Gram negative slideset

NHS England
NHS Improvement
WORKING TOGETHER FOR THE NHS
Gram-negative blood stream infections:
ensuring board assurance against national
standards
Tuesday 1 May 2018, Congress Centre
#improveIPC

Welcome and introductions
Linda Dempster, Head of Infection Control, NHS Improvement
#improveIPC

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Leading your way to success
Celia Ingham Clark
Medical Director for Clinical Effectiveness, NHS England
Interim NHS National Director of Patient Safety, NHS Improvement
#improveIPC

The NHS is facing a number of highly publicised pressures; during
this time strong consistent leadership is key.

Influencing Improvement in Patient Safety through
Effective Leadership
How do we influence and sustain positive change as system leaders?
Overcoming challenges and encouraging improvement, we want to support organisations and co design
change
As leaders in our NHS across health system boundaries and beyond this ambition has one overarching goal,
to improve patient safety & reduce harm to patients
We need to focus on improving recognition and management of sepsis
Create positive outcomes for our patients with BSI by learning from their experiences
Share and learn from Peers , what works well and can be replicated
What a Trust Board should be asking about improving Patient Safety.

How acute Trusts performed 2017 vs 2016
hospital onset E.coli
• In 2017 62 providers (41%) reduced their hospital onset E.coli infections by at least 10%.
• 2017 data shows a national reduction of 1.67% (compared to 2016).

Pledge to Improve Hand Hygiene?
#handhygiene #sepsis #improveipc
• 5th May is global WHO Hand Hygiene day
• Have you and your organisation made your pledge?

Background
• In May 2016, the Government announced its ambition to halve healthcare associated (HCA)
GNBSIs by 2021.
• This was in response to the final report of the global facing independent review of
Antimicrobial Resistance (AMR) led by Lord O’Neill.
• In November 2016 Ruth May at NHS Improvement was appointed as National Infection
Prevention Lead to co-ordinate this programme.
• The baseline for the ambition is set at the year end 2016/17 with an estimated 32,038 cases of
the 3 main organisms that were Healthcare associated .
• A 50% reduction ambition would see numbers of the three main infections, E.coli, Klebsiella
spp and Psuedomonas aeruginosa, fall to 16,019 by the year 2020/21.
• This is a significant improvement ambition and has this year been added to the SOF

@Glisser
Quick fire questions
Do you know the total number of E.coli BSI reported for your
organisation ?
Yes or No
Did you meet the 10% reduction?
Yes or No or Don’t know
Are you working collectively as a system to produce a cross-system
improvement plan?
Yes or No or Don’t know

Current data/position – Total E.coli
2000
2200
2400
2600
2800
3000
3200
3400
3600
3800
4000
Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
Numberofcases
Monthly counts of E. coli BSI by CCG for April 2016 - March2018 (published) against Monthly trajectories
of E. coli BSI by CCG (unpublished)
Actual 2016/17 (Published)
10 % Trajectory 2017/18 (Unpublished)
5% Trajectory 2017/18 (Unpublished)

What does current risk factor data tell us?
Most likely Source of infection
Community
Onset
Hospital
onset Total
Urinary Tract infection 4695 1021 5716
Hepatobiliary 1484 321 1805
Gastrointestinal or Intraabdominal collection (excluding
hepatobiliary) 469 305 774
Lower Respiratory Tract (pneumonia, VAP, bronciectasis, exac
COPD etc) 470 131 601
Prostate 110 22 132
• E.coli data submitted on the PHE Data Capture System (DCS) April - October 2017.
• Most likely sources of infection of are: Urinary Tract Infection (UTI) and Hepatobiliary.
• This data has supported the design of the 2018/19 improvement offer.
Prior Risk Factors (for infection sites listed & unknown infection
site) Yes No unknown total
Urinary catheters for UTI/ pyelonephitis 876 4344 2426 7646
Vascular catheters (CVC or PVC) for device related infection 327 855 1755 2937
Prostate biopsy for UTI/ PYE 90 5753 1803 7646
Surgery for all infection sites 785 534 83 1402
Hepatobiliary procedures for hepatobiliary infections 169 2303 1295 3767

Challenges
• Delivering reductions outside of secondary care, across health and social care
engagement of a wide range of organisations and teams is critical.
• The E.coli risk factor data needed to target interventions is not mandated, but is
included in the Quality Premium. There is variation in the completeness of this data.
• Klebsiella and Pseudomonas data collection is in year one. PHE will not be in a
position to provide comparable data until Q1 of 2018/19.
• While the Quality Premium offers an incentive to CCGs to reduce all E.coli infections,
not just the HCA ones, few achieve all of the hurdles required to be awarded the
payment, so there is no additional funding to support local initiatives.

Patient panel
Chair, Paul Reeves, Head of Nursing, Education and New Roles, NHS
Improvement
Jayne Nicholls, Sonia Adrissi and Kirsten Lavine, UK Sepsis Trust
#improveIPC

GNBSI- Data for action
Russell Hope
Head of Bacteraemia and CDI Surveillance Section
Public Health England
#improveIPC

Mandatory HCAI Surveillance:
Timeline
Summary of developments since 2001:2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
S. aureus bacteraemia (aggregate counts)
MRSA bacteraemia (enhanced, real-time)
S. aureus bacteraemia (enhanced, real-time)
Post Infection Review (PIR) for MRSA
bacteraemia
C. difficile infection over 65s (quarterly
aggregate)
C. difficile infection over 2s (enhanced, real-time)
GRE bacteraemia (quarterly aggregate counts)
Surgical site infection (orthopaedics)
E. coli bacteraemia (enhanced, real-time)
Klebsiella and Pseudomonas aeruginosa
bacteraemia
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Staphylococcusaureusbacteraemiareports and methicillin
susceptibility(England& Wales,1991-2003)
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
numberofreports
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
MRSAas%ofreportswith
methicillinsusceptibilityinformation
Staphylococcus aureus
methicillin resistance as a proportion of reports with methicillin
source: routine laboratory reporting to CDSC

0
5000
10000
15000
20000
25000
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Numberofbacteraemiareports
Calendar Year
S. aureus
MSSA
MRSA
S. aureus BSI Targets and
Surveillance Enhancements
Introduction of care for
catheters, cannulae &
tubes
Screening of high risk
and certain elective
pre-operative patients
for MRSA
Screening of high risk, all
elective & emergency
admissions patients for
MRSA
Clean your hands
campaign, Sept. 2004
Post Infection
Review initiated
Enhanced
MSSA
surveillance
Enhanced MRSA
surveillance
% MSSA and MRSA HCAI in 2017
27.4% of MSSA HCAI, c. 3 K cases
38.6% of MRSA HCAI, 327 cases

E. coli & MSSA BSI Numbers
Increasing
-30%
-20%
-10%
0%
10%
20%
30%
40%
Dec-2012 Jun-2013 Dec-2013 Jun-2014 Dec-2014 Jun-2015 Dec-2015 Jun-2016 Dec-2016 Jun-2017 Dec-2017
% change
since
2012
in
12 month
totals
Month
C. difficile infections and
MRSA, MSSA and E.coli bloodstream infections
% change in rolling 12 month totals since
the calendar year 2012.
December 2012 to December 2017
MSSA
ECOLI
CDI
MRSA

Why are GNBSI Important?
Pathogen GNR MRSA VRE C. difficile
Resistance +++ + + +/-
Resistance genes Multiple Single Single n/a
Species Multiple Single Single Single
HA vs CA HA & CA HA HA HA
Virulence +++ ++ +/- +
Environment +/- + ++ +++
Adapted from Jon Otter

Financial Case forAction
AMR Local Indicator
Sample Hospital with 464 patients in previous year:
Excess costs = £605,000 Excess deaths = 60
https://improvement.nhs.uk/resources/preventing-gram-negative-bloodstream-infections/

Gram-negatives Causing
Bacteraemia
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
NumberofCases
2009
2010
2011
2012
2013
2014
2015
2016
2017

E. coli Bacteraemia Hospital Onset vs.
Community Onset Cases
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
2012 2013 2014 2015 2016 2017
NumberofBacteraemia
Reports
Year
Community Onset Hospital Onset
18.9% Hospital
Onset, 2017

E. coli Bacteraemia Hospital Onset vs.
Community Onset Cases, 2017
0
500
1,000
1,500
2,000
2,500
3,000
3,500
NumberofBacteraemia
Reports
18.9% Hospital
Onset, 2017

E. coli Bacteraemia; Age and Sex Rate
per 100,000 Population, 2017
600 400 200 0 200 400 600
<1
1-14
15-44
45-64
65-74
75+
AgeGroup
Female Male

Resistance to Key Antibiotics in E. coli
Causing Bacteraemia, 2012 - 2016

Rises in E. coli BSI Related to
Rising Resistance
AMR Local Indicator Schlackow JAC 2012
“E. coli BSI rates risen due to rising rates resistant organisms”
Increase not just observed in hospital populations (>2days/ in hospital in last
year)
No difference in outcome observed” (yet)

Population Structure of E. coli Causing
Bacteraemia in the UK & Ireland
ST131
ST73
ST95 ST12
ST69
N=1923
Minimum spanning tree
Day et al JAC 2016

E. coli Bacteraemia Focus and AMR
Focus of bacteraemia
Antibiotic resistance
Onset
Cases with reported
primary focus
Total cases
Gastrointestinal (not
hepatobiliary)
Hepatobiliary UTI
Respiratory
tract
Others Unknown
All reported cases 23,899 41,237 6.7% 15.7% 49.0% 5.5% 6.7% 16.4%
Community-onset 19,068 33,454 5.1% 16.1% 52% 5.4% 5.6% 16.0%
Hospital-onset 4,831 7,783 13.0% 14.0% 38% 5.8% 11.0% 17.9%
Co-amoxclav Ciprofloxacin
3rd-generation
cephalosporins
Piperacillin/tazobacta
m
Gentamicin Carbapenems
Community-onset 41.5% 18.5% 11.5% 14.3% 9.9% 0.2%
Hospital-onset 51.6% 25.7% 17.8% 20.6% 14.4% 0.5%
>7 Days 53.2% 28.4% 18.7% 21.7% 15.7% 0.5%
Total non-susceptibility 43.4% 19.8% 12.6% 15.5% 10.7% 0.2%

Klebsiella spp. Bacteraemia Hospital Onset vs.
Community Onset Cases (April – December 2017)
0
100
200
300
400
500
600
700
NumberofBacteraemia
Reports
29.2% Hospital
Onset, 2017

Presentation title - edit in Header and Footer
Klebsiella spp. Bacteraemia; Age and Sex Rate
per 100,000 Population
(April – December 2017)
100 50 0 50 100 150 200
<1
1-14
15-44
45-64
65-74
75+
AgeGroup
Female Male

Klebsiella spp. Bacteraemia Focus and
AMR
Focus of bacteraemia (April – December 2017)
Antibiotic resistance (April – December 2017)
Onset
Cases with reported
primary focus
Total cases Gastrointestinal Hepatobiliary UTI
Respiratory
tract
Others Unknown
Community-onset 2,543 5,196 5.2% 23.0% 36.4% 7.2% 8.8% 19.3%
Hospital-onset 1,051 2,142 14.4% 13.9% 22.5% 11.6% 18.4% 19.3%
Co-amoxiclav
3rd-generation
cephalosporins
Ciprofloxacin Gentamicin
Piperacillin/tazobacta
m
Carbapenems
Community-onset 22.7% 10.0% 9.7% 6.2% 14.6% 0.8%
Hospital-onset 32.3% 19.4% 15.0% 9.8% 24.1% 2.4%
>7 Days 35.3% 20.8% 15.0% 9.8% 26.3% 2.4%
Total non-susceptibility 25.5% 12.7% 11.2% 7.3% 17.4% 1.3%

P. aeruginosa Bacteraemia Hospital Onset vs.
Community Onset Cases (April – December
2017)
0
50
100
150
200
250
300
NumberofBacteraemia
Reports
36.7% Hospital
Onset, 2017

P. aeruginosa Bacteraemia; Age and Sex
Rate per 100,000 Population
(April – December 2017)
40 20 0 20 40 60 80
<1
1-14
15-44
45-64
65-74
75+
AgeGroup
Female Male

P. aeruginosa Bacteraemia Focus and
AMR
Focus of bacteraemia (April – December 2017)
Antibiotic resistance (April – December 2017)
Onset
Cases with reported
primary focus
Total cases Gastrointestinal Hepatobiliary UTI Respiratory tract Others Unknown
Community-onset 926 2,095 3.8% 4.6% 33.8% 13.8% 20.6% 23.3%
Hospital-onset 581 1,217 8.6% 5.3% 24.1% 12.2% 28.7% 21.0%
Ciprofloxacin Ceftazidime Piperacillin/tazobactam Gentamicin Carbapenems
Community-onset 10.1% 5.9% 14.5% 4.7% 15.0%
Hospital-onset 13.0% 9.2% 17.1% 6.6% 19.8%
>7 Days 14.2% 10.2% 17.7% 6.7% 21.6%
Total non-susceptibility 11.1% 7.1% 15.5% 5.4% 16.8%

Comparison of CCG E. coli Bacteraemia
Rates Crude and Standardised

Comparison of CCG Klebsiella spp.
Bacteraemia Rates Crude and Standardised

Comparison of CCG P. aeruginosa
Bacteraemia Rates Crude and Standardised

Association Between Deprivation and Rates
of E. coli Bacteraemia by CCG, England
2012/13 to 2015/16
~ 40% variation
explained
by deprivation

Mortality
Number of deaths within 30 days of specimen collection by infection

Mortality
Thirty-day all-cause case fatality rate by infection

https://improvement.nhs.uk/resources/preventing-gram-negative-bloodstream-infections/
BSI, Community-Onset , Hospital-Onset and
Healthcare-Associated Cases

• indwelling vascular access devices (insertion, in situ, or removal)
• urinary catheterisation (insertion, in situ with or without manipulation, or
removal)
• other devices (insertion, in situ with or without manipulation, or removal)
• invasive procedures (eg endoscopic retrograde cholangio-
pancreatography, prostate biopsy, surgery including, but not restricted
to, gastrointestinal tract surgery)
• neutropenia (<500/µL at time of bacteraemia)
• antimicrobial therapy within the previous 28 days
• hospital admission within the previous 28 days
Key Healthcare-associated
Risk Factors

BSI, Community-Onset , Hospital-Onset and
Healthcare-Associated Cases
Area Name Estimated number of Gram-negative BSIs (2016/17) Percent of total
A+B+C All infections 53,544 100%
A Hospital onset 16,207 30%
B+C Community onset 37,337 70%
B Community onset, healthcare-associated* 15,925 30%
C Community onset, non-healthcare-associated* 21,412 40%
A+B Healthcare-associated 32,132 60%
*Community onset, healthcare associated cases only include E. coli as we do not have the data for Klebsiella spp. or
Pseudomonas aeruginosa to calculate proportion community onset which is likely to be healthcare associated at this time
Estimated E.coli, Pseudomonas aeruginosa and Klebsiella spp. bacteraemias in
England, 2016/17
Area Name Number of E. coli BSIs (2016/17) Percent of total
A+B+C All infections 40,303 100%
A Hospital onset 8,453 21%
B+C Community onset 31,850 79%
B Community onset, healthcare-associated* 15,925 40%
C Community onset, non-healthcare-associated* 15,925 40%
A+B Healthcare-associated 24,378 60%
Reported E. coli bacteraemias in England, 2016/17
*It is estimated that 50% of community onset E. coli cases are healthcare associated

Gram-negative Bloodstream Infections 50%
reduction in HCAI by end of FY 2020/21
0
10000
20000
30000
40000
50000
60000
70000
80000
ReportedGram-negative
bloodstreaminfection
Financial Year
GNBSI
Reduction Target

E. coli BSI Reductions 1st Year
Performance
Overall reduction target not achieved for 2017/18
However:
• GNBSI upward trend mostly curtailed
• E. coli cases lower in 2017/18 FY than previous year for 73 Trusts
• Trust with one of the highest E. coli rate in 2016/17 FY, 15% reduction in
all cases 27% reduction in HO cases for 2017/18 FY
Savings: 494 pt bed-days
£155,000
15 lives

Information for Action
fingertips.phe.org.uk/profile/amr-local-indicators

Conclusion
• Progress over last 10 years with MRSA and CDI, with dramatic
changes
• Increasing incidence & prevalence Gram-negative resistance
• Gram-negative bacteraemia ambitions 50% reduction of healthcare-
associated infections
• Mortality: E. coli bacteraemia highest number of deaths within 30
days of onset but the lowest case fatality rate
• Gaps: Surveillance of UTI, Identification of CO infections with
healthcare association, Monitoring impact of interventions

Acknowledgements
PHE HCAI & AMR dept.
AMR PB
NHSI and NHSE AMR and IPC teams
Participants IPC workshops
NHS trusts, CCGs, and GPs

Refreshment break
#improveIPC

IPC Provider workforce survey – outcomes
IPC board assurance review – outcomes
Karen Dunderdale, Senior Nurse Advisor, NHS Improvement
#improveIPC

Objectives
• Context for each piece of work
• Methodology of each piece of work
• Findings
• Recommendation

Context
Gram-negative bloodstream infections (BSIs) are a healthcare safety issue
From April 2017, there is an NHS ambition to halve the numbers of healthcare
associated Gram-negative BSIs by 2021.
Two themes have arisen following year one of the ambition
• Infection prevention and control teams have struggled to meet increasing
demands
• NHS provider boards are less sited on IPC than previously (High MRSA and
CDI)

Aims
The aim of the IPC survey:
• Identify what infection prevention & control teams look like now and
how they may look in the future
• Engagement of your board to infection prevention & control
The aim of the board review:
• Identify the level of board assurance in light of the CQC Well-led
reviews which now focuses more attention of the role of the Director of
Infection Prevention and Control ( DIPC) and the board assurance
process

Methodology of the workforce survey
Survey
• Questions designed to gain an understanding of the IPC workforce
• Piloted in 3 trusts (acute, mental health & community)
Design
• Survey monkey or spreadsheet return
Time period
• 1 March – 23 March 2018
Response rate
• 23% (n=55) 347
5
8 1
Type of organisation who responded
Acute
Mental health
Community
Specialist
Ambulance

Findings of the IPC workforce survey
32
9
9
1
1
2 1
What is the professional role of the DIPC?
Director of nursing & quality/chief nurse
Microbiologist
MD
Deputy MD
Nurse consultant IPC
Nurse
Executive director of quality and patient
safety

Findings of the workforce survey
1.00 WTE
(e.g. 10 PAs)
0.50 - 0.99
WTE (e.g. 5 -
9 PAs)
0.00 - 0.49
WTE (e.g. 0 -
4 PAs)
None Other (please
specify)
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
How many PAs (WTE) do you have for the DIPC role?
Responses

Band 9 Band
8d
Band 8c Band
8b
Band
8a
Band 7 Band 6 Band 5 Band 4 Band 3 Band 2 Band 1 Other
(please
specify)
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
List the band/grade of each staff member in the IPC team
Responses
0
2
4
6
DIPC microbiologist Antimicrobial
pharmacist
IPC doctor
Other grades

1.0
WTE
0.9
WTE
0.8
WTE
0.7
WTE
0.6
WTE
0.5
WTE
0.4
WTE
0.3
WTE
0.2
WTE
0.1
WTE
0.00%
20.00%
40.00%
60.00%
80.00%
List the WTE/PAs of each staff member in the IPC
team.

0
10
20
30
40
50
PhD MSc BSc/BA PG Cert Dip MBA NVQ
Numberofrespondants
What is the highest level of qualifications for
each member?

0
5
10
15
20
25
What other resources do you have access
to?

3.64% 0.00%
7.27%
18.18%
70.91%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
CEO COO Other Director MD DoN
What role is the named board executive lead for
IPC?

Within last
three
months
Between
three - six
months ago
Between six
- nine
months ago
Between
nine - twelve
months ago
Over twelve
months ago
Not
presented
Never
presented
Other
(please
specify)
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
When was the annual IPC report last presented to the board?
Responses

Yes Not yet, but plan
to do so
No Other (please
specify)
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
Have you developed a business case to change your IPC
team in the future?
Responses

What innovative roles are you planning to have in your IPC team in the future?
Workforce Increases in workforce
Review of roles to facilitate staff development
Apprenticeship roles
Band 4 roles
Data analysis
Volunteers
Antibiotic guardianship
Training
Technology
Quality improvement Mortality reviews
Sepsis detection

Board assurance review
The aim of the board review:
• To support providers to ensure they have robust IPC reporting
• Identify the level of board assurance in light of the CQC Well-led reviews
• Concerns have been raised that boards are less sighted on IPC particularly if
MRSA and CDI performance is good.

Methodology of the board assurance
review
Design:
• All acute, community, mental health board papers from public meetings
January 2017-December 2017
• Quality reports
• Performance reports
• Board minutes
• Specific board reports for IPC
• Action plans
• Improvement plans
• 134 organisations were reviewed
43
82
1
How often the board meets in
public
Bimonthly
Monthly
Quarterly

Findings of the board assurance review
3%
7% 7%
29%
62%
0.70%
0%
10%
20%
30%
40%
50%
60%
70%
CEO COO DoF MD DoN DIPC
Who presents at the board

Findings of board assurance review
0
20
40
60
80
100
120
Specific IPC reports Other reports to board Highlight reports Annual report
Percentageofacutetrusts
Board reports which reference IPC

Findings of the board assurance review
0
20
40
60
80
100
120
% reporting
CDIF
%reporting
MRSA
%reporting
MSSA
%reporting Ecoli %reporting
Klebsiella
%reporting
Pseudomonas
Percentageoftrusts
Organisms reported at the board

Recommendations
• Annual IPC reports should be publically available
• Boards to ensure that they have robust reporting in place to support the wide
patient safety agenda
• Publically available papers should reflect the discussion and debate around
IPC/Antimicrobial resistance
• NHS Improvement regional teams to support board assurance where GAPS in
website review have been identified
• Consider how assured you are with Hand Hygiene compliance
• Please ask me for your findings at the lunch break

Acknowledgements
• To all of you that completed the survey
• Linda Dempster, Head of IPC, NHS Improvement
• Gavin Eyres, Senior programme management lead, NHS Improvement, Visiting
research fellow, University of Chester
• Ruth May, Executive director of nursing, deputy CNO & national director for
infection prevention and control, NHS Improvement
• Jacquie McKenna, Director of nursing, professional leadership, NHS Improvement

Thank you for listening
Please contact me on karen.dunderdale@nhs.net
Follow me on twitter @karendunderdale

Well Led and Infection Prevention Control
Dr Edwin Selvaratnam
Clinical Fellow to Chief Inspector of Hospitals, Care Quality Commission
#improveIPC

Our Purpose
The Care Quality Commission is the
independent regulator of health and adult
social care in England
We monitor, inspect and regulate services
to make sure they meet fundamental
standards of quality and safety and we
publish what we find
There are five questions we ask of all care
services. They're at the heart of the way we
regulate and they help us to make sure we
focus on the things that matter to people.
84

Next Phase Methodology
• In addition to inspecting well-led at each service-level, we now
assess well-led separately at the trust-wide level for NHS Trusts
• Held annually
• Assessment of trust board and executive-level leadership and
governance, of overall organisational vision and strategy.
• Assessment of organisation-wide governance and management,
and of organisational culture and engagement
• The trust-level well-led rating is not based directly on the
aggregation of location/service level ratings (i.e. it is different to
the other four key questions)
86

Sources of Evidence
87
As with all CQC assessments, we draw on four broad sources of
evidence in a trust-wide well-led review:
1. Information from the ongoing relationship management with the
provider, NHS Improvement and other stakeholders
2. Nationally available data and local information that can inform the
inspection judgement
3. Information from activity carried out during the pre-inspection
phase
4. Information from core services inspections and use of resource
assessments

Well Led Inspection Framework
88

‘Must do’ Interviews
• Trust Chair
• Chief Executive
• Medical Director
• Nursing Director/Chief Nurse
• Chief Operating Officer
• Director of Finance/Chief Finance
Officer
• Director of HR
• Sample of Non-Exec Directors
• Sample of Governors, where
appropriate
• Director of Infection Prevention
and Control
• Freedom to Speak Up Guardian
• Chairs of Audit and Finance
Committees
89
• There are deliberately few ‘must do’ activities, however -where
possible- all well-led inspections should include an interview with:

Questions we may ask of Trusts:
• Are reliable systems in place to prevent and protect people from a
healthcare-associated infection?
• Is implementation of safety systems, processes and practices monitored
and improved when required?
• Do staff understand their roles and responsibilities in relation to infection
control and hygiene?
• Does the service maintain and follow policies and procedures in line with
current relevant national guidance?
• How are standards of cleanliness and hygiene maintained?
• How are you infection rates managed; including surgical site infections?
90

Questions we may ask of DIPC:
• Do they possess the appropriate skills, knowledge and expertise?
• How do they engage with your staff, board and the public?
• What is their vision and strategy for IPC and what are their monitoring
arrangements and integration with Trust board’s wider strategies?
• What are their current priorities and challenges relating to IPC?
• What is their governance structure within IPC and how have they
developed an appropriate culture?
• How do they maintain and strengthen antimicrobial stewardship?
• What systems are in place to monitor, manage and improve the
prevention and control of Infection?
91

Well Led Inspections
• 93 Well Led Inspections since September 2017
• 41 Acute NHS Trusts
• 10 Combined Acute & Community Trusts
• 7 Community Trusts
• 2 Ambulance Trusts
• 28 Mental Health Trusts & Combined MH & Community Trusts
• 5 Specialist Trusts
92

IPC themes from Well Led
• Evidence of robust governance arrangements
• Clear reporting mechanisms to the Trust Board
• Comprehensive annual IPC reporting
• Routine IPC audits which reflected inspection findings
• Staff prompted annually to review immunisations and encouraged
to have the flu vaccination
• Re-admissions reviewed by the microbiology team
• Strong culture of collective ownership around IPC
93

IPC themes from Well Led
• Premises not fit for purpose in relation to IPC
• Staffing issues – lack of Microbiologists, vacancies in IPC team
• Poorly resourced Infection control teams
• Estates and facilities, had a fundamental lack of understanding
regarding IPC and did not prioritise it
• Poor cleanliness in various departments
• Lack of consistent hand hygiene practice, lack of HH audits
• Weak or non existent culture around IPC governance and
strategy
94

IPC in Critical Care
• Are there systems in place to manage and monitor the
implementation of the IPC strategy?
• National Infections in Critical Care Quality Improvement
Programme [ICCQIP]
• National surveillance system for infection prevention and
control in critical care units in England [ICU, PICU, NICU]
• Participation is being questioned at Well Led as of Jan 2018
- 99 Trusts have registered and are actively participating
- 46 Trusts have not registered to programme
• Seeking assurances regarding enrolment into ICCQIP
95

CQC Monitoring & Inspection
• PHE HCAI data collections
currently used within CQC Insight
Dashboard
• MRSA (trust apportioned)
• Clostridium difficile (trust apportioned)
• E.coli (hospital onset)
• PHE HCAI data collections used
in Inspection Support Material
• MRSA (trust apportioned)
• MSSA (trust apportioned)
• Clostridium difficile (trust apportioned)
• Developing PHE HCAI Data
Collections planned for future use
in Insight Dashboard
• MSSA (trust apportioned)
• Klebsiella spp. (hospital onset)
• Pseudomonas aeruginosa
96

www.cqc.org.uk
@CareQualityComm | @edwin_selva
Dr Edwin Selvaratnam
Clinical Fellow to Chief Inspector of Hospitals
Thank you

Professional Panel
Panel Chair, Paul Reeves, Head of Nursing, Education and
New Roles, NHS Improvement
Dr Edwin Selvaratnam, Linda Dempster, Sara Mumford,
Russell Hope, Maureen Choong
#improveIPC

Lunch
#improveIPC

Table work session – Is your board
assured?
Chaired by Gaynor Evans, Infection Prevention and Control
Lead, GNBSI, NHS Improvement
#improveIPC

Project Catheter Safety: Outcome data
Lindsey Pearson, Continence Lead
Kim Corbett, Nurse Manager for Infection Prevention
Royal Wolverhampton
#improveIPC

Wolverhampton
City
• Population of 249,000
• Diverse, ethnic and
indigenous population
• High levels of social
deprivation
• Reduced life expectancy

Session outcomes
• Explain the background to and a project aimed at reducing long
term urinary catheterisation
• Identify some of the practicalities of addressing long term
urinary catheters
• Stimulate a discussion on the benefits of targeting catheters as
a means of preventing harm.

Background - Device-related bacteraemia

Composition of Device Related Hospital-
Acquired BacteraemiaFigure 2. Composition of devices reported as causing device-related hospital acquired bacteraemia by year
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
2016/17
2017/18
Line Urinary Catheter VAP VAP / Line Nephrostomy PVC Other

Community Device-related Bacteraemia
59%
4%
8%
8%
4%
4%
13%
CAB Causative Organisms 2017-2018
Escherichia coli
Klebsiella pneumoniae
Pseudomonas aeruginosa
Enterobacter cloacae
Proteus mirabilis
Klebsiella oxytoca
14%
70%
13%
3%
Related devices 2017-18
IV device
Urinary Catheter
Nephrostomy
ISC

Community device-related Bacteraemia
(catheter related cases)
0
2
4
6
8
10
12
Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17
Catheter related DRCAB’s as a proportion of all CAB’s
UC HABs
UC CABs

Project - Catheter Safety (PCS)
Aim
• Reduce community unplanned catheterisations and urinary catheter associated
bacteraemia (UCAB)
Objectives
• Standardise LTUC equipment in Wolverhampton
• Review patients with LTUC in Wolverhampton
• Reason for catheter
• Possible removal/alternative
• Correct prescription
• Food & fluid
• Bowels
• UTI and catheter problems
• Provide a plan and review process for all considered at high risk of bacteraemia (≥2
catheter changes in 3 months)

Reducecommunityunplannedcatheterisationsand
urinarycatheterassociatedsepsis(UCAB)
LTUC patients' are assessed to ensure
that only patients that clinically require a
LTUC have one.
- Number of people assessed as requiring LTUC
- Nursing Homes
- Residential Homes
- Own Homes
- Reasons for LTUC
- Number where TWOC is referred for
- Number where TWOC is successful
- Number where alternative s to LTUC is provided (ISC/conveen etc.)
- Number of patients commenced patient-held catheter record.
- Number of newly discharged patients with a LTUC under the care of
urology (prevalence).
Patients with a LTUC do not have
catheter associated blood stream
infection.
- Number of patients' on agreed products (e.g. all silicone catheter )
- Costs of LTUC related products
- Number of patients attending ED with catheter related issues compared to
pre project.
- Number of unplanned catheter changes compared to pre-project
- Number of ED admissions with catheter-related sepsis compared to pre-
project
- Monitor the number of patients discharged monthly with a urinary catheter
compared to pre-project.
- Training update (in relation to specific patient needs) .

Pre-project data
• Average number of catheterised patients discharged= 63/month
• Average number of unplanned catheter call outs = 152/month
• Number of long term urinary catheters pre project
• Average A&E attendances = 14 patients/month
• GP ‘Preferred list of products’ agreed (updated April 18).
03 /16 03 /17 09/17
637 591 545

PCS Outcomes
<2 catheter changes/3 mnt,
452, 63%
≥2 catheter changes/3 mnt,
263, 37%
716 catheterised patients assessed in 5 months, 191 of catheters were removed

Catheterised Patients – by location
60, 8%
29, 4%
626, 88%
Nursing Home (completed)
Residential Home (completed)
Own Homes (in progress)

Indication for catheter?
1
460
3
1
3
6
2
126
0 100 200 300 400 500
Gross Haematuria
Urinary Obstruction,
Urologic surgery
Decubitus ulcer
Input and output monitoring
Comfort care/Hospice Care
Immobility
Other
60
55
11
0 10 20 30 40 50 60 70
Not known
Neurogenic
Incontinence
‘Other’ breakdown

Background data
0
20
40
60
80
100
120
140
160
180
200
Pre project
data
Sep-17 Oct-17 Nov-17 Dec-17 Jan-18
ED attendances with catheter related issues
ED admissions with catheter-related sepsis
Unplanned catheter changes (District
Nursing)
Number of patients discharged monthly
with a urinary catheter
Number of ED admissions with sepsis
secondary to LTUC

Number of LTUC reported by district
nurses
583 582
600
561
555
561
565
530
540
550
560
570
580
590
600
610
Pre project data Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18

PCS outcomes continued
• Preferred list launched to GP’s and on formulary
• Assessed patients have documented reason for catheter
• Assessment information to be placed on portal
• Assessed patients moved to all silicone catheter from preferred list
• Patient held catheter record trialled in 3 nursing homes
• Patient specific plans and monitoring in one DN locality
• Business case commenced for catheter referral
• Improved engagement with DN’s.

Gram Negative Bacteraemia
• A 3 year City-wide action plan developed 17/18 is now included in the IP annual programme of work.
• Influencing the small drop in re 48 cases is thought to be further reductions in device related bacteraemia.
• 2018’s actions focus on catheterised patients both in acute and community settings.
0
5
10
15
20
25
30
35
40
45
E coli BSI Pre 48 hr
E coli BSI Post 48 hr
Total Gram negative BSI Pre 48 hr
Total Gram negative BSI Post 48 hr
Totals for 17/18
E coli Pre 48 hr = 58
E coli Post 48 hour = 256
Total GNB Pre = 92
Total GNB Post = 320

PCS Challenges & Next steps
Challenges
• Coding of district nursing activity
• Identifying reason for catheter (CH/GP/EPR/Patient /NOK…)
• Constant flow of discharged patients
• Poor documentation in care homes
• Liaison between multiple health care professionals.
Next steps
• Sustainability (commissioning conversations)
• Catheter review/TWOC clinics
• Number of unplanned catheter changes compared to pre-project
• Acute area actions to reduce catheter use identify is there is an effect gram-negative
bacteraemia

Collaborative approach to tackling Gram
Negative Bacteraemia - perspectives from
Foundation Trust and CCG
Dr Jo Malkin, Consultant Microbiologist, Claire Skull, Chair/ lead
continence and catheter group, Jane Lawson IPC Nurse
County Durham & Darlington
#improveIPC

www.cddft.nhs.uk
Who we are
CDDFT
 Largest provider of integrated health services in the North East with over 2 million
patient contacts per year
 One of the largest employers across the North East, with approximately 8,000 staff
 8 hospital sites
 Population of around 650,000 people
County Durham CCGs
 DDES 180,000
 ND 250,000
 Darlington 100,000

www.cddft.nhs.uk
Introduction
 Have been working collaboratively for a number of years
 Work together to improve patient outcomes
 Support of our organisations
 Value each others contribution
 Not target driven
 So…
 E. coli total figures down 5% from last year
 E. coli Trust apportioned down 23% from last year
 Commonest source Urinary Tract

www.cddft.nhs.uk
DON’s Perspective
 “As Executive Director of Nursing and Director of Infection Prevention and Control and on behalf of the
Foundation Trust board; I can say we are very supportive of the collaboration between the Foundation Trust
and CCG teams, in their aims of reducing HCAI infections specifically GNBSIs. We cannot achieve this
reduction by working in isolation. The team demonstrate strong leadership and vision to drive this agenda
forward, to achieve improved health outcomes and better experience for all our patients across the whole
health and social care sector. We look forward to widening this collaborative working across the region”
Noel Scanlon, Executive Director of Nursing, County Durham and Darlington NHS Foundation Trust
 “As a health economy we are working very closely together on this agenda to make sure that the changes
we make are agreed, understood and implemented across primary, community and secondary care. Our
Boards and Governing Bodies have been involved from the start and receive regular updates. They are very
supportive of the staff engaged in this important work”
Gill Findley, Director of Nursing, Durham Dales, Easington and Sedgefield CCG and North Durham CCG

www.cddft.nhs.uk
Early days
CDDFT Catheter Group
 Catheter Group established October 2010
 Led by Infection Control Surveillance Nurse
 Whole Health Economy Approach - membership including Matrons, Infection Control Nurses,
Continence Nurses, Urology Specialist Nurses, RGNs, Ward Managers, Community Nurses,
Procurement Specialist Nurse, Patient Safety Advisor, Care Home Representatives
 Projects included: documentation, audit and surveillance, standardisation of equipment,
education and training
 E. coli bacteremia case note review in place from June 2014 and reporting of HCAI through
Trust incidence reporting system

www.cddft.nhs.uk
Cause for concern
CDDFT - Trust Annual Point Prevalence Survey 2015
 Increase in prevalence of urinary catheters
 Increase in Catheter Associated Urinary Tract Infection (CAUTI)
 Identified CDDFT as an outlier for new UTIs (Lord Carter Model Hospital Nursing and Midwifery Dashboard)
 Increase in Patient Safety Incidents
 Increase in E. coli Bacteraemia related to urinary catheters
 Reduction in education and training
Escalated to Senior Nurse Infection Control and Director of Nursing
 Urinary catheter and continence care, core trainer and facilitator group
 Immediate actions put in place and development of a plan moving forward

www.cddft.nhs.uk
Appropriate urine dipstick testing

www.cddft.nhs.uk
Inappropriate urine dipstick testing
 The start of my journey April 2016 → RCA
 What are we doing within the Trust to tackle inappropriate dipstick
testing?
 What did we do?
 Additional comments to culture-positive urines, GP/Trust newsletter
 Arranged meeting with matrons and IPCT
 Engagement of clinical staff (took about 9 months) Feb to Oct 2017
 November 2017 – Agreed on wording and lay-out of poster to display on
all wards

www.cddft.nhs.uk
UTI Walk arounds
 Diagnosis, appropriate testing, audit, prevention and management
 Visited every ward at every hospital site
 Targeted all staff members
 Well-received
 Raised important issues
 Urine dipstick part of
 care bundles

www.cddft.nhs.uk
UTI pack
• Dehydration
guide
• Tips to
prevent UTI
• Fluid matrix
• Sample
request form
CCG Care homes
Quality
improvement
visits
• Infection
control
practices
• Standard of
cleanliness
• Liaise with
CQC and LA

www.cddft.nhs.uk
• GP surgeries
• Practice staff
• Federations
• Care homes
• LA
• Continence team
• Infection control
team
• Microbiologists
• Infection
control team
• Commissioning
• Medicine
optimisation
CCG
Acute
Trust
CDDFT
Primary
Care
Social
Care
CCG involvement
GNBSI

www.cddft.nhs.uk
DDES Trimethoprim to
Nitrofurantoin ratio

www.cddft.nhs.uk
Trimethoprim items
in over 70s

www.cddft.nhs.uk
Conclusion
What did we do right?
 Multi-faceted, team approach
 Enthusiastic, determined drivers
 High-level co-operation
 Involvement users
 What are the next stages?
 HOUDINI (Nurse led catheter removal protocol)
 Intermittent Self Catheterisation guidance
 Bladder scanning (equipment and training)
 Urology services (Commissioned from neighbouring Trusts)
 Patient hydration to prevent UTI in both acute and community settings
 Continence services (urinary catheters as last resort, ISC promotion, relation of pad usage to
potential UTIs)
 Hand hygiene messages in relation UTI prevention
 Non-urinary sources

www.cddft.nhs.uk
“Coming together is a beginning
Keeping together is progress
Working together is success”
Henry Ford

Reducing UTIs through hydration
Katie Lean, Patient Safety Manager, Patient Safety Collaborative,
Oxford AHSN
#improveIPC

A quality improvement project
Designed by care homes for care homes

Collaborative working
• Oxford AHSN, Patient Safety Collaborative AKI work stream and Windsor Ascot and Maidenhead CCG (Medicines
Optimisation)
Multidisciplinary
• AHSN patient safety manager, pharmacist, dietitian, care home staff (carers, chefs, nurses, activity co-ordinators,
managers), GPs
Pilot 1 group → target care homes with high UTI hospital admissions
• Started 1st July 2016
• 3 Residential Homes (25 residents in each)
• 1 Nursing Home (75 residents)
• Total residents 150 (> 60% with dementia)

Series, B. and Kilo, C.M., 1998. A Framework for
Collaborative Improvement: Lessons from the Institute for
Healthcare improvement’s Breakthrough Series. Quality
management in health care, 6(4), pp.1-13.

Overall Aim:
• Reduce hospital admissions for UTIs
by 5% from the previous year
Other Aims:
• To reduce number of antibiotic treated
UTIs in the care home
• To improve the general health and
well being of residents by promoting
hydration
• To raise awareness and educate care
staff of risks of dehydration - AKI,
UTIs, Falls
• To optimise UTI management and
prescribing

• Designed process measures with care
home managers
• 7 Structured Drinks rounds a day

• Outcome Measure – UTIs requiring antibiotics or admitted to hospital with
a safety cross

Cycle 1: UTI poster – Signs and Symptoms of a UTI – 1st June 2016

Cycle 2: Hydration training for care home staff 28th June 2016

• In groups of 8-30
• 2 hours
Topics
• Anatomy and Physiology of the urinary system
• Signs and symptoms of dehydration
• How to improve hydration
• The elderly and water
• AKI and
• UTIs [NICE QS90 – focuses on identification of UTIs in over 65 year olds]
• Medications and water
• How to implement and measure a structured drinks round
• Captured thoughts and ideas from care staff as to what would work
• “The training has given us understanding of why it’s important to ensure that
residents have enough fluids – it’s looking at the whole system, not just a drink.”
Care Home Staff Member

Cycle 3: Structured drinks round – 1st July 2016

• Timing - 7
• Colour
• Creative
• Variety of drinks
• Theme
• Make it special
something to look
forward to.
• Residents involved
through activities
Some families got involved

Cycle 4: Residents Training – 8th August 2016

Cycle 5: Drinks Diary – 14th Nov 2016

A resident who had a UTI
every 6 weeks used the
drinks diary (had capacity)
and realised how little they
were drinking. Increased
fluids of own free will.
Improvement in walking,
interaction socially and
been UTI free for over 10
months.

Cycle 5: Drinks Diary – 14th Nov 2016
Cycle 6: GPG – 1st July 2017

GPG for GPs – diagnosis,
prescribing, advice
GPG for care staff – UTI signs
and symptoms, risks of
dehydration, advice to promote
hydration, NO ROUTINE dip stick
testing
FORM U1 – identifying and reporting
signs and symptoms, UTI
management plan, improving
communication between care homes
and GPs

0
2
4
6
8
10
12
14
16
18
20
July 2015 - June
2016
July 2016 - July 2017 July 2017 - March
2018
UTI Admissions to Hospital - Pilot 1
UTI Admissions to Hospital -
Pilot 1
38%
Overall 66%
45%

Care home code Started Project Baseline Average (2 months) Average to date Greatest number of days
between UTIs (May 2016-March
2018)
E1 01/07/2016 1 UTI per 9 days 1 UTI per 54 days 174 days
H1 01/07/2016 0 UTIs 1 UTI per 76 days 243 days
M1 01/07/2016 1 UTI per 15 days 1 UTI per 69 days 225 days
L1 01/07/2016 1 UTI per 11 days 1 UTI per 20 days 92 days
0
200
Days Between UTIs Requiring
Antibiotics - E1
Days…
0
50
100
Days Between UTIs Requiring Antibiotics
- L1
Days since

Residents
• Ask for their drink if we are late!
• Resident A “I like the cold drinks like juice
and will continue to drink it even in the winter”
• Resident B “I enjoy the variety of drinks and sometimes have two cups”
Staff
• Noticed improved skin integrity and less falls
• Less GP visits
• Greater understanding within staffing groups
as to why hydration is important
• Taking part in more activities

• 5 Care homes in East
Berkshire
• 3 x nursing
• 2 x residential
(215 Residents)
• 31st July 2017
0
5
10
15
20
25
30
July 2016- June 2017 July 2017 - March 2018
UTI Admissions to Hospital - Pilot 2
UTI Admissions to Hospital -
Pilot 2
44 %
12 less UTIs to date
Care home code Started Project Baseline Average (2 months) Average to date Greatest number of days
between UTIs (June 2017-March
2018)
F2 01/06/2017 1 UTI per 11 days 1 UTI per 47 days 78 days
LH2 01/06/2017 1 UTI per 10 days 1 UTI per 17 days 46 days
N2 01/06/2017 1 UTI per 14 days 1 UTI per 22 days 39 days
OA2 01/06/2017 1 UTI per 3 days 1 UTI per 8 days 37 days
XO2 01/06/2017 1 UTI per 5 days 1 UTI per 17 days 66 days

• Packaged all project resources on PSC website
• Awarded HEETV funding for YouTube sketches
for care home staff
• Roll out of project/learning – East Berkshire CCG
• 3 care homes in Oxfordshire
• Supporting Chiltern CCG, Swindon CCG
• Learning shared with BLMK Sustainability and
transformation partnership
• Interest Vale of York CCG
• Facilitated Luton borough council to run project
• Interest from secondary care providers

• Resident at the heart of the project
• Project designed by care home
staff
• Minimal cost
• Easy measurement tools
• Easy to implement and sustain
• Simple to adopt in other care
homes and care settings
• Link with care home
pharmacist/other clinician within
the CCG/council

The 2018/19 GNBSI support offer
Ruth May
Executive Director of Nursing, NHS Improvement
Deputy Chief Nursing Officer & National Director – Infection
Prevention & Control
#improveIPC

2018/19 In Hospital approach to reducing
Healthcare associated E. coli BSI
1 • Urinary Tract Infection (including catheter associated infections) Collaborative with NHS England.
2 • Directors of Infection, Prevention and Control Executive Development Programme.
3 • Review of NHS Providers board assurance and action plans to support.
4 • Masterclass for Executives and Senior leaders on E.coli and urinary tract infections.
5 • Focused clinically led work streams on the highest known risk patients/interventions.
6 • Focused work stream linking with GIRFT and hepatobiliary sepsis.
7 • CQC regulation and the well led domain.
8 • Quality Improvement v’s Performance Management of NHS Providers.
9
• Seek further advice from Advisory Committee on Antimicrobial Prescribing, Resistance and Healthcare
Associated Infection (APRHAI)

Gaynor Evans, Infection, Prevention and Control Lead, GNBSI, NHS
Improvement
Closing remarks
#improveIPC

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