infection prevention and control report 2012-13cmft.nhs.uk/media/603473/infection prevention and...
TRANSCRIPT
Infection Prevention & Control Annual Report 2012/13
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CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST
Report of: Gill Heaton - Director of Patient Services/Chief Nurse
Paper prepared by: Julie Cawthorne Consultant Nurse Infection Prevention and Control
Date of paper: July 2013
Subject: Infection Prevention and Control Annual Report 2012/13 and Infection Prevention and Control Annual Plan 2013/14
Purpose of Report: Indicate which by �
• Information to note�
• Support
• Resolution
• Approval � (Annual Plan 2013/14)
Consideration of Risk against Key Priorities
(Impact of report on key priorities and risks to give assurance to the Board that its decisions are effectively delivering the Trust’s strategy in a risk aware manner)
This report provides an update on the Trust’s Infection Prevention & Control activities and information on actions in place in order to provide assurance to the Board of compliance with The Health & Social Care Act (2008): Code of Practice for the Prevention & Control of Healthcare Associated Infections.
Recommendations The Board of Directors are asked to:
1. Receive this report for April 2012 – March 2013 which provides information and assurance on the key activities of the Infection Prevention and Control Team and Trust staff for the year ending April 2012.
2. Approve the Annual Action Plan for April 2013 – March
2014
Introduction
The Board are asked to receive the Infection Prevention and Control Annual Report for 2012/13.
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Executive Summary This year the Trust experienced a mixed level of attainment with regard to the Healthcare Associated Infection (HCAI) objectives. The incidents of Clostridium difficile infection (CDI), achieved was 4% under trajectory. Conversley we are very disappointed to report that the objective for incidents of meticillin resistant Staphylococcus aureus (MRSA) bacteraemia was breached. The Infection prevention and control (IPC) team and the Trust staff have faced new and varied challenges not least from the assimilation of Trafford General Hospitals and the integration of the Trust-wide IPC and Tissue Viability (TV) nursing teams under one new management structure, within the Clinical and Scientific Services Division. Other challenges this year included the on-going problems associated with the management of carbapenemase producing Coliforms (CPC). The surveillance data for CPC however; showed that there was a decrease in the number of patients identified with a clinical isolate over the last six months. Key Achievements & Challenges
1. The data for CPC suggests that in the course of the last 12 months there has been an overall downward trend in the number of new patients identified with CPC from a clinical isolate.
2. The success of the Trust as leaders in Infection prevention and control
practice was evidenced when the Consultant Nurse was invited to present to Lewisham Hospital in June 2012 on how the Trust had embedded aseptic non-touch technique into clinical practice. .
3. In total 4460, (72%) of front line staff were vaccinated against Influenza this
year compared to 2921 for last year. This much improved rate of protection amongst frontline staff, and therefore indirectly to our most vulnerable patients, was one of the highest rates in the North West Region.
4. We were a national pilot site for Patient Led Assessment of Care Environments PLACE in January this year. This new assessment process which starts in May 2013 replaces the Patient Environment Assessment Team (PEAT) assessments.
5. The process for decontaminating flexible endoscopes within the satellite units was improved this year. Each division contributed resources towards the development of a dedicated peripatetic decontamination team which became operational in October 2012. This has led to a more consistent standard of decontamination of endoscopes. Furthermore; the down time of the endoscope washer disinfectors due to machine malfunction decreased reducing the number of interruptions to patient lists.
6. Environmental decontamination with Hydrogen Peroxide Gas (HPV), was used in several ward areas this year through an ad hoc managed service. The advantage of using HPV is that it kills more micro-organisms and is more consistent than manual cleaning alone.
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Further to the success of using HPV the IPC team worked collaboratively with Sodexo to pilot the use of a HPV machine that can be managed and run in house. This will be piloted in areas of high risk 2013/2014. An in-house service is less expensive and more flexible as it can be adapted to meet the service user needs.
7. The performance objective for CDI for 2012/13 was 77. The actual number of cases attributed to the Trust was 74 which was 4% under trajectory.
8. The number of MRSA bacteraemias attributable to the Trust was ten. Each
incident was rigorously investigated internally by a multi-disciplinary team. Lessons were learned and implemented into practice across the divisions. Of the ten MRSA bacteraemia incidents attributed to CMFT two were found to be unavoidable.
The Trust also provided a comprehensive written report to MONITOR in November 2012, following the seventh incident of MRSA bacteraemia. Subsequently no further action was taken by MONITOR against the Trust at that time. There were three additional incidents in quarter four (January to March 2013), these additional incidents were also reported to MONITOR.
9. The Trust was successful in unconditional registration with the Care Quality Commission following self - assessment against the Health and Social Care Act 2008: Code of practice for health and adult social care on the prevention and control of infections and related guidance (The Hygiene Code).
10. Trafford General Hospitals were assimilated into CMFT in April 2012. The integration of the two different service delivery models for IPC proved to be very challenging over the first few months nonetheless, much progress has been made with the implementation of several main objectives since January of this year.
11. Following consultation with the key stakeholders the IPC and TV nursing
services were integrated under a new management structure in September 2012. Integration of the two services into one specialist practitioner role commenced and will continue over the next 12 months.
There are strong clinical, professional, practice and interdisciplinary links
between the two nursing services. Integration will strengthen the service model by developing the skill set of each domain of practice to provide greater continuity of care and strengthening the resources available for advice and support. It will provide a more coherent structure making the best use of none clinical resources such as surveillance support therefore enabling practitioners to focus on clinical practice.
12. The Hand Hygiene Policy was enhanced by the development and launch of a 6-point hand hygiene pledge for all staff. The pledge incorporated the six most important moments for staff to undertake Hand Hygiene. Individual members of staff were asked to sign the pledge as a sign of their commitment to undertake the action. This initiative was first launched in the Division of Surgery but was subsequently adopted by other areas.
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13. The IPC team provided a teaching programme for all medical staff including both new members of staff and also established senior medical personnel. This included training in aseptic non-touch technique (ANTT) as well as other key IPC measures. This year 463 medical staff were trained compared to last year when 260 were trained.
14. The IPC team set up a focus group with a small number of patients who had experienced source isolation as a result of being colonised/infected with a HCAI. The aim of this small scale study was to gain insight into the process of understanding the patient’s perspective. The key findings indicated that the patients involved felt as though they were socially isolated from staff and other patients and experienced feelings of loneliness. This experience will be developed into a wider study in the future.
15. Audit of clinical practices such as Hand Hygiene as well as ANTT were incorporated into the Quality Care Round this year. Compliance rates for Hand Hygiene and ANTT remained above 95%. The point prevalence audit of antibiotic prescribing guidelines was performed on all wards on the central site in December 2012; overall compliance has improved since the last audit. These results were discussed at the Trust Infection Control Committee and feedback was given to the divisions for action.
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INFECTION PREVENTION and CONTROL ANNUAL REPORT
2012 / 2013
Author: Julie Cawthorne, Consultant Nurse,
Infection Prevention and Control.
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CONTENTS PAGE Section 1 Executive Summary 2 Section 2 Infection Prevention & Control Arrangements 8 Section 3 Budget Allocation to Infection
Prevention & Control Activities 10 Section 4 Surveillance of Healthcare Associated Infections 11 Section 5 Maintaining a Clean Environment 20 Section 6 Infection Prevention and Control Policies 23 Section 7 Education and Training 24 Section 8 Audit 26 Section 9 Conclusion 32 Appendices Appendix 1 CMFT Infection Prevention & Control/Tissue 33 Viability Structure Appendix 2 Infection Prevention & Control Committee Terms of Reference 34 Appendix 3 IPC Annual Plan 2012-2013 37 Appendix 4 Divisional ANTT /Hand Hygiene audit results 43 Appendix 5 IPC Annual plan 2013-2014 47
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SECTION 2: INFECTION PREVENTION and CONTROL ARRANGEMENTS 2.1 The Director of Infection Prevention and Control (DIPC)
Mrs Gill Heaton, Director of Patient Services/Chief Nurse, was designated to this post in 2006. The DIPC chaired the Trust Infection Control Committee and reported directly to the Trust Board.
2.2 The Infection Prevention and Control (IPC) Team
Following the assimilation of Trafford General Hospitals (TGH) in April 2012 the process of integration of the two IPC teams was commenced. This also included the integration of the tissue viability nursing services from TGH and CMFT under one new management structure within the Division of Clinical and Scientific Services Division. This process was managed by the Director of Nursing (adults) and Human Resources. The members of the IPC team from April to September 2013 can be found below (whole-time equivalent (WTE) unless otherwise stated).
2.2.1 CMFT IPC Team (Central Site) April 2012 – September 2012
The team comprised of the following personnel:
• Dr Andrew Dodgson, Microbiologist and Infection Prevention & Control Doctor (IPCD).
• Mrs Julie Cawthorne, Consultant Nurse, Infection Prevention & Control.
• Miss Janice Streets, Infection Prevention & Control Nurse Specialist.
• Mrs Michelle Worsley, Infection Prevention & Control Nurse Specialist.
• Mrs Melanie Phillips, Infection Prevention & Control Nurse Specialist.
• Miss Amanda Pagett, Infection Prevention & Control Nurse Specialist.
• Mr Federico Tabios Junior (0.6 WTE), Infection Prevention & Control Nurse Specialist, (until June 2012).
• Mrs Susan Crossland, Infection Prevention & Control Nurse Specialist (from May 2012).
• Mr Jonathon Bremmer, Healthcare Associated Infection (HCAI) Surveillance Officer.
The IPC nursing team was also supported by a full-time secretary.
2.2.2 Trafford Division IPC Team April 2012 – September 2012
• Dr Barzo Faris, Consultant Microbiologist.
• Mr Wayne Goddard, Biomedical Scientist, (until October 2012).
• Mrs Sharon Lowe, (0.91) Lead Nurse, Infection Prevention & Control.
• Ms Paula Halsall, Infection Prevention & Control Nurse Specialist, (until June 2012).
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A chart demonstrating the new team structure from September 2012, which included the tissue viability nursing service, can be found in appendix 1.
2.3 The Trust Infection Control Committee (ICC)
The Committee met every two months and had corporate responsibility for all infection prevention and control issues and monitoring the implementation of the Annual Infection Prevention and Control plan. The Committee had the following sub-committees which each provided regular reports to the committee meetings:
• Infection Prevention and Control Expert Group
• Medical Devices Committee
• Antibiotics Group
• Trust Decontamination Group
The Terms of Reference for the ICC can be found in Appendix 2. 2.4 Framework for Infection Prevention and Control (IPC)
The Trust Strategy for IPC defines the structure and activities of IPC within the Trust. It is located on the Trust IPC Intranet web-site.
2.5 IPC Annual Plan April 2012 – March 2013
We achieved compliance with 90% (27/30) of the objectives in the IPC Annual plan (please see appendix 3).
2.6 Compliance with the Hygiene Code
The Trust is required to register with the Care Quality Commission (CQC) annually. Assessment is based on the ten criteria in the Health and Social Care Act (2008): Code of practice for health and adult social care on the prevention and control of infections and related guidance (The Hygiene Code).
The Trust submitted evidence of a self-assessment and was registered unconditionally with the CQC.
2.7 Compliance with NICE Clinical Guidelines 139: Prevention and Control of Healthcare Associated Infections (HCAI’s) in Primary and Community Care
The NICE guidelines above were issued in May 2012. Following the assessment a status of partial compliance was declared. An action plan was developed and monitored through the divisional and corporate infection control committees. The action plan was completed within a six month time frame with the exception of two on-going issues that have been slightly delayed due to circumstances out with our control:
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• New Waste Policy – delayed due to be updated national guidelines.
• Intravenous Access for patients in the Community – a new initiative that has been commenced and will be completed by September 2013.
The Trust will declare full compliance once both these actions are
completed.
2.8 Reporting Structure
The Infection Control Committee reports to the Trust Clinical Effectiveness Committee and directly to the Board through the DIPC.
2.9 Infection Prevention and Control Structure within the Divisions
Each division addressed infection prevention and control issues at divisional level. This was either as a standing item on their local Clinical Effectiveness Group or at a separate Divisional IPC group. The divisions used these forums to develop new tools to enhance the prevention of infection, examples of these include:
• Six Golden Rules for Hand Hygiene
• Ten Top Tips to prevent infection
• Changes to cleaning specifications
• Developing standard operating procedures to promote consistent standards of practice
• Monitoring performance and escalating poor practice issues such as repeated breaches of the Trust hand hygiene policy.
2.10 The Infection Prevention and Control Weekly Review Meetings
The responsibility for reporting and reviewing incidence of HCAI was assigned to the divisions. Each division identified their own forums to discuss and address their incidence of HCAI. (These meetings were separate to the Divisional IPC groups).
SECTION 3: BUDGET ALLOCATION TO INFECTION PREVENTION and CONTROL ACTIVITIES 3.1 Funding for Infection Prevention & Control Services
The IPC team provided a Trust – wide service and funding was located within the Division of Clinical and Scientific Services. This included additional funding transferred from the Corporate and Trafford Divisions following the integration of the infection prevention and control and tissue viability nursing services.
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3.2 Microbiology Laboratory Services
• Funding for Microbiology services at the Central site (including outbreaks of infection), was covered by the Service Level Agreement between the Trust and the Health Protection Agency.
• Funding for Microbiology Services at Trafford Division was funded by the Division.
• Financial support for outbreaks of infection, (excluding laboratory costs), were sourced locally by the divisions.
3.3 Electronic Surveillance System
Recurrent funding for ICNet (electronic Infection Prevention & Control surveillance database) was met from the Division of Clinical and Scientific Support for the Central site and Trafford Division for Trafford Hospital.
SECTION 4: HEALTHCARE ASSOCIATED INFECTION (HCAI)
4.1 HCAI Performance Targets
The annual performance from 2007/8 – 2012/13 against the national HCAI objectives can be seen below in Fig 1. Over this period we have made considerable progress in reducing the overall incidence of HCAI. Fig. 1 Incidence of HCAI in CMFT April 2007 – March 2013
4.2 Meticillin Resistant Staphylococcus aureus (MRSA) Bacteraemias
Fig. 2 Incidents of MRSA bacteraemia reported to the Department of Health (including apportioned and non-apportioned)
Year Trajectory Actual Number Reported
April 2005 – March 2006 47 54
April 2006 – March 2007 35 59
April 2007 – March 2008 24 21
April 2008 – March 2009 24 17
April 2009 – March 2010 24 8
April 2010 - March 2011 21 7 + 4*
April 2011 - March 2012 6 4
April 2012 – March 2013 6 10+3*
2007/2008 2008/2009 2009/2010 2010/2011 2011/20122012/2013
*
CDI 274 185 123 106 82 74
MRSA 16 13 5 7 4 10
VRE 5 2 4 12 2 9
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*From 2010/11 the Department began to divide and attribute incidents of MRSA bacteraemia between the community and acute trusts. There were 10 post 48 hour incidents of MRSA bacteraemia (attributed to the Trust) and 3 pre-48 hour incidents (attributed to the PCT) reported in 2012/13
Fig 2 above demonstrates the impressive year on year improvement that we have achieved against the MRSA HCAI objective between April 2005 and March 2012. We are therefore extremely disappointed to report that this year the Meticillin Resistant Staphylococcus aureus (MRSA) bacteraemia objective was breached.
There were ten incidents of MRSA bacteraemia amongst nine patients against a MONITOR objective of no more than 6 cases (please see fig.3 below). Each incident was rigorously investigated internally by a multi-disciplinary team. Following all individual Root Cause Analysis the division in which the incident occurred undertook a review of local practice and procedures. Of the ten MRSA bacteraemia incidents attributed to CMFT two were found to be unavoidable.
Fig 3 Incidents of MRSA Bacteraemia April 2012 – March 2013
4.3 Incidence of MRSA bacteraemia in the Division of Surgery
There were three MRSA bacteraemia cases amongst two patients in the Division of Surgery between August and September 2012 involving patients who were cared for on ward 11. The investigation of these cases indicated that the main cause of infection included the management of central (CVC)/ Hickman lines (lines placed into large, central veins of the body), and the management of complex abdominal wounds, which resulted in the cross-contamination by staff between patients. A further patient who acquired a MRSA bacteraemia identified in critical care was also cared for on ward 11.
In addition to these cases ward 11 experienced an outbreak of MRSA in September 2012, (please see section 4.12)
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Apr-12May-
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Jun-12Jul-12Aug-12Sep-12Oct-12Nov-12Dec-12Jan-13Feb-13Mar-
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May-
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Jun-
12Jul-12
Aug-
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Sep-
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Mar-
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Apportioned 2 2 2 2 3 5 7 7 8 8 8 10
Reported 2 2 2 2 4 6 9 9 11 11 11 13
Trajectory 1 1 1 1 2 2 2 2 3 3 3 3
Cumulative MRSA bacteraemia cases (2012/13)Central & Trafford
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4.4 Division of Surgery Infection Control Work Programme from September 2012
Following the outbreak of MRSA and the incidents of MRSA bacteraemia on ward 11 there was an increased focus on infection prevention and control across the entire Division of Surgery. Working in partnership with the Director of Infection Prevention and Control, the Medical Director, and the Infection Prevention and Control team the Division identified the need to concentrate on and strengthen the on-going Divisional strategy to prevent the incidence of HCAIs and specifically cross infection. Measures introduced included;
• A presentation by the Director of Infection Prevention and Control of a review of Root cause Analysis. This was presented to 94 personnel which included all grades of medical, nursing and allied health professionals working within the Division of Surgery.
• Development of a standard operating procedure, the aims of which are to ensure daily monitoring of patients who are at high risk due to infections including MRSA.
• Identification of the need to develop a Trust-wide policy for the care of CVC/ Hickman lines managed outside the critical care environment. The Infection Control and Prevention Team are leading a working party to develop this policy.
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• Development of a protocol for complex wounds. This work was led by a Consultant Surgeon.
• The delivery of additional infection prevention and control sessions by the IPC nurse specialist to 16 members of the nursing teams on Ward 11 & 12. The content of this session included re-iteration of basic IPC principles i.e. hand hygiene and ANTT.
• Weekly screening of all patients on wards 11 & 12 for MRSA (since September 2012). On average this equates to about 100 patients screened per month.
• The development and commencement of Patient Safety Ward Rounds, led by a designated consultant and senior nurse.
• Enhanced Environmental Cleaning of both wards 11 & 12 with a hydrogen peroxide vapour (Bioquell) was undertaken in October 2012.
• The development and launch of a 6-point hand hygiene pledge for all staff who work within the division. Launched in September 2012, by the Clinical Head of Division, over 400 members of staff have signed the pledge committing to adherence to the 6-point ‘Golden Rules’ as to when hand hygiene should be undertaken.
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• A letter was distributed to all medical staff by the Clinical Head of Division and all nursing staff by the Head of Nursing, outlining that failure to comply with infection control policies will result in disciplinary proceedings.
4.5 Report to MONITOR
The Trust also provided a comprehensive written report to MONITOR in November 2012, following the seventh incident of MRSA bacteraemia. Subsequently no further action was taken by MONITOR against the Trust at that time. There were three additional incidents in quarter four (January to March 2013), these additional incidents were also reported to MONITOR.
4.6 Clostridium difficile Infection (CDI)
The Trust agreed a target of 77 attributable CDI cases in all patients over the age of two for the year 2012/13. The distribution of these cases can be seen in Fig. 4 below. Similarly to MRSA bacteraemia the cases of CDI that were attributable are those which occurred three days after admission. The total number of cases attributable to CMFT was 74 in 2012/13 (4% under trajectory).
Fig. 4 Incidence of CDI in CMFT April 2012 – March 2013
4.7 Reporting of Meticillin Sensitive Staphylococcus aureus (MSSA)
and Escherichia coli Bacteraemias Mandatory reporting of all MSSA bacteraemias commenced in January 2011. The Trust reported a total of 250 MSSA bacteraemias to the Health Protection Agency (HPA) in 2012/13. 105 of these were apportioned to CMFT (i.e. occurred 48 hours or more after admission). E.coli bacteraemia reporting began in June 2011. There were 283 incidents reported to the in 2012/13. There is no requirement to identify those attributable to the Trust.
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100
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Apr-12May-
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Jun-12Jul-12 Aug-
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Sep-12Oct-12Nov-
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Jan-13Feb-13Mar-
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May-
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Apportioned 2 8 12 15 20 27 35 46 52 57 69 74
Reported 9 18 25 33 43 57 72 85 94 102 116 121
Trajectory 6 12 18 24 30 36 42 49 56 63 70 77
Cumulative CDI cases (2012/2013)Central and Trafford sites
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To date no target has been set for reducing the incidence of MSSA or E.coli bacteraemia
4.8 Vancomycin Resistant Enterococci (VRE)
The Trust reported all incidents of VRE bacteraemia to the HPA. The total number of incidents for this year to date is seven, (annual totals run from October – September). Cases occurred in the Childrens Division (1), Division of Specialist Med (3), Clinical & Scientific Services Division (1) and Division of Surgery (3). This is an increase of five in the number reported within the same period last year (October-March). The IPC team have worked collaboratively with the Divisions of Surgery and Specialist Medicine to review and implement actions in areas of high incidence of VRE.
4.9 Surgical Site Infection (SSI) National Surveillance Scheme
The Trust participated in both mandatory orthopaedic and voluntary coronary artery bypass graft (CABG) reporting of SSI to the HPA.
4.9.1 Knee Replacement Surgical Site Infection (SSI) rates
The Trust is required to submit a minimum of one quarter of data per year to comply with mandatory reporting for orthopaedic implant surgery. This year the surveillance period was quarter four (January-March 2013). During this period data was collected and submitted on hip replacement surgery as well as joint knee replacement surgery. Information was collected from 72 patients. Results from Public Health England, (formerly HPA), have not been received by the Trust at the time of writing this report.
4.9.2 Coronary Artery Bypass (CABG) Surgery SSI
The Manchester Heart centre continued to voluntarily submit data to the HPA please see Fig 5 below.
Fig.5 Trends in rates of CABG SSI by surveillance period at CMFT
Year and Period
No. operations
Surgical Site Infection
Inpatient & readmission
Post discharge confirmed
All SSI*
No. % No. % No. %
2011 Q2 137 3 2.2% 1 0.0% 4 2.9%
2012 Q1 111 4 3.6% 1 0.9% 5 4.5%
2012 Q3 84 3 3.6% 4 4.8% 7 8.3%
2012 Q4 116 6 5.2% 3 2.6% 9 7.8%
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*All SSI = Inpatient and readmission, post-discharge confirmed and patient reported. The national average for CABG SSI is 4.3% for in-patient and re-admissions, (Surveillance of Surgical Site Infections in NHS Hospitals in England, Health Protection Agency, December 2012) 4.9.2.1 Management of SSI in the Heart Centre
• The Heart Centre continued SSI post discharge with telephone follow up. Patients with wound problems were asked to return to the wound care clinic. All organ space infections were investigated through Root Cause Analysis and where appropriate action taken.
• A refurbishment of the ward enabled a dedicated dressings room to be incorporated into the ward allowing for a specific treatment area for wounds.
• The Wound Care Surveillance Nurse worked alongside all staff new to the ward to develop their expertise in cardiac surgery wound care.
4.10. Carbapenemase Producing Coliforms (CPC’s)
The first CPC’s were recognised within the Trust in 2009. CPC’s produce an enzyme (KPC) which renders them resistant to all beta-lactam antibiotics. They are often also resistant to other classes of antibiotics, which may severely limit treatment options, particularly in the paediatric population. CMFT was the first Trust in the country to identify a problem with these organisms, and though other trusts have seen issues with organisms with different resistance mechanisms, to the best of our knowledge no other Trust has yet reported the number of CPC’s seen at CMFT. However it should be noted that no central reporting mechanism exists, nor is it likely that any other organisation have screened for these organisms as extensively as CMFT. Please see figs. 6 and 7 below demonstrating the incidence of clinical isolates of CPC at CMFT from 12/02/12 – 09/02/13. Fig 6. CPC Clinical isolate chart 12/02/12 – 11/08/12
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Please note definition of Terms Clinical isolate - a positive culture from a site where a micro-organism has the potential to cause infection. Colonisation - the mico-organism is present (i.e CPC lives in the gut), but does not cause infection
Fig 7. CPC clinical isolate chart 12/08/12 – 09/02/13
4.10.1 Incidence of CPC
The data above suggests that in the course of the last 12 months there has been an overall downward trend in the number of new patients identified with CPC in clinical isolate sites. During the last 12 months there were no weeks in which the number of cases identified exceeded the upper control limit (UCL) as indicated by the Trust-wide Statistical Process Control (SPC) charts (The last breach of the Upper Control Limit occurred 29/01/2012 – 04/02/2012). The data for the most recent six month period (fig 7) suggested that whilst identification of new patients with CPC in clinical isolate sites was an on-going occurrence, the overall picture may be more stable with new cases being identified at a lower rate per week. Despite the reduction in the amount of clinical isolates being identified the number of patients identified as being colonised with CPC from enteric screening continued to rise. Furthermore the number of CPC colonised inpatients increased due to readmissions of patients with existing CPC to the organisation. This has had a significant impact on isolation facilities available throughout the Trust.
4.11 Influenza Vaccination for Staff
The Influenza vaccination programme for staff was organized by a project management group which included; the Occupational Health Department, the IPC team, Pharmacy, the Communications team and clinical representatives.
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Vaccination clinics commenced in October to ensure an organised approach prior to any anticipated peak activity. In total 4460, (72%) of front line staff were vaccinated this year compared to 2921 for last year.
This much improved rate of protection amongst frontline staff, and therefore indirectly to our most vulnerable patients, was one of the highest rates in the North West Region
4.12 Summary of outbreak of MRSA on Ward 11 during September
2012
Ward 11 was closed on 7th September by the IPCT due to an outbreak of MRSA. Five new cases were identified from screening on 4th September 2012. The ward was closed for 8 days and re-opened to admissions on 15th September. A total of 224 bed days were lost.
4.12.1 Immediate actions undertaken in response to the outbreak
• Ward closed to all admissions/transfers on Friday 7th September
• All patients rescreened on 10th September and 12th September
• Outbreak meetings were held on 7th, 10th and 14th September
• Ward reopened on Saturday 15th September as no new cases from two consecutive screening.
4.12.2 Findings
• All samples sent to the Central Health Protection Agency (Colindale) for typing. Results identified that cross contamination had occurred.
4.13 Outbreaks of diarrhoea and vomiting
There were 10 outbreaks of Norovirus during 2012/13 with a loss of 997 bed days in total. (See Fig.9)
Ward Dates of closure
Number of days closed
Number of patients affected
Number of staff affected
Number of cases
confirmed by PCR
Bed days lost
8 Bay C only
01/05/2012 3 4 0 0 42
Debdale Unit
12/11/2012 7 0 0 0 84
AM2 02/12/2012 6 14 9 2 168
AM2 08/12/2012 2 2 0 0 56
3 18/12/2012 11 18 184
4 17/12/2012 7 15 6 1 159
45 09/01/2013 2 3 0 1 16
Ward 3&4 17/01/2013 6 21 3 3 60
Ward 32 27/02/2013 6 7 0 0 96
Debdale Unit
24/03/2013
8 5 0 0 112
Total 997
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Please note: The introduction of the new guidelines (2011) recommended that whole wards should not be closed at the onset of an outbreak. Alternatively, affected patients are cohorted in bays, this has reduced the number of bed days lost. In addition Debdale Unit opened extra beds due to winter pressures this is why the ‘total number of beds’ is different for the two outbreaks there.
SECTION 5: MAINTAINING A CLEAN ENVIRONMENT 5.1 DECONTAMINATION SERVICES
Sterilization of re-useable surgical devices was undertaken centrally on site at the Decontamination Services Department which is accredited to Directive 93/82/EEC annexe 5 and ISO 13485:2003. Decontamination of flexible endoscopes was undertaken in satellite units in the associated clinical areas across the Trust.
5.1.1 Trust Decontamination Group
The Compliance Manager for Estates was the designated Decontamination Lead for the Trust. The Trust has an appointed Authorised Engineer for Decontamination (AED). The Trust Decontamination Committee met four times this year and reported to the Trust Infection Control Committee on all Decontamination matters. In addition Decontamination Monitoring Group monthly review meetings were convened to address day to day operational concerns.
5.1.2 Decontamination of Endoscopes
The original Business Care proposal has been altered to accommodate available funding and the risk profile associated with the current facilities. The Proposals ranged from; full centralisation of services to achieve Best Practice of all facilities to; electronic tracking for all endoscopes and alterations to the existing satellite units to achieve Essential Quality Requirements. (As defined in Choice Framework for local Policy and Procedures 01-06)
5.1.3 Rinse Water Testing
The Trust monitored the quality of rinse water used in the Automated Endoscopy Reprocessors (AER`s). Samples were taken weekly. Adverse results were dealt with in a timely manner. Disruptions to service delivery caused by adverse water testing results have decreased since the implementation of the peripatetic decontamination team, (see 5.1.5 below).
5.1.4 Validation of the Automated Washer Disinfectors (AER’s)
Validation of AER’s is a national requirement. Lancer continued to service the units in accordance with the testing standards. This year there was a steady improvement in testing results.
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5.1.5 Peripatetic Decontamination Team
The divisions addressed the variable standards associated with the multiple numbers of clinical staff decontaminating endoscopes. Each division contributed resources towards the development of a dedicated peripatetic decontamination team which became in October 2012.
5.2 MANAGEMENT OF WATER QUALITY
The Strategic Water Quality Management Group reports to the Trust Infection Control Committee and met eight times this year. The Compliance Manager for Estates was appointed as the Responsible Person (Trust) in line with HTM 04-01. Dr Tom Makin, Consultant Microbiologist to the Department of Health continued in the role of Trust External Consultant and Water Advisor.
5.2.1 Management of the Risk for Legionella
The Control of Legionella Policy was ratified by the Trust ICC in September 2012. The policy was based on current legislation in HTM 04-01 and included; guidance and the managerial responsibilities for water quality on all Trust sites. Preparation for the Trust wide roll out of guidance for ‘Flushing of little or under used water outlets’ began in January 2013. This has been delayed pending the new guidance on Risk of Pseudomonas from water outlets in high risk clinical areas.
5.2.2 Management of the Risk of Pseudomonas aeruginosa from water
outlets in in high risk clinical areas
The Trust completed all the actions from the action plan implemented in compliance with “Best Practice Guidance on Water Sources and Potential Pseudomonas aeruginosa contamination of Water Systems”. This guidance was overseen and monitored by the Trust Strategic Water Group.
5.3 CLEANING SERVICES 5.3.1 Contracting Arrangements
The Trust cleaning services were provided by both internal and external contractors/teams.
• Sodexo Healthcare was the main contractor for the provision of cleaning services across the main island site.
• MITIE was the contractor for part of Old St Marys building.
• The Trafford Division and Intermediate Care Units were managed by in –house teams.
21
5.3.2 Monitoring Arrangement
As part of the contract Sodexo were required to self-monitor the performance of cleaning services against key performance indicators. These were reported to the Trust on a monthly basis for analysis and challenged where appropriate by the Facilities Monitoring Team.
The Contract with MITIE was monitored by the Trust Estates and Facilities Monitoring team.
The services at Trafford Division and the Intermediate Care Homes were managed and monitored through internal in-house arrangements with the service managers and local users.
In addition, the standards of cleanliness were monitored and reported for all sites through the Ward Accreditation Process and the Patient Experience Tracker results which informed areas of best practice and areas where additional focus was required.
5.3.3 The Role of the Infection Prevention and Control Team
The IPC Team worked in conjunction with the Trust Monitoring Teams, Clinical Divisions, Sodexo, MITIE and internal providers to ensure cleaning standards were met across the Trust. The IPC Team were represented on the Patient and Staff Environment Group
5.3.4 Cleaning Schedules
Cleaning schedules were publicly displayed in all clinical areas and processes were in place to report and escalate cleaning problems, including: the Trust Key Contacts process which provided users with information on what services should be delivered and how to escalate non-compliance; and, the cleaning matters process which required clinical and cleaning staff to record the completion of tasks and log additional or amended requirements.
5.3.5 Patient Led Assessment of the Care Environment (PLACE)
The Department of Health (DH) introduced a new assessment process to replace the Patient Environment Action Team (PEAT). This is known as the Patient Led Assessment of Care Environments (PLACE). We were a national pilot for PLACE in January this year. Formal assessment starts this year in May 2013.
A significant change from PEAT is that at least 50% of the team must now be patient assessors and in addition to the overall PLACE assessment the patient representatives will have their own assessment form to complete providing their overall views on the Trust, and any improvements they would like to see.
5.3.6 IPC Training for Domestic Staff
All new employees attended a generic Sodexo induction which included the principles of IPC. As in previous years this was supported by additional bespoke training specific for domestic staff.
22
The number of staff who received training this year was 372, (compared to last year when 334 staff received the training). This year Blue Arrow Agency staff were included in the programme.
The Sodexo Education Lead and Trust IPC team worked in collaboration to provide bespoke training sessions for all Sodexo Managers.
A new Matron appointment was made in March 2013 to work between the Trust and Sodexo. The post holder has already begun collaboration with the IPC team to facilitate the first PLACE assessment.
5.3.7 Decontamination of the Environment with hydrogen Peroxide Vapour (HPV)
Environmental decontamination with Hydrogen Peroxide Gas (HPV), was used in several ward areas this year through an ad hoc managed service. The advantage of using HPV is that it kills more micro-organisms and is more consistent than manual cleaning alone.
Further to the success of using HPV the IPC team worked collaboratively with Sodexo to pilot the use of a HPV machine that can be managed and run in house. This will be piloted in areas of high risk 2013/2014. An in-house service is less expensive and more flexible as it can be adapted to meet the service user needs.
SECTION 6: INFECTION PREVENTION & CONTROL POLICIES
All IPC Policies can be found on the IPC intranet web-site. Please find below a summary of the IPC policies updated this year. Each policy review took into consideration adaptations, as appropriate, for staff working in the primary care environment and was ratified by the Trust ICC. 6. Hand Hygiene Policy
The Hand Hygiene Policy was enhanced by the development and launch of a 6-point hand hygiene pledge for all staff. The pledge incorporated the six most important moments for staff to undertake Hand Hygiene. Individual members of staff were asked to sign the pledge as a sign of their commitment to undertake the action. This initiative was first launched in the Division of Surgery but was subsequently adopted by other areas. The aim was to enhance hand hygiene compliance amongst all members of staff in line with the Trust principle that IPC being everybody’s responsibility.
6.1 The Aseptic Non-Touch Technique Policy (ANTT)
The success of the Trust as leaders in Infection prevention and control practice was evidenced when the Consultant Nurse was invited to present to Lewisham Hospital in June 2012 on how the Trust had embedded aseptic non-touch technique into clinical practice.
23
0
500
2011-12 2012-13
32 46
260
463No of Sessions
organised by the IPC
team
No of staff attended
This year the ANTT policy and guidelines were reviewed and extended to include bespoke guidelines for anaesthetists working in the operating theatre.
6.2 Additional Policies reviewed during 2012/13
Other IPC Policies which were reviewed and/or revised are listed below:-
• Clostridium difficile Infection.
• Central Venous Catheter Management of Short-term Catheters.
• Management of Linen in the Clinical Environment.
• Glycopeptide Resistant Enterococci (GRE).
• Lancefield Group A Streptococcus. SECTION 7: EDUCATION AND TRAINING Training and educational programmes were developed in accordance with national policies, service requirements and local need. Programmes were updated to reflect contemporary practices and in response to learning from Root Cause Analysis investigations. 7.1 Induction and Mandatory Training
The IPC team delivered training on the key principles of Infection Prevention & Control at all Corporate Induction and Corporate Clinical and non-Clinical Mandatory training days. (In addition the team formatted on-line training for staff who undertook “e” learning). The Organisational Development and Training Department monitored attendance at mandatory update and Induction training and provided feedback to the divisions.
The IPC nurses also contributed to other training sessions including; asepsis in intravenous therapy.
7.2 Infection Prevention and Control Training for Medical Staff
The IPC team provided a teaching programme for all medical staff including both new members of staff and also established senior medical personnel (this included training in aseptic non-touch technique (ANTT)). This year over 100 more medical staff were trained compared to last year, (please see fig.8 below). Managing and recording competency assessment was the responsibility of the divisions
Fig. 8 Medical Staff attendance at IPC training April 2012 – March 2013
24
7.3 IPC Link Practitioners Forum
The roles and responsibilities of the Infection Control Link Practitioner (ICLP) were identified within a role description. The IPC nurses hosted a bi-monthly link practitioner meeting which was attended on average by 15 nurses from across the divisions per meeting.
7.4 Unscheduled Additional training
Following the emergence of carbapenem producing coliforms (CPC) amongst patients the IPC team co-ordinated a series of education sessions for medical and nursing staff across the Trust. The purposes of the sessions were to inform staff of the risks to patients of acquiring a CPC and the prevention and management of these incidents. The IPC Nurses and Consultant Microbiologists facilitated over forty four sessions between April 2012 and March 2013.
7.5 Bespoke training sessions
The IPC nurses worked closely with Human Resources (HR) to deliver bespoke training throughout the year for work experience and young people with an interest in healthcare. These sessions were well received.
7.6 IPC Annual Conference
The IPC team organised its fourth annual Infection Prevention & Control and first joint conference with Tissue Viability for all staff in October 2012. The event was attended by sixty eight members of Trust staff from the hospital and community settings. The day focussed on working together in partnership to improve the patient experience and encouraging commitment from all staff to promote excellent standards of practice. The event was successful and included a range of topics delivered by both internal and external speakers. The feedback was very positive with 95% of staff agreeing that the day met their needs and fulfilled their expectations.
7.7 Learning from the Patient Experience
The IPC team set up a focus group with a small number of patients who had experienced source isolation as a result of being colonised/infected with a HCAI. The key findings from this small review indicated that the patients involved felt as though they were socially isolated from staff and other patients and experienced feelings of loneliness. This information has been incorporated into local teaching sessions.
25
SECTION 8: AUDIT In accordance with the Health Act (2010) all NHS organisations are required to audit key policies and procedures for infection prevention and control to provide assurance that practice is effective in the prevention of Health Care Associated Infections (HCAI’s). 8.1 Audit of Hand Hygiene Practice and Aseptic Non-Touch
Technique (ANTT)
Hand Hygiene practice and ANTT were audited monthly as part of the Quality Care Rounds (QCR), at the central island site. Trafford Division were included from May 2012. The Community based Services undertook separate audits as they were not able to participate in the QCR process. If a ward/area experienced an increased incidence of infection the frequency of audit was increased and results locally actioned.
8.1.1 Audit of Hand Hygiene Practice
The results of these audits, and also the results of hand hygiene audits in the community services, (commenced September 2012), can be found in Appendix 4 . Compliance with hand hygiene remained constant across the Trust at 98% (please see fig. 9 below).
Fig. 9 Hand Hygiene Audit Results 2012/2013, (from QCR)
8.1.2 Audit of ANTT
Compliance with the demonstration of correct ANTT practice across the Trust remained constant at 98% (please see fig.10 below). Audit results for ANTT compliance within individual divisions can be found in appendix 4.
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
Trust-wide
26
Fig. 10 ANTT Audit Results 2012/2013, (from QCR)
8.2 Meticilin resistant Staphylococcus aureus (MRSA) Care Pathway
Audit
Baseline audits of Patient Integrated Care Pathways (ICPs) for MRSA were undertaken during December 2012/January 2013 by the IPC nurse team. Patients whom had been in-patients for >48hours were included. A summary report of key findings can be found in fig. 11.
Divisional reports were distributed to the Heads of Nursing for action within the divisions these included:
• Dissemination of results to all ward areas
• Monitoring of compliance with documentation on ICP’s on daily ward huddles.
Fig. 11 Results of Audit of MRSA ICP
Question Trust Wide Compliance
Is the patient isolated? 93%
Is not isolated, is patient nursed by basin? 93%
Patient screened as per Trust policy? 96%
ICP commenced within 12 hours of admission? 93%
All initial actions signed and dated? 54%
All screening results documented correctly? 36%
Correct decolonisation therapy prescribed? 75%
Octenisan given daily? 64%
Nasal treatment given? 82%
Patient information leaflet given? 96%
8.3 Clostridium difficile Infection Audit
A review of the Clostridium difficile Infection (CDI) investigation proforma was undertaken to audit compliance against the CDI policy. The proforma were completed by ward managers and addressed standards of practice relating to the care and management of patients with CDI. A total of 50 investigation forms were collated by the IPC team using the ICNet surveillance system (see below).
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
Trust
27
Divisional summaries were distributed and senior teams asked to develop assurance processes at ward level to ensure improvements are achieved.
Fig. 12 Results of Audit of CDI Proforma
No N/A Unknown Yes
% of Patients
% compliance
Q1. Initial severity marker assessment completed?
10 3 1 36 47 76.6
Q2. Severity markers reviewed daily by medical staff?
19 3 3 25 47 53.2
Q3. Treatment commenced within appropriate timeframe
5 6 3 36 44 81.8
Q4. Have the patient and family been informed of CDI result and given a ‘Green Card’?
8 3 0 39 47 83.0
Q5. Have patient/carers/relatives been given Clostridium difficile information leaflet?
4 5 0 41 45 91.1
Q6. Was the patient transferred into a side-room when they became symptomatic?
11 10 1 28 40 70.0
Q7. Chlorclean used for environmental decontamination?
1 5 0 44 45 97.8
Q8. Chlorclean used for equipment decontamination?
0 6 1 43 44 97.7
Q9. All staff compliant with bare below the elbows dress code?
0 5 1 44 45 97.8
Q10. Staff adhering to correct PPE use?
0 5 1 44 45 97.8
8.4 Audit of Blood Culture Contamination Rates
Trust wide trends in blood culture contamination rates have declined since data collection commenced. There is no national UK ‘standard’ for contamination rates, but rates should be below 3%, aiming for zero. The data for the all divisions (with the exception of Trafford Division which collected data between April and November 2012), were separated into two groups by patient age (those less than 16 years old, and those greater than 16 years old, (please see fig. 13 & 14 below). Overall average contamination rates for both groups averages 2-3%.
The overall contamination rate was 2.9%. There is no national UK ‘standard’ for contamination rates, however, The American Society for Microbiology suggest rates should be 3 % or below, aiming for zero.
28
Fig. 13. Age >16 years - Peripheral Blood Culture Trends (excluding Trafford Division) March 2012 – April 2013
Fig. 14. Age <16 years - Peripheral Blood Culture Trends (excluding Trafford Division) March 2012 – April 2013
8.5 Audit of Antibiotic Prescribing Guidelines- Point prevalence audit
The point prevalence audit was performed on all wards on the Central site in December 2012; overall compliance has improved since the last audit. These results were discussed at the Trust Infection Control Committee and feedback was given to the divisions for action.
2006/7
(Centra
l site)
2007/
8
2008/
9 2009/10
2010/1
1
2011/1
2
2012/1
3
Compliant 56% 79% 75% 74% 77% 79.8% 82.4%
Non-Compliant but Justified
7% 4% 3%
14% (combined with compliance NA)
13% 9.6% 9.7%
Non-Compliant
21% 9% 12% 12.8% 9% 10.6% 5.0%
Compliance N/A
16% 8% 10% - - - -
29
8.5.1 Antibiotic Prescribing Policy Audit at Trafford Division
During November 2012, an audit to assess the compliance of antibiotic prescribing against the antibiotic policy, for in-patients in Trafford Division was undertaken. A summary of compliance can be found below.
The audit’s primary focus was to assess compliance of antibiotic prescribing with the antibiotic policy. Compliance was just short of target, at 83.5% against a target of 90%. Results
Number of patients reviewed 251
Number of patients prescribed antibiotics 66 (26.3%)
Number of prescriptions for antibiotics 85
Numbers of patients with allergy documented 251 (100%)
Number of patients allergic to penicillin 29 (11.6%)
Number of prescriptions compliant with policy 71 (83.5%)
Number of prescriptions none compliant with policy
14 (16.5%)
Results of the audit were presented at the divisional Clinical Effectiveness meeting
8.6 Surgical prophylaxis audit
In line with the NICE guidance for prevention of surgical site infection antibiotic surgical prophylaxis was audited in May 2012 across adult surgical specialties on the central site. Compliance was less than 90% for all elements assessed.
Criteria 2012
Antibiotic surgical prophylaxis in accordance with guidelines 55%
The timing of the first intravenous antibiotic dose within 30 minutes before skin incision
74%
Antibiotic surgical prophylaxis for penicillin allergic patients 60%
Second dose in procedures > 3 hours 47%
Antibiotic prophylaxis patients with previous MRSA skin colonisation
0%
Actions
Extensive actions were put in place to address the audit results:
• Guideline review in line with new national guidance.
• Antibiotic focus on consultant ward rounds.
• Feedback of results and raising awareness at divisional level.
• The audit will be repeated in May 2013.
30
8.7 Audit of the Disposal of Sharps
The prevention of sharps injury is included in mandatory IPC training programmes. A trust wide audit was undertaken to measure compliance with policy by Frontier Medical, to establish the sharps practice within the trust. A total of 76 clinical areas were inspected. The audit tool included an assessment of the sharps container being used and questions to staff. The results can be found below.
Following the audit safety posters have been designed which provide information on the assembly of sharps containers correctly, correct and prevention of overfilling.
SECTION 9: CONCLUSION
The commitment of the Trust towards preventing and reducing the risk of infection, through a high quality service is clearly demonstrated within this report. The HCAI performance objective has become more and more testing over the past five years. We successfully met the challenge for the CDI target. Whilst the incidence of MRSA bacteraemia was a disappointing outcome it should be considered against the background of where we began our journey in 2005.and the number of patients treated. During the last year we have adapted the service to incorporate the Trafford Division. At the same time we have improved the interface between Infection Prevention & Control at the patient’s bedside.
100
100
28
99
97
100
97
100
99
100
100
100
97
93
100
97
87
99
Can a member of staff describe correct the…
Can a member of staff describe correct disposal…
Are safety posters clearly displayed?
Are syringes disposed of without detaching needles,…
Are containers correctly labelled?
Once filled are the containers securely closed?
Are sharps containers only filled to the fill line?
Are sharps containers temporarily closed when not in…
Are sharps containers used solely for sharps disposal?
Are NSPD tray systems visibly clean?
Are sharps containers regularly disposed of?
Are appropriate sharps containers used for various…
Are NSPD systems used correctly or sharps…
Are containers correctly assembled? (i.e. lids secured)
Are sufficient containers available? (e.g. in every…
Are containers sited appropriately?
Are NSPD systems available?
Are approved containers used in all cases?
Frontier Sharps Audit Results - September 2012
31
This has been achieved with increased training for front-line staff on local issues such as CPC and the increased accountability for Infection Prevention &Control issues at Divisional level.
The IPC Annual plan for April 2013 – March 2014 can be found in appendix 5 The Board of Directors are asked to:
1. Receive this report for April 2012 – March 2013 which provides
information and assurance on the key activities of the Infection Prevention
and Control Team and Trust staff.
2. Approve the Annual Action Plan for April 2013 – March 2014
Julie Cawthorne Consultant Nurse IPC Central Manchester University Hospitals NHS Foundation Trust May 2012.
32
APPENDIX 1
CMFT Infection Prevention & Control/Tissue Viability
Structure September 2012- March 2013
Professional
Lead
Divisional
Director
Consultant Nurse/Manager
PA Band 4
Surveillance
officer 5
Admin Support
3
Matron 8A
IPCN
Specialist
Nurse 7
IPCN
Specialist
Nurse 7
TVN
Specialist
Nurse 7
TVN
Specialist
Nurse 7
IPCN
Specialist
Nurse 7
IPCN
Specialist
Nurse 7
IPC/TVN
Practitioner 6
IPC/TVN
Practitioner 6
IPC/TVN
Practitioner 6
IPC/TVN
Practitioner 6
IPC/TVN
Practitioner 6
33
APPENDIX 2 INFECTION CONTROL COMMITTEE TERMS OF REFERENCE 1. CONSTITUTION
The Infection Control Committee is a sub committee of the Clinical Effectiveness Committee. The Infection Control Committee is chaired by the Director of Infection Prevention and Control who is the Chief Nurse/Director of Patient Services.
2. CORE MEMBERSHIP
• Director of Infection Prevention and Control/Director of Patient Services/Chief Nurse (Chair)
• Consultant Microbiologist/Infection Control Doctor
• Consultant Nurse, Infection Prevention and Control
• Consultant Virologist
• Consultant Microbiologists
• Antimicrobial Pharmacist
• Director of Nursing (Adults)
• Associate Director of Clinical Effectiveness
• Head of Patient Safety and Risk Management
• Head of Clinical Audit
• Trust Decontamination Lead
• Assistant Director of Facilities
• Trust Medical Devices Lead (CSS Representative)
• Acute Medicine and Community Division representative
• Specialist Medicine Division representative
• Surgery Division representative
• Children’s Hospital representative
• Eye/Dental Division representative
• Saint Mary’s Division representative
• Trafford Division Representative
• Public Health Infection Control Lead
ADDITIONAL MEMBERSHIP
• Consultant Physician Occupational Health
• Consultant Physician for Respiratory Medicine
• Consultant Communicable Disease Control
• A quorum shall be eight members including the Director of Infection Prevention and Control (or a nominated deputy) and the Infection Control Doctor and Consultant Nurse, Infection Prevention and Control (or nominated deputies).
34
3. ATTENDANCE AT MEETINGS
• The Infection Control Committee may require from time to time, the attendance of any Trust employee (or agent of the Trust) to attend the committee at the request of the Chair.
4. FREQUENCY OF MEETINGS
• The Infection Control Committee will meet every two months (six times a year). 5. OVERVIEW
• The purpose of the Infection Control Committee is to provide a two-way communication channel between the Trust Board and Infection Prevention and Control ensuring compliance against the Health and Social Care Act (2008).
• The Infection Control Committee is authorised to formulate recommendations for Infection Prevention and Control within the Trust and to convey these to the Trust Board.
6. SCOPE AND DUTIES
• To ensure the Infection Prevention and Control Strategy and all Infection Prevention and Control Policies, procedures and guidelines are in place, relevant and up to date with noted guidance.
• To provide advice and support on the implementation of the strategy and policies.
• To collaborate with the Infection Prevention and Control Team to produce guidance on the Trust’s Annual Infection Control objectives.
• To monitor progress of the objectives described in the Corporate Infection Prevention and Control Action plan.
• To monitor Trust wide trends of alert organisms and alert conditions and advise the Divisions, PFI and Infection Prevention and Control Team on actions.
• To consider reports on infections and infection control incidents.
• To ratify the Annual Infection Control Board Report.
• To draw the attention of the Chief Executive, through the Director of Infection Prevention and Control, to any serious problems or hazards relating to infection prevention and control.
• To describe, review and monitor the principle and significant risks related to infection control on behalf of the Trust and present these with the plan of controls to the Trust Significant Risk Review Group and Risk Advisory Committee at least annually.
• Members will disseminate relevant information to their clinical areas.
35
7. AUTHORITY
The Infection Control Committee is empowered to examine and investigate any activity within the Trust pursuant to the above scope and duties.
8. REPORTING
The Infection Control Committee reports to the Clinical Effectiveness Committee (see CMFT Clinical Effectiveness Organisational Chart page 29).
9. There are four sub-groups of the Trust Infection Control Committee. A nominated Chair person from each of the sub-groups, (or their nominated deputy) will provide a written report at each Infection Control Committee meeting.
10. REVIEW These Terms of Reference will be reviewed before April 2013. 11. KEY PERFORMANCE INDICATORS
• Attendance of the Infection Control Committee will be monitored on an ongoing basis and reported for information at each meeting. Core members are expected to attend (or send a nominated, named Deputy) to a minimum of four out of six meeting per year. Additional members are expected to attend in person a minimum of two out of six meetings per year.
• Minutes and reports of the Infection Control Committee.
• The Annual Infection Control Report will demonstrate the key activities and performance made Trust wide in infection prevention and control.
• Care Quality Commission annual assessment of compliance against the Health and Social Care Act (2008).
• Terms of Reference for Infection Control Committee reviewed annually.
36
Infection Prevention and Control
Annual Plan
April 2012 to March 2013
37
APPENDIX 3
1. Policies
Description of Policy/Standard
Outcome
Lead
ICC Date
End of Year Update
Prevention and M
anagement of Clostridium
difficile Infection
Update of existing policy
Michelle
Worsley
July 2012
Achieved
Management of a Patient with Lancefield
Group A Streptococcus
New Trust policy
Amanda
Pagett
July 2012
Achieved
Personal Protective Equipment
Update of existing policy
Melanie
Phillips
Sept 2012
Deferred due to
other key priorities
Use of Linen in the Clinical Environment
Update of existing policy
Janice Streets
Nov 2012
Achieved
NICE Clinical Guideline 74 – Prevention and
Management of Surgical Site Infection
Trust-wide assessment against key
priorities
Julie
Cawthorne
Nov 12
Deferred due to
other key priorities
e.g Complex wound
Management DoS
NICE Clinical Guideline 139 Prevention and
Control of healthcare associated infections in
primary and community care
Trust-wide assessment against key
priorities
Amanda
Pagett
Sept 2012
Achieved
Seasonal influenza vaccination programme for
staff
Clinical staff working in areas of high
risk to exposure of influenza will be able
to access vaccination
Julie
Cawthorne
Sept 2012
Achieved
Review of National Guideline for Control of
Risk of Pseudomonas in W
ater Supply
The Trust will have appropriate
framework for control of risks of
Pseudomonas
Julie
Cawthorne
May 2012
Achieved
Review of IPC Policies at Trafford Division
Assurance that IPC policies are
consistent Trust-wide
Sharon Lowe
July 2012
Achieved
Use of environmental disinfectant
Review of environmental disinfectants
used across the Trust
Janice Streets
March 2013
Deferred due to
other key priorities
38
2. Surveillance
Description of Surveillance
Outcome
Lead
ICC Date
End of Year
Update
Mandatory reporting of HCAI incidents
- MRSA/MSSA/E.coli/GRE
bacteraemias
- Clostridium difficile Infections
Compliance with national guideline
Dr Andrew
Dodgson
Bi-monthly
Compliant
Reporting of incidents of alert
organisms/conditions
Prevention and m
anagement of
incidents of infection
Dr Andrew
Dodgson
Bi-monthly
Compliant
Mandatory reporting of Surgical site
infections (SSI) for Orthopaedic Surgery
Compliance with national guideline
Debra
Arm
strong
March
2013
Compliant
Blood culture contamination rate
To m
onitor incidence of blood culture
contamination rates
Dr Ahmed
Qamruddin
Bi-monthly
Compliant
Pilot SSI surveillance in Division of
Surgery
To evaluate pilot in order to gain a
baseline rate of the incidence of SSI
Julie
Cawthorne
Sept 2012
Compliant
SSI paper ICC
March 13.docx
Catheter Associate Urinary Tract Infection
Incidence Survey in Division of Acute and
Community Medicine
To evaluate pilot in order to gain a
baseline rate of the incidence of UTI
Michelle
Worsley
May 2012
Compliant
39
3. Audit
Description of Audit
Outcome
Lead
ICC Date
End of Year
Update
Policy for Management of Patients with
MRSA
To provide level of assurance of
compliance
Amanda
Pagett
Quarterly
from Sept
2012
Audit results
feedback to ICC
and divisions for
local action
Policy for Management of Patients with
CDI
To provide level of assurance of
compliance
Amanda
Pagett
Quarterly
from Sept
2012
Audit results
feedback to ICC
and divisions for
local action
Antibiotic prescribing Audit
To provide level of assurance of
compliance
Fran
Garraghan
May 2012
Complete
Policy for the Prevention of sharps
inoculation injuries
To provide level of assurance of
compliance
Melanie
Phillips
March
2012
Complete
Hand Hygiene Technique Audit in the
Community setting
To provide assurance of compliance
with hand hygiene technique
amongst staff working in the clinical
community setting
Amanda
Pagett
Quarterly
from Sept
2012
Complete
40
4. Training and Education Programme
Description of Training /Education
Outcome
Lead
ICC Date
End of Year
Update
Induction/ Clinical and Corporate
Mandatory training
Staff will receive training on CMFT
IPC policies and procedures
Melanie
Phillips
Sept 2012 Complete
Induction for Junior doctors
Sept 2012 Complete
Liaison for training with Sodexo
Healthcare
Sodexo Healthcare will receive
advice on up-to-date IPC policies
and procedures from Trust IPCT
Janice
Streets
March
2013
Complete
Lecturer/practitioner role at Manchester
University
Establish clinical input into
Nurse/midwifery training for
Undergrad and post-grad students
TBC
March
2013
Post re-
considered by
University
Infection Prevention and Control Annual
Conference
To raise awareness of harm
Free
Care and Progress to-date
Melanie
Phillips
Nov 2012
Complete
41
5. Infection Prevention and Control Research/ Evaluation Projects
Description of Project
Outcome
Lead
ICC Date
End of Year
Update
Experiences of Patients in Source
Isolation
To gain insight into experiences of
patients in source isolation and use
the findings to improve the quality of
the patient experience
Melanie
Phillips
Sept 2012
Complete
Review of Environmental
Decontamination
Technologies
To inform
and update Trust-wide
policy for decontamination of the
environment
Janice
Streets
March
2013
Trial of HPV to
commence April
2013
Reducing the Risk of Pseudomonas
infection on Adult Critical Care
To assess the use of water filters on
hand wash basins
Andy
Dodgson
November
2012
Complete
Review potential for hand hygiene
surveillance
technology
To assess the potential for piloting
this technology in the Trust
Amanda
Pagett
July 2012
Project revised to
include CMFT in
international
study of use of
PPE
42
APPENDIX 4 Divisional Hand Hygiene audit results (Obtained from Quality Care Round data)
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
Acute Med and Comm
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
CSS
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
Dental
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
REH
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
Research
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
RMCH
43
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
Specialist Medicine
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
St Marys
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
Surgery
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
Trafford
44
APPENDIX 4 Divisional ANTT audit results (Obtained from Quality Care Round data)
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
Acute and Comm
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
CSS
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
Dental
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
REH
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
Research
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
RMCH
45
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
Spec Med
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
St Marys
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
Surgery
75%
80%
85%
90%
95%
100%
20
12
/04
20
12
/05
20
12
/06
20
12
/07
20
12
/08
20
12
/09
20
12
/10
20
12
/11
20
12
/12
20
13
/01
20
13
/02
20
13
/03
Trafford
Central Manchester University Hospitals NHS Trust
Infection Prevention and Control Annual Plan – 2013/14
46
APPENDIX 5
Infection Prevention and Control
Annual Plan
April 2013 to March 2014
Central Manchester University Hospitals NHS Trust
Infection Prevention and Control Annual Plan – 2013/14
47
6. Policies
Description of Policy/Standard
Outcome
Lead
ICC Date
Cleaning Policy
Policy update
Janice Streets
March 2014
Decontamination of Equipment Policy
Review of Current use of Products
Janice Streets
March 2014
Food Handling (for staff outwith facilities
services)
Policy Update
Jane Doyle
March 2014
Mattresses Trolleys Bed Cleaning Policy
Update policy following audit review
findings
Beverly Swift
July 2013
Personal Protective Equipment Policy
Policy update
Melanie Phillips
July 2013
Long-term
Central Line Policy
New Policy and Guidelines
Michelle W
orsley
July 2013
Seasonal influenza vaccination programme for
staff
Clinical staff will be able to access
vaccination
Julie Cawthorne
Sept 2013
Pulmonary TB Policy
Policy update
Janice Streets
Dec 2013
Creutzfeldt-Jakob Disease Policy
Policy Update
Jane Doyle
December
2013
Surveillance Policy
Policy Update
Julie Cawthorne
Jan 2014
Multi-resistant Coliform
s Policy
Policy Update
Sue Jones
September
2013
Infestations Policy
Policy Update
Michelle W
orsley
September
2013
Viral Haemorrhagic Fever Policy
Policy Update
Michelle W
orsley
December
2013
Central Manchester University Hospitals NHS Trust
Infection Prevention and Control Annual Plan – 2013/14
48
7. Surveillance
Description of Surveillance
Outcome
Lead
ICC Date
Mandatory reporting of HCAI incidents
- MRSA/MSSA/E.coli/GRE
bacteraemias
- Clostridium difficile Infections
Compliance with national guideline
Dr Andrew
Dodgson
Bi-monthly
Reporting of incidents of alert
organisms/conditions
Prevention and m
anagement of incidents
of infection
Dr Andrew
Dodgson
Bi-monthly
Mandatory reporting of Surgical site infections
(SSI) for Orthopaedic Surgery
Compliance with national guideline
HoN Surgery
March 2014
Blood culture contamination rate
To m
onitor incidence of blood culture
contamination rates
Dr Ahmed
Qamruddin
Bi-monthly
Surgical Site Surveillance (SSI) of Patients
undergoing Coronary Artery Bypass (CABG)
Surgery
To m
onitor incidence of SSI
Louise O’Connor
March 2014
Central Manchester University Hospitals NHS Trust
Infection Prevention and Control Annual Plan – 2013/14
49
8. Audit
Description of Audit
Outcome
Lead
ICC Date
Audit Of Static Mattresses
To replace worn or damaged static
mattresses
Beverly Swift
July 2013
Policy for Management of Patients with MRSA
To provide level of assurance of
compliance
Sue Jones
Quarterly from
July 2013
Policy for Management of Patients with CDI
To provide level of assurance of
compliance
Sue Jones
Quarterly from
Sept 2013
Antibiotic prescribing Audit
To provide level of assurance of
compliance
Kelly Alexander
May 2013
Policy for the Prevention of sharps inoculation
injuries
To provide level of assurance of
compliance
Beverly Swift
September
2013
Central Manchester University Hospitals NHS Trust
Infection Prevention and Control Annual Plan – 2013/14
50
9. Training and Education Programme
Description of Training /Education
Outcome
Lead
ICC Date
Induction/ Clinical and Corporate Mandatory
training
Staff will receive training on CMFT IPC
policies and procedures
Jane Doyle
Sept 2013
Induction for Junior doctors
Sept 2013
Liaison for training with Sodexo Healthcare
Sodexo Healthcare will receive advice on
up to date IPC policies and procedures
from Trust IPCT
Janice Streets
September
2013
Lecturer/practitioner role at Manchester
University
Establish clinical input into
Nurse/midwifery training for Undergrad
and post-grad students
Louise O’Connor
November
2013
Infection Prevention and Control Annual
Conference
Getting it right first time every time
Louise O’Connor
Nov 2013
Central Manchester University Hospitals NHS Trust
Infection Prevention and Control Annual Plan – 2013/14
51
10. Infection Prevention and Control Research/ Evaluation Projects
Description of Project
Outcome
Lead
ICC Date
Integration Of IPC/TV Nursing Services
Publication
Julie Cawthorne
March 2014
Review of Environmental Decontamination
Technologies
To inform
and update Trust-wide policy
for decontamination of the environment
Janice Streets
September
2013
Review potential of using IT surveillance to
assess compliance with use of Personal
Protective Equipment
To assess the potential for piloting this
technology in the Trust
Sue Jones
September
2013