infection prevention and control annual report 1 april

Infection Prevention and Control Annual Report

1st

April 2013 - 31st

March 2014

Produced by: The Director of Infection Prevention and Control

Written by:

Lead Nurse Infection Prevention & Control

Reviewing the period: April 2013 - March 2014 Approved by Infection Control Committee: July 2014 Received by Trust Board: July 2014

- 2 –

Annual Report – Infection Prevention and Control April 2013-March 2014

Table of Contents

Section:

Page:

1 Introduction

4

2 Infection Control Roles and Governance Structures Within the Trust 2.1 Corporate Responsibility 2.2 Infection Prevention and Control team and Members 2.3 Infection Control Committee 2.4 Internal Reporting Arrangements 2.5 Reports to the Executive Team and Trust Board 2.6 Risk Register

4 4 4 5 5 6 6

3 Infection Control Resources Within the Trust 6

4 Infection Control in 2014/15: The Local Picture 4.1 Aseptic Non Touch Technique 4.2 Infection Prevention and Control Strategy

6 6 7

5 Mandatory Surveillance During 2014/15 5.1 Mandatory reporting 5.1.1 Meticillin Resistant Staphylococcus aureus (MRSA) 5.1.2 Meticillin Sensitive Staphylococcus aureus (MSSA) 5.1.3 Surveillance of Clostridium difficile toxins 5.1.4 Escherichia coli bacteraemia 5.1.5 Surveillance Glycopeptide Resistant Enterococcal (GRE) bacteraemia 5.2 Other Resistant Bacteria 5.3 Surgical Site Infection 5.3.1 Orthopaedic 5.3.2 Caesarean Section

7 7 8 9

10 10 11 11 12 12 13

6 The Infection Control Team: Other Core Activity During 2014/15 6.1 Education and Training 6.2 Supporting and Working with Infection Control Link Staff 6.3 Implementation of the European Directive on Safer Sharps 6.4 Audit and Monitoring 6.5 Working with the Patients and Public 6.6 Working to Ensure Optimum Hospital Hygiene 6.6.1 Cleaning and Catering Services 6.7 Sterile Services 6.8 Redesigning Environments and New Builds 6.8.1 Endoscopy

14 14 15 15 15 16 16 16 18 18 19

7 Infection Control Policy and Procedures Within the Trust

19

8 Outbreaks and Incidents at the Trust in 2014/15 8.1 Pandemic Influenza 8.2 Gastroenteritis / Norovirus 8.3 Needlestick incidents and Prevention of Needlestick injuries 8.4 Legionella and Water Quality Monitoring

19 19 19 20 20

9 Management of Antibiotics Prescribing at the Trust in 2014/15

22

10 Safety and Quality in Infection Control: Statutory Duties 10.1 Care Quality Commission

23 23

- 3 –


11 Measures of Infection Prevention and Control: Shaping Practice to Improve Performance

24

12 Looking Forward to 2014/15 24

13 Conclusion

25

14 Acronyms

26

15 Appendix A : IP&C Policies

27

15 Appendix B: IP&C Strategy Metrics

28

- 4 –


1 Introduction to the Report

This is the annual report from the Director of Infection Prevention and Control (DIPC)

providing information on infection prevention and control activity across the

organisation. The purpose of this report is to provide detail to our patients, public,

staff, Trust Board, Commissioners and Monitor on the infection control agenda for the

previous year.

This report covers the period from 1st April 2013-31st March 2014 and provides

performance against national targets for:

Meticillin Resistant Staphylococcus Aureus (MRSA) bacteraemia figures,

Clostridium difficile Toxin (CDT) rates,

Healthcare associated infections

Other key activities and audit for the year.

Infection prevention and control remains a key patient safety and quality focus for the

organisation. This year was the first year NHS England set all MRSA bloodstream

infections targets as nil, as they continue to pursue a zero tolerance approach to

Health Care Associated Infections (HCAI). A zero target for MRSA, coupled with a

significant reduction in the Clostridium difficile threshold, proved very challenging for

the Trust at a time when there is greater scrutiny and challenge for reducing HCAI.

Whilst the Trust did not achieve the MRSA bloodstream infection target, performance

was sustained with only 1 case reported. Key achievements for 2013/14 include:

.

Clostridium difficile infections were reduced by 48% reporting only 12 cases

from a threshold of 14

No ward closures due to confirmed/suspected Norovirus through the winter

period, an achievement never seen before.

2.1 Corporate Responsibility

The Hillingdon Hospitals NHS Foundation Trust maintains a full compliment of staff

for infection prevention and control as required under the Health and Social Care Act.

The Director Infection Prevention and Control (DIPC) is both an Executive member of

the board and also the Director of Nursing and Patient Experience.

The Trust has two Consultant Microbiologists, one of whom holds the position of

infection control doctor and they continue to provide specialist advice and

microbiology support on a 24hour basis. The specialist nursing team and

antimicrobial pharmacist are available during office hours Monday to Friday.

2.2 Infection Prevention and Control (IPC) Team and Members

In May 2013 the Trust appointed a new Director of Nursing and Patient Experience

and as a result a new DIPC. Whilst this new appointment did not affect the specialist

nursing team, it did bring to the organisation an experienced DIPC and returned the

2 Infection Control Roles and Governance Structures Within the Trust

- 5 –


team to full strength with the return of the Deputy DIPC and Deputy Director of

Nursing.

Infection control team members consist of:

2.3 The Infection Control Committee

The Infection Control Committee (ICC) report an overview of the infection control

agenda and progress throughout the year to the Quality and Risk Committee (QRC).

ICC is a key forum for the development and performance management of the

infection control agenda across the organisation. The Committee meets bi monthly

and is chaired by the DIPC with key representation from across the organisation.

Membership includes the ICT, a number of senior management and senior nurses,

the Occupational Health Department, clinical governance staff, Pharmacy, Estates

and Facilities staff and external bodies such as the local Public Health England

(PHE) Health Protection Unit and Hillingdon Community Health (HCH).

A change in the NHS and consequently the community with the establishment of

Clinical Commissioning Groups (CCGs) has seen the Infection Control Committee for

HCH no longer exist. Whilst the Infection Control Nurses from HCH attend the Trusts

ICC it is challenging to collaboratively drive forward the IP&C agenda across the

health economy when there is no current ICC in the CCG.

2.4 Internal Reporting Arrangements

New to 2013/14 is a Patient Safety and Quality Report submitted quarterly. This

report includes key information on the Trusts quality and safety priorities reflecting

the new Clinical Quality Strategy. Infection control includes performance against

National objectives as well as progress on local trust initiatives and has been well

received across the organisation.

Infection Prevention and Control (IP&C) is also discussed monthly via divisional

dashboards at the Divisional Reviews with the Executive Team. These divisional

dashboards include HCAI data, overall IP&C performance and compliance to

antimicrobial prescribing.

- 6 –


2.5 Reports to the Executive Team and Trust Board

The Infection Control Team provide a range of measures to The Board monthly

which include cleaning scores, infection control audit results, compliance to restricted

antimicrobial prescribing, MRSA screening and other initiatives. IP&C performance is

also commented on in the monthly performance report so that direct feedback on

post infection reviews or root cause analysis is provided to the board and any

necessary actions.

2.6 Risk Register

The Trust includes the risk of HCAI on the corporate risk register. The risk is updated

and reviewed every 2 months at ICC, in order to reflect current priorities and

activities; and is presented to QRC for discussion and scrutiny.

The ICT continues to have a budget that is predominately staff pay. The team does

however continue to work closely with the procurement department to ensure the

trust purchases quality products, that are fit for purpose and deliver value for money.

In 2013 the ICT developed a business case to upgrade the current IT system ICNet

to the newer version NG. As part of this process the ICT bid in round one of the

Nursing Technology Fund (2013/14) to support this initiative. Whilst this was not

successful the organisation is planning to bid in the second round in the Spring 2014.

Some of the key activities over the past 12 months are outlined below:

4.1 Aseptic Non Touch Technique (ANTT)

ANTT is now an established technique across the Trust and remains key in reducing

intravenous (IV) related blood stream infections. Annual reassessments are

undertaken in each division, supported by the ICT. Across the organisation ANTT

was above 95% by the end of the year. The performance by division is demonstrated

in the chart below:

85%

90%

95%

100%

Medicine Surgery W&C CSS

91%

98%99%

100%

Divisional ANTT 2014 Competencies

Medicine

Surgery

W&C

CSS

3 Infection Control Resources Within the Trust

4 Infection Control in 2014/15: The Local Picture

- 7 –


4.2 Infection Prevention and Control Strategy

In the third and final year of the IP&C strategy the Trust successfully achieved a

number of measures (refer Appendix B) Those not achieved fully have been included

in the annual HCAI action plan and will form the basis of the new trust IP&C 3 year

strategy, these included:

C section surveillance

Further improvement in Antimicrobial prescribing and stewardship

5 The Infection Control Team: Mandatory Surveillance During 2013/14

5.1 Mandatory Reporting

The Trust reports the following mandatory HCAI statistics to both the Trust Board and

Public Health England (PHE) on a monthly basis.

Meticillin Resistant Staphylococcus aureus (MRSA) bacteraemia

Clostridium difficile infection

Meticillin Sensitive Staphylococcus aureus (MSSA) bacteraemia

Escherichia coli (E coli) bacteraemia

The Trust follows guidance for HCAI associated deaths. Where MRSA or C.diff is

included as a part 1A, 1B or 1C on a death certificate it is entered onto the Strategic

Executive Information System (STEIS).

Inclusion criteria in this data set are any incidents of C diff on the same ward if two or

more cases were reported in one week or three in a month. A Root Cause Analysis

(RCA) is undertaken on such cases and they are presented to ICC for monitoring and

scrutiny of any arising actions. In 2013/14 there were 3 cases reported under this

guidance as detailed below:

Reason for STEIS report Number of cases

MRSA on death certificate 2

C diff on death certificate 1

Two cases C diff on 1 ward in a week 0

Included in the above data is an MRSA case which was attributed to the CCG and

died shortly after admission and the MRSA case which was attributed to the

organisation sadly died. All of the above cases had root cause analysis (RCAs)

- 8 –


5.1.1 Meticillin Resistant Staphylococcus aureus (MRSA)

With the new NHS landscape and emergence of CCGs also came a change to the

MRSA bloodstream infection objectives and methods of attributing cases to

organisations.

Any Trust reporting a positive MRSA blood stream infection will be expected to

complete a Post Infection Review (PIR). The organisation for leading the case is

responsible for completing a PIR within 1 week of the date of assignment (acute

providers will be assigned the PIR for samples taken after the 1st two days of

admission and the CCG for those admitted septic.) The outcome of the PIR should

establish the organisation to which the bacteraemia should be finally assigned. The

final assignment will identify the organisation best placed to ensure that any lessons

learned are acted upon. It was envisioned that with this new system there would be

greater partnership working across the health economy.

The variety of MRSA objectives was abolished for 2013/14 with a zero tolerance

approach to MRSA bloodstream infections, therefore all organisations has a target of

zero for the year.

The following graph illustrates the MRSA bacteraemia reported by month for

2013/14; including those attributed to the CCG.

The Trust reported one MRSA bacteraemia in May 2013- this was a complex case

with the patient having multiple hospital admissions including treatment in a specialist

unit at another acute Trust. The root cause analysis included both acute trusts and

there was learning identified for both organisations, however under the current

system cases could only be attributed to either the acute trust taking the specimen or

the CCG. This case was therefore attributed to The Hillingdon Hospitals NHS

Foundation Trust.

Of the four cases attributed to the CCG three of these underwent an arbitration

process. This involved the ICT from both the acute trust and CCG and Public Health

England and this was facilitated by the Director of Public Health. The process looked

at the PIR and evidence from both organisations to demonstrate that policies were

followed and that patient safety was maintained and quality care delivered. After the

review, cases were attributed to either the CCG or Trust by the Director of Public

Health. In all three cases the Trust was able to demonstrate robust documentation

and all were attributed to the CCG.

- 9 –


MRSA bloodstream infections since 2003

Whilst the Trust was disappointed to not achieve the national target it did meet those

set by Monitor and sustained performance. The Monitor framework states “Where an

NHS Foundation Trust has an annual MRSA objective of six cases or fewer (the de

minimis limit) and has reported six cases or fewer in the year to date, the MRSA

objective will not apply for the purposes of Monitor’s Compliance Framework.’

MRSA screening remains an important part of the patient pathway and certainly

provided evidence for the PIRs. Currently the Trust can only provide MRSA

screening data based on the number of admissions, either emergency or elective

against screening requests via our laboratory system Sunquest.

In order to get an accurate picture of MRSA screening which is able to provide

patient specific data the Trust would need to invest in the upgrade to the ICNet

system as this would then be available at the touch of a button.

MRSA screening for 2013/14 is detailed below:

Group Activity Type YTD

Elective

Pathology MRSA Screenings 10669

PAS Admissions 10919

Screening Rate % 97.7%

Emergency

Pathology MRSA Screenings 13824

PAS Admissions 14902

Screening Rate % 92.8%

5.1.2 Meticillin Sensitive Staphylococcus aureus (MSSA)

The Department of Health have applied the same data definition previously

attributing cases as per MRSA bacteraemia. There is currently no PIR process for

these cases or national target so they are assigned by time from admission to

specimen being taken.

- 10 –


5.1.3 Surveillance of Clostridium difficile toxins

The annual objective for C. difficile was significantly reduced from the previous year’s

number to just 14. This was a significant challenge for the organisation having

finished 3 years with between 23-25 cases. A case attributed to the acute

organisation is defined as a case where the sample was taken on the fourth day or

later of an admission to that trust (where the day of admission is day one).

Following the previous year’s root cause analysis the Trust was aware that a

proportion of the positive cases were associated with inappropriate sampling. In

order to improve clinical practice and provide more accurate information for teams on

bowel management the ICT developed a new Bristol stool chart with the

multidisciplinary team. This was successfully passed through the clinical records

committee and is now used in clinical practice.

2013/14 demonstrated a significant reduction on previous year’s numbers reporting

12 cases which was a 48% reduction. This met both national and monitor targets for

the year.

C diff cases for 2013/14

The chart below details the number of cases per month

5.1.4 Escherichia coli (E coli) bacteraemia

E. coli is a species of bacteria commonly found in the intestines of humans and

animals. There are many different types of E. coli, and while some live in the intestine

quite harmlessly, others may cause disease.

- 11 –


There is no objective or target associated with this bacteramia and it is not included

in London performance data. However E coli bacteraemia contribute to a high

number of blood stream infections and the significant effect on both the patient and

burden on the health economy should not be underestimanted. In total there were

149 E coli blood stream infections for 2013/14 with the siginifcant number of patients

admitted with septicaemia.

By using the same data definitions as MRSA and MSSA attributed cases, the Trust

has reported the following cases as represented in the following graph.

5.1.5 Surveillance of Glycopeptide Resistant Enterococcal (GRE) Bacteraemia

GRE are resistant to glycopeptides (antibiotics such as vancomycin) and have been

nationally reported since 2003. During 2013/14 the Trust reported no cases, with the

last reported case being in 2010. Although the incidence remains low the ICT will

continue to monitor and report cases.

5.2 Other Resistant Bacteria

Carbapenemase-producing Enterobacteriaeae The Trust has received both a letter from Public Health England and a Patient Safety

Alert in relation to carbapenemase-producing Enterobacteriaceae and other

carbapenem-resistant organisms.

Enterobacteriaceae are a large family of bacteria that usually live harmlessly in the

gut of all humans and animals, but, in the wrong place, can cause serious infections.

Worldwide, a small but increasing number of strains of enterobacteriaceae have

become resistant to carbapenem antibiotics, which have been defined by WHO as

critically important antibiotics. Increasing trends in sporadic infections, clusters and

outbreaks of carbapenemase-producing Enterobacteriaceae (CPE) have been

observed in a number of NHS trusts in England. There is a high risk of this problem

becoming more widespread unless early and decisive action is taken by Trusts as

these bacteria represent a significant challenge in terms of prevention, treatment and

control.

In the UK, we have a window of opportunity to prevent widespread problems caused

by these organisms. Whilst we are seeing increasing numbers of carbapenemase-

producing Enterobacteriaceae, we have not yet reached the escalated situation seen

in other countries.

New guidance on the management and detection of these resistant organisms has

been produced and the Infection Prevention and Control Team are reviewing current

- 12 –


policies and practice to ensure we meet these new recommendations. Crucial to

these new guidelines is the ability to isolate a higher number of patients within the

organisation. This is clearly a challenge for all trusts as isolation facilities are at a

premium, and often risk based. If we are to fully implement the new guidance then in

2014 the ICT with the Trust will have to review the isolation facilities across the

organisation and provide recommendations on how isolation facilities can be both

improved and increased in number.

5.3 Surgical Site Infection

5.3.1 Orthopaedic

Surveillance of orthopaedic surgical site infection (SSI) is undertaken for both total

hip replacements and repair of fractured neck of femur only. Whilst this meets our

mandatory requirements for SSI the Trust would ideally like to extend this

surveillance over additional surgical techniques.

In the July - September 2013 submission period for total hip replacements and neck

of femur the Trust saw an unusual peak in the number of surgical site infections. For

this quarter the combined rates were 2% for hip replacement and 4.4% for repair

neck of femur, with National data for hip replacement at 1.2% and neck of femur

1.7%. This resulted in the Trust being identified as an outlier by PHE, as we are

outside national rates. In actual cases this represented four infections for neck of

femur in one data collection period which triggered the orthopaedic and infection

control team to review the cases.

The increased incidence of cases was discussed at the divisional audit day and ICC

in both January and March. Whilst initial investigation did not identify any immediate

themes such as the same surgeon a more detailed case review was undertaken by

the orthopaedic team. The Trust held a meeting with the wider multidisciplinary team

focusing on surgical site infection, the report on the cases and to identify any further

actions. In order to monitor the effectiveness of any change in practice the meeting

agreed to currently take forward work on:

Culture and behaviour within the theatre environment (including wearing of

scrubs outside theatre areas)

Maintenance of Normothermia- including pre, intra and post operative

rewarming

Skin decolonisation / washes prior to surgery

Dressing changes on non orthopaedic specialist wards.

Since 2013 the Trust has been reviewing the operating theatre environment and has

a planned programme of works which includes re-commissioning of the theatres.

Work on one orthopaedic theatre has been completed and the second orthopaedic

theatre has planned maintenance in May 2014, with the remaining theatres to follow.

Water testing for Pseudomonas aeruginosa was commenced in October 2013, as

this is national guidance for critical care areas where patients are either

immunocompromised or whose defences may have been breached ie: surgery. This

will be undertaken as per guidance every 6 months. The Trust did identify taps which

were positive and remedial work with re-testing was undertaken.

- 13 –


It should be noted that we did not report any SSIs in neck of femur for the following

two periods of surveillance but the increase in cases for July-September has clearly

affected the combined 4 month data.

There is only a small number of total hip replacements carried out at the Hillingdon

site. The majority of cases, as they are elective are undertaken at Mount Vernon

however patients with a Body Mass Index (BMI) over 40, ASA* 3 or 4 or require ITU

admission are done at the Hillingdon site. The one reported case for July-September

was very complex with a number of co-morbidities and high risk factors. PHE have

responded to a recent communication from the Trust that they would note that only

high risk cases are done at the Hillingdon site.

(*The ASA score is a subjective assessment of a patient's overall health that is

based on five classes (I to 5). 1 is patient has severe systemic disease that is not

incapacitating to 5 Patient has incapacitating disease that is a constant threat to life.)

The Trust is taking seriously this increased incidence and in collaboration with the

Infection Control Team, there is a current business case to upgrade ICNet to the NG

version and include the SSI module. This upgrade would enable real time monitoring

and greater ownership by the clinicians involved. Our strategy, risk register and HCAI

action plan all identify the need to expand SSI surveillance and for surgeons to have

the ability to analyse and own their own data in order to understand patient outcomes

and drive safer, quality care. Work on reducing surgical site infection is a priority for

2014/15.

Surgical site infections are estimated to account for 15 per cent of all hospital-

acquired infections and affect around 5 per cent of all patients undergoing a surgical

procedure. (PHE 2012) Monitoring of surgical site infections is complicated; while

many occur during hospitalisation, the majority manifest only after discharge, a

phenomenon that has increased as hospitals have sought to reduce the length of

inpatient stays. In these instances, the infection is often managed in primary care and

is only recognised by the host institution if the patient is readmitted and these cases

are typically not captured in monitoring/surveillance studies due to the manual nature

limiting scope of surveillance.

SSI data for 2013/14 is reflected in the table below

Trust

Site

Procedure Number of

cases

Number of

cases with SSI

% SSI National data

MVH Total hip

replacement

236 1 0.4% 1.2%

THH Neck of femur

fracture

169 5 3% 1.7%

THH Total hip

replacement

91 3 3.3% 1.2%

5.3.2 Caesarean section

Recent studies have shown that C-section infection could be as high as 9.6%

nationally in recent studies. The ICT have been working closely with the women and

children’s division in order to establish a C-section surveillance system as currently

- 14 –


the Trust does not have robust knowledge of current infection rates. With birth rates

increasing and patient choice we need to be able to monitor rates in order to drive

reductions, therefore encouraging more patients to choose the organisation.

A data collection sheet has been agreed with the division but there remain

challenges around receipt of completed data. A recent change in something as

simple as the colour of the data collection form has seen a significant increase in the

number of returns to the ICT office. In quarter 1 of 2014 it is anticipated that the Trust

will have some robust data to analyse.

6 The Infection Control Team: Other Core Activity during 2013/14

The ICT remains focussed on patient safety, reductions in HCAI and that no person

is harmed by a preventable infection. The team appreciate the focus and

commitment from the members of staff across the organisation, including the Trust

Board in ensuring they deliver safe quality care in a clean and suitable environment.

6.1 Education and Training

The ICT continue to deliver IP&C training to all members of staff across the

organisation; this training varies from regular formal sessions to individual bespoke

delivery at a ward or department level.

2013 saw a completely new approach for statutory and mandatory training across the

organisation. Instrumental to these changes was the move to ensure that the

organisation followed the ‘core skills training framework’ outcomes for subject

matters and included in this were refresher periods. The ICT had undertaken a risk

based approach in previous years, establishing 3 levels of training. This new system

has clinical and non-clinical staff only with refresher periods moving from every 2-3

years for clinical staff to annual and for non- clinical staff from once to every 3 years.

The ICT worked closely with the STaM training advisory group as subject matter

experts (SME) in IP&C. Concern was raised by the ICT at the time that current

training, which was over 80% across the organisation, would drop significantly and

measures would need to be in place to deliver extra-ordinary sessions.

The Trust announced in January the new move for STaM training with details of the

new fresher periods. An ‘amnesty’ period from February to March was announced

with a significant amount of additional sessions provided by SMEs. Linked to this

transition was the movement of the current reporting for STaM to a new system as

well as linking training records to ESR. Up to January 2014 the Trust was over 80%

compliant in all levels of IP&C training. Data for January and February was not

reported due to the ‘amnesty’, additional staff trained during this period is detailed

below:

Training Number of Staff attended

Non-clinical 76

Clinical 236

- 15 –


6.2 Supporting and Working with Infection Control Link Staff

Link nurses from wards and departments have a pivotal role as the member of the

team in order to drive forward the IP&C agenda. Each clinical area has a named link

nurse and in some departments and wards there are two members of staff who

support each other in this role.

The ICT held one link nurse study day in 2013 with representation from a number of

specialist staff. A key item on this agenda was work around waste management. The

Trust had just introduced new waste streams and it was essential that staff were

clear on the use of the new offensive and alternative waste streams including new

hard burn bins.

6.3 Implementation of the European Directive on Safer Sharps

July 2013 saw the introduction of new safety engineered devices and a week of

raised awareness on sharps, reporting and reducing risk. Educational stands were

held in both the main entrance and staff canteen, where representatives from the

new companies demonstrated their new products and were supported by the ICT,

Health and Safety Team and Occupational Health.

The new products had a staged roll out supervised by the procurement team and

supported with ward/departmental training by the company representatives. The

introduction of the new devices went smoothly as these products had been trialled in

key clinical areas prior to final approval.

Further work continued throughout the rest of the year with attention on risk

assessments for those devices where safety engineered products are not availanble

or practical.

6.4 Audit & Monitoring

The Trust and ICT currently use the Meridian (Optimum) system to support audit and

monitoring across the organisation. This system which is principally used for patient

experience data, is also used for some IP&C audits but cannot be used for all

measures due to limitations in the system.

Currently the system is used for hand hygiene, VIP, Bare Below Elbows by the ward

staff and for linen and isolation by the ICT. The Meridian system is due for contract

review at the end of the year and the ICT is working closely with the audit department

to ensure that the system is suitable for all of its users and provides appropriate data

and reports for the organisation.

The current audits & monitoring for IP&C in 2013/14 are detailed below:

Compliance with Hand Hygiene policy (monthly)

Compliance with Bare Below Elbows policy (monthly)

Compliance with Isolation policy (annually)

Compliance with Restricted Antibiotic Prescribing policy (quarterly)

Compliance with Linen policy (annually)

High Impact Intervention 1 Central Venous Catheter care (monthly)

High Impact intervention 2 Peripheral Line Care (monthly)

High Impact Intervention 4 Preventing Surgical site infection (bi annually)

- 16 –


High Impact Intervention 5 Ventilator Care (monthly)

High Impact Intervention 6 Urinary catheter care (monthly)

High Impact Intervention 7 Clostridium difficile care bundle (monthly)

High Impact Intervention 8 Cleaning and decontamination of clinical

equipment (bi-weekly)

6.5 Working with the Patients and Public

The Fighting Infection Together (FIT) is a public group that was established a number

of years ago. This longstanding group is one of a kind with people passionate about

infection prevention and the Trust as a whole. They provide a valuable interface, with

a critical eye between the public, staff and the ICT.

In addition to the support on infection control stands, producing and reading IP&C

leaflets and general awareness raising, they provided significant support in the Trusts

new hand hygiene products. In November 2013 after trials of new products the ICT

with the FIT group and procurement department approved the move from our

previous supply to our new supply Deb-cutan. This new product provided both a

foam sanitiser and soap that was gentle to hands as well as outstanding product

support with posters and our new ‘bus stop’ signs. The new hand hygiene signage is

clear, concise and eye catching with sanitiser signs in red throughout the

organisation.

New sanitiser signs in the main entrance 2013:

6.6 Working to Ensure Optimum Hospital Hygiene The Trust has undertaken a significant investment in order to ensure that we provide

a clean, safe, suitable environment for our patients, staff, visitors and the

organisation.

6.6.1 Cleaning & Catering services PLACE The new PLACE process has replaced the long standing PEAT (Patient Environment

Access Team) process in 2013. It has been introduced to both revitalise the

assessment of the patient environment process but also, more importantly, to ensure

that there is a greater focus on patient involvement in the process.

PLACE covers broadly the same areas as PEAT – namely privacy and dignity,

wellbeing, food, cleanliness and general maintenance of buildings and facilities. It

focuses entirely on the care environment and does not stray into clinical care

- 17 –


provision or staff behaviours. It extends only to areas accessible to patients and the

public (for example, wards, departments and common areas) and does not include

staff areas, operating theatres, main kitchens or laboratories.

In the past, all NHS providers have undertaken PEAT inspections and in the same

way, PLACE will continue to provide an invaluable resource in assessing the care

environment. This will directly support the provision of a high quality service to

patients.

The key feature of PLACE is the central role of patients in carrying out the

assessments. At least 50 per cent of the team must be patients, and local

Healthwatch must be offered the opportunity to be involved. Recruiting and training

patient assessors is carried out locally and there is criteria outlining who is eligible

and who is not available to become a patient assessor.

The PLACE assessments took place at Hillingdon and Mount Vernon in April 2013

and involved patient and staff assessors including representatives from Facilities,

Infection Control, Nursing and Estates. The four days of assessments covered

wards, Minor Injuries Unit, Accident and Emergency, outpatients, internal pubic areas

and grounds and buildings and generated almost 400 pages of assessment score

sheets. The assessment scores covered the key areas of hygiene and cleanliness;

condition, maintenance and appearance; privacy, dignity and wellbeing; and food and

hydration.

The results were published nationally in September 2013 with the Trust disappointed

to be below national average for cleanliness; privacy, dignity and wellbeing; and

condition and appearance at the Hillingdon site. Mount Vernon was above the

national average in all of the key domains. On the plus side the Trust’s food and

hydration scores were above the national average. In 2013 the results were used to

develop an Improvement Plan, which focused on the recurrent themes across the

organisation that led to possible failure to meet the required standard or a ‘qualified

pass’. This has resulted in a considerable amount of work that led to reception

changes, new signage, new patient and waiting area chairs, new patient wheelchairs,

an increased focus on cleanliness and hygiene and maintenance improvements.

Domain/Score Hillingdon % Score

Mount Vernon % Score

HH/MVH % Combined Score

National Average % Score

Cleanliness 86.67 98.48 87.66 95.74

Privacy, dignity & wellbeing

74.22 90.68 75.60 88.87

Condition, appearance and maintenance

75.54 90.12 76.76 88.75

Food & Hydration

86.18 92.04 86.67 84.98

- 18 –


Cleaning & Catering In August 2013 all cleaning and housekeeping rosters were reviewed and changed to

ensure that they better met the size and infection control risk of an area, the work

taking place there and the throughput. This led to many clinical areas receiving

increased cleaning inputs and achieved savings through better productivity and

utilisation of staff. The team engaged an external cleaning consultant to work with the

team on cleaning processes, equipment and training. Working with infection control

and nursing, for example, the cleaning team changed the processes and structure for

cleaning outpatient areas to improve the standards. There were considerable

catering service developments for both patient dining and retail services during the

year with a new patient and retail kitchen being installed and new patient menus

being introduced as well as a new HACCP manual developed to underpin food

handling and safety.

An internal audit was undertaken by TIAA to determine whether management had

implemented adequate and effective operational and management controls over the

Catering and Cleaning function.

The audit included focus on:

Policy and procedures to ensure the Trust’s catering and cleaning services

meet all applicable regulations and standards for NHS catering and cleaning

services (Trust has identified standards and regulations for compliance;

policies and procedure are in place; training is provided; cleaning

arrangements are in place).

And that Trust’s catering and cleaning service complies with the requirements

of CQC related standards (arrangements/action plans in place to ensure

compliance).

Overall the audit provided substantial assurance against the objectives.

Linen The London procurement program with facilities led the work to tender the linen and

sterile theatre packs contract in 2013. The infection control team played a crucial role

in the tender assessment process participating in the tender assessment group to

review the quality of linen and cleaning processes. Unfortunately the process in late

2013 needed to be repeated, from a contractual point of view, and this will take place

in April and May 2014.

6.7 Sterile Services

The sterile services contract with IHSS continues to provide a good service to the

organisation and is closely monitored by the facilities team in partnership with clinical

services. Performance remains high on equipment turnaround times, which is

encouraging as 2013 saw a number of additional trusts utilising the company and it is

essential that standards are maintained.

6.8 Redesigning Environments and New Builds

The ICT continue to work closely with the project team to ensure that the new

designs and builds are fit for purpose, meet the Health Technical Guidance and

provide a safe, clean environment. The new plans for 2013 included:

- 19 –


Redesign and upgrade of the delivery suites in maternity

New kitchen and catering facilities

Beaconsfield East dementia ward refurbishment

Redesign and commissioning of the urgent care centre

Re commissioning of orthopaedic theatre 1, including duct cleaning, re-

commissioning of the specialist airflow system and purchase of specialist

ventilation for the prep room.

6.8.1 Endoscopy

The Trust successfully redesigned and opened a new endoscopy unit at Mount

Vernon. This new unit provides a spacious dedicated endoscopy unit with associated

decontamination facilities. This new unit is the culmination of a number of years work

to ensure the organisation’s decontamination facilities meet Department of Health

guidelines and provide a suitable environment for both patients and staff.

The Hillingdon Hospital Endoscopy Unit will be completed as part of the new

emergency admission unit on the ground floor in 2014/15.

7 Infection Control Policy and Procedure Within the Trust

Infection Prevention and Control Policies are reviewed every three years or in light of

new best practice or guidance. There are 28 policies found under the Policy

Management Information System (PMiS) for infection control, which can be found in

Appendix A. All policies now follow the Trust permitted format and are approved at

the Infection Control Committee then ratified at the Clinical Governance Committee.

8 Outbreaks and Incidents at the Trust in 2013/14

8.1 Pandemic Influenza

The Pandemic Influenza Operational Policy is reviewed annually in preparation for

the winter season by the ICT and links with the Trusts winter preparations and

planning. This operational policy remains a flexible document that not only enables

the Trust to react to a potential new pandemic but is also to respond to an increase in

demand due to seasonal influenza activity or other possible increases in capacity due

to either a Severe Acute Respiratory Syndrome (SARS) or the newer Middle East

Respiratory Syndrome (MERS-CoV).

An increase in influenza activity was not evident over the winter period, with relatively

few confirmed flu patients admitted to the organisation. The Trust did however have a

few suspected MERS-CoV patients admitted to the organisation in November 2013.

This new respiratory syndrome is associated with travellers and residents from the

Middle East. This year it was evident that with the high numbers of travellers

returning from Hajj, the Trust could see potential admissions with suspected

influenza or MERS-CoV.

8.2 Gastroenteritis/Norovirus

Norovirus is always a particular challenge for organisations especially over the busy

winter period. This virus is spread easily from one person to another and is highly

infectious in nature. Whilst Norovirus activity remained high in the community setting

- 20 –


and other organisations had wards closed for the first time in years the Trust did not

close one ward or bay over winter due to confirmed/suspected Norovirus.

Seasonal activity was lower in comparison to previous years as can be seen in the

following chart from PHE. However the Trust still admitted cases with diarrhoea and

vomiting and successfully managed them in side rooms without impact on the

organisation. Possible contributing factors to the success of this year’s management

were:

Recent change of Hand Hygiene product and awareness leading to greater

compliance

New pull up banners in the main entrances highlighting Norovirus

A&E undertook a risk assessment for inpatients to identify those patients

currently not symptomatic but had been in household/ contact with relative

with known diarrhoea and vomiting, these patients were isolated as a

precaution.

8.3 Needlestick Incidents and Prevention of Needlestick Injuries

Occupational Health received 76 reports of needle stick injury for 2013/14, which is

three more than the previous year. It was noted that there was a significant rise in

reported needlestick injuries in July with 16 cases, compared with the usual 4-8 per

month. This rise coincided with the month where the Trust had ‘sharps awareness

week’ and is possibly due to the promotion of reporting. Certainly towards the end of

the year injuries from intravenous cannulae has significantly dropped due to the

introduction of the safety engineered device.

8.4 Legionella & Water Quality Monitoring

Legionella bacteria, which cause legionellosis, is an uncommon form of pneumonia

and the majority of cases are reported as single (isolated) cases but outbreaks can

and have occurred. Our duties, as an organisation, are provided in the approved

‘Code of Practice and guidance Legionnaires' disease: The control of legionella

bacteria in water systems (L8)’. This contains practical guidance on how to manage

and control the risks in your system. Control and prevention of the disease is through

treatment of the source of the infection, i.e. by treating the contaminated water

systems, and good design and maintenance to prevent growth in the first place.

The Trust continues to take this responsibility very seriously and is aware of the risks

inherent in a multi building site with a number of older facilities. The Trust has a

http://books.hse.gov.uk/hse/public/saleproduct.jsf?catalogueCode=9780717617722

http://books.hse.gov.uk/hse/public/saleproduct.jsf?catalogueCode=9780717617722

- 21 –


Water Quality group which meets regularly throughout the year monitoring Trust

performance for both Legionella and Pseudomonas. In February 2014 the Trust

tested a number of outlets as part of re-commissioning of units back into general use

following work or upgrades. A number of these outlets had positive counts and as a

result were chlorinated and a revised system put in place to ensure that outlets under

construction are tested and flushed just prior to handover.

Testing for Pseudomonas aeruginosa

P. aeruginosa is a Gram-negative bacterium, commonly found in wet or moist

environments. It is commonly associated with disease in humans with the potential to

cause infections in almost any organ or tissue, especially in patients compromised by

underlying disease, age or immune deficiency or whose defences have been

breached (for example, via a surgical site, tracheostomy or indwelling medical device

such as a vascular catheter). In most cases, colonisation will precede infection.

Some colonised patients will remain well but can act as sources for colonisation and

infection of other patients. Its significance as a pathogen is exacerbated by its

resistance to antibiotics, virulence factors and its ability to adapt to a wide range of

environments.

Contaminated water in a hospital setting can transmit P. aeruginosa to patients

through the following ways:

direct contact with the water through: ingesting bathing contact with mucous membranes or surgical site, or through splashing from water outlets or basins (where the flow from

the outlet causes splashback from the surface);

inhalation of aerosols from respiratory equipment, devices that produce an aerosol or open suctioning of wound irrigations;

medical devices/equipment rinsed with contaminated water;

indirect contact via healthcare workers’ hands following washing hands in contaminated water, from surfaces contaminated with water or from contaminated equipment such as reusable wash-bowls.

The Trust has identified areas across the organisation for testing of P. aeruginosa

and include ITU, NNU, Bevan and Theatres. In September 2013 the theatre complex

at Hillingdon was tested for P. aeruginosa and some water outlets came back

positive. As per guidance these outlets are taken out of use, remedial work is

undertaken and then retesting of the water supply is undertaken. Only after a number

of tests can the outlet be placed back in use.

Unfortunately during routine testing for theatres one of the positive outlets was

incorrectly labelled. This led to an incident of concern being raised and investigated

by the Trust to ensure that patients and staff were protected. All testing was

undertaken as per guidance with retesting in order to ensure results of <1 cfu/100ml.

No patients in the two weeks following the incident isolated Pseudomonas species.

The direct cause of the incident was attributed to human error exacerbated by a

number of additional factors detailed in the report. In order to prevent a similar

incident occurring the report recommended a number of actions which were

- 22 –


contained in a Pseudomonas action plan, a new Standard Operating Procedure and

signage was put into effect immediately.

9 Management of Antibiotic Prescribing at the Trust in 2013/14

The scale of the threat of Anti-Microbial Resistance (AMR) and the case for action

was set out in the “Annual Report of the Chief Medical Officer” published in March

2013. The UK Five Year Antimicrobial Resistance Strategy 2013-2018 set out actions

to address the key challenges to AMR. The overarching goal of the strategy is to

slow the development and spread of AMR. It focuses activities around three strategic

aims; improve the knowledge and understanding of AMR, conserve and steward the

effectiveness of existing treatments, stimulate the development of new antibiotics,

diagnostics and novel therapies.

Antimicrobial prescribing & stewardship (APS) competencies have been developed

by The Advisory Committee on Antimicrobial Resistance and Healthcare Associated

Infection (ARHAI) and PHE; the goal is to improve the quality of antimicrobial

treatment and stewardship and so reduce the risk of inadequate, inappropriate and ill

effect of treatment. The aim is to improve the safety and quality of patient care, as

well as contributing significantly to the reduction in the emergence and spread of

antimicrobial resistance

This year the Trust Antimicrobial Stewardship Group (ASG) started looking at Datix

incidents related to antimicrobials, it continues to monitor spending on antimicrobials

as well as Defined Daily Dosing (DDD)/1000 bed day report on selected restricted

antibiotics. Ward pharmacists continue to report restricted antibiotic use to the

antibiotic pharmacist, these are all reviewed by both the antibiotic pharmacist and the

consultant microbiologists with the average number of reported prescriptions as

184/month

The annual surgical prophylaxis audit which was completed in February 2014,

showed that 78% of patients were given antibiotics as recommended in Surgical

Prophylaxis Guideline. When looking at the timing of administration, in 88% of cases

the correct surgical prophylaxis antibiotic was given at the correct time, this is an

improvement from the 2012 audit.

The ‘Start Smart then Focus’ guidance and its subsequent action plan continue to be

developed. The audit programme for antibiotic compliance has recently changed

from monthly to quarterly. The frequency has been changed in collaboration with the

clinical audit department and ensures that with the new quarterly data an action plan

from divisions will be required to address low compliance. A recent meeting with the

ADOs, NSMs and CDs strengthened the focus on antimicrobial prescribing with a

commitment from specialties to undertake their own audits using a Trust template.

This will provide data specific to the specialty in order to drive performance.

The Trust Continues to take part in the European Antimicrobial Awareness day on

18th November of each year

- 23 –


10 Safety and Quality In Infection Control: Statutory Duties & External Visits

The Trust has an established assurance framework for IP&C as the safety of patients

and staff, and quality care is a key consideration for all organisations. The Health and

Social Care Act 2008 clearly reflects our duties and provides a collection of systems,

processes and procedures in order to define the risks to achieve high quality care.

10.1 Care Quality Commission

The Trust was inspected by the CQC over a number of days from 4th-7th October

2013. For Cleanliness and Infection Control the regulated outcome stipulates that;

‘People should be cared for in a clean environment and protected from the risk of

infection.’

The outcome of the inspection was reported by the CQC as the following:

‘Whilst the trust had many positive infection control indicators and audits showed a

low level of infection, we found a number of instances where the risks of the spread

of infection were increased.

We have judged that this has a minor impact on people who use the service, and

have told the provider to take action.

The provider was not meeting this standard’

The Trust was disappointed with the decision by the CQC which was based on:

Isolation doors not shut on all occasions

The use of a cordless phone-on one of the wards

Lack of knowledge amongst clinical staff on curtain changes

Cleaning of equipment

Damaged flooring/ condition of the building

As a result the Infection Control Team revised the current audit programme within the

organisation following the inspection. A new quick question assessment (QQA) tool

was devised using elements from the inspection such as correct use of personal

protective equipment, isolation standards and inspection of equipment in the clinical

area. This was then assessed twice a month and findings reported at both divisional

and Board level. The Trust will continue to audit mattresses annually as well as

adhoc inspections by staff to ensure damaged items are replaced.

The Estates and Facilities team have a robust programme of audit for cleaning of the

Trust and the supervising staff have all been given details of areas in which to pay

particular attention ie: high level dusting.

There is an existing PLACE improvement group which includes any Estates issues

that require rectification eg: damage to floors, and this has already been identified

and a report produced. There are a number of financial implications for the

organisation in particular the maintenance of the Estate and repairs to the existing

floors. A full report with costing on such repairs has been produced since the

inspection.

- 24 –


The Trust recognises that whilst it is not following best practice for closing all doors

when isolating patients, this has to be balanced against the risk to the patient. It was

explained during the inspection that as the doors are solid in some parts of the

building, when we have a confused, critically ill or patient at risk of falls then doors

cannot be closed for patient safety reasons. The Trust have however taken the

comments into account and are investigating the possibility of replacing the doors in

order to enable staff to patients clearly.

During the inspection the frequency of curtain changing was identified as a risk as

staff did not know the frequency of changes. The Trust does however have a named

person responsible for all curtains, where records are kept and these were not

requested during the visit. Staff know that they can request change of curtains when

these are damaged or stained and therefore this is not considered a risk to people

who use this service.

The Trust considers that these minor points raised in the inspection did not pose a

risk to patients or visitors. Where the inspection identified torn or damaged items

these were already condemned or replaced. Equipment and the general ward

environment is regularly inspected to ensure it meets standards.

11 Measures of Infection Prevention and Control: Shaping Practice to

Improve Performance

The ICT regularly review and update audit and monitoring to reflect both current

practice and to highlight any areas for improvement. The IP&C measures have been

used to drive performance and sustain best practice. In order to gain maximum

impact and to challenge the divisions around performance the league table

presentation was again reviewed and updated for 2013/14.

Whilst the ICT does utilise the Meridian system this does not fully integrate all of the

current audits and is time consuming to complete at ward level. It is essential in 2014

that when the audit system is reviewed that it is able to adapt to the ever increasing

demands of the organisation and supports staff in their work.

12 Looking forward to 2014/15

As we come to the end of the year new objectives for 2014/15 are established. As

with this year NHS England remain focused on a zero tolerance of MRSA blood

stream infections and have set the same objective of zero. This remains a

substantially challenging target across the NHS as the MRSA bloodstream infections

we see today are now complex, multi-factoral events. New from April 2014 is that

NHS England regional teams will take on the role of arbitrating disputed MRSA

bacteraemia cases which was previously held by Local Authority based Directors of

Public Health.

NHS England and Public Health England have noted that the rate of improvement for

C diff has slowed over recent years. There are indications that for some

organisations at least, C diff levels may be approaching their irreducible minimum

- 25 –


level at which these infections will occur regardless of the quality care provided.

Experts have now advised that a more flexible approach is now needed to objectives.

The new changes are primarily focused on further encouraging organisations to look

at each case they identify in order to understand what lessons they are able to learn

in order to improve patient safety.

Trusts have been divided into three cohorts for the purpose of calculating median C

diff rates; these are:

Teaching acute trusts

Non teaching acute trusts

CCGs

Recommendations for 2014/15

1. Upgrade of ICNet to NG version to enable :

Extended surgery interface and surgical site surveillance module

Dedicated Surgical outcome reports to support surgical directorates with

accurate rate reports on infection, readmission and mortality

Provide accurate real-time performance data on surgical infection rates

Enable real time Device Management tool to ensure that infection prevention

team is supported with accurate denominator data and microbiology reports

on device associated infections such as Catheter Associated Urinary Tract

Infections (CA-UTI) and Central Line Associated Bacteraemia (CLABSI).

Provide accurate MRSA screening data at both patient and ward level in

order to drive performance

2. Review of Isolation Facilities

In line with current guidance on isolation for new emerging infections the

current siderooms will not provide the required facilities for both staff and

patients. A risk assessment of the isolation facilities should be undertaken in

order to assess how the organisation will meet the ever increasing demands

for sideroom facilities.

13 Conclusion

The Hillingdon Hospitals NHS Foundation Trust has infection prevention and control

at the heart of its agenda. There have been significant achievements over the past

year for the organisation balanced against some disappointing performance in

PLACE and the CQC inspections. It is important that in this ever changing face of the

NHS where we are faced with new targets, emerging infections and financial

challenges that we ensure patients still receive safe quality care across the

organisation.

As ever infection prevention and control is not just the remit of the infection control

team but it is everybody’s responsibility and we would like to take the opportunity to

thank staff, patients, public, governors and all our stakeholders for their continued

support with this important agenda.

- 26 –


14 Acronyms

ANTT Aseptic Non Touch Technique

CCG Clinical Commissioning Group

C diff Clostridium difficile

CQC Care Quality Commission

DH Department of Health

DIPC Director of Infection Prevention and Control

FIT Fighting Infection Together

GRE Glycopeptide Resistant Enterococci

HCAI Healthcare Associated Infection

HII High Impact Intervention

HPA Health Protection Agency

ICC Infection Control Committee

ICN Infection Control Nurse

ICT Infection Control Team

IPC or IP&C Infection Prevention and Control

ITU Intensive Therapy Unit

MRSA Metecillin Resistant Staphylococcus Aureus

MSSA Metecillin Sensitive Staphylococcus Aureus

NNU Neo-natal Unit

PCO Primary Care Organisation

PEAT Patient Environment Action Team

PHE Public Health England

PIR Post Infection Review

SMART Specific, Measurable, Achievable, Realistic, Timely

UTI Urinary Tract Infection

- 27 –


15 Appendix A Infection Control Policies

Policy Number Policy

240 Animals & Pets In Hospital

188 Aseptic Technique Policy

178 Care & Management of Patients in Hospital with Diarrhoea Policy

183 Central Venous Catheter Insertion and Maintenance (CVC)

179 Clostridium Difficile (C diff) Associated Diarrhoea

169 Decontamination of Medical Devices

245 Employment Health Screening (including food handlers and drivers)

177 Hand Washing

244 Immunisation Policy (Occupational Health )

170 Isolation

185 Laundry Sorting

175 Meningitis including Meningococcal Septicaemia

174 MRSA Control (Methicillin-Resistant Staphylococcus)

167 Outbreak (Food Poisoning or Communicable Disease)

186 Re-use of Single Use Items Supplied for Single Use Only

165 Risks Associated with Infection Prevention and Control

166 Safe Handling & Removal of Infected Bodies

181 Scabies

172 Standard (Universal) Precautions

171 Surveillance

176 TB Prevention & Control

187 Transmissible Spongiform Encephalopathies (TSE) Creutzfeldt

Jacob Disease (CJD)

231 Urinary Catheter

189 Varicela Zoster Virus (Chickenpox/Shinges)

180 Viral Haemorrhagic Fever (VHF)- suspected cases of

173 Visual Infusion Phlebitis (VIP) Score

Strategy Priority Area and Strategy

Ref:

Action Plan Ref:

Priority Q1

Q2

Q3

Q4

Comments

6.1 Culture & leadership

Nos. 7&9

Receive and review Divisional HCAI action plans at ICC G G G G All divisions HCAI action plans presented bimonthly

Executive ward visits to include observation and discussion on IP&C measures G G G G Observation of care launched February 2013 which includes ward appearance

Sisters/Charge Nurses to enforce stricter IP&C measures – embed visitors’ charter, revised signage, enforce BBE/hand hygiene etc (recs from People in Partnership group work) – to be monitored through observation and discussion

A A A G Visitors’ charter implemented, new signage on for Hand Hygiene now Trust wide.

6.2 Accountabilities, responsibilities and organisational framework

Nos. 4,5&9

Discuss and endorse all RCA actions at executive level (trust attributed MRSA and CDI cases) and present actions to ICC

G G G G RCAs reviewed at ICC – itemised on agenda.

New Post Infection Review (PIR) process to be used across the organisation in line with Public Health England (PHE guidance. In case of arbitration cases DIPC and Lead ICN to attend

G G G G PIR process in place. 3 arbitration meetings attended to date all awarded to CCG

ToR refreshed 2012 for ICC and included more active medical representation A A A A Regular representative from Surgical division still pending

Antimicrobial Group to include revised membership, ensure robust annual action plan and bi-monthly reporting to ICC

A A G New member to ASG includes Lead Pharmacist. Reporting is an agenda item on ICC and papers now received

Each division to table one IP&C item at divisional governance forum per annum (e.g. antimicrobial stewardship)

A Dates to be confirmed and taken forward for 2014/15

6.3 Performance reporting

Nos. 3, 4, 5&8

Receive and review the HCAI assurance framework based on H&S Care Act at ICC every six months

G G HCAI Assurance Framework to ICC March.

Report key IP&C performance and compliance to ICC with exception reporting to QRC Committee

G G G G Robust reporting in place to ICC

Establish a surveillance system to enable performance reporting for SSI Caesarean section wounds

A A G SSI monitoring process agreed with W&C and date collection started March 2014

6.4 Accessible information

No. 11

Public website and staff Intranet information resources are to be reviewed and refreshed

G G G G FIT group reviewed current public information. LICN reviews staff Intranet monthly to ensure all aspects up to date.

Refresh posters in accordance with People in Partnership group work suggestions

A A G New posters for Hand Hygiene throughout Trust for hand hygiene. New Norovirus full pull up banners designed by FIT group in use.

6.5 Improving patient safety

No. 5, 13&14

Ensure that the review of IP&C policies is on track A A G Programme of review in place for all ICC policies and included in HCAI action plan.

Outbreak management procedures to be reviewed & amended based on learning from 2012/13 winter period

G G G G D&V protocol reviewed and approved September 2013. New banners in use and updated Norovirus leaflet reviewed and agreed by FIT group

Consider further and improved technology in relation to cleaning clinical areas post CDI/Norovirus etc

*G Further discussion with Estates and Facilities planned for Quarter 4 2013 after new in house cleaning contract embedded. New microfiber system purchased by Facilities to replace current system.

- 29 –


Comply with the new EU directive on sharp safety which includes introduction safety engineered devices

A A A A Sharp safety week in June. New Medical devices introduced July 2013. Further devices to be launched after trials

6.6 Surveillance & reporting

No.&10

Improve antimicrobial prescribing compliance to >95% A A A A Start Smart then Focus action plan in progress and clinical specialties undertaking own audits. Compliance still not consistently above 95% but discussion and engagement has significantly improved across the organisation.

ICT to validate local monitoring and performance to be published G G G G VIPS currently validated by ICT and urinary catheter audits. New QQA tool launched in November, adhoc validation.

Undertaken business case for ICNet upgrade to NG which includes SSI module and real time MRSA screening.

*G Business case complete. Not funded in 1st

round nursing technology fund and expression of interest submitted for 2

nd round funding

6.7 Risk assessment & audit

No. 12 Gain assurance that the replacement programme for hand wash basins is on schedule

* No budget for 2013/14 allocated to replace CHWB- £150K available for 2014/15 and audit planned April/May as major refurbs undertaken across organisation. Any new build/ refurb includes new CHWB

Risk assessments to be completed for sharp safety where new devices not available

A A

A A In progress, work only started in 2013 and will be ongoing process as new devices available.

Risk register for IP&C to be reviewed at ICC bimonthly and updated. G G G G Risk register updated bi monthly

6.8 Training & education

Nos. 1&3

Sustain compliance for IP&C training at > 80% A A G G Currently Trust overall performance 80% in all levels. New system to be launched Q3 across the organisation.

Deliver more robust ANTT programme and achieve compliance at >95% by March 2014

A A G New process resulted in annual assessment for 2013/14, staff required to have annual review to be completed by March 2014.

6.9 Partnership working

No. 6 Deliver annual joint IP&C awareness event with partners Due to change in PCT and new CCG there is currently no community ICC. Joint IP&C awareness event agreed for 2014.

FIT member engagement to agree IP&C patient information. To be included in new PLACE assessment process

G G G G FIT group reviewed IP&C leaflets Q2 and approved trial new hand hygiene products. FIT members included in PLACE assessments

infection prevention and control annual report 1 april

Documents