The Newcastle Upon Tyne Hospitals Nhs Foundation Trust

THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

Board Paper - Cover Sheet

Report Title Healthcare Associated Infections (HCAI) Agenda Item A5(i)

Lead Director Nursing & Patient Services Director

Report Author Helen Lamont, Nursing and Patient Services Director Ashley Price, Director of Infection Prevention and Control (DIPC) Classification NHS Unclassified

Purpose (Tick Approval Decision Information one only)

Links to  To put patients and carers at the centre of all we do and to Strategic provide care of the highest standard in terms of both safety Objectives and quality  To continue to be recognised as a first-class teaching hospital, counted amongst the top 10 in the country, which promotes a culture of excellence, in all that we do Links to CQC Regulation 12, 15, 20 Fundamental Standard(s) Identified Risk? Yes, specified in Risk Register. (If yes, risk  Breaches of target reference)  Significant outbreaks have financial, reputational and patient safety implications

Resource No additional resource implications Implications Legal Failure to effectively control infections may lead to patient harm, implications litigation against the Trust and loss of reputation. and equality and diversity There are no specific equality and diversity implications from this assessment paper. Benefit to Infection Prevention & Control is fundamental to providence and safe, patients and clean environment for patients, staff and visitors. the public

Report History This is a regular monthly update to the Board on Healthcare Associated Infections (HCAI) Next steps To read, discuss and approve this paper

HEALTHCARE ASSOCIATED INFECTIONS (HCAI)

EXECUTIVE SUMMARY

This paper summarises the Trust’s position in relation to HCAI and the external targets at the end of March 2016, Month 12 2015/16.

There were 9 C. difficile cases in March, bringing the total to date to 94 against a year-end target for 2015/16 of 77. 22 cases have been successfully appealed, bringing the recorded total to 72. Four more appeals are being considered and the decisions about three others were deferred by March’s Appeals Panel. The target of no more than 77 cases has been met, taking successful appeals into account.

Five MRSA cases have been attributed to the Trust in 2015/16. Seven were initially attributed to the Trust and following review, two were re-assigned as Third Party and are therefore no longer included in the Trust total.

A significant amount of work continues to ensure that risks of HCAI are minimised for the benefit of the patients and the Trust.

RECOMMENDATION

To (i) note the content of this report (ii) comment accordingly.

Mrs Helen Lamont Nursing & Patient Services Director

Dr Ashley Price Director of Infection Prevention and Control

11th April 2016

HEALTHCARE ASSOCIATED INFECTIONS (HCAI)

1. INTRODUCTION

This paper provides the monthly report to the Board in relation to Healthcare Associated Infections (HCAI) describing the progress against targets for the year, and reporting the Trust’s position for the end of March (Month 12 2015/16). The performance is summarised in the Healthcare Associated Infection report at Appendix i.

2. INFECTION UPDATE

(i) MRSA Bacteraemia – (Target = Zero Tolerance)

Five MRSA cases have been attributed to the Trust in 2015/16. Seven were initially attributed to the Trust and following review, two were re-assigned as Third Party and are therefore no longer included in the Trust total. In terms of 2016/17 targets, a ‘zero tolerance’ to MRSA bacteraemia continues.

MRSA bacteraemia - 2007/08 to 2015/16 (minus Third Party Assignment) 70 63

11 10 10 7 8 5 5 5

0 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

This year’s figure of five cases attributed to the Trust compares with five cases at the end of March 2015.

(ii) Clostridium difficile – (Target = 77)

The Board is aware that the Trust’s target was set at 77 cases for the 2015/16. The target of no more than 77 cases has been met, taking successful appeals into account.

The 2016/17 target will remain at 77 cases for the year (a rate of 16.3 cases per 100,000 bed days), with a penalty of £10,000 for each case over the target. The following excerpt from

5 the “Clostridium difficile infection objectives for NHS organisations in 2016/17 and guidance on sanction implementation” explains why the target is unchanged:

“The decision to carry over the 2015/16 objectives has been prompted by the fact that there has been a slight increase in the median CDI rate from the year to November 2014 to the year to November 2015…This should not be interpreted as suggesting that an ‘irreducible minimum’ of CDI cases has been reached for all organisations. Efforts must continue to reduce CDI across the NHS.” (NHS England, 2016)

In March, 9 Trust-attributable cases were identified, bringing the year-end total to 94 cases, against a target of no more than 77 cases. However, taking into account the 22 appeals (including five successful appeals in March); this means 72 cases for the year-end is the true position. Of the 10 appeals submitted in March, five were upheld, two were not upheld, and three were deferred to the next panel, pending further information. Four further appeals have been submitted to the final Appeals Panel of 2015/16. This means that the final number for the year could be as low as 65; the Board will be informed of the final number at May’s meeting.

The graph below demonstrates this year’s contractual performance when compared with the previous years, i.e. the total number of cases to date minus the number of cases successfully appealed. Appeals against C. difficile cases have been incorporated since 2013/14.

C. difficile Cases 2008/09 to 2015/16 (minus appeals) 600 550

420 400

301 304 300

200 150 152

101 95 80 77 100 76 75 66 65 72

0 Cases Target Cases Target Cases Target Cases Target Cases Target Cases Target Cases Target Cases Target 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

(iii) MSSA

In March there were seven MSSA bacteraemia attributed to the Trust, bringing the year-end total to 83 cases. This is compared with 68 cases at during 2014/15.

There are currently no national targets for MSSA but the Trust continues to monitor and report the numbers of MSSA bacteraemia, and is focusing work in this

6 area to enhance learning and practice. Root Cause Analysis (RCA) is now undertaken in all cases of MSSA identified post-48 hours of admission.

By analysing data from both the old and the new RCAs, invasive devices have been noted to be the primary source of MSSA bacteraemia in 50% of cases (9 of the 18 RCAs received). This emphasises the importance of correct ANTT practices relating to the insertion, management and removal of lines and other invasive devices.

(iv) E. coli

In March there were 14 E. coli bacteraemia attributed to the Trust, bringing the year-end total to 171 cases. This is compared with 133 cases at the year-end in 2014/15.

Of the 171 Trust-attributed cases during 2016/17, the urinary tract was the primary source in 32% of cases. Work is ongoing with the Continence Care Team to promote best practice relating to urinary catheter care and catheter removal, with a continued focus on promoting ‘no catheter, no CAUTI’ (catheter-associated urinary tract infection). Other reduction strategies for E. coli bacteraemia will be discussed at the IPC Operational Group in April as part of objective-setting for the 2016/17 financial year.

3. ONGOING WORK

(i) Communication

Mandatory Training In March, the IPC Mandatory Training figure was 87.4%. There has been an overall improvement in this figure since April 2015, when the figure was 69%, and has remained above 80% since September 2015

(ii) Outbreaks

There were six outbreaks during March; five of diarrhoea and vomiting, and one of MRSA (colonisation only, not infection). Norovirus was identified as the causative organism in four of the five diarrhoea and vomiting outbreaks.

The IPC Team and Patient Services were involved in managing these outbreaks, all of which are now closed.

(iii) Admissions Associated with Influenza

The Trust has seen a significant increase in the number of admissions from ‘flu, with a peak in January and February, with the number of cases decreasing towards the middle of March. The increase in the Trust reflects national and regional data on ‘flu admissions. So far, most cases are Influenza A (H1N1) strain but there has been an increase in Influenza B admissions since the end of February.

7 Point of care testing is being undertaken in Assessment Suite, which yields faster results than sending routine full respiratory samples to the lab and, as a consequence, most of the adult cases are now being identified in Assessment Suite, which allows for prompt intervention and robust precautions and management are in place on the affected Wards.

A graph of Trust admissions for flu is below.

The second graph shows the number of admissions for ‘flu during 2015/16 compared with 2014/15.

(iv) IPC Activity in March

The IPC Team are also undertaking new and additional work, building on what they already do to reduce HCAI on an ongoing basis. The following work was carried out in March:

 Routine water testing takes place on an ongoing basis

8  Ongoing collaborative work with Renal Services to reduce MSSA bacteraemia  Hand hygiene validation audits continued during March  A separate paper has been prepared by for the Executive Team the Directorate of Medicine, supported by IPC, relating to Ebola preparedness  A new approach to tackling C. difficile was discussed at the IPC Operational Group, with an increased focus on prevention and pro-active, multi-disciplinary working involving Microbiology, IPC and clinical staff (medical and nursing). This will be resource-intensive and further discussion with clinical staff is required, but a three-month trial in Medicine at FH and RVI, with a proposed start date of May 1st, was agreed.  Serious Infection Review Meetings were held to discuss cases of C. difficile –in both cases, there was a delay in stool specimen transit. This would not have changed the outcome for the patient but it might have delayed treatment.  The Microbiology lab continues to work with the Service Improvement Team to map and improve the process for transporting specimens from the Ward to the lab. Timely transit of samples is important to ensure patients receive a timely diagnosis.  This month sees the start of the ‘Year of Harm Free Care’ initiative; during April ANTT will be the focus of the month. During this month junior medical staff will be asked to undertake assessment in ANTT and cannulation and general awareness and key messages will be communicated through a variety of routes.  The IPC mandatory training e-learning has been revised and updated to ensure the information is accurate and includes seven bespoke programmes to improve completion compliance and understanding of key elements of practice.

4. RISKS AND RISK MITIGATION

Risks relating to Infection Prevention and Control are monitored and managed on an ongoing basis at the monthly Infection Prevention and Control Committee (IPCC) and the IPC Operational Group, which meets monthly. As well as the high-profile work to minimise MRSA and C. difficile infections, the IPC Team works hard to ensure that the Trust protects its patients from the threats posed by emerging infections. Lessons learned from cases of infection are communicated across the Trust monthly via forums, reports and bulletins.

The fact that the Trust has met its C. difficile target for 2015/16 mitigates the risk of financial penalties and reputational damage, which would be in addition to the harm caused to patients.

All key infection risks are recorded on the Trust’s Risk Register, with the person responsible being clearly identified, and the Register being regularly reported at IPCC.

5. SUMMARY

9 The current MRSA and MSSA bacteraemia position, along with the C. difficile position, continue to be a high priority in relation to patient safety and the potential financial and reputational risks to the Trust. The Trust has met is C. difficile target for 2015/16.

A significant amount of high profile Trust-wide work continues across all aspects of IPC to protect the patients in the care of the Trust.

6. RECOMMENDATION

To (i) note the content of this report (ii) comment accordingly.

Mrs Helen Lamont Nursing & Patient Services Director

Dr Ashley Price Director of Infection Prevention and Control

11th April 2016