 of 47

Health s Demographics Batch Service (DBS) using the NHS number and date of birth. Acute Trusts on the other hand are accountable for all CDI cases where the sample was taken on the fourth day or later of an admission to that Trust (where the day of admission is day one i.e. 72 hour cut off point). Where CDI is mentioned on part one of a death certificate a full RCA is required by the organisation to which the case is attributed. Since 2009 the DH encouraged the use of a local 2-test diagnostic algorithm for CDI testing. During 2011-12 work focused on the performance of various test kits to identify the best combination of existing CDI testing kits commissioned by the DH. March 2012 saw the publication of Updated Guidance on the Diagnosis and Reporting of Clostridium Difficile (DH 2012). This guidance included a testing algorithm that provided a step by step means of optimising performance, with the ability to clinically categorise patients with much greater accuracy. It sets out: Who should be tested and what type of samples that should be taken The types of tests that should be used for detecting infections What healthcare providers should do, depending on the outcome of the tests The two laboratories within Portsmouth Hospitals Trust (PHT) and UHS commenced the two stage testing for CDI during 2011-12. This process strengthens CDI testing, diagnosing and reporting in line with the above DH guidance. The two stage testing distinguishes between carriage and actual infection therefore improving the safety from onward transmission within inpatient areas as carriage with symptoms will ensure all precautions are applied. It needs to be noted that it is only toxin positive results that will contribute to targets as confirmed by the DH. Enhanced surveillance means the IPCT were aware of any cases within inpatient areas as well as cases attributed to the wider community within Portsmouth and Southampton cities. Trends and hotspots will be easily identified through this method of observation. During 2011-12 there were three actual cases of CDI within Solent NHS Trust inpatient areas. Internal surveillance for Solent shows this a reduction of 66% on the number of CDI cases for the previous year. For the three in-patient cases mini RCAs were completed in order to identify any actions for learning. The three cases occurred at different times, in different locations and there was no evidence of onward transmission of infection in any of the cases. All were complex cases requiring antibiotics which have been considered appropriate. Two out of the three cases developed symptoms within 72 hours of transfer from secondary care. The IPCT visits on a daily basis whilst a patient continues to have symptoms of active infection, a care bundle is used to ensure all actions are achieved. This care bundle was developed in line with the High Impact Interventions (HII) and can be seen at Appendix 1. Director of Infection Prevention and 8 of 47

. During the first Quarter of 2011 Portsmouth City PCO targets breached for two consecutive months. An urgent meeting was called with the Commissioners and an action plan developed. There were no further breaches. However, enhanced surveillance of all cases of CDI was maintained by the IPCT. Due to the Service Specification set up for NHS Portsmouth the Commissioners required a report on the five cases over trajectory breach within the Portsmouth area. For the purpose of enhanced surveillance all of the community cases were scrutinised. The analysis of available data provided reassurance that there had been no onward transmission of CDI. There were no identified links with GP practices across the city. The majority of the antibiotic prescribing had been appropriate. The average age was over 65 years as to be expected and most patients had co-morbidity and complex needs. Fourteen out of the 17 cases studied had received antibiotics and 11 out of the 17 cases had recent exposure to secondary care. Future recommendations include: Closer scrutiny of all CDI cases Actions to be instigated immediately if any trends or hotspots identified Recent antibiotic audits to be fed back to GP practices CDI policy reviewed to reflect best practice CDI High Impact Intervention (HII) tool used for all inpatient cases Current CDI surveillance form updated to ensure enhanced data capture Meticillin Sensitive Staphylococcus Aureus (MSSA) Mandatory MSSA bacteraemia surveillance was introduced in January 2011. The HPA has carried initial analysis of the data that is submitted via microbiology laboratories. The data so far suggests that skin and soft tissue infections make a significant contribution to MSSA bacteraemia. This differs from MRSA where such things as intravenous lines were a major contributory factor. A small working group has been set up to consider the results of the MSSA audit to develop a coherent screening programme for Staphylococcus Aureus. Further information will become available in the coming year. There are currently no targets or trajectories set against MSSA. Numbers have been collated as part of local surveillance, this will provide a baseline if reduction targets are set in the future. There were no cases within Solent NHS Trust in-patient areas during 2011-12. For information only the number of MSSA bacteraemia cases recorded for the PCO targets for Portsmouth and Southampton cities for 2011-12 was 49. Eschericia Coli (E.coli) Mandatory enhanced E.coli bacteraemia surveillance commenced in June 2011. There has been a year on year increase in gram negative bacteraemias as reported by the HPA voluntary CoSurv system. As a result of this it has been recommended by the DH to introduce mandatory E.coli surveillance. The enhanced surveillance will be able to gather together in one dataset of essential clinical data pertaining to the focus and aetiology of E.coli bacteraemias. The collection of data will continue for at least 12 months. There are currently no plans to set national targets or trajectories against E.coli bacteraemia cases. As with MSSA the numbers of E.coli have been collated locally, this will provide a baseline if reduction targets are set in the future. In July Director of Infection Prevention and 9 of 47

2011 the DH sent out clarification that the data collection is investigative rather than for performance management. During December 2011 initial analysis indicated that it is not easy to identify to date an intervention to reduce healthcare associated cases of E.coli bloodstream infections. The Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) requested that the HPA carry out further analysis of the data to try and recognise any additional risk factors that could identify appropriate interventions. Further information will become available in the coming year. It is important to note that good urinary catheter practice must always be considered. There were no cases within Solent NHS Trust inpatient areas during 2011-12. For information only the number of E.coli bacteraemia cases recorded for the PCO targets for Portsmouth and Southampton cities for 2011-12 was 110 (please note figures have only been collated from June 2011). Legionella On 31 January 2012 the Estates Health and Safety Officer for Southern Health NHS Foundation Trust was notified by the laboratory for Clearwater that a hot tap water sample taken from a WC (room 3132A) in Fanshawe Wing, Level B in the vicinity of the Nichols Town Surgery at the Royal South Hants Hospital contained legionella pneumophila serogroup 2-14. This water sample showed extremely high levels of legionella at 44,000 cfu/1000kl. It is well documented that legionella pneumophilla serogroup 1 is responsible for the majority of confirmed cases of legionnaires disease within the UK. This was one isolated area to date. The WC is in a quiet area within a consulting suite as opposed to a public thoroughfare, therefore it can be assumed it has limited use. The WC was immediately put out of action The risk of legionella being identified in an ageing building that has been modified to accommodate various healthcare services will always remain due to complex plumbing systems that have the ability to support the growth of legionella. This risk had been identified and water sampling occurs at three monthly intervals at the RSH which is in excess of any required legislation. The services of a recognised and accredited external contractor are employed to process results of any water samples taken from this area. Clearwater Technology Ltd interprets the results and assists with risk assessments accordingly. The primary mode of transmission of legionella is in the form of inhalation of aerosol droplets from a direct source, person to person transmission does not occur. Therefore, the presence of showers, whirlpool baths, Jacuzzis, cooling towers and air conditioning systems need to be considered in the risk assessment process. Host susceptibility is linked to those with a suppressed immune system, smokers and those with chronic lung conditions. It needs to be noted that this water feed did not include any in-patient areas. Initial assessment based upon the standard risk assessment with Solent NHS Trust Health and Safety policy indicated that the risk to the general public, staff and patients was minor at this time but had the potential to increase if further spread of legionella was identified. Director of Infection Prevention and 10 of 47

The first control measure of water pasteurisation of the level A calorifiers followed by flushing of all hot water outlets in the area supplied by this particular water feed was carried out with immediate effect. The process of pasteurisation and flushing continued morning and evening for two weeks. Much maintenance work subsequently took place on dead legs and thermostatic mixer valves. Further sampling took place at regular intervals. Early April showed that levels had fallen within normal parameters after extensive work and commitment from all staff involved. Barry Toward and the Estates Team have produced a management plan for the next phase of the monitoring and control of water safety within this vicinity. Information and learning has been disseminated to the Portsmouth City area so that safety programmes will be replicated across the whole organisation. The actual impact on Solent NHS Trust was identified as a near miss by intervention with no onward transmission to patients, staff or the public. There was however disruption to water services and financial cost to the organisation of approximately 50,000. A full report can be seen at Appendix 2. Gastroenteritis outbreaks causing ward closure During 2011-12 there were no confirmed outbreaks of diarrhoea and/or vomiting due to Norwalk virus or similar within Solent NHS Trust in-patient areas. Preparation for potential D&V outbreaks began early in the autumn and was the subject of the Link Advisor workshops. The D&V resource boxes were updated within all inpatient areas. There were four watching briefs where staff were very prompt to report two or more cases of diarrhoea and/or vomiting. This prompt reporting enabled all the appropriate precautions to be applied and stool samples obtained. On each of these occasions the cause was found to be due to other reasons rather than viral infection. The effect of Norwalk virus varied across the Portsmouth and Southampton areas. PHT saw few cases compared to previous years and did not close wards but managed to isolate affected patients in single rooms whilst wards remained fully operational. PHT now has much more capacity to isolate due to increased number of single rooms as a result of the Private Finance Initiative (PFI). UHS on the other hand was affected by vast numbers of outbreaks of Norwalk virus affecting many wards and thousands of bed days were lost. A review meeting was hosted by UHS to explore ideas and actions to prevent the extent of this level of D&V activity next winter. It is believed that one of the main contributing factors was the high number of symptomatic patients being admitted from nursing homes, it was felt that the majority of these patients could be managed in the community given the right support. It was agreed that more education and support is required for nursing homes and GPs. This will be explored by Commissioning Teams within Portsmouth and Southampton cities. The whole Health Economy needs to improve communication between providers with regards to potential or confirmed D&V outbreaks. A task and finish group consisting of managers and clinical staff will be set up with the aim of identifying a clearer pathway for nursing homes and GPs. Lines of communication to be strengthened. Solent NHS Trust will contribute to this group. Director of Infection Prevention and 11 of 47

The HPA runs a voluntary reporting system for data capture on hospital (acute or community) outbreaks of Norovirus. Solent NHS Trust will contribute to this reporting system. Influenza During 2011-12 the IPCT obtained weekly data from the HPA on influenza activity. The influenza GP consultation rates remained low to average during the year. The majority of positive influenza samples were attributed to influenza A (H3). Data gathered by the HPA revealed that within the general population 73% of people in England aged 65 years and over had received the 2011-12 influenza vaccine and for those within a clinical risk group aged under 65 years the uptake was around 50%. The DH circulated messages to NHS staff during 2011-12 encouraging all staff to take up the opportunity of receiving an influenza vaccine. It was mentioned that staff have a duty of care to ensure that they receive protection from influenza in the form of vaccination wherever possible. The Occupational Health Team promoted, advertised and tried to accommodate innovative ways to ensure the vaccination uptake was maximised throughout the organisation. The IPCT continued this drive via all education sessions. The following figures have been provided by Occupational Health and are representative of Solent NHS Trust for 2011-12. Staff Groups Percentage All Doctors (excluding GPs) 55.5% Qualified Nurses, midwives and health visitors (excluding GP Practice Nurses) All other professionally qualified clinical staff, which comprises of:- Qualified scientific, therapeutic & technical staff (ST&T) 40.7% 56.5% Qualified allied health professionals (AHPs) Other qualified ST&T Qualified ambulance staff Support to Clinical Staff, which comprises of:- 83.9% Support to doctors & nurses Support to ST&T staff Support to ambulance staff Director of Infection Prevention and 12 of 47

5.0 MRSA SCREENING The DH in the Operating Framework requirement for 2008/9 and 2009/10 identified that to meet the challenge of reducing HCAI the screening for MRSA of all elective admissions must take place from April 2009. This was then extended in the Operating Framework 2010/11 by requesting that NHS providers and commissioners must ensure MRSA screening of all relevant emergency admissions take place no later than 2011 (DH 2010). The current Solent NHS Trust MRSA policy reflects the requirement for all admissions to any inpatient area to be screened for MRSA within 24 hours of admission unless this cannot be achieved for a valid reason. The DH requires a 100% success rate. For the period of 2011-12 the IPCT collated MRSA screening compliance data in two ways. The first involved matching the number of screens processed by PHT and UHS laboratories against the number of patient admissions per quarter. This method gave a year end compliance rate of 113%. This inflated figure reflects that this process is not patient to screen matched and will therefore include any screens submitted for that quarter as some patients will required several sites to be included. So that accurate compliance can be monitored by area the IPCT carried out three Point Prevalence Surveys (PPS) during 2011-12. Below is a summary of that activity. The full report can be seen at Appendix 3 Sample 317 in-patients within Solent NHS Trust Aim To establish the overall percentage of in-patients that had been screened for MRSA within 24 hours of admission as per current MRSA policy and national guidelines. Key Findings Area No eligible No screened Percentage Community Wards (5) 234 188 80% Adult Mental Health (3) 65 41 63% Older Persons Mental Health (4) 51 47 92% Substance Misuse (1) 50 41 82% Totals 400 317 79% This audit was carried out three times in 2011-12 and the above table shows the overall percentage of patients screened within each speciality. This audit shows an increase from 75% in 2010-11 to 79% this year. The audit highlighted reasons for non-compliance such as; Specimens not labelled Not being sent to the laboratory in a timely way If a patient refuses or it is not appropriate to screen it needs to documented clearly (if so this will count as compliant for purpose of the audit) Actions Prioritised by commencing with area of lowest compliance score Director of Infection Prevention and 13 of 47

IPCT worked alongside staff within Adult Mental Health to identify how the process can be made easier for staff to follow Teaching sessions provided to include correct swabbing technique, correct labelling of specimens and checking on results Daily pick up of specimens now in place Development of an MRSA care plan for RIO in conjunction with IT, staff training provided 6.0 MRSA PATIENT HELD RECORDS (PHR) The SHA funded project to create the PHRs commenced in September 2008. This was part of a drive to further reduce HCAIs over the short and long term working across the health economy. The development of the PHR aimed to address the following issues with regards to MRSA: Patient involvement Patient education Family awareness Public awareness Address specific issues and concerns Link between primary and secondary care Since the completion of the project Solent NHS Trust has used the original supply of PHRs provided from project funds. The PHRs are utilised by any newly identified case of MRSA within our services. They are also sent out on a case by case basis to any GP patients when required. To date the SHA has not responded to the final report of the project. The future funding of the PHRs is therefore uncertain. A senior research fellow associated with the School of Health Sciences, Southampton, is currently writing a paper on the impact of the MRSA PHRs. Solent NHS Trust has contributed to that research and ethical approval has been given to extend the research to Solent podiatry patients. The project is due to be completed in January 2013. 7.0 AUDIT The Health and Social Care Act (2008) provides an assurance framework that ensures appropriate systems are in place for patient/service users and staff to be cared for where the risk of healthcare associated infections is kept to a minimum. To ensure continual improvement it is important to have effective policies and procedures relating to infection prevention and control in place and that they are rigorously and consistently applied. Preventing and controlling HCAIs continues to be a key priority for Solent NHS Trust. The Infection Control Nurses Association (ICNA) Audit tools were developed with the support of the Department of Health in 2004 to provide a standardised method of monitoring both clinical practice and the environment. The audits are criterion referenced and therefore is not pass or fail, but requires a commitment to work towards an action plan to achieve 100% compliance. All areas were asked to carry out the ICNA audits that were relevant to their area/service during December 2011. Where the score was less than 100% action Director of Infection Prevention and 14 of 47

plans were required to address issues identified. The action plans required sign off to complete the audit cycle. September 2011 saw the launch of a new set of audit tools from the Infection Prevention Society (IPS) to replace the existing tools described above. These are Quality Improvement Tools (QIT) and designed for detailed measurement of all aspects of practice and the environment. These tools will be introduced to Solent NHS Trust during 2012-13 with the support of the IPCT working alongside Infection Control Link Advisors (LA) set standards and criteria. 8.0 HAND HYGIENE OBSERVATIONAL AUDITS Hand hygiene observational audits were requested to be undertaken by inpatient areas and services during quarter one and quarter three. The audit tool was developed by the IPCT using elements of existing observational tools produced by Health Protection Scotland (2011) and the World Health Organisation (2005) and can be seen at Appendix 4. Training has been provided for Link Advisors. The audit tool has been designed to assist staff in observing hand hygiene behaviour and aims to allow for meaningful feedback to colleagues. This process will also provide assurance that timely and effective hand hygiene is taking place in accordance with the current hand hygiene policy. Below is a summary of that activity for 2011-12. Sample 26 in-patient areas and clinic settings within Solent NHS Trust (51% return) Aim To provide assurance that timely and effective hand hygiene is taking place in accordance with the current hand hygiene policy using an observational tool that has been developed based on the Five Moments for hand hygiene (World Health Organisation 2005) Key Findings Key Moments Percentage Bare below elbows 96% Before contact with patient 92% After contact with patient 94% Before clinical procedures 99% After clinical procedures 98% Before wearing gloves 95% After wearing gloves 97% After contact with patient environment 93% Overall compliance 96% This second audit of 2011-12 showed an increase in overall compliance from 88% to 96%. However, the return rate in the first audit was 64% compared to 51% for the second. Director of Infection Prevention and 15 of 47

Actions Improvement needed on return rates. Further communications, reminders required prior to submission date IPCT to ensure accurate list of all areas that should be taking part Lowest score recorded against before patient contact addressed via all education sessions including Essential Updates, workshops and training days Explore innovative ideas for lone workers where peer review is difficult Encourage Link Advisors to carry out the audit in areas other than their own Hand Hygiene Competencies Hand Hygiene (HH) is recognised as a clinical skill and for that reason the Link Advisors receive training to undertake practical hand hygiene assessments with all clinical staff in their respective clinical area/service on an annual basis. The IPCT held two drop in sessions at SJH and invited staff who had not had the opportunity to complete the assessment to do so. A total of 42 staff attended. Completed competencies were submitted to L&D for collation. For the period 2011-12 a total of 1,110 staff achieved this. The Workforce Team have estimated that this is 36% of all clinical staff employed within Solent NHS Trust. This level of return was disappointing and efforts will be focused on increasing compliance during the coming year. 9.0 PATIENT ENVIRONMENTAL ACTION TEAM (PEAT) 2011-12 saw the first annual PEAT inspection carried out with representation from Portsmouth and Southampton localities auditing each others environment. Consistent involvement across five sites with Solent NHS Trust included Board representation, Trust members, LINK members, patient representation, infection control, Quality Patient Safety Manager along with clinical and estates and facilities management. The five inspections were carried out over four days. Training had taken place prior to the inspections for key people involved. The following table shows predicted scores prior to DH verification. Site Date Environment Food & Hydration Privacy & Dignity Jubilee 02-Mar Excellent Excellent Good SJH 01-Mar Good Good Good SMCHC 05-Mar Excellent Excellent Excellent RSH 07-Mar Excellent Excellent Excellent WCH 07-Mar Excellent Excellent Excellent The IPCT will continue to support mini PEAT inspections for inpatient areas throughout the coming year. 10.0 OBSERVATIONS OF PRACTICE HIGH IMPACT INTERVENTIONS (HII) In 2005 the DH commissioned the Institute for Innovation and Improvement to adapt the Saving Lives delivery programme for non-acute/community settings in health and social care. Essential Steps was designed as a framework to support local organisations providing and commissioning health and social care services outside acute hospital settings. Director of Infection Prevention and 16 of 47

February 2011 saw the introduction of a set of revised tools to replace the above, entitled High Impact Interventions (HII). The aim of the HHI is to support HCAI reduction, further develop knowledge, skills and practice in infection prevention and form an essential part of an organisation s plan to implement best practice. The HHI tools and associated information can be viewed at www.clean-safe-care.nhs.uk. The first meeting of the Infection Prevention and Control Operational Group took place in May 2011 where a workshop was lead by the DIPC on the introduction of the HHI. During the year the IPCT developed several HHI tools. The Central Venous Catheter (CVC) care bundle has been developed for use with PICC lines being cared for in the community. A care bundle needs to instigated and completed each time a member of staff manipulates a PICC line. A Standard Operating Procedure (SOP) accompanies this care bundle and was approved NHSLA an Assurance Committee in January 2012, see Appendix 5. The Urinary Catheter care bundle was developed following the successful implementation of the urinary catheter insertion/care record. This care record was widely circulated and adapted to fit the needs of community teams as well as inpatient areas. It incorporates all elements of the HHI so that auditing against the catheter insertion/care record will be straightforward. The HII for antimicrobial prescribing states that a multidisciplinary antimicrobial stewardship committee should be set up to develop and implement Trusts antimicrobial stewardship strategy and guidelines. It is advised that local guidelines for the treatment of common infections and prophylaxis should be drawn up by each Trust and an antibiotic audit should be developed. An antibiotic study took place in December 2011 within Solent NHS Trust. The aim of the report was to review antibiotic prescribing on all the wards to assess if local guidelines were being followed. The results showed that there is great variation between wards regarding documentation when prescribing antibiotics. It also showed that there was some variation in which guidelines are in use. Consultant Medical Microbiologist Dr Helen Chesterfield will be providing antimicrobial prescribing guidance for Solent NHS Trust. A community hospital antimicrobial self assessment tool was completed and the overall score was 46%. This will provide a benchmark which future improvements may be measured against. An antimicrobial strategy is in the process of being written by Dr Chesterfield specifically for Solent. The HHI to reduce the risk of CDI has been developed and will be utilised by the IPCT with every case of CDI that occurs within any inpatient setting. This will provide reassurance that all necessary processes are in place to protect the patient and prevent onward transmission of infection. The HHI for enteral feeding has been developed and is currently being trialled within children s community nursing teams, see Appendix 6. Further work is needed to produce HHI care bundles for chronic wound management and decontamination. We still do not have a definitive answer as to whether peripheral cannulation is taking place. Once that has been established priority will be given to producing a care bundle for this practice if needed. Director of Infection Prevention and 17 of 47

11.0 ASEPSIS TRAINING AND PODIATRY At the end of the financial year 2010-11 work commenced with podiatry teams to look at improving the process of aseptic technique. The podiatry team deal with particularly complex foot wounds within a patient group that carry a high MRSA acquisition rate due to co-morbidity, multiple courses of antibiotics and contact with healthcare. An action plan had been produced and throughout 2011-12 work continued to address the following issues: Sourcing appropriate dressing trolleys Sourcing appropriate dressing packs Correct skin cleansing prior to wound care Use of sterile gloves for aseptic technique Storage of equipment within treatment rooms Location of hand sanitiser so it is placed near to the point of care Location of clinical waste bins and waste management during aseptic technique Commitment from the podiatry teams meant that all of the above was achieved in a short space of time. The podiatry service purchased bespoke training form an independent provider. This training was well attended and evaluated. Towards the end of 2011-12, the aseptic technique was re-audited within podiatry services and came out at 100% compliance against best practice. The number of MRSA cases within this particular client group has reduced over the same period. Audit of the process will continue within the podiatry teams. 12.0 SHARPS The European Economic Council Directive 2010/32/EU Implementing the framework agreement on prevention from sharps injuries in the hospital and healthcare sector states that member states should, as part of safe practice, provide medical devices incorporating safety-engineered protection mechanisms.i.e. safer sharps devices. Subsequently the IPCT and Occupational Health Lead have been working towards implementing safer sharps throughout the organisation. The IPCT carried out an audit to assess what safer sharps were already in use within the organisation. Of the 52 areas audited 40 were using some safer sharps, however the majority of areas using safer sharps had only one or two items in stock and no formal training in their use was documented. The audit also demonstrated that there are three main work processes where safety could be improved by the use of safer devices. These were: Scalpels (0% safer scalpels in use) Capillary blood lancets (69% of areas did not use safety lancets) Venepuncture (59% of clinical areas did not use safer devices) An action plan was produced to identify a way forward taking into account sharps injury reporting data and overall costs to the organisation. The aim of the action plan is to reduce the number of sharps injuries to staff and patients from medical devices. The action plan can be see at Appendix 7. Director of Infection Prevention and 18 of 47

13.0 EDUCATION AND TRAINING In conjunction with the Learning and Development Team (L&D) the IPCT were committed to providing infection control updates for staff at Corporate and Essential Update Training. 601 staff (95.4%) attended Corporate Induction and 2498 (78.5%) of staff received annual infection control updates via Essential Training Updates. This gives an overall percentage of 81% which is a significant increase against the figures for the previous year of 56% (figures provided by L&D). The objective for 2011-12 was to improve on the previous year s figures and aim for 85% attendance. 14.0 INFECTION PREVENTION AND CONTROL LINK ADVISORS Infection Prevention and Control Link Advisors (LAs) continued to provide an important and supportive role across the organisation during 2011-12. All clinical services are advised to appoint an appropriate person to act as an LA. Within the Terms of Reference the role is summarised as: Attend the two day Train the Trainer course within six months of taking up the role Carry out audits as appropriate to their area and progress any actions arising Carry out and submit six monthly hand hygiene observational audits Carry out and support High Impact Interventions appropriate to their area Carry out hand hygiene and other infection control training within their area Carry out hand hygiene competency assessments on all clinical staff within their area and submit results to L&D Attend a minimum of four Link Advisor workshops annually A total of 10 workshops were held during 2011-2012. Each session had an educational presentation, discussion on new policies, advice on audits that required completing and infection updates. They also facilitated a networking opportunity between colleagues and time to discuss issues with the IPCT. Evaluations for these sessions were very positive and show the workshops are appreciated and that LA s felt supported in their role Sometimes due to work commitments, the ability to attend every workshop can be challenging. To ensure they had access to the information, the workshop notes were distributed by email, and uploaded onto Sharepoint. Presentations and documents discussed during the workshop are embedded within the notes so that they can be shared with colleagues in their clinical area. In addition to the above workshops a seasonal newsletter IC Matters was produced by the IPCT, again this was sent out via email and also made available on Sharepoint. This year saw the introduction of the Train the Trainer programmes for Solent NHS Trust, three being held in July and October 2011, and February 2012. There has been a high demand for places, therefore further dates for May and September 2012 are available. Forty-four LAs received training on the two day courses held during 2011-12. The course is constantly being evaluated and updated to ensure new guidance and any changes in practice are addressed. Director of Infection Prevention and 19 of 47

In June 2011 The Wessex IPS branch held their one day conference. Solent NHS Trust L&D offered to fund 20 places for LAs. This provided an opportunity to receive additional professional development along with the chance of expanded networking outside the organisation. Fifteen Solent NHS staff attended. 15.0 POLICIES 2011-12 continued to see a considerable amount of work on the integration of remaining Infection Control policies. The IPCT has also taken the one year review date to re-examine and modify Solent NHS Trust policies to ensure that they remain reflective of best practice and fit for purpose. Unfortunately organisational changes have resulted in several policies exceeding review dates. Efforts are being made to address this, however priority is being given to those policies the Infection Prevention and Control Team feel are most clinically in need of review. 16.0 CONCLUSION 2011-12 has been a challenging year for the organisation and the IPCT has been no exception. The senior nurse left in May 2011 and that vacancy has not been filled. We also have the service specification with NHS Portsmouth for two and a half days per week and another member of staff has reduced from 37.5 to 30 hours per week. Therefore, the majority of our work over the past 12 months has been reactive and time for proactive work and surveillance has been compromised. HCAI numbers within Solent NHS Trust were encouragingly low and there was no evidence on onward transmission from one patient to another. However there is no room for complacency and enhanced surveillance continues and efforts remain focused upon patient and staff safety from avoidable infection. This report for 2011-12, based upon the annual plan has been developed using the following national guidance: The Health and Social Care Act (2008) Code of Practice for health and adult social care on the prevention and control of infections and related guidance NHSLA Risk Management Standards for NHS Trusts providing Acute, Community, Mental Health and Learning Disability Services and Independent Sector Providers of NHS Care (2011/12) HCAI compendium: High Impact Interventions (2011) Solent Healthcare Quality -Community Contract (2011-12) Chief Nursing Officers High Impact Actions for Nursing and Midwifery (2010) Director of Infection Prevention and 20 of 47

APPENDIX 1 Director of Infection Prevention and 21 of 47

Director of Infection Prevention and 22 of 47

APPENDIX 2 ` Report on Legionella pneumophilia serogroup 2-14 identified in Fanshawe Wing Royal South Hants Hospital (RSH) Document Information Prepared by Kenneth Topliss Specialist Infection Practitioner Version number 1.0 Issued 17 May 2012 BACKGROUND The risks identified in an ageing building that has been modified to accommodate various healthcare services will always remain due to complex plumbing systems that have the ability to support the growth of legionella. This risk had been identified during bi-annual risk assessment (see below) and water sampling occurs at three monthly intervals at the Royal South Hants Hospital (this is in excess of legislation within following reference). Health Technical Memorandum 04-01.(2006) Water systems The control of legionella hygiene, safe hot water, cold water and drinking water systems. T:\clininfo\Infection Prevention and Contr The services of a recognised and accredited external contractor are employed to process results of any water samples taken from this area. Clearwater Technology Ltd (CWT) interprets the results and assists with risk assessments accordingly. Director of Infection Prevention and 23 of 47

Keith Alexander (KA) Estates Health and Safety Officer for Southern Health NHS Foundation Trust and appointed Responsible Person (Water) was notified by CWT that a water sample taken from a WC (room 3132A) in Fanshawe Wing, RSH, Level B in the vicinity of the Nichols Town Surgery (hot water supply) contained legionella pneumophila serogroup 2-14. This water sample showed extremely high levels at 44,000 cfu/1000ml (acceptable level would be up to 100 cfu/1000ml). It is well documented that legionella pneumophilla serogroup 1 is responsible for the majority of confirmed cases of legionnaires disease within the UK. This was one isolated area at that point. The WC is in a quiet area within a consulting suite as opposed to a public thoroughfare, therefore it can be assumed it has limited use. Initial assessment based upon standard risk assessment (Solent Health and Safety Policy) showed score of two (outcome = minor 2 x 1 unlikely = consequence). This indicated that risk to public, staff and patients was minor at that point but had the potential to increase if further spread of legionella was identified. Actual impact on Solent NHS Trust was later identified as near miss by intervention with no spread to patients, staff or public. There was, however, some disruption of water services and financial cost to the Trust estimated at under 50k. INITIAL ACTIONS 31 January 2012 The WC was immediately put out of action. KA ensured that the first control measure of water pasteurisation of the level A calorifiers (Fanshawe Wing supplier) followed by flushing of all hot water outlets in the area supplied by this particular water feed was carried out with immediate effect. The process of pasteurisation and flushing continued morning and evening for two weeks. Maintenance personnel at RSH were advised by KA to: o Remove water supply to WC outlet o Ensure any spray or mist was not created when the outlet was run o Water must run directly to the drains and any spray or shower heads removed first o Records of flushing need to be maintained to provide evidence that the flushing was taking place at the required intervals o Ensure temperatures were checked when flushing to ensure correct temperatures were being maintained o Shower heads and similar spray outlets were cleaned and descaled 01 February 2012 KA informed the Infection Prevention and Control Team (IPCT). Ann Bishop (AB) met with KA at the RSH and several hours were spent conducting a risk assessment of the area. As a precaution the only two staff showers in the area were put out of action until further notice. All hot water outlets were having temperatures recorded and all were above the required outlet temperature, therefore providing assurance that the pasteurisation process was effective. AB produced an interim report for Judy Hillier (JH) Director of Infection Prevention and Control (DIPC) detailing all initial assessments and actions undertaken (see below). Director of Infection Prevention and 24 of 47

T:\clininfo\Infection Prevention and Contr It was also noted that within the WC from which the positive sample was taken a dead leg (dead end branch of a water supply that has been capped as no longer required so water does not flow) was found to be present that used to supply water to a urinal. This was removed later in the day using a freezing method to avoid movement of stagnant water within the dead leg. The Thermostatic Mixer Valve (see below) to the affected sink was also removed and found to be heavily coated in what appeared to be a very large biofilm, therefore providing the ideal opportunity for bacterial growth (see attached picture). T:\clininfo\Infection Prevention and Contr ACTIONS TAKEN TO MITIGATE RISK TO DATE After consultation between KA and Barry Toward (BT), Estates and Environment Manager, NHS Southampton Headquarters, it was decided to commission CWT to investigate further and carry out water sampling. Further water sample results from CWT from hot and cold outlets throughout the RSH during period 1-9 February 2012 are listed in Excel spreadsheet and plans below. T:\clininfo\Infection Prevention and Contr T:\clininfo\Infection Prevention and Contr The above spreadsheet and plans of Fanshawe Wing showed elevated levels of legionella serogoup 2-14 on B level (ranging from 120-940 cfu/1000ml) in the Dental Department staff room/walk in Centre (various rooms and toilets) and Nicholstown GP Surgery during sampling carried out from 1-9 February 2012. Sampling, however, showed that levels A, C and D (which included inpatient areas) were within normal parameters. Records held by the maintenance contractor indicate that procedures and temperature control have been within recommended guidelines (see below): H:\Legionella\RSH level B Feb 2012\B To Since this date a management regime of pasteurisation and sampling has been undertaken and site visits undertaken by HPA and Clearwater. Further sampling has shown a reduction in levels although one area in Dentistry remained higher than expected until further sampling on 3 and 10 April 2012 showed levels had fallen to within normal parameters (<20cfu/1000ml). Director of Infection Prevention and 25 of 47