Report to: Public Board of Directors Agenda item: 11 Date of Meeting: 27 June 2018

Transcription

1 Report to: Public Board of Directors Agenda item: 11 Date of Meeting: 27 June 2018 Title of Report: Annual Infection Prevention and Control Report 2017/18 Status: For approval Board Sponsor: Helen Blanchard, Director of Nursing and Midwifery Author: Yvonne Pritchard, Senior Infection Prevention and Control Nurse Appendices None 1. Executive Summary of the Report The attached report provides a summary of the progress against the 2017/18 Annual Infection Prevention and Control Programme and the proposed programme for this year. Infection Prevention and Control is aligned to the priority objective of keeping patients safe and minimising harm, and the key standard of improving quality by reducing infections. The report includes performance against national targets for MRSA bloodstream infections, Clostridium difficile reduction and Gram-negative bloodstream infections. 2. Recommendations (Note, Approve, Discuss) For approval. 3. Legal / Regulatory Implications CQC Registration 2017/18 CQC Regulation 12: Safe Care and Treatment CQC Regulation 15: Premises and Equipment The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance (2015) 4. Risk (Threats or opportunities, link to a risk on the Risk Register, Board Assurance Framework etc) 180 Insufficient isolation facilities 1488 Failure to achieve the annual C diff reduction target (2017/18, now closed) 1284 Risks associated with the use of Actichlor Plus for decontamination 5. Resources Implications (Financial / staffing) Potential financial penalty if C diff target is not met 6. Equality and Diversity None identified 7. References to previous reports Annual Infection Prevention and Control Report 2016/17 presented in May Freedom of Information Public Document Approved by: Helen Blanchard, Director of Nursing and Midwifery Version: 1 Agenda Item: 11 Page 1 of 1

2 Infection Prevention and Control Annual Report Annual Infection Prevention and Control Report 2017/18 Document Approved by: Helen Blanchard, Director of Nursing and Midwifery/DIPC Version: 1.1 Agenda Item: 11 Page 1 of 40

3 1.0 Contents Executive Summary Infection Prevention and Control Team governance and reporting structure MRSA bloodstream infections MSSA bloodstream infections Gram-negative bloodstream infections (including E coli, Klebsiella spp. and Pseudomonas aeruginosa) Clostridium difficile infections Norovirus outbreaks HCAI associated deaths Influenza Carbapenemase Producing Enterobacteriaceae (CPE) cross-infection incident Antimicrobial Stewardship Surgical Site Infection Surveillance Collaborative working with the Cleaning Department and PLACE inspections Collaborative Working with other trusts, CCGs and Public Health England Key progress against objectives 2017/ Risk Register Infection Prevention and Control Training Document Approved by: Helen Blanchard, Director of Nursing and Midwifery/DIPC Version: 1.1 Agenda Item: 11 Page 2 of 40

4 2.0 Executive summary 2.1 This is the annual report of the Director of Infection Prevention and Control (DIPC) and summarises the work undertaken at the Royal United Hospitals Bath NHS Foundation Trust to manage infections during the period 1 April 2017 to 31 March The Trust is compliant with the Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance which was revised in July During 2017/18 there was 1Trust apportioned MRSA bloodstream infections against a trajectory of There were 80 cases of MSSA bloodstream infections, of which 19 were Trust apportioned. This is a slight increase on last year s number of cases which were 78 in total; 18 of which were Trust apportioned. 2.5 There were 291 cases of E coli bloodstream infections, this includes both Trust and non-trust apportioned cases. The ambition to reduce these infections by 10% commenced in April This target was not achieved with a 1% rise in the infections occurring within 48 hours of admission however there was a 7.1% reduction in Trust apportioned cases. The target is shared by the whole health community. 2.6 There were 88 cases of Klebsiella spp. bloodstream infections. 67 were diagnosed within 48 hours of admission; 21 were Trust apportioned. 2.7 There were 36 cases of Pseudomonas aeruginosa bloodstream infections. 24 were diagnosed within 48 hours of admission; 12 were Trust apportioned. 2.8 There were 31 cases of Clostridium difficile infection of which 19 were Trust apportioned against a trajectory of no more than 22.The remaining 12 do not count towards the trajectory as the CCGs agreed there were no lapses in care. A further case may be removed pending a decision by Public Health England. 2.9 There were a total of 39 wards/bays closed during the period due to norovirus outbreaks. 534 bed days were lost as a result of the closures. This is a significant increase in lost bed days compared with 2016/ There were high levels of influenza between January and March 2018 which resulted in 53 bay/ward closures and 415 bed days lost. This is also a significant increase compared with the same time frame during 2016/17. Document Approved by: Helen Blanchard, Director of Nursing and Midwifery/DIPC Version: 1.1 Agenda Item: 11 Page 3 of 40

5 2.11 The antimicrobial stewardship programme has continued throughout the year and improvements have been made in the selection of antibiotics and prescribing. The 2017/18 CQUIN targets for 72 hour prescription reviews and the tazocin and carbapenem reduction targets were met. The total antibiotic consumption target was not achieved There has been a reduction in the number of surgical site infections reported during 2017/18. An improvement plan has been in place and progress against the actions reported to the Infection Prevention and Control Committee The target for compliance with infection prevention and control training was achieved at Level 1 with 94.5% compliance reported at the end of March Level 2 training compliance did not meet the target with 88% of staff trained by the end of March Compliance with the Hygiene Code was reviewed on a rolling programme at the Infection Prevention and Control Committee. Each criterion was assessed during the year and overall compliance reported A programme of audits were carried out during 2017/18. These included MRSA screening and decolonisation compliance, Clostridium difficile compliance with policy and commode cleanliness audits. Some infection prevention and control audits are now included in the peer audit programme which commenced in December Audit results are reported ay the Infection Prevention and Control Committee and are shared with the Divisions. Document Approved by: Helen Blanchard, Director of Nursing and Midwifery/DIPC Version: 1.1 Agenda Item: 11 Page 4 of 40

6 3.0 Infection Prevention and Control Team (IPCT) Structure and Arrangements 3.1 The Infection Prevention and Control Arrangements The Chief Executive holds the ultimate responsibility for all aspects of infection prevention and control within the Trust The Director of Nursing and Midwifery is the designated executive lead; Director of Infection Prevention and Control (DIPC). She reports directly to the Chief Executive and the Board and she is the chair of the Infection Prevention and Control Committee (IPCC). The Director of Nursing and Midwifery is the Senior Infection Prevention and Control Nurse s line manager The Infection Control Doctor (ICD) is a consultant microbiologist who provides expert microbiological advice and supports the DIPC. The ICD is the deputy chair of the IPCC The Senior Infection Prevention and Control Nurse is responsible for the operational management of the Infection Prevention and Control Team (IPCT) and for ensuring that the Infection Prevention and Control Strategy is embedded The Infection Prevention and Control Nurses (IPCNs) provide expert clinical advice and support to Trust staff in the delivery of the Strategy. The team covers all sites within the Trust including the Royal National Hospital for Rheumatic Diseases and the community birthing centres The team also provide cover via a service level agreement for Avon and Wiltshire Mental Health Partnership NHS Trust (AWP). This agreement covers outbreak management and a number of educational sessions. 3.2 The Infection Prevention and Control Team The team is made up of the following staff: 1 wte Senior Infection Prevention and Control Nurse Band 8a 1 wte Infection Prevention and Control Nurse Band wte Infection Prevention and Control Nurses Band wte Personal and Information Assistant Band The Infection Control Doctor role was been vacant throughout 2016/17. The post was filled during 2017 when a new consultant microbiologist started with the Trust in November. There is now also a deputy ICD who commenced the role in February Document Approved by: Helen Blanchard, Director of Nursing and Midwifery/DIPC Version: 1.1 Agenda Item: 11 Page 5 of 40

7 3.3 Infection Prevention and Control Committee governance and reporting structure Board of Directors Management Board Operational Governance Committee Trust Infection Prevention and Control Committee Infection Prevention and Control is also represented on the following groups and committees: Water Safety Group Antimicrobial Stewardship Committee Divisional board meetings (as required) Divisional governance meetings (as required) Strategic Resilience Meeting Emergency planning meetings, e.g. Pandemic flu Outbreak meetings Professional Nurse Forum Safer Staff Group Senior Sisters meetings (as required) Cleaning Working Group Uniform Policy Group Clinical Consumables Review Group BaNES and Wiltshire HCAI Partnership Board Capital projects, building and refurbishment meetings Surgical Site Surveillance meetings Theatres Environment Group Medical Device governance and capital allocation meetings Influenza peer-vaccinator meetings AWP Infection Control and Medical Devices Committee meetings Document Approved by: Helen Blanchard, Director of Nursing and Midwifery/DIPC Version: 1.1 Agenda Item: 11 Page 6 of 40

8 4.0 Meticillin Resistant Staphylococcus aureus (MRSA) bloodstream infections The reporting of MRSA bloodstream infections is mandatory for all NHS trusts. The Trust was given a target of zero infections for the year 2017/18. There were a total of 5 cases reported by the Trust during 2017/18. Four cases were community acquired infections and one was recorded as Trust apportioned as the blood cultures were taken more than 2 days after admission. A post infection review investigation was undertaken by the IPCT for the post 2 day case whilst the community acquired cases were investigated by the relevant CCGs. A serious incident investigation is also carried out for Trust apportioned cases. The post infection review and serious incident investigation of the Trust apportioned case identified that the source was probably a femoral line. The patient had multiple line insertions during the time in hospital. Insertion of the femoral line and rationale was not clearly recorded. The patient was known to be colonised with MRSA prior to the positive blood cultures however decolonisation had not been commenced until after the result was received. An action plan was created from the findings of the investigation and this was overseen by the Head of Nursing for Surgery and the Critical Care Services Matron. The completion of the action plan has been monitored by the Surgical Division Governance Committee. Figure 1: MRSA bloodstream infections 2017/18 Agenda Item: 11 Page 7 of 40 Page 7 of 40

9 Figure 2: MRSA bloodstream infections April 2013 March 2018 Figure 3: Regional MRSA rates 2017/18 Regional MRSA Rate per 100,000 occcupied bed days 2017/ Agenda Item: 11 Page 8 of 40 Page 8 of 40

10 5.0 Meticillin Sensitive Staphylococcus aureus (MSSA) bloodstream infections The mandatory reporting of MSSA bloodstream infections commenced on 1 January There are currently no reduction targets set for this infection; Public Health England (PHE) are collating data which may act as a baseline for trajectory setting in the future. Figure 4 shows the number of cases by month since April Locally we have set our own ambition to reduce MSSA bloodstream infections by 15% by the end of March Figure 4: MSSA bloodstream infections April 2013-March 2018 During 2017/18 there were 80 cases of MSSA blood stream infection; 61 within 48 hours and 19 cases where the blood cultures were taken more than 48 hours after admission (see figure 5). Agenda Item: 11 Page 9 of 40 Page 9 of 40

11 Figure 5: MSSA bloodstream infections 2017/18 A multidisciplinary root cause analysis (RCA) investigation was carried out for all post 2 day cases. It was not possible to identify the underlying cause of infection in 15 cases and these were reported either as an unknown source or contaminated sample. The most prevalent identifiable causes of MSSA bloodstream infections were identified as wound or skin infections and line associated infections. The line associated infections were predominantly identified in patients with PICC lines; on investigation these have occurred when the needlefree connector has been removed in error and not replaced. An alert has been circulated to all ward areas to warn staff of this issue and training sessions have been planned. Agenda Item: 11 Page 10 of 40 Page 10 of 40

12 Figure 6: Causes of MSSA bloodstream infections (all patients) 2017/18 The work to reduce MRSA and MSSA bloodstream infections is summarised in the driver diagram below, figure 7. This forms part of the overarching Infection Prevention and Control Strategy for the Trust. Agenda Item: 11 Page 11 of 40 Page 11 of 40

13 Figure 7: Driver diagram for the reduction of MRSA and MSSA bloodstream infections 6.0 Gram negative bloodstream infections In April 2017 the Secretary of State for Health launched an ambition to reduce Gram-negative bloodstream infections by 50% by Infection caused by these organisms has increased nationally; despite the decrease in other infections such as MRSA. E coli, Klebsiella spp and Pseudomonas aeruginosa account for 72% of all Gram-negative bloodstream infections therefore these organisms have been identified as the key focus for reduction. For the first year from April 2017 to March 2018 a target was introduced to reduce cases of healthcare associated E coli bloodstream infection by 10%. Approximately 75% of these infections occur before admission to hospital therefore a whole health economy approach has been utilised. The target is not Trust specific and is shared with the Clinical Commissioning Groups who are leading on achieving the Quality Premium. 6.1 Escherichia coli (E coli) bloodstream infections The mandatory surveillance of E coli bloodstream infections commenced on 1 June PHE analysed all reports submitted so that the data could be used to gain a better understanding of the prevalence and causes of these infections. Agenda Item: 11 Page 12 of 40 Page 12 of 40

14 From these infections were split into community apportioned (blood cultures taken within 72 hours of admission) and trust apportioned (blood cultures taken 72 hours or more after admission). From April 2017 the definition changed to non-healthcare associated (blood cultures taken within 48 hours of admission) and healthcare associated (blood cultures taken more than 48 hours of admission). Figure 8 shows the number of cases by month since April Figure 8: E coli bloodstream infections April 2013 March 18 In July 2017 further guidance was published to clarify what is considered to be a healthcare associated infection; this category now includes residents of care homes and patients discharged from hospital within the last 28 days regardless of when the blood cultures are taken, see Figure 9. Figure 9: Definitions of healthcare associated and non-healthcare associated E coli bloodstream infections The Trust is working closely with the Clinical Commissioning Groups and other healthcare providers who are members of the BaNES and Wiltshire HCAI Partnership Board to reduce these infections. This comprises of work streams identifying and addressing improvement actions for the most commonly identified sources of infection. Agenda Item: 11 Page 13 of 40 Page 13 of 40

15 During 2017/18 the Trust reported a total of 295 E coli bloodstream infections. PHE surveillance includes positive blood cultures taken at GP practices or community hospitals in the Trust figure as the IPCT reports these on the HCAI Data Capture System on behalf of primary care and provider organisations. There were 3 cases at St Martin s Hospital and one where the blood culture was taken at a BaNES GP practice. With these cases deducted from the overall total there were 291 E coli bloodstream infections recorded for the Trust. The CCGs are reporting on progress against the overall 10% reduction target, including the revised guidance on the definition of healthcare associated E coli bloodstream infections however for the purpose of this report the RUH figures for pre and post 48 hour cases will be stated. The split between pre and post 48 hour cases is shown in figure 10. Figure 10: E coli bloodstream infections pre and post 48 hours 2017/18 Pre 48 hours Post 48 hours April May June July Aug Sept Oct Nov Dec Jan Feb Mar TOTAL 238 = 1% 53 = 7.1% 2016/17 cases The 10% reduction target was not achieved by any of the local CCGs for 2017/18 however there has been a reduction in the rate of infection compared with the previous year. Figures 11 and 12 show the total number of cases reported by the local CCGs and the rate per 100,000 population. The CCG data includes bloodstream infections reported by other acute trusts. Agenda Item: 11 Page 14 of 40 Page 14 of 40

16 Figure 11: Total number of E coli bloodstream infections by CCG CCG 10% target /18 Total Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar BaNES Somerset South Glos Wiltshire Figure 12: Rate of E coli bloodstream infections per 100,000 population by CCG CCG Rate 2017/ 18 Rate for England overall Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar BaNES Somerset South Glos Wiltshire Each patient with a confirmed E coli bloodstream infection is reviewed by the microbiologists who identify the most likely source of infection based on their review of the patient and their underlying pathologies. The source or cause of infection and any risk factors are reported to PHE via the HCAI data capture system. The most common cause of E coli bloodstream infection was urinary tract infection, which accounted for 47% of cases (upper and lower urinary tract combined). Around 23% of urinary tract infections were associated with urinary catheter usage. The second most common source of infection was hepatobiliary which accounted for 22% of cases. Both of these categories are covered by work streams within the BaNES and Wiltshire HCAI Partnership Board. There were 12 cases (4%) where the source of infection was unknown, 26 (9%) cases where there was no underlying focus of infection and 1 (0.3%) case where there was no clinical sign of infection; this could have been a contaminated sample. Agenda Item: 11 Page 15 of 40 Page 15 of 40

17 Figure 13: Sources of E coli bloodstream infections 2017/18 The work to reduce E coli bloodstream infections is summarised in the driver diagram, see figure 14. This will be extended to include the reduction of Klebsiella spp. and Pseudomonas aeruginosa bloodstream infections in 2018/19. Agenda Item: 11 Page 16 of 40 Page 16 of 40

18 Figure 14: Driver diagram for the reduction of E coli bloodstream infections 6.2 Klebsiella spp bloodstream infections Klebsiella species are Gram-negative bacteria that are found in the environment and also in the human intestinal tract. They commonly cause healthcare associated infections and are the second most frequently identified source of Gram-negative bloodstream infection after E coli. The Trust has reported all Klebsiella spp. bloodstream infections to Public Health England via the data capture system during 2017/18. These infections have not been included in the first year of the reduction programme as the focus has been on E coli which accounts for the largest number of Gram-negative bloodstream infections. For the purposes of this paper they are reported as pre and post 48 hour cases, see Figure 16. There were a total of 90 cases of Klebsiella bloodstream infections reported. Two of the cases were reported for other health care providers; one BaNES GP and one case at Paulton Hospital (Virgin Care). The remaining 88 cases were split as follows: 67 pre 48 hours and 21 post 48 hours. Agenda Item: 11 Page 17 of 40 Page 17 of 40

19 Figure 16: Klebsiella spp. bloodstream infections 2017/18 Klebsiella pneumoniae was the most prevalent species isolated during 2017/18. See Figure 17. Figure 17: Klebsiella species isolated in blood cultures 2017/18 Each case was reviewed by the microbiologists and the potential source identified. Urinary tract infections (28%) and hepatobiliary (26%) were the most common sources. Agenda Item: 11 Page 18 of 40 Page 18 of 40

20 Figure 18: Sources of Klebsiella spp bloodstream infections 2017/18 Klebsiella spp bloodstream infections are included in the BaNES and Wiltshire HCAI Partnership Board Gram-negative bloodstream infection improvement plan for 2018/ Pseudomonas aeruginosa bloodstream infections Pseudomonas aeruginosa are Gram-negative bacteria found in soil and water. It is an opportunistic pathogen which can cause a wide range of infections, particularly in patients who are immunocompromised. The organism is known to cause infections by contaminating invasive devices such as urinary catheters. The Trust has reported all Pseudomonas aeruginosa bloodstream infections to Public Health England via the data capture system during 2017/18. These infections have also not been included in the first year of the reduction programme. There were a total of 37 cases reported during 2017/18, including a case at Paulton Hospital (Virgin Care). Of the remaining cases 24 were pre 48 hour samples and 12 post 48 hour samples, see Figure 19. Agenda Item: 11 Page 19 of 40 Page 19 of 40

21 Figure 19: Pseudomonas aeruginosa bloodstream infections 2017/18 The same process is used as with the other Gram-negative bloodstream infections; each case is reviewed by a microbiologist and the most likely source and risk factors are identified. The most common source of infection was identified as the urinary tract (36%). Pseudomonas aeruginosa bloodstream infections are also included in the BaNES and Wiltshire HCAI Partnership Board Gram-negative bloodstream infection improvement plan for 2018/19. Agenda Item: 11 Page 20 of 40 Page 20 of 40

22 Figure 20: Sources of Pseudomonas aeruginosa bloodstream infections 2017/18 Agenda Item: 11 Page 21 of 40 Page 21 of 40

23 7.0. Clostridium difficile infections The reporting of the number of cases of Clostridium difficile (CDI) infections is mandatory for all NHS Trusts. All cases over 2 years of age must be reported and those identified 3 days or more after admission are allocated as Trust acquired. Figure 21: CDI performance April 2011-March 2018 (post 3 day cases only) 8 Clostridium difficile infection Post 3 days recorded (RUH only) For 2017/18 the Trust was set a target of 22 cases. The total number of Trust apportioned cases reported at the end of March 2018 was 31, of which 19 were Trust apportioned. 12 cases were presented to the CCGs who confirmed no lapse of care and there was agreement that these cases would not count against the trajectory although they remain as recorded cases. Clostridium difficile was not isolated in one of the samples that were sent for typing however Clostridium glycolicum was isolated. The Infection Prevention and Control Team have requested that this case is removed from the trajectory as there is no evidence of Clostridium difficile. Further evidence is being sourced by the Microbiology Laboratory Manager to support the removal of this case. Figure 22 shows the Trust Clostridium difficile rate against other trusts within the region. Agenda Item: 11 Page 22 of 40 Page 22 of 40

24 Figure 22: Regional Clostridium difficile infection rates 2017/ During 2017/18 a Clostridium difficile improvement action plan was implemented following an NHSi supportive visit in February The team were invited for a follow up visit in January 2018 where it was agreed that there had been an improvement in performance. New actions were suggested to help maintain performance and further reduce unavoidable infections. These were added to the improvement plan and at the time of writing this report most actions are nearing completion or have been completed. Actions include: The undertaking of an external review of the Microbiology service and antimicrobial prescribing. This took place in November 2017 and a report with recommendations was received. Actions are being monitored through the Pathology Directorate and the Surgical Division. Identification of the DIPC and a statement regarding compliance against the Hygiene Code on the Trust website. Consider use of technologies for enhanced decontamination of the environment e.g. hydrogen peroxide vapour Revision of the CDI root cause analysis document to include compliance with antimicrobial e-learning and audit results Plan a Spring Clean and deep clean programme for all wards Revise the Cleaning Policy to include the cleaning of vents and radiators. A rolling programme has been agreed. Agenda Item: 11 Page 23 of 40 Page 23 of 40

25 These recommendations will be used to focus the Clostridium difficile reduction work during 2018/19 and will be part of the Infection Prevention and Control work plan. Prior to the visit the previous actions were summarised in the driver diagram, figure 23. These actions are part of the overarching Infection Prevention and Control Strategy and are included in the Clostridium difficile improvement action plan. Figure 23: Driver diagram for the reduction of Clostridium difficile infections 8.0 Norovirus outbreaks Norovirus is estimated to cost the NHS in excess of 100 million per annum in years of high incidence. Approximately 3000 people are admitted to hospitals in England with norovirus each year and this infection spreads very quickly placing a huge burden on health care services. In order to reduce the spread of norovirus prompt isolation of infected patients is essential. If patients are not isolated the virus, which is very infectious, can spread to neighbouring patients. The most effective way of managing an outbreak is to isolate the area where symptoms have occurred and prevent other patients from being admitted until symptoms have ceased. This can be a bay or a whole ward depending on the layout of the area and the number of patients involved. Agenda Item: 11 Page 24 of 40 Page 24 of 40

26 The Trust takes part in voluntary surveillance of norovirus outbreaks; these are reported to Public Health England via a database. This information is used to show regional trends in norovirus infection and helps with predicting when major outbreaks are likely to occur. Norovirus often occurs in cycles and it is recognised that there will be peaks of infection every few years. When a ward or bay is closed due to an outbreak the Infection Prevention and Control Team visit the area twice a day to document and monitor the severity of symptoms. During the winter months the team provide an on-call service for weekends and bank holidays so that closed wards can continue to be monitored and decisions to reopen wards can be made without having to delay until the next working day. Outbreak meetings are held at least once a day during the week if there are areas closed and plans for reopening the areas are made in consultation with divisional staff, the Site Team and Hotel Services. During 2017/18 there were a total of 39 areas closed at some time due to outbreaks of diarrhoea and vomiting. These comprised of 14 full wards and 25 bay/partial ward closures. There were a total of 534 bed days lost as a result of these closures and a total of 125 confirmed cases of norovirus. No causative organism was identified during two of the outbreaks. The number of bed days lost and the number of confirmed norovirus cases was significantly higher than in 2016/17. Based on the average cost of a bed day being 546 the estimated cost of the outbreaks during 2017/18 is 291,564. It is not possible to provide any comparative data with other local trusts as the voluntary reporting of outbreaks to PHE is not undertaken by all neighbouring trusts. The work to reduce ward and bay closures is summarised in the driver diagram, figure 24. This forms part of the overarching Infection Prevention and Control Strategy. Agenda Item: 11 Page 25 of 40 Page 25 of 40

27 Figure 24: Driver diagram for the reduction in the number of ward/bay closures due to the spread of norovirus infection 9.0 HCAI associated deaths All deaths where HCAI is recorded on the death certificate in part I, the primary cause, are reported as Serious Incidents (SIs) by the Trust. For each SI a root cause analysis investigation is carried out in order to identify possible causes and actions to be taken to prevent similar incidents. These incidents are also reported on the Strategic Executive Information System (StEIS). During 2017/18 there were a total of 6 HCAI associated deaths reported. These comprised of 5 cases where Clostridium difficile was reported as the primary cause and 1 where MSSA bloodstream was cited. 9.1 Clostridium difficile associated deaths Clostridium difficile was given as one of the primary causes of death in 5 patients during the year 2017/18. Three patients acquired Clostridium difficile infection prior to admission and these deaths were investigated by the appropriate CCGs. The other 2 cases were investigated by senior clinicians and nurses. C diff infection was identified as unavoidable in all cases however lessons learned were shared at the Operational Governance Committee and at divisional governance meetings. Agenda Item: 11 Page 26 of 40 Page 26 of 40

28 9.2 MSSA Bloodstream infection associated death MSSA Bloodstream infection was given as the primary cause of death in one patient during 2017/18. The patient acquired the infection from a peripheral venous cannula site. A cannula was inserted on admission and was in situ for 4 days. When it was removed the site was assessed as clean and with no signs of infection however two days after removal the patient became unwell and developed a high temperature. Blood cultures taken: MSSA isolated. The patient had been receiving chemotherapy and at first it was thought that she had developed sepsis related to this however it was noted that the line site was inflamed and that there was evidence of cellulitis. The patient was treated for the infection but unfortunately after a prolonged hospital stay she deteriorated and died. A root cause analysis was carried out at the time of the MSSA infection and it identified that the initial cannula had been left in situ for 24 hours longer than advised in the Trust policy however the line site was inspected on removal and it was documented that there were no signs of infection. The learning from this case is that line sites should continue to be inspected after removal as infection may occur shortly afterwards. This has been shared at the Operational Governance Committee and the divisional governance meetings Influenza There was a rise in the number of cases of Influenza A and Influenza B during Quarter /18. This was noted throughout the South West region. As a result of the number of cases there were 53 bay/ward closures within the Trust during this period. This is 18 more areas affected than at the same time during 2016/17. There were also a number of local care homes and schools reporting outbreaks of flu-like illness during the same period. The rise in the number of cases was predicted based on the preceding influenza season in the Southern Hemisphere. Although there was a significant rise in the number of cases very few patients required admission to Critical Care Services. In house testing for influenza has improved the turnaround time for receiving results significantly. Prior to the introduction of PCR testing on site the turnaround time was between 2 to 5 days. The current testing regime within the RUH laboratory has meant that results have been received within an hour of the swab being taken. This service does not run over the 24 hour period however during the winter months the laboratory was able to offer extended testing hours which helped with diagnosis and patient flow. Patients with suspected influenza must be isolated immediately however during the peak in activity it was not possible to isolate all patients. Parry was set up as the influenza cohort ward from 20 th February until 23 rd March Having the facility to directly admit patients with influenza to the ward freed up beds across the Trust and further bay closures were prevented. Agenda Item: 11 Page 27 of 40 Page 27 of 40

29 There were 415 bed days lost due to influenza bed closures, see figure 25, the cost of which was approximately 226,590 based on the cost of an average bed day. Figure 25: Ward/bay closures due to confirmed Influenza, January March 2018 Month Area affected Bed days lost Type of influenza detected January 2018 February 2018 Cardiac bays 3&4 7 Influenza B Robin Smith bays 5&6 6 Influenza B Waterhouse bays 2, 3&4 7 Influenza B Combe bays1&3 2 Influenza B Charlotte bay 9 1 Influenza B Cheselden bay 3* 7 Influenza B Combe bay 2 1 Influenza A Forrester Brown bays 2&4 2 Influenza B Philip Yeoman bay 1 7 Influenza B MAU Area A 1 Influenza B ACE Area B 0 Influenza A Surgical Short Stay female bay 11 Influenza A Haygarth bays 1&4 15 Influenza B Respiratory bays 1, 2&4 5 Influenza B Acute Stroke C bay 5 Influenza B Pierce bays 1&3 19 Influenza A & B MAU Area B 3 Influenza B Helena female bay 0 Influenza B Philip Yeoman bay 1 8 Influenza B Parry bays 1&3 13 Influenza B ACE Area A 2 Influenza B Respiratory bays 3&5 16 Influenza A & B Combe bays 2&3 11 Influenza B Haygarth bay 3 0 Influenza B Acute Stroke C Bay 14 Influenza B Midford bay 2 5 Influenza B Cheselden bay 1 10 Influenza B Charlotte bay 10 4 Influenza B Cardiac bays 5&6 24 Influenza A & B MAU Area C 2 Influenza A Cardiac bay 3 6 Influenza B Combe bay 2 0 Influenza A Haygarth Ward 25 Influenza A & B Acute Stroke B&C bays 10 Influenza B Waterhouse Ward 21 Influenza A William Budd bay 2 8 Influenza B Pulteney bay 3 1 Influenza B Waterhouse bay 1 2 Influenza A Cheselden Ward 8 Influenza B Agenda Item: 11 Page 28 of 40 Page 28 of 40

30 March 2018 Combe bay 4 3 Influenza B Respiratory bay 5* 7 Influenza B Forrester Brown Ward 15 Influenza A Acute Stroke B bay 2 Influenza B Pierce bays 1, 2&4* 16 Influenza A Midford bay 2 0 Influenza B Cardiac bay 1 3 Influenza A MSS Male bay 4 Influenza B Respiratory bays 3&4 11 Influenza A Acute Stroke C bay 31 Influenza A Haygarth bays 1, 2&3 21 Influenza A Respiratory bay 2 4 Influenza B Parry bay 1 4 Influenza A Midford bay 3 5 Influenza A TOTAL 415 *Norovirus outbreak also affecting area at the same time 11.0 Carbapenemase Producing Enterobacteriaceae (CPE) cross-infection incident Carbapenemase producing Enterobacteriaceae are a group of bacteria that produce enzymes which make them resistant to certain antibiotics. The bacteria occur naturally in the human gut. If a patient has received a number of courses of antibiotics the bacteria may develop the enzyme and become resistant over time. This particular group of bacteria are more likely to be identified in patients who have been hospitalised abroad where exposure to these antibiotics is widespread. In most patients this causes colonisation within the gut however patients with a weakened immune system may develop an infection which is very difficult to treat. In November 2017 two patients were diagnosed with the same type of CPE whilst they were inpatients in one of the Trust s departments. This triggered regular outbreak meetings to identify the source and prevent further spread of infection. All patient contacts were informed of the incident and were isolated whilst they remained inpatients. The Infection Prevention and Control Team increased the frequency of audit within the area and the unit was deep cleaned. A full investigation was commenced and all patients who were present on the unit at the same time as the two patients were screened for CPE. This screening took place over several weeks and in some cases after the patients had been discharged home. No further cases were identified. The root cause analysis of the incident has identified a number of issues that are being addressed through a comprehensive action plan. The actions include: Find a solution to improve communication between hospital trusts so that infection risks are flagged Improve accuracy and completion of initial risk assessments on Millennium Agenda Item: 11 Page 29 of 40 Page 29 of 40

31 Improve adherence to hand hygiene and infection prevention and control policies within the department where the incident occurred. Attention to cleanliness of equipment that is used for patient care/treatment A Trust wide programme of education to enhance understanding of CPE and the risks posed to patients Cessation of PAT dog visits to the area The CCGs have been informed of the incident and they have supported with screening of patients who had been discharged. Public Health England were also informed and their guidance sought. The investigation has been reported to the Operational Governance Committee and the action plan is being monitored by the committee and the divisional governance group Antimicrobial Stewardship An Antimicrobial Stewardship Programme is a key component in reduction of HCAIs and forms part of the quality improvement strategy for patient safety to reduce inappropriate prescribing and optimise antibiotic use. The RUH is committed to following the principles outlined in the DoH guidance Antimicrobial Stewardship: Start Smart then Focus Antibiotic Stewardship ward rounds A ward focused antimicrobial team (consisting of a Consultant Microbiologist with support from an Antimicrobial Pharmacist) do structured daily ward rounds on ITU. This team also meet weekly, along with an infection control nurse, and undertake a ward round to review all patients currently being treated for Clostridium difficile. The RCA for these cases includes detailed review of potential contribution from any off recommendation antibiotic use both in hospital and prior to admission. In the last 12 months weekly ward rounds have been introduced on MAU and Haematology incorporating clinicians and pharmacists on the specific wards. Increased training has been implemented for the clinical pharmacists to increase stewardship support Antibiotic Audits Trustwide antimicrobial audits Trustwide antimicrobial compliance audits have been carried out quarterly, reviewing the following criteria: - Whether indication for antibiotics is documented - Whether a stop or review date is doucmented - Whether antimicrobials are prescribed as per guidelines/microbiology advice A summary of trustwise results are shown in figure 26. A detailed breakdown of results by ward and consultant team are shared with medical and nursing teams.there will be a break for Q1 2018/19 to focus on improved data capture and real time feedback from the recently introduced Agenda Item: 11 Page 30 of 40 Page 30 of 40

32 electronic prescribing system. An in depth audit to guide stewardship on OPU has just been completed full results pending. Figure 26: Summary results of Antibiotic compliance audits Number of wards audited Number of prescriptions sampled Indication documented Within guidelines Review date on chart Quarter % 96.1% 71.2% Quarter % 91.9% 74.4% Quarter % 94.8% 78.7% Quarter % 94.7% 68.1% RUH achieved 3rd in the regional point prevalence survey monitoring guideline compliance and antibiotic review AMR and Sepsis National CQUIN 17/ hour review 72 hour review of antibiotics for serious infection. The national CQUIN programme for 2017/18 Reducing the impact of serious infections (Antimicrobial Resistance and Sepsis) includes an assessment of clinical antibiotic review between hours of patients with sepsis who are still inpatients at 72 hours. The CQUIN requires that a competent clinician reviews the antibiotic prescription within three days of commencement to determine if it is still needed, and if so, if the appropriate antibiotic is being used. Target to achieve the CQUIN payment were 25%, 50%, 75%, 90% for quarters 1,2,3 and 4 respectively. Summary results are shown in figure 27. All quarterly targets were achieved and we expect to receive the full CQUIN payment. Figure 27: Summary results CQUIN audit antibioitc review within 72 hours Q1 Q2 Q3 Q4 Overall compliance: (Number of antibiotic prescriptions that were reviewed by a senior clinician and adequate justification for continuation of same IV) 46 (80.7%) 38 (63.3%) 54 (88.5%) 53 (94.6%) Antibiotic consumption A national CQUIN aiming to reduce total antibiotic consumption and certain broad spectrum antibiotics was in place during the year. This is measured by Defined Agenda Item: 11 Page 31 of 40 Page 31 of 40

33 Daily Doses (DDD) per 1000 admissions and a 2% reduction compared to usage in 2016/17 was required to achieve the CQUIN payment. There were three parts to this CQUIN indicator: - Total consumption of carbapenems (i.e. Meropenem, Ertapenem) - Total consumption of piperacillin-tazobactam (Tazocin ) - Total antibiotic consumption (i.e. all antibiotics) For antibiotic consumption for the year : Tazocin reduction 47% - related to shortages - target met. Carbapenem reduction 37% - target met. Total consumption increased by 4% - target 2% reduction - target not met. Results are shown in figure 28. Although actual amounts of antibiotics dispensed was higher in 2016/17, when the increased activity is taken into account the percentage reduction was achieved. Figure 28:Summary of antibiotic consumption measured as DDDs/1000 admissions 2017/ /17 % change DDDs issued No of adm DDD /1000 adm DDDs issued No of adm DDD /1000 adm All antibiotics 456,196 88,324 5, ,737 86,205 4,973 +4% Piperacillin-tazobactam 5,830 88, ,661 86, % Carbapenems 4,111 88, ,364 86, % Piperacillin-Tazobactam reductions were significantly affected by national shortages. These shortages would also have affected total usage as 3 alternative antibiotics may have been used instead of a single agent. Focus to improve total consumption required. All antibiotic courses require: appropriate indication early review with clinical and microbiological results clinically appropriate early oral switch or stop date Current focus is on antibiotic review process aiming to implement epma technology to aid review and alert clinicians re unreviewed antimicrobials. Initial discussions re consideration of recruitment in ARK study involves comparison pre and post implementation of a validated toolkit to improve antibiotic review as part of a 36 hospital clinical trial. The CQUIN targets for current year have removed the Tazocin target and replaced this with a target to achieve 55% (or a minimum 3% increase) in usage of antibiotics from the Access category which includes narrower spectrum and lower resistance potential antibiotics. Agenda Item: 11 Page 32 of 40 Page 32 of 40

34 12.4 Antibiotic Stewardship Team A multidisciplinary Antimicrobial Stewardship Team is in place to ensure engagement on antimicrobial quality improvement projects across the RUH. The team meets quarterly and has nursing, medical, sugical and pharmacy representation Microguide app The microguide app was launched in November 2014 and contains most of the trust s antibiotic guidelines. Work plan ongoing to include all guidelines. The app has improved the accessibility of the guidelines and has received very positive feedback and high usage. Recent updates have improved the intranet interface Surgical Site Infection Surveillance (SSIS) The Trust takes part in the mandatory surveillance of surgical site infections which involves the reporting of infections post-operatively in patients undergoing certain types of Orthopaedic surgery. This includes surveillance of patients prior to and post discharge and also patients who are readmitted with post-operative infections. If the infection has occurred within 30 days of the surgery, or in the case of implant surgery within one year, the incident will be reported as a surgical site infection. The surveillance nurses are employed by the Surgical Division, and during 2017/18 they reported on surgical site infections in patients who had undergone hip replacement (THR), knee replacement (TKR) and repair of a fracture to the hip. The surveillance nurses have also collected and reported data for the 12 month period on certain types of Breast surgery however this is not mandatory. The Trust has continued to take steps to reduce the rate of infection over the last 12 months and success has been noted with respect of THR infections; two infections were reported in 2017 in comparison with twelve in The reporting position for TKR and fractured neck of femur have also reduced over the year albeit only slightly when looking at the 12 month picture. Therefore the Trust has continued to receive high outlier letters from PHE following each quarter. It is worth noting however that the trend in rate has reduced in year from 5.1% at its highest to 1.3% for TKR, and 0.8% to 0.0% for fractured neck of femur. In response to this, the Surgical Site Infection Surveillance Working Group (SSISG) continues to meet regularly to identify how further infections could be prevented and changes monitored. The group now meets bi-monthly and the membership includes a Consultant Orthopaedic Surgeon, Estates Manager, Theatre staff, Head of Nursing, Infection Prevention and Control Team, Cleaning Manager, Matron for Musculoskeletal and Ward Sisters. Actions were identified and have been put into place as follows: Agenda Item: 11 Page 33 of 40 Page 33 of 40

35 The Environmental Working Group for Theatres continues to meet monthly, managing any ongoing environment and maintenance concerns; High level cleaning in Theatres continues on a quarterly schedule and reports feed into the SSISG; New staff attended the SSIS training with Public Health England; The use of Pre-operative skin wash has been extended and now includes all breast surgery; Progress is reported to the Infection Prevention and Control Committee; All reported infections have a SBAR investigation and review is completed by a Consultant Surgeon. The Working Group will continue to meet bi-monthly whilst actions are being taken forward. Figure 29 shows the picture during the year whereas figure 30 shows the incidents of infections for the rolling last 4 periods. All deep or joint space infections have been investigated extensively and no identifiable causes or links were found. Figure 29: Surgical Site Infections 2017/18 Sourced for confirmation from PHE database Agenda Item: 11 Page 34 of 40 Page 34 of 40

36 Figure 30: Surgical site infections April 2016 December 2017 Agenda Item: 11 Page 35 of 40 Page 35 of 40

37 14.0 Collaborative Working with the Cleaning Team and PLACE Assessment The Cleaning Team play a vital part in maintaining a safe environment for patients and staff; there is a close working partnership between them and the Infection Prevention and Control Team. The Deputy Head of Hotel Services is a member of the Infection Prevention and Control Committee and the Clostridium difficile Working Group: there is IPCN representation at the monthly Cleaning Working Group. The Cleaning Action Plan and minutes of the Cleaning Working Group are discussed at the IPCC meeting to ensure that progress is being made in cleaning recruitment, cleaning policy and procedures review, purchasing of new equipment, de-cluttering of clinical and public areas and importantly the detailed monitoring of clinical and public area cleaning standards audit scores Cleaning audits 2017/18 For compliance with national standards of cleanliness there is a requirement to routinely audit clinical and non-clinical areas of the hospital. Very high risk areas require a weekly audit. High risk areas require a monthly audit. Significant risk areas require an audit every 13 weeks. This equates to 2784 audits per year, of which 99% were completed in 2017/18. Cleaning audit targets are: Very High Risk 98% - 81% of audits completed achieved 98% High Risk 95% - 79% of audits completed achieved 95% Significant Risk 85% - 96% of audits completed achieved 85% After each audit is carried out the areas that have been identified as non-compliant are rectified. The department will receive a post rectification audit, the majority of which score 100% PLACE Inspections 2017 The annual Patient Led Assessment of the Care Environment (PLACE) inspection was carried out over two weeks in April The IPCNs were involved with the assessment along with senior managers, patient representatives from BaNES and Wiltshire Healthwatch, Trust Public Governors, Friends of the RUH Volunteers and an independent external assessor. Inspection teams consist of two members of Trust staff together with two patient representatives. 12 wards and 8 out-patient departments were inspected as well as the emergency department, communal areas and external grounds and gardens. All scoring is completed by the patient representatives to ensure this process is a completely independent assessment of the hospitals cleanliness and environmental condition. Agenda Item: 11 Page 36 of 40 Page 36 of 40