infection prevention and control annual ......the ipacs has met on a bi-monthly basis under the...

INFECTION PREVENTION

AND CONTROL

ANNUAL REPORT

SEPTEMBER 2006 – AUGUST 2007

“WORKING TOGETHER TO REDUCE

HEALTHCARE ASSOCIATED INFECTIONS”

Gwyneth Wilson Deputy Chief Executive/Chief Nurse/

Director of Infection Prevention & Control

25 September 2007 The Queen Elizabeth Hospital King’s Lynn NHS Trust

Annual Report 2006 - 2007 - version 2 10 9 07.doc 2

Contents

1 INTRODUCTION

3

2 TRUST BOARD RESPONSE

4

3 DIRECTOR OF INFECTION PREVENTION AND CONTROL

4

4 TRUST EXECUTIVE BOARD

4

5 DIVISIONS

4

6 THE CONTROL OF INFECTION COMMITTEE

5

7 INFECTION PREVENTION AND CONTROL SERVICE

5

8 PROGRESS AGAINST ANNUAL PROGRAMME 2005/2006

6

9 DECONTAMINATION

10

10 NATIONAL SURVEILLANCE

11

11 2006 AUDITS

16

12 AUDIT PLAN 2007/2008

19

13 ANTIMICROBIAL PRESCRIBING

19

14 POLICIES

20

15 EDUCATION

20

16 OUTBREAKS AND INCIDENTS

24

17 SUMMARY OF OBJECTIVES AND PLANS FOR 2007/08 24

APPENDICES

A COMPLIANCE WITH HYGIENE CODE 27 B REVISED TERMS OF REFERENCE FOR CONTROL OF INFECTION COMMITTEE 34 C ROOT CAUSE ANALYSIS 38 D MANTRA NEWSLETTER 48



1 INTRODUCTION The term ‘Healthcare Associated Infections’ (HCAI’s) includes any infection acquired as a consequence of a person’s treatment by the NHS, or which is acquired by a healthcare worker in the course of their NHS duties. The prevention and control of Healthcare Associated Infections is a high priority across the NHS; however it is not possible to prevent all infections. Effective prevention and control of HCAI’s needs to be embedded into every day practices and applied consistently by everyone. In essence we all need to be:

‘Working together to reduce Healthcare Associated Infection’ The Queen Elizabeth Hospital is firmly committed to reducing HCAI’s and follows all of the documents which have been published over the past few years.

• Winning Ways – Department of Health 2003

• Towards Cleaner Hospitals – Department of Health 2004

• The Matrons’ Charter – Department of Health 2004

• Saving Lives – Department of Health 2005

• Essential steps to safe clean care – Department of Health 2006

• The Health Act - Department of Health 2006 In October 2006 the Health Act was published. Contained within the Act is the Code of Practice in relation to the prevention of HCAI’s. The Code, which is referred to as the Hygiene Code, sets out criteria by which NHS organisations ensure that patients are cared for in a clean environment and the risks of HCAI’s are kept as low as possible. Failure to observe the Code could result in the issue of an Improvement Notice by the Healthcare Commission or the Trust being reported for significant failings and placed on ‘special measures’. The Code consists of three overarching headings, which are divided into a number of elements:

• Management, Organisation and Environment

• Clinical Care Protocols

• Healthcare Workers The Queen Elizabeth’s compliance in relation to all elements of the Act can be found in Appendix A.

Infection Prevention and Control Annual Programme : Objectives 2007/2008

The Trust will continue to monitor compliance with the Hygiene Code and take action as necessary.

In May 2007 the Trust received a visit from the East of England Strategic Health Authority Clostridium difficile Action Team. Whilst the Trust has reduced the number of patients who have active Clostridium difficile associated diarrhoea, there were concerns that the Trust had a higher instance where Clostridium difficile was cited on the death certificate. The Action Team visited a number of wards and spoke to staff. Following the review a comprehensive action plan was developed and a workshop held to discuss the issues raised at the visit with the Trust Executive board. The action plan discussed continues to be monitored at a number of Trust meetings.



If a patient has Clostridium difficile cited on their death certificate a root cause analysis is undertaken and the Director of infection Prevention & Control (DIPC) and the Chief Executive meet with the patient’s consultant and the Ward Sister/Charge Nurse to discuss the case, thereby ensuring that all policies and procedures were followed and that the appropriate antibiotic regime was followed. The Consultant Microbiologist reviews all patients with Clostridium difficile who are not responding to the antibiotic regime in a timely manner, in collaboration with a physician and dietician.

2 TRUST BOARD RESPONSIBILITY The Trust Board recognises its responsibilities for overseeing infection control arrangements within the Trust and receives regular reports from the Director of Prevention and Control on:

� Surveillance Rates. � Outbreaks. � New National Guidance.

The Trust Board also receives monthly MRSA bacteraemia and Clostridium difficile rates. 3 DIRECTOR OF INFECTION PREVENTION AND CONTROL The Chief Medical Officer’s report Winning Ways (2003) required all NHS organisations to appoint a Director of Infection Prevention and Control as the Senior Officer with responsibility to:

• Oversee control of Infection Control Policies and their implementation.

• The Infection Prevention & Control Service.

• Report directly to the Chief Executive and Trust Board.

• Challenge inappropriate hygiene practice and antibiotic prescribing.

• Assess the impact of all plans / policies on Infection Control.

• Be a member of the Clinical Governance and Patient Safety teams/structures.

• Produce an Annual Report. The Deputy Chief Executive/Chief Nurse has held this appointment since 2004.

4 TRUST EXECUTIVE BOARD (TEB)

The TEB receives monthly information in relation to MRSA bacteraemias and Clostridium difficile rates and results of root cause analyses; any changes in practice and updates during and following any outbreak. The Action Plan from the Strategic Health Authority’s Clostridium difficile team visit is monitored each time the Executive Board meets (fortnightly).

5 DIVISIONS

Divisional General Managers have identified a lead in each Division/Directorate who will be responsible for Infection Prevention and Control issues. They receive weekly reports of MRSA colonisation, bacteraemias and Clostridium difficile rates, which they are asked to circulate and discuss at Divisional meetings. From September 2006 they also receive monthly alert organisms provided by Microbiology.



Monthly alert organisms include details of all inpatients who have any of the following infections:

• MRSA Colonisation (Methicillin Resistant Staphylococcus aureus) • MSSA (Methicillin Sensitive Staphylococcus aureus)

• Rotavirus • RSV (Respiratory Syncytial Virus) • Norovirus • SGA (Haemolytic Streptococci Group A) • Infections with leg ulcers • SPN (Streptococci Pneumoniae (Penicillin Resistant)) • Resistant Gram Negative

Infection Prevention and Control issues are also discussed at each Directorate bilateral meeting.

6 THE CONTROL OF INFECTION COMMITTEE The Control of Infection Committee continued to meet on a three monthly basis during 2006/07 under the chairmanship of the Deputy Chief Executive/Chief Nurse and has reported back to the Clinical Governance Committee according to its ‘Terms of Reference’. In 2007 the Committee has approved revised Infection Control ‘Terms of Reference’ (see Appendix B), ratified the Annual Report for 2005/06, received and considered environmental and infection control audit scores, received outbreak and incident reports, monitored progress against the Annual programme and overseen compliance with Saving Lives and Actions Plans in relation to the Strategic Health Authority Clostridium difficile visit.

Infection Prevention and Control Annual Programme: Objectives 2007/2008

The Control of Infection Committee will continue to meet three monthly under the chairmanship of the Deputy Chief Executive/Chief Nurse and will continue to report back to the

Clinical Governance Committee.

7 INFECTION PREVENTION AND CONTROL SERVICE The Infection Prevention and Control Service (IPACS) are working well as a team, being ably led by Professor Lynne Liebowitz who has had a huge positive impact on the Trust. The Professor provides a highly visible leadership role, regularly presenting to the Trust Board and Trust Executive Board; together with undertaking ward rounds. She also acts as an Adviser to the Department of Health and the East of England Strategic Health Authority. The Infection Prevention and Control Service consist of: Professor Lynne Liebowitz Consultant Microbiologist Lynne Roberts Lead Infection Prevention and Control Specialist Nurse Elspeth Hardy Infection Prevention and Control Specialist Nurse Jayne Daisley Personal Assistant to the Director of Infection Prevention and

Control Greg Sargent Deputy Pharmacist Graham Rogerson Biomedical Scientist Alison Keal Clinical Audit Facilitator Pat Fysh Infection Prevention and Control Co-ordinator Dr David Tupper Lead Consultant, Infection Prevention and Control



The IPACS has met on a bi-monthly basis under the chairmanship of the Microbiologist. 7.1 Terms of Reference of IPACS:

a) The IPACS will aim to provide a comprehensive modern flexible infection control and prevention programme which relies on a multi-model approach. Core functions include implementation of evidence-based practice, surveillance, audit, education, outbreak management and policy development/review.

b) The Service will meet on a regular monthly basis and minutes will be kept.

Information meetings will continue to be held as necessary.

c) The Service will be accountable to the Control of Infection Committee. The Infection Control Nurses are responsible to the Deputy Chief Executive/Chief Nurse. The Consultant Microbiologist is directly responsible to the Chief Executive and meets with the Director of Infection Prevention and Control on a fortnightly basis.

7.2 Infection Prevention and Control Link Nurses:

The Infection Prevention and Control Link Nurses scheme has been active in the Trust for a number of years. The Infection Control Link Nurses have a fundamental role to play in raising the profile of infection control in their respective clinical areas. An on-going educational programme takes place throughout the year in the form of an organised speaker and relevant teaching. The meetings are chaired by a member of the Infection Prevention and Control Service. In addition, the Infection Control Link Nurses have undertaken an active role in the infection control audit programme and, where possible, have implemented the necessary recommendations along with the ward manager. The IPACS would like to thank the Link Nurses for their hard work and invaluable contribution to the service.


The IPACS will continue to oversee the day-to-day implementation of infection control

practices in the Trust and to meet monthly to monitor on-going infection prevention and control issues, including outbreaks and surveillance.

8 PROGRESS AGAINST ANNUAL PROGRAMME 2005/06 8.1 Standards for Better Health

In May 2007 the Trust made the annual declaration to the Healthcare Commission regarding the 24 core standards against which all Trusts are judged, and which are seen as the minimum levels of acceptable practice. The Core Standards are divided into 7 domains and within each domain are several elements. Within the domain of Safety element C4a specifically considers Infection control, requiring Trusts to have systems in place which ensure that healthcare associated infections are reduced, with a specific emphasis being placed upon cleanliness and MRSA. This Trust was pleased to be able to report to the Healthcare Commission that we are fully compliant with this standard, the evidence being the month-on-month reduction in the levels of MRSA and HCAI’s being reported, and in-patient satisfaction survey results showing that 92.6% of patients felt the hospital was ‘very’ or ‘fairly’ clean. Following the development of a specific pathway for patients presenting to the hospital with diarrhoea, the Trust has been able to manage isolation for potentially infected patients in a much more structured way. This pathway, we believe, has been



instrumental in the prevention of a large scale outbreak of Norovirus the Trust has suffered from in previous years. In July 2007 the Healthcare Commission undertook a random inspection of the Trust and spent 45 minutes reviewing element C4A. Results will be published as part of the annual health check in October 2007. Also addressed within the domain of Safety are the areas of Decontamination, Medicines Management and Waste management, all of which are major factors towards reducing infection within the Trust. Due to the Trusts first class decontamination department, the aggressive way in which the use of antibiotics is managed and stringent collection and disposal processes for all waste, the Trust was pleased to report full compliance with each area.

8.2 NHS Litigation Authority (Risk Management)

During the course of the year the IPACS have been involved in the review of policies in preparation for the Trust’s assessment of the NHS Litigation Authority Level 1 Standard. This new scheme includes standards relating to hand hygiene and also to managing the risks associated with infection prevention and control.


The IPACS will continue to work with Trust Managers and Clinicians in order to implement the requirements relating to Standards for Better Health regarding Infection Prevention

and Control.

8.3 Saving Lives – a delivery programme to reduce Healthcare Associated Infections

Introduced in 2005 by the Department of Health, this nationwide initiative was designed to increase organisational focus on all aspects of infection prevention and control, particularly in reducing Healthcare Associated Infections. The Saving Lives toolkit consists of:

• A self assessment tool made up of nine key challenges and action plan • A balanced score card, generating red, amber and green, which allows prioritisation

in the action planning • Learning resources to guide design by an infection control plan • Seven high impact interventions to improve compliance with clinical procedures

Last year the Infection Prevention and Control team met to consider the current position and the work needed in relation to the achievement of the nine challenges through the development of a Trust-wide plan. The results of the self assessment identified a number of areas which needed to be tackled and these areas were included on the action plan and monitored by the Control of Infection Committee. Of the 9 challenges, one was fully compliant, 3 red and the remainder were classed as amber. In July 2007 the Control of Infection Committee repeated the self assessment and the results are depicted in the table below. There are no reds, 3 amber and 6 green. The areas for action from Challenges 1, 3, 4, 6, 8 and 9 have been incorporated into an action plan. The Control of Infection Committee will continue to monitor the outstanding areas of action during the course of 2007/08.



Saving Lives : Reducing HCAI including MRSA

Balanced Score Card: Self Assessment summary for infection control

The Queen Elizabeth Hospital King’s Lynn July 2007

Challenge 1 Challenge 2 Challenge 3 Engage senior management (clinical and non clinical) in order to secure the implementation of best practice in the prevention and control of

infection

Appoint infection control leaders at each level in the organisation to

ensure the promotion of good clinical practice and challenge inappropriate

behaviour

Implement a local surveillance programme in order to identify in

real time the infection status throughout the Trust by the provision of reports to each ward/unit at least

quarterly

Challenge 4 Challenge 5 Challenge 6 Adopt national evidence based guidance in order to ensure that

patients are treated according to best practice

Ensure the effective auditing of infection control practices

throughout the Trust through monitoring and implementation

Ensure that all Trust employees have a programme of education and training on the prevention and control of infection in order to

understand their responsibility for infection control and the actions they

must personally take

Challenge 7 Challenge 8 Challenge 9 Review the patient journey for

emergency and planned patients in order to reduce the risk of transmission of infection by minimising the movement of potentially infected patients.

Review the status of the built environment and the effectiveness of the facilities management services,

including cleaning, in order to provide a safe and clean environment

for patient care

Implement a local surveillance programme in order to identify in

real time the infection status throughout the Trust by the provision of reports to each ward/unit at least

quarterly

Overall Status

Key

Green 100% Full compliance

Amber 71 – 99% Review required

Red =<70% Trust Priority


The Control of Infection Committee will continue to oversee the Saving Lives Action Plan.

The seven high impact interventions are central to Saving Lives. The interventions are based on the principle that infection rates can be significantly reduced by front-line clinicians if they carry out all of these interventions correctly every time.

Historically the Saving Lives Audit (High Impact Interventions) has been undertaken on a Directorate basis. It was felt that all clinical areas should undertake all of the audits on a regular basis so in February 2007 all wards were provided with a timetable of audits and all of the



appropriate forms to complete. The completed audit forms were returned to the Clinical Effectiveness department where they were analysed and the results fed back to the wards and the Trust Executive Board. However, after two months of auditing, it became obvious that the audits were very complex and in some instances subjective. Therefore, a small working party was tasked with reviewing the audits and ensuring that they became much more informative and user friendly. These newly revamped audits were launched in June 2007 and will be reviewed in November 2007. The audits include:

• Urinary Catheter Care

• Hand Hygiene observation

• Enteral Feeding

• Medical Devices

• Blood Culture

• MRSA Screening

• Alcohol Hand rubs

• Decontamination of Medical Equipment

• Clostridium difficile

• Central Lines

• Care of Peripheral lines

• Care of ventilated patients 8.4 Hand Hygiene The Trust continues to promote good hand hygiene through the National Patient Safety Agency (NPSA) ‘Clean your Hands’ campaign. Over the past couple of years the Trust has used hand gels from one company and liquid soap from another. From October 2007, the Trust will be following the NPSA guidance and will be using soap, moisturiser and foam sanitiser by Debcuton. From trials, clinical staff are much happier with the hand foam rather than the gel which is currently used. Hand hygiene competencies are also in development for all clinical staff. This will be achieved by a ‘Train the Trainer’ approach overseen by the IPACS.


Develop hand hygiene competencies for all staff and roll out mandatory training in

relation to hand hygiene.

8.5 Infection Prevention and Control Ward Audits The Infection Prevention and Control Service (IPACS) conduct environmental audits, using the ICNA Audit Tools for monitoring Control Guidelines 2006. The areas risk assessed are disposal of waste, disinfection, decontamination of medical equipment, implementation of isolation procedures, ward cleaning, utilization of evidence based practices to prevent hospital acquired infections and hand washing agents and equipment. The audits are preformed with a senior member of the ward/Link nurse and the ward managers are given copies of the completed audit. At a later date the IPACS return to confirm that issues identified have been addressed.



8.6 Environmental Cleanliness Our cleaning strategy was ratified in June 2007. The strategy recognises the need for a multi disciplinary approach; this is a living document to ensure improvements in meeting the cleaning standards. Monitoring of the hospital cleanliness is carried out by the Trust's Domestic Services department (in-house) and Ward Sisters/Charge Nurses undertake audits on these on a fortnightly basis as directed by the cleaning standards document. These are discussed at the Control of Infection meeting. In April 2007 a hand held Auditing system was purchased by the Trust allowing for the completion of the 49 point audit electronically. The PEAT inspection is carried out annually and representatives from the Patient & Public Involvement Forum (PPI) and Non Executives are part of this Auditing Team. The overall score this year was again good, although many ward areas scored excellent. Cleaning is now provided 24 hours of the day since the introduction of the night cleaning team in March 2007, also the implementation of an Annual Steam cleaning programme for all wards and a curtain cleaning schedule to ensure all curtains are cleaned three times a year. The wards all have copies of their cleaning schedules and other cleaning information contained within a ward cleaning folder.

8.7 Food Hygiene The Catering Department carries out monthly audits of each area. An Annual inspection of the Snack bar, Main Kitchen, Dining Room and Catering store is carried out by the Environmental Health Officer, who sends a report to the IPACS, Head of Facilities and the Production manager. The Last Inspection was carried out on the 22nd of March 2007. The IPACS carry out an annual inspection and compile a report for the Head of Facilities. Quarterly food hygiene inspections are carried out using an ATP monitor. Food Hygiene training is carried out annually for all catering staff.

8.8 Legionella control The Trust has a named responsible person for Legionella control and currently complies with the Approved Code of Practice. A programme for flushing and Legionella sampling in high risk areas is in place. An operational Legionella group has been set up. The responsible person is a member of the Infection Control Committee and areas of concern are raised at committee meetings.

9 DECONTAMINATION The Sterile Services Manager is the designated Decontamination Lead for the Trust.


Collaborate with Facilities Management and the Heads of Nursing to maintain Towards Cleaner Hospitals.


Continue monitoring of all aspects of environmental hygiene.



The Sterile Services department was awarded ISO 13485 in May 2007. This award provides assurance that the medical equipment used primarily in Theatres meets national standards and as such, the department is able to operate as a stand-alone in-house facility with the opportunity to undertake work from GP and Dental Practices. The staff in Sterile Services continue to undertake training in decontamination at NVQ Levels 1, 2, 3 and 4 as appropriate. In early 2008, the Trust will be implementing Scantrak. This is software provided through Connecting for Health which enables all instruments to be tracked from use through the washing process. The purpose of this tracking is to ensure quick identification of instruments and which patient they have been used for should a problem with infection be identified at a later stage.

10 NATIONAL SURVEILLANCE 10.1 MRSA (Methicillin Resistant Staphylococcus Aureus) The Trust continues to participate in the mandatory MRSA bacteraemia surveillance, which was initiated in all acute NHS Trusts in April 2001. The data is now differentiated between community and hospital acquired and a Root Cause Analysis is undertaken for MRSA bacteraemias irrespective of whether it is community or hospital acquired. The results of the root cause analysis are provided to the clinical team responsible for the care of the patient; the Primary Care Trust and presented at the Trust Executive Board (see Appendix C). Following a root cause analysis an action plan is developed with the clinical area and is monitored by the appropriate Head of Nursing. The Trust continues to work to reduce MRSA bacteraemia. The Trust was set a target for a reduction of 60% based on a 2003/4 baseline. The year on year reduction is aiming at 12 or less bacteraemias by 2008/09. See table below.


To support the Sterile Services Manager in the implementation of the Scantrak software package.



The national surveillance scheme for surgical site infection (NINNS) was introduced in 1996. The surveillance scheme is currently co-ordinated by the Healthcare-associated Infection and Antimicrobial resistance (HCAI & AMR) a department of the Communicable Disease Surveillance Centre (CDSC) at the Health Protection Agency (HPA). Participation in surveillance was optional for Trusts until 2004. Currently it is mandatory for Trusts undertaking orthopaedic surgery, to participate in surveillance for a minimum of 3 consecutive months a year. Individual reports are provided for hospital trusts. Regional, national and international reports are compiled using anonymised data. Hospital Trusts have the option of participating in the surveillance scheme for a range of surgical procedures. In 2006-2007 this Trust provided data for large bowel surgery. The results for all procedures included in the scheme are given in the table below.

Reported MRSA Bacteraemias

2007 2006 2005 2004 2003 2002 2001 2000

Jan 4 2 3 5 2 3 6 3

Feb 0

2 0 3 4 6 3 0

Mar 0 2 6 3 4 2 5 1

Apr 1

0 4 10 0 1 3 1

May 0 2 5 3 1 3 3 4

Jun 0 2 3 6 2 4 1 2

Jul 2

0 1 1 2 4 2 2

Aug 1 0 2 3 1 4 0 0

Sep 0 0 0 3 3 3 2 4

Oct

1 0 7 3 2 4 1

Nov 1 3 4 4 5 3 3

Dec 3 1 6 3 0 3 6

Total 15 28 54 29 37 35 27



Surgical site infections April 2006 – March 2007

The Queen Elizabeth Hospital NHS Trust All Hospitals

Procedure

Number of Operations January 07 – March 07

% Infected

Last 4 Periods April 06- March 07

% Infected

All Periods % Infected % Infected

Total Hip Replacement

68 0.0 234 0.0 684 1.3 1.4

Hip Hemi-arthroplasty

43 0.0 151 1.3 387 1.3 4.2

Knee Replacement

56 0.0 233 0.0 641 0.2 0.8

Large Bowel Surgery

29 0.0 157 1.3 316 2.2 9.2

10.2 Clostridium difficile

In relation to Clostridium difficile Trusts were set an annual target based on the previous number of cases reported in 2005/06. The target had to be agreed by the Norfolk Primary Care Trust and The Queen Elizabeth Hospital target has been set at a 20% reduction based on last year’s out-turn. The 20% target reduction is based on reported laboratory specimens that are toxin positive, but does not necessarily equate to Clostridium difficile disease. A high proportion of the population, from children upwards, may have Clostridium difficile in their bowel without it causing any problems. Antibiotic therapy used for infections can kill off the normal gut flora that usually keeps the Clostridium difficile at bay and therefore can multiply. The Trust has developed strict antibiotic guidelines designed to reduce the number of patients who may develop symptoms of Clostridium difficile. The use of these guidelines is subject to audit by the Pharmacy department. The Trust has participated in the national Clostridium difficile surveillance scheme since its inauguration. These results represent laboratory Clostridium difficile toxin positive reports and do not necessarily equate to Clostridium difficile disease. From October 2007, the Clostridium difficile surveillance scheme becomes mandatory.



Patients Identified with Clostridium difficile 2006-2007

0

5

10

15

20

25

30

35

40

45

April May June July Aug Sept Oct Nov Dec Jan Feb Mar

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Clostridium difficile Comparison Graph 2004-2007

0

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50

60

70

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2004-2005 37 38 30 25 27 36 30 33 46 50 55 66

2005-2006 54 29 41 25 20 34 32 39 31 41 38 23

2006-2007 35 20 29 15 19 20 24 30 32 39 34 22

April May June July Aug Sept Oct Nov Dec Jan Feb Mar

There has been a significant decrease in the number of positive Clostridium difficile specimens from 473 in 2004/05 to 319 in 2006/07. 10.3 MSSA (Methicillin Sensitive Staphylococcus Aureus) Staphylococcus aureus is commonly found colonizing normal skin, particularly axilla, groin, perineum and nose. It causes a range of superficial infections of the skin and is responsible for one third of hospital acquired wound infections. It can also cause more serious infections e.g. septicemia, endocarditis and pneumonia. Transfer on hands is the most common mode of spread but also skin scale dispersion. It can become resistant to antibiotics resulting in MRSA. The graph below shows the total number of in-patients identified with MSSA by month. These patients may not be infected.



MSSA 2006-2007

0

5

10

15

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25

30

35

April May June July Aug Sept Oct Nov Dec Jan Feb March

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MSSA Comparison Graph 2004-2007

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2004-2005 27 28 32 25 39 29 19 21 32 25 23 22

2005-2006 23 25 38 47 31 35 33 37 26 27 18 33

2006-2007 23 20 31 33 28 33 29 26 18 21 16 19


10.4 Rotavirus:

Rotavirus is the major cause of diarrhoea and vomiting in young children worldwide. The infection is highly contagious and may lead to severe dehydration and even death. Rotavirus infection is also known as infantile diarrhoea, or winter diarrhoea, because it mainly targets infants and young children. The outbreaks are usually in the cooler months of winter.



Rotavirus 2006-2007

0

2

4

6

8

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12

14

April May June July Aug Sept Oct Nov Dec jan Feb MarchMonth

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Rotavirus Comparison Graph 2004-2007

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2

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2004-2005 11 6 1 1 0 0 0 0 0 0 12 9

2005-2006 12 5 12 0 1 0 0 0 0 0 1 3

2006-2007 12 7 9 1 0 1 0 12 2 3 4 13


10.5 Local Monthly Surveillance The Clinical Audit and Effectiveness Department disseminate information on MRSA, MSSA, Clostridium difficile, Rotavirus, Noravirus, RSV, Haemolytic Strep group A, CCU etc Fungi, Res Gram Neg, Salmonella and Mycobacterium sp to all wards via the monthly Nursing Outcomes Report. More detailed information in relation to patients who are colonised with MRSA or have Clostridium difficile positive stools are emailed to wards, senior nurses, clinical and divisional managers on a weekly basis. 11 2006 AUDITS

11.1 Hand Gel Availability Audit (High Impact Intervention 1) To determine compliance with Infection Prevention and Control Standards highlighted in Saving Lives (2005) and the health Act (2006) with regard to hand hygiene. The audit focused on the availability of hand gel, leaflets and posters in ward areas.



The audit concluded, following the implementation of the new beds, that the availability of ‘bed ends’ had a significant impact on the location of hand gel at the patients’ bedside.

• There were hand hygiene signs but leaflets were not always available on some wards.

• Hand hygiene champion posters were visible on less than 25% of the wards. Ward managers have been given the responsibility to address the issues raised on their wards and to have a nominated person to ensure leaflets and posters are available. On random inspection in September 2007, posters are now displayed on all wards and departments. 11.2 Waste Disposal Audit (Action Area 3 – Reducing Reservoirs of Infection) The objective of the audit was to ensure compliance with the Infection prevention and Control Policy with regard to waste management. The audit encompassed all Wards, the Endoscopy Unit and Theatres. The audit focused on point of care disposal, security and transportation. The audit concluded:

• More than 50% wards/areas had overflowing waste and/or linen bins.

• One third of wards/areas had dirty big waste/linen bins

• A problem with big waste and linen bins not being locked because locks were broken and/or there was no key available.

• Collection times were not always appropriate or information on collection times was not available.

The waste manager has been given the responsibility for ensuring that keys are available in all areas, reviewing the cleaning of bins and liasing with the Head Porter to identify appropriate collection times. Collection times have now been changed and wards can request extra bin emptying as and when required. 11.3 Infection Prevention and Control Folder Audit (Standards for Better Health Standard D1) The aim of the audit was to ensure that staff were aware of the location of the Infection Prevention and Control (IP&C) Folders, and that the policies / information within the folder are current and complete.

• Less than 50% of wards had complete folders.

• Specific policies on some wards were either missing or out of date.

• Some wards had materials unrelated to Infection Prevention and Control in their Folders. The Infection Prevention and Control team provided all wards and departments with complete folders. Clinical areas have been advised to nominate a member of staff to be responsible for the Infection Prevention and Control Folder. The nominated person will have newly ratified policies sent to them electronically. Folders and their contents should be maintained in good order to allow easy access to policies. 11.4 Compliance with MRSA Screening Policy (Strategic Health Authority Priority Area 4) The aim of the audit was to determine compliance with the Infection Prevention and Control MRSA Screening Policy.



The audit focused on admission, weekly screening and documentation in the nursing notes.

• 21% of patients who met the criteria for admission screening were tested. Only 3% of admission screening was documented in the nursing notes.

• 59% of patients who met the criteria for weekly screening were tested. 22% of weekly screening was recorded in the nursing notes.

Audit results were distributed to the Heads of Nursing, Ward managers and Link Nurses. Staff were required to familiarise themselves with the screening policy. Documentation of screening should be emphasised to all ward staff and will be re-audited. 11.5 Ward Movement of Patients (The Healthcare Commission- Stoke Mandeville Report) The Stoke Mandeville Report produced by the Healthcare Commission 2006 highlighted the importance of restricting patient movement between wards in order to reduce the risk of the spread of infection. The purpose of the audit was to ascertain the amount of patient movement between wards during in-patient episodes. A snapshot audit was conducted using information on patients who were in-patients on one day. The patients’ journey from admission to discharge was logged. Details of 414 patients were obtained.

• 79% of patients were transferred between more than 2 wards, although this may not necessarily be a problem if patients are admitted to the Medical Assessment Unit and/or Critical Care as part of their inpatient stay.

• 21% of these patients were transferred between the Medical and Surgical Directorates. An audit tool has been developed for a prospective audit. This included information regarding patient diagnosis, time of movement, reason for moving and person responsible for authorising the movement. Actions arising from the audit will be addressed. 11.6 Environmental Audits (Winning Ways - Action Area 3) Ward/Department Environmental audits continue to be carried out by the Infection Prevention and Control team. The audits focus on compliance with trust policy with regard to waste disposal, hand washing, disinfection, medical equipment, isolation precautions, environment and practice. The results for 2006-2007 are shown in the table below.



Waste

disposal Hand washing

Disinfection Medical equipment

Isolation precautions

Environment Practice Mean

A&E 94% 83% 60% 100% 100% 44% 100% 83%

Castle Acre 94% 88% 100% 100% 63% 100% 25% 81%

CCU 100% 88% 100% 100% 100% 90% 67% 92%

CDS 100% 88% 80% 100% 63% 100% N/A 92%

DSU recovery 100% 100% 80% 86% 100% N/A N/A 93%

DSU ward 100% 100% 60% 100% 100% 50% 75% 84%

DSU theatre 85% 75% 75% 83% 100% 50% N/A 78%

Elm 100% 100% 80% 100% 75% 80% 50% 84%

Endoscopy 100% 88% 60% 100% N/A 67% N/A 83%

Feltwell 94% 100% 80% 100% 100% 60% 50% 83%

Gayton 89% 100% 80% 100% 50% 75% 50% 78%

Leverington 89% 100% 60% 100% 86% 70% 50% 79%

Marham 94% 100% 80% 71% 86% 70% 66% 81%

MAU 100% 50% 80% 86% 50% 56% 75% 71%

Necton 89% 83% 40% 100% 100% 100% 75% 84%

Oxborough 89% 100% 40% 86% 38% 40% 75% 67%

Pentney 100% 100% 40% 71% 63% 50% 100% 75%

Rudham 100% 100% 60% 100% 38% 80% 100% 83%

SCBU 80% 100% 80% 100% 88% 63% 100% 87%

Shouldham 89% 100% 60% 86% 63% 90% 100% 84%

Stanhoe 94% 100% 60% 100% 88% 70% 100% 87%

Terrington West Raynham 95% 83% 100% 100% 88% 70% 100% 91%

Dermatology 100% 83% 100% 75% 75% 75% 33% 77%

Mean 95% 92% 72% 93% 78% 70% 73%

NB From the 10th September 2007 all wards will be undertaking weekly hand hygiene audits until they attain 85% or above compliance for one month. Thereafter the audits will become monthly. If, during the monthly audit compliance becomes less than 85%, it will become weekly again. If the weekly compliance is less than 85% wards will be expected to undertake daily audits until 85% or above is reached for seven consecutive days.

12 AUDIT PLAN 2007/2008

• Bacteraemia Monthly Surveillance and Nursing Outcomes Reporting

• HPA SSI Total Hip Replacement

• HPA SSI Total Knee Replacement

• HPA SSI Hip Hemi Arthroplasty

• HPA SSI Large Bowel Surgery

• Environmental Audits- Re audits

• Monthly High Impact Intervention Audits

• Infection Prevention and Control Manuals – Re-audit

• Ward Movement of Patients – Re-audit

• MRSA Screening – Re-audit

• Isolation Adherence

13 ANTIMICROBIAL PRESCRIBING Antibiotic prescribing policies for frequently encountered infections has been drawn up by the Antibiotic Stewardship Committee. These policies provide guidelines for the choice of appropriate empiric antimicrobial therapy based on the pharmacokinetic and pharmacodynamic



properties of the drugs, local susceptibility patterns of the most likely causative organisms, cost and toxicity of the agents and propensity for selection of resistant mutants. 13.1 The Antibiotic Stewardship The sub-committee of the Control of Infection Committee continues to meet and whose role is to provide firmer control of antimicrobial issues across the Trust. This group has developed, implemented and audited major policies to aid appropriate antimicrobial prescribing. The Microbiologist is a member of the Trust’s Drugs and Therapeutics Committee.

13.2 Monthly reporting of high cost, high usage antibiotics

A system has been set in place with Pharmacy IT so that monthly reports on the selected antibiotics are generated automatically. These reports are emailed directly to the Antibiotics Pharmacist for further analysis. An audit of adherence to the Trust’s antibiotic guidelines was undertaken in the summer of 2007. The conclusion of the audit was that there was a good degree of compliance with the Trust’s Antibiotic Policies. The audit is due to be repeated at the end of September and results will be discussed at the Trust Executive Board in October 2007.

14 POLICIES A sub-group of the Infection Prevention and Control Committee continues to meet to oversee the development and review of policies systematically, ensuring that all policies are up to date. Following this review, the Control of Infection Committee will ratify and then the policies are available on the Intranet. The Group consists of: Professor Lynne Liebowitz Consultant Microbiologist Gwyneth Wilson Director Infection Prevention & Control Dr David Tupper Lead Consultant, Infection Prevention & Control

Lynne Roberts Lead Infection Prevention & Control Specialist Nurse Elspeth Hardy Infection Prevention & Control Specialist Nurse Greg Sargent Deputy Pharmacist

15 EDUCATION Within the Trust we carry out a continuous education and training programme within which we highlight, discuss and educate on all aspects of Infection Prevention and Control. Some examples of which are listed below:

� Standard precautions in the prevention of cross infection in the health care setting. A back to basic approach to infection control which incorporates the essence of care.


Continue to undertake Root Cause Analyses in relation to MRSA bacteraemia and Clostridium difficile. Develop changes in practice as necessary.


Regularly review key policies in light of new evidence.



� Basic microbiology. � The spread of infection. � The prevention of this spread. � Hand hygiene, both practical and theory. � MRSA spread and prevention. � Clostridium difficile – spread and prevention. � Others, e.g. blood borne virus. � Environmental cleaning – within ward areas and the issues of poor hygiene practice � Link nurse programme (includes all of the above) � Clinical practice sessions e.g. iv infusion and TPN � Norovirus spread and prevention

During 2007, the Trust successfully piloted an E-Learning package specifically for clinical staff in relation to infection prevention and control. The package can be undertaken in one sitting which takes about 45 minutes or multiple sittings. The licence for this has been purchased by the East of England Strategic Health Authority. This package is not instead of face-to-face training, but as well as. The Consultant Microbiologist regularly provides teaching to medical staff both at ward, directorate and Trust level. During August, in preparation for the NHSLA assessment, the Infection Prevention and Control team has split their mandatory training into three levels (see below), identifying which group of staff need to undertake which level. This training is further supported by the use of MANTRA, the Trust’s newly devised Mandatory Training newsletter which is published on a monthly basis - see Appendix D. Evaluation of the new training levels will take place later in the year. Infection Control training (including hand hygiene training) levels LEVEL 1 Level 1 training will be provided to all staff at induction. Updates of level 1 training will be provided through Mantra. Where major changes to practice are introduced, additional training will be provided if required. Staff in the following departments (non clinical) require level 1 training: A&E Clerical Staff Complaints Medical Secretaries Receptionists Cancer Tracker Finance PALS Risk Management Clerical Human Resources Patient Services Supplies Clinical Audit Internal Audit PGMC Admin Trust Board Clinical Coding Library Print Room Voluntary Services Clinical Governance Medical Records LEVEL 2 Level 2 training will be provided as soon as possible after appointment and by annual updates. Where major changes to practice are introduced, additional training will be provided if required.



Staff in the following departments require level 2 training: Audiologists Chaplain Laboratories Pathology Bed Manager Children’s Centre Microbiology Pharmacy Breast Screeners Dieticians Orthoptisits Psychology Cancer Services Estates Outpatients Dept Wheelchair Dept Cardio Respiratory GUM Clinic LEVEL 3 Level 3 training will be provided as soon as possible after appointment and annual updates. Where major changes to practice are introduced, additional training will be provided if required. All staff working in the following wards and departments, require level 3 training: A&E Dept staff Dermatology Orthopaedics Stoma Care Anaesthetists Diabetes Nurses Paediatricians Surgical directorate Castleacre Domestic Phlebotomists Theatres Catering EEG Porters Ward Clerks CDS ENT Radiographers Corporate Nurses MacMillan Team Rehabilitation Dept

Women & Children Directorate

Critical Care Medical Directorate Rudham Ward Day Surgery Dental

Occupational Health Ophthalmic Dept

SCBU Sterile Services



TRAINING SESSIONS PROVIDED BY THE INFECTION PREVENTION AND CONTROL

SPECIALIST NURSES IN 2006

SESSION FREQUENCY Includes Hand

washing

Risk Mandatory Training Non-nursing 30 mins

Monthly √

Risk Mandatory Training Nursing 45 mins

Bi-monthly √

Introduction Fair for New Doctors A stand at fair, 10 min chat to a group of doctors.

Bi-annually √

Core introduction for hospital employees 15 mins

Monthly √

Nursing and Midwifery Introduction 1 hour 30 mins

Monthly √

Hotel Services Introduction 20 mins Monthly √

Administration of IV (Enhanced Clinical Practice Workshops) 45 mins

8 times per year √

Management of TPN (Enhanced Clinical Practice Workshops) 45 mins

5 times per year √

New RGN’s to The Trust 1 hour

Monthly √

Nursing Auxiliary training 2 hours Monthly √

Adaptation Nurse training 2 hours When there is an intake

√

Norovirus and MRSA drop in sessions Two sessions, once a year.

√

Risk Management Training for Medical staff One session per Directorate. 4 Directorates

√

Hand Hygiene drop in sessions 8 sessions per year √

Return to Practice Nurses Yearly √

Prevention of infection in clinical practice ICN/PDN Quarterly √

Risk management training to departments who request sessions, who are unable to release staff to mandatory sessions e.g. DSU, Audiology, Dermatology and Haematology.

Annually 1 hour. √



16 OUTBREAKS AND INCIDENTS

All outbreaks are reported to the Health Protection Agency and the Strategic Health Authority as per Trust policy.

Clostridium difficile (C. diff) on one of the medical wards in October 2006. The IPACS were aware of several patients with detected C. diff on the ward prior to the reconfiguration of the ward. Following the reconfiguration, three more patients were tested positive for C. diff. The IPACS took action to minimise the risk to the rest of the patient population by cohorting all of the C. diff patients into a bay, and closing that bay until all patients were asymptomatic for 48 hours or more. The bay was then deep cleaned before it was re-opened to admissions.

The Trust encourages all wards and departments to report clinical incidents related to infection control issues where policies and procedures have not been adhered to. Examples of such incidents would be where patients who are Clostridium difficile positive, but are unable to be nursed in side rooms. Failure to take the appropriate action resulted in the receipt of a positive test. Divisional clinical incident meetings take place on a monthly basis and all incidents are discussed with Ward Sisters/Charge Nurses; and lessons learnt shared with the group and across the Trust.

17 OUTCOME OF OBJECTIVES 2005/06

- The Control of Infection Committee will continue to meet three monthly under the chairmanship of the Deputy Chief Executive/Chief Nurse and will continue to report back to the Clinical Governance Committee.

Achieved and ongoing

- The IPACS will continue to oversee the day-to-day implementation of infection control practices in the Trust and to meet monthly to monitor on-going infection prevention and control issues, including outbreaks and surveillance.


- The IPACS will continue to work with senior managers and clinicians to implement the Standards for better health in relation to the reduction of Hospital Associated Infections. The IPACS will continue to be an integral part of the RMST pilot project.

Achieved


The IPACS plans to continue its educational programme for nursing and support staff ensuring that hand washing training is competency based and mandatory for all staff.

Link nurse meetings will continue and local induction sessions developed for

presentation by the link nurses.

Collaborative work with Director of Postgraduate Medical Education to ensure infection control training to all grades of medical staff.



- Reinforce aseptic technique and surgical wound dressing protocol, as well as implementation of the High Impact Intervention 3, Preventing Surgical Site Infections.

Achieved

- To work with the Sterile Services Manager in ensuring standards are met and resource issues are factored into Trust priorities.

Achieved. Sterile Services received accreditation in May 2006.

- Embed hand hygiene as a core requirement of good clinical practice. Audit outcomes of the ‘Clean Your Hands’ campaign

Achieved

- The IPaC plans to continue the provision of the educational programme for nursing and support staff.

Achieved.

- Continued monitoring of all aspects of environmental hygiene.


- To continue to participate in:

• Mandatory S.aureus bacteraemia surveillance

• Mandatory glycopeptide resistant enterococcal bacteraemia surveillance

• Mandatory Clostridium Difficile diarrhoea surveillance

• To achieve year on year reduction of MRSA bacteraemia in line with Government targets.


- To work with the Trust Risk Manager in ensuring standards are met and resource issues are factored into Trust priorities.

Achieved

- Further implement and audit Antimicrobial Policy. Achieved and ongoing

- Regularly review policies in light of new evidence. Achieved and ongoing

- Link nurse meetings will continue and local induction sessions developed


- Assess the implementation of the infection control E-learning package.

Achieved. Now part of Mandatory training updates.

- Collaborate with the Director of Post Graduate Medical Education to ensure infection control training is provided to all junior Doctors

Achieved

Author: Gwyneth Wilson, Deputy Chief Executive/Chief Nurse/Director of Infection

Prevention & Control Date: September 2007

APPENDIX A

COMPLIANCE W

ITH HYGIENE CODE – SEPTEMBER 2007

Duty 1

Evidence

a)

So far as is reaso

nably practicable, patients, staff and

oth

er persons are protected against risks of acq

uiring

Healthcare Associated Infections

thro

ugh appro

priate

care, in suitable facilities, and co

nsistent

with good

clinical practice.

•Governance Structure

•Infection Prevention and Control Policy

•Infection Prevention and Control Committee Term

s of Reference

•Infection Prevention and Control Sub Gro

up Term

s of Reference

•Handwashing part of KSF

•Annual Reports of Director of Infection Prevention and Control

•Admission and D

isch

arg

e Policy

•Pro

cedure for patients outlying in another specialty

•Bed Escalation Policy

b)

Patients presenting w

ith an infection or who acq

uire an

infection during treatm

ent, are identified p

romptly and

managed according to

good clinical practice fo

r th

e

purpose of

treatm

ent

and to reduce the risk of

transm

ission.

•A&E Path

way to Stanhoe

•Isolation Policy

Duty 2

Evidence

a)

A

Board

level

agreement

outlining

its

collective

resp

onsibilities for minim

ising the risks of infection and

the general means by w

hich it prevents and controls such

risks.

A N

on-Execu

tive D

irector is in place. The Board receives regular reports

and presentations from the M

icro

biologist and the D

irector of Infection

Prevention &

Control.

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COMPLIANCE W


Duty 2

Evidence

b)

The designation of

an individual as

the Director

of

Infection Prevention & Control accountable directly to

the Board.

The D

eputy Chief Execu

tive/Chief Nurse has been appointed as Director

of Infection Prevention & Control.

•Jo

b description

•Objectives

c)

The mech

anisms by which the Board intend to ensu

re

adequate reso

urces

are available to

secu

re effective

prevention

and

control

of

Healthcare

Acq

uired

Infections.

The Infection P

revention &

Control Committee R

eports to

the C

linical

Governance Committee.

The T

rust E

xecu

tive B

oard

has a standing A

genda item in relation to

infection control.

•Tru

st Execu

tive Board

Agenda

d)

Ensu

ring that

relevant

staff,

contractors and oth

er

persons whose norm

al duties are directly or indirectly

concern

ed with patient

care receive suitable and

sufficient training, inform

ation and su

pervision on the

measures

required to prevent

and co

ntrol

risks

of

infection.

Induction training.

MANTRA newsletter and identified levels for mandatory training.

Hand hygiene training to beco

me competency based and m

andatory.

e)

A p

rogramme o

f audit to e

nsure that key p

olicies and

practices are being implemented appro

priately.

High impact interventions.

Audits.

Environmental Audits.

Cleaning A

udits.

f)

A policy addressing the relevant

admission, transfer,

disch

arge

and

movements

of

patients

betw

een

departments;

and within and betw

een healthcare

facilities.

Outlying in a different specialty policy.

Admission and Transfer policy.

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Duty 3

Evidence

a)

Make a suitable and sufficient assessment of the risks to

patients in receipt

of

health care with respect of

Healthcare Acq

uired Infections.

Root cause analysis undertaken for all M

RSA bacteraemias and

Clostridium difficile deaths.

Report to the Trust Execu

tive Board.

Chief Execu

tive m

eets clinical team following the completion of a Root

Cause A

nalysis. Root Cause A

nalysis reported to the Primary Care Tru

st.

•Clostridium difficile and M

RSA stickers – patients’ notes

•Clostridium difficile and M

RSA data collection sheets

b)

Identified steps that need to be taken to

reduce and

control these risks.

Action plans from above

monitored thro

ugh Directorate bilaterals.

Clostridium difficile report and action plan.

c)

Reco

rded its finding in relation to a) and b)

d)

Implemented steps identified.

The results of infection control audits and environmental audits are

monitored by each

Directorate

e)

Appro

priate m

ethods are in place to m

onitor the risks of

infection that it is able to

determ

ine whether further

steps need to b

e taken to reduce o

r co

ntrol Healthcare

Acq

uired Infections.

The Trust uses RA pro

cedures to identify issues th

at require addressing.

f)

Provision of adequate iso

lation facilities.

Isolation Policy in existence.

Audit of policy compliance.

90 Single rooms available across the Tru

st.

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Duty 4

Evidence

a)

There are policies

for

the environment

which make

pro

vision for

liaison betw

een th

e members of

any

Infection Control Team and the persons

with overall

resp

onsibility for Facilities Management.

Policy.

b)

The Tru

st designates Le

ad Managers for cleaning and

deco

ntamination of equipment used for treatm

ent.

Nurse in Endoscopy and Sterile Services Manager have been designated

as Deco

ntamination leads.

c)

All parts of th

e premises in which th

e Tru

st provide

healthcare a

re suitable for the p

urpose, are k

ept clean

and are maintained in good physical

repair and

condition.

•Policy for pest control.

•Food safety for Ward

Pantries Policy.

d)

The cleaning arrangements detail the standard

of

cleanliness required in each

part o

f th

e Tru

st’s p

remises

and that a sch

edule o

f cleaning frequencies is p

ublicly

available.

•All areas have cleaning sch

edules.

•All toilets have ‘sign offs’ w

hen cleaned.

•Cleaning audited.

•Cleaning Strategy.

•Deco

ntamination Policy.

e)

There is adequate provision of su

itable hand wash

ing

facilities and antibacterial hand rubs.

•New soap contract signed.

•Alcohol gel at all entrances and beds, tugs etc.

f)

There are effective arrangements for the appro

priate

deco

ntamination of instruments and other equipment.

•Sterile Services has ISO 13485.

•Staff trained to NVQ level.

•Policies and pro

cedures.

•Pro

cedure for deco

ntamination of Health Equipment.

g)

The supply a

nd p

rovision o

f linen and laundry supplies

affects HSG (95) 18.

•Outside contractor for linen.

h)

Cloth

ing w

orn by staff w

hen carrying out th

eir duties is

clean and fit for purp

oses.

•Uniform

policy.

•White coats not worn by m

edical staff.

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Duty 5

Evidence

a)

The Tru

st pro

vides

inform

ation to patients and th

e

public

about

the org

anisation’s general systems

and

arrangements for preve

nting and controlling H

ealthcare

Acq

uired Infections.

•Communications Strategy.

•Public presentations about infection control to Patient Forum.

•Media stories.

b)

The Tru

st provides

inform

ation to patients re:

risks

regard

ing Healthcare Acq

uired Infections

relevant

to

their care; any preventative m

easures and on disch

arge.

•A range of leaflets are available both on the Intranet and in clinical

areas.

•Hospital Visiting Policy.

•Leaflet about being a good visitor.

•How visitors can help reduce infection.

•Patient Forum w

ork plan.

•Disch

arge Policy.

Duty 6

Evidence

a)

There is a d

uty to p

rovide inform

ation w

hen a

patient

moves from the care of one healthcare body to anoth

er.

•Disch

arge Policy.

•Microbiology reports sent out to Health Pro

tection Agency and

Primary Care Trusts.

•Evidence that infections are m

entioned in Transfer letters.

Duty 7

Evidence

a)

Co-operation of staff, co

ntractors and others involved in

the p

rovision o

f healthcare to enable the Trust to m

eet

its obligations under the Code.

•Copy of letter re: Norfolk H

ealth Eco

nomy.

•Primary Care Trust m

embers of th

e Tru

st’s Control of Infection

Committee.

Duty 8

Evidence

a)

Provision of isolation facilities.

•Policy in place.

•Copy of East of England Audit for Negative Pressure Rooms.

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Duty 9

Evidence

a)

There is a duty to ensu

re adequate laborato

ry support.

•Lots of Policies and Procedures.

•CPA accreditation.

Duty 10

Evidence

a)

Standard (Universal) Infection Control precautions

•

Policy and training.

b)

Aseptic tech

nique.

•


c)

Major outb

reaks of co

mmunicable infection.

•


d)

Isolation of patients.

•Policy, training and audit.

e)

Prevention of

occupational exposure to

blood born

e

viruses, including prevention of sharps injuries.

•Policy and training

•Sharps paper re: moving to safety needles.

•Health & Safety m

inutes re: Sharp

s injuries.

f)

Management of blood b

orne viruses and p

ost-exposure

pro

phylaxis.

•Policy and training.

g)

Closu

re of

wards, departments and premises

to new

admissions.

•Part of Major Outbreak Policy.

h)

Disinfection Policy.

•


i)

Antimicrobial Policy.

•

Guidelines and audit.

•Presentations.

j)

Reporting to Health Protection A

gency.

•

Copy of Reporting Form

.

k)

Policies:

-MRSA

-Clostridium difficile

-Transm

issible Spongiform

Encephalopath

y (TSE

)

•Policies.

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Duty 11

Evidence

a)

All staff have access to O

ccupational Health Services.

•

Leaflet available for staff.

b)

Occupational Health Policies.

•

Policies available.

c)

Induction and training – infection prevention and

control included in Induction a

nd training p

rogrammes

for all staff.

•Copy of Induction pro

gramme.

•Copy of training pro

gramme.

d)

There is a pro

gramme of ongoing education for existing

staff.

•Copies of various teach

ing programmes.

e)

There is a reco

rd of training and updates fo

r all staff.

•

Currently m

anual co

llection

f)

Infection Prevention and Control

is included in job

descriptions, PDP’s and Appraisals.

•Part of job descriptions e.g. part of KSF Core Standard

s. Will fo

rm

part of co

nsultant appraisals.

APPENDIX B

TERMS OF REFERENCE

Overall Purpose: To advise clinicians and managers on policies and procedures; and performance manage infection control across the Trust.

Primary Purpose: The Control of Infection Committee, as a sub-committee of the Trust Board reporting to the Risk Management Committee, provides the forum within which the Infection Prevention and Control Service can consult and advise the clinicians and managers of the Trust on control of infection policies and practice (the membership and role of the Infection Prevention and Control Service (IPACS) is summarised in Appendix I). The Control of Infection Committee and the Infection Prevention and Control Service should operate within the overall guidance on the control of infection in hospitals published by the Health Protection Agency (formerly the P.H.L.S.) in March, 1995. Responsibilities: The Control of Infection Committee’s role is advisory; responsibility for the clinical care of patients rests with the individual clinical staff concerned, whilst managerial responsibility for policy, systems and organisation, rests with the Trust Executive Board and the Chief Executive. Accountability: Trust Board, via the Clinical Governance Committee Relationships: All clinicians and managers throughout the Trust Membership:

• the Director of Infection Prevention & Control (chair)

• the Consultant Microbiologist (“Infection Control Doctor”) or representative

• the Infection Control Nurses

• a Health Protection Agency representative

• the Head of Risk Management

• a senior clinical representative from each of the Medical, Surgical/Anaesthetic and Women & Children Directorates

• senior nurses from each of the Medical, Surgical/Anaesthetic (to cover wards and theatres) and Women & Children Directorates

• the Occupational Health Nurse

• the Hotel Services Manager

• a senior pharmacist

• the Sterile Services Manager

• the Director of Nursing or representative

• the Estates Manager



• the Tissue Viability Nurse

• the Theatre Manager or representative

• an Audit Facilitator

• the Director of Public Health

The Director of Infection Control and Prevention/Chair will ensure that the Chief Executive is advised of any significant issues relating to infection control.

� The Control of Infection Committee will meet bi-monthly or more frequently as required. � Minutes will be circulated to the Clinical Governance Committee and the Trust Executive

Board. Functions: 1. Annual Programme 1.1 Based on the advice of the Infection Prevention and Control Service and taking into

account national policy and guidelines, the Committee will develop an annual programme of work to include: a) staff education b) Trust policy and guides to good practice c) local standards and audit d) surveillance. e) Special projects

1.2 The programme will be presented for endorsement and will contain clear objectives,

responsibilities and milestones for implementation. 1.3 Each Directorate will incorporate the relevant elements of the Annual Control of

Infection Programme within their performance management framework which is subject to regular report to the Trust Executive Board Bilaterals.

1.4 Control of Infection performance will form part of the specialty-based annual reports

to the Clinical Governance Committee. 2. Annual Report 2.1 The Chair of the Committee will present an Annual Report to the Trust Board each

year. The Report will: a) provide an analysis of reported infection within the Trust over the preceding 12

months b) an account of any major outbreaks c) progress on implementation of the Annual Programme d) the proposed Annual Programme for the year ahead. e) Include specialist reports

2.2 The draft Annual Report and Programme will be signed off by this Committee prior to

submission to the Trust Board.



3. Policy 3.1 Provide advice on and develop Infection Control policies. 3.2 Regular review and ratification of existing policies 3.3 Review policy implementation. 4. Communications 4.1 The Committee must ensure that Control of Infection issues are effectively

communicated within the Trust and to external bodies as appropriate (this does not affect the individual responsibilities of the Infection Prevention and Control Service and the Health Protection Agency).

4.2 The minutes of the Control of Infection Committee should be circulated to the Clinical Governance Committee; any appropriate issues will be reported to the Trust Executive Board.

4.3 Directorate representatives are responsible for ensuring that relevant Control of

Infection issues are addressed through their Directorate Management Teams. 4.4 Clinician Managers, through the regular performance management reports, will be

able to raise concerns or problems relating to Control of Infection policy or practice at Trust Executive Board Bilaterals.

4.5 The Chair of the Control of Infection Committee has a particular responsibility to raise

issues of policy implementation or matters of concern at the Trust Executive Board or Trust Board if appropriate.

5. Reporting of Incidents 5.1 The Committee will receive reports from the Infection Prevention and Control Service

and Committee members on incidents that have arisen within the Trust. 5.2 Clinical staff throughout the Trust should bring to the attention of the Infection

Prevention and Control Service any significant concerns that require an immediate response.

5.3 Clinical staff should raise issues of policy that require Trust-wide consideration with

the Control of Infection Committee - through their Directorate representatives. 5.4 The Infection Prevention and Control Service will report any Serious Untoward

Incidents (SUI’s) to the Health Protection Agency and the Strategic Health Authority. 6. Advice and Support to the Infection Control Team 6.1 The clinical and managerial members of the Committee are responsible for advising

the Infection Prevention and Control Service on control of infection issues, training needs and the practical implications of proposed policy.



7. Outbreak Plans 7.1 Discuss and endorse the plan for the management of outbreaks within the Trust and

monitor its implementation. 7.2 Discuss and endorse the major incident/outbreak plan and monitor and evaluate its

implementation. 8. Resources 8.1 Advise on the most effective use of resources available for implementation of the

programme and for contingency requirements. 9. Education 9.1 Promote and facilitate the education and training of all grades of hospital staff in

Control of Infection procedures.

Authors: Chair of Control of Infection Committee Ratified by: Control of Infection Committee Date: April 2006 Review Date: April 2008



APPENDIX C

TRUST EXECUTIVE BOARD MEETING INFECTION PREVENTION AND CONTROL FIGURES

ALERT ORGANISMS 1. Clostridium difficile infections (Episodes of patients in The QEH over the age of 2 years) HAI

1

CAI 2

Total for the month Total for the quarter (July 07 – Sept 07)

Total for the year (April 07 – March 08)

Admissions to Critical Care due to Clostridium difficile

Deaths where C.difficile indicated on Death Certificate

1 Those patients who had been an inpatient for more than 2 days before the onset of

symptoms and diagnosis. 2 Those patients who had been admitted with diarrhoea. 2. MRSA Date Date

Total MRSA bacteraemia Within 48 hours of admission After 48 hours of admission Running total in quarter (April 07 – June 07)

Running total for year (April 07 – March 08)

Deaths from MRSA Number of patients isolate with MRSA in The QEH

Outbreak Issues None Infection Prevention and Control related sudden Untoward Infections reported None

Other Issues None Lynne Roberts Lead Infection Control Nurse Specialist

APPENDIX 1

CLOSTRIDIUM DIFFICILE SUMMARY Date

SEX AND AGE

WARD AND CONSULTANT

ADMISSION DATE

DATE IDENTIFIED

DATE DIED

CAI or HAI

WHERE ON CERTIFICATE?

POSSIBLE ROOT CAUSE

CLOSTRIDIUM DIFFICILE

ROOT CAUSE ANALYSIS

Report Title Clostridium difficile Root Cause analysis

C Diff Death Number

Date

Completed by Lynne Roberts

Department Infection Prevention and Control Service

Annual Report 2006 - 2007 - version 2 10 9 07.doc of 47

C.diff DATA SET

Hospital No:

Which of the following applies? About the patient

Yes No

Name of reporting hospital QEH Chest Infection

Where patient admitted from Urinary Infection

Date admitted to hospital IVI line

Date of specimen Central line

Ward Intestinal problems

Consultant Gastric problems

Speciality of ward Previous antibiotics by GP

Emergency / Elective admission List below

Previous diagnosis of Clostridium difficile Yes / No

Date

Previous admission and discharge

What was the outcome of previous C.diff? Patient has been treated with?

Yes No

Discharged with no diarrhoea Augmentin

Discharged on treatment for C.diff Cefuroxime

R.I.P Ceftrazadine

Cephalexine

DATE OF DEATH

Clarythromycin

What section of death certificate Ia Ib Ic II II Flucoxacin

Who wrote certificate? Darcy Pearson Tazocin

Name, Grade and bleep number Tigecyclin

SHO Trimethoprin

Is this a Hospital or Community acquired infection? Metronidazole

Yes No Rifampicin

Hospital acquired Vancomicin

Community acquired

Any other information Which PCT?


2222 ROOT CAUSE ANALYSIS TIMELINE:

2.1 Consider the following:

(a) Has the patient had care at home – obtain details? (Carers, District nurses).

(b) Has the patient been to any other hospitals/healthcare settings?

(c) Has the patient had a previous diagnosis if C.diff?

(d) Has the patient had recent admissions?

(e) Has the patient had recent antibiotics in hospital or in community?

(f) How long has the patient had symptoms?

(g) Has the antibiotic therapy been reviewed?

(h) Has the antibiotic therapy been discussed with Consultant Microbiologist?

(i) Has the patient been isolated in side room?

(j) Discuss with medical/nursing team

DATE

DETAILS


3333 ROOT CAUSE ANALYSIS

3.1 Issues:

3.2 High Risk Patient:

3.3 Antibiotics:

Co-amoxiclav Pep/Taz Metronidazole Rifampicin Vancomycin Rifampicin 3.4 Specimens:

4444 DEATH CONCLUSION

Report Title MRSA Root Cause analysis

MRSA Bacteraemia No.

Date

Completed by Lynne Roberts

Department Infection Prevention and Control Service

Date reported to HPA

Reported by

MRSA BACTERAEMIA

ROOT CAUSE ANALYSIS


MRSA DATA SET

Hospital No:

Which of the following applies? About the patient

Yes No

Name of reporting hospital QEH Tracheostomy

Where patient admitted from Urinary Catheter

Date admitted to hospital IVI line

Date of specimen Central line

Ward Renal fistula temporary

Consultant Renal fistula permanent

Speciality of ward Chronic skin outbreaks

Emergency / Elective admission Leg ulcers

Previous MRSA specimen tested – none positive negative

Diabetic

12.7.07 Toes Osteomyelitis

15.7.07 Screen MRSA prior to admission

26.7.07 Screen Hospitalised in previous 6 months

Is a renal patient

What was the outcome of MRSA Bacteraemia? Patient’s MRSA has been treated with?

Yes No Yes No

Full recovery from bacteraemia Vancomycin + Tazocin

Death related to bacteraemia Rifampicin

Date of death Fusidic acid

Gentamycin

Is this patient’s bacteraemia? Flucoxacin

Yes No Tetracycline

True infection? Clindamycin

Contamination Macrolide

Is this a Hospital or Community acquired infection? Teicoplanin

Yes No Augmentin

Hospital acquired Vancomycin

Community acquired

Any other information Which PCT?

Norfolk PCT Previous admission

PCT informed?


5555 ROOT CAUSE ANALYSIS TIMELINE

5.1 Consider the following:

(a) Has the patient had care at home – obtain details? (Carers, District nurses).

(b) Has the patient been to any other hospitals/healthcare settings?

(c) Clearly note when the blood culture was taken in the timeline

(d) Note particularly what invasive devices were in situ before the blood culture

(e) Is the rationale for taking the blood culture evident?

(f) Discuss with medical/nursing team

DATE

DETAILS


6666 ROOT CAUSE ANALYSIS

6.1 Issues

6.2 High Risk

6.3 Antibiotics

Augmentin Augmentin Augmentin Augmentin Vancomycin Vancomycin

6.4 Specimens

7777 CONCLUSION

8888 THE QEH FINDINGS

Issue Action Required Lead Person Date for completion

Comments

WARD: IPACS DATE COMPILED: UNIQUE CODE: COMPILED BY: L Roberts


APPENDIX D

infection prevention and control annual ......the ipacs has met on a bi-monthly basis under the...

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