Director of Infection and Prevention ANNUAL REPORT 2017/18

Transcription

1 Director of Infection and Prevention ANNUAL REPORT 20/18 1

2 Introduction from the Director of Infection Prevention and Control It seems strange to link the importance of infection prevention and control to the TV programme Game of Thrones however, two quotes stand out from the programme that remind me of two key influences on patient safety in our hospitals and in our community. One is winter is coming and the other is advice from Lord Baelish to Sansa: Good hand hygiene and winter bugs both play a significant role in influencing the health and wellbeing of our population, especially those at their most vulnerable and those in hospital. This winter has been a particularly challenging winter with a number of patients acquiring flu. This report aims to provide an overview of the progress of our teams in reducing risk of spread of infection and through learning from our reviews of individual cases. I am proud to be the Board lead for infection prevention and control. I would like to acknowledge the hard work and commitment of many staff from across our healthcare community who have worked in partnership to promote good hygiene and prescribing practice. Together with our healthcare partners, we have created a vision and clinically-led strategic plan for the future. My annual report 20/18 provides an overview of our progress against this plan. I would like to thank Monika Pasztor and the consultant microbiology team along with Matron Joanne Gaffing and our dedicated infection prevention and control team for their continued support to the staff across the organisation and across Bay Health and Care Partners. Improvements in health and care are linked and the NHS and its public, private, and voluntary sector partners can only provide the best and most effective service for patients and public when we work together to achieve our objectives. Sue Smith Executive Chief Nurse, Deputy Chief Executive, and Director of Infection Prevention and Control 2

3 Summary Healthcare organisations monitor their improvement progress through key performance indicators (KPIs). These enable us to monitor progress against changes or improvements in practice to demonstrate whether these are working. Infection control KPIs are developed by the infection prevention and control committee to provide robust assurance that we continue to improve outcomes and that we are addressing on-going challenges in the prevention and control of HCAIs. The infection prevention and control committee reports directly to the Board level Quality Assurance Committee. KPIs provide evidence of assurance, or early warning of themes or concerns, regarding compliance with the regulations set out in the Health and Social Care Act and the Care Quality Commission regulations. Potential concerns or incidents are discussed three times a day at patient safety and flow meetings to enable speedy response and clear understanding of all staff of risks, mitigations and effect of actions taken. All reportable infections are discussed at the weekly patient safety summit chaired by the Medical Director or Executive Chief Nurse. UHMBT continues to promote and support a zero tolerance towards avoidable HCAIs. Over the last year data has been collected to help us understand and learn from our review of infections, including: Meticillin Resistant Staphylococcus aureus (MRSA) blood stream infections Meticillin Sensitive Staphylococcus aureus (MSSA) blood stream infections Clostridium difficile infections (CDI) Gram-negative blood stream infections caused by Escherichia coli (E. coli), Klebsiella species and Pseudomonas aeruginosa Norovirus outbreaks Periods of increased incidence of infections Hand hygiene and bare below the elbows compliance Antibiotic prescribing practice How did we do? The headlines for the financial year are as follows: We have reported 3 cases of MRSA blood stream infection; 1 of these was acquired in hospital associated and 2 were community associated cases. We reported 20 cases of hospital Clostridium difficile cases, significantly lower than our nationally set annual target of of these have been identified as having no lapses in care and are therefore deemed unavoidable. A total of 82 cases of MSSA blood stream infections were reported during the year, of which 65 were community-associated and hospital-associated cases. There is no national target for MSSA however; learning from them enables us to continuously improve our understanding and management of this infection. 309 cases of E.coli blood stream infections were reported, of which 264 were communityassociated and 45 were hospital-associated. We had a total of 50 cases of Klebsiella bacteraemia and 18 cases of Pseudomonas aeruginosa bacteraemia. These are the baseline total figures. The health care associated cases should be reduced by 50% by UHMBT had a total of 6 outbreaks of Norovirus-type gastrointestinal illness, within RLI and FGH, during the year. 3

4 Target Summary MRSA Blood stream infections Target for 20/18 Number in Q4 YTD apportioned to Acute Trajectory for end of Q4 Zero Above Target CDI actual -6 deemed as no lapses in care 44 Below trajectory METICILLIN RESISTANT STAPHYLOCOCCUS AUREUS BLOOD STREAM INFECTIONS Staphylococcus aureus (S. aureus) is a bacterium that commonly colonises human skin and mucosa without causing any problems. It can also cause disease, particularly if there is an opportunity for the bacteria to enter the body, for example through broken skin or during a medical procedure. If the bacteria enter the body, especially in somebody who is already unwell, the result could range from mild to lifethreatening illness including; skin and wound infections; infected eczema; abscesses or joint infections; infections of the heart valves (endocarditis); pneumonia; and bacteraemia (blood stream infection). To avoid health care associated MRSA bacteraemia and deep seated infection we screen those patients, and decolonise their skin if they come to us for foreign body insertion or known to be colonised with MRSA. Overall screening compliance for 20/18 was 93.1%, and the increasing trend on MRSA screening compliance can be seen on the graph below: Most strains of S. aureus are sensitive to commonly used antibiotics, and many infections can be effectively treated. Some S. aureus bacteria are more resistant. Those resistant to the antibiotic 4

5 meticillin are termed meticillin-resistant Staphylococcus aureus (MRSA) and often require different types of antibiotic to treat them. Those that are sensitive to meticillin are termed meticillinsusceptible Staphylococcus aureus (MSSA). MRSA and MSSA only differ in their degree of antibiotic resistance: other than that there is no real difference between them. Hospital-acquired MRSA infections at University Hospitals of Morecambe Bay remain lower than the national rate. During 20/18 our culture of zero tolerance to harm has continued in relation to avoidable cases of MRSA blood stream infections. We continue to work collaboratively with our commissioners, Public Health England, and partner organisations to learn lessons to support the reduction of avoidable HCAIs All Cases MRSA bacteraemia trends (England vs Trust) Rate per 100,000 bed days Although the MRSA all-case rate for the most recent year (2.4 per 100,000 bed days) is less than the rate in 2008/09 (7.8 per 100,000 bed days), the annual increase from 2015/16 has been maintained. This apparent increase needs to be continued to be monitored, to determine whether this represents a genuine increase, or variation around continuing, but slowing, declines in the rate of MRSA. The benchmark position when compared to other NHS Trusts can be seen in the following link: METICILLIN-SENSITIVE STAPHLOCOCCUS AUREUS BLOOD STREAM INFECTIONS Following a Secretary of State announcement on 5 October 2010, there was a mandatory requirement for all NHS acute trusts to report MSSA bacteraemia. This applied to all cases diagnosed after 1 January MSSA blood stream infections cases continue to be monitored by the Trust and data provided for national surveillance. In total this year there have been 65 community associated (identified within 48 hours of admission to hospital and hospital associated cases (reported post-48 hours after admission). 5

6 MSSA bacteraemia trends (England vs Trust) All Cases Trust apportioned cases Rate per 100,000 bed days Trust apportioned cases The Trust benchmark position in when compared to Trusts in the North West can be seen below: Trust Name Apr- May- Jun- Totals (England) Jul- Aug- Sep- Oct- Nov- Dec- Jan- 18 Feb- 18 Mar- 18 Aintree University Hospital Alder Hey Children's Blackpool Teaching Hospitals Bolton Countess of Chester Hospital East Cheshire East Lancashire Hospitals Lancashire Teaching Hospitals Liverpool Heart & Chest Hospital Liverpool Women's Manchester University Mid Cheshire Hospitals North Cumbria University Hospitals Pennine Acute Hospitals Royal Liverpool & Broadgreen University Hospitals Salford Royal Southport & Ormskirk Hospital

7 St. Helens and Knowsley Hospitals Stockport Tameside Hospital The Christie Hospital The Clatterbridge Cancer Centre The Walton Centre University Hospitals of Morecambe Bay Warrington & Halton Hospitals Wirral University Teaching Hospital Wrightington, Wigan & Leigh CLOSTRIDIUM DIFFICILE INFECTION Up to and including 20/18, NHS organisations have continued to be required to demonstrate year on year reductions in Clostridium difficile Infection (CDI) cases. However, as published data shows, the rate of reduction of CDI has slowed over recent years. Infection prevention and control experts from within the NHS and from Public Health England advise that this is likely to be due to a combination of factors, including the biology and epidemiology of the Clostridium difficile (CD) organism. There are indications that, for some organisations at least, the level of CDIs may be approaching their irreducible minimum level at which these infections will occur regardless of the quality of care provided. This can occur due to the fact that some people carry CD in their bowel and will develop symptoms due to their underlying clinical conditions or as a consequence of the antibiotics they have to take. Put simply, some infections are a consequence of factors outside the control of the NHS organisation that detected the infection. In total this year there have been 71 community-associated cases of CDI (identified pre-72 hours of admission to hospital, or found in specimens sent by local GPs). The annual trajectory in 20/18 for hospital-acquired cases of CDI was set at 44 cases for UHMBT. During the year there were 20 cases of hospital-attributed Clostridium difficile identified. Our aim is that no patient is harmed by a preventable infection and this is the maximum number of cases expected for our population, not a target. During the year, 14 of the 20 cases of CDI have been attributed to the Trust because there may have been an omission or poor audit result on a ward in the weeks leading up to the infection. It should be noted that lapses in care are not necessarily directly related to the individual case of CDI; however, there are times when an infection is deemed avoidable, and when this happens we always carry out a full investigation, are open and honest with the patient and their family, and ensure we learn and share lessons. 7

8 Number of Cases Hospital acquired CDI cases UHMBT Clostridium Difficile cases 1st April th February 2018 Number of Cases Financial Year Our teams undertook a post-infection review (PIR) for every hospital acquired case of CDI. These were led by the ward manager responsible for the patient s care and were supported by clinicians involved in the management of the patient. The IPC Matron attended monthly HCAI meetings to review all CDI cases with our commissioners and Lancashire County Council (LCC) Public Health Infection Prevention Team. The meetings provided an additional opportunity to further discuss each case and conclude whether the cases were linked with lapses in care and therefore apportioned to UHMBT. To comply with national reporting requirements, the total number of CDI cases assigned to UHMBT remains as a raw actual number on the National Public Health England Data Capture System (DCS), i.e. the number of cases identified 72 hours after a patient has been admitted. The reduced apportioned number is the number used for contractual purposes against our annual target of 44 (see graph below). A lapse in care would be indicated by evidence that policies and procedures consistent with national guidance and standards were not followed by the relevant provider. This would include evidence of: Transmission of CDI in hospital confirmed through ribotyping Poor compliance in cleaning standards, using performance indicators Poor compliance with infection prevention precautions such as hand hygiene Concerns identified with choice, duration, or documentation of antibiotic prescribing It must be noted that true causes of infection can rarely be identified. However, themes across UHMBT continue to mirror those nationally. These include issues in relation to the prescribing of antimicrobials (antibiotics) and proton pump inhibitors (PPI), and poor documentation; The introduction of electronic documentation and electronic prescribing during 2018 should help to reduce risks associated with paper records. 8

9 C Difficile cases 20/18 Headings have changed to reflect Monitor reporting requirements Apr Ma y Jun Jul Au g No Sep Oct v De c Ma Jan Feb r Trajectory Actual number of CDI cases per month Total CDI cases YTD including those deemed not due to lapses in care Monthly CDI cases apportioned to acute Trust due to lapses in care *liable to change as reviews outstanding* Cummulative total CDI cases apportioned to Trust due to lapses in care *liable to change as reviews outstanding* Learning from analysis of 20/18 CDI cases demonstrated commonalities that are acknowledged nationally and are a focus for clinician review across community and hospital, including: Of the 20 UHMBT cases: 35% of patients were prescribed proton pump inhibitors (PPIs) either in the community or in the hospital and were taking them at the time of diagnosis. PPIs are medication taken to reduce stomach acid). 85% of patients were recently prescribed antibiotics either in the community or in the hospital. 15% of patients were recently prescribed laxatives either in the community or in the hospital. 20% of patients had recent bowel surgery or inflammatory bowel conditions (including known previous CDI). No epidemiological link in between the cases identified by ribotyping (showing no evidence of spread between cases). 9

10 Gram-negative blood stream infection caused by E coli, Klebsiella and Pseudomonas aeruginosa Due to the successful reduction of the MRSA and MSSA bacteraemia nationwide there is a new focus on reducing health care acquired infections. There has been a voluntary national data collection of the rate of the Gram-negative bacteraemias and found that the most common ones are the E coli, Klebsiella and Pseudomonas aeruginosa, hence the new targets the data collection became mandatory via Health Care Associated Infection Surveillance System, Public Health. Escherichia coli (E. coli) bacteria are frequently found in the intestines of humans and animals. There are many different types of E. coli, and while some live in the intestine quite harmlessly, others may cause a variety of diseases. The bacterium is found in faeces and can survive in the environment. E. coli bacteria can cause a range of infections including urinary tract infection, cystitis (infection of the bladder), and intestinal infection. E. coli bacteraemia (blood stream infection) may be caused by primary infections spreading to the blood. This organism can cause hospital acquired blood stream infection due through use of some instruments or abdominal surgical procedures. Enhanced surveillance of E. coli bacteraemia has been mandatory for NHS hospitals since June Patient data of any E. coli bacteraemia is reported monthly to PHE. In total this year there have been 264 community-associated (identified within 48 hours of admission to UHMBT) and 45 hospital associated (post-48 hours after admission) cases reported. From 20/18 there is a national target to reduce gram negative bacteraemia, including E. coli infections by 50% over 5-years; and there is a Bay Health and Care partnership approach to achieve this. The University Hospitals of Morecambe Bay NHS Foundation Trust ranked number 22 out of the 59 most improved Trusts for reducing the number of patients with a Gram-negative bacteraemia in the last year. Klebsiella is the second most common Gram-negative enteric bacterium with similar significance to E coli. We isolated 50 cases of Klebsiella blood stream infections in the last financial year. Pseudomonas aeruginosa is an environmental microorganism. It is not part of the normal human flora, but prefers to live in wet environment and in water. This organism is naturally very resistant to commonly used antibiotics and antiseptics as well. Therefore overuse of antibiotics or antiseptic solutions can create high burden of Pseudomonas colonisation in the environment and in patients as well. This bacterium can build resistant biomass on wet surfaces and in the taps. Due to its nature it is a typical health care associated bacterium hence the attention paid to it. We have been monitoring the Pseudomonas aeruginosa water colonisation in out tap waters in augmented (intensive care) care units. We found a single unit with resistant Pseudomonas aeruginosa colonisation last year. There were 18 Pseudomonas aeruginosa blood stream infections identified last year and none were associated with water system colonisation in our augmented care units. There is a real time root cause analysis on all of the E coli, Pseudomonas aeruginosa and Klebsiella bacteraemia cases in order to identify any health care intervention associated cases. These are the cases should be reduce by 50% by

11 The main themes are urinary catheter associated E. coli bacteraemia and ERCP/MRCP associated Gram-negative blood stream infections nationally. ERCP (endoscopic retrograde cholangiopancreatography) and MRCP (magnetic resonance cholangiopancreatography) involve imaging and diagnosis of hepatobiliary and pancreatic conditions. Working teams have been set up for North Lancashire and South Cumbria together with Community providers and CCGs in order to make a mutual effort to reduce the Gram-negative blood stream infections. Urinary catheter passport has been created by one of the working groups and has been trialled and found to be useful for patients and carers. There is a local hydration campaign for public to prevent urinary tract related Gram-negative blood stream infections. This topic is now included into the training package to trainee doctors provided by the microbiologist team. There is an enhanced focus on the catheter and cannula management in the hospitals audited by the infection control team. This is a part of UHMBT s local plan to reduce Gram-negative blood stream infections. A summary of the action plan is outlined below: 1. Create a joint Use of Indwelling Catheter policy with community teams, to ensure that seamless care for patients across healthcare settings. 2. Liaise with Acute Care Matron regarding Vascular Access Policy not currently adhered to in relation to long-term line care 3. The IPC team will lead a training group, regarding IPC documentation particular focus on education/training on catheter care and cannula care (to involve Clinical Skills and Practice Educators). Will target Matrons, Ward managers and Clinical Leaders. 4. Create a Mandatory Training package on TMS, for all clinical staff who cannulate/catheterise on IPC documentation. 5. Work with Urology Team, regarding best practice in catheter care. 6. Education sessions within the Urology Training days provided as an MDT (IPC & Microbiology) 7. A Consultant Microbiologist to attend foundation doctor training days, along with an infection prevention nurse to undertake education relating to catheters and cannula which includes care plans. 8. A clinical incident will be entered for all blood stream infections, regardless of cause group. They will be action planned as per the independent investigation review process. CARBAPENEMASE PRODUCING ENTEROBATERIACEAE (CPE) The use of many different types of antibiotics in hospitals creates evolutionary pressures that encourage the development and spread of antibiotic-resistant bacteria. This process is a natural consequence of the use of antibiotics and cannot be stopped, only managed. Enterobacteriaceae are a group of bacteria carried in the gut of all humans and animals, which is perfectly normal. While they are usually harmless they may sometimes spread to other parts of the body such as the urinary tract or into the bloodstream (bacteraemia) where they can cause serious infections. 11

12 This can occur after an injury or via the use of medical devices such as urinary catheters or intravenous drips where the skin is punctured allowing the bacteria to get into the body. CPE is the name given to some strains of gut bacteria that have developed the ability to destroy an important group of antibiotics called carbapenems, making them resistant to these drugs. Carbapenems are considered to be antibiotics of last resort and doctors rely on them to treat certain stubborn infections when other antibiotics would or have failed. Infections caused by CPE can usually still be treated with antibiotics. However, treatment is more difficult and may require a combination of drugs or the use of less commonly used antibiotics to be effective At UHMBT the PHE CPE toolkit has been implemented. During 20/18 UHMBT reported no newly diagnosed cases of CPE. However, UHMBT continued to manage known previously colonised cases using the PHE toolkit that supports early detection, management and control of CPE. VANCOMYCIN/GLYCOPEPTIDES RESISTANT ENTEROCOCCI (VRE/GRE) Enterococci bacteria are frequently found in the bowel of normal healthy individuals. There are many different species of enterococci, but only a few have the potential to cause infections in humans. They can cause a range of illnesses including urinary tract infections, bacteraemia, and wound infections. Enterococci are naturally very resistant bacteria to antibiotics and antiseptics therefore they survive for a long time. Glycopeptide-resistant Enterococci (GRE) are enterococci that are resistant to glycopeptide antibiotics (vancomycin and teicoplanin). GRE are sometimes also referred to as VRE (Vancomycin- Resistant Enterococci). Infections caused by GRE mainly occur in hospital patients. However, GRE are sometimes found in the faeces of people who have never been in hospital or have not recently been given antibiotics. A total of 70 patients have had GRE isolated from non-invasive samples last year showing an emerging problem. Due to the resistant nature of the Enterococci especially the GREs it is an indicator bacterium of the standard of hand washing and cleaning technique. Following national and international recommendations we screen and isolate colonised patients with GRE in surgical units, and do enhanced cleaning around them. There has been no increased incident reported in FGH but several small increased incidents in surgical units at the RLI. These have been controlled and monitored by infection control team. There were 3 declared GRE outbreaks during 20/18, at the RLI site. The Department of Health advised that from 1 April 2013, VRE / GRE blood stream infection is no longer the subject of mandatory surveillance. Trusts are still encouraged to report this data voluntarily and UHMBT have continued to inform PHE of newly diagnosed cases. There was a single case of GRE bacteraemia in our hospitals in the last financial year. 12

13 TUBERCULOSIS (TB) Tuberculosis (TB) is an infection caused by a bacterium belonging to the Mycobacterium tuberculosis complex. TB is a notifiable disease in the UK. Suspected and confirmed diseases must be notified within three working days. TB usually affects the lungs but can also affect almost any other area of the body. Most transmissions occur from some people with pulmonary or laryngeal TB and are infectious. TB develops slowly and it usually takes several months for symptoms to appear. There were 3 new TB cases identified in RLI and one in FGH. Due to the delayed identifications two cases required contact tracing. There was no evidence of any in-hospital spread. SURGICAL SITE INFECTIONS (SSI) The prevention of healthcare-associated infection (HCAI) has been highlighted as a national priority for action by successive Chief Medical Officers. In April 2004 surveillance of SSI in orthopaedic surgery became mandatory for all English NHS Trusts. For the mandatory surveillance of SSI following orthopaedic surgery, all NHS Trusts must participate in a minimum of one surveillance period in at least one category of orthopaedic procedures during a financial year. UHMBT participates in the mandatory SSI programme with results that reflect that of similar organisations. Historically we have submitted data collected on hip and knee replacement surgery between July and September; however data collection across some of our surgical units has been sporadic over the year resulting in unreliable data. This will be a key focus for the Trust over 2018/19 when the governance and assurance around collection of this data will be monitored monthly to ensure data is consistently collected across all sites and enables us to draw on meaningful results. NOROVIRUS OUTBREAKS Norovirus causes gastroenteritis and is highly infectious. The virus is easily transmitted through contact with infected individuals from one person to another. Outbreaks are common in semienclosed environments such as hospitals, nursing homes, schools, and cruise ships and can also occur in restaurants and hotels. The virus typically lasts for one to two days. Symptoms include vomiting, diarrhoea, and fever. Most people make a full recovery within a couple of days but it can be dangerous for the very young, very sick, and elderly people. In total from April 20 to March 2018 UHMBT had 7 Norovirus type outbreaks on various wards across FGH and RLI sites. 142 total bed days were lost over the year due to Norovirus type illness. The total number of patients affected was 53, with 13 staff also affected 13

14 INFLUENZA Influenza viruses have badly hit the UK and European communities in this last winter season. It affected our hospitals as well. The data below enables understanding of the extend of the outbreak this winter when compared with a common season. This is national data captured from online flu surveillance (PHE Weekly National Influenza Report). The uptake of the influenza vaccine across our hospitals in the last year was 89.2% overall, which placed UHMBT the 4 th most successful organisation in the UK for uptake of Influenza vaccinations. The highest number of staff vaccinated was in the administration and estates group, with 94.68% vaccinated. The lowest uptake was in nursing and midwifery staff group, with 83.41% of staff vaccinated. Four different influenza types were circulating at the same time during this period, making cohort isolation difficult, and staff more vulnerable to the influenza cases (trivalent vaccine did not cover all of the circulation strains). There were 9 Influenza Outbreaks during 20/18 5 at RLI, 4 at FGH and 0 at WGH. 6 of these outbreaks were Influenza A, and 3 outbreaks were Influenza B. There was a loss of 31 bed days, and 27 patients were affected by an Influenza outbreak, which is a relatively low number compared to the numbers of patients being admitted from the community with Influenza. This shows that, although it was difficult to manage, every team did extremely well to keep the number of outbreaks in single figures across the entire organisation. Throughout 20/18, there were 96 episodes of staff sickness reported as Cold, Cough, Influenza. However, this way of reporting will skew the results, as it is not clear how many staff were absent with confirmed Influenza, and how many had a cold. Our laboratories had to perform 1939 influenza tests with 30% positive rate. Half of the samples were requested from A&E departments. We had 685 admissions with confirmed influenza in this last winter season. The continuous presence of the IPC team on acute wards and their support and 14

15 advice in correct use of isolation facilities and PPEs prevented more widespread outbreaks of influenza. ACTIONS TAKEN TO SUPPORT IMPROVEMENTS IN HCAI Governance In order to support and develop a more effective way of working across the healthcare economy a Bay-wide anti-microbial (AMR) steering group has been formed. The purpose of this group is to support the antibiotic prescribing strategy and provide an opportunity to explore the epidemiology of our two counties in more detail. Monthly meetings continue to be held between the IPC Matron, commissioners and Lancashire County Council to review all health-care associated infections (HCAI). Quarterly strategic infection prevention meetings continue to be held between the IPC Matron, microbiologists, PHE, NHS England and Lancashire County Council to review IPC strategies across the health economy of Lancashire and Cumbria. Infection Prevention Operational Group (IPOG) meets quarterly to review, monitor, and action operational infection prevention issues. This group reports to the Infection Prevention and Control Committee (IPCC). The IPCC, a sub-committee of the board of directors Quality Assurance Committee continued to meet quarterly to derive assurance on UHMBT s Infection Prevention cocommissioning contract and delivery. Antimicrobial Sub-Committee met quarterly to review, monitor, and action any issues related to antimicrobial management. Multidisciplinary walk rounds led by the Matron for Quality Standards and supported by the executive team, operational staff, governors, patient representatives, Healthwatch, and CCGs were undertaken on a regular basis across the Trust and reported through the quality assurance structure. Staff IPC mandatory training, aseptic technique and hand hygiene training continued to be centrally collated on a live database in the Training Management System (TMS). The IPC Matron has worked with the IT team to create an IPC dashboard to allow accurate, real-time information to be available whenever it is needed. This is now ready to be launched. Antimicrobial stewardship UHMBT Medical Director, Professor David Walker, provided leadership to support and gain medical engagement to promote good practice in antimicrobial stewardship. Senior pharmacy antimicrobial leadership has been reconfigured to ensure embedding of antimicrobial pharmacy in all existing pharmacists duties. The process for recording monthly point prevalence antibiotic audits by divisions has been established. Each division has monthly antimicrobial audits, undertaken by the Pharmacy team. A4 laminated versions of the local antimicrobial guidelines have been updated and distributed to all wards/depts. We introduced Micro-guide. Electronic system for local antibiotic policy that is available on all of the hospital desktops and can be downloaded to any smart phone. It was very well 15

16 received and increased the compliance of the local antibiotic guidelines. Pharmacy is supporting the monitoring of antimicrobial prescribing at ward level and undertakes a point prevalence audit on antibiotic prescribing. Daily audit has been run by pharmacy and microbiology and all of the meropenem and tazocin use is monitored on daily basis helping the compliance with CQUIN targets. The baseline target last financial year for Tazocin use was 23,764 vials as opposed to the achievement of the vials. The transient shortage of the tazocin in the market helped reducing the consumption. On the other hand it did not increase the use of Meropenem due to the daily monitoring of these antibiotics. The Meropenem consumption was 7,587 vials (against the target of 10,049 vials). The total antibiotic consumption was over the target due to the excess use in this winter. This was unavoidable as influenza hit our community badly and led to increased incident of bacterial respiratory tract infections (total antibiotic consumption: 1,051,937 against a target of 1,046,459) New height based gentamicin guideline has been introduced in order to reduce the risk of over- or under-dosing gentamicin. The compliance to the sepsis management has been monitored quarterly the annual compliance with receiving antibiotic within 1 hour of diagnosis was 77%. Education and training The IPC team has provided mandatory hand hygiene training for all UHMBT employees through induction days, monthly mandatory divisional study days, and ward-based enhanced training. Medical Students have had a shadow day included in their rotation, to allow an understanding of IPC principles. Communication of key messages via a number of media including social networks The World Health Organisation (WHO) Five Moments of Hand Hygiene is in use across UHBT with the support from the Communications team. This campaign continues to be communicated both internally and externally with the support from local media. The IPC team continues to work collaboratively with suppliers, our Procurement and Estates and Facilities teams to ensure that infection risk is considered and managed when commissioning works, new equipment or processes. Additional on-going infection prevention surveillance and support continues across UHMBT with daily infection prevention visits to high risk areas. Bespoke infection prevention training has been continued, in line with HBN 00-09, for all preferred contractors coming into UHMBT. This training is a pre-requisite for contractors to undertake prior to working on site. The IPC team continue to work with clinical staff and support clinical site managers with best options for bed utilisation. The IPC team have provided tools to all wards, with education relating to risk assessment for side-rooms. 16

17 The IPC team facilitated the national antibiotic awareness and hand hygiene days across UHMBT. These days were supported by UHMBT Consultant Microbiologists, and a microbiology and infection control quiz was run successfully for hospital staff at FGH and RLI Training has been provided to domestic staff regarding deep cleans. The IPC Induction education session has been updated, and continues to be provided to all new starters to the organisation. The IPC team has provided education for the Apprentice Nursing Scheme, prior to commencement of placement. There is an annual training schedule for medical students and foundation doctors by microbiology consultants providing lectures, interactive sessions, and lab based tutorials. Providing a clean safe environment The IPC team continue to have a daily presence at the Trust patient safety and flow meetings, and support unlocking delays in patient discharge, and enabling patients who need treatment to access available beds speedily and safely. IPC team continue to be involved in capital planning schemes to support high quality, safe refurbishments and new builds. The IPC Matron oversees assurance of standards and reduction of risk in partnership with divisional management teams through audit, monitoring of standards, and shared learning. UHMBT use ward fogging, a specialised decontamination method for the removal of environmental contaminants to ensure a safe, clean environment. Adenosine Triphosphate (ATP) hygiene testing (to measure actively growing microorganisms on equipment and estate) is available to use alongside fogging and provides objective information on the cleanliness of the environment prior to and following the process of fogging. Domestic staff continue to provide cover in all patient areas until 2030 hr, seven days a week after which, the rapid response team is employed within FGH and RLI to provide night cover. Training for domestic staff continues to be provided by British Institute for Cleaning Standards and is refreshed annually. UHMBT cleanliness and infection prevention group continue to meet monthly with matrons and reviewed any issues identified by monthly audits. Action plans were generated, monitored, and escalated through this group as appropriate. Decontamination services across all sites for UHMBT are centralised with an accredited facility on both the Royal Lancaster Infirmary (RLI) and Furness General Hospital (FGH) sites. UHMBT Theatres have continued with annual servicing of the ventilation systems. In addition regular microbial air count monitoring has taken place. Water Systems Management Following the Department of Health publication, water sources and potential Pseudomonas aeruginosa contamination of taps and water systems: advice for augmented care units (2012), UHMBT have continued to test and monitor waters from augmented care areas. Additional areas were tested where appropriate with consultant microbiologists leadership and advice.

18 UHMBT strategic water safety group is responsible for the oversight of water safety and continue to meet on a quarterly basis. Estates and Facilities, laboratory staff, consultant microbiologists, and the IPC team have continued to support the water management process across UHMBT. Communications The IPC team continue to meet monthly to update each other on areas of work and plan ahead. All IPNs receive an annual appraisal. The IPC team continue to work collaboratively with UHMBT Communications team who disseminated IPC communications both internally and externally as required. This was also supported by local media across Lancashire and Cumbria. The IPC team have an established a Twitter account that enables communication internally and externally with the public and other organisations. This has proved beneficial over the last year with sharing of best practice and communicating to a wider health economy. A communications campaign, supported by local media, continues to raise awareness of gastroenteritis and risk factors when visiting the hospital. The Friday Message and Executive Chief Nurse Newsletter continue to support and cascade messages from the IPC team across the organisation. Clinicians from Integrated Care Communities (groups of GP practices) and from hospital have led on making a number of self help and advice films available to our local population to help them understand what to do to reduce risk of or management of a minor infection. 18

19 Summary has been an incredibly challenging year for all of our staff and for the microbiology and IPC team. I am extremely pleased to see the continued number of infection prevention improvements that have been made, which continue to improve the patients experience and provide assurance in relation to safety and standards. The improvements made continue to demonstrate our positive culture of learning and improvement and our commitment to harm free care including the reduction in avoidable health-care associated infections. Infection prevention and control is the responsibility of all of us and is fundamental when delivering the vision and values and the behavioural standards. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating the principles of infection prevention into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care can be minimised. Our staff demonstrate through practice that they care about patient safety. We should all be proud of the reductions made in harms, including reductions in hospital-acquired infections, with particular reference to the continued decline in Clostridium Difficile Infections, and the improvements made in the reduction of Gram-Negative Bacteraemia. A key focus for 2018/19 will be the robust monitoring, reporting and learning from surgical site infections. The integration of community and hospital services in provides an opportunity for us to work as a united healthcare system to influence even bigger reductions in patient harms. We will continue to focus on the reduction of the Gram-negative blood stream infections across Bay Health and Care Partners. Working to a shared strategy will enable us to achieve much more than any part of the system could deliver in isolation I look forward to working with staff and leaders from across our healthcare economy to support further development of patient safety across Morecambe Bay. 19