INFECTION PREVENTION AND CONTROL ANNUAL REPORT

INFECTION PREVENTION AND CONTROL ANNUAL REPORT 2016-17 JH/TJN IPC Annual Report 2016-17 RLBUHT Page 1

CONTENTS PAGE 1. Introduction 4 1.1 Key Achievements 2016 17 1.2 Clostridium difficile 1.3 Meticillin resistant Staphylococcus aureus (MRSA) 5 2. Infection Prevention and Control Team 2.1 Staffing 6 2.2 Further proposed developments 3 Infection Control Group 7 4. External Reporting arrangements 4.1 Liverpool Clinical Commissioning Group (CCG) Assurance Framework 4.2 Mandatory Surveillance 5. External Reviews 8 Education 6.1 Link Practitioner study days 6.2 Flu Vaccination Training 6.3 Facemask face fit training 6.4 Aseptic non touch technique (ANTT) compliance 9 7. Policies and Guidelines updated during 2016-17 10 8. Audit Programme 11 8.1 Antibiotic Stewardship 8.2 Hand Hygiene Audits 8.3 Hand Hygiene Promotional Activity 12 8.3.1 Hand Hygiene Accreditation 8.3.2 Covert Personal Protection Audit 8.4 Annual Infection Prevention and Control Link Practitioner Audit Programme 13 8.5 Aseptic Non Touch Technique (ANTT) Knowledge Audit 14 8.6 Intravascular device audit 8.7 Environmental Hygiene 15 8.7.1 Healthcare Cleaning Contractors Cleaning Performance 2016-17 8.7.2 Macerator breakdowns 16 8.7.3 Annual Trust wide Sharps disposal audit carried out by supplier 17 8.8 Audit Programme 2017-18 9. Surveillance 9.1 Notification of alert micro-organisms from Liverpool Clinical Laboratories 18 to IPCT 9.2 Directorate/Divisional alert micro-organisms feedback and dashboard 9.3 E.coli bacteraemia 9.4 Glycopeptide resistant enterococci bacteraemia 19 9.5 MRSA colonisation acquisition JH/TJN IPC Annual Report 2016-17 RLBUHT Page 2

10. Seasonal Influenza vaccination 2016-17 20 10.1 Seasonal Influenza cases 2016-17 11. Emerging Infection Prevention and Control Issues 11.1 CPE 11.2 PODS 21 11.3 Middle East Respiratory Syndrome Coronavirus MERS CoV/Category 4 infections 22 12. Surgical Site Surveillance 23 12.1 Orthopaedic Surgical site surveillance 12.2 Non mandatory surgical site surveillance 13. Incidents and Outbreaks 26 13.1 Norovirus 13.2 Group A Streptoccocal blood stream infection 14. Risk register 26 15. Forward Plan 2017-18 27 Appendix A Infection Control Group Terms of Reference 28 Appendix B Infection and Prevention and Control Forward Plan 2016-17 31 Appendix C Infection Prevention and Control Link Nurse Study Days 37 Appendix D Infection and Prevention and Control Forward Plan 2017/18 39 JH/TJN IPC Annual Report 2016-17 RLBUHT Page 3

1. Introduction The Royal Liverpool and Broadgreen University Hospitals NHS Trust is committed to leading on and supporting initiatives to reduce Healthcare Associated Infection (HCAI) across the Liverpool and Merseyside health economy and continuously strives to improve infection prevention and control practice. 2016-17 has been a challenging year with a specific focus on minimising infection risk from invasive devices and procedures, reducing Clostridium difficile infections, addressing the challenges from antibiotic resistant bacteria and reinforcing basic infection prevention measures. This has been supported by a programme of surveillance, education, audit and peer reviews. In addition there have been issues with staffing within the Infection Prevention and Control (IPC) Team (IPCT) with vacancies and sickness and particularly with leadership due to the retirement of the Nurse Consultant in Nov 2016. Recruitment to the post was unsuccessful as there appears to be a national shortage of senior practitioners in the speciality. However, a part time Interim Head of Services/Associate Director of Infection Prevention and Control has been in post since Jan 2017 whilst recruitment ongoing. 1.1 Key Achievements 2016-17 Although the Trust had improved its performance in reduction of HCAI in 2015-16 this was not sustained in 2016-17 for Clostridium difficile infection (CDI). Table 1: Trust Attributable HCAI 2016-17 Organism April 2014 - March 2015 April 2015 - March 2016 April 2016 - March 2017 Clostridium difficile infection (CDI) 43 29 56 Meticillin resistant Staphylococcus aureus (MRSA) 7 2 1 Meticillin sensitive Staphylococcus aureus (MSSA) 31 26 28 1.2 Clostridium difficile As can be seen from Table 1 and figure 1 the Trust went above trajectory for C. difficile infections with 56 cases reported against a trajectory of 44 for the time period April 2016 to end March 2017. This was primarily due to an increased number of cases in the first 2 months of the year. The Trust was successful in 6 appeals with the Clinical Commissioning Group (CCG) and confirmation that there did not appear to be any breaches or lapses in practice. A further 5 appeals are being heard on 08/05/17. Root Cause Analysis (RCA) of the Trust acquired cases where improvements could be made include samples not always being taken in a timely fashion, patient risk assessment being underscored and delays in undertaking root cause analysis so that issues and lessons learnt can be identified and dealt with promptly. It is in these key areas where focus is being concentrated. JH/TJN IPC Annual Report 2016-17 RLBUHT Page 4

Figure 1: Clostridium difficile infection performance against trajectory 2016-17 60 50 40 30 Cumulative Trajectory - Trust attributable cases Cumulative Trust attributable cases 20 10 0 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 1.3 Meticillin resistant Staphylococcus aureus (MRSA) By the end of March 2017 the Trust reported two MRSA bacteraemia against a target of zero. Although the target was not met and was the same as the previous year, this was a significant improvement from seven and eight cases reported in the previous two respective years. Following a post infection review of the first case it was proved to be contaminant. This will incur a fine for the Trust. No lapses in practice were identified for the second bacteraemia reported and has since been attributed to Third Party. Focus on prevention continues to be around ANTT. 2. Infection Prevention and Control Team During 2016-17 the Infection Prevention and Control Team (IPCT) comprised: Director of Infection Prevention and Control Lisa Grant Director of Nursing Infection Prevention and Control Doctor Dr Tim Neal Consultant Medical Microbiologist. Consultant Nurse - Rebecca Molyneux 1 WTE ( Retired Nov 2016 Interim Head of Service/Associate DIPC 0.2 was appointed in Jan 2017 to support the IPCT and until successful recruitment to a WTE) IPCT members provide support for the two trust clinical divisions; formerly Medicine and Surgery subsequently Divisions 1 and 2. JH/TJN IPC Annual Report 2016-17 RLBUHT Page 5

Medicine Band 7 0.8 WTE Band 6 1 WTE Band 6 0.8 WTE Band 6 Divisional skills trainer (ANTT) 1 WTE (maternity leave from September 2016 due back May 2017). Permanent post to be reviewed Band 3 Health Care Assistant 1 WTE Surgery Band 7 1 WTE Band 7 0.2 WTE Band 6 1 WTE (from March 2017) Band 6 Divisional Skills trainer (ANTT) 0.8 WTE (secondment now permanent ) Band 3 Health Care Assistant 37.5 hrs per week (left Dec 2016) Admin/clerical/secretarial support Band 4 Clinical Information Officer 0.8 WTE Band 3 Secretarial/Admin Support 0.6 WTE (0.6 increased to 0.8 in May 2017) The Band 7 and 6 Infection Prevention and Control nursing team provide a support service during weekdays and from 8am to 4pm at weekends. This input will be reviewed 2017-18. Out of hours there is an on call service for urgent infection prevention and control advice accessed via the hospital switchboard. This is provided by medical microbiologists and virologists. 2.1 Staffing During 2015-16 approval was given for recruitment to a band 8C post following the secondment of the team leader to the Redevelopment team. Unfortunately recruitment was unsuccessful due to a lack of suitable applicants and an Interim Head of Service/Associate DIPC 0.2 was appointed in Jan 2017 to support the IPCT and until successful recruitment to a WTE. The post was also readvertised as a Band 8B due to the difficulty in recruitment and also with a view to the amalgamation with Aintree and RLBUHT) an extension to a fixed term contract for a band 3 health care assistant. This was actioned in 2016-17. a permanent band 6 divisional clinical skills training post as one of the post holders was on secondment and the other a fixed term contract. This was actioned in 2016-17. JH/TJN IPC Annual Report 2016-17 RLBUHT Page 6

2.2 Further proposed developments Hospital epidemiologist / senior clinical data analyst Acquisition of infection is linked to contacts between patients, staff and the environment as well as patient factors such as co-morbidities. These variables are monitored through different data sets such as clinical practice and environmental audits, training records, sickness and staffing levels, bed occupancy and acuity etc. The approval of a hospital epidemiologist role would enable description of the data and then prospective use to alert the IPCT to impending problems and improve the safety of patients. There would be some potential to be explored for collaborative working with the Perfect Ward team linking into performance review. 3. Infection Control Group (ICG) Bi-Monthly meetings of the Trust Infection Control Group scheduled during 2016-17 were chaired by Clinical Director Clinical Pharmacology and Infectious Diseases until May 2016 followed by the Medical Director to date. Reports received include those from: Hotel Services Estates Antimicrobial Group Clostridium difficile steering group Flu group Water safety group Surgical division Surgical Site Infection Infection Prevention and control team members Work is in progress to include additional Matrons reports The terms of reference of the ICG are included as Appendix A The Infection Control Group reports through the Patient Safety Sub-Committee to the uality Governance Committee. 4. External Reporting arrangements 4.1 Liverpool Clinical Commissioning Group (CCG) Assurance Framework Assurance data is reported monthly to the CCG and at Infection Control Group and incorporates performance data, exception reporting audit data and screening compliance. 4.2 Mandatory Surveillance The trust submits data on MRSA, MSSA E Coli and Clostridium difficile infections (CDI) by the 15 th day of each month to the Public Health England via an online Health Care Associated Infection Data Capture System. HCAI data is also submitted each month for the Trust uality Report and Corporate Information. JH/TJN IPC Annual Report 2016-17 RLBUHT Page 7

All isolates of Carbapenemase producing enterobacteriaceae (CPE) are routinely notified to Public Health England. The Trust also submits enhanced surveillance data to Public Health England and has participated in Regional Network Meetings. 5. External reviews During 2016-17 year the Infection Prevention and Control Forward plan reflected recommendations made by Merseyside Internal Audit review visits in relation to management of Clostridium difficile (see Appendice B). 6. Education The Infection Prevention and Control team members deliver sessions on numerous training programmes. Core skills and Preceptorship, Liverpool University Degree nursing course, John Moores Infection Prevention and Control link practitioners course, Liverpool University Medical Students Infection Prevention and Control patient safety sessions, medical students induction and junior doctor s induction, Consultants core skills. The Infection Prevention and Control team also host student nurse placements of four to six weeks duration which has been well evaluated with positive feedback. 6.1 Link practitioner s study days There are 177 link practitioners in the trust from a number of disciplines. Of these, 61 work in the out-patient departments. Infection Prevention Link practitioner s study days were held in October 2016 and March 2017 with average attendance of 60 link practitioners from across the trust. Feedback was positive from both study days (see Appendix C for Study Day Programmes). 6.2 Flu Vaccination training 74 members of staff attended influenza vaccination training to support the 2016-2017 seasonal flu vaccination campaign and ensure optimal uptake. Supplies of vaccine arrived in the Trust during the week commencing 19 th September 2016 and vaccinations commenced during that week. Times and locations of vaccination session were communicated via In Touch and the intranet. Managers of large departments e.g. radiology and physiotherapy were asked to provide rooms and dates for vaccinators to provide sessions in their departments. The Trust achieved the CUINN target of 75% with 76.1%. However this proved challenging and plans are in place to sustain this and improve the target for 2017-18. 6.3 Facemask face fit test training For some respiratory infections, especially when aerosol generating procedures are carried out, staff require protection with a high filtration (FFP3) face mask. There is a requirement that staff are face fit tested to ensure an effective seal. This testing takes a minimum of 20 minutes per member of staff and it is not a process that can be carried out at the last minute prior to patient care, so it is essential that sufficient staff are trained to fit test across the Trust and that front line staff know which face JH/TJN IPC Annual Report 2016-17 RLBUHT Page 8

mask provides optimal fit. In 2016-17 it was agreed that the Infectious Disease Unit would facilitate training session i.e. Train the Trainer. This has not been progressed to date and is on the Trust Risk register. However sessions are being arranged for May/June 2017. 6.4 Aseptic non touch technique (ANTT) compliance. Lapses in practice associated with the insertion and management of Vascular Access Devices contribute to the development of blood stream infections. During the 2015-16 year two Divisional Infection Prevention Clinical Training Facilitators were appointed for a year to roll out a robust trust wide ANTT peer review process with an initial focus on Nursing Staff s appropriate application of asepsis to the preparation and administration of Intravenous medication. Due to the effectiveness of Infection Prevention s ANTT peer review strategy the decision was made to include Medical staff and Allied Health Professionals in this process also. During the 2016-17 year one clinical Training Facilitator endeavoured to maintain this process due to Maternity leave. Unfortunately there was little provision for ANTT training from November 2016 to March 2017 due to sickness leave. The three step ANTT competency process includes: a mandatory theoretical element delivered via a PowerPoint presentation accessed via the ANTT page on Trust Intranet; Practical peer review in relation to cannulation or preparation and administration of Intravenous medication; and completion of ANTT peer review documentation to enable accurate recording on Electronic Staff Records (ESR)-refer to flow chart. The Infection Control Committee decided to include obtaining peripheral blood cultures in the ANTT peer review process in response to a rise in contamination rates, especially originating from the Emergency Department (E.D). Following a meeting with the E.D lead for infection prevention an action plan to focus on ANTT peer review was agreed. IPCT supported drop-in ANTT peer review sessions held in the Department and the ANTT Link staff were allocated protected time to ensure all staff who obtained blood cultures were competency assessed. In 2016-17 the Trust recorded an MRSA positive result which was identified as a consequence of contamination. The blood cultures were obtained by a member of medical staff not compliant with the Trust s ANTT peer review process. At Post Infection Review the importance of attendance to ANTT Peer Review sessions was reinforced. Attendance to ANTT sessions by medical staff decreased in numbers. In order to promote attendance, dates were published in the Patient Safety Bulletin, Learning and development advert, attached to pay slips, e-mailed to staff and displayed on the ANTT Intranet page. Staff are also required to state their ANTT status as part of their Induction checklist (via Postgraduate Team) and are notified of ANTT requirements on their appointment to the Trust (via Human Resources). JH/TJN IPC Annual Report 2016-17 RLBUHT Page 9

In recognition that it is challenging to release staff from the clinical setting the duration of the session was decreased by asking staff to watch the ANTT presentation prior to attending. A network of approximately 200 Nursing ANTT Links has been sustained throughout the Trust ensuring the delivery of ANTT training and peer review to all applicable staff members. Several ANTT sessions were facilitated at directorate level at their request and ANTT was incorporated into local induction programs such as Theatres, ITU and Chemotherapy Study Days. Table 2: Training figures Clinical skill Intravenous preparation and Administration (Nursing Staff conducted by ANTT Links) Cannulation (predominately Medical Staff on attendance to ANTT sessions) Obtaining Blood Cultures (predominately Medical Staff on attendance to ANTT sessions) April- July- Oct- Jan- Total Number of staff ANTT June Sept Dec March peer reviewed in clinical skill 314 227 90 56 687 103 157 45 21 326 61 137 28 30 256 Total 1269 NB: (Clinical Training facilitator on sickness leave from November 2016 to March 2017) Poor care of Vascular Access Devices (e.g. inaccurate VIP scoring, dirty dressings etc.) was a common theme from Post Infection Reviews. A Collaborative three hour Care of Vascular Access Devices (COVAD) update course was set up in 2015 with the aim of updating Nursing staff on providing quality line care. They were also ANTT peer reviewed in relation to CVC dressing change and blood sampling at the time. Unfortunately due to clinical pressures attendance became very poor so the course was discontinued in 2016. In response to a rise in MSSA bacteraemia and localised cannulae infections (cellulitis/phlebitis) Infection Prevention conducted ward-based teaching to over 200 staff members in relation to the key elements of preventing VAD associated infections. Staff were also reminded of the importance of educating patients by providing the information leaflet Peripheral Intravenous cannula: what you need to know about your device (authored by IPCT). JH/TJN IPC Annual Report 2016-17 RLBUHT Page 10

7. Policies and Guidelines updated during 2016-17 The following policies and guidelines were updated: Aseptic Non Touch Technique (ANTT) Peer Review Aseptic technique Patients with suspected Viral haemorrhagic Fever-Risk assessment and Management 8. Audit Programme 8.1 Antibiotic stewardship Antimicrobial prescribing audits are completed on alternate months for all antibiotic prescriptions within the Trust. The results are disseminated through a formal report to Governance Leads, Pharmacists, Infection Control Committee, Antimicrobial Management Group and Clostridium difficile - steering group (see Figure 2). In addition, results are fed back to individual ward teams during the Clostridium difficile Infection (CDI)/bacteraemia Post Infection Review (PIR) meetings and via the Director of Infection Prevention and Control (DIPC). The results are also circulated to ward managers and matrons with ward KPI data and during Perfect Ward meetings. Although there is significant variability, audit results are considerably improved compared to when the audit was initiated, however, it requires constant review to maintain standards. Figure 2: Antimicrobial prescribing audits 8.2 Hand hygiene audits Hand hygiene audits were completed monthly during 2016-17 by infection prevention and control link practitioners with average reported compliance between 80-100% for ward in- patient areas. These audits are supplemented with occasional quality check audits on the 50 ward inpatient areas co-ordinated by IPCT. JH/TJN IPC Annual Report 2016-17 RLBUHT Page 11

The following RAG rating is in place for Hand Hygiene audits within the Trust. Below 84% 85-99% 100% RED AMBER GREEN Feedback is provided directly to individual teams. Audit results are also directly accessible via the Infection Control Audit on the intranet menu page with ward managers requiring to complete action plans and provide assurance that compliance will improve. 8.3 Hand hygiene promotional activity 8.3.1. Hand Hygiene Accreditation The hand hygiene accreditation programme was re-launched in May 2016, the aim being to maintain and embed good hand hygiene practices for patients and staff. All heath care staff working within the ward clinical areas, including Drs, Nurses, Allied Health Professional, ISS staff etc., were to be peer reviewed on the correct Ayliffe method for hand hygiene technique, undertaken by the IPC link nurse. All staff were required to demonstrate compliance with hand hygiene policy, promote and encourage patient hand hygiene, ensure hand hygiene audits up to date, hand wash facilities are functional, accessible and have sufficient hand hygiene materials. The IPCT audited the ward areas and hand hygiene accreditation certificates awarded when objectives successfully met. The accreditation programme was rolled out gradually throughout the year, enlisting 8 ward areas at a time. Challenges were encountered with the programme being slow to implement, due to some wards having staffing problems, changeover of link nurses and ward managers and ward areas being relocated. To date 11 ward areas have successfully completed the hand hygiene accreditation programme (see table 3) Table 3: Wards areas which have completed the Hand Hygiene accreditation Ward Date passed 5X 23.12.16 HEC 23.12.16 3A 23.12.16 5B 23.12.16 Wd 1 26.04.16 2Y 26.04.17 4Y 13.03.17 7A 13.03.17 8HDU 26.04.17 6X 02.05.17 11Z 25.05.17 JH/TJN IPC Annual Report 2016-17 RLBUHT Page 12

The hand hygiene accreditation programme will continue in 2017-2018. 8.3.2 Covert Personal Protection Audit In May 2016 the Covert hand hygiene audits were amended to include auditing personal protective equipment (PPE). The unannounced audits were undertaken by student nurses using the standard Trust PPE audit tool. The audit consisted of undertaking 10 observations on each ward area, observing tasks and compliance on the correct use of PPE, disposal and hand hygiene following removal of PPE. 3 covert audits have been undertaken and results automatically calculated on share point. It is difficult to compare the 3 audit results due to the audit tool scoring system being previously modified to identify hand hygiene compliance. However there is some variation in the results due to share point only calculating the results on 10 full observations undertaken, therefore ward areas that have not completed 10 observations show a low compliance (see table 4). Table 4: PPE Audit Results Date No of wards Audited Average compliance score Non-compliance themes May 2016 43 61% Direct care, Toileting patients November 2016 February 2017 44 71% Waste and linen disposal, Toileting patients, Bed making, Cleaning equipment, Serving food, ANTT procedures, 43 80% Cleaning equipment, Serving food, Toileting patients, Waste and linen disposal. Bed making. ANTT procedures, Over the course of the 3 audits undertaken the audit tool has evolved and developed, a crib sheet has been introduced for the students to use when undertaking the audits to reduce any discrepancies on PPE use. RAG rating will be introduced on all future audits to monitor PPE compliance. Staff knowledge on the correct use of PPE will also be assessed to identify if there are any knowledge gaps which may require addressing before undertaking future audits. 8.4 Annual infection prevention and control link practitioners audit programme 2016-17 JH/TJN IPC Annual Report 2016-17 RLBUHT Page 13

Link practitioners undertook a programme of monthly audits during 2016-17. The audit programme and tools are accessed via Sharepoint on the intranet menu page. The programme for 2016-17 included weekly hand hygiene audits, PPE Observation audit and an overarching Link Practitioner audit. Care bundle audits i.e. intravascular insertion and ongoing care and urinary catheters were also included. Results are accessible for all staff to view and there is a facility to review details of individual audits, email results and record action plans. In addition IPCT, supported by the quality Matrons undertook a programme of weekly ward audits in all in patient areas. Results were recorded on a spread sheet, and were emailed weekly to Ward Managers, Matrons and Divisional Lead Nurses. Frequency was reduced to fortnightly in November 2016. Analysis of results determined that when issues were identified on wards, repeated audit of these areas did not improve compliance. It was evident from the repeated failures in these areas that the audit process was not effecting the change required. As a result, a review of the audit process was undertaken by the IPCT in February 2017, and a comprehensive audit programme has been devised for 2017/18. 8.5. Aseptic non touch technique (ANTT) Knowledge audit Infection Prevention s Trust-wide Aseptic Non Touch Technique (ANTT) Peer Review process has ensured ANTT is embedded in clinical practice however, it became evident from previous audits that staff lacked knowledge regarding the theory underpinning ANTT. Therefore, a mandatory theoretical component of ANTT was incorporated into the ANTT Peer Review process. The results indicated a significant increase in nursing staff knowledge regarding the principles of ANTT compared to the same period in 2015. This report was sent to the Trust s IV steering group and Infection Control Committee. The increase in staff knowledge regarding decontaminating needle-free devices may also be attributed to Infection Prevention s Scrub-a-dub-the-HUB Trust-wide Poster Campaign. Decontaminating needle-free devices is a high impact intervention for preventing catheter line associated blood stream infections (EPIC 3, 2014). It is essential that clinical staff possess knowledge regarding the indications and technique for undertaking this procedure in order to prevent bacteraemia. Results also indicated that nursing compliance with the Trust s ANTT mandatory Peer Review requirements has decreased by 7% when compared with the same period in 2015 therefore, an effective strategy for monitoring and addressing noncompliance is required. A process for submission of ANTT compliance data via the Dashboard at ward level has been proposed. Compliance would be monitored though Perfect Ward (governance for quality assurance). As ANTT knowledge (4 principles and 4 safeguards) can be applied to all invasive clinical skills/procedures (such as wound dressings and catheterisation) not just Vascular Access Devices, it would be beneficial to extend the mandatory theoretical element of ANTT training to all clinical staff in the new peer review year (April 2017- March 2018). 8.6 Intravascular devices audits JH/TJN IPC Annual Report 2016-17 RLBUHT Page 14

A Trust-wide audit of cannulae was conducted by the IPCT in uarter 4 2016. A total of 212 cannulae were reviewed on key aspects of care, such as accurate VIP scoring, dwell time and care of dressings. All findings were discussed with staff and Line managers at the time and any problems were rectified immediately. See Figure 3 for a summary of findings that were reported to the IV Steering Group (Including the IV Access team) and Infection Control Committee. This audit is due to be repeated in year 2017-18. Figure 3: Intravascular devices audits results Trust Wide Cannula Audit Compliance Yes No In situ for <72 (cannula only) OR if in >72hrs, reason documented / removed at 96hrs VIIAD- Inspection accurate & up to date (every shift) Y/N Exit site visable? Y/N (gauze present first 24hrs post insertion CVC- record n/a) Documented VIP = that seen by auditor 177 132 184 171 80 35 41 28 Dressing dated? Y/N 154 58 Dressing intact Y/N 202 10 Extension set secured? Y/N/n/a 154 58 Extension Set in situ Y/N n/a 148 64 Reason for insertion documented? Y/N 166 46 Designation of person who inserted VAD documented? Y/N Name of person who inserted VAD Documented? Y/N 118 103 94 109 8.7 Environmental hygiene 8.7.1 Healthcare Cleaning Contractors Cleaning performance for 2016-17 Whilst the majority of wards and clinical departments achieved at or above the required standards there have continued to be concerns regarding overall standards in a number of non-clinical areas this was exacerbated due to the increase in standards across all areas required by the Trust from October 2016. The Trust Contract Monitoring Team and Hotel Services management team have continued to work with ISS to achieve consistency of standards across all areas. JH/TJN IPC Annual Report 2016-17 RLBUHT Page 15

Between May and September 2016 a deep clean programme was carried out by ISS cleaning team across 14 wards which had experienced higher levels of infection. The areas were selected by the IP&C Team. The cleaning team also continued to respond quickly to opening and closing of areas at short notice e.g. escalation and winter pressures initiatives and continued to support the decant bay utilised for wards which have experienced infection and required full bay terminal cleaning and HP misting. ISS introduced a trial using UV light technology as a potential alternative in certain defined circumstances or rooms where HP misting is not possible. This has not been microbiologically tested and therefore, at this stage it is not conclusive regarding future use. The Rapid Response team carried out cleaning of 9714 bed spaces and HP misting of 1682 bed spaces (separate to deep cleaning activities highlighted above). Whilst this was the first full year of this information being recorded it does look to be a significant increase on the previous year. 8.7.2 Macerator breakdowns Macerators are located in the dirty utility rooms and used for the disposal of pulp products containing body fluids only. When macerators breakdown and/or leak, there is a significant risk of environmental contamination; this in turn increases the risk of transmission of Carbapenemase producing Enterobacteriaceae (CPE), Clostridium difficile and Norovirus Facilities provide a monthly report of the number of macerator breakdowns by department and the cause. Misuse of macerators includes overloading with pulp items and disposal of inappropriate items (see Figure 4). Estates have retrieved the following items: net knickers, incontinence pads, Contisoft wipes, cutlery and dentures. Other causes include: electrical / mechanical faults, blocked drains and vent tubes. Figure 4: Macerator breakdown 2016/17 Macerator Breakdown 2016/17 (Total=928) 45% 55% Misuse Other Cause JH/TJN IPC Annual Report 2016-17 RLBUHT Page 16

Macerator breakdown summary data is reported monthly via Perfect Ward for performance management purposes. This information is available on the Infection Control intranet site. In addition a uality Improvement Group has been set up chaired by Dr Nsutebu to more specifically define problems and identify effective measures to reduce risks of avoidable breakdowns. As a result of this, a uality Improvement (I) Driver Diagram was developed and Project Initiation Documentation (PID) produced. The misuse of macerators formed the basis of a Patient Safety and Experience Bulletin (issue 149), distributed via a Staff Notification email on 13th Apr 17. 8.7.3 Annual trust wide sharps disposal audit carried out by supplier Frontier Medical who supply the Trust s sharps disposal containers conduct a trust wide audit on an annual basis. A total of 343 containers were audited in July 2016. Overall, the conclusion of the audit was that sharps practice was good within the Trust. A RAG rating was applied to each element of the audit, areas of low compliance were: Lack of use of the temporary closure mechanism was rated as red, with a compliance score of 20% across the Trust. Sharps containers used for disposal of non-sharp materials was rated as amber, with a score of 64% compliance. Prominent placement of safety posters was also rated as amber, with a compliance score of 62%. A representative from Frontier Medical attended an Infection Control Link Nurse Study Day in October 2016 to provide feedback and education from the audit. Ongoing education is provided by the IPCT as issues are identified in clinical areas. 8.8 Audit programme 2017-18 The quality check hand hygiene audits have been in place since 2014 and were replaced in April 2016 by quarterly unannounced observation audits focussing on the appropriate use of personal protective equipment (PPE) which includes hand hygiene compliance. This will continue in 2017-18. The link practitioners will continue to undertake a monthly hand hygiene/ppe audits. Additional audits will be requested during outbreaks supplemented by unannounced audits by the IPCT. This will include any ad hoc audits deemed necessary in response to any untoward incidents/period of increased incidence of any organism The audit programme has been reviewed to include the annual comprehensive IPCT audit in addition to the audits undertaken by Link Practitioner and uality Matrons JH/TJN IPC Annual Report 2016-17 RLBUHT Page 17

All results will continue to be recorded on, and accessible for view on the Infection Control Audit site accessed via the intranet menu page and recorded on SharePoint provided by the IPCT to support monthly performance reviews by the Perfect Ward team. 9. Surveillance 9.1 Notification of alert micro-organisms from Liverpool Clinical Laboratories to IPCT The IPCT receive notification of alert micro-organisms isolated in the microbiology and virology laboratories continuously throughout the day electronically into an infection prevention and control system ICNET which is linked to PAS (patient administration system.) These alerts include positive Clostridium difficile, new CPE colonisations, all blood stream infections and MRSA colonised patients, additional test results which indicate potential for cross infection and a need to alert ward staff and conduct follow up visits. All in-patients identified for follow up are visited weekly and visit records are reviewed by the team and the Infection Control Doctor on a weekly basis. During 2016-17 ICNET system was upgraded with further work being undertaken which would allow results from Liverpool Clinical Laboratories to be electronically notified to Aintree Hospitals and Liverpool Heart and Chest hospitals with the potential to incorporate additional trusts. The upgraded system can also support enhanced surveillance activity incorporating antibiotic, surgical site and intravascular device templates which can be accessed by staff in addition to the Infection Prevention and control team. This also has the potential to improve inter trust communication regarding patients requiring special precautions. 9.2 Directorate/Divisional alert micro-organisms feedback and dashboard A dashboard was developed by the Nurse Consultant Infection Prevention and Control with support from the Information Technology Development team providing summary data of Trust attributable alert micro-organisms from April 2016 to March 2017 by Ward, Directorate and Division. These include numbers of patients who have become colonised with C.difficile, MRSA and CPE since admission. This is accessible to all trust staff via the Coeus link on the computer desktops and used to inform performance management reviews and a focus for infection prevention action. Weekly situation reports are also sent to ward managers, directorate and divisional leads. 9.3 Escherichia Coli (E.coli) bacteraemia JH/TJN IPC Annual Report 2016-17 RLBUHT Page 18

The Trust has reported 69 cases in the year April 2016 March 2017 (74 in 2015-16). Whilst this is a reduction further focus and analysis is required to identify contributory factors. Collaborative working between IPCT and the sepsis nursing team may help to highlight further priorities for action. Public Health England are developing an E coli bacteraemia Toolkit for release in April 2017 and the Clinical Commissioning Groups will all have a 10% reduction target. Individual Trust targets are yet to be agreed. 9.4 Glycopeptide resistant enterococci (GRE) / Vancomycin resistant enterococci (VRE) An increase in GRE bacteraemia cases has been identified during 2016-17 financial year compared with 2015-16 i.e. 19 cases against 12 in the previous financial year. This will require a focus for review and attention in 2017-18. 9.5 MRSA colonisation acquisition Although there is a focus on reporting MRSA blood stream infection there is the potential for patients to become colonised with MRSA whilst in hospital, without infection. This has been actively monitored during 2016-17 - 38 patients were identified with potential acquisition of MRSA. This is an increase from 2015-16 when there were 36 cases identified. For areas where MRSA acquisition occurs (see Figure 5). This will continue to be monitored with an aim to improve as colonisation may be the precursor to infection. During the last quarter of 2015-16 Prontoderm antiseptic foam was introduced which can be applied directly to the skin after showering / washing. Prontoderm nasal gel was also introduced. The effectiveness of this continues to be monitored by the IPCT. Effectiveness is monitored by weekly screening and review and follow up of patients and results by infection prevention and control team members Figure 5: Areas of MRSA acquisition: JH/TJN IPC Annual Report 2016-17 RLBUHT Page 19

2A 2B 2X 2Y SRU 3Y 4A 4B 5A 5B 5Y 6A 7A 7B 8A 8X 8Y 9X Royal Liverpool and Broadgreen University Hospitals NHS trust 12 No. of MRSA acquisitions 2016-2017 10 8 6 4 No. of MRSA acquisitions 2 0 10. Seasonal Influenza vaccination 2016-17 The CUIN target for staff vaccinated by the end of December 2016 was 75% and was achieved at 75.3%. A 76.1% staff vaccination rate was achieved by March 2017. All vaccinations were undertaken by trained staff in clinical areas of the trust supported by members of the IPCT. There is no service level agreement with the Occupational Health provider for staff flu vaccination. Therefore there was no Occupational Health support available and other Trust priorities limited the overall input available from the IPCT. Further focus in 2017-18 will be to increase amount of staff vaccinated. 10.1 Seasonal Influenza cases 2016-17 17 cases of influenza were identified in 2016-17 (See Table 5). Allocation of flu cases as Trust attributable is based on a five day incubation period for influenza with 10 cases identified. Table 5: No of confirmed influenza cases confirmed 2016-17. Identified 5 days or more post MONTH ALL admission. Oct-16 2 0 Nov-16 1 1 Dec-16 12 0 Jan-17 27 3 Feb-17 17 6 Mar-17 6 0 TOTAL 65 10 JH/TJN IPC Annual Report 2016-17 RLBUHT Page 20

Influenza A cases predominated with only 1 influenza B case identified during this period. 11. Emerging Infection Prevention and Control Issues 11.1 Carbapenemase producing Enterobacteriaceae (CPE) CPE are multiple antibiotic resistant strains of bacteria which are carried harmlessly in the bowel e.g Escherichia coli, Klebsiella, Enterobacter. These bacteria can cause infections if transferred to another site on the body e.g. urinary tract or blood stream. The antibiotics available to treat such infections are limited which increases the risk of treatment failure. CPE Screening During 2016-17 screening for CPE has continued with admission and weekly screening on high risk units i.e. Haematology and Critical Care units and readmission screening for all patients who have been in the Trust during the previous year. In addition patients whose in-patient stay is 30 days or more are rescreened. All transfers in from other trusts are screened and also patients who have been hospitalised abroad during the previous year. During August 2016 a cluster of patients colonised with CPE was identified on ward 8Y. Intensive screening and segregation of positive patients, contacts and negative patients and temporary bay closures helped to reduce the numbers of newly identified colonised patients. This was supported by terminal cleaning and Hydrogen Peroxide misting of bays and single rooms in addition to decontamination of equipment. In January 2017, PCR testing was introduced for screening new admissions who meet the criteria, and contacts of patients identified in bays. This allows prompt identification of new cases, reducing bed closures and minimising disruption to patient flow. For number of new colonised patients identified per month during 2016-17 (see Figure 6). Figure 6 11: No of new colonised patients 2016-17 JH/TJN IPC Annual Report 2016-17 RLBUHT Page 21

35 30 25 20 15 10 No. CPE +ve No. Trust acquired (inc. unknowns) 5 0 11.2 PODS custom built cubicles to enclose bed spaces. The demand for single room accommodation in the trust continues to increase with the identification of patients colonised with CPE. The PODS include extract ventilation and apart from providing segregation facility also support privacy and dignity. 11Bioquell PODS had already been installed in the Trust previously (see Table 6). In November and December 2016/17 additional PODS were installed on the Frailty Unit (AIFU), respiratory ward 6Y and Gerontology ward 2B. The POD installation scheme is now complete. Table 6: Location of Bioquell Pods JH/TJN IPC Annual Report 2016-17 RLBUHT Page 22

Location Number of Bed reduction PODS 7Y 2 (outpatient) Additional capacity for 7Y day care 10Z 2 (outpatient) Additional capacity for 10z day care Acute Medical Unit 1 Zero 5Y phase 1 2 4 (from six bedded bay) 4A phase 1 2 2 ( from 4 bedded bay) 5B phase 1 2 2 (from 4 bedded bay) AIFU phase 2 2 0 2B phase 2 2 2 (from 4 bedded bay) 6Y phase 2 2 2 (from 4 bedded bay) 11.3 Middle East Respiratory Syndrome Coronavirus MERS CoV/Category 4 infections There were no known cases of MERS-CoV/ Category 4 infections admitted to the Trust in 2016-17. However, following an incident during November 2015 where a suspected MERS-CoV patient was transferred from another Trust to the Infectious Diseases Unit (IDU) at the Royal some issues were identified in relation to transfer and admission for such patients. This resulted in a review of the current policy as reported in the 2015-16 annual report. The policy was updated to identify clearer roles and responsibility in particular in relation to final decision to step down infection control precautions and communication. This has not been tested in practice as no patients fitting the criteria were admitted to the Trust. However the Trust became the first respondent to any such admissions for a period during 2016-17 as both Newcastle and the Royal Free hospitals IDU were closed during the same time for refurbishment. Frequent communications between organisations externally and internally did not identify any further issues. This will be kept under review in 2017-18. 12. Surgical site surveillance (SSI) The development of infection at a surgical incision site following surgery results in a poor patient experience, a requirement for antibiotics and extension of the recovery period. The Trust participates in the mandatory surveillance of elective orthopaedic surgery which is supplemented with additional locally initiated prospective surveillance outwith the mandatory programme. 12.1 Orthopaedic Surgical site surveillance The data provided below in Table 7 relates to the time period April 2016 to end March 2017. The trust performs in line with or better than the national average for the mandatory surveillance. Table 7: Orthopaedic Surgical site surveillance Number of procedures Number of infections (%) Number of Superficial Number of Deep JH/TJN IPC Annual Report 2016-17 RLBUHT Page 23

Infections Infections RLUH (Trauma) Hip Replacement 94 0 0 0 Reduction of 117 0 0 0 long bone fracture Repair of 320 3 1 2 #NOF Total 531 3 (0.6%) 1 2 BGH (Elective) Hip replacement 70 0 (0%) 0 0 Knee replacement 106 4 (3.7%) increase from 2015-16 1 3 Total 176 4 (3.7%) 1 3 12.2 Non mandatory surgical site infection End of year report surgical site surveillance 2016/2017 4 procedures are currently reported within the surgical directorate: Whipples procedures (HPB), upper GI Hemi colectomy and lower limb amputations (LLA). Data is available for the last financial year on all 4 procedures. However upper GI and hemi colectomy are new to the program and only 1 year s data is available for comparisons. There is 4 years data available for comparison for HPB and LLA. 12.2.1 Upper GI 81 resections were included in the surveillance program. Out of the 81 resections there was 1 reportable infection, giving upper GI a % infection rate. Hemi Colectomy In total there were 69 resections with 5 reportable infections. This equated to a Colorectal infection rate of 6%. Fig 6: Colorectal infection rate JH/TJN IPC Annual Report 2016-17 RLBUHT Page 24

Fig 7: Procedures performed Lower Limb amputations (LLA) 105 lower limb amputations were carried out, with 3 reportable infections equating to a 2.8% vascular infection rate. Fig 8: Total procedures Vs Reportable infections JH/TJN IPC Annual Report 2016-17 RLBUHT Page 25

The total number of procedures has decreased from 137 in 2013/2014 to 105 in 2016/17, as a results of decisions are being made earlier in the treatment plan.care has also been standardised and the Major Amputation Care Bundle was introduced in 2014. Whipples procedure (HPB) 111 resections were carried out with 9 reportable infections equating to a 8% infection rate for HPB. This has increased from 2015-16. An investigation was carried out which did not identify any common causative factors or correlation with surgeons and all procedures undertaken according to policy. All patients operated on were also identified as high risk of post-operative infection due to underlying comorbidity. A full report was provided separately and there has now been a reduction seen in wound infections to date. Fig 9:Total procedures Vs reportable infections. JH/TJN IPC Annual Report 2016-17 RLBUHT Page 26

13. Incidents and outbreaks 13.1 Norovirus A total of 26 wards were affected by Norovirus between April 2016 and March 2017. Ward closures were a necessary precaution to minimise the risk of spread to patients and staff elsewhere in the Trust. During April 2016 and March 2017 a total of 570 bed days were lost during these outbreaks. These episodes reflected norovirus outbreaks in other trusts and community. 13.2 Group A β- haemolytic streptococcal blood stream infection Group A streptococci may be carried in the throat and present on the skin of a small proportion of people. They can cause wound and blood stream infections which are potentially serious although effective antibiotics are available to treat them. Blood stream infections caused by Group A streptococci are notifiable to Public Health England. There were 18 cases of Group A Streptococcal bacteraemia in 2016-17, however, all of these cases originated in the community, there were no Trust attributable cases. 14. Risk register The most significant infection risk on the Trust risk register is the identification of patients within the Trust colonised with multidrug resistant bacteria. Limited isolation facilities, a lack of a national recommendation for universal screening, no identified external funding for rapid testing and the need to maintain optimum practice at all times despite severe pressures on the Trust JH/TJN IPC Annual Report 2016-17 RLBUHT Page 27

from the numbers of admissions underpin the risk of spread. However, actions are in place to minimise such risks as identified in section 12 such as CPE screening, installation of pods and education. Breakdowns of macerators and toilet facilities increase the risk of spread of bacteria carried in the bowel including Clostridium difficile and CPE in clinical areas. (See actions taken in Section 9.8.2.) The lack of a ward decant facility has meant that whole ward deep cleans have not been carried out since 2013-14 although individual bays have been decanted as required to allow terminal cleaning and hydrogen peroxide misting. In a busy ward bacteria such as Clostridium difficile can accumulate over time and persist in the environment and thorough cleaning is difficult in an environment occupied 24hrs a day. Prevention of blood stream infections remains an important risk to manage due to the significant number of invasive procedures undertaken on vulnerable patients within the Trust and the fact that patients colonised with antibiotic resistant bacteria are being identified within the Trust. There are two infectious diseases wards within the Trust and the Trust is an identified surge unit for suspected Viral Haemorrhagic fever cases e.g Ebola, Lassa. There is a need to sustain resources and training for emergency preparedness 15. Forward Plan 2017-18. (Appendix E) The Trust has seen an overall improvement in some bloodstream infection although Clostridium difficile infection increased in 2016-17 and above target. Challenges for 2017-18 will include the proposed 10% reduction in Escherichia coli bloodstream infection. Prevention priorities for the forthcoming year will continue to focus on these areas for improvement and include: further focus on reducing Escherichia coli blood stream infection and Clostridium difficile infections. reducing turnaround of post incident reviews to have more prompt information, analyse trends/issues an share lessons learnt in a more timely fashion fostering more ownership and engagement within directorates particularly in relation to PIR and action plans a focus on measures to minimise the risks to patients from antibiotic resistant bacteria including optimal use of isolation facilities and reinforcing compliance by healthcare staff with basic infection prevention measures minimising infection risk from invasive devices and procedures. ensuring essential facilities e.g. hand wash basins, toilets, showers etc are maintained against a background of overall diminishing investment in the current hospital as the move to the new hospital originally due for 2017 JH/TJN IPC Annual Report 2016-17 RLBUHT Page 28