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of 14 DIPC Annual Report 2007/08 Dr Philippa Moore DIPC/ICD and Sam Lonnen, Community Infection Prevention and Control team lead

DIRECTOR OF INFECTION PREVENTION AND CONTROL GLOUCESTERSHIRE PRIMARY CARE TRUST

ANNUAL REPORT

2007-8

Contents Page

1. Executive summary 2 Organisation 2 National Context 2 Local Context 2 Activities 3 Infection Control Annual Work Programme 3

2. Description of Infection Control Arrangements 4 Organisational arrangements 4 Infection Control team 4 Infection Control Committee 4 Reporting to the Trust Board 4 Links to Prescribing and Formulary Committee 5 Links to Clinical Governance/Risk Management/Patient Safety 5 Support (IT etc) 5

3. HCAI statistics 5 Results of mandatory reporting 5 C. difficile 5 MRSA bacteraemia 7 GRE bacteraemia 8 Trends in HCAI statistics 8 Outbreaks 9

4. Hand Hygiene 9 Implementation of CleanYourHands campaign 9

5. Decontamination 10

Arrangements 10 Decontamination Action plan 10

5.3 Incidents and Enquiries relating to Decontamination 11

6. Cleaning Services 11 6.1 Management arrangements 11 6.2 Monitoring arrangements 11 6.3 Budget allocation 11 6.4 PEAT/Patient forum inspection results and user satisfaction measures 11 6.5 Cleaner hospitals (PEAT scores) 11

7. Audit 13 Extent of audit programme 13 Clinical Infection Control Audits 13 Common themes arising from audits 13 Audit focus for 2007/8 14

8. Training 14 Inductions and updates for all staff 14 Study Days 14 Team training 14

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1) Executive summary - Overview of infection control activities in the Trust 1.1 Organisation This annual report on infection control, from the Director of Infection Prevention and Control (DIPC) for Gloucestershire Primary Care Trust (GPCT), concentrates on the activities within GPCT Care Services set within the county context. Surveillance data is given for the county. The report also takes a retrospective look at developments, changes and progress over the year April 2007 to March 2008 and looks forward to the work programme for GPCT for 2008/09. Other infection control work within Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT) and the 2gether NHS Foundation Trust (formerly Gloucestershire Partnership Trust) is covered by the DIPC annual report of each organisation respectively. 1.2 National Context In October 2006 the Department of Health published the Health Act 2006: Code of Practice for the Prevention and Control of Healthcare Associated Infection. This document, revised in January 2008, legislated levels of service to be provided in a more detailed way than previous documents. The Healthcare Commission criteria for assessing core standards provides the framework for assessment for all NHS patient services, which is in addition to the criteria in Standards for Better Health The core standards include:

C4a Infection Control C4c Decontamination C21 Premises – maintenance and cleanliness

Department of Health reports, frameworks and actions for addressing Healthcare Associated Infection (HCAI) have strengthened the role and accountability of NHS organisations in responding to the management of infections. They also enable a higher degree of access and scrutiny to information by the public, patients’ forums and NHS staff. 1.3 Local Context GHNHSFT, PCT Care Services, and 2gether NHS Foundation Trust Mandatory surveillance has been in place since 2001 for MRSA bacteraemias (blood stream infections), 2003 for bacteraemias due to glycopeptide resistant enterococci (GRE), 2004 for C. difficile cases in patients over 65 years, and also for surgical site infections (SSI) in major cardiovascular and orthopaedic surgery. Within Gloucestershire these surveillance programmes mainly apply to Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT). The GHNHSFT rates for these targets in 2007/08 were: MRSA bacteraemia rate per 10,000 bed days 0.89 (national average 1.16); C. difficile rate in patients > 65 years per 1000 bed days 1.75 (national average 1.56); C. difficile rate in patients > 2 years per 1000 bed days 1.42 (national average 1.18); GRE bacteraemias 5 during October 2006 to September 2007 (national reporting data, no national average given due to low numbers).

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Within the community services, the high rates of C. difficile present a challenge across the community. For 2007/8 there will be enhanced reporting for C. difficile as there is for MRSA and GRE bacteraemias, and a trajectory for the county for the next 3 years. Bacteraemias are not a current issue for community settings and there is no major cardiovascular or orthopaedic surgery performed within PCT Care Services that is part of the national surveillance scheme. 1.4 Activities The Community Infection Prevention and Control team (CIPCT) has been busy and achieved much during the year. Activities have been concentrated around the education programme (both at induction and mandatory update), the audit programme which this year has included General Practice (GP) and dental surgeries, supporting the cleanyourhands campaign in the community hospitals and surveillance. With these activities we have achieved a reduction in both MRSA and C. difficile acquisition rates across the county. Within the 2gether Trust, the support of the focus group, in addition to the education and surveillance programme, has embedded infection control as a priority within the organisation. During the summer of 2007, Gloucestershire was affected by flooding. This major incident required considerable input from the infection control team as we provided advice and guidance to clinical teams on managing infection prevention in this challenging situation as well as advice on water management and remedial structural works. This situation also highlighted to the team deficiencies in the controls assurance around water supply management from an infection prevention point of view. NALCO, an independent contractor, was appointed and has started risk assessments of inpatient areas across the PCT for Legionella control. Following their assessment, remedial works are to be carried out as identified and planned preventive maintenance schedule will be strengthened in line with national guidelines. 1.5 Infection Control Annual Work Programme The proposed work plan for 2008/09 for the infection control team is attached as appendix 1. This plan follows on from previous years and expands activity especially in education. The theme for the 2008/09 audit plan is sharps and waste disposal and the team will be auditing using a tool based on the revised Infection Control Nurses Association tool (Audit tools for monitoring infection control guidelines within the community settings 2005). Outside the CIPCT work programme a great deal of the focus of work within Care Services supports the Infection Control Agenda, though is not listed within the team programme. The Quality and Services Improvement Group (formerly Matron’s Charter Group) will continue to be chaired by Julie Goodenough. This group acts on infection control and cleanliness issues in community hospitals. There is an Essential Steps steering group designed to ensure that best practice and audit is fully embedded in clinical practice with a pilot study being conducted at Berkeley Hospital with a planned roll out across the inpatient facilities across the PCT by the end of 2008.

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2) Description of infection control arrangements 2.1 Organisational arrangements The population of Gloucestershire is served by Gloucestershire PCT (GPCT) with its Care Services directorate responsible for provision of care within the community and community hospitals; and GPCT is the commissioning PCT for Gloucestershire Hospitals NHS Foundation Trust and the 2gether NHS Foundation Trust (formerly Gloucestershire Partnership Trust). Each Trust has its own DIPC. Gloucestershire PCT has joint Directors of Infection Control: the post being shared by Dr Philippa Moore (PM), Infection Control Doctor (ICD), and Jill Crook, Director of Clinical Development. This arrangement is mirrored within the county in the 2gether Trust with the post being shared between Dr Philippa Moore and Hazel Watson, Director of Nursing. The PCT ICD/DIPC post was contracted for 9 hours per week during 2007/08 increasing to 13 hours per week from 1st April 2008. 2.2 The Community Infection Prevention and Control Team (CIPCT) nurses were led by Kathy Pitt, Modern Matron, seconded to the team until June 2007, and are now led by Sam Lonnen (band 8a), Team Lead from 28th June 2007. There are two senior (band 6) infection control nurses (Sarah Hardy and Natalie Matthews) and one trainee (band 5) infection control nurse (Rebecca Walder). The team has had part time secretarial support from Carolyn Meddings between October 2007 and March 2008. The team are actively involved in recruiting to the new post of surveillance nurse (band 5, 20 hours a week). In addition there is close liaison with the Clinical Development Directorate Practice Development Facilitator for Healthcare Associated Infections (Sarah Warne). 2.3 Infection Control Committee The Community Infection Control Committee (CICC) meets quarterly and is chaired by Liz Fenton, Associate Director Nurse Leadership, Clinical Development Directorate. Membership includes the joint DIPCs, Community Infection Prevention and Control Nursing team, the Decontamination lead, representatives from the Care Services Directorate, and representation from Hotel Services, Risk Management, Health and Safety, Estates shared services, Procurement shared service, Tetbury Hospital Trust, GHNHSFT Infection Control team, and the Gloucestershire Health Protection Unit. PM attends the Infection Control Committees of other providers within the county including GHNHSFT, the 2gether Trust, and from May 2008 the Great Western Ambulance Service (GWAS), thus providing a link to ensure integration of infection control strategy across the county. 2.4 Reporting line to the Trust Board Infection Control matters are reported to the PCT Board monthly within the Care Services report and through Jill Crook for specific issues. Philippa Moore attends the PCT board for updates, specific issues, and presentation of the DIPC annual report.

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2.5 Links to Prescribing and Formulary Committee An antimicrobial management committee (AMC) has been convened for the PCT and operates mostly as a virtual committee. It reports to the ICC and GMMC. There are links with the GHNHSFT Microbiology/Pharmacy committee that oversees antimicrobial prescribing. The AMC has issued guidelines for antimicrobial prescribing in community hospitals and has advised General Practitioners to refer to the Health Protection Agency ‘Management of Infection Guidance for Primary Care’. The work of the AMC also includes review of prescribing across General Practice with investigation of discrepancies likely to impact on C. difficile.

2.6 Links to Clinical Governance/Risk Management/Patient Safety There are links with the clinical governance structure with CICC members attending the Integrated Governance Committee (JC), PCT Risk Group (PM), Complaints and Incidents Group (LF), Community Hospitals Clinical Governance Group (SL). 2.7 Support (IT etc.) The team is supported by the infection control software, ICNet. The system is purchased together with GHNHSFT with a PCT contribution to the onsite server and licenses. The programme allows analysis of databases used to help generate surveillance reports which are disseminated to clinical staff as quarterly bulletins. In addition, the team have access to PAS (Patient Administration System) and the Encore search facility of the GHNHSFT databases. 3) HCAI statistics 3.1 Results of mandatory reporting 3.1.1 Clostridium difficile Countywide cases There is seasonal variation in C. difficile incidence which is reflected in the incidence within Gloucestershire county. There were a total of 844 cases reported in Gloucestershire during 2007/08.

C. difficile cases

0

20

40

60

80

100

120

140

Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08

Month/Year

Num

ber o

f cas

es GPs/CommunityCOMMUNITY HOSPITALSDELANCEYCGHGRH

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There is a national target of a 30% reduction in cases of C. difficile from 2008/09 to 2010/11 but the target for NHS South West is a 34.5 % reduction due to the high number of cases in the region. For Gloucestershire the target will be an approximate 40% reduction in cases by 2010/11 to a maximum of 8.6 cases per 10,000 population (487 cases across the county per year by 2010/11). GHNHSFT GHNHSFT recorded 563 cases of C. difficile during 2006/07 against a target of 500. This amounted to a 21% reduction on the 715 cases recorded during 2005/06. The ongoing trend within GHNHSFT is downward as shown by the 12 month rolling average:

GHNHSFT C. difficile

0

20

40

60

80

100

120

Jan-0

3

Feb-03

Mar-03

Apr-03

May-03

Jun-0

3Ju

l-03

Aug-03

Sep-03

Oct-03

Nov-03

Dec-03

Jan-0

4

Feb-04

Mar-04

Apr-04

May-04

Jun-0

4Ju

l-04

Aug-04

Sep-04

Oct-04

Nov-04

Dec-04

Jan-0

5

Feb-05

Mar-05

Apr-05

May-05

Jun-0

5Ju

l-05

Aug-05

Sep-05

Oct-05

Nov-05

Dec-05

Jan-0

6

Feb-06

Mar-06

Apr-06

May-06

Jun-0

6Ju

l-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-0

7

Feb-07

Mar-07

Apr-07

May-07

Jun-0

7Ju

l-07

Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

Jan-0

8

Feb-08

Mar-08

Num

ber o

f cas

es

12 m

onth

ly ro

lling

ave

rage

GHNHSFT12 monthly rolling average

The GHNHSFT target to be achieved for 2010/11 is a maximum of 4.4 cases per 1000 acute trust admissions (274 cases). GPCT Care Services: Community Hospitals There were 113 cases of C. difficile in community hospitals during 2007/8 which represents a 30% decrease compared to 2006/07. This decrease is the result of much collaborative hard work including additional environmental cleaning, a commitment to rapid patient isolation if symptomatic, an improvement in hand hygiene compliance and an improvement in antibiotic stewardship as a result of education. The reduction has not achieved the target set for a maximum of 100 cases but it should be noted that approximately 20% of these cases are relapsed cases. These are patients recently diagnosed with C. difficile but not within the last 28 days.

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Community hospital C. difficile cases

0

5

10

15

20

25

Apr-06

May-06

Jun-

06Ju

l-06

Aug-0

6

Sep-0

6

Oct-06

Nov-06

Dec-06

Jan-

07

Feb-

07

Mar-0

7

Apr-07

May-07

Jun-

07Ju

l-07

Aug-0

7

Sep-0

7

Oct-07

Nov-07

Dec-07

Jan-

08

Feb-

08

Mar-0

8

Month/Year

Num

ber o

f cas

es

12 m

onth

rolli

ng a

vera

ge

Total12 monthly rolling average

GPCT Care Services: General Practice In addition there were 168 cases outside of inpatient facilities, mostly in General Practice, of which approximately 20% were known to be relapses. Gloucestershire 2gether NHS Foundation Trust (formerly Partnership Trust) The 2gether trust contributes relatively very few cases to the county totals. During 2007/08 there were 4 episodes of C. difficile among 3 patients (one patient relapsed more than 28 days after his initial diagnosis and therefore is counted as 2 episodes). 3.1.2 MRSA bacteraemia The target set for the healthcare community for 2007/08 was 18 bacteraemias. There were 36 bacteraemias recorded within Gloucestershire during 2007/08, all diagnosed within GHNHSFT. Despite the higher than target numbers, Gloucestershire remains below average for the South West region for cases of MRSA bacteraemia. Of the 36 cases diagnosed, 11 were pre 48 hours (i.e. diagnosed within 48 hours of patient admission) and 25 were post 48 hours. The post 48 hour bacteraemias are assumed to have been acquired within GHNHSFT. Of the pre 48 hour bacteraemias, 5 were associated with GHNHSFT healthcare recently, 1 was associated with healthcare at another acute trust out of county, 0 were associated with GPCT healthcare and 5 had not accessed healthcare recently. Summarising the causes of the bacteraemias within the county: Bacteraemia principal cause Pre 48 hours Post 48 hours Central line associated 2 8 Peripheral line associated 0 1 Urinary catheter 0 3 Surgical wound inc. prostheses 1 3 Other soft tissue infection 4 1 Pneumonia 4 1 Infective endocarditis 0 1 Contaminant 0 2 Not known/not entered 0 5 Totals 11 25

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Actions to address these causes and prevent further occurrences include the NPSA cleanyourhands campaign within GHNHSFT and GPCT community hospitals, Saving Lives within GHNHSFT and Essential Steps within GPCT, infection control education, revised policies. 3.1.3 GRE bacteraemia There have been no community cases of GRE bacteraemia during 2007/8. There were 5 cases within the county, all diagnosed within GHNHSFT. 3.2 Trends in HCAI statistics In addition to MRSA bacteraemias, the team report on all new cases of MRSA acquisition (colonisation or infection) at any site. During 2007/08 there were 58 new occurrences of MRSA among community hospital inpatients, and 196 among outpatients, mostly General Practice. For comparison, 894 cases were identified within GHNHSFT and 4 from the 2gether trust. Universal screening of elective and emergency admissions starting in April 2008 means that these figures are expected to change over the next year as more patients are detected as inpatients and decolonised. Over time this should lead to fewer patients being diagnosed in General Practice and eventually a reduction in the total burden of MRSA in the county. Preliminary work towards the roll out of Essential Steps within PCT care services was undertaken during 2007/08 with an implementation date in the 2008/09 work year. This Department of Health tool kit will enable Care Services staff to monitor their ability to prevent healthcare associated infections and embed best practice in all applicable procedures, particularly relating to aseptic technique, urinary catheter care, care of enteral feeding tubes, isolation of inpatients with healthcare associated infections and care of peripheral intravenous lines. This is mirrored within GHNHSFT by the use of the Saving Lives tool kits

ITEM 7


3.3 Outbreaks

Total bed days lost for this period: 878 for Gloucestershire community hospitals. 4 Hand hygiene 4.1 The ‘cleanyourhands’ campaign The cleanyourhands campaign continues in community hospitals supplemented by local ‘Stop’ posters encouraging patients and visitors to decontaminate their hands on entry/exit to patient care areas. Year 3 of the campaign will be launched in the community hospitals during 2008. Hand hygiene audits which started in October 2007 continue to be conducted by the CIP&C Team with results fed back centrally to the SHA on a monthly basis. Results shown below demonstrate an improvement in hand hygiene compliance over recent months.

HOSPITAL / UNIT

WARD ORGANISM DATE REPORTED

START DATE

FINISH DATE

DURATION PATIENTS AFFECTED

STAFF AFFECTED

BED DAYS LOST

Cirencester Windrush C. difficile 17/04/07 18/04/07 30/04/07 13 days 13 11 59 Stroud Jubilee C. difficile 30/04/07 30/04/07 11/05/07 12 days 6 0 21

Moreton Dulverton C. difficile + Norovirus 03/05/07 03/05/07 06/05/07 3 days 3 0 4

Stroud Jubilee C. difficile 25/05/07 24/05/07 08/06/07 16 days 19 4 51 Cirencester Coln C. difficile 03/07/07 01/07/07 19/07/07 19 days 14 0 12

Cirencester Coln C. difficile & Norovirus 10/10/07 09/10/07 16/10/07 6 days 6 7 45

Moore Cottage, Bourton

Erskine Norovirus 15/10/07 13/10/07 20/10/07 8 days 7 5 47

Cirencester Stratton Norovirus 23/10/07 22/10/07 28/10/07 5 days 3 2 37

Cirencester Coln C. difficile & Norovirus 22/10/07 21/10/07 01/11/07 11 days 15 3 83

Cirencester Beeches Norovirus 24/10/07 23/10/07 27/10/07 3 days 3 3 52 Cirencester Stratton Norovirus 23/10/07 22/10/07 28/10/07 5 days 3 2 37 Tewkesbury Avon Norovirus 16/11/07 15/11/07 26/11/07 11 days 11 2 84 Winchcombe Norovirus 20/11/07 20/11/07 26/11/07 7 days 3 1 7 Moreton Thursby Norovirus 24/11/07 24/11/07 04/12/07 10 days 11 4 10 Cirencester Beeches Norovirus 25/11/07 24/11/07 07/12/07 13 days 8 8 74 The Dilke Forest Unit Norovirus 26/11/07 24/11/07 06/12/07 12 days 14 3 47 Tewkesbury Severn Norovirus 28/11/07 28/11/07 05/12/07 7 days 7 3 37 Moore Cottage, Bourton

Erskine Norovirus 30/11/07 30/11/07 03/12/07 3 days 1 0 3

Moreton in Marsh

Thursby & Dulverton

Norovirus

12/12/07

12/12/07

17/12/07

6 days

4

2

16

Stroud Jubilee Nil 23/12/07 20/12/07 31/12/07 9 days 12 15 22

Stroud Cashes Green Norovirus 28/12/07 27/12/07 07/01/08 11 days 9 5 6

The Dilke Forest Unit Norovirus 07/01/08 06/01/08 24/01/08 16 days 17 1 59 Stroud Jubilee Norovirus 25/03/08 21/03/08 31/03/08 11 days 14 8 18

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Average % compliance with hand hygiene audits in quarter 4 of 2007-08 for all wards January 08 83% February 08 87% March 08 91%

Hand Hygiene Audit Results Quarter 4

0102030405060708090

100110

Jan-08 Feb-08 Mar-08

Month

% c

ompl

ianc

e

MoretonBourtonWinchcombeAvonSevernBeechesColnWindrushStrattonCashes GreenJubileePrincess Anne LydneyThe DilkeBerkeleySHA figure

The National Patient Safety Agency (NPSA) has provided the materials and guidance information enabling the Infection Prevention and Control Team to prepare GP’s, health centres, Sexual Health Services etc. to launch the community cleanyourhands campaign. This will result in the rest of the community being included in the campaign and will start at year 1 in September 2008. The campaign mirrors that of the acute trust which has already been rolled out in the PCT inpatient facilities. 5 Decontamination 5.1 Arrangements Chris Boden is the PCT Decontamination lead and is supported in this role by the infection control team. The decontamination lead, the DIPC and one of the infection control nurses attend the countywide decontamination committee which has reported back to the CICC. 5.2 Decontamination Action plan 2007/8 The decontamination action plan is a working document. April 2007 was the deadline for compliance with decontamination standards set out in the Health Technical Memoranda (HTM), Health Building Notes (HBN) and reiterated in the Health Act 2006. Much work has been undertaken to move toward centralised decontamination of sterile instruments. It is expected that by the end of 2008, the remaining local autoclaves will have been removed, and that there will be fully compliant decontamination facilities across the PCT or a plan for building refurbishment to achieve compliance. The issue of local decontamination in dental practice has not yet been resolved at a national level.

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5.3 Incidents and Enquiries relating to Decontamination There have been no adverse incidents relating to decontamination during 2007/08. The countywide decontamination group continued to meet sharing learning across GPCT and GHNHSFT in 2007/2008. The infection control team continue to be a point of contact for specific decontamination advice. 6 Cleaning services 6.1 Management arrangements The GPCT Hotel Services is headed by Anne Hannaford from the Care Services Directorate. The cleaning and catering services are managed centrally and in each locality a Hotel Services Manager is in post to manage the domestic services and catering at ward level. Head housekeepers or Team Leaders lead the cleaning teams in each location. Cleaning schedules are available to the public at all PCT facilities in line with the Healthcare Commission core standards and are available on the PCT website. 6.2 Monitoring arrangements The Trust uses a computerised monitoring system which complies with the National Standards of Cleanliness and the NHS monitoring forms. It is the Managers within Care Services who have responsibility to ensure that all areas are monitored against National Standards on a monthly basis. Results are forwarded to Matron’s or site managers. The data is collated centrally and the programme has the ability to produce quarterly or annual results for any particular area or type of area if the information is available. The Head Housekeepers instruct their teams in order to rectify any issues. 6.3 Budget allocation The original budgets were set following a review of the services. A management tool was used (similar to C4C which the NHS now endorses). Data was produced including measurement of areas, frequency of cleaning, floor type etc. and the hours for cleaning were calculated and budgeted for. The data has been updated as changes occur at the hospitals and the areas are staffed accordingly. 6.4 PEAT/Patient forum inspection results and user satisfaction measures Each locality holds Patient Environment Action Groups on a two monthly basis. This is attended by Hotel Services Managers, Matron, Ward Managers, Infection Control Lead (for the hospital) and a patient representative. The patient representatives are encouraged to carry out cleanliness audits, eat a meal with the patients, discuss the environment with patients and report back at the PEAG meeting. Results of PEAT scores are given in 8.2. 6.5. Cleaner hospitals (PEAT scores) PEAT VISITS. The infection control team joined the PEAT visits to the community hospitals. The 2007 results show an improvement over previous years across the county. A new category for Privacy & Dignity was added this year 2008 and Cleanliness is now categorised as Environment.

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Gloucestershire PCT Hospitals PEAT visit scores Community Hospital Year Cleanliness/

Environment Food Privacy &

Dignity Berkeley Hospital 2008

2007 2006 2005 2004

EXCELLENT EXCELLENT EXCELLENT EXCELLENT ACCEPTABLE

EXCELLENT EXCELLENT GOOD EXCELLENT GOOD

EXCELLENT

Stroud General Hospital 2008 2007 2006 2005 2004

EXCELLENT EXCELLENT GOOD EXCELLENT ACCEPTABLE

EXCELLENT EXCELLENT EXCELLENT EXCELLENT GOOD

EXCELLENT

Cirencester Hospital 2008 2007 2006 2005 2004

GOOD EXCELLENT EXCELLENT EXCELLENT GOOD

EXCELLENT EXCELLENT EXCELLENT GOOD ACCEPTABLE

EXCELLENT

Moore Cottage Hospital 2008 2007 2006 2005 2004

EXCELLENT EXCELLENT EXCELLENT EXCELLENT GOOD


EXCELLENT

Moreton District Hospital 2008 2007 2006 2005 2004

GOOD EXCELLENT GOOD GOOD GOOD

EXCELLENT EXCELLENT GOOD GOOD GOOD

EXCELLENT

Fairford Hospital (inpatient beds closed 2006)

2006 2005 2004

(Beds closed) EXCELLENT ACCEPTABLE

(Beds closed) EXCELLENT GOOD

Tewkesbury Hospital 2008 2007 2006 2005 2004

EXCELLENT EXCELLENT ACCEPTABLE ACCEPTABLE GOOD

EXCELLENT EXCELLENT GOOD EXCELLENT POOR

EXCELLENT

Winchcombe Hospital 2007 2006 2005 2004

GOOD ACCEPTABLE GOOD GOOD

GOOD EXCELLENT EXCELLENT GOOD

Dilke Memorial Hospital 2008 2007 2006 2005 2004

EXCELLENT EXCELLENT EXCELLENT EXCELLENT EXCELLENT


EXCELLENT

Lydney & District Hospital 2008 2007 2006 2005 2004

EXCELLENT EXCELLENT EXCELLENT EXCELLENT EXCELLENT

EXCELLENT EXCELLENT GOOD GOOD GOOD

EXCELLENT

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7 Audit 7.1 Extent of audit programme The CIPCT have continued to undertake a rolling programme of infection control audit using the ICNA Audit tools for monitoring infection control guidelines within the community settings, September 2005, focusing on the environment and hand hygiene. In addition to auditing the community hospital and mental health sites, the team audited a selection of dental and general practice surgeries using the West Midlands ICNA audit tool (1985). The areas audited are given a percentile score, and a score of 75% is acceptable. The table below shows the number of audits undertaken in each area of the county and the mean average score for those areas: 7.2 Clinical Infection Control Audits

Region Area audited Number of audits Average Score C&T Hospital clinical areas 7 74% Health Centres/GP Surgeries 6 74% Dental surgeries 1 78% C&V Hospital clinical areas 24 92% Health Centres/GP Surgeries 6 88% Dental surgeries 3 91% WG Hospital clinical areas 11 85% Health Centres/GP surgeries 7 79% Dental surgeries. 1 83% Tetbury Charitable Trust

Clinical areas. 5 89%

In addition the team are involved in a countywide podiatry services audit. 7.3 Common themes arising from audits Listed below are some common themes that have arisen from the audits undertaken. Many issues are able to be addressed immediately by the local teams; where this is not possible or there is wider learning, matters are taken to the Community Infection Control Committee, Matron’s Charter Group, and/or Risk Group.

a) Hospital clinical areas. General condition of the care environment that requires remedial work, redecorating etc. High level dusting and a general review of cleaning schedules that has now been undertaken with cleaning schedules now available for visitors to clinical areas to access. Non compliant hand hygiene facilities. This issue resulted in a PCT wide audit of hand hygiene facilities with a representative from Estates involved and a plan of work/costing to update and install hand wash basins.

b) Health Centres / GP surgeries. Waste issues. The availability of soft toys in waiting areas and consulting rooms. Soft furnishings. Carpet in clinical areas. Surgery cleaning issues. Sharps box labels not completed. Non-compliant hand washing facilities. No COSHH data sheets.

c) Dental surgeries. Poor waste segregation. Inappropriate decontamination areas which often took place in the same room as treating patients. No disinfection policy.

ITEM 7


No hypochlorite for blood spillages. No liquid soap for hand hygiene. No clearly defined clean and dirty areas.

7.4 Audit focus for 2008/9 The themes for audits in the community hospitals for the coming year 2008/2009 will be Sharps and Waste management. The detailed tools to be used have been adapted from the ICNA Audit tool for monitoring infection control within community settings (September 2005). For GP surgeries and dental surgeries, next year’s audits will be undertaken using the West Midlands tool as it encompasses all elements of infection prevention and control. 8 Training activities 8.1 Inductions and Mandatory updates for all staff Groups of staff that have attended these sessions have included trained and untrained Nursing staff, District Nurses, Practice Nurses, Porters, Voluntary Workers, Clerical Staff, Hotel Services Staff, Podiatrists, Community and Acute Mental Health Staff, Physiotherapists, Doctors, Occupational Therapists, Radiographers, Theatre Staff, Podiatrists, Speech and Language Therapists. It should be noted that between July 2007 and March 2008 a 160% increase in the number of mandatory update sessions were provided by the CIP&CT. The team continue to input into the curriculum and deliver sessions on community aspects of infection control on the course entitled ‘Certificate of Professional Studies Principles of Infection Control’ at the University of Gloucestershire. This course was set up in conjunction with the acute infection control team and the University. Over the last three years 18 PCT employees have completed this course. A total of 87 sessions were delivered with 4 sessions cancelled due to the floods in July 2007. There was a total attendance of 1528 staff. 8.2 Study days. The CIP&C Team provided a number of specific education days/sessions as follows: Gloucestershire PCT sites:

o July 2007: Infection control half day study day for Podiatrists o November 2007: Half day infection control presented to Dental Staff o February 2008: Infection Control Focus Update Study Day

8.3 Continual Professional Development o Natalie Matthews completed her Post Graduate Diploma in Infection control in June

2007. o Sarah Hardy attended the IPS Conference at Brighton in September 2007. o Sarah Hardy and Sam Lonnen attended a C. difficile workshop in Birmingham in

November 2007. o Sarah Hardy and Rebecca Walder attended the Infection Prevention Society

Community Networking and Education Study day in Northampton in February 2008. o A monthly Continuous Professional Development session has been running this

year, attended by the whole team, reviewing articles from the Journal of Hospital Infection.

2gether NHS Foundation Trust for Gloucestershire Annual Report of the Director of Infection Prevention

and Control 2007/08 Executive summary - Overview of infection control activities in the Trust During 2007/08 Gloucestershire Partnership Trust had an active infection prevention and control programme that built on the successes of the 2006/07 programme. Infection control remained a trust priority and the service within the trust was strengthened. This report provides evidence on how this service was strengthened, details the activity over the last year and looks forward to the plans for the trust, re-launched as the 2gether NHS Foundation Trust for Gloucestershire, for 2008/09. Infection Prevention and Control activities have centred around ensuring appropriate infection control infrastructure is embedded within the trust, education, audit, and measures to control the risk of Legionella, all under the umbrella of ensuring compliance with the Hygiene Code (Health Act, 2006, revised January 2008). The infection control team work closely with the infection control lead within the 2gether trust to ensure a comprehensive infection control service provision, which is particularly important for both patient safety and in the current political context, for trust assurance. The work programme for 2008/09 will further strengthen the trust’s position with regard to infection control and the programme is included as Appendix 1. Description of infection control arrangements Since the Department of Health document ‘Winning Ways’ was published in 2003, all trusts have been required to appoint a Director of Infection Prevention and Control (DIPC). This ensures that there is a person/persons with responsibility within the trust who can oversee all aspects of infection prevention and control. The DIPC role is held jointly between Dr Philippa Moore, Consultant Microbiologist and Infection Control Doctor and Hazel Watson, Director of Nursing. This enables the requirements of the DIPC role to be fulfilled by their respective expertise. The Trust has a service level agreement (SLA) with Gloucestershire PCT for the provision of infection prevention and control support from the community infection control team. The PCT contributes a quarter of the funding toward the established team consisting of one band 8a lead infection control nurse, Sam Lonnen, 2 band 6 qualified and experienced infection control nurses, Sarah Hardy and Natalie Matthews, one band 5 nurse, Rebecca Walder, (band 6 on completing infection control training) and secretarial support (post recently readvertised and offered to Sylvia Price who will start on 30th June 2008). In addition, 0.75 PA’s of an Infection Control Doctor have been funded, rising to 1.25 PA’s from April 2008 to account for the additional work inherent in the DIPC role and increase in infection control activity due to the requirement for compliance with the Hygiene Code.

Within the 2gether trust, the infection control lead, reporting to Hazel Watson, is Tina White, Matron Manager for Rehabilitation Recovery Services who took over from Sue Coombs on her retirement in September 2007. Liaison with clinical areas In order to facilitate liaison with all clinical areas, the infection control nurses are undertaking clinical visits on a monthly basis. This new development for 2008/09 will further strengthen infection control arrangements. The aims of the visits will be:

• To enable facilitation of the Trust’s compliance with Department of Health’s initiatives and legislation, Better Standards of Health, the Health Act (2006), cleanyourhands campaign and Essential Steps to Safe to Safe Clean Care.

• Dissemination of best infection prevention & control practice and to monitor compliance with Infection Control Policies.

• To strengthen and forge improved links between the Infection Prevention and Control Team and Clinical Staff at all levels.

• To provide on site advice and support to reduce any potential risk(s) of transmission of healthcare acquired infections.

• To develop and support Infection Prevention and Control Link staff (ICLinks) from each clinical area/specialty.

• To engage in informal education/discussion on infection control issues affecting the community hospital facilities.

Allocation of nurses will be: 2gether Foundation Trust for Gloucestershire Sarah Hardy Natalie Matthews Rebecca Walder Sam Lonnen Westridge Wotton Lawn units -

Dean Kingsholm Ward Priory Ward Greyfriars PICU – secure unit

Montpellier Unit – low secure

Charlton Lane - Bourton Leckhampton Sezincote

Holly House Laurel House St Mary’s The Vron Honeybourne What the Infection Prevention and Control Nurse will provide during their Clinical Visit

• To be the main contact for the facility that they cover • Attend department meetings if invited • Meet with the Matron • Informal observation of practice in clinical areas • Provide informal education • Follow up and support during outbreaks • Feedback to the team any alterations to buildings or planned new

builds • Promoting Multi-discipline contact • Review Infection Control Standards in Outpatients especially minor

operations • Conduct annual Infection Control Departmental Audits

• Link up with the Infection Prevention and Control Link staff (ICLinks) • Facilitate best Infection Prevention and Control Practice by

empowering ICLink’s • Provide question and answer sessions for staff • Promote the use of the Trust Infection Prevention and Control intranet

site • To circulate important Infection Prevention and Control Journal articles

of interest • To raise awareness of important Infection Prevention and Control

initiatives • To provide Infection Prevention and Control information to Patients and

Relatives where appropriate

Infection Control Committee (ICC) Prior to 2007/08, Gloucestershire Partnership Trust attended the joint PCT infection control committee. This committee however was heavily focussed on the higher risk PCT areas and the specific needs of mental health did not have priority. Therefore an independent Trust infection control committee was formed from the start of 2007/08. This committee meets quarterly and has a subcommittee (the Focus Group) that ensures committee decisions are acted on. Claire Gribbon provides secretarial support to these committees. Communication with other infection control committees within the county is maintained via Dr Philippa Moore who attends the GHNHSFT ICC, GWAS ICC and, together with the infection control team, GPCT ICC. Formation of a county wide ICC chaired by Dr Shona Arora, GPCT Director of Public Health has been agreed but has stalled with GPCT reorganisations. The committee is aimed at bridging the gaps between trusts in the county and social services. Once reformed the 2gether trust will have a representative on the committee. Infection Control Focus Group This is a subcommittee of the infection control committee and is chaired by Tina White. The infection control focus group is attended by the infection control team, other Matron Managers, Hotel Services and the medical liaison, Dr Toby Moate. This group ensures that the decisions of the committee are acted on and ensures that there is a cascade of infection prevention and control information and advice to all staff groups. This group is also involved in the planning and implementation of the cleanyourhands campaign and the launch of Essential Steps (see below). Reporting to the Trust Board Infection control reports are taken to the Board on a quarterly basis. Reporting is by one of the Directors of Infection Prevention and Control, Hazel Watson and/or Philippa Moore. Links to Clinical Governance/Risk Management/Patient Safety Links have been established with the Clinical Governance committee. Attendance by the Director of Infection Prevention and Control is as required by the agenda. The Infection Prevention and Control team lead attends the Risk Management/Patient Safety meetings as required.

Healthcare Associated Infections (HCAI) MRSA Gloucestershire county had a target to ensure that there were no more than 18 MRSA bacteraemias (blood stream infections) in patients during 2007/08. This target was not achieved and there were 36 bacteraemias during the year. The target for the next 3 years is to ensure that there are no more than 18 bacteraemias per year. This requires collaboration between GHNHSFT and GPCT to jointly reduce the risk factors for this potentially fatal infection. The 2gether trust has not contributed to these infections as there have been no MRSA bacteraemias in the trust over 2007/08. Risk factors for development of MRSA bacteraemia include being colonised with MRSA or having an MRSA infection other than in the blood stream (non bacteraemic infection). There were 4 newly identified cases of MRSA colonisation within the trust during 2007/08. Therefore the trust must remain vigilant to ensure that appropriate infection control policy and procedure is followed to minimise the risk of patient acquisition of MRSA with the subsequent risk of infection including bacteraemia. Consideration was given as to whether admissions to the 2gether trust should be routinely screened for MRSA but given the low rates of incidence the infection control committee concluded that there would be a poor return from this strategy. Any patient transferred from GHNHSFT known to have MRSA in the past is screened so that appropriate infection control precautions may be taken. The fact that GHNHSFT and GPCT community hospitals have introduced admission screening for all emergency and elective patients means that patients who are MRSA positive in the county are now more likely to be identified and decolonised. This will significantly reduce the risk of MRSA positive patients being transferred to the 2gether trust. Clostridium difficile Gloucestershire has had relatively high rates of C. difficile diagnosed mainly within GHNHSFT. This trust has achieved a 20% reduction in numbers of cases in inpatients and there has been a further 30% reduction in inpatients in PCT community hospitals. Cases diagnosed in General Practice have remained relatively stable averaging 14 per month. The county now has a target set by the Strategic Health Authority to reduce C. difficile cases to 3.7/1000 acute trust admissions within a total of 7.84/10,000 population over the next 3 years until 2010/11. This is a requirement for a substantial decrease of over 50% across the county. The 2gether trust contributes relatively few cases to the county totals. During 2007/008 there were 4 episodes of C. difficile among 3 patients (one patient relapsed more than 28 days after his initial diagnosis and therefore is counted as 2 episodes). Nevertheless the trust must remain vigilant ensuring that any cases are adequately cared for with appropriate infection control precautions, and that risks for development of C. difficile are minimised by appropriate antibiotic prescribing, hand hygiene and the use of standard precautions.

Glycopeptide Resistant Enterococci There is additional mandatory reporting of GRE bacteraemias. These are most commonly diagnosed in complex surgical and renal patients. The 2gether trust has not so far had a patient with GRE bacteraemia. Outbreaks and Incidents There have been no outbreaks of infectious disease or incidents reported to infection control during 2007/08. Hand hygiene • Implementation of ‘cleanyourhands’ The 2gether trust has signed up for the first wave implementation of the community cleanyourhands campaign which mirrors the campaign launched in acute trusts approximately 4 years ago. The campaign promotes hand hygiene at the point of clinical care, providing facilities for hand hygiene with point of care hand rub or hand wash facilities, posters reminding staff to clean their hands, and patient and visitor involvement with promotional material with the message ‘It’s OK to ask’. The campaign materials will be made available by the National Patient Safety Agency from July 2008. The campaign will start in all inpatient ward areas initially but will roll out to include all 2gether trust services through 2009/10. The timing of the campaign will coincide with the community launch in Gloucestershire PCT allowing joint promotion of the campaign to the public. This should also coincide with the launch in most PCTs and mental health trusts nationally. Additionally the campaign will be supplemented where appropriate with promotional material developed locally by the infection control team including the ‘Five Opportunities for Hand Hygiene’ posters and the ‘Stop, clean your hands’ posters. • Implementation of ‘Essential Steps’ Essential Steps to safe, clean care provides a framework for healthcare workers to use in facilitating best clinical practice to prevent and manage the potential spread of infections and ultimately improve patient and service use safety. It is a series of audit tool kits that have been designed to ensure that the correct actions are completed with all patients/service users every time they receive treatment or care. It aims to provide high reliability of key clinical procedures and care processes to reduce the risk of healthcare associated infections. There are several areas of focus and the ones of relevance to the 2gether trust are:

o Preventing the spread of infection o Hand Hygiene o Urinary catheter care o Enteral feeding (rarely but occasionally applicable) o Aseptic technique o Peripheral cannulation

There are additional modules on isolation of healthcare associated infections, rarely applicable to the 2gether trust, and patient screening (not applicable).

The tools allow monitoring of compliance to best practice with feedback to improve reliability. The use of these tools also reinforces the message of the cleanyourhands campaign. Cleaning services Cleaning services across the trust are under the overall supervision of Anne Hannaford of the PCT. Each area has a cleaning manager to oversee the work. The results of PEAT scores indicate an improvement in environmental cleanliness and provision of food for the areas. 2008 results are not yet published although assessments have been completed. The infection control nurses join the PEAT inspections to look at environmental compliance. Site 2006

Environment2006 Food

2007 Environment

2007 Food

Charlton Lane Excellent Good Excellent Excellent Colliers Court Good Good Excellent Excellent Holly House Excellent Excellent Excellent Excellent Weavers Croft Excellent Excellent Excellent Excellent Wotton Lawn Excellent Good Excellent Excellent Additionally cleanliness audits are conducted internally on a monthly basis. All inpatient areas and clinical areas have achieved 90% or over in these audits with the exception of Sezincote ward. Cleaning issues have been highlighted for attention in this area. Additionally Hotel Services have put together plans for ongoing yearly deep cleans of clinical areas in line with national requirements/recommendations. SHA monies have been used to purchase additional steam cleaning equipment which is useful for its anti MRSA and C. difficile effects. The use of vaporised hydrogen peroxide equipment has not been validated in mental health trusts and the trust took the decision not to use this technology in the cleaning programme. Policies The 2gether trust has policies that cover the full range of requirements set out in the Hygiene Code. These are currently being updated and tailored to the needs of the 2gether trust. The policies currently being updated include:

o Care of the patient with MRSA o Outbreak Management o Hand Decontamination o The A to Z of Decontamination o Care of the patient with Clostridium difficile o Linen and Laundry o Standard Precautions o Sharps Management

The 2gether trust will also adopt the PCT antibiotic management guidelines which will be formatted according to trust guidelines.

Guidelines and other infection control information is included in the trust website on infection control. Audit The theme of the 2007/08 audit programme was the environment and hand decontamination and the inpatient units were audited with a new in-depth audit tool from the Infection Prevention Society (formerly Infection Control Nurses Association). The range of properties audited was expanded compared to previous years. Scores were allocated and a traffic light system used for reporting. Scores of 85% or more were green, 60-84% amber and 59% or less red. Altogether 18 inpatient areas or wards were audited. The average score was 77.6%. 2 areas scored red, 9 amber and 7 green. The scores are shown in the graph below. It should be noted that scores for units cannot be compared against one another and cannot be compared against previous years as each unit is different and the audit tool has changed over the period. The scores reflect the fabric of the building as well as practice such that higher scores are more easiliy attainable in some areas. Nevertheless as a whole the audit results indicate that the trust is maintaining standards but has issues to address in some areas. Those areas (The Vron and Sezincote) with a low score in the red range were in a poorer general state of repair than others and cleaning issues needed to be addressed. For all areas an action plan to resolve issues highlighted was requested.

Audit results

0

20

40

60

80

100

120

Leck

hampto

n War

d

Bourto

n War

d

Sezinc

ote W

ard

Day H

ospit

al, C

harlto

n Lan

e

Wea

vers

Croft

Collier

s Cou

rt

Kingsh

olm W

ard

Greyfr

iars W

ard

Priory

War

d

Abbey

War

d

Dean W

ard

Montpe

llier U

nit

Holly H

ouse

Wind

rush

by D

elanc

y

91B H

uccle

cote

Road

Honey

bour

ne

St. Mar

y's

Laur

el Hou

se

The V

ron

Hollyb

rook

e

Wes

tridge

Scor

e % 2005-06

2006-072007-08

The 2008/09 programme will focus on sharps management and waste disposal. Estates and the Control of Legionella During 2007/08 a programme of risk assessments for Legionella control has been commenced once it became clear that the Estates department could not provide assurance of controls. This risk assessment programme has been completed in the major inpatient areas and has highlighted issues for action.

Relatively few works are required and most of the requirements highlighted by the assessments are around the need to put in place an effective planned preventive maintenance schedule. Costs for the works that have been identified are being calculated and will be submitted to the Board. Richard Butt Evans is leading for the 2gether trust on this work together with Philippa Moore in conjunction with the Estates Shared Service and NALCO, a company that won the tender for the risk assessments countywide. Additionally the cost of the planned preventive maintenance schedule is to be calculated and is likely to need to go out to tender as the Estates department will not have the capacity to undertake all work. Infection Prevention and Control Education All staff are required to attend infection control training as part of annual mandatory update. The team provide training for all members of staff but uptake has not been 100%. Additional options of e-learning are being explored since these packages are now considerably better than previously and may allow staff who are currently finding attendance difficult to complete update training at more convenient times to them. This is an important area that has been highlighted by Healthcare Commission and Department of Health reports to other trusts. The 2gether trust is committed to ensuring that the trust is fully compliant with this mandate. It is recognised nationally that infection prevention and control, as everybody’s business, can only be effectively promoted and embedded within a trust if the trust management are supportive. This is because implementation of infection control policy and procedure has to be part of the delivery of patient care at every level. The 2gether trust management have always been explicitly supportive of the infection control agenda. A half study day for managers was held on April 3rd 2007 to provide education tailored to managers on the requirements of this agenda including the requirements of the Hygiene Code. This study day was well received and helped to foster relations and an understanding between managers and the infection control team. An infection control study day for care staff took place on February 14th 2008 to which 2gether trust staff were invited. This day received excellent participation feed back and another day will be organised for late 2008 or early 2009. The infection prevention and control team also require continuous professional development. To this end they have a regular journal club to discuss peer reviewed published articles, attend national conferences including Compliance with the Health Act 2006 The 2gether trust is compliant with the Health Act requirements. Additional supportive work as outlined in the 2008/09 work programme will address areas that require strengthening.

Conclusions Patients, the public and staff of the 2gether NHS Foundation Trust for Gloucestershire can have confidence that the trust is taking its responsibility for infection prevention and control seriously. The trust has considerably strengthened its infection control activity during 2007/08 providing an excellent basis to enter 2008/09 with an expectation that best practice will be followed. The key area to improve on is to ensure that all staff have infection control education annually. Additionally there are further works to be completed by the Estates department to ensure full compliance with the mandatory control of risks associated with Legionella. Full compliance will require additional funding and will be assessed as the risk assessments on properties are concluded. The trust can be satisfied that the infrastructure in place can deliver the improvements where required internally, and that there is a mechanism in place to look at the needs around the Estates infection control requirements. Philippa Moore Joint Director of Infection Prevention and Control 6th June 2008

Authors: Dr. J.W.Stone (DIPC) and Lorna Robinson (Lead Nurse/Matron Infection Control)

GLOUCESTERSHIRE HOSPITALS

NHS FOUNDATION TRUST

INFECTION PREVENTION AND CONTROL ANNUAL REPORT

2007-08

Infection Prevention and Control Annual Report 2007-08

1. SUMMARY

2007-8 has been a year of great change for GHNHSFT with regard to infection prevention and control. Much progress has been made implementing the principles outlined in key national documents relating to the minimisation of levels of Healthcare Associated Infection (HCAI). There has been an increasing recognition within all levels of the organisation that infection prevention and control is everyone’s business. The Divisions and Directorates are becoming increasingly involved in implementing infection prevention and control actions and taking ownership and responsibility for infection prevention and control issues. The Trust Board is committed to minimising levels of HCAI and has been very supportive to the Infection Control Team (ICT) and the associated Directors in progressing improvements in the prevention and control of healthcare associated infection. The ICT has undergone some changes in the past year and the way it has taken forward actions within the Trust has been facilitated by alterations in the accountability arrangements for infection prevention and control. 2007-8 has also seen the publication and implementation of the Health Act 2006 (Hygiene Code of Practice) that sets wide-ranging and high standards for Infection Prevention and Control that the Trust is expected to be compliant with. The Trust will be assessed against these standards by the Healthcare Commission. In 2007 the Saving Lives delivery programme is being revised and reissued by the Department of Health to take into account the standards of the Hygiene Code. The Hygiene Code also covers areas of infection prevention and control that overlap with other departments / specialties such as Property and Medical Engineering, Hospital Cleaning and Decontamination of Equipment and Medical Devices. Since October 2006 the Trust Board receives a regular update on infection prevention and control from the Director of Infection Prevention and Control, the Lead Nurse/Matron Infection control, and the Trust Lead for Saving Lives The Trust Board has received regular progress report papers on infection prevention and control since October 2006. This report summarises the key issues and progress on infection prevention and control within the trust, and places an emphasis on infection control issues and outcomes within the whole organisation rather than focusing on the activities undertaken by the Infection Control Team.

2. INFECTION PREVENTION AND CONTROL ACCOUNTABILITY Infection prevention and control lines of accountability within GHNHSFT are as summarised

below. On-call Senior Management and microbiology support is available for infection prevention and control emergencies arising out of hours.

GHNHSFT: ACCOUNTABILITY CHART

The designated infection control lead is the Director of Infection Prevention and Control (DIPC) Dr James Stone, who has access to the Trust board via the Nursing and Medical Directors and has regular formal one-to-one meetings with the Chief Executive.

Cheryl Haswell Saving Lives

Lead (1WTE)

Saving Lives Practice & Educator

(1WTE)

Dawn Collinson

(1WTE)

Sean Elyan Medical Director

Dr Frank Harsent Chief Executive

Maggie Arnold Director of Nursing

Dr James Stone Director of Infection Prevention and

Control & Infection Control Doctor

(1WTE)

Lorna Robinson Lead Nurse/Matron

Infection Control (1WTE)

Lesley Chandler Senior Infection Control Nurse

(1WTE)

Marion Johnson Eve Spires

Coral Boston Kath Pitts

Trainee Infection Control Nurse x4

(3WTE & 0.6WTE)

Dr Rob Jackson Infection Control

Doctor (1WTE)

Helen Gornall Surveillance

(0.6WTE)

PA (0.5WTE)

2.1 Infection Control Committee Since September 2007 there has been an Infection Control Committee (ICC) which first met

fortnightly, but now meets on a monthly basis. The flowchart below shows the relation of other important groups which link into the ICC on a regular basis, and it must be noted that a representative from these groups always attend the ICC meetings.

2.2 Infection Control Team and Affiliated Members

The GHNHSFT infection control team (ICT) is composed of infection control personnel who work between three sites currently based at Gloucestershire Royal Hospital, Cheltenham General Hospital and Delancey Hospital.

The current team members are as follows: • Dr. James Stone, Director of Infection Prevention and Control, Consultant Microbiologist

and Infection Control Doctor • Dr. Robert Jackson, Consultant Microbiologist and Infection Control Doctor • Lorna Robinson, Lead Nurse/Matron Infection Control • Lesley Chandler, Senior Nurse Infection Control • Dawn Collinson, PA to Lead Nurse/Matron and Secretary to the Infection Control Nurses • Helen Gornall, Infection Control Surveillance Nurse • Marion Johnson, Trainee Infection Control Nurse • Coral Boston, Trainee Infection Control Nurse • Eve Spiers, Trainee Infection Control Nurse • Kath Pitt, Trainee Infection Control Nurse • Margaret Lamont, Bank Support Nurse 2007/08 has seen many changes take place within the team, and the current members would like to acknowledge the contribution made by former members throughout 2007/08. These individuals include Mrs Patsy Tandy, Lead Nurse Infection Control; Mrs Lucy Bocock, Senior Infection Control Nurse; Miss Susan Little, Infection Control Surveillance Nurse; Mrs Nicola Tandy, Trainee Infection Control Nurse; and Maria Tredinnick, Infection Control Support Nurse. It is recognised with the constant influx of work passed onto the team, there are areas which need the assistance of others, and those that are willing and have an interest in infection control have come forward to help. Therefore, in the interim the Surgical, Medical and Corporate directorates have appointed nursing clinicians who take a lead in their division for certain activities which involve infection control activities. It is important to mention them as when necessary they can offer support to the members within the ICT.

The following clinical nurses who are taking a lead within their divisions are: Alli Patchett – Saving Lives Practice Educational Corporate Division Tina Law – Support Nurse for the Surgical Division Fiona Campbell – Infection Control Co-ordinator for the Medical Division Cheryl Haswell – Trust Lead for Saving Lives Corporate Division

Education and Training The ICT continue to be part of the mandatory training sessions run by the Training and Learning Department. In addition to this the Consultant Microbiologists deliver extra sessions for staff on infection control, in order to achieve a more acceptable level of attendance at Trust teaching sessions which is a statutory requirement. The ICN’s have also taken part in extra Mandatory sessions; these include supporting the Role Transition Nurses, 1st year student nurses, THE Band 5 development programme and delivering infection control sessions to Lead HCA’s at Hartpury College. In the immediate future education and training in infection control will be taking a different direction, combining a dual approach of E-learning supported by ward based education delivered by the ICN’s. This can of course only be achieved with the increased presence of the ICN’s during clinical visits, which we are endeavouring to undertake on a daily basis. The ICT worked closely with Yvonne Robertson, Assistant Director of Nursing (Education) since autumn 2006, who provided valuable help with infection prevention and control project management within GHNHSFT and helped promote ownership and responsibility for infection prevention and control amongst the restructured divisions and clinical teams. Part of this role has now been passed to Cheryl Haswell, Trust Saving Lives Lead who works collaboratively alongside the members of the infection control team.

2.3 Links with multi-disciplinary groups It is recognised in order for Trust employees to be empowered and take accountability for infection control activities, it is vital members of the ICT advise key people from certain groups on infection control activities. Currently the ICT attend a variety of groups within the Trust and these include: • The Clean Your Hands Campaign Group • The Matrons Charter Group/Patient Environment Action Group (PEAG) • Trust Decontamination Group • Senior Nurse Committee (SNC) • Site Specific Lead Nurse Meetings • Health and Safety Committee • Waste Group • Occupational Health Forum • Pandemic Flu Group • Freedom of Information Group • Water, Environment and Buildings (WEB) Group • Legionella Action Group (LAG)

3. CLOSTRIDIUM DIFFICILE-ASSOCIATED DISEASE (CDAD)

Mandatory surveillance data for CDAD has been published on an annual basis by the Health Protection Agency (HPA) on behalf of the Department of Health (DoH) in calendar years since 2004. Historically this has been expressed as rates of infection for the over 65s in acute trust inpatient beds. All patients in the county over the age of 65 years who have unformed faeces samples submitted to the Microbiology Department are tested for Clostridium difficile toxin. All positive results are reported to the Health Protection Agency (HPA) so that a rate of infection can be calculated using denominator data for GHNHSFT inpatients. The rate of CDAD attributed to GHNHSFT as calculated by this means rose sharply between 2004 and 2005. Both the number of episodes of CDAD and the rate of infection are relatively unchanged in 2005 and 2006 and remain very high compared with other acute trusts in England. Even taking into consideration the fact that somewhere between 20-33% of the positive results are from samples submitted from patients in non-acute trust facilities the level of infection in GHNHSFT in 2006 was high. The published CDAD mandatory surveillance data on the HPA website is as follows for GHNHSFT for 2004-6:

2004 2005 2006 763 episodes 1073 episodes 1058 episodes 2.82 (rate) 3.97 (rate) 3.91 (rate)

The rate for the whole of England in 2006 was 2.39. The rate of CDAD infection for GHNHSFT was the 15th highest of all acute NHS Trusts in England. The level of CDAD within GHNHSFT was reported as a serious untoward incident (SUI) associated with infection in 2006. An incident meeting in July 2006 was attended by the Regional Epidemiologist and a review of control measures was undertaken. It was concluded that many correct control measures had been instituted but that some of these had been ineffective and additional interventions were likely to be necessary. Initial measures included:-

• Production of a new infection control policy for Clostridium difficile incorporating recently produced best practice guidance from the Dh

• Launch of the policy and supporting educational sessions • Getting better antibiotic usage data • Revising the antibiotic guidelines • Work on environmental cleaning and disinfection and agreeing standard common

definitions for cleaning terminology • Awareness raising amongst clinical staff about CDAD • Emphasis on the need for correct hand hygiene for staff attending CDAD patients • Reiteration of advice to reduce overall antibiotic use

Supplementary measures were recommended in the SUI meeting:-

• Further revisions to the antibiotic guidelines to reduce use of higher risk antibiotics, in particular the quinolones (ciprofloxacin and levofloxacin).

• Repeated requests to clinicians to reduce unnecessary antibiotic use • Enhanced cleaning introduced and deep cleans of wards being performed at GRH when

they are decanted for refurbishment • Creation of CDAD cohort wards to help minimise transmission of CDAD on all wards and to

compensate for a relative lack of isolation facilities, particularly on the CGH site • The facilities on the Hazleton ward cohort facility were improved by building a partition

across the main ward to facilitate patient segregation. Hand washing facilities upgraded at the entrance to Hazleton ward to promote hand washing with soap and water of individuals entering the ward

• Commode replacement programme following CDAD audit The CDAD cohort wards (Hazleton ward at CGH, and Ward 6A at GRH) have been in operation since January 2007. Extra staff have been employed to support the operation of these facilities. There is an ongoing commitment from the Trust Board to continue to keep both cohort wards open until there is sustained fall in levels of CDAD. The DoH HCAI improvement team expressed an interest in visiting GHNHSFT along with several other organisations to gather information to inform best practice guidance on CDAD control. This visit took place in May. Feedback from the visit by the DoH team included recommendations to improve mattress decontamination and replace any damaged mattresses. The team also reminded the trust of the importance of revising the antibiotic guidelines, and checking compliance with the guidelines through audit. The effectiveness of control measures including the introduction of the cohort wards can be seen on the levels of acute trust inpatients who have CDAD. Levels are being monitored and reported internally on a monthly basis both to the Pharmacy Antibiotic Group and the HCAI Steering Group. Levels of infection in the first few months of 2007 showed a rise compared with the last few months of 2006. The level of CDAD in the first 5 months of 2007 peaked in April but was significantly lower than in the same period of 2006. There is a seasonal pattern to levels of CDAD with a peak occurring in late winter / spring each year. This is linked to increased levels of hospital activity with high bed occupancy.

Number of inpatient cases of toxin producing clostridium difficile GHNHSFT - post 48hr samples only(Data source: HCAI website submitted data)

0

10

20

30

40

50

60

Num

ber o

f Inp

atie

nt C

ases

GRH 26 22 13 8 11 10

CGH+DEL 14 6 9 10 14 6

Post 48hr cases (Total) 40 28 22 18 25 16

Post 48hr target 48 33 32 27 27 26 25 24 31 33 33 33

Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09

Clostridium difficile toxin positive samples.

Inpatient Clostridium difficile toxin positive samples – all age ranges

(de-duplicated 28 days) Numerical Summary September 2008 Total Pre 48 hour Post 48 hour GRH 13 4 10 CGH 14 6 6 DEL 0 0 0 GHNHSFT 27 10 16

The data expressed as a rate of infection is shown in the following graph.

CDiff Incidence Rate per 1000 Inpateint Beddays at Acute Sites by Specialty

0

1

2

3

4

5

6

Jul 06 - Sept 06 Oct 06 - Dec 06 Jan 07 - Mar 07 Apr 07 - Jun 07 Jul 07 - Sept 07 Oct 07 - Dec 07 Jan 08 - Mar 08 Apr 08-Jun 08

Period (Quarterly)

CD

iff c

ases

per

100

0Critical CareGeneral MedicineRehabGeneral SurgeryT&OOncologyHaematologyObs & GynaePaediatrics

It is felt that the cohort wards have been a successful intervention. Their introduction has also had the benefit of freeing up isolation rooms on other wards to be used for other patients who required single room facilities for other infection control purposes. The breakdown of CDAD cases by individual hospital is shown in the following graph.

total number of inpatient cases of toxin producing Clostridium difficile per hospital GHNHSFT

January 2006 - September 2008 ( Data source: IC Net)

0

5

10

15

20

25

30

35

40

45

50

Jun-

06

Jul-0

6

Aug

-06

Sep

-06

Oct

-06

Nov

-06

Dec

-06

Jan-

07

Feb-

07

Mar

-07

Apr

-07

May

-07

Jun-

07

Jul-0

7

Aug

-07

Sep

-07

Oct

-07

Nov

-07

Dec

-07

Jan-

08

Feb-

08

Mar

-08

Apr

-08

M

ay-0

8

Jun-

08

Jul-0

8

Aug

-08

Sep

-08

Num

ber o

f inp

atie

nt c

ases

GRHCGHDEL

The following table shows the rate of CDAD per quarter for each specialty

CDiff Incidence Rate per 1000 Inpateint Beddays at Acute Sites by Specialty

0

1

2

3

4

5

6

Jul 06 - Sept 06 Oct 06 - Dec 06 Jan 07 - Mar 07 Apr 07 - Jun 07 Jul 07 - Sept 07 Oct 07 - Dec 07 Jan 08 - Mar 08 Apr 08-Jun 08

Period (Quarterly)

CD

iff c

ases

per

100

0Critical CareGeneral MedicineRehabGeneral SurgeryT&OOncologyHaematologyObs & GynaePaediatrics

Those specialties with small numbers of inpatient beds (critical care, oncology and haematology) will appear to have rates of infection that fluctuate more widely as a small change in the number of infections will greatly affect the rate of infection. The Dh issued two guidance letters with regard to CDAD in 2006-7. In December 2006 a “Dear Colleague” letter was published (Gateway reference 7490) titled Healthcare associated infections, in particular infection caused by Clostridium difficile. This letter provided new operational guidance on the management of C. difficile associated disease, instructed acute NHS Trusts to agree local targets for CDAD with commissioning PCTs and advised that as from January 2007 C. difficile and MRSA mandatory surveillance data is published quarterly. The locally agreed target for CDAD for GHNHSFT for 2006-7 was 500 inpatient episodes. It also reminded Trusts about the Hygiene Code (Code of Practice on the prevention and control of healthcare associate infections) and invited Trusts to apply for £300,000 of additional capital resources (capital challenge fund) for infection prevention and control. The Trust via the HCAI Steering Group has acknowledged and responded to this letter. The Capital Challenge Fund money has been successfully secured and has been used to fund improvements to the hospital environment, and to introduce microbiological diagnostic tests that will improve the management of HCAI and detection of antibiotic-resistant infections. Part of this money has been allocated to fund more rapid diagnostic tests for CDAD. All faeces samples sent to the Microbiology at CGH that require testing for CDAD are now tested using a direct toxin detection enzyme immunoassay (EIA) test. This test is now routinely performed 6 days a week with the additional ability to perform urgent ad hoc tests out of hours as required using a rapid toxin detection test kit. This brings turnaround times for laboratory diagnosis in line with those at the GRH Microbiology laboratory. In April 2007 the Chief Nursing and Chief Medical Officers issued a professional letter (PL/CMO/2007/4 PL/CNO/2007/2) about changes to the mandatory surveillance reporting arrangements for CDAD. This letter instructed acute trusts to start reporting episodes of CDAD electronically via the HPA HCAI Data Capture System rather than electronically using Cosurv to the HPA Centre for Infections. The HCAI Data Capture System was modified in 2006-7 to allow it to record CDAD as well as MRSA bacteraemias. This change in reporting requires manual data entry onto the HCAI Data Capture System rather than automatic data transfer from the Trust’s laboratory computer system so is considerably more onerous. The fields required are those to identify the case, date of birth; sex; specimen date; reporting laboratory and location of

the patient at the time the specimen was taken. The letter also instructed Trusts to report all episodes of CDAD in patients above the age of 2 years (previously mandatory surveillance reporting for CDAD was confined to positive results in the over 65 year olds). There is however not a requirement for laboratories to change their CDAD testing criteria on submitted faeces samples in the under 65s. This new reporting system is intended to facilitate trusts being able to monitor and meet their locally agreed CDAD targets (agreed with local commissioning PCTs) and to aid capturing information on local risk factors for CDAD. Further guidance from the HPA and DoH is awaited to clarify the detailed requirements for all elements of this new reporting system. The HCAI Data Capture System for CDAD has been used by the ICT since May 2007. This new system has transferred the burden of reporting from the Microbiology Department to the GHNHSFT ICT. The new system is significantly more labour intensive and currently is not set up for separate episode reporting of non-acute Trust CDAD infections. These issues have been raised with the HPA regionally and are as yet not satisfactorily resolved. Local monitoring of CDAD hot spots has been undertaken since October 2006 and has been enhanced since January 2008 by use of the ICNet surveillance system. This monitoring consists of calculating the top ten wards for total number of episodes of CDAD per quarter across GHNHSFT. This information has been used to decide priorities for enhanced environmental cleaning.

4. HEALTHCARE ASSOCIATED INFECTION STATISTICS

METICILLIN RESISTANT STAPHYLOCOCCUS aureus (MRSA) Meticillin Resistant Staphylococcus aureus (MRSA) continues to pose a challenge to GHNHSFT. These bacteraemias continue to be reported as part of the Department of Health national mandatory HCAI surveillance. For any month in which they occur, they are entered onto the system by the 14th of the following month. This is referred to as ‘lock down’, and once entered onto the system the figures cannot be altered. This procedure is currently undertaken by the Lead Nurse/Matron Infection Control Lorna Robinson and the Trust Saving Lives Lead Cheryl Haswell, as a delegated responsibility from the Chief Executive.

Monthly Number of Cases Reported On MRSA for the Healthcare communityApril 06 - September 08

Data Source: Enhanced MRSA Web-Based Data Capture System

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23

4

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7

89

10

11

12

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thly

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TARGET

Cases for Healthcare community 6 1 9 9 7 6 8 6 5 4 4 3 6 6 4 4 1 3 3 1 1 3 3 1 3 1 1 4 1 3

TARGET 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 1.5 1.5 1.5 1.5 1.5 1.5

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Between April 2006 and March 2007 there was a rise in bacteraemias in specialities such as renal medicine (nephrology) and oncology. These bacteraemias were investigated and found the use of intravascular devices (Central Venous Catheters (CVC) and Haemodialysis lines to be significant factor. Since the problem was identified a closer working relationship developed between renal medicine and the ICT to improve practise, optimise the clinical environment and introduce a system of regular MRSA screening not only for Acute Trust patients, but also those who require dialysis treatment undertaken in the satellite units run by Fresenius. The proportion of infections occurring in most specialties was as expected with the majority occurring in medical specialties including care of the elderly (Geriatric medicine and rehabilitation). There was an excess of bacteraemias in renal medicine (nephrology) and oncology which has been investigated and was mainly related to the use of intravascular devices (central venous catheters and haemodialysis lines). Work has been done in these specialties to specifically address these risk factors and sources of infection. There has been close collaboration between renal medicine and the ICT to improve practice, optimise the clinical environment and introduce a system of regular MRSA screening. This has led to a subsequent marked reduction in the number of bacteraemias. There was also an increase in the number of trauma and orthopaedic MRSA bacteraemias compared with previous years. Some of these were probably related to surgical site infections in the trauma (emergency) patients. These patients are often elderly and may have other risk factors for being colonised with MRSA at the time of admission. With this in mind it was recommended that MRSA screening of all trauma patients on admission to CGH and GRH be undertaken. Early detection of MRSA would enable early decolonisation and isolation of patients. This would minimise cross-infection and reduce the risk of development of deep-seated MRSA infection if an operation was performed. The changes incorporated on the nephrology Ward T7B are numerous, and alongside a refurbished ward, newly designed line room for the insertion of temporary lines for acute renal dialysis failure, ward staff have fully encompassed the advice and recommendations documented in the Health Act (2006), and the Saving Lives delivery programme. Since these changes have taken place ward T7B have adopted a zero tolerance to bacteraemias by incorporating and sustaining a vigilant review of infection control practices, by undertaking education and re-education on Central Venous Catheter (CVC’s) for staff members, regular updates on MRSA, and a rolling programme of patient handwashing sessions. To this date Ward T7B have had no bacteraemias in 2008. Some of the MRSA bacteraemias were detected in patients in the Emergency Department. This raises the possibility that the infection may have been community acquired (as it was diagnosed within 48 hours of admission) however some of these patients are readmissions and it is also possible that they acquired the MRSA as a result of a recent previous hospitalisation. When such infections occur the ICT liaise with infection control colleagues in the community to assess whether the infection may be community acquired for the purposes of root cause analysis. In 2006-7 much work had been done to investigate the underlying causes and risk factors for the MRSA bacteraemias so that we have a better local understanding of the causes and can intervene to minimise the number of episodes. The ICT developed a MRSA bacteraemia enhanced surveillance tool for use locally to collect this information. This tool was introduced in October 2006 and has proved a valuable tool for capturing this information and identifying common factors and trends. The PCT is required to provide a summary of all the MRSA bacteraemia RCAs in its provider trusts by the 15th of the following month. The analysis identified issues such as specialty, location of patient at the time of diagnosis, clinical significance of the bacteraemia (a proportion of the “bacteraemias” are known not to be genuine clinical bacteraemias and are known to be due to blood culture contamination during sample collection), length of stay at the time of the bacteraemia, underlying predisposing disease, likely source (site) of infection, whether the patient was known previously to have been

MRSA positive and invasive devices in situ. The issue of contaminated blood cultures contributing to a Trust’s MRSA bacteraemia figures has been acknowledged by the DoH who have now issued guidance under the auspices of the Saving Lives delivery programme on blood culture technique. Work has also been done locally to develop instructions and a training package on blood culture technique through collaboration between the Consultant Microbiologists and the Clinical Skills Facilitator Julia Brock. This training package on blood cultures has been updated, alongside a blood culture technique policy, and clinical based teaching session undertaken by the Saving Lives Practice Educator Alli Patchett. This training resource will be used at junior doctors’ induction and will be available as an e learning resource for all members of staff. Analysis of the MRSA bacteraemias has revealed that many patients have multiple invasive devices as risk factors for infection such as urinary catheters, central venous catheters and peripheral venous catheters. For some of these patients it is likely that the invasive device led to a local infection that resulted in a bacteraemia. All MRSA bacteraemias are filed electronically and then transferred onto the Risk Department Datix system. This information is collected by the Infection Control Nurses and the Surveillance Nurse, and once this has been undertaken the RCA is sent to the consultant looking after the patient at the time of the bacteraemia, in order for them to assist in identifying the root cause and suggest actions which can be taken to prevent future bacteraemias. Initially there was some difficulty in getting full and timely input from consultant staff and senior nursing colleagues but this has improved since the Medical Director sent a letter to all consultants asking for their assistance with this process. In 2008 the Department of Health introduced a comprehensive RCA tool which GHNHSFT agreed to pilot. However, due to staff shortages within the ICT this pilot is yet to be undertaken, but it is anticipated that after successfully recruiting further staff this will be something to incorporate fully in 2009. Analysis of the MRSA bacteraemia data has informed interventions to address the identified risk factors. The identified invasive device risk factors corresponded closely with the clinical procedures in the Saving Lives High Impact Interventions (HIIs), ie urinary catheters, central venous catheters, and peripheral venous catheters. The work being done on the Action on Healthcare Associated Infection action plan has been addressing these areas. In 2006 DH issued best practice guidance on MRSA screening. This guidance has been assessed by the ICT and the former HCAI Steering Group and recommendations to introduce extra MRSA screening have been approved by the Trust Board earlier in 2007. MRSA screening has been introduced into Renal Medicine, some types of elective surgery, for all trauma admissions across the Trust, and for Haematology and Oncology patients about to undergo insertion of central venous catheters. There has also been some adjustment to the requirements for screening of patients in Critical Care. The changes to the screening have generated extra work for clinical staff and for the Microbiology department and the ICT. The extra screening is a significant rise in specimen numbers for the Microbiology department and there is recognition that the laboratories require extra resources to accommodate this increased workload. Coinciding with the expansion in MRSA screening, work has been undertaken to introduce “Staph Packs”. These are topical agents used for MRSA decolonisation of patients comprising Hibiscrub and nasal mupirocin that can be prescribed by nursing staff under a Patient Group Directive. Dr Stone has worked closely with colleagues in Pharmacy to introduce this system which should minimise errors in the prescription of MRSA decolonisation treatment, make it more readily available and ensure that patients receive decolonisation treatment without any undue delay. The packs can also be made available in outpatient settings and include a MRSA patient information leaflet.

Meticillin Resistant Staphylococcus aureus (MRSA) Screening The GHNHSFT MRSA Policy has been revised to reflect this new practice and to incorporate the constant changes in line with national MRSA guidelines and recommendations. The numbers of MRSA bacteraemias are monitored monthly by the ICC and also by the DH. GHNHSFT, like all other acute NHS trusts, has been set a target of 60% reduction of MRSA bacteraemias by 2008. When the trajectory was decided several years ago the goal was to achieve 18 MRSA bacteraemias per annum by 2008. The MRSA bacteraemia trajectory is shown in the Statistical Process Chart below. The 1st April 2008 saw the introduction of a countywide approach to screen all elective and emergency patients for MRSA. This new initiative is to try and reduce the overall burden of MRSA colonisation in patients being admitted to the Acute Trust. With this in mind we hope to reduce the burden of MRSA infections with its attendant costs, morbidity, mortality and the added distress on patients and their families. During the last quarter of 2008 the ICN’s will undertake a Point Prevalence Study to audit compliance of the new screening and compliance with the appropriate use of the MRSA care plans. The ICN’s will publish the results later in the year in order for it to be published in the December 2008 board paper.

MRSA Incidence Rate per 1000 Inpateint Beddays at Acute Sites by Specialty

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Working with the Trust Discharge Assessment Team (DAT) is a new collaboration. DAT inform the ICN’s on a daily basis, of all transfers and discharges of patients with transmittable diseases. However, this information is also used in another way, as it allows us to audit compliance with the MRSA screening protocol of all patients admitted into the Acute Trust, as they should all be screened before subsequent transfer to all Community Hospitals. An invite to attend Bed Management Meetings to discuss issues or concerns surrounding inpatient movement both in and out of the Trust, has been accepted. This has been viewed by both parties in a positive way, as historically some decisions made by the ICT e.g. Ward Closures can conflict with the decisions made by the Bed Management team who must encourage the operational status of this Trust to continue.

Statistical process chart for end point MRSA infection target

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TargetActual DataLower Action LimitUpper Action LimitLower Warning LimitUpper Warning Limit

5. INFECTION PREVENTION AND CONTROL ACTION PLANS

In Autumn 2006 the HCAI Steering Group was formed and the ICT received additional support in the form of assistance from Yvonne Robertson, Assistant Nursing Director (Education). Yvonne was given the task of developing an action plan on HCAI, particularly related to actions to reduce numbers of MRSA bacteraemias and levels of CDAD. An initial action plan titled Action on Infection Control was taken to the October 2006 main board and was revised and expanded in December 2006 as Action on Healthcare Associated Infection. This action plan was wide ranging and influenced by the findings of the CDAD Audit and the MRSA Audits that had been undertaken earlier in the year. The action plan also included a section on the Hygiene Code. The action plan areas included environment, equipment and clinical practice and increasing clinical ownership of infection control issues. A key element of the action plan was the introduction of a scheme of enhanced cleaning and deep cleans. The deep cleans were done at GRH during decant of wards to allow renovation. An analogous system of deep cleaning at CGH was not feasible as there was no spare ward to allow for decanting. To address some areas of clinical practice it was necessary to perform some additional infection control training sessions eg for ward managers, link practitioners and lead health care assistants. Educational sessions were also organised and delivered for newly identified infection control medical champions – these sessions included talks on a range of key issues by the Assistant Nursing Director (Education), Medical Director, Senior ICN and the two Infection Control Doctors. When the DH MRSA Improvement Team visited GHNHSFT in March 2007 they assessed the Trust’s action plan on HCAI and made suggestions to make it more focussed. The Trust’s Action Plan was then amended in the light of these recommendations. The Action Plan included a range of infection prevention and control audits that were devised and undertaken by clinical teams in the first few months of 2007. These audits included hand hygiene, central venous catheters, peripheral venous catheters, and urinary catheters. Following on from the DH’s visit the Trust was required to give the Improvement Team 2 weekly updates on progress with its action plan. The Assistant Nursing Director (Education) has been coordinating this feedback and collating the progress reports from the four divisions. Significant progress has been made and sustained. There has been a marked change in infection control culture amongst clinical teams, particularly amongst the nursing staff. Medical staff are also

becoming more engaged concerning infection control. The DH set a target of 85% hand hygiene compliance. The results of the most recent Hand Hygiene compliance audits show rising levels of compliance towards this target but it has not yet been achieved. Further work needs to be done to address compliance differences between sites amongst nursing staff, to get compliance amongst medical staff up to the average level for all staff groups and to significantly increase compliance in staff such as allied healthcare professionals (AHPs). The Saving Lives Group was established in autumn 2006 under the chairmanship of the Director of Nursing. A Saving Lives Action Plan was developed in January 2007 and has subsequently been refined. The action plan included local implementation of the HIIs by the divisions. Each of the divisions has now started performing the selected HIIs on a regular basis and publishing their results and displaying them within the clinical area. The divisions are aiming for 100 % compliance with all steps of the chosen HIIs. The Medical Division is using the HIIs specifically for urinary catheter care, peripheral venous catheters, and central venous catheters. Some members of the ICC attend the six-monthly meetings of the Performance Improvement Network (PIN) arranged by the Dh, who also arranges update meetings for DIPCs An Action Plan for the Hygiene Code has been developed. This is likely to be altered when the revised Saving Lives programme that has just been revised to take into account the Health Act has been assessed by the HCAI Steering Group. This Action Plan will need to complement the Health Act Action Plan being developed by the Community ICT. The action plan is necessary to ensure that the Trust has sufficient assurance that it meets all of the standards contained in the Code of Practice. If the Healthcare Commission assess the Trust as lacking compliance on any of the standards it will be served with an improvement notice.

6. OTHER MANDATORY SURVEILLANCE Orthopaedic SSI surveillance

In 2006-7 GHNHSFT continued to meet its mandatory surveillance requirements by participating in further modules of orthopaedic surgical site infection surveillance. In previous years this surveillance has been coordinated by the infection control surveillance nurse with assistance from the clinical teams at CGH and GRH. However, members of the Surgical Division will be undergoing SSI Training in December 2008 and it is anticipated they will co-ordinate their surgical site infection reports directly to the Health Protection Agency (HPA).

At CGH surveillance of total hip replacements was undertaken between January and March 2007. In this time period 47 operations were performed with none becoming infected by the end of the surveillance period when the summary report was produced. At GRH surveillance of total knee replacements was undertaken between October and December 2006. In this time period 79 operations were performed with none becoming infected by the end of the surveillance period when the summary report was produced.

7. OTHER HEALTHCARE ASSOCIATED INFECTIONS

Extended spectrum β-lactamase producing organisms Extended spectrum β-lactamase (ESBL)-producing organisms are becoming an increasing cause of HCAI. In the early 1990s these organisms were relatively rare causes of limited hospital outbreaks of infection usually restricted to certain specialized units. These early ESBL-producing organisms were mainly a coliform called Klebsiella pneumoniae. In recent years new types of ESBL have evolved and have become widespread particularly in Escherichia coli.

These ESBL-producing E.coli are mainly found in individuals in the general population in the community. Unfortunately many of the strains of ESBL-producing coliforms are also resistant to other classes of antibiotics (such as gentamicin and quinolone antibiotics) and so are multiply-resistant. If patients become clinically infected with these bacteria then it can be difficult to treat their infections both in community and hospital settings. These infections pose not only a challenge because of limitation in antibiotic treatment options but also to limit cross infection in hospital settings and development of HCAI. For a number of years ESBL-producing coliform infections have been identified from community patients. A proportion of these individuals have infections that are sufficiently severe or multiply-resistant to necessitate hospital admission for treatment. These infections often require broad-spectrum parenteral antibiotic treatment with agents such as carbapenems antibiotics. Many of these infections affect the urinary tract. These organisms are commonly found in the urine of catheterized patients either just as asymptomatic catheter colonizers or as genuine causes of catheter-associated urinary tract infections (UTIs). Early in 2007 it was noticed that there was an increase in rates of infection in inpatients at GRH with an ESBL-producing strain of Klebsiella pneumoniae. Many of these patients were noted to have urinary catheters. When this was investigated further a key factor in many of these patients was the use of a newly introduced product to the GRH site, silver-impregnated urinary catheters. The use of this particular type of catheter has now been withdrawn within the Trust and this has corresponded with a reduction in levels of infection with this particular organism. These findings have been reported to the MHRA and infecting strains of Klebsiella pneumoniae have been sent to colleagues in research facilities for further evaluation including silver susceptibility testing. In the event the strains isolated were found not to be silver-resistant but were identified as a specific clonal type. The results have been published and were presented at the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) in May 2008.

The continuing occurrence of ESBL-producing organisms in GHNHSFT inpatients is a continuing challenge and requires vigilance with prudent and rational antibiotic prescribing to minimise the selective pressure on these organisms and care with infection control precautions (mainly standard precautions) when dealing with affected patients to minimise transmission. 2009 will see the completion of an infection control policy specifically to address multiple-resistant infections (other than MRSA) will be produced based on national guidelines for a variety of ‘alert organisms’. Acinetobacter baumanii is a highly-resistant gram-negative bacterium that has become more prevalent in the UK in recent years. It particularly causes infections in patients in critical care, neurosurgical and burns units in tertiary referral hospitals. A patient colonised with it was transferred into GRH in September 2007. Subsequently several patients became colonised or infected with it in the GRH Critical Care unit. The response was rapid and patients with it were identified and placed in strict isolation. When the number of critical care patients diminished it became possible to deep clean the unit using hydrogen peroxide vapour (Bioquell system) and the outbreak was controlled. In 2008 there have been no further cases. This was a major achievement as infections with this organism have closed critical care units or have continued to be indolent in other hospitals in the UK for many months or years.

8. ANTIBIOTIC USE, PRESCRIBING AND POLICY

It is well recognised that antibiotic use is an important factor in many healthcare associated infections. This is particularly so for CDAD but also for HCAIs caused by antibiotic-resistant

micro-organisms such as MRSA, Enterococcus species, multiply-resistant aerobic Gram negative organisms (such as ESBL-producing coliforms, Pseudomonas species and Acinetobacter baumanii) and Candida species. For example there have been a number of publications recently highlighting the fact that the reduction in quinolone and cephalosporin prescribing, that was brought in primarily to minimize C.difficile infection, has had a beneficial impact on MRSA acquisition. The prudent use of antibiotics in a hospital setting is therefore an important intervention to minimise levels of many HCAIs. In 2006-7 continuing high rates of CDAD prompted a review of antibiotic use and amendment of the GHNHSFT antibiotic guidelines. A number of clinical audits indicated that some inappropriate prescribing of antibiotics was occurring and that there was some non-compliance (justified and non-justified) with the antibiotic guidelines. The Countywide Antibiotic Group (Pharmacy Antibiotic Group) comprising the Director of Pharmacy, all the consultant microbiologists and the CGH and GRH antibiotic pharmacists, meet on a regular basis to look at antibiotic-related issues including guidelines. This group met in July 2007 to finalise revisions to the GHNHSFT antibiotic guidelines in readiness for publication at the beginning of August. Further interim modification were made in February 2008. In August 2008 the guidelines underwent additional changes. The overall effect on prescribing has been to minimise the use of third generation cephalosporins and quinolone antibiotics such as levofloxacin and ciprofloxacin. These changes are necessary to reduce levels of CDAD and are consistent with the recommendations from the Dh contained in the “Dear Colleague” letter (Gateway reference 7490) Healthcare associated infections, in particular infection caused by Clostridium difficile. Along with the changes to the antibiotic guidelines there has been a restriction in the availability of cephalosporins and quinolone antibiotics on the wards that should promote compliance. The most recent revised antibiotic guidelines were sent to clinicians for discussion and were ratified by the Hospital Medicines Management Committee before the end of July 2008. As with previous versions of the antibiotic guidelines these are available in compact paper hard copy format as well as on the Pharmacy webpages of the intranet. The new intake of junior doctors commencing in August 2008 were made aware of these guidelines during their induction and received educational sessions to support their use. Two senior pharmacists (one for each of the acute hospital sites) who had taken a special interest in antimicrobial prescribing since 2006 have been supplemented by the appointment of a full-time dedicated antibiotic pharmacist in 2008. The Trust has a comprehensive antibiotic policy which has a high degree of compliance as assessed by audit, but it is recognised there are still areas where change is necessary. Recently GHNHSFT has produced three pocket size information cards on Antibiotic Guidelines and there use. These cards have been highly praised by the DH and the Healthcare Commission. However, for up to the minute guidance the Trust website is available for more detailed information and a consultant medical microbiologist is contactable at all times (including out-of-hours) for specialist advice. Work is ongoing to develop the hospital intranet site for antimicrobial advice along the lines of the Nottingham programme. As well as antimicrobial prescribing it has been recognised that agents that reduce gastric acid (e.g. proton-pump inhibitors such as omeprazole) increase the susceptibility of patients to C.difficile disease. There is currently work being undertaken, in collaboration with Trust gastroenterologists, to produce a revised policy aimed at minimising the use of these agents – both in the Trust and the general community.

9. SURVEILLANCE Helen Gornall the Trust Surveillance Nurse produce’s quarterly and monthly surveillance reports on behalf of the Trust for the divisions. In addition to this Helen distributes weekly reports in order for the divisions to address in ‘real time’ current issues which arise. It also gives the ICT the opportunity to report changes as they occur and not wait until the production of the monthly report. This major change will commence in June 2008. Collaboration between Helen and the recently appointed Director of Patient Safety, Andrew Seaton, will look at how the Trust communicates the information and uses it most effectively to bring about necessary changes. 10. INFECTION CONTROL ANNUAL PROGRAMME 2008-09

The elements of this are covered by the various ongoing HCAI action plans within the Trust.

11. OBJECTIVES FOR THE FUTURE AND RESEARCH INITIATIVES • Increase ICN visibility in all wards and departments • Increase collaboration form infection control at the beginning of all new builds and support

the Estates and Facilities departments in adapting and modifying the existing built environment to improve it from an infection prevention aspect.

• Work towards and increase collaborative working with other members of all multidisciplinary teams

• Maintain planned audit programmes for 2008/2009 • Continue to deliver Principles of Infection Control Programme in collaboration with the

University of Gloucestershire • Plan a Trust wide Infection Control study day for 2009/2010 • Participate and feedback results to the Trust board and Dh from the pilot RCA • Development all ICN’s to become experienced, confident and approachable practitioners • Develop enhanced surveillance for surgical site infections (SSIs) in collaboration with the

Surgical Division, using the Health Protection Agency (HPA) - developed programme. • Research projects: participate in a national phase-2 trial for C.difficile vaccine; investigate,

in conjunction with the microbiology laboratory, the impact of new rapid methodologies for detection of MRSA and C.difficile; in collaboration with other workers investigate the role of probiotics in controlling C.difficile disease.

• Implement rapid, sensitive screening methodology for both MRSA and C.difficile following completion of evaluation (see above) to improve timeliness of patient isolation, utilisation of side-rooms and treatment.

Report on Clostridium difficile infections and MRSA bacteraemias, updated to December 2008.

Data presented in the Gloucestershire Primary Care Trust annual report of the Director of Infection Prevention and Control detailed numbers of infections until March 2008. This update presents the data until December 2008 and shows there have been sustained improvements in the nationally notifiable numbers of infections of both MRSA and C. difficile.

1. C. difficile Data is presented for the period April 2006 to December 2008 inclusive. a) GHNHSFT (Gloucestershire Hospitals NHS Foundation Trust) This graph shows the number of cases of C. difficile diagnosed within GHNHSFT along with a 12 monthly rolling average to demonstrate the trend. There have been sustained improvements.

GHNHSFT cases of C. difficile

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GHNHSFT number of casesGHNHSFT 12 monthly rolling average

b) PCT community hospitals This graph shows the same time period for the PCT community hospitals with inpatient beds: Lydney, The Dilke, Stroud General, Stroud Maternity, Berkeley, Cirencester, Moreton, Bourton, Tewkesbury, and Winchcombe.

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c) General Practice Cases diagnosed in General Practice have not yet shown a substantial decrease. Root cause analysis of these cases shows that the most important risk factor is recent hospital admission.

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rage

Number of cases12 monthly rolling average

d) Countywide summary

Countywide C. difficile data 12 monthly rolling averages

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

Dec-03

Mar-04

Jun-0

4

Sep-04

Dec-04

Mar-05

Jun-0

5

Sep-05

Dec-05

Mar-06

Jun-0

6

Sep-06

Dec-06

Mar-07

Jun-0

7

Sep-07

Dec-07

Mar-08

Jun-0

8

Sep-08

Dec-08

Month/Year

12 m

onth

ly ro

lling

ave

rage

num

ber o

f cas

es

GHNHSFT 12 monthly rolling averagePCT hospitals 12 monthly rolling average GP 12 monthly rolling average

2. MRSA Meticillin resistant Staphylococcus aureus (MRSA) may cause a variety of infections but the most serious is blood stream infection, also known as bacteraemia. There is a national requirement to notify MRSA bacteraemias and a target to reduce the numbers. Reductions have been achieved although further reductions are required.

MRSA bacteraemias

0

2

4

6

8

10

12

Oct-05

Nov-05

Dec-05

Jan-0

6

Feb-06

Mar-06

Apr-06

May-06

Jun-0

6Ju

l-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-0

7

Feb-07

Mar-07

Apr-07

May-07

Jun-0

7Ju

l-07

Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

Jan-0

8

Feb-08

Mar-08

Apr-08

May-08

Jun-0

8Ju

l-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

month/year

num

ber o

f cas

es

12 m

onth

ly ro

lling

ave

rage

Series2Series1

Dr Philippa Moore Director of Infection Prevention and Control Gloucestershire PCT and 2gether NHS Foundation Trust 05.01.09

JC – Jill Crook, SW – Sarah Warne, JG – Julie Goodenough, MM’s – Modern Matrons, JF – John Ford

Gloucestershire PCT Infection Prevention and Control Work Plan Review - September 2008

(EJF - Liz Fenton, PM - Philippa Moore, SH – Sarah Hardy, NM – Natalie Matthews, RW – Rebecca Walder, SP – Sylvia Price, SL – Sam Lonnen)

Subject Aim Lead Person

Completion Dates

Progress to Date/ Evidence of Success

Infection Prevention and Control Infrastructure

• Recruit Community Infection Prevention & Control Team Surveillance Nurse

• Complete overhaul of the Infection Control

Link (ICLink) role, competence, knowledge base and enrolment of suitable staff into all sites and staff groups.

• Education of link personnel through the

University of Gloucester course.

• Instigation of quarterly ICLink meetings.

• That ICLink’s are provided with the time to be involved in the following

Inclusion of link personnel in annual infection control audits.

ICLink’s to undertake Observational Hand

Hygiene audits and report results to HCAI project lead.

ICLink personnel to provide education sessions to other staff locally & promote good practice including hand hygiene.

• That IP&C Nurses strengthen patch based working with attendance at local meetings.

SL

SL

NM EJF to identify funding

SL

SH/NM/ RW/SL

SW

SH/NM/ RW/SL

SH/NM/ RW/SL

CompletedOctober

2008

March 2009

January 2009

March 2009

April 2008

April 2008

March 2009

March 2009

Surveillance Nurse in post from Monday 4th November 2008.

Agree level of competence required for role. Retrain current ICLink’s and recruit new staff into the role. Implementation of an ICLink contract or commitment to be agreed.

If sufficient numbers exist that the organisation of a wholly community focused infection control course through the University of Gloucester course coordinator takes place.

ICLink meetings that contain an update, educational session, presentation of an infection control initiative and ICVox (open forum for staff to participate in group clinical supervision) occur at 4 separate sites across the PCT on a four monthly basis. ICLink’s have been accompanying IP&C Nurses during the audit process.

That each inpatient area/unit/ward has an identified ‘Hand Hygiene Champion’ who conducts monthly Hand Hygiene audits and reports each month’s findings to the HCAI Project Lead, Sarah Warne.

As part of the role (which will link to KSF) ICLink’s will undertake educational sessions in their work area/unit/ward.

IP&C team have instigated &/or attended patch based local meetings.



Completion dates

Evidence of Success & Completion

Infection Prevention and Control Policy/Guideline development

• Review and renewing of relevant infection control policies on an annual basis or as/when required.

• That policies detailed by the Health Act (updated January 2008) are in place and available to staff across the PCT.

• Review of bed management policy (linked with GHNHSFT) looking at isolation facilities and transfer of patients with infection between wards, departments, hospitals and organisations.

PM/SH/ NM/RW/

SL PM/SW/ SH/NM/ RW/SL

SW

Completed August

2008 Completed

August 2008

February 2009

The following policies have been presented to the Policy Review Group for accreditation –

Clostridium Difficile Hand Decontamination Linen and Laundry Personal Protective Equipment Outbreak Policy Body Fluid Spills Sharps Management Standard Precautions Safe Disposal of Body Fluids Safe Specimen Collection

Completion of working bed management policy in use and understood by bed managers in the PCT and Acute hospitals.

Infection Prevention and Control Hand Hygiene Promotion

CleanYourHands campaign in community hospitals - launch year 3 of the campaign

• Observational hand hygiene audits owned by Modern Matrons at each site with support from the IP&C Team.

• Improved access to HTM 64 compliant hand washbasins for patients, visitors and staff in community hospitals.

• Improved availability of approved hand hygiene wipes for staff working in the community.

• That the PCT make use of ‘Floortography” to highlight the need for hand washing.

PM/SH/ NM/RW/

SL

JG/SH/ NM/

RW/SL

JF/ Estates

SL

SL

Completed September

2008 Completed July 2008

November 2008

Completed July 2008

October

The community CleanYourHands campaign financed by the GPCT IP&C Team launches year 3 with the involvement of directorate leads, general managers, matrons etc.

Each inpatient area/unit/ward has identified a ‘Hand Hygiene Champion’ to conduct Hand Hygiene audits and reports each month’s findings to Sarah Warne, the HCAI clinical development facilitator.

PCT facilities having been audited have HTM 64 compliant hand wash basins (HWB’s) sited at entrance/exits of care areas/units/wards.

Approved hand hygiene wipes are now available for staff where hand wash basin facilities do not exist. Including equipment decontamination at Arle Road. That appropriate sites are identified and fitted with ‘Floortography” (a Johnson Diversy product).


2008


Completion dates


Infection Prevention and Control Hand Hygiene Promotion continued

Community hand hygiene outside of community hospitals

• Having enrolled in the Community CleanYourHands campaign on February 14th 2008 the IP&C Team are instrumental in,

The implementation/rollout of Year 1 of NPSA CleanYourHands in community to GP surgeries, District Nurses and other PCT community care/service providers.

• Role out of hand wash basin (HWB)

installation at ward/unit entrances/exits and upgrade of HWB’s that are not HTM 64 compliant is conducted.

• Installation of ‘Talking Posters’ to prompt

staff, AHP’s and patients/visitors.

SL/NM

PM/SH/ NM/RW/ SP/SL

PM/SH/ NM/RW/ SW/SL

SL

September

2008

October 2008

March 2009

Completed September

2008

National Patient Safety Agency (NPSA) launch of Community CleanYourHands campaign will be launched in September 2008. That the Community CleanYourHands campaign is successfully implemented by District/ community nursing staff, GP surgeries/medical centres etc. Successful implementation will need to be audited by the IP&C Team.

That installation and HWB compliance is witnessed upon annual infection control audits at PCT inpatient facilities. That ‘Talking Posters’ are installed in areas where hand hygiene compliance is less than 90% to promote improvement.

Infection Prevention and Control other initiatives

• Assist in the self-assessment process of

Essential Steps to safe, clean care programme with ownership transferred to the Matrons once pilot at Berkeley has been completed.

• Appointment of a clinical development facilitator for HCAI providing support/co-ordination for initiatives aimed at reducing Health Care Associated Infections across the county.

NM/RW/ SW/HV

SW

October

2008

Completed June 2008

That pilot at Berkeley Hospital is successfully completed. Matrons across GPCT implement Essential Steps self-assessment.

Data collection for PCT, SHA related to HCAI audit activity. Support/co-ordination of policy and audit activity relating to Essential Steps and CleanYourHands as applicable within the county.



Completion dates


Infection Prevention and Control other initiatives continued

• Development & implementation of IP&C to Healthcare risk assessment documentation across the health community.

• That the Antibiotic Group continues to

monitor antibiotic use across the PCT and adherence to policy, adjustment of policy by review of MRSA and C. difficile rates as necessary, coordination of the development of an OPAT programme for the county, and monitoring of the use of silver dressings.

SW/SL

PM

March 2009

Completed

August 2008

Review and

update required January

2009

Pilot of proposed documentation in diverse healthcare settings. Embedding of content into existing transfer documentation. Appropriate versions of the assessment form in use in all appropriate settings i.e. hospitals, care homes, community. That the Antibiotic Group (which convened in July 2007) improves antibiotic prescribing with education, training and policy reinforcement. Root Cause Analysis (RCA) on each episode of C. difficile will indicate where prescribing is an issue that requires resolution.

See antibiotic group work plan 2008-09

Infection Prevention and Control of MRSA

• That the PCT rationalises the signage at entrances to premises providing patient care promoting hand hygiene.

• PCT inpatient facility infection control audits for 2008-2009 to focus upon sharps & waste management.

• Implementation of enhanced MRSA screening of elective and emergency admissions in collaboration with GHNHSFT to identify for decolonisation.

• Successful implementation of Essential Steps self-assessment coordinated by Matrons.

JG/SW

SH/NM RW/SL

PM/SH/ NM/RW/

SL

NM/RW/ SW

Completed July 2008

March 2009

March 2009

Imple-

mented April 2008

March 2009

Signage at entrances to PCT premises now delivers a clear and concise message that can be acted upon.

A post discharge questionnaire could provide valuable feedback on public perceptions of information overload.

That the audit program begins in April 2008 and is completed by year-end 31st March 2009. Enhanced MRSA screening is in place. That PCT units that have implemented Essential Steps successfully meet standards in self assessment.


• Launch of CleanYourHands in the community campaign.

SL

September 2008

That the Community CleanYourHands campaign is successfully implemented across the PCT.


Completion dates


Infection Prevention and Control of MRSA continued

• That Root Cause Analysis (RCA) is

conducted upon each MRSA bacteraemia & that constructive feedback is provided so that improvements to care can be accomplished

• Improvement of MRSA database to

distinguish between colonisation & infection rates.

• Formalisation of joint policy with GHNHSFT

for transfer of patients colonised or infected with alert organisms including MRSA.

• Accurate follow-up of decolonisation

treatment in low-level Mupirocin resistant MRSA in GPCT inpatient facilities.

• Improved communication with community

staff, nursing homes etc. regarding an MRSA diagnosis.

• Feed back MRSA rates via quarterly report.

SH/NM RW/SL

Surveillance Nurse

SW

Surveillance Nurse

Surveillance Nurse

PM

March 2009

March 2009 March 2009

March 2009

November 2008

March 2009

Timely reporting to the SHA and PCT facility that was involved in the MRSA bacteraemia. That Matron with responsibility for area is involved and that recommendations are followed. Review evidence of success and what differentiates between colonisation and infection. Agreement with GHNHSFT that this initiative meets completion.

Review evidence of success and what stipulates successful decolonisation. Review evidence of success and what stipulates successful communication – possible survey. Quarterly reports are delivered in a timely fashion that will inform and provide accurate information.

Infection Prevention and Control of C. difficile

• Year 3 of NPSA CleanYourHands in

community hospitals supported by enhanced emphasis on patient and visitor signage and promotion of hand hygiene at hospital and ward entrances.

• PCT inpatient facility infection control audits for 2008-2009 to focus upon sharps

SH/NM/ RW/SL

SH/NM RW/SL

June 2008

March 2009

That estates have installed the HWB’s surveyed /recommended by Dr Philippa Moore (DIPC) and Sam Lonnen (IP&C Lead Nurse). That signage delivers a clear and concise message that can be acted upon across the PCT. A post discharge questionnaire could provide valuable feedback on public perceptions of facilities available. That the audit program begins in April 2008 and is completed by year-end.


& waste management.


Completion dates



• That RCA is conducted upon each new

incidence/relapse case of C. difficile in a PCT inpatient facility providing constructive feedback is so that improvements to care can be accomplished.

• Monitoring of C. difficile rates and feedback

of surveillance data via Quarterly Bulletin. • Launch of Essential Steps post pilot

study/implementation at Berkeley Hospital via Matrons Charter Group.

• Launch of CleanYourHands in the community campaign.

• Formalisation of joint policy with GHNHSFT for transfer of patients colonised or infected with alert organisms including C. difficile.

• Continued compliance of Matrons Charter via QASI/Clinical Governance (Hospitals) Group.

• Issue antibiotic prescribing guidelines for

GP’s.

SH/NM RW/SL

PM

NM/SW

PM/SH/ NM/RW/ SP/SL

SW

JG/SL

PM

April 2008

April 2008

April 2008

Completed September

2008

March 2009

March 2009

Completed April 2008

Timely reporting to the PCT facility that was involved in the C. difficile case. That Matron with responsibility for area is involved and that recommendations are followed. That all new cases in PCT facilities are reported to Clinical Developments Director upon diagnosis and a Root Cause Analysis conducted with findings reported to Matrons Charter Group.

Essential Steps Steering Group achieves successful roll out and monthly self-assessments are undertaken showing compliance with Essential Steps key criteria.

That the Community CleanYourHands campaign is successfully implemented by District/ community staff, GP surgeries/medical centres and PCT commissioned Dentistry. Successful implementation will be audited by the IP&CT. Agreement with GHNHSFT that this initiative will meet with cooperation initially established in July 2007. Specific method still under review with expected completion/agreement in May 2008.

Matrons Charter Group now the QASI group and meets every 2 months to monitor the commitment/ actions of the Matrons Charter. See antibiotic group work plan. GP’s have received the antibiotic guidelines and implemented the guidelines when prescribing. Updating process underway.


• Monitor efficacy of probiotics after 6 months of implementation/administration.

•

TM

March 2009

Gather data on rates and recovery of patient of 85 years & over when prescribed BD probiotics for course of antibiotic therapy + 1 week.


Completion dates



• Establish a regular audit program with

annual report to cover all clinical areas for antibiotic prescribing that will ensure Initiation of antibiotic prescription is appropriate

Antibiotic prescription (antibiotic choice, dose frequency and route of administration) is in line with policy

That the duration of the antibiotic course is appropriate

PM

March 2009

That audits which examine key indicators of antibiotic policy compliance are met.

Infection Prevention & Control Audit

• Monitor Observational Hand Hygiene

results and implement action accordingly if audit score falls below 80%.

• GPCT inpatient facility infection control audits for 2008-2009 to focus upon sharps & waste management.

• To complete GP and Dentistry audits for

2008-2009 using improved audit tool.

• Snapshot audit of Use of side rooms/isolation facilities Clostridium difficile Linen and Laundry Hand Hygiene MRSA Outbreak

• Actively participate in PEAT visits to GPCT

SW

SH/NM RW/SL

SH/NM RW/SL

SH/NM RW/SL

SH/NM

March 2009

March 2009

March 2009 Completed December

2008 March 2009 March 2009 March 2009 March 2009 March 2009

Observational Hand Hygiene audit tool has been distributed to Modern Matrons who will allocate task of monthly audits with feed back of scores to Sarah Warne for reporting to the SHA. IP&C team will provide additional education if required. Audit program begins in April 2008 with completion required by 31st March 2009 (year-end).

Audit program dependant on GP’s and Dentists accepting the IP&C team offer of audit and actioning the findings reported. Snapshot audits are conducted by IP&C team upon clinical visits and reported back to unit manager and matron responsible for clinical area. IP&C Team Lead to join PEAT team for annual


community hospitals.

RW/SL inspections.


Completion dates


Decontamination of Reusable Instruments

• Launch of countywide endoscopy policy.

• Re-audit of compliance with new policy. • Inventory of equipment used in community

hospital outpatient areas to ensure coverage by decontamination policy

• Launch of new decontamination policy for ward/outpatient/community equipment.

CB/JG

CB/JG

MM’s

SL

March 2009 March 2009 March 2009

February 2009

That a countywide Endoscopy policy is formulated, agreed, disseminated and audited.

That A to Z of decontamination Policy includes all items of equipment used across the GPCT. Policy is agreed and made available in hard copy and intranet access.

Standards for Better Health and Assurance Frameworks

• Documentation collected in accordance

with Standards for Better Health. • Ensure compliance with all aspects of the

revised Health Act (January 2008) and the Healthcare Commission Core Standards.

• Attendance and report presentation at

GPCT risk meetings.

SH/NM RW/SL

PM/SH/ NM/RW/

SL

PM

March 2009

January 2009

Completed July 2008

That 100% compliance with standards for Better Health 2008/09 is returned. This element requires perpetual maintenance to meet compliance. That documentation of compliance is available for Healthcare Commission inspection. Risk Committee ceased to exist in August 2008.

Infection Prevention and Control Training

Primary Care Trust and community staff

• Inductions and Annual updates – provide an opportunity for an annual update for all PCT staff coordinated via the education department using directly led sessions, web based services.

• Teach at District Nurse PDM. • Teach at GP PLT.

PM/SH/ NM/RW/

SL

PM/SH/ NM/RW/

SL

March 2009

March 2009 March 2009

Infection Prevention and Control now no longer part of the PCT Induction program. The IP&C Team continues to provide Mandatory Update training as required including the provision of additional sessions (40% increase in sessions over coming 6 months).

Sessions provided (see weekly Minutes of IP&C Team Meetings, Quarterly ICCM and Education Data base for dates, venues numbers etc.)


• Ensure accurate database of staff attending infection control teaching.

PM/SH/ NM/RW/

SL/ Jayne Shaw

March 2009

That the IP&C Team provides training for District/community nurses and GP’s. Human resources maintain the Electronic Staff Records.


Completion dates


Infection Prevention and Control Training

• Study day – hold at least 2 infection prevention and control study days in 2008 - 2009.

Team training

• IP&C team members training as identified by KSF PDR

• Educational days/professional meetings such as IPS, SWIC etc.

• Monthly Continuous Professional Development (CPD) for the IP&C Team

• Graduate Certificate in Infection Control,

Oxford Brookes University.

SH/NM RW/SL

PM/SH/ NM/RW/ SP/SL

PM/SH/ NM/RW/ SP/SL

PM/SH/ NM/RW/

SL

RW

Completed November

2009 March 2009

March 2009

March 2009

September 2009

That two study days are provided for staff across the PCT & a successful evaluation takes place. That training needs of the IP&C Team are identified and if available IP&C team members attend and provide constructive feedback.

That IP&C team members attend educational training that will maintain and enhance role.

Journal review and feedback at CPD meetings that are held monthly. That Rebecca Walder successfully completes a Graduate Certificate in infection control.

Surveillance

• Enhanced screening of MRSA patients collaborative with GHNHSFT

• Improvement of MRSA database to distinguish between colonisation & infection rates.

• Formalisation of joint policy with GHNHSFT for transfer of patients colonised or infected with alert organisms including MRSA.

• Accurate follow-up of decolonisation

PM

Surveillance Nurse

SW

Surveillance Nurse

March 2009

March 2009

March 2009

MRSA screening of patients upon admission/ transfer to GPCT facilities results in accurate surveillance.

That a process is devised to differentiate between MRSA colonisation and infection is recorded accurately and can be accessed. That joint policy is agreed as a working document and is used in the transfer of patients with recognised alert organisms.

That documented evidence is maintained providing


treatment in low-level mupiricin resistant MRSA.

• Improved communication with community staff, nursing homes etc. regarding an MRSA diagnosis.

Surveillance Nurse

March 2009

March 2009

statistical information on the success or otherwise of decolonisation treatments.

Agreed actions with HPU and Sarah Warne regarding the informing and follow-up of MRSA positive patients are in place.



Completion dates


Other

• Provision of advice on infection control issues with regard to estates new builds.

• Provision of advice/input upon the Legionella risk reports and site visits.

• Enhanced liaison with procurement regarding equipment purchase and infection control products.

• Maintain updated details of clinical sites –

numbers of sites, clinical activity, ward layout and isolation facilities.

• Strengthen links between the IP&CT and

Patient Public Network.

• Develop, update and maintain CIP&CT website with links to details of education sessions, audit results, policies, patient information leaflets, reports and surveillance data where appropriate.

• Ensure all Infection Control databases are

appropriately registered and in keeping with Caldicott principles.

• Maintain profile of Infection Control by

contributing regular articles to PCT publications i.e. The Face and continue to publish and circulate the ‘Gloucester Bug’.

PM/SH/ NM/RW/

SL/

PM

SL

SP

SL

RW

SP

PM/SH/ NM/RW/ SP/SL

March 2009

March 2009

March 2009

March 2009

March 2009

March 2009

March 2009

March 2009

That the IP&C Team are involved at the planning stage of new builds, alterations & refurbishments to insure that infection control is built into the health care environment and that legislation, protocol and guidelines are followed. That a member of the infection prevention and control team attend site meetings with an estates representative and water test team to evaluate the corrective action options.

That regular meetings take place with the head of procurement to examine products that can enhance infection prevention & control practise. That information on changes to PCT services are known and shared within the IP&C Team. That the IP&C Team are involved in the Patient Public Network. That the IP&C Team are involved in PEAG Groups, PEAT inspections etc. That the CIP&C Team web page is regularly updated with comprehensive, research based information, policies and procedures to help maintain a high level of infection control knowledge amongst GPCT staff. That databases meet Caldicott principles. That the IP&C team make valued and informative contribution to PCT publications and that the IP&C teams own information publication is distributed every 3-4 months.



Completion dates


Meetings

Community Infection Control Committee Gloucestershire Infection Prevention and Control Committee (GIPCC – countywide) WEB group PCT Decontamination Group Team briefings Infection Control/Hotel Services meetings CCDC and HPA meetings Prison Communicable Disease and Infection Control Meeting Countywide Pandemic flu meetings Health and Safety meetings PEAT visits Local PEAG Meetings Clinical Governance – Adult Meetings Clinical Governance – Children’s Meetings Clinical Governance – Hospitals Meetings Tewkesbury Link Meetings. Clinical Policy Meetings. Stroud Hospital Management Meeting. Weekly Team Meetings. South West Infection Control Forum. IPS community network meetings. Joint Infection Control Nurse and Team Meetings.Weekly clinical visits to community hospitals.

PM/SH/ NM/RW/ SL/SP

March 2009

That the specific individual form the IP&C team or recognised deputy attends and makes a valued, informed and relevant contribution to the meetings that they attend.

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