Foreword

Healthcare Associated Infection will always be an issue, since some patients will becomeinfected as a consequence of another illness. Nevertheless, there is good evidence that aproportion of this infection may be prevented through careful attention to infection control procedures. It is incumbent upon all healthcare staff to be aware of their personal responsibilities towards the prevention and control of healthcare associated infection.

This strategy has been developed by the Welsh Healthcare Associated Infection sub-group(WHAISG) of the Committee for the Control of Communicable disease, and we are gratefulto them for providing their time and expertise. The strategy focuses on the personal responsibility outlined above and proposes the development of Trusts’ infection control infrastructure to emphasise these responsibilities at directorate level. We expect trusts todevelop local action plans to implement this strategy and we will seek regular updates ofprogress. A detailed summary of the actions required by Trusts can be found in part two ofthis document. A Welsh Health Circular highlighting these actions will also be issued to support the strategy.

The strategy continues to build on our partnership working. Local action plans will be published and we will look towards developing a national action plan in those areas wherethis is appropriate.

This strategy is primarily aimed at reducing healthcare associated infections in acute hospitals. However, healthcare associated infection is an issue throughout the healthcaresector and the next step will be to develop a strategy for reducing healthcare acquiredinfections in community settings. This will be followed by work on broader infection control issues. The full suite of documents will include:

• The strategy for the control of healthcare associated infection in hospitals;• The strategy for the control of healthcare associated infection in community settings;• Core guidance on infection control;• Strategy and management of infectious disease emergencies.

Trust chief executives will need to work closely with Local Health Boards and Local Authorities, as these strategies develop to ensure seamless care and management of healthcare associated and other infections.

As the strategy makes clear, we will use national standards to measure performance in thisarea and will work with the Welsh Risk Pool and Healthcare Inspectorate Wales to ensurethat individuals are aware of their personal responsibilities in this area. However, corporateresponsibility resides with chief executives and their boards and we will look to them todeliver this strategy for Wales.

© Crown Copyright. July 2004. Public Health Protection Division. Welsh Assembly Government

Healthcare associated infections continue to cause substantial patient morbidity and cost tothe health service. This strategy aims to support the reduction of these infections in Wales.The development of an infection control infrastructure emphasising the responsibilities ofall healthcare workers is the main focus. The proposed changes use a clinical governanceand risk management approach that expects clinical teams to confront their own problems,guided and supported by specialist infection control practitioners.

This approach was introduced in Improving Health in Wales – A Plan for the NHS and itspartners and the National Audit Office document The Management and Control of HospitalAcquired Infection in Acute NHS Trusts in England published in 2000. This strategy recommends a package of tools to support clinical teams in identifying problem areas and targeting remedial action. It considers requirements for specialist support, highlights theneed for safe physical environments, confirms the review of both specialist and non-specialist training in infection control practices, and emphasises the value of Informationand Communication systems that underpin these processes.

Structure of the document:

This document is aimed at all heath care staff. Part one presents the strategic objectivesand outlines the structure of the strategy. Part two is a summary of the key action points.Part 3 is divided into seven chapters and gives supporting information upon which thestrategy and actions are based. The document will be available via the HOWIS website, onthe micro site of the National Public Health Service (http://nww.nphs.wales.nhs.uk).

Introduction

Contents Page

Part one

The Strategic Objectives

How these Strategic Objectives will be achieved

Structure of the Strategy

Part two Framework Tables

Part three

Chapter one Healthcare Associated Infections in Hospitals: An Overview

Chapter two National Standards

Chapter three Infrastructure and Organisation

Chapter four Training and Education

Chapter five Surveillance and Audit

Chapter six Intervention and Performance Indicators

Chapter seven Information Technology and Communication

Part four Bibliography

Part five Annexes

Annex A

Annex B

Annex C

Annex D

Annex E

Annex F

5

3

4

3

21

23

24

28

29

32

34

37

37

38

36

39

40

41

42

3

Part one

The Strategic Objectives

• All staff will understand the impact of infection and infection control practices to enable them to discharge their personal responsibilities to patients, other staff, visitors and themselves.

• Patients will be treated in physical environments that minimise the risk of infection.

• Infection Control programmes must be supported by adequately resourced specialist infection control staff with sufficient skill mix to meet the needs of the NHS Trust’s infection control plan.

• Trusts will adopt comprehensive surveillance and audit programmes to monitor and direct their infection control programmes. Programmes will be based upon local need as directed by the Trust infection control plan and programme but will adopt national programmes as they are developed and agreed by the NHS Wales Management Board.

• Reduction in infection rates will form part of Trust programmes and strategies. This will be embedded within overall Trust management schemes and will have links to clinical governance, risk management, performance management and the ‘Balanced Scorecard’.

• Trusts will develop systems to ensure effective recording, analysis, sharing and access to their own data, and access to information sources appropriate to their needs for managing infection in their Trust.

How these Strategic Objectives will be achieved

• National Standards that are up-to-date and evidence based will be adopted to ensure consistent and effective infection control practice across Wales.

• Infection control must be embedded as a core item of the management agenda and accountabilities of all staff and managers (as appropriate to their function).

• Specialist epidemiological support will be available to Trust infection control teams as required, to support their infection control programmes.

• Effective training schemes will be available to meet the needs of all staff. The schemes will cover undergraduate, pre-registration, in-service (NHS and non-NHS), post-registration (both generalist and specialist) and continuing professional development.

4

Structure of the Strategy

This strategy builds on Improving Health in Wales and aims to support the reduction inhealthcare associated infection. The strategy focuses on

• Standards – Chapter two;• Infrastructure and organisation – Chapter three;• Training and education – Chapter four;• Surveillance and audit – Chapter five;• Interventions and development of performance indicators – Chapter six;• Communication – Chapter seven.

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ion

co

ntr

ol c

om

mit

tee.

Deli

very

Fra

mew

ork

Sp

eci

ali

st I

nfe

ctio

n C

on

tro

l Su

pp

ort

Str

ate

gic

ob

ject

ive:

Infe

ctio

n c

on

tro

l pro

gra

mm

es m

ust

be

sup

po

rted

by

adeq

uat

ely

reso

urc

ed

spec

ialis

t in

fect

ion

co

ntr

ol s

taff

wit

h

suff

icie

nt

skill

mix

to

mee

t th

e n

eed

of

the

Tru

st’s

infe

ctio

n c

on

tro

l pla

n.

The

man

agem

ent

arra

ng

emen

ts

ou

tlin

ed in

‘Ho

spit

al In

fect

ion

Co

ntr

ol –

gu

idan

ce o

n t

he

con

tro

l of

infe

ctio

n in

ho

spit

als’

1w

ill c

on

tin

ue

to g

ive

the

pri

nci

pal

man

agem

ent

arra

ng

emen

ts f

or

infe

ctio

n c

on

tro

l arr

ang

emen

ts (

chap

ter

two

).

Ho

wev

er, i

nfe

ctio

n c

on

tro

l gu

idan

ce a

nd

reco

mm

end

atio

ns

are

to b

e re

view

edre

gu

larl

y b

y W

HA

ISG

to

ref

lect

cu

rren

th

ealt

hca

re p

ract

ice.

1 H

osp

ital

Infe

ctio

n W

ork

ing

Gro

up

. Ho

spit

al In

fect

ion

Co

ntr

ol –

gu

idan

ce o

n t

he

con

tro

l of

infe

ctio

n in

ho

spit

als.

Lo

nd

on

: Dep

artm

ent

of

Hea

lth

an

d P

ub

lic H

ealt

h L

abo

rato

ry S

ervi

ce. 1

995.

10

Resp

on

sib

ilit

y

•N

PHS

(Wal

es).

Mo

nit

ori

ng

•In

fect

ion

an

d C

om

mu

nic

able

Dis

ease

Serv

ice

& W

elsh

Ass

emb

ly G

ove

rnm

ent.

Tim

esc

ale

•O

ng

oin

g.

Resp

on

sib

ilit

y

•W

elsh

Ass

emb

ly G

ove

rnm

ent.

Tim

esc

ale

•D

ecem

ber

200

5.

Act

ion

s

3(vi

) Th

e N

atio

nal

Pu

blic

Hea

lth

Ser

vice

fo

r W

ales

to

en

sure

ava

ilab

ility

of

spec

ialis

t ep

idem

iolo

gic

al e

xper

tise

b

ased

in t

he

Co

mm

un

icab

le D

isea

se

Surv

eilla

nce

Cen

tre

to s

up

po

rt lo

cal

serv

ices

.

3(vi

i) T

he

Wel

sh A

ssem

bly

Go

vern

men

t

will

eva

luat

e th

e re

sult

s o

f th

e su

rvey

of

iso

lati

on

fac

iliti

es in

W

ales

an

d in

du

e co

urs

e p

rovi

de

gu

idan

ce o

n t

he

acco

mm

od

atio

n

req

uir

ed a

nd

co

nsi

der

th

e n

eed

fo

r ca

pit

al in

vest

men

t in

th

e lig

ht

of

furt

her

pla

nn

ing

.

Deli

very

Fra

mew

ork

Sp

eci

ali

st E

pid

em

iolo

gic

al

Su

pp

ort

Str

ate

gic

ob

ject

ive:

Spec

ialis

t ep

idem

iolo

gic

al s

up

po

rt w

illb

e av

aila

ble

to

Tru

st in

fect

ion

co

ntr

ol

team

s as

req

uir

ed, t

o s

up

po

rt t

hei

r in

fect

ion

co

ntr

ol p

rog

ram

mes

.

Suff

icie

nt

exp

ert

advi

ce a

nd

su

pp

ort

fo

rth

e st

rate

gy

to b

e m

ade

avai

lab

le b

yth

e N

atio

nal

Pu

blic

Hea

lth

Ser

vice

fo

rW

ales

(N

PHS)

.

Faci

liti

es

Str

ate

gic

ob

ject

ive:

Pati

ents

will

be

trea

ted

in p

hys

ical

en

viro

nm

ents

th

at m

inim

ise

the

risk

of

infe

ctio

n.

The

Wel

sh R

isk

Poo

l an

d N

atio

nal

Cle

anlin

ess

Stan

dar

ds,

to

get

her

wit

hw

ork

fro

m t

he

Nat

ion

al P

atie

nt

Safe

tyA

gen

cy, f

orm

a c

om

pre

hen

sive

fra

me-

wo

rk f

or

infe

ctio

n c

on

tro

l an

d h

ygie

ne

man

agem

ent.

11

Resp

on

sib

ilit

y

•Tr

ust

Ch

ief

Exec

uti

ves.

Mo

nit

ori

ng

•A

s in

Act

ion

Pla

n.

Tim

esc

ale

•A

nn

ual

ly t

hro

ug

h t

he

Act

ion

Pla

n.

3(vi

ii) T

rust

s w

ill n

eed

to

pro

vid

e ap

pro

pri

ate

iso

lati

on

fac

iliti

es t

o

mee

t th

eir

nee

ds.

12

Resp

on

sib

ilit

y

Rev

iew

was

co

ncl

ud

ed o

n 3

1 M

arch

200

4an

d f

ind

ing

s w

ill b

e ta

ken

fo

rwar

d t

oW

HA

ISG

fo

r fu

rth

er w

ork

.

Resp

on

sib

ilit

y

•Fu

rth

er d

etai

led

info

rmat

ion

will

be

sen

t to

Tru

sts

by

the

Wel

sh A

ssem

bly

G

ove

rnm

ent

to in

dic

ate

the

intr

od

uct

ion

of

trai

nin

g p

rog

ram

mes

.

Tim

esc

ale

•B

y 20

06.

Act

ion

s

4(i)

Th

e W

ales

Cen

tre

for

Hea

lth

has

re

view

ed o

n b

ehal

f o

f W

HA

ISG

curr

ent

trai

nin

g a

nd

ed

uca

tio

n in

infe

ctio

n c

on

tro

l. Th

e re

view

co

vere

d:

•Id

enti

fyin

g t

he

pro

vid

ers

(e.g

. ac

adem

ia, R

oya

l Co

lleg

es, i

n-s

ervi

ce);

•Id

enti

fyin

g ‘g

aps’

in t

he

pro

visi

on

of

infe

ctio

n c

on

tro

l ed

uca

tio

n &

tra

inin

g;

•Ta

ke a

cco

un

t o

f ed

uca

tio

n a

nd

tr

ain

ing

at

the

follo

win

g le

vels

:

•Pr

e-re

gis

trat

ion

an

d u

nd

erg

rad

uat

e;•

In-s

ervi

ce (

NH

S an

d n

on

-NH

S);

•Po

st-r

egis

trat

ion

an

d p

ost

gra

du

ate

(gen

eral

ist)

;•

Post

reg

istr

atio

n a

nd

po

stg

rad

uat

e(s

pec

ialis

t);

•C

on

tin

uin

g p

rofe

ssio

nal

d

evel

op

men

t.

Deli

very

Fra

mew

ork

Train

ing

an

d E

du

cati

on

Str

ate

gic

ob

ject

ive:

Effe

ctiv

e tr

ain

ing

sch

emes

will

be

avai

lab

le t

o m

eet

the

nee

ds

of

all s

taff

.Th

e sc

hem

es w

ill c

ove

r u

nd

erg

rad

uat

e,p

re-r

egis

trat

ion

in s

ervi

ce (

NH

S an

d n

on

NH

S), p

ost

-reg

istr

atio

n (

bo

th g

ener

ally

and

sp

ecia

list)

an

d c

on

tin

uin

g

pro

fess

ion

al d

evel

op

men

t.

(See

nar

rati

ve in

Ch

apte

r fo

ur)

Tru

sts

to e

nsu

re t

rain

ing

an

d e

du

cati

on

is p

rovi

ded

to

all

staf

f to

mee

t th

eir

nee

ds.

13

Resp

on

sib

ilit

y

WH

AIS

G.

Tim

esc

ale

Intr

od

uct

ion

of

trai

nin

g p

rog

ram

me

in20

06 b

uilt

up

on

th

e ab

ove

dev

elo

pm

ents

.

4(ii)

A

new

tra

inin

g p

rog

ram

me

will

b

e d

evel

op

ed t

hat

•B

uild

s o

n t

he

curr

ent

trai

nin

g a

nd

ed

uca

tio

n in

fras

tru

ctu

re;

•Se

eks

to a

dd

ress

an

y d

efic

ien

cies

iden

tifi

ed in

th

e re

view

;•

Del

iver

s m

ult

i-d

isci

plin

ary

infe

ctio

n c

on

tro

l tra

inin

g f

or

spec

ialis

ts a

nd

no

n-s

pec

ialis

ts.

14

Resp

on

sib

ilit

y

Resp

on

sib

ilit

y

•Tr

ust

Ch

ief

Exec

uti

ve a

nd

Co

nsu

ltan

t in

In

fect

ion

Co

ntr

ol.

Mo

nit

ori

ng

•W

HA

ISG

pro

ject

tea

m;

•Tr

ust

inci

den

t re

po

rtin

g p

roce

du

res

an

d N

atio

nal

Pat

ien

t Sa

fety

Ag

ency

nat

ion

al r

epo

rtin

g.

Act

ion

s

5(i)

Tru

sts

will

un

der

take

nat

ion

al

surv

eilla

nce

pro

gra

mm

es a

s th

ey a

re

d

evel

op

ed a

nd

ad

apte

d. T

he

nat

ion

al

surv

eilla

nce

pro

gra

mm

e w

ill d

evel

op

an

d g

ive

Tru

sts

a co

mp

reh

ensi

ve

po

rtfo

lio o

f su

rvei

llan

ce t

oo

ls t

hat

w

ill p

rovi

de

com

par

ato

rs w

ith

oth

er

hea

lth

care

inst

itu

tio

ns

bo

th n

atio

nal

ly

and

inte

rnat

ion

ally

. Th

is w

ill in

clu

de:

•Su

rgic

al s

ite

infe

ctio

n s

urv

eilla

nce

ex

ten

ded

to

oth

er s

pec

ialit

ies;

•In

fect

ion

s in

ITU

: pilo

t in

200

5;•

Lab

ora

tory

co

nfi

rmed

infe

ctio

ns

du

e

to

Clo

stri

diu

m d

iffi

cile

. To

be

intr

od

uce

d a

s a

con

tin

uo

us,

m

and

ato

ry, p

rog

ram

me

in 2

004.

Deli

very

Fra

mew

ork

Su

rveil

lan

ce

Str

ate

gic

ob

ject

ive:

Tru

sts

will

ad

op

t co

mp

reh

ensi

ve

surv

eilla

nce

an

d a

ud

it p

rog

ram

mes

to

mo

nit

or

and

dir

ect

thei

r in

fect

ion

co

ntr

ol p

rog

ram

mes

. Pro

gra

mm

es w

illb

e b

ased

up

on

loca

l nee

d a

s d

irec

ted

by

the

Tru

st in

fect

ion

co

ntr

ol p

lan

an

d

pro

gra

mm

e, b

ut

will

ad

op

t n

atio

nal

pro

gra

mm

es a

s th

ey a

re d

evel

op

ed a

nd

agre

ed b

y th

e N

HS

Wal

es M

anag

emen

tB

oar

d. (

See

nar

rati

ve in

Ch

apte

r fo

ur)

Tru

sts

to e

nsu

re t

rain

ing

an

d e

du

cati

on

is p

rovi

ded

to

all

staf

f to

mee

t th

eir

nee

ds.

(See

nar

rati

ve in

Ch

apte

r fi

ve)

Serv

ice

pro

vid

ers

will

un

der

take

n

atio

nal

su

rvei

llan

ce p

rog

ram

mes

as

they

are

dev

elo

ped

an

d a

do

pte

d.

Pro

cess

as

ou

tlin

ed b

y W

HC

200

3 (4

3)2

and

cu

rren

tly

con

sist

of:

•B

acte

raem

ia s

urv

eilla

nce

;•

Surg

ical

sit

e in

fect

ion

su

rvei

llan

ce;

•H

osp

ital

ou

tbre

ak s

urv

eilla

nce

;•

Cu

rren

t vo

lun

tary

sch

emes

; Cen

tral

va

scu

lar

dev

ice

asso

ciat

ed in

fect

ion

p

ilot.

2 W

elsh

Ass

emb

ly G

ove

rnm

ent.

Hea

lth

care

ass

oci

ated

infe

ctio

n s

urv

eilla

nce

. WH

C 2

003(

43)

Ap

ril 2

003.

Ava

ilab

le a

th

ttp

://h

ow

is.w

ale

s.n

hs.

uk/g

site

CW

/do

cum

en

ts/3

68/w

hco

rth

o.d

oc

acce

ssed

15t

h S

epte

mb

er 2

003.

15

•O

ther

lab

ora

tory

co

nfi

rmed

b

acte

raem

ias.

Th

ere

will

be

a p

arti

cula

r fo

cus

on

bac

tera

emia

s d

ue

to g

lyco

pep

tid

e re

sist

ant

ente

roco

cci.

Tim

esc

ale

As

liste

d b

ut

also

as

furt

her

ad

vise

d v

iaW

elsh

Hea

lth

Cir

cula

r, fo

llow

ing

re

com

men

dat

ion

of

WH

AIS

G a

nd

ac

cep

tan

ce b

y th

e N

HSD

Man

agem

ent

Team

.

16

Resp

on

sib

ilit

y

Resp

on

sib

ilit

y

•W

HA

ISG

pro

ject

tea

m.

Mo

nit

ori

ng

•N

atio

nal

Clin

ical

au

dit

pri

ori

ties

p

rog

ram

me.

Tim

esc

ale

•M

arch

200

5.

Resp

on

sib

ilit

y

•Tr

ust

Ch

ief

Exec

uti

ves

to s

ub

mit

ex

pre

ssio

ns

of

inte

rest

to

pilo

t th

e to

ol.

Mo

nit

ori

ng

•W

HA

ISG

.

Tim

esc

ale

•B

y 30

No

vem

ber

200

4;•

Au

dit

rep

ort

co

mp

lete

d b

y Fe

bru

ary

20

05.

Act

ion

s

5(ii)

Tru

sts

to e

nsu

re t

hat

Infe

ctio

n c

on

tro

l au

dit

is t

o b

e in

clu

ded

as

par

t o

f th

e tr

ust

wid

e p

rog

ram

me

of

clin

ical

au

dit

. (N

atio

nal

au

dit

to

ols

will

be

ado

pte

d a

s ag

reed

wit

h N

HS

Man

agem

ent

Bo

ard

/Nat

ion

al

Ass

oci

atio

n o

f C

hie

f Ex

ecu

tive

s).

5(iii

) Th

e U

K a

ud

it t

oo

l co

mm

issi

on

ed b

y

the

Dep

artm

ent

of

Hea

lth

an

d

curr

entl

y b

ein

g d

evel

op

ed b

y th

e In

fect

ion

Co

ntr

ol N

urs

es A

sso

ciat

ion

w

ith

key

sta

keh

old

ers,

incl

ud

ing

th

e W

elsh

Ass

emb

ly G

ove

rnm

ent,

to

be

pilo

ted

wit

hin

sel

ecte

d T

rust

s w

ith

a

vi

ew t

o a

do

pti

on

nat

ion

ally

. Tru

st

Ch

ief

Exec

uti

ves

to s

ub

mit

ex

pre

ssio

ns

of

inte

rest

to

pilo

t th

e to

ol b

y 30

No

vem

ber

200

4.

Deli

very

Fra

mew

ork

Au

dit

Clin

ical

au

dit

pro

vid

es a

n im

po

rtan

t to

ol

to m

on

ito

r th

e im

ple

men

tati

on

of

po

licie

s an

d o

per

atio

nal

per

form

ance

.

Deli

very

Fra

mew

ork

Inte

rven

tio

ns

an

d P

erf

orm

an

ceIn

dic

ato

rs

Str

ate

gic

ob

ject

ive:

Red

uct

ion

in in

fect

ion

rat

es w

ill f

orm

par

t o

f Tr

ust

pro

gra

mm

es a

nd

str

ateg

ies.

This

will

be

emb

edd

ed w

ith

in o

vera

lltr

ust

man

agem

ent

sch

emes

an

d w

ill h

ave

links

to

clin

ical

go

vern

ance

, ris

k m

anag

emen

t, p

erfo

rman

ce m

anag

emen

tan

d t

he

‘Bal

ance

d S

core

card

’.

(See

nar

rati

ve in

Ch

apte

r si

x)W

HC

200

3(43

)2re

qu

ires

eac

h T

rust

to

set

and

reg

iste

r an

nu

ally

wit

h t

he

Hea

lth

care

Ass

oci

ated

Infe

ctio

n P

roje

ctte

am, l

oca

l pri

ori

ty t

arg

ets

for

mea

sura

ble

infe

ctio

n r

edu

ctio

n.

17

Resp

on

sib

ilit

y

Resp

on

sib

ilit

y

•Tr

ust

Ch

ief

Exec

uti

ve O

ffic

ers.

Mo

nit

ori

ng

•N

HS

Reg

ion

al O

ffic

es t

hro

ug

h t

he

B

alan

ced

Sco

reca

rd.

•W

HA

ISG

pro

ject

tea

m.

An

nu

al

revi

ew/r

epo

rt.

Tim

esc

ale

•A

nn

ual

.

Act

ion

s

6(i)

In a

cco

rdan

ce w

ith

WH

C 2

003

(43)

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Part one

Chapter one: Healthcare Associated Infections in Hospitals: An Overview

Background

1.1 The treatment and care of patients in hospital is often complicated by the development of infection, which arises from a variety of factors that make people susceptible tomicrobial challenge. These include: the reduction of the effectiveness of the body’simmune system by many illnesses; the presentation of disease in the very young and thevery old who are particularly prone to infection; medical interventions which compromise normal protective mechanisms; and the potential for transmission of pathogenic organisms from patient to patient when they are managed in close proximity. The prevention and control of infections is a major challenge, and success inthis area was a prerequisite in the development of complex medical procedures. Thereduction of infections over the past hundred years has been achieved through a multiplicity of approaches that result from an increasing understanding of microbial disease. These include sound hygienic practices, effective methods for sterilisation, asepsis, antisepsis, and environmental control; the discovery and use of antibiotics; thedevelopment of laboratory methods and the application of epidemiological science.Incorporation into clinical practice has been facilitated and supported by education andtraining, a range of management processes to ensure good practice, and the development of a cadre of infection control specialists. Despite this, healthcare associated infections remain common. National surveys suggest that nine per cent ofinpatients have a hospital associated infection at any time.

1.2 Healthcare associated infections (HAIs) are particularly important adverse events because of:

• Their frequency and scale – infection not only affects an individual but can be transmitted to others and represent a significant public health problem.

• Their impact on delivering services – HAIs impede good outcomes from treatment, increase length of stay and often lead to temporary closure of services or require additional resources to maintain services;

• Their bearing on public expectations – historically health has been improved by measures to prevent infections;

• Their negative image – HAIs are partly a reflection of poor hygiene and unsuitable environments.3

3 Scottish Executive (Guidance on core standards for the control of infection in hospitals, healthcarepremises and the community interface). July 1998. Available at:www.scotland.gov.uk/library5/health/preventinfect.pdf

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The impact of healthcare associated infections and their potential control

1.3 Effects of HAIs vary from discomfort to prolonged or permanent disability. In a small proportion of patients, death may result. The costs of hospital associated infection, including extended length of stay, are difficult to measure. It is also uncertain howmany of these infections are preventable in the context of current medical practice andavailable technology. However, in 1995 the Hospital Infection Working Group of theDepartment of Health and Public Health Laboratory Service suggested that 30 per centof hospital acquired infections could be avoided by better application of existing knowledge and realistic infection control practices (Department of Health,1995). TheNational Audit Office report published in 2000 (National Audit Office, 2000) recorded aprofessional consensus that at least a 15 per cent reduction should be achievable.Continued progress in this area was highlighted in the NHS in Wales strategy, ImprovingHealth in Wales – A Plan for the NHS and Its Partners (National Assembly for Wales,2001). Hygiene is identified as a high priority for hospitals, and hospital associated infections should be reduced to ensure that patients are cared for in a safe environment.

1.4 Hospital and clinical management are key to limiting hospital associated infections and include:

• Identifying risk factors and minimising their impact;• Improving patients’ resistance to infection;• Early identification and effective treatment of infections;• Preventing transmission of micro-organisms from person to person;• Maintaining a clean environment with low levels of microbial contamination.

These processes have been built into routine clinical activities. Data from the nationalStaphylococcus aureus bacteraemia surveillance scheme indicate that, to some degree, equilibrium has been achieved. Therefore, initiatives that result in significant change topractice will be required if progress is to be achieved.

Some lessons from the Severe Acute Respiratory Syndrome (SARS)outbreak

1.5 The SARS outbreak highlighted some important principles in the prevention of transmission of micro-organisms in hospitals. The coronavirus responsible for this condition readily spread from patient to patient or from patients to staff. Infectionsassociated with a high mortality resulted and required urgent reassessment of the infection control procedures in operation in affected hospitals (MMWR, 2003). It isprobable that some of the agents commonly associated with cross-infection in UK hospitals, such as Norovirus, have a similar capacity for transmission. The SARS outbreakhas thus provided us with a timely reminder that not only should sound and evidence-based infection control policies be in place but considerable attention must be paid toensuring that they are rigorously and consistently applied. This requires a sound understanding and commitment to effective infection prevention and control practiceamong staff throughout the healthcare system. This strategy focuses on the development of systems designed to achieve this objective.

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Chapter two: National Standards

2.1 The NHS in Wales strategy, Improving Health in Wales – A Plan for the NHS and its partners, highlights the need to underpin the achievement of measurable improvements in health outcomes with the setting, monitoring and reviewing ofnational standards of care. The key standards in relation to infection control aredefined by the Welsh Risk Pool. These aim to ensure that there is a managed environment which minimises the risk of infection to patients, staff and visitors, andwhich addresses

• Management accountabilities;• Resources made available to support infection control activities;• Policies and guidelines for the management of infection across the organisation;• The review and revision of infection control arrangements;• Training in the management of infection;• Surveillance and audit;• Communication;• Performance indicators.

2.2 National Standards for Cleanliness of NHS Trusts provide a structured approach to defining environmental hygiene requirements.

2.3 The Welsh Risk Pool and National Cleanliness Standards form a comprehensive framework for infection control and hygiene management. It is important that these are accompanied by a dynamic process of refinement and review that takes account of changing need and development of the evidence base.

2.4 Additionally, this strategy recognises the need to develop and learn from the evidence base. As new standards are developed that assist in managing infection, these will be adopted and endorsed by the Healthcare Standards Advisory Board and published onthe NPHS web site alongside this strategy.

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National Standards: Action

Action to be taken by Trusts:

2 (i) Trusts to comply with current infection control standards. In doing so, Trusts to consider:

• Role of clinical directorates within the accountability framework; • Formal incorporation of the national surveillance programmes; • Incorporation of outcome measures within the performance indicators;• Consideration of the potential for extending external audit processes to

complement internal audit arrangements.

Action to be taken by Healthcare Inspectorate Wales:

2 (ii) Welsh Risk Pool standards for infection control to be adapted by Healthcare Inspectorate Wales to accommodate evolving aspects of the national infection control strategy and development of the evidence base.

Action to be taken by Trust Chief Executives:

2(iii) Opportunities to be explored to build upon the new National Standards for Cleanliness of NHS Trusts to develop additional recommendations that further strengthen infection control.

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Chapter three: Infrastructure and Organisation

Responsibilities of NHS staff

3.1 A key challenge for the prevention of HAIs is to ensure that procedures are in place that reduce the risk of adverse events at every patient contact. The NHS in Wales strategy, Improving Health in Wales – A Plan for the NHS and Its Partners highlights the need for a management culture emphasising the critical importance of care in a safe environment and the personal responsibility of every member of staff. A key objective of the strategy is to introduce a clean culture throughout the healthcare system and to ensure that hygiene and infection control are embedded in the management agenda and the accountability of all staff. At national level, the NHS Management Executive and National Assembly Committee for Trust Chief Executives have indicated their strong support for these objectives. The National Audit Office (National Audit Office, 2000) also highlighted the need for full engagement of NHS Trust Boards and Chief Executives. This level of engagement is explored within Welsh Risk Pool audits. Systems need to be in place to ensure that this high level commitment continues through to front line practitioners.

Management accountabilities

3.2 Improving Health in Wales – A Plan for the NHS and its partners and the National Audit Office report The Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England, both anticipate the implementation of management arrangements for infection control. These foster and develop ownership of the infection control agenda by all staff. This Strategy reinforces current guidance in this area by requiring clinical directorates to formally adopt accountability for the infection control and hygiene practices of staff working in their unit. Several Trusts in Wales have already taken this approach and Annex A illustrates the infection control strategy developed by one of them.

Management Accountabilities: Action

Action to be taken by Trusts:

3(i) Trusts should review management arrangements to ensure that clear lines of accountability have been established.

3(ii) Each of the Trust’s directorate management teams should appoint a member to beformally accountable for infection control practice. Trusts should recognise the infection control obligations of all directorates, both clinical and non-clinical. This appointee should become a core member of the Trust’s infection control committee.

3(iii) Each directorate should work with the Trust Infection Control specialists to determine the priorities for action in their area of activity and the directorate’s contribution to the Trust – wide infection control programme.

3.3 Through these actions, it is hoped that a rounded ‘balanced scorecard’ approach to infection control that incorporates strategic vision, standards, benchmarking, scrutiny and action plans will be developed across the NHS in Wales. This will be through partnership working between the NHSD, Trusts, directorates and individuals.

Specialist infection control support

3.4 A cadre of infection control doctors and nurses provide specialist advice; leadership; outbreak management; policy formulation; epidemiological skills; and education in relation to infection prevention and control in all NHS Trusts in Wales. The infection control doctors are consultant medical microbiologists who are able to commit variableproportions of their professional time to this area of activity. The Infection Control Nurses (ICNs) are usually wholly employed on infection control duties. There are noguidelines in the UK on specialist infection control staffing. Data from the United States indicates that for their healthcare system there should be at least one ICN for every 250beds (Haley et al, 1985). The deployment of ICNs in Welsh hospitals in 2001 is illustratedin Annex B. The figures do not include the non-acute beds covered by ICNs in manyTrusts. Some increase in the numbers of infection control nurses in Wales has takenplace over recent years. However, workloads have also risen as a result of increasingpublic and political focus on hospital associated infections, the spread of methicillinresistant staphylococcus aureus (MRSA) and other antibiotic resistant micro-organisms.Increased patient throughput, higher bed occupancy, staff shortages, the developmentof improved surveillance and audit systems and a very large, and increasing,requirement for staff training in infection control have added to the burden. The RoyalCollege of Pathologists has guidelines on the amount of time that infection controldoctors should spend on infection control. It is unlikely that these recommendations arebeing met in many Trusts. Trusts will also need to address the optimal skill-mix ofInfection Control teams (ICTs) to fully discharge of their functions. In addition tomedical and nursing input into the ICT, full support for a comprehensive infectioncontrol programme now requires a multi-disciplinary approach that can, in addition, usescientific, epidemiological and data handling skills.

3.5 Other problems in relation to the work of Infection Control Teams have been brought to the attention of the Welsh Healthcare Associated Infection Sub-Group (WHAISG). In 2001, 42 per cent of ICNs had no clerical support, on-call arrangements were variable and remuneration often inadequate and ICTs were often not consulted in relation to estates issues. However, the central problem for ICTs is gaining the full engagement and commitment from clinical staff in relation to adherence to infection control practice.

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Specialist Infection Control: Action

Action to be taken by Welsh Assembly Government:

3 (iv)The current review of resources available for the control of communicable disease in Wales by the Committee for the Control of Communicable Disease will identify good practice and provide updated recommendations on staffing and resources for Trust Chief Executives to consider.

Action to be taken by Trusts:

3(v) The directorate staff member appointed to be accountable for infection control practice should become a core member of the Trust’s infection control committee.

Specialist Epidemiological Support

3.6 Hospital epidemiology is the study of the distribution and determinants of infection in hospitalised patients and the application of this study to the prevention and control ofhospital associated infection. Consultant epidemiologists and clinical scientists at theCommunicable Disease Surveillance Centre have an in-depth understanding of statistics,epidemiology and research methods that can be applied to the investigation and control of hospital outbreaks and clusters of infection. Similar expertise is also available from Consultants in Communicable Disease Control based in local health protectionteams. These skills are currently used in the interpretation of routine surveillance data.However, surveillance is not an end in itself but rather a mechanism to provide information for action. Trust infection control teams may require further specialist epidemiological support to investigate and identify the cause of any adverse findingsdetected by surveillance. Specialist epidemiological expertise can also help in the designand evaluation of interventions implemented to reduce hospital associated infection.

Specialist Epidemiological Support: Action

Action to be taken by NPHS (Wales):

3(vi) The National Public Health Service for Wales to ensure availability of specialist epidemiological expertise for Trusts based in the Communicable Disease Surveillance Centre to support local services.

Facilities

3.7 Effective infection control systems require a range of estates and engineering issues to be addressed. These include:

• A clean environment;• Safe water supplies and cooling systems;• Operating theatres with appropriate clean air systems;• Equipment for sterilisation and decontamination;• Isolation facilities with effective negative pressure ventilation.

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3.8 The House of Lords Select Committee report (House of Lords Select Committee on Science and Technology,1998) stated that: ‘Isolation of patients is an expensive buteffective form of infection control.’ Patients may be nursed in isolation if they have adisease or condition with the potential to spread or because they are highly susceptibleto acquiring infection as a result of an underlying condition or therapy. Isolation ofinfected patients may be required on admission, as well as for those who becomeinfected during their hospital stay. There are two main categories of isolation. The first,protective isolation, aims to shield the immuno-compromised patient from micro-organisms that may be acquired from other people or the environment. The second, source isolation, aims to prevent the transfer of pathogens or resistantorganisms from infected or colonised patients to others. Concern about the provision inWales of isolation facilities for the latter, and particularly accommodation with effectivenegative pressure ventilation to provide a high level of containment, prompted theWelsh Assembly Government to undertake a survey of the facilities currently available.This demonstrated an acute shortage of accommodation with negative pressure ventilation. Recent planning in Wales in relation to the threats posed by multi-drugresistant tuberculosis, SARS and bioterrorism has emphasised this deficiency.

Facilities: Action

Action to be taken by Welsh Assembly Government:

3(vii) The Welsh Assembly Government will evaluate the results of the survey of isolation facilities in Wales, and provide guidance on the accommodation required and consider the need for capital investment in the light of further planning.

Action to be taken by Trusts:

3 (viii) Trusts will need to provide appropriate isolation facilities to meet their needs.

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28

Chapter four: Training and Education

4.1 This strategy places strong emphasis on the need for all healthcare workers to understand and discharge their roles and responsibilities in relation to infection control within the clinical governance and risk management framework, and expects clinical teams to confront their own problems, guided and supported by specialist infection control practitioners. This was firmly advocated in Improving Health in Wales – A Plan for the NHS and its partners and in the National Audit Office document, TheManagement and Control of Hospital Acquired Infection in Acute NHS Trusts in England published in 2000. Ensuring effective training schemes to support these objectives is critical in achieving success in this area.

4.2 The NAO report (2000) highlighted a number of problems associated with the delivery of education and training programmes. These included:

• Insufficient access to training programmes to provide learning reinforcement;• Incomplete provision of induction training for all groups of staff, particularly in

relation to senior doctors; cleaners; food handling staff; nursing students; and medical students;

• Incomplete staff attendance at annual updates;• A lack of audits to examine the effectiveness of training.

4.3 It is uncertain whether such problems exist in Wales; however, the Welsh Healthcare Associated Infection Sub-Group has anecdotal evidence that this may be the case. Difficulties experienced by Infection Control Teams in achieving high coverage of Trust staff have been highlighted. Developing infection control expertise in a broader range of staff and giving responsibility for in-service training and instruction at ward and directorate level has also been emphasised.

4.4 In addition, a deficiency in the provision of specialist infection control training is also noted. There is potential for developing specialist programmes in Wales. There is also a dearth of training in hospital epidemiology throughout the UK. Wales has the professional resources to fill this gap.

Training and Education: Action

Action to be taken by Welsh Healthcare Associated Infection Sub Group

4 (i) The review of training and education undertaken by the Wales Centre for Health will be considered in June 2004.

4 (ii) A new training programme will be developed and further detailed information will be sent to trusts to indicate the introduction of training programmes by 2006.

Chapter five: Surveillance and Audit

The importance of surveillance and audit for infection control

5.1 Improving Health in Wales – A Plan for the NHS and Its Partners emphasised the importance of good information to plan service delivery, evaluate progress and demonstrate improvements. In infection control, surveillance plays a central role in providing the intelligence to underpin strategic objectives as well as informing priorities and focus of day to day operations. Measurement of local infection rates over timeusing standard methods allows comparison with national and international data andwill facilitate:

• Recognition of clusters or outbreaks of infection;• An understanding of a Trust’s relative performance;• Setting of priorities;• Targeting of appropriate control measures;• Monitoring the outcomes of interventions.

Incorporation of an effective surveillance programme with regular feedback of resultsto clinical staff has proved to contribute to reductions in the incidence of HAIs (Haley etal, 1985). The Welsh Risk Pool Standards recognise and require that surveillance programmes are in place using defined methods.

5.2 To achieve the above, surveillance must be structured, with agreed definitions, consistent data collection methods and appropriate statistical analysis to underpin conclusions. Frequent and timely feedback to clinical staff is essential.

5.3 Locally, Trusts Infection Control Teams and clinical directorates will be responsible for implementation of surveillance with close collaboration, involvement and participation of other staff. Trusts should ensure that resources are available to support the surveillance programme. Adequate staffing and good management are especially important.

5.4 Nationally, the Welsh Healthcare Associated Infection project team will

• Facilitate and co-ordinate the local surveillance in Trusts;• Collate data at national level on behalf of the Welsh Assembly Government;• Compile national reports;• Help disseminate good practice.

5.5 In 1996, a project examining hospital infections was established in Wales via funding from the Welsh Office. The objectives were

• To quantify the burden of healthcare associated infections in Wales;• To describe and explain variation in healthcare associated infections over time and by

hospital and speciality;• To develop a hospital outbreak/incident reporting system with a mechanism to

promptly disseminate information on lessons learned and good practice;• To develop an effective clinical surveillance system to capture data on post discharge

infections;

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• To develop an audit system to identify preventable factors and to implement observational audit to establish compliance with good practice;

• To determine risk factors for acquisition and outcome of colonisation by MRSA of differing types.

5.6 Much of the activity of the project has been devoted to establishing sound methods for surveillance to delineate hospital associated infections in Wales. Surveillance schemes for hospital ‘alert’ organisms and clinical infections have beendeveloped, which Trusts adopted on a voluntary basis. The information from these schemes has proved valuable in tracking hospital associated infection in Wales, and highlighting areas of concern. (See Annex C: MRSA reporting via CoSurv and Annex D: Hospital Outbreak Reporting.)

5.7 This method for surgical site surveillance has been developed on a UK-wide basis. It is also accepted as the European Union approach for a surveillance programme involving22 countries from 2004. The data collected will also be compatible with surveillance undertaken in the US and other non-EU countries.

5.8 The first mandatory surveillance programme was introduced in Wales in 2001. This focused on Staphylococcus Aureus bacteraemias. Laboratory confirmed patient events are reported on a quarterly basis, from all acute Trusts in Wales. This matched developments in England, Scotland and Northern Ireland. In Wales, the data items collected were increased after the first six months of surveillance, to allow speciality-based rates of Staphylococcus Aureus bacteraemias to be calculated and lineassociated infections identified. This has allowed problem areas to be highlighted andtargeted for control measures (See Annex E ). Mandatory surveillance will beimplemented for other organisms and conditions.

Surveillance: Action

Action to be taken by Trust Chief Executives and Consultants in Infection Control:

5(i) Trusts to undertake national surveillance programmes as they are developed and adapted. The national surveillance programme will develop and give Trusts a comprehensive portfolio of surveillance tools that will provide comparators with other healthcare institutions both nationally and internationally. This will include:

• Surgical site infection surveillance extended to other specialities;• Infections in ITU: pilot in 2004;• Laboratory confirmed infections due to Clostridium difficile. To be introduced as a

continuous, mandatory, programme in 2004.

Audit

5.9 Clinical audit provides an important tool to monitor the implementation of policies and operational performance. It can also provide insight into problems highlighted by surveillance. In a survey undertaken in 2001, 83 per cent of ICTs undertook audit in clinical areas. This usually comprised of exercises that examined environmentalcleanliness, handwashing or knowledge of policies. The Welsh Risk Pool Standards require all Trusts to have an annual programme of internal audit of infection control policies and procedures. The introduction of external audit will now be considered.

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Audit: Action

Action to be taken by Trust Chief Executives

5(ii) Trusts to ensure that infection control audit is to be included as part of the Trust-wide programme of clinical audit. (National audit tools will be adopted as agreed with NHS Management Board/National Association of Chief Executives).

5(iii) The UK audit tool commissioned by the Department of Health and currently being developed by the Infection Control Nurses Association with key stakeholders (including the Welsh Assembly Government) to be piloted with a view to adoption nationally. Trust Chief Executives to submit expressions of interest to pilot the tool by 29 January 2005.

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Chapter six: Interventions and Performance Indicators

6.1 Improving Health in Wales – A Plan for the NHS and It’s Partners notes that effective performance management is essential for a successful organisation and particularly important at a time when so many demands are placed upon it. Health professionals, supporting staff, managers and the public need to know how they are doing against agreed objectives. The principles laid out in the document for effective performance management to be implemented and maintained are highly relevant to infection control, that is, good leadership at all levels and processes built on five basic buildingblocks:

• Bold aspirations;• A coherent set of objectives, measures and targets to monitor progress in realising

these aspirations;• Ownership and accountability to ensure that those individuals who are best placed to

ensure delivery do so;• Rigorous performance review to ensure that continuously improving performance is

being delivered in line with expectations;• Reinforcement to motivate individuals to deliver the targeted performance.

6.2 These principles have strongly influenced this strategy, which proposes that our central aspiration should be to produce measurable reductions in infections. It recognises thatthis can only be achieved if all healthcare workers contribute to this process. This mustbe done in a strong performance management framework, with mechanisms in place toensure communication to staff regarding progress.

Interventions and Performance Indicators

6.3 The Welsh Risk Pool Standards require that Trusts identify key indicators that are capable of showing improvements in infection control and/or providing early warning of risk. There are a number of process indicators that can be valuable in this context:

• Percentage of staff trained in infection control;• Progress against infection control audit;• Progress against planned infection control programme.

6.4 However, the use of outcome measures as performance indicators is strongly recommended. These could include:

• Number and scale of infection control incidents/outbreaks reported;• Rates of hospital associated infections.

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6.5 Unfortunately the evidence base in relation to the rates of infection that might be anticipated in a hospital that manages its infection control activities effectively is deficient and the targets that might be set in relation to outcome indicators speculative. For this reason Welsh Health Circular (2003) 43 seeks to facilitate the development of outcome performance indicators that have general application forbenchmarking and monitoring purposes nationally. It does this by

• Use of performance indicators that seek to reduce infections;• Providing sufficient flexibility to allow Trusts to identify their own priorities for action

(see Annex F as an example of practice);• Requiring the use of nationally agreed surveillance methods to assist in interpretation

and ensure that the lessons learnt, and the good practice identified, have wide applicability.

Interventions and Performance Indicators: Action

Action to be taken by Trust Chief Executives:

6(i) In accordance with WHC 2003(43), each Trust is to set and register annually with the Healthcare Associated Infection Project Team, local priority targets for measurable infection reduction.

Action to be taken by WHAISG:

6(ii) Promulgation of best practice annually (or as required) to be provided by the Welsh Healthcare Associated Infection Sub-Group (WHAISG).

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Chapter seven: Information Technology and Communication

7.1 The recently published Review of Health and Social Care in Wales (Welsh Assembly Government, 2003) highlighted the deficiencies in information technology available tothe NHS in Wales and recommended a long-term programme for information and communication technologies with increased investment as a priority. Good InformationManagement and Technology (IM&T) support is essential for efficient working in infection control, particularly:

• Gathering, recording, analysing and disseminating data for surveillance purposes;• Improved access to clinical information;• Tracking patient locations;• Assessing impact of staff activity on infection outcomes;• Deriving proxies for the effectiveness of infection control management;• Monitoring microbiology results, antibiotic resistance and prescribing;• Facilitating communications and making available updates, policies and guidelines;• Gaining access to expert advice.

The management of hospital infection will be significantly improved if future investment in the NHS IM&T infrastructure results in increased capacity in these areas.This must take account of the specialised systems for infection control.

Communication

7.2 Major improvements of Trust clinical, diagnostic, pharmacy, administration and management systems are necessary to obtain maximum benefit for infection preventionand control. Nationally, IM&T systems have been developed to support ICT record keeping and surveillance: InControl (which has now been developed as a commercialproduct, ICNet). Another product, DataStore, has been developed in Wales. It is functional in NPHS laboratories and is being installed in NHS departments. DataStorewill assist laboratory reporting for surveillance purposes and improve laboratories ability to gain access to, and analyse, their data. Further funding from the WelshAssembly Government has produced a Welsh Healthcare Associated Infection website toimprove information access and exchange. This site will support this strategy and can beaccessed via the NPHS website.

7.3 To fully utilise use these IM&T systems, Information and Communication Technology skills training is required to develop expertise in this area.

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Information Technology and Communications: Action

Action to be taken by Welsh Assembly Government and Trusts:

7 (i) The Welsh Assembly Government and NHS Trusts will take account of the needs of infection control in the development and implementation of future IM&T programmes.

Action to be taken by Trusts:

7(ii) Trusts will ensure that appropriate resources are available to provide Infection Control Teams with specialist IT tools and software.

Action to be taken by NPHS (Wales):

7(iii) The Welsh Healthcare Associated Infection website will be developed as the major vehicle for communication and information exchange, including regular update of strategic developments.

7(iv) Further development of Datastore by WHAISG project team will be used to improve the effectiveness and efficiency of laboratory reporting for surveillance purposes.

7(v) The training review undertaken by WHAISG will include IM&T requirements.

Part four

Bibliography

Haley R.W., White J.W., Culver D.H., Meade Morgan W., Emori T.G. and Munn VP et al.1985. The efficacy of infection surveillance and central programs in preventing nosocomialinfections in US hospitals (SENIC). American Journal of Epidemiology; 121:182-205.

Department of Health (1995).Hospital infection control: guidance on the control of infection in hospitals. HSG(95)10.London: Department of Health.

Stationary Office (1998).House of Lords Select Committee on Science and Technology.Resistance to antibiotics, and other antimicrobial agents. London: Stationery Office.

National Assembly for Wales (2001).Improving Health in Wales – A Plan for the NHS and its partners. Cardiff: National Assemblyfor Wales.

National Audit Office. 2000. The management and control of hospital acquired infection inacute NHS trusts in England. London: Stationery Office;

Plowman R. Craves N. Griffin M. Roberts J. Swan A. Cookson B. and Taylor L. 2000. The socio economic burden of hospital acquired infection. London: Public Health Laboratory Service.

Risk Management and Organisational Control WHC. (2000).13.

Welsh Assembly Government. 2003.The Review of Health and Social Care in Wales: Reportof the Project Team.

Update: Severe Acute Respiratory Syndrome – Toronto. Canada. 2003. Morbidity andMortality Weekly Reports. June 13: 52(23);547-550.

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Part five

Annexes

Annex A

Infection Control Strategy: Pontypridd and Rhondda NHS Trust.

Vision

To have in place measures and processes to enable us to continually reduce the risk of hospital acquired infection.

Goals

1. The Trust has a culture that recognizes that control of infection is everybody’s business.

2. The development of effective and efficient control of infection is strategically planned.

3. The reduction of infection is an integral part of each Directorate’s risk management action plan and the Trust-wide risk management strategy.

4. The roles and responsibilities of individuals and groups are clear.

5. Good practice is promoted across the Trust through a better understanding of the principles of control of infection.

6. Access is available to appropriate and necessary training and education opportunities in relation to control of infection.

7. Directorate-specific individual procedure documents are introduced which are based on a series of underpinning corporate principles.

8. The incidence of preventable infection is reduced.

9. Necessary actions are taken to prevent the spread of epidemic MRSA which minimize the number of patients affected by MRSA with minimal disruption of routine hospital activity and without compromising patients’ access to necessary clinical care.

10. There are an agreed set of indicators of performance for each Directorate and progress against these targets is monitored and evaluated.

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Annex B

Number of acute beds covered by Infections Control Nurses in NHS Trusts in Wales. Variable numbers of non-acute beds are also covered. (2003).

Trust No. of acute beds No. of ICNs Acute beds/ICN

1

2

3

4

5

6

7

8

9

10

11

12

13

1783

1398

531

625

195

595

1343

65

846

635

300

436

621

5

10

2

3

1

3

3

2

2

4

2

2

3

357

140

266

208

195

198

447

33

423

159

150

218

207

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Annex C

MRSA reporting via CoSurv

Since 1993, data on Staphylococcus Aureus from blood cultures and CSF has been collectedvia CoSurv, including methicillin susceptibility. In 1996, surveillance was expanded to all newMRSA, associated with colonisation and infection, from hospital and community settings.This surveillance has documented the rise in methicillin resistance over time, the variationby place and the population groups most affected. Data has shown that although therewas a steep rise in the incidence of MRSA in Wales between 1996 and 1998, since then theincidence has remained relatively stable. The CoSurv data has been audited and supplemented by two MRSA incidence surveys and a survey of policies for transfers ofpatients with resistant organisms. These surveys have delineated the problem by hospitaland extended the surveillance into examining policies and procedures.

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Annex D

Hospital outbreak reporting

A hospital outbreak reporting system was developed in 1997. Infection Control Teams (ICT)complete a monthly questionnaire on any outbreaks that have occurred. Originally the surveillance was by paper questionnaire, but this has developed over time into reportingvia an electronic questionnaire sent by e-mail to the project team and now into web basedreporting and querying of the database. Surveillance documents the causes of the out-breaks, the number of patients and staff involved and the control measures undertaken,providing an information resource for ICT and allowing the analysis of the success of different control strategies.

Although voluntary reporting is undertaken by approximately half the infection controlteams in Wales, data shows that viral gastroenteritis is by far the most common outbreak inhospitals in Wales only, and that numbers of outbreaks of this organism have increasedrecently.

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Annex E

Surgical Site Infection reporting

A voluntary surveillance scheme for surgical site infections was developed in 2001.Surveillance is via questionnaires produced for use with optical mark reader technology.The questionnaires are completed by surgical/infection control personnel in hospitals. Localanalysis is carried out by a surveillance co-ordinator based at each hospital, using a database written by the programme team. Stratified analysis of the data based on theAmerican NNIS risk index for infection is the basis of the reports in the database. All-Walesanalysis is provided by the programme team.

Four hospitals in Wales have been running the SSI surveillance for orthopaedic proceduresand three for obstetrics and gynaecology/Caesarian sections on a voluntary basis.

Annex F

Staphylococcus Aureus bacteraemia reporting

The project team was approached by the infection control team of a hospital, who wereconcerned because their MRSA bacteraemia rates were consistently among the highest inWales. An examination of their data by specialty suggested that their rates for nephrologywere higher than in other Trusts. A case notes review was carried out on nephrologypatients with a MRSA bacteraemia over a one-year period. It was found that in 9 of 11patients an intra-vascular line had been inserted during the three weeks previous to thepositive bacteraemia. The rate of MRSA bacteraemia per 100 line insertions was found tobe statistically significantly higher in this unit compared to a similar unit in a neighbouringhospital. A review of the line insertion policies and practice was carried out. Subsequent tothis the MRSA bacteraemia rate for nephrology in the hospital has decreased, as has theoverall MRSA bacteraemia rate.

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