Infection Prevention & Control Report to Trust · PDF fileInfection Prevention & Control...

Infection Prevention & Control Report, October 2016 of 18

Infection Prevention & Control Report to Trust Board

Meeting Date – 3rd November 2016

1. Executive Summary The Trust’s reduction target for Clostridium difficile associated disease (CDAD) in 2016/17 is 48, a reduction of 16 cases or 25% compared to last year. To date 32 cases have been reported. 19 of the cases are classified as healthcare-acquired or associated, as they occurred more than 48 hours after admission to hospital (definition used by Public Health Agency (PHA)). However, this is not always an accurate predictor of being healthcare-associated. The remainder are classified as community-acquired as the patients presented with symptoms within a 48 hour period after admission. The MRSA bacteraemia target for 2016/17 is seven, a reduction of two cases or 22.22% on the previous year’s performance. There have been three cases reported so far this year, all of which have been categorised as community-associated. Following the identification of two patients who tested positive for Glutamate Dehydrogenase (GDH) within one week in the HDU, Altnagelvin, the Infection Prevention & Control Team (IPCT) reviewed infection prevention and control (IPC) practice in the Unit over the course of a week. The two patients had been nursed beside each other for a very short period of time. GDH is a chemical found in C. difficile and the majority of patients do not require treatment as they do not have CDAD. The mode of spread of GDH is the same as C. difficile and the same level of IPC measures are required. All IPC audits were compliant during the week and indicate a level of assurance regarding practice. The two samples have now been sent for ribotyping to ascertain if there is any connection. The IPCT have commenced focused education and support with FY1 medical staff, in the first instance, with regard to aseptic non-touch technique (ANTT) at both the Altnagelvin and South West Acute Hospital (SWAH) sites.

2. Results of Evaluation of Infection Prevention & Control Mandatory Training

An annual evaluation of the Mandatory Training provided by the IPCT was carried out at sessions during September 2016. A total of 109 staff responded. The results were as follows:


The IPCT are currently reviewing the different learning platforms available and are working towards supporting face-to-face delivery with e-learning for Induction, Mandatory and ANTT Training. The Team, in collaboration with the South West Regional College, are also exploring the development of virtual reality action training, which could transform Mandatory Training with huge educational, research and business potential.

3. S. aureus Bacteraemia Performance MRSA Bacteraemia The 2016/17 target for MRSA bacteraemia is seven cases, which equates to a reduction of 22.22% on the baseline figure of 2015/16 (9 cases). So far this year the Trust has reported three cases, all of which have been categorised as community-associated. As such, the Trust is currently on track to achieve the target, with a cumulative decrease of 42.86% compared to last year. The PHA has advised that community-associated infections will remain as part of the target/ published figures. These cases are not related to the healthcare environment, which limits the Trust’s ability to influence a reduction in numbers. All community-associated cases are, however, reviewed to ensure there has not been any healthcare intervention within the previous two weeks. On a six-monthly basis, the PHA presents the number of cases according to the time of sampling following hospital admission. Although, as stated by the PHA, this should not be taken as inferred attribution of infection (hospital or community). Since the beginning of April 2016 no cases have been categorised as Trust hospital-associated. As of 26th October 2016, the total number of days since the last Trust hospital-associated MRSA bacteraemia is: Altnagelvin – 420 days (Last recorded case was in Ward 4) SWAH – 256 days (Last recorded case was in Ward 8) Tyrone County Hospital (TCH) – 650 days (Last recorded case was in the Rehab Unit)


* The value for Oct 16 is subject to change as the report was compiled prior to the end of the month.


MSSA Bacteraemia There is no target associated with MSSA bacteraemia for 2016/17, however surveillance remains mandatory. MSSA is part of the skin normal flora of approximately 25-30% of the well population. It is, therefore, more difficult to control endogenous (self) exposure, which is the reason for removing the target associated with this organism. The controls in place for MRSA will go some way to protect patients, but do not provide the same level of safeguard because of the ubiquitous nature of the organism. So far this year the Trust has reported 22 cases.



Since the beginning of April 2016 six cases have been categorised as healthcare-associated. As of 26th October 2016, the total number of days since the last healthcare-associated MSSA bacteraemia is as follows: Altnagelvin – 5 days (Last recorded case was in the Children’s Ward) SWAH – 11 days (Last recorded case was in Ward 3) TCH – 981 days (Last recorded case was in the Rehab Unit) A breakdown of this year’s cases by hospital site and acquisition type is given in the table below. Key: CAI Community-associated infection HAI Hospital-associated infection


4. C. difficile Performance The 2016/17 target for C. difficile (≥ 2 years) is 48 cases, which equates to a reduction of 25% on the baseline figure of 2015/16 (64 cases). So far this year the Trust has reported 32 cases, with 13 of those being categorised as community-associated. Therefore, reduction is currently off profile, with a decrease of just 14.28% compared to last year.


A breakdown of this year’s cases (as of 26th October 2016) by hospital site and acquisition type is given in the chart below.


Key: CAI Community-associated infection HAI Hospital-associated infection


C. difficile Care Bundle and C. difficile Care Pathway Audits Evidence based care bundles are effective when all elements of care are performed consistently. Therefore, scores are represented as either pass (100%) or fail (anything less than 100%). There is no differentiation between those achieving a very low score and those achieving 95%. This is done deliberately to highlight the importance of 100% compliance with the bundle as a whole. The C. difficile care bundle and the C. difficile care pathway audit are undertaken by an IPCN twice weekly, whilst the patient remains an inpatient. This should also be supported by daily ward self-audits in relation to the same. During the period September-October 2016, the following wards/ departments were found to be non-compliant with some elements of the C. difficile care bundle and/ or the C. difficile care pathway. Altnagelvin Ward 1 Ward 2 TOU Ward 40 Ward 41 AMU Ward 43 The main trend for non-compliance with the C. difficile audits relates to hand hygiene. There is also inconsistent compliance with other elements, e.g. environmental decontamination and isolation/ cohort nursing.

5. Pseudomonas Pseudomonas aeruginosa is an opportunistic pathogen or coloniser, well known in the hospital environment. Pseudomonas is predominantly an environmental organism and is highly attracted to water sources. Pseudomonas is ubiquitous in the alimentary tract of humans and, therefore, carriage is normal and its presence is not indicative of infection. The


term ‘colonisation’ is used to describe the identification of any organism without signs of infection. Specific groups of patients who are immunocompromised are at a higher risk of colonisation or infection than the normal population. The Trust has stringent measures in place regarding the surveillance and management of Pseudomonas in augmented care areas and participates in the PHA surveillance as detailed below. Pseudomonas Surveillance (Augmented Care* Areas Only)

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

13/14 2 0 2 1 0 0 0 1 0 0 2 0 8

14/15 0 1 0 0 0 1 3 0 1 0 0 0 6

15/16 0 0 0 0 0 0 0 0 0 1 0 0 1

16/17 0 0 0 0 0 0 0†

* The PHA defines augmented care as NNICU, Adult ICU/ HDU, Renal, Oncology/ Haematology. † This value is subject to change as the report was compiled prior to the end of the month.

There have been no healthcare-associated positive blood cultures in augmented care areas since March 2014.

6. Hand Hygiene Compliance The Trust’s overall self-reported hand hygiene scores are 90% when non-submission areas are included. These areas score an automatic 0%. 15 areas out of 192 applicable areas failed to submit scores for September 2016; they are as follows: Altnagelvin – Endoscopy, Outpatients and Roe Valley Outpatients SWAH – Ward 7 and Cardiac Investigations TCH – Ward 5, Cardiac Investigations and Outpatients RHEs – Thackeray Place Residential Home Day Care – Creggan Day Centre, Gortin Day Centre, Newtownstewart Day Centre and Drumhaw Day Centre Other Community – The Cottages Children’s Respite and Avalon House Roe Valley Outpatients, Ward 7, TCH Outpatients, Thackeray Place Residential Home, Gortin Day Centre and Newtownstewart Day Centre also did not submit scores for the previous month.


However, when adjusted for non-submission areas, the Trust’s overall self-reported hand hygiene scores improve to 100%.


The hand hygiene dashboard has been circulated to Directors for action through their governance arrangements. It is important to note that independent audit scores conducted by the IPCT and Lead Nurses tend to be lower than self-reported scores.

7. Antimicrobial Management Team The Antimicrobial Management Team met in September 2016. The results of the global point prevalence survey of antimicrobial consumption and resistance are to be broken down by speciality and shared with clinical leads. Antimicrobial prescribing audit reports for the Acute Services and Primary Care & Older People’s Services Directorates were noted. Regional comparisons of antimicrobial consumption were also noted. On European Antibiotic Awareness Day, 18th November 2016, a mini point prevalence survey is to be completed.


8. Regional IP&C Governance Assessment Tool for Augmented Care Areas – Quality Improvement Plan

The Regulation & Quality Improvement Authority (RQIA) conducted an announced inspection of the Trust on 24th February 2015 to look at three criteria contained within the IPC Governance Assessment Tool for Augmented Care Areas. The report of that inspection was issued in June 2015 and a quality improvement action plan was approved by the Corporate Management Team. The improvement cycle is three years and the action plan was returned to RQIA on 24th July 2015. Current progress with the action plan is discussed at the Augmented Care IPC Forum meetings and is detailed below.


Key:

Red Not actioned

Amber In progress

Green Actioned

Ref No.

Recommendations Action required Responsible person Date for completion/ timescale

Status (RAG rating)

Criterion 1: Board – Level Leadership to Prevent HCAIs (Healthcare-Associated Infection)

1. It is recommended that the appraisal process is further developed and implemented.

Nursing Staff appraisal systems will be further developed in conjunction with NMC revalidation requirements and clinical supervision structures.

Acute Services Director/ Director of Nursing/ AD Women’s and Children’s Directorate

September 2017 Amber

This requirement will be added to the Infection Prevention and Control (IPC) Three Year Strategic Plan 2013-16 year three monitoring report.

Head of Infection Prevention

September 2015

Green

2. It is recommended that the trust continues to develop and implement a process of patient and public involvement in the delivery of care and services

Patient and public involvement has been strengthened in the most recent approved version of the IPC Three Year Strategic Plan 2013-16 year three monitoring report. Directorates report on progress with this plan at alternate meetings of the Chief Executive Healthcare Associated Infection (CE HCAI) Accountability Forum.

Directors (Bedded Directorates)

Ongoing Amber

3. It is recommended that an augmented care group is set up to facilitate shared learning among staff and areas. Staff email access and the use of SharePoint is reviewed to ensure standardisation in practice across wards/ departments.

An Augmented Care Task & Finish Group met in November 2015 for the first time. They will meet bi-monthly and the chair will be rotated. At the conclusion of all actions outlined in this action plan the group will amalgamate with one of the multiple existing IPC related meetings as a standing item. Mechanisms for shared learning have been

Head of Infection Prevention

Completed and ongoing March 2016

Green


Ref No.


Status (RAG rating)

established and this will be a standing item quarterly on the Trust Surveillance meeting

4. It is recommended that trusts meet with the PHA to agree the way forward in relation to ongoing quality improvement in the reduction of MRSA and CDI. (Regional)

Two meetings have already taken place between key Trust representatives including the Chief Executive and Dr Doherty and Dr Geoghegan respectively. A further meeting by Dr Geoghegan took place on 2nd September 2015 when she attended the CE HCAI Accountability Forum, then met with the Chief Executive, Medical Director and Head of IPC after the meeting. PHA and DHSSPSNI are looking for potential approaches to improvement that are wider than just targets for infection – a set of indicators that could be used to improve performance and they are asking trusts to feedback their suggestions.

PHA Completed and ongoing

Green

5. It is recommended that the IPC staffing levels are reviewed to take account of the increasing workload, participation in audit and challenges within IPC. IPC link nurses should have protected time to carry out their role.

Business case proposals for additional staff were presented at the Medical Directorate SMT on 16th September 2015. It was agreed that both proposals should be submitted separately to the Commissioner for individual consideration.

Head of IPC

September 2017

Amber

A briefing paper to discuss protected time for Link Nurses was passed at the CE HCAI Accountability Forum on 22nd July 2015 and it has been agreed that Link Nurses will have protected time.

Directors

October 2015

Green

A whole Trust study day to help reinvigorate the Link Personnel system went ahead on 8th October 2015 and was addressed by the Chief Executive. This will be followed up by meetings for Link Personnel in 2016.

Head of IPC Completed Green


Ref No.


Status (RAG rating)

6. It is recommended that the trust review the frequency of senior level walk rounds and that all staff attend mandatory IPC training.

A review of walk rounds will be completed with a view to increasing frequency in augmented care.

Medical Director

March 2017

Amber

Senior walk rounds will be added to the IPC Three Year Strategic Plan 2013-16 year three monitoring report.

Head of IPC

September 2015

Green

All staff are required to attend mandatory IPC training every other year.

Director of Acute Services/ AD Women’s and Children’s

December 2015

Amber

Criterion 5: Environmental Cleanliness

7. It is recommended that the trust continue to review and improve access to all services out of hours.

24 hour arrangements for high priority decontamination already exist. A review of support services provision across the Trust is already underway; any additional hours for augmented care may be identified as part of the process.

Director for performance and Service Improvement.

Completed

Green

Support services are always involved in incident control/ outbreak meetings and have been since inception of the Trust.

Head of IPC Completed Green

8. It is recommended that the trust continue to work with the DHSSPS, PHA and HSC Board to develop and implement refurbishment plans.

There is currently limited capital availability; all essential projects are progressing.

Assistant Director Facilities Management

Completed and ongoing

Green

Criterion 8: Admission, Discharge and Transfer

9. It is recommended IPC is included when reviewing guidance documents. All trust documents

Action one for the Augmented Care Task & Finish Group will be to review all current admission and discharge documentation and

AD Nursing Governance/ Head of IPC

September 2017 Amber


Ref No.


Status (RAG rating)

should be reviewed and include ownership and a review date.

link in with the overall lead. The IPC Lead Nurse Forum has developed an adult regional IPC risk assessment and transfer form which is currently in use in the Belfast Trust. The group have agreed that further refinements are required before the document can be rolled out regionally.

10. It is recommended that the IPC Admission/ Transfer Risk Assessment form is reviewed. A robust system should be in place to ensure that staff are instructed when to use the form and the need to either retain a copy of the form or a record that the form has been completed. (Regional)

Work on the regional Neonatal risk assessment is well underway. The Head of IPC represents the Trust on the regional working group. Adults as described at 9.

Head of IPC Regional

11. It is recommended that the DHSSPS with the PHA and trusts review the use of the ECR to capture patients’ infection status. The ECR system should integrate with current IT systems, or where necessary, one regional IT system to capture all relevant patient information should be put in place. (Regional)

The Trust IPC Team currently use the ECR to access relevant patient information from other Trusts. A regional approach to the use of ECR and a regional surveillance system is very welcome.

Regional Regional

12. It is recommended that the trust continue to work internally with staff and externally with the PHA and primary care to improve antimicrobial stewardship and prescribing. (Regional)

The Trust IPC Three Year Strategic Plan 2013-16 year three monitoring report includes a section on antimicrobial stewardship. A regional approach to this is welcomed by the Trust.

Regional Regional


Ref No.


Status (RAG rating)

13. It is recommended that the provision of patients’ antibiotic information leaflet is monitored. An overarching guidance/ information leaflet should be developed on the use of equipment in the community.

An audit will be planned as part of the actions for the Antimicrobial Management Team.

Medical Director December 2016 Amber

Referred to the Medical Devices Working Group.

AD of Nursing Workforce Planning & Modernisation

December 2016 Amber

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