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INFECTION PREVENTION
AND CONTROL DEPARTMENT
ANNUAL REPORT 2013/2014
Emma Dowling
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Associate DIPC
CONTENTS GLOSSARY ............................................................................................................................. 3
1.0 Executive Summary .................................................................................................. 4
2.0 Introduction ............................................................................................................... 6
3.0 Infection Prevention and Control Roles and Structures within the Trust ................... 7
3.1 Out of hours Infection Prevention and Control Service ............................................. 8
3.2 The Infection Prevention and Control Committee ...................................................... 8
3.3 Reports to the Executive Team and Trust Board ...................................................... 8
4.0 Infection Prevention and Control Risk Register ......................................................... 9
5.0 MRSA Bacteraemia (Blood stream infections) ........................................................ 10
5.1 MRSA screening ..................................................................................................... 11
5.2 Escherichia coli bacteraemia ................................................................................... 14
5.3 Water Hygiene Report (prepared by Nick Kay – Head of Health, Safety & Risk) .... 16
6.0 Clostridium difficile associated diarrhoea ................................................................ 22
6.1 Summary of main themes from the CDI RCA’s ....................................................... 23
6.2 RCA findings ........................................................................................................... 23
6.3 Clostridium difficile Ward Round ............................................................................. 25
6.4 Other Resistant Bacteria ......................................................................................... 14
7.0 OUTBREAKS, WARD CLOSURES, PERIODS OF INCREASED INCIDENCE ...... 26
7.1 Norovirus outbreak .................................................................................................. 26
7.2 Summary of Ward Closures due to Norovirus ......................................................... 27
8.0 SURGICAL SITE INFECTION SURVEILLANCE .................................................... 28
9.0 SAVING LIVES: HIGH IMPACT INTERVENTIONS ................................................ 29
10.0 TRAINING AND EDUCATION ................................................................................ 30
10.1 Infection Prevention Mandatory training .................................................................. 31
10.2 Teaching training record.......................................................................................... 32
10.3 Alert Labels ............................................................................................................. 32
10.4 Alert Sheets ............................................................................................................. 33
10.5 Infection Prevention and Control Link Nurses ......................................................... 34
11.0 COMPLIANCE WITH THE HEALTH AND SOCIAL CARE ACT 2008 .................... 35
12.0 POLICIEIS, PROCEDURES & PROTOCOLS ......................................................... 37
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13.0 AUDIT ..................................................................................................................... 38
13.1 Monthly Hand Hygiene Audit Compliance Scores ................................................... 39
14.0 PATIENT LED ASSESSEMENTS OF THE CARE ENVIRONMENT -PLACE ......... 39
14.1 Environmental audit ................................................................................................ 41
15.0 KEY ACTIONS / ACHIEVEMENTS IN INFECTION PREVENTION FOR 2013/14 . 42
15.1 Hand Decontamination -Hand Towels ..................................................................... 43
16.0 OBJECTIVES AND WORK PLAN FOR 2014/15 .................................................... 44
Appendix 1 Infection Prevention and Control Programme for
2013/2014 ............................................................................................................................ 46
GLOSSARY
ARHAI
Advisory committee on Antimicrobial Resistance and Healthcare Associated Infection
ADIPC Associate Director Infection Prevention and Control
CNS Clinical Nurse Specialist
DoH
Department of Health
DIPC Director of Infection, Prevention & Control
CCG
Clinical Commissioning Group
C. diff Clostridium difficile
CDI Clostridium difficile infection
CQC
Care Quality Commission
GDH
Glutamate Dehydrogenase
GRE
Glycopeptide resistant Enterococci
HCAI Healthcare Associated Infection
IPC Infection Prevention & Control
IPCN Infection Prevention & Control Nurse
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IPCT Infection Prevention & Control Team
KPI Key Performance Indicator
MRSA Meticillin resistant Staphylococcus aureus
MSSA Meticillin sensitive Staphylococcus aureus
OPD Out patients Department
PPM
Planned Programme of Maintenance
PIR Post Infection Review
Q A Quality Assurance
RCA Root cause analysis
SHA Strategic Health Authority
SSI Surgical Site Infection
SUHFT Southend University Hospital Foundation Trust
1.0 Executive Summary
This annual report fulfils the Trust’s statutory requirement under section 1.3 of the Health and
Social Care Act 2008 for the Director of Infection Prevention and Control (DIPC) and
Associate Director of Infection Prevention and Control (ADIPC) to provide a report on
infection control activity across the organisation. In addition to the Trust’s obligation, this
report provides key information to the public, patients, staff, Trust Board, the CQC, Monitor
and our Commissioners of the activity relating to infection prevention and control. This report
covers the period from 1st April 2013 - 31st March 2014 and provides an assessment of
performance against national targets for the year and includes key issues such as;
• Meticillin Resistant Staphylococcus Aureus (MRSA) bacteraemia figures
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• Clostridium difficile Toxin (CDT) rates,
• Audit activities and other key priorities for the year.
The Trust continued to have both patient safety and Health Care Associated Infections
(HCAI) as a priority within the organisation. 2013/14 has been another challenging year for
both the organisation and infection prevention and control team (IPCT), as there is greater
scrutiny and surveillance on HCAI as well as ever reducing ceilings for infections. The Trust
sustained a clear focus and energy on the infection prevention and control agenda, sharing
key learning and best practice in order to deliver on both HCAI national targets
This year the Trust experienced a mixed level of attainment with regard to the Healthcare
associated Infection (HCAI) objectives. The Trust achieved the MRSA bacteraemia objective
set by the DH at zero cases .This is the first time the Trust has reported 0 cases and it is
great achievement for all concerned.
Conversely, we were very disappointed to report that the objective for incidents of Clostridium
difficile was breached at 31 cases against a very challenging ceiling of just 18 – (see section
6.0 for full details)
In line with the Infection Prevention and Control (IP&C) Strategy, work has continued to
ensure that we maintain compliance with:
The Health and Social Care Act 2008
NHSLA Risk Management Standards for Acute Trusts
The Care Quality Commission registration Outcome 8
The Trust emphasis on of ‘Saving Lives’ continues and included the application of
evidence based improvements in intravenous line care, isolation utilisation, antibiotic
usage and the surgical site infection bundle
The Trust successfully achieved the overall target of 95% hand hygiene compliance
with a total of 95.87%. Training in hand hygiene for all staff and improvements to hand
hygiene facilities continued through the year.
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Training in infection prevention and control included outbreak management and was
delivered through staff induction, mandatory updates, link nurse sessions and ward
based update sessions using the new training record booklet ( see section 10.2)
There was just 1 ward closed during December 2013 due to suspected Norovirus. In
total 12 bed days were lost due to the suspected Norovirus outbreak
2.0 Introduction
The term Healthcare Associated Infection (HCAI) encompasses any infection by any
infectious agent acquired as a consequence of treatment. Micro-organisms (germs)
responsible for HCAI can be viruses, fungi, parasites and, more frequently, bacteria. HCAI
can be caused either by micro-organisms already present on the patient’s skin and mucosa
(endogenous) or by micro-organisms transmitted from another patient or health-care worker
or from the surrounding environment (exogenous).
The risk of transmission and potential harm applies at any time during health-care delivery,
especially to immuno-compromised or vulnerable patients and/or in the presence of
indwelling invasive devices (such as urinary catheter, intra-venous catheter, endotracheal
tube, drains).
Infection prevention and control clearly has a very important role to play in ensuring that
patients receive a high quality of care and have improved clinical outcomes. The infection
prevention & control agenda faces many challenges including the ever increasing threat from
antimicrobial resistant micro-organisms, the emergence of new human pathogens, growing
service developments, national guidelines and very strict targets.
Healthcare associated infection is of increasing media and political interest being seen as a
visible and unambiguous indicator of the quality and safety of patient care.
The foundations of infection control are built on a number of simple, well-established
precautions proven to be effective and widely appreciated. “Standard Precautions”
encompass the basic principles of infection control that are mandatory in all health-care
facilities. Their application extends to every patient receiving care, regardless of their
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diagnosis, risk factors and presumed infectious status, reducing the risk to patients and staff
of acquiring an infection. Hand hygiene is very much at the core of Standard Precautions and
is the undisputed single most effective infection prevention control measure.
The main essential elements of controlling and preventing infections related to health care
are:
Identifying risk factors and minimising their impact
Improving patients’ resistance to infection
Early identification and effective treatment of infections
Preventing transmission of micro-organisms from person to person
Maintaining a clean and fit for purpose environment including equipment with minimal
levels of microbial contamination
3.0 Infection Prevention and Control Roles and Structures within the Trust
The Infection Prevention and Control Team (IPCT) is an integral part of the organisation
providing advice, expertise, knowledge and support to encourage and enable members of
staff working across the Trust to enhance and sustain their performance in infection control
principles and practice. The IPCT shapes policy, educates and provides information to the
public, patients, staff and colleagues across the health economy undertake surveillance and
outbreak control management.
The Infection Prevention and Control Team Members consist of:
Dr Stephen Barrett - Consultant Microbiologist and Director of Infection Prevention &
Control
Dr Nada Elhag - Consultant Microbiologist and Director of Infection Prevention &
Control
Dr Marilyn Meyers - Consultant Microbiologist
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Sue Hardy –Chief Nurse/Deputy Chief Executive and Executive Lead for Infection
Prevention & Control
Cheryl Schwarz - Associate Director of Nursing
Emma Dowling - Infection Prevention and Control Matron /Associate Director of
Infection Prevention and Control
Judith Holdsworth - CNS
Claire Whittington - CNS
Laura Search – Personal Assistant to the Infection Control Team
Elaine Bibby - PA to Consultant Microbiologists & Administrator to Microbiology Dept.
3.1 Out of hours Infection Prevention and Control Service
The IPCN team provides 24 hours availability ‘on call rota’. The Consultant Microbiologists
are also available on a rota out of hours.
3.2 The Infection Prevention and Control Committee
The Infection Prevention and Control Committee (IPCC) is the main forum for monitoring and
delivery of the IPC Strategy as well as the development and implementation of a trust wide
annual HCAI action plan. It also monitors the delivery of the IPC strategy and holds to
account Business Units for performance in IPC using the Infection Control Dashboard,
Members include the Chief Nurse, Deputy Chief Nurse, ICT, Matrons, Occupational Health
Department, Pharmacy, Estates and Facilities, Sterile Services and external bodies such and
our Commissioners and Public Health England
The IPCC reports to the Clinical Assurance Committee (CAC) where an overview of the
Trust’s measures of Infection prevention and control with appropriate actions are shared.
3.3 Reports to the Executive Team and Trust Board
The IPCT provides a monthly performance report to the Executive Team on a number of
infection prevention and control measures. This includes the Trust’s current position against
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Department of Health ceilings for MRSA bacteraemia and C difficile infections. The Trust
Board receives a report on the incidence of MRSA bacteraemia and of C.difficile, and of
learning and practice changes instigated as a result of the outcome of root cause analysis
and Post Infection Reviews (PIR).
4.0 Infection Prevention and Control Risk Register
The following risks remain on the IPC Risk Register after review by the IPC Matron
ID Risk Title Existing
risk level
37 Healthcare associated infection (MRSA bacteraemia) may lead to patient
harm or morbidity
LOW
573 Outbreak (defined as 2 incidents over 2 weeks) of C.difficile may lead to
patient harm
LOW
687 Failure of sluice washer disinfectors may lead to cross contamination and
service disruption
LOW
1630 Healthcare associated infection (MRSA colonisation) may lead to patient
harm
LOW
1631 Healthcare associated infection (Clostridium difficile) may lead to patient,
staff and visitor harm
LOW
1647 Incorrect use or disposal of used sharps may lead to injury or ill health from
exposure to blood-borne viruses
LOW
1731 Staff failure to adhere to ward visiting restrictions and infection control
interventions, during a suspected or confirmed Norovirus outbreak may lead
to cross contamination and further disruption to hospital services
LOW
1803 Failure to reduce rates of C.difficile in line with challenging Trust
performance targets may impact on our reputation and Monitor Governance
rating
HIGH
1823 Failure to meet challenging Trust performance target for MRSA bacteraemia
may impact on our reputation and Monitor Governance rating
HIGH
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1816 Failure to maintain the negative pressure isolation rooms to the required
standard may lead to cross contamination
LOW
5.0 MRSA Bacteraemia (Blood stream infections)
The Department of Health (DoH) commenced mandatory surveillance of MRSA bacteraemias
in 2001. This includes all bloodstream infections with MRSA to establish whether it was
acquired in the hospital or community and considered to be a contaminant or not.
In 2013/14 the Trust had a ceiling of zero MRSA bacteraemia cases for the financial year
2013/2014.Several factors have contributed to this success, including MRSA screening,
universal decolonisation, decreased blood culture contamination rate, improved cannula care
etc. However the ceiling is once again set at 0 which remains a challenge for the Trust.
Figure 1
MRSA Bacteraemia Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Total
Specimens allocated to the Acute Trust 0 0 0 0 0 0 0 0 0 0 0 0 0
Zero Tolerance
Figure 2.This graph demonstrates both Hospital and Community attributable MRSA Bacteraemias since 2009 to March 2014
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5.1 MRSA screening
Since April 2009, in line with the NHS Operating Framework 2008-2009, all patients admitted
to NHS hospitals are screened for MRSA.
Significant work continued over the past year to ensure that screening for MRSA was
undertaken for all elective and non-elective admissions
The mandatory MRSA screening guidance currently extends to a range of individuals
screened to include people at low risk of MRSA colonisation or infection, such as patients
without serious comorbidity. The Department of Health’s impact assessment of universal
screening assumes that everyone screened has an equal risk of colonisation.
At this Trust, in September 2010 it was agreed by the Infection Prevention and Control Team
and Director of Nursing as part of our measures to reduce Health Care Associated Infections
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(HCAI’s) that all patients despite being screened for MRSA carriage would benefit from
suppression therapy before their procedure to reduce their bacterial load.
The current screening practice within SUHFT is that all patients who attend surgical pre
assessment clinics are screened first and then provided with an anti-bacterial body wash and
instructed to use this on the 2 days prior to and on the day of their procedure. They continue
to use this product throughout their admission in an attempt to reduce skin bacterial load and
ultimately minimise the risk of possible surgical site infections. Patients with underlying skin
conditions or undergoing radiotherapy treatment are risk assessed on an individual basis to
determine their suitably to use the wash. In the event of a positive screen the patient is
managed as per Trust Policy IC007.
These measures have been shown to be effective in prevention and controlling MRSA, as is
evident from our bacteraemia and MRSA acquisition rates (figures 1, 2 3, 4, and 5).
Between January 2013 and December 2013 over 10,000 MRSA elective patient screens
were processed with a very low yield of new cases of MRSA carriage (48 positive screens).
The 48 positive screens were reviewed. These included previously known cases, care home
residents, health care workers, patients undergoing orthopaedic procedures and patients due
for vascular procedures, who would be identified as high risk and therefore would have met
the criteria for screening.
The proposal for 2014/2015 is to stop universal screening and re-introduce a check list
activated risk assessment for MRSA screening of elective patients, which was the policy
previously used in the Trust until 2009. The check list algorithm will be designed to highlight
high risk patients, for example previously known MRSA carriers, health care workers, care
home residents, patients undergoing orthopaedic or vascular procedures. It should be noted
that there has not been a Trust attributed MRSA bacteraemia since January 2013.
Dr Barrett (Director of Infection Prevention and Control) has had discussions with the
Department of Health recently in relation to MRSA screening; it appears that the forthcoming
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report to NHS England will recommend that MRSA screening now be limited to groups at
particular risk, namely:
• Patients previously identified as colonised with or infected by MRSA.
• Patients admitted to critical and intensive care units.
• Patients admitted to high risk specialties: - vascular, renal/dialysis, neurosurgery,
cardiothoracic surgery, orthopaedics/trauma haematology/oncology/bone marrow
transplant
Trusts will of course be at liberty to define further groups for screening according to local
circumstances.
We understand that a number of Trusts throughout the country are also planning to adopt this
limited screening policy in anticipation of the forthcoming report.
Figure 3
Elective screening data YTD
Total elective admissions 13,586
Elective admissions screened where screening was applicable 12,701
% of elective Admissions screened 93.5%
Emergency screening data YTD
Total emergency admissions 16,969
Emergency admissions screened 16,127
% of emergency admissions screened 95%
Figure 4 Hospital – Screen obtained post 48 hours of admission-Colonisations
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Figure 5 Community – Screen obtained Pre 48 hours of admission
Other antibiotic-resistant Ba
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cteria
Escherichia coli bacteraemia
The DoH extended mandatory surveillance reporting to include bacteraemia due to this
organism from June 2011; the Trust has been collating this information since April 2010. No
trajectories have been set by the DoH for these cases, monitoring by monthly cases will
continue to be recorded as shown in Figure 6.
Figure 6
5.3 Meticillin Sensitive Staphylococcus aureus bacteraemia
The Department of Health has not yet set reduction targets for MSSA bacteraemias, but for
the year 2013/2014 the Trust report 10 cases identified post 48 hours of admission.
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Fig 7 shows MSSA bacteraemias detected during the year and whether they were
considered Community-acquired (<48 hours after admission), of Hospital-acquired (>48
hours after admission).
Figure 7
5.4 Glycopeptide resistant Enterococci (GRE) bacteraemia.
Enterococci are bacteria that are commonly found in the bowels of most humans. Many GRE
are resistant to multiple other antibiotics and are most commonly seen in groups of patients
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in intensive care units, renal, liver or haemato-oncology units who have been given multiple
antibiotics. In 2013/14 there no Healthcare Acquired GRE bacteraemia.
5.5 Water Hygiene (prepared by Nick Kay – Head of Health, Safety & Risk)
Highlighted below is an outline of some of the measures which are in place to manage water
hygiene monitoring and control within Southend University Hospital NHS Foundation Trust
and satellite properties under the Trust responsibility.
Legionella Bacteria
Legionella is a waterborne bacterium which is present in the water that feeds the Trust. For it
to grow and spread within the hot and cold water systems it needs the presence of sludge,
scale, algae, rust, and organic matter, and the ideal temperature of 20–40 degrees C. It is
transferred via water droplet e.g. aerosols from showers
Current Situation
Currently the Trust has a contract with Evolution Water Services who are the specialist
contractor and who carry out a number of planned preventative maintenance (ppm’s) tasks
and other control measures in line with the current guidance and legislation that is in place
namely: HTM– 04 and the ACOP ‘Legionnaires’ disease - The control of legionella bacteria in
water systems (L8), and HSG274 - Legionnaires’ disease: Technical guidance Part 2: The
control of legionella bacteria in hot and cold water systems.
In addition to the PPMs carried out by Evolution the Trust also carries out regular flushing of
water outlets which are used less than twice a week, which increases the turnover of water
and prevents the bacteria forming in stagnant water.
An approved sampling regime is in place to sample water systems throughout the Trust and
in satellite properties under the Trust responsibility.
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Once a legionella bacterium is detected from elevated sample results various engineering
controls are implemented to try and eliminate the risk of the bacteria reforming. This includes:
removal of flexible hoses if present, increasing temperature, changing or relocating
thermostatic mixing valves, descaling the outlets, daily flushing or chlorination of the
complete water system.
During the last 12 months rather than take water outlets out of use, therefore creating
disruption to the wards or departments, in most cases point of use water filters (shown below)
are attached to the outlet. These filters allow the outlet to continue to be used safely whilst
engineering action is taken. These filters ensure that patients and staff were not put at any
risk from these elevated counts. The filters last for up to 60 days, and fail safe by blocking
and stopping supply of water. Point of use filters are also designed for showers.
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The graph below shows all the legionella sampling which has taken place since Evolution
started their contract with the Trust.
Below shows the samples taken over the last four years. In 2014 the percentage clear was
reduced due to a problem with the energy centre which feeds the Education Centre, the
temperature of the hot water system fell to 40oC for a period of time long enough for
legionella bacterium to form in a majority of the outlets sampled. As soon as the elevated
samples were received both the hot and cold water systems were chlorinated overnight.
Annual Samples 2011 2012 2013 2014
Initial Samples Taken/Year 30 479 245 53
Elevated Samples 3 46 17 10
Clear Samples 27 433 228 43
These samples were from the Education Centre following problems with the energy centre
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Percentage Elevated 10.0 9.6 6.9 18.9
Percentage Clear 90 90.4 93.1 81.1
All outlets which have returned with elevated sample results are resampled once engineering
actions have been taken, and when results come back clear they are put on to the flushing
register for domestics to flush daily – as a precaution.
Going forward a new sampling regime will be implemented which adheres to the relevant
legislation and will target outlets which have produced elevated counts previously.
This regime will be agreed by the Water Assurance Committee which is chaired by the
Director of Infection, Prevention and Control, with committee members comprising of the
Responsible Person for legionella control in water systems, their deputy, Infection Control
Matron, EFM Quality Assurance and a member of Unison.
Pseudomonas aeruginosa
Pseudomonas aeruginosa is a waterborne bacterium which hit the press in the early part of
2012 which resulted in the death of 4 babies: 1 in Londonderry and 3 in Belfast.
It is a tough bacterial strain, which is able to survive in harsh environments. It is found widely
in soil and stagnant water, and can infect humans and plants. It does not usually cause
illness in healthy people, but is described as an "opportunistic" organism, causing serious
infection when our normal defences are weakened. This means that it represents a genuine
threat to the most vulnerable hospital patients, most commonly intensive care patients, those
with depleted immune systems such as cancer patients, people with severe burns and
premature babies in neonatal units
In 2012 an interim document was produced advising action which needs to be taken to
manage Pseudomonas aeruginosa; this was superseded by the release of an HTM 04
Addendum in 2013.
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To determine what areas within the hospital may possibly be affected all those which fell
under ‘augmented care’ were included on a sampling regime which was risk rated by the
Water Assurance Committee with support from Evolution Water Services. Sampling began in
the later part of 2012 and finishing in March 2014.
As highlighted above sampling has taken place from latter part of 2012 to March
2014, with the results as shown on the graph below
In March 2014 a total of 110 samples were taken on one specific ward within the Trust. 26 of
the samples obtained returned with an elevated count. Unlike legionella sampling
Pseudomonas aeruginosa sampling consists of both the hot and cold water taps being
sampled.
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The elevated samples that were obtained were identified within a specific area of the ward
which, on investigation it was concluded that the elevated counts were due to the outlets only
being used sporadically. Also it was identified that there was a build-up of scale on the end of
the taps increasing risk of elevated counts.
Immediate actions were undertaken to prevent re-occurrence which were a daily flushing
programme, installation of self-flushing showers, all outlets descaled with a plan to implement
a planned programme of maintenance to include regular descaling of outlets.
When initial sample results are received, prior to any engineering actions taking place a
further two samples are taken: one as soon as the outlet is opened, and a second after
water has flowed out of the outlet for two minutes. This confirms if the bacterium is in the
outlet itself or in the water system. Until the results have been returned, as a precaution to
protect the end user point of use filters are installed, or in the case where the filters cannot be
fitted, additional hand hygiene measures are implemented and the outlets are flushed daily.
The first regime of sampling was set up by the Water Assurance Committee to gain a base
line for future sampling – to ensure the correct areas are sampled. Going forward, the HTM
Addendum will be reviewed further and advice taken from Evolution Water Services as how
to be in full compliance with this new guidance.
6.0 Clostridium difficile associated diarrhoea
Acute Trusts in England are required to report cases of Clostridium difficile infection that are
considered to have been acquired in that Trust, defined as 72 hours post admission. The
ceiling set for hospital acquired cases at SUHFT in 2013/14 was just 18 cases. The total
number of cases for 2013/14 was 31 cases, 58% over trajectory.
2013 - 2014 C difficile Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Total
Specimens allocated to the Acute Trust 3 0 4 2 2 1 2 2 4 2 2 7 31
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6.1 Summary of main themes from the CDI RCA’s
Clostridium difficile is the main cause of antibiotic associated diarrhoea. As a HCAI these
cases are monitored by the DoH, through mandatory surveillance data supplied by on a
monthly basis by all Trusts.
Main themes identified from RCA’s undertaken
Not comprehensive documentation on Bristol Stool chart
Delay in sending stool specimen or isolating patient as other reasons for loose stools considered but not recorded /documented
Once positive stool culture result obtained- all patients isolated within 1 hour
No evidence of cross infection identified
All patients presented with multiple co morbidities and risk factors
30 out of 31 cases had been prescribed antibiotics
6.2 RCA findings
The RCA process has identified that in many cases patients presenting with CDI have more
than one risk factor. An increased number of risk factors in a patient may increase the
predisposition for CDI. Risk factors comprise: multiple comorbidities (Figure 8). Underlying
bowel disease, high risk medications (Figure 9), advanced age, multiple hospital admissions,
bowel surgery and immunosuppression
Figure 8
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310%
931%
828%
931%
Number of Risk Factors per Case(Annual data 2013-14)
0
1
2
3
4
5 or more
.
Figure 9
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Studies confirm that antibiotics predispose to CDI and also indicate a potential link with
Proton Pump Inhibitors (PPI). In addition, laxatives, nutritional supplements and
chemotherapy are indicated as potential factors in CDI therefore all of these medications are
included in the RCA reports.
Figure 10 This graph demonstrates the average age and the male female ratio of patients at this Trust.
6.3 Clostridium difficile Ward Round
In response to the DH Guidelines the weekly multidisciplinary clinical review of all inpatient C.
difficile patients within the Trust continues. The review team includes a Consultant
Microbiologist, DIPC, Consultant Gastroenterologist, antimicrobial pharmacist, IPCN,
Microbiology Registrar and if possible the patient’s own clinician. The objective of the ward
round is to ensure that the infection is being treated as a ‘condition in its own right’ to ensure
optimum treatment and that the patient is receiving all necessary supportive care. The C
difficile Ward Round sticker shown below which is completed on the ward round by the
Consultant Microbiologist on the ward round as a highly visual communication aide.
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7.0 OUTBREAKS, WARD CLOSURES, PERIODS OF INCREASED INCIDENCE
7.1 Norovirus outbreak
The IPCT have worked hard to reduce the impact of Norovirus outbreaks on the Trust. One
element of this work was teaching sessions aimed at all staff groups to assist with the early
recognition and isolation of suspected / confirmed cases. These sessions were delivered to
all wards/clinical areas from September 2013 through to December 2013. The IPCT have
worked collaboratively with the Control Room, Clinical Site Managers, Discharge
coordinators, Accident and Emergency, Domestic Services, and the Communications
Department.
Alcohol gel used throughout the Trust (B Braun) has anti-viral properties and effective against
Norovius.
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7.2 Summary of Ward Closures due to Outbreaks
There were two episodes of ward closure due to presumed infection as tabulated below.
Ward Closed Reason Clean started Clean completed
Estuary 13.12.13 Suspected Norovius due to 4
patients with unexplained symptoms of
vomiting and loose stools
15.12.13 16.12.13 OPENED
12 bed days lost
The key lesson learnt during this period:-
• The importance isolationing patients admitted from residential homes that are closed
due to suspected or confirmed outbreaks.
Ward Closed Reason Clean started Clean completed
Gordon Hopkins 1 x Bay closed to admissions for 48 hours
Influenza A 20.02.13 20.02.13
Influenza A outbreak on Gordon Hopkins Ward – type A H3. 4 Patients in male non acute bay
and 1 female in sideroom. Patients recovered well – 2 beds blocked to new admissions for 48
hours only. Nil impact on bed capacity. No staff members affected. It was noted that the
patients affected had not had their seasonal flu immunisation.
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8.0 SURGICAL SITE INFECTION SURVEILLANCE
Orthopaedic Surgery
The DH requires all hospitals performing orthopaedic surgical operations (joint
replacements and implants for fracture surgery) to monitor surgical site infections
(SSI) for a minimum three month period each year. Details of this surveillance
undertaken in the Trust are tabulated below. (Large and Small bowels count separate
categories)
Results obtained from the Health Protection Agency’s Surveillance of Surgical Site Infections.
April – June 2013
Category
Total number of
SUHFT operations
Number of SSI’s
SUHFT (%infected)
Total no. of operations
for all hospitals
Total no. of SSI’s for all
hospitals
All hospitals
(% infected)
Hip replacement
102 1 1.0% 216865 2666 1.2%
July – September 2013
Category Total Number SUHFT Total no. of Total no. All
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number of SUHFT
operations
of SSI’s (%infected) operations for all
hospitals
of SSI’s for all
hospitals
hospitals (%
infected)
Abdominal hysterectomies
26 2 7.7% 5564 232 4.2%
Please note. There were a total of 26 Abdominal hysterectomies undertaken during this period and only 2 infections reported. The 2 surgical teams concerned undertook a review of the patients concerned and it was concluded in both cases that despite best practice both developed post-operative wound infections. They noted that both cases were extremely complex due to the patients presenting with multiple comorbidities, multiple risk factors and complex surgical procedures. (Both patients had undergone chemotherapy and radiotherapy prior to their procedures)
October – December 2013
Category
Total number of
SUHFT operations
Number of SSI’s
SUHFT (%infected)
Total no. of operations
for all hospitals
Total no. of SSI’s for all
hospitals
All hospitals
(% infected)
Repair neck of femur
44 0 0% 82385 1407 1.7%
Amputations
4 0 0% 2217 100 4.5%
Accumulative data for previous 5 years for all hospitals (5 year benchmark)
9.0 SAVING LIVES: HIGH IMPACT INTERVENTIONS
Saving Lives was introduced by the DH in June 2005.The High Impact Intervention tools are
based upon a ‘care bundle’ concept, integrating the latest evidence based guidelines and
providing a means for staff to measure compliance to key clinical procedures. High impact
interventions assist clinical governance by ensuring that all patients receive a consistently
high quality care.
During 2013/2014 the following audits were undertaken on the following care bundles.
%
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compliance
achieved
Hand hygiene – Trust wide audited compliance percentage 95.87%
HII 1: Central venous catheter care bundle – insertion 99.1%
HII 1: Central venous catheter care bundle – on-going care 98.8%
HII 2: Peripheral intravenous cannula care bundle – insertion 98%
HII 2: Peripheral intravenous cannula care bundle – on-going care 96.8%
HII 3: Renal dialysis catheter care bundle - insertion 97.1%
HII 3: Renal dialysis catheter care bundle – on-going care 97.1%
HII 4: Care bundle to prevent surgical site infection – pre-operative 100%
HII 4: Care bundle to prevent surgical site infection – peri-operative 99.8%
HII 5: Care bundle for ventilated patients 99.8%
HII 6: Urinary catheter care bundle - insertion 98.9%
HII 6: Urinary catheter care bundle – on-going care 97.5%
HII 7: Prevention of spread of Clostridium difficile 100%
HII 8: To improve the cleaning and decontamination of clinical equipment 97.6%
The results are presented monthly in graph format and are also available via the Infection
Prevention and Control Dashboard. Any compliance issues are addressed through the
Matrons and reported at the Infection Prevention and Control Committee. Infection prevention
and control training and support at ward level with using the data collection tools and
uploading data has resulted in a marked improvement with our data when compared to last
year’s figures.
10.0 TRAINING AND EDUCATION
Main teaching programme Frequency Providers
IPC induction for all staff (including medical) Fortnightly IPCN/DIPC
Facilities staff/Contractors as required IPCN
Renal Unit X 6 a year IPCN
NHS Professionals as required IPCN
Newly qualified nurse development course twice a year IPCN
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1 day IC workshop (all grades) quarterly IPCN/DIPC
IC awareness days quarterly IPCN/DIPC
Link Nurse Session quarterly IPCN
HCA Induction monthly IPCN
Day stay theatre / Post-op annually IPCN
Mandatory Infection Control E learn IPCN
Junior doctors bi-annually DIPC
(ARU) IC for student nurses on request IPCN
Sharps Awareness day Yearly IPCN
++New education programmes are added as required++.
10.1 Infection Prevention Mandatory training
In order to ensure flexibility, Mandatory Infection Prevention and Control training was
introduced in February 2013 via E learn. This is available to all staff grades via the staff
Intranet. This course has to be undertaken biannually-. Staff members that do not have
access to a computer can book face to face training via the iLearn system. The proportion of
staff trained during the year is shown below.
.
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10.2 Teaching training record
A teaching training record was devised by the Infection Prevention and Control Team. This
booklet is provided to all Trust staff by their IPCN.When face to face training is delivered in
the clinical setting. Examples of subjects in the record are C diff, MRSA, isolation, obtaining
MRSA swabs and invasive device tool update, as shown below:
10.3 Alert Labels
Following the the move from (Patient Administration System) PAS to the Medway system in
January 2014, the Trust no longer used the previous CAT A alert system to identify patients
that had previously been identified as MRSA positive or C difficile positive or C difficile
carriers. For these patients we had previously placed an alert sticker CAT A sticker on the
clinical records (see below) .The IPCT amended the sticker to identify these at risk patients in
line with the Medway system.
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.
CATA label ALERT label
10.4 Alert Sheets
Following the introduction of ‘zero tolerance’ for MRSA bacteraemia and the challenging C
difficile ceiling set by the DoH, the IPCT wanted to ensure that all clinical and medical staff
were aware if a patient had previously been known to be MRSA, C diff, or C difficile carrier .A
simple alert sheet was developed that is placed in the front of patients’ medical records
on admission. This ensures that the relevant policies, pathways and precautions are
followed. The process is started in the A/E department. If an emergency admission is
identified from the Medway system with an Infection Control Alert, the relevant Alert Sheet is
placed in the patient’s clinical record. The Infection Prevention team will also check to ensure
that this sheet has been placed in the medical records when visiting their patients.
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10.5 Infection Prevention and Control Link Nurses
The IPCT continues to provide the Infection Prevention and Control Link Nurse programme.
Link Nurse sessions are run quarterly and provide an education session and, usually include
a guest speaker to support the nurses to maintain their enthusiasm and commitment.
Numerous topics are covered and have included for example, hand hygiene, MRSA
screening and outbreak management. The sessions run for approximately two hours.
The aim of these sessions is to update on any new guidance / policies and to increase the
flow of Infection Prevention and Control communications.
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Infection Prevention and Control Link Nurse Programme 2013/2014
Date Guest Speaker - ICN Agenda items
10.04.13 Claire Whittington Sam Ferrick Gamma Health Care
Use of Clinell wipes and decontamination ‘I am clean label’ update C diff RCA feedback Bed pan washers – reporting problems Hand Hygiene audit discussion
14.08.13 Judy Holdsworth
Stool Charts MRSA screening Invasive Device Tool update Deep clean request - discussion Sharps Safety issues C diff RCA feedback
18.12.13 Emma Dowling Norovius and outbreak management –red folders update Influenza update –Q and A session C diff RCA feedback White paper towels- hand decontamination
05.03.14 Judy Holdsworth C diff RCA feedback Update with HCAI ceilings When to take a stool sample discussion MRSA screening /regimes Anti-bacterial body wash – discussion
11.0 COMPLIANCE WITH THE HEALTH AND SOCIAL CARE ACT 2008
The Health and Social Care Act 2008 Code of Practice for the prevention and control of
Healthcare Associated Infections (HCAI’s) became operational in April 2009 and was revised
in April 2011. Known as the Hygiene Code, it now includes primary dental care and
independent sector ambulance providers. The Code of Practice outlines the compliance
criteria the Trust is required to meet and supporting guidance for implementation. The Annual
Work Plan and GAP Analysis details the Trust’s compliance.
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The GAP Analysis (i.e. analysis of areas where requirements are not completely met) shows
with the Hygiene Code. The 10 criteria and supporting evidence are RAG (Red-Amber-
Green) scored.
RED-Non –compliance based upon insufficient evidence
AMBER-Processes in place but requires development
GREEN-Evidence available to support compliance
AS shown in the table, this Trust has no red scores, which would indicate non-compliance. At
the time of this report there is now only one amber score
Criterion Compliance criteria point Compli
ant Comments
1 Systems to manage and monitor the prevention and control of infection. Those systems use risk assessments and consider how susceptible service users are and any risks their environment and other users may pose to them
2 Provide and maintains a clean and appropriate environment which facilitates the prevention and control of HCAI.
Weekly spot check monitoring of cleanliness by the facilities Department. Monthly joint audits with input from Matrons and IPC (when available) Domestic Service QA Team monitor cleaning and audit in accordance with the National Standards of Cleanliness 2007.
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3 Provide suitable accurate information on infections to service users and their visitors. Patient information leaflets reviewed and updated
4 Provide suitable accurate information on infections to any person concerned with providing further support or nursing / medical care in a timely fashion.
5 Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment are care to reduce the risk of passing on the infection to other people.
MRSA screening for both elective and emergency patients not 100% compliant
7 Provide or secure adequate isolation facilities
8 Secure adequate access to laboratory support as appropriate
9 Have and adhere to policies, designed for the individual’s care and provider organisations that will help to prevent and control infections.
10 Ensure, so far as reasonably practicable, that care workers are free of and are protected from exposure to infections during the course of their work, and that all staff are suitably educated in the prevention and control of infection with the provision of health and social care.
12.0 POLICIES, PROCEDURES & PROTOCOLS
In line with the Health and Social Care Act 2008 infection prevention and control policies,
procedures and protocols continue to be developed as required, reviewed and updated by
the IPCT, ensuring that practice and guidance is current and evidenced based.
All polices can be accessed via the Intranet site. Those reviewed during the last year are as
follows.
No. Policy Author Published Date
Review Date
IC005 Infectious Patient in the Operating Theatre
ED April 2013
April 2015
IC006 Plan of the Control of Outbreaks
ED
May 2013 May 2015
IC007 MRSA Policy ED February February 2016
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2014
IC011 Collection of Infection Control Surveillance Data
ED August 2013 August 2015
IC019 Isolation Policy ED June 2013 June 2015
HS06 Prevention of Sharps Injury ED July 2013 July 2015
IC031 Viral Haemorrhagic Fever –New Policy
ED July 2013 July 2015
IC032 Influenza –New Policy
ED April 2013 April 2015
13.0 AUDIT
The Code of practice for the prevention and control of Healthcare associated infections under
the Health and Social Care Act 2008 requires that all NHS organisations have in place an
audit programme to ensure key policies and practices are being implemented appropriately.
The following table gives details of policies audited where practice and knowledge were
examined and the % compliance results obtained. No repeat audits were required.
Month Audit
Score
April 2013
TB IC 002 No Patients to audit
May 2013
Isolation Policy IC 019 96.5%
June 2013
MRSA IC 007
C diff IC 0017 Quarter 1
98% 99.5%
July 2013
Prevention of Sharps Injury HS06 92%
August 2013
Hand Decontamination IC 009 100%
September 2013
MRSA IC 007
C diff IC 0017 Quarter 2
99.7% 98.2%
October 2013 Isolation Policy IC 019 100%
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November 2013
Diarrhoea and Vomiting IC025
Hand Decontamination IC 009
No D and V patients to audit 100%
December 2013
MRSA IC 007
C diff IC 0017 Quarter 3
99.7%
97.85%
January 2014 HINI ‘Swine Flu’ IC 023
Diarrhoea and Vomiting IC025
No Influenza patients to audit
February 2014 Standard Precautions IC 022
100%
March 2014 MRSA IC 007
C diff IC 0017- Q4
99.2%
97%
13.1 Monthly Hand Hygiene Audit Compliance Scores
Effective hand hygiene is the cornerstone of good infection prevention and control practice.
Hand hygiene is audited monthly using an observational audit. The results are discussed at
the IPCC. The collated results are shown below.
Q1 Q2 Q3 Q4 Average
99.5% 100% 93.5% 90.5% 95.87%
14.0 PATIENT-LED ASSESSEMENTS OF THE CARE ENVIRONMENT –“PLACE”
The Patient-Led Assessments of the Care Environment (PLACE) programme was introduced
in 2013 as a new system for assessing the quality of the care environment.
Our assessments were carried out in June, 2013. The table below indicates where we were
against the National Average for 2013.
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Feedback and improvements to the PLACE information system have enabled the HSCIC to
further develop their system reports in preparation for the 2014 assessments. As part of our
continual improvement this information will be available for the formulation of action plans.
Our 2014 assessments were carried out in March. All results will be final as of the 7th July;
whilst the Trust will be free to use these results for internal purposes, and to share them with
our Patient Assessors, the HSCIC ask that the Trust do not release them to the media, and
refrain from making any public statements until the 2014 results have been published by
them; this is scheduled for August 27th.
Graphic below is data from 2nd April – 21st June 2013:
The PLACE 2014 assessments were carried out in March 2014.
The purpose of the PLACE assessments continues to be to assess hospitals across a range
of environmental aspects against common guidelines. The assessments focus entirely on the
care environment and do not cover clinical care provision. The teams assessed how the
environment supports patient’s privacy and dignity, food, cleanliness and general building
maintenance.
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At least 50% of those involved in undertaking assessments must meet the definition of a
patient; namely anyone whose relationship with the hospital is as a user rather than as a
provider of services.
14.1 Environmental audit
Environmental audits are carried out on a monthly basis. The audit team consists of,
Matron
Domestic supervisor
Member of the Quality Assurance Team
On a rota basis, a member of the Infection Prevention and Control Team
This audit tool records the cleanliness, according to a visual check against the NHS National
Standards of Cleanliness 49 Elements. Elements include floors, walls, beds, sinks, baths and
medical equipment. The area being assessed is defined as a functional area according to the
designated risk factor.
Environmental audits are expressed as “Cleanliness standards”, as shown below. An Audit is
required to score 95% or above to pass. Audits below this score will require an action plan
and re-audit to be carried out within a specified period.
Cleanliness standards - % of compliance to National Standards of Cleanliness Audit
Q1 Q2 Q3 Q4 Average
93.7% 92.6% 91.83% 94.2% 93%
Any areas of concern are identified to the relevant Matron, who is required to ensure that the
remedial actions needed are carried out to improve those areas.
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15.0 KEY ACTIONS / ACHIEVEMENTS IN INFECTION PREVENTION FOR 2013/14
Actions Key Points
Achieving 0 cases of MRSA bacteraemia
0 cases of MRSA compared to 2012/13 of 3
cases
Infection Prevention and Control Dashboard
Successfully up and running for over 18 months.
The Dashboard provides a system for Matrons to
upload their High Impact Intervention Scores
IPC Policy Audits Annual rolling programme of Infection Prevention
& Control audits with timely feedback to clinical
teams achieved
MRSA Screening for elective and Emergency admissions
The ICPT provided support to ensure compliance
with the target.
Facilities and Estates Successfully worked in conjunction with the Trust
Estates and Facilities Management Team to look
at building work/projects/new legislation which
require Infection Prevention & Control advice
Continued use of the Infection Prevention and Control e-learning programme for all staff
Commenced Trust wide February 2013
Mandatory bi-annual updates for Infection Prevention & Control for all staff groups
Continued to provide and support the Trust
programme at induction and Mandatory Training
sessions – update bi-annually
Policies updated as per programme All IPC Policies updated as required
New Policies produced in line with current legislation
Viral Haemorrhagic Policy published July 2013
Leaflets All IPC Leaflets updated as required
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Change from green to white paper hand towels
December 2013
Introduction of an Infection Control Alert for C diff / C diff carriers.
November 2013
Development and production of C diff Ward Round Sticker to provide highly visual documentation
June 2013
Surgical Site Surveillance The IPCT has continued to follow a rolling
programme.
IPC Link Nurse Continuing work to develop link nurse role to
enhance Infection Prevention & Control
throughout the Trust
Infection Prevention and Control MRSA and C diff Alert Sheets developed and implemented
October 2013
15.1 Hand Decontamination -Hand Towels
Hand hygiene has always been a top priority at our Trust. A busy hospital needs effective
products that perform well and that are a high quality.The Infection Prevention Matron
received feedback from wards and departments that the green paper towels were not fit for
purpose and that there was a need for a more hygienic, efficient and cost effective hand
towel solution
Our Trust recognised the need to
reduce waste and make
procurement more cost
effective. Therefore in December
2013 the Trust moved from
using green to white paper hand
towels.
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16.0 OBJECTIVES, FUUTURE DEVELOPMENTS AND WORK PLAN FOR 2014/15
The attached work programme underpins the detail of the work to be undertaken by the infection prevention and control service to:
Implement effective systems to prevent and control Health Care Acquired Infections
Continue to promote a ‘zero tolerance’ culture, and educate all staff, patients, relatives and visitors of the importance of all infection prevention and control procedures (including hand decontamination)
Identify risks in infection control and work with colleagues to provide solutions to reduce, control or eliminate those risks
Continue to undertake audits of Infection Prevention Policies and the environment. Programme to include external Trust premises
Produce new policies as required- this to include an Infestation Policy
Produce an ‘Antibiotic man’ poster for all clinical areas as an education tool
Promote, improve the reliability of and monitor the clinical infection control practices
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Continue to provide clear, concise and evidence based policies and guidelines, which are accessible to all staff group
Undertake a formal review of the Invasive Device Too (IDT). Develop and introduce section within the tool for Epidural lines
Continue to educate staff in relation to an Infection Alerts on the new Medway system
Develop and produce an Infection Prevention and Control Training record ‘passport’ for ad hoc localised infection prevention training. This will complement the corporate training needs analysis
To network with other providers through the CCG Infection Prevention and Control network meetings
Improve pan Essex communication from lessons learned from the RCA /Post Infection review process
Please see Appendix 1 for Infection Prevention and Control Programme detailing the IPCT work programme for 2014/2015
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Appendix 1 Infection Prevention and Control Programme for 2014/2015
Compliance criteria points
Programme of work 2013/14 By whom (lead) Evidence Date to be achieved
1. Systems for the prevention and control of infection. These systems use risk assessments and consider how susceptible service users are and any risks that their environment and other users pose to them.
Quarterly Infection and Prevention report to the IPCC and CCG
Matron IPC Report / Quarterly
Continue to raise the profile of the Infection Prevention and Control Team through the Trust.
Director of Infection Prevention &
Control (DIPC) and IPC Matron, ADIPC
On-going
Ensure Infection Prevention Team is represented in essential Trust Committees, such as the Health and Safety
DON / ADN /Matron IPC ADIPC
On-going
Present annual programme 2014/15 (including annual audit programme) and Annual Report 2014/15 to Board of Directors through the Quality Assurance Committee. Ensure report available to the public (Published on web site). Additional briefing to Board of Directors at least yearly.
DIPC / IPC / Matrons
Minutes / Risk register/ Web Site
August 2014
Review healthcare associated infection risks identified on the Trust Assurance Framework/Risk Register regularly (monthly ,quarterly and as required) and report to Board of Directors
IPC Matron
Minutes / Risk register
Monthly / Quarterly
Provide HCAI statistics for performance reporting at Board of Directors and at the IPCC, including details of trends
DIPC IPC Matron
Minutes Monthly
Continue to undertake root cause analysis and Post Infection Reviews for HCAI (MRSA bacteraemia, Clostridium difficile). Evidence of lessons learnt through the RCA process are shared and agreed .Evidence of actions implemented produced an action plan.
DIPC, IPCT, Ward Managers, Matrons.
Completed RCA Tools. Minutes
Quarterly
Review all outbreaks and clusters of HCAI to the Infection Control Committee.
DIPC,IPCT
Minutes. Annual report
On-going
Assess new and existing policies with regard to infection prevention and control and make recommendations for change in line with current legislation.
IPCT Update programme with review dates
On-going
Plan and deliver a full education programme for all staff.
IPCT
Programme / emails /
On-going
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Compliance criteria points
Programme of work 2013/14 By whom (lead) Evidence Date to be achieved
attendance records
Update and review the e-learning module for clinical/non clinical Develop new styles of providing education for all staff
IPCT E learning Programme / presentation
material / records of undertaking
On-going
Continue to deliver and develop quarterly Link Nurse sessions. Sessions to include RCA and PIR feedback.
IPCT Programme / presentation
material / records of attendance
Quarterly sessions during
2014/2015
Continue education and support for ward staff to undertake hand hygiene compliance. Hand hygiene compliance to be monitored in all in-patient areas monthly. Areas of non-compliance to be discussed at IPCC
IPCT Minutes On-going
High Impact Interventions Audits undertaken monthly. Provide feedback at IPCC regarding progress and recommended actions.
Matrons Graphs On-going
2. Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections.
Infection prevention participation with environmental audits and report poor compliance via the IPCC
IPCT Matrons Audit reports minutes
Bi-monthly
Continued Infection Prevention and Control input /participation with PLACE assessments.
IPCT PLACE reports and minutes
As required
Provide expert advice to all service developments to ensure infection risks are considered and good infection prevention facilities/practices built into the development. In particular, ensure that infection prevention is considered in the built environment through provision of infection prevention expertise to capital projects from concept stages to commissioning, as well as more minor refurbishment projects.
IPCT Evidence of sign off of projects
As required
3. Provide suitable accurate
Continue to produce, update and publish Public Information leaflets as required
IPCT
Update programme with review dates
On-going
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Compliance criteria points
Programme of work 2013/14 By whom (lead) Evidence Date to be achieved
information on infections to service users and their visitors.
Update and review the contents and design of the Infection Prevention and Control Web site as and when required
ICPT Web Site On-going
4. Provide suitable accurate information on infections to any person concerned with providing further support or nursing/ medical care in a timely fashion
Review and update letters as required - GP D/N in conjunction with CCG and local GP’s.
IPCT + CCG ICN Letters 1ST July 2013
Audit of Discharge Policy care transfer form to monitor compliance relating to patients infection status
Discharge team Audit Reports Quarterly
Ensure evidence required by commissioners is presented to IPCC Sharing learning across South Essex at quarterly IPC network meetings
IPCT Minutes Bi-monthly
Quarterly
5 . Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people.
Continue to participate in the Surgical Site Surveillance Schemes Team. A formal review of categories collected to be undertaken by end of Q1. Reports circulated to relevant surgeons and SSI data reported at IPCC
ADIPC +IPCT Programme of categories with collection dates.
Reports Attend training
sessions
On-going
Monitor screening emergency and elective patients data and report to IPCC and CCG Review the Department of Health Guidance in relation to MRSA screen for elective patients. Produce formal risk assessment based screening MRSA programme for elective patients Continue to develop the Infection Prevention and Control DASHBOARD Ensure that anti-biotic compliance audit is presented to the IPCC
IPCT
ADIPC
IPCT
Monthly
On-going
On-going
Quarterly
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quarterly. This audit will monitor the general usage of antibiotics in adult in- patients, and this will provide compliance with the Department of Health requirements for antimicrobial stewardship
Department of pharmacy
6. Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection.
See criterion 1 (programme of education, audit and monitoring of practice) Continue to roll out of the” Infection Prevention Training Record”. This will provide staff with an up to date record of their IPC training Share this Essex wide
IPCT Training records On-going
7.Provide or ( secures) adequate isolation facilities
Provide specialist infection prevention and control advice to new build or refurbishment projects such as bathroom facilities, isolation facilities and theatre maintenance
IPCT As required
8. Secure adequate access to laboratory support as appropriate.
Nil work issues for the IPCT
9. Have and adhere to policies, designed for the individual’s care and provider organisations,
Revise policies as per schedule or following publication of new evidence/guidelines Produce policy for the Management of the patient with an Infestation Produce a policy in relating to Air Sampling Theatres
IPCT
ADIPC
ADIPC
Ratified at IPCC and the Procedural Document Group
As required
October 2014 On-
going(almost complete)
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which will help to prevent and control infections.
Continue with audit programme of IPC policies compliance with Policies
IPCT On-going
10.Ensure, so far as is reasonably practicable, that care workers are free of and are protected from exposure to infections that can be caught at work and that all staff are suitably educated in the prevention and control of infection associated with the provision of health and social care.
Provide specialist infection prevention input to Occupational Health policies as required.
IPCT
IPCT
As required
Support the Occupational Health Service Department in the importance of staff having influenza vaccination.