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Infection Control Annual Report

2016 – 2017

UCLH NHS FOUNDATION TRUST INFECTION CONTROL ANNUAL REPORT

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1.0 Contents

2.0 Executive Summary

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3.0 Summary of performance 2016-2017

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3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8

MRSA bacteraemia Clostridium difficile Methicillin sensitive staphylococcus aureus (MSSA) bacteraemia E. coli bacteraemia Intravenous device related infections Infection control compliance Surveillance and infection control audits Antibiotic stewardship

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3.9 Gram negative micro-organisms

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3.10 Influenza

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3.11 Norovirus 8 3.12

MRSA screening

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4.0 Other significant issues

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4.1 Estates and planning

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4.2 4.3

Outbreaks and incidents Decontamination

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Appendix 1 Infection control provision and arrangements

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Appendix 2 Graphs and tables

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Appendix 3 Definition of catheter associated and related blood stream infection

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1.0 Executive Summary 1.1 This is the report of the Director of Infection Prevention and Control (DIPC) and summarises

the work undertaken in the organisation for the period 1 April 2016 to 31 March 2017.

1.2 There were 2 cases of MRSA bacteraemia against a trajectory of 0

1.3 There were 29 cases of MSSA bacteraemia during this period.

1.4 There were 90 cases of hospital-acquired Clostridium difficile in UCLH during this period

against an ambition of <97 cases. 80 cases were successfully appealed and 10 cases were

classified as lapses in care which included delay in sampling and isolation. Root causes were

primarily associated with appropriate antibiotic usage and recurrent C.difficile infection.

1.5 The C. difficile taskforce group continued to led on the C. difficile reduction plan. As most of

the actions initiated by group also contributed to the prevention, management and monitoring

of Carbapenemase producing organisms (CPOs) the work of the group also encompassed

this area.

1.6 By March 2017 the Infection Control Quality Improvement tool was in use by all areas and

replaced the previous hand hygiene compliance monitoring tool.

1.7 The surveillance of surgical site infection (SSI) continued. Infection rates did not change

significantly from the previous year (2015-16) in most followed-up categories of surgery. In

Spinal surgery rates decreased from 2.78% to 0%, in Large Bowel surgery rates decreased

from 18.3% to 11% and infection rates for caesarean sections were consistently below

national average of 1.43% vs. 3.56%.

1.8 Pseudomonas and Legionella in water continues to be monitored and managed.


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2.0 Summary of Infection Prevention and Control performance 2016-17

3.1 MRSA bacteraemia

3.1.1 There were 2 cases of MRSA bacteraemia against a national trajectory of 0. (Graph 1

Appendix 2).

3.1.2 In both cases the root cause was associated with drains i.e. a CSF drain and a biliary drain.

3.1.3 Education, training and support was provided to improve practice in invasive devices insertion,

management and documentation of ongoing care.

3.2 Clostridium difficile (C.difficile)

3.2.1 UCLH reported 90 hospital-attributed C.difficile cases in this period (Graph 2a, Appendix 2).

The ribotype strains identified were diverse reflecting the distribution and carriage in the

community and not indicative of transmission (Graph 2b, Appendix 2).

3.2.2 UCLH continues to test more cases than most other trusts for C.difficile infection. The

rationale is that early detection and treatment improves patient outcomes. However this

increases ascertainment. In addition cases are predominantly identified in patients with

haematological or oncological conditions requiring chemotherapy where early treatment is

particularly beneficial.

3.2.3 80 of the 90 hospital acquired C. difficile toxin positive cases were successfully appealed via

the clinical commissioning group (CCG). Successful appeals predominantly related to patients

requiring antibiotics which were prescribed and delivered in accordance with the UCLH policy

which reflects best practice. 10 cases were classified as ‘lapses in care’. This included

isolation in a single room delayed, poor completion of stool chart and stool sampling delay and

inappropriate C. difficile infection treatment. This is a 16% reduction in lapses in care identified

compared to last year.

3.2.4 Most of the cases were attributed to the administration of appropriate antibiotics to patients

with infections which were not preventable and life threatening if not treated with antibiotics.

As in previous years, many of these patients were immuno-suppressed. Reviews indicated

that antibiotic prescribing was appropriate and in line with microbiological and clinical advice.

3.2.5 Laxative usage was appropriate in the cases reviewed and was often used to treat

constipation induced by treatment such as pain control. A high percentage of cases had an

underlying bowel disease such as Crohns disease or previous colectomy and it was

sometimes difficult to determine when they had a change in bowel pattern. Approximately 17%

of the cases reported had recurrent C.difficile infections and 10% had had C. difficile antigen

detected previously.

3.2.6 The C. difficile taskforce group continues to lead and monitor the C. difficile reduction plan

based on key learning from RCA results. The main learning points from the review of these

cases for 2016-7 were associated with recognizing diarrhea as soon as possible, obtaining

specimens early and disseminating learning from the RCA process.

3.2.7 A weekly review of C. difficile toxin and antigen patients by Infection Control and Microbiology

was introduced in September 2016. This coincided with an improved method of recording


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details of the infection and care required in documentation. The aim is to monitor progress and

intervene at an earlier stage to avoid further relapses/recurrences or failed treatments.

3.2.8 The results of an evaluation of UV decontamination following cleaning indicated that it could

be used instead of HPV in some instances. UV decontamination was subsequently added to

the cleaning processes used.

3.2.9 Deep cleaning of the patient environment across the Trust is undertaken annually.

3.3 Meticillin sensitive staphylococcus aureus (MSSA) bacteraemia

3.3.1 Graph 3 (Appendix 2) illustrates the trend at UCLH from April 2006:

3.3.2 There were 29 cases of hospital acquired MSSA bacteraemia in 2016-17. UCLH undertakes

an RCA similar to the MRSA PIR in these cases. The root causes are summarised in Table A

below, some cases had more than one root cause.

Table A - RCA of MSSA cases

Likely source of MSSA BSI Total

Traumatic wound 2

Infected CVC 9

Skin soft tissue infection 3

Chest infection/ VAP 2

Infected DVT 1

Infected arterial line 1

Surgical wound 2

Infected peripheral IV cannula 6

Likely contaminated blood culture 1

Other infection 0

Unknown 2

3.3.3 Education, training and support was provided to improve practice in invasive devices insertion,

management and documentation of ongoing care.

3.3.4 A blood culture pack is in use and prompts good practice in sampling and documentation.

3.4 E. coli bacteraemia

3.4.1 An E. coli bacteraemia reduction ambition for the whole health economy has been established

by the Department of Health. A 10% reduction rate is proposed for 2017-18 and 50% overall

reduction by 2020.

3.4.2 UCLH has been working with PHE, CCG and CSU to develop a sustainable strategy to

approach this ambition.


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3.5 Intravenous device related infections

3.5.1 UCLH has been one of the pilot sites for the Public Health England bacteraemia surveillance

in critical care. As few UK organisations currently collect this data there is no UK comparator

data.

3.5.2 The definitions of catheter associated blood stream infection (CA-BSI) and catheter related

blood stream infection rate (CR-BSI) are included in Appendix 3. Haematology and oncology

patient were included from the 1st of October 2016.

3.5.3 The results of the audit are summarised in Table C below.

Table C - VADs audit October 2015 – March 2016

Line

days

CA-

BSI CA-BSI Rate CR-BSI CR-BSI Rate

Central

VADs

14171 23 1.62 Per 1000 line days 10 0.71 Per 1000 line days

Midlines 5687 5 0.88 Per 1000 line days 3 0.53 Per 1000 line days

3.5.4 An audit of peripheral vascular devises in October 2016 indicated improvement was required

in documentation and daily review of these devices.

No

3.6 Infection control compliance

3.6.1 Education, training and promotion work continued to promote hand hygiene and infection

control compliance.

3.6.2 The observation based hand hygiene compliance monitoring system was replaced by a

continuous quality improvement tool during this period and incorporated work to remove

factors which are a barrier to compliance and to focus on improvement.

3.6.3 The tool was introduced with training across the trust and by March 2017 the new ICCQI

reporting tool was in use by all reporting areas. This did however lead to a drop in scores as

the aim was to seek areas for improvement and a lower score is expected. (Graph 4,

Appendix 2)

3.6.4 Evaluation by users of the ICCQI tool was positive. An audit of hand hygiene product

availability which had been selected as an area for improvement indicated significant

improvement.

3.6.5 Training in hand hygiene continued throughout the year and e-learning is mandatory on

induction.

3.7 Surveillance and infection control audits

3.7.1 Surveillance of infection information is available to staff at ward, division and board level. Data

are validated regularly by the Trust epidemiologist who produces a weekly report and

identifies trends for discussion and possible action.

3.7.2 Surveillance of surgical site infection (SSI) is undertaken in most of the specialities for at least

3 months every year. Post- operative patients are followed up for 30 days following surgery (1

year where an implant is involved) and we report this data to PHE on a quarterly basis. This is

summarised in Table 1 Appendix 2.


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3.7.3 Infection rates did not change significantly from the previous year in most categories of

surgery. In Spinal surgery rates decreased from 2.78% to 0%, in Large Bowel surgery rates

decreased from 18.3% to 11% and in caesarean sections SSI rates were consistently below

the national average (1.43 vs. 3.56%). 3.7.4 In total knee replacement the rate was 1.50% vs.

national rate 0.45%. This was investigated and no significant issues were identified. The

numbers of infections are low and minor changes in numbers have a disproportionate effect

on the rates reported.

3.7.5 A National point prevalence survey (PPS) of antibiotic usage and healthcare acquired

infections was undertaken in November 2016. PHE estimated t the prevalence of HAI is

approximately 8.5% at UCLH and the percentage of patients receiving antibiotics is 33.3%

which is in line with National data.

3.7.9 Trust wide audits undertaken during this period included:

Intravenous line management and documentation audit

Safety sharp devices audit

Hand hygiene product availability audit

3.7.10 Results of these audits were fed back to staff and education and support was provided. The

new IC QI tool enables staff to include areas of low compliance in a continuous improvement

cycle.

3.8 Antibiotic stewardship

3.8.1 The Antibiotic usage committee (AUC) met monthly and reported to the Quality and Safety

Committee.

3.8.2 The Antimicrobial Resistance CQUIN focussed work on antimicrobial stewardship, guideline

review, use of alternative antibiotic agents and doses and reduction in duration of therapy.

3.8.3 Monthly audits were conducted manually Trust wide to measure review of antibiotic

prescriptions within 72 hours of initiation.

3.8.4 The AUC has a rolling agenda to produce, review and ratify all trust antimicrobial guidelines.

3.8.5 The antibiotic App is established and has been updated to reflect current guidelines and

recent changes.

3.8.5 An e-learning package is now included on the UCLH learning portal for all doctors and

pharmacists as ‘essential for role’ training.

3.8.6 A generic presentation was developed to allow Committee members to promote stewardship

messages at their respective governance / audit days.

3.9. Gram negative micro-organisms

3.9.1 In 2016-17 14 patients with carbapenemase producing organisms (CPO) (mostly Klebsiella

pneumoniae and E. coli, but also other gram negatives, such as Citrobacter freundii and

Acinetobacter pittii) were detected: 12 in UCLH inpatients, one from a GP practice and one

from a private patient (Graph 7, Appendix 2). The prevalence of carbapenem resistant

organisms is likely to rise alongside neighbouring trusts in the near future. At present UCLH

has been successful in limiting the incidence by good infection control procedures and spread

is very limited. Hence screening has been limited to reactive screening of wards when cases


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have been identified. Reduction in the usage of broad spectrum antibiotics is key to overall

control and management of CPO.

3.9.2 During 2016/17 a number of highly resistant gram negative micro-organisms were isolated

from patient’s samples, many of which were imported from abroad or from other health care

providers. This is becoming a significant issue for the Trust and the introduction of screening

for specific organisms will be made mandatory in future.

3.9.3 Three graphs 5, 6, 7a in Appendix 2 illustrate the incidence of gram negative bacteraemia but

not the resistance patterns inpatients within the Trust. We present recent trends of

Carbapenem resistance in the two most common Gram-negative causes of bacteraemia: E

coli (graph 7b) and Pseudomonas species (graph 7c) to illustrate the fact that the occurrence

of multiply resistant cases depends on the organism detected in blood. Although these cases

are rare among UCLH inpatients, their occurrence warrant close monitoring as most are

potentially fatal and highly spreadable. Overall the number of these cases is significantly

higher than MRSA or MSSA. As antibiotic resistance increases it will be increasingly difficult

to treat these patients in future therefore a robust system to identify and manage high resistant

organism will be a priority.

3.10. Influenza

3.10.1 An outbreak of Influenza was declared by the Trust in December 2016 (See 4.2). The increase

in Influenza cases was higher in Quarter 4. (Graph 8, Appendix 2)

3.11. Norovirus

3.11.1 There was a peak of Norovirus in Quarter 4 which coincided with the Influenza outbreak

declared by the Trust. (Graph 9 Appendix 2,).

3.12. MRSA screening

3.12.1 MRSA molecular screening has been proven not to be cost effective for all patients requiring

screening. A culture based screening method has been introduced with little impact on timings

of results or patient care.

3.12.2 The MRSA screening policy has been reviewed to identify risk category groups for the

introduction of targeting screening according to DH guidance

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/345144/Implem

entation_of_modified_admission_MRSA_screening_guidance_for_NHS.pdf,,

4.0 Other significant issues

4.1 Estates and Planning

4.1.1 The ICT directorate continued to support and provide advice to numerous schemes to develop

or create facilities and services.

4.1.2 Collaborative work with the Estates and Facilities Division continues to improve monitoring

and reporting on cleaning standards and maintenance and monitoring of the estate.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/345144/Implementation_of_modified_admission_MRSA_screening_guidance_for_NHS.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/345144/Implementation_of_modified_admission_MRSA_screening_guidance_for_NHS.pdf


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4.1.3 The monitoring and eradication of Pseudomonas in taps and showers continues. A system of

regular shower head changes in high risk areas has been established and water outlet testing

is in place.

4.1.4 The operational Water Management group has led on mitigation and management of this

issue with support from ICT. The Water Management Group meets on a quarterly basis and is

led by Estates manager with representatives from Microbiology, Infection Control and

contractor services attending the meetings.

4.1. 5 Enhanced water testing has been undertaken on the Neonatal unit (NNU), Haematology and

Oncology areas in compliance with DOH guidelines and advice.

4.2 Outbreaks and incidents

4.2.1 Virology incidents

4.2.2 Bay and ward closures associated with patient exposure and transmission of viral infections

resulted in 906 hospital bed days lost. Of these 716 were associated with an outbreak which

commenced in December 2016.

4.2.3 Summary of the outbreak December 2016-February 2017

In December 2016 there was a sudden increase in admissions with influenza. This coincided

with capacity pressures over the Christmas and New Year period. Simultaneously, a high

number of RSV cases were also identified which mainly affected the elderly population. An

influenza outbreak was declared on 29.12.2016 (Figure 1).

The outbreak lasted eight weeks and included cases of Influenza A, RSV and Norovirus cases

(Table 2). During this period a ‘Flu’ ward was identified and used twice. The lessons learnt from

this outbreak will be used to improve policies, guidleines and processes.

Figure1: Number of positive respiratory samples


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Table 2: Bays and Ward closures during the outbreak December 2016- February 2017

4.2.4 Measles

There were 12 confirmed measles cases during this period including a member of staff, all of

which were community acquired. Many of these cases required investigation and contact

tracing of exposed staff and patients.

4.2.5. Microbiology incidents

4.2.6. Tuberculosis

There were two incidents of open pulmonary TB which required look back exercises involving

staff and patients. There was no evidence transmission.

4.2.7. Carbapenemase producing organism (CPO)

Twelve inpatients had a CPO during this period, one of which was identified as hospital

acquired. A look back exercise was unable to identify links between shared staff and

equipment. A deep clean of the clinical area using HPV was performed. No further hospital

acquired cases have been identified to date.

4.2.8. Isolation

Isolation in single rooms in the Trust continues to be of limitation and an increase in isolation

facilities is included in planned development. An isolation prioritisation tool is in use and usage

is based on a risk assessment by the infection control team and clinical site managers. An

isolation prioritisation tool for paediatrics was finalised and introduced this year. The aim was to

optimise current paediatric isolation capacity and reduce the need to transfer patients to other

hospitals for isolation.

4.3. Decontamination

4.3.1 Decontamination processes have been reviewed across the Trust

4.3.2 A decontamination specialist advisor works alongside the infection control team monitoring

and reporting decontamination processes

4.3.3 The management of trans-esophageal echocardiogram TOE probes that are in use within the

Trust is part of the on-going monitoring.

Flu A RSV Noro Other virus Flu A RSV Noro Other virus

Week 1 26/12/16-01/01/174 0 1 0 0 0 0 0

Week 2 02/01/17-08/01/176 0 0 0 0 0 0 0

Week 3 09/01/17-15/01/1719 5 0 0 1 0 0 0

Week 4 16/01/17-22/01/1711 5 1 0 0 0 0 0

Week 5 23/01/17-29/01/178 0 4 1 0 0 2 0

Week 6 30/01/17-05/02/175 0 2 2 1 0 5 0

Week 7 06/02/17-12/02/178 1 0 0 0 0 3 0

Week 8 13/02/17-19/02/170 0 0 0 0 0 0 0

Bays closed Wards closed


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4.3.4 The decontamination advisor is part of the CJD group at NHNN, which is designed to look at

specific requirements and processes for neurological surgical instruments as well as working

closely with sterile services advising in best practice for the management and decontamination

of surgical instruments.

4.3.5 A formalised process for the review of manufacturers decontamination guidance for medical

devices and equipment during the procurement process continues, to ensure that there are

compatible systems in place for cleaning and decontamination prior to equipment being

brought into the organisation.

4.3.6 The team continue to support areas in developing and reviewing risk assessments as well as

ensuring there are up to date written procedures (SOPs) and ongoing training programmes for

the local management of decontamination. Particular focus has been on services which use

Nasoendoscopes and working with service leads to standardising processes across the Trust.

Annette Jeanes

Director of Infection Prevention and Control

18/7/2017


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Appendix 1

Infection Control Provision and Arrangements . 1.0 The Infection Control department provides an infection control service for the University

College London Hospitals NHS Foundation Trust (UCLH). A service is also provided for Harley Street @ UCH.

2.0 The Trust is required to meet the duties of the Hygiene Code, NHS Litigation Authority (NHSLA) and the Core standards of the Care Quality Commission. In addition there is a requirement to demonstrate compliance with NICE and best practice guidance.

3.0 The infection control service is delivered and facilitated by an infection control team which includes staff in different disciplines and boards. The team covers all sites of the Trust. The funded establishment1 currently is:

9.6 WTE infection control nurses (ICN)

1.0 WTE consultant nurse

1.0 WTE microbiologist

1.0 WTE epidemiologist

4.6 WTE surveillance staff

1.0 WTE antibiotic pharmacist

1.0 WTE Infection Control Co-ordinator

0.4 WTE decontamination advisor

3.0 Other members of the team include:

Microbiologists, virologists, Infectious diseases, environmental monitoring officers, matrons, infection control liaison practitioners, Occupational Health and sterile services.

The neonatal and special care baby unit fund an embedded part-time infection control nurse who is supported and supervised by the infection control team.

The UCH ITU fund part-time infection control link nurses who are supported by the infection control team.

5.0 The Director of Infection Prevention and Control (DIPC) is the infection control nurse

consultant. The job description of the DIPC contains both roles. In 2015 the role also includes management of the IC team and decontamination lead.

6.0 The core infection control service includes an infection control advisory service, proactive infection prevention work and education and training throughout the organisation. It also undertakes audit, policy formulation and advice, surveillance and epidemiology, outbreak and control management. A significant aspect of their work is advising on planning.

7.0 An advisory service is operated daily and out of hours. This is provided by the on-call microbiology and virology service. At week-ends and on bank holidays there is an infection control nurse on-call from 09.00-17.00.

8.0 There is a daily meeting of microbiology, virology and infection control staff to review clinical information and service responses. The core infection control team meets weekly to formally review infection control issues and performance.

9.0 The Trust infection control committee (TICC) is chaired by the DIPC and meets bi-monthly with representatives from boards and key service areas. The minutes are available on the intranet. This committee reports to the QSC.

10.0 The ICT work closely with the CCG and PHE and other stakeholders. Examples include: C.difficile RCAs are reviewed regularly with the CCG. Post infection reviews are undertaken on all MRSA & MSSA bacteraemia and MRSA PIR are reported to PHE

1 This includes posts which are funded by other departments such as pharmacy and posts which are not filled


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Appendix 2

Graph 1 MRSA bacteraemia cases. HA = hospital-acquired (detected 2+ days after admission), CA = community-acquired (detected within 2 days of admission). T15 are private inpatients.

Graph 2a: Clostridium difficile cases; HA = hospital-acquired (detected 3+ days after admission, includes lapses in care, successful appeals and pending appeals), CA = community-acquired (detected within 3 days of admission), T15 as in Graph1; NREP = not reportable (because the illness was attributable to factors other than C difficile [HPA/PHE guidelines]). The HA incidence (black line with triangular markers) reflects the subset of HA cases relevant to the ambition – the increase at the end of the year is a reflection of the changes in appeal methodology introduced in February 2015.


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Graph 2b: Distribution of C diff ribotypes, cases detected in 2016-17; HA = hospital-acquired (detected 3+ days after admission, includes lapses in care, successful appeals and pending appeals), CA = community-acquired (detected within 3 days of admission), COMM = detected in the community (GP, outpatients etc).


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Graph 3: MSSA bacteraemia cases; HA = hospital-acquired (detected 2+ days after admission); CA = community-acquired (detected within 2 days of admission); T15 is a private patient’s ward. The ambition is an internal reduction aspiration.

Graph 4: Hand Hygiene compliance incorporating quality improvement reporting


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Graph 5 Pseudomonas aeruginosa bacteraemias; HA = hospital-acquired (detected 2+ days after admission); CA = community-acquired (detected within 2 days of admission); T15 is a private patient’s ward.

Graph 6 E coli bacteraemia; HA = hospital-acquired (detected 2+ days after admission); CA = community-acquired (detected within 2 days of admission); T15 is a private patient’s ward.


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Graph 7 Number of patients colonized/infected with carbapenemase-producing organisms

Graph 7a Other gram negative bacteraemia (hospital-acquired only, i.e. detected 2+ days after admission).


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Graph 7b Percent Carbapenem resistance in E coli bacteraemias (all inpatients regardless of when detected, i.e. hospital- and community-acquired cases). +

Graph 7c Percent Carbapenem resistance in Pseudomonas species bacteraemias (all inpatients regardless of when detected, i.e. hospital- and community-acquired cases).


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Graph 8 Influenza cases. HA = hospital-acquired (detected 2+ days after admission); CA = community-acquired (detected within 2 days of admission); T15 is a private patient’s ward.

Graph 9: Norovirus cases. HA = hospital-acquired (detected 5+ days after admission); CA = community-acquired (detected within 5 days of admission); T15 is a private patient’s ward.


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Table 1 Surgical operations carried out at UCLH during 2016; N f-up = number followed up by the SSISS team; N Inf = number of infections detected in hospital among followed-up surgeries (HPA/PHE definitions);

Category of surgery

Number of operations

N f-up (%)

N Inf. (%)

National %‡

Caesarean section Cranial Knee replacement Large bowel Limb amputation Repair of neck of femur Small bowel Spinal Total hip replacement Thoracic surgery Urology

2212 1494 304 215 15 81

226 829 378 486 3616

420 (19) 284 (19) 200 (66) 272 (80) 2 (13) 14 (17) 173 (77) 157 (19) 243 (64) 328 (67) 497 (14)

6 (1.43) 6 (2.11) 3 (1.50) 19 (11.0) 0 (0.0) 0 (0.0) 11 (6.36) 0 (0.0)

1 (0.41) 3 (0.91) 8 (3.22)

3.56 (*) 1.56

0.45 (*) 9.28 2.84

- 6.53 1.20 0.51

- -

‡Comparisons with national rates use the subset of data collected nationally between April 2011 to October 2016 where that exclude patient-reported infections (PHE guideline); and there is no attempt to control for case-mix in this comparison. (*) = statistically significant difference (Chi-square test for proportions – highlighted only where the UCLH sample size is greater than 10 operations).


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