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2017/18 Annual Infection Prevention and Control Report

& 2018/19 Healthcare Associated Infection

Reduction Plan

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2017/18 Annual Infection Prevention and Control Report and 2018/19 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 2017/18 and the broad plan of work for 2018/19 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 2017/18 5

Untoward Instances and Outbreaks 21

Mandatory Surveillance of Surgical Site Infections 21

Refurbishments and new builds 23

Decontamination 23

Cleaning Services 24

Water Safety 25

Antimicrobial Stewardship 25

Staff development and training 30

Isolation 30

Laboratory Services 31

Audit Programme 32

Occupational Health 33

Implications 33

Recommendations 34

References and Further Reading 34

Appendices to the Annual Report

Appendix 1 IPCT Structure 35

Contents HCAI Reduction Plan

HCAI priorities 36

HCAI Reduction Plan 37

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.

47

Appendix 3 - Audit Programme 48

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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 2017/18. 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

Klebsiella spp. Pseudomonas aeruginosa

6. The structure and headings of the annual report and plan follows the ten criteria outlined in the 2015 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

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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12. The Board of Directors receive: Monthly IPC Report

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 an IPC report when requested.

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

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 HCAI 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 ambitions are agreed by the Trust Board in the Aintree Quality Strategy

Annual Delivery Plan for 2017/18. 20. The Trust continues to undertake a number of interventions in relation to infection prevention

and control as detailed within the HCAI Reduction Plan 2017/18. 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.

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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).

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 infection (CDI)

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

Influenza

Alert Conditions

Scabies Chickenpox and shingles Two or more possibly related cases of acute infection e.g. gastroenteritis Surgical site infections

HCAI reduction priorities for 2017/18 25. The national HCAI objectives for 2017/18 set by NHSE were;

MRSA – a continued zero tolerance to all MRSA bacteraemias

CDI - to have no more than 46 patients with Trust attributable CDI.

26. In 2017/18, the Trusts HCAI Reduction Delivery Plan supported the Trusts Quality Strategy and set out to;

MRSA – to have no patients with trust apportioned MRSA bacteraemia

CDI – to continue with a local ambition of no more than 23 patients (with lapses in care)

MSSA – to reduce the numbers of patients with MSSA bacteraemia by 15% based on 2016/17 outturn (</= 31 or less cases)

Central line associated infections (CLABSI) – to reduce the number of patients with central line associated infections by 10% based on 2016/17 outturn (</= 21 or less cases)

2 Alert organisms are organisms identified as important due to the potential seriousness of the infection they cause, antibiotic

resistance or other public health concerns. This is a nationally recognised term; these organisms may be part of mandatory or voluntary surveillance systems and are used as indicators of general infection prevention and control performance.

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Staphylococcus aureus 27. 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 28. There is no national objective set for MSSA bacteraemia. Within the Trusts Quality Strategy

the Trust set an ambition to achieve a 15% reduction in cases from 2016/17 </= 31 or less cases. This was achieved with 26 patients with MSSA bacteraemia in 2017/18 compared to 37 patients in 2016/17.

Fig 1: MSSA bacteraemia (Trust-apportioned cases)

29. All cases of MSSA bacteraemia using the Post Infection Review Framework. Clinical Teams

present each case to the weekly IPC Operational Group. The provenance of infection associated for each case is identified below. Three cases are awaiting formal review.

Table 1: Provenance of MSSA bacteraemia infections

Source of infection Number of cases

Peripheral Line 6

Unknown 6

Contaminant 1

Chest 3

Endocarditis 1

Epidural abscess 1

Abdominal sepsis 1

Surgical site infection 1

Discitis 1

PICC line 1

2013/14 2014/15 2015/16 2016/17 2017/18

Total 81 72 82 94 82

Trust Cases 28 19 25 37 26

Non-Trust Cases 53 53 57 57 58

0

20

40

60

80

100

Cas

es

MSSA bacteraemia

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Source of infection Number of cases

Soft tissue 1

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

and 2016/17. Fig 2: MSSA bacteraemia provenance 2015/16 – 2017/18

31. The number of MSSA bacteraemias with a likely or possible cause associated with a

peripheral line has decreased over the past 3 years. Improving Aseptic No Touch Technique (ANTT) practice has remained a key area of focus.

MRSA 32. The national HCAI objective for MRSA blood stream infections for 2017/18 was zero patients

with avoidable MRSA bacteraemia.

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 2 non Trust apportioned cases and 1 Trust apportioned bacteraemia.

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; this was the same as 2016/17.

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

2017/18

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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

October

November

December

January 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 2017/18

Total Reported 4 5 9 7 3

Trust Assigned 3 2 2 1 1

CCG Assigned 1 3 7 4 2

Third Party 0 0 0 2 0

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 87.35% and 92.51% compliance throughout 2017/18.

Table 4: MRSA Screening Compliance

MRSA Admission Screening

Month Trust wide Surgical Division Medical Division April 2017 92.11% 94.93% 89.58% May 2017 92.54% 96.69% 88.97% June 2017 90.17% 94.68% 85.71% July 2017 92.35% 93.49% 91.36% August 2017 92.96% 94.25% 91.76% September 2017 92.72% 95.74% 90.11% October 2017 91.65% 94.53% 89.15% November 90.23% 97.22% 85.88% December 91.10% 92.74% 89.94% January 87.35% 95.83% 82.15% February 88.35% 93.49% 83.84% March 85.40% 89.16% 83.19%

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MRSA inpatient screening 38. In 2017/18, MRSA screening for patients who had a length of stay for 30 days was monitored.

Compliance was improving in Q1 and 2. It deteriorated in Q3, however is now showing signs of improvement in Q4.

Table 5: MRSA 30 day screening performance

MRSA 30 day Rescreening

Month Trust wide Surgical Division Medical Division Support Services

April 62.83% 64.00% 54.79% 100%

May 61.04% 69.44% 53.06% 85%

June 73.72% 87.88% 67% 82.61%

July 71.89% 52.50% 72.81% 93.55%

August 62.57% 69.44% 62.07% 52.63%

September 63.69% 79.55% 54.72%% 77.78%

October 75.66% 62.22% 80% 79.41%

November 36.36% 53.15% 27.41% 18.18%

December 38.14% 63.16% 33.72% 30.77%

January 46.56% 69.23% 43.75% 11.11%

February 64.08% 63.29% 66.67% NA

MRSA acquisitions 39. The number of patients who may have acquired MRSA (either colonisation or infection) is

also monitored. Over the past three years the number has increased;

2015/16 – 21 cases

2016/17 - 34 cases

2017/18 – 43 cases

40. Challenges with being able to isolate all patients with MRSA colonisation may have impacted on this increase.

Clostridium difficile infection (CDI)

41. The CDI NHS England target for 2017/18 was no more than 46 cases. The trust also set an

internal quality goal of no more than 23 patients with trust-apportioned infection5.

42. In total there have been 63 cases of CDI, this is a 37% increase in total Trust apportioned cases from 46 cases 2016/17 to 63 cases in 2017/18 (Fig 4). Performance is measured on cases were there have been potential lapses in care. 20 cases have been successfully appealed with the CCG as having no lapses in care and therefore are not included in the

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

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year-end performance figure meaning that there have been 436 cases that count towards performance.

Fig 4: Trust- apportioned CDI 2014/15 – 2017/18 (all cases)

Fig 5: Trust- apportioned CDI – all Trust apportioned cases and non- appealed cases

2014/15 – 2017/18

43. Since the inception of the CDI appeals process in 2014/15, performance improved yearly and the percentage of patients with lapses in care decreased, however in 2017/18 this has increased from 27 cases to 43 cases. 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.

44. 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.

6 All 46 cases will still be the displayed number on the Public Health England website

2014/15 2015/16 2016/17 2017/18

Cases 64 54 46 63

0

10

20

30

40

50

60

70

Trust Apportioned CDI

0

10

20

30

40

50

60

70

2014/15 2015/16 2016/17 2017/18

All trust apportioned cases

Non appealed cases(performance)

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45. There have been 7 periods of increased incidence (PII7) of infection compared to 5 in

2016/17. These are outlined in Table 6. Table 6: Period of increased incidence of infection

Ward Month No of patients Comments

34

May/June 2 ribotypes different

Critical Care

July 2 ribotypes different

Ward 15

August 2 ribotypes different

Critical Care August/September 6 4 ribotypes different, 2 the

same, not thought to be

linked

Ward 3

December 3 ribotypes different

Ward 11

January 2 ribotypes different

Ward 33

January 2 Awaiting one ribotype

46. In Q2 there was an increase in the total number of cases of CDI. In October 2017 a CDI

Task Force was held with the aim to provide an understanding of the current situation and to

gain collective ideas regarding how we could reduce the risk of further infections. Invitations

were extended to internal colleagues and also external organisations including the CCG,

NHSI and Public Health England. The task force reviewed the current state in terms of

performance, epidemiology, microbiology and lessons identified through the PIR process. A

review and challenge of current control measures in respect of infection prevention and

antibiotic stewardship was undertaken.

47. Feedback from the meeting was positive and in addition to the actions already in placea CDI

Action Plan was developed. This has been monitored through the Infection Prevention and

Control Group on a monthly basis. The numbers of patients reduced in Q3 and 4; Q 1 – 17,

Q2 – 21, Q3 – 12, Q4 – 13

Non-Trust Apportioned CDI Cases 48. There was a slight decrease in the number of patients with non-trust apportioned CDI from 46

44 cases in 2016/17 to 42 cases in 2017/18

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

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Fig 6: Non Trust- apportioned8 CDI

Gram-negative blood stream infections 49. In June 2017, NHS Improvement set a national ambition to reduce healthcare associated

Gram-negative blood stream infections (healthcare associated GNBSIs) by 50% by March 2021. These include;

E. coli

Klebsiella spp.

Pseudomonas aeruginosa

50. In 2017/18 the focus was on E.coli (Eschericia coli) with a 10% or higher reduction in all cases. This was supported by objectives laid out in the Quality Premium for the CCGs.

51. The Trust had previously been collecting and submitting E coli surveillance data to PHE and

from April 2017 submission of data was also required for Klebsiella species and Pseudomonas aeruginosa.

Escherichia coli (E- coli) bacteraemia 52. 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.Fig 7 indicates the number of patients (Trust and Non Trust apportioned) over the previous 4 years; the Trust apportioned cases have remained stable.

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

2014/15 2015/16 2015/16 2016/17 2017/18

Cases 70 48 46 44 42

0

20

40

60

80

100

Non Trust Apportioned CDI

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Fig 7: E-coli bacteraemias

Klebsiella species bacteraemias

53. Klebsiella species belong to the family Enterobacteriaceae. Klebsiella species are a type of

gram negative rod shaped-bacteria that are found everywhere in the environment and also in

the human intestinal tract (where they do not cause disease).Within the genus Klebsiella, 2

common species are associated with the majority of human infections: Klebsiella pneumoniae

and Klebsiella oxytoca. Both species are commonly associated with a range of healthcare-

associated infections, including pneumonia, bloodstream infections, wound or surgical site

infections and meningitis

54. In healthcare settings, Klebsiella infections are acquired endogenously (from the patient’s

own gut flora) or exogenously from the healthcare environment. Patient to patient spread can

occur via contaminated hands of healthcare workers or less commonly by contamination of

the environment. Air- borne spread of Klebsiella does not normally occur.

Fig 8: Klebsiella species bacteraemias

2014/15 2015/16 2016/17 2017/18

Total 298 306 314 293

Trust Apportioned 64 68 65 67

Non-Trust Apportioned 234 238 249 226

0

50

100

150

200

250

300

350C

ase

s E.coli bacteraemias

2017/18

Total 68

Trust Apportioned 27

Non-Trust Apportioned 47

0

10

20

30

40

50

60

70

80

Cas

es

Klebsiella species bacteraemias

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Pseudomonas aeruginosa bacteraemias

55. Pseudomonas aeruginosa is a Gram-negative bacterium often found in soil and ground water. P. aeruginosa is an opportunistic pathogen and it rarely affects healthy individuals. It can cause a wide range of infections, particularly in those with a weakened immune system.

56. These infections are sometimes associated with contact with contaminated water. In hospitals, the organism can contaminate devices that are left inside the body, such as respiratory equipment and catheters. P. aeruginosa is resistant to many commonly-used antibiotics.

Fig 9: Pseudomonas aeruginosa bacteraemias

57. Although the majority of GNBSI are non-Trust attributed, recent evidence suggests that over

half of these have had some healthcare interventions either from acute, primary or community care. Therefore, the main aim was to achieve the reductions by working together across the whole health and social care sector.

58. The Trust has been contributing to the South Sefton and Liverpool CCG GNBSI Group and the associated Sub Groups. The GNBSI Action Plan was submitted to NHS Improvement.

Glycopeptide Resistant Enterococci (GRE) 59. 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.

2017/18

Total 29

Trust Apportioned 6

Non-Trust Apportioned 23

0

5

10

15

20

25

30

35

Cas

es

Pseudomonas aeruginosa bacteraemias

Page 16 of 49

Fig 10: GRE Bacteraemia Reports

60. 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.

Carbapenemase Producing Enterobacteriaceae (CPE) 61. 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 initial guidance. The guidance has been reviewed in 2016 building on our learning experiences and those from other Trusts.

62. 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 screen. This change has shown dividends in releasing isolation rooms as high risk patients required isolation until negative swabs were received.

Inpatient 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 these areas are considered low risk.

63. In 2017/18 the Trust has undertaken CPE screens on 1302 patients.

9 Available from here:

http://www.hpa.org.uk/Publications/InfectiousDiseases/AntimicrobialAndHealthcareAssociatedInfections/1312Toolkitforcarbapenementero/

2013/14 2014/15 2015/16 2016/17 2017/18

Total 5 3 7 5 6

Trust Cases 4 2 6 4 4

Non-Trust Cases 1 1 1 1 2

0

1

2

3

4

5

6

7

8C

ase

s GRE bacteraemias

Page 17 of 49

64. In total there have been 50 in-patient episodes of patients with CPE throughout 17/18, this compares to 36 cases in 2016/17. Table 7 shows the attribution of the cases, the majority of cases were repeat admissions.

Table 7: CPE – attribution of cases

Hospital-attributable

Community-attributable

Other hospitals Repeat admissions

CPE cases 2017/18

1

9 4 (3xRLUH, 1x SDGH)

36

65. There was one case of hospital-attributable CPE in December 2017 following transfer of a

patient from Ward 16 to intermediate care.

66. In terms of the community attributable cases and risk factors;

1 case with NDM-type CPE was linked to an inpatient stay abroad, in Cuba.

1 case had prolonged hospital admissions in the Walton Centre and Warrington Hospital

3 cases had recent admissions to the Royal Liverpool. OXA-48 was identified from these patients and this is consistent with the predominant strain at this Trust.

Table 8: CPE type

CPE Type OXA 48 NDM KPC Awaited

Cases 8 3 2

1

Central line related blood stream infections (CLABSI) 67. There is no national objective set for CLABSI. Within the Quality Strategy, the Trusts internal

quality goal in 2017/18 was to reduce the number of patients with CLABSI by 10%; to </= 21

cases. This was achieved; 17 patients had a CLABSI compared to 25 in 2016/17.

68. Data to date indicates an improvement in the numbers of patients with CLABSI. It should be noted that there is a potential for cases not to be reported. The data relies on notification to the IV Team from clinical teams and/or microbiology.

69. Possible factors contributing to this include;

Existing data collection methods not capturing all patients with CLABSI

Dual skin prep pre line insertion.

Reconfiguration and relaunch of trust wide IV Study Day.

IV Team providing more care and maintenance, due to lack of ward staff trained to provide care and maintenance.

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Fig 11: Central Line Associated Blood Stream Infections

Fig 12: CLABSI Causative microorganisms

Of the 18 Patients who developed a CLABSI, 4 patients grew multiple organisms

Of the 5 patients who developed Gram positive rod line related infections, none were

ESBL

Of the 3 patients who developed Staph. Aureus line related infections, 0 were MRSA

Of the 3 patients who developed Enterococcus line related infections, 2 were VRE

Achievements in 2017/18 include;

Establishing and training new IV specialist nurses into the IV Team with the addition of a

new IV Team Health Care Assistant.

Insertion of 779 medium and long term vascular access devices with a 99% success rate

(inclusive of training period of a new IV Specialist Nurse).

88% of PICCs were inserted using ECG method, negating the need for x-ray confirmation

and associated delays.

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

CLABSI 2017/18 2 2 3 5 5 5 6 8 12 14 15 17

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 1.75 3.5 5.25 7 8.75 10.5 12.25 14 15.75 17.5 19.25 20.5

0

5

10

15

20

25

30

Nu

mb

er o

f C

ase

s

CLABSI 2017-2018 (Trust Infection Cases)

0

1

2

3

4

5

6

COAG -VE STAPHGRAM -VE RODS CANDIDA S.AUREUS ENTEROCCUS FUNGUS

Page 19 of 49

532 patients had a positive outcome including completing treatments, being discharged

home or transferred to another health the care provider with the vascular access device.

There is an overall complication rate of 14% inclusive of infection, thrombosis,

malposition, accidental/inappropriate line removal, MARSI and occlusion.

All CLABSIs are investigated using a post infection review tool.

The IV Team provide clinical support to all ward staff in relation to care, maintenance and

troubleshooting for all midline and central venous catheters inserted trust wide.

The IV Team provide daily outpatient appointments for line insertion and troubleshooting

(5 days per week)

The average waiting time for line insertion has increased from 2.6 working days to 3.3

days

The IV Study Day has been relaunched after restructuring and updating it to include a

significant practical session for staff. The IV Study Day has been formatted for E-Learning

scheduled to commence April 2018

Training has been provided for medical staff in clinical skills and practical education in

theatres to insert Midlines.

A business case to expand the IV Team has been recently been partially approved

After identifying and increase in Midline related thrombosis, an alternative device has

been implemented after trialling 3 devices. This new midline has currently provided a

significant reduction and thrombosis and a cost saving of approximately £35 per

procedure

The IV Team are currently involved in a project with QEP after a Dragons Den bid in 2017

to reduce the number of unsuccessful cannula attempts for patients

The IV Team are part of the ANTT working group and contribute to relaunching ANTT

using e learning as a platform

The IV Team have been unable to perform any trust wide audits due to lack of capacity

The Trust has invested in additional resource into the IV Team in order to increase

capacity and improve patient safety and quality. These posts will be recruited to in

2018/19. Additional posts include a Band 8a Lead Nurse, Band 6 IV Access Nurse and

Band 3 Support Worker.

Ventilator Associated Pneumonia (VAP)

70. VAP is a consequence of invasive ventilation and prolonged critical care. A wide variation of

proposed definitions exist and also debate about its significance. Aintree is the only unit in Cheshire and Merseyside Critical Care Network routinely collecting any form of VAP data and has done so for 4 years. The case definition is broad, ‘the initiation of antibiotics for respiratory infection after more than 48 hours of invasive ventilation which are then continued without another cause of infection being found’. It is based on antibiotic prescribing and cases found through Pharmacy review of charts. Ventilator days are counted by the Critical Care audit team for routine data collection. Figure 13 indicates the year on year reduction in the number of cases and rate of VAP since the collection of the data in 2014/15

Page 20 of 49

Fig 13: VAP cases and rate 2014/15 – 2017/18

71. VAP Care Bundle Adherence - After discussion with Greater Manchester CCN and review of

recent ICS statements, a VAP bundle was developed;

appropriate antibiotic if VAP diagnosed

planned, performed sedation holding or documented reason why not performed

prescribed oral care

head up positioning to 30/40° or documented reason why not performed

appropriate use of gastroprophylaxis 72. An audit is done on one day per month by the IPC lead and Critical Care Pharmacist.

Adherence is 100% with the exception of March 2018 which was 91.7%. Influenza 73. In 2017/18 227 patients with influenza were admitted to the Trust, this is compared to 32

patients in 2016/17. 118 patients had Influenza A and 109 patients had influenza B. The increase of influenza was reflected nationally.

Fig 14: Number of cases of influenza per month

2014/15 2015/16 2016/17 2017/18

Cases 38 27 29 24

VAP Rate per 1000 ventilator days 12.4 11.3 9.7 8.5

0

5

10

15

20

25

30

35

40C

ase

s VAP cases and rate

Oct Nov Dec Jan Feb March

Total 1 0 42 114 41 29

0

20

40

60

80

100

120

Cas

es

Influenza cases

Page 21 of 49

74. Increased support and communications regarding identification and management of influenza

was in place and in addition;

IPCT daily Flu briefing held to support the management of cases and contacts

Information fed into the site team meetings

Daily internal flu sitrep distributed

Daily reporting to NHS England on cases of Flu A seasonal influenza debrief was held on 13th March and outcomes have been discussed at the TIPCG. This will be fed into the Trust Pandemic Influenza Group for lessons learned for 2018/19 season.

Untoward Incidents and Outbreaks 75. The incidence of viral gastroenteritis has been lower than in 2016/17. In 2017/18 there were

93 bed days lost due to confirmed or suspected norovirus compared to 105 in 2016/17. The IPCT proactively manage the outbreak and work with the site team regarding the appropriate isolation of patients and closures of bays when required.

Table 9: Outbreaks Caused by Viral Gastroenteritis (suspected or confirmed)

Wards

affected

Number of staff

affected

Number of patients affected

Organism detected

Bed days lost

April 0 0 0 0 0

May 1

Ward 3 2 15 None 20

June 30

A2H 0 5

3 16

None None

0 11

July 15 0 4 None 0

August 1 0 7 None 5

September VIC 0 3 None 2

October 3 0 4 None 2

November 2 0 8 None 4

December 25 2 10 None 4

A2H 0 3 None 0

23 0 2 None 3

January 16 0 4 None 10

22 0 2 None 0

11 0 2 None 3

February 22 0 4 None 4

11 0 2 None 2

32 0 9 None 5

March 3 0 5 None 0

A2H 0 7 None 0

Mandatory Surveillance of Surgical Site Infections in Orthopaedic Surgery 76. 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 is undertaken using a standardised Post Discharge Questionnaire (PQ) to capture information.

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77. 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. The mandatory requirement is one category for one quarter, however the Trust submits on all 3 categories for each quarter. It therefore it is challenging to compare against all Trust numbers.

78. 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 was 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. In 2017/18 there has been a slight increase in the numbers of cases to 12 across all categories.

Table 10: Total Knee & Total Hip Replacement (TKR & THR) and Hemi-arthroplasty/Repair of Fractured Neck of Femur Surgical Site Infection Surveillance Jan- Dec 2016/17

Total Knee Replacement 2016 2017

Total Hip Replacement 2016 2017

Repair of neck of Femur 2016 2017

Total numbers of procedures

354 303 324 329 334 325

Questionnaires returned

54.7% 47.5%

49.1% 49.5%

58.1% 51.6%

No. of patients readmitted due to infection

1 1 1 1 5 5

No. of post discharge infections confirmed

0 2 0 3 0 0

No. of pt. reported infections

0 3 0 0 0 0

Deep incisional infections

1 1 1 3 4 4

Superficial infections

0 2

0 1

1 1

All infections

1 3 0.3% 1.0%

1 4 0.3% 1.2%

5 5 1.5% 1.5%

Results from all Hospitals for this category for past 5 years

1.3%

1.0%

1.3%

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79. In 2017/18 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 this has not been progressed.

Compliance Criterion

What the registered provider will need to demonstrate

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

Refurbishment and New Builds 80. 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.

81. 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 82. 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

83. Within the last year the Group has;

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 register local decontamination activities

Received and noted updates on the procurement of Trust main Sterile Services Contract (still ongoing)

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

Reviewed the results of Decontamination Audits and recommended actions as necessary. 84. 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/Trust Lead Decontamination.

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Decontamination Audits 85. 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.

86. 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/Trust lead Decontamination and fed back to the Decontamination group

87. 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.

88. Central decontamination unit has now been completely refurbished, with just minor cosmetic

work to finish off. No loss of theatre/clinic time during this major piece of work.

Cleaning arrangements Monitoring Arrangements 89. Domestic Services have now enhanced 3 tier self-auditing process that is in place by

introducing supervisors visits and ADM walk rounds

27. Supervisors Visit – this provides a record of the activities that have been undertaken by a supervisor whilst on a ward, this includes speaking to the walk manager, checking machinery is in good order and reporting defects that are noted

28. The ADM walk round is completed on a daily based on one particular ward where the

assistant managers conduct an assessment which includes checking that floor buffing has taken place, schedules are on display and accurate and water safety procedures are being adhered.

90. 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

91. Quality assurance results are now displayed on all wards and these are updated on a twice

per month basis. Structures 92. Domestic Services now have step up staff for both the supervisory and ADM roles, this

ensures that when individuals are absent the services does not suffer from a lack of resource. 93. A full review of the cleaning schedules has been carried out by the Domestic Services

managers, this includes an overall summary that is now on display on all wards

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Training 94. Refresher training has been completed in for all staff on all tasks undertaken within the

delivery of the service New initiatives 95. 2 way radio communications have now been introduced in order to allow not only internal

communications but instant contact with IPC and the site managers in relation to the requirement for HPV fogging and clinical cleans.

96. Curtain changes - An annual plan has been constructed and communicated to all wards and

furthermore a plan has been implemented by the domestic Services Manager

97. Steam cleaning - Implementation of steam cleaning across all theatres is now in progress.

98. The introduction of the domestic Managers forum where staff get the opportunity to meet with the DSM on a twice e per year basis to discuss any issues or concerns.

99. 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 a sustained performance at 98%, in Quarter 3 theatres have declined slightly to 89%. Q 4 data awaited

Water Safety 100. The Trust has an established Water Safety Group (WSG) which reports to the TIPCG.

101. An external review of the Water Safety Plan has been undertaken and this action plan is

being monitored at the WSG.

102. All augmented care areas have filtered water in place which should be used for patient bathing. Water sampling also take place in these areas as per national guidance

Antimicrobial Stewardship

103. 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 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.

104. 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

Compliance Criterion

What the registered provider will need to demonstrate

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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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.

105. Antimicrobial Shortages have been an ongoing battle with multiple first line antibiotics

going to limited quotas or becoming unavailable e.g. Tazocin. This has meant antimicrobial choices have been changed at short notice on numerous occasions with increased surveillance via the antimicrobial pharmacists becoming a daily responsibility; ensuring no critical medicines are missed. Some of the changes have resulted in using antimicrobials empirically with higher risk for causing CDI e.g. quinolones.

106. 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 is a specific version for Critical Care. New versions of the cards are currently being printed these will be available to all clinical staff involved in prescribing antimicrobials.

107. 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. The SSTF stickers will be updated in line with the proposed CQUIN indicators for 2018/2019. To try and help standardise antibiotic reviews to improve overall content.

108. 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 was written to encompass 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.

109. 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. It is considered a gold standard approach by some of the clinical teams, who appreciate engagement and ongoing education from microbiologists and pharmacists.

110. 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. There will be ongoing review of Fidaxomicin use.

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

service which can be referred 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

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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. Pharmacy team with flag up any patients commenced on carbapenems which have not been discussed by microbiology. Preventing the overuse of carbapenems will have an impact on the Trusts CPE burden.

112. 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.

113. Antimicrobial incidents - incidents involving antimicrobials are quarterly reviewed. The

antimicrobial pharmacists supported by the extended pharmacy team, seek to feedback any errors made and discuss any solutions. Incidents are a standing agenda item at AMG any issues/actions are escalated through IPC, Medicines Safety and Medicines Governance Groups.

114. 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

115. The results indicate that 2/3 KPI’s have been achieved. Any errors found are summarised

and fed back to prescribers via a variety of mechanisms. During the day of audit, errors are fed back to a proportion of the wards in real time.

Table 7: Results for financial year April 2017 – March 2018

KPI and Target %

Month Trust Medicine Surgery

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

April * Tazocin substitution throughout Trust

May 77% 78% (49/63) 74% ( 17/23)

June 89% 86% (49/57) 96% (24/25)

≥ 80% by the end of quarter 2 July 91% 91%(197/216) 89% ( 99/111)

August 95% 95%(177/186) 94% ( 97/103)

September 89% 87.5%(203/232) 93%(108/116)

≥ 85% by the end of quarter 3 October 86% 86%( 193/225) 86% (83/96)

November 91% 91% (250/274) 89% (92/103)

December No audit due to staffing

January 91% 91% (270/296) 89% (77/87)

February 87% 88%(199/226) 82% (55/67)

March 86% 86% (205/238) 85% (95/110)

Stop date recorded or prescription reviewed within 48-72 hours Target 90% (90% or less, need to improve)

April Tazocin substitution throughout Trust

May 94% 95% (60/63) 91% (21/23)

June 100% 100% (57/57) 100% ( 25/25)

July 99% 100% (216/216) 97%

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(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)

(108/111)

August 98% 98%(182/186) 97%(100/103)

September 99% 99% (230/232) 99%(115/116)

October 98% 98% 98%

November 95% 95% (260/274) 97% (100/103)

December No audit due to staffing

January 94% 94% (230/274) 93%( 81/87)

February 95% 95% (215/226) 94% ( 63/67)

March 93% 94% (223/238) 92% (101/110)

Indication recorded (notes/EPMA) 100% (95 -99%, need to improve)

April - - -

May 99% 100% (63/63) 96% ( 22/23)

June 100% 100% (57/57) 100% (25/25)

July 99% 99% (215/216) 99% (110/111)

August 99% 98% (183/186) 100% (103/103)

September 99% 99%(229/232) 100%(116/116)

October 94% 95%(214/225) 94%(90/96)

November 98% 96% (269/274) 98% (99/103)

December No audit due to staffing

January 98% 99% (294/296) 98% (85/87)

February 98% 99% (224/226) 96% (64/67)

March 98% 98% (233/238) 99% (109/110)

*No results for April & December - point prevalence not completed, time constraints due to implementing Tazocin

substitution and capacity over Winter/Christmas period

116. 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.

117. NICE NG15 Antimicrobial Stewardship action plan is reviewed / updated every 3 - 4 months. The Trust is complaint for the majority of the recommendations, some are partially compliant and this is mainly due to waiting for the roll out of ICNet pharmacy, a surveillance tool purchased by LCL. It is currently in configuration stage and waiting a launch date. The action plan is monitored at AMG every 4 months.

118. AMS education gap analysis - The gap analysis identifies how much education already

takes place. Development of ‘essential staff’ training tracker will be the next step. The gap analysis has been presented at AMG and IPC Group. There are currently outstanding actions which have been escalated and supported via IPC Group

119. 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.

120. There are several ongoing developments in 2018/2019 including;

Nurses AMS cards will be produced this month – a questionnaire looking at what nurses think AMS is and what their role is within AMS was circulated and results collated. Part of the recommendation includes development of an antibiotic AMS credit card to support nurses; include gentamicin dosing and monitoring and promoting start smart the focus.

IPC Leads and antibiotic audit – a process for auditing within directorates is included in the AMS policy. The newly appointed IPC lead will confirm IPC leads ongoing objectives, including ongoing audit and feedback. Results will be used to support further learning and any CDI appeals that originate from that directorate.

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As part of the CDI Outbreak action plan for 2017-2018, a project looking at how well infections are diagnosed was proposed. The project is a quality improvement project and is waiting suitable volunteers (FY2’s) to take forward.

Joining of AMG groups across sites should happen this year. This will allow sharing of ideas and innovations.

Work streams with the EPR team are underway to try and ensure antimicrobial prescribing is safe and effective as possible.

Compliance Criterion

What the registered provider will need to demonstrate

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

121. The Trust provides all service users with information as required. This includes

information leaflets for patients, visitors and staff.

122. Staff are also provided with policies, clinical guidelines, standard operating procedures, are pathways and care plans to provide condition specific information.

123. IPC information is also provided for services users via the Trust internet (external) and

intranet (internal) sites.

124. Information is shared internally via the communication teams: message of the week, All About Aintree.

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

regarding the importance of clean hands. 126. The Trust provides condition specific information to support staff to provide safe care in a

variety of ways:

- Condition specific care plans and care pathways - Interdepartmental transfer forms - Inter-hospital transfer forms - 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.

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

available out of hours. 128. The IPC Team visit all patients at regular intervals according to their infection or possible

infection. 129. 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.

Compliance Criterion

What the registered provider will need to demonstrate

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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Compliance Criterion

What the registered provider will need to demonstrate

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

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

131. 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. The IPCT have developed a range of Grab Pack materials to help with this.

132. 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.

133. 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.

134. 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.

135. The IPC Team used their work with the simulation centre to develop learning resources

using simulation and visualisation techniques. These have evaluated very well.

136. There continues to be ongoing development of staff within the IPC and IV Team;

One member of the team successfully completed a NHS Leadership Academy endorsed Leadership and Change Management course.

One member of staff has successfully completed the Management of an IPC Service module

One member of the Team is an AQUIS Leader and two members are AQUIS practitioners.

Three members of the team completed the ILM – Legionella Risk Management – Responsible Persons Training

Compliance Criterion

What the registered provider will need to demonstrate

7 Provide or secure adequate isolation facilities.

Isolation facilities 137. The current proportion of single rooms is 19%. This percentage changes with the slight

fluctuations of the bed base.

138. 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.

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139. The target time for isolating patients with unexplained (and potentially infectious diarrhoea) is less than two hours. This is monitored by the IPCT who undertake a snapshot of at least 10 patients with diarrhoea per month; compliance ranged from 69-100% throughout the year.

140. There have been increasing challenges with the ability to isolate patients with diarrhoea

which increases the risk of transmission of any gastrointestinal infection. Figure 4 indicates

the number of times when bays have been closed overnight due to not being able to isolate

patients with diarrhoea. There was a particular challenge in Q4 due to the impact of the

numbers of patients with influenza who required isolation. In addition to the provision of the

side room plan, the IPC Team also attend site meetings to support risk assessments when

required.

Fig 18: Bays closed overnight

141. 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.

Compliance Criterion

What the registered provider will need to demonstrate

8 Secure adequate access to laboratory support as appropriate.

Laboratory Services 142. 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.

143. There is 24 hour microbiology advice available.

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

Compliance Criterion

What the registered provider will need to demonstrate

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

0

10

20

30

40

50

60

70

Quarter 1 Quarter 2 Quarter 3 Quarter 4

Number of times bays closed overnight awaiting patient isolation

Number of times bays closedovernight awaiting patientisolation

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145. 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.

146. 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

147. 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.

148. 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.

Compliance Criterion

What the registered provider will need to demonstrate

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 149. 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 are compliant.

150. 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 and again in 2017, OHS have conducted an extensive Trust look back exercise. It is pleasing to note that following the 2017 outbreak and subsequent look back there were very few of those identified at risk patient facing staff (6) who were still outstanding their MMR vaccination.

TB incident/Outbreaks:

There was a TB incident from Respiratory in 2016 which resulted in a look back exercise. This was completed. TB health surveillance remains ongoing for at risk work areas on an annual basis. This is initiated by the OH service and supported at ward/departmental level to ensure compliance.

151. The Occupational Health Service leads the seasonal flu vaccination campaign. The flu

campaign commenced 9th October 2017 with the aim of completing the campaign by the end of February 2018 its aim was to achieve the 70% CQUIN target set by the 31st December

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2017. The flu vaccine however was still available from OH up until the end of February 2018. There were a total of 22 trained flu link immunisers of which 12 actually participated in the flu campaign.

152. In relation to staff uptake 87.5% of frontline staff were vaccinated. Overall the numbers of Doctors vaccinated was 95.9%, Nurses 77.5%, Allied Health Professionals 95.6%, Support 91.3% and Other 49.9%. This equates to 3207 of all Trust staff.

153. In relation to the Directorates, Medicine had 1,275 staff vaccinated, Surgery &

Anaesthesia 745 staff vaccinated, Corporate Services 327 staff vaccinated, Estates & Facilities 266 staff vaccinated and Diagnostics and Support Services 593 staff vaccinated. It is pleasing to report that over 75% of our entire workforces were vaccinated during this year’s campaign resulting in organisational herd immunity.

154. The 2018 – 2019 Flu Campaign is currently in the process of being planned. Following

guidance form PHE the vaccine for 18/19 campaign will be a quadrivalent vaccine for those aged 18-65 years. An alternative vaccine will be made available for those employees >65years of age in accordance with PHE guidance.

155. There were 121 incidences across the Trust reported to Occupational Health between

April 2017 and March 2018.

This consisted of:

19 splash incidents

69 needle stick type incidents (29 sharp safe needles and 40 non sharp safe needles

31 incidents with a solid instrument ie scalpel, blade, razor

2 scratch incidents

156. The Needle Stick Injury Steering group meets bi monthly to discuss the issues and identify a way forward. The Inoculation Injuries Policy was reviewed by OH and 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

157. 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

158. No workforce implications.

Other

159. 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.

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Recommendation

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

healthcare associated infections in 2017/18 and approve the Reducing HealthCare

Associated Infections Plan for 2018/19.

References and further reading

Aintree University Hospital Trust 2016/17 Annual Infection Prevention and Control Report and 2017/18 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 Lankstead – Assistant DIPC

The Infection Prevention and Control Team Emma Hughes – Antibiotic Pharmacist Diane Haddock - Head of Organisational Health and Effectiveness Emily Smith – IV Access Nurse Shirley Smith – IV Access Nurse Rob Parker – Consultant Anaesthetist and Infection Control Lead for Critical Care Jean Russel and Sally Tippins – Clinic Managers Orthopaedics Keith Rimmer – Decontamination Lead Lee Sallery – Domestic Services Manger

Owner Dianne Brown, Director of Nursing and Quality

Date 11/04/18

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Appendix 1

IPCT Structure 2017/18 (including the IV team)

Post Post holder WTE

Board Executive Lead (DIPC)

Mrs Dianne Browne – Chief Nurse Not defined

Assistant DIPC Mrs D Lankstead 1WTE

Chair of the Trust Infection Prevention and Control Group

Mrs Dianne Browne – Chief Nurse Not applicable

Trust Infection Control Doctor (ICD)

Dr C Jukka

5 PAs

Consultant Medical Microbiologists

Appointed by Liverpool Clinical Laboratories Not defined

Band 8a IPC Matron Ms F Browne 1 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

3 WTE

Band 3 IPC Support Worker

Mrs A Jones 0.6 WTE

Band 7 IV Nurses Mrs E Smith Ms S Smith

2 WTE

Band 3 IPC Support Worker

Mrs C Graney 1 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 2018/19 Priorities 2018-19 IPC Key Quality Goals Safe Care – Reducing Harm

A reduction the numbers of patients with CDI </= 46 cases

Zero patients with trust apportioned MRSA bacteraemia

A reduction in the numbers of patients with MSSA bacteraemia by 10% based on 2017/18 outturn (</=22 or less cases)

Reduced the number of central line associated infections by 10% based on 2017/18 outturn (</=15 or less cases) The plan is built upon the criteria of the 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 (2015). This is mapped against the NICE (2011) Prevention and control of healthcare-associated infections Quality improvement guide and NICE (2016) Healthcare-associated infections Quality standard in Appendix 2. The Code of Practice sets out 10 criteria against which the Trust is assessed on how it complies with registration requirements for infection prevention. The plan builds on the 2017/18 plan, which outlined many actions that are now completed and embedded as on-going processes. Appendix 2 denotes the Infection Prevention audit plan for 2018/19.

BRAG Key

Complete

On-Track

Delivery Issues

Unable to Deliver

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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

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

To agree the corporate priorities for HCAI reductions

April 2018 DIPC

To agree the Divisional objectives for the reduction of HCAIs

April 2018 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 2018 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 18 Oct – March report in May 19

IPC Doctor Medical and ADIPC

Review and update TIPCG terms of reference August 18 DIPC and ADIPC

Review and update TIPC Operational Group May 18 ADIPC

1b - Promote a culture of continuous quality improvement in

Provide quarterly updates on the HCAI reduction plan to the TIPCG

July 18, Oct 18, Jan 19, April 19

ADIPC

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

April and monthly ADIPC

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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

IPC

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 undertake a thematic review of 20 cases of Ecoli (trust apportioned or with a previous hospital admission within 28 days)

Sept 2018 IPC Team

To implement 18/19 IPC audit plan and report at TIPCG monthly within the Divisional reports

Monthly IPC Team

To develop a process for independent audits within the Divisions

June 2018 Divisional DONs

To implement the process for independent audits within the Divisions

August 2018 Divisional DONs

To maintain IPC Link practitioner forum – quarterly meetings

April 18, July 18, Oct 18, Jan 19

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 2017/18 and report at IV access group and TIPCG

June 18 IV team

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

April and monthly IV team

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

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

IPCT

1c – To collaborate with

To contribute to the EPR work streams Ongoing ADIPC

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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

partner Trusts to standardise IPC practice and processes

To progress with IPC Quality Workstream with RLUHT and report progress

Ongoing ADIPC

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

Objective

Programme of work (action)

Timescale &

Milestones

Lead

BRAG Progress/

Comments Q1

Q2

Q3

Q4

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

Review MONIT scores weekly at the IPC Operational meeting

April 18 and weekly Domestic Services Manager

Monitor UV tagging results quarterly at TIPCG July 18, Oct 18, Jan 19

IPCT

Provide expertise and specialist IPC input into Estates and Facilities meetings

On- going IPCT

Explore approach for deep clean programme and present at IPCG

June 18 Estates Manager, Domestic Services Manager, ADIP

Review the roles and responsibilities framework for cleaning

July 2018 Estates Manager, Domestic Services

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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

Programme of work (action)

Timescale &

Milestones

Lead

BRAG Progress/

Comments Q1

Q2

Q3

Q4

Manager, IPC Matron

Develop an Infection Prevention and Control in the built environment SOP

July 2018 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 2018 – ongoing

Decontamin-ation Lead

The TIPCG will receive report from the Decontamination Working group

April 2018 – ongoing

Decontamin-ation Lead

The Decontamination guidance will be revised to include Cleaning and Decontamination

July 2018 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

April 2018 – ongoing

Maintenance Manager

The TIPCG will receive report from the Water Safety group

April 2018 – ongoing

Maintenance Manager

The Trusts Water Safety Plan will be reviewed. August 2018

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

Objective

Programme of work (action)

Timescale &

Milestones

Lead BRAG Progress/Comments Q

1 Q2

Q3

Q4

3a - To ensure the prudent use

Collaborative antimicrobial ward rounds within directorates

Weekly - ongoing Trust antimicrobial lead

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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

Programme of work (action)

Timescale &

Milestones

Lead BRAG Progress/Comments Q

1 Q2

Q3

Q4

of antimicrobials throughout the Trust (antimicrobial stewardship)

Explore options for education in focused ward areas using the ward round model ( rotational ward rounds dependent on audit results/incidents)

To be confirmed after consultation – May 2018

Trust antimicrobial lead

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

Monthly AMT

To ensure the Antibiotic Management Group (AMG) operate according to its terms of reference

April 18 – ongoing

Trust antimicrobial lead

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

April 2018 – ongoing

Antimicrobial pharmacist

Monthly antimicrobial point prevalence audit data to be shared with TIPCG, MGG and divisional assurance groups

April 2018 - ongoing

April 2018 – ongoing

AMG minutes and point prevalence audit data with learning points to be disseminated to directorate IPC leads

April 2018 – ongoing

April 2018 – ongoing

Ensure the Trusts Antimicrobial stewardship (AMS) programme and action plan is kept up to date. NICE NG15 action plan reviewed at AMG every 4 months

April 2018 – ongoing

AMT

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

April 2018 – ongoing

Antimicrobial pharmacist

To work collaboratively with LCL to implement ICNet Pharmacy

April 2018 – ongoing

Antimicrobial pharmacist

3b – To ensure all staff who

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

May 18 AMT

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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

Programme of work (action)

Timescale &

Milestones

Lead BRAG Progress/Comments Q

1 Q2

Q3

Q4

prescribe, administer and provide advice on antimicrobials, understand what antimicrobial stewardship is, and their responsibility in ensuring it is implemented.

Explore how IPC leads will help deliver AMS action plan

May 18 Antimicrobial pharmacist/ Medical Director/ IPC lead clinician

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

Programme of work (action)

Timescale &

Milestones

Lead BRAG Progress/Comments

Q1

Q2

Q3

Q4

4a - There is timely communication with staff, patients, visitors and carers

Patients and carers have access to relevant patient leaflets.

Ongoing

Improve awareness of hand hygiene during WHO Hand Hygiene day; focus on the use of gloves. Participate in the RCN Pilot.

May 18

Improve awareness of IPC during IPC week October 18

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throughout the care pathway about HCAI to reduce the harm

IPC indicators are reflected on the How We are Doing Boards

Monthly

Compliance Criterion 5

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

Programme of work (action)

Timescale &

Milestones

Lead BRAG Progress/Comments Q

1 Q2

Q3

Q4

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 relevant health and social care organisations are made aware of the patients HCAI status

To undertake a snap shot audit of clinical records August 18 IPCT

Compliance Criterion 6

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

Programme of work (action)

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 SOP to be presented at TIPCG

April 18 IPC Matron

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ANTT Trust wide relaunch July 2018

Divisional Practice Educators

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

Programme of work (action)

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 audit the appropriate use of isolation and signage

September 18 ADPIC

Compliance Criterion 8 - Secure adequate access to laboratory support appropriate

Objective

Programme of work (action)

Timescale &

Milestones

Lead BRAG Progress/Comments

Q1

Q2

Q3

Q4

8a - The microbiology service is accredited

To ensure there are systems in place to monitor SLA with Liverpool Clinical Laboratories

Ongoing CHOD/DDN for Support Services

8b - To work collaboratively to implement ICNet NG

To contribute to the Liverpool Clinical Laboratories ICNet NG implementation group and lead relevant sub groups according to project plan

Ongoing ADIPC

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

Objective

Programme of work (action)

Timescale &

Milestones

Lead BRAG Progress/Comments Q1

Q2

Q3

Q4

9a - To ensure evidence based IPC guidelines are available

The IPC guidelines are monitored and reviewed in line with new guidance, these will also be reviewed with RLUHT

Ongoing IPC Matron

9b - Address the infection risk from CPE

Monitor numbers of screens and clinical isolates at IPC group

April 18 and monthly

IPCT

Input all cases into the PHE surveillance system April 18 IPCT

Audit compliance with CPE 30 day screening April 18 and monthly

IPCT

Review CPE Guideline with RLUHT to standardise practice

July 18 IPCT

Implement changes as per guideline and provide training

August 18 IPCT

9c - 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 18 and monthly

IPCT

Audit compliance with MRSA 30 day screening April 18 and monthly

IPCT

Review MRSA pre op screening process Sept 18 IPCT, Pre Op Matron

9d - To reduce the risk of patients developing CDI

Explore the establishment of a clinically led CDI Working Group

June 2018 Associate Medical Director for Clinical Governance

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Compliance Criterion 10 - Providers have a system in place to manage the occupational health needs and obligations of staff in relation to infection.

Objective

Programme of work (action)

Timescale &

Milestones

Lead BRAG Progress/Comments Q1

Q2

Q3

Q4

10a - Ensure that healthcare workers are protected from communicable diseases and from work exposures

Occupational health advice is available Ongoing Occupational Health

Occupational health provide a six monthly report to TIPCG regarding key issues

Ongoing Occupational health

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Appendix 2

Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance (updated 2015)

NICE (2011) Quality Improvement Guide for Healthcare Associated Infections

NICE (2016) Quality Standard. Healthcare associated infections.

Compliance Criterion

The registered Provider is required 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

NICE- QIS : 1 NICE – QS 1

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

NICE- QIS : 2

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

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.

NICE -QIS : 4

5 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.

NICE-QIS : 5

6 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

NICE-QIS : 6

NICE – QS:3

7 Provide or secure adequate isolation facilities NICE-QIS : 7 NICE – QS:4

8 Secure adequate access to laboratory support appropriate NICE-QIS : 8

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

NICE-QIS : 9

10 Providers have a system in place to manage the occupational health needs and obligations of staff in relation to infection

NICE-QIS : 10

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Appendix 3

Audit Title/s Audits Completed by Present Date (DD/MM/YY)

High Impact Intervention No 1 Central line insertion Ward staff Monthly IPCG

High Impact Intervention No 1 Central line on-going care Ward staff Monthly IPCG

High Impact Intervention No 2. Peripheral Intravenous Line-on insertion Ward staff Monthly IPCG

High Impact Intervention No 2 Peripheral Intravenous line-Continuing Care Ward staff Monthly IPCG

High Impact Intervention No 3. Renal line insertion Ward staff Monthly IPCG

High Impact Intervention No 3 Renal Line-ongoing Ward staff Monthly IPCG

High Impact Intervention No 4. Preventing Surgical site infections (pre / post-operative)

Ward staff Monthly IPCG

High Impact Intervention No 5. Care of Ventilated / Tracheostomy Patients-Regular Observations/ Continuing Care

Ward staff Monthly IPCG

High Impact Intervention No 6. Urinary Catheter-on insertion Ward staff Monthly IPCG

High Impact Intervention No 6 Urinary Catheter-continuing care Ward staff Monthly IPCG

MRSA management assurance checklist IPC Team Monthly IPCG

ICN Spot Checks: Commodes, glucometers, general environment, cannula care

IPC Team

Monthly IPCG

Hand Hygiene - internal audit Ward staff Monthly IPCG

Hand Hygiene - external audit Hand hygiene product supplier Yearly

Standard precautions audit Student Quality Ambassadors 6 monthly

Isolation Precautions Ward staff Annual IPCG

Enteral Feeding Ward staff Annual IPCG

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Management of Unexplained Diarrhoea IPC Team Weekly IPCG

MRSA Admission Screening IPC Team Monthly IPCG

MRSA 30 Day Screening IPC Team Monthly IPCG

CPE 30 Day Screening IPC Team Monthly IPCG

Sharps Ward staff Annual IPCG

Personal Protective Equipment Ward staff 6 Monthly

IPCG

Patient mattresses Ward staff Monthly