Infection Prevention & Control Annual Report 214/215 Page 1 of 37
Table of Contents Introduction... 4 Executive Summary... 4 Mandatory Surveillance:... 6 Meticillin Resistant Staphylococcus aureus (MRSA) Bacteraemia... 6 Meticillin Sensitive Staphylococcus aureus (MSSA) Bacteraemia... 8 Escherichia coli (E coli) Bacteraemia... 9 Extended-Spectrum Beta-Lactamases... 1 Clostridium difficile Infection (CDI)... 11 Period of Increased Incidence (PII)... 15 Summary of Testing Available... 15 Clostridium difficile Infection (CDI) Mortalities... 16 Glycopeptide Resistant Enterococci (GRE) Bacteraemia... 16 Glycopeptide resistant enterococci are enterococci that are resistant to the group of antibiotics known as glycopeptides. These include vancomycin and teicoplanin.... 16 Carbapenemase-Producing Enterobacteriaceae (CPE)... 17 Voluntary Surveillance... 17 Norovirus... 17 Influenza... 19 Seasonal Influenza... 19 Pseudomonas Aeruginosa... 21 Legionella... 21 The bacterium Legionella pneumophila and related bacteria are common in natural water sources. Since legionella bacteria are widespread in the environment, they may also contaminate and grow in purpose-built water systems such as cooling towers, evaporative condensers, hot and cold water systems and whirlpool spas.. 21 Streptococcus A... 21 Invasive Group A Streptococcus (igas)... 21 Scarlet Fever... 21 Panton-Valentine Leukocidin (PVL)... 23 Page 2 of 37
Viral Haemorrhagic Fever (Ebola)... 23 Community Cleaning Scores... 26 Surgical Site Infection Surveillance... 33 Total Knee Replacement... 33 Caesarean Section... 33 Infection Prevention & Control Policies / Guidelines / Service and Practice Developments... 34 Policies... 34 Estates and Facilities Management Trust Project Involvement... 34 IP&C Team Meeting Membership... 35 Education & Training... 35 Training Provided by the IP&C Team... 35 IP&C Mandatory Training... 36 Serious Incidents related to Infection Prevention & Control... 36 Priority Improvement Plan for 215/16... 37 Page 3 of 37
Introduction Providing safe, quality care for all patients at the Great Western Hospitals NHS Foundation Trust (GWH) is fundamental to all its care delivery services. The Trust recognises the importance of preventing and reducing the incidence of healthcare associated infections where possible. All staff in the Trust work hard to provide the best possible experience for patients and visitors as well as making the Trust a great environment to work in. Good practice is celebrated; open and honest reporting ensures any deficits in care provision, or the care environment, are dealt with appropriately and promptly. This report outlines our performance during 214-15, which includes the reportable data, outbreaks and collaborative working for infection prevention and control undertaken in the Trust. Executive Summary In 213 a zero tolerance approach was introduced for Meticillin-Resistant Staphylococcus Aureus Bacteraemia (MRSAB). During 214/215 two cases (both acute) of MRSA bacteraemia were reported as attributable to GWH. This was a reduction of three cases reported the previous year. All reported cases have been investigated using the Post Infection Review tool in line with national guidelines and uploaded to the NHS England site. Learning has been shared locally, within mandatory training, at IP&C link worker meetings and at the Infection Control Committee. The Trust reported seventeen cases Clostridium difficile infections (CDI) within the Acute Hospital and two cases within the Community Hospitals, making a total of nineteen cases. The nationally mandated goal for 214/215 was no more than twenty eight Trust apportioned cases. The Trust reported a reduction of seven cases from the previous reporting year. The learning from these infections is disseminated throughout the Trust. Collaborative working with staff from the Trust, The Hospital Company, Carillion and General Practitioners is vital for a cohesive approach to reducing CDI numbers. There was one period of increased incidence (PII) of CDI identified in 214-15. A PII is defined by the Department of Health as two or more new cases of CDI occurring on or after day 4 of admission (not relapses) in a 28 day period on a ward. Further details are included within this report. There were eight ward closures during 214-15 all at the acute hospital. Norovirus was identified as the epidemiological cause. A total of 317 bed days were lost due to these ward closures, impacting at times on other outpatient service areas. GWH reported 12 influenza confirmed admissions to ICU/HDU with a total of 47 cases being identified within the Trust (including the ICU/HDU cases). Of the 12 cases reported within ICU/HDU, four were H1N1 pdm9 and eight were H3N2, the Trust reported one flu related mortality during 214-15. Of the 47 cases reported within the Trust, three were repeat positive cases (all H3N2). A total of 26 influenza A H3N2; six A H1N1 pdm9; three flu B were reported. Page 4 of 37
Women and Children s Division, in collaboration with the IP&C team, repeated the Surgical Surveillance and data interpretation of caesarean section surgical site infections; this demonstrated an improvement in care and a reduction in the infection rate from the previous study. The IP&C team worked collaboratively with local resilience teams, Public Health teams, Public Health England and Trust staff to develop action plans and train staff in use of personal protective clothing to manage the threat of Viral Haemorrhagic Fever which escalated during the summer of 214. The Trust has achieved and maintained a low blood culture contamination rate, this has been achieved by targeting staff who have taken multiple contaminated samples and providing re-training for these staff on a one to one basis and implementing the use of 3 second timers to ensure skin preparation is adequate. This has been achieved despite the number of blood cultures increasing, primarily as a result of the Sepsis Six work. The screening of patients for multi-drug resistant organisms such as carbapenemase-producing Enterobacteriaceae (CPE) has been implemented by staff and proactively supported by the site management team to flag those patients who have been repatriated from city hospitals and hospitals abroad to ensure screening takes place. To date the Trust has not detected any cases of CPE in this way, but remains vigilant. This system is now supported by an IT system, which has been introduced. Business plans were submitted for a winter weekend working option for the IP&C team to provide support for ward closures from December to May, although it was acknowledged there is a desire for the support, the funding was not available for the service to be viable. The key streams of work for the IP&C team during 215-16 include: Work in collaboration with staff to further reduce the rate of Clostridium difficile seen in our longer stay patients Improve percentage of patients isolated in less than (<) 2hours when presenting with diarrhoea In collaboration with clinical staff and pharmacy department decrease high risk antibiotic prescribing and link with information from the Electric Prescription and Medicines Administration (EPMA) system Continue to work with the Trust, Carillion and The Hospital Company to agree a cleaning contract that provides a safe and clean environment for our patients to an agreed audit standard dependant on the risk of the area Continue to scope and consider new and emerging technologies to assist in improving the patient experience whilst in our care Work collaboratively with the Oxford Academic Health Science Network to reduce Catheter Associated Urinary Tract Infections and to improve the patient experience Page 5 of 37
Mandatory Surveillance: Healthcare associated infections (HCAI) are infections resulting from care or treatment in hospital, both as an inpatient or an outpatient, within a nursing home or the patient s own home. HCAI can affect any part of the body, including the urinary system (urinary tract infection), the lungs (pneumonia or respiratory tract infection), the skin, surgical wounds (surgical site infection), the digestive system (gastro-intestinal) and the blood stream (bacteraemia). In England it is mandatory for Health Trusts to report all cases of blood stream infections caused by Staphylococcus aureus (both Meticillin resistant and Meticillin sensitive), Glycopeptide resistant enterococci (GRE) and Escherichia coli (E coli) together with Clostridium difficile to Public Health England (PHE). Other infections, which make up the majority, are reported on a voluntary basis, such as influenza and norovirus. PHE allocate cases of Meticillin sensitive Staphylococcus aureus (MSSA) bacteraemia to either Trust or Clinical Commissioning Group (CCG) by counting the day of admission as day 1 (even if it is 23:59); on day 3 of admission the case then becomes apportioned to the Trust. Internally E coli bacteraemias are allocated in using the same methodology. Meticillin Resistant Staphylococcus aureus (MRSA) Bacteraemia Those resistant to the antibiotic meticillin are termed meticillin-resistant staphylococcus aureus (MRSA) and are more resistant to antibiotic therapy. All cases are reported in line with national guidance and investigated using the PHE Post Infection Review (PIR) tool. Staphylococcus aureus is a bacterium that commonly colonises human skin and mucosa (e.g. inside the nose) 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 an indwelling medical device or procedure. If the bacterium does enter the body illnesses which range from mild to life threatening may then develop. Most strains of Staphylococcus aureus are sensitive to the more commonly used antibiotics and infections can be effectively treated. During 214/15 we reported two cases of MRSA bacteraemia (both acute site attributable) against a national trajectory of zero cases. The learning from the reported MRSA bacteraemias during 214-15 led us to make improvements in the following areas and will continue to be a theme in the 215/16 work plan Improve record keeping for invasive devices. Peripheral venous Cannula insertion and removal is consistently documented on the care chart. Venous infusion line care advice for patients to be given and documented in patient care records. When that advice is not followed this should be clearly documented; such as a patient who disconnects their own infusions to leave the ward. Prompt adherence to decolonisation regimes when patients are found to be MRSA positive and receiving inpatient care. Page 6 of 37
Number of paitents Number of patients Number of patients Acute Cases of Trust Apportioned MRSA Bacteraemia 8 6 4 2 6 5 3 2 2 2 29-1 21-11 211-12 212-13 213-14 214-15 12 1 8 6 4 2 12 1 4 6 Total MRSA Bacteraemias Reported from GWH Lab 5 3 4 5 2 2 29-1 21-11 211-12 212-13 213-14 214-15 All reported MRSA Bacteraemia (PHE) 3 5 7 2 CCG Apportioned GWH Apportioned The Trust s rate for 214-15 was 1.1 per 1, bed days. This is higher than both the regional (.71) and national (.91) rates. Regionally the highest rate was 2.42 and the lowest. Due to the low numbers nationally, we do not consider ourselves to be an outlier. An additional seven cases were assigned to the two local CCGs during 214/15. The rate per 1, population; Swindon CCG 2.76 and Wiltshire 1.68. Regionally the rate varied between.23 and 4.1 (1.7 median) and 1.49 nationally. This demonstrates the incidence of MRSA bacteraemia is particularly high for our area, which includes Swindon, Wiltshire and Gloucestershire population; as reported by Public Health England. Nationally a total of 798 cases of MRSA bacteraemia were reported. Following the post infection review, 316 were apportioned to Acute Trusts (4%), 368 were CCG attributable (46%) with the remaining 114 cases apportioned to third parties (14%). 8 6 4 2 Third Party CCG Acute Trusts The standard nasal ointment used for MRSA decolonisation by the Trust (Bactroban) became temporarily unavailable during 214. Whilst this was out of stock, patients within GWH and community hospitals (supplied by Royal United Hospitals, Bath s pharmacy) were supplied an alternative licenced product during this period. There were additional precautions to be taken around the use of the product for patients with nut allergies. IP&C supported staff through this phase, as the prescriptions varied in use (i.e. times per day and number of days required). No concerns or difficulties were raised and an alternative product (Octenisan) was used for those with nut allergies. Page 7 of 37
Number of patients Number of patients Number of patients Meticillin Sensitive Staphylococcus aureus (MSSA) Bacteraemia MSSA Bacteraemias unlike MRSA Bacteraemias, are more sensitive to antibiotics and therefore slightly easier to treat. 8 6 4 2 35 Total MSSA Bacteraemias Reported from GWH Lab 46 49 33 37 CCG Apportioned GWH Apportioned GWH have reported 11 acute cases for two consecutive years. The numbers of CCG cases identified through Swindon s laboratory demonstrate a slight increase in cases during 214-15. The majority of the root causes are as a result of: pneumonia, skin and soft tissue concerns or central line associated infections. 16 12 8 11 11 21-11 211-12 212-13 213-14 214-15 1 Total MSSA Bacteraemia Reported from GWH Lab 214-15 The majority of cases are attributable to the CCG both locally (81.7%) and nationally (71.6%). 8 6 4 CCG 2 GWH 1 9 8 7 6 5 4 3 2 1 Nationally reported MSSA Bacteraemia (PHE) 214-15 CCG Acute Trust There has been a general increasing trend in the reported numbers of MSSA bacteraemia (all reports) with an overall increase of 16.9% from October to December 211 to January to March 214-15. The percentage of the total number of MSSA bacteraemia reports nationally indicate that Trust apportioned cases have decreased. This implies that non-trust apportioned cases are increasing at a faster rate, which suggests MSSA bacteraemia are increasing in the community. Page 8 of 37
Number of patients Number of patients Number of patients Escherichia coli (E coli) Bacteraemia E. coli in the bloodstream is usually a result of acute infection of the kidney, gall bladder or other organs in the abdomen. However the number of E. coli bacteraemias reported to the Public Health England mandatory surveillance system has increased over recent years to the extent that E. coli is now the most common cause of bacteraemia reported. Total Ecoli Bacteraemias Reported 25 2 15 1 5 35 3 25 2 15 1 5 137 138 149 195 23 26 23 33 211-12 212-13 213-14 214-15 Nationally All Reported E coli Bacteramia 214-15 CCG Apportioned GWH Apportioned All The main source for these blood stream infections continue to be associated with the urinary tract, although generally this is not associated with urinary catheterisation. Other causes include hepatobiliary and respiratory. The majority of these infections are being detected upon admission. These are internally apportioned only; as PHE do not currently apportion these bloodstream infections between Acute and CCG s. Nationally the total number of E coli has increased steadily since July 211, when the national mandatory surveillance programme was initiated, with seasonal peaks between July and September each year. A 1% increase has been reported from the previous year s rate with an overall increase of 5.4% since 211. 3 25 2 15 1 5 All E Coli Bacteraemia Reported by GWH Lab 214-15 CCG GWH The Trust did not experience the seasonal July September peak (in accordance with PHE findings). Quarterly numbers were consistent with only a variance of 1 cases between maximum and minimum reported numbers. (Quarter 1: 61; Quarter 2: 51; Quarter 3: 55 and Quarter 4: 61). An increase of 53 cases was recorded over the year, which is an increase of 23% from numbers reported during 213-14. Page 9 of 37
Number of patients Number of patients Extended-Spectrum Beta-Lactamases Extended-Spectrum Beta-Lactamases (ESBL) are enzymes that can be produced by bacteria making the bacteria resistant to some, widely used, antibiotics. Most ESBLs are detected from urine samples. There were 22 ESBL bacteraemia s reported during 214-15. This has more than tripled in number from the seven reported during 213-14. 21 were E.coli and one Klebsiella pneumoniae (three were repeat positive specimens). Three (E. coli) were attributable to GWH. The source of two these cases was the urinary tract, and both patients were catheterised. The source for the third case was hospital acquired pneumonia. 4 35 ESBL Identified in GWH Lab 214-15 4 35 Test in Which ESBL Was Identified 214-15 3 25 2 15 1 5 3 25 2 15 1 5 NBL Eye Pus Faecal Wound Urine Blood Culture Page 1 of 37
Clostridium difficile Infection (CDI) Clostridium difficile is the most common cause of hospital acquired diarrhoea. It is an anaerobic bacterium that is in present in the gut of 3% of healthy adults and 66% of infants. It rarely causes problems in children or healthy adults as it is kept in check by the normal bacterial population of the intestine. When certain antibiotics disturb the balance of bacteria in the gut Clostridium difficile can multiply rapidly and produce toxins which cause the illness. Clostridium difficile can be spread by the hands of healthcare professionals and other people who come into contact with infected patients or environmental surfaces such as floors, bed pans, commodes or toilets contaminated with the bacteria or its spores. Spores are produced when Clostridium difficile bacteria encounter unfavourable conditions, such as being outside the body. The Clostridium difficile spores are very hardy and can survive on clothes and environmental surfaces for several months. The longer a patient remains in hospital the greater their risk of developing Clostridium difficile becomes, vigilance of these patients is advocated, especially if they have received at least one course of antibiotic therapy. The national mandated trajectory for 214/15 was to report no more than twenty eight, Acute and Community Hospital apportioned cases. The Trust has reported nineteen cases in total; seventeen Clostridium difficile infections were within the Acute Hospital and two cases within the Community Hospitals. The Trust has seen a downward trend of Clostridium difficile during 214/15. During June 214 the Trust requested a re-visit from an external Lead Infection Prevention & Control Nurse to review the actions taken to reduce the Clostridium difficile rate. The feedback confirmed positive changes had been implemented, both in the ward environment and in the culture of ward and infection prevention and control staff. It was observed the time to isolation remained a challenge as did implementing an annual deep clean of wards. It was also felt there were more opportunities to engage Matrons in systems to sustain positive changes in the environment and regular decluttering of storage areas. Limiting the use of broad spectrum antibiotics and only prescribing high risk (for Clostridium difficile) antibiotics such as Cephalosporins and Ciprofloxacin is recommended unless prescribed on Microbiology advice or on following antibiotic guidelines. Start SMART and focus is clearly detailed within the Antibiotic Stewardship Algorithm. The risk of Clostridium difficile is thought to increase with the use of proton pump inhibitors (PPI), especially if being prescribed with broad spectrum antibiotics. Medical staff are being asked to review the indication for PPI on admission and switch /stop where possible. Page 11 of 37
Number os patients Number of patients 1 8 6 4 2 Total Clostridium difficile Reported from GWH Lab or GWH Community Hospital CCG GWH Isolating symptomatic patients within 2 hours of developing symptoms of Clostridium difficile limits the spread of the spores to nearby patients and the environment. We are not yet achieving this as frequently as we would like and this remains a priority for staff to achieve. Use of personal protective equipment (PPE) such as aprons and gloves when entering a room for clinical care and hand washing with soap and water rather than alcohol gel alone, are necessary interventions to limit the spread of Clostridium difficile from patient to patient. This practice is well embedded and monitored regularly through care bundle audits. 16 14 12 All reported Clostridium difficile (PHE) 214-15 The number of Clostridium difficile reported nationally has been on a general decreasing trend between October to December 211 and January to March 215 with an overall reduction of 22.1%. Similar to the total number of Clostridium difficile cases nationally reported, Trust apportioned Clostridium difficile decreased by 25.5%. 1 8 6 4 CCG Acute Trust The number of Trust apportioned Clostridium difficile and all reported Clostridium difficile (January to March 215) has increased by 17.2% and 12.7% respectively when compared to January to March 214). 2 We do appear to experience seasonal spikes during the summer months, although upon review, most cases are classed unavoidable Clostridium difficile infection. Where cases are deemed as avoidable, this has related to missed opportunities for prudent antibiotic prescribing or improved attention to cleaning standards. 214/15 Quarter 1 Quarter 2 Accumulative Quarter 3 Accumulative Quarter 4 Accumulative Total GWH C.diff trajectory 7 7 14 7 21 7 28 GWH Actual per Quarter 3 8 11 5 16 3 19 Deemed avoidable; cases 2 1 3 avoidable cases where better care could have prevented C.diff infection Page 12 of 37
Number of patients 35 3 25 2 15 1 5 GWH accumulative cases of Clostridium difficile April May June July Aug Sept Oct Nov Dec Jan Feb Mar 212-13 213-14 214-15 214-15 saw a significant reduction in the number of reported cases of CDI from the previous two years, despite this we experienced a significant increase in numbers during the summer months, which resulted in us breaching our internal trajectory of 7 cases during Q2. The summer spike was also experienced nationally. A lot of time and focus has been spent on environmental cleaning this last year, which may have attributed to our improved infection rate, alongside staff awareness and drive to reassess the use of proton pump inhibitors when admitted to hospital and requiring a course of antibiotics. Areas where we have Improved : time to collect specimen increased number of cleaning audits satisfactory Decrease in PPI use observed Areas that we need to improve upon: Increase our time to isolation (within 2 hours) only 31% of our patients were isolated within this time frame. Work we will continue to focus on: Continued use of PCR testing to diagnose carriage cases Improve % of patients isolated in <2hours for diarrhoea Decrease high risk antibiotic prescribing and link with information from the Electric Prescription and Medicines Administration (EPMA) system Page 13 of 37
Per 1, bed days 3. 25. 2. 15. 1. 5.. Acute Trust Rates of CDI 214-15 The Trust performed well during 214-15, compared to other organisations in the South West. The Trust was positioned third best within the South West with a rate of 9.72 per 1, beds days at the end of March; having reported 19 cases. The Trust was one of five UK Acute Trusts to be shortlisted for a national Patient Safety award, for outstanding performance in providing a safe hospital environment for patients; it was based on a range of indicators, including rates of hospital-acquired infections and mortality. Page 14 of 37
Period of Increased Incidence (PII) A period of increased incidence of CDI is defined as two or more new hospital apportioned cases, not including relapses, in a 28 day period within the same ward. The Infection Prevention & Control team will instigate precautionary PII s where there is a concern cases might be connected to prevent avoidable harm where possible, where the definition is not met. During 214-15 there was one PII and two precautionary PII s initiated. In all three incidence the patients did not have the same strain of C.difficile. Although ribotyping was the same in two of the incidences, further fingerprinting was completed to look at the familiar strain, which was deemed different, and therefore not linked to each other and cross infection was ruled out by the reference laboratory. Summary of Testing Available In England, an enhanced surveillance program with a centrally funded scheme providing rapid access to ribotyping. The C. difficile Ribotyping Network for England and Northern Ireland [CDRN]) began in 27. This uses polymerase chain reaction (PCR) is a technology in molecular biology used to amplify a single copy or a few copies of a piece of deoxyribonucleic acid (DNA), generating thousands to millions of copies of a particular DNA sequence. Timely typing and fingerprinting is important for infection control teams to identify and attempt to control transmission of C. difficile. Finger printing known as Multiple locus variable-number tandem repeat analysis (MLVA) is also performed by the CDRN at Leeds General Infirmary (CDRN reference lab) and informs institutions about whether there is contemporaneous evidence for C. difficile transmission from cases linked by ribotyping in specific locations. Jupiter: A precautionary Period of Increased Incidence (PII) which was initiated in June due to two patients testing positive that had been linked to the ward, it was subsequently confirmed after undertaking the polymerase chain reaction (PCR) ribotyping of isolates from these patients that the ribotyping has identified as 2 separate types therefore not attributed to cross contamination within the ward. A total of 65 prescriptions for antibiotics were identified for patients on this ward during the period of increased incidence. All restricted antibiotics were microbiology approved. Patient Type Patient A 15 Patient B 5 Saturn: During July/August 214, two stool samples were sent for typing and returned as the same 15. Further identification was requested and during September the fingerprinting confirmed that the two samples were unrelated and did not indicate cross infection on the ward. A total of 88 prescriptions for antibiotics were identified for patients on Saturn during the period of increased incidence. All restricted antibiotics were microbiology approved Patient Type Fingerprint Patient A 15 HPA14m6274231852 Patient B 15 HPA14m6974431855 Neptune: A precautionary PII was initiated during August 214. A patient, who had been nursed on Neptune ward for four days at the beginning of August, tested C.difficile positive from a subsequent sample taken on 14.8.14, following a readmission to LAMU; the patient had history of loose stools since discharge. As this patient was nursed in an adjacent four bedded bay to the side room of an inpatient known to be hospital acquired C.difficile; a precautionary PII (Period of Increased Incidence) was instigated. Ribotyping of the samples revealed the same 14/2 type. Therefore further identification was requested; the fingerprinting confirmed that the two samples were unrelated and did not indicate cross infection on the ward. Patient Type Fingerprint Patient A 14/2 HPA14m73753186 Patient B 14/2 HPA14m6234231853 Page 15 of 37
Number of positive tests Number opf patinets Clostridium difficile Infection (CDI) Mortalities Of the 19 cases of C.difficile, two patients died during their hospital admission having had a C.difficile diagnosis. Neither of the two patients that passed away had C.difficile recorded on part one of the death certificates. This was deemed appropriate for both cases. Glycopeptide Resistant Enterococci (GRE) Bacteraemia Glycopeptide resistant enterococci are enterococci that are resistant to the group of antibiotics known as glycopeptides. These include vancomycin and teicoplanin. There was one acute GRE blood stream infection reported during 214-15, identified whilst the patient was on the Oncology Unit as a repeat positive. (The patient had a history of GRE previously detected on admission and attributed to the CCG so not truly classed as acute attributable). 6 5 4 3 2 1 GRE Reported from the GWH Lab 214-15 6 5 4 3 2 1 Test in Which GRE Was Identified 214-15 Pus Wound Pleural Fluid Blood Culture Urine Tissue Page 16 of 37
Carbapenemase-Producing Enterobacteriaceae (CPE) CPE is the name given to a group of bacteria that have become very resistant to antibiotics including those called carbapenems. Many of these bacteria usually live harmlessly in the gut of humans or that of animals and help you digest food. However, if they get into the wrong place such as the bladder, respiratory tract or bloodstream they can cause infection. Carbapenems are a group of powerful antibiotics that can only be given in hospital directly into the bloodstream intravenously using a cannula. Until now, they were antibiotics that could always be relied upon when other antibiotics failed. CPE therefore represents one of the most serious emerging global infectious disease threats. The UK is seeing an increase in the incidence of infection and colonisation by these multi-drug resistant organisms. In conjunction with the site managers and an IT identification system, patients repatriated from hospitals abroad or larger UK city hospitals are being screening for CPE. This has been included within the Infection Prevention & Control risk assessment used upon admission to the Trust. There have been an increased number of patients transferred in to the Trust with prior detection of CPE colonisation, requiring isolation. To date no patient has screened positive on proactive screening following transfer into the Great Western Hospital. One CPE has been identified through the GWH laboratory in a urine specimen, which was requested by the patient s GP. There had been no contact with the Acute services. Lack of an effective antibiotic to treat an infection could be life threatening for a patient and the emergence of CPE in Britain is being taken very seriously at national level. Voluntary Surveillance Norovirus Ward and bay closures are reported to PHE, when the criterion for an outbreak of diarrhoea and vomiting is met. Each ward and bay closure is investigated by IP&C and the ward manager upon re-opening, with recommendations and shared learning with Divisions and the ICC. This includes a laboratory confirmed case of norovirus as well as suspected norovirus cases. Page 17 of 37
Number of Days 1 9 8 7 6 5 4 3 2 1 Number of Ward Closures and Bed Days Lost 993 293 317 219 17 1 26 6 11 3 5 8 Number of Wards Closed Number of Bed Days Lost due to Ward Closure Key improvements required by wards related to accurate documentation throughout the outbreak with communication with IP&C to facilitate decision making; housekeeping staff adhering to the appropriate dilution of chlorine for ward cleaning; recommending patients are not moved between bed spaces without prior consultation with the IP&C team or Microbiology. Some key lessons learnt include; Two departments sharing an area had no communication between them. This has been bridged with a joint safety briefing, which enables staff to identify IP&C concerns It is difficult to manage two areas with a shared sluice (and prevent spread of infection) during an outbreak of diarrhoea and vomiting It would be ideal for all bays to have doors to minimise cross contamination of an airborne virus such as Norovirus, this is difficult due to the nature of the unit and the patients which it cares for. Page 18 of 37
Influenza For the majority of people flu is an unpleasant, but not life threatening illness. However, severe winter flu and its complications can make people very ill and can be life threatening (you are 11 times more likely to die from flu if you are in a clinically at risk group). Seasonal Influenza Nationally there are three surveillance schemes in operation for influenza which provide two weekly reports to all Trusts: The UK Severe Influenza Surveillance System (USISS) is the Intensive Care Unit (ICU)/High Dependency Unit (HDU) scheme which is a mandatory, national surveillance system. It was established in cooperation with the Department of Health to report the aggregate number of deaths and admissions with confirmed influenza in ICU/HDUs across the UK. The USISS sentinel hospital surveillance scheme, which is a voluntary element of the system (to which we contribute) reports the weekly aggregate number of confirmed influenza cases hospitalised at all levels of hospital care from a limited number of hospitals of which GWH is one, with detailed epidemiological data collected on cases aged 16 years and under. In addition the national PHE syndromic surveillance system includes reports from GP in hours and out of hours consultations, sentinel Emergency Department attendances and NHS 111 calls monitor a range of syndromic indicators sensitive to community influenza activity (not all of these patients will be tested or swabbed for flu). During 214-15 an increased number of flu cases were identified both nationally and within the Trust. GWH reported 12 influenza confirmed admissions to ICU/HDU with a total of 47 cases being identified within the Trust (including the ICU/HDU cases). The Trust reported one flu related mortality during 214-15. The lab also processed three positive flu tests for GP patients (two were influenza A H3N2 and one influenza B). Of the 12 cases reported within ICU/HDU, four were H1N1 pdm9 and eight were H3N2. Of the 47 reported within the Trust, three were repeat positive cases (all H3N2). A total of 26 influenza A H3N2; six A H1N1 pdm9; three flu B were reported. It was necessary to close a bay due to influenza in one of the community wards this winter. It was felt the probable source of the influenza was one of the patient s relatives. One of the recommendations of the subsequent incident investigation was that staff should be vigilant and confident to challenge visitors if they are themselves unwell. Nationally flu vaccination in healthcare workers was 54.6% nationally with GWH reporting 5% Nationally moderate levels of influenza activity were seen with H3N2 being the predominantly circulating for the majority of the season, which corresponds with the picture seen within GWH with flu B circulating later in the season, whilst GWH saw H1N1 pdm 9 within GWH. The impact of H3N2 was mainly seen in the elderly with many outbreaks in care homes. Nationally levels of excess mortality significantly higher than the last notably significant H3N2 season of 28/9. Peak admissions to hospital were higher than seen in the previous few seasons, but less than the recent notable season of 21/11. Page 19 of 37
Number of patients 4 Trust Inpatients with a Confirmed Influenza Result 35 3 25 2 15 214/15 213/14 1 5 A H1N1 pdm9 A H3N2 B Page 2 of 37
Pseudomonas Aeruginosa Pseudomonas aeruginosa is often found in water, the more frequent the direct or indirect contact between a susceptible patient and contaminated water, and the greater the microbial contamination of the water, then the higher the potential for patient colonisation or infection. Routine six monthly water sampling is collected from augmented care inpatient areas. This includes the Intensive Care Unit, Dove ward and the Special Care Baby Unit. Pseudomonas aeruginosa has been detected from the water within the Special Care Baby Unit (SCBU) during 214-15. There has been no colonisation of babies detected during this time frame. Clearing all positive outlets for any length of time has proved a challenge on the unit, despite having changed the pipework and new taps installed on the unit. No bath water is drawn from the hand wash basins; all bath water is sourced from a permanent filtered supply in the clean utility area. The Water Management meeting continues to monitor the routine water testing results and undertake the necessary remedial actions to the water infrastructure to reduce the risk. Legionella The bacterium Legionella pneumophila and related bacteria are common in natural water sources. Since legionella bacteria are widespread in the environment, they may also contaminate and grow in purpose-built water systems such as cooling towers, evaporative condensers, hot and cold water systems and whirlpool spas. Streptococcus A Group A strep (strep A) are often found on the surface of the skin and inside the throat. They are a common cause of infection in both adults and children. Invasive Group A Streptococcus (igas) When strep A bacteria penetrates deeper inside the tissues and organs of the body, it becomes what is known as an invasive infection. Scarlet Fever Is a contagious infection that causes a widespread, fine pink/red rash on the skin, which feels like sandpaper in combination with a sore throat, flushed cheeks and a swollen tongue. It is caused by Streptococcus pyogenes or group A streptococci and is a notifiable disease, which means health professionals There were a handful of positive legionella samples with very low counts during 214/15, none in inpatient areas when detected. Remedial action has been effective in resolving the counts detected on testing. Within the South West region there has been increased reporting of Group A strep and scarlet fever during 214/15. At the peak 3 cases in one week were reported within the Swindon and Wiltshire catchment area. As can be seen of the 394 identified within the GWH lab, only 1.5% was an invasive infection (igas). IP&C were not asked for any clinical advice or made aware of any cases of scarlet fever admitted to the organisation. Wiltshire Community Children s services were informed of the reporting statistics. Page 21 of 37
must inform local health protection teams of suspected cases. National Scarlet Fever Numbers 12 1 8 6 4 2 212-13 213-14 214-15 Page 22 of 37
Panton-Valentine Leukocidin (PVL) PVL is a toxic substance produced by some strains of Staphylococcus aureus, which is associated with an increased ability to cause disease. PVL is part of routine IP&C surveillance activity, there are currently no concerns regarding the incidence and prevalence of any hospital acquired infection. The Laboratory have detected and reported 38 new cases during 214-15. Of these 11 were MRSA PVL and 27 were MSSA PVL. This has shown an increased from the 2 recorded during the last financial year. Of these, 8 were MRSA PVL and 12 MSSA PVL. Viral Haemorrhagic Fever (Ebola) The World Health Organisation and Centres for Disease Control and Prevention issued an alert in March 214 via PHE notifying Trusts of an outbreak of Ebola virus disease in Africa. Ebola virus disease is a rare but severe disease in humans and non-human primates caused by the Ebola virus. A person infected with Ebola virus will typically develop a fever, headache, joint and muscle pain, a sore throat, and intense muscle weakness. This is followed by vomiting, diarrhoea, rash, symptoms of impaired kidney and liver function, and in some cases, both internal and external bleeding These symptoms start suddenly, between two and 21 days after becoming infected. During 214-15 the UK experienced its first cases of imported Ebola haemorrhagic fever, these cases were contained and no cross infection occurred. In response to the emerging information available Trust action plans were written in conjunction with the resilience manager. Personal Protective Equipment (PPE) training (including FFP3 masks) was delivered to multiple staff groups in the Emergency Department, Minor Injuries Units, Community Hotel Services Departments a designated ward and maternity services by IP&C, the training initially following international advice. There was a delay in the dissemination of UK specific advice, which resulted in multiple changes to the Trust plans at the end of the year to deliver PPE training in line with Public Health England advice. The Trust cared for one patient who fitted the national criteria to be isolated and tested for Ebola; the patient subsequently tested negative. Lessons learnt following the event were shared within the resilience network. These lessons were primarily around adding more detail to the action cards to assist staff when under additional pressure and to train additional staff to support the time the patient is held in the department. Page 23 of 37
Persentage Blood Culture Contamination Rates Blood Culture Contamination Rate 7 6 Infection prevention & Control has been working with staff to ensure blood culture contamination rates are less than 5%; as set with commissioners during 213/14, with a stretched objective to achieve and maintain 3% in line with the Department of Health s Saving Lives document. The Trust average for the year is 3.7%. However we are not able to fully explain why the contamination rate increases to above 5% during one month and significantly reduces the next. 5 4 3 2 1 Month and Year Lower is better The Emergency Department take the largest number of blood cultures within the organisation and often, as a result have the largest number of contaminated samples assigned to them. The Emergency department staff have been receptive to one to one training from IP&C to help reduce and sustain the contamination rate within this department. The department has also embraced the 3 second skin preparation drive implemented in 215. This has been supported by 3 second egg timers, A5 posters to promote adherence and managed through the safety brief. Contamination Percentage Median Nationally there is no centralised reporting of blood culture contamination rates so we are unable to benchmark with other organisations. Page 24 of 37
January February March April May June July August September October November December January February March Environment and Cleanliness Standards 1% 98% 96% 94% 92% 9% 88% 86% 84% 82% 8% Cleaning Performance - Jan-14 to Mar 15 Carillion have been challenged by the Trust regarding their ability to consistently provide and sustain the Trust s desired cleaning standard within their existing contract. The Trust has a desire for an audit score of 95% and above in ward areas, an increase from the original contractual agreement of 85%, which was not consistently meeting Trust and Public expectations. Engagement meetings have been held regularly with department managers to ensure cleaning remains high on the agenda and the Trust receives the service it requires for our patients and service users. (Desired cleaning audit score vary depending on the room/department use, for example theatres would require a higher audit score of 98%) Average Score Contracted Target Action plans have been shared with the Trust by Carillion and close monitoring has taken place within the Cleaning Standards group and at Board level. The cleaning contract has been under review in conjunction with all parties. It is envisaged revised departmental cleaning schedules will be implemented during 215/16. Our community ward sites are cleaned predominantly by Trust employed staff and monitoring of the cleaning standards is completed by the Facilities team. For community sites the Managerial audits are conducted quarterly by Estates and the site manager, IP&C attend on an ad hoc basis to monitor the patient areas and feed back to the cleaning standards group. Page 25 of 37
Community Cleaning Scores Our community ward sites are cleaned predominantly by Trust employed staff and monitoring of the cleaning standards is completed by the Facilities team. For community sites the Managerial audits are conducted quarterly by Estates and the site manager, IP&C attend on an ad hoc basis to monitor the patient areas and feed back to the cleaning standards group. Page 26 of 37
percentage Ward care bundle scores Clinical areas self-audit monthly against a number of set IP&C criteria, known as a care bundle, these look at various aspects of care provided and the cleanliness of the environment. If the audit criteria are not met (95%) there is an expectation for an action plan to be written by the clinical area and a re-audit completed by the clinical area within the month to demonstrate a positive improvement in clinical practice. The audit results are accessible to all managers, collated and reported on the monthly dashboard by IP&C. The monthly IP&C audits will be reviewed during 215-16 with the divisional Clinical Governance leads to ensure the data is presented in a manner which provides value to the Division. The care bundle audits are reinforced and triangulated by spot checks by the IP&C team and Matrons and discussed at the Cleaning Standards Group monthly and reported in the monthly quality report. A weekly Managerial walkabout targets individual areas on a rota for the acute site. The team includes a member of the IP&C team, Estates and Facilities Management team and the Carillion team, who provide housekeeping services for the Trust. The results from the inspections are fed back to the department managers and to the Cleaning Standards Group for triangulation with other data. Cleanliness of Patient Care Equipment 1 Patient Equipment Cleanliness Self-Audits Decontamination of patient care equipment and the environment is essential to patient care and reducing the risk of healthcare associated infections through cross-infection. As responsibility for cleaning different elements of patient equipment (including beds) is shared between housekeeping and nursing, a plan detailing responsibility, frequency and what to clean standard items with is in place. 98 96 94 92 9 88 86 Patient Equipment Aim >95% Page 27 of 37
percentage percentage Central Venous Catheters (CVC) Patients with a central venous catheter are at risk of acquiring a healthcare associated infection if all elements of care is not delivered or adhered to. The low performance in December (92%) for on-going care related to the documented assessment for the need of the central line not being completed. This may have been due to the increase in emergency admissions during this period when high numbers of acutely ill patients were being admitted. 1 98 96 94 92 9 88 86 Central Venous Catheter Management Self-Audits ** CVC insertion not audited each month ** Central Venous Catheter Insertion Central Venous Catheter Ongoing Care Aim >95% Peripheral Venous Catheters (PVC) Patients have peripheral venous catheters inserted for a number of reasons, and as this is an invasive device, there is a risk of acquiring a healthcare associated infection if all elements of care is not delivered or adhered to. As above December and January proved to be very challenging due to the number of acutely ill patients being admitted, the majority of who would have required a peripheral venous catheter insertion. It was identified that the reduction in care bundle compliance related to the documented assessment of the required need for the catheter to remain in situ rather than poor practice. It should be noted that during this period the number of elements audited rose by approximately 23 between November and December increasing by a further 215 in January. 1 98 96 94 92 9 88 86 Peripheral Venous Catheter Management Self-Audits Peripheral Venous Catheter Insertion Peripheral Venous Catheter Ongoing Care Aim >95% Page 28 of 37
percentage Urinary Catheter Care Patients with an indwelling catheter are at a greater risk of acquiring a healthcare associated infection. The urinary catheter care bundle is aimed at best care for patients limiting risks. This and the Safety Thermometer data provide a snap shot of care standards and associated infections and where improvements need to be made in care. The Trust have joined the Oxford Allied Health Science Network, to work as a collaborative to improve urinary catheter care and reduce the numbers of associated infections. This will be an on-going project over the next 12 months to make the required improvements across the organisation. 1 98 Urinary Catheter Management Self-Audits Safety Thermometer Data: All patients with a urinary catheter All Organisations, All Wards, All Settings, All Services, All Ages, All 18% 16% 14% 12% 1% 8% 6% 4% 2% % Mar 14 Apr1 4 May 14 Jun1 4 Jul1 4 Aug 14 Sep1 4 Oct1 4 Nov 14 Dec 14 Jan1 5 Feb1 5 Catheters 16.5 15.1216.1614.7415.415.5615.9512.4315.8516.7115.9616.1615.66 1-28 days 1.55 7.94 9.31 8.11 8.84 9.8 8.7 7.44 11.3211.44 9.7 1.131.84 >28 days 3.35 5.41 4.74 5.5 3.49 2.58 4.3 3.76 3.66 4.65 4.51 5.76 4.82 Days Not Known 2.6 1.77 2.12 1.57 2.71 3.18 3.84 1.23.87.63 1.76.26 Patients 1194 1184 1182 128 129 1163 141 1223 1148 1119 121 1145 1162 Mar 15 96 94 92 9 88 86 Urinary Catheter & New UTI: All Organisations, All Wards, All Settings, All Services, All Ages,.6%.5%.4%.3% Urinary Catheter Insertion Urinary Catheter Ongoing Care Aim >95%.2%.1% % Mar 14 Apr 14 May 14 Jun1 4 Jul1 4 Aug 14 Sep 14 Oct1 4 Catheter & New UTI.34.25.42.33.39.52.29.8.61.63.49.44.43 Mean.4.4.4.4.4.4.4.4.4.4.4.4.4 Patients 1194 1184 1182 128 129 1163 141 1223 1148 1119 121 1145 1162 Nov 14 Dec 14 Jan1 5 Feb 15 Mar 15 Page 29 of 37
percentage percentage Reducing the Risk of Clostridium difficile These self-audits are performed weekly on any ward with an inpatient suffering from Clostridium difficile infection. This ensures they are adhering to best practice such as, reviewing antimicrobial use, keeping side room doors closed and cleaning is being completed twice a day. The plan for 214/15 is to have the care bundle completed daily by the nursing staff, for all patients with active Clostridium difficile. This will ensure that any lapses in care are addressed immediately and not left for multiple days to be rectified. The Low percentage in September was due to a care bundle score of 4% being returned from one ward area. 1 98 96 94 92 9 88 86 84 82 8 Care to Reduce Clostridium difficile Self-Audits Care to reduce Clostridium difficile Aim >95% Hand Hygiene 1 Hand Hygiene Self-Audits Hand hygiene audits are an opportunity to refresh staff s knowledge about the importance of decontamination of their hands with necessary PPE in the form of gloves, when appropriate. It is also provides an opportunity to ensure staff with skin problems in the form of dermatitis have been referred by their manager to the Occupational Health Department for advice. There is a concern that departments are constantly reporting 98% and above. This reported compliance level is considerably higher than that reported in the annual hand hygiene audits. 98 96 94 92 9 88 86 The plan for 215/16 is to review the value of the monthly hand hygiene audit and agree an alternative method if appropriate. Hand Hygiene Aim >95% Page 3 of 37
Annual Hand Hygiene Audits The purpose of the annual audit is to maintain compliance with the Hand Hygiene and Skin Care Policy and complement the monthly care bundle selfaudits performed within clinical areas. The annual audit is intended for a senior member of clinical staff to undertake as part of the assurance that compliance is maintained and any actions identified through monthly audits have been acted upon. The audit instructions provide advice on immediate rectification of any non-compliance rather than waiting for publication of the report. Audit reports are sent to the relevant directorate senior clinician for dissemination, staff engagement and learning purposes. The IP&C team work, where required, with the audit department and the divisions to assist with the prompt resolution of non-compliance. The Clinical Audit Department collate the electronic evidence to support completion of actions Planned Care 14 teams were audited comprising 128 members of staff. Of these, seven teams were compliant, providing assurance as to the validity of the monthly self-audits. For the seven non-compliant teams action plans were drawn up and monitored until satisfactory completion. Unscheduled Care (USC) 15 teams were audited during quarter 2, which included 133 members of staff. 13 of the 15 teams were compliant with the remaining two teams completing action plans allowing reassurance of required standards within the Division. Integrated Community Health (ICH) 17 teams were audited encompassing 193 members of staff across multiple Trust sites. 11 teams were compliant with action plans introduced to facilitate compliance. Satisfactory completion has been achieved in all areas. Diagnostics and Outpatients Due to the nature of the Division, a total of 32 teams were audited, a total of 227 members of staff both within acute and community services. Of these, 22 teams were compliant, all acute based. The main issues were staff not adhering to the bare below elbows policy and the wearing of inappropriate jewellery. The Hand Hygiene Policy has been reviewed with the requirements of the laboratory areas taken specifically into account. Women s and Children s 191 members of staff were audited within 19 teams with 11 teams being compliant, 1 of which achieving 1%. Availability of alcohol based hand rub at the point of care decreased in compliance, however post-audit assurance has been received that this is now readily available to staff. Bare below the elbows is an area for focus for the Division. Page 31 of 37
percentage MRSA Screening The national advice and recommended screening plan to acute services changed significantly during 214 following publication of the NOW study results in 213 (study data collected in 211). The modified guidance advises and outlines a more focused, cost-effective approach to MRSA screening. The guidance recommends Trusts to move to focussed screening programmes designed to promote a more efficient and effective method for identifying and managing high risk MRSA positive patients. The Trust presented and discussed the pros and cons of amending the Trust screening plan, and a decision was made to not change our Emergency admission screening policy due to the risk assessment becoming too complex for staff to follow and risk vulnerable patients being missed. The IP&C team have worked locally with two services within the Trust to reduce MRSA screening in line with the national guidance. The first being the ceasing of elective orthopaedic discharge screening for all apart from those with a history of MRSA and long stay patents (greater than 14 days). Secondly within the oncology day therapy services the existing screening protocol was reviewed and, with the ICC agreement the frequency of repeat screening reduced to six monthly rather than six weekly. This is based on the historic evidence collected by the team to demonstrate there was no added value to screening this group of patients at this frequency. 1 98 96 94 92 9 88 86 84 82 8 MRSA Screening Compliance 214-15 Data un-validated from 1.11.14 All Admissions Contract Minimum MRSA missed screens were validated by the IP&C team until 1 st November. Staffing capacity within the IP&C team led to a review and cessation of the validation service. At that point it was anticipated that initially the screening compliance rates might reduce, but that this could be improved up with better support from informatics. IP&C continue to monitor the rates and work with informatics to ensure the raw data is robust from the onset and reduce the need to validate so many cases. Elective screening (Surgical including Maternity) has continued to sustain high compliance rates with screening, Community wards also consistently achieve a screening rate of 95% and above. The emergency admissions prove to be the more challenging group for staff to achieve a rate of 95% and above and continue to be the focus of training. Page 32 of 37
Surgical Site Infection Surveillance Total Knee Replacement It is a mandatory requirement for Acute Trusts to submit certain data for the surveillance of healthcare associated infections. This was introduced by the Department of Health in April 24. The national mandate is directed at all NHS Trusts and requires those undertaking orthopaedic surgical procedures to carry out a minimum of three months surveillance in each financial year. During 213/14 surgical site surveillance was performed on patients following total knee replacement surgery including revision surgery between April and June 213. This was repeated during April and June 214 due to the number of complex cases audited last year, leading to a higher than expected infection rate. During 214/15 the rate has reduced to 4.7%. A similar number of patients were audited. This confirmed there were no deep seated infections and no re-admissions due to infection. All infections identified were found to be superficial. The national average for all infections is 1.7%. The Division instigated an improvement plan that could be implemented in conjunction with discharge lounge to provide suitable post-discharge wound advice to patients. The following graph demonstrates the trend of all infections identified for post-operative total knee replacements within GWH. Caesarean Section The audit aimed to identify any areas of improvement which could lead to a reduction in post caesarean section wound infections and related maternal readmissions. Oct-14 Nov-14 Dec-14 Total Total number of caesarean section 96 72 112 28 Total number of confirmed wound 4 1 4 9 infection Total % of deliveries resulting in postoperative infection 4.1% 1.3% 3.5% 3.5% Commissioners requested re-audit examining all caesarean sections taking place at Great Western Hospital during Quarter 3 assessing rates, trends and related care pathways in relation to maternal postoperative infections. Findings showed the overall percentage of caesarean section deliveries resulting in confirmed post-operative wound infection during Quarter 3 214/15 was 3.5% significantly lower than the expected national average of 9%. Audit findings show 97% compliance for MRSA screening for those women having Emergency Caesarean Section, 5 out of 155 cases had no MRSA screen. Care pathways related to prevention and reduction of post-operative infection were found to be highly compliant but development of a post-operative wound care leaflet for all women having Caesarean Section is recommended. Work was already on-going to develop a collaborative leaflet between Maternity, Tissue Viability and IP&C as part of the action plan from the previous audit. Page 33 of 37