NLG(15)419

DATE OF MEETING 29th

September 2015

REPORT FOR Trust Board of Directors – Public

REPORT FROM Infection Control Viv Duncanson

CONTACT OFFICER Deputy Medical Director, Dr Bryony Simpson

SUBJECT Infection Prevention & Control Team Annual Report

BACKGROUND DOCUMENT (IF ANY) Annual Report 2014-2015

REPORT PREVIOUSLY CONSIDERED BY & DATE(S) N/A

EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN AND / OR NED CHALLENGE THAT THE BOARD NEED TO BE MADE AWARE OF)

N/A

HAVE THE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS?

N/A

HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS?

N/A

ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS?

N/A

IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED?

N/A

ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF?

N/A

WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED?

N/A

WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO SUSTAINABILITY IMPLICATIONS (QUALITY & FINANCIAL) & CLIMATE CHANGE?

N/A

THE PROPOSAL OR ARRANGEMENTS OUTLINED IN THIS PAPER SUPPORT THE ACHIEVEMENT OF THE TRUST OBJECTIVE(S) AND COMPLIANCE WITH THE REGULATORY STANDARDS LISTED

ACTION REQUIRED BY THE BOARD To Board are asked to note the contents of the report

Page 1 of 46

INFECTION PREVENTION & CONTROL TEAM

ANNUAL REPORT

TO THE

DIRECTOR OF INFECTION PREVENTION & CONTROL

2014-2015

Infection Prevention & Control Team

14 August 2015

Page 2 of 46

CONTENTS

Summary and Highlights .............................................................................................. 4

1 Arrangements for Infection Prevention & Control (IPC) ...................................... 5

1.1 The Infection Prevention and Control Committee (IPCC) ............................................................. 5

1.2 The Infection Prevention and Control Team (IPCT) ...................................................................... 8

2 Meticillin Resistant Staphylococcus aureus (MRSA) .......................................... 8

2.1 MRSA Bacteraemia ....................................................................................................................... 8

2.2 Other MRSA Cases ........................................................................................................................ 9

2.3 MRSA Screening .......................................................................................................................... 10

3 Other Bacteraemias in the Mandatory Reporting Scheme ................................ 12

3.1 Meticillin-Sensitive Staphylococcus aureus (MSSA) Bacteraemias ............................................. 12

3.2 Escherichia coli (E. coli) Bacteraemias ........................................................................................ 13

4 Clostridium difficile .............................................................................................. 15

5 Antibiotic Resistant Organisms .......................................................................... 19

6 Antibiotic Stewardship ......................................................................................... 22

7 Isolation (including Outbreaks and Incidents) ................................................... 28

7.1 Isolation....................................................................................................................................... 28

7.2 Ebola............................................................................................................................................ 30

7.3 Incidents and Outbreaks ............................................................................................................. 30

7.3.1 Outbreaks ............................................................................................................................ 30

7.3.2 Incidents .............................................................................................................................. 31

8 Surgical Site Infections ........................................................................................ 32

9 Decontamination ................................................................................................... 33

10 Vascular Access and Invasive Devices .............................................................. 33

11 Audit ...................................................................................................................... 37

12 Education .............................................................................................................. 43

13 Visits from External Regulating Bodies .............................................................. 45

14 Community & Therapies Services ....................................................................... 45

Page 3 of 46

Tables and Figures

Table 1.1: Infection Prevention & Control Committee Attendances 2014-15 .......................................... 6

Table 1.2: Summary of Trust Delivery Plan Progress Report March 2015................................................. 7

Table 2.1: MRSA Bacteraemias since 2006 ................................................................................................ 8

Table 2.2: MRSA Bacteraemias: Apportionment by Organisation ............................................................. 9

Table 2.3: New Non-Bacteraemic MRSA Cases 2014-2015 ....................................................................... 9

Table 2.4: Overall Routine MRSA Admission Screening Compliance ...................................................... 10

Figure 2.1: Annual MRSA screening rates by site and month ................................................................... 11

Table 3.1: MSSA Bacteraemias 2005-2015 .............................................................................................. 12

Figure 3.1: MSSA bacteraemias by month and source ............................................................................. 13

Figure 3.2: Probable source of MSSA bacteraemia ................................................................................... 13

Table 3.3: E. coli Bacteraemias ................................................................................................................ 14

Figure 3.3: Hospital-acquired vs Community-acquired E. coli bacteraemia ............................................. 15

Table 4.1: Clostridium difficile Cases by Year 2008 – 2015 ...................................................................... 15

Figure 4.1: Clostridium difficile Apportioned to the Trust April 2014 to March 2015 .............................. 16

Figure 4.2: Community vs Hospital cases .................................................................................................. 16

Figure 4.3: Percentage all-cause 30-day mortality in CDAD cases ............................................................ 17

Figure 4.4: CDAD expected mortality pre-diagnosis, all cases .................................................................. 18

Figure 4.5: Expected mortality in CDAD cases who did not survive 30 days ............................................ 18

Figure 4.6: Mortality attributable to Clostridium difficile ......................................................................... 18

Figure 5.1: Urinary coliforms 1st line sensitivity ........................................................................................ 19

Table 5.1: Percentage Resistant and ESBL-producing Urinary Coliforms ................................................ 20

Figure 5.2: ESBL-producing Urinary Coliforms 2nd line sensitivity............................................................. 20

Table 5.2: Potential Carbapenemase Producers Identified ..................................................................... 22

Table 7.1: Number of Patients Placed in Isolation ................................................................................... 28

Table 7.2: Top Twelve Reasons for Isolation ........................................................................................... 29

Table 7.3: Failure to Isolate Incidents ...................................................................................................... 29

Table 7.4: Numbers affected and Lost Bed Days due to Viral Gastroenteritis ........................................ 30

Table 8.1: Surgical Site Infections April 2010 to December 2014 ............................................................ 32

Table 8.2: Surgical Site Infections April 2005 to March 2010 .................................................................. 33

Table 10.1: Catheter Related Blood Stream Infection Rates ..................................................................... 34

Table 10.2: Upper Extremity Deep Vein Thrombosis Rates ....................................................................... 35

Table 11.1: Hand Hygiene Audit Summary ................................................................................................ 38

Table 11.2: Infection Prevention and Control Audit (FLO Tool) Summary ................................................ 39

Table 12.1: Training Records as Extracted from OLM ................................................................................. 45

Page 4 of 46

Summary and Highlights

The year 2014-2015 was another busy period for the Trust’s Infection Prevention and Control activities. Despite relentless pressures we managed to continue our satisfactory performance in tackling the major threats, including MRSA and Clostridium difficile. Our use of MDTs to manage each C. difficile case has, at least in part, led to a reduction in 30 day mortality. The incidence of multi-antibiotic resistant bacteria is increasing. This is a natural phenomenon but it increases the pressure on our IPC service because it strains our already limited isolation facilities and requires a higher usage of more toxic, expensive, and less efficacious antibiotics. Some of the emerging multi-resistant organisms pose a severe threat to the Public Health because of their ability to transfer resistance to other bacteria. In addition, there are IPC problems that are recurrent and will remain so. Thus norovirus and influenza outbreaks will always occur in our hospitals and a great deal of resource is required to control them. Worldwide threats such as Ebola and MERS-CoV have impacts on us even before we ever see a case. Expensive Personal Protective Equipment and isolation facilities together with time-consuming training are essential but competence is difficult to maintain because the cases are rarely seen. Antimicrobial stewardship is making slow progress overall and there are some areas which may benefit from more focused attention. The Trust generally performs well in keeping the consumption of most classes of antibiotics below that of our surrounding sister organisations but more work needs to be done to reduce our usage of carbapenems. The IPCT believes that it is essential for the Trust to maintain a high level of vigilance. This includes a Board-level DIPC. There are worrying signs of complacency amongst clinical staff as evidenced by poor attendance at IPCC, RCAs and other IPC meetings. There has also been a rise in the number of failures to adhere to policy consequent, again in part, to the employment of staff from overseas and the use of agency staff who have an inadequate knowledge or understanding of our IPC policies and ethos. There is much to be proud of but there remains much to be done and we can never drop our guard. Even with the best possible IPC practice, we can never eradicate the risks from infections and people who we care for in our Trust will occasionally acquire infections which may lead to suffering or even death. It is the responsibility of us all to keep these unfortunate events to an absolute minimum and to be able to provide evidence of satisfactory policies, surveillance and good practice through root cause analysis of all serious IPC incidents.

Page 5 of 46

1 Arrangements for Infection Prevention & Control (IPC)

The Trust’s arrangements for the prevention and control of infection are contained within the document, Infection Prevention & Control Strategy: Overview of the Trust Approach and Arrangements for Infection Prevention & Control [IC/SP2], which is held by the Directorate of Clinical & Quality Assurance/Trust Secretary. This document details the responsibilities of various parties within the organisation and their governance and management arrangements. While the Chief Executive has the final responsibility for all aspects of infection control, the functional responsibility lies with the Director of Infection Prevention and Control (DIPC) who is currently the Medical Director.

1.1 The Infection Prevention and Control Committee (IPCC)

The Infection Prevention and Control Committee oversee the function of the Infection Prevention and Control Team. It is a sub-committee of the Trust Board and, as such, is chaired by a non-executive director. Its Terms of Reference were last reviewed in May 2014. The Committee should sit six times a year providing the main forum for regular, routine consultation on infection control issues between Senior Management, the IPCT, Group Leads for infection prevention and control, senior clinicians and the Health Protection Unit. The main functions of the IPCC are monitoring implementation of the Infection Control Annual Programme, and receipt and ratification of all infection control policies and reports.

Table 1.1 below shows attendance at the meetings for the 2014-2015 year. Overall, adequate representation was achieved from the critical parts of the organisation despite changes in personnel and re-organisation, with Senior Management, the IPCT and at least one operational department being represented at every meeting. Representation from clinical and operational units was patchy with the presence of management being far commoner than clinical representation. Attendance on behalf of external bodies, particularly commissioners, remained generally poor. Occupational Health attended two meetings this year. One meeting had to be cancelled due to an excessive number of diary clashes. The Infection Control Annual Programme (of work), which is ratified by the IPCC, sets objectives based on the outcomes of audit, monitoring and surveillance and identifies priorities for action to meet the needs of the organisation and ensure patient safety and provide evidence that relevant policies have been implemented to reduce healthcare-acquired infection (HCAI). New legislation, guidance and policy that have operational implications are also reviewed and prioritised into the Annual Programme of work. The Annual Programme is monitored by the IPCC and progress reported every 6 months. Areas of risk are identified and placed on the appropriate risk register. The committee is responsible for the formation of and overseeing the implementation of the Trust HCAI Delivery Plan as laid down by The Hygiene Code requirements for CQC registration and the committee receives regular progress updates on this. As part of this process, a regular gap analysis is required to determine where the Trust currently stands with regard to national standards. However, last year the code was updated but the final version of the updated code has not, as yet, been received. As such, it has not been possible to conduct an updated gap analysis. It would be fair to say, however, that the outstanding issues from last year still remain so. In addition, the IPCT keeps an up-to-date and ongoing record of progress against the Delivery Plan. The March 2015 progress report contains four major headings each divided into a number of sub-headings and each further divided into a number of action points. Table 1.2 below summarises these. The full report may be obtained from the IPCT on request. The partially completed and outstanding actions are noted in the footnotes to the table.

Page 6 of 46

Table 1.1: Infection Prevention & Control Committee Attendances 2014-15

Position April/ May

June/ July

August/ September

October/ November

December/ January

February/ March

Non-Executive Director (Chair)

M E E T I N G

C A N C E L L E D

Trust Chairman (Vice-chair until May 2014)

Chief Executive D

Medical Director (DIPC) (Vice Chair after May 2014)

D**

Chief Nurse

Director of Clinical & Quality Assurance***

D D D

Consultant Microbiologist (SGH)

Consultant Microbiologist (DPoW)

Senior Nurse Infection Control (ADPIC)

Consultant Pharmacist (Antimicrobials)

*Diagnostics & Therapeutics

*Operations D

*Facilities

*Community & Therapy Services

ICN Community Services

#ICN Care Plus Group

# PHE representative

PCT/CCG representatives

Clinical Consultant **

Occupational Health

* Designated Representative from # External Body D Appropriately senior Deputy present ** Acting Medical Director *** The Chief Operating Officer is a member of the committee in their role as Trust Decontamination Lead but is usually deputised for by someone from Clinical & Quality Assurance who has a more day to day responsibility for decontamination.

Page 7 of 46

Table 1.2: Summary of Trust Delivery Plan Progress Report March 2015

HEADING SUB-HEADING

ACTION

POINTS

COMPLETED

PARTIALLY

COMPLETED

OUTSTANDING

PERFORMANCE

Board Assurance/Board

Level Leadership to Prevent

HCAIs

10

10

0

0

Performance and

Governance Arrangements

8

7

0

1(1)

PROCESS

Environmental Cleaning and

Equipment

11

11

0

0

Outbreak Prevention and

Management

4

3

0

1(2)

Root Cause Analysis

11

11

0

0

Admission, Discharges and

Transfers

4

4

0

0

Screening and surveillance

of HCAI

6

6

0

0

PRACTICE

Saving Lives High Impact

Intervention

2

1

1(3)

0

Isolation and Cohort Nursing

8

7

1(4)

0

Antibiotics

3

2

1(5)

0

Hand Hygiene

2

2

0

0

PEOPLE – Be A

Learning

Organisation

Training & Education

6

6

0

0

Communication

7

7

0

0

Total

82

77

3

2

1. Lack of hand washing sinks still outstanding from last year – awaiting major structural reconfiguration of

areas in question.

2. Unable to progress use of EPR system for outbreak management at this time due to competing priorities for

EPR development team’s resources.

3. Only one minor work stream remains outstanding.

4. Some issues regarding Ebola preparedness remain at one end of the patch.

5. Despite considerable progress, antimicrobial stewardship issues remain.

Page 8 of 46

1.2 The Infection Prevention and Control Team (IPCT)

We are pleased to report that Viv Duncanson, our Senior Nurse, won the accolade of National Infection Prevention Practitioner of the Year which was awarded by the Infection Prevention Society. She was also awarded the CEO’s special recognition award at the Trust’s local STARS awards and recognised that no such awards could have been achieved at either national or local level without the backing of a supportive team. Dr Peter Cowling has chaired a number of national groups including a review of the national MRSA screening procedure. Although the team’s numerical strength remains unchanged from last year, there have been changes in personnel. One of the IPCNs, Wendy Merrett, left us and we wish her a long and happy retirement. The team has welcomed her replacement, Marion Hewis. We are also aware that two senior members of the team will retire within the next six months or so. Their loss will be keenly felt and they will both be extremely difficult acts to follow. The team operates across the entire trust, working with all clinical teams and in every area that handles patients. The IPCNs are now increasingly visible in clinical areas. A surprisingly large, but unseen, part of the team’s role also occurs behind-the-scenes working with Estates and Facilities solving problems associated with infection risks from water supplies, ventilation systems and new builds.

2 Meticillin Resistant Staphylococcus aureus (MRSA)

2.1 MRSA Bacteraemia

Nationally, there remains a zero tolerance for preventable MRSA bacteraemias. Thus, once again the Trust had a target of zero hospital-acquired cases. As in previous years, every case of MRSA bacteraemia must undergo a rigorous Root Cause Analysis investigation (known as a PIR) which assigns the case to either the Trust, the community or, occasionally, to a third party eg another hospital. This year we recorded a grand total of six cases of MRSA bacteraemia but five of these were of community origin leaving the Trust responsible for only one case. Once again, due to the small numbers of cases, it is not appropriate to discuss the issues arising from the PIR investigations in this report because this could compromise patient confidentiality.

Table 2.1: MRSA Bacteraemias since 2006

Year Trust-acquired Total

2006/2007 29 (60.4%) 48

2007/2008 22 (66.7%) 33

2008/2009 11 (57.9%) 19

2009/2010 3 (18.8%) 16

2010/2011 8 (50.0%) 16

2011/2012 4 (57.1%) 7

2012/2013 2 (40.0%) 5

2013/2014 5 (55.6%) 9

2014/2015 1 (16.7%) 6

Page 9 of 46

Table 2.2: MRSA Bacteraemias: Apportionment by Organisation

2014/2015 2013/2014 2012/2013 2011/2012

Northern Lincolnshire & Goole

1 5 2 4

North East Lincolnshire

2 (0) 4 (3) 0 (1) 2 (2)

North Lincolnshire 3 (1) 3 (1) 3 (1) 4 (2)

Lincolnshire 0 (0) 0 (0) 0 (0) 0 (0)

West Lincolnshire 1 (0) 1 (1) - -

East Riding 0 (0) 1 (1) 0 (0) 1 (0)

Other

0 (0) 0 (0) 0 (0) 0 (0)

Total 6 (1) 9 (5) 5 (2) 7 (4)

2.2 Other MRSA Cases

Not all MRSAs are found in blood cultures. The bulk of MRSA isolates come from routine wound swabs and from swabs taken specifically to look for the presence of the organism (screening swabs). Most patients, from whom the organism is isolated, are not infected but rather merely colonised, ie harmlessly carrying the organism. It is very difficult to look at the raw data and determine how many patients are in fact infected but the rule of thumb is that infections account for less than ten percent of isolates. Since Table 2.3 differentiates clinical samples from screening samples, it is reasonable to assume that infections account for, at most, the total in the CLIN column but are, in reality, likely to form only a proportion even of these. Previous year’s numbers are shown in parentheses for comparison.

Table 2.3: New Non-Bacteraemic MRSA Cases 2014-2015

Site Month/

Year

Total

Cases

Previous

Cases

New

Inpatient

Cases

CLIN GPC OA OH Other

DPOW Apr-14 22 16 6 0 0 5 0 1

DPOW May-14 16 11 5 0 0 5 0 0

DPOW Jun-14 20 9 11 0 1 9 1 0

DPOW Jul-14 18 9 9 2 2 4 0 1

DPOW Aug-14 19 8 11 1 3 7 0 0

DPOW Sep-14 23 8 15 2 0 9 0 4

DPOW Oct-14 22 10 12 0 1 10 0 1

DPOW Nov-14 20 11 9 3 0 5 0 1

DPOW Dec-14 24 15 9 6 0 3 0 0

DPOW Jan-14 16 11 5 3 1 1 0 0

DPOW Feb-14 13 7 6 1 0 4 1 0

DPOW Mar-14 17 9 8 2 0 6 0 0

Sub-Total - 230(240) 124(132) 106(108) 20(17) 8(11) 68(72) 2(4) 8(4)

Page 10 of 46

Site Month/

Year

Total

Cases

Previous

Cases

New

Inpatient

Cases

CLIN GPC OA OH Other

SGH & GDH Apr-14 19 6 13 2 1 10 0 0

SGH & GDH May-14 34 11 23 3 7 12 0 1

SGH & GDH Jun-14 35 13 22 2 5 14 0 1

SGH & GDH Jul-14 30 9 21 1 5 15 0 0

SGH & GDH Aug-14 28 18 10 1 1 8 0 0

SGH & GDH Sep-14 26 12 14 4 0 9 0 1

SGH & GDH Oct-13 22 9 13 1 3 9 0 0

SGH & GDH Nov-13 25 14 11 1 1 9 0 0

SGH & GDH Dec-13 22 13 9 2 2 4 1 0

SGH & GDH Jan-14 23 14 9 4 1 3 0 1

SGH & GDH Feb-14 18 8 10 3 1 6 0 0

SGH & GDH Mar-14 20 10 10 1 4 4 0 1

SGH & GDH - 302(303) 137(128) 165(175) 25(23) 31(22) 103(124) 1(1) 5(5)

Overall Total 532(543) 261(260) 271(283) 45(40) 39(33) 171(196) 3(5) 13(9)

2.3 MRSA Screening

Up until the end of this year, there was a national requirement to screen all patients admitted for the presence of MRSA. The compliance standard was the total number of screens divided by the total number of admissions so a figure well in excess of 1.0 was easily achieved. For some years however, we have used internally a more specific marker that matches screens to patients to determine to what extent our screening programme caught all admissions. Whilst 100% compliance is unreasonable to expect, rates in excess of 90%, and preferably 95%, should be obtained. The figures actually achieved for the last few years are shown in Table 2.4 with the day cases being included in the “All Patients” line.

Table 2.4: Overall Routine MRSA Admission Screening Compliance

Patient Group 2014/2015 2013/2014 2012/2013 2011/2012

All Patients 94.0% 91.9% 93.3% 93.9%

Elective admissions 99.5% 92.6% 94.4% 95.2%

Non-elective admissions 96.1% 91.5% 93.5% 93.2%

Figure 2.1 below shows the overall picture by site and month for the last year and a typical

monthly report.

OH Other Hospital

GPC GP/Pre assessment/ Community (positive in Community prior to first positive in the Trust)

OA On Admission Screen

CLIN Clinical Specimen

Other Other Screen

( ) Figures for 2013-2014

Page 11 of 46

Figure 2.1: Annual MRSA screening rates by site and month

Page 12 of 46

3 Other Bacteraemias in the Mandatory Reporting Scheme

3.1 Meticillin-Sensitive Staphylococcus aureus (MSSA) Bacteraemias

The reporting of Meticillin Sensitive Staphylococcus aureus (MSSA) bacteraemias became mandatory from January 2011. The numbers of MSSA bacteraemias detected during the current year are shown in Table 3.1 below. Historically, only absolute numbers of MSSA bacteraemia were collected and these are shown below for comparison purposes only. At the moment, there is no requirement to differentiate “Hospital-Acquired” from “Community-Acquired” cases but some data relating to this has become available for the last few years. The definition of Trust-Acquired vs Community-Acquired is based on the positive blood culture sample being collected on or after the 3rd day of admission. All actions taken to minimise MRSA bacteraemias will have the effect of minimising MSSA bacteraemias. To date, we are aware of no plans nationally to issue a limit value or target for this condition though the local commissioners have tried and we are resisting this.

Table 3.1: MSSA Bacteraemias 2005-2015

Year Total MSSA

Bacteraemias NL&G Hospital

-Acquired Community -

Acquired Other Hospital

-Acquired

2005/06 62 N/A N/A N/A

2006/07 89 N/A N/A N/A

2007/08 81 N/A N/A N/A

2008/09 73 N/A N/A N/A

2009/10 55 N/A N/A N/A

2010/11 78 N/A N/A N/A

2011/12 61 20 (32.8%) 40 (65.6%) 1 (1.6%)

2012/13 62 10 (16.1%) 50 (80.6%) 2 (3.2%)

2013/14 69 19 (27.5%) 49 (71.0%) 1 (1.4%)

2014/15 71 14 (19.7%) 56 (78.9%) 1 (1.4%)

Figure 3.1 shows the isolates broken down by source and month. There were no cases from Goole. The national mandatory surveillance system requires an assessment of the likely source of origin of the infection and this is displayed in Figure 3.2. The source of a Staphylococcal infection is often not obvious so it is not unusual not to be able to identify one. As usual, skin/soft tissue and bone and joint sources are deemed to be the commonest source of infection when one is identified. The number of infections related to recreational drug use was less this year than in previous years.

Page 13 of 46

Figure 3.1: MSSA bacteraemias by month and source

Figure 3.2: Probable source of MSSA bacteraemia

3.2 Escherichia coli (E. coli) Bacteraemias

The national reporting of Escherichia coli in blood cultures became mandatory from June 2011 following an observation by the then Health Protection Agency that E. coli was now the commonest isolate from blood cultures. To date, we are not aware of any plans to issue a limit value or target for this condition. Local figures are shown in Table 3.3

0

1

2

3

4

5

6

7

8

9

10

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

Trust-Acquired DPoW Trust-Acquired SGH Community-Acquired Other Hospital-Acquired

0

4

8

12

16

Grimsby Scunthorpe & Goole

Page 14 of 46

Table 3.3: E. coli Bacteraemias

Year Total E. coli

Bacteraemias NL&G Hospital

Associated Other Hospital

Associated Community Associated

2011/2012 215 35 (16.3%) 5 (2.3%) 175 (81.4%)

2012/2013 283 39 (13.8%) 0 (0.0%) 244 (86.2%)

2013/2014 280 35 (12.5%) 0 (0.0%) 245 (87.5%)

2014/2015 300 34 (11.3%) 0 (0.0%) 266 (88.7%)

The trend towards increasing numbers is mirrored in the national data. National figures also suggest that the rates are slightly higher in the North of the country. The ESPAUR Report (Public Health England, September 2014) notes the following:

Likewise local Public Health England (PHE) surveillance also shows an increasing trend with hospitals in Yorkshire and the Humber showing rising numbers each quarter. The quarterly figures are shown below (corresponding all of England figures are in brackets):

2013 Q4 1005 (8623)

2014 Q1 1007 (8380)

2014 Q2 1034 (8886)

2014 Q3 1100 (9475)

Figure 3.3 shows the difference, in relative proportions, between hospital acquired and community acquired E. coli infections. In inpatients, urinary tract and hepatobiliary infections are proportionally rarer because these are usually the reason for the initial admission whereas intra-abdominal infections are commoner reflecting post-surgical complications. The two “respiratory” sources in the community are questionable and probably should be reassigned to “No-obvious source” because E. coli does not cause respiratory infections in non-ventilated patients.

Likewise local Public Health England (PHE) surveillance also shows an increasing trend with hospitals in Yorkshire and the Humber showing rising numbers each quarter. The quarterly figures for 2013/14 are shown below (corresponding all of England figures are in brackets):

2013 Q4 1005 (8623) 2014 Q1 1007 (8380) 2014 Q2 1034 (8886) 2014 Q3 1100 (9475)

Figure 3.3 shows the difference, in relative proportions, between hospital acquired and community acquired E. coli infections. In inpatients, urinary tract and hepatobiliary infections are proportionally rarer because these are usually the reason for the patient’s initial admission whereas intra-abdominal infections are commoner reflecting post-surgical complications. The two “respiratory” sources in the community are questionable and probably should be reassigned to “No-obvious source” because E. coli does not normally cause respiratory infections in non-ventilated patients.

Incidence of E. coli bloodstream infections

Between 2010 and 2013, the overall incidence of E. coli bloodstream infections in England, based on voluntary

reporting to LabBase2, increased by 12% from 47.0 to 52.6 cases per 100,000 population (Table 2.2). Some degree

of seasonal variation was noted with more isolates reported each year in quarter 3 (Figure 2.1). Year-on-year

increases were seen in the South of England (overall increase over 4 years of 17%), London (19%) and the

Midlands and East of England (11%) while in the North, the incidence increased between 2010 and 2012 but

decreased in 2013 to give an overall increase over the four-year period of 6%. Comparison with the numbers of E.

coli bloodstream infections reported to the national mandatory reporting scheme (which started in June 2011)

showed 84% case ascertainment through voluntary reporting to LabBase2 in both 2012 and 2013. A comparison of

both voluntary and mandatory reporting at regional level showed inter-regional variation in case ascertainment,

ranging from 90% in London, 87% in the Midlands and East, 86% in the South to 78% in the North. Of the 25 ATs,

five (three in the North and two in the South) reported <70% of cases in 2013.

Table 2.2 Incidence of E. coli bacteraemia by NHS Region, 2010 to 2013, based on voluntary reporting to

LabBase2 Rate per 100, 000 population

NHS Region 2010 2011 2012 2013 South 40.6 44.8 45.7 47.7

London 42.3 46.7 47.9 50.2

Midlands and East 49.0 52.2 52.7 54.3

North 53.0 57.7 57.5 56.4

England 47.0 51.0 51.5 52.6

Page 15 of 46

Figure 3.3: Hospital-acquired vs Community-acquired E. coli bacteraemia

4 Clostridium difficile

The Trust has, for many years now, taken an active and aggressive approach to limiting the numbers of cases of Clostridium difficile-associated disease (CDAD) sometimes known as Clostridium difficile infection (CDI). Last year we posted a total of twenty four cases against a target limit of thirty Trust-acquired cases of CDI for the period. This year, following a national rebasing exercise, the Trust was set a target limit of thirty three cases. We are happy to report that this year we achieved this taxing target reporting a grand total of only twenty cases. We had a further twenty two cases identified in the hospitals subsequently deemed to be from community sources and no cases were imported from other institutions. Table 4.1 below shows the number of cases reported by the Trust for the last few years. The table excludes the cases identified in samples submitted from General Practice that numbered seventeen this year.

Table 4.1: Clostridium difficile Cases by Year 2008 – 2015

Year Grimsby Scunthorpe & Goole Combined

Total for Year Total HAI Total HAI

2008/2009 64 48 (75.0%) 100 84 (84.0%) 164

2009/2010 43 25 (58.1%) 41 27 (65.9%) 84

2010/2011 36 24 (66.7%) 27 19 (70.4%) 63

2011/2012 38 31 (81.6%) 29 14 (48.3%) 67

2012/2013 29 21 (72.4%) 25 17 (68.0%) 54

2013/2014 21 13 (61.9%) 21 11 (52.4%) 42

2014/2015 27 13 (48.1%) 15 7 (46.7%) 42

Figure 4.1 below is the official distribution, by month, of cases assigned to the Trust from Public Health England (2013/14 data shown as yellow bars).

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hospital-Acquired Community-Acquired

Unknown/ No obvious source

Other

Indwelling Intravascular device

Bone and joint

Skin/soft tissue

Other Intra-abdominal

Genital tract (inc. prostate)

Hepatobiliary

Respiratory tract

Urinary tract

Page 16 of 46

Figure 4.1: Clostridium difficile Apportioned to the Trust April 2014 to March 2015

Of the twenty cases designated as Trust-acquired last year, eighteen were deemed not preventable, one possibly preventable and only one was deemed preventable. Appropriate action plans were drafted and implemented to prevent recurrence. Similarly to last year, a proportion of the hospital-acquired cases, this year only one as opposed to the four last year, were only apportioned to the Trust due to delays in the collection of the samples (delayed identification cases – See Figure 4.2) showing the significant continuing improvements made over the year.

Figure 4.2: Community vs Hospital cases

Imported from Other Hospital

Community-Acquired

Delayed Identification

Hospital-Acquired

Page 17 of 46

All cases of CDAD are supposed to be the subject of a multidisciplinary team review (MDT) to assess their ongoing management needs and to assess their underlying co-morbidities. This MDT review also forms the first part of the Root Cause Analysis process for each case. Unfortunately, these MDTs may be cancelled for a number of reasons; most commonly the lack of availability of key players or, increasingly, the changes in the general status of the patient rendering them unnecessary, eg patient has already recovered or been discharged. Of the twenty cases last year, for one reason or another, seven patients (35%) did not have an MDT.

CDAD can be a significant disease that can carry considerable mortality. Over the past few years, mainly through the mechanism of the MDTs mentioned above, we have significantly reduced the 30-day (all-cause) mortality in the affected patients. Figure 4.3 below shows the all-cause 30-day mortality rates for CDAD patients over the last few years.

Figure 4.3: Percentage all-cause 30-day mortality in CDAD cases

Additionally, for the last few years, we have attempted to predict the mortality associated with Clostridium difficile-associated disease (CDAD) by roughly calculating the expected mortality of the patient due to underlying conditions present at the time of but NOT related to the diagnosis of CDAD. This is also part of the role of the MDT. As noted above, the MDTs did not occur on seven patients and unfortunately, for reasons that are unclear, the relevant data is missing for a further five patients this year. In order to avoid bias, this missing data is shown in grey. The trend over the last few years suggests that the improvement in mortality may be more of a reflection of the underlying co-morbidities of the patients getting CDAD suggesting that we are getting better at preventing cases in the extremely unwell. This data is summarised in Figures 4.4 and 4.5. For those patients who did succumb within thirty days of a diagnosis of CDAD, Figure 4.6 shows the mortality assessed as directly attributable to the Clostridium difficile disease. This year, in only one case could cause of death be even possibly attributed to Clostridium difficile.

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

2014/2015

2013/2014

2012/2013

2011/2012

2010/2011

2009/2010

2008/2009

% Mortality Data Missing

Page 18 of 46

Figure 4.4: CDAD expected mortality pre-diagnosis, all cases

Figure 4.5: Expected mortality in CDAD cases who did not survive 30 days

Figure 4.6: Mortality attributable to Clostridium difficile

2011/12

2012/13

2013/14

2014/15

0% 20% 40% 60% 80% 100%

>90% 76 - 90% 26 - 75% 10 - 25% <10% No MDT Data missing

0% 20% 40% 60% 80% 100%

2014/2015

2013/2014

2012/2013

2011/2012

<10%

10-25%

26-75%

76-90%

>90%

Missing data

0% 20% 40% 60% 80% 100%

2014/2015

2013/2014

2012/2013

2011/2012

2014/2015 2013/2014 2012/2013 2011/2012

Definate 0 1 1 1

Probable 0 1 1 0

Possible 1 2 3 2

Unlikely 0 0 6 6

Not 3 5 5 8

Missing Data 0 1 0 3

Page 19 of 46

5 Antibiotic Resistant Organisms

Antibiotic resistance remains a major concern for many agencies worldwide. Locally, surveillance of antibacterial resistance rates continues to show only a very slow and steady increase over the last few years. As yet, we are not seeing the massive increases in major resistance that has been experienced recently in places like Italy and Greece. Figure 5.1 shows the sensitivity of urinary coliforms (the most common group of significant organisms isolated from clinical samples) to first line antimicrobials in the Greater Lincolnshire area. It is neither practicable, nor desirable due to the passage of patients across notional catchment area boundaries, to restrict this sort of data to a single Trust. While there is a clear downward trend, it only represents a couple of percentage points over the last six or seven years.

Figure 5.1: Urinary coliforms 1st line sensitivity

Likewise and of more concern, amongst the large numbers of basically sensitive organisms mentioned above, there is a growing population of resistant organisms, some of which carry ESBLs (Extended Spectrum Beta Lactamases) about which there is so much alarm. Table 5.1 below shows the rise in isolation rates of these organisms. Whilst the rates appear low and the rises small, it is worth remembering that each data point in the graph above or line in the table below represents something in the order of 20,000 isolates so a small percentage rise can, in fact, represent several hundred cases.

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

% S

en

sitiv

e

All Urinary Coliforms

Co-amoxiclav Amoxicillin Cefalexin

Nitrofurantoin Trimethoprim

Page 20 of 46

Table 5.1: Percentage Resistant and ESBL-producing Urinary Coliforms

Time Period

Resistant Organisms % of all Coliforms

ESBL producers % of Resistant Organisms

ESBL producers % of all coliforms

Mar 08 – Aug 08 4.80% 20.79% 1.00%

Sep 08 – Feb 09 6.93% 16.67% 1.16%

Mar 09 – Aug 09 5.26% 24.32% 1.28%

Sep 09 – Feb 10 5.17% 25.97% 1.34%

Mar 10 – Aug 10 5.21% 35.38% 1.85%

Sep 10 – Feb 11 5.26% 32.16% 1.69%

Mar 11 – Aug 11 5.83% 37.19% 2.17%

Sep 11 – Feb 12 7.23% 28.43% 2.06%

Mar 12 – Aug 12 6.44% 36.03% 2.32%

Sep 12 – Feb 13 6.12% 42.05% 2.58%

Mar 13 – Aug 13 6.28% 44.19% 2.78%

Sep 13 – Feb 14 7.02% 36.75% 2.58%

Mar 14 – Aug 14 7.20% 38.94% 2.80%

Sep 14 – Feb 15 6.86% 47.48% 3.26%

Whilst, inevitably, there is some period to period variation, the underlying trend towards increased incidence is clearly visible. Figure 5.2 below shows the sensitivity rates of these ESBL producing organisms to several second and third line antimicrobials remembering that these organisms are, by definition, resistant to all the penicillin and cephalosporin groups of antibiotics (typical first line oral antibiotics and the mainstay of in-hospital intravenous antimicrobials) unless otherwise stated. Drugs with an asterisk are parenteral use only compounds.

Figure 5.2: ESBL-producing Urinary Coliforms 2nd line sensitivity

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

% S

en

sit

ive

ESBL Producing Coliforms Ciprofloxacin Ertapenem* Fosfomycin Gentamicin*

Mecillinam Nitrofurantoin Temocillin* Trimethoprim

Page 21 of 46

The general trend here is clearly one of stable resistance rates within this organism population. This is unusual but may be due more to our stable population in this area than anything else. However, when combined with the slowly increasing incidence rate, the overall picture is one of gradually increasing resistance. This, in turn, leads to an increased reliance on reserve antibiotics such as Carbapenems (see Section 6). The “last line” in antibiotics we have are a group of agents called Carbapenems. Resistance to these agents is usually accompanied by resistance to multiple other classes of antimicrobial making infections from bacteria showing this characteristic extremely difficult to treat. Resistance takes one of three forms; intrinsic, “membrane system changes” and carbapenemase production. Intrinsically resistant species have been known for years and are not a concern since their resistance pattern is stable and resistance cannot be transferred to other bacteria. They are usually also susceptible to other antibiotics. Furthermore, intrinsically carbapenem-resistant species are, as a rule, rarely pathogenic. Bacteria showing resistance by “membrane system changes” pose a bigger problem. This mechanism of resistance can be viewed as a variant of the intrinsic mechanism and consists of changes to the complex efflux pumps and porin (channel) molecules that allow bacteria to pass nutrients through their rigid cell walls and membranes without which the organism could not survive. It is found in species that are not expected to be intrinsically resistant such as Pseudomonas spp. Although this mechanism cannot be passed from organism to organism, it can be very difficult to determine whether or not the resistance pattern being displayed is due to efflux pump up-regulation and/or porin loss, or to the production of a carbapenemase. Thus patients displaying infection or colonisation with these organisms have to be isolated and treated as if they were carbapenemase producers until such time as an extensive molecular analysis has been performed on the isolate. Such an analysis may take several days, or even weeks, meaning that prolonged, enhanced-level isolation is required. The real worries are the carbapenemase producers. These are bacteria that produce an enzyme that destroys the incoming antibiotics. Carbapenemases destroy not only carbapenems but also penicillins and cephalosporins - in other words approximately sixty per cent of all available antibiotics. There are several flavours of these enzymes, all known by various acronyms such as; KPC, VIM, NDM, IMP, OXA, etc. Furthermore, this mechanism of resistance may be readily spread from one bacterium to others, even members of different genera and species. The potential for spread of these infections is therefore huge since it is not just the spread of a bacterium that needs to be controlled but effectively the spread of a gene. Once the gene is resident in a person’s intestinal flora (and staff can catch it too), the characteristic can almost never be eradicated. Thus the detection of one of these organisms triggers a major contact tracing exercise. Over the course of the last year we have had several episodes where potential carbapenemase producers were identified and these are listed in Table 5.2 below. Of the seven cases identified, only two were eventually shown to be carbapenemase producers.

Page 22 of 46

Table 5.2: Potential Carbapenemase Producers Identified

Case Number

Location Specimen Type Organism Resistance Mechanism

Carbapenemase Type

1 Surgery DPoW

ICN Screen Klebsiella pneumoniae-pneumoniae

Carbapenemase OXA

2 ITU SGH Sputum Pseudomonas aeruginosa Carbapenemase IMP

3 ITU SGH Sputum Pseudomonas aeruginosa Membrane -

4 ITU SGH Sputum Pseudomonas aeruginosa Membrane -

5 Surgery DPoW

Wound Swab Pseudomonas aeruginosa

Membrane -

6 ITU DPoW

Broncho-alveolar Lavage

Pseudomonas aeruginosa Membrane -

7 General Practice

Urine Pseudomonas aeruginosa Membrane -

Case numbers 2, 3 and 4 were associated with a single outbreak investigation but there was no evidence of cross infection and the organisms turned out, on further analysis, to be unrelated. No secondary cases were identified from the case-finding exercise performed after the detection of case number 1.

6 Antibiotic Stewardship Promoting optimal antimicrobials stewardship is the primary role of the Consultant Pharmacist, Antimicrobials (CPhA), who liaises between the Pharmacy Department and Infection Prevention & Control Team and with clinicians Trust wide on this issue. The prevention of the development antimicrobial resistant micro-organisms is a hot topic nationally and internationally, with relevant guidance being issued by organisations such as NICE and Public Health England. Good antimicrobials stewardship is key to slowing this development, as the pipeline for the development of new antimicrobials is lacking in new classes of these agents. The Trust’s Morbidity and Mortality Action Plan continues to concentrate on the treatment of sepsis as one of its key targets to reduce morbidity and mortality. Additionally, there will be national CQUIN targets for the management of sepsis and the rapid deployment of the most appropriate antibiotics is a crucial aspect of ensuring optimal patient outcomes. A Sepsis Morbidity and Mortality Group has been formed to examine factors that increase the risk of sepsis, the harm from sepsis and to check whether the management of sepsis follows national guidelines. As part of this process, Microbiologists, CPhA and a nurse with a specialist interest in sepsis have developed a chart to show the recommended local antibiotic choices for the treatment of sepsis and other commonly encountered infections in all body systems. Additionally, antibiotic stocks in therapeutic areas have been reviewed in order to ensure rapid availability of critical antibiotics when needed. The sustainability of the Antimicrobials Steering Group has been achieved by incorporating it as a subgroup of the Trust’s Medicines and Therapeutics Committee so that antimicrobials issues are considered and discussed monthly by a range of Trust clinicians including the CPhA and a Consultant Microbiologist. Members of the NLAG Infection Prevention & Control Team continue to attend meetings of the Humberside Health Community to network and share good practice in the management of health care acquired infections, including the optimum use of antimicrobials. Recently, this group has focused some of its attention on the containment and treatment of CPE infections, including the availability of appropriate antimicrobials.

Page 23 of 46

In order to improve compliance with good antimicrobial prescribing standards, the CPhA has led the development of a modified Trust prescription sheet, with dedicated antibiotic prescribing sections incorporated. These will encourage prescribers to include indications, course durations and 48-hour review of all antibiotics, as per local and national standards. Audit of antibiotic prescribing and usage continues, including audit of antibiotic prescribing standards, surgical prophylaxis and appropriate antibiotic use in the treatment of COPD exacerbations. The CPhA continues to develop and deliver antibiotic education and training on the prudent use of antimicrobials to new doctors in the Trust on both the annual changeover and monthly, as needed. Education sessions on good antimicrobial stewardship have also been incorporated into FY2 training and ad hoc training sessions have been delivered when a need has been identified eg to minimise the risks associated with aminoglycoside treatment. The Path Links Antimicrobial Formulary Committee continues to meet on a 6-monthly basis to review and develop the Antibiotic Formulary and Prescribing Advice for Adult and Paediatric Patients to keep it up to date with changes in national guidance and local sensitivity and resistance patterns of micro-organisms. The committee is also exploring the incorporation of the Adult and Paediatric publications into an application to be made available on mobile devices and desktop computers to improve availability and access and plan to deliver on this within the 2015/16 year. Analysis and Comparison of NLAG Antibiotics Prescribing 2015-2016 The following charts present antibiotics prescribing data for Northern Lincolnshire and Goole NHS Foundation Trust, in comparison with other Acute Trusts within Yorkshire and Humber SHA and as antibiotics classes prescribed as proportions of the total. To ensure a direct comparison between Trusts of different sizes, standardised units of Defined Daily Doses per 1000 Trust beds have been used. Data has been extracted from the “Define” system, which monitors drug issues from Pharmacy clinical systems.

The position of Northern Lincolnshire and Goole NHS Foundation Trust’s antibiotics prescribing is at the median for Acute Trusts in Yorkshire and Humber SHA. In 2013 - 2014, it was higher than the median. This suggests some optimisation of the volume of use over the last year.

Page 24 of 46

Page 25 of 46

Northern Lincolnshire and Goole NHS Foundation Trust is an above average user of penicillins within the SHA, particularly in combination with beta-lactamase inhibitors (co-amoxiclav and piperacillin / tazobactam).

Northern Lincolnshire and Goole NHS Foundation Trust uses less cefalosporins than the SHA average, which is commendable as this class of beta-lactams poses a higher risk of encouraging Clostridium difficile proliferation.

Page 26 of 46

Northern Lincolnshire and Goole NHS Foundation Trust is the second highest user of carbapenems within Yorkshire and Humber SHA, particularly meropenem. This is a concern, as Carbapenemase Producing Enterobacteriaceae (CPE) are already a prominent multi-resistant problem in several countries worldwide and are now emerging in a number of centres in the UK and will become more significant over coming years.

Northern Lincolnshire and Goole NHS Foundation Trust is just below the median for Macrolides (mainly clarithromycin) usage in Yorkshire and Humber SHA, which is a reduction relative to other Y&H Trusts in comparison to last year. This class has a place in managing atypical bacteria in Community Acquired Pneumonia and in penicillin allergic patients, so usage is justified.

Page 27 of 46

Northern Lincolnshire and Goole NHS Foundation Trust’s clindamycin usage has moved to below the median for Yorkshire and Humber SHA, compared with the previous year. This antibiotic used to have a bad reputation as being a direct cause of pseudomembranous colitis, but is safer in this respect when used in appropriate / higher doses. It has a definite place in the management of necrotising fasciitis, but also for treating other infections in patients with penicillin allergy, e.g. cellulitis, diabetic foot, etc.

Northern Lincolnshire and Goole NHS Foundation Trust is the lowest user of glycopeptide antibiotics (vancomycin and teicoplanin) in Yorkshire and Humber SHA. Overuse of these antibiotics leads to the development of glycopeptide resistant enterococci. We use slightly more defined daily doses per 1,000 Trust beds of teicoplanin than vancomycin.

Page 28 of 46

Northern Lincolnshire and Goole NHS Foundation Trust is also the lowest user of aminoglycoside antibiotics (Amikacin, gentamicin, netilmicin and tobramycin) in Yorkshire and Humber SHA. Gentamicin is the compound mainly used, with a much lower proportion of tobramycin. This class of antibiotics has a low propensity to encourage Clostridium difficile proliferation, and is extremely effective at clearing septicaemia caused by organisms sensitive to this class. Although the spectrum of activity of the class is broad, it does not cover all organisms and the drugs are only available for parenteral or nebulised use.

7 Isolation (including Outbreaks and Incidents)

7.1 Isolation

A large proportion of the IPCN’s time is taken up dealing with problems regarding isolation of patients. There is a chronic shortage of suitable isolation rooms on both sites but more so at the Grimsby site. Table 7.1 shows the number of patients isolated for infective causes over the last few years. It does not include isolation/use of single rooms for other reasons, eg disruptive patients, end-of-life care, etc. other than “protective isolation” which is used for patients who are at significantly increased risk of contracting an infection, eg post-chemotherapy patients.

Table 7.1: Number of Patients Placed in Isolation

2014/2015

2013/2014

2012/2013

Scunthorpe General Hospital & Goole District Hospital

2105 1772 1577

Diana, Princess of Wales, Hospital, Grimsby

2358 2358 2451

Total 4463 4130 4028

Page 29 of 46

Table 7.2 shows the twelve commonest reasons for isolation and their relative frequency on each site this year. There are very few surprises in the list with gastroenteritis, MRSA and cellulitis continuing to dominate. The arrows indicate whether or not this condition was relatively more or less common than last year. Of some concern, given the shortage of isolation facilities at Grimsby, “Inappropriate isolation” - being the isolating of patients who did not require it - was the 10th most common reason for isolation on that site.

Table 7.2: Top Twelve Reasons for Isolation

Scunthorpe General Hospital & Goole District Hospital

Diana, Princess of Wales, Hospital, Grimsby

Reason for Isolation Total Percentage Reason for Isolation Total Percentage

Diarrhoea and/or Vomiting 914 43.42% Diarrhoea and/or Vomiting 1140 48.35%

MRSA 583 27.70% MRSA 415 17.60%

Cellulitis 225 10.69% Cellulitis 264 11.20%

Bronchiolitis 70 3.33% Bronchiolitis 127 5.39%

Meningitis 55 2.61% Tonsillitis 73 3.10%

Resistant Organism 31 1.47% Meningitis 71 3.01%

Influenza 28 1.33% Protective Isolation 66 2.80%

Protective Isolation 27 1.28% Rash 21 0.89%

Chickenpox or Shingles 18 0.86% Quinsy 21 0.89%

Tuberculosis 17 0.81% Inappropriate Isolation 17 0.72%

Scabies 12 0.57% Resistant Organism 16 0.68%

Miscellaneous 9 0.43% Tuberculosis 14 0.59%

Total “Top 12” 1989 94.49% Total “Top 12” 2245 95.21%

Given the shortage of isolation facilities, especially at Grimsby, as mentioned above, it is inevitable that there would be failures to correctly isolate a number of patients. Table 7.3 explores these failures and the reasons for them. As expected, a small number are due to the physical absence of appropriate facilities on the unit where the patient is required to be (typically coronary or intensive care) and these are listed as “No Facility Present”. A more frequent occurrence is where all suitable facilities are already in use (No Facility Available). Small numbers of patients occasionally have good clinical reasons for them not to be isolated (e.g. Falls Risk exceeds Infection Control risk) and these are listed under “Clinical Decision”. Regrettably, despite intensive educational campaigns, failure to follow correct procedures (Failure in Procedure) remains by far the commonest cause of failure to isolate incidents.

Table 7.3: Failure to Isolate Incidents

Reason for failure to Isolate

Scunthorpe General Hospital &

Goole District Hospital (% of SGH & GDH)

Diana, Princess of Wales, Hospital, Grimsby

(% of DPoW )

Total (% of all cases)

Failure in Procedure 72 (74.2%) 123 (66.5%) 195 (69.1%)

No Facility Available 12 (12.4%) 45 (24.3%) 57 (20.2%)

No Facility Present 3 (3.1%) 15 (8.1%) 18 (6.4%)

Clinical Decision 10 (10.3%) 2 (1.1%) 12 (4.3%)

Not isolated (% of all cases)

97 (34.4%) 185 (65.6%) 282 (100%)

Page 30 of 46

7.2 Ebola

The West-African countries of Sierra Leone, Liberia and Guinea seem a long way from Northern Lincolnshire but the massive outbreak of Ebola Haemorrhagic Fever there had a huge impact on the work of the IPCT this year. The possibility of a case being imported into this area required the IPCT to completely review the policies and procedures for dealing with patients who potentially had a Viral Haemorrhagic Fever (VHF). With staff safety as a key priority, in the absence of guidance from the centre in the early months and following a near-miss incident (see below), the team researched, advised and sourced an initial supply of Personal Protective equipment (PPE). Following evidence that the British nurse who contracted Ebola in Sierra Leone caught it whilst removing their PPE, a step by step, pictorial guide for the donning and doffing of PPE was then produced and rolled out to the areas where a potential patient with Ebola may be expected to be managed, namely; both ECCs, ITUs, Ward C6 and Ward 22. Key members of staff were trained by the IPCT in the safe use of PPE and posters and training materials were produced. Successful, table top exercises were subsequently performed to test procedures. In addition cleaning procedures for areas that may have to cope with patients potentially infected with a viral haemorrhagic fever like Ebola were revisited and appropriate plans, including the arrangements for calling in an external contractor to fumigate the areas were put in place. Fortunately, no genuine cases were encountered although a couple of false alarms did occur and these, along with the aforementioned table top exercises, provided useful insights and pointers to required improvements that were subsequently implemented.

7.3 Incidents and Outbreaks

7.3.1 Outbreaks

We were not as fortunate this year in comparison with last year which seemed to have been an unusually easy year with respect to outbreaks of viral gastroenteritis - the final figures being more akin to those of two years ago than last year (data shown for comparison). Our approach of cohorting affected bays in line with national policy was, however, successful in preventing full ward closure in six of the nineteen outbreaks (32%). Overall bed pressure remains the largest problem in managing these outbreaks.

Table 7.4: Numbers affected and Lost Bed Days due to Viral Gastroenteritis

Month No. of Wards Affected

No. of Patients Affected

No. of Staff Affected

No. of Bed Days Lost

April 2014 1 5 0 1

May 2014 0 0 0 0

June 2014 1 4 0 7

July 2014 0 0 0 0

August 2014 2 23 22 120

September 2014 1 14 6 54

October 2014 0 0 0 0

November 2014 0 0 0 0

December 2014 5 41 29 298

January 2015 2 26 11 116

February 2015 4 43 27 135

March 2015 3 26 11 128

Total 2014/2015 19 182 106 859

Total 2013/2014 6 47 14 87

Total 2012/2013 39 323 138 1075

Page 31 of 46

7.3.2 Incidents

Throughout the year the team have had to handle a number of Infection Control-related incidents. Some of the more interesting ones are listed below:

Between July and October 2014, three patients were found to have a Pseudomonas in their sputum that was resistant to multiple antibiotics including the carbapenems. All three patients were identified as having been cared for in the same intensive care unit with one having been transferred to the other hospital’s ITU due to bed pressures. An Outbreak Control Meeting was held, an investigation commenced and an action plan drafted. Following the investigation, no evidence of further spread or cross infection was found and no significant breaches in practice were detected.

In December 2014 a care home was closed with a suspected outbreak of influenza. The community IPCNs were not informed promptly and this led to several patients being admitted to hospital and not isolated on admission because the hospital was not aware of the outbreak. The patients were all subsequently identified, isolated and treated appropriately and then discharged back to the care home following their recovery.

A patient with symptoms compatible with Ebola attended A&E following advice from NHS 111 to attend a local hospital. The patient, who had been working in Sierra Leone until nine days previously was admitted to a side room in the ECC and attended by staff wearing the best PPE they had available. A Viral Haemorrhagic Fever (VHF) assessment was completed and the patient remained in A&E until blood tests confirmed the diagnosis as malaria. The patient was subsequently transferred to Castle Hill Hospital. A number of issues were raised by this incident including the resistance to accept the patient by the only ward in the hospital with facilities suitable for holding this patient as well as a failure of communication with the laboratory regarding the “Extreme High Risk” nature of the blood sample and that VHF was being considered as part of the differential diagnosis.

Following this incident the IPCT reviewed the patient care pathway for potential VHF and made significant changes including ensuring the provision of appropriate PPE and training in the correct use of it. In addition, PHE and the national Imported Fever Service were also involved during this patient’s admission in Hull because a number of their processes were also found to be lacking.

In November 2014, a urine sample received from a patient tested positive for the presence of CPE. The patient had been an inpatient for three weeks but had not met the criteria of requiring screening as outlined on the CPE Admission Assessment Criteria. Contact screening was performed for four weeks on patients from three wards but no positive contacts were detected. PHE was informed.

Six patients were identified with Clostridium difficile over a period of a few weeks on a single ward. An Outbreak Control Group was formed in accordance with Trust policy. No cross infection was identified. A number of actions were identified which were included in the Trust Clostridium difficile Action Plan and these were monitored by the site specific Clostridium difficile action group. A DIPC review was scheduled for each case.

Page 32 of 46

Following four confirmed cases of community-acquired Legionella disease in the Grimsby area, Public Health England (PHE) declared the situation an outbreak. All four patients were admitted to DPoW, treated and subsequently discharged home. Nationally teleconferenced, multi-agency outbreak control meetings, in line with PHE procedures were held and all reasonable investigations and control measures were taken. No positive environmental samples were obtained, no obvious point source was determined and there have been no subsequent cases however enhanced surveillance is ongoing.

8 Surgical Site Infections

Surgical site infection (SSI) reporting following joint replacement continues to be a mandatory requirement. It is monitored by means of the HPA Surgical Site Infection Surveillance Service (Formerly NINSS). The current surveillance process ensures that infections are recognised and reviewed on an individual basis using a multi-disciplinary approach. Each case of hip or knee replacement or repair of neck of femur that fulfils the criteria for the HPA definition of SSI is subject to a formal root cause analysis process (RCA). While the Trust is seeing an increase in reported infection associated with joint replacement, nationally there has also been an increase. The Trust is now moving closer towards the national average but remains significantly below it. The numbers of infections are so small that ascertainment errors continue to have the potential for having disproportionate effects upon the overall rate. Table 8.1 below shows the reported infection rates for the last 5 years for each of the hospital sites.

Table 8.1: Surgical Site Infections April 2010 to December 2014

Table 8.2 below shows the reported infection rates for each hospital for the prior 5-year period (2005 – 2010). The national average is shown for comparison. While figures concerning infections in hip fractures have been routinely collected in Scunthorpe for several years, Grimsby only started routinely collecting the data in 2011 (hence the difference in numbers of operations.) Trauma surgery is not routinely performed in Goole.

All Hospitals

Grimsby Scunthorpe Goole

National Rate (%)

No. Ops

No. Inf

% Inf No. Ops

No. Inf

% Inf No. Ops

No. Inf

% Inf

Hip Replacement 1.2 861 5 0.7 677 5 0.7 616 2 0.3

Knee Replacement 1.7 889 8 0.9 744 1 0.1 921 2 0.2

Repair Neck of Femur

1.6 815 7 0.9 1034 10 0.9 5 0 0

Page 33 of 46

Table 8.2: Surgical Site Infections April 2005 to March 2010

9 Decontamination

There is little to report on decontamination this year. The externally contracted HSDU service with Synergy has bedded in and we are experiencing few problems. The new endoscope washer-disinfectors installed in Grimsby have also bedded in and plans are well advanced for the replacement of the corresponding units in Scunthorpe and subsequently for Goole. Inevitably, there were a number of minor decontamination issues that arose but these were addressed by the Decontamination Committee over the year. The major outstanding issue currently exercising the Committee is the arrangements for the decontamination of instruments used by the community chiropody service. A number of approaches are being examined including increasing the proportion of items that are sent to Synergy for reprocessing rather than being reprocessed in local community facilities.

10 Vascular Access and Invasive Devices

The Vascular Access and Invasive Devices team currently offers a service to insert Peripherally Inserted Central Catheters (PICC) and Midline Catheters. These devices enable patients with poor venous access to receive antibiotics, chemotherapy, blood products, fluid replacement and Total Parenteral Nutrition (TPN) reliably with minimal discomfort. The majority of oncology PICCs are placed by the Oncology Team and that data is not included in this report. The service continues to develop but has not yet reached full capacity as was anticipated. Maggie Parker IDCNS at DPOW completed PICC training in September 2014 but the Lead Nurse for Invasive Devices left the post in November 2014. The PICC service at DPOW is enthusiastically supported by Dr Gooch (Consultant Anaesthetist) whose hands-on approach supports training for anaesthetic staff and the IDCNS. A dedicated room in X-ray ensures a more streamlined approach to PICC placement and support from Radiology staff is much appreciated Ellie Bellamy, IDCNS for Scunthorpe, joined the team in October 2014 and, while the Lead Nurse supported her training for a few months after his departure, the acute PICC service at Scunthorpe was reluctantly suspended in December 2014. Ellie completed her training in April 2015 and is currently re-establishing the acute PICC service at Scunthorpe. Completion

All

Hospitals Grimsby Scunthorpe Goole

National Rate (%)

No. Ops

No. Inf

% Inf No. Ops

No. Inf

% Inf No. Ops

No. Inf

% Inf

Hip Replacement 1.1 1144 6 0.5 461 0 0 1029 3 0.3

Knee Replacement 1.1 1171 4 0.3 527 3 0.6 1442 3 0.2

Repair Neck Of Femur

1.9 17 0 0 397 4 1.0 1 0 0

Page 34 of 46

of a dedicated area to insert PICCs is eagerly anticipated and, with the support of Dr Hassenbaccus (Consultant Anaesthetist), a uniform vascular access service will be established cross-site. April 2015 saw the establishment of the Vascular Access Devices Steering Group (VADSG) whose principle aim is to advise and oversee the vascular access strategy on behalf of the hospitals and health care professionals within NLAG Foundation Trust. This group brings together key staff in Infection Prevention, clinical nurse specialists in Oncology and Haematology, anaesthetists and the IDCNS. The VADSG will not only meet the Governance agenda with regard to a safe unified vascular access service, but will also offer clinical support and knowledge sharing. Statistics Between 1st June 2014 and 1st June 2015, two hundred and fifty seven PICC/Midline catheters were inserted by the IDCNS. In addition a further nineteen were attempted but not successfully placed giving an insertion success rate of 93% that is comparable to the previous year. The two main complications for PICC placement are Catheter-Related Blood Stream Infections (CRBSI) and Upper Extremity Deep Vein Thrombosis (UEDVT). Both complication rates are displayed ‘live’ on the PICC database. Catheter Related Blood Stream Infection Within this report period 4 patients have developed a CRBSI making a total number of 6 since the PICC service started; one patient at DPOW and 3 at SGH giving a rate of 0.7 per 1000 catheter dwell days since June 2013. Note must be taken of considerable missing data for catheter dwell days up to June 2014. In this report period 2014/2015, missing data accounts for 8 patients, therefore the CRBSI rate would be lower than that recorded. All patients with a CRBSI had PICC placement to facilitate TPN. Further CRBSI data is seen in Table 10.1.

Table 10.1: Catheter Related Blood Stream Infection Rates

Number Cases

Rate per 1000 catheter dwell days

Dwell days Organisms/

Number patients

Total since Service started

6 0.7 8609*

2013 – 2014 2 0.51 3914* Candida = 2

2014 – 2015 All occurred between June - September

4 0.85 4695* Klebsiella Pneumoniae = 2 Candida Glabrealis = 1 Staphylococcus aureus = 1

15/9/2015 – to date 0 0

*missing data from catheter dwell days

Epic 3 (2014) analysis of studies relating to CRBSI for a variety of intravascular devices concluded CRBSI rates varied from 2 - 5 per 1000 catheter dwell days. While looking primarily at intensive care patients with central venous catheters, Matching Michigan (2012), reported a reduced rate of CRBSI of 1.88 /1000 catheter dwell days following the introduction of recognised best practice. The ultimate aim is to report zero CRBSI for all PICC and Midline Catheters and this has this been achieved in the last 9 months. Due diligence to High Impact Intervention CVC Care Bundles at PICC insertion and ongoing care has to be robustly reinforced through education and zero tolerance to poor practice.

Page 35 of 46

All six CRBSI cases were discussed at a meeting with the Deputy Director Infection Prevention, IDCNS DPOW and both Consultant Microbiologists. From this meeting a root cause analysis format has been developed for any subsequent CRBSI. This has been retrospectively applied to a case and found to be easy to use. The rates of CRBSI and UEDVT are a standing agenda item on both the bi-monthly IPC and VADSG meetings. Given that all cases of CRBSI had a PICC placed for TPN, its use was discussed in general. The need for TPN in some patients was not often clear and in two cases was required while PEG insertion was awaited. The Deputy Medical Director is currently addressing this issue. The good working relationship with dieticians is consolidated by the IDCNS contribution to the on-going nutrition meetings Upper Extremity Deep Vein Thrombosis (UEDVT) UEDVT is a known complication of PICC placement. A total of 10 patients developed UEDVT from June 2013 to June 2015; 7 at DPOW and 3 at SGH. Further break is down given in Table 10.2.

Table 10.2: Upper Extremity Deep Vein Thrombosis Rates

Number Cases

Rate per 1000 catheter

dwell days

Dwell days

Rate %** Affected Vessel/ Number patients

Total since Service started

10 1.16 8609* 1.82

2013 - 2014 3 0.76 3914* 1 Subclavian = 2 Jugular/subclavian/axillary = 1

2014 – 2015

7 1.49 4695* 2.7

Axillary = 2 Brachial = 2 Brachial and axillary = 1 Subclavian = 1 Axillary and subclavian = 1

*missing data from catheter dwell days. ** data presented as % for comparison to data in the literature

Nancy L. Moureau (PICC Excellence, Inc. Hartwell, GA USA) presented comparative evidence of thrombosis risk relating to PICC at the World Congress Vascular Access 2015. Rates of UEDVT reported by several authors, was in the range of 2 - 27%. We have recalculated our data in percentage format to offer some comparison to the literature. The Vascular Access Steering Group is now focused to research and implement best practice guidelines relating to UEDVT prevention and treatment. Interestingly, 4 patients showed clinical signs of UEDVT but were negative on Doppler ultrasound. Reassuringly UEDVT is also the focus of other national Vascular Access Services - all of which are happy to share knowledge and experience. Education The IDCNS are building on the work of our predecessors. Medical and nursing staff at DPOW and SGH are given bedside practical training ensuring competence in PICC management specifically:

Flushing and maintaining PICC patency

Redressing PICCs

Removing PICCs

Taking blood samples from the PICCs including blood cultures (only medical staff and critical care staff perform this task)

Page 36 of 46

Competence is measured using written assessment criteria and is primarily completed by the IDCNS. The first combined PICC and Central Venous Catheter study day was attended by 10 nursing staff at DPOW and positively reviewed. Further courses are planned allowing staff to relate more theory to their practice. Specific medical assessment competencies ‘Direct Observation of Procedural Skills’ (DOPS) are also completed by the IDCNS IDCNS Education Both IDCNS have completed their training package to insert PICCs. This has been augmented by courses delivered by the Telflex and SonoSite companies whose products we use. Ongoing ultrasound training will be accessed through local universities. The Infection Prevention Society Intravenous Forum provides up to date study events to share best practice and promote networking. IDCNS were pleased to attend and present on the Trust’s Nutritional Study Day in December 2014 run by Miss Kaur Consultant Surgeon at SGH. Patient Experience Various patient experiences are best illustrated by case study:

Patient A Patient required 6 weeks’ treatment for endocarditis with Gentamicin and Vancomycin. Peripheral vascular health rapidly deteriorated leading to discomfort and delayed administration of antibiotics. Insertion of a PICC gave the patient relief and reassurance that the condition would be effectively treated. Patient B This patient was investigated for recurring sepsis of unknown origin. The patient was anxious and emotional and PICC placement gave reassurance of effective treatment. Positive feedback was given via ‘Friends and Family’. Patient C One of several patients who had a PICC placed to continue antibiotics for resolving pneumonia. Administration of once daily antibiotics, on an outpatient basis, allowed this patient to recover at home. Early discharge freed a hospital bed. Patient D Recovering from spinal surgery complicated by an infection, the patient received daily antibiotic therapy for 6 weeks provided by the Hospital at Home Service. Many other patients with similar conditions such as cellulitis benefit from this service and the IDCNS provide support by gaining reliable access in the form of PICC or Midline catheters. Patient E Patient with drug-induced renal diabetes insipidus was continually removing IV cannula that interrupted life-saving IV fluid therapy and compounded dehydration. PICC placement ensured reliable access for IV fluids and blood sampling to normalise biochemistry.

The Future The service is well utilised by medical and surgical teams and it is anticipated a period of stability will now follow the establishment of two IDCNS providing a parallel service at DPOW and SGH. The anticipated appointment of a Nurse Consultant for the Deteriorating Patient will also provide two extra days per week for PICC insertion.

Page 37 of 46

With support through the Vascular Access Steering Group it is anticipated that new technologies will be utilised to ensure PICCs are optimally placed on first attempt. In the majority of cases this will reduce the need for post-procedure chest X-rays. PICCs and midline catheters are two of several vascular access devices. It is now apparent that some patients require alternatives such as Hickman catheters and Implantable Central Venous Access Ports. Relocation of the IDCNS to the Critical Care Directorate will strengthen working relationships with anaesthetists ensuring new vascular access procedures are safely developed. A Vascular Health Tool, soon to be introduced, will guide clinical staff to the most appropriate vascular access device for their patient. Ultimately patents will receive the most appropriate vascular access device at the right time with best evidence based on-going care. References H.P. Loveday*, J.A. Wilson, R.J. Pratt, M. Golsorkhi, A. Tingle, A. Bak,J. Browne, J. Prieto, M. Wilcox 2014. epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 86S1 S1–S70 Julian Bion, Richardson A , Hibbert P, Beer J, Abrusc T, McCutcheon M, Cassidy J, Eddleston J, Gunning K, Bellingan G, Patten K, Harrisond 2012 Matching Michigan: a 2 year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England BMJ Qual Saf 0:1-14

11 Audit

A new audit tool – the Front Line Ownership (FLO) tool - was devised for the 2014/15 period. Key aspects from audit tools that were already in use were included in order to produce a streamlined, easy to use audit tool using a bundle type approach that covered the main important aspects of infection prevention and control practice. The 10 sections that are included in the audit are:

Hand Hygiene Facilities

General Environment

Patient’s Immediate Area / Bed Space

Isolation of Infected Patients

Dirty Utility / Waste Disposal

Kitchens

Sharps Safety

Storage Area and Clean Utility/ Treatment Room

Patient Equipment

Clinical Practice

Page 38 of 46

Audits are now submitted electronically on to the share-point area of the intranet and a summary of results is produced (see Table 11.2 below). Where deficiencies are identified, an action plan is produced. The audit results and actions plans are reviewed and discussed at the bi-monthly Site Infection Control meetings / Community quality meetings. The IPCNs and Matrons have carried out validation audits using the same FLO tool. It is envisaged that further development of the auditing process will be progressed this year with the audit tool being hosted by the WebV system. As well as the FLO tool, monthly hand hygiene observational audits continue to be performed. Despite the high number of observations obtained from each division, there continue to be depressingly high numbers of monthly “No Return” reports submitted. These are summarised in Table 11.1. The Trust still maintains a zero tolerance policy towards deviations from the hand hygiene policy and the bare below the elbows policy. Any staff member found to be non-compliant receives a letter from the medical director or Chief Nurse and has to undergo a 1:1 session with an IPCN on hand hygiene. In addition, the IPCNs were members of the Mock CQC inspection teams and performed multiple inspections throughout the Trust.

Table 11.1: Hand Hygiene Audit Summary

Division Number of

audits Monthly

“No Returns” 3 or more

No Returns

Medicine SGH 2480 17 Wd 24 6xNR Wd 18 3xNR

Medicine DPoW 2122 7 Endoscopy 3xNR

Medicine GDH 671 4 -

Surgery SGH 1479 2 -

Surgery DPoW 2031 13 -

Surgery GDH 737 1 -

Family Services SGH/GDH 1499 1 -

Family Services DPoW 1575 2 -

Diagnostics SGH 1186 1 -

Diagnostics DPoW 1583 3 -

Diagnostics GDH 570 2 -

Page 39 of 46

Table 11.2: Infection Prevention and Control Audit (FLO Tool) Summary

Ward Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Overall Score

Total Returns

Total Nil Return

Percentage Returns

Medicine

DP

OW

Amethyst Ward & Day Case 98.8% 94.9% 97.5% 97.4% 98.8% 98.8% 94.7% 97.3% 100.0% 97.3% 92.0% 97.4% 97.1% 12 0 100.0%

D1 Day case 98.8% 97.5% 97.5% 97.4% 97.1% 97.2% 96.4% 96.7% 100.0% 94.4% 91.5% 95.8% 96.7% 12 0 100.0%

C1 Kendall NR 94.7% 82.7% 88.8% 88.5% 93.5% 94.9% NR NR NR NR 96.3% 91.3% 7 5 58.3%

C5 (Respiratory) 97.5% 98.8% 98.7% 95.1% 100.0% NR NR NR 98.7% 100.0% 97.4% NR 98.3% 8 4 66.7%

C3 AMU Short Stay 92.6% 93.8% 96.2% 97.5% 93.8% 98.8% 95.0% 98.7% 87.8% NR 91.5% NR 94.6% 10 2 83.3%

AMU Assessment 92.6% 93.8% 96.2% 97.5% 97.5% 96.3% 93.7% 97.5% NR 82.9% NR 90.4% 93.8% 10 2 83.3%

C1H NR 98.8% 98.6% 98.7% 88.6% 96.3% 98.7% 88.0% 92.1% 95.0% 92.4% 93.7% 94.6% 11 1 91.7%

C6 100.0% 100.0% 98.7% 96.1% 97.5% 97.5% 98.8% 97.4% 97.4% 97.4% 97.5% 96.2% 97.9% 12 0 100.0%

Stroke Unit/C7 93.8% 96.0% 94.9% 93.8% 96.3% 98.8% 96.3% 96.3% 97.4% NR NR 92.6% 95.6% 10 2 83.3%

CCU (D) 95.8% 97.5% 97.5% 98.7% 100.0% 100.0% 98.6% 98.6% 100.0% 98.6% 100.0% 100.0% 98.8% 12 0 100.0%

DIU 100.0% 98.6% 100.0% 100.0% 100.0% 100.0% 100.0% 95.0% 98.5% 100.0% 100.0% 92.9% 98.7% 12 0 100.0%

ECC 98.8% 100.0% 100.0% 100.0% 97.3% 95.9% 98.6% 93.2% 93.8% 92.6% 96.3% 89.2% 96.3% 12 0 100.0%

HDU 100.0% 100.0% 97.5% 98.8% 100.0% NR 98.8% 98.8% NR NR NR NR 99.1% 7 5 58.3%

SGH

CDU (MAU) 95.1% 100.0% 96.3% 100.0% 98.7% 92.4% NR NR 98.7% NR 97.5% NR 97.3% 8 4 66.7%

ECC 96.9% NR 98.6% NR 80.0% 93.9% 96.9% NR 98.7% 94.8% 96.1% 96.1% 94.7% 9 3 75.0%

PIU 100.0% NR 97.1% NR NR 95.9% NR 100.0% 98.6% 98.4% 78.5% NR 95.5% 7 5 58.3%

Stroke Unit 98.8% 96.1% 100.0% 97.5% 98.7% 98.7% 98.8% 98.7% 93.5% NR 98.7% NR 97.9% 10 2 83.3%

Ward 16 96.2% 91.0% 98.8% 92.6% NR 91.4% NR 96.3% 100.0% 98.7% 98.7% 96.1% 96.0% 10 2 83.3%

Ward 17 96.3% 97.5% 98.7% 97.4% 96.0% 94.3% 90.8% 98.8% 100.0% NR 100.0% NR 97.0% 10 2 83.3%

Ward 18 92.4% 91.7% 93.3% 98.6% 98.6% 98.6% 95.7% 97.3% 100.0% 98.8% 100.0% 96.2% 96.8% 12 0 100.0%

Ward 2 Short Stay 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.6% NR NR NR 93.1% 99.1% 9 3 75.0%

Ward 22 96.1% 97.5% NR NR 97.5% NR 98.8% NR 98.7% 98.6% 100.0% 100.0% 98.4% 8 4 66.7%

Ward 23 97.5% NR 82.7% 94.9% 97.5% 96.1% NR 95.9% 97.5% NR 98.8% NR 95.1% 8 4 66.7%

Ward 24 NR NR 98.7% NR NR NR NR 94.4% 75.9% NR 91.0% 98.7% 91.8% 5 7 41.7%

CCU (S) 97.5% NR NR 97.1% NR 98.6% 98.6% NR NR NR NR NR 97.9% 4 8 33.3%

Page 40 of 46

Ward Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Overall Score

Total Returns

Total Nil Return

Percentage Returns

Surgery and Critical Care

DP

OW

B2 97.4% 100.0% 100.0% NR 96.3% 93.6% 94.7% 92.3% 100.0% 97.4% 96.0% 93.0% 96.4% 11 1 91.7%

B3/HOBS 95.8% NR 95.9% 93.2% 89.6% NR 87.8% NR NR 93.2% 89.3% NR 92.1% 7 5 58.3%

B4 84.8% NR 100.0% 100.0% 98.8% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% NR 98.4% 10 2 83.3%

B6 98.8% 100.0% 100.0% NR NR NR NR NR NR NR NR 88.0% 96.7% 4 8 33.3%

B7 100.0% 100.0% NR NR 100.0% NR 93.3% NR NR NR NR 87.8% 96.2% 5 7 41.7%

DSU (D) 96.6% 96.0% NR 98.4% NR 100.0% 94.9% 98.2% 94.2% 98.3% 98.6% NR 97.2% 9 3 75.0%

ITU 100.0% 100.0% 100.0% NR 98.6% 100.0% 94.7% 96.2% NR 100.0% 97.5% NR 98.6% 9 3 75.0%

Theatres (DPOW) 100.0% 94.5% 100.0% 100.0% 99.2% NR 95.1% 96.7% 98.4% 100.0% 100.0% 98.1% 98.4% 11 1 91.7%

SGH

Ward 10 100.0% 100.0% NR NR NR 100.0% 100.0% NR NR 100.0% 100.0% 100.0% 100.0% 7 5 58.3%

Ward 11 95.1% 96.3% 97.5% 92.6% 98.7% NR 97.5% NR 97.5% 97.5% 97.4% 97.4% 96.8% 10 2 83.3%

Ward 25 93.8% 98.7% 98.8% 98.7% 98.8% 97.5% 97.5% NR NR 97.5% 97.5% NR 97.6% 9 3 75.0%

Ward 27 96.5% 93.9% 94.2% 95.5% 93.5% 95.0% 96.7% 93.4% 98.3% 95.0% 95.2% 96.6% 95.3% 12 0 100.0%

Ward 28/HOBS 98.8% NR 98.8% 98.8% 98.7% 96.3% NR 97.5% 98.8% 93.8% NR 97.5% 97.7% 9 3 75.0%

ICU 96.9% 96.9% 89.4% 95.9% 96.0% 97.3% 93.3% NR 100.0% 97.3% 97.2% 98.8% 96.3% 11 1 91.7%

Max Fax 96.9% 96.9% 89.4% 95.9% 100.0% 97.3% 93.3% NR 100.0% 97.3% 97.2% 98.8% 96.6% 11 1 91.7%

Theatres (SGH) NR 100.0% 98.2% 98.3% 96.3% 95.8% 96.0% 90.7% 100.0% 95.8% 100.0% NR 97.1% 10 2 83.3%

Page 41 of 46

Ward Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Overall Score

Total Returns

Total Nil Return

Percentage Returns

Women and Children

DP

OW

B1 Laurel 98.8% 98.4% 98.6% 97.3% 98.7% 94.3% 100.0% 98.7% 100.0% 100.0% NR 97.4% 98.4% 11 1 91.7%

Jasmine 100.0% 100.0% 98.6% 100.0% 100.0% 100.0% 92.3% 100.0% 100.0% 100.0% 100.0% 100.0% 99.2% 12 0 100.0%

Honeysuckle 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 12 0 100.0%

Blueberry 98.6% 98.8% 96.9% 95.0% 97.1% 98.8% 100.0% 97.5% 98.7% 98.8% 98.6% 98.6% 98.1% 12 0 100.0%

Holly 100.0% 98.5% 97.0% 97.4% 97.5% 98.7% 100.0% 97.5% 98.6% 100.0% 98.6% 100.0% 98.7% 12 0 100.0%

Acorn & Day Unit 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.2% 100.0% 100.0% 100.0% 100.0% 99.9% 12 0 100.0%

Rainforest 97.5% 94.6% 95.9% 94.4% 93.0% 80.8% 90.9% 87.5% 87.3% 88.2% 97.0% 93.2% 91.7% 12 0 100.0%

NICU (D) 100.0% 98.4% 100.0% 98.6% 97.1% 98.4% 100.0% 100.0% 98.6% 100.0% 97.0% 98.6% 98.9% 12 0 100.0%

Children's Assessment NR NR NR 100.0% 100.0% 93.5% 87.5% 91.7% 95.2% 96.0% 93.2% 100.0% 95.2% 9 3 75.0%

Children's Outpatient 96.7% 96.7% 96.8% 95.3% 95.2% 95.4% 100.0% NR 96.8% 96.9% 96.9% 98.4% 96.8% 11 1 91.7%

Mat Theatre 96.2% 86.4% 96.8% 95.3% 100.0% 98.1% 100.0% 98.2% 94.5% 98.3% 99.1% 100.0% 96.9% 12 0 100.0%

SGH

Ward 19 100.0% 100.0% 100.0% 100.0% 98.8% 98.8% 100.0% 96.3% 100.0% 96.3% 93.8% 98.8% 98.5% 12 0 100.0%

CDS 96.3% 93.5% 96.8% 95.2% 95.5% 92.3% 100.0% NR NR 100.0% 92.9% 100.0% 96.2% 10 2 83.3%

Ward 26 98.8% 98.7% 97.4% 97.4% 97.4% NR 100.0% NR 100.0% 100.0% 98.7% 100.0% 98.8% 10 2 83.3%

Disney 98.8% 98.6% 100.0% 100.0% 98.5% 98.5% 100.0% NR 97.1% 96.7% 98.5% 98.5% 98.7% 11 1 91.7%

NICU (S) 95.3% 98.4% NR 96.4% NR 94.7% 100.0% 98.4% 98.4% 96.7% 93.2% 93.1% 96.5% 10 2 83.3%

PAC NR 96.8% NR 94.9% 98.3% 96.6% 100.0% NR 98.2% 98.3% 96.6% NR 97.5% 8 4 66.7%

Paediatrics OPD 96.7% 98.5% NR 93.0% 98.3% 100.0% 100.0% 100.0% 100.0% 100.0% NR 100.0% 98.6% 10 2 83.3%

Page 42 of 46

Ward Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Overall Score

Total Returns

Total Nil Return

Percentage Returns

Diagnostics

DP

OW

X-Ray(D) NR 97.9% 97.9% 98.2% 96.0% 98.1% 98.0% NR 98.1% NR NR 100.0% 98.0% 8 4 66.7%

CTMRI/Ultra Sound(D) NR 100.0% 100.0% 97.9% 100.0% NR 100.0% NR NR NR NR 100.0% 99.7% 6 6 50.0%

Breast (Pink Rose) NR NR NR NR 100.0% 100.0% 100.0% 100.0% 100.0% 95.0% 98.3% 98.3% 98.9% 8 4 66.7%

Med Physics NR NR NR 83.3% 89.8% 88.5% 88.3% 88.3% 86.4% 96.6% 93.1% 96.7% 90.1% 9 3 75.0%

Endoscopy (D) 100.0% 100.0% 100.0% 100.0% 98.4% 100.0% 100.0% 100.0% NR 100.0% NR NR 99.8% 9 3 75.0%

OPD (D) NR 98.6% 98.6% 94.9% 92.9% 96.4% 98.1% 98.2% 94.5% 98.2% 98.1% 96.3% 96.8% 11 1 91.7%

SGH

X-Ray(S) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 12 0 100.0%

CTMRI(S) NR 100.0% 100.0% 100.0% 100.0% 98.4% 100.0% 100.0% 100.0% 100.0% 98.5% 98.4% 99.6% 11 1 91.7%

Endoscopy (S) 100.0% 100.0% 100.0% NR NR 100.0% 100.0% 100.0% 100.0% NR NR NR 100.0% 7 5 58.3%

OPD (S) NR 98.0% 98.0% 89.8% 90.2% 97.8% 97.4% 97.4% 100.0% 95.1% 97.2% 100.0% 96.4% 11 1 91.7%

Ward Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Overall Score

Total Returns

Total Nil Return

Percentage Returns

Goole

GD

H

Ward 3 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% NR 100.0% 100.0% 100.0% 11 1 91.7%

Ward 5/6 98.8% NR 100.0% 100.0% 100.0% 98.8% 98.7% 100.0% 100.0% 100.0% 100.0% 98.6% 99.5% 11 1 91.7%

GNRC 91.4% 92.9% 98.8% 98.6% 98.5% 98.6% 96.3% NR 92.4% 94.1% 97.0% 89.2% 95.3% 11 1 91.7%

Radiology GDH 100.0% NR NR 100.0% 100.0% 100.0% 96.4% 100.0% 100.0% 96.5% 100.0% 98.2% 99.1% 10 2 83.3%

OPD GDH NR 100.0% 100.0% 100.0% 100.0% NR 100.0% NR NR NR NR NR 100.0% 5 7 41.7%

MIU 100.0% NR 97.0% 100.0% 98.5% 98.4% NR 100.0% 96.8% NR 96.8% NR 98.4% 8 4 66.7%

DSU (Ward7) 100.0% NR 100.0% 100.0% 100.0% 100.0% 98.4% 100.0% NR 100.0% NR NR 99.8% 8 4 66.7%

Opthalmology NR NR 100.0% 100.0% 100.0% 100.0% 98.2% 98.2% 98.2% 100.0% 100.0% 100.0% 99.5% 10 2 83.3%

Goole Midwives 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% NR 100.0% 11 1 91.7%

Goole Endoscopy 100.0% NR 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.5% 99.9% 11 1 91.7%

Theatre GDH 96.6% 98.3% 96.6% 92.4% 100.0% NR 95.0% 97.5% 99.1% 99.1% 99.1% 100.0% 97.6% 11 1 91.7%

Page 43 of 46

12 Education

From April 2014 to March 2015, members of the Infection Prevention & Control Team (IPCT) have again provided a very comprehensive, evidence-based education programme for all members of Trust staff. This has been delivered in accordance with the Trust’s Training Needs Analysis (TNA), to ensure appropriate Infection Prevention and Control (IPC) training is delivered, whilst meeting, not only the requirements of staff, but also those of NHSLA, CQC, and CQUINS. The IPCT have also delivered IPC training to staff working on Trust premises but employed by other organisations, including Hull York Medical School (HYMS) medical students, building contractors and healthcare students from the University of Hull and local colleges. All staff newly appointed by the organisation are required to attend the Trust’s Induction Programme, which the Infection Prevention and Control Nurses (IPCNs) have continued to participate in by delivering a session. This contains all the essential elements needed to comply with mandatory training requirements, incorporates an introduction to the team, an overview of the key principles of IPC and an awareness of limits set for the Trust in relation to numbers of MRSA bacteraemia and Clostridium difficile cases. The IPC section of the Trust’s HUB (intranet) is demonstrated, including how to access policies. In addition to the Trust induction, newly qualified nurses attend a further workshop delivered by the IPCNs as part of their Preceptorship programme, the aim being to help facilitate their transition from student to registered nurse and help convert the theoretical aspects of IPC into practical situations. To assist with their integration into the Trust, the cohorts of nurses recruited from overseas receive several additional IC education sessions delivered by the IPCNs. Newly appointed ward or deputy ward managers undergo a 1:1 with an IPCN. The IPCNs deliver a lecture to the Junior Doctors as part of their induction that includes practical hand hygiene to supplement the national on line induction package they are required to complete. The Consultant Antimicrobial Pharmacist delivers education centring on the key points of good antimicrobials prescribing on new doctors’ inductions in February and August each year and additionally, in between, as required. The IPCT continue to offer a diverse range of options to assist staff needing either annual or 3-yearly IPC training to achieve their requirements. In addition to Trust induction, these include: delivering sessions on the Trust’s general mandatory training days and division-specific days, intravenous additives training, high dependency nursing course, management of invasive devices workshops (facilitated by the Vascular Access Team), Clostridium difficile workshops, Carbapenemase-producing Enterobacteriaceae (CPE) workshops, Infection Prevention and Control Link Network meetings, working with key trainers for specific staff groups to devise packages which are relevant for their staff and offering healthcare workers -including students - the chance to shadow a team member. E-learning options for IPC training remained available through the National Learning Management System (NLMS), and also a short film produced by the ICT in relation to obtaining blood cultures. The more innovative ways devised include workbooks for both clinical and non-clinical staff to enable them to achieve their mandatory infection control training. Separate C. difficile workbooks for medical staff and nursing and allied health professionals have also been produced. The uptake for completing all workbooks has been high. Any of the above training sessions or methods cover all of the topics required to fulfil mandatory training requirements including asepsis, hand hygiene, isolation practices, use of personal protective equipment, standard universal precautions, decontamination, waste disposal sharps safety and accidental exposure incidents.

Page 44 of 46

A significant amount of IC training for the year was devised and delivered in response to international infection issues including the Ebola crisis and the emerging threat from the Carbapenemase Producing Enterobacteriaceae (CPE) multi-resistant organisms. Extensive theoretical and practical training has been delivered to key areas of the Trust in relation to the management of patients presenting at the Hospitals with suspected Ebola or from an Ebola affected area. This included updating the policy, producing laminates for donning and doffing Personal Protective Equipment (PPE), practical exercises, use of glow powder to highlight potential contamination, use of the buddy system and training facilitators to cascade the training. This proved effective when required to be utilised in a real life situation involving a patient self-presenting claiming to be at risk of Ebola. The IPCNs have facilitated regular education workshop on CPE that will continue throughout the next year. These focus on the significance of the multi-resistance and danger to the population, cross infection risks, screening and isolation requirements and use of PPE. The IPCT have worked collaboratively with the WebV team to incorporate the CPE risk assessment screening questions on WebV as part of the patient admission and have educated ward staff on its use. In addition, the IPCT have supported clinical areas with the application of the policy when patients have been identified as at risk or found to have a positive CPE result. In relation to Clostridium difficile, the IPCNs have continued to provide regular workshops for staff, with good attendance figures and improved engagement from bank staff. Training dates are scheduled to continue throughout 2015. C. difficile education figures of 99.3% exceeded the Trust CQUIN requiring 95% of eligible staff to have received training. Any additional training requirements identified as part of the Clostridium difficile and MRSA bacteraemia Root Cause Analyses have been delivered to the affected area by IPCNs to help reduce healthcare-acquired infections. Infection Prevention and Control Link Network (ICLN) meetings are held 3 to 4 times per year at Grimsby, Scunthorpe and Goole sites and also for the Community and Therapies staff. Topics covered in the last year included viral gastroenteritis, CPE, Ebola, lessons learned from IC RCAs, hand hygiene and use of the ‘Sure-wash’ machine. Link workers are encouraged to cascade information from the meetings to their work areas. All new link workers undergo an induction with an IPCN. New staff requiring once only IPC training achieve this by attending Trust Induction. An education leaflet remains available for staff that had previously been identified as being employed by the Trust for several years without any formal recording of IPC training. In addition to the mandatory training sessions, members of the IPCT have also delivered or facilitated training covering numerous aspects of IPC including sharps safety, the World Health Organisation (WHO) 5 moments for hand hygiene, the process for undertaking hand hygiene audits, and how to use the Frontline Ownership Audit Tool (FLO Tool). The IPCT have continued to implement fun ways of raising the profile of Infection Prevention and Control amongst all staff groups including the caption competitions and a ‘where’s Danni Bear’ competition (sharps safety). IPCNs demonstrated the Blockbusters quiz board at the Annual Best Practice Day. There has also been continued use of the “Glo Box” for hand hygiene training. Social media, including professional tweets, have been increasingly used to highlight local education campaigns nationally and also raise awareness amongst local staff. Recent campaigns include the launch of “The Gloves Are Off” campaign aimed at reducing unnecessary glove usage. The IPCT have introduced “Display Boards” in wards and departments to raise awareness of key IC messages. The boards have been changed regularly by the team and subject areas covered have included; Clostridium difficile, PICC and vascular devices, urinary catheters,

Page 45 of 46

asepsis, antibiotic resistance, Carbapenem Resistant Enterobacteriaceae and correct glove use. Another innovative way for staff to achieve their mandatory IC training involved the trial of a “Sure Wash” machine that requires practical hand hygiene technique to be performed in addition to the successful completion of an IC quiz. Following positive trials 2 machines have been purchased. Staff identified as breaching practice with regard to hand hygiene still attend a 1:1 session facilitated by the IPCN, in line with the zero tolerance approach to hand hygiene. This includes reviewing the audit in question, reiterating the hand decontamination policy and practical use of the “Glo box”. IPC training attendance continues to be recorded on the Oracle Learning Manager System (OLM) and compliance reports are produced monthly by the Training department. Members of staff are aware of the need to check their own compliance matrix on NLMS. The year in question has shown excellent compliance with the end of the financial year figures as shown in Table 12.1 below.

Table 12.1: Training Records as Extracted from OLM

Row Labels No Yes Grand Total

% Compliance

208|LOCAL|Infection Control - 3 Yearly|

33 754 787 96%

208|LOCAL|Infection Control - No renewal|

7 1211 1218 99%

NHS|MAND|Infection Control - 1 Year|

532 3251 3783 86%

Grand Total 572 5216 5788 90%

In addition to these figures, the IPCNs delivered education to 32 3rd year, 29 4th year and 34 5th year HYMS students. Bespoke induction sessions have been delivered to local healthcare college students prior to commencing practical placements within the Trust. A number of contractors have received IPC training before commencing work on site. These sessions will continue in the next financial year.

13 Visits from External Regulating Bodies

Over the course of the year, the Trust had several visits from external bodies with regulatory functions. These visits included visits from NHS England, the Royal College of Nursing and the Local CCGs. In addition there were personal visits, in an official capacity, from the Sheriff of Lincoln and Mr Nic Dakin, MP for Scunthorpe. None of these visits raised issues with the provision of Infection Prevention and Control in the Trust.

14 Community & Therapies Services

Overview

Infection prevention & control provision has been delivered by both hospital and community-based teams across North Lincolnshire since April 2011, providing a fully integrated, united

Page 46 of 46

approach to infection prevention and control. Both teams work well collaboratively providing a robust service supporting one another on the delivery of infection prevention and control both within Northern Lincolnshire & Goole NHS Foundation Trust and North Lincolnshire. Of particular benefit is the continued access to services within NLAG including accessing microbiology results enabling the IPCT to improve patient care and management. During 2014/15 the Community Infection Prevention & Control Team has continued to provide a service to both Community & Therapy Services across Northern Lincolnshire & Goole NHS Foundation Trust. Representation of infection prevention & control service provision is demonstrated with attendance at monthly Community & Therapy Governance meetings. In addition every two months an Infection Prevention and Control meeting for all heads of service meets. The meeting provides assurance and an opportunity to applaud good practice and additionally confirm and challenge suboptimal compliance and practice – following the embedding of Community & Therapy Services. In spite of changes in structure amongst community/ therapy teams and challenges during 2014/15, meetings have continued with improved attendance amongst managers ensuring ownership and acknowledgement of ongoing challenges/ emerging threats related to infection prevention and control. Assurance is achieved through the dissemination of a RAG rated spreadsheet. Minutes from this meeting including actions and issues are forwarded to the Infection Control Committee. During 2014/15 a review of audit requirements was undertaken in line with the hospital Infection Prevention & Control Team. A Frontline Ownership audit tool was developed for use across Community Therapy Services with continuation of the “Reducing the Risks”: a rolling programme of team based audits aligned to Essential Steps (2005) and the Hygiene Code (2006) for Community Services staff. For 2014/15 changes and adaptions to assisting audit tools and programmes have provided a robust structure for Infection Prevention & Control within Community & Therapy Services with managerial and link ownership of infection prevention and control. Community & Therapy Services Link Practitioner Forum During 2014/15 the Community & Therapy Services link practitioner forum has continued to meet quarterly utilising teleconferencing facilities to capture teams at both hospital sites in addition to Community Services teams in North Lincolnshire. Expectation is that 75% attendance is achieved therefore link practitioners would be expected to attend 3 out of the 4 meetings to achieve compliance. Because of the subtle differences in audit requirements and the interface between therapy staff that are hospital-based and those who are based in the community, the link meeting was separated during 2014/15 at the request of link practitioners resulting in separate meetings for Therapy and Community Services staff. The link meetings continue to provide an opportunity to deliver key messages, discuss HCAI alert organisms, review audit processes and results, discuss issues and concerns and provide specific education to the link practitioners. They are consistently well attended with committed link practitioners across Community & Therapy Services. Infection Risk Assessment Tool

During 2014/15 an updated version of the Infection Risk Assessment Tool was successfully piloted across Community Services at the request of the users to ease assessment of patients as the previous version was prone to subjectivity. The tool is available on SystmOne for Community Service staff to use to aid management of patients especially those deemed high risk. The tool has been forwarded to other providers across Yorkshire and the Humber to pilot and potentially adopt.