NLG(19)265 · to improve performance. ... Peripheral cannulae associated phlebitis remains within...

NLG(19)265

DATE OF MEETING 5th November 2019

REPORT FOR Trust Board of Directors – Public

REPORT FROM Maurice Madeo - Deputy DIPC

CONTACT OFFICER Maurice Madeo / Ellie Monkhouse

SUBJECT Annual DIPC report

BACKGROUND DOCUMENT (IF ANY)

PURPOSE OF THE REPORT: Give the board a synopsis of the activities undertaken by the Infection Prevention & Control team to maintain Patient Safety and performance against a number of key indicators.

EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)

43% reduction in C.difficile cases No MRSA hospital onset cases 18 months Influenza vaccination in frontline workers >78% Deep cleaning remains behind schedule – DPOW 75% C.difficile cases detected at DPOW Feedback mechanisms for staff improved inc development of a hand hygiene app with WebV. Antimicrobial stewardship remains a challenge and further work required to improve performance. Reduction in isolation capacity with ward 10 & 11 closure on SGH site impacting on winter viruses management during surges. Onsite presence of consultant medical microbiologists limited impacting on visibility and attendance of high level meetings.

TRUST BOARD ACTION REQUIRED The Board is asked to take note of the report and take action as required.

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INFECTION PREVENTION & CONTROL TEAM

ANNUAL REPORT

TO THE

DIRECTOR OF INFECTION PREVENTION & CONTROL

2018-19

Written by M. Madeo Deputy DIPC / Senior Nurse IPC on behalf of the DIPC / Chief Nurse

Ellie Monkhouse.

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Contents:

Table and Figures ............................................................................................................. 4

Executive Summary .......................................................................................................... 5

Performance ...................................................................................................................... 5

Governance ....................................................................................................................... 5

Training / Education ........................................................................................................... 5

Areas for further improvement and support include: .......................................................... 6

Introduction ..................................................................................................................... 7

Infection Prevention and Control Workforce arrangements ................................................ 7

Infection Prevention & Control Team at March 2019.......................................................... 8

Infection Prevention & Control Committee ......................................................................... 8

Surveillance of Healthcare Associated Infection ................................................................ 9

MRSA Bacteraemia ........................................................................................................... 9

Blood Culture Contamination Rates ................................................................................. 10

Clostridioides difficile (formerly known as Clostridium difficile) Infections ......................... 11

Post Infection Review ...................................................................................................... 14

Some of the initiatives introduced to reduce the risk of infection including CDI. ............... 14

Staphylococcus aureus bacteraemia ............................................................................... 16

Gram negative blood stream infections inc E.coli. ........................................................... 17

Surgical Site Infection Surveillance .................................................................................. 21

CDCU post procedure infection ....................................................................................... 24

Influenza / Viral respiratory disorders .............................................................................. 25

Respiratory syncytial virus – paediatric. ........................................................................... 27

Ventilator associated pneumonia. .................................................................................... 27

Point Prevalence Surveillance ......................................................................................... 28

Carbapenem Resistance and CPEs ................................................................................ 29

Facilities Service update .................................................................................................. 30

Ward Environmental Audits (Flo) ..................................................................................... 31

Decontamination ............................................................................................................. 32

Water Safety Group ......................................................................................................... 32

Pseudomonas Water Testing .......................................................................................... 33

Antimicrobial Management .............................................................................................. 33

Patient Information .......................................................................................................... 33

MRSA colonisation .......................................................................................................... 34

Patients with Unexplained Diarrhoea ............................................................................... 34

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Outbreaks ........................................................................................................................ 35

Hand Hygiene .................................................................................................................. 36

Isolation Facilities ............................................................................................................ 37

Microbiology Laboratory .................................................................................................. 38

Infection Prevention and Control Policies ........................................................................ 38

Training and Education .................................................................................................... 39

Community & Therapies Services – information provided by Noelle Williams IPCN ......... 41

Overview ......................................................................................................................... 41

Surveillant organisms ...................................................................................................... 41

Audit ................................................................................................................................ 42

Community & Therapy Link Practitioner Forum ............................................................... 42

Decolonisation Service .................................................................................................... 43

Infection Risk Assessment Tool ....................................................................................... 43

Activity and Engagement ................................................................................................. 44

Appendices .................................................................................................................... 45

Appendix 1: Infection Control acute committee attendance 2018-19 .............................. 45

Glossary .......................................................................................................................... 46

Publications / Conference presentation. .......................................................................... 47

Appendix 2 -Antimicrobial Stewardship ............................... Error! Bookmark not defined.

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Table and Figures

Table 1 MRSA bacteraemia cases since 2006 ...................................................................... 9

Table 2 Hospital onset E.coli bacteraemia cases 2018-19. ................................................. 20

Table 3 Orthopaedic hip and knee replacement infection rates ........................................... 22

Table 4 Surgical Site Infections January 2014 to December 2018...................................... 23

Table 5 Influenza vaccination uptake by frontline workers .................................................. 26

Table 6 PPS Feedback ...................................................................................................... 28

Table 7 Flo Audit Scores .................................................................................................... 31

Table 8 PLACE scores 2018 NLaG .................................................................................... 32

Table 9 Policies updated within last year............................................................................. 38

Figure 1 Total Number of MRSA Bacteraemia Hospital Onset Yorkshire & Humber 2018-19.

............................................................................................................................................. 9

Figure 2 Blood culture contamination data trust wide for 2018-19 ....................................... 10

Figure 3 DPOW ECC SGH ECC ................................................................ 11

Figure 4 Breakdown of C.difficile cases by ward ................................................................. 11

Figure 5 Number of C.difficile cases .................................................................................... 13

Figure 6 days between CDI cases ...................................................................................... 13

Figure 7 - MSSA Trust apportioned cases ........................................................................... 16

Figure 8 Comparison of NLaG performance for MSSA infection ....................................... 17

Figure 9 E.coli resistance national trend ............................................................................ 17

Figure 10 E.coli blood stream infections with reduction trajectory...................................... 18

Figure 11 - Gram-negative patients by age ......................................................................... 18

Figure 12 Trust apportioned Gram negative cases ............................................................ 19

Figure 13 Common causes of E.Coli bacteraemia in cases detected at NLaG .................. 20

Figure 14 Hospital onset E.Coli bacteraemia counts ......................................................... 21

Figure 15 SSI High Impact Intervention Feedback ............................................................ 24

Figure 16 Number of Influenza cases detected comparing 2017-18 - 2018-19 season ..... 25

Figure 17 Influenza cases detected on critical care units. ................................................. 26

Figure 18 Number of RSV cases detected ....................................................................... 27

Figure 19 VAP feedback ................................................................................................... 27

Figure 20 Patients with diarrhoea and time to isolation .................................................... 35

Figure 21 Patients and staff affected with suspected viral gastroenteritis .......................... 36

Figure 22 Hand Hygiene overall compliance scores .......................................................... 37

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Executive Summary

This report is a record of activities relating to the prevention and control of healthcare

associated infection (HCAI) in Northern Lincolnshire and Goole NHS Foundation Trust

during the year April 2018 to March 2019.

The main focus this year has been to continue the work around Gram negative reduction

and antimicrobial stewardship. There has also been targeted surveillance using a modified

Point Prevalence Surveillance toolkit to help capture early deviations from best practice and

instigate corrective measures as required. The team have worked closely with facilities

colleagues to revise the deep cleaning program, refresh the cleaning products and

implement the use of disposable curtains.

There have been a number of achievements in the past twelve months, which include:

Performance

Influenza vaccination of >78% of frontline workers

No Trust apportioned MRSA bacteraemia for 18 months

Peripheral cannulae associated phlebitis remains within acceptable range

The appropriate use of high risk antimicrobials remains a challenge but progress

made.

5 lapses in care / practice associated with C.difficile infection from cases reviewed

which is a reduction from previous year.

21 cases of Hospital Onset Healthcare Associate C.difficile cases compared to 39

last year which signifies over 43% reduction.

Development of KPI feedback mechanisms for frontline staff e.g. IPC dashboard

Governance

Availability of real time IPC ward data for clinical settings e.g. Alert organisms

Development of an IPC WebV database.

Training / Education

IPC Conference day well attended with external speakers.

Link practitioner days well received although staff having difficulty in attending.

Updated the Antimicrobial website to help adherence with related policies.

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Areas for further improvement and support include:

There remain a number of challenges for the Trust that need to be considered going forward.

The lack of single rooms across the trust is being addressed at DPOW through the opening

of A1 and reconfiguration of the C floor wards. However SGH has lost 11 single rooms due

to closure of the Coronation block wards. This lack of single rooms impacted significantly

over the winter period and impeded the management of influenza cases efficiently. The

closure of A1 post winter is impacting on timely isolation of patients with loose stools. This

may also impact on the ability to achieve the revised C.difficile trajectory for 2019/20.

The lack of Consultant Medical Microbiologists onsite 5 days a week continues to impact on

the delivery of a proactive service with antimicrobial stewardship ward rounds. The use of IV

antimicrobials needs reducing as showing at 50% at present.

The Trust is still awaiting the purchase and installation of MALDI-TOF within microbiology to

help speed up culture results and help guide appropriate antimicrobial prescribing. This has

been an ongoing issue for the last 3 years and impacting on the ability to reduce use of high

risk antimicrobials in a timely manner.

Poor attendance at IPCC which makes it very difficult to involve divisions in the planning and

review of proposed workstreams and share lessons.

Improve the uptake of influenza vaccination in frontline workers especially nurses and

medical staff, although CQUIN was achieved.

Increase adherence with antimicrobial Start Smart and Focus. To help achieve an overall

reduction in antimicrobial consumption and meet the new CQUIN targets re urinary tract

infection in >65years of age.

Delays in deep clean programme due to operational pressures especially on the DPOW site

increases the risk of dissemination of infections such as C.difficile. This continues to be

problematic despite escalation.

Better management of invasive devices such as peripheral venous catheters e.g. early

removal. This is being picked up in the Point Prevalence Surveillance now undertaken 4

times a year.

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Introduction

This report is a record of activities relating to prevention and control of healthcare associated

infection (HCAI) in North Lincolnshire & Goole Hospitals NHS Foundation Trust during the

year April 2018 to March 2019. Healthcare associated infection remains a top priority for the

public, patients and staff and remains one of the Trust’s strategic objectives. Avoidable

infections are not only potentially devastating for patients and healthcare staff, but consume

valuable healthcare resources and impact on antimicrobial resistance pressure. Investment

in infection prevention and control remains both necessary and cost effective.

The purpose of this report is to inform patients, public, staff, the Trust Board of Directors,

Council of Governors and Clinical Commissioning Groups (CCG) of the infection prevention

and control work undertaken in 2018-19 and provides assurance that the Trust remains

compliant with the Health and Social Care Act 2008: code of practice on the prevention and

control of infections and related guidance (Department of Health, 2015). This report is

structured using the criteria in the Health and Social Care Act 2008 – Code of Practice for

Health and Adult Social Care on the Prevention and Control of Infections and related

guidance which sets out the criteria against which a registered provider’s compliance with

requirements relating to cleanliness and infection control will be assessed by the Care

Quality Commission (CQC).

Infection prevention and control is the responsibility of everyone in the healthcare community

and is only truly successful when everyone works together. Success is the product of

everyone getting everything right first time, every time. This annual report shows how we are

performing, where we do well and where we would like to do better

1. Systems to manage and monitor the prevention and control of infection. These

systems use risk assessments and consider the susceptibility of service users and

any risks that their environment and other users may pose to them.

Infection Prevention and Control Workforce arrangements

The Trust’s arrangements for the prevention and control of infection are contained within the

document, Infection Prevention & Control Strategy: Overview of the Trust Approach and

Arrangements for Infection Prevention & Control [IC/SP3], which is held by the Directorate of

Governance & Assurance/Trust Secretary. This document details the responsibilities of

various parties within the organisation and their governance and management

arrangements. While the Chief Executive has the final responsibility for all aspects of

infection control, the functional responsibility lies with the Director of Infection Prevention and

Control (DIPC) who is currently the Director of Nursing who took over this role from the

Medical Director in January 2019. The deputy DIPC for IPC oversees the day to day

activities of the IPC team and delivery of the IPC Strategy 2016-19

incorporating the annual work plan.

The number of consultant microbiologists available within PathLinks

continues to have challenges with recruitment. This has left the

availability of onsite consultant microbiologists severely stretched

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/449049/Code_of_practice_280715_acc.pdf

http://nlgnet.nlg.nhs.uk/Infection.Control/Shared%20Documents/Policies,%20Guidelines%20and%20Strategy%20Documents/Overview%20of%20the%20Trust%20Approach%20and%20Arrangements%20for%20Infection%20Prevention%20and%20Control%20%5bIC-SP-002%5d.pdf

http://nlgnet.nlg.nhs.uk/Infection.Control/Shared%20Documents/Policies,%20Guidelines%20and%20Strategy%20Documents/Overview%20of%20the%20Trust%20Approach%20and%20Arrangements%20for%20Infection%20Prevention%20and%20Control%20%5bIC-SP-002%5d.pdf

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minimising the amount of ward rounds and attendance at relevant meetings.

Infection Prevention & Control Team at March 2019

Maurice Madeo (1 WTE) Deputy Director Infection Prevention and Control/lead nurse

IPC Practitioners AfC 7 Jayne Girdham (1 WTE) Marion Hewis (1 WTE) Linda Barker (1 WTE) Andrea Cockerill Webster (1 WTE) Joanne Jones (1 WTE) Noelle Williams (1 WTE – community)

SHCA Angela Miller AfC 3 (0.8 WTE) Secretary Lynn Carnaby AfC3 (0.6 WTE)

The infection control service is provided 7 days a week with an on- call service available to cover the weekends and Bank holiday periods. All nurses who provide on call advice service have completed a programme of study and are experienced infection prevention and control specialists. There is also 24/7 consultant medical microbiologist cover through Path Links.

Infection Prevention & Control Committee

The Trust’s Infection Prevention and Control Committee, was a formal sub-committee of the

Trust Board of Directors however a decision was made to revert back to a standalone

committee that reports to the Quality and Safety committee. The IPC committee oversees

and directs all infection prevention and control activity in the Trust, is responsible for

ensuring appropriate implementation of national guidance and that infection prevention and

control policies are in place, regularly reviewed and compliance audited.

The annual infection control programme and IPC strategy are endorsed by this committee

and updates are received on a periodic basis. The committee membership includes

representatives from Occupational Health (co-opted), consultant microbiologist, Senior

Infection Prevention and Control nurses, senior divisional nurses or representatives,

Consultant Pharmacist, Antimicrobials, CCG representatives, Estates / facilities, medical

director or deputy and others co-opted as required. The attendance at IPCC has been

disappointingly poor during the year making cascade of information difficult. In order to

improve engagement with clinical colleagues it was decided to merge the IPCC with the

Microbiologists based at

NLaG

Dr Cowling (locum SGH 2 days)

Dr Dave (1 WTE – SGH)

Dr Murugesh (1 WTE – DPOW)

DIPC

Ellie Monkhouse

Director of Nursing

Infection Control Data

Officer

Lyn Clare AfC 5 (1 WTE)

Kelly Greaves (1 WTE) AfC Band 6

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antimicrobial CQUIN group as the content was related. Unfortunately, the antimicrobial

CQUIN group was also poorly attended by clinicians as such this has been escalated to the

Medical director to help resolve this issue. A refresh of the committee is anticipated with a

review of the Terms of reference.

Surveillance of Healthcare Associated Infection

One of the main elements of Infection Prevention workstream is undertaking active

surveillance. Surveillance is more than just the recording or reporting of infections. Data is

collected in accordance with strict definitions and protocols to ensure consistency. Some

surveillance data are only reported internally and other data are reported externally either as

part of mandatory or voluntary surveillance schemes. However, the most important element

of surveillance is feedback to clinicians. Feedback prompts review of, and where necessary,

planned improvements to clinical practice. There are a number of mandatory surveillance

activities that are routinely undertaken to meet Public Health England requirements and is

growing year on year with increasing demands on the team.

MRSA Bacteraemia

Nationally, there remains a zero tolerance for preventable MRSA bacteraemia cases. Thus,

once again the Trust had a target of zero avoidable hospital-acquired cases. As in previous

years, every case of MRSA bacteraemia must undergo a rigorous Post Infection Review

Process to help identify any obvious root causes and learn lessons. I am pleased to report

the Trust has not identified any hospital onset MRSA bacteraemia cases for 18 months.

Table 1 MRSA bacteraemia cases since 2006

Year Trust-apportioned Total

2006/2007 29 (60.4%) 48

2007/2008 22 (66.7%) 33

2008/2009 11 (57.9%) 19

2009/2010 3 (18.8%) 16

2010/2011 8 (50.0%) 16

2011/2012 4 (57.1%) 7

2012/2013 2 (40.0%) 5

2013/2014 5 (55.6%) 9

2014/2015 1 (16.7%) 6

2015/2016 0 (0.0%) 3

2016/2017 3 (75%) 4

2017/2018 1 (33%) 3

2018/19 0 2

Overall the Trust has performed very well compared to many other Trusts within the region

as can be seen in the Yorkshire and Humber PHE data below.

Figure 1 Total Number of MRSA Bacteraemia Hospital Onset Yorkshire & Humber 2018-19.

https://improvement.nhs.uk/resources/mrsa-guidance-post-infection-review/

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Blood Culture Contamination Rates

Blood culture is an essential investigation required in patients with suspected sepsis. It is

essential a blood culture sample is taken using an approved procedure to reduce the risk of

skin contamination. Blood culture contamination rates have been consistently around 6%

each month but the aim is to achieve a rate of 3% or below. A system has now been

developed whereby contamination levels are monitored trust wide and disseminated to

clinicians as well as being available on the HUB. One of the key actions implemented is all

staff taking blood cultures will be checked to determine they have undergone the approved

competency training. Staff found to have consistently high rates of blood cultures reported as

possible contaminants will be referred for refresher training via the clinical skills team. A

quality improvement project has also been commenced at DPOW ECC site to establish

whether taking blood cultures from newly inserted peripheral lines contributes to the

contamination rates within this location.

Figure 2 Blood culture contamination data trust wide for 2018-19

The blood culture contamination rates remain slightly higher within the emergency care

centre at DPOW compared to SGH. There are a number of activities in place to further

explore the rationale for the discrepancies including observation and enhanced surveillance.

A number of safety huddles within ECC and admission units have been attended by IPC

staff and clinical facilitators to cascade the

message about blood culture contamination.

Additional training and education has been

developed by the clinical skills team with IPC

input. Contamination rate data is posted onto the

intranet site and cascaded to clinical leads on a

regular basis to help sustain the message.

Contamination rates from the emergency care

centre can be seen below.

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Figure 3 DPOW ECC SGH ECC

Clostridioides difficile (formerly known as Clostridium difficile) Infections

Figure 4 Breakdown of C.difficile cases by ward

Clostridioides difficile infection

(CDI) remains an unpleasant,

and potentially severe or fatal

infection that occurs mainly in

elderly and other vulnerable

patient groups especially those

who have been exposed to

antibiotic treatment.

Clostridioides difficile is a

bacterium that releases a toxin

which causes colitis (inflammation of the colon), and symptoms range from mild diarrhoea to

life threatening disease. Asymptomatic carriage also occurs. Infection is often associated

with healthcare, particularly the use of antibiotics which can upset the bacterial balance in

the bowel that normally protects against C. difficile infection. Infection may be acquired in the

community or hospital, but symptomatic patients in hospital may be a source of infection for

others.

The C.difficile objective guidance for 2018-19 continued the use of lapse in care as a

performance indicator. A lapse in care would be indicated by evidence that policies and

procedures consistent with local guidance or best practice were not followed.

The trust had a CDI objective of no more than 20 cases and ended the year on 5 lapses in

care and 21 hospital onset cases detected at NLaG. The number of cases identified as a

hospital acquired case (>3 days post admission) has significantly decreased compared to

the previous year by over 40% with 77% of cases identified at Diana, Princess of Wales site.

The higher number of CDI cases at DPOW is a continuous trend and may be related to a

significant number of confounding factors such as:

SGH

DPOW

0

1

2

3

Number of C.difficile Hospital Onset cases detected within NLaG 2018-19 by ward.

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Greater length of stay

Frequent patient moves

Antimicrobial stewardship not optimal

Delay in deep cleaning schedules

Lack of isolation capacity

Hand hygiene facilities suboptimal (addressed with C floor redevelopment)

Medical model of care – frequent consultant changes due to ward moves.

Activity levels and staffing establishments.

The SGH site had 5 cases of CDI, Goole detected 0 cases and DPOW 16 cases. The

majority of cases occurred on medical wards, however given the movement of medical

patients between traditional surgical wards the allocation to specialty is not always clear cut

especially during winter months. The main area of concern is the poor physical environment

of the medical floor at DPOW and poor antimicrobial stewardship. The IPC team routinely

submit stool samples for ribotyping to the reference laboratory to help establish the presence

of virulent strains of C.difficile and also monitor if there is a possible relationship between

cases and no hypervirulent strains have been detected.

During the year the C floor reconfiguration has resulted in additional ensuite facilities

including single rooms. In addition, the temporary opening of A1, which has 14 single rooms

helped manage patients with loose stools more proactively. Unfortunately, A1 use has now

ceased which may have an impact on the timeliness of isolating patients with communicable

infections and hinder the deep cleaning programme.

Overall the trust is performing well compared to Yorkshire & Humber data comparing

performance based on 100,000 bed days.

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The average cost of a CDI is estimated to be around £7,000. Local data showed patients

who develop this infection had an average length of stay 6 times greater (36 days) compared

to non-infected patients (5 days).

Figure 5 Number of C.difficile cases

The distribution of cases over the year apart from September does not show any form of

trend. The increase in September is difficult to explain but could be related to the number of

senior clinicians on leave resulting in delay in review of antimicrobial prescribing.

The number of days between CDI cases is recorded. This does show an improvement

compared to last year as expected with a reduction in cases. With the opening of A1, the

days to CDI detected has improved, unsure if this is related but will certainly help.

Figure 6 days between CDI cases

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Post Infection Review

Following a case of Healthcare Onset Healthcare associated C.difficile infection a PIR is

undertaken with relevant clinical staff to ascertain if there have been any deviations from

best practice. The five lapses detected were mainly associated with the use of antimicrobials

e.g. prolonged courses. A number of PIRs have also noted a delay in the deep cleaning of

wards. Work continues to identify cohort facilities to allow this process to continue. All acute

wards should have a full deep clean a minimum of once a year, where possible incorporating

the use of UVC, however in some cases wards have been behind schedule up to 18 months.

This has been discussed at IPCC for follow up and action as required.

Some of the initiatives introduced to reduce the risk of infection including CDI.

The IPC team have been actively undertaking a streamlined version of the national PPS on acute wards. This helps to identify any issues with invasive devices, antimicrobials and infection related issues. Feedback is provided using an infographic format usually same day.

Educational roadshows to promote hand hygiene as part of the May hand hygiene awareness week.

As part of an ongoing QI project the IPC team are developing an assessment tool, using principles of the PUG (pressure ulcer) wheel. The tool will help support the Mouth care policy that has been written – with the aim to reduce lower respiratory tract infections and ultimately antimicrobial prescribing. The tool was presented at the Nursing & Midwifery conference May 2019.

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Winter roadshows preparing staff on how to deal with winter viruses such as influenza and management of infectious patients. Also emphasising the importance of good antimicrobial stewardship and the role of the nurse.

The Trust has moved across to a managed disposable curtain system. The curtains have an integrated antimicrobial coat helping to reduce the incidence of cross infection. The IPC team undertook an in-house microbiological evaluation of the curtains and they performed well compared to market competitors.

Further collaboration with facilities team saw the trust move away from traditional chemicals to a new simple to use agent proven to help reduce the environmental burden of C.difficile.

Collaboration with WebV team saw the development of a urinary catheter icon. This enables the team and others to identify the number of urinary catheters in use across the Trust and the rational for their use. The aim is to challenge their use and encourage removal as soon as possible to reduce the risk of infection.

The challenges for the next year will be keeping within the CDI objective trajectory. The new

definitions of Healthcare Onset Healthcare Associated and Community Onset Healthcare

Associated will by default allocate significantly more CDI cases to the Trust. The CDI

objective trajectory for 2019-20 has been uplifted to no more than 36 cases as a result. The

national data capture system which allocates cases to the Trust has not been modified with

the new definitions which will result in some mismatch between Trust reported cases and

national numbers. It is anticipated these definitions will increase the workload for the team

due to review of cases classed as HOHA and COHA. As part of the PIR process this

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involves the lead clinician managing the patient, Antimicrobial Consultant pharmacist,

matron, IPC representative, CCG nurse representative and patient or family member

(invited). The PIR will decide if any lapses in care / practice have occurred taking into

account prescribing and care leading up to the infection.

C.difficile allocation of cases from 2019-20

Staphylococcus aureus bacteraemia

Staphylococcus aureus is a bacterium commonly found colonising the skin and mucous

membranes of the nose and throat. Although approximately a quarter of the population carry

this organism harmlessly, it is capable of causing a wide range of infections from minor boils

to serious wound infections and from food poisoning to toxic shock syndrome. In hospitals, it

can cause surgical wound infections and

bloodstream infections. When

Staphylococcus aureus is found in the

bloodstream it is referred to as a

Staphylococcus aureus bacteraemia. The

reporting of Meticillin Sensitive

Staphylococcus aureus (MSSA)

bacteraemias became mandatory from January 2011. Prior to that only voluntarily collected

data was available.

The number of trust apportioned MSSA bacteraemias detected during the current year are

shown in Figure 7. The definition of Trust-Acquired vs Community-Acquired is based on the

positive blood culture sample being collected on or after the 3rd day of admission. All actions

taken to minimise MRSA bacteraemias will have the effect of minimising MSSA

bacteraemias. The number of cases detected deemed healthcare acquired compared to the

previous year have decreased slightly from 15 to 12. The majority of MSSA bacteraemia

cases are detected within 2 days of admission and in many cases the source is not always

obvious despite a review by the IPC team. The commonest theme, where identified, is

related to skin and soft tissue. A breakdown of the cases shows 8 were detected at DPOW

and four at SGH with 10 of the cases within medical specialties.

Figure 7

Figure 7 - MSSA Trust apportioned cases

77777

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Figure 8 Comparison of NLaG performance for MSSA infection

The overall numbers of MSSA remains low and this is reflected in the Trust’s performance

nationally.

Gram negative blood stream infections inc E.coli.

Halving the numbers of healthcare-associated Gram-negative bloodstream infections

(GNBSIs) by 2021 is a key government ambition, announced as a key action in Lord

O’Neill’s Review of Antimicrobial Resistance (AMR.) In 2017 we saw the implementation of a

new national ambition to reduce the incidence of healthcare-associated Gram negative

bacteraemias caused by Escherichia coli, Klebsiella spp. and Pseudomonas aeruginosa by

50% (compared to baseline year April 2017 to March 2018) by April 2021. The trend of

increasing numbers of E.coli bacteraemia cases is mirrored in the national data. The

ESPAUR Report (Public Health England, 2018) notes the following:

“The proportion of isolates of Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca

and Pseudomonas spp. resistant to key antibiotics remained broadly stable between 2013

and 2017. Non-susceptibility to piperacillin/tazobactam and co-amoxiclav in E. coli appeared

to increase slightly between 2016 and 2017, as did non-susceptibility to

piperacillin/tazobactam in Pseudomonas spp.” ESPAUR, 2018.

Figure 9 E.coli resistance national trend

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Locally the number of E.coli bacteraemia cases remains a significant burden for patients.

The criteria for reporting Gram negative blood stream infections changed in 2017-18 to

incorporate Klebsiella spp. and Pseudomonas aeruginosa.

Figure 10 E.coli blood stream infections with reduction trajectory

The number of E.coli blood stream infections detected after day 2 of admission has

increased from 29 cases in 2017-18 to 51. The

number of cases detected is very dependent on

the presenting patient condition and timeliness of

the blood culture. The extreme temperature during

the spring and summer period would also have

had some impact on the number of cases

presenting with urogenital issues exacerbated by

dehydration. The Trust reported 315 cases which

is a combination of Healthcare Onset and

Community Onset cases of which 51 were

deemed Healthcare Onset (16%). As can be appreciated with this number of cases reported

with around 86% of E.coli blood stream infections detected within 2 days of admission, many

of the required interventions will require a health economy approach if a long lasting

reduction is to be made. The necessary actions should take into consideration the age

profile of these patients (Fig 11) where the average age of gram-negative patients is 73.1

years and 68.3% of gram-negative patients are 70 yrs. or over. Due to the age profile a

significant number will have numerous co-morbidities and risk factors e.g. dementia,

increasing their risk of infection. Therefore measures such as hydration, removal of urinary

catheters, appropriate diagnosis and treatment of urinary tract infections, better surgical

management are some of the key priorities for secondary and primary care.

Figure 11

Figure 11 - Gram-negative patients by age

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Figure 12 Trust apportioned Gram negative cases

In addition to E.coli the Trust reports the number of Klebsiella and Pseudomonas aeruginosa

blood stream infections.

Pseudomonas aeruginosa is a Gram-negative bacterium often found in soil and ground

water. P. aeruginosa is an opportunistic pathogen and it rarely affects healthy individuals. It

can cause a wide range of infections, particularly in those with a weakened immune system.

These infections are sometimes associated with contact with contaminated water. In

hospitals, the organism can contaminate devices that are left inside the body, such as

respiratory equipment and catheters. P. aeruginosa is resistant to many commonly-used

antibiotics.

The trust detected 29 cases of Pseudomonas aeruginosa with 12 Healthcare Onset, which

was similar to previous years.

Klebsiella species belong to the family Enterobacteriaceae. Klebsiella species are a type of

gram negative rod shaped-bacteria that are found everywhere in the environment and also in

the human intestinal tract (where they do not cause disease).Within the genus Klebsiella, 2

common species are associated with the majority of human infections: Klebsiella

pneumoniae and Klebsiella oxytoca. Both species are commonly associated with a range of

healthcare-associated infections, including pneumonia, bloodstream infections, wound or

surgical site infections and meningitis

In healthcare settings, Klebsiella infections are acquired endogenously (from the patient’s

own gut flora) or exogenously from the healthcare environment. Patient to patient spread

can occur via contaminated hands of healthcare workers or less commonly by contamination

of the environment.

Last year there were 72 cases of Klebsiella with 13 Healthcare Onset which is similar to the

previous year.

A breakdown of the hospital associated E.coli cases shows the majority being detected

within the medical units such as gastroenterology ward and acute surgical ward having most

cases. However given the number of patient outliers the ward location cannot assume this is

always the correct specialty associated with the infection.

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Table 2 Hospital onset E.coli bacteraemia cases 2018-19.

Examination of the main source of E.coli infection locally in the stack chart would suggest

the urinary system and hepatobiliary are the main predisposing risk factors and this is where

targeted interventions are to be directed e.g. avoid / removal of urinary catheters, better

surgical pathways. The national picture in the infographic is not too dismilar to our local

position.

Figure 13 Common causes of E.Coli bacteraemia in cases detected at NLaG

It is acknowledged that the reduction although welcomed, much more needs to be done to

ensure the number of cases is kept as low as possible and best practice is embedded

across the whole health economy. The IPC team have attended regional workshops to

2018/19

2018/19

Total

Row Labels Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

E-Coli

DPOW

Amethyst & D1 Hazel 0 0 0 1 0 0 0 0 0 0 1 0 2

ECC DPOW 1 0 0 0 0 0 0 0 0 0 0 0 1

High Dependancy Unit 0 0 0 1 0 0 0 0 0 1 0 0 2

ITU 0 0 0 0 0 1 0 0 0 1 0 0 2

Stroke Unit DPOW 1 1 1 0 0 0 0 0 0 0 0 0 3

Ward B3 0 1 0 0 2 0 0 0 0 0 1 0 4

Ward C1H 2 0 1 0 0 0 0 0 0 0 0 0 3

Ward C1K 0 0 0 1 0 0 0 0 1 0 0 0 2

Ward C2 1 0 0 0 0 0 0 0 0 0 0 0 1

Ward C5 0 0 0 0 1 0 0 0 0 0 1 0 2

Ward C6 1 1 0 1 0 0 0 0 0 0 1 0 4

Coronary Care Unit DPOW 1 0 0 0 0 0 1 0 0 0 0 0 2

DPOW Total 7 3 2 4 3 1 1 0 1 2 4 0 28

GDH

Ward 3 GDH 0 0 0 0 0 0 1 0 0 0 0 1 2

GDH Total 0 0 0 0 0 0 1 0 0 0 0 1 2

SGH

A&E 1 0 0 0 0 0 0 0 0 0 0 0 1

ICU 0 1 0 0 0 0 0 0 0 0 0 0 1

Ward 18 0 0 0 0 0 0 0 1 2 0 0 0 3

Ward 19 0 0 0 0 0 0 0 0 1 0 0 0 1

Ward 22 0 1 0 0 1 0 1 0 0 0 0 0 3

Ward 23 0 1 1 0 0 0 0 0 1 0 0 0 3

Ward 24 0 0 0 0 1 1 0 0 1 0 0 0 3

Ward 25 0 0 0 0 0 1 1 0 1 0 0 0 3

Ward 28 0 0 0 0 0 0 1 0 0 0 0 0 1

NICU SGH 0 1 0 0 0 0 0 0 0 0 0 0 1

Coronary Care Unit SGH 0 0 0 0 0 0 0 0 0 0 1 0 1

SGH Total 1 4 1 0 2 2 3 1 6 0 1 0 21

E-Coli Total 8 7 3 4 5 3 5 1 7 2 5 1 51

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ascertain the latest evidence based practice and how this can be embedded into the Trust

where required. Given the risk factors for gram negative reduction are so generalised and as

yet not fully understood, it is important as a Health economy we adopt measures that are

within our control. All cases of Hospital Onset Gram negative infections are reviewed to

identify the source of infection if known and identify if any lapses in care / practice have

occurred. Where a lapse has been identified a review meeting is held with the ward manager

and Matron to help avoid future cases.

As a trust our rate of E.coli bacteraemia is comparible to many other trusts however we

always strive for improvement in reducing the number of cases.

Figure 14 Hospital onset E.Coli bacteraemia counts

As a Trust we reported 530 mandatory organisms on the national data capture system

excluding the influenza winter reporting. With the expansion of alert organisms reporting this

contributes significantly on the core activity of the team. Each case takes time to review and

if needed arrange follow up reviews.

Surgical Site Infection Surveillance

The Department of Health introduced mandatory surveillance of certain categories of surgery in 2004. It is a requirement that each trust should conduct surveillance for at least 1 orthopaedic category for 1 period (3 months) in the financial year. The categories are:

hip replacements knee replacements repair of neck of femur reduction of long bone fracture

The Infection Prevention and Control team in conjunction with our orthopaedic colleagues

undertake continuous surveillance of primary total hips (THR) and primary total knee (TKR)

on all three hospital sites. There has been some adjustment to the number of orthopaedic

implant surgery undertaken at SGH site due to the closure of the Coronation block for in-

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patient activity due to the detection of legionella SG1. As such the majority of elective major

joint arthroplasty surgery is undertaken at Goole and DPOW.

Table 3 Orthopaedic hip and knee replacement infection rates

Overall the infection rates remain low but due to the small denominator the infection rate can

quickly become skewed. The Trust received a letter from PHE alerting us to the infection

rate for Total Knee replacement to be above the 90th percentile, infection rate of 0.9% at

DPOW for the period Oct-Dec 2018 (n=2 out of 230 cases). When a surgical site infection is

detected a thorough RCA is undertaken to identify if there were any deviations from best

practice. In the cases reviewed there were no significant deviations from best practice

identified. As a team we undertake a very robust method of monitoring patients fully for the

whole year.

All

Hospitals

Grimsby Scunthorpe Goole

National Rate (%)

No. Operati

ons

No. Infection

s

% Infectio

n

No. Operation

s

No. Infection

s

% Infectio

n

No. Operation

s

No. Infection

s

% Infectio

n

Hip Replacement

0.6 715 1 0.1%

516 6 1.2%

496 1 0.2%

Knee Replacement

0.5 718 3 0.4%

540 3 0.6%

853 4 0.5%

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Table 4 Surgical Site Infections January 2014 to December 2018

As part of the surveillance process the team also ensure theatres are adopting best practice

in accordance with the High Impact Intervention surgical site prevention bundle. Now that

sufficient data has been collected a dashboard has been produced and shared with Theatre

colleagues to ensure the high standards of practice are maintained.

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Figure 15 SSI High Impact Intervention Feedback

CDCU post procedure infection

The Infection Prevention team were notified in August of a possible issue with surgical site

infection occurring in patients undergoing a loop recorder insertion. Four patients developed

post insertion wound leakage and commenced antibiotics by their GP or following their Out

Patient appointment review.

A small incident group was convened to establish the root cause and ensure measures put

into place to address any shortcomings. It was found the method of skin closure may have

been one of the main contributory factors and this was addressed with good outcome. No

further cases have been reported since the review.

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Influenza / Viral respiratory disorders

Influenza season is a yearly event with most cases occurring during the period of November

to March. The severity of influenza disease and impact on services is often difficult to predict

due to the fluctuating presentation of the virus.

Path Links Pathology currently

provides in house PCR

(Polymerase chain reaction)

testing for the respiratory

viruses Influenza A (FluA),

Influenza B (FluB) and

Respiratory Syncytial Virus

(RVS) from the Scunthorpe

site. Some clinical samples are

also sent to the reference

laboratory based in Cambridge

where further specialised investigations are performed.

The winter of 2018-19 turned out to be less aggressive than the previous season overall for

the Trust however there were still some significant variations across the two main sites. The

majority of patients identified with influenza were Influenza A virus with the predominant

being A(H1N1). The quadrivalent vaccine appeared a good match in terms of protection.

This was clearly visible in the almost total eradication of influenza type B detected compared

to the previous season, where it contributed up to 50% of all influenza cases.

The number of influenza cases detected at SGH site was three fold greater this year. SGH

detected 152 positive patients compared to DPOW who identified 39 patients from

December to mid-March.

Figure 16 Number of Influenza cases detected comparing 2017-18 - 2018-19 season

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The high number of cases detected at SGH site did pose some difficulties with appropriate

timely isolation of cases. The closure of the Coronation block (ward 10 & 11) resulting in a

net loss of 11 single rooms clearly added to the operational issues in managing infectious

patients safely. The IPC team were in daily contact with the operational teams to best

manage patient flow and where necessary incidence meetings were convened to manage

any bed closures. The impact of influenza was also seen within the critical care units

especially at SGH during the early phase of the season where they had more cases up to

January than in the previous 10 years. The units had guidance from the IPC team and

Consultant microbiologist.

Figure 17 Influenza cases detected on critical care units.

One of the best ways to protect vulnerable patients and front line staff from influenza virus is

the influenza vaccine. There was an expectation that organisations have to achieve a front

line worker uptake of at least 75%. NLaG achieved a respectable 78.3% uptake

in front line workers using a peer vaccination approach.

Table 5 Influenza vaccination uptake by frontline workers

Season Dr Nurse AHP/STT Support Total

2017/18 83.7% 65.5% 67.1% 80.5% 72.6%

2018/19 77% 76% 98% 75% 78%

Further work is required with improving uptake in frontline workers as it’s the best form of

defence we have in reducing dissemination of the virus. The peer vaccinator model was very

successful and this will be hopefully adopted again for the next influenza season. The top 3

peer vaccinators received a prize to thank them.

Staff receiving certificates for top 3 peer influenza vaccinators during 2018-19.

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Respiratory syncytial virus – paediatric.

From October to March there were 157 cases of Respiratory Syncytial Virus (RSV) infection

detected during the year with the majority of samples taken on the paediatric unit, this is a

slight increase to the previous year. The infection causes bronchiolitis in babies and young

adults especially during the winter months. The vast majority of cases are self-limiting and

the paediatric wards are well versed in managing such cases. 76 cases were detected on

Disney ward and remaining at DPOW Rainbow.

Figure 18 Number of RSV cases detected

Ventilator associated pneumonia.

The Intensive Care units across the trust have been utilising a VAP High Impact Intervention

developed by the IPC team. The HII is completed on a daily basis and the units will have

access to up to date key performance data to ensure staff are complying with best practice

guidance.

Figure 19 VAP feedback

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Point Prevalence Surveillance

As part of the ongoing review process the IPC team began to undertake a modified version

of the national Point Prevalence Surveillance twice a year. The main advantage of utilising

this approach is that it enables the team to gain an immediate insight into the practices on

the ward re invasive devices, antimicrobial prescribing and management of patients with

infections. All patients within the ward are reviewed and staff are then provided with a verbal

resume and this is followed up with a written report usually the same day. Divisions are

provided with a dashboard (see below) that is available on the HUB site to help support any

changes in practice.

Table 6 PPS Feedback

In total there were 609 patients reviewed as part of the Point Prevalence Surveillance over 2

period during the year. The results identified a Hospital associated infection rate of 7% which

is slightly above the national average. The commonest infection was related to the

respiratory tract e.g. hospital or community acquired pneumonia. The PPS identified 53% of

patients had a peripheral cannula insitu and 74% of these had their visual infusion phlebitis

score recorded as per policy. There were 22% of patients identified with a urinary catheter

and 48% of these had a pathway in place. As part of the focused work around reducing

Gram negative infection the team have developed and implemented a urinary catheter plan

of care to ensure the device is reviewed on a daily basis to determine if still required. The

pathway was launched in September and is in the process of being embedded. The PPS

also established that around 45% of patients are receiving antimicrobials with 57% of these

being intravenously, which is a high and requires greater focus. The commonest

antimicrobial in use was co-amoxiclav and this contributed to almost half of all agents in use.

Once the PPS results are fed back to the ward staff and clinical leads, if any significant

deviations from best practice are detected the IPC team will help support the area by

working with colleagues to help support the required changes. Overall the results show there

is much work to be done by nursing and medical colleagues to help minimise the risk of

avoidable infection.

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Carbapenemase-producing Enterobacteriaceae

The management of patients with an antibiotic resistant organism is an increasing priority

nationally. The emergence of Carbapenemase-producing Enterobacteriaceae (CPEs) is

predicted to pose significant challenges nationally in the near future. Carbapenem antibiotics

are a powerful group of B-lactam antibiotic used in hospitals. Until recently they have been

able to be used to treat infections when other antibiotics have failed. Emerging resistance

patterns have rendered in some cases Carbapenems ineffective. Public Health England

have issued toolkits for use in either acute or community settings to enable the early

detection, management and control of CPE. A Trust policy is in place to support and guide

staff to provide safe and effective management of patients colonised or infected with

resistant bacteria and minimise the risks of transmission in patients.

The Trust undertook over 300 tests for CPE

2018/19 NLG

Count of Rectal Swabs for CPE Screening 271

Count of Faeces Samples for CPE

Screening

49

In 2018-19 the Trust identified a small number of cases that were associated with travel

abroad.

The WebV admission document has been updated to allow staff to risk assess all

admissions to determine their level of CPE risk. Patients that are deemed to be at risk are

then isolated and screened as per policy until the result and risk assessment has been

reviewed by the IPC team.

Actual Location Description

Result Result Expansion

Acute Medical Unit -Grimsby OTHCPE CARBAPENEMASE DETECTED type = OTHER

High Obs Unit ward B3 Grimsby

OXA OXA type CARBAPENEMASE DETECTED

Stroke Unit DPOW Grimsby PCPASE Presumptive Carbapenemase

Neuro Rehab Centre Goole Hosp

PCPASE OXA type CARBAPENEMASE DETECTED

Ward 5 - Goole (DTC) PCPASE Presumptive Carbapenemase

ITU- Grimsby PCPASE Presumptive Carbapenemase

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2. Provide and maintain a clean and appropriate environment for managed

premises that facilitates the prevention and control of infections.

The Facilities Department has continued to support the work of the IPC team. The work of

the deep clean team in helping to maintain a proactive deep cleaning program is well utilised

and seen as a significant factor in helping to control the spread of pathogenic organisms.

The aim of the deep cleaning programme is to clean high risk wards / departments a

minimum of once a year but ideally twice a year. There are some difficulties in gaining

clinical access in particular on the DPOW site with some areas out of compliance by over 18

months. Whilst routine environmental cleaning will take place the importance of a thorough

synchronised deep clean programme cannot be overemphasised in helping to keep the

number of environmental C.difficile spores to a low number. There are a significant number

of acute wards at DPOW that remain out of compliance and this has been escalated to IPCC

and Quality & Safety Committee.

Facilities Service update

Improving cleanliness through a review of our existing processes and procedures was an

integral part of our business plans for 2018 – 19. Through effective ownership and support to

clinical services, we set ourselves an objective of achieving a reduction of hospital outbreaks

of infection. By delivering robust cleaning regimes, restricting and preventing the impact of

bed capacity loss for our operational colleagues, we will work with Infection Prevention &

Control to help reduce staff sickness, improve patient safety, and provide a clean, safe

environment supporting the Trust to deliver its priorities with the use of modern technologies,

innovations and practice of cleaning functions.

During 2018 – 19 the Facilities Services team have made some significant changes to

practices, improving the patient environment, introducing better cleaning chemicals, which

are safer, deliver better bug fighting properties, and are less harmful to our staff, the

environment and the estate.

Our 2018 PLACE outcomes reflected the improvements we have made against the prior

year results. Overall as an organisation we climbed from 98.40% to 99.34%, with individual

sites all scoring in the highest 99th percentile.

Our cleaning chemicals are now much simpler to measure dosing, reducing daily cleaning

tasks to just one chemical. We have totally removed the use of chlorine based products for

routine cleaning, moving forward with a regular universal cleaner, and a medical grade high

level disinfectant. Our daily universal cleaner retains potent disinfecting properties,

maintained by a change to single use cleaning cloths to maintain its efficacy as a cleaning

solution. For enhanced level cleaning requirements, our Medi-9 product is ready to use, with

a biocidal, virucidal, fungicidal capability, ready for use in high risk infectious outbreaks. This

change in chemical use and process has contributed towards a Trust reduction in prior year

C.difficile cases of 43% during 2018 - 19.

All of our wards and departments were previously furnished with linen curtains for privacy

and dignity. These curtains were in excess of 15 years old, held no resemblance to the

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décor or environment, some had damage and were simply degrading of the care

environment. The team reviewed the market, met with suppliers and working with our IPC

colleagues, identified a solution which provided a single standard for curtains. Our new

curtains are protected with a biocidal surface and are exchanged every 4 months. The

change reduced our carbon footprint by removing the need to launder linen curtains, whilst

off-setting cost efficiencies through removing the need to change curtains for non-other than

the highest risk infectious outbreaks. This also reduced time spent hanging heavy curtains,

on an almost daily occurrence, improving the occurrence for manual handling on our teams.

The change also reflected in a positive response to the care environment, and directed the

responsibility of ordering and exchanging the curtain stock to the Facilities Services

department.

Our continued development also aims at reviewing the equipment provided to our dedicated

teams. Technology advances in disposable products including micro-fibre, meaning less

need for chemicals, with even a consideration of none for daily cleaning being possible,

whilst still achieving the quality we require. Future plans will include a review of our cleaning

trollies, mopping processes and chemical use, delivering further efficiencies in labour and

chemical use and cost.

Enabling us to stay ahead of the advancements in cleaning is our two Facilities Services

Managers, Michelle Smith and Karl Cliff. Having served as members, both are now

contributors and leaders within the Association of Healthcare Cleaning Professionals

(AHCP). Michelle represents as the Yorkshire & Trent Branch regional chair, with Karl

representing the group at the National Council of Members forum. This additional role

provides a great level of awareness and forms key relationships for networking with

likeminded healthcare professionals alongside service and industry leads. This engaging

profile will ensure our Trust is well placed and informed to continue our aim of providing the

highest level of safe, quality, effective cleaning principles. (summary produced by Keith Fowler – Head of facilities)

Ward Environmental Audits (Flo)

The average scores per section are highlighted below. The main areas for future

improvement are generally associated with environmental fixture and fittings such as floor

and wall condition. Any items that are potential patient safety concerns are dealt with by

estates and facilities in a timely manner.

Table 7 Flo Audit Scores

The trust has an extensive program of environmental audits using

the Flo audit tool on WebV. The IPC team undertake a minimum

of one Flo audit per year to quality control the process. The

Quality Matrons undertake the Flo audits on a Monthly to

quarterly basis depending on the scores achieved. The ward

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sisters / charge nurses undertake monthly - quarterly audit schedules depending on previous

results. The main issues with the general environment are related to maintenance issues

e.g. damaged floors or walls which will be logged with estates.

The IPC team have over the last year developed a dashboard which allows interrogation of

the Flo audit scores across sites, wards, divisions and groups of staff. The audit scores were

reviewed at the Matrons forum and nursing metrics panel to identify any trends and actions

required. Due to the issues in extracting the audit scores and maintaining the issue log, the

Flo audit tool will be phased out and replaced with a ward assurance tool (15 steps) that

incorporates key IPC questions. In addition the IPC team are exploring the development of a

bespoke audit tool just for the IPC team to ensure generic standards are maintained when

the Flo tool is archived.

The latest Patient Led Assessments of the Environment (PLACE) scores (see below)

suggests the trust has significantly improved from the previous year and is now above the

national average for cleanliness and condition/appearance.

Table 8 PLACE scores 2018 NLaG

Cleanliness Food &

Hydration

Privacy, Dignity

and Wellbeing

Condition Appearance

and Maintenance

Dementia Disability

99.3% 93.1% 84.5% 94.9% 66.9% 79.0%

Decontamination

A member of the Infection Prevention and Control team attends the decontamination group.

This group oversees decontamination issues including the function of the Synergy run

HSDU. The committee is responsible for ensuring that reprocessing systems are revalidated

as required and dealing with problems by exception. It serves as a conduit between

equipment reprocessing departments and the IPCC.

Water Safety Group

The Deputy DIPC and Consultant microbiologist are members of this group to help ensure

relevant guidance is adopted to help reduce the risk of waterborne infections such as

Pseudomonas and Legionella. The group has implemented a number of standard operating

procedures to ensure the daily flushing of little used outlets and their correct cleaning /

maintenance including the use of L8 guard.

The SGH neonatal unit (augmented care) continues to have the Point of Care filters on the

majority of its wash hand basins due to intermittent positive counts of either Pseudomonas

aeruginosa or Legionella species. The Coronation block at SGH continues to be out of action

for inpatient overnight stay activities due to the detection of legionella in multiple outlets. This

has resulted in the closure of ward 10 & 11 and Theatre F&G. A decision as to the future use

of this block is still to be fully concluded, in the meantime legionella control measures are in

place.

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Pseudomonas Water Testing

In 2012 the Department of Health issued national guidance for managing Pseudomonas

within the water system of hospitals in-particular the augmented care units. These high risk

units have a regular water check depending on results and where Pseudomonas or

legionella species are identified discussion takes place with the IPC team on measures

required to mitigate the risk. There is a robust ongoing program within the clinical settings to

ensure flushing is undertaken within little used outlets and that wash hand basins are used

appropriately. The L8 guard reporting system is working well and generally achieving a good

level of flushing compliance. In order to support the appropriate use of clinical wash hand

basins (WHBs) a new adhesive poster has been placed next to WHBs within high risk units

to reinforce the message.

3. Ensure appropriate antibiotic use to optimise patient outcomes and resistance

Antimicrobial Management

As part of the action plan developed

following the antimicrobial users audit

undertaken where users stated they

would like easier methods to access

information, the IPC team and consultant

antimicrobial pharmacist put together a

SharePoint website and this was

recently updated. This is broken down

into common systems for ease of

access. The feedback has been

excellent.

The IPC nurses have commenced a number of Start Smart and Focus audits across the

wards to ensure that best practice is adopted when prescribing antimicrobials and the

rationale for each agent is clearly documented. This together with the work of pharmacy

colleagues has seen a gradual improvement in the appropriate use of antimicrobial agents

including Meropenem. The progress of prescribing certain high risk antimicrobials is tracked

using Statistical Process Control charts and additional information is also available via the

antimicrobial dashboard.

4. Provide suitable accurate information on infections to any person concerned

with providing further support or nursing / medical care in a timely fashion.

Patient Information

The trust has an IPC www website with information for the general public. There are a

variety of guides for common healthcare associated infections.

http://nlgnet.nlg.nhs.uk/Pharmacy/SitePages/Antibiotics.aspx

http://www.nlg.nhs.uk/patients/infection-prevention/

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The intranet HUB has a multitude of information leaflets for patients that can be quickly

printed off by staff as required as well as quick reference guidance on ‘how to’ manage

patients with infections.

5. Ensure that people who have or develop an infection are identified promptly

and receive the appropriate treatment or care to reduce the risk of passing on the

infection to other people.

MRSA colonisation

Not all MRSA positive results are found in blood cultures. The bulk of MRSA isolates come

from routine wound swabs and from swabs taken specifically to look for the presence of the

organism (screening swabs). Most patients, from whom the organism is isolated, are not

infected but rather merely colonised, i.e. harmlessly carrying the organism. It is very difficult

to look at the raw data and determine how many patients are in fact infected but the rule of

thumb is that infections account for less than ten percent of isolates.

The MRSA screening criteria within the trust was modified in 2014/15. This was in

accordance with national recommendations where targeted screening rather than blanket

screening was encouraged. If an MRSA colonisation is detected within a high risk

environment a rapid review is undertaken to ensure best practice is maintained and any

lessons learnt are shared.

Patients with Unexplained Diarrhoea

As part of the C.difficile reduction strategy the IPC team monitor patients who have had a

faecal sample submitted to the laboratory for suspected infection. One of the main key

performance indicators is patients presenting with type 5-7 stools should be isolated within 4

hours. In approximately 85% of cases this was achieved. Due to the limited number of single

rooms currently available across the main hospital sites, especially at SGH this will continue

to pose challenges especially during the peak winter season. Going forward new

refurbishment plans will have a minimum of 30% isolation capacity to help meet current

demands and this is evident in the C floor redesign.

http://nlgnet.nlg.nhs.uk/Infection.Control/SitePages/Patient%20Information/Patient%20Information%20Index%20Page.aspx

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The IPC team also review whether the stool sample submitted is deemed appropriate based

on clinical information. Staff are given feedback if samples are deemed inappropriate to help

improve practice and reduce pressure on single rooms.

Figure 20 Patients with diarrhoea and time to isolation

Outbreaks

Outbreaks occur when there are two or more linked infections which may or may not be

preventable. Usually, these events are, by definition, unpredictable. There may be a

heightened alert for outbreaks of organisms with a typical seasonal activity such as influenza

and norovirus, or alternatively there may be an international alert as for Ebola Fever. The

Infection Prevention and Control Team may become aware of incidents and outbreaks

through formal schemes, e.g. structured ward liaison or laboratory based surveillance, the

Trust electronic incident reporting system and audit, or through informal routes, such as

unusual patterns observed and reported by an individual in the Trust. Early ascertainment is

key to detecting and acting on incidents and outbreaks to minimise adverse outcomes.

Norovirus is a common cause of viral gastroenteritis, characterised by rapid onset of nausea,

vomiting and diarrhoea. The virus is easily transmitted by direct contact with an infected

person, contact with contaminated surfaces or objects or consumption of contaminated food.

In preparation for the norovirus and influenza season, the IPC team undertook a number of

roadshow sessions to raise awareness and help staff to identify optimal methods for

managing patients with viral gastrointestinal symptoms and those with suspected influenza

symptoms.

The number of full ward closures due to virus related infections reduced dramatically from

the previous year from 15 to 2. The norovirus season has been less severe this year which

would have helped.

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Figure 21 Patients and staff affected with viral suspected gastroenteritis

The two ward closures this year were related to the dissemination of Influenza A virus. A

small incident group meeting was held to discuss control measures and lessons learnt which

was around failure to isolate symptomatic patients and inappropriate use of face masks.

6. Ensure that all care workers are aware of their responsibilities in preventing

and control of infection.

Hand Hygiene

Hand Hygiene remains a fundamental component in the prevention of nosocomial infections.

The IPC team continue to promote hand hygiene compliance incorporating the WHO five

moments tool. Hand hygiene compliance including bare below the elbows is an expectation

for all clinicians. Ward staff continue to record opportunistic hand hygiene observations on a

monthly basis and these are supplemented by IPCN observations to provide some quality

assurance. Areas that are found deficient are provided with a feedback plan and remedial

actions worked through with the sister / charge nurse and Matron.

A WebV hand hygiene App was launched in the last quarter of the year allowing staff to use

the smart phones on wards / depts. to record compliance. The App has been well received

by staff as it makes the process much easier and also incorporates a count of observations

completed. Overall hand hygiene compliance remains good.

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Figure 22 Hand Hygiene overall compliance scores

6. Provide or secure adequate isolation facilities

Isolation Facilities

The C floor wards at DPOW are currently undergoing a

significant Capital development scheme. When completed the C

floor, medical wards will have an additional 7 single rooms with

ensuite facilities available. This has also been boosted by utilising

A1 which has 14 single rooms into the scheme and proved

particularly useful during winter to help manage patients with

suspected winter viral infections. The main concern with DPOW

is the lack of utilisation of A1 on a more regular basis when it is ideally suited to facilitate

deep cleaning programme and management of patients with communicable infections.

As previously mentioned the SGH site now is more vulnerable due to the closure of Ward 10

and 11 with a net loss of 11 single rooms. The lack of isolation capacity is highlighted on the

Board Assurance Framework as a risk which may impact on the overall number of C.difficile

cases and risk of cross transmission.

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7. Secure adequate access to laboratory support as appropriate.

Microbiology Laboratory

The Path Links Microbiology laboratory continues to work closely with the IPC team, to

ensure appropriate testing of samples and rapid communication of results, particularly with

regard to C difficile, norovirus, MRSA screening and other “alert” organisms. Laboratory staff

will be joining members of the Scunthorpe ICPN on a few ward rounds over the coming

months to develop their understanding of the pressures and needs on the team, and how the

laboratory can actively help to support and address these.

The Microbiology laboratory continues to review how can it assist the work of the ICPN

through introduction of new rapid techniques with new technology imminent in the serology

and molecular laboratory.

The Microbiology laboratory has had a recent UKAS accreditation surveillance visit in March

and have just received a very positive report from the Assessor Team.

8. Have and adhere to policies, designed for the individual’s care and provider

organisations, that will help to prevent and control infections.

Infection Prevention and Control Policies

There are an extensive number of policies, guidelines and how to documents that are

maintained by the IPC team in a timely manner. Recent policies updated can be seen below.

Table 9 Policies updated within last year

Name of Policy Date for review

Decontamination of Medical Equipment Prior to Inspection

Service or Repair Policy

23/03/2022

HIV Policy 01/03/2020

Surveillance Policy 04/05/2022

Hand Decontamination Policy 24/06/2019

Varicella Zoster Virus Protocol 11/08/2019

MRSA Policy 17/02/2021

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Isolation Policy 01/05/2022

Safe Use and Disposal of Sharps Policy 08/11/2019

SARS Policy 04/08/2021

Viral Haemorrhagic Fevers & Other Hazard Group 4 Agents

(VHF Policy)

20/11/2019

Glove Usage Policy 14/12/2019

Medical Devices Policy 06/01/2020

Transmissible Spongiform Encephalopathy Agents – (TSE

Policy)

17/01/2020

9. Have a system in place to manage the occupational health needs of staff in

relation to infection.

The Occupational Health team have played a pivotal role in helping the trust achieve a

respectable overall vaccination uptake with strong support from the IPC team and peer

vaccinators. There is an accidental inoculation steering group that meets to review any

incidents and how interventions can be implemented to reduce risks for staff and patients /

visitors. A member of the IPC team is a standing member of this group.

The Occupational Health Team were closely involved in a Brucella exposure incident

occurring in the laboratory. Staff deemed as exposed were closely followed up and clinical

samples taken to ensure any transmission was picked up early and treated effectively. There

were no cases of cross infection detected from this exposure.

Training and Education

The IPC team continue to make education of staff one of its key priorities. There are a wide

variety of educational portfolio materials available for clinical and non-clinical staff to help

maintain their mandatory training requirements.

The materials include:-

Surewash machines

Workbooks for clinical and non-clinical staff

Link practitioner programme

Ward based training

Care Camp

Induction

Clinical updates

Road shows with interactive quiz e.g. Antibiotic awareness week

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Junior Doctors / HYMS training

Grand round session re antimicrobial awareness

Bugs R Us conference day

IPC blog site for staff and students

To assist with the influenza campaign a myth busting slideshow was integrated onto the

Surewash system with great success.

Over 6000 members of staff have undertaken some form of IPC training.

https://ipc427.wordpress.com/

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Community & Therapies Services – information provided by Noelle Williams

IPCN

Overview

2018/19 has been another year of change for the Community Infection Prevention & Control

team. The team remains embedded as a sub set of the Acute Trust IPC team, with dual

input across both acute and community interfaces in the transitioned provider only role, and

the team continues to deliver the IPC service at Goole hospital, which includes the Neuro

Rehabilitation Centre now managed by the Trust.

The team formerly consisting of a 1.0 wte Band 7 CNS IPCN and a 0.8 wte Band 3 AHCA

IPC has seen a reduction of 0.4 wte in the Band 3 role; sequestered time to SSI prevention

strategy now sits within the acute team, this off sets centralisation of the provider community

teams to distinct hubs; in effect reducing the number of community environments for auditing

in the current financial year.

However with the retirement of the commissioning IPCN in December 2018, support to

commissioned services has notably increased. At the time of writing this report there is still

no acknowledged appointee into this role although active recruitment has commenced.

Representation of infection prevention & control service provision continues to be

demonstrated with attendance/input at monthly Community & Therapy Governance

meetings. Following the change in leadership to the Community Divisional Head of Nursing

in this year, the stand alone Community Managers IPC meeting content has been

incorporated within the terms of reference for the governance group. This has cemented

ownership and acknowledgement of on-going challenges/ emerging threats related to

infection prevention and control. Minutes from this meeting including actions and issues

continue to be forwarded to the Infection Control Committee and are available to view via the

Hub.

Commitment to mandatory training for the Community & Therapy group continues, taking

the form of scheduled IPC facilitated offerings and additional mop up sessions delivered at

Community and Therapy bases on an adhoc basis, with complimentary learning options

available via the ‘Sure wash’ system.

Current community and therapy services IPC training figures stand at 84% inclusive of

yearly/no renewal and 3 yearly face to face requirements. Further, data interrogation

substantiates a 93% compliance rate for 3 yearly face to face training which remains above

the required average.

Surveillant organisms

Objective

Organism

2017/18

2018/19

17/18 18/19 Performance Performance

Zero Zero MRSA 1 1↔

31 30 C.difficile 30 20↓

130 130 E.coli 127 106 ↓

N/A N/A MSSA 41 43

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N/A N/A CPE 0 (1)

Audit

As in the previous year, two distinct community focused audit tools are in use. The

community version of the Trust Frontline Ownership audit tool, available on the WebV

system is completed quarterly by the Therapy group. If a score less than 82% is achieved

then audits are increased to monthly, until the identified issues are resolved. The Community

& Therapy IPCN validation tool functional via WebV is also used to record all validation

audits undertaken by the Community Infection Prevention & Control team.

The Community nurses audit, is also accessible this year via WebV with results data

available within the IPC dashboard on the Hub. The IPCN validation audit on this platform to

complement this remains outstanding.

Hand hygiene audits are recorded annually on OLM as a practical assessment for all

Community & Therapy staff. Monthly point of care audits are requested of those staff groups

in group clinical environments; namely the chronic wound management team, podiatry

teams, MacMillan Home Health care teams and Dental clinics. These audits are available to

view via the IPC hub dashboards.

The re launching of the Catheter passport and associated Catheter pathway are integral in

this year’s evaluation of the Trust Gram Negative Reduction plan. Collaboration with the

community Continence service is ongoing to achieve this within community settings.

The Community focus for the ‘Oral care project’, jettisoned in the previous year, eventually

launched in March 2019.A change in the originally appointed care home became necessary

and version 2 which is underway is due to complete early within the coming financial year .

The service improvement project, proposed by the Lead Infection Prevention & Control

nurse (looking to standardise disinfectant wipes across the Trust) in the previous year has a

been evaluated and accepted into practice by the Assisted Living Centre Community

Equipment Store .

Community & Therapy Link Practitioner Forum

The full study day format (offered twice across site as in the previous year) continues in

2018/19. The numbers in attendance for Community & Therapy staff as shown in Table 1

below continue to fall in comparison to previous years. A disappointing reduction of 26

attendees compared to attendance of the quarterly meeting format of 2015/16. The singular

study day appears to work very well for Hospital based staff but does not fit so well with

community workers and their revised way of working. Although the sessions evaluated well

this format fails to provide the necessary support and timely information to enable the

workers to ultimately fulfil their link role adequately. A Newsletter/formal updating emails are

to be considered going forward.

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Table 1 Link Practitioners Training Completed

Period No. of community link practitioners attending annually

Offering

2015/16 34 Quarterly meetings

2016/17 26 ↓ Singular study day



Decolonisation Service

The established decolonisation clinic, originally commissioned to provide decolonisation

treatment to North Lincolnshire patients’ identified as MRSA positive from admission

screening with results available post discharge continues into this financial year.

Unfortunately the service no longer has capacity to offer the previous MRSA/MSSA

screening for North Lincolnshire residents who access healthcare out of area and require

screening and possible decolonisation treatment prior to elective clinical

intervention/surgery. As evident in table 2, the yearly comparison data shows a steady

decline in patient numbers using the decolonisation service .This is consistent with the return

to targeted screening in the acute Trust(s) following the 2015 revised screening guidance.

This is also seen as the trend for Out of area accesses which have also fallen.

Table 2 MRSA decolonisation events

Period No. of MRSA patients treated

No. of Out of Area accesses

2014/15 97 51

2015/16 82 ↓ 35 ↓

2016/17 82 ↔ 43 ↓

2017/18 79 ↓ 27 ↓

2018/19 42 ↓ 20 ↓

Infection Risk Assessment Tool

The scheduled review of this tool which concluded in September 2018 highlighted a

disproportionate weighting of patients with chronic conditions which scored highly on the

assessment but which would not benefit from early IPC intervention. Acute high risk cases

which were the proposed group for capture were not readily identified. It was therefore

agreed within the governance forum that the risk assessment tool would no longer meet a

mandatory criterion and that future referral modes for IPC intervention would be established

via clinical assessment.

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Activity and Engagement

Global Hand Hygiene week with Community Services

The main priorities for 2019/20 will be to continue working with Commissioners and other

care providers to help tackle the Gram negative reduction ambition.

Review the decolonisation service with commissioners to ensure patients are provided with a

timely and local decolonisation service.

Look at other ways to provide staff and link practitioners with up to date information and

updates.

Continuing work with estates team to review the community properties are ‘fit for purpose’ for

North Lincolnshire community staff.

Implementation of the Oral care policy within community services.

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Appendices

Appendix 1: Infection Control acute committee attendance 2018-19

Position May

2018

July

2018

Sept

2018

Nov

2018

Jan

2019

Medical Director

(DIPC) N N Yes N N

Chief

Nurse/Deputy Y N N N N

Consultant

Microbiologist

(SGH)

Y N N Y N

Consultant

Microbiologist

(DPoW)

N Y Y Y Y

Senior Nurse

Infection Control

(ADPIC)

Y Y Y Y Y

Consultant

Pharmacist

(Antimicrobials)

Y Y Y Y Y

Operations N N N Y N

Facilities / Estates Y N N N Y

Community &

Therapy Services Y N N Y N

ICN Community

Services Y Y Y N Y

Clinical

Consultant Y N N N N

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Glossary

MRSA Meticillin resistant Staphylococcus aureus is a bacterium that is resistant to commonly used antibiotics such as flucloxacillin.

C.difficile Is the organism most frequently identified as the cause of antibiotic-associated diarrhoea

Bacteraemia The presence of bacteria in the blood

Colonisation The prescence of a bacteria on or in the body without causing infection

ESBL Extended-Spectrum Beta-Lactamases are enzymes produced by bacteria, making them resistant to broad-spectrum antibiotics.

PIR Post Infection Review is a systematic review of an event to determine if any deviation from best practice and lessons to be learnt.

Antimicrobials Antibiotics

Dashboard Is a way of presenting data in a visual format.

Carbapenemase-producing Enterobacterales

Resistance to carbapenem antibiotics

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Publications / Conference presentation.

2 posters presented at Federation of Infection Societies annual conference

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Appendix 2 -Antimicrobial Stewardship

Promoting optimal antimicrobials stewardship is the primary role of the Consultant Pharmacist, Antimicrobials, who works closely with Pharmacy staff and the Infection Control Team and with clinicians Trust-wide on this issue.

Slowing the development of micro-organisms resistant to antimicrobials is a national and international priority, with relevant guidance and mandatory actions being issued by organisations such as NICE (NG15 and associated Quality Standard; Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use) and the national Antimicrobial Resistance CQUINs: CCG1a, Lower Urinary Lower Urinary Tract infection in older people and CCG1b, Antibiotic Prophylaxis in Colorectal Surgery. Good antimicrobials stewardship is key to achieving these actions, as the pipeline for the development of new antimicrobials has slowed significantly and is lacking in the discovery of new classes of antimicrobials:

Courtesy of British Society of Antimicrobial Chemotherapy President, Professor Philip Howard.

CQUIN Achievement

The Antimicrobial Resistance and Sepsis CQUIN was monitored and actioned by the Trust’s Specialist Nurse for Sepsis and the Consultant Pharmacist, Antimicrobials. In 2018 – 19, Part 2c (antibiotics review within 72 hours) was achieved, with 100% of prescriptions audited having been reviewed within this timescale. Steady progress with this was made over 2018 -2019, as shown by this chart on the PHE ‘Fingertips’ website (NLaG trend, pale blue):

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However, we were less successful in meeting some of the sub-criteria within those reviews and particularly, performing IV to Oral Switch, as one of those review decisions. In order to raise awareness of this option amongst clinicians, a member of the Pharmacy staff began a project to provide wards and other clinical areas with an IV to Oral Switch decision-assisting algorithm and suggested choices of suitable oral antimicrobial agents, when IVOS is indicated. That work is ongoing.

In terms of Part 2d, consumption, we are higher than the average non-teaching Trust, in terms of our antibiotic consumption per 1,000 admissions and were above our target consumption value by ~31%.

We achieved our target reduction of Piperacillin / tazobactam prescribing, being lower than the non-teaching Trust average consumption, but not that for the carbapenems.

However, the Trust has done a lot of work to reduce the prescribing of meropenem and ensure that it is appropriate, with good success:

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Antimicrobials Prescribing Strategy

The Consultant Pharmacist, Antimicrobials maintains and updates the Trust’s Antimicrobials Prescribing Strategy every three years and its associated action plan annually, so that local actions reflect the requirements of national and international strategies and aim for optimum Antimicrobials Stewardship.

It covers:

Monitoring of and interventions on antimicrobial resistance.

Examining the influence of antimicrobials use, as a risk factor for Hospital Onset, Healthcare Acquired Infections.

Further risk assessment of activities involving antimicrobials use.

Maintenance of Trust Antibiotic Formularies and Prescribing Advice.

Maintenance of the Trust’s Antimicrobials Steering Group.

Incorporation of the principles of good antimicrobials stewardship into the Trust’s electronic Prescribing and Medicines Management System.

Contribution of appropriate antimicrobials use to the management of sepsis.

Education and training on good antimicrobials stewardship, for all relevant Trust staff.

Information for patients and carers.

Antimicrobials Guidance and Review

The Consultant Pharmacist, Antimicrobials provides these functions in a number of ways:

Participation in the review, maintenance and development of the Path Links Antimicrobials Formulary and Prescribing Advice, to ensure that it is fit-for-purpose locally and also meets national guidance, such as the NICE guidance items released last year, on the management of infections.

Antimicrobials ward rounds in specific areas (on the Trust’s Critical Care Units), in conjunction with the Consultant Microbiologists.

Provision of detailed antibiotics history reviews for patients identified as Hospital Onset, Healthcare Acquired infections and participation in post-infection reviews of those patients.

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Provision of Specific Process Charts (SPCs) and additional information to Divisional Governance Groups and Associate Medical Directors, for consideration of and action, as necessary on, local antimicrobials consumption trends.

Antibiotic Audits

The Consultant Pharmacist, Antimicrobials arranges or conducts appropriate antibiotics audits, to power the Trust’s antibiotics dashboard and also provides expert advice on the application and successful completion of any local and national audits, enabling successful compliance with, for example, Antimicrobials Resistance National CQUINs.

Additionally, the Infection Control Team conducts twice-yearly point prevalence surveys, examining antibiotics prescribing quality standards, the use of invasive devices and the management of patients with infections, with relevant feedback to Ward Consultants and Nurse Managers.

Education and Training

Training on Antimicrobial Stewardship and antimicrobials medication is provided in a number of ways:

On-line mandatory training.

Monthly Antimicrobial Stewardship session delivered by the Consultant Pharmacist, Antimicrobials, on new doctors’ induction sessions.

“Key messages on antimicrobials prescribing;” Antimicrobial Stewardship sessions on the FY1 doctors’ core training programme.

Pharmacists’ monthly Antimicrobial Stewardship sessions, with CQUIN updates and antimicrobials case studies.

Annual Grand Round presentations for doctors on both main sites, on Antimicrobial Stewardship, to coincide with World Antibiotics Awareness Week and European Antibiotic Awareness Day.

Pre-registration Pharmacist activity, during World Antibiotics Awareness Week and European Antibiotic Awareness Day, including running stands to communicate with Trust staff and patients, on the prudent use of antibiotics.

Delivery of influenza and pertussis vaccination training sessions for Trust peer and patient vaccinators.

Patient Information

Patient information Leaflet IFP-0755, “Antibiotics Information for Patients and Carers,” is kept up-to-date.

Specific Projects

Dedicated prescription charts: Parenteral Vancomycin Inpatient Prescription, Administration and Monitoring Chart and a revised Once Daily Gentamicin Prescription Chart and associated guidance, have both been launched this year.

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