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Infection Prevention & Control

Annual Report

2012-2013

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Report To Risk and Quality Committee

Meeting Date May 2013

Title of Report Infection Prevention and Control – Annual Report 2012/13 Action Sought For Approval Estimated time 30 minutes Executive summary This report from the Director of Infection Prevention and Control (DIPC) is the annual report to the Trust Board on healthcare acquired infections. It is a summary of key data on healthcare acquired infections relevant to the Board. The report highlights continued excellent performance for infection prevention and control within the Trust. The Trust has met both Clostridium difficile and MRSA targets set by the Strategic Health Authority. The Trust currently has the lowest levels of Clostridum difficile associated disease (CDAD) in the East of England and the 5th lowest in Midlands and East after 4 small specialist trusts. The Trust also achieved the lowest number of cases of MRSA bacteraemia in the past decade moving form 86 cases 2002/03 to 2 cases in 2012/13. Devolution of accountability for IP&C to local clinical teams continued during 2012/13 through strengthening of the role of IC link practitioners and IC leads for all trust divisions, and through regular reporting by the IC leads to the Trust Infection Prevention and Control Committee and presentations by consultant IC Leads to their respective divisional rolling half days. The trust has declared compliance with the Hygiene Code and is unconditionally registered with the CQC. Presenting Director - A Thompson, Director of Nursing and Patient Experience & Director for Infection Prevention

and Control Authors - F M Awadel-Kariem, Infection Control Doctor/Lead Consultant Microbiologist - H O’Connor, Nurse Consultant/Assistant Director for Infection Prevention and Control Acknowledgement The authors would like to acknowledge the contribution of colleagues to this report CQC Outcomes supported by this report 8 Cleanliness and infection control Equality impact assessment No adverse impact

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CONTENTS

Section Page

1 Introduction 4

2 Compliance with the Health and Social Care Act 2008

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3 Criterion 1: a- Systems to manage the prevention and control of infection 5

4 Criterion 1: b- Monitoring the prevention and control of infection 8

5 Criterion 2: Clean and appropriate environment 16

6 Criterion 3&4 : Information on infections to service users and their visitors & Information on infections to other providers 19

7 Criterion 5: Identification and prompt management of infection 19

8 Criterion 6: Involvement of all staff 21

9 Criterion 7: Isolation facilities 21

10 Criterion 8: Laboratory support 22

11 Criterion 9: Policies 22

12 Criterion 10: Health care workers: Infection Status, Protection from Infection & Education in infection prevention & control

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13 CQC visits 23

14 Conclusion 23

Appendix A Annual Plan 2013/14 24

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1. Introduction The Trust Board recognises and agrees their collective responsibility for minimising the risks of infection and has agreed the general means by which it prevents and controls these risks. The responsibility for infection prevention and control is designated to the Director of Infection Prevention & Control (DIPC) supported by the Lead Infection Control Doctor and Nurse Consultant/Assistant DIPC. The Infection Prevention & Control (IPC) Annual Report, together with the Quarterly Risk and Quality Committee IPC Report, Annual IP&C Plan and IPC Assurance Framework are the means by which the Trust Board assures itself that prevention and control of infection risks are being managed effectively and that the Trust remains registered with the Care Quality Commission (CQC) without conditions. In addition, the Annual Report seeks to assure the Trust Board that progress has been made against the 2012/13 Annual Plan, to reduce healthcare associated infections (HCAIs) and sustain improvements in infection prevention and control practices for 2013/14. It demonstrates that priorities identified in the Annual Plan last year have been addressed by employing a robust programme of work that enabled some notable successes on which to build on. These improvements have been achieved despite major reconfiguration as part of ‘Our Changing Hospital’ programme.

Achieving the target for Clostridium difficile for the third consecutive year.

Achieving the very demanding MRSA bacteraemia target of 3 cases only.

Improving prescribers’ compliance with the Trust-wide reduction in the use of antibiotics that are known to precipitate Clostridium difficile and other HCAIs.

Improving prescribers’ compliance with antimicrobial prophylaxis for trauma and orthopaedic surgical cases.

Addressing the new threat of Pseudomonas aeruginosa in the water supply of augmented care units.

Trust–wide improvement with decontamination of equipment at ward and clinic level

Re-assessment of all nursing staff in Trauma and Orthopaedics in aseptic technique practices.

Achieving 100% compliance with elective MRSA screening

Challenges remain. These include: efforts to further improve the turn around of action plans relating to audits of the clinical area thereby closing the loop on issues identified; improving screening in the Emergency Department of MRSA and maintaining the Annual Deep Clean programme.

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Whilst progress has been made in the past year, the reduction of surgical site infection rates in Trauma and Orthopaedic surgery remains a priority for improvement in patients’ outcomes. The provision of this report fulfils the legal requirements of sections 1.1 and 1.3 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. The information provided in this report should be released to the public following the Trust Board’s approval. 2. Compliance with the Health and Social Care Act 2010 The CQC has used the Code of Practice as a key feature of registration. Failure to observe the Code may either result in an improvement notice being issued to the Trust by the CQC following an inspection, or in it being reported for significant failings and placed on “special measures”. All NHS organisations must be able to demonstrate that they are complying with the Code. The Trust continues to be registered with the CQC, without conditions. 3. Compliance with Criterion 1: a- Systems to manage and monitor

the prevention and control of infection IPC is the responsibility of everyone in the organisation. Key roles and arrangements are detailed below: 3.1 IPC Structure:

The Chief Executive Officer has overall responsibility for the control of infection within East and North Hertfordshire NHS Trust. 3.2 Senior IPC Management Team:

The senior IPC management team includes the DIPC, the Assistant DIPC (ADIPC) and the Infection Control Doctor (ICD) meet every two weeks to discuss activity and issues.

3.2.1 The DIPC

The DIPC is the Executive Lead for the IPC service, and oversees the implementation of the IPC plan through her role as Chair of the Trust Infection Prevention and Control Committee (TIPCC). The DIPC approves the Annual IPC report and release it publicly. She reports directly to the Chief Executive and the board on IPC matters. The DIPC has the authority to challenge inappropriate practice.

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3.2.2 The Assistant DIPC

The ADIPC is a Consultant Nurse reporting directly to the DIPC and working with the ICD. The role includes:

- Supporting and deputising for the DIPC - Manages and chairs the Divisional IP&C Committees which meet

monthly reporting to the TIPCC and Divisional Boards. - Chairs the Joint IP&C monthly meeting of Consultant

Microbiologists, Nursing Team and Antimicrobial Pharmacists leading the Trust Decontamination service

- Managing the IP&C & Deep clean budgets - Ensures that all policies and guidelines related to infection

prevention are valid and implemented across the service - Managing infection control nurse’s service level agreements with 3

external hospices, the Surgicentre and Hertfordshire Partnership Trust

- Leading the deep cleaning programme - Producing together with the DIPC and the ICD, the IPC Strategy,

Annual Plan, Assurance Framework and Annual IPC Report.

3.2.3 The Infection Control Doctor

The ICD is the Clinical Lead for the IPC service. The role includes:

- Supporting the DIPC - Overseeing local IPC policies and their implementation by ensuring

that adequate laboratory support is in place - Chairs the Pseudomonas Risk Assessment Group and sits on the

Legionella Steering Group. - Supervise IPC education for doctors and delivers the mandatory

training lecture for consultants. - Providing expert clinical advice on infection management. - Managing an infection control doctor service level agreement with

the Hertfordshire Community NHS Trust. - Producing, together with the assistant DIPC, the annual IPC report - Has the authority to challenge inappropriate practice including

inappropriate antibiotic prescribing decisions. The ICD reports to the DIPC on IPC matters.

3.3 The Infection Control Nursing Team: In 2012-2013 the team consisted of:

1.0 WTE Lead Nurse 1.4 WTE Clinical Nurse Specialists Infection Control (Additional CNS 1.0 WTE on maternity leave until February 2014) 1.0 WTE Infection Control Nurse 0.96 WTE Admin Support

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The Surgical Site Surveillance Nurse is also part of the wider team 1.0 WTE Surgical Site Surveillance Nurse

3.4 The Consultant Microbiologists

In addition to the Infection Control Doctor, the Trust employs two more consultant medical microbiologists (CMMs). All three CMMs play an active role in infection prevention. There is cover 24 hours a day, 7 days a week provided by a CMM for clinical microbiology/Infection prevention. One consultant microbiologist is a designated Deputy ICD. 3.5 The Antimicrobial Pharmacists

The Trust employs 1.2 WTE Antimicrobial pharmacists who work closely with the Deputy ICD and other members of the infection prevention & control team to ensure compliance with the Trust’s antimicrobial policies and antimicrobial stewardship programme. One antimicrobial pharmacist is the secretary of the Trust Antimicrobial Forum (TAF), a subcommittee of the New Drugs and Formulary Committee. As members of the TAF, the antimicrobial pharmacists co-write antimicrobial policies with the CMMs together with consultants from other specialities and other trust staff, as needed. Antimicrobial guidelines are ratified by the Therapeutics Policy Committee.

The role of the antimicrobial pharmacists also includes:

- attending and contributing towards the Trust Infection Prevention & Control Committee meetings and the Joint Infection Prevention & Control Committee meetings (with the infection control team)

- supporting the ICD and the CMMs to ensure best practice in antimicrobial stewardship throughout the trust

- joining on Antimicrobial Ward Rounds with the CMMs - carrying out audits in line with national guidance. This is to

determine antimicrobial use and compliance with Trust antimicrobial policies throughout the trust

- providing training regarding antimicrobial stewardship to clinical staff within the Trust.

3.6 The Trust Infection Prevention & Control Committee (TIPCC)

The Committee is chaired by the DIPC. Its membership includes, in addition to the Medical Consultant leads from all specialities, Consultant for Communicable Disease Control, occupational health representative, clinical governance officer, head of estates and facilities, isolation ward lead nurse, education lead and the antimicrobial pharmacists. Matrons are invited to attend the meetings when their divisions make their quarterly report. One meeting was dedicated to infection control education when the membership was divided into smaller groups that tackled specific IC problems. A final discussion emphasised the main learning points which were then documented in the meetings minutes. The terms of reference and membership were

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reviewed in 2012. The TIPCC meets 11 times a year (not August) and reports to the Trust Board via the Risk and Quality Committee.

3.6.1 Medical Consultant Infection Prevention Leads

Each speciality has a designated lead that forms the link within their division and the Trust Infection Prevention Committee. Their role includes a quarterly report on local infection prevention issues, taking back information to their divisions and working with the divisional matrons on new clinical initiatives and the resolution of local issues supported by the ADIPC at monthly divisional meetings. An example this year is the focus on trust-wide reduction of CAUTI (catheter .associated urinary tract infection.) through coordinated initiatives and the reduction in surgical site infection, with a focus but not entirely on Trauma and Orthopaedics.

3.7 The Annual Plan

An Annual plan is prepared by the ADIPC in conjunction with the Infection prevention team and agreed at TIPCC prior to approval by the Board. The plan of work is mapped to the duties of the code of practice. Progress against the annual plan is monitored by the TIPCC and reported to the RAQC quarterly. The plan for 2013-2014 can be found at Appendix A. 4 Compliance with Criterion 1: b- Monitoring the prevention and

control of infection 4.1 Mandatory Surveillance: Mandatory surveillance comprises of MRSA, MSSA, Escherichia coli (E.coli.), Vancomycin resistant enterococci bacteraemias (VRE), cases of Clostridium difficile infection and surgical site infection in fracture neck of femur, total hip and knee replacement surgery. 4.1.1 MRSA blood stream infections (BSI) Isolates of MRSA (Meticillin resistant Staphylococcus aureus) from blood cultures have been reported since 2002; enhanced reporting using the Health Protection Agency MRSA Data Capture System began in 2006. National and local MRSA bacteraemia figures may be seen at: http://www.hpa.org.uk/infections/topics_az/staphylo/default.htm Table below shows the performance of the Trust since the introduction of Mandatory Surveillance in 2002 (red font indicates MRSA BSI numbers exceeding yearly targets). Year 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13 Total 86 56 50 58 53 33 18 10 5 3 2 Target n/a n/a n/a 39 31 22 21 15 3 3 3

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Root cause analysis (RCA) of MRSA BSI, using the NPSA RCA tool, was introduced in early 2007. This is used as a learning tool to identify the causes of the MRSA BSI and to review whether or not the blood stream infection was avoidable and to take appropriate action if it was. During 2012/13, the Trust has adopted an internal ‘Never Event’ approach to MRSA BSI and the RCA format has been modified accordingly. Following an extensive training initiative during the past year the trust has made a significant improvement in avoiding contaminated samples of blood leading to false positive results.

4.1.2 Clostridium difficile-associated disease (CDAD) C difficile a type of bacterium found in the gut that can cause diarrhoea in certain circumstances. It can cause a spectrum of symptoms from mild antibiotic-associated disease (CDAD) to severe colitis. The bacterium is found without ill effects in a percentage of the population such as neonates (hence we do not test patients <2 years of age) and the elderly, where up to 50% in some studies are colonized without ill effects. As the current testing technologies only detect the presence of the bacterium, but cannot comment on whether clinical disease is present on not, the DH has produced a number of guidelines advising laboratories on when to test and which groups of patients not to test routinely. New episodes of laboratory confirmed C.difficile toxin positive samples are reported as mandatory reporting since 2004. A new way of counting CDAD numbers was introduced from April 2008 trying to define hospital-acquired versus community acquired cases. This had resulted in improved working across whole health economy in relation to target organisms. The incidence of C.difficile infection has reduced nationally year on year for the past three years. National and local results can also be seen at: http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/ClostridiumDifficile/ Table below shows the performance of the Trust since the introduction of Mandatory Surveillance in 2004.

Year 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13 Total 474 487 594 457 108 81 56 12 13 Target n/a n/a n/a 414 183 90 63 65 14

The Trust has seen a significant improvement in CDAD numbers over the last 30 months in spite of processing a higher percentage of samples than most Trusts in our region, as stated by the most recent data from the regional HPA epidemiology unit (see table below showing C. difficile toxin testing data for acute Trusts in the East of England, July 2011 – June 2012).

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Acute trust Samples

examined Samples tested for C. difficile toxin

Tests positive for C. difficile toxin (ages 2+)

Percentage tested

Basildon & Thurrock University Hospitals

7983 2307 60 29%

Bedford Hospital 4409 1234 50 28% Cambridge University Hospitals

10555 3266 73 31%

Colchester Hospital University

11476 2873 47 25%

East & North Hertfordshire 7349 3790 80 52% Hinchinbrook Healthcare 3547 910 18 26% Ipswich Hospital 8726 3518 88 40% James Paget University Hospitals

5649 3733 77 66%

Luton & Dunstable Hospital 7222 1907 42 26% Mid Essex Hospital Services 10520 3209 80 31% Norfolk & Norwich University Hospitals

14097 8477 159 60%

Papworth Hospital 703 493 9 70% Peterborough & Stamford Hospitals

8484 2858 78 34%

Princess Alexandra Hospital 7673 1293 45 17% Southend University Hospital

5547 3420 79 62%

The Queen Elizabeth Hospital King's Lynn

6004 263 65 4%

West Hertfordshire Hospitals 9518 1406 61 15% West Suffolk Hospitals 8179 4191 100 51% In addition to the improvements in the patients’ outcomes and experience and in the image of the trust (as the CDAD rate is considered by many authorities to be a reliable proxy for hospital cleanliness), there are significant financial savings. The cost of a single case of CDAD to the hospital has been estimated to be $9197 to $11,456 (£5,846-£7,297). This represents a reduction in the cost to the health economy from £3.9M in 2006/07 to £76,000 last year. The mandatory surveillance numbers for this year have been excellent, continuing the positive trend of the last two years and giving the Trust the lead position within the East of England, and the 5th across Midlands and East with only 4 small speciality trusts having lower CDAD numbers. We continue to receive requests for advice from other trusts who want to emulate our successes. 4.1.3 Other Mandatory Surveillance organisms We also report on bacteraemias caused by Meticillin sensitive Staph aureus (MSSA), Vancomycin-resistant enterococci (VRE) and E.Coli. The table below shows the numbers of these bacteraemias for 2011/12.

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Bacteraemia MSSA VRE E coli 2011/12 18 7 30 2012/13 15 4 43

VRE bacteraemia: VRE in vancomycin-resistant enterococcus. Enterococcus is a low pathogenicity bacterium that is inherently resistant to many antibiotics and can acquire resistance to effective antibiotics such as vancomycin. VRE is difficult to treat and in certain groups (where it can cause opportunistic infections, such as transplant patients, patients in the ITU and renal patients with indwelling devices) can present a challenge. Following the observation of an increase in VRE bacteraemias in the renal unit in 2011/12, the Infection Control Lead for the renal unit worked with the ICD to review the bacteraemia cases. It was concluded that these bacteraemias were not linked. Some had originated at other organisations. Recommendations were made. Table 1 2009-10 2010-11 2011-12 2012-13 Total VRE bacteraemias 1 3 7 4 Renal unit VRE bacteraemias 1 0 4 0 The ICD continued to monitor the occurrence of VRE bacteraemia at the Unit and noted that the measures introduced by the unit seemed to work as no further VRE bacteraemias were seen in 2012/13 in the renal unit. However, there has been a simultaneous increase in the number of clinical samples with VRE both in the hospital and in the renal unit (see table 2). The consultant microbiologist leading on renal microbiology was asked to assess this increase and to liaise with the renal unit to assess whether any change in practice had occurred. Clinical isolates were sent to the reference laboratory for typing. A number of “new” strains were identified. Table 2 2009-10 2010-11 2011-12 2012-13

Hospital Renal (%)

Hospital Renal Hospital Renal Hospital Renal

Fluid 0 0 1 1 0 0 3 2MSU 8 1 3 2 9 6 40 21CSU/U 3 0 8 1 9 2 28 14Line tips 3 2 0 0 4 2 3 2Other* 4 1 2 2 14 1 11 3Total 18 4 (22) 14 6 (43) 36 11 (31) 85 42 (49) A comprehensive action plan was developed to address this increase in VRE in the renal unit in 2013/14.

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4.1.4 MRSA admission screening

As of April 2009, all non emergency patients are being screened for MRSA carriage as well as the existing high risk patients previously screened in accordance with DH guidelines. Screening of all admissions became mandatory on March 2011. At East and North Hertfordshire NHS Trust, screening of all admissions was commenced much earlier starting February 2010. The table below shows the numbers of MRSA screens for 2012/13.

MRSA Screens Elective Emergency Total 20,788 25,256

Positive 147 400Percentage 0.7% 1.6%

The Trust has achieved 100% compliance for Elective screening. Emergency screening has proved more challenging with a slow improvement during the year to achieve 90.94% compliance. Challenges have been posed by the increase in activity within the Emergency Department (ED) which has seen an annual increase in patients admitted to hospital via the ED of 3.6% on the previous year (1,150 patients). Progress is constantly reviewed with refreshed initiatives. 4.2 Incidents related to infections (including outbreaks): 4.2.1 Norovirus Outbreaks:

Norovirus is a highly contagious pathogen responsible for outbreaks in the community (e.g., schools, cruise ships, residential homes, etc.). Norovirus outbreaks occurring in hospitals are normally acquired as a result of increased activity in the community and delayed isolation of a symptomatic patient admitted from the community. Health Protection England (formally the HPA) had stated that for the 2012/13 season Norovirus activity was 7% higher than last season nationally (see graph of laboratory reports received by the HPA below).

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HPA Graph However, different trusts have been affected differently. Many trusts, including ours, were significantly impacted, from the points of view of operational, business continuity and bed days lost. The impact on our Trust was significant mainly due to the number of wards affected. Table of the trust data 2012-13

Ward Patients affected

Staff affected

Outbreak dates Laboratory confirmed

(positives/total submitted)

Codicote 12 5 April 2012 Yes (3:5) Stanborough 10 4 May 2012 Yes (1:1) SSU 11 3 December 2012 Yes (1:3) AAU 12 0 December 2012 Yes (2:7) Barley 13 4 December 2012 Yes (2:3) Codicote 12 4 December 2012 Yes (1:2) Codicote 8 5 February 2013 Yes (3:4) Pirton 9 4 March 2013 Yes (4:5) Barley 15 7 March 2013 Yes (4:5)

During the past year the Trust has seen a reduction in the number of Norovirus outbreak totalling 9 for 2012/13 season, compared to 15 for 2011/12 season. It is believed that the re-introduction of fogging wards post outbreaks, the deep clean programme and public awareness which include public pop up banners stating periods of high activity in the community and advising the public not to visit unless essential, telephone message via switchboard at time of outbreaks and public notice boards displays in main hospital corridors. The local Health Protection Unit has provided the Trust with bi-weekly updates on outbreaks in residential and nursing homes which are routinely circulated to all wards and the Emergency Department. In

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addition, regular reports of the number of positive samples from our region were monitored and email alerts were issued when a significant increase in the number of positive samples was observed. These alerts helped to inform staff of local norovirus activity and, in turn, to maintain awareness and vigilance in looking out for patients presenting with diarrhoea and vomiting on admission leading to prompt isolation as required. 4.2.2 Influenza:

Looking at the national and regional pictures, data from Health Protection England shows that influenza activity has been low on a par with 2011/12. This is reflected in our local data from East and North Hertfordshire NHS Trust as presented in the table below which compares rates for the 2012/13 season with previous years:

2010/11 2011/12 2012/13 Influenza A (H1 Swine) 24 0 1 Influenza A (H1 Seasonal) 0 0 0 Influenza A (H3 Seasonal) 1 0 3 Influenza B 7 2 1 Flu virus not isolated 57 38 51 Total requests 89 40 56

Despite maintaining a high degree of vigilance and an active testing strategy there have been relatively few cases of ‘flu at East and North Hertfordshire. The majority of strains detected have been seasonal influenza strain type A (H3) and there has been only a single case of Swine Influenza A (H1N1) detected. 4.2.3 Carbapenem-resistant bacteria:

Carbapenems (such as meropenem) are a powerful group of broad-spectrum antibiotics which are often the last effective defense against multi-resistant bacteria. Infections with carbapenem-resistant enterobacteria are an emerging threat. It is seen mainly in the Indian subcontinent but has also been reported in the Mid-East, North Africa, Europe and the USA. In this country, less than 100 cases have been identified by the Health Protection Agency with bacteria that are carbapenem resistant. Many have been associated with patients who have received prior treatment abroad, in India or Pakistan, but there are reports of a few incidents of cross infection in the UK. During 2012/13, the IPC team dealt with one such case in a renal dialysis patient returning from a visit to Pakistan, where haemodialysis was administered in a hospital setting. Strict infection prevention & control measures were implemented in accordance with the national guidelines. No cross-infection within the renal dialysis unit, or elsewhere in the trust, was observed and the patient was discharged from hospital with no evidence of continued presence of the organism. 4.2.4 Surgical site infection

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It is a mandatory requirement to conduct surveillance of orthopaedic surgical site infections using the Surgical Site Infection Surveillance Service of Public Health England. The requirement is for a 3 month module of surveillance of one of the Orthopaedic options:

Open reduction of long bone fracture

Total Hip Replacement (THR)

Total Knee Replacement (TKR)

Repair Neck of Femur Fracture (RNoF) In 2011 the trust received notification from the Surgical Site Surveillance Unit that the current SSI rates were above the national average as reported in the annual report last year. In response to this, Root Cause Analysis meetings were initiated to examine all cases of surgical site infection following orthopaedic surgery. Cases were systematically examined by the multidisciplinary team. This has resulted in a robust action plan which ran throughout the year. A second stage plan commenced in January 2013 for the coming calendar year. The focus was initially nursing activity on the ward which included reassessment of all nursing staff in aseptic technique, focus on the timing of dressing removal by clinicians, antimicrobial prophylaxis by anaesthetists, intra-operative and post operative normothermia management and improved documentation. Surveillance data was submitted in all three categories for quarters 2, 3 & 4 of 2012. Whilst a slight improvement was seen the total annual rate of infection remained above the national average. It is hoped that with the continued implementation of the second stage plan, a continued decrease will be seen over the coming year. Active surveillance will continue. Progress is reflected in the table below.

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Operation

Period 1 1.1.12 -31.3.12

Period 2 1.4.12-31.6.12

Period 3 1.7.12-30.9.12

Period 4 1.10.12-31.10.12

Total No infections Ytd

Period 1 1.1.13-31.3.13 2013

National Average. Ytd

Total Knee

Rep.

No surveillance

0 (0%) 3 (25%) 0 (0%) 3 (8.1%) 0 (0.0%) 0.5-0.6%

Total Hip Rep.

No surveillance

0 (0%) 3 (7.1%) 0 (0%) 3 (2.8%) 1 (1.7%) 0.7-0.8%

#NOF No surveillance

5 (5.4%) 4 (3.9%) 1 (2.2%) 11 (4.0%) 2 (1.9%) 1.5-1.8%

Operation

Period 1 1.1.12 -31.3.12

Period 2 1.4.12-31.6.12

Period 3 1.7.12-30.9.12

Period 4 1.10.12-31.10.12

Total No infections Ytd

Period 1 1.1.13-31.3.13 2013

National Average. Ytd

Total Knee

Rep.

No surveillance

0 (0%) 3 (25%) 0 (0%) 3 (8.1%) 0 (0.0%) 0.5-0.6%

Total Hip Rep.

No surveillance

0 (0%) 3 (7.1%) 0 (0%) 3 (2.8%) 1 (1.7%) 0.7-0.8%

#NOF No surveillance

5 (5.4%) 4 (3.9%) 1 (2.2%) 11 (4.0%) 2 (1.9%) 1.5-1.8%

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5. Criterion 2: Clean and appropriate environment

5.1 Environmental Cleaning 5.1.1 Cleaning Services

The majority of services are managed by an external company G4S for Lister, QEII and Hertford County hospitals. Sodexho managed services at Mount Vernon Cancer Services Hospital in 2012/13 until January 2013 when the service went in – house and the SLA was reviewed by the IP&C Team. The cleaning services in the satellite renal dialysis units were managed through SLAs with either the respective Trusts that they are located in or as a stand alone service the Bedford Unit is managed by an external company named Cleaning Matters.

5.1.2 Deep Clean Programme

The Trust continues with the Annual Deep Clean Programme commenced in 2008. This programme is managed by the Assistant DIPC on behalf of the IPC Team and aims to cover all in patient wards. This year the programme extended to outpatient departments on three sites as bed pressures were very challenging and access to all wards was not possible. We continue to use steam cleaners and chlorine releasing disinfectants for regular cleaning and for terminal cleaning following the identification of infectious cases and outbreaks of infectious diseases. Hydrogen peroxide vapour fogging was successfully reintroduced in to the deep cleaning schedule.

5.1.3 Monitoring arrangements

A team of dedicated monitoring officers undertake and record technical monitoring on a weekly basis as required by the National Specification. The monitoring of waste streams is also included in their daily audits. Additional focused monitoring also takes place in liaison with the IPC team. Ward Sisters/Charge Nurses, Matrons and Divisional Nurses undertake the bi-weekly cleaning audit in their clinical areas. Failure to achieve 95% compliance with the cleaning audit results in a written action plan which is followed up by the Assistant DIPC and discussed at monthly Divisional IPC meetings. The Trust Facilities Manager and Assistant DIPC meet monthly with the contract Manager for the G4S contactor with the external G4S Manager to discuss monitoring standards and the impact of the ‘Our changing hospital’ programme and Deep Clean programme. 5.2 Environmental Monitoring 5.2.1 Water safety (Legionella Committee & Pseudomonas Group) 5.2.1.1 Legionella Steering Group:

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East and North Hertfordshire NHS Trust accept its responsibility under the Health and Safety at Work etc. Act 1974 and the Control of Substances Hazardous to Health Regulation 2002 (as amended), to take all reasonable precautions to prevent or control the harmful effects of contaminated water to residents, patients, visitors, staff and other persons working at or using its premises. The Chief Executive Officer appointed a Responsible Person (Robert Jones) (Legionella) to take day-to-day responsibility for the control of the hot and cold water services and to be responsible for assessing and controlling identified risks from Legionella. The Legionella Steering Group meets quarterly and is attended by representatives from Estates, Infection Prevention and Control (IPC), Capital Projects, External Legionella Consultants (Hydrop) and Pharmacy (QC). The current Trust Legionella Policy & Procedure document has been reviewed and has been ratified by the TIP&CC in September 2012; the document is to be reviewed in August 2013. The Trust’s appointed Legionella Control Consultants undertake two yearly water risk assessment advising and identifying any control measures that need to be established. During 2012/13, water sampling for legionella has been undertaken on perceived High risk locations x 12 at Lister hospital only; following the quarterly sampling carried out on the 22/10/2012, it was found that there was 1 x water positive sample with non-pneumophila legionellae. The location is as follows:- Hot/Cold

REF Floor Date Room Result

CFU/Vol Temp CL02

95C 3 17/01/13 Off A&E – 2H55 22,000 25.6 0.05 Remedial action was implemented. The tap and TMV were removed & disinfected to BS6700 and replaced. This was perceived to be an infrequently used outlet within a consulting room which is not occupied all the time. Staff were appraised of the situation, given flushing forms and were told to complete them and return them to estates. This sink & tap has now been removed from use. The local flushing of infrequently used outlets is working well at the QEII Hospital, where the housekeepers have taken ownership of this task. Flushing forms are being returned to estates with 95% compliance recorded. There are issues at Lister Hospital with local ownership, some forms being returned only spasmodically by a combination of ward staff, G4S & housekeeping staff. A recent audit has identified only 65% compliance; however, all augmented care areas show a high level of compliance and staff awareness. Significant improvements have been noted recently in the flushing form returns from ward areas, which can be directly attributed to the IPCT involvement when carrying out their ward audits.

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The steering group continue to advise the Capital Projects and Our Changing Hospital teams on current legislation and best practice, recently advising them to move away from the current practice of installing sensor type taps in new builds, as anecdotal evidence suggest that the design and internal components of the taps may be a harbouring the proliferation of micro-organisms, particularly but not exclusively with respect to Ps. aeruginosa. The steering group was also able to advise the new ICU project manager and project director with respect to current guidance and best practice on the design of the negative pressure rooms exhaust system & final HEPA filter installation. 5.2.1.1 Pseudomonas Risk Assessment Group: In March 2012, the report “Water sources and potential Pseudomonas aeruginosa contamination of taps and water systems: Advice for augmented care units” was issued. It gave details on testing and monitoring aspects, and what action to take in event of a problem as well as advice which can be drawn on to help inform local water safety action plans. The CMO recommended that local risk assessment processes should be undertaken to provide an assurance of compliant with: {HTM 04-01 The control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems} and that manufacturers’ installation and maintenance instructions have been followed. It aims to identify actions to mitigate risks and ensure appropriate sampling; monitoring and clinical surveillance arrangements are being implemented and adhered to. In compliance with these directives a multi-disciplinary group was formed in the Trust that included the Infection Control Doctor (Chair), the ADIPC, the Quality Control Department, the Estates and Facilities Team and senior nurses from relevant augmented care units. As per the current DOH guidance six monthly water sampling has been carried out for Pseudomonas aeruginosa within augmented care areas, with the exception of the Neonatal Unit (NNU), where monthly water sampling has been performed. During late October & early November 2012, Ps. aeruginosa water sampling was carried out on all locations as listed above, out of a total of 163 water samples taken, the following came back positive:- Hot/Cold

REF Floor Date Room Result

CFU/VolRemedial

action Re-test

Pass Y/NF5 L10 15/10/12 Treatment Room

(by door) 36 BS6700 Y

P3 L11 15/10/12 Dressing Clinic 18 BS6700 Y

NNU 5 L3 22/10/12 ITU - By door sink A 115 BS6700 Y

NNU 9 L3 22/10/12 SCBU 1 1 BS6700 Y

i13 L4 29/10/12 ICU Bay 3 1 BS6700 Y Hot/Cold

REF Floor Date Room Result

CFU/VolRemedial

action Re-test

Pass Y/NF7 L10 29/10/12 Consulting room 2 110 BS6700 Y

T3 L4 21/11/12 Theatre 3 scrub LH 6 BS6700 Y

T5 L4 29/11/12 Theatre 5 scrub centre 140 BS6700 Y

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T6 L4 29/11/12 Theatre 6 scrub centre 96 BS6700 Y

There has been an on-going Ps. aeruginosa issue with the drinking water supply to the NNU which has culminated in the drinking water supply to be switched off in patient/visitor accessible areas in October 2012. A bottled drinking water supply has been made available since this event. The contamination has been traced to within the NNU & Day Assessment Unit (DAU) exclusively. Following extensive remedial works, a large section of pipe at the entrance to the unit has been recently replaced. The entire pipe-work system, including the new pipe section has now been disinfected to BS6700 and water samples have now been taken (awaiting results). If this proves positive for Ps. aeruginosa again then the plan is to move forward through the NNU and survey the existing pipe-work layout and replace it as and when deemed necessary. The new ENHT renal satellite unit, located in Bedford, opened in April 2013. For re-assurance purposes, the ENHT Estates have taken additional Ps. aeruginosa water samples on all clinical sinks within the unit. These have subsequently all proved negative – the building owners, Diaverum, have provided their operating policies and procedures for the new building and they have stated that they will be undertaking six monthly Legionella & Ps. aeruginosa water sampling. These records will need to be audited at least annually by ENHT. Ps. aeruginosa water sampling for other augmented care areas is due to be carried out during April/May 2013. 6. Criterion 3 & 4: Information on infections to service users and their visitors & information on infections to other providers In addition to the public pop banners used to inform the public of increased incidence of the winter vomiting bug Norovirus and a separate banner for notification of an actual outbreak the Trust continues to use the switchboard as mechanism for informing the public at these times. A pre recorded message is used at time of outbreaks and removed once they are over. Information leaflets are available on the Trust website for the patients and public to access at any time in respect of infections. On the National Infection Prevention & Control week in November 2012, the infection control nursing team held public information stalls at the Lister, QEII and Mount Vernon hospitals with a focus on hand hygiene. Furthermore, they held a stall at the Trust Annual General Meeting demonstrating the importance of hand hygiene to the general public. Washable information labels have been placed on all in-patient lockers and dialysis trolleys informing the public of the importance of hand hygiene whilst in the hospitals and drop down signage has been mounted from the ceilings in long corridors informing the public of gel dispensers at the entrances to departments and asking for their use. 7. Criterion 5: Identification and prompt management of infection

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The ICD and the consultant microbiologists provide advice on the prompt diagnosis and treatment of infections, including appropriate use of antibiotics. Close working relationship are also in place to facilitate the reporting of infections of public health significance to the local Health Protection Unit (HPU). In addition, the ICD works closely with the Public Health Office (PHE) in the management of infection-related serious incidents in the hospital, such as Norovirus outbreaks and open TB cases. The IPCNs also liaise with their Public Health nursing colleagues in respect of infection control incidents such as TB cases and gastrointestinal outbreaks. During 2012/13, the ICD contributed to a number of HPA surveillance programmes, including E coli bacteraemia enhanced surveillance and surveillance of Influenza-relate ITU-admissions. During the last year the Antimicrobial Stewardship agenda have continued to promote the Trust’s ongoing commitment in ensuring the evidence-based prudent use of antibiotics. The following approaches are employed:

1. Policies and guidelines on the use of antibiotics in adults, children and neonates and on the use of antifungal agents are available to all Trust’s prescribers on the Knowledge Centre. These policies and guidelines have been reviewed and/or updated during 2012/13.

2. Clinical audit has enabled adherence to various aspect of Trusts policies and guidelines to be assessed. These audits include an annual point prevalence audit, which is concerned with the extent of prescribing in the Trust and a ‘stop policy audit’ which is concerned with the adherence to the antimicrobial stop policy.

3. Education has formed a vital part of driving the antimicrobial stewardship agenda. Presentations were delivered to clinicians formally via Grand Rounds at both the Lister and QEII sites. This formal education was supplemented by an e-learning package for clinicians and is specifically set around antimicrobial prescribing.

4. From a broader perspective the Trust has worked closely with other secondary care NHS Trusts in the Hertfordshire and Bedfordshire region to benchmark and survey antimicrobial prescribing. Through this work we have managed to adopt a collaborative approach to antimicrobial stewardship and share best practice.

5. The Trust was an active participant in the Health Protection Agency fourth national prevalence survey on antimicrobial use. The report was published in May 2012.

6. The Trust has engaged in the Department of Health project to reduce catheter associated urinary tract infections. It is reported that urinary tract infections (UTIs) are the most commonly occurring Health Care Associated Infection (HCAI); amounting to 19.7% of all HCAIs. 60% of healthcare associated urinary tract infections are related to catheter insertion (DoH 2007), which means that 12% of all hospital acquired infections was from catheter insertion. This year we have continued to implement initiatives aimed at reducing CAUTIs (catheter associated urinary tract infections) embedding the use of all-one catheterisation pack,

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and the algorithm to assess the need for catheterisation and swift removal when no longer required. A business case for the procurement of additional bladder scanners giving all wards access to one was presented to the trust. This initiative was supported by a Consultant Urologist and the Consultant Physician of the stroke ward where a scanner was purchased last year. The IP&CT are currently awaiting the outcome. A collaborative study was completed with West Herts Community Continence team and resulted in a Long Term Catheter Passport being developed. This is now in use and funding is currently being sought for printing. Currently all nursing staff who perform urinary catheterisation are being reassessment for aseptic technique using a cascade approach to assessment. It is anticipated that this will take most of the coming year to capture all nursing staff.

7. A six month audit of Caesarean wound infection is currently underway and

due for completion the end of April 2013. 8. Criterion 6: Involvement of all staff The IPC team work closely with all Trust staff to implement good practice and reduce HCAIs. IPCT is an integral part of Trust induction for all new staff (with presentations on both Infection Prevention and Antimicrobial Stewardship) and periodical mandatory updates. In addition, a number of educational activities have been developed:

o Monthly mail shots to all clinicians discussing topical IPC related issues in the Trust.

o A report by the ICD is now an integral part of the “Learning Points” issued monthly to all Clinical Directors for discussion at the specialities monthly meetings.

o The IPC team has presented information on screen savers displayed on Trust wide computers at varying intervals throughout 2011/12, highlighting key IPC issues. For example one screen saver was dedicated to Clostridium difficile (CDAD) while another was dedicated to the new safety needle-based blood culture collection system.

o The IPCNs have developed a monthly new shot to all staff called

‘Quick Pics’ which highlights news and areas to focus on o The IPCT hold an Annual Infection Prevention & Control

Conference for all Trust staff which includes multidisciplinary presentations highlighting good practices and challenges throughout the past year, how they have been managed and lessons learnt to share with colleagues.

9. Criterion 7: Isolation facilities

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The Trust has a dedicated isolation ward with 14 beds (3X 4 bedded bays with doors and 2 side rooms). The number of side rooms available across the Trust is approximately 50 (some with en-suite facilities). This number has varied with the reconfiguration of the wards. It is important to note that in the maternity unit all rooms are single rooms (with en-suite facilities). During 20121/13, the use of the isolation ward has proved challenging due to the enormous pressure on beds in the trust. However, we have managed to isolate the majority of Clostridium difficile cases in the unit. The isolation ward is deemed essential to maintaining the low numbers of infection across the trust involving a range of microorganisms and their accompanying clinical infections. 10. Criterion 8: Laboratory support Since 2006 the Microbiology Department has undergone a process of evolution which has led to the restructuring of the workflows within the department and the introduction of automation to the department. The cumulative effect of this has been to increase productivity by 160% with a 17% decrease in staff numbers. The in house cost per test has similarly reduced from £9.26 in 2006 to £6.63 in 2012. During 2012/13, two Consultant Microbiologists have resigned from the Trust. For a substantial part of the year the ICD was supported only by 2 locum staff. Despite these disruptions, the Microbiology Department continued to deliver a full clinical microbiology. Two substantive consultant staff were recruited and have joined the Trust in September 2012. Despite the disruptions from critical staff losses and the effect of the strategic re-organisation process, the department has maintained and developed the service. The Laboratory is fully accredited by Clinical Pathology Accreditation. The Kiestra automated system, installed in the laboratory in May 2008, is still reaping efficiency savings within the department and the development of the Vision toolbox for digital reading of MRSA cultures has proved very effective. The Department has recently acquired the MALDI-TOF identification system which has been shown to improve the speed of the identification of bacteria with substantial savings in consumables and time of staff. The combination of Kiestra and MALDI-TOF has brought about marked improvement in productivity. The laboratory is now able to handle increased workload with less staff. 11. Criterion 9: Policies All polices required for compliance with the Health Code are in place and audited through the Annual Plan. The results of audits are shared and discussed at Divisional level and any remedial actions required are addressed through a written plan of action which is followed up and signed off when

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completed through the divisional meetings by the ADIPC. Support is given to the clinical areas to adhere to policies by the IPCT. Most of these policies are written by the IPC team members with support from other trust staff with expertise in the relevant areas. Some policies are written by other teams in the trust with relevant experience. However, these policies are all listed under the IPC policies and guidelines on the Knowledge Centre (KC).

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12. Criterion 10: Health care workers: Infection Status, protection from infection & education in infection prevention & control

In 2012/13, the Occupational Health (OH) Department has worked closely with the IPC team to ensure that staff were protected against infection. The department has been fully involved in IPC related incidents that affect staff health, such as Norovirus outbreaks, needle-stick injuries and staff exposure to rash illness in patients including chicken pox, and skin integrity in relation to use of hand hygiene products. The department has also been responsible for the flu immunisation programme and ran an annual campaign with the training and utilization of 50 flu champions around the Trust to vaccinate in the work place as well as scheduled clinics in Occupational Health. It involved significant promotion with information disseminated through a number of sources. Senior team members were surveyed and volunteers (flu champions) were requested to help promote the flu campaign. The uptake of the vaccine by frontline staff has increased on last years figures by 2% which is positive however the over all percentage for all staff has fallen by 0.7%. Promotion of the vaccine continues as we strive to reach the target of 43% of all Trust staff vaccinated. Number of

vaccinations given –all staff

% of vaccinations given –all staff

Number of vaccinations given -front line staff

% of vaccinations given - front line staff

Year

2011/12

2012/13

2011/12

2012/13

2011/12

2012/13

2011/12

2012/13

Total

1923 1764 33% 32.3% 1416 1527 33.1% 35.7%

13. CQC visits There have been no CQC visits to the Trust specifically in relation to infection prevention. The improved performance in all IPC issues over the past year and the future maintenance of this high standard will ensure that the Trust continues to be compliant with the Health and Social Care Act 2008: Code of Practice, and is fully accredited by the CQC.

14. Conclusion In 2012/13 the Trust IPC service has performed well, building upon the notable successes of the previous year. This has been made possible by the continuous and sustained efforts of all Trust staff at all levels (from Board to Ward) in maintaining vigilance in our fight against healthcare associated infections. Continued adherence to the IPC policies will ensure that we continue to perform well in the coming period.

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