1. 1 Infection Control Progress Report to the Trust Board Nizam Damani Clinical Director: Infection Prevention & Control 28 th May 2009

2. 2 Priorities for Action Target (35% reduction) BASELINE 2007-08 TARGET 2009-10 No. per month MRSA1490.75 MSSA46332.75 C difficile 134998.25

3. MRSA Bacteraemias

4. MRSA bacteraemias in Southern Trust

5. 55 Southern Trust New cases of MRSA Jan 2008 –26 th May 2009

6. 66 Southern Trust New cases of MSSA Jan 2008 –26 th May 2009

7. 7 MSSA

8. 10 Point Plan to control Staph aureus infections 1.Hand hygiene - Campaign started in Dec 08 - Compliance monitored - Installation of hand wash basins 2. Cleaning & Decontamination of environment/equipment - Compliance monitored - Investment of > 400 k to improve clinical environment and achieve high standard of cleaning - 155 commodes replaced

9. 10 Point Plan to control Staph aureus infections 3. Device Related Infections – Central Venous Catheter Bundles – Peripheral IV Bundles –Urinary Catheter Care bundles 4. Blood cultures : Reduce contamination & ‘ false positive’ - Training of Junior doctors - Introduce blood culture pack - Competency based training - Audit of Blood culture contamination 5. Root Cause Analysis : MRSA & MSSA Bacteraemias - Training completed on 23 rd March and 24 th April 09

10. 10 Point Plan to control Staph aureus infections MRSA 1.Antibiotic Stewardship -Prudent use : restricted use of Quinolones & 3 rd generation Cephalosporins since Dec 2008 2.Screening of high risk individuals /units -ICU, NNU, Orthopaedics & Vascular, Renal, known positive etc -Resource consequences if screening is extended to other groups of patients

11. 10 Point Plan to control Staph aureus infections MRSA 3.Isolate patients in a side ward. - If not available, carry out risk assessment - Six bedded isolation unit is ready 4.Implement contact precautions for infected and colonized patients 5.Decolonize patient and give Vancomycin as surgical prophylaxis

12. Swine Flu

13. Summary of the Trust Infection Interventions C difficle, MRSA & MSSA C difficleMRSAMSSASwine flu Hand hygiene √ √√√ Isolation of Patients √√ × √ Antibiotic Stewardship √√(+) × Standard (Contact) Precautions √√√√ Clean : Environment & Patient’s care items √√√√ Root Cause Analysis √√√ × Visitors Policy √√√√ Devices related infections× √√ × Reduce Blood Culture Contamination rate × √√ × Screening of patient with MRSA× √ ×× Decolonization/ treatment of MRSA× √ ×× Surveillance:Outcome and Process √√√(+)

14. 14 Antibiotic Stewardship

15. Expenditure on Antibiotics Recurrent Saving of ~ 25,000 £ per month

16. 16 Expenditure on Medical & Surgical wards Impact of Antibiotic ward rounds in Medical wards

17. Antibiotic Stewardship Feedback to individual consultants on compliance and antibiotic ward rounds Extend Antibiotic ward round to other Medical & Surgical wards –Resource issues: medical, microbiologists & pharmacist Audits of surgical prophylaxis Engagement of General Practitioners antibiotic stewardship and use of Proton Pump Inhibitors –Training at three SALT seminars in October 2008 –Meeting with the GPs Lead Continuing Education of medical staff

18. Zero tolerance to Catheter-related Bloodstream Infections (CR-BSI

19. 19 Zero tolerance to Catheter-related Bloodstream Infections (CR-BSI) NNIS Benchmark : 3.3 infections per 1000 line days for CVC No CR-BSI for past 19 months Daisy Hill Hospital

20. 20 Southern Trust Zero tolerance to Catheter-related Bloodstream Infections (CR-BSI) NNIS Benchmark : 3.3 infections per 1000 line days for CVC NO CR-BSI in Intensive Care Unit for past 7 months

21. 21 Southern Trust Zero tolerance to Catheter-related Bloodstream Infections (CR-BSI)

22. Zero tolerance CR–BSI Pre- intervention (Oct. 06 – March 07) Post – intervention (April 07 – March 09) Cost saving (£6,209)* No of bed days saved** No of CR- BSI 19 X 4= 76 5+4+4+1= 14 62 x £6,209= £384,958 62 x 7 days= 434 *CR-BSI costs £6,209 per patient :Dept. of Health NHS. Saving lives, 2007 ** Soufir L et al. Infect Control Hosp. Epidemiol. 199; 20 (6): 296-401.11

23. 23 Southern Trust to Lead the development of Regional Guidelines on the Management of Central line infections in Paediatrics

24. 24 IV: Peripheral Line Training of Junior doctors in aseptic technique Awareness training by dedicated member of ICT –Peripheral & Central Line Bundle Training of the Infection Prevention and Control Link group on ‘IV Bundle’ and audit tool Audit of peripheral line practices by ICT both pre and post training Documentation: New dedicated documentation chart Regional tender: Port-less cannula / pack for insertion Standardise needle free systems Introduced competency based training programme for all clinical staff

25. 25 C difficile

26. 26 C difficile

27. 27 C difficile Source: CDSC May 2009

28. 28 Cohort ward open Restrict unnecessary movement of patients 1 st Dec 08 RCA started Improved compliance HH, antibiotic, cleaning New antibiotic Guidelines Cephalosporins & Quinolones removed Hand hygiene Campaign 10 point plan June 2008

29. RCAs Findings Risk factorsNo of cases % Patient was isolated according to Trust Policy 57/7477 % Intra-hospital transfer in last 6 months42/7457 % Inter-hospital transfer in last 6 months22/7430 % Patient transported by ambulance in last 6 months 32/7443 % Resident in Nursing/residential homes in last 12 months 4/7419 %

30. Six bedded bay

31. Ward toilet

33. www.tfihealthcare.com Ward toilet

34. Side room with NO en-suite toilet Ward toilet Sluice Area

35. Side room with en-suite toilet Spread of C.difficile spores is contained C.difficile spores

36. C difficile disease transmission & impact on hospital & Community 1 2 3 4 Less than 1 to eliminate disease

37. 37 Southern Trust New cases of C diff Jan 2008 – 18 th May 2009

38. Run Chart Pre-intervention period 1 st quarter Nov 08 – Jan 09 Post-intervention period 2nd quarter Feb – April 09

39. Is it worth investing in prevention of Healthcare Associated Infection ? Pre intervention period Nov 08 - Jan 09 Post intervention period Feb – April 09 Difference No of patients 791762 fewer cases Cost saving : 62 x £ 4000 * = Total saving of £ 248,000 achieved Cost saving : 62 x £ 8000 = Total saving of £ 496,000 ? No. of bed days : 62 x 21* days = Total of 1302 bed days released No. of bed days : 62 x 47 days = Total of 2914 bed days released * Dept of Health, 2007

40. RCA analysis: C difficile 28th Oct – 31st March 09: n =74 Average length of stay : 6.5 weeks NHS average : 3 weeks

41. 41 Findings of RCAs on C difficile…1 Review all patients on Proton Pump Inhibitors (PPIs) –Review started at DHH History of bowel habits must be documented as part of routine medical history Risk assess all patients with diarrhoea at A&E Guidelines on sending specimen for C difficile for patients on laxatives and other agents which can cause diarrhoea All confirmed C difficile infection patients must be isolated in side ward with en-suite toilet facilities within 2 hrs

42. 42 Findings of RCAs on C difficile…2 Symptomatic patients with previous history of C difficile infections must be admitted to a side ward with en-suite toilet facilities Inter & intra-hospital movement must be kept to absolute minimum Patient flow issues Communication to wards/ hospitals/ambulance /nursing home/GPs/CCDC/ services must be documented All staff must be trained in RCA analysis Trust wide forum to shared learning from RCA & MM 30 days mortality: Agree process to review and document

43. 43 Need data on individual ward compliance on all elements of the bundle

44. Challenge Sustainability ! ‘ …it takes all the running …to stay at the same place. If you want to get somewhere else, you must run at least twice as fast as that. - Lewis Carol -Through the looking Glass 44

45. 45 Thank you