Agenda Item 10.4 CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Reprt f: Paper prepared by: Chief Nurse - Cheryl Lenney Cnsultant Nurse Infectin Preventin and Cntrl - Julie Cawthrne, Infectin Cntrl Dctr - Dr Andrew Ddgsn, Date f paper: August 2016 Subject: T update the Bard n the management and cntrl f Carbapenemase prducing enterbacteriacea (CPE) Purpse f Reprt: Indicate which by Infrmatin t nte Supprt Reslutin Apprval Cnsideratin f Risk against Key Pririties (Impact f reprt n key pririties and risks t give assurance t the Bard that its decisins are effectively delivering the Trust s strategy in a risk aware manner) 1. Patient Safety 2. Patient experience 3. Prductivity and Efficiency Recmmendatins T receive an update n CPE acrss the Trust. Cntact Dr Andrew Ddgsn (cnsultant Micrbilgist and Infectin cntrl dctr) 0161 276 5686
1. Intrductin 1.1 This paper prvides an update n prgress, f the key activities and develpments in the management f CPE acrss the Trust frm January August 2016. 2. Changes t CPE Screening Plicy 2.1 In January 2016 a review f a chrt f patients previusly knwn t be carrying CPE wh were re-screened n admissin identified that a significant number (65%) n lnger had detectable levels f CPE n re-screening and therefre did nt represent a significant risk f nward transmissin f CPE t ther patients. 2.2 Subsequent t this review and fllwing cnsultatin with the Trust Infectin Cntrl Cmmittee and Public Health England (PHE), a risk based peratinal/wrking apprach t screening was adpted and rlled ut acrss the MRI frm 12th April 2016. 2.3 All previusly CPE psitive patients are re-screened n admissin, thse wh screen CPE negative (subsequently referred t as CPE nt detected), are admitted int the general ward ppulatin fllwing risk assessment and are clsely mnitred during their admissin (i.e. re-screened every 72 hurs). 2.4 Data n relevant risk factrs is regularly cllected by the IPC team n all patients n the pathway during their in-patient stay. An analysis f the data will be undertaken (when sufficient data has been cllected), which will help t shape future plicy at lcal and natinal level. 2.5 T date (12 th August) 314 patients wh were previusly knwn t be CPE psitive have been admitted, 34 (10.8%) remained CPE psitive n admissin, 195 were CPE nt detected n admissin. Of thse patients wh were identified as CPE nt detected 30 were subsequently fund t be CPE psitive frm a re-screen during their admissin and were transferred t a chrt ward. 3. Reductin in the Capacity f Chrt Wards March and April 2016. 3.1 The Trust reduced the CPE chrt bed base by 38 beds n Ward 37, frm 85 t 63 beds (March 2016). Ward 37 subsequently re-pened as a Renal Ward. This decisin was based n a sustained reductin in the number f in-patients with CPE. 3.2 The chrt bed base was further reduced t 47 during April 2016. The patients n Ward 32 (16 beds) were re-screened intermittently ver a tw week perid t establish hw many remained CPE psitive. The results f the screens fund nly tw patients were CPE psitive. The Ward was deep cleaned and re-pened t receive CPE negative patients in May. 4. Assessment f CPE/Islatin Chrt Facilities August 2016 4.1 The changes t the CPE screening plicy assumes that there will be a cntinued decrease in the number f in-patients wh are CPE psitive. T ensure we are prviding high quality safe Page 2 f 5
care and ptimising the bed base within the MRI an assessment f the current prvisin f islatin facilities fr patients with CPE was undertaken ver a tw week perid in July. The results indicated that there is a requirement fr an average f 26 islatin /chrt beds per day (subject t unpredictable fluctuatins), t care fr patients wh are CPE psitive acrss the MRI. 4.2 A plan t decmmissin Ward 14 as the Surgical CPE chrt ward frm the 5 th September was discussed and agreed at the MRI and Traffrd Capacity and Operatinal Efficiency Grup in July. This will leave Ward 15 (27 beds) as the remaining CPE chrt ward fr medical and surgical patients wh are clnised with CPE. Additinal capacity fr islatin f patients wh are CPE psitive will be in prvided in single rms acrss the MRI divisins. This may impact n the use f single rms t care fr patients fr ther reasns such as ther infectins r at the end f life and will be mnitred daily. 4.3 The prvisin f dedicated chrt facilities fr patients wh are CPE psitive has been a majr cntributing factr in reducing the transmissin f CPE. The IPC team are mnitring the incidence f newly acquired CPE amngst all in-patients t ensure that CPE acquisitin rates are nt increasing fllwing the intrductin f the changes t plicy, (see Chart 1 belw which shws the number f new CPE acquisitins acrss the MRI frm January July 2016). Please nte the number f acquisitins in July includes a cluster f five cases frm patients n Ward 45. Chart. 1. Number f new CPE acquisitins acrss the MRI frm January July 2016. Page 3 f 5
5. Triggers fr Escalatin f CPE Islatin/Chrt Facilities 5.1 There is a risk that by reducing chrt ward capacity there may be a rise in the number f new CPE acquisitins amngst in-patients. T mitigate this risk a set f triggers have been develped by the IPC team that will be reviewed daily at the Bed Meeting (13:00 hurs). A prcess fr escalatin thrugh the Duty Manager is being develped. These triggers include: There shuld be n mre than 10% f patients (islated in side rms with en suite facilities if apprpriate), clnised/infected with CPE (KPC) n a ward fr example tw - three patients n a 28 bedded ward. When there are eight r mre patients (depending n hw many wards/beds there are in the divisin), with CPE (KPC) the Divisin shuld identify a chrt area n a ward that has a dedicated chrt f staff and patients shared facilities. If there is an utbreak r a significant increase in the number f patients wh acquire CPE KPC there will be a need t create a new chrt ward. 6. Transmissin f Carbapenemase resistant Enterbacteriaceae (TRACE) prject. 6.1 As previusly reprted, the Trust IPC team are wrking in cllabratin with PHE and the NIHR Public Health Research Unit (PHRU) and the natinal lead fr infectin cntrl Prfessr Derrick Crk n this study t investigate the rle f the envirnment in transmissin f CPE. 6.2 The prject initially cmmenced in January 2016 as a framewrk t prvide assurance fllwing clsure and significant remedial wrk n Wards 3 and 4 that was undertaken due t an utbreak f a clnal KPC E. cli acrss the Manchester Heart Centre. The prject entails screening f the envirnment as well as patient screening fr CPE. Fllwing additinal funding frm PHE, the TRACE prject was extended in July fr a further six mnths, t include fur additinal wards; 45, 46, AM1 and AM2. These wards were chsen predminantly due t their high incidence f CPE acquisitin amngst in-patients. 6.3 An versight grup has been established t prvide directin t and versee the wrk f the TRACE prject. The grup is chaired by the DIPC and reprts t the Trust Infectin Cntrl Cmmittee. 7. Summary. 7.1 The intrductin f the new CPE Screening Plicy has had a significant and psitive benefit t patient safety t date. Caring fr patients wh are CPE nt detected in specialist areas as ppsed t chrt/islatin wards has imprved the quality f patient care and patient flw. 7.2 Furthermre, the Trust is at the frefrnt f develping natinal as well as lcal plicy fr the management and cntrl f patients with CPE. The changes t the CPE screening plicy and the TRACE prject will ptentially prvide a rich surce f data that will further the glbal knwledge base with regard t CPE and anti-micrbial resistant rganisms. Page 4 f 5
7.3 The Trust priritises the preventin, management and cntrl f infectin and recgnises the imprtance f IPC as a significant patient safety issue. 7.4. The financial, peratinal and patient safety impact f CPE n patient flw is cntinually mnitred thrugh the Trust frmal cmmittee structures. Changes t the management f CPE and a reductin in the number f acquisitins shuld impact psitively n this psitin. 7.5 The preventin and management f CPE is n the Trust risk register and perfrmance and utcmes are mnitred thrugh the Risk Management and Infectin Cntrl Cmmittees. Page 5 f 5