director of infection prevention and · pdf fileas director of nursing and patient safety and...
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North Tees and HartlepoolNHS Foundation Trust
Director of Infection Prevention and Control Annual Report 2009-10
2Jack washes his hands overlooked by...himself.
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Contents
Page
Executive Summary 4
1. Structure 6
2. Summary of DIPC Reports to the Board 8
3. Resources 9
4. Healthcare Associated Infection Statistics 10
5. Infection Prevention and Control Initiatives 12
6. Policies 15
7. Decontamination 16
8. Audit 18
9. Providing a Clean and Safe Environment for our Patients 19
10. Inspection by External Bodies 21
11. Training Activities 21
12. Summary 22
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2010/11 Quality Account
Executive SummaryCleanliness and the threat of picking up an unwanted infection are some of the most important concerns of patients, especially when they come into hospital.
As Director of Nursing and Patient Safety and Director of Infection Prevention and Control I am passionate about the things which are important to patients. I may have the lead for infection prevention and control but tackling it is truly a team effort. Every single person in the Trust contributes to this very important work. From nursing to medical to support staff in every area we work together tirelessly to make the improvements we would want if we were in hospital ourselves.
However there is now a new dimension to our work. This is the first full year that we have had community staff working for the Trust and this has given us an opportunity to adapt our standards to make them suitable for use in people’s homes and
in community facilities as well as in our hospitals. We are working hard to make sure our patients and clients benefit from all of the strands of our infection prevention and control strategy.
There have been some major achievements and developments throughout the year and they are highlighted in this annual report.
The arrival of hydrogen peroxide fogging equipment and a dedicated deep clean team has made a significant contribution to our success in tackling Clostridium difficile. The appointment of a community infection prevention and control nurse has seen a raised awareness and a more effective way of ensuring the highest standards are maintained in people’s homes and in community premises.
I highlight these areas, but they are just a few of the many strings we have to our bow as far as tackling the spread of infection goes. We have a team, and patients and relatives are also an important part of the team.
If we all work together we will continue to see improvements as the years progress
I would like to thank everyone who has contributed to the results we have achieved this year. I commend this report to you.
Sue SmithDirector of Nursing and Patient Safety Director of Infection Prevention and Control
Pharmacist Alison Dabbous and pharmacy technician Claire Spinks5
1. Structure
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The Chief Executive holds overall responsibility for Infection Prevention and Control in the Trust. The Director of Nursing and Patient Safety is the designated Director of Infection Prevention and Control (DIPC) for the Trust and reports directly to the Chief Executive and the Board.
The Infection Prevention and Control Team (IPCT) consists of the DIPC, a Consultant Microbiologist as Infection Control Doctor (ICD), an assistant director of IPC and a nursing team who are supported by link workers in clinical areas. The team includes a secretary and a surveillance and clerical support officer. A senior Biomedical Scientist from the microbiology laboratory and the antimicrobial pharmacist are honorary team members. Since November 2008 the Trust has also hosted the Infection Prevention and Control team from the Community Services Directorate (previously North Tees PCT and Hartlepool PCT), resulting in an integrated team providing professional support and clinical advice to hospital and community provider services. The team meets formally on a two-monthly basis.
The IPCT reports to the Infection Control Committee (ICC) whose members represent all appropriate areas within the Trust and in partner organisations
including estates and facilities, nursing, occupational health, pharmacy, clinical governance, local primary care trusts and the local health protection unit. The Committee also has a patient representative. The Infection Control Committee meets formally on a quarterly basis and monitors progress against the annual work programme, national reports and other initiatives and reports to the Clinical Governance Committee. Operational sub groups of the ICC monitor operational performance and associated action plans.
The IPCT also links in with other Trust committees and groups and is represented on the Audit and Clinical Effectiveness Committee (ICD), Clinical Governance Committee (Senior Matron), Drug and Therapeutic Committee (Consultant Microbiologist), Health, Safety and Welfare Committee (Senior Matron), Patient Safety Committee (Senior Matron), Trust Resilience Forum (Senior Matron), Pandemic Flu Group (ICD and Senior Matron).
Board of Directors
Infection Prevention Control Team
Clinical Governance Committee
Infection Control Committee
Operational Groups
Fig. 1 Reporting arrangements
7Chief executive Alan Foster
2. Summary of Reports to the Board
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A quarterly quality report is prepared for the board of directors by directorate matrons, general managers and clinical directors which includes infection prevention and control information from each directorate.
The DIPC presents an infection prevention and control report to the Board monthly. This report gives information about MRSA and Clostridium difficile infection, hand hygiene compliance, progress with MRSA screening performance, outbreaks and updates on innovations and activities being implemented across the Trust. An expanded report will be presented from April 2010 to include surveillance of other infections such as sensitive Staphylococcus aureus blood stream infections and compliance with best practice for interventions such as central lines and urinary catheters.
Staff Nurse, Marinelle Garcia
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3. Resources
The IPCT is resourced to meet the financial and clinical requirements of the service. The team supports all infection prevention and control activities within the hospitals and community provider services, and contributes to wider organisational business and development plans. We work in partnership with our commissioners to ensure that we achieve best value for money across the healthcare economy.
4. Healthcare Associated Infection Statistics
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The Trust has continued to participate in the mandatory national programme for surveillance of Staphylococcus aureus bacteraemia (blood stream infections), MRSA bacteraemia, Glycopeptide Resistant Enterococcus (GRE) bacteraemia and Clostridium difficile diarrhoea.
In 2009-10 the Trust target was to have no more than 14 MRSA bacteraemia cases. At the end of March 2010 a total of 11 cases had been reported by the Trust, demonstrating a reduction on the previous year when 12 cases were reported. Five of these infections were acquired in hospital; the remaining six were acquired prior to admission to hospital. Root cause analysis has been carried out for each case and this process has been improved
and strengthened during the year. All cases have been presented to the executive team within four weeks of the incident, with lessons learned identified and shared across the Trust. Fig 2 shows MRSA bacteraemia performance for the last three years. The table below shows the reduction achieved in the number of infections per 10,000 occupied bed days.
Year 2007/8 2008/9 2009/10
No of bacteraemia reported 28 12 11
No of infections per 10,000 occupied bed days 1.32 0.503 0.489
The target for 2010/11 will be based on a rate per 10,000 occupied bed days and will include only those cases acquired in hospital. In previous years all cases have been counted against the Trust target but the hospitals and primary care trusts (commissioners) now have separate targets.
Fig. 2 MRSA bacteraemia (all cases)
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A reduction target for Clostridium difficile cases between 2008 and 2011 was required by the Strategic Health Authority with the Trust target for 2009-10 being to have no more than 168 hospital acquired cases. The total number of cases reported at the end of March 2010 was 136, which again
was a reduction both against the agreed target and the previous year. Fig 3 shows C difficile infection performance for the last three years. The table below shows the reduction in number of infections per 10,000 occupied bed days.
Year 2007/8 2008/9 2009/10
No of post 48 hour C difficile cases reported 210 158 136
No of infections per 10,000 occupied bed days 9.934 6.634 6.054
Year 2007/8 2008/9 2009/10
No of outbreaks 26 22 21
No of patients affected 338 253 211
Rate per 10,000 occupied bed days 15.989 10.623 9.393
No of staff affected 32 56 51
Total number affected 370 309 262
During 2009-10 no cases of GRE bacteraemia were reported by the Trust.
The mandatory surveillance of orthopaedic surgical site infection was carried out during two quarters in 2009-10. No infections were reported from the 19 hip prosthesis and 163 repair of neck of femur procedures carried out.
During the course of the year there have once again been outbreaks of diarrhoea and vomiting on wards which have affected patients and
staff. Safeguarding patients from infection without compromising acute services remains a major consideration in the management of these outbreaks. During 2009-10 there were 21 outbreaks affecting medical, orthopaedic and rehabilitation wards. A total of 211 patients and 51 staff were affected, with norovirus (winter vomiting virus) being identified as the causative agent in the majority of cases. This is a reduction on the number of outbreaks reported during previous years as can be seen below.
Fig. 3 Clostridium difficile diarrhoea (“hospital acquired cases”)
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Clean your hands
The National Patient Safety Agency (NPSA) cleanyourhands campaign has been in place for four years now. All clinical areas within our Trust are participating in this campaign, including community services. Audits of compliance with hand hygiene are carried out monthly by the ward/department staff, with the results being fed back to clinical staff. In June 2009 the Trust implemented a new hand hygiene compliance tool based on the Lewisham audit tool. The new tool was introduced to give a better picture of hand hygiene practices by different staff groups in clinical areas. The introduction of the new tool initially led to a reduction in compliance scores but there has been steady improvement since, with the Trust consistently achieving over 90%.
The ‘5 moments for hand hygiene’ initiative led by the NPSA and World Health Organisation was introduced into the hand hygiene training and monitoring in the Trust in 2008/9 and has continued this year, with a member of the Trust IPCT being involved in the national training programme. The basic idea of this initiative is that hand hygiene is carried out ant the right time i.e. at the point of care. Our patients should see staff cleaning their hands before delivering any care. Visitors and carers can play their part too with alcohol hand rub and hand wash basins being available at the entrances to all wards and departments in our hospitals to provide access to hand hygiene facilities.
5. Infection Prevention and Control Initiatives
Your 5 moments forHAND HYGIENE
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WHEN? Clean your hands before touching a patient when approaching him or herWHY? To protect the patient against harmful germs carried on your hands
WHEN? Clean your hands immediately before any aseptic taskWHY? To protect the patient against harmful germs, including the patient’s own germs, entering his or her body
WHEN? Clean your hands immediately after an exposure risk to body fluids (and after glove removal)WHY? To protect yourself and the health-care environment from harmful patient germs
WHEN? Clean your hands after touching a patient and his or her immediate surroundings when leavingWHY? To protect yourself and the health-care environment from harmful patient germs
WHEN? Clean your hands after touching any object or furniture in the patient’s immediate surroundings, when leaving - even without touching the patientWHY? To protect yourself and the health-care environment from harmful patient germs
AFTER CONTACTWITH PATIENTSURROUNDINGS
AFTER PATIENTCONTACT
AFTER BODY FLUIDEXPOSURE RISK
BEFORE AN ASEPTICTASK
BEFORE PATIENTCONTACT1
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BEFORE ASEPTICTASKBEFORE PATIENTCONTACT1
AFTERPATIENTCONTACT4
AFTER CONTACTWITH PATIENTSURROUNDINGS5
3 AFTER BODY FLUID
EXPOSURE RISK
Your 5 moments forHAND HYGIENE
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WHEN? Clean your hands before touching a patient when approaching him or herWHY? To protect the patient against harmful germs carried on your hands
WHEN? Clean your hands immediately before any aseptic taskWHY? To protect the patient against harmful germs, including the patient’s own germs, entering his or her body
WHEN? Clean your hands immediately after an exposure risk to body fluids (and after glove removal)WHY? To protect yourself and the health-care environment from harmful patient germs
WHEN? Clean your hands after touching a patient and his or her immediate surroundings when leavingWHY? To protect yourself and the health-care environment from harmful patient germs
WHEN? Clean your hands after touching any object or furniture in the patient’s immediate surroundings, when leaving - even without touching the patientWHY? To protect yourself and the health-care environment from harmful patient germs
AFTER CONTACTWITH PATIENTSURROUNDINGS
AFTER PATIENTCONTACT
AFTER BODY FLUIDEXPOSURE RISK
BEFORE AN ASEPTICTASK
BEFORE PATIENTCONTACT1
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2
BEFORE ASEPTICTASKBEFORE PATIENTCONTACT1
AFTERPATIENTCONTACT4
AFTER CONTACTWITH PATIENTSURROUNDINGS5
3 AFTER BODY FLUID
EXPOSURE RISK
Your 5 Moments for Hand Hygiene
May 2009
12345
WHEN? Clean your hands before touching a patient when approaching him/her.
WHY? To protect the patient against harmful germs carried on your hands.
WHEN? Clean your hands immediately before performing a clean/aseptic procedure.
WHY? To protect the patient against harmful germs, including the patient's own, from entering his/her body.
WHEN? Clean your hands immediately after an exposure risk to body fluids (and after glove removal).
WHY? To protect yourself and the health-care environment from harmful patient germs.
WHEN? Clean your hands after touching a patient and her/his immediate surroundings, when leaving the patient’s side.
WHY? To protect yourself and the health-care environment from harmful patient germs.
WHEN? Clean your hands after touching any object or furniture in the patient’s immediate surroundings, when leaving – even if the patient has not been touched.
WHY? To protect yourself and the health-care environment from harmful patient germs.
BEFORE TOUCHINGA PATIENT
BEFORE CLEAN/ASEPTIC PROCEDURE
AFTER BODY FLUIDEXPOSURE RISK
AFTER TOUCHINGA PATIENT
AFTERTOUCHING PATIENTSURROUNDINGS
1
2
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BEFORETOUCHINGA PATIENT 4 AFTER
TOUCHINGA PATIENT
5 AFTERTOUCHING PATIENTSURROUNDINGS
BEFORE
CLEAN/ASEPTIC
PROCEDURE
RISK
FLUID EXPOSUREAFTER BODY
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this document. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
WHO acknowledges the Hôpitaux Universitaires de Genève (HUG), in particular the members of the Infection Control Programme, for their active participation in developing this material.
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Saving Lives/Essential Steps
The Department of Health (DH) Saving Lives initiative, which includes the use of a care bundle approach to practice, has been implemented in the Trust for four years now, and use of the associated tools has improved during that period. Staff enter audit data into an electronic database which automatically creates graphs to make feedback to wards and departments easier. The audit tools monitor performance related to hand hygiene, intravenous line care, urinary catheter care, surgical site infection and Clostridium difficile. Compliance with best practice is reported monthly as part of the strategic dashboard viewed by the board of directors. New and revised tools have been produced by the DH and the Trust has included these tools in its programme. Community colleagues have a similar initiative called Essential Steps which has been designed for use outside of the hospital. Compliance with the use of these tools in the community has increased from 30% to over 95% during the last year, with more than 60 teams now returning data monthly.
MRSA screening
An MRSA screening programme has been in place in the Trust since 2006 with additional groups of patients being added since then. During 2009/10 the Trust introduced screening of all elective (planned) patients. Although large numbers of patients are being screened each month, only a small percentage has been found to be colonised with MRSA. Emergency admissions aged 40 and over have been screened during this year with the programme being extended to all emergency admissions aged 16 and over from April 2010. In December 2008 the Trust introduced weekly screening onto two wards that care for patients at high risk of acquiring MRSA. In 2008/9 seven of the MRSA bacteraemia cases reported by the Trust were acquired on these wards. In 2009/10 only two bacteraemia were acquired on these wards and these cases were deemed to be unavoidable.
NPSA Matching Michigan
The Trust signed up to the NPSA Matching Michigan project at the end of March 2009. This project is based on the good work carried out in Michigan, USA and focuses on reducing central line associated blood stream infections. The Trust was involved in the national 3 month pilot study at the start of last year, prior to national roll-out. Data collection commenced in May 2009 and at the end of March 2010 a total of 10 central venous catheter (CVC) associated blood stream infections were reported by the Trust. The Trust has led the way in investigation of positive infections, with other Trusts mirroring our approach. Positive infections are now viewed as avoidable and an investigation is undertaken into each positive case with findings and actions reported back throughout the organisation. This proactive approach and other project initiatives have been showcased at national NPSA events. Other initiatives addressed by the project group include standardisation of dressings and CVC insertion packs, establishing a training programme for CVC care, revision of current guidelines and production of a CVC care document which is currently in the pilot stage. Following evaluation this will be rolled out to other appropriate areas within the Trust.
© Crown copyright 2006275553 1p 30k Jun06 (BEL)Produced by the Department of Health
If you require further copies of this title please quote 275553/Essential steps to safe, clean care and contact:
DH PublicationsPO Box 777 London SE1 6XHE-mail: [email protected]
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275553/Essential steps to safe, clean care may also be made available on request in Braille, on audio, on disk and in large print.
www.dh.gov/publications
Essential steps to safe, clean careReducing healthcare-associated infections in Primary care trusts; Mental health trusts; Learning disability organisations; Independent healthcare; Care homes; Hospices; GP practices and Ambulance services.
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Infection Control Week
In November 2009 the IPCT co-ordinated displays, competitions and events for National Infection Control Week. This year the focus of the week was raising awareness about Clostridium difficile and its prevention and management.
Quality Review Panel
As part of the Trust’s ambition to become the safest in the UK, offering the best patient experience, a peer review programme, the quality review panel, has been established. This is a monthly review carried out by around 30 nursing staff of varying grades which looks at the environment, cleanliness, nursing care and documentation and patient experience. The aim is to embed a culture in which staff are continuously paying attention to detail. The overall score for the Trust has been around 90% for the first year of the review panel, with patient experience being consistently close to 100%.
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The Trust has a programme for revision of core infection prevention and control policies as required by the Health and Social Care Act 2008. All policies are available on the Trust Intranet site. Key policies are available to the public on the Trust public website.
6. Policies
Policy Code Policy Title Status
IC1 Outbreak Policy For review Feb 2011
IC2 Hand Hygiene Policy For review Feb 2012
IC3 Infection Control Policy For review Apr 2013
IC5 CJD Policy For review 2010
IC6 MRSA Policy For review 2010
IC7 Viral Haemorrhagic Fevers Policy For review 2010
IC11 Tuberculosis Policy For review 2010
IC12 Disinfection and Sterilisation Policy For review Oct 2012
IC13 Urethral Catheter Management Policy For review Apr 2012
IC14 Clinical Specimen Policy For review Dec 2012
IC15 Patient Isolation Policy For review Nov 2011
IC16 Scabies Policy For review Mar 2012
IC17 Standard Precautions Policy For review Jan 2012
IC18 Peripheral Cannulation Policy For review May 2011
IC19 Clostridium difficile Policy For review Apr 2011
IC20 MRSA elective screening For review 2010
IC21 Theatre Policy For review 2013
C51 Antibiotic Strategy For review 2010
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The Trust has a designated lead for decontamination. This role includes decontamination of medical devices and patient equipment.
7. Decontamination
Matters relating to decontamination are discussed at the medical devices group and the decontamination sub group, both of which have representation from the acute and community services IPCT.
A programme of decontamination audits is carried out throughout the year in hospital and community premises by a team consisting of the sterile services manager, theatre manager and an infection prevention and control nurse.
The Trust has a medical equipment library on both sites, meaning that much of the multiple patient use equipment is now decontaminated by experienced and trained staff in a dedicated facility.
The Trust has previously experienced some issues around the quality of rinse water in the automated decontamination machines used for endoscopy equipment. This water quality problem has been resolved. Both hospital sites have had significant investment in the facilities available and both are now consistently producing water of the quality required. This is monitored weekly and the results from the quality control laboratory are reported routinely at the Decontamination Group. The Trust has also invested in drying cabinets which means that scopes can now be stored up to 72 hours after processing before use. For the future the Trust is looking to provide additional capacity to allow the centralisation of high level disinfection facilities which will replace the local processing of equipment.
Assistant matron for infection prevention and control Debra Jenkins demonstrates handwashing 17
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All wards/departments where audit has been carried out are required to produce an action plan to address any areas of weakness, and these are reviewed three months after the initial audit. A report on the audits and actions completed is presented to various forums including the Infection Control Committee.
The Trust has an extensive and robust annual IPC audit programme. All clinical areas have been assessed during 2009-10 including hand hygiene practice, sharps safety, personal protective equipment and environmental cleanliness In accordance with the annual programme there have also been audits of compliance with the MRSA policy, MRSA screening policy, isolation policy, peripheral cannulation policy and Clostridium difficile policy. Other policies are audited as appropriate, for example when they have been put into use, such as the outbreak policy.
8. Audit
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Domestic services staff are now fully integrated into the Trust following the award of the contract to the in house service. Monitoring of cleaning standards is carried out monthly and reviewed by the Cleaning Group, which has representation by clinical matrons and the IPCT. There has been significant investment in developing the service including the introduction of ward hygienists and the use of hydrogen peroxide vapour which has been shown to be particularly effective against Clostridium difficile. The hygienists have implemented a programme of deep cleaning patient equipment and training ward staff to clean effectively. New cleaning technologies are used wherever possible to enhance levels of cleanliness and ensure clinical areas are always ready to receive a new patient into an appropriately cleaned environment.
The national Patient Environment Action Team (PEAT) programme is an annual assessment of food, cleanliness, infection control and patient environment. Patients, patient representatives and members of the public are part of this assessment process. In 2009 the Trust was rated as excellent for environment and food and good for privacy and dignity, which is a new benchmark. Internal PEAT visits are carried out monthly on both sites and involve patient representatives, nurses, domestic staff, estates staff and an IPCT member.
The Trust results from the 2009 National Inpatient Survey showed that the Trust has improved in all areas relating to infection prevention and control.
The IPCT are involved in the capital planning programme, giving input on all building and refurbishment within the Trust. This includes advice on surface finishes, fixtures and fittings, furnishings and dust prevention during the projects. During 2009-10 there has also been a significant amount of work done on planning our new hospital which will have a higher proportion of single rooms and en suite facilities than our current hospitals. The new hospital is being designed to be easy to clean and to assist in the prevention of infection in every possible way.
Good management of outbreaks and timely reopening of affected wards after cleaning has been facilitated by partnership working between clinical staff, the IPCT and domestic services staff. This means that patient safety is maintained during outbreaks and the Trust’s capacity to admit new patients is not compromised.
9. Providing a clean and safe environment for our patients
Year 2008 2009
Score for general cleanliness 86% 87%
Score for bathroom and toilet cleanliness 83% 83%
Score for doctors hand hygiene 84% 82%
Score for nurses hand hygiene 85% 86%
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The Trust has invested in a programme of equipment replacement meaning that items such as commodes and mattresses can be replaced quickly if they become damaged. The availability of additional equipment has also facilitated the deep cleaning of items by allowing a swap out so that wards still have equipment while their own is being cleaned in a decontamination facility.
Productive Ward has continued to be rolled out across the Trust, leading to a reduction in clutter, streamlining of supplies on wards, standardisation of products and increased awareness of the impact of the ward environment on issues such as infection prevention and control. Information relating to MRSA and C difficile rates and hand hygiene compliance is displayed on participating wards.
New technology – ward hygienists Karen Brown and Angela Alderson get ready with the fogging machine
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An unannounced visit was made by the CQC in February 2010 They found no evidence that the Trust has breached the regulation to protect patients, relatives and others from the risks of acquiring a healthcare associated infection. There were no areas of concern in relation to 15 of the 16 key standards inspected, with one area for improvement being recommended. Dust was found in some clinical areas and on some equipment; the
need for some repairs and decoration was identified and improvement to storage was recommended in some areas. The inspection report was published on 24th February 2010. Action was immediately taken to address the recommendations, and the CQC subsequently published an updated report on its website stating that actions are completed and no further visits will be required.
The Trust has declared full compliance with the Care Quality Commission (CQC) core standards relating to infection prevention and control.
10. Inspection by external bodies
11. Training
The IPCT are involved in planning and providing training for:
•Trust induction for all staff involving a practical hand washing exercise
•Junior doctors induction which includes competency assessment for hand hygiene, blood culture sampling techniques and antibiotic prescribing
•Mandatory training which is a requirement for all clinical staff
•Clinical governance sessions within directorates
•Multidisciplinary undergraduate sessions
•Trust Board education session
•Governors infection prevention and control training
•Pandemic flu training, awareness and mask fitting
A variety of means of delivery are employed to maximise access to training for all staff for example computer-based learning, drop in and ward/ department based sessions.
The IPCT have been provided with opportunities for their own personal development in the form of attendance at appropriate internal and external training courses, and the completion of degree level modules covering infection prevention and control.
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In summary I hope this report gives you a clear picture of the many strands of our work. I believe it demonstrates a good performance and our relentless determination to provide the safest environment for patients, wherever they are. However good enough is not good enough for us.
Tackling infection is a continuous challenge but we will not rest until we have eliminated all avoidable spreads of infection.
Thank you for taking the time to read through this report.
12. Summary
23John Lewandowski pictured with staff from ward 11 at UHH
North Tees and HartlepoolNHS Foundation Trust
www.nth.nhs.uk