Agenda Item 6 Report to East Sussex Health Overview by elusivelyeasy


									                                                                                         Agenda Item 6

Report to:             East Sussex Health Overview and Scrutiny Committee (HOSC)

Date:                  6th July 2009

By:                    Director of Law and Personnel

Title of report:       East Sussex Hospitals NHS Trust – Infection Control

Purpose of report:     To outline the Trust’s approach to infection control and analyse the
                       causes, action taken and lessons learnt in relation to the outbreak of
                       C Difficile at Eastbourne District General Hospital in early 2009.

HOSC is recommended:
  1. To consider and comment on the Trust’s approach to infection control.

1.      Background
1.1    Healthcare associated infection (HCAI) is a major challenge for healthcare systems around
the world. HCAI refers to infections acquired in hospitals or as a result of hospital interventions.
They are caused by a wide variety of microorganisms, often by bacteria that normally live
harmlessly in or on the body. While people are most likely to acquire HCAIs during treatment in
acute hospital, they can also occur in GP surgeries, care homes, mental health trusts, ambulances
and people’s own homes – in fact anywhere that people are receiving clinical treatment.

1.2      Although the majority of HCAIs cause minimal harm and can be treated like any other
infection, nationally there are particular challenges from two types of infection – MRSA and C
Difficile - which can have severe consequences for patients. National strategies on HCAI have
therefore focussed on these infections, but effective infection control measures also help tackle
other HCAIs.

1.3      MRSA is a strain of the S. aureus bacterium which is resistant to commonly used
antibiotics and is present in around 3% of the population. MRSA can infect surgical wounds and
ulcers, and can cause more serious infections if it enters the bloodstream. These infections are
likely to be more prevalent and more severe in patients with weakened immune systems or other
underlying diseases. MRSA is usually spread through skin to skin contact, or by touching
materials and surfaces contaminated from someone infected with MRSA.

1.4    C Difficile is a bacterium which lives in the gut of around 3% of healthy adults. It is kept at
bay by normal gut bacteria, but if those bacteria are killed by antibiotics, C Difficile can proliferate.
Toxins released by C Difficile cause diarrhoea, which can occasionally be very severe and life
threatening. In most cases the infection develops after cross-infection from another patient. Over
80% of cases of C Difficile infection are in people aged over 65.

1.5    It should be remembered that for most people, the risk of acquiring an infection is very low,
and lower still for those people who spend only one or two days in hospital. Only a very small
proportion of people treated by the NHS will be infected by an HCAI.

2.      National and local policy

2.1     Control of HCAI is a major priority for the NHS both locally and nationally. The Department
of Health has issued a number of policy and guidance documents in this area in recent years,
including a ‘Code of Practice on the prevention and control of healthcare associated infections’
(DH, 2009), commonly known as ‘The Hygiene Code’. From April 2009, NHS bodies providing
services are required to register with the Care Quality Commission in relation to their compliance
with this code.

2.2     Incidences of certain HCAIs, including MRSA and C Difficile, must be reported through a
national system, and the number of infections is published on a quarterly basis. There are national
targets for each NHS Trust to reduce infections and, locally, ‘stretch’ targets have been set which
go beyond the national targets.

2.3    Levels of HCAI and Trusts’ compliance with the Code of Practice is monitored in a number
of ways including through local commissioners of services (NHS East Sussex Downs and
Weald/NHS Hastings and Rother), the Strategic Health Authority and the Care Quality
Commission. Trusts’ performance in relation to HCAI is also a factor influencing whether or not
they can be granted Foundation Trust status.

2.4     Within Trusts, it is important that there is strong leadership in relation to infection control,
from the Board level downwards, and that infection control measures are embedded into everyday
practice within hospitals.

2.5     Control of HCAI is often associated with cleanliness of hospitals and hand washing. While
these are crucial aspects of infection control, the measures required go much wider than this, and
different actions will be important for different types of infection. Factors to consider include:

     •   Whether there is appropriate prescribing of antibiotics.
     •   Availability of isolation facilities for patients with infections to prevent spread.
     •   Screening of patients prior to, or on admission to identify those with MRSA present.
     •   Effective management of catheters and cannula (tubes for draining fluid or administering
     •   Ensuring bed occupancy levels allow scope for sufficient cleaning etc between patients.
     •   Analysing the causes of each incidence of reportable infection and learning lessons.

3.       East Sussex Hospitals Trust

3.1      In the early months of 2009 East Sussex Hospitals Trust (ESHT) experienced an outbreak
of C Difficile at Eastbourne District General Hospital (DGH). The outbreak was thought to be due
the very high number of patients admitted over the winter with severe respiratory infections
requiring antibiotic therapy which increases peoples’ susceptibility to the infection, particularly in
the frail and elderly. On 24th March 2009, the Trust confirmed that 62 cases of C Difficile had been
identified since 1st January 2009 (including some patients who had been admitted with the
infection from the community). The outbreak was declared over in April 2009.

3.2     As well as the very serious impact on the patients affected and their families, the outbreak
also had a significant impact on the operation of the hospital. New medical admissions were
restricted to enable deep cleaning to be undertaken and patients to be isolated in a single ward.

3.3     HOSC monitored the situation closely during the outbreak, receiving weekly updates from
the Trust and seeking assurances that all appropriate action was being taken, with the involvement
of the Health Protection Agency, NHS East Sussex Downs and Weald/NHS Hastings and Rother
and the Strategic Health Authority. HOSC also requested that the Trust present a report to the
Committee analysing the causes and action taken in relation to the outbreak, the Trust’s ongoing
approach to infection to control and any lessons learnt.

3.4    ESHT has supplied a report covering these issues which is attached at appendix 1. Kim
Hodgson, Chief Executive, Dr Barry Phillips, Director of Infection Prevention and Control and
Beverley Thorp, Deputy Chief Nurse, will attend HOSC to present the report and discuss the
issues arising.

ANDREW OGDEN                           Contact officer: Claire Lee, Scrutiny Lead Officer
Director of Law and Personnel          Telephone: 01273 481327
                                                                            Agenda Item:6
                                                                               Appendix 1

Subject:          Eastbourne District General Hospital Clostridium Difficile
                  Outbreak – A Report for the East Sussex HOSC
Date:             6th July 2009
Author:           Dr Barry Phillips DIPC East Sussex NHS Trust


As an important component of our drive to deliver high quality, safe care for
patients, infection control has always been taken seriously at East Sussex
Hospitals NHS Trust.        The trust has implemented and developed a
comprehensive programme of activities to embrace national initiatives and to
reduce infection rates.

In the last quarter of 2008/2009 an outbreak of Clostridium difficile associated
diarrhoea presented at Eastbourne District General Hospital within the medical
division. This note sets out the background to infection control in the trust; the
approach taken to control the C Diff outbreak; the approach the trust is taking to
identify lessons; and priorities for 2009/10.


Within the East Sussex Hospitals Trust, the Chief Nurse is the Executive lead for
Infection Prevention & Control. Dr Barry Phillips (Critical Care Consultant) is the
trust’s Director of Infection Prevention & Control (DIPC), supported by a
dedicated Infection Control Team. Both he and the Chief Nurse report directly to
the Chief Executive. Infection Control is discussed at every Board and Executive
Team meeting.

Each Division within the trust has a designated clinician lead for infection control.
There are also approximately 80 infection prevention link nurses across the trust.
Some highly specialised clinical areas, for example operating theatres, have also
developed dedicated infection control groups to facilitate the implementation of
infection control initiatives. A dedicated Intravenous Therapy team has been
established (from September 2007) to significantly reduce IV-device related
MRSA infections. Infection control is included in staff induction and appraisal.

The trust has worked closely with its PCT colleagues and local health economy
leads to agree joint strategies for the reduction of healthcare associated
infections, which can lead to hospital admission. PCT infection control leads are
members of the Trust Infection Control Committee and of a weekly steering
group which analyses all reportable infections, both community and hospital
acquired. The group has successfully introduced methods of sharing information
between the hospital and community healthcare providers in relation to specific

                                                          East Sussex Hospitals NHS Trust
                                                             HOSC Infection Control report
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                                                                                                                                                                                                           Agenda Item:6
                                                                                                                                                                                                              Appendix 1


For 2008/09, the trust agreed with our Primary Care Trust partners trajectories
for reducing Clostridium difficile toxin positive (CDT) cases for all patients aged 2
and over. The graph below shows trust performance against these local and
national limits.
                                  Num ber of C-Diff cases (aged over 2 and attributable to the
                                               M ont hly Act ual                                       Nat ional Limit (Vital Signs)
                                               Local St retch Limit                                    Previous year actual



















MRSA bacteraemia

In 2008/09, the Trust reported 22 MRSA bacteraemia infections, of which 12
were hospital acquired, 8 were acquired prior to admission to the Trust
(community acquired or other healthcare related) and 2 were contaminated
samples. This is a reduction of 58% on the previous year. The following graph
illustrates the Trust position against local and national reduction limits.
                                                                Num ber of MRSA Bacterae m ia
                                                   M ont hly A ct ual                    Local Limit                    Nat ional Limit





















                                                                                                                                                     East Sussex Hospitals NHS Trust
                                                                                                                                                        HOSC Infection Control report
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                                                                          Agenda Item:6
                                                                             Appendix 1

Each episode of MRSA bacteraemia is investigated by a root cause analysis
(RCA), which includes input from the Medical Microbiologist, nursing staff and
the patient’s consultant.

In common with other NHS trusts, East Sussex Hospitals Trust is required to
register with the new Care Quality Commission and declare its compliance
against the code for the prevention of healthcare associated infections. The trust
has successfully been registered by the CQC without conditions.

Clostridium difficile associated diarrhoea (CDAD) – the 2009 outbreak

As a matter of routine good practice, East Sussex Hospitals Trust closely
monitors cases of Clostridium difficile associated diarrhoea and investigates
periods of increased incidence, defined by Department of Health guidelines as
when 2 or more cases are present in the same area within 30 days. During
2008/09 a number of small outbreaks were identified, managed and confined to
single patient bays. Each of these incidents was examined and any relevant
lessons identified and acted upon.

Following investigations into increased incidence during January and February
2009 an outbreak of 027 strain Clostridium difficile was identified within the
medical wards at the Eastbourne DGH. The outbreak had a significant impact on
hospital activity. On March 6th the Infection Control Team recommended the
closure of six medical wards to new admissions to allow vacation, deep cleaning
and decontamination with hydrogen peroxide prior to reopening to new
admissions. To support this process new medical admissions were temporarily
diverted to its sister site Conquest Hospital, and other neighbouring Trusts.

The trust’s response – managing the outbreak

From the start of this outbreak, the trust followed a twin-track approach, based
on a treatment strategy to deliver the best possible care to the increased number
patients who developed CDAD and a prevention strategy to reduce the number
of new cases developing. This approach was driven forward through daily, multi-
disciplinary meetings, chaired by the Chief Executive and involving the Health
Protection Agency (HPA), the South East Coast SHA, our PCTs and key
members of the trust dealing with the outbreak.

The key features of these complementary strategies are set out below.

Treatment Strategy:

•   Rapid set up of a dedicated isolation ward on the Eastbourne Hospital site.
    This involved setting up a ring fenced 15 bedded cohort isolation facility on
    East Dean ward (with its structure and operation based on a hybrid of similar
    units at Worthing and Brighton). The East Dean isolation ward has been
    working well with an approximate nursing to patient ratio of 2:1.

                                                        East Sussex Hospitals NHS Trust
                                                           HOSC Infection Control report
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                                                                            Agenda Item:6
                                                                               Appendix 1

•   Establishing a multi disciplinary ward round, with direct input from a
    microbiology consultant, senior nursing staff, physiotherapy, occupational
    therapy, nutritionist pharmacy and surgery.

•   Providing clear information to patients and their family on diagnosis of C.Diff,
    including upon movement to East Dean. This was also disseminated to GPs
    and community services through close links with Community and PCT
    Directors of Infection and Prevention Control.

•   Additional measures around cleaning, purchasing of equipment and facilities
    alterations which allowed the rapid set up of this isolation ward. This has
    been overseen by senior facilities staff.

•   Dedicated Consultant care with resident locum medical doctor and daily
    medical registrar availability to support the resident. The resident doctor
    dedicated to East Dean is employed from 9am-5pm 5 days a week. He has
    an outreach assessment protocol which allows early assessment for
    admission to East Dean of patients with known diagnosis of C. Diff. Weekend
    cover is provided by medical on call teams which provide a daily review of
    patients on East Dean.

Prevention Strategy:

•   A programme of deep cleaning and Hydrogen Peroxide vaporisation of all
    medical wards. This has been undertaken as a rapid rolling program
    designed to keep potentially at risk patient groups away from the general
    medical patient population.

•   Dissemination of outbreak alerts through the divisional directors, the infection
    control team, infection control link facilitators and junior doctor

•   Clear rules for the admission and discharge of patients have been
    established with social services.

•   Laboratory support has been extended to allow routine weekend C Diff
    testing with protocols for involvement of the microbiology consultant.
    Movement of the newly diagnosed C Diff patient must then occur within 1
    HOUR to East Dean ward. Towards the later stages of the outbreak, an in-
    house capability for rapid testing for the 027 stain was established
    (addressing previous delays in outsourcing strain testing.)

•   Boost to the infection control team by secondment of nurses and secretarial
    support from other departments and community (PCT infection control

•   Rapid review of root cause analysis done on each of the CDAD cases to
    establish early learning points.

                                                          East Sussex Hospitals NHS Trust
                                                             HOSC Infection Control report
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                                                                              Agenda Item:6
                                                                                 Appendix 1

•   Introduction of new antibiotic policy guided by consultant microbiologists and
    the post graduate centre. Introduction of limited dosage antibiotics through
    regular feedback on daily divided dosage data to clinical directorates and to
    the board and regular auditing of policy compliance across all clinical

•   Establishment of link Physicians to enable close monitoring of infection
    control measures, audits and care bundle compliance at a Divisional level
    within the trust.

Following close liaison with the Health Protection agency and implementation of
the strategies set out above, the outbreak was declared over on 14 April.

Learning lessons and next steps

East Sussex Hospitals Trust invited experts from the Health Protection Agency
into the trust for a peer review exercise to look at the way we were managing the
outbreak of Clostridium difficile at Eastbourne District General Hospital. The
review team praised the trust for acting promptly to identify the outbreak and
reacting to implement containment and control measures, including the provision
of a dedicated cohort ward for patients affected. They have made a number of
recommendations (ranging from the very specific such as the positioning of
elbow taps in sluices to more general observations on how to build on the
already strong culture of infection control in the trust).

The trust has drawn up an action plan to take forward all of these
recommendations: follow up work is already in hand and well advanced. The
trust is currently preparing a report, setting out the background to the outbreak,
key lessons and recommendations, and what we are doing about them. Broadly
speaking, our analysis of events leading up to the outbreak suggests the
following factors in combination were the main drivers:

    •   20% higher than normal winter peak hospital admissions
    •   Background of high incidence of winter flu like symptoms
    •   Use of antibiotics for respiratory infections (this was clinically necessary to
        treat the primary medical condition)
    •   Elderly population
    •   Highly virulent strain of Clostridium Difficile (ribotype 027)

An Infection Control Steering Group continues to meet on a weekly basis,
bringing together clinical leaders with the trust and local health economy. This
group consists of the trust’s Chief Executive, Medical Director, Chief Nurse,
Divisional Directors and Nurses, Microbiology Consultants and Infection Control
Team, and PCT and HPA representatives as needed. Its remit is to:

        •   Scrutinise each case of reportable hospital acquired infection, and to
            ensure co-ordinated action across the organisation.

                                                            East Sussex Hospitals NHS Trust
                                                               HOSC Infection Control report
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                                                                              Agenda Item:6
                                                                                 Appendix 1

       •   Implement recommendations by the Health Protection Unit peer review
           visit and introduce a gap analysis of current practice to recent
           Department of Health documents such as “Clostridium Difficile: how to
           deal with the problem.”

Looking Forward – 2009/10

The trust’s performance against infection control targets for the first three months
of 2009-2010 is shown below:

                                         MRSA                     CDAD
             Month                  Limit   Actual        Limit      Actual
 APRIL                                2       2            14          7
 MAY                                  2       0            14          5
 JUNE                                 2       0            13          5
 Quarter 1                            6       2            41         17

The Eastbourne District General site was the subject of a hygiene compliance
spot check by the Care Quality Commission on 9th June 2009. The CQC has
given the trust a clean bill of health and found no areas for concern against the
criteria they examined.

The trust’s over-arching infection control plan for 2009/10 has a number of
objectives, focusing on:

   •   continuing to meet limits for the reduction of MRSA bacteraemia and
       Clostridium difficile associated diarrhoea

   •   ensuring compliance with external guidelines, including the Hygiene Code,
       NHS Litigation Authority standards and Department of Health guidance:
       Clostridium difficile ‘How to deal with the problem’.

   •   ensuring compliance with revised internal trust policies on MRSA
       screening and decolonisation, and keeping trust policies under review in
       line with external guidance and evidence based practice.

   •   regular reporting and review of antibiotic prescribing by clinicians for
       review by Divisions.

   •   compliance with National Cleaning Standards and increasing our Rapid
       Response Cleaning service to provide full service for extended hours.

   •   supporting the further development of the trust Infection Control team;
       embedding the role of the Link Physicians for Infection Control within the
       trust’s Divisions; and delivering enhanced infection control training for all
       staff groups.

                                                           East Sussex Hospitals NHS Trust
                                                              HOSC Infection Control report
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                                                                        Agenda Item:6
                                                                           Appendix 1

•   completing development of an electronic data capture system for
    monitoring infection control compliance with Hand Hygiene, high impact
    interventions and MRSA screening.

•   developing and implementing a project for reduction of risk of urinary
    device related infections.

                                                      East Sussex Hospitals NHS Trust
                                                         HOSC Infection Control report
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