annual report 2011-2012 control...episodes of cross infection. our c difficile objective/ambition...

INFECTION PREVENTION

& CONTROL

ANNUAL REPORT 2011-2012

Date Produced: June 2012 Approved by Infection Prevention & Control Committee: June 2012 Approved by Healthcare Governance Committee: July 2012 Approved by Trust Board: July 2012

Executive Director: Dr Jean O’Driscoll

Director of Infection Prevention & Control

Written and Compiled by: Niamh Whittome Lead Nurse, Infection Prevention & Control & The Infection Prevention & Control Team

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CONTENTS PAGE Page No.

Executive Summary 2

Introduction 3

Infection Prevention & Control Arrangements 3

The Infection Prevention & Control Programme 3

Surveillance 4

English National Points Prevalence Survey 7

Outbreak Reports 8

Serious Incidents 9

Hand Hygiene 9

Link Practitioner Programme 10

Decontamination 10

Patient Environment Action Teams (PEAT) 11

Infection Control Manual 11

Educational Activities 12

Audit Activity 12

Antibiotic Review Group 12

Risk Management/Clinical Governance 13

Building Projects 13

Committee/Group Membership 13

Other Activities 13

Appendices

1. C.difficile Recovery Plan 14

2. Staff „flu uptake 23

3. Infection Prevention & Control Governance Structure 24

4. Infection Control Programme 2011/2012 25

5. Infection Control Programme 2012/2013 33

6. Surveillance Data 46

7. Link Practitioner Programme 48

8. Education 49

9. Audit Reports 52

10. OH Needlestick/Sharps Review 2011/2012 74

11. Antibiotic Review Group 76

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EXECUTIVE SUMMARY This was another busy year for the Infection Prevention and Control Team. We had been given a very challenging C difficile “objective” of no more than 45 cases based on our excellent performance in 2010/11 and, unfortunately, we were not able to achieve our objective, having 64 cases by year end (58 last year against a limit of 65 cases). This was chiefly due to 3 Outbreaks at Wycombe Hospital at the start of the year which immediately took us above our trajectory and, although our performance improved as the year progressed, we never recovered sufficiently to bring us back on track. We developed a robust C difficile Recovery Plan (Appendix 1) with support from the CEO and Executive Directors which resulted in no further episodes of cross infection. Our C difficile objective/ambition for 2012/13 is the same as in 2011/12, i.e. no more than 45 cases by year end. We had a single truly BHT-attributable MRSA Bacteraemia case in April 2011. A second case was considered to be also BHT-attributable by the Department of Health, although it was detected within 48 hours of the patient‟s admission, and was investigated as a “Community” case by the PCT. We remained below our objective of 3 cases by year end. In 2012/13 our MRSA Bacteraemia objective/”ambition” is to have no more than 1 case for the year. We continued to report MSSA Bacteraemias and started to report E.coli Bacteraemias in June 2011. Only 6 of the 50 MSSA Bacteraemia cases were BHT-attributable ie detected 2 or more days after admission. No targets have yet been allocated for this measure. Of the 220 E.coli Bacteraemia cases identified during the year, only 45 were detected 3 or more days after admission. Again, no targets have been set for this indicator. The urinary tract was the main focus of these bloodstream infections (143) cases, with 37 being associated with the use of urinary catheters. A focus on reducing catheter-associated UTIs is planned for 2012/13. Norovirus circulated in the local community for much of the year and our hospitals experienced many outbreaks, resulting in ward closures and service disruption. We have written a new Norovirus Guideline and will have a “Norovirus focus month” (August) when we will use a multi-pronged approach in an attempt to minimise the impact of further outbreaks. For the second consecutive year our infection rate following hip and knee prosthetic surgery was below the UK average. BHT participated in the UK-wide Point Prevalence Study of Healthcare-Associated Infections and Antibiotic Use in November 2011. Our infection rate of 4.6% was below the UK average rate of 6.4% and our use of antibiotics was less than the average usage in UK Trusts, both of which point to the Trust being a better-performing Trust regarding healthcare-associated infections. We were spared cases of influenza this year and the uptake of the vaccine amongst staff improved due to concerted efforts by the Occupational Health Department. (Appendix 2) Audits of Infection Prevention and Control practices continued according to the Audit Programme. There were particularly impressive numbers of observations in the monthly Hand Hygiene audits totalling 223,953 for the year, with an overall compliance of 98%. By ensuring good practices are ingrained in everyday working life we will keep patient safety top of everyone‟s agenda. Dr Jean O’Driscoll Director of Infection Prevention & Control Buckinghamshire Hospitals NHS Trust

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INTRODUCTION The following report outlines the department‟s activities over the past 12 months. Commitment to preventing the spread of infection is essential from all staff in all departments and at all levels of management in order to maintain a high standard of infection prevention & control practice throughout the Trust.

Staff Changes We welcomed Martine Cabral & Joanne Law to the team in July & November. The IPCT is now fully established. FY1 & FY2 Doctors worked within Microbiology at Stoke Mandeville and undertook some Infection Prevention & Control audits. We also benefited from Registrars (ST3) on Oxford Rotations.

INFECTION PREVENTION & CONTROL ARRANGEMENTS The Trust serves a population of approximately 725,000 people with inpatient beds at Stoke Mandeville, Wycombe, Amersham, Marlow, Thame and Buckingham Hospitals. Dr O‟Driscoll has continued in her role as Director of Infection Prevention & Control and the infection prevention & control governance arrangements for the Trust are described in Appendix 3. The IPCT currently consists of the following staff:

Dr Jean O‟Driscoll – DIPC Jackie Dalton – IPCN

Dr Kathy Cann – Consultant Microbiologist Sharon Nyadzo – IPCN

Dr Ruby Devi – Consultant Microbiologist Joanne Law-IPCN

Dr David Waghorn – Consultant Microbiologist Martine Cabral-IPCN

Niamh Whittome- Lead Nurse IPC Karen McIntosh – Secretary

Amanda Adkins - IPCN Karleen Mulder – Secretary

Lisa Andrews – IPCN Lorraine Shaw - Secretary

THE INFECTION PREVENTION & CONTROL PROGRAMME Appendix 4 shows the Infection Prevention & Control programme for the year 2011-2012. The Programme clearly defines the priorities for the Trust in relation to infection prevention & control activities as agreed by the Trust Infection Prevention & Control Committee which monitors the progress of this programme. Appendix 5 outlines the programme for 2012-2013.

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SURVEILLANCE (Mandatory & Voluntary) Clear case definitions for in- house surveillance have been developed and applied to data reported in this report. These can be found in Appendix 6.

Clostridium difficile (Mandatory Surveillance) We continue to participate in the mandatory reporting of Clostridium difficile infection. Table below shows our Clostridium difficile figures for the year. Our limit for the year was 45. Our year end numbers were 64 (provisional data; to be confirmed in July).

BHT C difficile Trajectory 2011-12

0

10

20

30

40

50

60

70

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

cumulative limit

cumulative actual

Tabled below are our reported cases from April 2011- March 2012 using the in house definitions in appendix 6:

Acquisition 2-64 years 65 + years

Total cases

W&A SMH CIC W&A SMH CIC

BHT acquired 2 5 0 33 19 5 64

BHT associated 2 8 0 2 6 1 19

Community *(a) 2 2 0 3 9 0 16

(b) 0 0 0 2 2 0 4

(c) 0 0 0 0 0 0 0

(d) 0 0 0 2 1 0 3

N/A cases i.e relapses 1 0 0 5 1 0 7

Meticillin Resistant Staphylococcus Aureus (MRSA) Non-bacteraemias (Voluntary Surveillance) The number of Buckinghamshire Healthcare NHS Trust (acquired and associated) non bacteraemia MRSA cases, detected by the laboratories from April 2011 to March 2012 are displayed in the table below:

SMH W&A CIC Total

BHT Acquired Cat 1 30 19 3 52

BHT Associated Cat 2 20 19 2 41

Total MRSA non-bacteraemia 50 38 5 93

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Meticillin Resistant Staphylococcus Aureus (MRSA) Bacteraemias (Mandatory Surveillance) Mandatory reporting of MRSA bacteraemias continues. Two cases were attributed to the Trust (although one case was detected within the first 48 hours of the patient‟s admission) which was below the limit of 3 cases. All MRSA bacteraemias have a Root Cause Analysis (RCA) undertaken. Learning points from these are shared through the Infection Prevention & Control Committee meeting and discussed at Divisional governance meetings.

MRSA Bacteraemia Cumulative Trajectory

2011/12

0

1

2

3

4

Apr-

11

May-

11

Jun-

11

Jul-11 Aug-

11

Sep-

11

Oct-

11

Nov-

11

Dec-

11

Jan-

12

Feb-

12

Mar-

12

Cumulative limit

Actual

Limit: maximum of 3 cases at year end (Baseline: 03/04: 47 cases)

MSSA Bacteraemias (Mandatory Surveillance) MSSA Bacteraemias detected April 2011 to March 2012

SMH W&A Total

Total Numbers 31 19 50

BHT attributed 4 2 6

Glycopeptide Resistant Enterococci Bacteraemia (Mandatory Surveillance) The Trust laboratory detected 3 new cases of VRE Bacteraemias.

Extended Spectrum Beta Lactamase Producing Organisms (ESBLs) (Voluntary Surveillance) ESBL producing organisms (including strains of E. coli and Klebsiella sp.) confer resistance to a wide range of beta lactam antibiotics. They may also be resistant to other classes of antibiotics. Treatment options are therefore limited and prompt infection control precautions are required when ESBL isolates are detected The Trust laboratory has identified 347 new isolates in urine specimens from April 2011 – March 2012. Of these 226 were specimens received from General Practitioners (195 in 2010/11 and153 in 2009/10). 118 were from the acute Trust (78 in 2010/11 and 90 in 2009/10).

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E.coli Bacteraemias (Mandatory Surveillance started June 2011)

SMH WGH TOTAL

Total numbers 122 97 220

Cases detected after 72 hrs of admission 19 26 45

Most likely primary focus: Urinary tract

Gastrointestinal Hepatobiliary

Skin/soft tissue Other/Unknown

83 60 143

8 6 14

15 14 29

3 0 3

11 19 30

Urosepsis associated with urinary catheter 21 16 37

Likely or possible HCAI? 17 16 33

Multi Resistant Acinetobacter Baumannii (MRAB) (Voluntary Surveillance) MRAB is a bacterium that is found commonly in the environment. Approximately 25% of people may carry Acinetobacter on their skin or in their bowels asymptomatically. The Trust laboratory identified 6 new isolates of MRAB 2011/12 (23 in 2010/11).

Delay in Isolation of Infected/Potentially Infected Patients (Voluntary Surveillance) Delayed Isolation data has continued to be collected per patient bed day, and permits an ongoing audit of the Trust‟s Isolation Policy. This information however relies on data obtained via a variety of means (e.g. bed management team, IPCT, ward staff) and therefore reflects a trend, not necessarily accurate information. This information is now part of the Capacity Governance Report which is reported monthly to the Risk Monitoring Group and Nursing, Midwifery & Therapy Board to enable the Trust to identify risks associated with delayed isolation of patients.

Orthopaedic Surgical Site Surveillance (Mandatory Surveillance) Since its formation in 2003, BHT has taken part in the national Surgical Site Infection Surveillance (SSIS) organised by the Health Protection Agency (HPA). The programme was established to encourage hospitals to use surveillance to improve the quality of patient care by enabling them to collect and analyse data on surgical site infections (SSI) using standardised methods. With Trusts feeding their data into a central agency i.e. the HPA, it has allowed individual hospitals to compare their rates of SSI with collective data from all hospitals participating in the service. There are 12 defined categories of surgical procedures within the national SSIS programme, but orthopaedic SSIS has been mandatory for all Trusts to perform since 2004/05. The figures are presented separately for Wycombe & Amersham (W&A) and SMH because they are analysed and reported separately by the Centre for Infection in Colindale. The figures below include all infections (in-patients, readmissions and post discharge)

Total number of procedures April 11 – March 12 (W&A sites):

Totals Infections (W&A) National Infection Rate

Hip replacements 364 2 (0.5%) 1.1%

Knee replacements 429 4(0.9%) 1.4%

Total number of procedures July 11 – Sept 11

Totals Infections (SMH) National Infection Rate

Repair of neck of femur 77 4(5.1%) 1.9%

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ENGLISH NATIONAL POINT PREVALENCE SURVEY - on Healthcare-associated infections and antimicrobial use BHT participated in the fourth National Point Prevalence Survey (PPS) on healthcare-associated infection (HCAI) and the first National PPS on antimicrobial use (AMU) in England coordinated by the Health Protection Agency. The aim of the PPS was to determine the burden of HCAI and AMU in acute hospitals and to use the results to identify priority areas for the future. The PPS data collection took place between September and November. Data was analysed from 103 organisations and surveyed 52,442 eligible patients. The overall prevalence of HCAI was 6.4% (a total of 3,360 patients). BHT‟s overall prevalence was 4.6%. See pie chart for distribution of healthcare-associated infection sites

The overall prevalence of AMU was 34.7%. AMU were most frequently prescribed for community acquired infections (53%) and the most common antimicrobials prescribed were combinations of beta-lactam antibiotics and enzyme inhibitors. BHTs overall prevalence was 31.5% (lower than the national average).

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See below table for indication for patient and antimicrobial use.

N % of total (95% CI) N AM Rel %

Total 152 31.5% (27.3 - 35.8) 216 100.00%

Indication for antimicrobial use

Treatment intention 119 24.6% (20.9 - 28.7) 171 79.20%

Community infection (CI) 95 19.7% (16.2 - 23.5) 137 63.40%

Hospital infection (HI) 23 4.8% (3.0 - 7.1) 32 14.80%

Other healthcare-ass. infection (LI) 1 0.2% (0.0 - 1.1) 2 0.90%

Surgical prophylaxis 12 2.5% (1.3 - 4.3) 16 7.40%

Single dose (S1) 2 0.4% (0.1 - 1.5) 3 1.40%

One day (S2) 2 0.4% (0.1 - 1.5) 2 0.90%

>1 day (S3) 8 1.7% (0.7 - 3.2) 11 5.10%

Medical prophylaxis 13 2.7% (1.4 - 4.6) 16 7.40%

Unknown 1 0.2% (0.0 - 1.1) 1 0.50%

Route of administration

Parenteral 95 19.7% (16.2 - 23.5) 126 58.30%

Oral 79 16.4% (13.2 - 20.0) 90 41.70%

Other/unknown 0 0.0% (0.0 - 0.8) 0 0.00%

Reason in notes

Yes 143 29.6% (25.6 - 33.9) 204 94.40%

No 9 1.9% (0.9 - 3.5) 12 5.60%

Unknown 0 0.0% (0.0 - 0.8) 0 0.00%

The results of the PPS will help the IPCT and antimicrobial pharmacist target interventions for our infection prevention and control programme. It will help

Identify high risk areas

Identify priorities for local surveillance

Identify where IPC policies may need to be modified

Identify where staff may need education & training

Antimicrobial stewardship

OUTBREAK REPORTS A total of 26 outbreaks of confirmed norovirus occurred between April 2011 - March 2012. A further 30 were unconfirmed but resulted in ward or bay closures. (For April 2010 – March 2011 the Trust had reported 14 confirmed outbreaks of norovirus)

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SERIOUS INCIDENTS 8 Serious incidents were reported between April 2011-March 2012 including 6 outbreaks. All incidents were reviewed at Trust-wide monthly Serious Incident meeting chaired by the CEO and reported to NHS Buckinghamshire and the local Health Protection Unit. Root cause analysis of each incident was undertaken and learning shared across the Divisions. Incident Reports were drawn up which included Action Plans. Ongoing checks that recommended actions have taken place are made at Divisional Governance meetings and at Infection Prevention & Control Committee meetings.

HAND HYGIENE The Trust‟s Hand Hygiene campaign continued throughout 2011-2012. The Trust has continued to work with the National Patient Safety Agency (NPSA) as part of the national hand hygiene campaign and has utilised all resources made available by the NPSA to assist the local hand hygiene strategy. The hand hygiene strategy has continued to evolve as a result of local need and identified risks following incidents/audits. The Trust also signed up for the World Health Organisation (WHO) Global hand hygiene challenge. The following has been achieved during 2011-2012:

Audit of hand hygiene continued as per the annual audit programme. Assessment of „Bare Below the Elbows‟ compliance was included within the hand hygiene audit tool. The focus of the audit tool was around the WHO 5 moments as part of the national „clean your hands Campaign‟. A central hand hygiene drive continues to be the central drive for inputting the monthly hand hygiene observational audit results. Dissemination of the results to all staff groups and wards/departments was undertaken with Infection Prevention & Control Leads and Modern Matrons taking responsibility within their areas for local improvement. Areas with results below the compliance level of 90% must complete weekly audits until the compliance level is achieved (see appendix 9). Areas must produce an action plan to the address areas of low compliance or non participation. The results are also discussed at divisional board meetings. These audits will continue as per the new audit programme for 2012-2013.

The academic component of mandatory hand hygiene is now provided by an e learning module. Hand hygiene practical sessions are organised monthly via the training department. The sessions are face to face and run by the IPCT and the hand hygiene practical and competency assessment is completed. These are now well established within the mandatory training programme, annually for patient facing staff and bi-annually for non patient facing staff. It is also included within the Trust Induction training for all new starters. Training for other groups e.g. University of Bedford students has also continued.

Infection control Link Practitioners have been trained to carry out the practical element of the hand hygiene training to help capture more staff within their areas.

A section on hand hygiene was included in the Infection Control Knowledge Survey.

The Trust was involved in the WHO Global Hand Hygiene Day 05/05/2011 which was aimed at children. Activities included assessing hand hygiene compliance with the light boxes, hand printing and the distribution of a poster for children to colour in.

Infection Prevention & Control week (17/10/2011): The focus was around the changes and intervention of Infection control over the last 25 years. Information boards were placed at the larger hospital sites and packs set to the community areas. The boards were manned by an IPCN to answer any questions. The IPCN also visited wards to focus on education and hand hygiene practice. Photographs were taken and displayed on IPC notice boards and in the IC Times.

Infection Prevention & Control week (17/10/2011) a competition was held for staff to design a poster to promote patient hand hygiene. The poster was then printed by the company for which we use their hand hygiene wipes. The poster has been distributed to wards.

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IPCT and communications produced and re-launched a video highlighting the process of hand hygiene and which products are appropriate during outbreaks. This was placed on the Trusts Internet site which linked to you tube, and is also being played at the main entrances to the Trust.

LINK PRACTITONER PROGRAMME The ICLP year has continued to be well supported by a dedicated group of staff, mainly trained nurses and midwives, including some healthcare assistants. A growing number of colleagues from the Community have been attending also. Key individuals from within the Trust have continued their support by giving presentations to the group which have been well evaluated. A broad spectrum of topics has been covered during the year including auditing, emergency planning and side room management. Please see appendix 7 for a copy of the study day programmes. Numerous „outbreaks‟ occurred during the year and these were fed back to the ICLPs so that lessons learnt from the outbreaks could be shared with as many colleagues across the Trust as possible. These outbreaks included Clostridium difficile, Norovirus, Pseudomonas and Extended Beta Lactamase ( ESBL). A session on the comparison of the lessons learnt between a Multi Resistant Acinetobacter baumanii (MRAB) and an ESBL outbreak indicated that lessons learnt from these outbreaks indicate Staffing levels, Hand Hygiene compliance and environmental management continue to be key issues. Surveillance highlights early detection, and prompt correction which can improve clinical outcomes and help ensure correct antimicrobial therapy. The overall aim of all the teaching on the ICLP study days is to embrace Infection Prevention & Control principles and to engage staff in a thought provoking way to tackle some of the difficulties we face in our day to day workplace. The group encourages networking and sharing of experiences. The ICLPs continue to achieve a great deal of work around the auditing process. The monthly Hand Hygiene audits continue to be completed well as is the yearly IPC audit programme which in turn gives rise to a number of reports that are then fed back to Trust members. The vision for the ICLPs is to continue to grow in numbers and attendances on the study days, so that information can continue to be fed back to a large number of staff within the trust. This is particularly important for learning from the outbreaks and incidents as they occur in real time.

DECONTAMINATION The Trust continues to work towards the provision of a single site CSSD facility. It will be designed to service all of BHT's activity and current contract provisions and is expected that the new unit will come on line during the next financial year. Members of the IPCT attend the Trust‟s Decontamination Committee meetings which are Chaired by the Director of Property Services.

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PATIENT ENVIRONMENT ACTION TEAMS (PEAT) The IPCT were involved in the annual PEAT inspections in February 2011 and January 2012. The final report for 2012 has not yet been received. The following results were taken from https://report.npsa.nhs.uk/PEAT/Results/Trust/?id=10304 the National Patient Safety Agency website.

Year Sites Results

Environment Food Privacy & Dignity

2011 Amersham Good Excellent Good

Stoke Mandeville Good Excellent Good

Wycombe Good Excellent Good

Buckingham Good Excellent Excellent

Thame Good Excellent Good

Marlow Good Excellent Good


Stoke Mandeville Acceptable Excellent Excellent

Wycombe Good Excellent Excellent

Waterside Unit Good Good Good


Stoke Mandeville Acceptable Good Good

Wycombe Acceptable Excellent Acceptable

INFECTION CONTROL MANUAL The infection control manual continues to be updated and new sections added as required and in accordance with the 5 year updating plan. The following sections were updated in 2011-12.

Updated Infection Control Manual Sections

1.5 CJD

1.9 Lice

1.11 MRSA

1.13 Management of Newly Emerging Pathogens

1.14 Scabies

1.17 Guidelines for Seasonal and Pandemic Influenza

2.10 Last Offices

2.1 Hand Hygiene Policy

2.8 Enteral Feeding

3.1 Outbreak of Infections

3.2 Domestic Services

3.5 Sharps

3.6 Isolation Policy

3.7.1 Isolation Procedures – Source

3.8 Laundry

3.9 Pest Control

3.12 Spillages of Organic Material and Clinical Waste

4 Decontamination Policy

5.1 Dental & Oral Surgery

All sections of the manual were also uploaded onto the Trust intranet in addition to being distributed to be included in hard copies of the manual located in clinical areas.

https://report.npsa.nhs.uk/PEAT/Results/Trust/?id=10304

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EDUCATIONAL ACTIVITIES In April the IPCT and training department launched an IPC e-learning module for staff. Separate modules have been developed for non-clinical & clinical staff. Hand Hygiene practical face to face sessions are delivered monthly on set dates organised by the training department. These are one hour long sessions. Hand hygiene competency is then assessed. We continue to deliver face to face Induction training for all new Trust staff. See appendix 8 for more detailed information regarding further education sessions

AUDIT ACTIVITY The audit programme for the year can be found in the Infection Prevention & Control Annual Programme see Appendix 5. The following audits were undertaken:

Ward/Department Environmental Audits

Patient equipment audits

Ward kitchen audits

High Impact Intervention (HII) Urinary Catheter Care audit

HII Care Bundle for ventilated patients.

HII Peripheral Line audit

HII Surgical Site Infection audit

HII Central Line Venous Catheter Formal reports provided by Care Ongoing Management Clinical Audit & Effectiveness

Hand hygiene observational audits Department

Hand Hygiene Practice & Facilities audit

Sharps Management

Infection Control Knowledge Survey

Isolation Policy Audit

MRSA and Clostridium difficile policy audits

MRSA Sticker Audit

Outbreak Policy Audit

Patient Passport Audit

Personal Protective Equipment

Transfer Form audit

Needlestick Injuries audit All formal reports are disseminated to relevant wards, departments, committees to highlight key findings and recommendations for their action. See appendix 9.

ANTIBIOTIC REVIEW GROUP The group has continued to meet throughout the year. A report of activity can be found in Appendix 11.

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RISK MANAGEMENT/CLINICAL GOVERNANCE Dr O‟Driscoll has represented Infection Prevention & Control at the Risk Monitoring Group (formerly Clinical Risk Review Panel) and is responsible for producing the Infection Prevention & Control Clinical Governance reports. Dr O‟Driscoll is also a member of the Healthcare Governance Committee and attends Trust Board meetings. She provided Infection Prevention & Control reports to each Board and has direct access to and monthly meetings with the Chief Executive.

BUILDING PROJECTS Upgrade works at Buckingham Community Hospital Thame Community hospital upgrade Upgrade works at Chalfont‟s and Gerrards cross Hospital NSIC Reception & Salon, St Joseph‟s bathrooms. SMH A&E reconfiguration WH W8/9 Stroke Reconfiguration WH Microbiology-Pathology Reconfiguration Winslow Health Centre 5B upgrade works WH Rayners Hedge

COMMITTEE/GROUP MEMBERSHIP Infection Prevention & Control Committee Trust wide Infection Prevention & Control Group Health and Safety at Work Committee Quality Standards Committee Risk Monitoring Group (formerly Clinical Risk Review Panel) Medical Devices Committee Medical Equipment Purchasing Committee Nursing Midwifery & Therapy Board Ward Team Leader Meetings Senior Practitioner Forum The Domestic Services Review Group (SMH & W&A) County Environmental Health Committee Regional Professional Development Group (microbiologists) Decontamination Committee Buckinghamshire PCT Infection Prevention & Control Committee. Healthcare Governance Committee Critical Care Delivery Group Orthopaedic Infection Group SDU governance Meetings Divisional Board Meetings Tissue Viability

OTHER ACTIVITIES

Infection Control Times The Infection Control Times newsletter has continued to be distributed monthly.

Infection Prevention & Control Notice Boards Updated as necessary in response to global and national events i.e. WHO Global Hand Washing.

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Appendix 1 BHT recovery plan to minimise numbers of C difficile cases at Wycombe Hospital

Issues Actions required Lead Due by Update

Cleaning:

Annual deep cleans were stopped last year. The Government invested in the deep clean programmes initially to help Trusts achieve a starting point from which they could reassess their ongoing cleaning requirements.

To be reinstated on the Wycombe site and to prioritise wards for early clean

IG/NW 30/9/11 2/9 Wendy Martin & Estates working up a programme for starting the deep cleans. 9/9 Programme to start with Ward 9 next week. 20/9 Ward 9 has been deep cleaned. A programme for the other wards is in place.

C diff spores may be persisting in the environment.

Hydrogen peroxide is to be introduced to maximise cleaning.

JOD/IG 30/9/11 2/9 JOD has met with 2 companies. Heatherwood &Wexham Park to be visited to see how it is used there. 9/9 To be used on Ward 9 and 6B. 20/9 Used on Ward 9. 21/10 Used on Ward 6B

Assurance monitoring of cleaning performance by Contractor needs to be increased

Trust monitoring to be reiterated to Site Managers. Maximisers to be used.

IG Immediate 9/7 Spot checks only being done. 9/12 IG is assured that monitoring is adequate. Ward Managers need to report any deficiencies in ward cleaning to the Help Desks.

Cleaning schedules are not in place on all wards.

Cleaning schedules to be reissued to all wards. Wards to be clear as to their content.

WM 10/8/11 2/9 WM has assured us these have been sent to all wards. 9/9

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Cleaning:

English is not always understood or spoken by some Medirest staff when questioned about cleaning requirements.

Medirest to provide assurance that an appropriate level of English is spoken and understood by its staff.

IG 1/10/11 9/9 Medirest working on this. 20/9 Medirest had an external independent assessor in on 19/9. All staff who have English as a second language were assessed. All staff were above level 1 in competency and quite a few above level 2. A course of English lessons has been booked for this staff group. 15/11 The understanding of relevant phrases from the Infection Control Manual is being assessed.

Some wards are not storing items properly and off the floor which impacts on cleaning by Domestic staff.

Storage to be improved by looking at possible storage areas on the wards, eg removing unused bathroom.

IG/LS To start in September.

Ward staff to request collection of items immediately if no longer required or broken.

Immediate. 2/9 In place.

Rubbish amnesty. One day to be identified for wards to get rid of unused items.

LS 30/9/11 9/9 To be linked to Deep Clean.

Ward staff need to be reminded of their responsibilities for decontamination of patient equipment. Some staff have been unclear about this when questioned.

A-Z of Decontamination to be reissued quarterly to all ward managers. They are to read it and sign it and return a sheet to say it has been read.

NW 30/9/11 Revised date set by LS at IPCC on 9/12 of January 31st

19/8 A-Z cleaning inventory reissued to all ward managers. Posters updated and being delivered to all wards once laminated. 9/9 Posters being sent out/hand delivered Highlighted in IPC Times for areas to contact IPCT if they have not yet received theirs. 20/9 Few areas have returned the signed sheet to date. 24/10 10/90 have returned signed sheet. 02/12 29/90 returned. 5/2/12 70 of 90 returned. 27/3/12: 83 of 90 returned.

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Cleaning:

“Enhanced” cleans are not always done to the required standard.

These need to be visually checked by the nursing staff before being signed off.

LS Immediate 9/9 In place.

Matrons Rounds are not always being conducted formally.

Weekly rounds are required to include a record of ward cleanliness.

LS 1/9/11 10/8. New template to be agreed on 12/8. 9/9 Still to be agreed. Debbie Blease leading on this. 20/9 Template agreed at NMTPB 19/9. 24/10 Being piloted. To be rolled out in November. 15/11 Has been rolled out. LS is assured that these are in place.

Infection Control Nurses are not regularly meeting with Matrons consistently to review cleanliness due to operational pressures.

Regular recorded meetings are to take place to include reviews of ward cleanliness.

NW 1/9/11 2/9 IPCNs for each division making contact with matrons. IPC observation form devised for use during the ward visits. 9/9 Programme in place.

ATP monitoring by IPCT to be expanded.

An additional 5 monitors to be purchased. Funding to be identified

NW/IG 1/9/11 2/9 Price list obtained from 3M, to go to IG for purchasing. 9/9 To be sent to IG again. 20/9 5 additional monitors have been ordered. 08/12 Monitors received, NW drawing up programme for implementation

Domestic Services Review Group not meeting regularly on the WH site.

This Group is to be reinstated. AW 30/9/11 2/9 AW has asked for the meeting to be restarted. Dates to be confirmed 20/9 First meeting to take place in October. 24/10 First meeting to take place 27th Oct. 15/11 First meeting was unquorate. A Trust-Wide meeting is to be set up. 2/12 WH DSR to be reconvened 15/12.

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Operational Changes:

Impact on infection control of provision of new service, movement of an existing service, provision of escalation to a new area or by increasing beds on a currently open ward, not always considered.

Formal risk assessment of any changes to be undertaken.

BP/IPCT Immediate 2/9 Jane McVea leading on this for the PCT. 17/11 Meeting with Sandra Cotter to discuss further. Template to be developed. 5/2/12 Template has been developed.

Estates:

Cracked surfaces impede cleaning and will allow microbes/dirt to settle.

All surfaces, fittings and fixtures should be smooth and designed for easy cleaning. Deficiencies are to be replaced or repaired.

IG On-going 10/8 Already started. 9/9 To start with Wards 9 and 8. 23/9: Dedicated Building Manager is developing a 10-year plan.

Clinical hand wash basins across most wards within the tower block and ward 9 do not comply with HBN 00:10. Hand wash basins are in place with oval or square basins. HBN handwash basins recommend an integral back outlet basin with no plug.

To be installed. Replacement basins will comply with HBN 00-10. Parts of ward 9 WH works include replacing all handwash basins to comply with HBN 00-10.

IG 1/9/11 Handwash basins are risk assessed and any damaged basins reported to estates for replacement. 9/9 Ongoing. 23/9: Due to finish 5th October. 24/10 HWBs have been installed at entrances to wards 6B, 3B and 5B.

Unused bathrooms. On a number of wards storage space is a problem and all available space is used. This can include bathrooms being used to store equipment such as mattresses, drip stands & trolleys.

A review of space should be undertaken with ward managers to identify that rooms are being used correctly and the potential to change the room‟s usage. Funding to be sourced.

IG 1/10/11 9/9 Ongoing. 23/9: WM is reviewing all wards daily on a two-week roster, averaging 2 wards/ epts. per day.

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Estates:

Insufficient numbers of side-rooms. Provision of partitions/temporary closure systems to be investigated.

NW/IG 30/9/11 Discussed at the winter planning meeting 25/8. options to be explored further by IPCT & Estates. 9/9 Plastic dividers being looked at. 1) 24/10 Plastic dividers could be used at times of Norovirus outbreaks; Trust can contact company at the time. 2) ↑ Side-rooms due to reopening of 4A/4B as MAU/Short Stay Ward. 15/11 Active management of side-rooms to be checked. 2/12:To be highlighted again in December‟s Infection Control Times.

Nursing Staff: Levels

Skill mix per shift is not always adequate.

Review of balance of permanent and temporary staff per dependence and acuity.

LS 1/9/11 9/9 Ongoing. 3B to have increased levels of staff. 17/11 LS feels is satisfactory.

Leadership (Nursing Staff):

Insufficient support for nurses acting up into ward manager roles has been identified as a problem with leadership on some wards

A formal process is to be documented. LS 31/8/11 25/8 The ADN group are working with HR to agree a formal and consistent approach/policy to this which will be signed off by the Nursing Midwifery and Therapy Board. 9/9 Still to be signed off. 20/9 This has been signed off.

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Temporary/Bank Nursing Staff:

Sometimes temporary/bank staff don‟t follow Trusts standards.

Agencies know what is expected. Complaints need to be directed to them.

SH 1/9/11 1/9 Being monitored.

NHS-P staff should go where there is a need and not where they want to go.

SH On going 10/8. This is being monitored.

Bed Management:

Too many patient moves between and within wards occur.

Three or more moves to be reported as an Incident. Capacity Governance report to give more details about moves, i.e. numbers of moves per patient.

BP 1/9/11 9/9 No evidence that this is happening. 20/9 Being monitored and to be reported in September‟s Capacity Governance Report. Still no incidents being reported. 18/10 Reported in September‟s Report. Still no incidents being reported. 16/11 Patient moves appear to have decreased.

C difficile patients are being moved. They are not to be moved. BP 10/8/11 9/9

Due to capacity pressures on ward staff to accept patients quickly, bed space cleaning is not being done effectively.

A reasonable time for thorough cleaning must be allowed between discharges and transfers.

BP 10/8/11 9/9

Information on infection status of patients is not always handed over on transfer. The Infection control transfer form is rarely used

Transfer form to be used on all patients between wards and discharge to other healthcare facilities, including patients with any diarrhoeal illness.

LS Immediate 9/9 Ongoing. 20/9 Documentation working group devising a Transfer form to be used on all adult patient moves into, within and out of the Trust (Alison Fabre leading this group; due to be finalised by mid-October) NW has commented on the form to ensure infection prevention information recorded. 24/10 Transfer form and Policy revised. 15/11 Due to be reaudited in Jan-Feb 2012.

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Isolation of patients:

Sometimes patients are not being isolated quickly enough.

Incident reports to be completed on each occasion.

LS 10/8/11 9/9 Ongoing.

C diff+ patients should ideally remain in a side-room for their entire admission as much as possible.

NW 10/8/11 9/9 Ongoing.

GDH+ patients must be managed the same as CDT+ patients, as they may start producing toxin.

IPCT 10/8/11 9/9 Revised Guidance to be issued. 20/9 Deisolation posters now laminated and being issued via internal mail along with memo explaining the change. Poster updated on intranet site.

Detection of diarrhoea:

Bowel movements are not being documented adequately on initial assessment/admission of patients.

Bristol Stool Charts should be used for all patients with altered bowel movements throughout their admission.

LS 10/8/11 9/9 In place.

Hand Hygiene:

Doctors are not always aware of when soap and water should be used for hand hygiene rather than alcohol gel.

Doctors to be reminded of this. GL 1/9/11 12/8 Memo sent to SDU Leads including advice on minimising C. diff risks. 2/9 Memo sent to all doctors about the use of soap and water.

Hand hygiene audits are completed monthly and incorporate a variety of staff groups. Observation numbers can be low in some groups relating to specific tasks. There is an „others‟ group which incorporates a variety of staff groups such as Pharmacists and Social Workers. These can be difficult to identify later on.

Increase the numbers of observations. The current tool suggests 20 observations per staff group over a one month period. Individual groups must be identified at the time of auditing.

IPCT 1/9/11 1/9 Tool to be amended to allow mention of specific groups. Wards to be advised to keep a record of any groups not complying so that any trends can be identified. 9/9 Ongoing. 20/9 Tool amended. Changes to be highlighted.

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Hand Hygiene:

Patients are not always assisted with their hand hygiene especially before meals.

Ward staff to provide assistance. LS Immediate 9/9 Audit results to be circulated. 20/9 Summary of results highlighted in September IPC times Full report to be disseminated to all wards by 30/9 Re-audit November 2011 15/10 Highlighted to Global Hand Washing Day

Antibiotic Use:

Prolonged courses of antibiotics pose a risk to development of C diff infection.

Daily review of drug charts. New drug charts to be introduced.

JOD 1/9/11 9/9 New drug charts to be issued early October. 3/10 New drug charts released

Proton Pump Inhibitor use:

Overuse. Guideline to be issued. JOD 10/9/11 9/9 Has gone to Clinical Guidelines subgroup for approval. 20/9 Approved subject to a few minor amendments. 5/10 Uploaded to Intranet

Laxative Use:

Overuse. Guideline to be developed. VA 1/10/11 2/9 Guideline being written. 9/9 Draft Guideline has been written and sent to Gastroenterologist. 2/12. Brief guidance to be issued to Ward Managers and Link Practitioners. 2/12 Sent to all ward mangers 7/12 Highlighted at ICLP day

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Mattress checking:

Mattresses are not being checked regularly.

Rolling programme of checking to be developed.

LS 1/9/11 2/9 Guidance to be reissued. 9/9 To go on September‟s Infection Control Times 14/9 Mattress maintenance procedure reissued to all ward managers and advised that a documented system must be in place to undertake mattress checking. 11/10 Infection Control Nurses to check with Matrons that mattress checking is in place.

See key to Lead Name initials overleaf

JOD Dr Jean O‟Driscoll Director of Infection Prevention & Control BP

Bob Peet Director of Operations

IG Ian Garlington Director of Property Services VA Vaneeta Anand

Lead Pharmacist for Medicine

LS Lynne Swiatczak Chief Nurse & Director of Patient Care WM Wendy Martin Head of Facilities, Property Services Dept

GL

Dr Graz Luzzi Medical Director NW Niamh Whittome

Matron, Infection Prevention & Control

SH

Sandra Hatton Director of Human Resources IPCT Infection Prevention & Control Team

AW Anne Walker Associate Director of Nursing

Dr Jean O’Driscoll Director of Infection Prevention & Control Buckinghamshire Healthcare NHS Trust 8th August 2011 Reviewed 1st September 2011

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Appendix 2 Staff flu uptake at month ending 31st March 2012

BHT uptake of flu vaccine

target = 50%of staff

2897

2306

0

500

1000

1500

2000

2500

3000

3500

Target Current total

Nu

mb

er

BHT staff influenza vaccine uptake - by staff

group

0

10

20

30

40

50

60

Doctor Nurse AHP Cin.Supp. A&C total

Perc

en

tag

e

BHT staff influenza vaccine uptake - by division

0

10

20

30

40

50

60

CIC Medicine Surgery W&C Spinal &

support

Corporate

Perc

en

tag

e

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Appendix 3

INFECTION CONTROL GOVERNANCE STRUCTURE

Chief Executive and Trust Board

Governance Committee

Infection Control Committee

Infection Control Leads Group

SDU Governance Groups

Link Practitioners Wards/Departments

Risk Monitoring Group

Trust wide Infection Control Meeting

Director of Infection Prevention and

Control

Infection Prevention & Control Team

Dr J O‟Driscoll Director of Infection Prevention and Control May 2012.

Modern Matrons SDU Infection Control Leads

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Appendix 4

INFECTION PREVENTION AND CONTROL PROGRAMME 2011/2012

1. Summary:

The Infection Prevention and Control Annual Programme will clearly define the priorities for the Trust in relation to infection prevention and control activities as agreed by the Trust Infection Prevention and Control Committee (IPCC) which will also monitor the progress.

2. Aim of the Buckinghamshire Hospitals NHS Trust Infection Prevention and Control Programme

To reduce preventable healthcare-associated infections within the activity of BH NHS Trust by a process of:

Surveillance / Reporting Promotional Campaigns

Development, review and implementation of Infection Control Policies.

Response to local / regional / national initiatives

Education / Training for clinical and support staff Research

Audit of infection prevention and control practice Compliance with the Code of Practice for Prevention and Control of Healthcare Associated Infections.

Implementation of Saving Lives High Impact Interventions.

Maintenance of the expertise of Infection Control specialist staff who will provide guidance on Infection Control measures

The programme has been risk assessed using the Trust‟s risk matrix. The risk of not completing the actions identified is stated and then scored. The severity of the risk will always remain the same. The likelihood of the risk occurring is stated as it is at the current time (refer to date given). When the programme is reviewed at each ICC the likelihood of that risk occurring will also be reviewed and adjusted accordingly. It is expected that all stakeholders will work through the aspects of the programme that requires their input in order to keep the associated risk to a minimum. The aim of risk assessing the programme is to enable the Trust to easily identify priorities if the need arises.

3. Identified targets for the Trust

MRSA objective: No more than 3 cases of BHT-attributed (ie detected more than 48 hours after admission) MRSA Bacteraemias. Trajectory illustrated in Appendix A.

C difficile objective: No more than 45 cases of BHT-attributed (ie detected more than 72 hours after admission) C difficile cases. Appendix B.

4. Identified targets for Divisions and Service Delivery Units (SDUs)

Annual Infection Control environmental audits by the Infection Prevention and Control Team (IPCT): 100% of wards to achieve at least 85% compliance.

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Monthly reporting of: o Hospital acquired infections (MRSA and C. difficile) o MRSA, MSSA and E.coli Bacteraemias o Hand hygiene compliance

Identification and management of Red and Amber Risks related to Infection Prevention and Control on Balanced Scorecards.

Root Cause Analysis of BHT-attributed MRSA and MSSA Bacteraemias undertaken and forms returned within 5 working days of notification of Bacteraemia

Implementation of the Saving Lives High Impact Interventions

Appropriate use of antibiotics

5. The Infection Prevention and Control Programme 2011/12 has been developed using the following Department of Health guidance.

Winning Ways: working together to reduce Healthcare Associated Infection in England December 2003

Saving Lives: a delivery programme to reduce Healthcare Associated Infection including MRSA June 2005

NHSLA Standards

Standards for Better Health

Code of Practice for Infection Prevention and Control (Health Act October 2006 updated January 08 – replaced by Health and Social Care Act 2008)

Clean, Safe Care – January 08

NAO Audit 2009

6. The incorporation of Community Health Buckinghamshire (CHB) into BHT as the Community and Integrated Care (CIC) Division from 1st April 2010 has provided challenges and opportunities for strengthening infection prevention and control for the local population which needs to be further developed. Priorities for 2011/12 include: - Improving the care of in-dwelling urinary catheters across the healthcare boundaries - Improving the transfer of information about specific infection risks across the healthcare boundaries

- Improving uptake of Infection Prevention and Control training by healthcare staff - Improving the uptake of influenza vaccination by healthcare staff

The purpose of this programme is to identify all key work streams required to ensure all appropriate actions are being taken by Buckinghamshire Healthcare NHS Trust to minimise the risk of healthcare acquired infections.

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Trust Board Objectives Actions Lead Timescales Update Board takes an active part in ensuring that Trust-acquired infections are reduced to a minimum.

The Board will receive Infection Control updates at each Public Meeting.

DIPC Bimonthly

The Board will receive the Annual Report. DIPC August 11

The Infection Prevention and Control Committee will receive regular Reports from Divisions including a summary of any Infection Control concerns. An exception report will go to the Healthcare Governance Committee.

KG Ongoing

Ensure IPC is incorporated into all Executive Director job descriptions, with identified outcome measures.

SH Ongoing

RAG rating* March 2012 Green

Divisions Objectives Actions Lead Timescales Update

To ensure that reduction of Trust-acquired infections are a priority for Divisions and SDUs.

IC information will be publicly displayed on wards including C diff numbers, MRSA numbers and compliance with hand hygiene and Saving Lives audits.

ICLPs Ongoing

Each SDU will include an Infection Report update at Divisional Governance Meetings.

SDU Infection Control Leads

Bimonthly

SDUs will partake in the Infection Prevention Performance Monitoring.


Ongoing

The use of transfer forms to highlight HCAI information needs to be strengthened. The Trust‟s Discharge Policy needs to be ratified, released and audited.

Matrons July 11

IC risks are fed into SDU/Divisional Risk Registers and reviewed monthly.

EH Ongoing

Lessons from IC SUIs reviewed regularly and acted upon. Divisional Chairs and Lead Nurses

Ongoing


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Infection Control Team in liaison with others Objectives Actions Lead Timescales Update Education 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.

Ensure that all employees (including locum bank staff and contractors) receive infection control induction training at commencement of employment.

ADOs Ongoing

Ensure that all the above receive annual updates in infection control including hand hygiene competency assessment.

ADOs Ongoing

Ensure all relevant staff receive training in aseptic techniques and are assessed as competent.

Lead Nurse/GL Ongoing

All staff who: o Carry out urinary catheterisation o Provide ongoing care for individuals with

urinary catheters o Insert peripheral and central venous catheters o Provide ongoing care to patients with

peripheral or central venous catheters will receive training which includes the management of associated infection control risks related to these devices.



Surveillance Prompt action is taken when required following feedback of surveillance data.

Continue mandatory surveillance of:

MRSA Bacteraemias

IPCT Ongoing

C difficile IPCT Ongoing

Glycopeptide resistant enterococci IPCT Ongoing

Orthopaedic surgery wound infections IPCT Ongoing

MSSA Bacteraemias IPCT From Jan 2011

E.coli Bacteraemias IPCT From June 2011

Continue voluntary surveillance:

C difficile (weekly reporting)

IPCT

Ongoing

MRSA (non-Bacteraemias) IPCT Ongoing

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Objectives Actions Lead Timescales Update

ESBL IPCT Ongoing

Multi-resistant Acinetobacter baumanii IPCT Ongoing

Line-associated infections DIPC Ongoing

Ventilator-associated pneumonia (ITU/HDU) DIPC Ongoing

Catheter-associated UTIs (CAUTIs) DIPC Monthly from April 11

Continue to participate in the “Matching Michigan” Project (commenced Dec 09)

DIPC -

Blood culture contaminants DIPC Ongoing


Decontamination There are effective arrangements for the appropriate decontamination of instruments and other equipment

Ensure that the Decontamination Programme quality assures Trust‟s decontamination process – achieved through Decontamination Committee. Specifically to:

i) Audit Decontamination policy and practices – including training of staff.

ii) Ensure compliance with HTM2030 and other relevant HTM documents.

iii) Implement any relevant new guidance.

IG Ongoing

Make recommendations about purchase of new equipment and changes to operating environment.

IPCT


Policies The Trust has appropriate policies in place in relation to preventing and controlling the risks of HCAIs.

Circulate updated policies to IPCC NW Ongoing

Policies ratified by IPCC NW Ongoing

Policies to be revised: As required per rolling programme

IPCT As required


Audit of Policies Compliance with key policies is ensured through the implementation of high impact interventions and monitored

Policies to be audited

MRSA

IPCT

Nov 11

C. difficile IPCT June 11

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Objectives Actions Lead Timescales Update through audit.

Assess standards of practice through audit of High Impact Interventions.

See separate Audit Programme (Appendix C) AA Ongoing

RAG rating* March 2012 Amber

Antibiotic Prescribing Minimise antibiotic resistance by appropriate prescribing.

Antibiotic Review Group to continue to update and merge relevant guidelines.

DW

Ongoing

Audits of antibiotic prescribing to be undertaken regularly and results acted upon.

DW/AC

Ongoing

Monthly update of antibiotic usage graphs with feedback of unusual/inappropriate prescribing to Division.

AC/DIPC

Ongoing

Ensure education on antibiotic prescribing to all doctors as required by national guidelines.

DIPC

Ongoing

RAG rating* March 2012

Amber

Environmental audits Ensure environmental standards are maintained.

Ensure environmental audits are carried out annually. IPCT Ongoing

Matrons to monitor through rounds, Domestic Service review meetings.

Managers/Audit Dept/Chief Nurse/ Matrons

Ongoing

Review PEAT scores NW When available


Green

MRSA Screening Compliance with Health Act requirements for MRSA screening.

Continue to ensure that all eligible elective and emergency admissions are screened.

Director of Operations

Ongoing


MRSA and MSSA Bacteraemias Improve MRSA and MSSA bacteraemia rates though identification of root causes,

Ensure timescales for RCA reporting are met and corrective actions/learning shared across Divisions.

Infection Control Leads.

Ongoing

Report root causes and action to Governance Committee and Trust Board.

DIPC Ongoing

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Objectives Actions Lead Timescales Update corrective action and sharing of learning.


Green

Reduce IV line-associated infections.

Monitoring of central line infections. DIPC Ongoing

Monthly monitoring of peripheral line infections. DIPC Ongoing


Green

Reduce needle stick injuries & preventable occupational infections.

Audit NSIs, identify preventable causes and take appropriate action.

WPH

Ongoing

Monitor and encourage uptake of staff vaccination, eg influenza, varicella and MMR.

WPH Ongoing


Green

Link Practitioner Programme Continue to build on existing programme incorporating new initiatives as required.

LA Ongoing


Green

Hand Hygiene Monitor results of Patient Experience Tracker System IPCT Ongoing

Continue with „Clean your hands‟ campaign IPCT Ongoing

Ensure all staff groups in all clinical SDUs achieve 90% or more compliance on monthly audits.

ADNs Ongoing

Ensure clinical staff comply with „Bare below the Elbows‟

IPCT Ongoing

Focus on patient and visitor hand hygiene IPCT Ongoing

Review the hand hygiene component of the Annual Staff Survey and take action to correct any deficiency highlighted.

IPCT When results available


Green

Emergency Planning Participate in Trust‟s emergency planning Specifically for:

Pandemic Influenza (All relevant staff should undergo fit-testing of recommended masks)

KC

Ongoing

Deliberate release – CBRN KC Ongoing


Green

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Objectives Actions Lead Timescales Update Building development and Cleaning issues

Ensure a cleaning strategy exists that is regularly monitored by the Board

IG Ongoing

Continue input into building developments and refurbishments

IPCT Ongoing

Check that Legionella Risk Assessments are carried out Trust-wide and any identified remedial actions required carried out

IG

Ongoing

Annual Joint Reviews with Contractors IG Sept 11

Annual cleaning update IG Sept 11


Green

Reactive, core clinical roles Clinical advice/support to all areas:

Management of infectious patients

IPCT

Ongoing

Investigation of outbreaks and clusters IPCT Ongoing


Standards for better health To ensure compliance with S4BH C4a is maintained. Evidence to support compliance with C4a and the Health Act is identifiable and readily available

NW/IPCT

Ongoing


Green

Provision of information for patients, relatives and staff:

Development of Trust‟s website NW Ongoing

Provision of relevant leaflets. New leaflets to be produced as required.

NW Ongoing


Ensuring that all employees adhere to their responsibilities in relation to Infection Control

IC will be included in all appraisals and PDPs SH Ongoing


Key to Leads:

JOD Dr Jean O‟Driscoll, DIPC AC Anna Colthorpe NW Niamh Whittome

JB Juliet Brown IG Ian Garlington KG Keith Gilchrist

SK Sam Knollys SH Sandra Hatton IPCT Infection Prevention & Control Team

EH Liz Hollman GL Dr Graz Luzzi WPH Workplace Health

KC Dr Kathy Cann DW Dr David Waghorn AA Amanda Adkins

APPENDIX 5

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INFECTION PREVENTION AND CONTROL PROGRAMME 2012/2013 1. Summary:

The Infection Prevention and Control Annual Programme will clearly define the priorities for the Trust in relation to infection prevention and control activities as agreed by the Trust Infection Prevention and Control Committee (IPCC) which will also monitor the progress.

2. Aim of the Buckinghamshire Healthcare NHS Trust Infection Prevention and Control Programme

To reduce preventable healthcare-associated infections within the activity of BH NHS Trust by a process of:

Surveillance / Reporting Promotional Campaigns

Development, review and implementation of Infection Control Policies.

Response to local / regional / national initiatives

Education / Training for clinical and support staff Research

Audit of infection prevention and control practice Compliance with the Code of Practice for Prevention and Control of Healthcare Associated Infections.

Implementation of Saving Lives High Impact Interventions.

Maintenance of the expertise of Infection Control specialist staff who will provide guidance on Infection Control measures

The programme has been risk assessed using the Trust‟s risk matrix. The risk of not completing the actions identified is stated and then scored. The severity of the risk will always remain the same. The likelihood of the risk occurring is stated as it is at the current time (refer to date given). When the programme is reviewed at each ICC the likelihood of that risk occurring will also be reviewed and adjusted accordingly. It is expected that all stakeholders will work through the aspects of the programme that requires their input in order to keep the associated risk to a minimum. The aim of risk assessing the programme is to enable the Trust to easily identify priorities if the need arises.

3. Identified targets for the Trust

MRSA objective: No more than 1 case of BHT-attributed (ie detected more than 2 days after admission) MRSA Bacteraemias. Trajectory illustrated in Appendix A.

C difficile objective: No more than 45 cases of BHT-attributed (ie detected more than 3 days after admission) C difficile cases. Appendix B.

4. Identified targets for Divisions and Service Delivery Units (SDUs)

Annual Infection Control environmental audits by the Infection Prevention and Control Team (IPCT): 100% of wards to achieve at least 85% compliance.

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Monthly reporting of: o Hospital acquired infections (MRSA and C. difficile) o MRSA, MSSA and E.coli Bacteraemias o Hand hygiene compliance

Identification and management of Red and Amber Risks related to Infection Prevention and Control on Balanced Scorecards.

Root Cause Analysis of BHT-attributed MRSA and MSSA Bacteraemias undertaken and forms returned within 5 working days of notification of Bacteraemia

Implementation of the Saving Lives High Impact Interventions

Appropriate use of antibiotics

5. The Infection Prevention and Control Programme 2012/13 has been developed using the following Department of Health guidance.

Winning Ways: working together to reduce Healthcare Associated Infection in England December 2003

Saving Lives: a delivery programme to reduce Healthcare Associated Infection including MRSA June 2005

NHSLA Standards

Code of Practice for Infection Prevention and Control (Health Act October 2006 updated January 08 – replaced by Health and Social Care Act 2008)

Clean, Safe Care – January 08

NAO Audit 2009

6. Priorities for 2012/13 include: - Improving the care of in-dwelling urinary catheters across the healthcare boundaries - Improving the transfer of information about specific infection risks across the healthcare boundaries

- Improving uptake of Infection Prevention and Control training by healthcare staff - Ensuring that the patient environment is clean - Learning from patient complaints

The purpose of this programme is to identify all key work streams required to ensure all appropriate actions are being taken by Buckinghamshire Healthcare NHS Trust to minimise the risk of healthcare acquired infections.

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Trust Board Objectives Actions Lead Timescales Update

Board takes an active part in ensuring that Trust-acquired infections are reduced to a minimum.

The Board will receive Infection Control updates at each Public Meeting.

DIPC Bimonthly

The Board will receive the Annual Report. DIPC July 12

The Infection Prevention and Control Committee will receive regular Reports from Divisions including a summary of any Infection Control concerns. An exception report will go to the Healthcare Governance Committee.

KG Ongoing

Ensure IPC is incorporated into all Executive Director job descriptions, with identified outcome measures.

SH Ongoing

RAG rating March 2012 Green

Divisions Objectives Actions Lead Timescales Update

To ensure that reduction of Trust-acquired infections are a priority for Divisions and SDUs.

IC information will be publicly displayed on wards including C diff numbers, MRSA numbers and compliance with hand hygiene and Saving Lives audits.

ICLPs Ongoing

Each SDU will include an Infection Report update at Divisional Governance Meetings.


Bimonthly

SDUs will partake in the Infection Prevention Performance Monitoring.


Ongoing

The use of transfer forms to highlight HCAI information needs to be strengthened and the Trust‟s Discharge Policy audited.

Matrons Ongoing

IC risks are fed into SDU/Divisional Risk Registers and reviewed monthly.

EH Ongoing

Lessons from IC SEs reviewed regularly and acted upon. Divisional Chairs and Lead Nurses

Ongoing

RAG rating March 2012 Amber

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Infection Control Team in liaison with others Objectives Actions Lead Timescales Update

Education 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.

Ensure that all employees (including locum bank staff and contractors) receive infection control induction training at commencement of employment.

ADOs Ongoing

Ensure that all the above receive annual updates in infection control including hand hygiene competency assessment.

ADOs Ongoing

Ensure all relevant staff receive training in aseptic techniques and are assessed as competent.


All staff who: o Carry out urinary catheterisation o Provide ongoing care for individuals with

urinary catheters o Insert peripheral and central venous catheters o Provide ongoing care to patients with

peripheral or central venous catheters will receive training which includes the management of associated infection control risks related to these devices.



Surveillance Prompt action is taken when required following feedback of surveillance data.

Continue mandatory surveillance of:

MRSA Bacteraemias

IPCT Ongoing

C difficile IPCT Ongoing

Glycopeptide resistant enterococci IPCT Ongoing

Orthopaedic surgery wound infections IPCT Ongoing

MSSA Bacteraemias IPCT From Jan 2011

E.coli Bacteraemias IPCT From June 2011

Continue voluntary surveillance:

C difficile (weekly reporting)

IPCT

Ongoing

MRSA (non-Bacteraemias) IPCT Ongoing

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ESBL IPCT Ongoing

Multi-resistant Acinetobacter baumanii IPCT Ongoing

Line-associated infections DIPC Ongoing

Ventilator-associated pneumonia (ITU/HDU) DIPC Ongoing

Catheter-associated UTIs (CAUTIs) including monitoring of this element of the Safety Thermometer

DIPC Ongoing

Continue to participate in the “Matching Michigan” Project (commenced Dec 09)

DIPC -

Blood culture contaminants DIPC Ongoing


Decontamination There are effective arrangements for the appropriate decontamination of instruments and other equipment

Ensure that the Decontamination Programme quality assures Trust‟s decontamination process – achieved through Decontamination Committee. Specifically to:

iv) Audit Decontamination policy and practices – including training of staff.

v) Ensure compliance with HTM2030 and other relevant HTM documents.

vi) Implement any relevant new guidance.

IG Ongoing

Make recommendations about purchase of new equipment and changes to operating environment.

IPCT


Policies The Trust has appropriate policies in place in relation to preventing and controlling the risks of HCAIs.

Circulate updated policies to IPCC NW Ongoing

Policies ratified by IPCC NW Ongoing

Policies to be revised: As required per rolling programme

IPCT As required


Audit of Policies Compliance with key policies is ensured through the implementation of high impact

Policies to be audited

MRSA

IPCT

C. difficile IPCT

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interventions and monitored through audit.

Isolation IPCT

Assess standards of practice through audit of High Impact Interventions.

See separate Audit Programme (Appendix C) AA Ongoing


Antibiotic Prescribing Minimise antibiotic resistance by appropriate prescribing.

Antibiotic Review Group to continue to update and merge relevant guidelines.

DW

Ongoing

Audits of antibiotic prescribing to be undertaken regularly and results acted upon.

DW/AP

Ongoing

Monthly update of antibiotic usage graphs with feedback of unusual/inappropriate prescribing to Division.

AP/DIPC

Ongoing

Ensure education on antibiotic prescribing to all doctors as required by national guidelines.

DIPC

Ongoing

RAG rating March 2012

Amber

Environmental audits Ensure environmental standards are maintained.

Ensure environmental audits are carried out annually. IPCT Ongoing

Matrons to monitor through rounds and ATP testing programme, Domestic Service review meetings.

Managers/Audit Dept/Chief Nurse/ Matrons

Ongoing

Heads of Facilities to monitor weekly. IG Ongoing

Review PEAT scores NW When available

Uploading results of weekly monitoring to the intranet. IG Commence March 2012


Green

MRSA Screening Compliance with Health Act requirements for MRSA screening.

Continue to ensure that all eligible elective and emergency admissions are screened.

Director of Operations

Ongoing


MRSA and MSSA Bacteraemias

Ensure timescales for RCA reporting are met and corrective actions/learning shared across Divisions.

Infection Control Leads.

Ongoing

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Improve MRSA and MSSA bacteraemia rates though identification of root causes, corrective action and sharing of learning.

Report root causes and action to Governance Committee and Trust Board.

DIPC Ongoing


Green

Reduce IV line-associated infections.

Monitoring of central line infections. DIPC Ongoing

Monthly monitoring of peripheral line infections. DIPC Ongoing


Green

Reduce needle stick injuries & preventable occupational infections.

Audit NSIs, identify preventable causes and take appropriate action.

OHW

Ongoing

Monitor and encourage uptake of staff vaccination, eg influenza, varicella and MMR.

OHW Ongoing


Green

Link Practitioner Programme Continue to build on existing programme incorporating new initiatives as required.

LA Ongoing


Green

Hand Hygiene Monitor results of Patient Experience Tracker System IPCT Ongoing

Ensure all staff groups in all clinical SDUs achieve 90% or more compliance on monthly audits.

ADNs Ongoing

Ensure clinical staff comply with „Bare below the Elbows‟

IPCT Ongoing

Focus on patient and visitor hand hygiene IPCT Ongoing

Review the hand hygiene component of the Annual Staff Survey and take action to correct any deficiency highlighted.

IPCT When results available


Green

Emergency Planning Participate in Trust‟s emergency planning Specifically for:

Pandemic Influenza (All relevant staff should undergo fit-testing of recommended masks)

KC

Ongoing

Deliberate release – CBRN KC Ongoing

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Green

Building development and Cleaning issues

Ensure a cleaning strategy exists that is regularly monitored by the Board

IG Ongoing

Continue input into building developments and refurbishments

IPCT Ongoing

Check that Legionella Risk Assessments are carried out Trust-wide and any identified remedial actions required carried out

IG

Ongoing

Annual Joint Reviews with Contractors IG Sept 12

Annual cleaning update IG Sept 12


Green

Reactive, core clinical roles Clinical advice/support to all areas:

Management of infectious patients

IPCT

Ongoing

Investigation of outbreaks and clusters IPCT Ongoing


Standards for better health To ensure compliance with Criterion 8 of the Health & Social Care Act is maintained. Evidence to support compliance is identifiable and readily available.

NW/IPCT

Ongoing


Green

Provision of information for patients, relatives and staff:

Development of Trust‟s website NW Ongoing

Provision of relevant leaflets. New leaflets to be produced as required.

NW Ongoing


Learning from complaints Six-monthly review by IPCT. Lessons learned widely circulated.

IPCT Start Jan-Jun 2012


Ensuring that all employees adhere to their responsibilities in relation to Infection Control

IC will be included in all appraisals and PDPs SH Ongoing


Amber

Operational changes Ensure that the impact on infection control of a new service, BP Commence

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movement of an existing service, provision of escalation to a new area or by increasing beds on a currently open ward is formally considered.

March 2012


Key to Leads:

JOD Dr Jean O‟Driscoll, DIPC AP Antibiotic Pharmacist NW Niamh Whittome

JB Juliet Brown IG Ian Garlington KG Keith Gilchrist

SK Sam Knollys SH Sandra Hatton IPCT Infection Prevention & Control Team

EH Liz Hollman GL Dr Graz Luzzi OHW Occupational Health & Wellbeing

KC Dr Kathy Cann DW Dr David Waghorn AA Amanda Adkins

JD Jackie Dalton

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APPENDIX A

MRSA BACTERAEMIA TRAJECTORY APRIL 2012 – MARCH 2013

Total number of cases by March 2013: no more than 1 Monthly limit for Trust:


Limit 1 0 0 0 0 0 0 0 0 0 0 0

MRSA Bacteraemia Cumulative Trajectory

2012/13

0

1

2

3

4

Apr May Jun July Aug Sept Oct Nov Dec Jan Feb Mar

Cumulative limit

Limit: maximum of 1 case at year end (Baseline: 03/04: 47 cases)

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APPENDIX B

Clostridium difficile TRAJECTORY FOR BHT (includes CIC) APRIL 2012 – MARCH 2013

Total number of cases by March 2013: no more than 45 Monthly limit for Trust:

BHT C difficile Trajectory 2012/13


Limit 4 4 4 4 4 4 4 4 4 3 3 3

BHT C difficile Trajectory 2012/13

0

5

10

15

20

25

30

35

40

45

50


Cumulative limit

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APPENDIX C

Infection Prevention & Control Audit Programme 2012/13

Month Audit Details Areas to Complete Audit Undertaken by Return to

Ap

ril

Environmental, Kitchen & Patient Equipment Audit Medicine, Access & CIC Divisional Infection Control Nurse

IC Knowledge Survey All Wards/ Departments/ Areas

All clinical staff Electronic Survey

Hand Hygiene Observational Audit All Wards/ Departments/ Areas

Designated person(s) from ward/

department/ area

Enter results onto Hand Hygiene Drive Community Staff as previously instructed

Ma

y


HII – Urinary Catheter Care Audit (Insertion & ongoing management)

All Wards/ Departments/ Areas


department/ area IPCT

HII – Care Bundle for Ventilated Patients

NSIC & ITU Designated

person(s) from ward/ department/ area

IPCT



department/ area


Ju

ne


HII – Peripheral Line Audit – Insertion & continuing care including VIP Form including DSU, Endoscopy, X-ray, Day Stickers



department/ area OPAT Team

HII – Surgical Site Infection Pre-op Burns & Plastics procedures IPCT

HII – Surgical Site Infection Peri-op Theatres - Burns & Plastics





department/ area


Ju

ly


Personal Protective Equipment All Wards/ Departments/ Areas





department/ area


Au

gu

st

Environmental, Kitchen & Patient Equipment Audit NSIC & CSS Divisional Infection Control Nurse



department/ area


Isolation Precautions Audit All Wards/ Departments/ Areas



Se

pte

mb

er


IC Clostridium difficile Policy Audit All Wards/ Departments/ Areas Microbiology

HII – Surgical Site Infection Pre-op General Surgery & Vascular procedures

IPCT

HII – Surgical Site Infection Peri-op Theatres General Surgery & Vascular procedures



Safe Handling & Managements of Sharps – Re audit






department/ area


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One element of the Trusts 5 patient promise is to provide a clean and safe hospital for our patients. By completing various audits we can show we are monitoring and addressing any issues to improve our patients stay. The aim is to provide a focus on elements of the care process and a method for measuring implementation of policies and procedures. NB This programme is subject to change

Key: IPCT = Infection Prevention & Control Team DIPC = Director of Infection Prevention & Control

Month Audit Details Areas to Complete Audit Undertaken by Return to

Oc

tob

er


HII – Long Line Venous Catheter Care ongoing Management



department/ area OPAT Team

HII – Surgical Site Infection Pre-op T&O Elective & Emergency procedures

IPCT

HII – Surgical Site Infection Peri-op Theatres - T&O Elective & Emergency procedures





department/ area


No

ve

mb

er


IC Isolation Policy Audit All Wards/ Departments/ Areas Microbiology

IC MRSA Policy Audit All Wards/ Departments/ Areas Microbiology

HII – Surgical Site Infection Pre-op Ophthalmology, ENT & Oral procedures

IPCT

HII – Surgical Site Infection Peri-op Theatres - Ophthalmology, ENT & Oral procedures





department/ area


Dec

em

be

r

Environmental, Kitchen & Patient Equipment Audit W&C and Surgery Divisional Infection Control Nurse

HII – Surgical Site Infection Pre-op Urology procedures IPCT

HII – Surgical Site Infection Peri-op Theatres - Urology procedures





department/ area


Ja

nu

ary


Hand Hygiene Facilities All Wards/ Departments/ Areas





department/ area


Feb

ruary


Safe Handling & Managements of Sharps




Transfer Form All Wards/ Departments/ Areas



HII – Surgical Site Infection Pre-op Gynae procedures IPCT

HII – Surgical Site Infection Peri-op Theatres –Gynae procedures





department/ area


Ma

rch


Outbreak Policy All Wards/ Departments/ Areas IPCT / DIPC

HII – Surgical Site Infection Pre-op Spinal procedures IPCT

HII – Surgical Site Infection Peri-op Theatres – Spinal procedures





department/ area


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Appendix 6 SURVEILLANCE DATA

DEFINITIONS OF HEALTH CARE ASSOCIATED INFECTIONS

MRSA Non Bacteraemias Case definitions 1. Probable BHT acquired: BHT inpatients > 48hrs before diagnosis or inpatient at a BHT site

within 48hrs of the diagnosis. 2. BHT associated acquisition: patients who have been inpatients <48hrs or in a community

setting AND have been BHT inpatients or regularly attend BHT for therapeutic interventions >48hrs (add up attendances to see if total greater than 48 hours) and within the previous 3 months ago.

3. Non BHT acquired:

a) home : BHT inpatient < 48 hrs but resident in own home b) nursing home /residential home BHT inpatient <48 hrs but resident in nursing/residential

home c) community hospital: BHT inpatients < 48 hrs but resident in a community hospital and have

not had an IP episode anywhere in the last 3 months. d) other acute Trust: BHT inpatients <48hrs and transferred from another acute Trust or had

an in-patient episode in the other acute Trust in the last 3 months. e) another country: BHT inpatients < 48 hrs and transferred form another country or have

been an IP in another country in the last 3 months f) private hospital: BHT inpatients <48 hours and transferred form a private hospital or been

an inpatient in a private hospital in the last 3 months

MRSA Bacteraemias

Case definitions 1. BHT - Bacteraemia acquired during hospitalisation which was not present or incubating at the

time of admission and was identified 48 hours or more after admission 2. BHT- associated:- Bacteraemia in outpatients OR Bacteraemia within 48hours of admission in patients who regularly attend BHT for therapeutic

interventions e.g. haematology/renal. OR Bacteraemia occurring within 48hours of admission in patients admitted from the community

who have been discharged from BHT within the past 90 days 3 Community

a) Home Bacteraemia detected within 48 hours of admission in patients admitted from own home and no hospital stay in previous 90 days.

b) Nursing / residential home Bacteraemia detected within 48 hours of admission in patients admitted from nursing/residential home and no hospital stay in previous 90 days.

c) Other hospital Bacteraemia detected within 48 hours of admission in patients admitted from a hospital outside Bucks Hospitals Trust.

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Clostridium Difficile

Case definitions: 1. Probable BHT acquired: Patients are inpatients >72hrs at a BHT site before onset of symptoms

and diagnosis OR

Have been discharged and develop symptoms within 72hrs of discharge and positive result confirmed (i.e via GP, patient does not have to be an inpatient to be categorised as Cat1)

2. BHT associated acquisition: patients have been inpatients <72 hours or in a community setting

AND have been BHT inpatient >72 hours ago and < 3 months ago. 3. Non BHT acquired -

a) Home: BHT inpatients <72hours but resident in own home b) Nursing home/residential home: BHT inpatients <72hours but resident in a nursing

home/residential home c) Community hospital: BHT inpatients <72hours but resident in one of the community settings

listed. d) Other acute Trust: BHT inpatients <72hours and transferred from another acute Trust or

been an inpatient at another acute Trust in the last 3 months e) another country: BHT inpatients <72hours and transferred form another country or been an

inpatient in another country in the last 3 months f) private hospital: BHT inpatients <72hours and transferred form a private hospital or been an

inpatient in a private hospital in the last 3 months 1st December 2009

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Appendix 7 Infection Prevention & Control Link Practitioners Programme 2011-12 Study Day 1 – September 2011

Clostridium Difficile Problems at Wycombe Hospital

Emergency Planning

Infection Control Auditing

MRSA Outbreak: A Nursing Report

Comparison of an ESBL and MRAB Outbreak. Have we learnt the Lesson?

Study Day 2 – December 2011

Infection Control Update on Clostridium difficile Recovery Plan, Outbreaks, Norovirus, Pseudomonas

OPAT Team and IV Therapy

Changeover to Vygon IV Connections

BP Cuffs - What are you using? Single patient use vs reusable

Side room Management and scenario workshop (Group work)

Hand Hygiene Competency Training

Study Day 3 – March 2012

Diabetes and Infection Control – Managing & Monitoring the infected Diabetic Patient in the Community

Infection Control in Practice on a Mental Health Ward & in the Home Environment

Infection Control Update

Reducing Catheter-Associated Urinary Tract Infections (CAUTI‟s)

ATP testing / Hand Hygiene/Norovirus „game‟

Extended Spectrum Beta-Lactamase (ESBL) Outbreak, Neonatal Unit, SMH,

December 2011

ATP testing / Hand Hygiene/Norovirus „game‟

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Appendix 8 Education Mandatory Infection Control Training Training Attended by Staff Groups from 1st April 2010 to 31st March 2011

Division Infection Control

Hand Hygiene

Total combined training

Total Staff

% Infection Control and Hand Hygiene training

Number of staff

completed both Hand

Hygiene and Infection Control

Clinical Support Services

596 337 933 801 116% 294

Community 318 149 467 671 70% 101

Corporate 375 84 459 779 59% 64

Medicine Division 592 235 827 1043 79% 176

NSIC 195 72 267 296 90% 55

Surgery Division 603 196 799 1200 67% 142

Women & Children

484 237 721 927 78% 169

Grand Total 3163 1310 4473 5717 78% 1001

55% of staff have completed Infection Control Training (this excludes separate hand hygiene sessions) within the last 12 months (01.04.2011 to 31.03.2012)

78% of staff have completed both Infection Control and Hand Hygiene training. 1001 members of staff have been recorded as completing both sessions of Infection Control and Hand Hygiene.

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Hand Hygiene and Infection Control training by Staff Groups within Divisions from April 2011 to Mar 2012 The table below does not segregate the duplications of those staff that are recorded as completing Hand Hygiene and Infection Control

Division Staff Group Total

completed Total of

staff

% no. of staff

trained

Clinical Services Division Add Prof Scientific and Technic 5 5 100%

Additional Clinical Services 166 158 105%

Administrative and Clerical 169 137 123%

Allied Health Professionals 329 228 144%

Healthcare Scientists 86 110 78%

Medical and Dental 30 56 54%

Nursing and Midwifery Registered

148 107 138%

Clinical Services Division Total 933 801 116%

Community & Integrated Care Add Prof Scientific and Technic

2 1 200%




Estates and Ancillary 0 1 0%



213 301 71%

Students 0 3 0%

Community & Integrated Care Total 467 671 70%

Corporate Add Prof Scientific and Technic 3 6 50%







65 74 88%

Corporate Total 459 779 59%

Medicine Division Add Prof Scientific and Technic 77 73 105%







382 395 97%

Students 0 2 0%

Medicine Division Total 827 1043 79%

Spinal Injuries Division Add Prof Scientific and Technic 6 12 50%






103 107 96%

Students

0 2 0%

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Spinal Injuries Division Total 267 296 90%

Surgery Division Add Prof Scientific and Technic 25 63 40%








387 443 87%

Students 0 5 0%

Surgery Division Total 799 1200 67%

Women & Children Add Prof Scientific and Technic 2 2 100%







420 515 82%

Students 2 19 11%

Women & Children Total 721 927 78%

Grand Total 4473 5717 78%

Student Nurses A number of lectures were given during the year to pre-registration students. These included: Semester 1 – Introduction to infection control Semester 1 – Hand hygiene Semester 3 – Health care associated infection Semester 4 – Care of the immuno-compromised infection Semester 6 – Care of the surgical patient Semester 9 – Infection control management issues and IV lines

Post Basic Nurse Education A variety of lectures were given for trained staff. These include:

IV Therapy.

Venepuncture & Cannulation.

Staff Nurse Development Programme – Part 1

Staff Nurse Development Programme – Part 2 Return to Practice

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Appendix 9 – Audit Reports

Infection Prevention & Control Audit Programme 2011/12

Month Audit Details Comment

Apri

l

Hand Hygiene Observational Audit Undertaken by all Wards/ Departments/ Areas

Ma

y

Infection Prevention & Control Audit (including Environment, Kitchen and Patient Equipment

Undertaken by Infection Prevention Nurses

HII – Urinary Catheter Care Audit (Insertion & ongoing management)

Undertaken by all Wards/ Departments/ Areas

HII – Care Bundle for Ventilated Patients Undertaken by NSIC & ITU


Ju

ne



HII – Peripheral Line Audit – Insertion & continuing care including VIP Form including DSU, Endoscopy, X-ray, Day Stickers


HII – Surgical Site Infection Pre-op Burns & Plastics Procedures

Audit not undertaken by department HII – Surgical Site Infection Peri-op Burns & Plastics Procedures


Ju

ly

Dekomed Bedpan Washer Audit to be undertaken by Dekomed

This audit is completed by Estates Department therefore the company was not require to undertake this audit.



Personal Protective Equipment Undertaken by all Wards/ Departments/ Areas


Au

gu

st


Safe Handling & Managements of Sharps Undertaken by all Wards/ Departments/ Areas

Septe

mber

IC Clostridium difficile Policy Audit Deferred

HII – Surgical Site Infection Pre-op

Not undertaken by department HII – Surgical Site Infection Peri-op General Surgery & Vascular procedures


Octo

be

r

HII – Long Line Venous Catheter Care ongoing Management


HII – Surgical Site Infection Pre-op - T&O Elective & Emergency

Undertaken by department HII – Surgical Site Infection Peri-op T&O Elective & Emergency

Hand Hygiene Observational Audit


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Novem

ber

IC Isolation Policy Audit Deferred

IC MRSA Policy Audit Deferred

HII – Surgical Site Infection Pre-op Ophthalmology, ENT & Oral procedures

Undertaken by department HII – Surgical Site Infection Peri-op Ophthalmology, ENT & Oral procedures


Decem

ber

Infection Control Manual Audit Undertaken

HII – Surgical Site Infection Pre-op Urology procedures

Undertaken by department HII – Surgical Site Infection Peri-op Urology procedures


January

IC Knowledge Survey Deferred

Hand Hygiene Facilities Undertaken by all Wards/ Departments/ Areas


Febru

ary

Safe Handling & Managements of Sharps Undertaken awaiting final report

Transfer Form Undertaken by all Wards/ Departments/ Areas

HII – Surgical Site Infection Pre-op Gynae

HII – Surgical Site Infection Peri-op Theatres -Gynae


Marc

h

Outbreak Policy Deferred

HII – Surgical Site Infection Pre-op Spinal procedures Undertaken numbers too small (less

than 5) to create report HII – Surgical Site Infection Peri-op Spinal procedures


Summary of Results HII Urinary Catheter Care Audit (Insertion & Ongoing Management) Urinary Catheter Care – Insertion 34 wards/teams took part in the audit and there were 250 observations in total. 99% full compliance was achieved, i.e. for 99% observations all applicable elements were complied with. Of the 250 observations the only non-compliances were:

2 cases in Gynae Theatre where hand hygiene was not performed.

1 case in the Cystoscopy Suite where personal protective equipment was not used. Urinary Catheter Care – Continuing Care A total of 373 observations were recorded from 30 wards/teams. Overall, all applicable elements were performed in 94% cases. 7 areas/wards should have produced action plans but only 2 of them did.

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HII Care Bundle for Ventilated Patients A total of 120 observations were recorded. Results are shown in the table below. Overall results are shown for 2008, 2009 and 2010. However:

Only ITU, WH and ITU, SMH took part in the 2008 audit

Only St George‟s and ITU, WH took part in the 2009 audit

Only St Andrew‟s, St Francis‟ and St George‟s took part in the 2010 audit. Therefore results are not directly comparable.

Hand hygiene

prior

Personal protective equipment

Safe management of equipment

Hand hygiene after

All applicable elements performed

2011 2010

Ward Appl Obs

% Yes

Appl Obs

% Yes

Appl Obs

% Yes

Appl Obs

% Yes

Appl Obs

% Yes

Appl Obs

% Yes

ITU, WH 20 100% 20 100% 20 100% 20 100% 20 100%

ITU, SMH 34 100% 34 100% 34 100% 34 100% 34 100%

St Andrew's 20 100% 20 100% 20 100% 20 100% 20 100% 31 74%

St Francis' 20 100% 20 100% 20 100% 20 100% 20 100% 20 90%

St George's 20 95% 20 100% 20 100% 20 100% 20 95% 27 48%

St Patrick‟s 6 100% 6 100% 6 100% 6 100% 6 100%

TOTAL 2011 120 99% 120 100% 120 100% 120 100% 120 99%

TOTAL 2010 78 81% 77 90% 76 100% 77 90% 78 69%

TOTAL 2009 40 98% 40 100% 40 100% 40 100% 40 98%

TOTAL 2008 60 80% 43 100% 26 100% 60 85% 60 77%

HII Peripheral Line Insertion & Continuing Care Peripheral IV line insertion 1153 observations were made from 40 wards/areas, the majority of which were from theatres. Overall compliance for the different elements of the tool were as follows:

Insertion using aseptic technique 99%

Skin preparation performed 99%

Dressing in situ 100%

Insertion of device documented 94%

All applicable elements complied with 92% Theatres were less compliant than in 2010. However, other areas had a significantly improved compliance. This resulted in a slightly improved compliance overall. Compliance for all applicable elements varied by ward from 40% to 100% but there were very low numbers of observations from many wards, so comparing percentages between wards or audits is not meaningful. Compliances for all applicable elements within divisions varied from 83% (Spinal) to 100% (Clinical Support Services).

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Peripheral IV line continuing care 535 observations were made from 41 wards/areas. The chart below shows compliance for each element of the observational tool.

Peripheral Line Continuing Care Compliance

84% 84%

99%92%

82%

47%

99%

75%

91% 88%96%

83%81%

95%

75%

92%93% 89%80%

0%

20%

40%

60%

80%

100%

VIP fo

rm p

rese

nt

Inse

rtion

docu

ment

ed

Type

Position

Perso

n in

serti

ng

Dat

e/tim

e of

inse

rtion

IV in

<72

hrs

Con

tinuing

clinical

indi

catio

n

Rem

oval d

ocum

ente

d

Perso

n re

mov

ing

Dat

e of

rem

oval

Rea

son

for r

emov

al

Doc

umen

ted

each

tim

e ac

cess

ed

Asept

ic a

cces

s

Asses

sed

daily

using

VIP

crit

eria

Appro

priate

act

ion

Dre

ssing

clean

& in

tact

IV a

dmin s

et la

belle

d

All ap

plicab

le e

lem

ents

Personal Protective Equipment

No. of questions

Hospital Ward/Area Yes No N/A

or NR %

compliance

Medicine

AH Bucks Neuro Rehab Unit 16 100%

Wilkinson Ward 14 2 100%

SMH Ward 8 Stroke Unit 13 3 100%

Ward 9 13 3 100%

Ward 10 16 100%

Ward 20 16 100%

A&E 16 100%

Day Hospital 10 6 100%

Endoscopy 15 1 100%

WH Ward 2A 16 100%

Ward 3B 14 2 100%

Ward 5B Stroke Unit 15 1 100%

Ward 6B 15 1 100%

Ward 9 15 1 94%

Cath Lab 15 1 100%

MAU 16 100%

Endoscopy 15 1 100%

EMC 15 1 94%

Surgery

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No. of questions


or NR %

compliance

SMH Wards 1 & 2 16 100%

Ward 6 15 1 100%

Pre-Op Assessment 8 8 100%

ITU 15 1 94%

Eye Outpatients 12 4 100%

Mandeville Theatre 15 1 94%

WH Ward 12A 12 4 100%

Ward 12B Orthopaedics 16 100%

Ward 12C 15 1 100%

Day Surgery Unit 10 6 100%

ITU 16 100%

Pre-Op Assessment 12 4 100%

ENT Pre-Op 11 5 100%

Main Theatre 15 1 100%

Gynae Theatre 15 1 100%

Women & Children

SMH Ward 3 14 1 1 93%

Ward 4 15 1 100%

Rothschild 15 1 100%

Paediatric Day Unit 15 1 94%

Labour Ward 15 1 94%

Birth Centre 13 2 1 87%

WH Children's Day Unit 14 2 100%

Birth Centre 14 2 88%

Spinal Injuries

SMH St Andrew's Ward 15 1 100%

St David's Ward 16 100%

St Francis' Ward 14 2 100%

St George's Ward 13 3 100%

St Joseph's Ward 15 1 100%

St Patrick's Ward 16 100%

Spinal Outpatients 16 100%

Cystoscopy 14 2 100%

Clinical Support Services

AH Medical Photography 7 9 100%

SMH&WH Breast Screening 12 1 3 92%

SMH Ward 5 Haematology 15 1 94%

Radiology CT 15 1 100%

Radiology MRI 13 3 100%

Radiology Nuclear Med 15 1 100%

Radiology Ultrasound 13 3 100%

Radiology Interventional 15 1 100%

Medical Photography 7 9 100%

WH Radiology CT 13 1 2 93%

Radiology Nuclear Med 14 2 100%

Radiology MRI 12 4 100%

Medical Photography 7 9 100%

Access

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No. of questions


or NR %

compliance

SMH Outpatients 12 4 100%

WH Outpatients 13 3 100%

Community & Integrated Care

Buckingham Inpatients 16 100%

Chartridge Inpatients 11 5 100%

Florence Nightingale Inpatients 13 3 100%

Marlow Inpatients 14 2 100%

Thame Inpatients 13 3 100%

Waterside Inpatients 15 1 100%

Buckingham Outpatients 12 4 100%

Chalfont & GX Outpatients 12 4 100%

Brookside GUM 14 2 100%

Podiatry Outpatients 12 4 100%

Wheelchair Service Outpatients 8 8 100%

Community Amersham ACHT 14 2 100%

Marlow ACHT 11 5 100%

Southern ACHT 14 2 100%

Thame ACHT 13 3 100%

Wycombe ACHT 15 1 100%

TOTAL 1092 14 174 99%

Environmental, Kitchen and Patient Equipment Audit

Divisions Wards Site Yes No #

N/A #

questions % Score

SU

RG

ER

Y (

no

t T

he

atr

es

)

ITU SMH 108 22 57 130 83.1%

ITU WH 121 40 26 161 75.2%

SMW1 SMH 134 29 24 163 82.2%

SMW2 SMH 140 24 23 164 85.4%

SMW6 SMH 132 25 30 137 96.4%

SMW7 SMH 111 44 31 155 71.6%

DSU WH 121 25 41 126 96.0%

Oral Surgery & Orthodontic OPD AH 46 13 128 59 78.0%

12A WH 115 40 32 155 74.2%

12B WH 120 34 34 153 78.4%

12C WH 138 26 23 164 84.1%

New Wing Recovery SMH 62 9 116 71 87.3%

Main Recovery WH 64 28 95 92 69.6%

Loakes Recovery WH 43 16 128 59 72.9%

Plaster Room WH 41 13 133 54 75.9%

Plaster Room SMH 37 10 140 47 78.7%

ENT POA WH 39 0 148 39 100.0%

ENT OPD SMH 49 14 124 63 77.8%

Plastics OPD SMH 74 13 100 87 85.1%

Burns Unit SMH 142 17 28 159 89.3%

Burns OPD SMH 49 4 134 53 92.5%

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N/A #

questions % Score

SURGERY (Theatres

only)

Mandeville Wing Theatre SMH 67 11 22 78 85.9%

Loakes Theatre WH 57 27 16 84 67.9%

New Wing Theatre SMH 59 16 25 75 78.7%

Gynae Theatres WH 50 18 32 68 73.5%

Main Theatre WH 50 21 29 71 70.4%

WO

ME

N &

CH

ILD

RE

N

Wycombe Birth Centre WH 128 23 36 151 84.8%

SMW4 SMH 110 45 32 155 71.0%

Rothschild SMH 94 49 44 143 65.7%

Gynae ANC & OPD WH 60 39 88 99 60.6%

SMW3 SMH 134 33 20 166 80.7%

Labour Ward SMH 99 39 49 138 71.7%

NNU SMH 93 11 83 101 92.1%

Aylesbury Birth Centre SMH 92 28 67 120 76.7%

Children's Day Unit WH 118 36 33 154 76.6%

NS

IC

Occupational Therapy SMH 35 38 114 73 47.9%

St Francis SMH 149 14 24 163 91.4%

Spinal Gym SMH 31 28 128 59 52.5%

Spinal OPD SMH 85 7 95 92 92.4%

St Georges SMH 127 35 25 162 78.4%

St Patrick SMH 129 27 31 156 82.7%

Hydrotherapy SMH 47 21 119 68 69.1%

St Andrews SMH 118 40 29 158 74.7%

Cystoscopy SMH 80 11 96 91 87.9%

St Josephs SMH 112 29 46 141 79.4%

St Davids SMH 126 24 37 150 84.0%

CO

MM

UN

ITY

INT

EG

RA

TE

D C

AR

E

Waterside AH 126 21 40 147 85.7%

Chalfont OPD 82 8 97 90 91.1%

TCH 149 7 31 156 95.5%

Chartridge AH 137 15 34 152 90.1%

Marlow Marlow 151 4 32 155 97.4%

Bucks Comm Hosp (Ward) 118 9 60 127 92.9%

Florence Nightingale Hospice SMH 135 7 45 142 95.1%

ME

DIC

INE

Brookside Clinic 61 8 118 69 88.4%

A&E SMH 88 29 70 117 75.2%

SMW8 SMH 119 38 30 157 75.8%

SMW9 SMH 109 35 43 144 75.7%

SMW20 SMH 107 48 32 155 69.0%

CDU WH 119 41 27 160 74.4%

SMW22 SMH 78 46 63 124 62.9%

Hayward Unit WH 105 37 45 142 73.9%

Day Hospital Mandeville Wing SMH 108 18 61 126 85.7%

WH4B WH 102 56 29 158 64.6%

WH5B WH 110 51 26 161 68.3%

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N/A #

questions % Score

ME

DIC

INE

CO

NT

…

WH6B WH 113 51 23 164 68.9%

WH3B WH 114 41 32 155 73.5%

SHAW (GUM) Clinic WH 76 20 91 96 79.2%

Derm OPD AH 55 31 101 86 64.0%

WH2A WH 93 57 37 150 62.0%

Wilkinson Ward AH 130 17 40 147 88.4%

Bucks Neuro Rehab Unit (BNRU) AH 109 50 28 159 68.6%

WH9 WH 126 26 35 152 82.9%

Endoscopy WH 87 23 77 110 79.1%

Endoscopy SMH 110 33 44 143 76.9%

MAU WH 62 38 87 100 62.0%

SM10 SMH 111 47 29 158 70.3%

CL

INIC

AL

SU

PP

OR

T

SE

RV

ICE

S

CCHU SMH 90 22 75 112 80.4%

5A (Sunrise) WH 81 25 81 106 76.4%

Radiology WH 53 25 109 79 67.1%

Radiology AH 54 2 131 56 96.4%

Radiology SMH 67 22 98 89 75.3%

SMW5 SMH 138 15 34 153 90.2%

Breast Screening WH 60 16 111 76 78.9%

ACCESS Main OPD SMH 58 39 90 97 59.8%

OPD WH 64 33 90 97 66.0%

Safe Handling & Managements of Sharps

54 wards/areas returned audit tools.

Overall compliance was 95%.

Scores varied by unit from 78% “Yes” responses to 100%.

2 wards had overall compliance less than 85%.

Some units did not answer some of the questions.

Compliance for each question varied from 54% to 100%.

The questions with the poorest compliance were: o Are sharps trays with integral sharps bins available for use? (54%) o There are NO inappropriate items, e.g. packaging or swabs, in the sharps containers? (78%) o Is the temporary closure mechanism used when bins are not in use? (81%) o Are sharps trays compatible with the sharps bins in use? (83%)

18 of the 54 units (33%) achieved 100% compliance and did not require an action plan.

17 of the 54 units (31%) returned complete action plans with actions included for all “No” responses.

9 of the 54 units (17%) should have completed an action plan but didn‟t.

10 of the 54 units (19%) returned incomplete action plans, where there was no action for at least one of the “No” responses.

.

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HII Long Line Venous Catheter Care ongoing Management The table below shows the number of observations where compliance occurred or did not occur for each element of the tool. Some elements (e.g. catheter access, admin sets replaced) were not applicable for all observations.

Ward/Area Hand hygiene

Catheter site inspection

Dressing Catheter injection

ports

Yes No Yes No Yes No Yes No

Medicine

Ward 8, SMH 1 1 1 1

Surgery

Ward 6, SMH 9 9 9 9

ITU, SMH 20 20 19 1 19

Ward 12A, WH 3 3 3 3

Ward 12C, WH 2 2 2 2

ITU, WH 30 30 30 30

CSS

Ward 5, SMH 120 120 120 120

CCHU, SMH 20 20 20 20

Sunrise Unit, WH 7 7 6

Community

Aylesbury ACHT 4 4 4 4

Buckingham ACHT 1 1 1 1

Marlow ACHT 4 4 2 2 4

Wycombe ACHT 1 1 1 1

Chalfonts Hospital 4 4 4 4

Wing DN team 1 1 1 1

TOTAL 227 0 223 4 223 3 219 0

Ward/Area Catheter access

Admin set replacement

Avoid routine catheter

replacement

All applicable elements complied

with

Yes No Yes No Yes No Yes No

Medicine

Ward 8, SMH 1 1 1

Surgery

Ward 6, SMH 9 8 9 9

ITU, SMH 19 17 20 19 1

Ward 12A, WH 3 3 3 3

Ward 12C, WH 2 2 2 2

ITU, WH 30 29 1 29 1

CSS

Ward 5, SMH 120 120 120 120

CCHU, SMH 20 20 20

Sunrise Unit, WH 7

Community

Aylesbury ACHT 4 4 4

Buckingham ACHT 1 1 1 1

Marlow ACHT 4 4

Wycombe ACHT 1

Chalfonts Hospital 4

Wing DN team 1 1 1 1

TOTAL 214 181 22 160 200 27

Surgical Site Infection – Trauma & Orthopaedic (Elective & Emergency) procedures

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Pre-Operative components

Number Yes No N/A

No. of procedures audited 20

MRSA Screen Taken 4 illegible MRN

numbers 8 8

MRSA Result Positive Negative

0 8

MRSA Decontamination

Clearly Documented in notes?

Comments

Procedures undertaken in Trauma & Orthopaedic Theatres during the week of 10th to 16th October 2011 were audited. 20 procedures were recorded – 4 had illegible MRN numbers. Of the 16 (80%) procedures undertaken where the patient could be identified 8 (40%) were screened for MRSA, 8 (40%) were not. No one tested positive for MRSA.

Peri-Operative components

Elements performed Number of Patients

Yes No N/A


Prophylactic Antimicrobial Administered

20 15/15 eligible (100%) 5/20 (44%)

Hair Removal 20 3/11 eligible (27%) 9 (45%) 8(40%)

Hair Removal Method Shaving Clippers

1 2

Glucose Control 20 Not possible to evaluate 19/20(95%)

Normothermia 20 20/20 (100%)

For 16 (80%) patients, the tool was completed correctly.

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Surgical Site Infection – Ophthalmology, ENT & Oral procedures


Number Yes No N/A


MRSA Screen Taken 11 10 1


0 10



Comments

Procedures undertaken in Ophthalmology, ENT & Oral Theatres during the week of 14th to 20th November 2011 were audited. 46 procedures were recorded. Of the 46 procedures undertaken MRSA screening was indicated for 11 (24%) patients following the Trust guidelines. 10 (91%) were screened, 1 (9%) was not. None tested positive for MRSA.

Peri-operative components


Yes No N/A


WHO checklist 46 45(98%) 1(2%)

Prophylactic Antibiotic Administered

46 18(39%) 30(65%)

Hair Removal 46 3(7%) 43(93%)


Glucose Control 46 1(2%) 39(85%)

Normothermia 46 46

For 2 (4%) patients, the tool was completed incorrectly. For 2 (4%) procedures both No & N/A were answered for Prophylactic Antibiotic Administered For 6 (13%) procedures Glucose Control was not answered

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Surgical Site Infection – Urology procedures


Number Yes No N/A


MRSA Screen Taken 28 3


1 27

MRSA Decontamination 1

Clearly Documented in notes? 1

Comments

Procedures undertaken in Urology Theatres during the week of 16th to 23rd December 2011 were audited. 31 procedures were recorded. Of the 31 procedures undertaken MRSA screening was indicated for 28(90%) patients following the Trust guidelines. One patient tested positive for MRSA. For this one case MRSA decontamination was not undertaken and the patient notes were not marked for MRSA.

Peri-Operative components


Yes No N/A


WHO checklist 31 31(100%)


31 26(84%) 4(13%)

Hair Removal 31 7(23%) 2(6%) 21(68%)


5(71%)

Glucose Control 31 1(3%) 29(94%)

Normothermia 31 28(90%)

For 1 (3%) procedure Prophylactic Antibiotic Administered question was not answered For 1 (3%) procedure Glucose Control question was not answered For 3 (10%) procedures Normothermia question was not answered

Hand Hygiene Facilities Audit

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Hosp Ward/Area Yes No N/A NR % Yes Questions with “No” answers

AH Bucks Neuro Rehab Unit 43 1 1 98% 44

AH Oral Surgery/Orthodontics 38 1 6 97% 16

AH Medical Photography 28 3 14 90% 10, 14, 16

AH X-Ray 29 1 15 97% 18

AH Wilkinson Ward 41 2 2 95% 4, 8

SMH Ward 1/2 43 1 1 100%

SMH Ward 3 41 3 1 93% 10, 12, 28

SMH Ward 4 42 3 100%

SMH Ward 5 44 1 100%

SMH Ward 6 42 1 2 98% 4

SMH Ward 7 42 3 93% 7, 44, 45

SMH Ward 9 42 2 1 95% 4, 45

SMH Ward 11 Burns Unit 42 1 2 98% 44

SMH Ward 20 44 1 100%

SMH St Andrew's 44 1 100%

SMH St David's 41 4 100%

SMH St Joseph's 45 100%

SMH Spinal Outpatients 42 3 100%

SMH Cystoscopy Suite 37 8 100%

SMH A&E 43 1 1 98% 45

SMH Birth Centre 45 100%

SMH Mobile Breast Screening Unit 28 5 11 1 85% 4, 10, 12, 16, 18

SMH Day Hospital 40 5 100%

SMH ENT Outpatients 29 2 14 94% 16, 18

SMH Gynae Special Clinics 42 1 2 98% 15

SMH ITU 42 2 1 95% 3, 16

SMH Labour 42 1 2 98% 45

SMH Medical Photography 26 1 18 96% 14

SMH Oral Surgery/Orthodontics 36 1 8 97% 45

SMH Pre-Op Assessment 29 1 15 97% 15

SMH Radiology 42 3 93% 16, 44, 45

SMH Ophthalmic Theatre 38 5 2 88% 16, 18, 28, 44, 45

SMH Eye Outpatients 40 5 100%

WH Ward 3B 35 5 5 88% 8, 12, 19, 25, 27

WH Ward 5B 37 5 1 2 88% 4, 25, 27, 28, 44

WH Ward 6B 45 100%

WH Ward 9 42 2 1 95% 16, 44

WH Ward 12A 44 1 98% 44

WH Ward 12B 44 1 98% 28

WH Cardiac Day Unit Cath Lab 41 3 1 93% 7, 44, 45

WH EMC 39 3 1 2 93% 4, 12, 14

WH Endoscopy 39 5 1 89% 4, 18, 23, 44, 45

WH ENT Pre-Op 38 1 6 97% 10

WH ITU 40 4 1 91% 12, 17, 44, 45

WH MAU 37 7 1 84% 11, 18, 23, 25, 26, 44, 45

WH Medical Photography 20 4 21 83% 4, 14, 15, 17

WH Pre-Op Assessment 34 11 100%

WH Radiology 34 5 6 87% 10, 12, 16, 18, 45

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Hosp Ward/Area Yes No N/A NR % Yes Questions with “No” answers

WH SAU 41 4 100%

WH Main Theatre 33 6 5 1 85% 1, 10, 15, 16, 24, 25

WH Gynae Theatre 33 6 6 85% 1, 10, 13, 15, 24, 25

Comm Brookside Clinic 37 1 7 97% 4

Comm Buckingham Inpatients 38 7 84% 10, 13, 17, 19, 28, 44, 45

Comm Buckingham Outpatients 34 2 8 1 94% 10, 17

Comm Chartridge 32 10 3 76% 4, 17, 19, 24, 25, 28, 32, 34, 44, 45

Comm Florence Nightingale House Inpatients

36 7 1 1 84% 4, 10, 11, 14, 28, 44, 45

Comm Marlow Inpatients 42 1 2 98% 45

Comm Waterside 40 3 2 93% 25, 44, 45

Comm Amersham Intermediate Community Care

19 26 100%

TOTAL 2246 130 269 10 95%

Transfer Form Audit 18 completed Transfer Form Audit proformas were returned.

30 of the 257 patients (12%) had infection control issues.

132/257 (51%) transferred patients had infection control and prevention issues handed over.

20/30 (67%) patients with infection control issues had the issues handed over.

Results for handover were very similar to 2011 results.

The percentage of IC issues handed over varied considerably by division.

154/257 (60%) transferred patients had infection control and prevention issues recorded in notes.

13/30 (43%) patients with infection control issues had the issues recorded in notes.

Generally infection control issues were documented more frequently in the notes in 2012 (60%) than in 2011 (37%). However, the few patients that actually had infection control issues were documented less frequently than in 2011 (43% vs 61%).

The Inter-Healthcare Transfer Form or the Referral Form was only used for 60/257 (23%) transfers.

206/257 (80%) transfers were handed over either verbally or using a form.

Only 7/30 (23%) of those with infection control issues were handed over with Transfer or Referral Forms and 24/30 (80%) handed over either verbally or using a form. These results are the same as for all patients.

Surgical Site Infection – Gynaecological procedures

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Number Yes No N/A


MRSA Screen Taken 18 18


0 18



Comments

Procedures undertaken in Gynaecology theatres during the week of 13th to 19th February 2012 were audited. 18 procedures were recorded. All 18 patients were screened for MRSA in line with Trust guidelines. No patients were found to be MRSA positive following screening.

Peri-Operative components For 1 (3%) procedure Prophylactic Antibiotic Administered question both No and N/A were recorded For 1 (6%) procedure the Hair Removal question was not answered

For 3 (17%) procedures the Glucose Control question was not answered For 3 (17%) procedures the Normothermia question was not answered


Yes No N/A


WHO checklist 18 (100%)


8 eligible 6 (75%) 3 (38%) 1(13%)

Hair Removal 18 0 (0%) 8 (44%) 9 (50%)


Glucose Control 5 eligible 1 (20%) 4 (80%)

Normothermia 8 (44%) 5 (28%) 2 (11%)

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Hand Hygiene Observational Audit

INFECTION PREVENTION & CONTROL DEPARTMENT

Ward/Departmental Hand Hygiene Audit Results April 11 - March 12

Red = Non Participation

Amber = Below 90% - Non compliant

Divisional % 100% 100% 100% 99% 99% 99% 100% 100% 97% 98% 100% 94%

Division Ward/Department Site Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12

ACCESS OPD SMH 100% 100% 100% 100% 98% 100% 100% 100% 100% 97% 100% #DIV/0!

OPD WH 100% 100% 100% 99% 100% 99% #DIV/0! 100% 95% 100% 100% 94%

Divisional % 99% 100% 100% 100% 100% 99% 100% 99% 99% 100% 99% 99%


CLIN

ICA

L S

UP

PO

RT

SE

RV

ICE

S

Breast Screening SMH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Breast Screening WH 100% 100% 100% 100% 100% 97% 100% 100% 100% 100% 100% 100%

CCHU Cancer/ Haematology Care

SMH

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

SMW5 SMH 100% 99% 100% 99% 100% 100% 100% 100% 100% 100% 100% 100%

Clinical Photography SMH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Clinical Photography WH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Clinical Photography AH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Dietetic Clinic SMH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Dietetic Clinic WH/AH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Orthotist SMH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Orthotist WH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Orthotist AH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Radiology SMH 100% 100% 100% 100% 100% 99% 100% 99% 99% 99% 96% 99%

Radiology WH 99% 100% #DIV/0! 100% 99% 100% 100% 100% 100% 100% 100% 100%

Radiology AH 100% 100% 100% #DIV/0! 100% 100% 100% 100% 100% 100% 100% 100%

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SLT Clinic SMH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% #DIV/0!

SLT Clinic WH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

SLT Clinic AH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Sunrise Unit WH 100% 100% 100% 99% 100% 95% 100% 95% 92% 100% 99% 97%

MSK SMH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

MSK WH 100% 100% 100% 100% 96% 100% 100% 100% 100% 100% 100% 100%

MSK AH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Divisional % 98% 98% 98% 95% 97% 95% 97% 97% 98% 96% 97% 97%


NS

IC

St Andrews SMH 100% 98% 99% 99% 99% 99% 100% 100% 100% 100% 100% 99%

St David SMH #DIV/0! 96% 100% 98% #DIV/0! 99% 99% 99% 96% 91% 98% 98%

St Francis SMH 99% 98% 96% 97% 97% 94% 95% #DIV/0! 97% 97% 96% 98%

St George SMH 94% 95% 95% 94% 99% 96% 91% 91% 97% 91% 91% 92%

St Josephs SMH 100% 99% 97% 98% 96% #DIV/0! 99% 98% 98% 99% 98% 97%

St Patrick SMH 100% 98% 98% 99% 100% 100% 93% 99% #DIV/0! 98% 90% 95%

Spinal Gym SMH 94% 95% #DIV/0! 93% #DIV/0! 95% #DIV/0! 95% #DIV/0! 92% 100% 98%

Spinal OPD SMH 100% 100% 100% 93% 99% #DIV/0! 99% 95% 100% 95% 99% 94%

Occupational Therapy

SMH 84% 88% 83% #DIV/0! 86% 80% 92% 88% 97% 94% 100% #DIV/0!

Cystoscopy SMH 96% 97% 98% 89% 90% 90% 98% 99% 95% 98% 98% #DIV/0!

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Divisional % 97% 97% 97% 97% 97% 98% 98% 96% 97% 97% 98% 99%

Division Ward/Department Site Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 M

ED

ICIN

E

3B WH 87% 99% 95% 94% 97% 96% 98% 96% 91% 98% 91% #DIV/0!

4B (escalation) WH Closed Closed Closed Closed Closed Closed Closed Closed Closed Closed Closed Closed

5B (Stroke Unit) WH 99% 97% 98% 96% 99% 97% 98% 97% 97% 100% 100% #DIV/0!

6A (escalation ward) WH Closed Closed Closed Closed Closed Closed Closed Closed Closed Closed Closed Closed

6B WH 99% 99% 99% 98% 99% 98% 100% 99% 98% 99% 100% 99%

9 WH 98% 99% 98% 91% 100% 100% 100% 93% 100% 100% 100% 100%

A & E SMH 100% 100% 100% 100% 98% 98% 96% 100% 97% 97% 99% 99%

CCU (2A) WH 100% 93% 97% 100% 99% 100% 99% 95% 97% 98% 98% #DIV/0!

Cardiac Day Unit & Lab

WH 94% 100% 87% 95% 97% 96% 97% 96% 99% 100% 99% 98%

Day Hospital SMH 98% 99% 98% 100% 100% 100% 97% 97% 98% 100% 100% 99%

Dermatology OPD AH 98% 90% 89% 91% 93% 96% 90% 95% 90% 91% 86% #DIV/0!

Drake Day Unit AH 100% 100% 100% 100% #DIV/0! 100% 100% 100% #DIV/0! 100% 100% #DIV/0!

EAU (SMW10) SMH 91% 90% 90% 91% 95% 93% 92% 93% 96% 95% 95% 95%

EMC WH 90% 98% 100% 100% 100% 95% 98% 98% 99% 98% 99% #DIV/0!

Endoscopy SMH 100% 100% 100% 100% 99% 100% 100% 100% 100% 99% #DIV/0! #DIV/0!

Endoscopy WH 100% 100% 99% 100% 100% 100% 99% 100% 100% 100% 100% 100%

GUM Clinic (SHAW) WH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Hayward Unit WH 100% 100% 94% #DIV/0! 98% 100% 100% 100% #DIV/0! 100% 100% #DIV/0!

MAU WH 94% 75% #DIV/0! 98% 98% #DIV/0! 90% 72% 100% 95% 98% #DIV/0!

SMW20 SMH 99% 98% 99% 99% 98% 100% 99% 100% 100% 100% 100% #DIV/0!

SMW22 (escalation) SMH #DIV/0! #DIV/0! 96% #DIV/0! #DIV/0! 99% 98% 98% 98% 98% 98% #DIV/0!

SMW8 SMH 95% 99% 99% 100% 96% 98% 100% 100% 100% 100% 100% #DIV/0!

SMW9 SMH 95% 94% 97% 97% 96% 98% 97% 97% 93% 93% 99% #DIV/0!

Wilkinson Ward AH 97% 99% 99% 89% 82% 99% 100% #DIV/0! 99% 89% 100% #DIV/0!

Bucks Neuro Rehab Unit

AH #DIV/0! #DIV/0! #DIV/0! 99% 98% 95% 97% #DIV/0! 94% 95% 96% #DIV/0!

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Divisional % 95% 97% 97% 98% 97% 97% 98% 97% 96% 97% 98% 98%

Division Ward/Department Site Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 W

om

ens &

Child

rens

SMW4 SMH #DIV/0! 92% 89% #DIV/0! 80% 92% 100% 99% #DIV/0! 93% 99% 100%

Labour Ward SMH 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% #DIV/0!

Aylesbury Birth Centre

SMH 92% 100% 100% 100% 100% 100% #DIV/0! 100% 100% 100% 100% 100%

Wycombe Birth Centre

WH 100% 100% 100% 100% 100% 100% 97% 100% 100% 100% 100% 100%

Gynae OPD & Antenatal Clinic

SMH

97% 92% 86% 89% 98% 95% 99% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Gynae OPD & Antenatal Clinic

WH

98% 96% 100% 100% 100% 100% 100% 99% 93% 100% 100% 95%

Rothschild Ward SMH 96% 99% 99% 99% 97% 98% 98% 98% 98% 98% 99% 99%

NNU SMH 100% 100% 100% 100% 100% 98% 100% 100% 92% 95% 99% 92%

Ward 3 Paediatrics SMH #DIV/0! #DIV/0! 99% 99% 96% 97% 99% 97% 100% 99% 100% 100%

Childrens Day Unit WH 94% 92% 81% 96% 98% 97% 100% 100% 100% 99% 97% #DIV/0!

Paediatric Decisions Unit

SMH

#DIV/0! 98% 100% 97% 99% 97% 95% 91% 88% 93% 91% 92%

Paediatric OP Clinic SMH 90% 93% 98% 94% 92% 94% 92% 86% 92% 95% 91% #DIV/0!

Paediatric OP Clinic WH 91% 96% 94% 97% 92% 91% 96% 99% #DIV/0! 99% 100% 100%

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Divisional % 97% 97% 97% 98% 97% 96% 97% 98% 98% 99% 98% 99%

Division Ward/Department Site Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 S

UR

GE

RY

12A WH 96% 98% 99% 99% 90% 95% 94% 95% 100% 99% 98% 100%

12B WH 99% 99% 97% 100% 99% 99% 99% 98% 99% 99% 98% 99%

12C 98% 97% 99% 99% 93% 100% 100% 100% 99% 99% 98% 99%

Burns Unit (SMW11) SMH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Burns OPD SMH 95% 100% 94% 100% 100% 100% 100% 92% 100% 100% 100% 99%

Plastics OPD SMH 100% 100% 100% 100% 97% 100% 100% #DIV/0! #DIV/0! 100% #DIV/0! #DIV/0!

Day Procedures Unit SMH 96% 97% 96% 97% 96% 95% 99% 98% 96% 97% 99% #DIV/0!

Day Surgery Unit WH 96% 97% 97% 99% 97% 98% 87% 99% 90% 95% 97% 100%

ENT Clinic OPD SMH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

ENT POA WH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Gynae Recovery 100% 99% 97% 100% 100% 98% 92% 99% 100% 100% 99% 100%

Gynae Theatres 94% 86% 93% 100% 98% 96% 94% 96% 100% 100% 100% 100%

ITU SMH 100% 100% 99% 100% 100% 100% 98% 100% 100% 100% 100% 100%

ITU WH 90% 95% 95% 95% 94% 93% 96% 97% 97% 98% 97% 99%

Loakes Recovery WH 100% 100% 100% 100% 100% 93% 90% 99% 100% 97% 100% 100%

Loakes Theatres WH 96% 97% 99% 95% 90% 92% 96% 97% 98% 99% 96% 96%

Main Recovery WH 100% 100% 100% 100% Closed 87% 100% 98% 100% 100% 100% 100%

Main Theatres WH 100% 89% 97% 95% Closed 100% 95% 96% 92% 99% 95% 92%

New Wing Theatre SMH #DIV/0! 89% 98% 95% 99% 98% 100% 100% 98% 100% 95% 99%

New Wing Recovery SMH #DIV/0! #DIV/0! #DIV/0! #DIV/0! 100% #DIV/0! #DIV/0! 100% 97% #DIV/0! #DIV/0! 99%

Mandeville Unit SMH 95% 93% 99% 94% #DIV/0! #DIV/0! 97% 98% 98% 98% 97% 99%

Ophthalmic OPD SMH 98% 96% 87% 86% 98% 97% 99% 97% 97% 98% 95% 90%

Oral Surgery & Orthodontic OPD

AH

95% 98% 90% 100% 100% 98% 93% 100% 100% 100% 100% 100%

POA SMH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

POA WH/AH 84% 93% 89% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Orthodontic OPD SMH 100% 100% 96% 97% 95% 100% 100% 100% 100% 99% 99% 100%

Plaster Room WH 97% 98% 98% 98% 98% 98% 98% 98% 97% 98% 99% 99%

Plaster Room SMH 94% 94% 95% 94% 95% 91% 94% 96% 94% 94% 94% 96%

SAU (POD) WH 100% 98% 98% 95% 84% 98% 97% 97% 95% 100% 98% 99%

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SMW1 SMH 93% 93% 92% 93% 93% 93% 97% 96% 99% 98% 100% 98%

SMW2 SMH 93% 92% 93% 94% 91% 90% 98% 97% 99% 100% 100% 98%

SMW6 SMH 99% 98% 98% 98% 98% 98% 97% 98% 100% 99% 98% 99%

SMW7 (Plastics) SMH 99% 96% 97% 96% #DIV/0! 98% 96% 99% 99% 97% 99% 97%

Divisional % 98% 94% 94% 93% 98% 96% 97% 98% 98% 98% 98% 95%


CIC

Buckingham Community Hospital OPD

100% 88% 100% 91% 88% 100% 100% 100% #DIV/0! 100% 100% 100%

Buckingham Community Hospital Ward

#DIV/0! 100% 100% 100% 100% 100% 100% 100% #DIV/0! 100% 100% 100%

Florence Nightingale House

SMH

98% 100% #DIV/0! 98% 96% 98% 98% 100% 100% 98% 99% 100%

Thame Community Hospital

92% 95% 98% 96% 96% 93% 98% #DIV/0! 97% 90% #DIV/0! #DIV/0!

Chartridge AH #DIV/0! 98% 100% 96% 94% 99% 98% 98% 99% 100% 97% 87%

Marlow Community Hospital

#DIV/0! #DIV/0! 100% 100% #DIV/0! 91% 100% 100% 99% #DIV/0! 100% 100%

Waterside AH 99% 100% 100% 88% 99% 100% 99% 99% 98% 100% 89% 100%

Brookside Clinic 98% 97% 98% 98% 96% 98% 98% 98% 93% 97% 98% 99%

Chalfont & Gerrards Cross OPD

#DIV/0! 35% 85% 81% 94% 79% 85% 92% 97% 88% 94% 100%

Amersham 99% 95% 100% 80% 98% 100% #DIV/0! #DIV/0! 100% 100% 100% 92%

Aylesbury #DIV/0! 100% #DIV/0! #DIV/0! 100% 100% 100% #DIV/0! #DIV/0! #DIV/0! 100% 100%

Buckingham #DIV/0! 99% 97% #DIV/0! 100% 100% 100% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Marlow #DIV/0! 100% #DIV/0! 100% 100% 95% 89% 100% #DIV/0! 100% #DIV/0! 100%

Southern 95% 100% #DIV/0! 100% 100% 97% 100% 100% 100% 100% 100% 100%

Thame 98% #DIV/0! #DIV/0! #DIV/0! 100% 100% #DIV/0! 100% 100% 98% #DIV/0! #DIV/0!

Wycombe 97% 100% 95% 74% 100% 93% 90% 88% 92% 100% #DIV/0! 84%

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Hand Hygiene Observational Audit From April 2011 to March 2012 staff observed 223,953 situations in wards and clinics where hand hygiene should have been carried out or staff should have been “bare below elbows”. Overall, hand hygiene was carried out in 98% cases, a slight increase on the 2010/11 compliance of 97%. Compliances for each staff group were:

Doctors 94%

Nurses 99%

HCAs 99%

Phlebotomists 98%

Therapists 98%

Other staff 98% Compliance had increased or remained the same for all staff groups since 2010/11.

Compliance for each division was:

Surgery 98%

Medicine 97%

Women & Children 97%

Spinal 97%

Clinical Support Services 99%

Access 99%

CIC 97% Compliance had increased or remained the same for each division since 2010/11.

Compliance for each situation was:

Before patient contact 97%

Before aseptic/clean task 99%

After body fluid exposure risk 99%

After patient contact 97%

After contact with patient surroundings 96%

Bare below the elbows 98% Again, compliance had increased or remained the same for all situations since 2010/11. Compliance by ward/area varied from 84% to 100%.

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Appendix 10

BHT OH needle stick/sharps incidents review (April 2011– March 2012)

1 Introduction The OH Department collates information from self reported needle stick injuries (NSI) and splash incidents. From April 2011 – March 2012, 225 needlestick/sharps/splash incidents were reported to OH. This compares with 180 cases reported in 2010-11 and 144 cases reported in 2009-10 (N.B. BHT and PCT merged on 01.04.10). 2 Basic demographics There was insufficient data to analyse 27 cases, but of the 198 remaining cases:

100 (50%) occurred at Stoke Mandeville Hospital (SMH).

48 (24%) at Wycombe Hospital (WH).

29 (15%) in dental practices.

16 (8%) in community locations.

5 (3%) at Amersham Hospital. 3 Locations reporting > 4 needle stick/sharps incidents were as follows:

Stoke Mandeville Hospital

Total

Theatres 16

A&E 8

NSIC 7

ITU 6

Day T 5

Labour W 5

Last year the data suggests that the departments and wards with the most reported incidents at SMH were Theatres, NSIC, Labour Ward, Obstetric theatres and A&E. A similar pattern persists this reporting year. Of the 16 theatre reports this year: 6 occurred during a procedure (mainly related to suturing); 7 occurred after procedure/on disposal (e.g. counting instruments, placing item into sharps bin); 3 not identified. Of the 8 A&E reports: 4 occurred during a procedure (e.g. phlebotomy, inserting femoral line); 3 occurred after procedure/on disposal (e.g. after phlebotomy, after shaving a patient); 1 not identified.

Wycombe Hospital

Total

Theatres 9

EMC 5

Last year the data suggests that the departments and wards with the most reported incidents were Emergency Medical Centre (EMC), Ward 12, 2A, Theatres and ITU. Of the 9 theatre reports this year: 5 occurred during a procedure; 0 occurred after procedure/on disposal; 4 not identified. Of the 5 EMC reports: 2 occurred during a procedure; 2 occurred after procedure/on disposal; 1 not identified.

Dental practices 29 NSI were reported in different dental practices: 7 cases involved a dentist; 16 involved dental nurse; 2 involved a dental hygienist; 1 not known. Incidents were reported during procedures and after procedure/on disposal (dental nurses recorded several cases involving the cleaning of instruments).

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4 Conclusions & recommendations

SMH theatres and A&E, and WH Theatres and EMC had most recorded needlestick/sharps/splash incidents.

Consideration should be given to more detailed analysis of SMH theatres and WH EMC to see if incidents can be reduced in these areas – with a focus on vigilance (during and after procedures), phlebotomy and general disposal (of sharps into bags and bins).

Dental practices, especially dental nurses should take care when cleaning instruments after procedures.

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Appendix 11

ANTIBIOTIC REVIEW GROUP (ARG) ANNUAL REPORT APRIL 2011 – MARCH 2012

Introduction The Antimicrobial Review Group (ARG) is a subgroup of the Drugs and Therapeutics Committee (DTC) and reports to both the DTC and the Trust‟s Infection Control Committee. Its purpose is to authorise the antimicrobial content of all new Trust guidelines, to review and update old guidelines and to ensure the appropriate introduction of new antimicrobials onto the Trust Formulary. In addition the ARG plays a key role in Antimicrobial Stewardship across the Trust, with review and audit of antimicrobial prescribing. This role extends to primary care with the production of antimicrobial guidelines for general practitioners, in association with community pharmacists, one of whom is also a member of the ARG. The group is chaired by Dr. David Waghorn, Consultant Microbiologist. A key member of the ARG is the Trust‟s Specialist Antimicrobial Pharmacist. Between April and October 2011, Anna Colthorpe filled this role. Following Miss Colthorpe‟s departure, Rachael Stannard was appointed as her replacement and began work within the Trust in February 2012.

1. Trustwide Guidelines The following new Trust guidelines with ARG input were released within the 12 month period April 2011 – March 2012: 207.7 Guidelines for antibiotic treatment of infections within Obstetrics &

Gynaecology (new specific maternity sepsis section). 463.4 Caesarean Section guideline (new antibiotic prophylaxis section). 525.1 Guideline for the screening of pregnant women for Hepatitis B and

immunisation of babies at risk. 769.1 Paediatric guideline for the management of meningococcal disease. 770.1 Paediatric guideline for the management of bacterial meningitis. 771.1 Paediatric guideline for the investigation of unexplained acute

encephalopathy.

In addition, new antibiotic guidelines for the following clinical conditions were written and released for primary care – acne, bronchiectasis, diverticulitis, prostatitis and post-natal endometritis. During the 12 month period, a total of 52 Trust guidelines already in operation were reviewed and revised by the ARG.

2. Antimicrobial Website The first version of the Trust‟s Antimicrobial Website was introduced in 2008. It has provided valuable information to all Trust clinical staff on the use of antimicrobials together with results of audits and access to all relevant Trust antimicrobial guidelines. It also acts as a website for the immediate dissemination of important antimicrobial issues such as drug safety alerts. During the year a second version of the Antimicrobial Website was developed and released, with improved layout and easier navigation for users. In line with one of the Antimicrobial Website‟s main objectives, namely to act as an educative tool, a self-assessment questionnaire section based on individual Trust guidelines has been introduced. This is updated monthly but with previous guideline/question sets archived for continued availability. The Antimicrobial Website is an important on-going component of the Trust‟s commitment to improve antimicrobial stewardship.

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3. Antibiotic Flash Card The Trust‟s Antibiotic Flash Card, containing a summary of the most important and commonly encountered infections and their appropriate empirical treatment, remains a mainstay in terms of good antibiotic prescribing. It is reviewed and updated annually then a hard copy is distributed to all new clinical staff. A large poster version of the Flash Card has been distributed to all clinical areas around the three main hospitals and it is also available on the Antimicrobial Website.

4. New Trust Prescription Chart A revised Prescription Chart was launched across the Trust in October 2011 following a wide consultation and pilot phase which led to further amendments. Significant changes to the antimicrobial page have been made including a requirement for clinicians to state the clinical reason for prescribing and the duration of therapy. During the next 12 months it is hoped to audit the quality of prescribing as part of the antimicrobial stewardship programme.

5. Antimicrobial Stewardship The Health & Social Care Act (2008) has resulted in legislation whereby Trusts need to monitor their use of antimicrobials. The term Antimicrobial Stewardship has been introduced to formulate these requirements in more detail. In November 2011, the Department of Health published a document describing how an Antimicrobial Stewardship programme should be implemented. The ARG reviewed this document and it was confirmed that the Trust has already implemented or introduced the vast majority of the recommendations made in the last few years. Areas requiring further work include development of the audit programme and the continuation of antibiotic ward rounds.

6. Audit Programme This year saw a number of important antimicrobial related audits performed. They included the following: Omitted doses of intravenous antibiotics. Thames Valley antimicrobial stewardship programmes in Trusts across region. Flash Card empirical antibiotic prescribing guidelines – how closely are these followed? Administration of first dose of antibiotic in septic patients within Spinals Unit. A Trustwide surgical prophylaxis audit has also been performed with the first report due to be issued early in the next 12 month period. This is one of the mandatory requirements for the Trust to comply with the antimicrobial stewardship/monitoring section of the Health & Social Care Act.

7. Antibiotic Ward Rounds Between April and October 2011, a total of 16 ward rounds took place. Prescription charts of all patients on antimicrobials were reviewed to assess clinical appropriateness and their accordance with Trust guidelines. Interventions were made on 31% of prescriptions, a fall of 8% from the previous year. Due to the departure of the Trust‟s specialist antimicrobial pharmacist, the clinical changes across the Trust hospitals and other work pressures for the consultant microbiologists, ward rounds were abandoned between November 2011 and March 2012. However with the appointment of the new specialist pharmacist and the recommendations in the Dept of Health‟s Antimicrobial Stewardship document, ward rounds will be re-instated early in the next 12 month period. These rounds are used to educate junior medical and pharmacy staff who will be encouraged to join the ward round when possible.

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8. IV Therapy at Home Service (OPAT) The OPAT service received renewed impetus during the year. A new senior nurse lead was appointed, managing three other members of staff. The majority of work continued to originate from orthopaedics and from patients repatriated from outside Trusts. An admission avoidance programme was developed for cases of cellulitis referred by GPs or for suitable patients seen in Accident & Emergency. The OPAT nurses also started to take responsibility for the insertion and care of peripherally inserted central lines, being used for both hospital and out-patient drug administration.

9. National directives, publications, alerts The ARG kept up to date with all national directives and publications associated with antimicrobials. This included issues such as supporting the national Antibiotic Action website (highlighting the urgent need for new antibiotics) and the International Antibiotic Awareness Day in November. In the autumn, with the help of the Infection Control Department, the Health Protection Agency‟s national Point Prevalence Survey on healthcare associated infections (HAIs) and antimicrobials was completed across the Trust. Results revealed a Trust HAI rate of 4.6% in comparison with a national HAI rate of 8-10%. Relevant drug alert information was also publicised via the Antimicrobial Website throughout the year. Dr. D. J. Waghorn Chairman, Antimicrobial Review Group April 2012.

annual report 2011-2012 control...episodes of cross infection. our c difficile objective/ambition...

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