Board of Directors 25 November Report to: Title: Author: Sponsoring Director Purpose: Decision Sought: Board of Directors Infection Prevention and Control Report Dr Claire Thomas, DIPC Donna Green 6 monthly update on Infection Prevention and Control issues Information only 1. PURPOSE The purpose of this paper is to update the Executive Committee on the status of infection prevention and control in HHFT. 2. SUMMARY Infection prevention is a key quality and performance indicator for the organisation. Infection prevention and control is a responsibility of ALL staff. Mandatory DH targets are challenging with significant potential financial penalties (see section 3): o Clostridium difficile and isolation remains a major challenge; target for 2017 is 34. As at end October there have been 14 cases of reportable hospital acquired C. difficile o Hospital acquired MRSA bacteraemia target for -2017 is 0 and to date there have been no cases The Antibiotic management team continues to provide education and auditing antimicrobial use; and compliance and appropriateness of antimicrobial use are excellent and lower than national levels. There are major national CQUIN challenges for antibiotics. See section 13. There is a CQUIN target to achieve flu vaccination of more than 75% of frontline healthcare workers. The last two years had achieved approximately 65%. Clinics and walk rounds to clinical areas are being provided and Health4Work are happy to visit any groups that contact them. Communications team are assisting with promotion. 1/11
3. SURVEILLANCE 3.1 SURVEILLANCE APRIL OCTOBER HHFT ceiling End Oct MRSA bacteraemia MSSA bacteraemia E. coli bacteraemia C. difficile infections MRSA screening 0 HAI No target No target 34 HAI reportable At least 100% 0 HAI 13 HAI 18 HAI 14 HAI reportable* 92% 38 CAI 119 CAI 40 HAI non-reportable Oct 59 CAI *C. difficile: Mandatory reporting to Public Health England (PHE) is required when the screening test (PCR) and toxin detection are both positive. All hospital acquired infections (HAI) receive an internal multidisciplinary team Root Cause Analysis (RCA). A large number of positive screens are incidental findings in patients who do NOT have clinical evidence of C. difficile disease. These cases nevertheless represent an infection control risk. Please be aware of the number of hospital acquired cases that did not fit the reporting criteria and community acquired cases that were admitted to the organisation and still pose a risk of infection. Strict isolation of patients symptomatic of diarrhoea is crucial to prevent environmental spread. 3.2 INFECTION CONTROL RCA PANEL The Infection Control RCA panel is held monthly on both the BNH and RHCH sites (two panels a month) to review any patient who has acquired a healthcare associated infection (HCAI) and warrants a review using internal RCA and CCG criteria. The trust can appeal reportable hospital acquired C. difficile in cases where no lapse of care has been identified. Out of 11 cases reviewed, three cases were considered suitable for appeal; one case was deemed no lapse of care and would not count towards any financial penalty. One case was not successful and one case deferred until January 2017. Infection Control RCA Panel Report September : Summary of discussion points and key learning - C. difficile: Delay in care prompt isolation, sending of stool sample Lapse in care commode cleanliness, documentation Non-attendance at RCA panel by medical and nursing team 2/11
3.3 SURGICAL SITE SURVEILLANCE Total hip replacement Total knee replacement Note: 2014-2015 Q3 Total knee replacement BNHH was investigated and no commonality or trends were identified. Total hip replacement Total knee replacement NoF repair Note: From June 2014 responsibility for surgical site surveillance at RHCH was taken over by the infection control team. The high overall rates seen since then include superficial infections; the majority of which are patient reported symptoms that when combined with low case numbers creates a bias. Quarterly look back exercises have revealed no commonality or trends. 3/11
3.4 MRSA SCREENING Screening requirements and compliance continue to be monitored to manage high risk MRSA positive patients. Screening has improved, however the infection prevention team continue to monitor, educate and support clinical areas to improve further, as we are doing targeted screening in HHFT. MRSA Admission screen within 48 hours Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 BNHH 92% 96% 97% 98% 96% 100% 96% RHCH 87% 90% 70% 85% 85% 90% 85% HHFT 91% 94% 92% 94% 92% 97% 92% 3.5 VRE SCREENING VRE screening is in place trust wide for patients on admission to critical care, this allows us to identify colonised individuals and put appropriate measures in place without compromising patient pathways or care and compliance is monitored by the infection prevention and control team. Compliance with VRE Screening on admission to Critical Care Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 BNHH 83% 90% 93% 93% 95% 93% 94% RHCH 93% 89% 89% 82% 80% 95% 78% 4. INFECTION PREVENTION & CONTROL ANNUAL PLAN The infection control Annual Plan for -2017 has been submitted to the CCG and progress reviewed at end of quarter two. Following departure of a band 6 infection control nurse, a new band 6 trainee infection control nurse has been appointed and will be joining the team in November. A new band 7 Infusion Devices Nurse has joined the team and is currently completing external training. He will be the single point of contact in the use of Guardrails and other aspects of infusion devices used across the Trust and will provide specialist advice and training where required. Following implementation of the Daniels sharps bins across sites there have been some issues regarding sharp safety. The IPCT have undertaken an audit of practice and fed back to ward areas any concerns. Daniels has also undertaken an audit and this data has been reviewed by the IPCT. The IPCT will now be undertaking further audits around sharps until an improvement has been maintained. Updated policies for Chickenpox and Shingles, C. difficile, TB and Norovirus and Outbreak Management have been approved and awaiting publication. Further infection control policies are going through a process of review and update in line with evidence based practice and national guidance 4/11
A winter emergency preparedness session planned for November has been cancelled due to low numbers of clinical staff booking on the event. The Trust has formally agreed to standardise the FFP3 masks used across the site and all relevant staff will need to be mask fit-tested to these mask with both duck bill and cone shaped masks being available to suit different face types. Training on how to fit-test using the new masks has been provided by Full Support Healthcare Ltd and additional fit test training is being offered by the infection prevention and control team. Managers and service providers must allow front line clinical staff to attend mask fit testing training, once competent, trainers must fit test at least 2 colleagues each month in the trust to increase the pool of those who have been mask fit tested in a timely manner in order to have adequate trained staff in each shift. On the Link Practitioners re-launch they were also all updated on how to mask fit test. Hand hygiene dispensers have been upgraded across all sites with new tall automatic gel stands for main entrances and gels located at ward entrances, bay and side room entrances as well as at the point of care e.g. bed ends with new signage consistent across all sites An electronic surveillance system (IC Net) has been fully operative since March and is used by the IPCT on a daily basis to collect data, monitor and review patients with an infection, carry out contact tracing and produce reports. 5. AUDITS The regular rolling programme of audits is continuing as detailed in the annual plan. Implementation trust wide of the same day infection control monthly Saving Lives audits (IV cannula ongoing care and urinary catheters and central venous lines insertion and ongoing care). Hand hygiene audits are carried out monthly by the wards and from 1 October 2015 ICQC monthly audits have been replaced with quarterly point prevalence studies. Any areas that achieved 80% or below in the quarterly audit will be re-audited for the following two months and supported with additional training if full compliance is not achieved over the period (see section 5.2 below). Commode audits are undertaken quarterly for areas that achieved full compliance in the previous 3 months; monthly audits for areas that fail the 3 monthly audit and weekly audits for areas that fail the previous month until full compliance is achieved. Any concerns or discrepancies are followed up by the IPCT. All infection control audits are carried out and fed back to the clinical area and clinical service lead on the day of the audit. Indwelling device audits are undertaken on a monthly basis and compliance is fed back to ward areas on the day of audit. A Point Prevalence audit on central lines was undertaken in quarter 2 by the IPCT on the BNHH and RHCH sites. The data collected does suggest that CVC care is completed in the majority of cases, reflected by the low VIP scores. However, due to poor documentation, or noncompletion of VAD forms, some areas scored negatively or as none or poor compliance. 5/11
Labelling of dressings and administrations sets for IV medications and fluids remains an ongoing problem and this is being investigated further. A Point Prevalence audit on Urinary Catheter care and insertion of 40% of the patient groups with urinary catheters in situ on the day of audit was undertaken in quarter 2 by the IPCT on the BNHH and RHCH sites, results will be published once available. This is not a CCG requirement for -2017 however will the IPCT will continue to monitor. 5.1 AUDIT RESULTS APRIL - OCTOBER Element Apr May Jun Jul Aug Sep Oct HII 1CVC Insertion % 100% 100% 100% 100% 100% 100% 100% HII 1 CVC Ongoing Care % 90% 83% 94% 100% 93% 86% 100% HII 2 PVC Ongoing Care %* 76% 79% 68% 77% 79% 76% 67% HII 2 PVC Insertion % * 45% HII 6 Urinary Catheter Insertion % * 97% 92% 95% 96% 98% 95% 26% HII 6 Urinary Catheter Ongoing care %* 78% 71% 81% 76% 88% 85% 20% HII 7 C. difficile care % 89% 64% 80% 73% 81% 81% 87% Commode Hygiene % 94% 92% 88% 84% 94% 97% 88% Hand Hygiene (ward audits) % 99% 96% 97% 96% 97% 97% 98% Hand Hygiene (ICQC audits ) % Not due Not due NB: The low scores for HII 7 C. difficile care relate to inconsistency with documentation and evidencing the three times daily cleaning and this has been discussed with Facilities and an improvement seen. *In October new audit tools were introduced in accordance with Epic3 and although wards were aware of the change-over the low audit scores relate to poor documentation and this will be monitored. 5.2 HAND HYGIENE AUDITS ROLLING MONTHLY AVERAGE 93% Not due Not due 98% Not due 6/11
6. DECONTAMINATION On a recent walk round it was noted that the decontamination of tonometer heads in the Ophthalmic Outpatients were not compliant with Trust protocol. When reviewed this was only a BNH issue. A meeting with the lead of Ophthalmology has been arranged. A group is to be set up to look at the decontamination strategy for the whole Trust including the new Critical Treatment Hospital. 7.1 ENVIRONMENTAL CLEANING AUDITS UNDERTAKEN JULY-OCTOBER Monitoring Completed AWMH High Risk AWMH BNHH High Risk BNHH RHCH High Risk RHCH July 100% 100% 100% 100% 100% 100% August 100% 100% 100% 100% 100% 100% September 100% 100% 100% 100% 100% 100% October 100% 100% 100% 100% 100% 100% Target 100% 100% 100% 100% 100% 100% Average Score AWMH High Risk AWMH BNHH High Risk BNHH RHCH High Risk RHCH July 98% 97% 99% 97% 98% 96% August 98% 96% 99% 99% 98% 96% September 98% 97% 99% 98% 98% 97% October 98% 97% 99% 98% 99% 96% Target 98% 95% 98% 95% 98% 95% 7/11
7.2 PLACE Scores - Cleanliness Cleanliness AWMH BNHH RHCH HHFT HHFT Score 99.77% 98.10% 98.15% 98.19% National Average 98.06% 98.06% 98.06% 98.06% 7. OUTBREAKS APRIL - OCTOBER There were no outbreaks in the period however there were two look back exercises: Measles case In August a patient, who was 25 weeks pregnant, was admitted to the Antenatal Ward BNH with symptoms of feeling unwell and with a rash. She was isolated on admission. The patient had been in contact with family members with suspected Scarlet Fever and it was believed that this patient also had this. The patient was moved to Women s Health Unit due to the perceived risk of Group A Streptococcal infection and was placed in a side room. Bloods were taken to rule out Measles and sent to the reference laboratory. The patient was discharged before results were known. The results were confirmed to be Measles positive. A look back exercise was undertaken and staff and patients who had had significant contact were identified. Health4Work undertook an investigation to identify staff immunity and one staff member was found to be non-immune. The staff member was offered the MMR vaccine and had to be off work till 21 days post exposure with the patient. Actions from the meeting noted that none of the side rooms on Antenatal, Postnatal or Women s Health have any ensuite facilities; this was placed on the risk register. Commodes are also not available on the Maternity area and these were going to be sourced. Staff immunity to Measles was not clear and Maternity are working with Health4Work to review staff immunity. TB case A Healthcare worker (HCW) diagnosed with fully sensitive Mycobacterium tuberculosis in mid- August. Symptoms date from the end of June. The case was determined to be cavitatory disease, by the reviewing respiratory team, and ourselves, with the scans suggesting a lesion communicating with the airway. The HCW was asked to stop work immediately and liaise with their manager, and is now on treatment. A look back exercise is in progress with the DIPC, PHE, Communications, Health4Work, Respiratory Clinical Nurse Specialist, Respiratory teams, and ward team. The CEO has been kept in touch throughout. Screening of close family members was performed, and following extensive discussions, risk assessments, of ward staff, it was decided to offer screening to all staff contacts; and the patients who had been on the ward > 2 days during the infectious period. Letters have been sent out and advice is being provided by the DIPC and respiratory nurse specialist as required. Screening is on-going, and MDT meetings are being held regularly. 8/11
8. PERIODS OF INCREASED INCIDENCE APRIL - OCTOBER Ward Site Month Commenced Organism Number of patients affected (HAI) Same strain confirmed E2 BNHH Jun C. difficile 0 (reportable) Unable to 2 (non-reportable) identify AMCU RHCH Jul C. difficile 1 (reportable) Unable to 1 (non-reportable) identify Shawford RHCH Jul C. difficile 1 (reportable) Same strain 1 (non-reportable) identified C3 BNH Jul C. difficile 2 (non-reportable) Not same strain E2 BNH Aug C. difficile 1 (reportable) Not same 2 (non-reportable) strain AAU RHCH Oct C. difficile 2 (reportable) Results 0 (non-reportable) awaited Status of PII Closed Closed Closed Closed Closed In progress 9. HHFT COMPLAINTS RELATING TO INFECTION PREVENTION (INCLUDING CLEANLINESS) APR - SEP Month Type Location Description Apr Formal Dermatology Cleanliness complaint RHCH Apr Formal C2 Failure to wash hands complaint BNHH Jul 16 Informal Outpatients Failure to adopt infection control measures Complaint Dept BNH Aug 16 Informal Twyford ward Cleanliness in clinical area (all aspects and areas) complaint RHCH Aug 16 Informal Phlebotomy Failure to comply with hand hygiene requirements complaint BNH Aug 16 Formal E4 BNH Cleanliness in clinical area (all aspects and areas) complaint Aug 16 Informal Wainwright Cleanliness in clinical area (all aspects and areas) complaint Ward RHCH Aug 16 Formal complaint Clarke ward RHCH Cleanliness in clinical area (all aspects and areas). (This is part of larger complaint.) Aug 16 Formal complaint Delivery Suite BNH Failure to adopt infection control measures. (This is part of larger complaint) Aug 16 Informal complaint Emergency Dept BNH Cleanliness in clinical area (all aspects and areas) 9/11
10. EXECUTIVE WALKROUNDS The DIPC/Lead Infection Prevention and Control Nurse carry out regular environmental executive walk-rounds across sites with the Chief Nurse and Estates and Facilities Directors as available and any issues identified are fed back to the area at the time. Areas visited have included Maternity, Dental area and Critical Care, Resus ED and AAU BNHH, AAU and AMCU at RHCH and X-ray BNHH. 11. BUILDING WORKS AND DEVELOPMENTS Building and development plans within the organisation must be planned in parallel with infection control to ensure not only compliance but a safer environment for services. The team need to be closely involved in any reorganisation of medical services as these present the greatest risk to the organisation in terms of new outbreaks of infection (Norovirus, flu etc). The Infection Prevention and Control Team continue to work with Estates on various projects across sites. 12. ANTIMICROBIAL APR - SEPTEMBER CQUIN progress: 1. Pip/Taz consumption has reduced by 60% since the beginning of /17 but further reductions are required to achieve the annual reduction of 1%. We are consulting with the Respiratory physicians regarding alternatives at the moment. 2. Carbapenem stewardship at HHFT is excellent and below English average 3. Overall antibiotic consumption has not risen as much as anticipated through use of alternatives for Pip/Taz (often 2-3agents), probably attributable to increased review and awareness of antibiotic prescribing. However, we are unlikely to achieve the CQUIN target (99%): currently 103% 2013/14 baseline 4. Antibiotic prescription review is maintaining > 90% which is Q4 target We are participating in the ECDC PPS which is an international Antimicrobial Point Prevalence Study that will give us local and international benchmarking data in mid-2017 as well as our own reports for local comparison with data from previous years. This data will be used with national/international resistance surveillance data which will inform future Antimicrobial Stewardship in Europe. We are in the process of reviewing and updating our Empirical Guidance on MicroGuide and the community UTI guidelines. The Antimicrobial Management Team (AMT) is presenting at the Federation of Infection Societies Annual Conference and the 10th Healthcare Infection Society International Conference on 8 November on Antimicrobial Stewardship in the UK. Two Band 6 pharmacists are in post and are supporting the CQUIN by undertaking audits, data entry and taking on additional pharmacy commitments, releasing the antimicrobial pharmacists for antibiotic stewardship activities. 10/11
13. RECOMMENDATION The Board of Directors is kindly asked to note the report. 11/11