infection prevention and control annual report 2016-17 annual report 2016-17.pdf · as director of...

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Nicola Lucey, Director of Nursing and Quality and Infection Prevention and Control

Anne Smith, Consultant Nurse, Infection Prevention and Control

Professor Craig Williams, Consultant Microbiologist, Infection Control Doctor

Infection Prevention and Control Annual Report 2016-17

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EXECUTIVE SUMMARY

The Trust met the trajectories set for MRSA bacteraemia and Clostridium difficile infections for 2016-17.

Enhanced surveillance was undertaken to review cases of Escherichia coli bacteraemia. This surveillance highlighted the importance of working across the health economy to achieve the mandated reduction in the forthcoming year.

There has been only one outbreak of Norovirus during the year.

Surveillance of Surgical Site Infections for hip replacements demonstrates further surveillance and scrutiny of post discharge reports of infection is required. None of the patients reporting post discharge infections required readmission.

Surveillance of Breast infections demonstrates that the interventions put in place following last year’s surveillance have been effective in reducing infections.

Participation in pilot surveillance of Central Venous Catheter related bloodstream infections in Critical Care Unit demonstrated significantly lower rates of infection for the Trust when compared with other participating Trusts.

The CQUIN target for antimicrobial prescribing were met.

The Trust achieved above the national average for several elements of the PLACE assessments for the year.

The Sterile Supplies department continues to maintain a full Quality Management System in line with BSO standards.

Delivery of an effective antimicrobial resistance programme effectively requires investment in an efficient surveillance system.

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INDEX

EXECUTIVE SUMMARY 1

1 INTRODUCTION 3

2 INFECTION PREVENTION AND CONTROL ARRANGEMENTS 4

3 EDUCATION 4

4 POLICY DEVELOPMENT / REVIEW 5

5. HEALTHCARE ASSOCIATED INFECTIONS 5-11

6 OUTBREAKS OF INFECTION 11

7 SURGICAL SITE SURVEILLANCE 12-17

8 INFECTION CONTROL WEEK 18

9 ANTIMICROBIAL REPORT 20-26

10 FACILITIES REPORT 27-30

11 ESTATES REPORT 31-33

12 DECONTAMINATION REPORT 33-36

13 CONCLUSION 37

14 APPENDIX 1 – WORKPLAN 2017-18

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INTRODUCTION

This is my first annual Infection Prevention and Control report since taking up my position in September 2016 as Director of Nursing and Quality with the responsibility as Director of Infection Prevention and Control (DIPC). The Trust values are committed to “delivering compassionate and safe healthcare.” In 2016-17 I am proud to say we have met the trajectory for healthcare associated infections.

Reducing the risk of infections is a fundamental principle of high quality, safe care. It requires a consistent approach to all elements of both practice and cleanliness of the environment. Preventing healthcare associated infections is integral to Trust values and Infection prevention and control remains a key priority for the Trust and the control and prevention of infection reflects how the culture and values of the Trust directly impact upon the care that patients receive.

I am pleased to report good progress against the trajectory for Healthcare Associated Infections, meeting both the target for zero cases of MRSA bacteraemia and reporting 8 cases of Clostridium difficile against a projected number of 14

Preventing healthcare associated infections is reliant upon achieving consistently high standards of care throughout each interaction between patients and health and social care staff. To achieve this requires all staff to deliver care that is underpinned by the Trust values of integrity, respect, teamwork and excellence.

The NHS is undergoing a period of change with services being adapted to meet both the increasingly complex care of patients and, most importantly, to ensure that within all care settings, the high standards of care that patients expect to receive from the trust are maintained.

This high level of care is essential against the background of the emergence of antimicrobial resistant organisms as a national and international threat. It is estimated that 700,000 deaths occur every year from drug resistant diseases. This rate will rise exponentially if action is not taken. I believe every healthcare professional has a role in the global campaign to reduce the burden of antimicrobial resistance, therefore in my role as DIPC I remain committed to developing and supporting the delivery of the Infection Prevention and Control work plan (Appendix 1) in the forthcoming year.

Nicola Lucey

Director of Nursing and Quality

Director of Infection Prevention and Control

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1. INFECTION PREVENTION AND CONTROL ARRANGEMENTS 1.1. Infection Prevention Committee (IPC)

The IPC met 6 times during 2016-17. It is a requirement of The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections, that all registered providers: “have in place an agreement within the organisation that outlines its collective responsibility for keeping to a minimum the risks of infection and the general means by which it will prevent and control such risks”.

The IPC is chaired by the Director of Nursing & Quality, Nicola Lucey who also acts as the Director of Infection Prevention and Control (DIPC) with responsibility for reporting to Trust Board.

1.2. DIPC Reports to Trust Board and Quality Committee

The DIPC has presented to the following items during 2016-17:

Monthly MRSA Bacteraemia surveillance; Monthly Clostridium difficile surveillance; Monthly hand hygiene rates; Outbreak and incident reports

1.3. Infection Prevention and Control Team (IPCT)

The IPCT has welcomed new members in the year and consists of: Nicola Lucey- Director of Nursing and Quality, and Infection Prevention and Control;

Professor Craig Williams, Consultant Microbiologist and Infection Control Doctor;

Anne Smith, Nurse Consultant Emma Hoyle, Matron Abigail Warne, Specialist Nurse (Trainee) Cheryl Heard, Administrator Rhian Pearce, Antimicrobial Pharmacist.

2. EDUCATION A total of 47 formal education sessions for both clinical and non-clinical staff were hosted by the IPCT during the year. This achieved an overall compliance with IPC training of 93% of staff As part of routine daily work the IPCT undertake informal education sessions with staff on relevant aspects of IPC work. The IPCT are involved in the current review of delivery of Mandatory Training for staff. Current plans are to deliver these sessions using scenario based techniques aligned to patient pathways.

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2.1 Link Staff Meetings 2016

The link staff role in Infection Prevention and Control at DCHFT has been pivotal over the past 11 years. The role has provided a clear contact for communication to be distributed from the IPCT to the wards and departments.

Link staff act as a link between their own clinical area and the Infection Prevention and Control team. Their role is to increase awareness of infection control issues in their ward and motivate staff to improve practice. They have been shown to be of value to the Trust by improving clinical ward audit scores, helping infection control nurses implement policies and collecting data on hospital-acquired infections.

Regular meetings have been in place through this time. The purpose of these meetings have been to share good practice, provide training to the link staff and to ensure that current infection control issues are shared accordingly. Over the past year there were six link staff meetings, rates of staff were variable and the Divisional Matrons have been tasked to look at their areas to ensure the staff are released to fulfill their role. The link staff have been supported by visiting trainers from Gojo, Water Hygiene Centre and GUM. Infection Control Link Staff are key to ensuring that Infection Prevention and Control is embedded full into standards of care and they are a valued group at Dorset County Hospital. 3. POLICY DEVELOPMENT/REVIEW The following policies have been developed/ reviewed during the year:

Infectious disease Specimen Collection Seasonal influenza Scabies Pets for therapy Clostridium difficile

4. HEALTHCARE ASSOCIATED INFECTIONS 4.1. Meticillin Resistant Staphylococcus Aureus (MRSA) bacteraemia

There were no cases of MRSA bacteraemia in 2016-17. The last case of MRSA bacteraemia assigned to the Trust was July 2013. This provides confidence that the IPC practices in place have been sustained. Our performance is in keeping with national data whereby Trust apportioned cases of MRSA (blood samples taken

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≥48hours post admission) have significantly reduced. National data demonstrates a reduction from 8.6 per 100,000 population in 2007/08 to 1.5 per 100,000 in 2015-16.

4.2. Staphylococcus aureus bacteraemia (MSSA)

4.2.1 Staphylococcus aureus is a bacterium that commonly colonises the skin and mucosa of people without causing any infections. It is opportunistic and has the potential to enter the body e.g. via a wound, broken skin or intravenous line or a medical procedure. This creates the potential for illnesses ranging from mild to life threatening, and can require prolonged treatment with antibiotics.

4.2.2 The chart below demonstrate rate of MSSA from 2011- 16 compared to rates for England. (Source data Public Health England: Fingertips)

4.2.3 Trust data for 2016/17 demonstrates that 78% of cases were cultured from patients within the first 48 hours of admission. These cases are generally considered to be “Community Acquired”.

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4.2.4 Whilst our rates of MSSA are below the national average it is important to take into account that 23.6% (n9) of these patients had a healthcare intervention at the Trust within 3 months of the bacteraemia. It is therefore important to continue to review the care pathways of these patients to determine whether there are any additional opportunities to prevent infection.

4.2.5 Four of these patients attended for regular dialysis sessions. Staphylococcus aureus infections are a recognised risk associated with haemodialysis patients. The bacterium is found in both healthy and compromised patients. A characteristic of Staphylococcus aureus is its ability to form biofilms on prosthetic materials as well as the ability to invade tissue and disseminate throughout the body. The renal units now screen patients routinely every 3 months for Staphylococcus aureus and patients screening positive are treated with a decolonisation regimen. Following root cause analysis of renal patients with MSSA bacteraemia some changes in for dialysis technique have been introduced to further reduce the risk of infection.

4.2.6 The insertion and management of temporary Central Venous Catheters presents a potential serious infection risk. In the forthcoming year the IPCT will work with the renal team to develop surveillance to further inform practice and minimise associated infection risks. This work will be supported by the development data linkage between the ICNeT surveillance system and Vital PaC to allow continuous surveillance of invasive devices.

4.3. Escherichia coli bacteraemia

4.3.1 Escherichia coli (E. coli) bacteria are frequently found in the intestines of humans and animals. There are many different types of E. coli, and while some live in the intestine quite harmlessly, others may cause a range of infections including urinary tract infection, cystitis (infection of the bladder), and intestinal infection. E. coli bacteraemia (blood stream infection) may be caused by primary infections spreading to the blood.” (PHE 2014)

4.3.2 A quality premium measure to reduce Gram Negative Bloodstream Infections and inappropriate antibiotic prescribing in at risk groups has been introduced nationally for 2017-18. It is recognised that to achieve this reduction a whole health economy approach is required. The following thresholds for reduction have been set nationally:

10% reduction or greater for the quality premium in all E. coli

Bloodstream infections (BSI) based on 2016 performance data. Collection and reporting of a core primary care data set for all E. coli

BSI. (NHS England 2015).

4.3.3 Enhanced mandatory surveillance for E. coli bacteraemia was introduced in 2011 for acute trusts with E coli. bacteremia reported monthly to Public Health England. Since the introduction of this surveillance E. coli bacteraemia

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has increased nationally by 31% (8,275 to 10,864 cases) which represents an increase in rate from 61.7 to 78.8 cases per 100,000 population (PHE 2016).

4.3.4 Trust data demonstrates a rise in cases of E. coli BSI during the period May-

August 2016 compared with the same period last year. Dorset as a county has the third highest rate of E. coli BSI in the South West region for the period July- September 2016 (PHE 2016).

The chart below demonstrates data for Clinical commissioning Groups in the South West region. (PHE HCAI Quarterly report June to September 2016)

4.3.5 DCH data 2014-17 (Source data Public Health England 2017)

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4.3.6 In response to the Trust increased number of E. coli bacteraemia this year a review of cases (24) for June and September was undertaken.

4.3.7 Recent presentations on antimicrobial resistance at Public Health England South West Study day identified a work stream to improve the management of elderly patients in Residential Care Homes (RCH) with urinary tract infections. Of the 24 patients included in this study:

8 patients (33%) were residing in RCH, 16 (66%) in their own homes.

Catheter associated urinary tract infections were frequently associated with E. coli blood stream infections. Of the 24 patients reviewed 3 (12.5%) had urinary catheters in situ at the time of the positive blood cultures.

4.3.8 The source of E. coli infections can be difficult to determine particularly in elderly patients with multiple comorbidities. 15 (62.5%) of the sample patients had urine samples that cultured E. coli at the same time as their positive E. coli blood culture. Of these 24 patients, 4 (16.6%) were infected with bacteria producing extended spectrum beta lactamases (ESBL) bacteria. ESBL are enzymes that confer resistance to most beta-lactam antibiotics such as penicillins and cephalosporins so treatment options are limited.

The following chart demonstrates the source of the infections for the sample group.

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PHE (2016) voluntary reported data in 2015/16 shows that urinary tract infections (UTI) account for 46.3% of cases. Local DCH sample data suggests that 59% of cases in our population are attributed to UTI.

4.3.9 A national study of 30 day mortality post sample among E. coli bacteraemia patients in England was undertaken by Abernethy et al (2015).This study identified death certificates of patients which mentioned sepsis/septicaemia/bacteraemia or E. coli as the cause of death. Mortality was 18.2% in the study group.

Review of the 30 day mortality for the 24 patients in the DCH population identified a mortality rate of 16.6%). 2 of these patients died in hospital, urosepsis was identified on Part 1a on both death certificates. The other 2 patients died post discharge. Of note all 4 patients resided in Residential Care homes. 3 of the 4 patients were admitted with urinary catheters in situ.

The age range of these patients was 77-89 with a mean age of 82 years. The mortality review by Abernethy identified that patient’s ≥85years with E. coli bacteraemia had a six fold increase in the risk of death.

4.3.10 PHE (2016) suggest that 75% of E. coli cases have an onset is less than 2 days of admission, suggesting that their onset occurs in the community. In their discussion they suggest that interventions to reduce E. coli bacteraemia may best be targeted at the community. However, because of the high prevalence of E. coli bacteraemia even a low proportion of cases being of hospital onset equates to thousands of cases (circa 9,000 a year) so still warrants attention.

This review of a sample of DCH patients identified the following:

E. coli bacteraemia is the most common bacteraemia at DCH Of the sample all E. coli bacteraemia were identified <2days of

admission suggesting most are considered Community Acquired. Incidence of E. coli bacteraemia at DCH is higher in females to males Urinary tract infections are the most common source of E. coli

bacteraemia at DCH Patients admitted from RCH with E. coli bacteraemia associated with

urosepsis have a high mortality rate. 2 of the 24 cases of E. coli were ESBL producers. Patients with E. coli bacteraemia frequently had considerable length of

stay in hospital- this may reflect other co-morbidities outside the scope of this review.

These data suggest that interventions to reduce mortality among patients with E. coli bacteraemia should involve primary and secondary care with a focus on a effective treatment of underlying infections and earlier and earlier more accurate diagnosis and treatment of E. coli bacteraemia and underlying

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urosepsis. In a letter to the lancet (2012) Melzer & Welch suggest that the Department of Health should focus upon reduction of E. coli infections associated with medical devices as opposed to organism specific surveillance as what really matters is the association between the organism and insertion and care of a medical device.

4.3.11 It would be prudent to form a whole health economy approach to achieving a reduction in E. coli bacteraemias and we would suggest the following work streams to support this:

Improve clinical information when urine samples are requested to support effective management of patients with urinary tract infections;

Review Dorset wide compliance with Urinary Catheter Care Pathway. Consider project to support Residential Care Homes and Social Care

staff to develop effective strategy to effectively assess and appropriately manage patients who require urinary catheterisation.

Support community work-stream for reduction in antimicrobial usage. 4.4. CLOSTRIDIUM DIFFICILE INFECTION (CDI) 4.4.1 This has been the most successful year for reducing cases of CDI. The Trust

trajectory for the year was 14 cases. In total the Trust reported 13 cases detected >3 days after admission; of these cases 5 were appealed as non-preventable with no lapses in care; this resulted in 8 cases reported as hospital acquired. It should also be noted there were no cases of CDI acquired in the Trust for quarter 4 period.

4.4.2 All samples are forwarded to the PHE reference laboratory for ribotyping. This provides an overview of the different strains of Clostridium difficile toxins and an opportunity to ensure that any potential linked cases are reviewed and outbreaks detected early. Over the course of the year we identified 7 different phage types, two samples were the same but not linked in either wards (1 a

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medical ward, 1 surgical ward) or timing of samples (1 in July the second in October). We can confidently say that we have not had any outbreaks or linked cases of CDI in the Trust 2016-17.

4.4.3 All cases of hospital acquired CDI require a Root Cause Analysis

investigation. The results are presented to Patricia Miller, Chief Executive Officer and scrutinised to identify any relevant learning from the cases. The learning actions when completed are then fed back and signed off by the relevant Matron at the Infection Prevention Committee.

5. OUTBREAKS OF INFECTION 5.1. Norovirus –is the most common cause of outbreaks in hospitals that result in

either ward closure of restricted admission and discharge activity. In 2016 Public Health England (PHE) reported a total of 563 outbreaks of Norovirus in hospitals in England. Of these reported outbreaks 148 occurred in Southwest Hospitals. There are 17 acute hospital trusts in the South West region.

In 2016-17 DCH reported 1 confirmed outbreak of Norovirus. The outbreak was on an elderly care ward, a total of 10 patients were symptomatic. The ward was closed to admissions for 9 days.

It is very difficult to quantify IPC events that are prevented. The PHE South West data for Norovirus outbreaks would suggest that the incidence of Norovirus outbreaks at the Trust is much lower than would be reasonably predicted. Staff, particularly on admission wards and the emergency department are very aware of the importance of rapid isolation of symptomatic patients. The IPC team undertake daily ward rounds of every ward in the Trust. These rounds involve, discussing with clinical staff, patients who are isolated, levels of cleaning required for individual rooms and recommendations for sampling. This level of scrutiny would appear to be effective at preventing outbreaks of norovirus. This work would not be possible without the support received from our IC team who supported our vision to deliver safe effective care at the patient bedside.

6. SURGICAL SITE SURVEILLANCE

Surgical site infections (SSIs) are defined to a standard set of clinical criteria as infections that affect the superficial tissues (skin and subcutaneous layer) of the incision and those that affect the deeper tissues (deep incisional or organ space).

Preventing surgical site infections is an important component of Infection Prevention and Control programmes. There is a Mandatory requirement by the Department of Health for all Trusts’ undertaking orthopaedic surgical procedures to undertake a minimum of three months’ surveillance in each financial year.

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During 2016-2017 the IPC team have supported 2 modules for surveillance of hip replacement and 1 module for Breast surgery. Surveillance is more robust following the introduction of ICNet. The system facilitates readmission alerts, and data upload from PAS, theatre and microbiology systems and the ability to directly upload the data to PHE SSI site.

6.1. Surgical Site Surveillance of Hip Replacement

Further to discussion with the Orthopaedic surgeons it was agreed to focus the audit on hip replacement surgery. Previous audits had focussed on knee replacement surgery audit and current practice with hip replacement was felt appropriate to revisit.

SSI for hip replacement involves 3 stages of surveillance: Stage 1- collection of data relating to the surgical procedure and inpatient stay Stage 2 (not mandatory) collection of post discharge surveillance at 30 days post procedure Stage 3- review of patients readmitted within 365 with SSI Data reports have been published for the 2 quarters audited – 1st April – 30th June 2016 and 1st July – 30th September 2016.

The following tables demonstrate the number of operations completed, and number of completed post discharge questionnaires for April- June 2016 (Table 1) and July- September 2016 and last 4 periods for which data was available (Table 2).

The Orthopaedic Surgeons review every case identified as a potential SSI at their monthly Governance meeting. This review is alongside a review by Consultant Microbiologist and Infection Prevention & Control Nurse. The surgeons are confident that the post discharge infections cases identified this year represent skin contamination and are not serious infections. Identification that these cases are infections on the SSI database relate to the feedback from the patient, General Practitioner and wound swab results. Rates of post discharge identified infections have subsequently reduced as demonstrated in the tables 1 and 2.

The percentage of post discharge questionnaires returned by patients is significantly higher than the national data for all hospitals.

Table 1 April – June 2016 Hip Replacement Surveillance

Operations & Surgical Site Infections Dorset County Hospital NHS Foundation Trust Apr-Jun 2016 Last 4 periods

Operations Total number No. with PQ given % with PQ completed

94 94 81.9%

94 94 81.9%

No. of inpatient/readmission % infected

0 0.0%

0 0.0%

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Surgical Site Infection

No of post discharge confirmed % infected

2 2.1%

2 2.1%

No of patient reported % infected

0 0.0%

0 0.0%

All SSI % infected

2 2.1%

2 2.1%

Table 2 July- September 2016 Hip Replacement Surveillance

Operations & Surgical Site Infections Dorset County Hospital NHS Foundation Trust Jul-Sep 2016 Last 4 periods


63 63 74.6%

157 157 79.0%



0 0.0%

0 0.0%


1 1.6%

3 1.9%


0 0.0%

0 0.0%

All SSI % infected

1 1.6%

3 1.9%

Table 3 shows the results from all hospitals in this surgical category (hips) for the previous 5 years (2011-2016) for purpose of comparison. Operations & Surgical Site Infections All hospitals

Without PQ

With PQ Total

Operations Total number % with PQ completed

116573 -

155036 74.9%

271609 0.0%



848 0.7%

556 0.4%

1404 0.5%


190 0.2%

415 0.3%

605 0.2%


No data No data

829 0.5%

916 0.3%

All SSI % infected

1038 0.9%

1800 1.2%

2925 1.1%

Source data: Public Health England (2016) PHE have advised that results should be interpreted with care as the estimated incidence of SSI will be imprecise where the number of operations is small.

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The Orthopaedic Director has requested that we collect SSI data for hip replacements in 2017-18. 6.2. Surgical Site Surveillance of Breast Surgery (Oct-Dec 2016- data not

available for 2016-2017 Annual report)

Following the data collected January – March 2016 and ongoing review of Breast Surgery it was agreed with the Breast Surgeons to complete the SSI October – December 2016. This data is not yet available formally via PHE.

The previous quarter of data collection (January – March 2016) identified a higher SSI rate of 6.5% (see table below). The data analysis noted that one patient was recorded twice within the data collection as met the criteria within the PHE guidance with an ongoing infection between surgeries.

Operations & Surgical Site Infections Dorset County Hospital NHS

Foundation Trust Jan-Mar 2016 Last 4 periods


62 62 64.5%

270 270 70.4%



0 0.0%

1 0.4%


2 3.2%

9 3.3%


2 3.2%

2 0.7%

All SSI % infected

4 6.5%

12 4.4%

Source data: Public Health England (2016)

Following this period of surveillance, the Breast Surgeons and Infection Prevention & Control Team met to develop a plan on how to further address SSI in patients undergoing breast surgery.

It was agreed that SSI rates could be reduced with the development within the screening process for patients undergoing breast surgery included both MRSA and MSSA. If patients are identified as being colonised with either organism, decolonisation treatment is provided. Screening has now been extended to include axilla as well as nose and groin swabs. In addition, decolonisation is offered to all patients undergoing reconstructive surgery and major implant cases.

The unpublished data for October – December 2016 has been reviewed and 1 case identified as a SSI (1.58%). This is a significant improvement from the previous quarter audited.

The Breast Surgeons and Infection prevention & Control Team will be meeting on a quarterly basis to review any cases that are highlighted through ICNet surveillance as potential infections.

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The results from the unpublished quarter are encouraging and surveillance is now completed annually.

6.3. Peripheral Venous Cannula (PVC)

In 2014 national guidance was published for the prevention of healthcare associated infections in NHS Hospitals. A full GAP analysis was undertaken and the insertion and management of Peripheral Venous Cannula (PVC) was one area that required improvement. PVC’s are commonly used devices in acute hospitals, used for the administration of intravenous fluids and drugs. Failure to monitor these devices correctly can result in early signs of infection being missed with the potential for serious infections to develop. The evidence presented in the national guidance suggests a move away from routine PVC replacement to regular review and early removal if signs of infection are evident or when the PVC is no longer required. Regular auditing commenced in January 2016 and remains ongoing. Initial results in January 2016 showed a lapse in compliance from the previous year but since then improvement has been noted and IPCT support and input to the clinical areas has reinforced documentation policy. Since January 2017 weekly audits have demonstrated compliance of 95% and above. It is evident that teams across the trust are working hard to achieve the desired 100% compliance and are committed to optimising patient safety.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PVC Overall Compliance %

6.4. Surveillance of Critical Care Central Venous Catheter (CVC) associated Blood Stream Infections (BSI)

Public Health England launched a pilot surveillance for critical care units to analyse rates of CVC related BSI. 18 Trusts submitted data for this surveillance module.The following results were reported for the period May- July 2016.

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Dorset County Hospital Critical Care Unit

Adult CCUs§

Total number of positive blood cultures 7 188Total number of patient days 537 14,605 Total number of blood culture sets taken 69 2,023 Rate of positive blood cultures per 1,000 patient days 13.0 12.9 Rate of positive blood cultures per 1,000 blood culture sets taken

101.4 92.9

Total number of BSIs† 2 91Rate of BSI per 1,000 patient days 3.7 6.2 §18 units provided full denominator and event data and are included in the total Adult CCU metrics. Additional units

provided only event data and so could not be included in the overall totals and overall rates. †see appendix for defini ons

Counts and rates of ICU‐associated blood stream infections, CVC‐associated ICU‐associated BSI and

CVC‐related ICU‐associated BSI in Dorset County Hospital Critical Care Unit

Dorset County Hospital Critical Care Unit

Adult CCUs§

Number of ICU‐associated BSIs† 1 76 Number of patient days, amongst patients in the ICU>2 days

353 9,586

Rate of ICU‐associated BSI per 1,000 patient days‡ 2.8 7.9

Number of CVC‐associated ICU‐associated BSIs† 1 32 Number of CVC days, amongst patients in the ICU>2 days

189 5,078

Rate of CVC‐associated ICU‐associated BSI per 1,000 ICU‐CVC days‡

5.3 6.3

Number of CVC‐related ICU‐associated BSI† 0 13Rate of CVC‐related ICU‐associated BSI per 1,000 ICU‐CVC days

0.0 2.6

CVC utilisation‡ 53.5% 53.0%

These tables demonstrate a significantly low rate of Blood stream infections per 1,000 patient days compared with the overall rate for combined results. The second table provides confidence that the rate of Critical Care associated blood stream infections for patients in the unit for > 2 days is also significantly lower at 2.8 compared with 7.9 rate per 1,000 bed days and the rate of Central Venous Catheter associated Blood stream infection is below the overall rate for all trusts. This supports the Intensive Care strategy for the insertion and management of Central Venous Catheters, demonstrating effective safe care.

In the forthcoming year further work to review CVC management and infection rates in patients outside of Critical Care Unit will be undertaken. This work stream will be particularly relevant for renal patients with temporary CVC’S

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7. AUDIT

The following audits have been undertaken by the IPCT:

Urinary Catheter audit MRSA Decolonisation audit Screening for Carbapenamase producing enterobacteriaceae audit Sharps audit Sluice audits Peripheral Venous Cannula Audits Hand hygiene audits Isolation audits Sepsis audits Weekly Managerial environmental audits

Reports for audits have been submitted via clinical Audit Committee. 8. INFECTION CONTROL WEEK This year’s Infection Control Week focused on Antibiotic resistance and the emergence of multi-drug resistant infections. The theme for the week included going back to WWII, the time when antibiotics were first put into mass production. The wards and departments put up some wonderful educational display boards and worked hard to highlight the importance of multi-drug resistant infections and antimicrobial stewardship. On the Wednesday some teams also adopted traditional nursing uniforms ready for the annual judging of the displays led by Patricia Miller, Nicola Lucey and Dr Cathy Jeppesen. The winners included: Best Educational Board – Maternity Unit Best Costumes – Abbotsbury Ward Best Individual Costume – Jane Whiting, Ward Clerk, Abbotsbury Ward Overall Winner – Ridgeway Ward Runners up – Hinton, IIAU, Moreton and Lulworth We were also supported with Reps from Schülke, Vernacare, Daniels, Shermond and GoJo who kindly donated prizes for the winners and some came in to promote IPC with stands in Damers restaurant.

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Abbotsbury Ward staff dressed for the Infection Control Week.

8.1. Sepsis awareness month

Sepsis is a rare but serious potentially life threatening complication of an infection. Early recognition and treatment reduces the mortality rate significantly. During the year the IPCT have worked closely with Dr Ruth Thomas, Sepsis Lead Clinician to raise awareness and promote the implementation of the care bundle “ Sepsis Six”.

September 2016 was nationally promoted as Sepsis Awareness Month. The Trust launched its new toolkit and documentation during this month and promotional events were carried out. The Infection Prevention & Control Team supported the Sepsis Awareness Campaign 2016. Each clinical area was encouraged to participate by developing a presentation for display in their departments supporting the campaign. The promotion week was represented well by areas. Patricia Miller (Chief Executive Officer), Nicky Lucey (Director of Nursing), Dr Ruth Thomas (Sepsis Lead) and Emma Hoyle (Infection Prevention & Control Matron) visited all areas and awarded the following areas with prizes.

Abbotsbury Ward – Winner

Moreton Ward – Commended

Kingfisher Ward – Runner Up

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Members of the IPCT are actively involved with the work of the Sepsis Committee and plan to continue with support in the forthcoming year.

9. ANTIMICROBIAL REPORT – Rhian Pearce, Antimicrobial Pharmacist

Antimicrobials: Summary report for financial year 2016/17.

9.1. Overview

Antibiotic misuse is widespread and has potentially profound adverse consequences, most notably the development of antimicrobial resistance. Judicious antimicrobial prescribing is recognised as a key component in slowing the development of resistance. In addition, some Healthcare Associated Infections (HCAI’s) such as Clostridium difficile diarrhoea result from a complex interplay between antibiotic usage and other factors (e.g. hand hygiene, environmental cleaning, and patient factors). Prudent prescribing, with avoidance of unnecessary, or unnecessarily broad spectrum, high-risk antibiotics and attention to appropriate antibiotic course duration lessens the risk.

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A growing body of evidence demonstrates that Antibiotic Stewardship (AMS) can both optimize the treatment of infections and reduce adverse events. This now features heavily on the government’s healthcare agenda, with numerous publications and directives issued to drive the adoption of stewardship programmes across all healthcare settings. 9.2. Summary 2016/17

The Antimicrobial Stewardship Committee (ASC) has met sporadically throughout the year and has, in recent months, suffered from dwindling clinician engagement. Since clinical leadership support is critical to the success of any antibiotic stewardship programme we are pleased to welcome two new medical consultants to the committee.

EPMA reporting capacity has improved significantly. Several reports have been developed to allow targeted intervention and improve data capture to support a wide range of stewardship activities.

Audits have been performed on an ad-hoc basis. A formal programme of sustained auditing has been hampered by limited resource and IT support. Existing paper based audit tools are being transferred to an electronic system (audit R) to improve data capture and automate reporting. Timely reporting with feedback to clinicians is recognised as a major driver for changing behaviour and improving prescribing.

Participation in the South West Region Annual Point Prevalence Audit. Results will be available at the end of April (please contact Rhian Pearce [email protected] if you require a copy of this report)

DCHFT are expected to meet the AMR CQUIN (Commissioning for Quality and Innovation) for 2016/17, avoiding a financial loss of £258,643 (see 3.1 for further detail).

DCHFT performs well/satisfactorily against the national benchmark for antimicrobial consumption and 72hr empiric review of antibiotic prescriptions (see 3.2 for further detail).

A formal work plan has been developed outlining key objectives and corresponding time frames. Broadly, objectives reflect key national recommendations relating to stewardship.

Mandatory training sessions in Antimicrobial Stewardship have been provided for all Foundation level doctors.

Continued work on increasing the range of antimicrobial guidance available on the Micro Guide smartphone app.

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Participation in Clostridium difficile RCA meetings and identifying themes related to antimicrobial prescribing and pharmaceutical review of patients.

9.3. AMR and 72hr empiric review CQUIN targets for the financial year 2016/17

Antibiotic prescribing in English hospitals has been increasing steadily, adjusted for admissions; rising by 6% between 2010 and 2014. Piperacillin-tazobactam and carbapenem prescribing has risen more sharply; by 62% and 42% respectively in 5 years. These increases in prescribing have coincided with increased antimicrobial resistance. This ongoing rise in antibiotic prescribing and resistance prompted NHS England to instate two mandatory national CQUINs relating to antibiotic usage for the financial year 2016-17:

1) Reduction in antibiotic consumption as measured by Defined Daily Dose (DDD) per 1,000 admissions against the baseline (2013/14) as follows:

i. Reduction by ≥1% of total antibiotic consumption

ii. Reduction by ≥1% of consumption of carbapenems

iii. Reduction by ≥1% of consumption of piperacillin-tazobactam

2) To provide documented evidence of review of antibiotics within 72hrs of starting, for 90% of antibiotics by the final quarter.

Together these targets represent £258,643 of locally-commissioned income.

9.4 DCHFT’s performance against the CQUIN targets

Piperacillin‐Tazobactam consumption

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DCHFT are comfortably achieving the AMR CQUIN targets across all three indicators. To date, this corresponds to a mean reduction in total antimicrobial consumption, adjusted for admissions, of 14% below target, a 17% reduction for piperacillin-tazobactam and a 26% reduction for Carbapenems. Although data for Q4 is still outstanding it is anticipated that DCHFT will meet the AMR CQUIN targets for the finacial year 2016/17.

* 0.99 (consumption data for 2013/14 in DDDs/1000 admission)

Results to date indicate that DCHFT will achieve the CQUIN target for 72 hr review of antimicrobials in Q4. A sustained improvement can be seen over the last three quarters with an achievement of > 90% compliance in Q3.

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9.5. DCHFT CQUIN indicators against the national picture

In 2013/14 antibiotic consumption was higher than the national average. A progressive reduction in consumption coupled with an increase in admissions over the last 3 years has brought all three AMR CQUIN indicators below the national average; 4% (total antibiotics), 17% (piperacillin-tazobactam) and 52% (meropenem) less than the corresponding national value. In addition, the percentage of antibiotics with documented evidence of review is higher than the national average (see chart overleaf). It should be noted that these data are unadjusted for the confounding effects of case mix, age and sex. As such, direct comparison between DCHFT and the national average is limited

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a. DDDs are from Acute Trust submissions for the 2016/17 AMR CQUIN made to PHE Admissions are from hospital episodes statistics, available at HSCIC. b. Results are based on Q1 and Q2.

9.6. Anti-infectives spend for year 2016/17

The table below shows the cost of anti-infective drugs prescribed at DCHFT over the last 5 financial years. Figures include issues to inpatients and outpatients and cover

all clinical directorates as reported from JAC DSUM

Overall total spend has continued to decrease, this reflects a net reduction in total acquisition cost of antimicrobials and a decrease in overall usage. Of note, antibiotic spend has decreased slightly, which correlates with an overall reduction in prescribing. Antifungal spend has plateaued following a decrease last year resulting

Year 2012/13 2013/14 2014/15 2015/16 2016/17 Antibiotics £402,540 £424,415 £372,273 £349,149 £334,500Antifungals £128,338 £118,739 £168,391 £74,239 £76,525 Antivirals £501,053 £503,467 £504,693 £536,935 £493,356

Totals £1,031,931 £1,046,621 £1,045,357 £960,323 £904,381

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from a change in first-choice echinocandin from caspofungin to micafungin which has a significantly lower acquisition cost.

9.7. Summary of future work

To delineate channels within the organisation to effectively disseminate audit results and garner support for AMS. As an example, we intend to regularly attend governance meetings with the view of making AMS a standing item on the agenda.

Updating and streamlining the existing audit programme to incorporate CQUIN specific indicators for 2017/18

To develop a strategy to improve antimicrobial review and de-escalation. This is will be of particular importance as this forms part of the AMR CQUIN for the 2017/18 financial year. In addition, continuation of the SEPSIS CQUIN in 2017/18 may result in overprescribing of broad spectrum antimicrobial regimens and inappropriate continuation of these agents. A Small scale study is in progress to explore existing deficits in the review process of antimicrobials and identify potential barriers to de-escalation.

To develop a systematic approach for reviewing local susceptibility patterns as part of the antibiotic guideline development process.

To establish an AMR CQUIN group to specifically monitor progress against the 2017/18 AMR CQUIN and steer intervention. This group will report to the AMS committee and sepsis committee.

We plan to introduce a comprehensive package of antimicrobial prescribing and stewardship training for doctors, nurse prescribers and pharmacists. This will be delivered via e-learning.

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10. INFECTION CONTROL ANNUAL REPORT 2017 - FACILITIES (PAUL ANDREWS)

CLEANING SERVICES

10.1. Management Arrangements

The Head of Estates and Facilities is responsible for high standards of cleaning service delivery across all areas of the Trust. The Housekeeping and Portering Manager is responsible for the ‘day to day’ running of the service supported by an ‘in house’ team which is made up of a Housekeeping Team Leader supported by Housekeeping Supervisors and Housekeeping staff.

Mandatory training for all housekeeping staff is currently recorded as 94 %

10.2. Monitoring Arrangement

In order to ensure that cleanliness and environmental standards are maintained to the highest standards robust technical and managerial monitoring systems have been put in place.

Technical cleaning audits are carried out weekly and monthly by a team of appropriately trained personnel to provide and monitor data as required by the national cleaning standard. The minimum target score set by the Trust (using the NHS National Standards of Cleanliness Criteria) is 98% for very high risk areas and 95% for high risk areas. In areas where the target score is not reached there is a rectification timeframe set at 24 hours for very high risk and 48 hours for high risk areas. Additional focused monitoring and validation of the audit scores also takes place in liaison with the IPC team. As a Housekeeping team we have maintained 100% auditing in all very high and high risk areas for 2016/17.

On a day to day basis, the Ward Sisters/Charge Nurses and Matrons play a role in ensuring standards are being met with a number of inspections being taking place jointly.

The audits are managed by ServicTrac and although there are no national targets for cleaning percentages within the National Specification of Cleanliness (2007/09), good practice suggests the following targets to work towards:

Very high risk areas 98%

High risk areas 95%

Significant risk areas 85%

Low risk areas 75%

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The cleaning audits comprise of 49 element standards which are used when calculating the scores. All audits are recorded and calculated using ServiceTrac software. This software produces graphs and statistics that can be used in detailed reports as detailed below.

In addition, weekly Managerial Audits are undertaken to verify the cleaning outcomes of technical audits and to identify areas for improvement. The managerial audit team consists of the Trust Board representative with responsibility for infection control, senior managers from Estates and Facilities, senior nurses with responsibility for Infection Control, pharmacy and public representatives. All patient and visitor areas are checked for cleanliness, standard of decoration and state of repair, condition of furniture, fabric fixtures and fittings. The opportunity to talk to patients and receive their feedback is also encouraged. An action plan is produced following the audit which is sent to the individual Ward Sister/Charge Nurse and Matron responsible for the ward/department. A follow up meeting ensures that all actions identified are completed.

A Patient-led assessment of the care environment (PLACE) meeting takes place quarterly and oversee the cleanliness agenda. Reports are produced detailing cleaning results from Technical and Managerial audits. Cleaning reports are also presented to the Infection Prevention Committee and the Decontamination Committee meetings.

Feedback from ‘Friends and Family’ continued to rate the standard of cleaning across the Trust as very high, and the housekeeping department consistently receive positive feedback in the high standard of cleaning undertaken in wards and departments. A recent survey in 2016 undertaken by Picker Institute Europe rated Dorset County Hospital NHS Foundation Trust cleanliness at 99%.

10.3. The Role of the Infection Prevention and Control Team

The IPC Team worked in conjunction with the Trust Housekeeping Team to ensure cleaning standards were met across the Trust. Where a low score has been recorded these are subjected to scrutiny of the Housekeeping and Portering

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Manager and an agreed action plan is submitted to rectify the concerns. This work is in conjunction with the IPC department, Matrons and ward sisters with monitoring and re auditing of the area until consistent improvement is displayed. The IPC department shares a daily report which gives the Housekeeping Supervisors direction and guidance and on the recommendations for cleaning of single rooms following vacation of patients. This ensures resources are effectively and efficiently utilised. This has assisted in prioritising single rooms at times of greatest need. We worked closely with the IPC team to develop a plan for cleaning of side rooms and who is responsible for each task. This has worked extremely well in focusing nursing and housekeeping staff to ensure that nothing is overlooked.

10.4. Cleaning Schedules Review

All Cleaning schedules were reviewed and updated in January 2017 to reflect the Housekeeping provision to the Trust which meets the National Standards for Cleanliness. These schedules are displayed in all in patient areas and meet individual service needs of the wards and departments and are reviewed when service improvements dictate. Housekeeping staff are required to complete a weekly record of rooms cleaned and this records when weekly cleans of areas are undertaken. This process includes a robust reporting programme to our Estates Team to rectify any faults and to escalate cleaning concerns.

10.5. Patient Led Assessment of the Care Environment (PLACE)

These new self-assessments are undertaken by teams of NHS and private/independent health care providers, and include at least 50 per-cent members of the public (known as patient assessors). They focus on the environment in which care is provided, as well as supporting non-clinical services such as cleanliness, food, hydration, and the extent to which the provision of care with privacy and dignity is supported. This ensures a transparent, credible, impartial and robust process of evaluation against the PLACE standards.

2015 PLACE ASSESSMENT SCORES

Hospital Cleanliness % Food % Privacy, Dignity and Wellbeing %

Condition Appearance

and Maintenance %

Dorset County Hospital

98.7% 90.86% 85.07% 91.14%

National Average

98.1% 88.2% 84.2% 93.4%

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10.6. IPC Training for Domestic Staff

The Trust ensures that cleanliness standards are consistent and provides a comprehensive training package to domestic staff which includes the principles of Infection Protection and Control. 94% of Housekeeping staff received training last year (2016/17).

10.7. Deep Cleaning

The deep cleaning programme of ward areas was started during 2017 and plans are in development to continue this in 2017-18, with areas identified and working alongside our Estates colleagues to address works that are required prior to the housekeeping deep clean using the HPV machine.

The Trust embraces the process of decontamination with hydrogen peroxide vapour (HPV) misting machines and uses this as normal practice where a ‘deep cleaning’ requirement has been identified by Nursing or the Infection Control Team and where upgrades or refurbishment has taken place.

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11. INFECTION CONTROL ANNUAL REPORT – ESTATES ELEMENT (ANDREW MORRIS)

11.1. Water Quality During 2016 the Water Quality Management Group (WQMG), supported by an external Water Services Specialist, continued to oversee and monitor and the Trusts water services. The bi-annual risk assessment for legionella was completed in June 2016. The assessment of potential risk posed by water systems is considered “Very Low”, which is unchanged from the previous year. Following the updating of HTM guidance, the Trusts Water Safety Plan has been rewritten. The new plan was written by an external Water Services Specialist and it is currently scheduled for ratification / adoption. Pseudomonas aeruginosa sampling is ongoing. The results are reported to the both the WQMG and Infection Control Committee, with any required actions being agreed and implemented. During the programme period, legionella sampling resulted in the isolation of 1 positive sample (non 1 -14 serogroup) for the Prince of Wales Kitchen Tap (May 2016). Following full investigation, an area of low flow and a small number of dead legs were identified and rectified. Enhanced sampling was adopted with no further isolations identified. The Estates Department continue to support and work with the Infection Control team on water issues. 11.2. Support for the Deep Clean Programme Because of the historical problems in completing the Deep Clean Programme, Estates & Housekeeping representatives were invited to attend a task and finishing group by the Matron for Outpatients to review what could be done to facilitate and sustain a deep clean programme. Winter bed space pressures have proved to be a particular challenge in this regard. As part of the review, six wards were inspected and Estates work noted in anticipation that when spaces became available the trades team would attend accordingly. The programme has commenced, with bays in Abbotsbury Ward being made available for redecoration in February/March and steady progress is being made. 11.3. Replacement floor coverings In 2016/17, despite financial constraints the following areas benefited from new flooring:

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Area Description Area (m2) Completion Date Easton Ward New vinyl flooring in

procedure room 30 July 2016

Service Corridor Non-slip coating replaced

145 September 2016

Children’s Centre Carpet replaced with vinyl

282 March 2017

Education Centre Carpet replaced with carpet tiles when reception base removed

37 November 2016

During 2016 the Estates Team recruited a Maintenance Worker with a flooring background and established links with flooring suppliers. This has allowed minor flooring repairs to be completed more effectively using the in-house team, saving cost and significantly reducing the timescale for minor repairs to be undertaken. 11.4. Decoration and Environment The opportunities to deliver complete Ward redecorations were much reduced due bed space pressures and resultant inability to deliver the aforementioned Deep Clean Programme. There is a further issue with the demand for such work being greater than the available resource to progress such works. However, decoration work has progressed in corridors, toilets and washing facilities where one unit has been taken out of service at a time. Decoration to sluice rooms and kitchens has been completed in co-operation of the ward staff. These works have been undertaken in Abbotsbury, Barnes, Endoscopy, Fortuneswell, Lulworth, Maternity, Maud Alexander, Orthodontics, Prince of Wales Wards, ED and the Stroke unit. The estates team continue to respond to defective areas, identified through the auditing process, thus ensuring a decorative standard which is of an acceptable standard. 11.5. Ventilation The position with regard to achieving a programme of Ward Area high level deep cleans remains challenging. Estates through the Weekly Managerial Audit process remain responsive to any deficiencies reported. During 2016/17, Estates and the Housekeeping team have facilitated a high level deep cleaning to Critical Services (Theatres / Invasive procedure). Any deficiencies are reported through to the Decontamination Committee. The Estates Department have continued to undertake formal annual validations of critical ventilation plant, in compliance with HTM 03-01.

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11.6. Ward Audits The Estates Department have continued to support the weekly managerial ward audits in association with Infection Control, Pharmacy Housekeeping and Patient Representatives. 11.7. Capital Projects in 2016/17 Capital schemes during 2016/17 saw the following improvements completed:

Easton Ward new procedure room – completed July 2016 New temporary medical records building constructed outside renal to allow

the Radiotherapy Bunker construction to commence – completed October 2016

73 toilet seats in public areas and elderly care wards replaced with dementia friendly blue models – completed October 2016

Fire curtain improvements above Evershot Ward – completed October 2016

Oncology phlebotomy from Fortuneswell Outpatients combined in to medical outpatients service by reconfiguring rooms – completed November 2016

Office in rehab reconfigured to increase capacity – completed January 2017

Scanning bureau formed in the Education Centre library – completed January 2017

Sluice in Lulworth Ward reconfigured to allow for a new sink and drainer – completed February 2017

Fire door effectiveness survey – completed February 2017 Damers School Site contamination survey – completed February 2017

Work has also commenced to deliver a partnership scheme with Poole Hospital NHS Foundation Trust to provide two Radiotherapy Bunkers and improved Cancer consultation facilities. A significant refurbishment of the main catheterization laboratory is also underway.

A new default document is in place to allow contractors to risk assess infection control. This was included as part of the Radiotherapy Bunker pre-construction work and is now being included as a standard document for all projects that carry an infection control risk. Ventilation filtration enhancements were implemented to air handling units that would see increased contamination due to the Radiotherapy build and other building projects due in 2017/18.

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12. DECONTAMINATION REPORT (Julie Knight, Decontamination Lead)

12.1. Sterile Services

Quality Management System - Accreditation

The department continues to maintain a full Quality Management System

External Audit by Notified Body Intertek in May 2016 and November 2016 resulted in the department maintaining certification to BS EN ISO 13485 with no non-conformance issued at the time of the audit.

This Accreditation continues to give quality assurance on the products produced but also allows the department to provide services for external customers. The department is now processing for two external customers.

The next surveillance audit is planned for April 2017 and will be a re-certification audit completing the 3 year cycle.

12.2. Environmental Monitoring

The Clean room Validation is completed by an external laboratory on a quarterly basis. This consists of:

Settle Plates Contact Plates Active Air Samples Particle Count Water – Total Viable counts(TVC) Detergent testing

The laboratory also tests:

Product bio burden on five washed but unsterile items – Quarterly Water End toxin - Annual

Latest testing of all areas occurred on 15 February 2017 and the pack room was given a Class 8 clean room status, which is appropriate for the service.

There were action levels recorded from testing on the transport hot locks used to deliver processed items. A deep clean has been undertaken, regular cleaning increased and also shelving removed to improve access for cleaning.

The water quality issues have abated and recent results have been well within acceptable limits.

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12.3. Tracking and Traceability

Work has begun with theatres to commence recording patient registration against sterile items at the point of operation. This has been successfully implemented in Theatre 3 and orthodontics. A roll out programme has been recommended for all treatment areas which require funding. The case for this has been presented at Decontamination Committee, Divisional Meeting and Health Informatics. A trial of scanning prosthesis at point of use is also about to commence.

There were some issues identified with staff compliance in using TDoc electronic tracking in Endoscopy Treatment rooms. Although paper traceability was maintained the staff were not always using the electronic system which significantly reduced the efficiency of the system in a look back situation. This is now being addressed by Sister Hart in Endoscopy and March showed a significant improvement.

12.4. Shelf Life Testing

Products that had been packed and sterilised for greater than 365 days (our maximum shelf life were sent for testing using the new wrap. These came back negative giving us good assurance that our shelf life period continues to be appropriate.

12.5. Staff Training

4 members of staff on the certification course in conjunction with Ruskin University which will be equivalent to the NVQ 4 in the New Healthcare science NVQ scheme. It is hoped they will complete examination in November this year.

12.6. Endoscopy Decontamination Unit

Quality Management System - Accreditation

The department went through certification audit in November 2016 as an extension to scope of our existing certification. The external auditor found good compliance with EN ISO 13485 Quality System requirements and there were not any non-conformances issued.

In order to be able to register processing of endoscopes with the MHRA and serve external customers works need to be completed to provide a controlled environment and product release area. Once the space has been vacated in the room adjacent and minor works undertaken arrangements will be made to seek re-audit.

12.7. Trust Wide Audits

An annual audit was carried out of department that uses reusable and single use surgical instruments.

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The audit looks at:

How sterilised instruments are received, checked and stored Stock rotation and management of expiry dates Checks prior to use Temporary storage and containers used to return contaminated items

The audit also looks at how departments control the use and disposal of single use items, preventing re-use. This includes ensuring there is a local protocol and posters are clearly displayed.

Any non-conformances from these audits are recorded on a log in Decontamination Portal on SharePoint. These are then monitored and required actions followed up through the decontamination committee

12.8. Key Issues raised at audit

2 key themes continue:

Sterile items being stored in open storage within treatment areas and therefore at risk of advantageous contaminate.

Poor stock rotation resulting in items going out of date or being used after expiry date.

The incidences have significantly reduced and this year’s audits have seen a marked improvement. The decontamination Lead has been working with the departments to support them in addressing issues raised.

Future Plans for audit The transportation of processed and contaminated endoscopes is currently under review. As part of the service provided to us Cantel Medical are supporting us with a free independent survey of our transportation and will provide us with a report for us to develop an action plan. Their expertise in this area will be very beneficial.

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CONCLUSION

2016-17 has been a most successful year in respect of Infection Prevention and control, all trajectories for infection were met. Consistently during weekly environmental audits patients described the ward environments as clean. However, the IPC team have taken on the findings of the CQC inspection and worked with relevant teams to address their identified shortfalls in relation to ensuring patient equipment is cleaned to the required standards.

Antimicrobial resistance (AMR) is defined as “the loss of effectiveness of any anti –infective medicine”. It is a potential “time bomb”; the time to take action is now. NICE Antimicrobial stewardship guidelines published in 2015 recommend that the following actions are taken when developing:

To monitor and evaluate antimicrobial prescribing and how it relates to local resistance patterns;

To provide regular feedback to individual prescribers in all care settings

To integrate audit into existing quality improvement programmes.

Develop systems to provide annual feedback to individual prescribers benchmarked against local and national antimicrobial prescribing rates and trends.

Patient safety incidents related to antimicrobial use, including hospital admissions for potentially avoidable life-threatening infections.

To assist in local formulary decision-making groups with updating prescribing guidance.

The current pharmacy electronic system lacks the functionality to meet NICE AMR 2015 recommendations.

The IPC team have demonstrated the effectiveness of the surveillance system, achieving trajectories for MRSA, Clostridium difficile and reducing outbreaks of infections such as norovirus. The IPC team alerted Trust Board for several years of the benefits to patient safety prior to achieving an effective surveillance system. We are now beginning to realise the benefits of this system. Current AMR surveillance is limited, cumbersome and effectively reduces the time the AMR team can spend improving antimicrobial prescribing. We are seeing increasing numbers of patients with multi-drug resistant infections in the Dorset population. We have retrospectively reviewed cases of patients whose outcomes may have been better had the ability to identify frequent admissions could have been improved. There is an overarching responsibility to take action to deliver the AMR programme effectively. Providing effective surveillance to Clinicians is the starting point in establishing an effective AMR programme. The IPC team will develop a business case to support

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introduction of an electronic surveillance system that links prescribing and local resistance patterns and rapid feedback to Clinicians’ to inform practice. We believe efficient systematic approach to antimicrobial stewardship would meet the trust values of integrity, respect, teamwork and excellence.

The introduction of mandatory reporting of gram negative bacteria (E. coli and klebsiella species), with targets for reductions will refocus healthcare professionals efforts. It is important to engage across the health economy to achieve this reduction, particularly in relation to the management of urinary tract infections and the insertion and management of urinary catheters and effective antimicrobial prescribing. This will be a challenging area of work and reduction of these serious bloodstream infections can only be achieved by developing a cohesive strategy across health and social care sectors. It is therefore important to build on the success of the IPC work plan to deliver care that is compassionate, safe and consistent.

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Infection Prevention & Control Work Programme 2017‐18 APPENDIX 1

Objective Action Operational Lead

Date of completion

Measure of success Evidence

1. Achieve trajectory for Clostridium difficile infection (CDI) of ≤ 14 cases (does not include cases whereby no lapses of care were identified.

Review impact of revised CDI data collection/ categorisation against trajectory. This is not significant for 2017‐18 but has the potential for next year.

Emma Hoyle Sept 2017 All cases of CDI will have complete data sets on PHE HCAI data capture system. Analysis of this data set will be reported at the IPC with revised PHE definitions. Analysis will be on a case by case basis.

Undertake Root Cause analysis of all hospital acquired cases of CDI.

Matron where

the case of CDI

occurs.

April 2017

All cases of CDI will have RCA investigation and relevant action plan if deficits identified. RCA’s will be discussed by IPC team and any trends reported to . Infection Prevention & Control Group.

The RCA process will be reviewed and developed accordingly.

Emma Hoyle March 2018 All cases of CDI will be investigated and a reflective look back exercise completed to confirm if any changes to the RCA process are required.

Ensure process is in place for Matrons to feedback completion of action plans to Infection Prevention & Control Group.

Matron where the case of CDI occurs.

At IPC meetings

Learning from RCA’s will be shared across the Trust. Lessons learned will be reported and action plans monitored at IPC. Ward dashboards will incorporate CDI data for cases acquired as inpatients. Review process at IPCG

1


Date of completion


2. Divisions to develop IPC HCAI improvement plans for 2017‐2018

Divisional Matrons to develop HCAI improvement plans Divisional Heads of Nursing work with Clinical staff to review IPC programme relevant to Division.

Divisional Matrons Heads of Nursing / Quality

September 2017

Heads of Nursing to report progress against divisional IPC plan at IPCG on rotational basis.

IPC performance matrix standards to be met. Learning from performance data to be disseminated.

Heads of Nursing / Quality

April 2018 Evidence that IPC performance matrix is discussed and actioned at Divisional Governance meetings.

3. High standards of hand hygiene practice throughout the Trust.

Hand hygiene audits to be undertaken by all clinical wards/departments. Wards/departments that achieve<90% to present action plan to Infection Prevention Committee.

Ward Sisters/ Departmental Managers

Monthly

Hand hygiene results >95% and sustained at this level for all wards/departments. Departmental Managers to report to IPC with action plan when hand hygiene results <90%.

Validation of hand hygiene audits

IPC Team Matrons

Monthly

High level compliance with WHO 5 moments of care hand hygiene standards.

Participate in World Health Organisations Hand Hygiene Day.

IPC Team Trust wide

May 5th 2017 Staff engage with WHO Hand

hygiene day to promote best practice.

4. Reduce rates of Gram‐negative blood stream infections (BSI)

Review assessment of indication for urinary catheter Revise urinary catheter policy

Emma Hoyle May 30th

2017 Urinary catheter policy revised, published and staff aware of changes.

2


Date of completion


to reflect national guidance.

Ensure on‐going assessment and plan is in place for all patients with urinary catheter

Ward Sisters July 2017 All patients with urinary catheter will have urinary catheter care pathway in place and evidence of regular review.

Strengthen the communication between health and social care team on patient transfer. Ensure patients and carers receive appropriate information/ education on risks. Develop tools to empower patients who can self‐care.

Ward Sisters July 2017 All patients discharged with urinary catheter in place will have clear plan for review. Urinary catheter discharge pathway to be commenced as soon as self‐care established for patient.

Build on current audit programme for urinary catheters

Emma Hoyle September 2017

Undertake audit programme to reflect that:

1. There is evidence of rationalisation for insertion of urinary catheters

2. All patients with urinary catheter in place have a urinary catheter care pathway booklet in place

3. Implement audit of CAUTI and feedback results to Heads of Nursing.

Review current cleaning arrangements for patients with gram negative current infections

Emma Hoyle July 2017 To ensure optimal cleaning in place to reduce the potential transmission of GNB.

3


Date of completion


Show figures of gram negative bacteraemia cases on wards, making them visible to patients and visitors in the same way that MRSA and C.difficile cases are currently displayed.

Andy Parkinson TBA All wards will have visible dashboard showing numbers of HCAI.

5. Undertake surveillance of Blood Stream Infections in Critical Care Unit.

Interpret data and feedback to Divisional Matron

IPCCritical Care Team

May 2017 Data analysed and reported to Divisional Matrons

Divisional Matron feedback data to Divisional Governance meetings and where required develop plan to improve performance.

Miles Tompkins Quarterly Rate of Catheter related blood‐stream infections is identified and if appropriate improvement plan developed and implemented.

Ensure Vitalpac/ICNet device feed active and device module ratified. Develop reports to enable active audit.

IPC Team November 2017

CVC Catheter surveillance in place. Establish rate of BSI associated with CVC and undertake review to benchmark data.

4. Surveillance of Surgical Site Infections

Complete PHE SSI modules for Hips. Review results with clinicians. Orthopaedic surveillance SSI cases to be discussed at Orthopaedic Governance meetings. If required, action plan to be developed and implemented Results to be presented at Divisional Governance Meetings and IPC.

IPC Team Orthopaedic Lead

Quarterly Surgical site surveillance meets national mandatory requirement Rates of SSI are within acceptable parameters.

4


Date of completion


Complete PHE SSI module for Breast. Review results with clinicians. Breast surveillance SSI cases to be discussed at Quarterly Breast meetings. If required, action plan to be developed and implemented Results to be presented at Divisional Governance Meetings and IPC.

Breast Lead Quarterly Surgical site surveillance meets national mandatory requirement Rates of SSI are within acceptable parameters.

5. Audit programme‐ to audit compliance with Key IPC policies

PVC audits undertaken to ensure compliance with observation standard.

IPC Team Quarterly PVC observations will be observed every shift and recorded on Vital Pac.

Urinary catheter documentation

IPC Team

Quarterly

Audit demonstrates improvement in documentation of the care of patients with urinary catheters. Refer to Section 4

Undertake audit of isolation precautions to ensure appropriate signage, PPE precautions are in place. Ensure that audit incorporates patients who should be in isolation.

IPC Team January 2018

Audit identifies appropriate precautions to effectively manage patients with infections.

Audit compliance with CPE screening recommendations.

IPC Team May 2017 Audit identifies that documentation supports appropriate risk assessment is undertaken for patients

5


Date of completion


admitted to Trust.

Undertake annual Sharps Audit to ensure Trust wide adherence to recommended practice

IPCTeam September 2017

Audit identifies compliance with safe management of storage and disposal of sharps.

Support the Sepsis audit to ensure that compliance with national standards are met.

IPC Team March 2018 Audit identifies that appropriate screening and action is taken for patients presenting at DCHFT.

6. Deep clean programme Maintain current annual deep clean programme with Facilities/Matrons/ Estates. Execute agreed deep cleaning programme.

Facilities Manager

September 2017.

Deep clean programme is undertaken.

.

7. Sepsis Support the DCHFT Sepsis Screening and Treatment Policy

Emma Hoyle April 2018 CQUIN Sepsis screening target will be met.

8. Education Support DCHFT e‐learning mandatory training programme

IPC Team April 2017 Education reflects national and local requirements for mandatory IPC training.

Winter IPC preparedness training ‐ programme to incorporate norovirus and influenza. Stage 1 of training IPCT to attend Ward Sisters Away Day to promote Winter preparedness Stage 2 – Training to be rolled out but IPCT Trust wide

IPC Team October 2017

Effective isolation of infective patients and risk assessments completed

6


Date of completion


9. Infection Control Week Develop plan for IPC week.Organise and implement plan. Urinary Catheters agreed as theme.

IPC Team October 2017

Staff engaged with IPC programme.

10. Environment is safe and meets national standards.

Participate in annual PLACE inspection Participate in weekly environmental technical audits.

DIPCIPC Team Facilities Manager Estates Manager Patient representatives Pharmacy

May 2017

The environment is safe and clean. Review of weekly audits identifies deficits and monitors remedial actions have been taken.

Emma Hoyle

Anne Smith

infection prevention and control annual report 2016-17 annual report 2016-17.pdf · as director of...

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