REPORT SUMMARY SHEET - PDF Free Download

Quality care for you, with you REPORT SUMMARY SHEET Meeting: Date: Title: Lead Director: Corporate Objective: Purpose: High level context: Trust Board 27 th October 2016 Infection Prevention and Control HCAI Report Medical Director Safe, high quality care For assurance Summary of Key Issues for Trust Board HCAI Performance against last years, 2015/16 Priorities for Action (PfA) Targets for MRSA bacteraemia and Clostridium difficile infection (CDI) C. difficile infections Year to date, (19 th October 2016) 14 cases SHSCT target from PHA 2016/17 is 32 cases MRSA bacteraemia Year to date, (19 th October 2016) 4 cases 0 cases considered preventable SHSCT target from PHA 2016/17 is 5 cases. MSSA bacteraemia Year to date, (19 th October 2016) 25 cases 4 cases considered preventable PHA does not set a target for MSSA bacteraemia. Key issues/risks for discussion: Update on current in year HCAI information Internal/External engagement: HCAI Strategic Forum 2 nd November 2016 HCAI Clinical Forum 26 th October 2016 & 30 th November2016

TABLE OF CONTENTS 1 HCAI Performance 2015/16 (Year to Date 16 th May 2016) 3 2 Update on Infection Prevention & Control Issues.....6 3 IPC Independent Audit Activity... 9

1 HCAI Performance 2016/17 (Year to Date 19 th October 2016) HCAI PfA targets for 2016/17 have been confirmed by the Public Health Agency [PHA] as: 5 MRSA bacteraemias & 32 C. difficile cases. Southern Trust Performance MRSA 2016/17 TARGET 2016-17 No. of cases per month Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Number of MRSA Cases 2016/17 MRSA Preventable 5 0.416 3 0 0 1 0 0 0 4 Total (2015/16) (5) (0.416) (1) (1) (2) 2016/17 year to date (19 th October 2016) there have been 4 MRSA bacteraemia cases and none were considered to be preventable. Southern Trust MRSA Episodes Cumulative Total 1 st April 2015 19 th October 2016

Southern Trust Performance Clostridium difficile 2016/17 2016/17 year to date (19 th October 2016) there has been 14 C. difficile cases. Southern Trust Clostridium difficile Episodes Cumulative Total 1 st April 2015 19 th October 2016

Southern Trust Performance MSSA 2016/17 (Year to date 19 th October 2016) For 2016/17 surveillance of MSSA bacteraemias remains mandatory ONLY within the SHSCT. To facilitate on-going surveillance of MSSA bacteraemias during 2016/17; MSSA target data for 2009/10 is used as a comparison. Year to date (19 th October 2016) there have been 25 MSSA cases. To date 4 have been identified as preventable. Southern Trust MSSA Episodes Cumulative Total 1 st April 2015 19 th October 2016

2 Update on Infection Prevention & Control Issues Clostridium difficile infection (CDI) in SHSCT From 1 st April 2016 to 19 th October 2016 there have been 14 cases of CDI in the SHSCT. All cases of CDI diagnosed within the Trust are investigated fully by IPCT in collaboration with the clinical team on the day of diagnosis [or the next available working day] and all undergo a strict multidisciplinary Root Cause Analysis (RCA) with an aim of identifying, implementing, promoting and sustaining shared learning for all clinical staff. IPCT continue to work on a framework whereby trend analysis of CDI HCAI RCA outcomes can be used to identify and reduce problems in quality of care and patient safety. IPCT utilise learning intelligence from RCAs to help illustrate or support recommended IPC practice. Outcomes from RCAs are taken on a regular basis to the 2 key IPC Forums, HCAI Clinical and HCAI Strategic Forum and IPCT use this shared platform to help inform key operational stakeholders regarding the RCA process and actions. Intelligence is gathered to this regard via SHSCT CDI Sub-Group who meets on a monthly basis to review and discuss all SHSCT RCA findings that are completed. The CDI sub-group reviews from a multidisciplinary perspective - outcomes, learning and death data to ensure a robust process remains in place and all information is considered. In addition our SHSCT bespoke CDI Trigger and surveillance system developed by the IPCT will in due course be shared to help promote co-ownership between clinical staff and IPCT. This unique alert system aims to inform staff including IPC of pro-active timely measures that may need to be put in place at clinical level to help avoid a concerning situation becoming worse from an IPC perspective.

SHSCT /RQIA Augmented Care Audit Programme Augmented care Sisters meetings continue. The first meeting was in May 2016 and IPCT continue to deliver on the request for monthly meetings until December 2016. Initially these meetings are for Hematology and Renal staff as this will allow IPC to focus on them and ensure they are adequately prepared for RQIA audit. In December 2016 the situation will be reviewed with an expectation to then engage with others in augmented care settings i.e. Delivery suites on both Acute sites. This collaborative working revolves around 3 RQIA audit tools: clinical audit tool governance audit tool and environmental audit tool While IPC will concentrate all its efforts on the clinical audit tool all areas need to be mindful of the governance audit tool also. Regular updates on the Trust IPC augmented care action plan and progress will continue to be given by IPCT at the SHSCT HCAI Clinical Forum (monthly) and HCAI Strategic Forum (every 2 months) as appropriate. Norovirus & Influenza Update Regionally IPCT continues to be notified daily of Norovirus (V&/or D) and Influenza (Flu A/B) incidence across Northern Ireland Care Homes. The Lead IPCN circulates this to the Operational Directors, Heads of Service and all other key stakeholders within the SHSCT for information and dissemination on a daily basis. The purpose of this is to be proactive in helping to prevent further outbreaks of infection within Trust facilities. At present in NI there 2 outbreaks of D &/or V in nursing /residential facilities [1 in BHSCT and 1 in NHSCT] There are no documented Influenza Outbreaks in Care Homes in NI at present. This is monitored very closely by the SHSCT IPCT on a daily basis. Trust Facilities Influenza We currently have no Flu Outbreaks within the SHSCT. Norovirus Currently we have a confirmed Norovirus outbreak in Ward 2 South Medical, CAH.

It is thought the Index case had exposure to possible Norovirus at home before admission to Hospital. Symptoms started 16 th October 2016 5 patients have been affected and no staff affected on 19/10/2016. Ward remains closed on 19/10/2016 to new admissions, IPC precautions and enhanced cleaning continues as recommended. The IPCN maintains daily visits to the ward for support and information. RCA - Community Engagement No further updates to report. Water Safety Funding has been agreed by the Trust to fund input from an independent Water safety Consultant who will report with a view to maximising safety and cost effectiveness of water management in the SHSCT. This is due to be completed in November 2016. The next Trust water safety meeting is due to be held late October 2016. Cutan Alcohol Hand Rub / Cutan Liquid soap Cutan is now well established within the acute, non-acute and community settings. IPC Community Master Class focussed on Hand Hygiene on the 14 th September 2016 in Portadown Health Centre and was well attended with a variety of community staff attending. Alcohol hand rub is freely available at all patient care areas and at the point of care. Regionally BSO Procurement are hosting a procurement group looking at the Regional contract for hand soaps, alcohol gels/foams and hand creams. The lead IPCN and Lead Occupational Health Nurse from the SHSCT are members of this panel. Work continues within the CAG group. Ebola Management Plan The Trust Ebola Management Plan remains outstanding. Lead Microbiologist/IPC Doctor will follow this up with the Head of laboratories for the SHSCT. SHSCT -Moving forward - Peripheral Line training in 2016 This was presented to HCAI Clinical Forum members and ANTT training sessions will recommence for Acute clinical staff from October 2016-December 2016 in the first instance. These sessions will be delivered by IPCNs and further phases of training have now been organised. SHSCT IPC Training/Education A subgroup of IPCNs continues to work with the IPS Education Sub-group and SHSCT ELD colleagues to develop IPC mandatory training packages. A blended learning approach is the focus with information leaflets, e-learning and face to face teaching methods. This is a complex piece of work that will focus on the IPC mandatory training of ALL staff who works in the Trust. Progress will be reported on in due course.

IPC Independent Audit Activity Hand Hygiene and Bare Below the Elbow Self Audit Scoring The Southern Trust promotes good hand hygiene at the point of care. The point of care represents the time and place at which there is the highest likelihood of transmission of infection via healthcare staff whose hands act as mediators in the transfer of microbes. One of the best ways to measure hand hygiene compliance is observation audit and the Trust had an on-going programme of hand hygiene audit. The compliance threshold for hand hygiene is 90% and areas that are non-compliant are required to re-audit daily until compliance is achieved. Being Bare below the Elbow is also an important factor for compliance with hand hygiene. The dress code policy requires staff to have sleeves short or rolled up to the elbow in order to allow access to the wrist for good hand hygiene technique and remove jewellery, such as watches. The policy also prohibits staff form wearing nail varnish, false nails or gel nails. Non-compliance is reported to the Trust Senior Management Team weekly and passed on to Operational Directors for corrective action to be taken. The IPCT independent audit results are fed back immediately to the ward manager and on a monthly basis to Operational Directors for corrective action.

Hand Hygiene Compliance by Trust Location [Independent Audits] Compliance for the period on the Craigavon Area Hospital site exceeds the compliance threshold of 90%. On the Daisy Hill Hospital site, there has been no breach of the compliance threshold since October 2013. Compliance for the period on the Lurgan Hospital and South Tyrone Hospital sites exceeds the compliance threshold of 90%.

Hand Hygiene Compliance by Staff Grouping A review of compliance by staff group indicates a dip in compliance by medical staff. The Medical Director wrote to all doctors to stress the importance of hand hygiene and supported this with face to face presentations [with the Consultant Microbiologist] at the Trust Morbidity and Mortality meetings.

Bare Below the Elbow / Nail Varnish-Extension Compliance