2016/17 Annual Infection Prevention and Control Report ......19. The annual reduction aspirations are agreed by the Trust Board in the Aintree Quality Improvement Plan 2016/17 (AQUIP)

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2016/17 Annual Infection Prevention and Control Report

& 2017/18 Healthcare Associated Infection

Reduction Plan

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2016/17 Annual Infection Prevention and Control Report and 2017/18 Healthcare Associated Infection Reduction Plan

Introduction 1. This is a two-part document; a report on the developments and performance related to

Infection Prevention and Control (IPC) during 2016/17 and the broad plan of work for 2017/18 to reduce the risk of healthcare associated infections (HCAIs). The report outlines the challenges faced in-year and the Trusts approach to reducing the risk of HCAI for patients.

2. A zero tolerance approach continues to be taken by the Trust towards all avoidable HCAIs. Good IPC practice is essential to ensure that people who use the Trust services receive safe and effective care. Effective IPC practices must be part of everyday practice and be applied consistently by everyone. The publication of the IPC Annual Report is a requirement to demonstrate good governance and public accountability.

3. The report acknowledges the hard work and diligence of all grades of staff, clinical and non-

clinical who play a vital role in improving the quality of patient and stakeholders experience as well as helping to reduce the risk of infections. Additionally the Trust continues to work collaboratively with a number of outside agencies as part of its IPC and governance arrangements including:

NHS South Sefton Clinical Commissioning Group (CCG)

NHS Liverpool CCG

NHS Knowsley CCG

Liverpool Community Health Trust

Cheshire and Merseyside Public Health England (PHE) Local Centre

Contents

Subject Page

Executive Summary 3

Monitoring and Governance 3

Healthcare Associated Infection Statistics and Targets 4

Healthcare associated infection priorities 2016/16 5

Untoward Instances and Outbreaks 17

Mandatory Surveillance of Surgical Site Infections 17

Refurbishments and new builds 19

Decontamination 19

Cleaning Services 20

Antimicrobial Stewardship 21

Staff development and training 28

Isolation 30

Laboratory Services 30

Audit Programme 29

Occupational Health 29

Implications 30

Recommendations 31

References and Further Reading 32

Appendices to the Annual Report

Appendix 1 IPCT Structure 33

Contents HCAI Reduction Plan

HCAI priorities 34

HCAI Reduction Plan 35

Appendices to the HCAI Reduction Plan

Appendix 2 - Code of Practice for Health and Adult Social Care on the prevention and control of infections and related mapped against NICE guidance.

45

Appendix 3 - Audit Programme 46

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Executive Summary 4. The annual report for Infection Prevention and Control outlines the Trust’s Infection

Prevention and Control (IPC) activity in 2016/17. In addition it highlights the role, function and reporting arrangements of the Director of Infection Prevention and Control (DIPC) and the Infection Prevention and Control Team (IPCT).

5. There are national contractual reduction objectives for MRSA bloodstream infections and Clostridium difficile infections and there are four infections that are mandatory for reporting to Public Health England listed below. These will be included in the report. Meticillin Resistant Staphylococcus aureus (MRSA) bloodstream infections Clostridium difficile infections Meticillin Sensitive Staphylococcus aureus (MSSA) bloodstream infections Escherichia coli (E.coli) bloodstream infections

6. The structure and headings of the annual report and plan follows the ten criteria outlined in

the 2010 edition of the Health and Social Care Act 2008; Code of Practice on the prevention and control of infections and related guidance1.

Key Issues

Compliance Criterion

What the registered provider will need to demonstrate

1 Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider how susceptible service users are and any risks that their environment and other users may pose to them.

Governance and Monitoring IPC Governance 7. The Board of Directors has collective responsibility for keeping to a minimum the risk of

infection and recognises its responsibility for overseeing IPC arrangements in the Trust.

8. The Trust Director of Infection Prevention and Control (DIPC) role is incorporated into the role of the Chief Nurse..

9. The DIPC is supported by the Assistant DIPC, IPC Doctor, and the Trust Antimicrobial

Pharmacist. The wider IPCT structure is tabled in Appendix 1.

10. The DIPC delivers an Annual HCAI Reduction Report to the Board of Directors and the forthcoming HCAI Reduction Delivery Plan based on the national and local quality goals.

11. The Executive Team receive:

Daily updates on patients with Clostridium difficile infections, MRSA and MSSA

12. The Board of Directors receive:

Monthly IPC Report

1Department of Health (2015) Health and Social Care Act 2008: code of practice on the prevention and control of infections and

related guidance.

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13. The Trust reports IPC performance on a monthly basis, more frequently or on an ad hoc basis if required. This is reported on a Trust and Divisional basis via the IPC Group.

Infection Prevention and Control Group 14. The Trust Infection Prevention Group (TIPCG) provides a forum to support the delivery of a

zero tolerance approach to avoidable HCAIs. The TIPCG reports into the Safety and Risk Committee and the Quality and Safety Committee also receive a monthly IPC report.

15. Infection prevention key performance indicators were agreed for each Division and these were monitored through the TIPCG.

Monitoring Clinical Commissioning Groups (CCGs) 16. NHS South Sefton CCG is Aintree’s main commissioning organisation. IPC is a key element

of quality commissioning and forms part of a joint commissioning quality schedule.

17. The CCGs participate in the Post Infection Reviews for all patients who develop MRSA bacteraemia in line with the NHS England guidelines. They also oversee the CDI appeal panel with support from external experts.

Commissioning Support Unit (CSU) 18. The Trust returns a monthly Assurance Framework to the Cheshire and Merseyside

Commissioning Support Unit; this framework outlines performance against a number of key performance indicators (KPIs). This in turn is used as part of a performance pack for the relevant CCGs.

Infection Control Standards and Assurance 19. The annual reduction aspirations are agreed by the Trust Board in the Aintree Quality

Improvement Plan 2016/17 (AQUIP) and Quality Strategy Annual Delivery Plan for 2016/17. 20. The Trust continues to undertake a number of interventions in relation to infection prevention

and control as detailed within the HCAI Reduction Plan 2016/17. This work is led by the Director of Infection Prevention and Control (DIPC) and supported by the Assistant DIPC.

21. The Trust reports the numbers of patients with CDI, MRSA and MSSA bacteraemia daily to

the executive team daily and monthly to the Trust Board.

Healthcare Associated Infection Statistics and Targets Surveillance 22. The Infection Prevention Team (IPCT) undertakes continuous surveillance of target

organisms and alert conditions. Patients with pathogenic organisms or specific infections, which could spread, are identified from microbiology reports or from notifications by ward staff. The IPCT advises on the appropriate use of infection control precautions for each case and monitors overall trends.

23. For surveillance purposes, the Trust has implemented ICNet surveillance system in

collaboration with Liverpool Clinical Laboratories, Royal Liverpool University Trust (RLUHT) and Liverpool Heart and Chest (LHCH). Currently the access to ICNET is limited and it is being used primarily as a results and documentation system. This is due to the lack of PAS

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interface which is expected to be resolved mid-2017. The full surveillance function will then be realised.

24. The IPC Team visit all patients at regular intervals according to their infection or possible

infection, such infections/conditions are listed below;

Target/Alert Organisms2

MRSA

Clostridium difficile

Group A Streptococcus

Salmonella spp

Campylobacter spp

Mycobacterium tuberculosis

Glycopeptide resistant Enterococci

Multi - resistant Gram negative bacilli e.g. extended spectrum beta-lactamase (ESBL) producers

Carbapenemase-producing Enterobacteriaceae (CPE)

Neisseria meningitidis

Aspergillus

Hepatitis A

Hepatitis B

Hepatitis C

HIV Alert Conditions

Scabies

Chickenpox and shingles

Influenza

Two or more possibly related cases of acute infection e.g. gastroenteritis

Surgical site infections

HCAI reduction priorities for 2016/17 25. In 2016/17, the Trusts HCAI Reduction Delivery Plan supported the Trusts Quality Strategy

and set out to;

Reduce the numbers of patients with CDI by 30% based on 2015-16 outturn (

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Staphylococcus aureus 26. All Staphylococcus aureus bacteraemias – sensitive to meticillin (MSSA) or resistant to

meticillin (MRSA) – are reported on a mandatory basis through the Public Health England (PHE) HCAI Data Capture System (DCS). The Trust’s incidence of MSSA and MRSA cases is reported on the PHE website. The incidence of these cases is reported publicly as acute trust attributable or otherwise. The reduction of all avoidable bloodstream infections including MSSA and MRSA continues to be an aim of the Trust.

MSSA 27. There is no national objective set for MSSA bacteraemia. Within the Trusts Quality Strategy

the Trust set an ambition to achieve a 50% reduction in cases from 2015/16

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29. Figure 2 depicts the numbers of likely or possible causes of infections compared to 2015/16.

Patients may have several possible or likely sources. Fig 2: MSSA bacteraemia provenance 2015/16 and 2016/17

30. In comparison to 2015/16, the number of MSSA bacteraemias with a likely or possible cause

associated with a peripheral line has decreased however there has been an increase in other access devices including central venous catheters, renal lines and epidural lines.

31. The key areas for focus in 2016/17 included improving Aseptic No Touch Technique (ANTT) practices. ANTT is now applicable to all clinical staff and a programme of re training the ANTT Cascade Trainers was launched and it was included as part of the Aintree Accreditation Award assessment criterion.

MRSA 32. The national HCAI objective for MRSA blood stream infections for 2016/17 was 0 avoidable

MRSA bacteraemia cases.

33. Cases are initially defined as non-trust apportioned if blood cultures are collected on the day of admission or the day after; all other cases are apportioned to the Trust. In line with national MRSA Post Infection Review (PIR) Guidance3 the Trust leads on the investigation of all Trust apportioned cases and is required to assist in non-trust apportioned cases were necessary.

34. In line with national MRSA Post Infection Review Guidance4 the Trust investigates every

MRSA bacteraemia in collaboration with other relevant care providers associated with the case. This process identifies lessons to be learned across the patient’s pathways and also determined the final assignment of the case to the CCG, Trust or Third Party.

35. The Trust has reported 5 non trust apportioned cases 2 Trust apportioned bacteraemias. The

final assignment of the cases is presented in Table 2. Following the PIR of all the cases there was one case finally assigned to the Trust compared to 2 cases in the preceding two years

3 NHS England Guidance on the reporting a Guidance on the reporting and monitoring arrangements and post

infection review process for MRSA bloodstream infections from April 2014 version 2 https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2014/02/post-inf-guidance2.pdf

0

2

4

6

8

10

12

14

16

2015/16

2016/17

https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2014/02/post-inf-guidance2.pdf

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Table 2: MRSA Apportionment and Final Assignment

Month Apportioned Final Assignment

Non trust Trust CCG Trust Third Party

April

May

June 1 1

July

August

September 1 1

October

November 1 1

December 1 1

January 1 1 1 1

February 1 1

March

Fig 3: MRSA bacteraemia cases 2013/14 – 2016/17

MRSA Screening

36. The Trust continues to use a robust approach to screening the majority of patients, either pre operatively or on admission. The following patient groups are screened as indicated below:

2013/14 2014/15 2015/16 2016/17

Total Reported 4 5 9 7

Trust Assigned 3 2 2 1

CCG assigned 1 3 7 4

Third Party 0 0 0 2

0

1

2

3

4

5

6

7

8

9

10

Cas

es

MRSA bacteraemia Assignment

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Table 3: MRSA Screening by Patient Group

Patient group Screening

Elective admissions.

MRSA screening for all elective surgical patients takes place in the Pre-Operative Assessment Clinic. Exemptions are listed below:

Day case ophthalmology

Day case dental

Day case endoscopy

Minor dermatology procedures e.g. warts or other liquid nitrogen applications.

Patients having more invasive dermatological procedures should be routinely screened

Time of listing Eradication of MRSA attempted before admission

Critical Care, haematology and the Ventilator Inpatient Centre.

On admission to Critical Care and haematology and weekly thereafter. On admission to the Ventilator Inpatient Centre and monthly thereafter.

Renal dialysis patients On admission to the programme and quarterly thereafter

All other patients including emergency admissions

On admission

All patients All in patients every 30 days.

37. Screening compliance is monitored on a monthly basis. It is based on all admissions during

one week per month who are screened on day 0, 1 or 2 (day 0 being day of admission). The contractual target for MRSA screening is 100% of eligible patients requiring screening. The Trust has achieved between 88.48% and 93.13% compliance throughout 2016/17.

Table 4: MRSA Screening Compliance

Month Trust wide Surgical Division Medical Division

April 2016 88.89% 93.10% 84.52%

May 2016 93.13% 96.21% 90.00%

June 2016 91.09% 93.62% 88.80%

July 2016 94.33% 96.36% 93.04%

August 2016 93.49% 94.38% 92.64%

September 2016 90.93% 92.12% 89.78%

October 2016 91.51% 92.15% 90.94%

November 2016 90.59% 93.24% 89.67%

December 2016 90.25% 93.55% 87.02%

January 2017 91.87% 96.02% 88.68%

February 2017 88.48% 95.26% 84.23%

March 2017 91.58% 94.57% 89.09%

38. The IPCT have delivered on going targeted support to wards requiring improvements in

MRSA screening.

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39. In 2016/17 the compliance with rescreening of patients was also monitored. This has been

supported by the matrons and the data indicates there has been a gradual improvement.

Fig 5: MRSA Rescreening Achievement

Glycopeptide Resistant Enterococci (GRE) 40. GRE are strains of enterococci resistant to the glycopeptide antibiotics (vancomycin and

teicoplanin). Enterococci are bacteria normally found in the gut that may cause infections including bacteraemia. GRE bacteraemia is strongly associated with prolonged hospital stays and specialist areas such as renal units, haematology units and intensive care units. GRE bacteraemias may be difficult to treat because only a few effective antibiotics are available.

Fig 5: GRE Bacteraemia Reports

41. The Trust has a robust process in place to screen all high risk patients for multidrug resistant

organisms (MDRO). This includes patients admitted onto Critical care, the Ventilator Inpatient unit and haematology. GRE is included in the MDRO screen and in quarter 2 and 3 there was an increase in GRE colonisations within haematology.

0

10

20

30

40

50

60

70

80

90

100

Acheivement with MRSA Rescreening

% Compliance

2013/14 2014/15 2015/16 2016/17

Total 5 3 7 5

Trust Cases 4 2 6 4

Non-Trust Cases 1 1 1 1

0

1

2

3

4

5

6

7

8

Cas

es

GRE bacteraemias

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Clostridium difficile infection (CDI)

42. The CDI NHS England target for 2016/17 was no more than 46 cases. The trust also set an internal quality goal of no more than 23 patients with trust-apportioned infection5. In total there have been 46 cases of CDI, 19 cases have been successfully appealed as having no lapses in care and therefore are not included in the year-end performance figure meaning that there have been 276 cases that count towards performance. There continues to be a decrease in the overall number of patients with Trust apportioned CDI.

Fig 6: Trust- apportioned CDI

43. Each case has been investigated by the clinical teams using a standardised post-incident

review (PIR) process and fed back to the IPC Operational Group. Any gaps in service delivery are discussed and actions agreed and their delivery monitored through the Datix system. If there are no lapses in care, the case is heard by the CCG CDI Appeals Panel with a view to removing the case for performance purposes.

44. Since the inception of the CDI appeals process in 2014/15, performance has improved yearly and the percentage of patients with no lapses in care has decreased from 35% to 41%. It should be noted that the term “lapse in care” does not directly correlate with increased patient harm, it is a terms used to identify any lessons learned.

Fig 7: Trust- apportioned CDI – all Trust apportioned cases and non- appealed cases

5 Trust apportioned - if sample is collected after day 0, 1, 2 (day 0 being day of admission) Positive results on the same

patient within 28 days are not reported as separate episode 6 All 46 cases will still be the displayed number on the Public Health England website

2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17

Cases 340 103 80 63 70 74 64 54 46

0

50

100

150

200

250

300

350

Trust Apportioned CDI

0

10

20

30

40

50

60

70

2014/15 2015/16 2016/17

All trust apportioned cases

Non appealed cases(performance)

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45. There have been 5 periods of increased incidence (PII7) of infection on wards 11, 16 and 34 and 31. In all cases the ribotypes were distinct. The PIIs were monitored at the IPC Weekly Operational Group and actions were put in place as per national guidance.

46. There has been one confirmed outbreak of limited extent on ward 31 with 2 patients with the

same ribotype. This is compared to 5 outbreaks of limited extent affecting 10 patients in 2015/16. The IPCT provided support and addressed the key issues identified through outbreak meetings.

47. Highlighted actions taken in 2015/16 to reduce the risk of CDI include;

Implementation of the HCAI Reduction Plan

The treatment of patients with moderate and severe disease CDI with fidaxomicin. This

aims to reduce relapse and has the potential reduce the spore formation and hence

contamination of the environment

The collaborative IPC ‘sweeps’ following a patient with CDI. This involves IPC, domestic

services, facilities and ward staff and the aim is to identify and reduce risks associated

with transmission.

The introduction of optifibre.

Continued delivery of ward based CDI training using the CDI grab pack

The delivery of department based drop in IPC mandatory training

The use of hydrogen peroxide vapour following all cases of CDI

Antibiotic ward rounds are undertaken on high priority wards and daily on Critical Care.

The introduction of antimicrobial stewardship reports at the Divisional Assurance Groups

to highlight areas for action

UV tagging system to monitor cleaning ward based cleaning.

Collaborative learning with the CCG and NHS England has continued throughout the

year.

Non-Trust Apportioned CDI Cases 48. There was a slight decrease in the number of patients with non-trust apportioned CDI from 48

cases in 2015/16 to 46 cases in 2016/17.

Fig 8: Non Trust- apportioned8 CDI

7 PII two or more cases (occurring >48 hours post admission, not relapses) in a 28 day period on a ward.

8Non-Trust apportioned if the sample is collected on day 0,1,2 ( day of admission is 0)

2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2015/16

Cases 107 110 88 57 72 53 70 48 46

0

50

100

150

200

250

300

350

Non Trust Apportioned CDI

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Escherichia coli (E- coli) bacteraemia 49. 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 variety of diseases. The bacterium is found in faeces and can survive in the environment and can 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.

50. E.coli bacteraemias are reportable to Public Health England (PHE) as part of the mandatory

surveillance system. All cases are reported to PHE and although nationally there is no option to report by non-trust or trust, we are able to do so locally.

Fig 9: All E-coli bacteraemias

Antimicrobial Resistance: Extended Spectrum Beta-lactamase Producers (ESBL) 51. ESBLs are a group of enzymes produced by bacteria. The enzymes break down antibiotics

such as cephalosporins and penicillin’s, but the bacteria are usually susceptible to and hence treatable with the carbapenem antibiotics. The epidemiology of these bacteria is not fully understood. The emergent nature of this field of microbiology is underlined by the absence of any national case definitions for community or hospital-acquired infections with ESBL producers, or recommendations on what constitutes an episode of infection with ESBL producing bacteria. This data is collected locally, only ESBL producing E.coli are reportable to PHE.

Fig 10: ESBL Producing Bacteria (clinical isolates)

2013/14 2014/15 2015/16 2016/17

Total 306 322 306 312

295

300

305

310

315

320

325

Cas

es

Ecoli bacteraemias

2013/14 2014/15 2015/16 2016/17

Total 32 33 14 23

Trust Cases 4 6 3 7

Non-Trust Cases 24 27 1 16

0

5

10

15

20

25

30

35

Cas

es

ESBL bacteraemias

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Antimicrobial Resistance: Carbapenemase Producing Enterobactericae (CPE) 52. CPE have similarities to ESBLs but with a wider range of effects on antibiotics – breaking

down the carbapenem group of antibiotics. There have been a number of outbreaks of CPE in the past 12 months, in the North West and in London particularly. In 2013, the DH issued guidance in the form of a toolkit9 and the Trust developed its own guidance initial guidance. The guidance has been reviewed in 2016 building on our learning experiences and those from other Trusts.

53. The guidance concentrates on prevention: isolation of high-risk individuals and screening

being of particular importance. There has been two main changes in the second version including;

Admission screening – due to the implementation of sensitive Polymerase Chain Reaction (PCR) testing by Liverpool Clinical Laboratories, the Trust has changed practice from for high risk patients from three admission screens two days apart to one admission. This change has shown dividends in releasing isolation rooms as high risk patients required isolation until a negative swab was received.

In patient screens – due to the increased incidence of CPE in the surrounding Trusts and the flow of patients throughout the region, the Trust has been prudent to commence screening of all patients with a stay of over 30 days and then 30 days thereafter. Exclusions to this include Critical Care and Haematology as they undertake weekly screens and Aintree to Home and Ward 34 as this is considered rehabilitation.

54. In 2015/16 the Trust has undertaken CPE screens on 1242 patients. 55. In total there have been 36 in-patient episodes of patients with CPE throughout 16/17 this

includes readmissions of patients with a history of CPE. There was one case of trust apportioned CPE in May 2016 in Critical Care and there have been four cases of non-trust CPE identified; two patients had a history of being in a high risk Trust and two patients had been in hospital abroad. There were 5 patients who admitted and known to be CPE positive from other Trusts.

Central line related blood stream infections 56. In 2016/17 it was agreed to focus on reducing Central Line Associated Blood Stream

Infections (CLABSIs) as opposed to Central Line Related Blood Stream infections (CLRBIs) as the definition for CLABSIs is broader than that for CRBSIs.

57. There is no national objective set for CLABSI. Within the Quality Strategy Delivery Plan, the

Trusts internal quality goal in 2016/17 was to reduce the number of patients with CLABSI by

30%; from 25 to

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Fig 11: Central Line Associated Blood Stream Infections

58. The Trust also monitors the rate of CLABSIs. Against a national rate of 2-5 cases per 1000

catheter days, the Trust rate was 1.18 cases per 1000 catheter days.

59. Achievements in 2016/17 include;

The insertion of 859 vascular access devices (VADs) with a 99.5% insertion success rate.

Following the successful Dragons Den bid in 2015/16 to purchase Nautilus machine which confirms the PICC tip placements and negates the need for X-ray, 556 were confirmed using this method. This has improved the patients experience and ensured prompt treatment for patients.

656 lines had positive outcome. 421 completed treatments, 207 were discharged home & 82 lines were removed due to complications. A complication rate of 18.2 cases per 1000 catheter days was reported for all VADs inserted.

All CLABSIs are investigated using a post infection review tool.

The average waiting time has increased slightly from 2.4 working days to an average of 2.6 days. A business case is in development to expand the Team.

The IV team have influenced and piloted the Vessel Health Framework (VHF) within cardiology and haematology. They have presented this work at regional, national and international conferences and Aintree will continue to be involved in the implementation of this tool.

Training was provided on the IV Study Day, CVAD Management, HDSW & Doctors Training respectively.

The IV Team contribute to the ANTT Steering Group and support ANTT training for Cascade Trainers.

The IV team has undertaken 1 Trust-wide IV management audits and presented the findings.

The IV Team were nominated for the Rising Star in IV Therapy Award in the British Journal of Nursing Awards and ranked 3rd in the category.

The IV Team have published papers and posters nationally and internationally10

10 Ventura, R., O'Loughlin, C. and Vavrik, B. (2016). Clinical evaluation of a securement device used on midline catheters. British Journal of Nursing, 25(14), pp. S16-S22.

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

CLABSI 2016-2017 1 1 4 6 9 14 16 18 20 21 21 25

CLABSI 2015-2016(INFECTION CASES)

2 4 7 9 13 14 16 17 20 21 22 25

Trajectory 1.5 3 4.5 6 7.5 9 10.5 12 13.5 15 16.5 18

0

5

10

15

20

25

30

Nu

mb

er

of

Cas

es

CLABSI 2016-2017 (Trust Infection Cases)

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Ventilator acquired pneumonia (VAP) 60. There is no national objective set for VAP. The Trust has set an ambition to achieve a 15%

reduction in cases from 27 cases to

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Untoward Incidents and Outbreaks 64. The incidence of viral gastroenteritis has been higher than in 2015/6, particularly in quarters

3/4. The IPCT proactively manage the outbreak and work with the site team regarding the appropriate isolation of patients and closure of bays were required.

Table 5: Outbreaks Caused by Viral Gastroenteritis

Wards

affected

Number of staff

affected

Number of patients affected

Organism detected

Bed days lost

April AMU 0 4 None 5

24 0 3 None 1

May - - - - -

June 21 3 13 Norovirus 5

July

24 0 9 None 53

21 0 4 None 0

20 0 3 None 0

31 0 3 None 1

August 33 0 5 None 10

AMU 0 3 None 11

September 2 0 4 None 2

AMU 1 6 None 4

October - - - - -

November

10 0 2 None 3

22 0 3 None 2

15 0 3 None 3

December

8 9

15 ACCU

20(A2H) 21 23 30 32

5 0 0 0 0 4 2 6 6

8 3 3 3

10 15 13 9 6

Norovirus None None None None None

Norovirus Norovirus Norovirus

6 0 0 0 0

66 17 13 3

January

AMU 3

15 32

1 0 0 6

3 2 3 8

None None None

Norovirus

0 2 1 6

February 0 0 0 0 0

March 0 0 0 0 0

Mandatory Surveillance of Surgical Site Infections in Orthopaedic Surgery 65. PHE require surveillance to be performed for at least one type of procedure (total hip

replacement, hip hemiarthroplasty, total knee replacement and open reduction of long bone fracture) for at least one quarter of the year. Mandatory surveillance covers the period up to discharge or 30 days following the procedure, whichever comes first. Additionally with surgery where a device is inserted follow-up is required after 12 months. Post discharge surveillance

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is undertaken using a standardised Post Discharge Questionnaire (PQ) to capture information.

66. The surveillance of these is undertaken by the surgical division and from 2013 includes

patients undergoing repair of fractured neck of femur including hemi arthroplasty, total hip replacement and total knee replacement. The data is based on local data and has been submitted to PHE. All reports are available on PHE web site.

67. In 2015/16 based on the increased incidence of total hip replacement infections within the year, the orthopaedic team implemented a number of innovative solutions to reduce infection rates; these included the ongoing use of a patient ‘passport’, a post-operative Arthroplasty Clinic, which also provides direct access for patients if required and all wound care management of post op joint replacement was carried out in Fracture Clinic where wounds could be assessed and monitored. In 2016/17 there has been a decrease in the number of patients with infections in all categories and the total number of infections has reduced from 20 cases in 2015/16 to 7 cases in 2016/17.

Table 6: Total Knee & Total Hip Replacement (TKR & THR) and Hemi-arthroplasty/Repair of Fractured Neck of Femur Surgical Site Infection Surveillance Jan- Dec 2015 and Jan-Dec 2016

68. In 2016/17 it was planned to undertake an external review of processes within the Trust to

reduce the risk of orthopaedic SSIs, however due to the developments in theatres and the external reviewers’ availability, this has not been undertaken. This will be progressed in 2017/18.

Total Knee

Replacement

2015 2016

Total Hip

Replacement

2015 2016

Repair of neck of

femur

2015 2016

Total Number of

procedures

327 354 310 324 334 334

Questionnaires

returned

236 193

(57.2%) (54.7%)

205 159

(57%) (49.1%)

174 194

(55.6%) (58.1%)

No. pts readmitted

due to infection

7 1 5 1 7 5

No. post-discharged

infections confirmed

0 0 1 0 0 0

No. pt reported

infections

0 0 0 0 0 0

All infections 7 1

(2.1%) (0.3%)

6 1

(1.9%) (0.3%)

7 5

(2.1%) (0.5%)

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2 Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections.

Refurbishment and New Builds 69. The Estates and Facilities Department ensured that the IPCT have been regularly involved,

consulted and engaged in the planning stage of numerous work projects. This has enabled IPC expertise to actively influence improvements to IPC in the built environment.

70. IPC are asked for input on two broad aspects of work:

a) Planning – IPC are asked for input in reviewing plans to ensure that any refurbishments or new builds offer the best facilities to reduce the risk of infections in line with any relevant Health Building Notes and Health Technical Memorandum

b) Operation – IPC are asked to review methods to reduce the risk of any infections presented by the actual refurbishment/build process.

Decontamination Decontamination Group 71. This group meets on a quarterly basis to consider all aspects of decontamination within

Aintree Hospitals. The terms of reference for the group have been agreed by the Trust IPC group, and the group consists of a mix of subject matter experts and service users. The group regularly receives reports on operational matters concerning decontamination. It interprets national guidance and sets local policy with regard to decontamination

72. Within the last year the Group have;

Revised guidance on decontamination of Flexible endoscopes, developing and approving local SOP’s to implement changes made to national guidance.

Application of the new revised standards a new suite of documents now titled HTM 0101 and HTM 0106.

Revised the requirements to both register and maintain a register local decontamination activities

Received and noted updates on the procurement of Trust main Sterile Services Contract

Received and noted updates on the outsourcing of equipment and facilities used in provision of local decontamination facilities

Reviewed and carried out transition of sterilant from Sterolox to Pericetic Acid used in high level disinfection within Trust validated equipment, providing advice to the project group. This transition was carried out with no loss of activity to our theatres and clinics.

Reviewed the results of Decontamination Audits and recommended actions were necessary.

73. There is a Sterile Services Group which meets monthly to discuss operational performance of

(Synergy Health PLC.) the Latter has now been acquired by the Steris group of companies. In addition there is a Joint Management Group which meets quarterly to review the contract. Any concerns of these groups with regard specifically to decontamination are reported to the Decontamination group by the decontamination manager.

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Decontamination Audits 74. Decontamination audits are organised and carried out by the Decontamination Manager/Trust

lead for Decontamination in accordance with an annual work plan which is agreed by the Decontamination Group. The results are discussed at the Trusts Decontamination Group, which turn reports to the IPC Group.

75. All decontamination and sterilisation of reusable medical devices is carried out off site by the Trust sterile services partner (Synergy Health PLC this company have now been taken over by the Steris Group of companies. The company operate to an accredited system and are external audited on a regular basis by AMTEC. This is reviewed by the Trust decontamination manager and fed back to the Decontamination group

76. Central decontamination and high level disinfection of flexible endoscopes is carried out

principally in ECC, however there are a small satellites units located within Cardiology, and Main B theatres. These operate to local SOP’s and are audited bi-annually as part of the decontamination managers work plan.

77. Central decontamination unit will be undergoing a major refurbishment in 2017, this will

involve the purchase of eight new endoscope washer disinfectors and a new reversed osmosis plant, The tender was conducted by Crystal Consulting and the technical scoring of the relevant bidders was carried out by the Trusts new AE(Ds) Mr Terry Easy and Mr Andrew Birch from Milton management along with senior members of the Trust with Gayle Merrygold in attendance from Crystal consulting .the financial scoring was carried out by Crystal Consulting who manage the service.

78. A preferred bidder has been decided on and we are just waiting for BAFO to come through

before we inform all of the results of this tendering process.

79. Offsite decontamination of Flexible non lumen endoscopes is carried out in small clinic this clinic is subject to bi-annual audit by the trust decontamination manager and are now working to a Trust agreed SOP.

Cleaning arrangements Monitoring Arrangements 80. Domestic Services have an established a 3 tier self-auditing process. This process monitors

the standards of the service provided to ensure compliance with the National Cleaning Guidelines (2009) and also provides assurance to IPC Group and the Trust Board:

Supervisors complete checks on their own areas in the form of an electronic audit which is then submitted into the managers

Managers undertake area electronic auditing. This is submitted to the wards and to the weekly IPC operational meeting where any issues are discussed

The Contracts Manager will complete three audits per week on an ad hoc basis. This allows the service to check consistency of results from the department. Any variances are highlighted to the management and actioned accordingly

81. Quality assurance results are sent to ward/department managers each month electronically and scores are available upon request by contacting Domestic management. The Trust We continues to provide a consistent and acceptable service maintaining our scores over the 95% threshold

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82. Domestic Services have invested in the current performance monitoring system we have used for the last 12 years and now have a web based program which allows monitoring to be uploaded from the wards directly to the web page. The reports will be able to be viewed in real time by all departments in the trust.

83. The IPC team perform assurance testing using an Ultra Violet light method. UV gel is

administered to key items/areas and this is left for 24 hours. Upon return, the Ultra Violet light is shined on the item to ensure it received the appropriate cleaning. The results have shown continual improvements in the cleaning required by both the domestic services and ward staff. Cleaning of items and patient areas have improved from the wards to 98% and theatres have improved to 92%

Domestic Service Review Structures 84. Domestic Services have performed a full in depth analysis of the current domestic services

and structure. This has led to a change in supervisory hours and the addition of a “float” supervisor who covers all leave and sickness within the current structure. We have observed the management duties and realigned them to the needs of the service.

85. A full review of the cleaning schedules has been carried out by the Domestic Services

managers.

86. There has been a full review of the restructure of the Domestic Services risk register Training 87. In collaboration with the IPC Team an IPC refresher training programme has been developed

and delivered to all Domestic assistants. This has This ensure that we adhere to any changes in policy

New initiatives 88. Following the successful roll out of the new microfiber system in the clinical areas in 2016 we

have now invested in this across the Trust. 89. An enhanced cleaning team has been established as apart as the already formed periodic

team. This team focusses solely on the areas which haven’t received the yearly decant and deep clean and is done as part of the overall deep clean plan

90. A rolling programme of cleaning commodes has been established whereby the commodes

are deep cleaned through the decontamination centre every 3 months.

Antimicrobial Stewardship 91. Antibiotic Management Group (AMG) – the AMG meets every two months and reviews all

aspects of antimicrobial use throughout the Trust. The antimicrobial management team (AMT) includes antimicrobial pharmacists and clinical microbiologist(s) who are all members of the AMG. The team update and maintain the Trust’s antimicrobial formulary, the stewardship strategy/policy and raise agenda items to be discussed at the AMG. The AMG reports to the



3 Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people.

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Infection Prevention and Control Group (IPCG) and Medicines Governance Group (MGG). Aintree and RLUBHT AMG’s are currently in the process of merging, once a clinical microbiologist has been nominated as the group’s chair. The merging of groups will allow continued sharing of ideas and implementation of AMS strategy across both sites.

92. Antimicrobial website - the website has been updated with antibiotic choices agreed by both

Aintree and RLUH microbiology and pharmacy AMT’s. The new guidelines aim to be Tazocin sparing and remove cephalosporins from first line use. Communication of changes will be ongoing and supported by the clinical ward pharmacy team. The website is an interactive and has built in links to directorate specific guidelines, it has a function for user comments, these are used to try and improve any guidelines.

93. Antimicrobial credit cards - empirical antibiotic credit cards summarising formulary indications

and antibiotic choice have been such a success since first being developed in 2009 (now on version 8), they are still produced and remain a firm favourite of senior doctors. There are now specific versions for Critical Care, AED (prescribing for outpatients) and ophthalmology. New versions of the cards are currently being distributed to all clinical staff involved in prescribing antimicrobials.

94. Start Smart Then Focus (SSTF) - SSTF posters have been developed to promote the

principle of good antimicrobial prescribing. They are visible on all wards as an aide memoire for prescribers and nurses. The poster is visible on the antimicrobial website for reference. SSTF stickers are used by pharmacists in the case notes to prompt antibiotic reviews.

95. Antimicrobial stewardship (AMS) policy - the AMS policy has been developed to outline roles

and responsibilities of staff involved with the use of antimicrobials, it includes processes for monitoring, audit and feedback. It is designed to help implement the Trusts AMS strategy. It includes the antimicrobial prescribing code as an appendix, which summarises AMS good practice points for key members of staff. The antimicrobial stewardship policy should be read by all members of clinical staff including nurses, pharmacists, prescribers and microbiologists.

96. Antimicrobial ward rounds - antimicrobial ward rounds first started at Aintree in 2006. Each

clinical inpatient department had a weekly antibiotic ward round undertaken by a consultant medical microbiologist, consultant (IPC lead for directorate) and clinical pharmacist. This service has now been limited to high risk areas which have high levels of prescribing and manage high risk patients. Daily antibiotic ward rounds are conducted within critical care, where there is high number of infections due to the patient population and environment, ward rounds are held in person five days/week. Operationally the wards round help with surveillance and improving stewardship through education, they help maintain engagement and good relationships with clinicians.

97. Multidisciplinary Clostridium difficile ward round - there is a weekly multi-disciplinary

Clostridium difficile ward round, which reviews all patients who are newly diagnosed CDI toxin positive and GDH/PCR positive or any patients were concerns are raised by the IPC nurses. All patients will now receive Fidaxomicin irrespective of severity score. This has been supported by IPC colleagues who have provided evidence of reduced periods of increased incidence of CDI cases on wards. The change in practice has been noted as a cost pressure and raised via medicines governance.

98. Microbiology consult service and microbiology handover meetings - there is a consult service

which can be refereed to via sigma or via telephone, the patients who need ongoing review or patients identified as having a bacteraemia are kept on a dashboard. The dashboard is discussed at least twice weekly at microbiology handover, it is a multidisciplinary forum led by microbiology and attended by pharmacists, IPC and IV access team nurses. Any patients with antimicrobial prescribing issues should be highlighted at this forum and followed up.

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99. Electronic prescribing medicines administration (EPMA) web portal and clinical pharmacy team - the pharmacy web portal supports operational aspects of AMS. A summary antimicrobial report can be produced for all ward areas and includes information on indication, start and stop dates and current duration. These reports can be used by all members of staff (antibiotic champions) at different ward forums e.g. board rounds. The web portal highlights all patients on IV or oral antimicrobials within the nurse’s and pharmacists web portal as critical medicines. Ward pharmacists prioritise patients on antimicrobials, they help add indications to EPMA and police the antimicrobial guidelines. Ward pharmacists aim to be proactive in highlighting complex patients to microbiology, or were it is obvious that an antimicrobial prescription is not being reviewed.

100. Pharmacy led therapeutic drug monitoring (TDM) service - in house teicoplanin assay.

There had been multiple Datix reports over the turnaround time for teicoplanin assays which were processed at a laboratory in Bristol. LCL laboratories had no suitable mechanism to get results on to sigma, resulting in delays in dose titration. Due to failures in the system this was added to the Trust risk register. Now an in house assay has been developed and a SOP formalised. This has allowed the switch to teicoplanin as first line Glycopeptide. The pharmacy team provide a TDM service for the Trust in and out of hours, advising on the dosing and monitoring of vancomycin, gentamicin and teicoplanin. There is a communication SOP around monitoring of out of range levels. This allows pharmacy to safely titrate doses of high risk antibiotics.

101. Antimicrobial incidents - incidents involving antimicrobials are reviewed each quarter. Any

themes are discussed at weekly meeting of harm. We seek to feedback any errors made, and discuss any solutions. This is also noted at AMG.

102. Restricted antimicrobial report and audit - A daily antibiotic report is sent to the

antimicrobial pharmacists and microbiology duty doctor to highlight all patients on restricted antimicrobials to look over and investigate if needed. This report is used at handover meetings. The report is used to try and highlight patients were microbiology follow up would be beneficial, try and make the service more proactive than reactive. All restricted antimicrobials contained in the restricted list on the antimicrobial website should only be prescribed after consultant microbiology recommendation or if listed for a specific indication e.g. meropenem for neutropenic sepsis. The recent carbapenem audit carried out by one of our pre-registration pharmacists with the support of microbiology showed the following;

Table

103. The majority of prescribing (47%) of carbapenems is non-empirical. The selection of a carbapenems was inappropriate in 29% of the non-empirical choices for use. Microbiology was not involved in these cases. Majority of these cases were prescribed within ward 24, haematology ward were carbapenems are freely available and are used regularly for neutropenic sepsis. This is subject to further investigation.

104. Currently there is no IPC lead within haematology. In 83.3% of cases, cultures were taken

before initiation of treatment, without treatment delay in any case, as per guidelines (100%). It is appropriate to start empirical treatment or obtain advice from microbiology upon initiation without culture results, then review these results within 48 hours. In 93.3% of cases, a 48-hour review of antibiotic therapy was completed.

N=30 Record (R) EPMA duration

(R) EMPA indication

(R) Notes indication

(R) Notes duration

Micro involved

Appropriate dose

48 hour review

Cultures prior

Appropriate choice?

YES 10 20 8 19 30 26 25 23

NO 20 10 22 11 0 4 5 7

% YES

33.3 66.6 26.6 63.3 100 86.6 83.3 76.6

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105. Point prevalence audits - Antimicrobial point prevalence audits are carried out each

month. Three Key Performance Indicators (KPI’s) for antimicrobial stewardship were agreed with the Trusts Infection Prevention and Control Group, supported by the medical director. The KPI’s are reported monthly at IPC group, including breakdown of inappropriate prescribing for feedback to prescribers. Results and recommendations are also noted at AMG, MMG and divisional assurance groups. These are outlined in Table 7

106. The results indicate there has been improvement and all KPIs have been achieved. Thank

you for all the hard work maintaining KPI’s has been fed back to the prescribers. This has also been communicated via the medical director’s bulletin and at grand round.

Table 7: Results for financial year April 2016 – March 2017

KPI and Target % Month Trust Medicine Surgery

Appropriate antimicrobial prescribing ≥ 75% by the end of quarter 1

April 85% - -

May 85% - -

June 89% - -

Quarter 1 average 86% - -

≥ 80% by the end of quarter 2 July 96% - -

August 88% 89% 86%

September 92% 94%(68/72) 83% (15/18)

≥ 85% by the end of quarter 3 October 95% 95% (57/60) 95% (18/19)

November 91% 88% (30/34) 95% (19/20)

December 93% 91% (52/57) 100% (18/18)

January 95% 97% (79/81) 87% (26/30)

February 92% 89% (39/44) 97% (34/35)

March 96% 95% (62/65) 98% (42/43)

Quarter 4 Trust average 94%

Stop date recorded or prescription reviewed within 48-72 hours Target 90% (90% or less, need to improve) (Stop date recorded includes, stop date added at point of prescribing, and review of prescriptions without a stop date at 48-72 hours with antibiotic being stopped or a stop date added at this point)

April 93% - -

May 93% - -

June 89% - -

Quarter 1 average 85% - -

July 80% - -

August 81% 96% 67%

September 100% 100% 100%

October 98% 98% 100%

November 100% 100% 100%

December 96% 100% 83%

January 95% 96% (78/81) 93% (28/30)

February 97% 95% (42/44) 100% (35/35

March 99% 100% (65/65) 98% (42/43)

Quarter 4 Trust average 97%

Indication recorded (notes/EPMA) 100% (

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107. The national CQUIN for AMR and Sepsis was published in March 2016. The CQUIN is in

two parts. Part one asks the Trust to report the number of Day 3 antibiotic reviews (50 prescriptions each month). This data is already reviewed, and will become part of the monthly point prevalence audit. Part two will be reporting antibiotic consumption data with the aim of reducing total antibiotics, IV Tazocin and carbapenem defined daily dose (DDD’s)/1000 admissions by 1%. This year’s data for Q4 is being collated and up to Q3 part 1 of the CQUIN is being achieved. Part 2 of the CQUIN is more difficult to achieve due to numerous reasons, which have been documented and shared with quality leads. Public Health England’s ‘fingertips’ website is updated each quarter with the Trust DDD’s;

Fig 13: DDD of antibiotics dispensed by AUHT pharmacy to all inpatients and outpatients per 1000 admissions

Fig 14: DDD of piperacillin/ tazobactam dispensed by AUHT pharmacy to all inpatients and outpatients per 1000 admissions

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Fig 15: DDD of carbapenems dispensed by AUHT pharmacy to all inpatients and outpatients per 1000 admissions

108. Following Q3 it is expected that the Tazocin consumption reduction will be achieved. Total consumption is approx. 2% above target and the Meropenem consumption reduction will not be achieved due to the high dose regime we use. This has been a change in practice since 2013/14.

109. The CQUINs for AMR and sepsis have now been linked for the years 2017-2019. We have suggested putting it forward for a local variation contract, which will need to be agreed by NHS England due to it being a national CQUIN. This approach is supported across the other Trusts in the region. This will be presented at Pan Mersey APC for discussion.

110. IPC Operational Group and post infection reviews - antimicrobial stewardship themes are

being collated each quarter from the weekly IPC operational meeting as part of feedback to IPC leads and their teams.

111. Internal audit – an internal audit of AMS was undertaken at the request of DIPC and

Medical Director. The audit findings showed that they were reasonably assured that there were suitable processes and interventions in place or in development to support successful AMS. The action plan that was developed has been completed by March 2017.

112. AMS education gap analysis - this has been developed after a recommendation in the

internal audit. The gap analysis identifies how much education already takes place. Development of ‘essential staff’ training tracker will be the next step. The gap analysis and action plan is to be presented at the next AMG.

113. IPC Leads and antibiotic audit - a new process for auditing within directorates has been

developed and incorporated into the AMS policy. This has been piloted successfully within medicine and surgery. The IPC leads will conduct audits every quarter and feedback results in real time to colleagues as well as present results at divisional audit meetings. Results will be used to support any CDI appeals that originate from that directorate.

114. European Antibiotic Awareness Day (EAAD) - the Trust promotes the EAAD initiative

each year, and utilises communications via intranet and social media. This year the Trust’s focused on the Antibiotic prescribing code, promoting Start Smart Then Focus and explaining to patients what impact antimicrobial resistance would have on them.

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115. Improving capacity - a permanent Band 7 antimicrobial pharmacist came to post in

January 2017. This will allow for no gaps in support for AMS. 116. There have been several developments in 2016/17 including;

Investigating using Aintree’s Learner app to incorporate the antimicrobial guidance. This suggestion was made by one of our enthusiastic junior doctors.

ICNet Pharmacy implementation had been delayed due to IT functionality. This is now in its’ development phase with the developing company working with both AMT’s to incorporate their AMS strategies.

Outpatient Antibiotic Therapy (OPAT business case) – An OPAT service has been in operation at Aintree since 2005. The service has grown uncontrollably that there is no capacity in the service to allow staff to implement all BSAC recommendations including monitoring and follow up at a virtual ward round.

Lead antimicrobial prescribing pharmacist has completed none medical prescribing course. How lead pharmacists across both Trusts will help steward antimicrobials such as carbapenems at ward level is being discussed. Hopefully the successful implementation on ICNet Pharmacy will help support this role and allow for all outcomes to be recorded.



4 Provide suitable accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion.

117. The Trust provides all service users with information as required. This includes information leaflets for patients, visitors and staff.

118. Staff are also provided with policies, clinical guidelines, standard operating procedures,

are pathways and care plans to provide condition specific information.

119. IPC information is also provided for services users via the Trust internet (external) and intranet (internal) sites.

120. Information is shared internally via the communication teams: message of the week, All

About Aintree. 121. The trust has continued to implement Stop, Gel, Go to inform staff, patients and visitors

regarding the importance of clean hands. 122. The Trust provides condition specific information to support staff to provide safe care in a

variety of ways:

a. Condition specific care plans and care pathways b. Interdepartmental transfer forms c. Inter-hospital transfer forms d. Discharge information – community healthcare providers are informed by the Trust IPC

team when patients are discharged as agreed. Patients with Clostridium difficile infection (and their GPs) are sent the regional standard information cards.

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123. The IPC team continue provide a 7 day service and an on call microbiology service is

available out of hours. 124. The IPC Team visit all patients at regular intervals according to their infection or possible

infection. Table 1 outlines the activity of the team, these data includes visits and phone calls associated with a patient with an alert organism or condition only.

Table 8

2013/14 Visits 9,317

Telephone calls 122

2014/15 Visits 10,691 Telephone calls 204

2015/16 Visits 10,568 Telephone calls 307 2016/17 Visits 12853 Telephone calls 194

125. Where necessary colleagues in Public Health England are available for outbreak advice

when necessary and they are a member of the Infection Prevention and Control Group.



6 Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection.

Staff Development and Training

126. All staff roles include IPC in the job description. How this is applied is outlined at the individual’s local induction when in post.

127. Training was a key tool in improving staff knowledge on IPC practices. The IPCT

delivered training across the entire spectrum of staff and for a wide range of purposes from generic Trust-wide sessions at induction to bespoke training on very specific issues.

128. The IPCT participates in Trust Induction for all new starters including junior doctors. The

IPCT also supports specific induction training to all grades of staff as requested by each business unit.

129. The IPCT fully support the Trust mandatory training programme, delivering sessions for all

staff at mandatory training sessions. These sessions are recorded on the Trust central training records. The IPC team have developed bespoke training sessions for wards to enable them to attend mandatory training.

130. Compliance with attendance at key IPC training (induction, annual mandatory and ANTT

training) is tracked within the Divisional IPC Reports and is monitored at the Trust IPC Group and Divisional Assurance Groups.



5 Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people.

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131. The IPC Team used their work with the simulation centre to develop learning resources using simulation and visualisation techniques. These have evaluated very well.

132. Three members of the IPC team have received formal training in human factors.

133. One member of the Team is an AQUIS Leader and one member is an AQUIS practitioner.

134. Until September 2017, the Assistant Director of Infection Prevention and Control was an

Executive Board member of the Infection Prevention Society and the term has now been completed.



7 Provide or secure adequate isolation facilities.

Isolation facilities 135. The current proportion of single rooms is 18%. This percentage changes with the slight

fluctuations of the bed base.

136. The target time for isolating patients with unexplained (and potentially infectious diarrhoea) is less than two hours. This is monitored by the IPC team weekly and reports to the IPC Group monthly via the IPC Board Report. Compliance ranged from 80-100% throughout the year.

137. Each ward/department maintains an isolation plan and the IPCT send out a Trust wide

RAG rated side room plan daily. This identifies who is managed in a side room and the reason for their isolation. This is used by the wards and the site team to enable the correct placement of patients.

138. The IPCT collaborate with the site team with respect to isolation facilities and available for

advice 08:30-18:00 Monday – Friday and 08:45-16:45 Saturday and Sunday. There is an on-call microbiology service for advice outside of these hours.



8 Secure adequate access to laboratory support as appropriate.

Laboratory Services 139. Liverpool Clinical Laboratories (LCL) is a contractual joint venture between Aintree

University Hospital NHS Foundation Trust and other Liverpool Hospitals and brings together under a single governance and management structure. The pathology and laboratory services are on the Royal site.

140. There is 24 hour microbiology advice available.

141. The IPC team have been working collaboratively with LCL, the RLBUH’s and Liverpool Heart and Chest to implement the electronic surveillance system; ICNet.



9 Have and adhere to policies, designed for the individual’s care and provider organisations that will help to prevent and control infections.

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142. The Trust has policies, guidelines and standard operating procedures in line with the

Health and Social Care Act 2008; Code of Practice on the prevention and control of infections and related guidance.

143. These documents are monitored utilising a variety of audit tools to measure staff

compliance with guidance. Additionally there is bespoke training for all staff types to ensure they are kept informed of current guidance.

Audit Programme

144. There is an extensive IPC Audit plan. This includes audits undertaken by the clinical staff on their wards and also audits undertaken by the IPC team. The results are feedback to the Divisions on a monthly basis.

145. Monthly hand hygiene compliance audits continue and continue to demonstrate good

compliance. However some of that compliance can be questioned due to bias. Audits have also been undertaken by the Student Quality Ambassadors using World Health Organisation (WHO) methodology.



10 Ensure, so far as is reasonably practicable, that care workers are free of and are protected from exposure to infections that can be caught at work and that all staff are suitably educated in the prevention and control of infection associated with the provision of health and social care.

Occupational Health 146. The Occupational Health Service (OHS) provides pre-employment health assessments

and assessment of immunity and provides vaccinations for new staff. There is also a recall system in place in which staff are recalled (if appropriate) for vaccinations when due to ensure that they are kept up to date and our compliant.

147. The service has also supported advice and treatment in the event of outbreaks or

incidents requiring staff screening or treatment. For the past year this has included;

An ongoing measles look back exercise:

Following the measles outbreak in the Mersey region in 2012, OHS have conducted an extensive Trust look back exercise and this will continue to be an ongoing.

TB incident/Outbreaks:

There was a TB incident from Respiratory in 2016 which resulted in a look back exercise. This was completed.

There was also a TB incident on Critical Care in June 2016. Lists of names were forwarded on to OHS of staff that had direct contact with the patient (positive BALS confirmed pulmonary TB). This remains ongoing as some staff are now working at St Helen’s and Knowsley Hospital and as a result they are now involved in their care and follow up.

148. The Occupational Health Service leads the seasonal flu vaccination campaign. The flu campaign commenced 10th October 2016 with the aim of completing the campaign by the end

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of November 2017and aimed to achieve the 75% CQUINN target set by the 31st December 2016. The flu vaccine however was still available from OH or flu link immunisers thereafter if required up until the end March 2017. There were a total of 20 trained flu link immunisers of which 9 actually participated in the flu campaign.

149. In relation to staff uptake 84.3% of frontline staff were vaccinated. Overall the numbers of Doctors vaccinated was 99.3%, Nurses 75.9%, Allied Health Professionals 69.8%, Support 96.5% and Other 46.8%. This equates to 3,104 of all Trust staff.

150. In relation to the Directorates Medicine had 1,253 staff vaccinated,

Surgery & Anaesthesia 743 staff vaccinated, Corporate Services 226 staff vaccinated, Estates & Facilities 231 staff vaccinated and Diagnostics and Support Services 651 staff vaccinated.

151. The 2017-2018 Flu Campaign is currently in the process of being planned.

152. There were 119 Incidences across the Trust reported to Occupational Health between

April 2016 and March 2017. This consisted of 19 splash injuries, 69 needle stick type injuries, 29 injuries with a blunt instrument i.e. scalpel, blade, or drill, 1 bite injury and 1 scratch injury.

153. As a result a Needle Stick Injury Steering group has now been set up to discuss the

issues and identify a way forward. The Inoculation Injuries Policy was reviewed with Health & Safety and updated in March 2017 and this has been renamed the ‘Prevention and Management of Inoculation Injuries and Blood Borne Virus related Incidents and Events’.

Implications

Financial

154. Healthcare associated infections have a significant financial impact in terms of cost of

treatment and extended length of stay. There are no capital or revenue financial implications

from this report.

Workforce

155. No workforce implications.

Other

156. Potential implications for non-achievement of the key infection prevention quality

objectives have been highlighted throughout the body of the report, particularly in relation to

challenges in specific areas.

Recommendation

157. The Committee is asked to note the progress with actions in place to reduce reducing

healthcare associated infections in 2016/17 and approve the Reducing HealthCare

Associated Infections Plan for 2017/18.

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References and further reading

Aintree University Hospital Trust 2015/16 Annual Infection Prevention and Control Report and 2016/17 Healthcare Associated Infection Reduction Plan

Department of Health (2015) Health and Social Care Act 2008: Code of Practice for Health and Adult Social Care on the prevention and control of infections and related guidance

NICE (2011) Prevention and control of healthcare-associated infections Quality improvement guide

NICE (2016) Healthcare-associated infections Quality standard.

NHS England (2014) Guidance on the reporting a Guidance on the reporting and monitoring arrangements and post

infection review process for MRSA bloodstream infections

Public Health England (2013) Carbapenemase-producing Enterobacteriaceae: early detection, management and control toolkit for acute trusts.

Author(s) Debbie Wright Dr Cecilia Jukka The Infection Prevention and Control Team Rolly Ventura Emma Hughes Mike Ryan Keith Rimmer Paul McCormick

Owner Dianne Brown, Director of Nursing and Quality

Date 21/04/17

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Appendix 1

IPCT Structure 2016/17 (including the IV team)

Post Post holder WTE

Board Executive Lead (DIPC)

Mrs N Firth until September 2016 Mrs Andrea Thomas from September 2016-March 2017

Not defined

Assistant DIPC Ms D Wright 1WTE

Chair of the Trust Infection Prevention and Control Group

Mrs N Firth until September 2016 Mrs Andrea Thomas from September 2016-March 2017

Not applicable

Trust Infection Control Doctor (ICD)

Dr C Jukka

5-6 PAs

Consultant Medical Microbiologists

Appointed by Liverpool Clinical Laboratories Not defined

Associate Medical Director (AMD) for IPC; Consultant Orthopaedic Surgeon

Mr S Montgomery until January 2017 0.1 WTE

Band 8a IPC Matron Ms F Browne 1 WTE

Band 7 IV Nurses Mr R Ventura Mr C Oloughlin

2 WTE

Band 7 IPC Nurse Mr D Burns Mrs W Moens

2 WTE

Band 6 IPC Nurses Ms E Donnelly Mrs A Heaton J Hagan

2.6 WTE

Band 3 IPC Support Worker

Mrs A Jones 0.6 WTE

Band 3 IV Support Worker Mrs C Graney 1.0 WTE

Band 3 Administration and clerical support

Mrs J Graham Mrs J Jevons

1.6 WTE

Band 2 Administration and clerical support

Ms R May 1 WTE

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Health Care Associated Infection Reduction Plan 2017/18 Priorities 2017-18 Key Quality Goals as outlined Quality Strategy Annual Delivery Plan: Safe Care – Reducing Harm

A reduction the numbers of patients with CDI

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Compliance Criterion 1 Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider how susceptible service users are and any risks that their environment and other users may pose to them

Objective

Programme of work (action)

Timescale &

Milestones

Lead

BRAG Progress/

Comments Q1

Q2

Q3

Q4

1 a. There are appropriate management and monitoring arrangements for zero tolerance approach to HCAIs

To agree the corporate priorities for HCAI reductions

April 2017 DIPC

To agree the Divisional objectives for the reduction of HCAIs

April 2017 DIPC DDNS DMDs DCOO

Each Division to submit their IPC report to TIPCG and Divisional Assurance meetings

April and monthly DDNS DMDs DCOO

Clinical teams to undertake case review using principles of RCA and PIR and present to the weekly IPC Operational Group;

All cases of MRSA bacteraemia

All cases of acute apportioned CDI

All cases of acute apportioned MSSA

All cases of non-acute CDI or MSSA with a recent link to the Trust

All cases of CLABSI

April 2016 and ongoing

Clinical teams

All deaths due to CDI (recorded on Part 1 of the death certificate and all patients diagnosed with CDI and who have died within 28 days of diagnosis to undergo a mortality review. To be reported at the TIPC every 6 months.

April – Sept report in Nov 17, Oct – March report in May 18

IPC Doctor Medical and ADIPC

Review and update TIPCG terms of reference August 17 DIPC and ADIPC

Review and update TIPC Operational Group

May 17 ADIPC

1b Promote a culture of continuous

Provide quarterly updates on the HCAI reduction plan to the TIPCG

July 17, Oct 17, Jan 18, April 18

ADIPC

Provide monthly reports to Safety and Risk Committee and reports through to Quality and

April and monthly ADIPC

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Objective


Timescale &

Milestones

Lead

BRAG Progress/

Comments Q1

Q2

Q3

Q4

quality improvement in IPC

Safety Committee.

To present surveillance data regarding HCAIs monthly at the TIPCG – Trust wide and Divisional

Monthly IPC Team

To provide benchmarking data for CDI, MRSA and MSSA.

Quarterly ADIPC

To develop ward based heat map for alert organisms/conditions

May 17 IPCT

To implement IPC audit plan for 2017/18 and report at TIPCG monthly within the Divisional reports

Monthly IPC Team

To maintain IPC Link practitioner forum – quarterly meetings

April 17, July 17, Oct 17, Jan 18

IPC Matron

IPCT to support areas with a reduction in AAA accreditation regarding IPC elements

On going IPC Matron

To present IV annual plan for 2016/17 and report at IV access group and TIPCG

May 17 IV team

To monitor themes from for central line associated infections and present at TIPCG

April and monthly IV team

Provide quarterly reports from the ANTT leadership group to the TIPCG

June 17, Sept 17, Jan 18

ADIPC

Provide a gap analysis regarding ANNT training process

June 17 ADIPC

Review of cases of VAP 6 monthly at the TIPPG May 17 and Nov 17 Critical Care IPC Lead

Undertake an review of the IPC processes and management of surgical site infections

September 2017 IPC Trust wide Clinical Lead

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Objective


Timescale &

Milestones

Lead

BRAG Progress/

Comments Q1

Q2

Q3

Q4

Identify actions and develop an action plan following the review

December 2017 Division of Surgery DMD and DDN.

Report an overview of Group A Strep cases on a quarterly basis

Jan – March report in May 17, April – June report in August, July – Sept report in Nov, Sept – Dec report on Feb 18.– March

Relaunch IV Steering Group July 17 ADIPC

Compliance Criterion 2 Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention of infections

Objective


Timescale &

Milestones

Lead

BRAG Progress/

Comments Q1

Q2

Q3

Q4

2 a Maintenance of a clean, safe and appropriate environment which facilitates the prevention

Review MONIT scores including bedded area reports weekly at the IPC Operational meeting

April 17 and weekly Domestic Services Manager

Monitor UV tagging results quarterly at TIPCG July 17, Oct 17, Jan 18

IPCT

Provide expertise and specialist IPC input into Estates and Facilities meetings

On- going IPCT

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Compliance Criterion 2 Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention of infections

Objective


Timescale &

Milestones

Lead

BRAG Progress/

Comments Q1

Q2

Q3

Q4

and control of HCAI

Explore approach for deep clean programme and present at IPCG

May 17 Estates Manager, Domestic Services Manager, ADIP

Review the roles and responsibilities framework for cleaning

July 2017 Estates Manager, Domestic Services Manager, ADIPC

Explore the use of the Estates, Domestic and IPC audit tool as a proactive tool to monitor standards in the environment

July 2017 Estates Manager, Domestic Services Manager, ADIPC

Develop an Infection Prevention and Control in the built environment SOP

June 2017 ADIPC

2b Decontamination standards are monitored and adhered to.

The Trust decontamination Lead will ensure that the Decontamination Working group will operate according to its terms of reference

April 2016 – ongoing

Decontamin-ation Lead

The TIPCG will receive report from the Decontamination Working group


Decontamin-ation Lead

2c Water safety requirements are monitored and adhered to

The Trust Water Safety Lead will ensure that the Water Safety group will operate according to its terms of reference


Maintenance Manager

The TIPCG will receive report from the Water Safety group


Maintenance Manager

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Compliance Criterion 3 Ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance.

Objective


Timescale &

Milestones

Lead BRAG Progress/Comments Q

1 Q2

Q3

Q4

3a - To ensure the prudent use of antimicrobials throughout the Trust (antimicrobial stewardship)

Collaborative antimicrobial ward rounds within directorates

Weekly - ongoing Trust antimicrobial lead

Trusts antimicrobial management team (AMT), will address any inappropriate prescribing, and feedback to prescribers.

Monthly AMT

To ensure the Antibiotic action sub group (AASG) operate according to its terms of reference


Trust antimicrobial lead

AASG assurance reports to be sent to TIPCG and medicines governance group


Antimicrobial pharmacist

Ensure the Trusts Antimicrobial stewardship (AMS) programme and action plan is kept up to date


AMT

Ensure the Trusts AMS audit plan is kept up to date and completed


Antimicrobial pharmacists

To work collaboratively with LCL to implement ICNet Pharmacy

Date TBC for with LC and ICNET

Antimicrobial pharmacist

Report on the internal antimicrobial stewardship review

AMT

3b – To ensure all staff who prescribe, administer and provide advice on

AMS to be part of induction and mandatory training for staff (job specific).

November 17 AMT

Antimicrobial stewardship policy outlining staff roles and responsibilities to be approved and circulated to all staff

May 2017 Antimicrobial pharmacist

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Compliance Criterion 3 Ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance.

Objective


Timescale &

Milestones


1 Q2

Q3

Q4

antimicrobials, understand what antimicrobial stewardship is, and their responsibility in ensuring it is implemented.

IPC lead Clinicians role on antibiotic stewardship agreed – incorporated into AMS policy

May 17 Antimicrobial pharmacist and Medical Director

Compliance Criterion 4

Provide suitable accurate information on infections to service users, their visitors and any person concerned with providing further support or nursing/ medical care in a timely fashion.

Objective


Timescale &

Milestones

Lead BRAG Progress/Comments

Q1

Q2

Q3

Q4

4a There is timely communication with staff, patients, visitors and carers throughout the care pathway about HCAI to reduce the harm

Patients and carers have access to relevant patient leaflets.

Ongoing

Improve awareness of hand hygiene during WHO Hand Hygiene day

May 17

Improve awareness of IPC during IPC week October 17

IPC indicators are reflected on the How We are Doing Boards

Monthly

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Ensure prompt identification of people who have or are at risk of developing an infection so that they receive timely and appropriate treatment to reduce the risk of transmitting infection to other people.

Objective


Timescale &

Milestones


1 Q2

Q3

Q4

5a Address the infection risk from CPE

Monitor numbers of screens and clinical isolates at IPC group

April 17 and monthly

IPCT

Input all cases into the PHE surveillance system April 17 IPCT

Audit compliance with CPE 30 day screening April 17 and monthly

IPCT

Revise CPE grab pack based on revised guideline April 17 IPCT

Revise mandatory training to add additional detail on CPE

April 17 IPCT

Deliver ward based training to all wards July 17 IPCT

5b To improve MRSA screening for all relevant patients on or prior to admission.

Monitor MRSA screening in line with revised guidelines and report on a ward and Divisional basis

April 17 and monthly

IPCT

Audit compliance with MRSA 30 day screening April 17 and monthly

5c To minimise the risk of cross infection for alert organisms

IPC team to review all patients and provide ongoing advice and support to clinicians regarding IPC

Ongoing IPCT

5d To ensure all relevant health and social care organisations are made aware of the patients HCAI status

To undertake a snap shot audit of clinical records Oct 17 IPCT

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Systems to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the process of preventing and controlling infection

Objective


Timescale &

Milestones

Lead BRAG Progress/Comments Q1

Q2

Q3

Q4

6a Staff to receive appropriate IPC training

IPC is part of induction and mandatory training. IPC Mandatory training to be monitored monthly in the Divisional IPC reports

April and monthly DDNs

ANTT plan to be presented at TIPCG June 17 IPC Matron

6b IPC workforce and capability

Ensure that all IPC team and IV team are skilled, knowledgeable and have an appraisal process in place to ensure clear objectives and development needs

Ongoing ADIPC/ IPC Matron

Compliance Criterion 7 - Provide or secure adequate isolation facilities

Objective


Timescale &

Milestones

Lead BRAG Progress/Comments

Q1

Q2

Q3

Q4

7a To provide advice regarding appropriate isolation use

IPC team to undertake a daily review of isolation rooms and provide a RAG rated plan to the bed managers

Daily IPCT

To explore the use of ICNet for isolation prioritisation September 17 ADPIC

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Compliance Criterion 8 - Secure adequate access to laboratory support appropriate

Documents

2016/17 Annual Infection Prevention and Control Report ......19. The annual reduction aspirations are agreed by the Trust Board in the Aintree Quality Improvement Plan 2016/17 (AQUIP)