Report to the Safety and Quality Governance Committee 2014/15 · 2014-09-22 · DIPC Report 2013/14 Version1 Page 1 Attachment 6 Report to the Safety and Quality Governance Committee

DIPC Report 2013/14 Version1 Page 1

Attachment 6

Report to the Safety and Quality Governance Committee 2014/15

Date 11th July 2014

Subject Director of Infection Prevention & Control Report

Report of Infection Prevention & Control

Author Linda Hawtin/ Dr Reham Soliman/ DIPC Elizabeth Libiszewski

Board Action Required Approval X Discussion

Decision Information

Executive Summary and purpose

This report gives an overview of Infection Prevention and Control activities throughout the year 2013/2014 and shows the reporting and accountability structure in place to assure the Board of Directors and stakeholders that the Trust is meeting the standards required to ensure effective infection prevention and control. The Trust has a proactive Infection Prevention and Control Team (IPCT) that is very clear on the actions necessary to deliver and maintain patient safety. Equally, it is promoted and recognised that infection prevention and control is the responsibility of every member of staff within the Trust and must remain a high priority for all to ensure the best outcome for all patients.

Legal/regulatory Care Quality Commission

Equality Impact/risks: Equality Delivery System 2 – EDS2 Nov 2013)

Impact

Positive Negative Neutral

x

Assurance/monitoring Board of Directors


Director of Infection Prevention and Control Annual Report

April 2013 to March 2014

Page

1 Introduction 4

2 Executive Summary 4

3 Description of infection Prevention & Control arrangements 3.1 Infection Prevention & Control team 3.2 Infection Prevention & Control Link Nurses 3.3 Communication within the team

5 5 7 7

4 Governance structure and reporting line to the Trust Board

8

5 Hospital Infection Control Committee (HICC) 8

6 Joint working with East Coast Community Health 8

7 Healthcare Associated Infection 7.1 MRSA bacteraemia 7.2 Clostridium difficile infections 7.3 Methicillin sensitive Staphylococcus Aureus (MRSA) 7.4 E. coli bacteraemia

9 9 10 11 11

8 Incidents and Outbreak 8.1 Norovirus 8.2 Vancomycin resistant Enterococci (VRE) 8.3 Pseudomonas 8.4 Endophthalmitis Outbreak 8.5 Breast Surgery Infections

11 12 12 12 13

9 Surgical Site Infection Surveillance Service (SSISS) 9.1 Repair of neck of femur 9.2 Knee replacements 9.3 Hip replacements 9.4 Breast surgery 9.5 Large bowel

13 14 14 14 15 15

10 Audits 10.1 Hand decontamination audits 10.2 Environmental audits of clinical areas

16 16

11 Pathology transformation 17

12 Pharmacy/Antibiotic stewardship 12.1 Audit

17 18

13 Cleaning services 13.1 User satisfaction measures 13.2 PLACE

18 19 20

14 Decontamination 14.1 Areas of concern 14.2 Achievements

22 23 23


15. Training & Education 24

16 Infection Prevention and Control Annual Programmes 2012/13 and 2013/14

24

17 Future challenges 17.1 HCAI numbers 17.2 Patient flow 17.3 Carbapenemase-producing Enterobacteriaceae

24 24 24

18 Acknowledgements 25

.


The Annual Report of the Director of Infection Prevention and Control

April 2012 to March 2013 1. Introduction The Director of Infection Prevention and Control (DIPC) report is a requirement stipulated in ‘The Health and Social Care Act” ( DoH 2008).This report describes the Infection Prevention and Control activities for the James Paget University Hospitals NHS Foundation Trust (JPUH) for the year ending March 2014. The report will be presented to the Board of Directors in July 2014. It will also be made available to staff, patients and the public via the JPUH intranet and internet. The Act stipulates that an NHS organisation must ensure that they have effective systems in place to control Healthcare Associated Infection (HCAI). The prevention and control of infection is part of the Trust’s overall risk management strategy. The on-going development of clinical practice and the continuous evolution of micro-organisms present new challenges in Infection Prevention and Control, which need constant review. Prevention of HCAIs remains a top priority for the public, patients, staff and the organisation. Avoidable infections are not only potentially devastating for patients and healthcare staff, but consume valuable healthcare resources. The Trust puts infection prevention and control and basic hygiene at the heart of good management and clinical practice, and is committed to ensuring that appropriate resources are allocated for effective protection of patients, their relatives, staff and visiting members of the public. In this regard emphasis is given to the prevention of HCAI’s, the prudent use of antibiotics and cleaning regimes. 2. Executive Summary

This report gives an overview of Infection Prevention and Control activities throughout the year 2013/2014 and shows the reporting and accountability structure in place to assure the Board of Directors and stakeholders that the Trust is meeting the standards required to ensure effective infection prevention and control. The Trust has a proactive Infection Prevention and Control Team (IPCT) that is very clear on the actions necessary to deliver and maintain patient safety. Equally, it is promoted and recognised that infection prevention and control is the responsibility of every member of staff within the Trust and must remain a high priority for all to ensure the best outcome for all patients. Clostridium difficile and MRSA bacteraemia reporting continues via the national Mandatory Enhanced Surveillance System (MESS) which requires validation and sign off each month by the Head of Infection Prevention and Control. In addition Methicillin-sensitive Staphylococcus aureus (MSSA) bacteraemia has also been reported since January 2011 and E.coli bacteraemia since June 2011, there are no targets for either of these to date. The ceiling (target) for MRSA bacteraemia & C difficile toxin results was challenging for 2013/2014; the Trust continued with zero MRSA bacteraemias (2 consecutive


years), and 19 cases of C diff infection against a ceiling of 14. This was 5 above trajectory; however 4 cases were successfully appealed at a regional level as being unavoidable due to best practice being adhered to during the patients’ hospital stay and prior to admission in the community. These results are evidence of good infection control practice throughout the Trust including the very high standard of cleaning maintained by the in house cleaning team.

The team were successful with their bid for ICNet and it should be “live” and in use from June 2014. This should make it easier to demonstrate trends of antibiotic resistance and also enhance the ability of the Infection Prevention Nurses to monitor the alert organism patients efficiently and effectively. 2014/15 holds many challenges for the Infection Prevention and Control Team and the Trust as a whole;

Zero tolerance of any avoidable MRSA bacteraemia

A ceiling of only 17 hospital attributable cases of C diff infection

Building works within the hospital which includes a new theatre/day care facility

Increased incidence of antibiotic resistant organisms nationally and globally 3. Description of Infection Prevention and Control arrangement 3.1 Infection Prevention and Control Team (IPT) In line with The Health Act 2008, the IPT consisted of the following people during 2013/2014:-

Director of Infection Prevention and Control (DIPC)

Elizabeth Libiszewski

Infection Prevention and Control Doctor/ Consultant Microbiologist

Dr Reham Soliman (Part time 0.7wte)

Head of Infection Prevention and Control

Linda Hawtin

Consultant Microbiologist/Antibiotic lead

Dr. Lasantha Ratnayake

Infection Prevention and Control Nurse Specialist

Mandy Hoadley (Part time 0.8wte)


Pat Lear


Michelle Turner


HCAI Surveillance Co-ordinator Kati Rowse (Part time 0.8wte)

Infection Prevention & Control Secretary

Vicky Young

Microbiology Secretary

Jackie Harman

Antibiotic Liaison Officer Charles Waweru (resigned April 2014)

Throughout the year the team provided education, training, support and advice to all Trust members of staff with regard to infection control matters and liaised regularly with patients and relatives providing information on alert organisms, offering advice and reassurance when required. The team worked with Clinicians, Divisional Managers, Operational Managers together with Managers who have responsibility for Estates, Hotel Services, Clinical Risk and Governance and the Decontamination lead. The remit of the team included;

To have in place policies, procedures, and guidelines for the prevention, management and control of infection across the organisation in line with the requirements of “The Health & Social Care Act” 2008;

To communicate information relating to communicable disease to all relevant parties within the Trust;

To ensure the training in the principles of infection control is accurate and appropriate to the relevant staff groups;

To provide appropriate infection control advice, taking into account national guidance, to key Trust committees;

Continuous surveillance of patients with alert organisms whilst in patients;

To undertake national mandatory surveillance and any further surveillance required due to an increase in infections in specific areas; and to share information between relevant parties within the NHS when transferring the care of patients to other healthcare institutions or community settings.

To complete the yearly environmental audit plan. The Infection Prevention and Control Nurses (IPCNs) are onsite between the hours of 8.30am and 5.30pm Monday to Friday (excluding bank holidays). There is always an IPCN and a Consultant Microbiologist on call. (Microbiologist on call is rotational with the NNUH & QEHKL).


3.2 Infection Prevention and Control Link Nurses We have a positive group of Link Nurses across the Trust with a minimum of one clinical nurse per area. They are expected to promote best infection prevention & control practice within their clinical area of expertise. Infection Prevention & Control Link Nurse Meetings & Course These meetings were held on a quarterly basis. The meetings were not so well attended this year with an average of 10 to 15 staff per meeting, when asked most of the staff stated they could not get off their designated ward as it was too busy. A questionnaire has been sent to all link nurses to find out if there is a better time, content etc they would prefer for the meetings. The main focus of the meetings was an update from the Infection Prevention and Control Nurses regarding:-

New guidance from Department of Health and Health Protection Unit.

Current “hot topics” within the Trust i.e. outbreaks, sharps initiatives etc.

Updates on reportable HCAIs

Information regarding forthcoming events

Round robin i.e. discussion of any areas of interest or concern

Invited speakers talked about; POCT within the Trust, the role of the community infection control team and advances in HIV treatment for patients.

There was an in house link nurse course again this year organised by Pat Lear, Infection Prevention & Control Specialist Nurse. It was held one day a week from Sept 5th to Oct 2nd. Eight link nurses attended, speakers included; Dr Matt Williams, Consultant Gastroenterologist, JPUH “C diff a Consultants perspective”, Lisa Hannant, Head BMS at the JPUH “Tb The microbiology”. Each Link Nurse was required to pick an area of practice relating to infection control they would like to improve in their area of work and do a power point presentation of this to their Ward Manager, the Deputy Director of Nursing, IPCNs and the Matron from their Division. The presentations were very good and demonstrated learning from the course. 3.3 Communication within the Infection Prevention and Control Team Members of the Infection Prevention and Control team continued to participate actively in multi-disciplinary committees and working groups as follows:-

Equipment Support Group

Infection Prevention & Estates Group

Joint Infection Control Committee (JICC)

Theatre project Group

Decontamination Committee

Patient Lead Assessments of the Care Environment (PLACE)

Hospital Infection Control Committee (HICC)

Healthcare Governance Committee

Point of Care Testing Group


Nutrition Steering Group

Family & Diagnostic Divisional Board meetings

Regional HCAI Group

Regional Infection Prevention Society meeting

Clinical Leaders Network meeting

Antimicrobial Management Group 4. Governance Structure and Reporting Line to the Trust Board Reporting & communication to the Trust Board of Directors for 2013/14 was via the Safety, Quality and Governance Committee. The Trust Board of Directors received numerical data regarding C diff & MRSA figures, and any relevant information regarding infection trends causing concern, national initiatives, and general infection prevention & control concerns via the DIPC. In line with ‘The Health Act’ 2008, revised 2013, the DIPC reported directly to the Chief Executive. The DIPC, Head of Infection Prevention & Control and Infection Control Doctor met formally every month. 5. Hospital Infection Control Committee (HICC) The HICC met bi monthly 2013/14. The HICC over sees the Annual Infection Prevention and Control Plan and approves new and updated Infection Control Policies before they are submitted to the readers’ panel for final approval. The HICC also receives reports from various areas/committees of the hospital with major infection prevention and control related activities e.g. Decontamination, Estates, Pharmacy, Domestic Services, Occupational Health and Antimicrobial Management Group. The format of the HICC has been reviewed; reporting of the Divisions to HICC is still in the early stages of implementation 6. Joint working with the Clinical Commissioning Group (CCG) This occurred at various levels:-

Day to day communication between IPCNs regarding alert organisms and patients transferred between the Hospital and Community via email and telephone.

The Head of Infection Prevention and Control attended CCG Joint Infection Control Committee (JICC) meetings. Infection issues relating to Community and Hospital were discussed.

A joint Infection Prevention & Control action plan between the CCG & JPUH was agreed regarding the increased incidence of C diff acquisition in both the community and acute setting; this was reviewed at each JICC and HICC.

Representatives from the CCG and Public Health were invited to visit the Trust by the DIPC in view of our increased incidence of C diff in November 2013. They visited a variety of clinical areas. Their findings were generally favourable regarding infection prevention & control; all areas were clean, staff knew and demonstrated


good infection control practice.Reccomendations included; increased cleaning time in the Sandra Chapman Centre (SCC) due to the amount of patients visiting the department each day, reinforce the use of the green cleaning tape, regular clean of sluice master rim, door between ward 17 & SCC kept closed and to consider auditing outpatient prescriptions of antibiotics in the SCC. An action plan was developed and regularly reviewed by the DIPC and Infection Prevention & Control team. 7. Healthcare Associated Infection The Trust has an obligation to collect and submit to Public Health England the following data monthly:-

MRSA bacteraemias,

C diff toxin positive cases,

MSSA & E coli bacteraemias. The results for the trust were as follows:- 7.1 MRSA bacteraemia A total of zero MRSA bacteraemia cases were reported by the Trust from April 2012 to March 2013. This was below the Trust ceiling of 1. The Trust has performed extremely well over the last 7 years reducing MRSA bacteraemias year on year. (See graph below)

MRSA bacteraemias

Annual Total Episodes

0

10

20

30

40

50

60

2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15


7.2 Clostridium difficile infections in hospital patients for 2012/13 A total number of 19 cases were recorded within the Trust. This was above the ceiling figure of 14 hospital attributable cases. It was recognised regionally that as the C diff figures had declined in such vast numbers in both primary and secondary care it was possible we were getting to the minimum number of C diff cases which could be expected. It was therefore decided to introduce an appeals process; a full Root Cause Analysis (RCA) for each case would continue to be completed, this would then be discussed at a multi-disciplinary primary/secondary care meeting where it would be determined if the case was avoidable or unavoidable i.e. unavoidable would need to demonstrate all care received by the patient both within primary & secondary care within the previous 3 months was optimal. An appeal document would then be generated and sent to the regional HCAI lead nurse for review with the assistance of a microbiologist. If they agreed a case was unavoidable it would not be included in the figures reported to the CCG; however it would not reduce the figures reported to Monitor. The JPUH successfully appealed 4 cases. This suggests at least 4 cases out of the 19 cases were definitely unavoidable and best practice followed throughout the patients care pathway. The infection prevention & control team have devised a “sticker” which is placed on the antibiotic page of the drug chart for any patient who is identified as C diff GDH positive/toxin negative or positive to both. This is to remind staff to carefully consider antibiotic prescribing for these at risk patients. It has been recognised regionally as good practice and suggested that other hospitals adopt the same approach. The Head of Infection Prevention & Control joined an Intensive Support Team, supporting the Queen Elizabeth Hospital (QEH), Kings Lynn, due to a substantial increase in their C diff cases. The support team visited the hospital in March 2014; the visit included visiting wards, talking to staff, reviewing timelines, reflecting on practice at the JPUH which could be adopted at the QEH. The support team will undertake a follow up visit in May 2014. The graph below shows the number of Clostridium difficile cases since January 2004, again an extremely good improvement year on year.


Clostridium Difficile

Annual Total Hospital Attributable Episodes

0

50

100

150

200

250

300

350

400

2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15

7.3 Methicillin sensitive Staphylococcus aureus bacteraemia (MSSA) April 2013 – March 2014 there were 3 hospital cases. This is a significant improvement from the previous year; 10 cases in 2012-13. . Hospital acquired cases are investigated by the IPCNs in a similar format to MRSA bacteraemias, and the patient monitored throughout their stay by the IPCNs 7.4 E.Coli bacteraemia April 2013 – March 2014 there were 19 hospital cases. This is a similar number to the previous year; 13 cases. The majority of cases are related to urinary tract infections, a large proportion of which do not have a catheter. The patients identified with infection as an in-patient are investigated by the IPCNs to determine if there was any link with practice, to date there has been no commonalities between cases. 8. Incidents and Outbreaks 8.1 Norovirus For the period April 2013 to March 2014 there was little activity until December when there was an outbreak affecting 4 ward areas; 56 patients were affected, 8 of who were confirmed Norovirus. The outbreak was over within 4 weeks. All affected areas were closed with exception of Acute Coronary Unit (ACU). If ACU is affected with patients with Norovirus, patients are risk assessed prior to admission and if their clinical needs can be accommodated elsewhere they will be. To ensure patient flow continues on ACU during a Norovirus outbreak patients from ACU whose clinical needs can be met elsewhere are transferred to a single room on ward 2.


The IPCN’s assessed each area daily and worked closely with; the operational centre regarding patient flow, domestic supervisors regarding cleaning, Matrons and Ward Managers in respect of safe patient care and discharge. A full data set was kept for each area including a time line & epidemic curve. Public Health England was kept fully informed throughout this time and IOlog was completed by the IPCN’s. IOlog is a voluntary regional Incident & Outbreak logging system which allows all healthcare institutions to input data regarding their situation (there is no patient identifiable information, it is figures & ward names). Each healthcare institution determines who can see their information; however the idea is to share information within the region and give Public Health England a better understanding of infection prevalence. 8.2 Vancomycin Resistant Enterococci (VRE) VRE continues to be monitored as an alert organism. For the year 2013/14 there has been minimal cases and none causing clinical concern. 8.3 Pseudomonas In line with guidance from the Department of Health (DH) “Water systems, Health Technical Memorandum 04-01; Addendum. Pseudomonas aeruginosa –advice for augmented care units” the Trust Operational Policy & Procedures for the Management of Water Hygiene” was ratified. Cases of Pseudomonas infection in the Intensive Care Unit (ICU) have continued to be minimal. Active surveillance has been established by the Infection Prevention & Control team, including the Surveillance Coordinator to monitor the Pseudomonas as an alert organism in all of the four augmented care areas (ICU/HDU, Ward 17, SCC, SCBU and Renal unit) The tap water in the augmented care areas is tested every 6 months; 50% of all taps. If there are any problems with the results there are documented actions to be taken by the Estates & Planning department. A new tap has been trialled in the ICU called “Optitherm”. It is not a touch free unit, however it has the advantage of providing cold water only, easily cleaned, and if thermal disinfection is required it can be removed from the circuit without disruption of other taps. The trial should be complete by the end of April 2014, and the final decision as to using these taps across the unit and in new areas of development within the hospital will be made at the HICC in May. 8.4 Endophthalmitis outbreak In February 2014, there was a small outbreak of Endophthalmitis following Intravitreal Lucentis injections. There were three cases in a 2 week interval. The normal is; 1 per 3000 cases and the JPUH undertake an average of 95 cases per week. An outbreak incident meeting was held, and a full review of practice and patient risk factors were reviewed. An action plan was agreed which included some changes of practice which were considered possible risk factors.


A revised standard operating procedure was agreed by the Ophthalmologist and Microbiologist for Intravitreal Lucentis injections. Active surveillance has been set up for any Endophthalmitis case, promoting early intervention if required. 8.5 Breast Surgery Infections In June 2013 the Breast Care Specialist nurses informed the IPCNs they considered there was an increase of infections in breast surgery. The IPCNs investigated and agreed these were true infections (following the HPA surgical site infection criteria). An incident meeting was held with the relevant surgeons and theatre staff. An action plan was agreed and included; theatre protocol for all theatres, review of the NICE guidelines for surgical patients. Active surveillance continued and there were no further cases of infection. Active surveillance continues and surveillance data was collected as part of the national surveillance scheme for the period Jan to March 2014 and no infections were identified. 9. Surgical Site Infection Surveillance Service (SSISS) The Trust continued to participate in the mandatory Surgical Site Infection Surveillance Service (SSISS). Since 2004 all trusts that perform orthopaedic surgery have been required to undertake surveillance for a minimum of 3 months for any of the orthopaedic categories. For the year 2013/14 the following surveillance was undertaken:-

3 months of “repair of neck of femur”

6 months of “breast surgery”.

9 months of “knee replacement”

12 months of “hip replacement” The surveillance included post discharge questionnaires with an average return rate of 80%. When an infection is considered by the IPCN an email is sent to the surgeon who undertook the surgery asking for their opinion of the case and infection class. Once the infection has been agreed a meeting is set up within the Elective Division to review the case and agree any actions required. The following staff partake in the review; Elective Divisional Manager, surgeon, Microbiologist, DIPC, Head of Infection Prevention & Control, Theatre Manager and Surveillance Nurse. The IPCNs and the Surveillance Coordinator should be commended for the in depth and accurate surveillance they undertake. It is very time consuming work however thoroughness is essential to ensure all infections are identified correctly and investigated.


9.1 Repair of neck of femur

Type of SSIS

Period of surveillance

Total no. of operations carried out

% SSI Selected

period JPUH

% SSI Last 4

Periods JPUH

% SSI All hospitals

Repair of neck of femur

Jan – Mar 2014

90

1.1%

2.6%

1.8%

There were 90 operations carried out in the first 3 months surveillance period for “neck of femur repair” and the infection rate was below the average of all hospitals for the period. However prior to this surveillance period it was identified by the IPCNs there was an increase of infections in this group of patients, and when historical data was reviewed from previous surveillance periods the infection rates are very unpredictable; above the percentage for all hospitals some quarters and below for others. Therefore surveillance of “neck of femur repair” will continue throughout 2014/15 to get better data for analysis. 9.2 Knee Replacements

Type of SSIS



% SSI Selected

period JPUH

% SSI Last 4

Periods JPUH

% SSI All hospitals

Knee replacement

Jul – Sep 2013

109

0.0%

1.9%

1.7%

Knee replacement

Oct – Dec 2013

120

0.8%

1.5%

1.7%

Knee replacement

Jan – Mar 2014

91

0.0%

1.5%

1.7%

In 2012/13 the knee replacement surgery had a slightly higher infection rate than the bench mark of all hospitals, however it was not considered cause for concern by the Consultant Orthopaedic Consultant (2.5% equated to 2 infections out of 79 Procedures). The surveillance has continued from July 2013 and to date the infection rates have been very good, below the national average for each quarter. 9.3 Hip Replacements

Type of SSIS



% SSI Selected

period JPUH

% SSI Last 4

Periods JPUH

% SSI All hospitals

Hip replacement

Apr-Jun 2013

104

3.8%

2.8%

1.2%

Hip replacement

Jul-Sep 2013

112

0.0%

2.0%

1.2%

Hip replacement

Oct-Dec 2013

110

0.9%

1.5%

1.2%

Hip Jan-Mar


replacement 2014 91 0.0% 1.5% 1.2%

Hip replacement surgery caused concern April to June 2013. The cases were reviewed and it was agreed:

All staff to be reminded of Theatre etiquette

Local Analgesic (LA) pumps directly into the operation site to be reviewed, later determined they were not required after discussion with other users who had also stopped using them. The main problem was leakage from the pump making the wound damp/wet.

Hand decontamination/scrub times to be audited. Glow & Tell to be undertaken by all staff

Sustained improvement was seen in the following 9 months. Hip replacement surveillance will continue in 2014/15. 9.4 Breast Surgery

Type of SSIS



% SSI Selected

period JPUH

% SSI Last 4

Periods JPUH

% SSI All hospitals

Breast

Surgery

Oct-Dec

2013

76

2.6%

3.6%

4.5%

Breast

Surgery

Jan-Mar

2014

68

0.0%

3.6%

4.5%

Breast infection rates were within the national benchmark for all participating hospitals. However the cases for Oct to Dec were fully reviewed by the surgeons, breast care specialist nurses and ICD and it was determined that there was no cause for concern; these were unavoidable infections. Breast surgery surveillance will continue in 2014/15 9.5 Large Bowel

Type of SSIS



% SSI Selected

period JPUH

% SSI Last 4

Periods JPUH

% SSI All hospitals

Large Bowel Jan-Mar 2014

40

5%

11.4%

11.1%

This surveillance period demonstrated an infection rate which was half the national benchmark. Large bowel surveillance will be considered again at the end of 2014.


10. Audits 10.1 Hand Decontamination Audits From the 1st of April to 31st October 2013, hand decontamination audits were carried out in all inpatient areas and theatres on a monthly basis by senior members of staff (not Infection Control). Areas which achieved 91% or above compliance remained as monthly audits, while areas showing lower percentage compliance were required to audit with increased frequency for the following month – fortnightly audits for 81-90% compliance and weekly audits for 80% compliance or below. Clinical areas that did not complete the audit (within the specified time frame) were required to report to the IPCN giving details of non-compliance to be included in the next Trust Board Report. From 1st November 2013 data collection for all areas other than Theatres was taken over by the Infection Control team on a bi-monthly basis. Each audit is conducted on an observational basis over a 20 minute period. The standard measured is correct hand hygiene observed when a member of staff is presented with any of the following hand hygiene opportunities:

Before patient contact

Following patient contact

After removal of PPE (e.g. gloves, aprons)

Prior to a clinical procedure

After a clinical procedure

Prior to handling food

After handling contaminated items

After leaving isolation room Completed audit sheets were sent to the audit office and monthly reports were compiled by Infection Prevention Nurse (IPN) Specialist, which were reported to the Divisions. See appendix A for a summary of compliance for each inpatient area/theatre. 10.2 Environmental Audits of clinical areas These audits are undertaken on a yearly basis by the IPCNs. The audit tool used was adapted from the Infection Prevention Society. There is a yearly plan outlining when each area will be audited. The clinical areas are not informed when the audit will take place. This is the first year an environmental audit has been completed for all clinical areas including outpatients; this is mainly due to Tracey Parrish, an HCA who has worked 1 day a week with the team throughout 2013/14.


Each clinical area was expected to achieve 95% or above. Issues identified were discussed with the nurse in charge at the time and any other relevant group e.g. domestic services and rectified immediately if this was possible. A full written report was then completed and sent to the ward manager and Matron. Areas that scored 90% or below were required to attend a meeting with an IPCN and Matron for their area, the domestic supervisor attended as required. The Ward Manager was required to submit an action plan to address the issues, with timescales for achievement. The clinical area concerned would then be re-audited on the issues identified within 2 months. Overall the audit results were favourable, and those areas causing concern did action the changes required, and were much improved when re audited. 11. Pathology transformation The Microbiology Laboratory is now formally part of a networked service to provide Pathology services to the community as well as the NNUH, JPUH, and QEHKL under the banner of the Eastern Pathology Alliance (EPA). All the community and the acute trust microbiology services transferred on the 11th November 2013. Microbiology has also transferred across to the NNUH who host EPA.

We now have 2 substantive Consultant Microbiologists who are employed by the NNUH on behalf of JPUH and are based at the JPUH for their day to day work as agreed through job planning;

Dr Reham Soliman (part time-7 PAs) Consultant Microbiologist, Infection Control Doctor.

Dr Lasantha Ratnayake (full time) Consultant Microbiologist, Antibiotics Lead.

The delivery of clinical microbiology, support for antimicrobial prescribing initiatives and Infection Control at the JPUH is not affected by the establishment of EPA. We continue to provide clinical advice and liaison relating to any microbiological testing carried out by EPA, for clinicians at JPUH and for GPs who would normally refer their patients to JPUH. The EPA provides out of hours clinical advice and support for the diagnosis and management of infection, including contribution to the management of outbreaks of infection where appropriate. Out of hours advice is covered by a combined on call rota which covers all 3 sites. The Infection Prevention & Control Team was successful with their bid for ICNet and it should go live from May 2014. This will make it easier to demonstrate trends of antibiotic resistance and also enhance the ability of the IPCNs to monitor patients with alert organisms efficiently and effectively.

12. Pharmacy/ Antibiotic Stewardship A full report is attached at Appendix B


12.1 Antibiotic Audits From January 2013 a new Audit Schedule was implemented. This measured six standards:

Stop/Review date stated

Indication stated on the drug chart

Is prescription as per Trust policies

Appropriate samples sent to Pathology

Completion of Allergy Box

Are IV antibiotics prescribed for a maximum of 72 hours where appropriate All wards were audited on a quarterly cycle and a standard report circulated to Ward Managers, appropriate Consultants, Divisional Managers and Directors. Audit results have improved throughout 2013/14. The overall compliance improved from 17% to 88% in the quarter ending March 2014. Unfortunately the Antibiotic Liaison Officer (Mr Charles Waweru) left the Trust at the end of March 2014, he undertook all of the audit work, and therefore it should be noted that all the audit work has stopped pending appointment of an Antibiotic Pharmacist.

13. Cleaning Services

Cleanliness in hospitals is about more than keeping the place clean. It makes a statement to patients and visitors about the attitudes of Staff, Managers and the Trust Board in terms of attention to detail, the level of care and the way the hospital is organised and run. It is not possible to have a “good” hospital without it being a clean and tidy hospital. The James Paget Hospital Domestic Services team is responsible for the cleaning at:

Site

Area Cleaned (m²)

James Paget Hospital

49,407

Newberry Clinic, Gorleston

651

2001 saw the implementation of the National Standards of Cleanliness in the NHS, to ensure the patients experience the same high standards of cleanliness in hospitals across England. In March 2004 the NHS Healthcare Cleaning Manual was published. The National Standards of Cleanliness answers the question “Is the hospital clean?” the NHS Cleaning Manual provides the foundation to issues around “How to Clean the Hospital”.


Both the National Standards of Cleanliness and the NHS Cleaning Manual dictate that cleanliness is everybody’s responsibility to ensure the following.

A clean, comfortable and safe environment for patients, clients, visitors, staff and members of the general public.

Increased patient confidence in local healthcare settings in relation to environmental hygiene and the organisational commitment to reduce the incidence of healthcare associated infection.

The opportunity to improve cleanliness in terms of the National Standards of Cleanliness and Patient Environment Action Teams.

13.1 User Satisfaction Measures The quality of the service is measured by the following methods:

The results from the Maximiser Audit Tool

Audits by the Domestic Services Manager visiting the wards asking the Matron/Ward Manager for feedback on cleaning standards

PLACE results

Inpatient surveys

Complaints/compliments received

Infection Control Team yearly audits of all clinical areas

Ad hoc spot checks by Matrons, Senior Managers and external agencies – CQC, CCG and Healthwatch

Patient – Lead Assessments of the Care Environment (PLACE) The 2013 Patient-Led Assessments of the Care Environment (PLACE) programme commenced on 2nd April 2013. This programme replaces the former Patient Environment Action Team (PEAT) programme. Although those who were familiar with the PEAT process will see many similarities with the revised process, there are also a number of significant changes. Key Changes; Patient/Public Involvement In accordance with the Prime Minister’s commitment to give patients a real voice in assessing the quality of healthcare, including the environment for care, at least 50% of those involved in undertaking assessments must meet the definition of ‘patient’:-

‘Anyone whose relationship with the hospital is as a user rather than a provider of services’

This definition allows for anyone to act as a ‘patient’ representative except:-

- Current employees of the organisation; - Former employees of the organisation who have left employment within the

preceding 2 years; - Anyone with a professional relationship with the organisation – e.g. as a

facilities service provider.


Members of the Trust Council of Governors or members of Trusts are eligible to act as ‘patient representatives’ within their own Trust since their primary role is to represent the interests of patients/the public. However, it is good practice that patient assessors are not drawn solely from this group. Responsibility for providing training for Patient Assessors will rest with individual organisations, and we strongly recommend that some form of training is provided.

Assessment of Food services The number of wards on which an assessment for food should be undertaken depends on the hospital size as follows:-

- Up to 6 wards – One - 7 to 12 wards – Two - 13 to 18 wards – Three - 19 to 24 wards – Four - 25 wards or more – Five

Patient Assessment Summary There is now an additional ‘free-text’ form to be completed only by the ‘Patient Assessors’. This form will not play any part in the scoring process, but the comments included in it are entered into the EFM system and organisations are expected to respond to any comments as appropriate in their action plans. 13.2 PLACE at James Paget University Hospital James Paget University Hospital PLACE assessment took place on 8th May 2013, covering both JPUH and Lowestoft hospitals. A number of briefing sessions were held prior to the day to ensure the team members were updated with the new assessment. We struggled to recruit patient representatives for this round of PLACE, relying heavily on our governors to take the patient assessor roles. This was recognised nationally as an issue. The James Paget will need to canvass patient volunteers to be involved in the process, taking into account the length of the inspection and the amount of walking involved. Barry Eade from NNUH carried out the External Validation role of the process. The results and feedback from the team were loaded onto the “Health and Social Care Information Centre” website. Feedback was given to them on this process as the new system required entry for each area and ward, making it a very lengthy process as opposed to a summary of the wards under each category previously. An action plan was drawn up to address any areas identified on the inspection and sent to the heads of departments responsible.


The results were published nationally on 18th September 2013. The results for Lowestoft Hospital and James Paget University Hospital are as follows:

Green % = national average Blue % = Lowestoft result

Green % = national average Blue % = JPUH result


Cleanliness Both sites scored extremely high in this section and the assessors commented regularly on the high level of cleanliness across both sites. Food Food was recorded in the high quartile for both sites, slightly disappointing that the score 83.08% at the JPUH was scored lower than Lowestoft 88.47% considering the food is transported from JPUH to Lowestoft and is the same menu. The result at JPUH was affected by the comments of one patient assessor. Privacy, Dignity & Well Being The James Paget received a good result for this category, scoring about the national average. The categories within this section include:

TV/radio access

Computer/telephone access

Recreation areas

Ward privacy, dignity and well being

Confidentiality

Changing and waiting (outpatient assessment)

Unfortunately with the age of Lowestoft Hospital and the design of the outpatient areas and wards the score at Lowestoft (70%) was lower than the national average (88.87%). There are minimal actions that can be taken to improve this score whilst the site review is taking place. Condition, Appearance & Maintenance The result for the JPUH was in the higher quartile (93.61%). Lowestoft (84.79%) fell below due to the age of the building and investment not being made in the building whilst the site review takes place. For the age and design of the building the site still managed to score a high percentage. The patient assessor highlighted how well the building was maintained considering its age. 14. Decontamination

The Head of Decontamination Services continues to be, R Ashmore, Manager of the Hospital Sterile Services Department. The Decontamination Group met bi-monthly. It has a large remit including; Theatres, HSDU, Renal Unit, Endoscopy and all areas of the Trust using and purchasing reusable/single use equipment. As attendance has been extremely poor this year, this has been discussed at the Hospital Infection Control Committee and members have been written to requesting improved attendance. The Head of Decontamination Services continues to chair the group. The following are a list of completed actions and concerns regarding decontamination within the Trust.


14.1 The areas of concern in decontamination are as follows:-

Age of HSDU autoclaves - the HSDU autoclaves are 15 years old and

the equipment has been subject to significant repair over recent years

as they are beyond their planned economic life. A bid to replace the

autoclaves was approved by TIG in June 2011 to commence in April

2012 but following review of the originally agreed arrangements, a

revised bid needed to be prepared. Remedial repairs have kept the

autoclaves functioning and changes have been made to the steam

supply to improve the reliability of the machines. External review has

confirmed that the autoclaves are operationally safe though they had

failed the annual steam test. They have subsequently passed the

steam test. A revised bid was approved by TIG at the May 2013

meeting.

HSDU tracking does not provide single instrument tracking and this

needs to be reviewed and a TIG bid finalised if this remains a priority

for the Division.

A replacement for the manual tracking systems for endoscopy (Health

Edge) has been subject to TIG bid which is still awaiting clarification

from the department before it can be considered and finalised.

14.2 The following achievements were made within the area of decontamination:-

The Endoscopy department has been successful with a TIG bid to replace its non-compliant Medisafe washer. A Steelco AED has been chosen to replace the Medivator AED. We are awaiting delivery of the new machine.

The HSDU was successful in retaining its ISO13845 accreditation with two minor non conformities in each of its six month audits.

The Endoscopy Unit achieved accreditation by the Joint Advisory Group (JAG) in March 2013

HSDU was named as the Trust’s Department of the Year for it efforts in supporting the high theatres activity during the late summer and autumn at the Remarkable People Awards held at Potters on 25th October 2013.


15. Training and Education The Infection Prevention and Control Team provide educational updates and training to all JPUH staff in varied formats throughout the year. Compliance for 2013-14 was 72%, with a target of 75%. This is the best compliance infection control has achieved. Eight extra sessions were added in September/October and the same is planned for 2014/15. 16. Infection Prevention and Control Annual Programmes 2013/14 (Appendix C) The Infection Prevention and Control Annual Programme demonstrated the achievements to-date and the programmes in place to ensure the principles of the “Health & Social Care Act” are followed. Therefore the foundations of infection prevention and control are solid and the Trust is ready for any eventuality that may occur. 17. Future Challenges 17.1 HCAI numbers At the present time there are only 3 targets which must be achieved annually regarding infection control:-

Target for Clostridium difficile; ≤ 17 hospital attributable cases for 2013/14.

Target for MRSA bacteraemia; Zero tolerance of any avoidable cases.

3 months surgical site surveillance yearly 17.2 Patient Flow The operational pressures mean that bed occupancy is high and patients’ moving between wards and specialities increases the risk of spread of infection. Priority must continue to be given to protecting elective bed capacity in 2014/15. 17.3 Carbapenemase-producing Enterobacteriaceae (CPE) Carbapenem antibiotics are a powerful group of B-Lactam antibiotic used in hospitals. Until recently they have been the antibiotic of choice when other antibiotics have failed to treat Gram negative infections, unfortunately the Carbapenems in some incidences are also being rendered ineffective. Public health England published a toolkit for the early detection, management and control of CPE to minimise the spread of these organisms in acute care settings. The JPUH in cooperation with the NNUH and QEHKL are in the


process of establishing guidelines for the three hospitals which will aim to minimise and control the spread of CPE. These are the known challenges however infection prevention & control is not predictable, and therefore there will most definitely be additional challenges ahead as bacteria & viruses do not conform to predictability and therefore it is essential the trust recognises and respects infection prevention & control as an immeasurable quantity. 18. Acknowledgments All JPUH staff for working with the Infection Prevention and Control Team in order to tackle the challenges faced this year and to continue the exemplary record of zero MRSA bacteraemias and only 18 hospital attributable C diff cases. All microbiology laboratory staff for their hard work and especially their flexibility in re-scheduling work to prioritise and accommodate urgent infection prevention and control requests both during and outside normal working hours especially in the challenging climate they have found themselves this year with the laboratory reconfigurations. Good infection prevention and control requires reliable, accurate and rapid diagnosis of infections and identification of the causative pathogen. Antibiotic Liaison Officer, Charles Waweru, for his hard work in carrying out the antibiotic audits and the marked improvement in results due to his input on the wards. The Infection Prevention and Control Team for their dedication, hard work, flexibility and resilience, in yet another challenging year.

Documents

Report to the Safety and Quality Governance Committee 2014/15 · 2014-09-22 · DIPC Report 2013/14 Version1 Page 1 Attachment 6 Report to the Safety and Quality Governance Committee