Infection Control Annual Report

Transcription

1 Infection Control Annual Report

2 1.0 Contents 2.0 Executive Summary Summary of performance MRSA bacteraemia Clostridium difficile Methicillin sensitive staphylococcus aureus (MSSA) bacteraemia E. coli bacteraemia Intravenous device related infections Infection control compliance Surveillance and infection control audits Antibiotic stewardship Gram negative micro-organisms Influenza Norovirus MRSA screening Other significant issues Estates and planning Outbreaks and incidents Decontamination Appendix 1 Infection control provision and arrangements Appendix 2 Graphs and tables Appendix 3 Definition of catheter associated and related blood stream infection UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 2

3 1.0 Executive Summary 1.1 This is the report of the Director of Infection Prevention and Control (DIPC) and summarises the work undertaken in the organisation for the period 1 April 2016 to 31 March There were 2 cases of MRSA bacteraemia against a trajectory of There were 29 cases of MSSA bacteraemia during this period. 1.4 There were 90 cases of hospital-acquired Clostridium difficile in UCLH during this period against an ambition of <97 cases. 80 cases were successfully appealed and 10 cases were classified as lapses in care which included delay in sampling and isolation. Root causes were primarily associated with appropriate antibiotic usage and recurrent C.difficile infection. 1.5 The C. difficile taskforce group continued to led on the C. difficile reduction plan. As most of the actions initiated by group also contributed to the prevention, management and monitoring of Carbapenemase producing organisms (CPOs) the work of the group also encompassed this area. 1.6 By March 2017 the Infection Control Quality Improvement tool was in use by all areas and replaced the previous hand hygiene compliance monitoring tool. 1.7 The surveillance of surgical site infection (SSI) continued. Infection rates did not change significantly from the previous year ( ) in most followed-up categories of surgery. In Spinal surgery rates decreased from 2.78% to 0%, in Large Bowel surgery rates decreased from 18.3% to 11% and infection rates for caesarean sections were consistently below national average of 1.43% vs. 3.56%. 1.8 Pseudomonas and Legionella in water continues to be monitored and managed. UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 3

4 2.0 Summary of Infection Prevention and Control performance MRSA bacteraemia There were 2 cases of MRSA bacteraemia against a national trajectory of 0. (Graph 1 Appendix 2) In both cases the root cause was associated with drains i.e. a CSF drain and a biliary drain Education, training and support was provided to improve practice in invasive devices insertion, management and documentation of ongoing care. 3.2 Clostridium difficile (C.difficile) UCLH reported 90 hospital-attributed C.difficile cases in this period (Graph 2a, Appendix 2). The ribotype strains identified were diverse reflecting the distribution and carriage in the community and not indicative of transmission (Graph 2b, Appendix 2) UCLH continues to test more cases than most other trusts for C.difficile infection. The rationale is that early detection and treatment improves patient outcomes. However this increases ascertainment. In addition cases are predominantly identified in patients with haematological or oncological conditions requiring chemotherapy where early treatment is particularly beneficial of the 90 hospital acquired C. difficile toxin positive cases were successfully appealed via the clinical commissioning group (CCG). Successful appeals predominantly related to patients requiring antibiotics which were prescribed and delivered in accordance with the UCLH policy which reflects best practice. 10 cases were classified as lapses in care. This included isolation in a single room delayed, poor completion of stool chart and stool sampling delay and inappropriate C. difficile infection treatment. This is a 16% reduction in lapses in care identified compared to last year Most of the cases were attributed to the administration of appropriate antibiotics to patients with infections which were not preventable and life threatening if not treated with antibiotics. As in previous years, many of these patients were immuno-suppressed. Reviews indicated that antibiotic prescribing was appropriate and in line with microbiological and clinical advice Laxative usage was appropriate in the cases reviewed and was often used to treat constipation induced by treatment such as pain control. A high percentage of cases had an underlying bowel disease such as Crohns disease or previous colectomy and it was sometimes difficult to determine when they had a change in bowel pattern. Approximately 17% of the cases reported had recurrent C.difficile infections and 10% had had C. difficile antigen detected previously The C. difficile taskforce group continues to lead and monitor the C. difficile reduction plan based on key learning from RCA results. The main learning points from the review of these cases for were associated with recognizing diarrhea as soon as possible, obtaining specimens early and disseminating learning from the RCA process A weekly review of C. difficile toxin and antigen patients by Infection Control and Microbiology was introduced in September This coincided with an improved method of recording UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 4

5 details of the infection and care required in documentation. The aim is to monitor progress and intervene at an earlier stage to avoid further relapses/recurrences or failed treatments The results of an evaluation of UV decontamination following cleaning indicated that it could be used instead of HPV in some instances. UV decontamination was subsequently added to the cleaning processes used Deep cleaning of the patient environment across the Trust is undertaken annually. 3.3 Meticillin sensitive staphylococcus aureus (MSSA) bacteraemia Graph 3 (Appendix 2) illustrates the trend at UCLH from April 2006: There were 29 cases of hospital acquired MSSA bacteraemia in UCLH undertakes an RCA similar to the MRSA PIR in these cases. The root causes are summarised in Table A below, some cases had more than one root cause. Table A - RCA of MSSA cases Likely source of MSSA BSI Total Traumatic wound 2 Infected CVC 9 Skin soft tissue infection 3 Chest infection/ VAP 2 Infected DVT 1 Infected arterial line 1 Surgical wound 2 Infected peripheral IV cannula 6 Likely contaminated blood culture 1 Other infection 0 Unknown Education, training and support was provided to improve practice in invasive devices insertion, management and documentation of ongoing care A blood culture pack is in use and prompts good practice in sampling and documentation. 3.4 E. coli bacteraemia An E. coli bacteraemia reduction ambition for the whole health economy has been established by the Department of Health. A 10% reduction rate is proposed for and 50% overall reduction by UCLH has been working with PHE, CCG and CSU to develop a sustainable strategy to approach this ambition. UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 5

6 3.5 Intravenous device related infections UCLH has been one of the pilot sites for the Public Health England bacteraemia surveillance in critical care. As few UK organisations currently collect this data there is no UK comparator data The definitions of catheter associated blood stream infection (CA-BSI) and catheter related blood stream infection rate (CR-BSI) are included in Appendix 3. Haematology and oncology patient were included from the 1 st of October The results of the audit are summarised in Table C below. Table C - VADs audit October 2015 March 2016 Line days CA- BSI CA-BSI Rate CR-BSI CR-BSI Rate Central VADs Per 1000 line days Per 1000 line days Midlines Per 1000 line days Per 1000 line days An audit of peripheral vascular devises in October 2016 indicated improvement was required in documentation and daily review of these devices. 3.6 Infection control compliance Education, training and promotion work continued to promote hand hygiene and infection control compliance The observation based hand hygiene compliance monitoring system was replaced by a continuous quality improvement tool during this period and incorporated work to remove factors which are a barrier to compliance and to focus on improvement The tool was introduced with training across the trust and by March 2017 the new ICCQI reporting tool was in use by all reporting areas. This did however lead to a drop in scores as the aim was to seek areas for improvement and a lower score is expected. (Graph 4, Appendix 2) Evaluation by users of the ICCQI tool was positive. An audit of hand hygiene product availability which had been selected as an area for improvement indicated significant improvement Training in hand hygiene continued throughout the year and e-learning is mandatory on induction. 3.7 Surveillance and infection control audits Surveillance of infection information is available to staff at ward, division and board level. Data are validated regularly by the Trust epidemiologist who produces a weekly report and identifies trends for discussion and possible action Surveillance of surgical site infection (SSI) is undertaken in most of the specialities for at least 3 months every year. Post- operative patients are followed up for 30 days following surgery (1 year where an implant is involved) and we report this data to PHE on a quarterly basis. This is summarised in Table 1 Appendix 2. UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 6

7 3.7.3 Infection rates did not change significantly from the previous year in most categories of surgery. In Spinal surgery rates decreased from 2.78% to 0%, in Large Bowel surgery rates decreased from 18.3% to 11% and in caesarean sections SSI rates were consistently below the national average (1.43 vs. 3.56%) In total knee replacement the rate was 1.50% vs. national rate 0.45%. This was investigated and no significant issues were identified. The numbers of infections are low and minor changes in numbers have a disproportionate effect on the rates reported A National point prevalence survey (PPS) of antibiotic usage and healthcare acquired infections was undertaken in November PHE estimated t the prevalence of HAI is approximately 8.5% at UCLH and the percentage of patients receiving antibiotics is 33.3% which is in line with National data Trust wide audits undertaken during this period included: Intravenous line management and documentation audit Safety sharp devices audit Hand hygiene product availability audit Results of these audits were fed back to staff and education and support was provided. The new IC QI tool enables staff to include areas of low compliance in a continuous improvement cycle. 3.8 Antibiotic stewardship The Antibiotic usage committee (AUC) met monthly and reported to the Quality and Safety Committee The Antimicrobial Resistance CQUIN focussed work on antimicrobial stewardship, guideline review, use of alternative antibiotic agents and doses and reduction in duration of therapy Monthly audits were conducted manually Trust wide to measure review of antibiotic prescriptions within 72 hours of initiation The AUC has a rolling agenda to produce, review and ratify all trust antimicrobial guidelines The antibiotic App is established and has been updated to reflect current guidelines and recent changes An e-learning package is now included on the UCLH learning portal for all doctors and pharmacists as essential for role training A generic presentation was developed to allow Committee members to promote stewardship messages at their respective governance / audit days Gram negative micro-organisms In patients with carbapenemase producing organisms (CPO) (mostly Klebsiella pneumoniae and E. coli, but also other gram negatives, such as Citrobacter freundii and Acinetobacter pittii) were detected: 12 in UCLH inpatients, one from a GP practice and one from a private patient (Graph 7, Appendix 2). The prevalence of carbapenem resistant organisms is likely to rise alongside neighbouring trusts in the near future. At present UCLH has been successful in limiting the incidence by good infection control procedures and spread is very limited. Hence screening has been limited to reactive screening of wards when cases UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 7

8 have been identified. Reduction in the usage of broad spectrum antibiotics is key to overall control and management of CPO During 2016/17 a number of highly resistant gram negative micro-organisms were isolated from patient s samples, many of which were imported from abroad or from other health care providers. This is becoming a significant issue for the Trust and the introduction of screening for specific organisms will be made mandatory in future Three graphs 5, 6, 7a in Appendix 2 illustrate the incidence of gram negative bacteraemia but not the resistance patterns inpatients within the Trust. We present recent trends of Carbapenem resistance in the two most common Gram-negative causes of bacteraemia: E coli (graph 7b) and Pseudomonas species (graph 7c) to illustrate the fact that the occurrence of multiply resistant cases depends on the organism detected in blood. Although these cases are rare among UCLH inpatients, their occurrence warrant close monitoring as most are potentially fatal and highly spreadable. Overall the number of these cases is significantly higher than MRSA or MSSA. As antibiotic resistance increases it will be increasingly difficult to treat these patients in future therefore a robust system to identify and manage high resistant organism will be a priority Influenza An outbreak of Influenza was declared by the Trust in December 2016 (See 4.2). The increase in Influenza cases was higher in Quarter 4. (Graph 8, Appendix 2) Norovirus There was a peak of Norovirus in Quarter 4 which coincided with the Influenza outbreak declared by the Trust. (Graph 9 Appendix 2,) MRSA screening MRSA molecular screening has been proven not to be cost effective for all patients requiring screening. A culture based screening method has been introduced with little impact on timings of results or patient care The MRSA screening policy has been reviewed to identify risk category groups for the introduction of targeting screening according to DH guidance entation_of_modified_admission_mrsa_screening_guidance_for_nhs.pdf,, 4.0 Other significant issues 4.1 Estates and Planning The ICT directorate continued to support and provide advice to numerous schemes to develop or create facilities and services Collaborative work with the Estates and Facilities Division continues to improve monitoring and reporting on cleaning standards and maintenance and monitoring of the estate. UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 8

9 4.1.3 The monitoring and eradication of Pseudomonas in taps and showers continues. A system of regular shower head changes in high risk areas has been established and water outlet testing is in place The operational Water Management group has led on mitigation and management of this issue with support from ICT. The Water Management Group meets on a quarterly basis and is led by Estates manager with representatives from Microbiology, Infection Control and contractor services attending the meetings Enhanced water testing has been undertaken on the Neonatal unit (NNU), Haematology and Oncology areas in compliance with DOH guidelines and advice. 4.2 Outbreaks and incidents Virology incidents Bay and ward closures associated with patient exposure and transmission of viral infections resulted in 906 hospital bed days lost. Of these 716 were associated with an outbreak which commenced in December Summary of the outbreak December 2016-February 2017 In December 2016 there was a sudden increase in admissions with influenza. This coincided with capacity pressures over the Christmas and New Year period. Simultaneously, a high number of RSV cases were also identified which mainly affected the elderly population. An influenza outbreak was declared on (Figure 1). The outbreak lasted eight weeks and included cases of Influenza A, RSV and Norovirus cases (Table 2). During this period a Flu ward was identified and used twice. The lessons learnt from this outbreak will be used to improve policies, guidleines and processes. Figure1: Number of positive respiratory samples UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 9

10 Table 2: Bays and Ward closures during the outbreak December February 2017 Bays closed Wards closed Flu A RSV Noro Other virus Flu A RSV Noro Other virus Week 1 26/12/ Week 2 02/01/ Week 3 09/01/ Week 4 16/01/ Week 5 23/01/ Week 6 30/01/ Week 7 06/02/ Week 8 13/02/ Measles There were 12 confirmed measles cases during this period including a member of staff, all of which were community acquired. Many of these cases required investigation and contact tracing of exposed staff and patients Microbiology incidents Tuberculosis There were two incidents of open pulmonary TB which required look back exercises involving staff and patients. There was no evidence transmission Carbapenemase producing organism (CPO) Twelve inpatients had a CPO during this period, one of which was identified as hospital acquired. A look back exercise was unable to identify links between shared staff and equipment. A deep clean of the clinical area using HPV was performed. No further hospital acquired cases have been identified to date Isolation Isolation in single rooms in the Trust continues to be of limitation and an increase in isolation facilities is included in planned development. An isolation prioritisation tool is in use and usage is based on a risk assessment by the infection control team and clinical site managers. An isolation prioritisation tool for paediatrics was finalised and introduced this year. The aim was to optimise current paediatric isolation capacity and reduce the need to transfer patients to other hospitals for isolation Decontamination Decontamination processes have been reviewed across the Trust A decontamination specialist advisor works alongside the infection control team monitoring and reporting decontamination processes The management of trans-esophageal echocardiogram TOE probes that are in use within the Trust is part of the on-going monitoring. UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 10

11 4.3.4 The decontamination advisor is part of the CJD group at NHNN, which is designed to look at specific requirements and processes for neurological surgical instruments as well as working closely with sterile services advising in best practice for the management and decontamination of surgical instruments A formalised process for the review of manufacturers decontamination guidance for medical devices and equipment during the procurement process continues, to ensure that there are compatible systems in place for cleaning and decontamination prior to equipment being brought into the organisation The team continue to support areas in developing and reviewing risk assessments as well as ensuring there are up to date written procedures (SOPs) and ongoing training programmes for the local management of decontamination. Particular focus has been on services which use Nasoendoscopes and working with service leads to standardising processes across the Trust. Annette Jeanes Director of Infection Prevention and Control 18/7/2017 UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 11

12 Appendix 1 Infection Control Provision and Arrangements. 1.0 The Infection Control department provides an infection control service for the University College London Hospitals NHS Foundation Trust (UCLH). A service is also provided for Harley UCH. 2.0 The Trust is required to meet the duties of the Hygiene Code, NHS Litigation Authority (NHSLA) and the Core standards of the Care Quality Commission. In addition there is a requirement to demonstrate compliance with NICE and best practice guidance. 3.0 The infection control service is delivered and facilitated by an infection control team which includes staff in different disciplines and boards. The team covers all sites of the Trust. The funded establishment 1 currently is: 9.6 WTE infection control nurses (ICN) 1.0 WTE consultant nurse 1.0 WTE microbiologist 1.0 WTE epidemiologist 4.6 WTE surveillance staff 1.0 WTE antibiotic pharmacist 1.0 WTE Infection Control Co-ordinator 0.4 WTE decontamination advisor 3.0 Other members of the team include: Microbiologists, virologists, Infectious diseases, environmental monitoring officers, matrons, infection control liaison practitioners, Occupational Health and sterile services. The neonatal and special care baby unit fund an embedded part-time infection control nurse who is supported and supervised by the infection control team. The UCH ITU fund part-time infection control link nurses who are supported by the infection control team. 5.0 The Director of Infection Prevention and Control (DIPC) is the infection control nurse consultant. The job description of the DIPC contains both roles. In 2015 the role also includes management of the IC team and decontamination lead. 6.0 The core infection control service includes an infection control advisory service, proactive infection prevention work and education and training throughout the organisation. It also undertakes audit, policy formulation and advice, surveillance and epidemiology, outbreak and control management. A significant aspect of their work is advising on planning. 7.0 An advisory service is operated daily and out of hours. This is provided by the on-call microbiology and virology service. At week-ends and on bank holidays there is an infection control nurse on-call from There is a daily meeting of microbiology, virology and infection control staff to review clinical information and service responses. The core infection control team meets weekly to formally review infection control issues and performance. 9.0 The Trust infection control committee (TICC) is chaired by the DIPC and meets bi-monthly with representatives from boards and key service areas. The minutes are available on the intranet. This committee reports to the QSC The ICT work closely with the CCG and PHE and other stakeholders. Examples include: C.difficile RCAs are reviewed regularly with the CCG. Post infection reviews are undertaken on all MRSA & MSSA bacteraemia and MRSA PIR are reported to PHE 1 This includes posts which are funded by other departments such as pharmacy and posts which are not filled UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 12

13 Appendix 2 Graph 1 MRSA bacteraemia cases. HA = hospital-acquired (detected 2+ days after admission), CA = community-acquired (detected within 2 days of admission). T15 are private inpatients. Graph 2a: Clostridium difficile cases; HA = hospital-acquired (detected 3+ days after admission, includes lapses in care, successful appeals and pending appeals), CA = community-acquired (detected within 3 days of admission), T15 as in Graph1; NREP = not reportable (because the illness was attributable to factors other than C difficile [HPA/PHE guidelines]). The HA incidence (black line with triangular markers) reflects the subset of HA cases relevant to the ambition the increase at the end of the year is a reflection of the changes in appeal methodology introduced in February UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 13

14 Graph 2b: Distribution of C diff ribotypes, cases detected in ; HA = hospital-acquired (detected 3+ days after admission, includes lapses in care, successful appeals and pending appeals), CA = community-acquired (detected within 3 days of admission), COMM = detected in the community (GP, outpatients etc). UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 14

15 Graph 3: MSSA bacteraemia cases; HA = hospital-acquired (detected 2+ days after admission); CA = community-acquired (detected within 2 days of admission); T15 is a private patient s ward. The ambition is an internal reduction aspiration. Graph 4: Hand Hygiene compliance incorporating quality improvement reporting UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 15

16 Graph 5 Pseudomonas aeruginosa bacteraemias; HA = hospital-acquired (detected 2+ days after admission); CA = community-acquired (detected within 2 days of admission); T15 is a private patient s ward. Graph 6 E coli bacteraemia; HA = hospital-acquired (detected 2+ days after admission); CA = community-acquired (detected within 2 days of admission); T15 is a private patient s ward. UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 16

17 Graph 7 Number of patients colonized/infected with carbapenemase-producing organisms Graph 7a Other gram negative bacteraemia (hospital-acquired only, i.e. detected 2+ days after admission). UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 17

18 Graph 7b Percent Carbapenem resistance in E coli bacteraemias (all inpatients regardless of when detected, i.e. hospital- and community-acquired cases). + Graph 7c Percent Carbapenem resistance in Pseudomonas species bacteraemias (all inpatients regardless of when detected, i.e. hospital- and community-acquired cases). UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 18

19 Graph 8 Influenza cases. HA = hospital-acquired (detected 2+ days after admission); CA = community-acquired (detected within 2 days of admission); T15 is a private patient s ward. Graph 9: Norovirus cases. HA = hospital-acquired (detected 5+ days after admission); CA = community-acquired (detected within 5 days of admission); T15 is a private patient s ward. UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 19

20 Table 1 Surgical operations carried out at UCLH during 2016; N f-up = number followed up by the SSISS team; N Inf = number of infections detected in hospital among followed-up surgeries (HPA/PHE definitions); Category of surgery Number of operations N f-up (%) N Inf. (%) National % Caesarean section Cranial Knee replacement Large bowel Limb amputation Repair of neck of femur Small bowel Spinal Total hip replacement Thoracic surgery Urology (19) 284 (19) 200 (66) 272 (80) 2 (13) 14 (17) 173 (77) 157 (19) 243 (64) 328 (67) 497 (14) 6 (1.43) 6 (2.11) 3 (1.50) 19 (11.0) 0 (0.0) 0 (0.0) 11 (6.36) 0 (0.0) 1 (0.41) 3 (0.91) 8 (3.22) 3.56 (*) (*) Comparisons with national rates use the subset of data collected nationally between April 2011 to October 2016 where that exclude patient-reported infections (PHE guideline); and there is no attempt to control for casemix in this comparison. (*) = statistically significant difference (Chi-square test for proportions highlighted only where the UCLH sample size is greater than 10 operations). UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 20

21 UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 21

22 UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT 22