Infection Protection and Control Annual Report 2017/2018 · P a g e | 6 - Infection Prevention and Control Department the incidence of MRSA bacteraemia, C. difficile infection, and

P a g e | 1 - Infection Prevention and Control Department

Infection Protection and Control

Annual Report

2017/2018

Authors:

Emma Dowling – DDIPC/Head Nurse Laura Search – Office Manager


Compliance Criteria One .............................................................................................................................................. 5 Risk assessment ........................................................................................................................................................... 5

Director of Infection Prevention & Control (DIPC) and Deputy DDIPC ................................................................... 5

The Infection Control Committee ................................................................................................................................ 5

Assurance Framework ................................................................................................................................................. 5

Infection Prevention & Control Programme ............................................................................................................... 6

Infection Prevention & Control Infrastructure ........................................................................................................... 6

Compliance Criteria Two .............................................................................................................................................. 7 Cleaning Services ......................................................................................................................................................... 7

Compliance Criteria Three ........................................................................................................................................... 8 Compliance Criteria Four ........................................................................................................................................... 10 Compliance Criteria Five ............................................................................................................................................ 10 Surgical Site Infection Surveillance .......................................................................................................................... 11

Compliance Criteria Six ............................................................................................................................................. 12 Compliance Criteria Seven ........................................................................................................................................ 12 Compliance Criteria Eight .......................................................................................................................................... 12 Laboratory Support .................................................................................................................................................... 12

Compliance Criteria Nine ........................................................................................................................................... 13 Policies ........................................................................................................................................................................ 13

Hand Hygiene Audit .................................................................................................................................................... 13

High Impact Interventions Audits ............................................................................................................................. 13

Compliance Criteria Ten ............................................................................................................................................ 13 Link Nurse Meetings ................................................................................................................................................... 14

Performance against National Targets ..................................................................................................................... 15 MSSA Bacteraemia ..................................................................................................................................................... 15

Clostridium difficile .................................................................................................................................................... 15

Other Resistant Bacteria: ........................................................................................................................................... 16

Surveillance of Glycopeptide Resistant Enterococci (GRE) Bacteraemia ........................................................... 16

1 Appendix 1 – Work plan 2017/2018 ............................................................................................................... 21 2 Appendix 2 – Governance structure ............................................................................................................. 25 3 Appendix 3 – Antimicrobial Stewardship ..................................................................................................... 25 4 Appendix 4 – VRE leaflet ............................................................................................................................... 27 5 Appendix 5 – Ward graphs ........................................................................................................................... 27 6 Appendix 6 – Infection Prevention and Control hospital webpage ........................................................... 28 7 Appendix 7 – Mandatory Training compliance ............................................................................................ 28 8 Appendix 8 – Published policies /SOP’s ..................................................................................................... 29 9 Appendix 9 – Hand Hygiene compliance ..................................................................................................... 29 10 Appendix 10 - MRSA Bacteraemia graph ..................................................................................................... 30 11 Appendix 11 – MSSA Bacteraemia graph .................................................................................................... 30 12 Appendix 12 – Clostridium difficile graph ................................................................................................... 31 13 Appendix 13 –Escherichia coli graph ........................................................................................................... 31


GLOSSARY AMR Anti-Microbial Resistance

ARHAI Advisory committee on Antimicrobial Resistance and Healthcare Associated Infection

BICSc The British Institute of Cleaning Science

C. difficile Clostridium difficile

CCG Clinical Commissioning Group

CDI C. difficile infection

CGC Clinical Governance Committee

CNS Clinical Nurse Specialist

CPA Clinical Pathology Accreditation

CQC Care Quality Commission

CQRG Clinical Quality review Group

CQUIN Commissioning for Quality and Innovation

DDIPC Deputy Director of Infection, Prevention & Control

DIPC Director of Infection, Prevention & Control

DoH Department of Health

EoE East of England

EPS Electron Prescribing System

GDH Glutamate Dehydrogenase

GRE Glycopeptide resistant Enterococci

HCAI Healthcare Associated Infection

HCPC Health and Care Professions Council

HII’s High Impact Interventions

IOSH Institute Of Occupational Safety Health

IPC Infection Prevention & Control

IPCC Infection Prevention and Control Committee

IPCN Infection Prevention & Control Nurse

IPCT Infection Prevention & Control Team

JCT Joint Commissioning Team

KPI Key Performance Indicator

MRSA Meticillin resistant Staphylococcus aureus

MSSA Meticillin sensitive Staphylococcus aureus

NHSI National Health Service Improvement

NHSLA National Health Service Litigation Authority

NICE National Institute for Health and Care Excellence

OPD Out patients Department

PALS Patient Advice and Liaison Services

PHE Public Health England

PIR Post Infection Review

PLACE Patient Led Assessments of the Care Environment

PPM Planned Programme of Maintenance

QA Quality Assurance

QAC Quality Assurance Committee

RCA Root cause analysis

SSD Sterile Services Department

SSI Surgical Site Infection

SLT Senior Leadership Team

SUHFT Southend University Hospital Foundation Trust

TKR Total Knee Replacement

TMV Thermostatic mixing valve

UKAS United Kingdom Accreditation Service

UTI Urinary Tract Infection

WTE Whole time equivalent


Executive Summary This report has been written by the Deputy Director of Infection Prevention and Control (DDIPC), on behalf of the Director of Infection Prevention and Control (DIPC), to summarise the work undertaken within the organisation for the period 1

st April 2017 - 31

st March 2018. As in previous years the report follows the format of the Code of Practice

10 criteria for infection prevention control (Health and Social Care Act 2008 (revised 2015) to demonstrate the Trust’s compliance with the requirements of the Act.

In August 2017 NHSI were invited to the Trust to assist in an external review of infection prevention processes at the Trust. The inspection RAG rated was red due to Estates issues and Governance reporting. Through a robust action plan and with engagement throughout the Trust following a re-inspection in January 2017 this rating was de-escalated to Amber. Feedback from the last inspection demonstrated that there had been a notable improvement although areas for further improvement were required. A re-visit is planned for May 2018.

There were 33 cases of Clostridium difficile infection at SUHFT during this period against the Department of Health objective ceiling of 30 cases. None of the cases, using the Public Health England (PHE) criteria, were classified as direct lapses in care.

There were 5 cases of MRSA bacteraemia against the Department of Health zero tolerance requirements. Of the 5 cases 2 identified that policy/protocol was not followed. All lessons learnt were shared locally. Cases of Norovirus were promptly identified and managed effectively which supported minimal disruption to services and patient flow. Of the five outbreaks experienced this year only two resulted in full ward closures and two in a bay closure only. An outbreak of Norwegian (Crusted Scabies) was reported on one of the Medicine for the Elderly Wards. The Index case was admitted from Residential Care provisionally diagnosed with eczema. Following discharge back to Residential Care this was confirmed as Scabies. 10 Trust staff members were subsequently affected. In conjunction the OH, PHE and the IPCT the outbreak was managed, staff treated and contact tracing undertaken. The surveillance of surgical site infection (SSI) has been maintained during 2017/18, with lower rates of infection than national benchmarking

The mean hand hygiene compliance score was 90.5%. The IPCT also carried out ad-hoc hand hygiene audits.

Good antibiotic stewardship is one of the key issues in helping reduce the vulnerability of patients to developing Clostridium difficile infection. The pharmacy department have developed and implemented strategies to enhance compliance with the principles of good antibiotic stewardship. Antibiotic audits are performed on a planned schedule and monitor good prescribing practice with regard to start, stop or review dates and a written indication of the need for the antibiotic.

Enhanced monitoring to control legionella and pseudomonas aeruginosa in tap water in high risk areas throughout the Trust continued. The Trust has maintained a safe water system. No hospital acquired cases of legionella have ever been linked to SUHFT buildings

A continued close working relationship has been maintained with the Estates and Facilities and the Project Team has been maintained to support fit for purpose design in relation to infection prevention and control both in the development stage and during works. There have been a number of successfully completed projects, including provision of additional winter beds to support increased clinical activity, development of a new High Dependency Unit, completion of a primary care GP unit and the development of the Elective Admissions Lounge, and Diabetic Centre.

Introduction Infection prevention and control remains a high priority for Southend Hospital University NHS Trust. Keeping patients safe from avoidable harm is everyone’s responsibility. The Trust has a wide ranging programme of activity that focusses on continual improvement in order to deliver the best care. This report provides details of the progress made with infection prevention and control from April 2017- March 2018. It has been a challenging year with national objectives for Methicillin Resistant Staphylococcus aureus (MRSA) blood


stream infection and C. difficile infection, setting out a zero tolerance to avoidable infections. The DIPC reports monthly to the Trust Board of Directors for assurance purposes. This annual Report is part of the process that tracks and monitors the Trusts performance against regulatory requirements set out in the Code of Practice (Health and Social care Act, 2008). The IPCT work plans focus on implementing systems that embed IPC into the everyday practice of all Trust staff. The Infection Prevention and Control team works closely with external agencies. A strong working relationship is maintained with the local Clinical Commissioning Groups (CCG), Public Health England (PHE) and NHS Improvement (NHSi)

Compliance Criteria One Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider how susceptible service users are and any risks that their environment and other users may pose to them.

The Trust Board recognises its responsibilities for overseeing infection prevention and control arrangements across the Trust guided by Compliance Criterion One. This includes the Infection Prevention and Control Strategy which outlines individual and the Trust’s collective responsibility for keeping to a minimum the risks of infection and the general means by which it will prevent and control such risks.

Risk assessment

• Infection prevention and control (IPC) is included in all Executive objectives and individual Directors are identified as responsible for the implementation of specific areas of the IPC strategy

• Infection Prevention and Control performance data is continually monitored and reported monthly. The Trust Board receives a report on the Infection Prevention and Control performance data at each bi-monthly trust board meeting; and quarterly reports updating on compliance with the Health and Social Care Act in addition to this an Infection Prevention and Control Annual Report is produced

• Compliance with the Health and Social Care Act (2008) and any action plans pertaining to infection prevention and control are monitored through the Infection Prevention and Control Committee (IPCC), Clinical Governance Committee (CGC) and the Trust Board

• IPC performance is discussed at meetings with the Director of Nursing and monitored through the CQRG (Clinical Quality review Group)

• The Infection Prevention and Control Team (IPCT) are actively involved in necessary risk assessments to ensure risks involving infection prevention are identified and managed. Issues requiring risk assessment and subsequent entry on the Trust Risk Register are monitored according to the risk score. Risks identified as 15 and above are automatically placed on the Corporate Risk Register and reviewed monthly with close scrutiny by the Director of Nursing, DIPC and the Executive and Trust Corporate Management Team.

Director of Infection Prevention & Control (DIPC) and Deputy DDIPC

• The Director of Nursing is also the Director of Infection Prevention and Control DIPC • The DIPC’s job description and objectives reflect the responsibilities set out in Winning Ways: working together

to reduce Healthcare Associated Infections in England (DoH 2003) • The Head Nurse for Infection Prevention Control is the Deputy Director Infection Prevention and Control

(DDIPC) • The DDIPC and Office Manager provide a performance report to the DIPC on a monthly basis • Progress on the Infection Prevention and Control Annual Work Plan (Appendix 1) will be reported by the

DDIPC at the IPCC

The Infection Control Committee

IPCC is a key forum for the development and performance management of the infection prevention and control agenda across the organisation. The Committee meets on a monthly basis and is chaired by the DIPC with key representation from directorates across the organisation. Membership includes the IPCT, senior management and senior nurses, the Occupational Health Department, clinical governance staff, Pharmacy, Estates and Facilities staff and external bodies such as the local Public Health England Team and the Clinical Commissioning Group (CCG) Infection Prevention and Control team.

Assurance Framework

The Infection Prevention and Control Strategy (IC016) was reviewed in January 2017 to ensure that relevant updates in relation to regulatory requirements are added. The Strategy sets out clear objectives for the trust to ensure that patients’ safety in respect of IPC is delivered. The DDIPC provides a monthly performance report to the Executive Team on a number of infection prevention and control measures. This includes the Trust’s current position against Department of Health ceilings for MRSA bacteraemia and C. difficile infections. The Trust Board receives a report on


the incidence of MRSA bacteraemia, C. difficile infection, and of learning and practice changes instigated as a result of the outcome of root cause analyses and Post Infection Reviews (PIR). Post Infection Reviews and Root Cause Analysis are undertaken for all cases of C. difficile infection and MRSA bacteraemia that are hospital apportioned. Any case not hospital apportioned is investigated by the CCG to identify any links to the hospital or community issues. The assurance process includes both internal and external measures. Internally the accountability is exercised via the IPCC ensuring that there is robust scrutiny of compliance with national standards, local policies, and clinical practice and following post infection reviews (PIR). External assurance is obtained through the Care Quality Commission (CQC) registration and unannounced visits, assessment by the National Health Service Litigation Authority (NHSLA) against their standards for infection prevention and control and the Patient Led Assessments of the Care Environment (PLACE). PLACE involves local people (known as Patient Assessors) going into hospitals as part of teams to assess how the environment supports the provision of clinical care, assessing areas such as privacy and dignity, food, cleanliness, general building maintenance and dementia. From 2016 the assessment will also look as aspects of the environment in relation to those with disabilities. It should be noted however that the assessment focuses exclusively on the environment in which care is delivered and does not cover clinical care provision or how well staff are doing their job. PLACE results were to be made public in August 2017 by the Department of Health.

Infection Prevention & Control Programme

• The infection prevention and control programme is published annually and areas of the audit programme are monitored through the IPCC

• The annual work programme for 2017/2018 is attached (Appendix 1) includes details of audit and policy revision

Infection Prevention & Control Infrastructure

The Infection Prevention and Control Team structure is as follows: • The Director of Nursing is the Director of Infection Prevention and Control • WTE Head Nurse Infection Control /Deputy Director Infection Prevention and Control Band 8b • WTE infection control nurses (ICN) x 2 Band 7 .Since July 2017 team capacity has been significantly reduced

with one Band 7 nurse vacancy • WTE Infection Control Office Manager Band 6 • The budget for Infection Control is held by the Director of Nursing and managed by the Head Nurse for

Infection Control/DDIPC Two locum Consultant Microbiologists covering the service (see criterion 8). The Consultant Microbiologists provide an out of hour’s service. (Appendix 2 – Governance Structure) Movements of Patients

The movement of patients is one of the most significant aspects of infection prevention and control management particularly in an outbreak situation. A key daily activity is ensuring patient safety when allocating beds or relocating patients. The IPCT produce and disseminate to relevant personnel the ‘Daily Isolated Patient List’. This document comprises of patients that are currently either:

• Positive MRSA carriage/Previously known MRSA carriage • C. difficile infection • Previous C. difficile infection • C. difficile carrier • Multi drug resistant organisms • Pulmonary Tuberculosis • Norovirus • Any other infection that may require isolation or IPCT input

The team also advises regarding prioritisation of patients for isolation/single rooms. The IPCT ensure that all patients requiring isolation are appropriately placed and prioritise isolation requirements through risk assessment and the best use of resources available. The IPCT works closely with site managers to ensure patients safety regard to priority for isolation


Compliance Criteria Two Provide and maintain a clean and appropriate environment which facilitates the prevention and control of HCAI.

Cleaning Services

The Domestic Service department continues to meet the NHS National Specification of Cleanliness 2007 Standards.

Each ward is allocated between 9-11 hours for daily operational cleaning duties with two shift patterns to provide continuous cleaning on the wards. This is reduced to 7.5 on each ward area over weekend and bank holiday periods. To help maintain these standards the department maintains cleaning equipment such as (Scrubber Dryers, ride on scrubber, Steamers/ buffers and Vacuum cleaners) for wards/ departments and public areas. The department has also recently purchased new Flood machines and cordless hand buffers.

Domestic Management continues to collaborate with the Facilities training department to facilitate the transition of the Facilities Training department into a Training Centre of Excellence. This process is to enhance the current BICS standards into an in-depth NHS Cleaning module, tailored to the NHS cleaning environments and its challenges.

Domestic Management continues to collaboratively work with other services such as the waste department to ensure that the waste the Trust is generating is not only disposed of correctly and safely, but to ensure there are efficient and effective methods in place that work towards reducing the Trust’s carbon footprint, i.e. Tiger bag implementation, recycling of household waste etc.

The Domestic services have implemented a Domestic Helpdesk, whereby all cleaning requests throughout the trust can be directed to and dealt with swiftly.

Monitoring arrangements

Unannounced audits are continually carried out by the Quality Assurance department throughout the Trust. Where an audited areas fails the expected pass mark, a senior manager /DDIPC will be invited to attend the re audit. Audit results are reviewed at the IPCC and reported to the Trust Board. The score rating for the risk categories as per NHS 2007 Specification of Cleanliness is as follows:

• Very high risk area 98 % • High 95 % • Significant 85 % • Low 75 % Domestics Services Cleaning Patient Survey – continue to be carried out to obtain patient feedback on the cleanliness of their environments. Domestic management analyse the data and continually evolve the service around the specific needs of each area.

Ward Manager/Matron Logs - Are carried out by domestic supervisors weekly to ascertain the views of the senior ward management in highlighting and rectifying issues as they happen and to obtain feedback on their wards/ areas cleanliness.

Supervisor Checks – Are conducted daily by the domestic management team on wards to monitor that cleaning

standards are being achieved on wards/departments.

Domestic cleaning Technical Audits - Are conducted on a daily basis on all ward areas by domestic supervisors to help maintain the cleanliness of the areas, this information is then used to identify any attention to detail cleaning needed and a general view of the standard of each individual area.

Domestic Team Briefs/ newsletters – Domestic services supervisors’ holds monthly Domestic staff team briefs. This enables effective dissemination of information to all staff members including topics such as product changes/ implementation, training of new processes. This also is a good forum for feedback to the staff about any relevant topics regarding the cleaning service. Domestic management also provide the domestic staff with a monthly newsletter highlighting the feedback from patient surveys, audit scores and other relevant information to ensure an efficient service is provided at all times.

ISO Triple Crown Accreditation – The Estates and Facilities Directorate has been accredited with ISO:9001Quality management systems – OHAS:18001Health and Safety and ISO:14001- Environmental Awareness certification, which incorporates the Domestic/Cleaning department. By being accredited in these fields it evidences that the EFM/domestic service is being managed efficiently and to very high standards. These standards are audited throughout the year by a third party to ensure adequate compliance to these standards. The Domestic department


have a highly trained Cleaning Response Team (CRT) in place who are responsible for the following duties:

Terminal and C. difficile daily cleaning – Terminal cleans are requested by ward areas the CRT carry out this enhanced cleaning of the room once vacated, when needed these areas are decontaminated using Hydrogen Peroxide Vapour (HPV) decontamination equipment (Nocospray). Isolation rooms used for the care of patients with C. difficile infection have daily cleans carried out as per the daily isolated patient list, once a patient has been discharged, then a terminal clean is carried out and decontamination of the room completed using HPV technology. Also following any refurbishment or building works the CRT will carry out a deep clean of that area prior to it being handed back to the service.

Detailing programme - The Domestic department has a detailing programme in place for all ward areas. Supervisors identify areas in need of attention to detail on wards and these are then carried out by the CRT/ domestic staff.

Flood / spillage control – Emergency response of water suction is provided when needed for any spillages/ floods

within the Trust by Cleaning Response Team and deep cleaning of affected areas after incidents is then carried out.

Ad Hoc Deep cleaning – The domestic department receives daily requests for deep cleaning, including cleans required from post building works, major spillages etc. All of these requests are coordinated via the Domestic department’s helpdesk and carried out by the Cleaning Response Team.

Curtain hanging – There is a 6 monthly disposable curtain changing periodical in place delivered by an external contactor (Berensden), on all ward /patient areas, however the Cleaning Response Team hang/replace any ad hoc curtain changes in between this periodical as and when these are requested by wards or in the event of an outbreak.

Compliance Criteria Three Ensure appropriate anticrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance.

Summary of Antimicrobial Stewardship

Antimicrobial stewardship (AMS) is an essential element in the Trust. This is recommended in the ‘UK five year antimicrobial resistance strategy’ to tackle the growing challenges of antimicrobial resistance, and optimise patients’ outcomes through regular ward rounds, teaching sessions and provision of electronic prescribing system and Micro Guide APP to aid prudent prescribing of antibiotics.

Antimicrobial Audit

Antimicrobial audits are carried out twice yearly to monitor the quality of prescribing in line with ‘Start Smart, then Focus, principle of antimicrobial prescribing. Prompt action plans are provided where the quality is below expectation.

The outcomes of the last audit carried out in March 2018 are shown below:

STANDARDS % adherence achieved

1. 100% of prescriptions for antimicrobial comply with the Trust guidelines 74%

2. 100% of prescriptions for antimicrobial therapy that meet the inclusion criteria have stop/review dates documented on e- Prescribing

67%

3. 100% of prescriptions for antimicrobial therapy that meet the inclusion criteria have indication documented

93%

4. 100% of prescriptions for antimicrobial therapy that meet the inclusion criteria have drug allergies documented on e-Prescribing

97%

5. 100% of prescriptions appropriate for IV to ORAL switch within 48-72hrs are switched 41.7%

6. 100% of prescriptions for antimicrobial therapy that meet the inclusion criteria have an appropriate ‘antimicrobial prescribing decision’ documented

100%

Following the audit outcomes, IV to ORAL switch bulletin was developed and placed in conspicuous areas on the wards. This is to guide prompt IV to ORAL switch by the doctors. Nurses’ involvement to prompt the doctors to switch is currently being considered.

Pharmacy is also looking at other areas to support improvement in the quality of antimicrobial prescribing, such as mandatory e-learning.


Antimicrobial Consumption

Antimicrobial consumption is monitored in line with the directives of Antimicrobial Resistance (AMR) CQUIN. Given that high consumption of antimicrobials is associated with increase in antimicrobial resistance; consumption data and evidence of antimicrobial prescription review are submitted to the Public Health England (PHE) at every quarter.

PHE results indicate antimicrobial consumption is on the increase both nationally and within the Trust. This is attributed mainly to the use of multiple narrow spectrum antibiotics in order to reduce the use of pip-tazobactam and meropenem.

Secondly, due to the increase in the level of resistance, many patients do not respond to first line treatment, hence most of these patients would require escalation of treatment with other broad spectrum antibiotics, thereby increasing the volume of antibiotics usage in the Trust.

However, the report from PHE continues to indicate a low usage of antibiotics in the Trust in comparison to the mean consumption in all Trusts in England. Similarly, consumption of the two most broad spectrum antibiotics used in the country, meropenem and pip-tazobactam are lower at Southend than England average values. (See Appendix 3 for antibiotic consumption and review graphs)

AMR CQUIN also requires documented evidence of inpatient antimicrobial prescription review within 72hours of starting. The minimum expected target for prescription review is 25% of all prescriptions in the first quarter, followed by 25% increment for each subsequent quarter. The Trust outcome was a starting point at 84.7%, and the percentage has remained within 90 % range since then.

Antimicrobial Supply Problems

As with other NHS Trusts, the Trust continues to experience intermittent supply problems with many of the essential intravenous antimicrobials. This has necessitated taking a number of steps to reduce the impact of the supply constraint; one of which includes changing the empirical recommendations for many of the common indications.

The prescribers are promptly updated of any supply issue, and the available alternatives so as to optimize patients’ outcomes

Antimicrobial Management of Uncomplicated UTI

In order to reduce the nationwide rise in Gram negative bloodstream infections, which are thought to be associated with inappropriate treatment of UTI, PHE reviewed, and updated the antimicrobial treatment of uncomplicated UTI. The Trust guidelines were also updated to reflect PHE recommendations. Nitrofurantoin is now used as first line antimicrobial for UTI in the Trust, with several other options for those whom nitrofurantoin is not suitable.

Empirical Antimicrobial Guidelines

The guidelines are reviewed and updated yearly in collaboration with the microbiologists and infection diseases physician.

National guidelines, NICE recommendations and local sensitivity patterns are always taking into consideration during this process.


Compliance Criteria Four Provide suitable accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion.

Patient Advice and Liaison Services (PALS)

The Trust is committed to working in partnership with patients and staff to help improve patient experience. The PALS Department is part of this commitment to provide high standards of care to support patients, carers and the public who use the Trust services. During 2017/2018 there were a number of concerns raised to the IPCT. Some of the issues included; patients acquiring an infection, environmental cleanliness and lack of communication with the family regarding the patient’s infection status. These issues are addressed in the everyday work of the IPCT, for example when an IPCN visits the wards providing education on infections and communicating this information with the patients and their family/carers. This can be carried out both verbally or by providing information leaflets. Reporting Acquisitions of infections and periods of increased incidents of infections are reported through Datix and reviewed through a Post Infection Review. Patient Information Leaflets All information developed for patients or their visitors is agreed through the IPCC and undergoes patient/ user group review before publication. Leaflets giving information and advice about specific infections are reviewed and up dated on a regular basis .This year several new patient information leaflets have been written (Example of new Leaflet Appendix 4)

Infection Control Data / Information Each ward area has information displaying individual ward or department performance HCAI’s (IPC ward graphs Appendix 5) The Infection Prevention Control web page provides information and guidance for the public (IPC webpage – Appendix 6)

In the case of an outbreak, signs are used to inform visitors of the problem and patients’ relatives are kept informed by telephone if visiting is suspended

Infection Prevention and Control policies are made available to all staff on the hospital’s internal STAFFnet site as they are produced, reviewed and updated

Compliance Criteria Five Ensure that patients who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people.

MRSA Elective Screening

The rationale for screening non-emergency patients is to identify MRSA carriers, enabling application of topical decolonisation or suppression treatment either immediately prior to admission or on admission and the use of appropriate systemic antimicrobial prophylaxis at time of procedure, if this is appropriate. Any patient who meets a risk assessed criteria which puts them at greater risk of acquiring MRSA will be offered screening.

The trust has continued to screen all elective patients in the following subsets:

Major Orthopaedic, vascular, plastic or abdominal hysterectomy This covers the surgical patients who are at greatest risk from developing a MRSA infection

Screening rates are monitored monthly and the proportion of patients screened is on average 89%. Although, the Trust has not achieved the internally set target of screening 95% of patients.


MRSA Screening of Emergency Admissions

The Trust aims to screen 100% of patients admitted as emergency admissions. On average were achieve 90% compliance. Screening identifies MRSA carriers, enabling application of topical decolonisation or suppression treatment early in the admission and will inform the use of effective systemic antimicrobial prophylaxis, if this is appropriate. Patient Alert

Patients who are identified as having: • Positive MRSA carriage • Previously known MRSA carriage • C. difficile infection • C. difficile carrier (GDH) • Any other Multi drug resistant organism

The IPCT continue add an Alert onto the Medway electronic patient record system to ensure that the above patients with an Alert organism are easily identified to all staff on subsequent admissions to facilitate their appropriate care.

The IPCT updated the Alert Sicker which is placed on patient medical records to ensure it was more emphasized

Microbiology results are available to staff with access to the hospital’s pathology (ICE) system. Policies regarding the management of patients with specific infections are available on the Trust Intranet to ensure that patients are managed appropriately to reduce the risk of transmission to other patients and/or staff. The placement of all patients identified as having, or of being suspected as having, an infection is reviewed daily by one of the Infection Prevention and Control Nurses (IPCNs). Post Infection Reviews (PIR) Root Cause Analysis (RCA’s) The IPCT have continued to contribute to PIR meetings where the root cause for all Trust MRSA bacteraemia and CDIs are discussed. Members consider whether the infection occurred through lapses in care and, if this is the case, an action plan is developed by the area/ward involved. Meetings are attended by one of the Infection Prevention and Control Nurse Specialists, to ensure decisions relating to cases are escalated where necessary. Overviews of the Trust cases are raised at the Clinical Governance Committee for assurance purposes. All lessons learnt and good practice identified is shared Trust Wide. Surgical Site Infection Surveillance

The aim of SSISS is to enhance the quality of patient care by encouraging participating hospitals to use data obtained from surveillance. Rates of surgical site infection (SSI) in a specific group of surgical procedures can then be compared against a mean rate for all participating hospitals. This information can be used to review and guide clinical practice. Data is collected by a member of the IPCT using a standard surveillance sheet, surveillance the inpatient period and the post discharge period until the 60

th day.

This Trust has participated in SSISS for Orthopaedic procedures since its inception in 1997. Surveillance of patients following surgery is very labour intensive so with the current staffing IPCT was only able to perform two surveillance periods for this the period 2017/2018 To obtain more accurate and meaningful data surveillance for Total Knee replacements (TKR) was undertaken for a 6 month period.

Total Knee replacements

Apr-Jun 2017

Total number of operations for selected period

Number of SSI’s for selected period

All SSI’s for selected period (%infected)

108 1 0.9%

Jul-Sep 2017

Total number of operations for selected period

Number of SSI’s for selected period

All SSI’s for selected period (%infected)

104 1 1.0%


Please note. There were a total of 212 Total Knee replacements undertaken during this 6 month period and 2 infections reported. The 2 orthopaedic surgeons concerned undertook a review of the patients concerned and it was concluded in both cases that despite best practice both developed post-operative wound infections post discharge from hospital within the 60 surveillance period.

Compliance Criteria Six Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection.

All permanent and bank staff are required to attend an induction session which includes a session on Infection Prevention and Control

Specific induction sessions are provided for locum medical staff

Infection Prevention and Control is part of the annual mandatory training required by all permanent and bank hospital staff and monitored through the mandatory training matrix. Specific infection prevention and control e-learning has been developed and updated annually as an alternative to attending a face to face session (See Appendix 7 for compliance graph)

All policies and guidelines are published on the Intranet to which all staff and permanent contractors have access

Any external contractors undertaking temporary work (e.g. building or refurbishment) in the hospital are required to produce method statements and are supervised by the Estate and Facilities staff in line with the Managing Contractors Policy. They also receive an Infection Control ‘Tool Box’ talk

Compliance Criteria Seven Provide or secure adequate isolation facilities.

Patients who cannot be isolated due to lack of side rooms are formally risk assessed to ensure that priority for the single room is given to the patient with the greatest need. On a daily basis the Infection Prevention and Control Nurses review all patients requiring isolation. The IPCT are available to provide guidance on single room prioritisation. The IPCT are involved in capacity meetings at times of high capacity in the Trust to optimise the use of isolation facilities within the hospital. There are 120 siderooms within the Trust.

As per National Guidelines, confirmed or suspected smear-positive Tuberculosis cases must be nursed in a single room with ensuite facilities. However patients with Multi Drug Resistant TB must be nursed in a negative pressure room. Therefore, if a patient is identified as Multi Drug Resistant TB they must transferred to the nearest provider with facilities for a negative pressure room. Currently the Southend University Hospital’s negative pressure rooms are not operational; the nearest provider is Basildon and Thurrock University Hospital. The Royal London and Addenbrooks Hospital in Cambridge also have negative pressure room facilities. During 2017/2018 we did not have any cases which required negative pressure isolation facilities.

Compliance Criteria Eight Secure adequate access to laboratory support.

Consultant Microbiologists are employed by the Trust and are based on the hospital site; consultants from both Basildon and Southend visit the hub regularly to maintain a clinical presence and regular monthly meetings are held. Decisions are discussed and agreed collaboratively at these meetings by consultants from both Hospitals and the biomedical management staff from Pathology First. There are regular joint venture board meetings, clinical governance board meetings and operations and contracts meetings.

The Trust was able to recruit an NHS locum Consultant Microbiologist to one post at the end of February 2017, they have been assisted by a long term agency Consultant up until December 2017 since then there was support from a Locum Consultant who has previously worked as a substantive member of staff the for the Trust. The second post continued to be advertised throughout the year without success, however a new consultant microbiologist has recently been appointed and they will take up the post in mid-summer 2018. Laboratory Support

The Pathology Department at Southend Hospital is provided by a joint venture private company comprised of Southend University Hospital, Basildon and Thurrock University Hospital and IPP (Integrated Pathology Partnership); the company is called Pathology First and has a monitored contract to provide a clinically led service for all disciplines of Pathology. The Microbiology laboratory is accredited by CPA and is working towards ISO standards for accreditation to UKAS which took place in Autumn 2017, however the hub laboratory will be included in the Basildon University Hospital’s UKAS “extension to scope” surveillance visit which is due to take place late April 2018. The main laboratory services are situated off site at a central Hub laboratory and it also has a small presence in the


Emergency Service Laboratory (ESL) on the hospital site.

Compliance Criteria Nine Have and adhere to appropriate policies, designed for the individual’s care and provider organisations that will help to prevent and control infections.

Policies are reviewed and updated systematically as per the review cycle and several new policies have been developed and ratified this year.

Policies

Appendix 8 – Infection Prevention & Control Polices

Hand Hygiene Audit

Hand hygiene is the single most important measure for reducing transmission of HCAIs in hospital. To ensure that the profile of this vital precaution remains high, compliance with the hand hygiene policy is audited monthly, based on the World Health Organisation’s “five moments for hand hygiene”. The performance is recorded on the Infection Prevention Dashboard and the results for the year are shown below. In the hand hygiene audit, staff audit fellow staff members on their hand hygiene technique, knowledge of the hand hygiene policy, bare below the elbow compliance and hand washing facilities

The average compliance for the year 2017/2018 was 90.50%.The IPCT also carries out ad-hoc hand hygiene audits. These results are sent to the Matrons’ for dissemination to their teams. (Appendix 9 – Hand Hygiene Compliance Graph)

High Impact Interventions Audits

High Impact Interventions (HII’s) are based on the care bundle model and published by the Department of Health as part of the Saving Lives: reducing infection, delivering clean and safe care programme. The HII’s are specifically aimed at reducing the risks of acquitting a HCAI.

Currently the following seven HIIs are audited monthly and the hospital wide results are included in the Infection Prevention and Control monthly Dashboard reports.

HII1 Insertion and on-going care of central venous devices.

HII2 Insertion and on-going care of peripheral intravenous devices.

HII3 Renal Dialysis Catheter Care Bundle

HII4 Preoperative and perioperative actions to prevent surgical site infection

HII5 The reduction of ventilation – associated pneumonia

HII6 Insertion and on-going care of urinary catheters

HII7 Reducing the risk from C. difficile

The HII7 (Reducing the risk from C. difficile) audit is carried out on each patient confirmed as having C. difficile

associated disease and every element of the care bundle has been carried out on each case. The high level of compliance with the HIIs is reflected in the performance against national targets. For example, the Invasive device tool (IDT) audits associated with the care of peripheral lines, central lines and urinary catheters illustrates the high standard of care provided to patients with these invasive devices. This is likely to be one of the factors in reducing not only MRSA bacteraemia but also those associated with Meticillin sensitive Staphylococcus aureus (MSSA).

Compliance Criteria Ten Ensure, so far as is reasonably practicable, that care workers are free of and are protected from exposure to infections that can be caught at work and that all staff are suitably educated in the prevention and control of infection associated with the provision of health and social care.

In 2017/18, the Occupational Health Department continued to provide a comprehensive service and worked closely with allied colleagues including Infection Prevention Control, Public Health England, the Blood Borne Virus team and Pharmacy to ensure that staff are protected against infection. The department has been fully involved in Infection Prevention related incidents that affect staff health such as needle stick injuries and staff exposure to skin conditions including scabies. The department has also been responsible for coordinating and delivering the Influenza Immunisation programme. In addition staff are suitably educated in protecting themselves and patients from communicable diseases. Induction training is undertaken for all new staff.


Staff have access to Occupational Health advice and out of hours medical advice via Accident and Emergency in the event of exposure to a blood borne virus. The Trust continues towards reducing occupational exposure to blood borne viruses including the prevention of sharps injuries through compliance with the EU directive for Safer Needles and Devices. A total of 125 sharps injury incidents/bodily fluid exposure incidents were reported to Occupational Health in 2017. A review of incidents noted a high number of incidents resulting from the use of Insulin pen needles. The Trust’s Diabetic Team recently completed a trial of safer insulin pen needles. The Occupational Health Department will conduct an audit on the number of incidents relating to insulin pen needles once safer insulin pen needles have been introduced and in use. Since mid-2017 the UK has experienced a shortage of Hepatitis B vaccine due to global manufacturing issues. In response to the shortage, Public Health England developed temporary recommendations on Hepatitis B vaccine use including risk-based prioritisation of vaccine, dose-sparing and deferral of boosters. Recent correspondence from Public Health England advises that vaccine supplies are now improving and more vaccine is becoming available during 2018. However supplies will remain constrained due to backlog demand from 2017 and low UK allocations from some manufacturers. Supply management and restrictions will therefore continue until further notice. Public Health England, working with manufacturers has published a phased recovery plan to support the re-introduction of the vaccine in a phased approach to maintain continuity of supply during 2018. Occupational Health continues to receive sufficient stock of Hepatitis B vaccines for use in identified high risk groups such as Exposure Prone Procedure workers (EPP) and post exposure incidents. ‘Catch –up’ vaccinations commenced in May 2018 and are being phased throughout 2018. This plan is heavily reliant on Pharmacy stock levels. Occupational Health worked closely with the Infection Prevention Control team and Public Health England in managing and containing an outbreak of Norwegian Scabies. The Pharmacy Department played a crucial role by facilitating the relevant treatment to staff. The season’s Influenza campaign 2017/18 came to a close in March 2018.There was a significant increase in uptake. IMMFORM reporting March 2018 shows that 61.0% of frontline staff received the Flu vaccine in comparison to the Flu campaign 2016/17 whereby 52.21% frontline staff had the vaccine. The percentage of staff who had received the vaccine as of 14th March is 62.3%. Planning is underway for the next campaign 2018/19.

Education Induction, Training Programmes and On-going Education

A blended learning approach continues with the provision of both face to face training and e-learning for clinical staff

Training compliance rates remain high despite considerable operational pressures on the organisation throughout the year

Additional education is provided on a one to one basis during routine clinical visits by the Infection Prevention and Control Nurses and in response to patient specific clinical enquiries from wards and departments.

TB eLearning video

A new TB eLearning training video was produced in 2017. The purpose of the training video is to improve the knowledge and skills of practitioners when caring for patients with suspected or confirmed Tuberculosis. The training video takes around 20 minutes to complete. It is available to all grades of staff.

Link Nurse Meetings


The IPCT continues to provide the Infection Prevention and Control Link Nurse programme. Link Nurse sessions are run quarterly and provide an education session and, usually include a guest speaker to support the nurses to maintain their enthusiasm and commitment. Numerous topics are covered and have included for example, hand hygiene, MRSA screening and outbreak management. The sessions run for approximately two hours. The aim of these sessions is to update on any new guidance / policies and to increase the flow of Infection Prevention and Control communications.

Performance against National Targets Meticillin Resistant Staphylococcus aureus (MRSA) Bacteraemia

Staphylococcus aureus is a bacterium commonly found colonising humans. Although most people carry this organism harmlessly, it is capable of causing a wide range of infections from minor boils to blood stream infections. MRSA is a strain of staphylococcus aureus that is resistant to flucloxacillin and other antibiotics. The Department of Health introduced mandatory surveillance and reporting of MRSA bloodstream infections in 2001 and since April 2005 NHS acute Trusts have been set annual targets for reducing MRSA blood stream infections. For the period April 2017 to March 2018, the Trust ceiling for MRSA blood stream infections was zero Acute Trust apportioned cases. The Trust did not achieve this target with 5 MRSA bloodstream infections reported. (Appendix 10 – MRSA bacteraemia Graph)

MRSA bacteraemia – number of post 48 hour cases 0 Tolerance ceiling

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

1 0 0 1 1 0 0 0 0 1 1 0

All of the MRSA bacteraemia cases underwent a thorough Post Infection Review Process (PIR). Three of the five cases were identified and agreed as unavoidable i.e. There were no breaches in policy or practice which resulted in the case occurring. The remaining two case were agreed as avoidable due to the fact there had been breaches in local policy .The following learning points were identified :

Poor Invasive Device Tool documentation- resulting in a delay in removing a device

Failure to cover for MRSA with empirical antibiotics when patients are previously known to be MRSA positive

Failure to include the MRSA status on a referral for line insertion. Lessons learnt were shared at ward level ensuring that all clinical staff were aware both good practice and any failures to follow policy. Also all cases with the lessons learnt were an agenda item at the IPCC, HCAI Network Group, Senior Sisters meetings, Professional Nurse and Midwifery Forum and at the Heads of Nursing Meetings. Post Infection Review (PIR) of MRSA Bacteraemia Cases

The Trust undertakes a PIR following all cases of MRSA bacteraemia in order to identify key issues and themes. Action plans are developed to address issues identified. The PIR is completed by the clinicians and nursing teams involved in the care of the patient, a strategic review of the PIR is undertaken by the Microbiologist, antimicrobial pharmacist, Public Health, Infection Control Nurse and the Director of Infection Prevention and Control – the results of this review are then fed back to the clinical teams. The PIR is required to be uploaded onto a PHE database within 14 working days of notification of the bacteraemia. This requirement was achieved in both cases.

MSSA Bacteraemia

The IPCT continue to report all Meticillin Sensitive Staphylococcus aureus Bacteraemia (MSSA) cases via the MESS system on a monthly basis. It was anticipated that national trajectories would be set for individual Trusts for MSSA bacteraemias; however, to date that has not yet occurred. For each post 48 hours of admission MSSA bacteraemia case, a review is undertaken by the IPCT to identify any key themes which require actions. (Appendix 11 – MSSA Bacteraemia graph)

Clostridium difficile

Mandatory surveillance for C. difficile in over 65 year olds has been undertaken since 2004. Since 2007 episodes of C. difficile infection in patients between the ages of 2 and 65 have also been reportable.

Episodes (or cases) are reported via the Public Health England Data Capture System. An episode consists of one or more C. difficile toxin positive stools during a 28 day period. Cases that occur on or after day 4 of a hospital


admission (with day 1 being the day of admission) are apportioned to the acute Trust with those identified on days 1-3 of admission likely to have been community acquired and therefore not hospital apportioned.

All samples for patients who tested positive for the toxin more than 72 hours of admission (post 72 hours) are sent to reference facilities for strain typing to determine whether the cases represent cross infection. Strain typing is a specialised service provided by a reference laboratory. This is an indispensable service which helps us to manage and minimise C. difficile. Strain typing is undertaken to identify possible clusters of C. difficile cases. This year no linked cases were identified. In addition, there were no predominant strains present in the trust. (Appendix 12 - Clostridium difficile Graph)

The table below shows the hospitals performance during the year. The annual ceiling for C. difficile was 30 cases. The hospital reported 33; all cases were thoroughly investigated via a Root Cause analysis (RCA).

Clostridium difficile (Toxin positive) - number of post 72 hour cases Year total ceiling – 30

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

5 2 4 1 3 1 1 4 7 2 3 0 33

The Root Cause Analysis (RCA) process is completed by the relevant ward manager and clinical team for all hospital apportioned cases. The RCA is presented at the RCA meeting and reviewed by the Infection Prevention and Control Team, Clinician, Consultant Microbiologist, Antibiotic Pharmacist and CCG Infection Prevention and Control Nurse. The RCA process is required to identify direct lapses in care which may have resulted in C. difficile infection. This information is scrutinised by the Clinical Commissioning Group (CCG). Of the 33 hospital acquired C. difficile infections, this year 0 direct lapses in care contributing to infection were identified however there were lessons learned from some of the cases. Learning/actions are fed back to the ward team, RCA findings are discussed by the DDIPC at the Infection Prevention and Control Committee and Clinical Governance Committee. If there are sufficient patients within the Trust or patients requiring review a C. difficile ward round will be undertaken. This is attended by Consultant Microbiologists, Antimicrobial Pharmacist, an Infection Prevention and Control Nurse and the Gastroenterologist. This ward round provides expert review and advice, when required, on the treatment and management of the patient. The IPCT continues to provide education throughout the year on promoting the use of the Bristol Stool Chart, the importance of rapid isolation of patients with diarrhoea and actions that reduce the transmission of CDI in the clinical area.

Other Resistant Bacteria: Surveillance of Glycopeptide Resistant Enterococci (GRE) Bacteraemia

GRE are resistant to Glycopeptides (antibiotics such as vancomycin) and have been nationally reported since 2003. During 2017/18 the Trust reported nil cases.

Escherichia coli (E coli) bacteraemia

E. coli is a species of bacteria commonly 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 disease. There is no objective or target associated with this bacteraemia and it is not included in our performance data. However E coli bacteraemia contribute to a high number of blood stream infections and the significant effect on both the patient and burden on the health economy should not be underestimated. In total there were 280 E coli blood stream infections in 2017/18 a significant number of patients were admitted with an established bacteraemia. The Health Secretary has launched new plans to reduce infections in the NHS. He has announced government plans to halve the number of gram-negative bloodstream infections by 2020 at an infection control summit. E. coli infections – which represent 65% of gram-negative infections – killed more than 5,500 NHS patients last year and are set to cost the NHS £2.3 billion by 2018. There is also large variation in hospital infection rates, with the worst performers having more than 5 times the number of cases than the best performing hospitals.

The DDIPC in conjunction with the CCG plan to produce an E coli Action Plan which aims provide the Board on the progress of planed actions aimed at reducing the incidence of E.coli bacteraemia across the Trust. As approximately three-quarters of E. coli BSIs occur before people are admitted to hospital, the reduction plan will require a whole health economy approach.

By using the same data definitions as MRSA and MSSA attributed cases, the Trust has reported the following cases as represented in the following graph. There appears to be a strong association with of urinary catheters for genitourinary related bacteraemia .There has been a lot of work Trust wide and within primary care in relation to reducing unnecessary urinary catheterisation. This has included training and improved documentation. (Appendix 13 – E coli Bacteraemia graph)


18.2% decrease for plus 48 hours cases, 9.9% increase for less 48 hour cases.

Carbapenemase-producing Enterobacteriaceae

Carbapenems (such as Meropenem) are a powerful group of broad-spectrum antibiotics which are often the last effective defence against multi-resistant bacteria. Infections with Carbapenem-resistant enterobacteria are an emerging threat. Many have been associated with patients who have received prior treatment abroad. The Trust has a policy in place for the screening and subsequent management of suspected or confirmed cases In 2017/2018 there were nil cases reported.

Outbreaks In common with Other Acute Trusts, SUHFT experienced outbreaks of diarrhoea and/ or vomiting which required restrictions to the movements of patients into and out of ward areas. The IPCT closely monitor these outbreaks where they provide advice to the ward staff and also advise the Trust on the restrictions that are required to manage the outbreak situation. Ward summary of outbreaks 2017/2018

Date of onset

Ward / bay closed Date

closed (if applicable)

No of staff

No of patients

No of positive

staff samples

No of positive patient

samples

No relatives

with symptoms

Date ward / bay

opened

No of bed days lost

Paglesham 01/12/2017 Admissions blocked,

ward monitored n/a 14 9 0 0 0 05/12/2017 n/a

G Hopkins / CCU

14/12/2017 All 3 symptomatic patients isolated

n/a 0 3 0 3 3 N/A n/a

Blenheim 20/12/2017 Bay 4 closed (full) 21/12/2017 2 19 0 3 1 27/12/2017 n/a

Shopland 21/01/2018 Ward closed 22/01/2018 13 4 0 3 3 26/01/2018 4

Windsor 11/02/2018 Bay 3 and 4 closed 12/02/2018 0 6 0 2 2 14/02/2018 0

Flu/Respiratory Virus inpatient cases: In January and March 2017 several large local residential homes were closed due to respiratory outbreaks. All patients admitted to the Trust were promptly isolated, had viral swabs obtained and infection control precautions were put in place. This ensured that that cross transmission of influenza did not occur. Confirmed case summary by ward.

Ward Flu organism Sample

date

ITU Flu B 11/01/2018

Castlepoint Flu B 14/01/2018

Princess Anne Flu B 14/01/2018

Westcliff Parainfluenza 14/01/2018

Westcliff Flu B 16/01/2018

Rochford Flu A H3 17/01/2018

Princess Anne Flu B 16/01/2018

Castlepoint Flu B 17/01/2018

Windsor Flu A 23/01/2018

ITU Human metapneumovirus 28/01/2018

Gordon Hopkins Flu B 31/01/2018

Neptune Human metapneumovirus 31/01/2018

Windsor Flu B 01/02/2018

Gordon Hopkins Flu B 01/02/2018

Rochford Influenza B 14/02/2018


AMU RSV 16/02/2018


P Anne Flu A 21/02/2018


AMU Flu A 28/02/2018

A/E Flu A 01/03/2018

Bedwell Flu B 27/12/2018


ITU Flu A 09/03/2018

Rochford Flu A 16/03/2018


Water Safety Water Hygiene

Highlighted below is an outline of some of the measures which are in place to manage water hygiene monitoring and control within Southend University Hospital NHS Foundation Trust and satellite properties under the Trust responsibility. Legionella Bacteria

Legionella is a waterborne bacterium. For it to proliferate within the hot and cold water systems it needs the presence of sludge, scale, algae, rust, and organic matter, and the ideal temperature of 20–40 degrees C.

Current Situation

Currently the Trust has a contract with a specialist contractor who carry out a number of planned preventative maintenance (ppm’s) tasks and other control measures in line with the current guidance and legislation that is in place namely: HTM–0401 and the ACOP ‘Legionnaires’ disease - The control of legionella bacteria in water systems (L8), and HSG274 - Legionnaires’ disease: Technical guidance Part 2: The control of legionella bacteria in hot and cold water systems.

In addition to the PPMs carried out by the specialist contractor the Trust also carries out regular flushing of water outlets which are used less than twice a week, which increases the turnover of water and prevents the bacteria forming in stagnant water.

The Trust’s WSG (Water Safety Group) have an approved sampling regime that is in place to sample water systems throughout the Trust and in satellite properties under the Trusts responsibility.

If an elevated count of legionella bacterium is detected from sample results various engineering controls are implemented to eliminate the issue and the risk of the bacteria reforming. This includes: removal of flexible hoses if present, increasing temperature, removing, changing or relocating thermostatic mixing valves, descaling the outlets, increasing flushing of the outlet or chlorination of the complete water system.

All outlets which have returned with elevated sample results are resampled once engineering actions have been taken, and when results come back clear they are put on to the flushing register for domestics to flush daily – as a precautionary measure.

Pseudomonas aeruginosa

Pseudomonas aeruginosa is a waterborne bacterium which was highlighted in the press in the early part of 2012 which resulted in the death of 4 babies: 1 in Londonderry and 3 in Belfast.

It is a tough bacterial strain, which is able to survive in harsh environments. It is found widely in soil and stagnant water, and can infect humans and plants. It does not usually cause illness in healthy people, but is described as an "opportunistic" organism, causing serious infection when our normal defences are weakened. This means that it represents a genuine threat to the most vulnerable hospital patients, most commonly intensive care patients, those with depleted immune systems such as cancer patients, people with severe burns and premature babies in neonatal units. In 2012 an interim document was produced advising action which needs to be taken to manage Pseudomonas aeruginosa; this was superseded by the release of the HTM 04-01 Part C in 2016.

To determine what areas within the hospital may possibly be affected, all those which fell under ‘augmented care’


were included on a sampling regime in accordance with the HTM 04-01 which was risk rated by the Water Assurance Committee with support from Evolution Water Services. This is reviewed on a frequent basis.

Sampling began in the later part of 2012 and is an on-going process which is carried out on 6 monthly regime.

Unlike legionella sampling Pseudomonas aeruginosa sampling consists of both the hot and cold water taps being sampled. Any elevated results that are identified within the ward, are investigated for any remediation works that maybe required which typically would include investigation works, descaling of outlet, servicing of TMV valves, removal of any flexible hoses and increased flushing.

The Trust continues to take this responsibility very seriously and is aware of the risks inherent in a multi building site with a number of older facilities. The Trust has a Water Quality Group which meets monthly. The purpose of this committee is to monitor and provide assurance in relation to all water safely issues.

Sterile Services Sterile Services Report

During the last year the Sterile Service Department (SSD) management together with the DDIPC and the Trust Clinical Director made the decision to move reprocessing of flexible endoscopes from the Endoscopy unit under the SSD umbrella to improve the delivery of the service. All of the automated endoscopy re-processors (AER’s) were removed from Endoscopy Unit.

The SSD Department is accredited to ISO13485:2016 - Medical Devices Quality Management System. The departmental quality system was amended to reflect the changes from the updated regulations and the external notifying body was informed, and the Trust is awaiting an audit date to assess changes put in place.

Key actions/achievements in Infection Prevention and Control for 2017/2018

Actions Key Points IPC Policy Audits Annual rolling programme of Infection Prevention & Control audits

with timely feedback to clinical teams achieved

MRSA Screening for elective and Emergency admissions target 95% compliance

The IPCT provided on-going support to ensure compliance with the target to help improve compliance with screening

Continuing support and advise in relation to Facilities Estates and the Project Team

Successfully worked in conjunction with the Trust Estates and Facilities Management Team to look at building work/projects/new legislation which require Infection Prevention & Control advice

Mandatory bi-annual updates for Infection Prevention & Control for all staff groups

Continued to provide and support the Trust programme at induction and Mandatory Training sessions

Policies updated as required All IPC Policies updated as per programme

New Policies and SOPS’s produced in line with current legislation

New policies produced as required

All IPC Leaflets reviewed as needed All IPC Leaflets updated

Surgical Site Surveillance maintained The IPCT has continued to follow a rolling programme

IPC Link Nurse sessions continued Continuing work to develop link nurse role to enhance Infection Prevention & Control throughout the Trust

TB Learning video e learning TB video produced and introduced to the Trust aimed at all levels of staff

Commode cleaning poster required to ensure standardised cleaning protocol

Posters updated and laminated posters provided to all clinical areas

Group A streptococcus information required regarding isolation and general Management

Group A Streptococcus Standard Operation Procedure produced and published on the STAFFnet

Document folder required on STAFFnet to provide access to key infection control paperwork/order codes etc.

Infection Prevention and Control folder in place.


Key Objectives 2018/2019 – Annual Plan With the proposed merger of Mid Essex, Southend and Basildon Hospital Trusts the aim the Infection Control Team is to align all policies and procedures access all three sites, to set up a formal process to share learning, standardise products used and have greater communication/joint working processes. The structure at the time of producing this report has yet to be agreed and formalised. During the next 12 months the IPCT aims to ensure a high quality and effective service across the whole Trust. The IPCT will adopt a zero tolerance approach to HCAI’s and ensure that all staff in the Trust are aware of their responsibilities in relation to Infection Prevention and Control. The trajectories set by the DoH for MRSA (Zero) and CDI (29) for the forthcoming 12 months remain challenging. The team will continue to carry out enhanced surveillance in line with DoH guidance for the following infections:

Meticillin Resistant Staphylococcus Aureus (MRSA) BSI

Clostridium difficile

MSSA BSI

E Coli BSI

Klebsiella

Pseudomonas BSI

Acienetobacter BSI RCA’s action plans generated will be used to provide feedback to Clinical Directorates of any key themes. The responsibility will lie with Matrons to provide the IPCT with assurance regarding the implementation of actions put into place to address issues raised. There will be continued focus and emphasis on sharing lessons learnt within all Clinical Directorates and across the MSB


1 Appendix 1 – Work plan 2017/2018

This programme follows The Health and Social Care Act 2008 – (Regulated Activities) Regulations 2014, published July 2015.

The Code of Practice on the prevention and control of infections reflects the changes required to meet the H&SC Act; Regulation 12 –Safe Treatment and Care and Regulation 15 – Premises and Equipment. The Code sets out the criteria used by the Care Quality Commission (CQC) registration requirement on cleanliness and infection control.

Infection prevention also plays a role in optimising antimicrobial use and reducing antimicrobial resistance with good antimicrobial stewardship. This is one of the key components of the Department of Health Antimicrobial Resistance Strategy 1.

To comply with the Code of Practice, the key priorities of the Infection Prevention and Control Team are:

To facilitate the Trust to meet national and local performance indicators for the prevention of healthcare associated infections

To ensure compliance with the Saving Lives Programme and raise standards of practice

To audit compliance to Trust Infection Prevention and Control Policies

To continue (and improve) established programme of audit and surveillance to provide assurance that HCAI is managed effectively

To continue and improve the established education programme, in particular extending the knowledge and role of the Trust IP&C link workers

Progress on this work programme will be reported to the Infection Prevention and Control Committee

CQC Code of Practice Compliance criteria

Programme of work 2017/2018 By whom (lead) Evidence Date to be achieved

1. Systems for the prevention and control of infection. These systems use risk assessments and consider how susceptible service users are and any risks that their environment and other users pose to them.

Monthly DIPC Reports to the Board IPCC and CCG Deputy Director of Infection Prevention &

Control (DDIPC)

Report Monthly Quarterly Reports to the Clinical Governance Committee

Continue to raise the profile of the Infection Prevention and Control Team through the Trust

Deputy Director of Infection Prevention &

Control (DDIPC)

Feedback On-going

Ensure Infection Prevention Team is represented in essential Trust Committees, such as the Health and Safety DON / DIPC/ DDIPC

Minutes On-going

Present annual programme 2018/16 (including annual audit programme) and Annual Report 2015/16 to Board of Directors through the Quality Assurance Committee. Ensure report available to the public (Published on web site). Additional briefing to Board of Directors at least yearly

DIPC / IPC / Matrons Minutes/Risk

register/Website August 2015


Review healthcare associated infection risks identified on the Trust Assurance Framework/Risk Register regularly (monthly, quarterly and as required) and report to Board of Directors

DIPC Minutes/Risk register

Monthly / Quarterly

Provide HCAI statistics for performance reporting at Board of Directors and at the IPCC, including details of trends

DIPC Minutes Monthly

Continue to undertake root cause analysis and Post Infection Reviews for HCAI (MRSA bacteraemia, Clostridium difficile)

DIPC, IPCT, Ward Managers, Matrons.

Completed RCA Tools/Minutes

Quarterly

Evidence of lessons learnt through the RCA process are shared and agreed

Evidence of actions implemented produced an action plan

Review all outbreaks and clusters of HCAI to the Infection Control Committee DIPC,IPCT Minutes/Quarterly Report/Annual

report

On-going

Assess new and existing policies with regard to infection prevention and control and make recommendations for change in line with current legislation

IPCT Update programme with review dates

On-going

Plan and deliver a full education programme for all staff IPCT Programme/emails /attendance records

On-going

Update and review the e-learning module for clinical/non clinical staff

Develop new methods of providing education for all staff

IPCT E learning Programme / presentation

material / records of undertaking

On-going

Continue to deliver and develop quarterly Link Nurse sessions. Sessions to include RCA and PIR feedback

IPCT Programme/ presentation

material/records of attendance

Quarterly sessions

during 2015/16

Continue education and support for ward staff to undertake hand hygiene compliance. Hand hygiene compliance to be monitored in all in-patient areas monthly. Areas of non-compliance to be discussed at IPCC

IPCT Minutes On-going

High Impact Interventions Audits undertaken monthly. Provide feedback at IPCC regarding progress and recommended actions

Matrons Infection Prevention Dashboard

On-going

2. Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections.

Infection prevention participation with environmental audits and report poor compliance via the IPCC

IPCT Matrons Audit reports minutes

Bi-monthly

Continued Infection Prevention and Control input /participation with PLACE assessments

IPCT PLACE reports and minutes

As required

Provide expert advice to all service developments to ensure infection risks are considered and good infection prevention facilities/practices built into the development

IPCT Evidence of sign off of projects

As required


In particular, ensure that infection prevention is considered in the built environment through provision of infection prevention expertise to capital projects from concept stages to commissioning, as well as more minor refurbishment projects

Collaborate with Estates Department and Health & Safety dept. regarding Legionella management. IP&C represented at Water safety management group. Report to IPCC

DDIPC/IPCT Water Safety Management Group

minutes/ IPCC Minutes

Bi-monthly

Collaborate with Estates Department regarding risk of Pseudomonas infection from water outlets in Augmented care areas

DDIPC/IPCT

Water Safety Management Group

minutes/ IPCC Minutes

Monthly reporting

Monitor laboratory results for Pseudomonas aeruginosa in augmented care units

3. Ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance.

Antimicrobial Stewardship Group

Anti-microbial Pharmacist

Audit reports On-going

Empirical use of antibiotics pocket guidelines for prescribing in adults – reviewed annually

Antimicrobial audits

Weekly C diff rounds – Antimicrobial prescriptions reviewed

Annual report to IPCC and Antimicrobial Stewardship Group

4. Provide suitable accurate information on infections to any person concerned with providing further support or nursing/ medical care in a timely fashion

Review and update letters as required - GP D/N in conjunction with CCG and local GP’s

IPCT + CCG ICN Letters As required

Ensure evidence and data required by commissioners is available and also presented to IPCC

DDIPC Minutes monthly

Sharing learning continues across the South Essex Area at the quarterly IPC network meetings

IPCT Minutes Quarterly

Continue to review and update all patient Information leaflets as guidance/circumstance requires and ensure availability

IPCT Information Leaflets As required

5. Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people.

Continue to participate in the Surgical Site Surveillance Schemes IPCT Programme of categories with

collection dates/reports/attend

training sessions

On-going

Reports circulated to relevant surgeons and SSI data reported at IPCC

Monitor screening of emergency and elective patients data and report to Matrons, IPCC and CCG

IPCT Data % Monthly

Review the Infection Prevention and Control DASHBOARD IPCT/DIPC

September 2018


6. Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection.

See criterion 1 (programme of education, audit and monitoring of practice) IPCT Training records/agenda

item at IPCC

Monthly review

Ad hoc sessions as required e.g. Physiotherapists, Phlebotomists, Domestic Team etc

IPCT Attendance records As required

7. Provide or ( secures) adequate isolation facilities

Provide specialist infection prevention and control advice to new build or refurbishment projects such as bathroom facilities, isolation facilities and theatre maintenance

Project Team /IPCT Sign off sheets from Estates Department

As required

Policy for Transfer Patients Policy requires review and update to include the isolation and screening requirement s of repatriations to the Trust

DDIPC/ Clinical Site Management Team

Ratified Policy August 2018

Collaboration with Estates with regard to capital projects /refurbishments to ensure isolation facilities are considered and included.

IPCT/Estates/Projects Documentation /Sign off sheets

As required

8. Secure adequate access to laboratory support as appropriate.

Collaborate with IPP (Integrated Pathology Partnership) regarding Standard operating Procedures (SOPs) relevant to IP&C

Consultant Microbiologist/Laboratory

Manager

Minutes from meetings/emails

As required

9. Have and adhere to policies, designed for the individual’s care and provider organisations, which will help to prevent and control infections.

Revise policies as per schedule or following publication of new evidence/guidelines

DDIPC/IPCT Ratified at IPCC and the Procedural Document Group

As required

Continue with audit programme of IPC policies compliance with Policies DDIPC /IPCT Reports at IPCC On-going

10. Ensure, so far as is reasonably practicable, that care workers are free of and are protected from exposure to infections that can be caught at work and that all staff are suitably educated in the prevention and control of infection associated with the provision of health and social care.

Provide specialist infection prevention input to Occupational Health policies as required.

DIPC / IPCT

Policies

Vaccination data

As required

Support the Occupational Health Service Department in the importance of staff having influenza vaccination

DIPC/ IPCT

Liaise with Occupational Health Service regarding any vaccinations, prophylaxis or antibiotic therapy required as circumstance dictate

IPCT/OH


2 Appendix 2 – Governance structure

NHS England Area Team

45 Day

JCT

7 Day

EMR (Early Management Report)

Governance Team

Trust Board

QAC Exception Reports & also DIPC report from CGC

Execs/ Business Unit/ Exception/ Escalation

CGC

IPCC

Business Units to action

SI’s HCA Incidents RCAEnvironment

Cleaning Audit

HII AuditCompliance

with TrainingMRSA

ScreeningWard

ClosuresPolicies of

AuditSSI’s

Wards & Departments

Infection Prevention & Control Assurance Framework

SLT

3 Appendix 3 – Antimicrobial Stewardship

Reducing the Impact of Serious Infections CQUIN - Graphs


The reduction of total antimicrobial consumption remains a challenge, mainly because the Trust uses combinations of antibiotics to provide a broad spectrum antimicrobial activity, and preserve the use of Piperacillin-tazobactam and carbapenems.

It is also worth noting that consumption of antimicrobials at Southend has always been relatively low in comparison to other East of England Trusts, even prior to the CQUIN. As such, it becomes a very challenging task to reduce even further with all the interventions in place especially when dealing with an aging, immunosuppressed population.


4 Appendix 4 – VRE leaflet

SOU4752

5 Appendix 5 – Ward graphs


6 Appendix 6 – Infection Prevention and Control hospital webpage

http://www.southend.nhs.uk/your-services/medical-services/infection-control/

7 Appendix 7 – Mandatory Training compliance

http://www.southend.nhs.uk/your-services/medical-services/infection-control/


8 Appendix 8 – Published policies /SOP’s

No. Policy ICN Published

Date

CM60 Decontamination ED Nov-17

IC005 Infectious Patients in the Operating Theatre ED May-17

IC006 Plan for the control of outbreaks in Southend Hospital ED May-17

IC009 Policy for hand decontamination ED Jan-18

IC019 Isolation Policy ED Jun-17

IC035 Linen Handling Policy ED Nov-17

IC036 Microbiological Sampling of Theatres ED Sep-17

IC038 Mattress Policy ED May-17

IC039 Management of PVL-associated Staphylococcus aureus infections ED Aug-17

IC040 Infection Prevention and Control Practice in the Operating Department

ED Sep-17

IC041 Toy Cleaning Policy ED Nov-17

SOP N018

Whooping cough ED Jun-17

SOP N030

iGAS SOP ED Oct-17

9 Appendix 9 – Hand Hygiene compliance

http://intranet/polguide/cp/icp/Documents/IC005%20Infectious%20Patients%20in%20the%20Operating%20Theatre.pdf

http://intranet/polguide/cp/icp/Documents/IC006%20Plan%20for%20the%20control%20of%20outbreaks%20in%20Southend%20Hospital.pdf

http://intranet/polguide/cp/icp/Documents/IC009%20Policy%20for%20hand%20decontamination.pdf

http://intranet/polguide/cp/icp/Documents/IC019%20Isolation%20Policy.pdf


10 Appendix 10 - MRSA Bacteraemia graph

11 Appendix 11 – MSSA Bacteraemia graph


12 Appendix 12 – Clostridium difficile graph

13 Appendix 13 –Escherichia coli graph