Infection Prevention & Control Report to Trust Board Meeting Date 7 th September 2017 1. Executive Summary The Trust s reduction target for Clostridium difficile associated disease in 2017/18 is 44; a reduction of 12 cases or 21.43% compared to last year. It is likely that this challenging reduction target will not be achieved. To date 28 cases have been reported. 14 of the cases are classified as healthcare-acquired or associated, as they occurred more than 48 hours after admission to hospital (definition used by the Public Health Agency [PHA]). However, this is not always an accurate predictor of being healthcare-associated. The remainder are classified as community-acquired as the patients presented with symptoms within a 48 hour period after admission. The MRSA bacteraemia reduction target for 2017/18 is five. Since the beginning of April one case has been reported. It was categorised as community-associated. As such, the Trust is currently on track to achieve the target, with a cumulative decrease of 51.92% compared to 2016/17. As of 30 th August 2017, the total number of days since the last Trust hospital-associated MRSA bacteraemia is: nagelvin Hospital 728 days (Last recorded case was in Ward 4) South West Acute Hospital (SWAH) 564 days (Last recorded case was in Ward 8) Tyrone County Hospital (TCH)/ Omagh Hospital & Primary Care Complex (OHPCC) 958 days (Last recorded case was in the Rehab Unit) Ward 2 TOU, nagelvin, was closed for nine days due to a suspected Norovirus outbreak. Ten patients and two staff members reported symptoms, but the cause is unknown as Norovirus testing from the Virology Laboratory in Belfast was negative. There was a long delay in receiving the laboratory results from Belfast due to a malfunction with the testing equipment. This increased delay in receiving results and closure of the ward led to trauma admissions being diverted and elective orthopaedic surgery cancelled. All infection prevention and control (IP&C) measures were put in place to rectify deficiencies identified in safe practice and the clinical care environment. Ward 4, Waterside Hospital, has experienced an increase in the number of patients reporting symptoms of unexplained vomiting and diarrhoea. Norovirus is suspected and the results of samples sent to the Virology Laboratory in Belfast are awaited. All IP&C measures have been put in place and the ward is closed to any new admissions or transfers. 2. Attendance at Infection Prevention & Control Training Induction/ Mandatory Training 34 Induction and Mandatory Training sessions were delivered by the IP&C Team during the period April-June 2017. That is an average of 2.83 two-hour sessions per week within primary and secondary care settings across the Trust. As of the end of June, 1107 staff have attended the training (725 in the Northern Sector and 382 in the Southern Sector). The attendance target for each year is 50% of the total number of staff who require training. The actual attendance rate is 25.95% for the 12 months ending June 2017. Infection Prevention & Control Report, August 2017 Page 1 of 6
The IP&C Team are continuing to explore more flexible methods of training. This includes the development of an e-learning programme, which would complement face-to-face teaching. They are also engaged in early exploratory work for the development of Virtual Reality Action Training in conjunction with the South West Regional College, which could transform Mandatory Training with huge educational, research and business potential. 3. C. difficile Performance The 2017/18 target for C. difficile ( 2 years) is 44 cases, which equates to a reduction of 21.43% on the baseline figure of 2016/17 (56 cases). So far this year the Trust has reported 28 cases, with 14 of those being categorised as community-associated. Therefore, performance is currently off profile, with an increase of 20% compared to last year. * The value for Aug 17 is subject to change as the report was compiled prior to the end of the month. Infection Prevention & Control Report, August 2017 Page 2 of 6
A breakdown of the cases by hospital site and acquisition type (as of 30 th August 2017) is given in the chart below. Key: CAI HAI Community-associated infection Hospital-associated infection C. difficile/ Glutamate Dehydrogenase (GDH) Care Bundle and Audits Evidence based care bundles are effective when all elements of care are performed consistently. Therefore, scores are represented as either pass (100%) or fail (anything less than 100%). There is no differentiation between those achieving a very low score and those achieving 95%. This is done deliberately to highlight the importance of 100% compliance with the bundle as a whole. Five main elements of care have been identified as being necessary to reduce the incidence of C. difficile infection (CDI). They are prudent antibiotic prescribing, hand hygiene, environmental decontamination, use of personal protective equipment and isolation/ cohort nursing. The risk of infection reduces when all of the elements within the clinical process are performed every time for every patient. The risk of infection increases when one or more elements of a procedure are excluded or not performed appropriately. Monitoring of the elements outlined in the care bundle ensures that all necessary aspects of the clinical process are appropriately performed (as required by the particular situation). The care bundle should be used when cases of CDI are either suspected or proven. The C. difficile care bundle and the C. difficile care pathway audit are undertaken by an IP&C Nurse whilst the patient remains an inpatient. Support and advice on compliance issues are discussed with ward staff at the time of the audits. Daily ward self-audits should also be completed by the ward team to give assurance regarding level of compliance. In January 2017 the IP&C Nurses commenced similar audits for GDH cases. This improvement work regarding GDH is to reduce the likelihood of C. difficile bacteria starting to produce toxins, leading to CDI. As a result of an outbreak of a virulent and pathogenic strain of C. difficile in another Northern Ireland trust, there are currently enhanced assurance mechanisms in place by the Medical Director and Director of Nursing on compliance and non-compliance with the C. difficile/ GDH care bundle audits. Infection Prevention & Control Report, August 2017 Page 3 of 6
The two dashboards below summarise the performance of wards/ departments audited by the IP&C Team since April 2017. On occasion more than one audit may be completed during the month for a particular ward/ department. In such instances an average score is shown on the dashboards. These scores are marked (A). Consistent compliance with the C. difficile/ GDH care bundles remains a challenge. The findings indicate issues around prudent antimicrobial prescribing, environmental decontamination and hand hygiene compliance. C. difficile Audits Ward 1, Ward 20, Ward 31, Ward 32 ESU, Ward 42, Ward 50 Sperrin, CCU, ICU/ HDU, Ward 1 MSAU, SWAH Ward 2, SWAH Ward 3, SWAH Ward 6, SWAH Ward 7, SWAH Ward 9, SWAH Ward 3, Waterside Apr-17 May-17 Jun-17 Jul-17 Aug-17 100% (A) 80% x 2 Care Bundle 84% (A) 100% 100% x 1 x 1 Care Bundle 67% 100% Care Bundle 50% 50% 0% Care Bundle 50% Care Bundle 34% (A) x 1 x 1 Care Bundle 67% Care Bundle 75% Care Bundle 50% GDH Audits Apr-17 May-17 Jun-17 Jul-17 Aug-17 Ward 1, Ward 2 TOU, Care Bundle 84% (A) 100% 100% Ward 7, (A) 100% Infection Prevention & Control Report, August 2017 Page 4 of 6
Ward 31, Ward 32 ESU, Ward 40, Ward 41 AMU, Ward 50 Sperrin, CCU, ICU/ HDU, Ward 3, SWAH Ward 8, SWAH Care Bundle 0% 100% Care Bundle 75% 80% 50% 0% 100% 100% Care Bundle 0% Care Bundle 50% (A) 100% 67% Care Bundle 34% (A) 4. Pseudomonas Pseudomonas aeruginosa is an opportunistic pathogen or coloniser, well known in the hospital environment. Pseudomonas is predominantly an environmental organism and is highly attracted to water sources. Pseudomonas is ubiquitous in the alimentary tract of humans and, therefore, carriage is normal and its presence is not indicative of infection. The term colonisation is used to describe the identification of any organism without signs of infection. Specific groups of patients who are immunocompromised are at a higher risk of colonisation or infection than the normal population. The Trust has stringent measures in place regarding the surveillance and management of Pseudomonas in augmented care areas and participates in the PHA surveillance as detailed below. Pseudomonas Surveillance (Augmented Care* Areas Only) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total 14/15 0 1 0 0 0 1 3 0 1 0 0 0 6 15/16 0 0 0 0 0 0 0 0 0 1 0 0 1 16/17 0 0 0 0 0 0 0 1 1 1 0 0 3 17/18 0 1 0 0 1 * The PHA defines augmented care as NNICU, Adult ICU/ HDU, Renal, Oncology/ Haematology. This value is subject to change as the report was compiled prior to the end of the month. Since the beginning of April 2017 two cases have been reported, both categorised as healthcare-associated. The most recent healthcare-associated positive blood culture in an augmented care area pertained to an inpatient admission in Ward 50, nagelvin, in August 2017. All IP&C measures and assurance audits were carried out. Environmental screening and water sampling were performed and all tested negative for Pseudomonas aeruginosa. Infection Prevention & Control Report, August 2017 Page 5 of 6
5. Learning from Root Cause Analysis (RCA) Process RCA is a technique that helps answer the question of why an infection occurred in the first place. It seeks to identify the origin of the problem using a specific set of steps and tools to determine why it happened and to develop an action plan to reduce the likelihood of it happening again. C. difficile Quarter 1 2017: January-March A total of 20 C. difficile cases were reported within this period. 15 were either hospital or healthcare-associated and were, therefore, investigated using an RCA approach. Most cases were due to the use of proton pump inhibitors and antibiotics, mainly for treating acute and recurring infections, and prophylactically during chemotherapy. Of the 15 cases examined, three were deemed to have been avoidable. Methicillin-Resistant Staphylococcus Aureus (MRSA) Bacteraemia Quarter 1 2017: January-March There were two cases recorded during the quarter, but only one was healthcare-associated. This was due to an underlying urinary tract infection and the presence of a nephrostomy tube. Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteraemia Quarter 1 2017: January-March There were 13 MSSA bacteraemia cases in total, but only four met the healthcareassociated definition and were investigated via RCA. The main root causes were poor compliance with the care of intravenous lines and urinary catheters and underlying infection. Three of the MSSA cases were deemed to be preventable. Infection Prevention & Control Report, August 2017 Page 6 of 6