Infection Prevention Update - The Royal Wolverhampton Hospitals ...

The Royal Wolverhampton NHS Trust
Trust Board Report
Meeting Date: 20 th May 2013
Title:
Executive Summary:
Action Requested:
Report of:
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Contact Details:
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Implications:
Public or Private:
(with reasons if private)
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(eg from/to other committees)
Appendices/
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Background Reading
Infection Prevention Update
MRSA bacteraemia objective of zero for 2012-13 was
breached by single case in November.
The Trust finished within its C. difficile objective for the
year.
New record low numbers of RWT-attributable MSSA
bacteraemias and MRSA acquisitions in 2012-13, but
the DRHABs target was missed.
Surgical site infection project, with universal SSI
surveillance, the work of the IV Team and the urinary
catheters group all continue.
Compliance with mandatory training on hand hygiene
and infection prevention reached the NHSLA target of
95% compliance during the year, but finished the year
below this level.
Compliance with the Health and Social Care Act
(2008) remains good, with 100% compliance in eight of
the ten criteria.
Accept the information presented.
Infection Prevention and Control Team
Dr M Cooper, Director of Infection Prevention and Control
Tel 01902 307999 ext 8250 Email mike.cooper1@nhs.net
Significant but not generally quantifiable financial savings
are produced by maintaining optimal infection prevention
performance.
Public Session
Infection Prevention and Control Committee
Appendix 1 – MRSA Bacteraemias
Appendix 2 – MSSA Bacteraemias
Appendix 3 – Hospital Acquired Bacteraemias (HABs) and
Device-Related HABs (DRHABs)
Appendix 4 - Blood Culture Contaminants
Appendix 5 - MRSA Acquisitions
Appendix 6 - Clostridium difficile
Appendix 7 - Escherichia coli Bacteraemias

Title: Infection Prevention and Control
Appendix 8 - Compliance with Infection Prevention
Mandatory Training
Appendix 9 - Compliance with the Code of Practice
Appendix 10 - Current Projects and Norovirus Outbreak
NHS Constitution:
(How it impacts on any
decision-making)
In determining this matter, the Board should have regard to
the Core principles contained in the Constitution of:
Equality of treatment and access to services
High standards of excellence and professionalism
Service user preferences
Cross community working
Best Value
Accountability through local influence and scrutiny
Background Details
1 1. The Trust external targets for 2012-13 were: MRSA bacteraemia - 0 and
Clostridium difficile toxin positives - 57. These targets apply to New Cross
Hospital only. Local commissioners set an additional target for West Park
Hospital of 12 C. difficile toxin positive cases per year, which means
Monitor accepted a target of 69 cases for RWT.
National mandatory surveillance of MSSA and E. coli bacteraemias is
undertaken, though no external targets were set for these. There was,
however, an internal target for MSSA bacteraemias, along with internal
targets for C. difficile PCR positives (which includes recently discharged
patients in addition to in-patients), and device-related hospital acquired
bacteraemias (DRHABs). Admission screening for MRSA carriage allows
us to monitor the number of MRSA acquisitions that occur, and monthly
targets are set for this for the organization, each clinical Division and every
ward.
Compliance with Infection Prevention elements of mandatory training,
relevant High Impact Interventions and other measures are monitored
monthly at the Infection Prevention and Control Committee.
Compliance with the Code of Practice is monitored through ‘Health Assure’
(formally called Performance Accelerator).
Details of the above can be seen in the Appendices.
Page 2 of 14

Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Number
Title: Infection Prevention and Control
Appendix 1 – MRSA Bacteraemias
MRSA bacteraemias – monthly totals (and attributable to RWT)
11-12
(RWT)
12-13
(RWT)
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
0 1 0 0 0 1 0 0 0 0 0 0
(0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0)
0 0 0 0 2 1 0 1 2 0 0 0
(0) (0) (0) (0) (0) (1) (0) (0) (0) (0) (0) (0)
Annual target 2012-13 = 0 for RWHT; 2 for Wolverhampton PCT
Total for 2012-13 = 1 for RWHT; 2 for Wolverhampton PCT
Of the six MRSA bacteraemias in the above table, five were pre-48 hour cases, but
two of these were in patients who had had recent in-patient care in New Cross. The
one post-48 hour cases was classified as unavoidable after an RCA was carried out.
6
Performance Against Target MRSA Bacteraemias 2012 -
2013
5
4
3
2
1
RWT
Target
RWT
Performance
PCT
Target
PCT
Performance
0
Page 3 of 14

April
May
June
July
August
September
October
November
December
January
February
March
Number
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Number
Title: Infection Prevention and Control
Appendix 2 – MSSA Bacteraemias
MSSA bacteraemias – totals and number attributable to RWT
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
11-12
(RWT)
2
(1)
5
(1)
2
(2)
5
(5)
6
(6)
4
(2)
8
(4)
9
(5)
2
(1)
5
(3)
3
(1)
3
(2)
12-13
(RWT)
4
(4)
3
(1)
4
(0)
8
(5)
10
(4)
6
(4)
5
(3)
4
(0)
4
(2)
5
(2)
5
(2)
4
(2)
35
Performance Against Target MSSA Bacteraemias 2012 -
2013
30
25
20
15
10
Target
2012-13
Performance
2012-
13
5
0
We finished within our internal target of 30 RWT-attributable MSSA bacteraemias for
2012-13, with 29, which is the lowest total since we began collecting this data. Of the
29 cases during the year, 18 were related to IV lines (seven Renal, seven
Haematology / Oncology, one NNU, 1 CCU, two ‘others’); eight were secondary to
skin or soft tissue infections (no surgical site infections); one was related to a urinary
catheter; one was a contaminant and there was one of unknown source.
100
90
80
70
60
50
40
30
20
10
0
Cumulative RWT-Attributable MSSA Bacteraemias from
April 2005
2005-06
2006-07
2007-08
2008-09
2009-10
2010-11
2011-12
2012-13
Page 4 of 14

Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Number
Title: Infection Prevention and Control
Appendix 3 – Hospital Acquired Bacteraemias (HABs) and Device-Related
HABs (DRHABs)
The number of HABs and DRHABs are monitored internally. We set an internal
target of 84 DRHABs for the year. The graph below shows our performance against
the target for 2012-13. No target was set for HABs.
Hospital Acquired and Device-Related Hospital Acquired
Bacteraemias 2012 - 13
40
35
30
25
20
15
10
HABs
DRHABs
Target for
DRHABs
5
0
There were 100 DRHABs overall during the year, which is an increase on last year’s
total of 93. The sources of the DRHABs is shown in the table. The IV Team became
operational in September 2012 and it was hoped that there would be a significant
reduction in the number of line-associated DRHABs over the rest of the year.
Unfortunately this has not yet been seen, principally because most of the lineassociated
DRHABs have been in areas, such as renal dialysis and Haematology,
where the IV Team are not responsible for placing the lines. Work is being
undertaken in these areas to try to reduce the number of such infections. The Trust
had a CQUIN around urinary catheter management, and considerable work has been
undertaken both in the hospital and community to reduce the number of infections
related to these devices.
Devices Associated with DRHABs 2012-13
Apr
12
May
12
Jun
12
Jul
12
Aug
12
Sep
12
Oct
12
Nov
12
Dec
12
Jan
13
Feb
13
Mar
13
B/C taken 966 1062 1035 1051 915 980 1052 978 1152 1107 1014 1119
B/C positives 96 99 83 88 76 80 93 72 97 93 75 98
B/C significant 67 68 69 69 60 62 70 52 74 64 56 62
Contaminants 29 31 14 19 16 18 23 20 23 29 19 36
HABs 29 24 29 25 21 31 35 20 28 29 21 25
DRHABs 6 3 11 9 10 15 9 4 11 10 6 6
IV Lines 5 2 10 7 8 7 7 2 9 5 5 6
Urinary cath 1 1 0 2 1 6 1 2 2 3 1 0
VAP 0 0 0 0 0 0 0 0 0 1 0 0
Nephrostomy 0 0 1 0 0 2 1 0 0 0 0 0
?VAP/?Line 0 0 0 0 1 0 0 0 0 0 0 0
?Line / ?PEG 0 0 0 0 0 0 0 0 0 1 0 0
Page 5 of 14

Apr-Jun 08
Jul-Sep 08
Oct-Dec 08
Jan-Mar 09
Apr-Jun 09
Jul-Sep 09
Oct-Dec 09
Jan-Mar 10
Apr-Jun 10
Jul-Sep 10
Oct-Dec 10
Jan-Mar 11
Apr-Jun 11
Jul-Sep 11
Oct-Dec 11
Jan-Mar 12
Apr-Jun 12
Jul-Sep 12
Oct-Dec 12
Jan-Mar 13
Percentage Contaminants
Title: Infection Prevention and Control
Appendix 4 - Blood Culture Contaminants
Contaminated blood cultures are a common problem which can lead to unnecessary
patient investigations, prolonging the in-patient stay and wasting resources. In
addition, antibiotics may be given to treat these pseudo-bacteraemias, increasing the
risk of complications, such as C. difficile. The blood culture Phlebotomy Team
enables the majority of blood cultures to be taken by dedicated staff fully trained in
the necessary techniques. This has resulted in a substantial reduction in the number
and rate of blood culture contaminants. In 2008-09, the average blood culture
contamination rate was 5.64 percent; in 2012-13 it was 2.21 percent. There is no
standard for this measure in the UK, but in the USA 3% is the generally agreed
standard.
7
Percentage of Contaminated Blood Culture Sets by
Quarter
6
5
4
3
2
1
0
Page 6 of 14

April
May
June
July
August
September
October
November
December
January
February
March
Number
Durnall Unit
Deanesly
CHU
A4 / Gynae
A5/A6D/S…
PAU/C1/C2 /…
NNU
CTW
Cardiology…
Critical Care
D1 / A12
D2 / A14
D3 / A9
D4 / A10
VSU / B7
D5 / A5
D6 / A6
EAU / AMU
Stroke Unit
RDU/CAPD
D22 / C22
D8 / A8
D15 / C24
D16 / C25
D17 / C15
D18 / C16
D19 / C18
D20 / C19
D21 / C17
D7 / A7
West Park
Number
Title: Infection Prevention and Control
Appendix 5 - MRSA Acquisitions
The screening of all admissions to RWT has enabled the acquisition of MRSA in the
hospital to be monitored. The first graph shows the wards where MRSA acquisitions
were found to have occurred in 2012-13. All wards that have had clusters of cases
have had meetings with and additional input from the Infection Prevention Team.
This has led to a resolution of the problem in all cases. The second graph shows the
cumulative MRSA acquisition numbers for the Trust over the past few years. It can
be seen that a new record low total was set in 2012-13
MRSA Acquisitions 2012-2013
10
8
6
4
2
0
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
200
180
160
140
120
100
80
60
40
20
0
Cumulative RWT -Attributable MRSA Acquisitions from
April 2008
2008-09
2009-10
2010-11
2011-12
2012-13
Page 7 of 14

Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Number
Title: Infection Prevention and Control
Appendix 6 - Clostridium difficile
New Cross West Park W’ton PCT RWT PCR
toxin positive
(target)
toxin positive
(target)
toxin positive
(target)
positive
(target)
Apr 2012 2 (5) 0 (1) 4 (7) 9 (9)
May 2012 6 (5) 0 (1) 7 (7) 19 (9)
Jun 2012 2 (4) 1 (1) 4 (6) 14 (9)
Jul 2012 5 (5) 2 (1) 10 (7) 11 (9)
Aug 2012 4 (5) 0 (1) 7 (7) 10 (9)
Sep 2012 4 (4) 0 (1) 5 (6) 12 (9)
Oct 2012 5 (5) 0 (1) 6 (7) 13 (9)
Nov 2012 2 (5) 0 (1) 3 (7) 13 (9)
Dec 2012 4 (4) 0 (1) 2 (6) 8 (9)
Jan 2012 2 (5) 0 (1) 6 (7) 8 (9)
Feb 2012 2 (5) 0 (1) 7 (7) 8 (9)
Mar 2012 2 (4) 1 (1) 4 (6) 11 (9)
Totals (Target) 40 (57) 4 (12) 65 (80) 136 (108)
The New Cross and West Park Hospitals and PCT external targets refer to the
figures based on the national definition of C. difficile cases introduced from April
2012. It can be seen that New Cross, West Park and Wolverhampton PCT all
finished the year within their targets. The Wolverhampton PCT figure, however, does
not include any patients diagnosed in other laboratories and therefore may not be
complete. The targets set for the year 2013-14 are 39 for RWT (including West Park
Hospital cases) and 65 for Wolverhampton CCG.
C. difficile Toxin Positives and Targets 2012 - 13
100
RWT
80
RWT Target
60
West Park
Hospital
40
20
West Park
Hospital
Target
Wolves PCT
PCT Target
0
The RWHT Internal Target figure is set against our own definition of attribution which
includes patients who have recently been discharged from RWT, and is based on
PCR test results, which is a measure of colonisation with the organism and therefore
the spread of C. difficile, rather than with clinical disease. The target was an
ambition based on results from the previous year, when the same testing method
was employed. It is a concern that this target was exceeded by over 25%. The
second graph below shows the comparison between 2012-13 and 2011-12. The
Page 8 of 14

Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Number
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Number
Title: Infection Prevention and Control
decrease in the total was less than 7%. New strategies are probably needed if this
number is to be further reduced.
160
140
120
Cumulative C. difficile PCR Positives and RWT Internal
Target 2012-13
100
80
60
RWT Target
RWT
40
20
0
Cumulative C. difficile PCR Positives 2011-12 and 2012-
13
160
140
120
100
80
60
RWT 2011-12
RWT 2012-13
40
20
0
Page 9 of 14

Number of E.coli bacteraemias
Number of E.coli bacteraemias
Title: Infection Prevention and Control
Appendix 7 - Escherichia coli Bacteraemias
National mandatory reporting of all E. coli bacteraemias began in June 2011, though
locally we have robust data from April 2009. The Accountability Framework for NHS
Trust Boards states that E. coli bacteraemias should be reported as part of each
organisation’s Quality and Governance indicators. The first graph below gives the
annual totals for E. coli bacteraemias for those that occurred in RWT in-patients and
for those found on admission. The majority of cases are admitted with it.
Number and Source of E.coli Bacteraemias From April 2009
160
140
120
100
80
60
RWTattributable
Non-RWTattributable
40
20
0
2009-10 2010-11 2011-12 2012-13
Of the RWT-attributable cases, it is likely that realistically only the DRHAB-related
cases are preventable, although it is unlikely that all of these are actually
preventable. The second graph shows the number of HABs (excluding DRHABs)
and DRHABs for each year for the RWT-attributable cases. This suggests that
overall less than 8% of E. coli bacteraemias are possibly preventable.
E.coli Bacteraemias - HABs and DRHABs From April 2009
100
90
80
70
60
50
40
30
20
10
0
2009-10 2010-11 2011-12 2012-13
HABs
(excluding
DRHABs)
DRHABs
Page 10 of 14

Administrative
& Clerical
Ancillary
Building &
Engineering
Allied Health
Professions…
Nursing &
Midwifery &…
Scientific &
Technical &…
Medical &
Dental
Senior
Managers
TRUST
TOTAL
Administrative & Clerical
(1321)
Ancillary (636)
Building & Engineering
(59)
Allied Health Professions &
Support Staff (468)
Nursing & Midwifery
Tranined (1884)
Nursing & Midwifery
Untranined (658)
Scientific & Technical &
Support Staff (38)
Technicians/Healthcare
Scientists (539)
Medical & Dental (605)
Senior Managers and NEDs
(174)
TRUST TOTAL (6295)
Percentage
Title: Infection Prevention and Control
Appendix 8 - Compliance with Infection Prevention Mandatory Training
Hand Hygiene and Infection Prevention Training and Hand Hygiene
Competency Assessment
100.0%
95.0%
Uptake of Hand Hygiene and Infection Prevention
Training at March 31st 2013 by Professional Groups
Training
90.0%
85.0%
Hand
Hygiene
Assessment
Target
80.0%
75.0%
RWHT Uptake of Hand Hygiene Training 31st March 2007
to 2013
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
31.03.07
31.03.08
31.03.09
31.03.10
31.03.11
31.03.12
31.03.13
Page 11 of 14

Percentage
Title: Infection Prevention and Control
NHSLA requires that hand hygiene training compliance is at least 95% to match level 3
requirements. The first graph shows that several staff groups have to improve their
training compliance levels to achieve this. Overall compliance was 92.5% at the end of
March, which is the lowest since July 2012 and a marked deterioration from the 95.6%
achieved in October 2012. Once again, the groups that are potentially the most
concerning are ‘Medical and Dental’ and both of the ‘Nursing and Midwifery’ groups; it is
important the compliance of these groups improves and this improvement is maintained.
The second graph, however, shows how the compliance at the end of 2012-13 was higher
than has been achieved in any previous years.
Antimicrobial Prescriber Training
Uptake of Antimicrobial Prescriber Training
100
90
80
70
60
30.05.07
31.03.08
31.03.09
50
40
30
20
31.03.10
31.03.11
31.03.12
31.03.13
10
0
Division 1 Division 2 Total
NHSLA requires that antimicrobial prescriber training compliance is at least 95% to match
level 3 requirements. While the current compliance level is higher than at the end of
either of the previous two years, it is still below the 95% target. The Antimicrobial
Stewardship Group is exploring different methods of delivering training and assessing
competence. Training and compliance with training was a key element of the
Antimicrobial CQUIN that the Trust was set this year. The Trust achieved all of the CQIN
objectives.
Page 12 of 14

Title: Infection Prevention and Control
Appendix 9 - Compliance with the Code of Practice for the Prevention and
Control of Healthcare Associated Infections (2008)
Criterion 01: Systems to manage and monitor the prevention and HCAI Self
control of infection. These systems use risk assessments and Assessment
consider how susceptible service users are and any risks that their Rating: Green
environment and other users may pose to them.
Criterion 02: Provide and maintain a clean and appropriate HCAI Self
environment in managed premises that facilitates the prevention Assessment
and control of infections.
Rating: Yellow
Criterion 03: Provide suitable accurate information on infections to
service users and their visitors.
HCAI Self
Assessment
Rating: Green
Criterion 04: Provide suitable accurate information on infections to HCAI Self
any person concerned with providing further support or Assessment
nursing/medical care in a timely fashion.
Rating: Green
Criterion 05: Ensure that people who have or develop an infection HCAI Self
are identified promptly and receive the appropriate treatment and Assessment
care to reduce the risk of passing on the infection to other people. Rating: Green
Criterion 06: Ensure that all staff and those employed to provide HCAI Self
care in all settings are fully involved in the process of preventing Assessment
and controlling infection.
Rating: Green
Criterion 07: Provide or secure adequate isolation facilities.
Criterion 08: Secure adequate access to laboratory support as
appropriate.
HCAI Self
Assessment
Rating: Green
HCAI Self
Assessment
Rating: Green
Criterion 09: Have and adhere to policies, designed for the HCAI Self
individuals care and provider organisations, that will help to prevent Assessment
and control infections.
Rating: Amber
Criterion 10: Ensure, so far as is reasonably practicable, that care HCAI Self
workers are free of and are protected from exposure to infections Assessment
that can be caught at work and that all staff are suitably educated in Rating: Green
the prevention and control of infection associated with the provision
of health and social care.
Actions are underway to achieve full compliance and it expected this will be achieved over
the next three months. The areas where we are not fully compliant with relate to the
Waste Policy, decontamination and the use of safe sharps.
Page 13 of 14

Title: Infection Prevention and Control
Appendix 10 - Current Projects and Norovirus Outbreak
IV Team (incorporating OPAT – Outpatient Parenteral Antimicrobial Therapy) –
intravenous lines are the single biggest risk factor for RWHT-acquired MSSA
bacteraemias and DRHABs. The purpose of the IV Team is to reduce line-related
infections to an irreducible minimum and eliminate all avoidable infections related to these
devices. Since the introduction of the IV Team (from September 2012), most line-related
infections have been in patient groups the IV Team does not directly access (Renal,
Haematology and some Oncology), and the number of DRHABs related to lines has not
decreased as had been hoped. The experience being gained by the line team is now
being used to reduce line-associated infections in these areas. The OPAT work has been
a huge success in enabling earlier discharge of patients from hospital, or admission
avoidance.
Urinary Catheter Working Group - the second commonest cause of device-related
bacteraemias is urinary catheters. The district-wide Urinary Catheter Group is reviewing
all aspects of urinary catheter use and care. The aim of this group is to ensure these
devices are only used when absolutely necessary and when they are used that they are
inserted and used optimally to reduce the risk of infections. The greatest impact is likely
to result from a reduction in both the number of catheters inserted and the duration that
these devices are left in-situ.
Surgical Site Infection Surveillance - the Surgical Site Infection project is underway,
collecting data from all appropriate surgical interventions in RWHT and trialling what is
considered to be the optimal surgical skin preparation across almost all surgical
specialties in the Trust.
Norovirus Outbreak
Norovirus outbreaks hit the UK earlier in the winter of 2012-13 than in the previous year
and continued into the Spring. This pattern was seen in Wolverhampton and both RWT
and local care homes experienced outbreaks of suspected and proven norovirus. Entire
ward closures were rare and the number of beds blocked due to norovirus was kept to a
minimum, particularly due to the introduction of in-house molecular amplification testing
for norovirus. Extensive use of hydrogen peroxide environmental decontamination was
also a key element in the control strategy. Through the support given by the Infection
Prevention Team, admissions related to norovirus from affected Wolverhampton care
homes were once again minimal this winter.
Page 14 of 14