INFECTION CONTROL REPORT 2006-7 by jayjkayelle

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									               SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST


Meeting             Trust Board                              Date            29 July 2009

Subject             Infection Prevention and Control         Enclosure       O
                    Annual Report 2008-09


Nature of item      For information          
                    For approval
                    For decision


Decision
required (if any)


General             Report Author            Dr Steve Mather, Medical Director
Information         Lead Director            Dr Steve Mather, Medical Director


Received or         Meeting
approved by         Date


Resource            Revenue
Implications        Capital
                    Workforce
                    Use of Estate
                    Funding Source


Freedom of          Confidential (Y/N)       N
Information         (if yes, give reasons)
                    Final/draft format       Final

                    Ownership                Trust

                    Intended for release     Yes
                    to the public


Decision Made
                   South Warwickshire General Hospitals NHS Trust

                          Report to Trust Board – 29 July 2009

               Infection Prevention and Control Annual Report 2008-09


INTRODUCTION

The Trust Board receives a monthly infection control report which details the MRSA and
Clostridium difficile (C. difficile) rates, together with any update on unusual circumstances.
This continuous updating reduces the importance of an annual report other than as a
summary of activity and infection rates throughout the year, albeit with important
commentary.

2008-2009 has been a year of mixed fortune in infection control for the Trust. On the
positive side, the Consultant Microbiologist team has been strengthened by having a full
complement of two full-time staff. The two consultants share the workload, whilst being
part of the Microbiology network, also sharing the role of infection control doctor and, on
occasions, deputising as the DIPC (Director of Infection Prevention and Control). The
Infection Control Team has been increased by one whole time equivalent (WTE) trainee
infection control nurse. This increase takes the complement of nursing staff to 2.89 WTE.
The downside has been the loss of Michael Nevill, who provided a much-needed audit
function within the team, and the impending loss of Jackie Woodmass, the administrative
officer, who will be leaving to take up a full-time post with Warwickshire PCT.

The Trust infection priorities remain with the control of MRSA acquisition and
bacteraemias and the incidence of C difficile.

The Department of Health (DoH) MRSA Action Team continued to visit throughout the
year and they continue to monitor the actions of the Trust and a number of
recommendations have been made. A final visit is expected in the first quarter of 2008-
2009 after which, we hope that the DoH and the SHA will be satisfied with infection control
procedures at the hospital. The isolation facility is expected to relocate later this year
following the construction of additional ward accommodation. The two new wards will have
a greater number of single rooms as well as smaller bays which will allow for isolation of
both C difficile and MRSA colonised patients.


MRSA

The MRSA target set for the year by the PCT and the SHA continued to be a challenging
12 cases per annum. Recorded MRSA bacteraemias have increased such that the Trust‟s
absolute target of 12 bacteraemias had been exceeded by 4 at the year end. At the time of
writing this report, one of those bacteraemias had been accepted as being the
responsibility of another acute Trust leaving the total number of bacteraemias recorded at
15. Because of tolerances allowed in the target, organisations may see a 25% increase in
each quarter and still be deemed to have achieved the annual rolling target. In contrast
with C difficile, the counting of MRSA bacteraemias still does not differentiate between
bacteraemias which have occurred during the patients‟ stay in hospital and those detected
            SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST

on admission to the Trust. Thus, the Trust has to accept responsibility for those
bacteraemias which are detected on admission in addition to those occurring during a
hospital stay.

However, when split between hospital acquired and first 48 hour detected, the Trust‟s
performance improved from previous years (20 cases in 2006-2007, 11 cases in 2007-
2008). The final figures show that the Trust recorded 7 MRSA bacteraemias in 2008-2009
with a further 8 bacteraemias being detected on admission.

It can be seen that MRSA acquisition in hospital has halved from the previous year (192
cases in 2007-2008 against 95 cases in 2008-2009). Although still high, this measure
more accurately reflects the improvement in hygiene in clinical areas over the year. The
numbers of patients admitted with MRSA colonisation and those who were previously
known to be colonised, make up the bulk of patients in the hospital who are colonised with
MRSA. This illustrates strikingly that MRSA is a problem for the whole of the health
community, not just the acute Trust. The previous year‟s figures for patients admitted with
MRSA colonisation and those previously known to be positive are 65 cases and 160 cases
respectively. This indicates a worsening picture in the community during 2008-2009.



                                                  MRSA
              MRSA       MRSA         MRSA        hospital      MRSA
              hospital   previously   admitted    acquired      bacteraemia
 MONTH        acquired   positive     with        bacteraemia   admitted with

 APRIL            6          7          11            1               3
 MAY             10          4          10            0               1
 JUNE            10          3          14            0               0
 JULY             9          6           8            2               0
 AUGUST          10         11          11            0               1
 SEPTEMBER        7          9          14            1               0
 OCTOBER         15         14          23            0               0
 NOVEMBER        10         13          20            0               2
 DECEMBER         5         12          13            1               0
 JANUARY          4         14          16            0               0
 FEBRUARY         4          5          15            1               0
 MARCH            5          9          23            2               1

                                                       **
 TOTAL           95         107         178           8               8

** (includes the re-assigned bacteraemia)




Dr S P Mather                                                                            3
Medical Director/DIPC                 June 2009
                         SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST



In graphical form:

25                                                                                                                                MRSA hospital
                                                                                                                                  acquired
20                                                                                                                                MRSA previously
                                                                                                                                  positive
15                                                                                                                                MRSA admitted with

10                                                                                                                                MRSA hospital
                                                                                                                                  acquired bacteraemia
 5                                                                                                                                MRSA bacteraemia
                                                                                                                                  admitted with
 0




                                                                                                  JANUARY
                   MAY




                                          AUGUST




                                                                                                            FEBRUARY

                                                                                                                       MARCH
          APRIL




                                  JULY
                          JUNE




                                                                OCTOBER

                                                                            NOVEMBER

                                                                                       DECEMBER
                                                    SEPTEMBER




In tabular form:


  60

  50

                                                                                                                               MRSA bacteraemia admitted w ith
  40
                                                                                                                               MRSA hospital acquired bacteraemia
  30                                                                                                                           MRSA admitted w ith
                                                                                                                               MRSA previously positive
  20
                                                                                                                               MRSA hospital acquired

  10

     0
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In response to a personal communication to the Secretary of State for Health, I have been
informed that the Department of Health will be reviewing the method of counting MRSA
bacteraemias. This has been confirmed by the National Director of Microbiology at the
Department of Health (Professor Brian Duerden) at a national meeting on Health Care
Acquired Infection and the DoH website has announced a Stakeholder Engagement
Exercise on MRSA objectives by the National Quality Board. The following is taken directly
from the consultation document:


“What should an MRSA Objective look like?

We are suggesting broadening the organisations the Objective will apply to from the
current target. The 50% reduction target was applied only to acute trusts, so they were
held responsible for all MRSA bloodstream infections. We believe it is better to hold acute
trusts responsible for infections likely to have been acquired during a patient‟s admission

Dr S P Mather                                                                                                                                                    4
Medical Director/DIPC                                                     June 2009
             SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST

and make primary care trusts (PCTs) accountable for all MRSA bacteraemia in their
population. PCTs and acute trusts will therefore have to work together to reduce MRSA
bacteraemia wherever they occur. This will give a clear goal to acute trusts, making sure
they maintain their progress, while at the same time introducing a sharper focus on
infections which develop or originate in community settings. This sort of shared
responsibility has already been introduced in setting the local target reductions for
Clostridium difficile, another healthcare associated infection.

We are suggesting that the Objective is based on a rate of infections: for acute trusts this
will be based on their activity (bed days) and for PCTs, their population. This is the best
way of taking into account the considerable variation in sizes of hospitals and PCT areas.

Because we don‟t yet know what the best achievable rate is, we are looking at current
performance as a benchmark for what is achievable. For example, we could recommend
setting the Objective as a rate around the median of organisations‟ current performance.
This means that the bottom half of trusts would need to improve at least to the standard of
the trusts at the 50% mark. Another option would be the best-performing quartile, meaning
that the bottom three-quarters of trusts would need to improve to the level of those at the
25% mark.

Both of these options for the level would be very challenging for the NHS to achieve. The
best-performing quartile would be particularly challenging, and we are suggesting that the
Objective is based on a rate of infections: for acute trusts this will be based on their activity
(bed days) and for PCTs, their population. This is the best way of taking into account the
considerable variation in sizes of hospitals and PCT areas.

“In the community we have not always recognised it is also our responsibility to minimise
cross infection, and play our part in reducing the overall level of MRSA. This is a welcome
opportunity to address that to the benefit of all our patients. All health professionals are in
this fight together" Sir John Oldham, GP, Head of Quest for Quality and NQB
member.


This is welcome news for SWGHT. If our performance on MRSA bacteraemia were only to
remain at the level recorded in 2008-2009, we would be comfortably exceeding the target
of 12 bacteraemias per annum.


CLOSTRIDIUM DIFFICILE - ASSOCIATED DIARRHOEA / DISEASE (CDAD)

C difficile acquisition has dramatically reduced when compared to 2007-2008, the monthly
rate being consistently half that of the previous year This is partly due to the separation
between hospital-acquired C difficile and C difficile occurring in the first 48 hours following
admission to the Trust, but the staff are to be congratulated on their success in effectively
halving the acquisition rate of C difficile in patients already resident in the Trust. Two
months show a cluster of C difficile cases (December and February) to nearly twice that of
other months. It is felt that this is due to the loss of the isolation facility at a time when the
bed occupancy of the Trust was at an all-time high. However, even these two peaks were
no higher than the average monthly rate for the previous year. Several deaths were
recorded as being attributable to C difficile in one of these clusters but, taken over the

Dr S P Mather                                                                                   5
Medical Director/DIPC                June 2009
             SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST

year, there was a significant reduction in deaths from 66 in 2007-2008 to 9 in 2008-2009
where C difficile was either the main cause or a contributory cause of death and a further 2
cases where C difficile was present but not contributing to death. Whilst any unavoidable
death in hospital is a matter of concern, this is still a significant achievement.

The Trust‟s C difficile target for 2008-2009 was rebased at 132 cases as has the target for
2010-2011 which has now been set at 75 cases for the year. The target for 2009-2010 has
been derived as approximately the midpoint between those two trajectories, i.e. 108 cases




The actual figures recorded during 2007-2008 were:


                      HOSPITAL            FIRST 48
                  ACQUIRED (all cases    HOURS (all
                    over the age of 2   cases over the       COMMUNITY
     MONTH                years)        age of 2 years)       ACQUIRED
 April                       6                 1                  0
 May                         3                 0                  5
 June                        5                 2                  4
 July                        5                 5                  3
 August                      4                 1                  9
 September                   4                 2                  2
 October                     5                 0                  4
 November                    6                 1                  6
 December                   11                 1                  9
 January                     8                 3                  3
 February                   11                 3                  6
 March                       8                 3                  9
 TOTAL                      76                22                 60




Dr S P Mather                                                                             6
Medical Director/DIPC             June 2009
                   SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST



In graphical form:



                                                            Cdiff 2008 - 2009               TRAJECTORY

  30                                                                                        COMMUNITY ACQUIRED (2-
  25                                                                                        65)
  20                                                                                        COMMUNITY ACQUIRED (over
                                                                                            65)
  15
                                                                                            FIRST 48 HOURS (2-65)
  10
   5                                                                                        FIRST 48 HOURS (over 65)
   0
                                                                                            HOSPITAL ACQUIRED (2-64)
                   ay


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                                                                                            HOSPITAL ACQUIRED (over
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                                                                                            65)




In tabular form:


   100%


       80%
                                                                                                COMMUNITY ACQUIRED (2-65)
                                                                                                COMMUNITY ACQUIRED (over 65)
       60%
                                                                                                FIRST 48 HOURS (2-65)
                                                                                                FIRST 48 HOURS (over 65)
       40%
                                                                                                HOSPITAL ACQUIRED (2-64)
                                                                                                HOSPITAL ACQUIRED (over 65)
       20%


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Dr S P Mather                                                                                                               7
Medical Director/DIPC                                June 2009
                            SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST

The MRSA and C diff figures have been analysed on a ward-by-ward basis and these are
presented below in histogram and tabular form:

                                                                          Ward Aquired MRSA & C.diff April 2008-2009


 16

 14

 12

 10                                                                                                                                                                                                                                                 MRSA (Non
                                                                                                                                                                                                                                                    Bacteraemia)
  8                                                                                                                                                                                                                                                 MRSA
                                                                                                                                                                                                                                                    Bacteraemia
  6                                                                                                                                                                                                                                                 C diff

  4

  2

  0
      48 Hr

              23 Hr

                      Beaumont

                                 Castle

                                          Charlecote

                                                       Coronary Care

                                                                       Dugdale

                                                                                 Guy

                                                                                       Hatton (SSS)

                                                                                                      ITU

                                                                                                            Labour

                                                                                                                     Macgregor

                                                                                                                                 Malins

                                                                                                                                          Mary

                                                                                                                                                 Nicholas

                                                                                                                                                            Oken

                                                                                                                                                                   SCBU

                                                                                                                                                                          Squire

                                                                                                                                                                                   Swan

                                                                                                                                                                                          Victoria

                                                                                                                                                                                                     Whittaker

                                                                                                                                                                                                                     Willoughby

                                                                                                                                                                                                                                  Warwick Unknown
                                                                       MRSA (Non                                                   MRSA
Ward                                                                                                                                                                                                 C diff
                                                                       Bacteraemia)                                              Bacteraemia
48 Hr                                                                       7                                                                                                                                    4

23 Hr

Beaumont                                                                               2                                                                                                                   3
Castle                                                                                 10                                                        1                                                        12
Charlecote                                                                             4                                                                                                                   4
Coronary Care                                                                                                                                    1
Dugdale                                                                                1                                                                                                                         5
Guy                                                                                    4                                                         2                                                               6
Hatton (SSS)                                                                           6                                                                                                                         4
ITU                                                                                    10                                                                                                                        2
Labour
Macgregor
Malins                                                                                 7                                                                                                                   4
Mary                                                                                   15                                                        1                                                        10
Nicholas                                                                               4                                                                                                                   2
Oken                                                                                   2                                                                                                                   1
SCBU                                                                                   1
Squire                                                                                 6                                                                                                                         6
Swan                                                                                   1
Victoria                                                                               5                                                                                                                         1
Whittaker
Willoughby                                                                             4                                                         2                                                               9
Warwick Unknown                                                                                                                                  1


Dr S P Mather                                                                                                                                                                                                                                                      8
Medical Director/DIPC                                                                                       June 2009
             SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST

MRSA WOUND INFECTIONS/ORTHOPAEDICS

A period of increased incidence of surgical site infection in orthopaedics was noted in June
2008. The Infection Prevention and Control Team were alerted to 3 patients having been
re-admitted to the orthopaedic ward due to surgical site infection following surgery in April
2008. In depth surveillance and analysis was commenced and these 3 patients were
confirmed as having MRSA infections. Phage typing on 2 of these cases showed different
types of MRSA therefore cross-infection in these cases was excluded. One further case of
MRSA wound infection, which resulted in an MRSA bacteraemia, was noted. In addition 3
other cases of surgical site infection caused by organisms other than MRSA were also
noted.

Investigation did not identify any single causative factor. However several possible
contributory factors were noted including environmental and operational matters. Remedial
actions have been taken within orthopaedics which include ward refurbishment, increased
cleaning, better storage, more sensible use of operating lists, increased staff recruitment,
and the establishment of nurse educators.

MEASLES

An outbreak of measles was identified within the community of South Warwickshire in
October 2008. As a result, Warwick Hospital had a total of nine measles cases through the
Trust either as outpatients or inpatients during October and November. A large contact
tracing exercise was necessary as the initial case admitted to hospital was not recognised
as measles and the patient was cared for in a main ward area. All patients (and their GPs)
who were in contact with this patient were sent contact letters. All staff contacts were
traced by Occupational Health (OH) and offered MMR vaccine if non-immune on testing.
Thereafter awareness regarding measles was increased. Subsequently all patients who
have presented with possible measles have been admitted directly into isolation. No
further patient contact tracing has been required and OH has been informed of staff
contacts on an ongoing basis. Throughout this outbreak period close liaison has been
maintained with the Health Protection Agency.

NOROVIRUS

Seasonal Norovirus outbreaks were noted in October and again in December. Whilst
contributing to disruption of Trust activity, these outbreaks were contained in the normal
manner.

A Trust-wide outbreak of Norovirus was noted in February 2009 and lasted until mid-May
2009. A total of 9 wards were affected with 4 of these wards being infected on more than
one occasion.

The outbreak presented a major challenge for the Trust with over 200 patients and staff
affected. Daily outbreak meetings were held and on-call advice was provided by the
Infection Prevention Nurses during this difficult time. Of particular note was the unusually
long duration of this outbreak and re-infection of wards. A “look-back” exercise is planned
with assistance from the SHA. A large contributory factor was the winter pressure which
the Trust was subject to and this highlighted the need to maintain a permanent isolation
facility with flexibility to move from MRSA isolation to C difficile isolation according to the

Dr S P Mather                                                                                9
Medical Director/DIPC               June 2009
            SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST

prevailing needs of the Trust. Multiple patient moves may also have contributed to the
prolonged outbreak and this will be addressed in the coming year with the new ward
construction.


HAND HYGIENE

The importance of effective hand hygiene and compliance by all has continued to be
emphasised and ongoing Trust-wide audit results are demonstrated below.




A Trust-wide compliance level of 95% or above is considered optimal and on the majority
of occasions this has been achieved. Hand hygiene practices continue to be taught during
all Infection Prevention training, which is delivered to all grades of staff.

OTHER INFECTIONS

A significant increase in Hospital Standardised Mortality Rate (HSMR) was noted in
January and March. This statistical calculation does not inform health organisations of the
reasons for the increase. Perusal of the notes of all deceased patients during those two
months shows that pneumonia is the biggest single cause of death with the vast majority
of those deaths occurring in the over 80 year old group. In nearly all of those cases, the
pneumonia was the primary reason for hospital admission. Whilst it may not be possible to
reduce the number of pneumonias in the Trust, specific actions are to be taken to target
this group of patients. In particular, a single medical protocol for managing chest infections
is to be followed, no matter which ward the patient is admitted to and nursing protocols are
being developed which will ensure optimal nursing and physiotherapy care delivery.

CONTINUING TRUST ACTIONS TO CONTROL HEALTHCARE ACQUIRED
INFECTIONS

      The Infection Prevention Board continues to meet monthly. Hand hygiene and
       Saving Lives audit results are presented by the ward managers. The results of Root
       Cause Analyses are discussed and actions distributed.


Dr S P Mather                                                                              10
Medical Director/DIPC              June 2009
            SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST


      A district DIPC forum has been established, hosted by the PCT. This facilitates
       discussion between various agencies and allows co-operative working across the
       county
      Root cause analysis is now a routine procedure followed in all cases of MRSA
       bacteraemia and where a cluster of CDAD cases have occurred in one area of the
       hospital. All relevant clinical staff are involved and the results are shared with the
       Infection Prevention Board by the responsible consultant
      Hand hygiene audits are carried out regularly in each clinical area. Areas scoring
       less than 95% compliance are audited weekly until the compliance rates are
       deemed satisfactory, where after these are monthly. In contrast with the preceding
       year, hand hygiene audits are significantly improved with 95% being achieved in
       nearly all clinical areas. Antimicrobial prescribing continues to be monitored on a
       regular basis. The „five day‟ prescription policy is audited regularly. Ward
       pharmacists have the power to enforce the five day rule for antibiotic prescriptions.
      A revised policy for the insertion of intravenous cannulae was introduced in 2007.
       This has resulted in a significant reduction of MRSA bacteraemias solely due to
       cannula insertion, with the last identified case noted in September 2007.

THE FUTURE

The Trust Board is committed to a zero-tolerance to HCAI and, through continued
application of existing and revised protocols within the Trust, together with close co-
operation with our partners in the healthcare economy, we continue to make every effort to
reduce the number of HCAI. It has to be recognised, however, that infectious organisms
are impossible to eradicate and that rigorous infection control actions must be effected in
the community as well as in secondary care, before a significant reduction in HCAI can
occur.

THANKS

The Trust owes a debt of gratitude to all of the Infection Control Team for their continued
hard work, often in trying circumstances. Without their efforts, we would not have achieved
the results which we did, meeting the MRSA target and easily exceeding the C diff target.

THE INFECTION CONTROL TEAM 2008-2009


Dr Jan Van den Ende               Consultant Microbiologist and Infection Control Doctor

Dr Thekli Gee                     Consultant Microbiologist

Mrs Christine Georgeu             Matron for Infection Prevention & Control

Mrs Kate Wheeler                  Infection Control Nurse

Mrs Gill Pinder                   Infection Control Nurse

Mrs Lizzie Robinson               Trainee Infection Control Nurse

Mrs Jackie Woodmass               Infection Control Administrator

Dr S P Mather                                                                              11
Medical Director/DIPC              June 2009

								
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