Paper 10.0

TRUST BOARD

AGENDA ITEMNUMBER

5.6

TITLE OF PAPER DIPC/Annual Infection Control Report 2015/2016

Confidential NO

Suitable for publicaccess

YES

PLEASE DETAIL BELOW THE OTHER SUB-COMMITTEE(S), MEETINGS THIS PAPER HAS BEENVIEWED

Control of Infection Committee

STRATEGIC OBJECTIVE(S):

Best outcomes

Excellent experience

Skilled & motivatedteams

Top productivity

EXECUTIVE SUMMARY

This report provides an overview of the Trust’s infection control performanceand activities during 2015/2016 and provides the programme for 2016/2017.Appendices also include:

Influenza vaccine uptake

An overview of the recent Infection Control Summit hosted by the Secretary ofState to discuss the 2017 objectives to reduce gram negative bacteraemia andthe use of antibiotics in risk groups.

RECOMMENDATION: The Board is asked to approve the report

SPECIFIC ISSUES CHECKLIST:

Quality and safety

Patient impact

Employee

Other stakeholder

Equality & diversity

Finance

Paper 10.0

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AUTHOR NAME/ROLE Ann Trail, Nurse Consultant and Deputy Director for Infection Control/Clive

Grundy, Director for Infection Control

PRESENTED BYDIRECTORNAME/ROLE

Dr Clive Grundy, Director for Infection Control

DATE 18 November 2016

BOARD ACTION Approve

DIRECTOR OF INFECTION PREVENTION & CONTROL (DIPC) REPORT&

ANNUAL REPORT OF THE CONTROL OF INFECTION COMMITTEE2015-2016

COIC Meetings16th June 201516th September 201515th December 20158th March 2016

Membership and AttendanceThe membership can be seen in Appendix 1. Attendances were good except for some Divisionalrepresentatives.

Terms of ReferenceThe group terms of reference were last reviewed and/or revised in: 2013The terms of reference were ratified in November 2007

Achievements / Progress on Objectives 2015/2016 All HCAI reduction targets/trajectories were achieved

Constraints Faced by the COIC/Infection Control Team Resource implications due to delays in filling vacancies Clash with clinical commitment was the commonest reason given for COIC apologies for

absence. Insufficient ICT personnel to carry out comprehensive surgical wound surveillance

Significant Risks Identified and Actions Taken CPE ward outbreak resulting in ward closure (Falcon Ward) until resolved. CPE Toolkit

initiated and in place. Major Ebola outbreak in West Africa and ongoing Middle East Respiratory Syndrome

(MERS) in the Arabian Peninsula warranted new local policies (now in place) for thesedangerous infections.

Which Policies have been Approved and/or Ratified Appendix 3

Other Issues Norovirus ward outbreaks had a significant impact on the Trust in the latter half of

2015/2016 Influenza vaccination of staff rate continues to be disappointing. See Appendix 4.

2

Objectives/Forward Plan 2016/2017 Appendix 2

Report compiled by: Ann Trail, Nurse Consultant/Deputy Direction, Infection Prevention andControl and ratified by Control of Infection Committee.Date: 17th June 2016Updated 7th November 2016 by Clive Grundy, DIPC.

3

Contents Page

2.0 Infection Control Arrangements 42.1 Infection Control Team 42.2 Control of Infection Committee 42.3 Accountability 42.4 Infection Control Programme 2016/2017 43.0 Surveillance 43.1 MRSA Bacteraemia 4/53.2 MRSA Bacteraemia 2009/2010 – 2015/2016 43.3 Targeted MRSA Screening 53.4 Clostridium Difficile Performance 53.5 Clostridium Difficile All Cases 2009/2010- 2015/2016 53.6 Clostridium Difficile Root Cause Analyses 5/63.7 Clostridium Difficile RCA Themes 63.8 MSSA Bacteraemia Performance 63.9 E.Coli Bacteraemia Performance 6/74.0 Audits 74.1 Antibiotic Compliance Audits 74.2 Hand Hygiene 74.3 Hand Hygiene by Ward 2015/2016 8/94.4 High Impact Intervention Audits 94.5 Ward Departmental Environmental Audits 9-114.6 Commode Audit 114.7 Peripheral Cannula Audits 115.0 Outbreaks of Infection 115.1 Norovirus 11/125.2 Carbapenemase-Producing Enterobacteriacae (CPE) 126.0 Hospital Hygiene 127.0 Surgical Site Infections 12/137.1 Colorectal SSIs 137.2 Orthopaedic (Fractured Neck of Femur) SSIs 138.0 Policies 139.0 Education 1310.0 Annual Influenza Vaccination of staff rates 13Appendix 1 Control of Infection Committee Members 14/15Appendix 2 Infection Control Program 2016/2017 16-20Appendix 3 Policies 21/22Appendix 4 ASPH Occupational Health Figures for Annual Influenza

Vaccination of staff rates23

Appendix 5 Overview of IPC Clinical Summit 8th November 2016 24-26

4

2.0 INFECTION CONTROL ARRANGEMENTS2.1 Infection Control Team

Role Band WTEConsultant Microbiologist and DIPC 1.0Consultant Microbiologist and Infection Control Doctor 1.0Consultant Microbiologist and Antibiotic Lead 1.0Nurse Consultant/Deputy DIPC 8C 1.0Senior Infection Control Nurse 7 1.0Infection Control Nurse Specialist 6 1.0Antimicrobial Pharmacist 1.0Admin Support 0.8

2.2 Control of Infection CommitteeThe Control of Infection Committee (COIC) meets quarterly and includes representatives fromEstates and Facilities, Public Health England (PHE), NW Surrey CCG, Clinical, Divisions,Occupational Health, Microbiology, Pharmacy, Infection Control and Senior Managers. There isalso a Patient Representative. A full list of committee members can be seen in Appendix 1.

The agenda items included: reports from Infection Control related incidents from clinical areas,Infection Control policies/guidelines, Antimicrobial Management, Decontamination Committeefeedback, reports from Estates and Facilities and IC outbreak reports.

2.3 Accountability

The Control of Infection Committee reports to the Quality Governance Committee, which reports tothe Trust Board. For matters of serious or urgent concern the Infection Control Team reportsdirectly to the Chief Executive or appropriate Hospital Director.

2.4 Infection Control Programme 2016/2017The Infection Control Programme for 2016/2017 (Appendix 2) was ratified, and will be reviewedquarterly, by the Control of Infection Committee.

3.0 SURVEILLANCE3.1 MRSA Bacteraemias PerformanceThere was no avoidable post 48hr MRSA bacteraemia in 2015/2016. The last avoidable Trust

attributed case was in February 2015. The annual agreed trajectory continues to be zero avoidable

cases per year.

3.2 MRSA Bacteraemias All Cases 2009/2010- 2015/2016

5

3.3 The move to targeted MRSA screening

In 2014 the Department of Health issued ‘Implementation of modified MRSA screening guidancefor NHS’. This outlined a more focused approach to MRSA screening, concentrating on high riskpatients and areas and based on the findings of the “NOW” study. Following Trust Boardagreement, the Trust MRSA policy was amended to adopt this approach. The subsequent savingsmore than finance the implementation of the laboratory screening test necessary for the CPEToolkit.

3.4 Clostridium difficile PerformanceThe Trust agreed trajectory for Clostridium difficile for 2015/2016 was a maximum of 17 post 72hour cases with lapse in care. There were 15 cases.

3.5 Clostridium Difficile All Cases 2009/2010- 2015/2016

3.6 Clostridium Difficile Root Cause AnalysisLearning is shared via an RCA on each case using an extended proforma agreed with the CCG.The Infection Control Team (ICT) meets quarterly with the CCG Chief Nurse/Associate Director ofQuality and Patient Safety Manager to review the cases and agree if a lapse in care occurred.The table below outlines RCA findings for all 15 cases of which 5 were deemed to have lapses incare.

Date Ward RCA Findings Outcome07.04.15 MSSU Delay in obtaining sample Lapse in care08.05.15 Swift Inappropriate antibiotics and failure to document indication for use Lapse in care18.05.15 Maple No lapse in care Unavoidable24.05.15 Wordsworth No lapse in care Unavoidable04.07.15 Holly No lapse in care Unavoidable17.09.15 MSSU No lapse in care Unavoidable14.10.15 Heron Antibiotics not in line with guidelines Lapse in care26.10.15 MSSU No issues identified Unavoidable09.11.15 Aspen Sample taken within 72hrs not tested. No other issues. Unavoidable

--Trajectory

6

22.01.16 Falcon No lapse in care Unavoidable25.01.16 Kingfisher No lapse in care Unavoidable20.02.16 AMU No lapse in care Unavoidable25.02.16 Aspen No lapse in care Unavoidable05.03.16 May Antibiotics used not in line with Trust guidelines Lapse in care09.03.16 May 2 cases on ward with identical typing, indicating transmission (during a

Norovirus outbreak)Lapse in care

3.7 RCA Themes

3.8 Meticillin Sensitive Staphylococcus aureus (MSSA) bacteraemia performanceThere is no Trust reduction target for MSSA bacteraemias. There were a total of 10 post 48hrcases in 2015/2016. During 2016/2017 the aim is to undertake an RCA for each post 48hr case toidentify any learning/lapses in care.

3.9 Escherichia coli bacteraemia performanceThere was no Trust reduction target for E.coli bacteraemias in 2015-16. There were a total of 236E.coli bacteraemia cases in 2015-2016, 26 of which were hospital-acquired. All HCAI E.colibacteraemias are reviewed and, if considered device related, a review of practices is undertaken.

4.0 AUDITS4.1 Antibiotic Compliance Audits

7

Regular snap shots of compliance with prescribing guidelines are performed by the wardpharmacists (See table of results below). The last audit of 2015-16 took place in October 2015.

Oct11

Mar12

Oct12

Apr13

Nov13

Jun14

Nov14

Mar15

Oct15

Allergy box of prescription chart filled in 95% 94% 95% 97% 94% 95% 98% 95% 93%

Antibiotics prescribed in line withguidelines

95% 92% 94% 95% 95% 95% 93% 96% 96%

Additional instruction box filled withindication

94% 93% 86% 92% 90% 91% 89% 91% 91%

Start date filled in 99% 99% 99% 99% 98% 98% 99% 99% 99%

Stop/review date filled in or number ofdays treatment stated

90% 86% 71% 78% 80% 79% 72% 70% 71%

Surgical & orthopaedic patients: 1 pre-dose prophylaxis with correct antibiotic

100% 100% 100% 97% 100% 100% 100% 97% 97%

Surgical & orthopaedic patients: Nil postdose prophylaxis, when appropriate*

82% 80% 90% 88% 87% 84% 83% 83% 88%

*No antibiotic prophylactic doses should be given post-op unless the surgery was > 4hrs duration or severe blood loss>

1.5L at op or for a few high risk surgeries.

The COIC debated possible actions to improve the continuing poor performance with stop/reviewdate.

4.2 Hand HygieneHand hygiene audits using the WHO ‘5 key moments for hand hygiene’ are undertaken eachmonth in wards and clinical areas. The graph below demonstrates overall Trust compliance.

4.3 Hand hygiene Compliance by Ward 2015/2016The table below highlights hand hygiene compliance by ward. Please note 0% denotes where award/department has omitted to submit their audit data.

WARD Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Aspen 100% 100% 100% 100% 100% 100% 0% 100% 100% 100% 100% 100%

Birch / CCU 96% 100% 98% 100% 100% 100% 100% 95% 100% 100% 100% 100%

MHDU 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Holly 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Cedar 97% 88% 92% 91% 100% 91% 70% 100% 94% 95% 99% 97%

May 99% 99% 97% 99% 93% 100% 100% 70% 0% 100% 99% 100%

Maple 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Chaucer 100% 100% 100% 100% 100% 100% 100% 100% 0% 100% 100% 100%

Fielding 99% 95% NA NA NA NA NA NA NA NA NA NA

Dickens 99% 99% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

8

Swan 86% 0% 99% 100% 88% 100% 100% 100% 100% 99% 100% 100%

Kingfisher 96% 98% 97% 98% 100% 100% 98% 96% 96% 0% 100% 98%

Falcon 97% 100% 98% 100% 100% 100% 100% 98% 100% 100% 87% 100%

SDU 100% 100% 97% 100% 0% 98% 97% 88% 100% 0% 0% 94%

AMU 92% 93% 98% 100% 97% 100% 100% 100% 0% 99% 0% 100%

Cherry 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

SAU 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

NICU 100% 99% 100% 98% 100% 100% 99% 0% 100% 99% 99% 100%

Oak 95% 90% 91% 98% 0% 96% 96% 96% 100% 100% 0% 0%

Ash 100% 100% 100% 0% 100% 100% 100% 100% 100% 100% 100% 100%

Paeds A/E 100% 95% 96% 97% 94% 95% 94% 94% 90% 0% 90% 0%

Theatres (SPH) 96% 100% 100% 100% 98% 100% 100% 100% 0% 100% 100% 0%

Theatres (AH) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

DSU/Urology (SPH) 0% 100% 98% 100% 100% 100% 100% 100% 0% 99% 100% 0%

DSU (AH) 100% 100% 100% 100% 99% 100% 100% 100% 100% 100% 100% 100%

Endoscopy (SPH) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

X-Ray (SPH) 0% 92% 0% 100% 0% 100% 0% 50% 0% 69% 90% 0%

X-Ray (AH) 100% 100% 100% 100% 100% 100% 90% 100% 100% 93% 100% 99%

Maxfacs/Orthodontics 100% 99% 98% 97% 0% 100% 99% 98% 100% 99% 100% 100%

Eye Clinic (SPH) 97% 0% 99% 98% 98% 98% 99% 96% 97% 0% 99% 99%

Eye ward/clinic (AH) 100% 100% 100% 100% 0% 100% 100% 100% 100% 100% 100% 100%

A/E 97% 86% 95% 98% 94% 89% 94% 93% 90% 94% 96% 96%

ITU 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Heron 100% 97% 83% 99% 100% 100% 100% 100% 100% 100% 100% 100%

Admissions Lounge 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Rowley Bristow 100% 99% 97% 100% 99% 100% 0% 100% 100% 100% 0% 0%

Joan Booker 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 0%

Labour 100% 100% 100% 94% 98% 100% 97% 100% 0% 100% 100% 100%

OPD (AH) 100% 100% 100% 0% 100% 100% 100% 100% 100% 100% 100% 100%

OPD (SPH) 100% 100% 100% 85% 90% 100% 0% 0% 100% 0% 100% 100%

Colposcopy 93% 97% 79% 92% 100% 99% 100% 100% 100% 100% 100% 100%

Discharge Lounge 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Maternity Ultrasound/ANC 97% 95% 98% 99% 100% 95% 98% 98% 98% 98% 99% 99%

Infusion Suite (AH) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 0% 100%

Swift ward 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 98% 100%

Abbey Birth Centre 100% 100% 100% 100% 100% 100% 100% 100% 100% 0% 100% 100%

Haematology Day Unit 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 0% 100%

4.4 High Impact Intervention Audit ScoresThese are care bundle audits performed monthly by nursing staff on the wards. High impactintervention (HII)1 and 2 are each divided into two audits – one for insertion and one for continuingcare of central (CVC) and peripheral lines respectively. HII6 is for insertion and care of urinarycatheters and HII7 is for Clostridium difficile management.

The RAG scoring is. >90% green 80-90% amber <80% red

9

HII 1insertionCVC

HII 1continuingcare CVC

HII 2insertionPeriph

HII 2continuingcarePeriph

HII 5 VentHII 6insertionCatheter

HII 6continuingcareCatheter

HII 7C. diff

Apr-15 100% 98% 92% 95% 100% 100% 100% NA

May-15 100% 91% 88% 94% 100% 95% 95% 100%

Jun-15 100% 87% 83% 94% 100% 100% 99% 100%

Jul-15 100% 98% 91% 94% 100% 100% 94% 100%

Aug-15 100% 80% 77% 86% 100% 88% 89% 100%

Sep-15 100% 98% 93% 97% 100% 100% 99% NA

Oct 15 100% 88% 79% 85% 100% 94% 95% 100%

Nov 15 100% 100% 97% 98% 100% 100% 100% 100%

Dec 15 100% 82% 65% 78% 100%% 70% 75% 100%

Jan-16 100% 81% 77% 86% 100% 90% 90% 100%

Feb-16 100% 72% 71% 98% 100% 83% 77% 100%

Mar-16 100% 86% 83% 89% 100% 84% 89% 100%

4.5 Ward/Departmental Environmental Audits

During 2015/2016 ward/department audits were undertaken by the Infection Control Team as

tabled below and “RAG” rated accordingly. Due to a long term vacancy within the team only 15/46

audits were undertaken. Of these 1 was rated as red, 3 as amber and 11 as green. Action plans

were completed for those ward/departments which rated amber/red to rectify the failures with a

review to check that actions had been taken.

Medicine 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

Aspen 72% 89% 78% 98% 93% 91% 82% 90% 91%

Birch/CCU 76% 83% 87% 94% 91% 98% 95% 99% 99%

Maple 85%Relocati

ng84% 95% 94% 98% 88% 97% 97% 97%

May 88% 70% 90%relocatin

g95% 97% 94% 94% 94% 90%

Holly 60% 88% 81% 96% 94% 92% 95% 93% 93%

Cedar 73% Refurb 84% 92% 97% 96% 92% 96% 93% 98%

Swift N/A N/A N/A N/A N/A N/A N/A N/A 92% 92%

Surgery 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

Kingfisher 76% 78% 94% 93% 95% 92% 95% 97%

Heron N/A N/A N/A N/A 96% 94% 95% 95% 94%

Falcon 79% 65% 86% 93% 93% 89% 85% 83% 93%

AdmissionsLounge

N/A N/A N/A N/A 96% 94% 93% 98%

SAU 76% 91% 92% 89% 94%

Swan N/A N/A N/A N/A N/A N/A N/A 83% 89%

Critical Care 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

ITU 87% 90% 96% 96% 91% 92% 96%

SDU 92% 86% 86% 98% 95% 95% 96% 86% 72%

MHDU 80%Relocati

ng96% 96% 97% 91% 92%

Paediatrics 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

Ash 85% 87% 93% 83% 83% 96% 92% 89% 82%

Paed A&E 88% 90% 90% 85% 88%renovati

on88%

Oak 87% 89% 94% 85% 85% 97% 92% 92% 82%

10

NICU 74% 82% 88% 88% 96% 88% 97%

SCU 93%

Paed OPD SPH 72% 95% Refurb 98% 93%

Childrens OPD -AH

61% 61% 90% 94% 99%

Other 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

OPD 85% 91% 89% 79% 94%

HaematologyDay Unit

82% 78% 99% 92%

Blanche Heriot 71% 88% 99% 93% 93%

Endoscopy 96% 99% 92%

Day Surgery 97% 92% 92% Urology

Theatres 95% 98% 94% 89% 95%

Rowley BristolUnit

94% Refurb 92% 85% 79%

DischargeLounge

90% 93% 98% 77% 98%

X-ray N/A N/A N/A N/A N/A N/A 67% 92%

EmergencyServices

2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

MAU 76% 84% 87% 92% 83% 93% 94%

A&E 76% 84% 83% 83% 95%

MSSU N/A N/A N/A N/A N/A N/A N/A 97% 89% 96%

ASHFORD 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

Dickens 73% 74% 82% 96% 97% 93% 92% 84%

Fielding 93% 98% 97% 88% 86% 82% Closed

Wordsworth 86% 78% 91% 92% 96% 92% 96% Closed

Chaucer 90% 86% 90% 93% 92% 92% 91% 94%

OPD 92%renovati

onrenovati

onrenovati

on87%

DSU 90%not

scored92% 88% 95%

Theatres 94% 96% 91%

Eye Clinic 95% 96% 98%

X-ray 91% 98%

Infusion Suite

Maternity 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

Labour WardNo

Score79% 83% 85% 82% 89%

Joan Booker 78% 81% 87% 89% 90% 91% 87% 90%

Labour Theatre 78% 95% 91% 91% 93%Audited

notscored

88% 97%

11

4.6 Commode Audit

A total of 61 commodes were reviewed and assessed for

fit for purpose- in a good state of repair with all parts intact

cleanliness

The results highlighted that 19 (31%) were not fit for purpose as damaged or had missing parts,

and 21 (34%) were visibly soiled.

As a result of the audit, condemned commodes were replaced and there is a rolling programme to

replace commodes. In view of the poor cleanliness rate, the commode audit needs to be regularly

repeated.

4.7 Peripheral Cannula Audits

In July 2015 a peripheral cannulation audit was undertaken across both sites. All adult inpatient

wards and departments that use cannulation packs were audited. The audit was carried out to

obtain a snapshot of current practice around peripheral vascular access management. The audit

demonstrated that whilst there was an increase in the use of cannulation packs, the amount of

documentation forms used remained the same. There was a slight increase in the number of

cannula sites being documented although the use of a care plan had reduced. Those that had

been recorded demonstrated that more cannulas had been left in situ longer than the 96 hours

allowed.

In view of this, a repeat audit was undertaken in December 2015 across all adult medical wards,

since it had been mainly the medical ward documentation that had reduced the overall score in the

original audit. The second audit reflected this: whilst the number of cannulation packs used in the

Medical unit was far lower than in the original audit, documentation of the monitoring of site and the

use of care-plans continued to be inadequate. Further work to improve and document cannula care

needs to be done.

5.0 OUTBREAKS OF INFECTION

5.1 Norovirus

During 2015/2016 Norovirus was a significant burden on both the hospitals and community. Thetable below demonstrates which wards were affected by the virus and closed to admissions tocontain outbreaks.

Ward Closed Patients Staff Organism Days

closed

Swan Bays B, D & E 26.02.16 14 13 NV 9

Maple 29.02.16 13 3 NV 12

Cherry Bays 1 & 2 03.03.16 5 0 NV 4

Heron Annex 04.03.16 2 0 NV 3

Holly Bays 1 & 2 02.03.16 7 3 NV 8

BACU Bays A, B & C 04.03.16 7 2 NV 10

May Bays 1 & 2 06.03.16 5 0 NV 7

Maple Bay 3

Whole ward

30.04.16

03.05.16

18 1 NV 7

May Bay 2 30.04.16 2 0 NV 7

Aspen Bays D/A changed to cohort Bay

Bay B

02.05.16 4 1 NV 7

4

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5.2 Carbapenemase-Producing Enterobacteriaceae (CPE) OutbreakEnterobacteriaceae are coliform bacteria that usually live harmlessly in the gut but are thecommonest cause of UTIs and bloodstream infections. The commonest coliform causing both isE.coli. Carbapenems are an invaluable group of antibiotics used to treat these serious and/orresistant infections. Some enterobacteriaceae become resistant to carbapenems by producing anenzyme carbapenemase (hence their name Carbapenemase-Producing Enterobacteriaceae).More UK hospitals are now seeing CPE cases appear and there is a national toolkit for acute trustsfor the early identification and management of CPE, which most trusts (including ASPH) had notinitiated because of the lack of a locally - available screening test for CPE and faecal carriage.Unfortunately SPH endured an outbreak of CPE in late April and early May 2015. A total of 8patients were identified as CPE positive and full outbreak measures were implemented. 1 surgicalward had to be closed to admissions for 10 days. There were 3 outbreak control meetings of keyplayers, the last one being a debrief at the end of the outbreak. Action agreed with Estates hasreduced drain blockages and so decreased the threat of CPE from the environments.The Infection Control Team formulated a CPE policy based on the National Toolkit for Acute Trustsfor the early detection and management of CPE. Identification, isolation and screening of patientsat high risk of CPE was implemented and there has been no outbreak since. The local CPE policyhas so far proved effective in protecting our 2 hospitals and their patients from CPE. It must remainin place.

6.0 HOSPITAL HYGIENEGood patient environment scores - as in previous years we received broadly good scores for thequality of our environment in the Patient-Led Assessments of the Care Environment (known asPLACE). These inspections were carried out in March 2015 at Ashford and April 2015 at St Peter’sHospital. The table below shows the scores for both cleanliness and the condition andmaintenance of hospital areas.

Areas: Ashford Hospital St Peter’s Hospital National Average

Cleanliness (of hospital areas) 99.23% 99.52% 97.57%

Condition, Appearance and Maintenance 87.39% 88.29% 90.11%

Cleanliness was rated above the national average at both hospitals and has been for consecutiveyears, highlighting the dedication of our Housekeeping Team, who were shortlisted for the BuildingBetter Healthcare Awards in the category of Facilities Team of the Year in 2015.

Both hospitals scored marginally lower than the national average for condition, appearance andmaintenance. We have been undergoing a programme of painting and refurbishment over the lastcouple of years and continue to identify areas for improvement with a work plan in place.

7.0 SURGICAL SITE INFECTIONSSurgical Site Infections (SSI) account for 16% of all Health Care Associated Infections (Englishpoint prevalence survey, 2011). They not only cause significant morbidity but also add extrafinancial burden onto the NHS due to the need for further medical care and extended hospital stay.SSI rates vary between different categories of surgeries and patient populations, for examplecolorectal surgery has a high risk of SSI. Patient factors such as diabetes, immune deficiency,obesity etc., predispose to SSI. External factors including hand hygiene, surgical technique,physical environment/ ventilation, equipment used etc., influence significantly as well. Surveillanceof SSIs to understand the trend in the incidence/ prevalence of these infections helps theorganisation and relevant teams to intervene as necessary to optimise clinical outcomes.

ASPH participates in national colorectal and orthopaedic (repair of fractured neck of femur)surgical site infections surveillance annually, over 1 quarter of the year each. The ICT believes thatwound surveillance for infection should extend well beyond this.

13

7.1 Colorectal Surgical Site InfectionsThe SSI rate in patients having colorectal surgery (Oct – Dec 2015, Q4) was 14% (7 of 50patients). Colorectal SSI rates in previous years were 19.1% (2011, Q4), 16.2% (2012, Q4) and8.3% (2014, Q2). The national average for Oct – Dec 2015 in comparator hospitals was 12.1%.Review of the patients who developed SSIs revealed that most either had risk factors such asimmunosuppression or underwent complex procedures. It is not clear if change in the time of theyear that the surveillance was done this year (winter compared to summer) had any influence onthe rate of SSI. The DIPC, Infection Control Doctor, Antimicrobial Lead Consultant and ColorectalSurgeons have subsequently met and discussed interventions including further changes toantibiotic prophylaxis to reduce the SSI rate. Continuing to participate in this surveillance is veryimportant to evaluate the effectiveness of these interventions and the infection risk to our patients.

7.2 Orthopaedic (Fractured Neck of Femur) Surgical Site InfectionsThe SSI rate among patients undergoing repair of fractured neck of femur during last year (Jan –March 2015) was 5.5%, which is higher than the ASPH average rate of 3% in the previous 4 years.This is also considerably higher than the average SSI rate of comparator hospitals (1.6%). Thisresult was made available by PHE in July 2015. Since then, meetings have taken place betweenthe Infection Control Team and Orthopaedic Surgeons to discuss interventions to improveoutcomes. A further surveillance (Jan – March 2016) took place shortly after the introduction ofthese interventions and the report on this from PHE gives our ASPH SSI rate a 3.2% compared to1.7% for comparator hospitals i.e. an improvement but still too high. It should be noted that all SSIsin the ASPH survey involved only superficial or deep incision, not the joint, whereas 15 % ofsurveyed infections in the comparator hospitals involved the joint. Nevertheless Prosthetic JointInfections (PJIs) do occur at ASPH and there will be a further drive to minimise these.

8.0 PoliciesInfection Control policies have been reviewed and updated in line with new guidelines andevidence. A full table of policies reviewed can be seen in Appendix 3.

9.0 EducationMandatory Infection Control Training including hand hygiene assessment has been predominantlycarried out by face to face sessions and delivered by the Infection Control Nurses. Use of theSurewash hand hygiene assessment machine with added quiz has been used for some areas.

Members of the ICT have kept themselves updated by undertaking the following:

o Completion of Public Health Nursing Masters degree.o Infection Control for Clinical Practice Courseo Infection Prevention Society Study Dayo Quality Study Dayo Preventing Illness 1 Day Conference

10.0 Annual Influenza Vaccination rates of staffAppendix 4 shows the annual figures, submitted by Nadine Williams, Occupational HealthManager.It can be seen that in 2015-16 only 38% of ASPH Healthcare workers were vaccinated againstinfluenza in the Trust. This is a vaccine that is required annually to maintain immunity. Vaccinatingstaff in turn helps to protect patients. The target figure is ≥ 50%. 38% is a slight improvement on the year before but the rate among doctors continues to be woeful (22→21%) and nurses don’t do much better (32→28%). This compares to a better rate among support staff (43→68%). OH staff make heroic efforts to offer the vaccine and bust myths about it. A “myth-buster” campaign in goodtime before the vaccination season starts at the beginning of October 2017 may have a positiveeffect, if fully supported by senior managers. We also need to get better at giving influenzavaccine to larger-stay inpatients in higher risk categories e.g. aged >65 years.

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Appendix 1

CONTROL OF INFECTION COMMITTEE

NAME TITLE

Mark Atkins Consultant Virologist

Ian Beeton Consultant Cardiologist

Graham Biggar Head of Estates & Facilities

Gillian Bradshaw Clinical Practice Education

William Britton Hotel Services & Facilities Manager

Constant Busch Orthopaedic Consultant

Heather Caudle Chief Nurse

Dr Farnaz Dashti* Medical Microbiologist

Liz Delicata Deputy Sister, NICU

Dawn Gantley Clinical Nurse Leader, Surgery

Kate Gorman North West Surrey CCG

Dr A Groves Paediatric Consultant

Dr HC Grundy* Medical Microbiologist

Hani Habayeb Antibiotic Pharmacist

Sally-Anne Harris* Infection Control Nurse

Keith Hayward Estates Manager

Mr T. Johnson Consultant Surgeon

Dr Margot Nicholls CCDC, PHE

Annabel Nutley Microbiology Secretary

Deborah Parkinson Midwifery Lead

Vennila Ponnusamy Consultant Neonatologist

Dr Jay Rangaiah* Medical Microbiologist

Suzanne Rankin Chief Executive

Jonathan Robin Consultant Physician MAU

Sue SextonAssociate Director of Nursing, Theatres, Anaesthetics,Surgery & Critical Care

Danny Sparkes Patient Panel/Public Governor

James Thomas Consultant Gynaecologist

Ann Trail* Consultant Nurse, Infection Prevention and Control

Jane Urben Associate Director for Midwifery

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NAME TITLE

Maciel Vinagre Assistant Hotel Services Manager

Ian White Clinical Lead for Critical Care

Marty Williams Head of Patient Safety

Nadine Williams Occupational Health Manager

Stephen Winchester Consultant Virologist

Members of the ICT

Appendix 2 INFECTION CONTROL ANNUAL PROGRAMME – 2016/17

INTRODUCTION

As an acute service provider Infection Prevention and Control is of the highest priority at Ashford & St Peter's Hospitals NHSFoundation Trust (ASPH) which has a zero tolerance approach to healthcare associated infections (HCAIs). Effective infectionprevention and control is an essential component of a quality health service. ASPH aims to meet the requirements of the infectioncontrol assurance framework by:

reducing infection related morbidity and mortality

reducing the cost of patient care by preventing healthcare associated infection

providing a safe working environment for staff

having a quality and risk profile linking in to the Trust quality framework

The Infection Control Programme is agreed by the Control of Infection Committee and forms part of the Trust assurance framework. Theprogramme also links into Health Assure which demonstrates compliance with the Health and Social Care Act 2008 (2015) and alsogains reassurance of compliance from the Trust’s divisions. This annual programme logs activity and ongoing work in our challenge tofurther reduce HCAIs.

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ISSUE ACTION PROGRESS BY WHOM FREQUENCY

Not to breach MRSAbacteraemia trajectoryof zero avoidable cases

To be 100% compliant withscreening of elective admissions,patients admitted to high riskareas and patients with a pasthistory of MRSA.

Launch IV Steering Group to workto standardise policies andpractices to ensure safe and costeffective IV care for patientsacross the Trust (replaces IVLeague)

Compliance audits to be undertaken.

Identify expertise within the organisationand draft Terms of Reference for thegroup. Co-ordinate first meeting.

NCIC, ICT

NCIC, ICT

Review annuallyor whenbacteraemiaoccurs.

Bi-monthly

MSSA & E. colibacteraemia reporting

All MSSA & E. coli bacteraemiasare to be reported on PublicHealth England data capturesystem.

All community and hospital acquired casesare reported as per the national mandatorysurveillance program. Each case to havean initial review undertaken in regards torisk factors followed by an RCA wherecases are considered HCAI or devicerelated.

DIPC, ICT, ICD As a case occursOngoing

Not to breachClostridium difficiletrajectory of 17 hospitalacquired cases withlapse of care.

Clostridium difficile Action Plan inplace. This encompasses all workundertaken to comply with ourDoH trajectory.

Lapses in Care review to be undertakenquarterly with CCG and any identifiedlearning actioned accordingly.Weekly C.difficile ward rounds by ICTcontinue.

DIPC, NCIC, CCGICT, ICD, ConsultantMicrobiologists,Antibiotic Pharmacist,Clinical Directors,Chief Nurse,Medical Director

Quarterly

Compliance andevidence with the Health& Social Care Act 2008

Demonstrate compliance with theHygiene code as registered withthe CQC.

Review document to ensure compliancewith updates.

DIPC, NCIC, ICDChief Nurse, Head ofFacilities,DecontaminationLead, OccupationalHealth, Head ofQuality, DivisionalLeads

Three monthlyreview

Audit and surveillance Audit and Surveillance Hand hygiene and Saving Lives Ward Managers Monthly

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ISSUE ACTION PROGRESS BY WHOM FREQUENCY

programme undertaken: Hand hygiene Saving Lives high Impact

Intervention audits Environmental Clinical

undertaken monthly and entered into theBest Care Dashboard which is seenmonthly by TEC and Trust Board. Annualaudits reported in the annual DIPC report.

Clinical NurseLeadersICN's

and ongoing

Surgical sitesurveillance.

Mandatory orthopaedic modulerequired annually. Further SSIsurveillance undertaken asresources allow.

Vascular SSI module planned for October-December 2016, then Orthopaedic SSIJanuary to March 2017.

The gold standard would be continuoussurveillance to obtain meaningful data, toinclude to 30 days post-discharge, but weare not resourced to achieve this.

Surgical LeadVascular TeamClinical GovernanceWard ManagerICN'sClinical NurseLeaders

Further modulesas workloadallows

Infection Control policies Ensuring all infection controlpolicies are up to date and in linewith national guidance.

All but 4 policies are now within theirreview date.

CNIC, DIPC, ICD,ICN's,Appropriateclinical personnelCOIC

Bi annual

2016/2017

Hand hygienecompliance and training

All clinical staff must undertakehand hygiene at the point of care.All clinical staff must attend anannual infection control, includinghand hygiene, update. Non clinicalstaff 3 yearly.

Staff to take personalresponsibility in regards toensuring hand hygiene materialsare available.

New hand hygiene initiatives to belaunched.

Compliance is measured via audit,increased handwashing audits required inoutbreak/raised numbers to obtain 100%compliance. All clinical staff required toattend an annual hand hygiene update,although attendance for some divisions ispoor. Hand hygiene must remain a highpriority within the organisation. InfectionControl needs to be embedded in allclinical staff’s annual appraisal.

Staff survey continues to show animprovement of availability of handhygiene and consumables though usageand cost continues to rise.

Surewash computerised system now

All healthcare workersclinical and non-clinical

All staff

ICT

Monthly review

Annual

Ongoing.

Ongoing

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ISSUE ACTION PROGRESS BY WHOM FREQUENCY

purchased and is actively used for trainingand in outbreak situations. New initiativesand raised awareness programmes tocontinue.

Antibiotic Compliance All clinical staff who prescribeantibiotics do so in accordancewith the Trust’s AntibioticGuidelines.

Quarterly snapshot audits undertaken,analysed results fed back to allprescribers. See C. difficile Action Plan fordetails.Results also fed into COIC, Drugs &Therapeutics Committee and AntibioticGroup.

Antibiotic Lead,Antibiotic PharmacistConsultantMicrobiologists

Quarterly audit,AntibioticGuidelinesreviewed andupdatedcontinuously.

Infection control training To ensure Infection Control islinked in with the Trust’s trainingneeds analysis & Training Matrixby all staff to receive InfectionControl training on induction andthereafter annually for all clinicalstaff and three yearly for non-clinical staff.

To continue to strive to achieve 100%compliance in regards to mandatorytraining.Review and update training packages andTraining Tracker module (available formedical staff) to reflect current policiesand up to date guidance.Hand hygiene remains a practicalassessment/training.

Compliance rates at 80-90% despitemonthly updates available. Surewashcomputer system with quiz to be reviewedas an alternative method of training.

ICNsAll Trust staffManagers to ensurecompliance

ICT

Monthly review

Estates and CapitalProjects

To ensure Infection Control Teamprovides guidance on preventingcross infection in healthcareenvironments

DIPC or Deputy to sign off newbuilds/remodelling that Infection Controlhas had an input. This is usually via anemail once plans have been viewed.There continues to be active dialogue,especially with all recent upgrades/newbuilds. The Projects DevelopmentManager now reports on all newdevelopments as a standing item at theCOIC.

DIPC, CNIC, ICD,Estates, Capital Team

Infection Controlinput asrequested

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ISSUE ACTION PROGRESS BY WHOM FREQUENCY

Decontaminationcompliance

To ensure Trustwide compliancewith all aspects ofdecontamination to prevent crossinfection

Decontamination meetings continue.Review all areas in the Trust that locallydecontaminate scopes/equipment.Risk assess and action plan formulated byDecontamination Lead and CNIC.To decontaminate all scopes in unit,awaiting further funding for equipment &scopes to complete.

DecontaminationLead, DIPC,CNIC,ICD Matrons,Business Managers

Quarterly

Reduction of CatheterAssociated UrinaryTract Infections(CAUTIs)

To reduce the number of shortterm catheters used, inappropriatediagnosis of UTI and inappropriateantibiotic usage for this condition.

Safety thermometer monthly dataof CAUTI to be verified by ICT.

Daily monitoring form, “Clock starts here”to review need for catheter daily has beensuccessfully implemented.

A significant reduction over the last yearand remains ongoing.

Discussed and agreed with Qualitydepartment.

ICNs, Ward staff

ICNs

ICNs

Quarterly review

Ongoing

MonthlyInfection risk fromCarbapenemaseProducingEnterobacteriaceae(CPEs) and othercarbapenem resistantorganisms.e.g Acinetobacterbaumannii

To embed into organisation thepolicy for the early detection,management and control of CPEs.

Monitor compliance with screening of highrisk patients.Monitor isolation of high risk patientsRisk assessment of isolation facilities toenable safe isolation of patients.

NCIC, ICNs Ongoing

Abbreviations:DIPC = Director of Infection Prevention & Control ICT = Infection Control TeamCNIC = Consultant Nurse Infection Control DTC = Drugs & Therapeutics CommitteeCOIC = Control of Infection Committee ICD = Infection Control DoctorICN = Infection Control Nurse

Appendix 3

Title Policy LeadLastReview

Next Review

Admission, Transfer and Discharge of InfectedPatient Policy Infection Control Team Nov-15 Sep-17

Aseptic Technique PolicyInfection Control Team Mar-14 Apr-16

Blood Culture Policy for AdultsDIPC/ICD/Ann Trail Sep-14 Sep-16

Care of tunnelled central venous access devices(HICC) Ann Trail May-16 May-18

Central Venous Catheter Care PolicySue Cottle Aug-15 Aug-17

CJDInfection Control Team Mar-14 Apr-16

Cleaning and Disinfection PolicyInfection Control Team Aug-15 Aug-17

Clostridium Difficile DiarrhoeaInfection Control Team Aug-15 Aug-17

Control of Tuberculosis in HospitalInfection Control Team Aug-15 Aug-17

Glove PolicyInfection Control Team Apr-16 Apr-18

Glycopeptide Resistant EnterococciInfection Control Team Mar-14 Mar-16

Hand Hygiene Policy for Healthcare WorkersAnn Trail Jan-15 Jan-17

Infection Control Guidance for Design,Construction and Renovation / RefurbishmentProjects

Infection Control Team Apr-16 Apr-18

Infestation PolicyAnn Trail Sep-14 Sep-16

Introduction to Infection Prevention ControlInfection Control Team Apr-16 Apr-18

Isolation PolicyAnn Trail Aug-15 Sep-16

Last Offices for the Infectious Adult PatientInfection Control Team Apr-16 Apr-18

Linen PolicyInfection Control Team Apr-16 Apr-18

Management of Diarrhoea and VomitingInfection Control Team Apr-16 Apr-18

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Meningococcal DiseaseInfection Control Team Mar-14 Mar-16

MRSA PolicyInfection Control Team Aug-15 Aug-17

Multi Resistant Gram Negative BacilliInfection Control Team Mar-14 Apr-16

Outbreak PolicyAnn Trail Sep-14 Sep-16

Peripherally Inserted Central Catheter (PICC)Care Policy for Adults Infection Control Team Apr-16 Apr-18

Peripheral Venous Catheter Care Policy for AdultsInfection Control Team Apr-16 Apr-18

Respiratory Viruses PolicyInfection Control Team Nov-15 Nov-17

Safe Handling and Disposal of SharpsInfection Control Team Apr-16 Apr-18

Short Term Indwelling Urinary CathetersInfection Control Team Apr-16 Apr-18

Spillage of Blood and Body FluidsInfection Control Team Apr-16 Apr-18

Standard Precautions PolicyInfection Control Team Apr-16 Apr-18

Surgical Site Infection Prevention TreatmentInfection Control Team Apr-16 Apr-18

Viral Haemorrhagic Fevers (Ebola) Infection Control Team Sep-14 Sep-16

Ebola Information Centre

Operational Procedure

VHF Action Card

VHF Algorithm

Appendix 4

ASPH 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Doctors/Dentist 19% 7% 7% 34% 34% 33% 34% 47% 22% 21%

Nurse/Midwifes 25% 8% 10% 26% 33% 34% 35% 46% 32% 28%

All other Professionals 18% 7% 15% 37% 44% 44% 48% 54% 51% 39%

Support to Clinical Staff N/A N/A 24% 53% 38% 53% 98% 65% 43% 68%

Total HCW 24% 12% 15% 37% 37% 40% 47% 51% 36% 38%

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Appendix 5

From: Ann TrailSent: 10 November 2016 13:28To: Heather CaudleCc: Clive GrundySubject: IC Summit- overview

Dear Heather,Please find an overview of the IC Summit held this week. Below are the questions which Ruth Mayasked which we could consider in preparation for the challenges ahead.

• Are you confident that you have the correct systems and processes in place to assuranceyour Board?

• Is your organisation compliant with the Health and Social care Act?

• Do you know your IPC risks?

• Do you see SSI data – if so, for what procedures and is this ongoing surveillance?

• Does the Board challenge the DIPC for assurance?

• Does your IPC team have the skills, capacity and capability?

• How do you work across the health and social care sector on improvement?

• Who owns the IPC agenda in your organisation?

Kind regards,Ann

Ann TrailNurse Consultant/Deputy Director of Infection Prevention and ControlAshford & St Peter's Hospitals NHS Foundation Trust, Guildford Road, Chertsey, Surrey, KT16 0PZ

Overview of the Infection Prevention & Control Clinical Summit held on 8th November2016

A clinical summit, hosted by the Secretary of State for Health, was held to review the burdenand potential interventions that can reduce the risk of gram negative blood stream infections(BSIs) covering urinary tract infections, intravascular devices, and surgical site infections.

Gram-negative bacteria are bacteria commonly found in the gut where they do no harm;however, they can cause infection at other body sites, mainly in patients who are vulnerabledue to other underlying diseases, injury or hospitalization. Infection often happens when thebacteria enter the body through an open wound or via a medical device such as a catheter.Infections caused by Gram-negative bacteria can cause urinary tract infection, woundinfection and other complications such as pneumonia or infection in the blood. This canprolong the length of stay in hospital and, in some cases, can cause death.

The Government is committed to an ambition to reduce Gram-negative bloodstreaminfections (initially E.coli) by 50% by 2020. From April 2017 there will be a CQUIN and aQuality Premium for reducing Gram negative blood stream infections and inappropriateantibiotic prescribing in at risk groups.

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Action to achieve these targets is a priority and enhanced infection prevention and control isa prerequisite both for healthcare associated and community onset E.coli BSIs.

E.coli BSIs at ASPHs

Our hospitals see 20-25 E.coli blood stream infections per month. The majority may beconsidered community cases e.g. sample taken within the first 48hrs of admission. Howeverwe will need to review all cases for any recent healthcare intervention which may havecontributed to their infection.

The graph below shows community and hospital E.coli BSIs from April to October 2016.

The Key Messages from the Summit Were:

Group work at the summit was focused on barriers to infection control and the interventionsrequired to minimise risk (urinary catheter and IV care, surgical site infections and antibioticprescribing) Key themes identified were:

The role of the DIPC should be strengthened with direct reporting to the trust board Surgical Site Surveillance to be extended beyond orthopaedics to other specialties All clinical staff required to insert, use, or look after vascular catheters should have

adequate training Medium and long term vascular access devices must only be accessed by people

with documented competency in their use.

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Patients with medium/long term vascular access and carers should be educated inthe care of their lines by a healthcare worker trained in the insertion and care of suchlines

Appropriate insertion and care urinary catheters with use of scanners Patients leaving hospital with a urinary catheter in situ, and those catheterised in the

community, should be provided with a catheter passport giving details of thecatheterisation

All hospital patients should have their state of hydration checked and recorded duringeach nursing shift

Appropriate diagnosis and treatment of UTIs Antibiotic treatment of urinary infection should follow treatment guidelines and not

stopped prematurely Good Infection Prevention and Control practice should be adhered to by all staff.