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Director of Infection Prevention and Control Infection Control Annual Report 2012/2013

AndObjectives for 2013/14

The Infection Prevention & Control Team 12/13Dr J Rao Consultant Microbiologist/DIPCDr Y Pang Consultant MicrobiologistDenise Potter Assistant Director of Infection Prevention and Control Christine Fisher Specialist NurseSusan Burns Clinical Nurse SpecialistLynda Slater Clinical Nurse SpecialistSimon Watson Data AnalystVictoria Linford Data Analyst (SWYPFT)Sue Todd PALouise Scorah Clerical Assistant(part year)Jack Hawley Apprentice (part Year)

Barnsley Hospital

NHS Foundation Trust

CONTENTSPAGE

Executive Summary 5

1.0 Introduction 7

2.0 Infection Prevention & Control Arrangements 8

3.0 Saving Lives 10

4.0 Health and Social Care Act 2008 (revised 2010) 11

5.0 Policies & Procedures 11

6.0 Visits, Reports and Projects 12

7.0 Antimicrobial Prescribing 17

8.0 Audits 18

9.0 Surveillance 22

10.0 Clusters/Outbreaks 33

11.0 Complaints 33

12.0 Serious Incidents 34

13.0 Patient Assessment 34

14.0 Educational Initiatives 34

15.0 Research 36

16.0 Health Promotion 36

17.0 Capital Schemes/Estates/Equipment 36

18.0 External Visits 37

19.0 National & Regional Work 37

20.0 Objectives 37

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Appendices


Appendix 1 Lines of Communication and AccountabilityAppendix 2 Surgical site infection surveillanceAppendix 3 Control of Infection Performance indicatorsAppendix 4 Control of Infection Performance indicators ContinuedAppendix 5 TrainingAppendix 6 Catheterisation CQUIN

ABBREVIATIONS IPCT Infection Prevention & Control Team HCAI Health Care Associated Infection NHSLA National Health Service Litigation Authority MRSA Meticillin Resistant Staphylococcus aureus DIPC Director of Infection Prevention & Control ICN Infection Control Nurse CSU Clinical Service Unit DICC District Infection Control Committee CEO Chief Executive Officer CQC Care Quality Commission RCA Root Cause Analysis PEAT Patient Environment Action Team HBV Hepatitis B Virus CVP Central Venous Pressure DH Department of Health IPC Infection Prevention & Control SWYPFT South West Yorkshire Partnership Foundation Trust ICD Infection Control Doctor HCCP Hazard Analysis of Critical Care Points SHA Strategic Health Authority PPE Personal Protective Equipment NNU Neonatal Unit ITU Intensive Care Unit PAS Patient Administration System IPCC Infection Prevention & Control Committee COSHH Control of Substances Hazardous to Health C diff Clostridium difficile C.diff Toxin Clostridium difficile Toxin C.diff Antigen Clostridium difficile Antigen CDAD Clostridium difficile Associated Diarrhoea PGD Patient Group Directive CCG Clinical Commissioning group GDH EIA Glutamase dehydrogenase enzyme immunoassay ANTT Aseptic Non-Touch Technique


EXECUTIVE SUMMARY

Infection Prevention & Control Annual Report 2012/13 and Objectives 2013/14

The Infection Prevention and Control (IP&C) Annual Report provides a summary of all the IP&C activities and outputs across the Hospital for the year of 2012-2013. Within the Health and Social Care Act of 2008 the Hygiene Code (2010) requires all NHS Boards to receive and acknowledge such annual reports prior to publically releasing them.

Healthcare associated infection is of increasing media and political interest being seen as a visible and unambiguous indicator of the quality and safety of patient care. The infection prevention and control agenda faces many challenges including the ever increasing threat from antimicrobial resistant micro-organisms, the emergence of new human pathogens, growing service developments, national guidelines and targets.

Following an unannounced inspection by the Care Quality Commission (CQC) in May 2009 the Trust was found to be fully compliant against all of the duties laid down within the Hygiene Code confirming our registration without conditions. This placed the Trust within the top percentage of Trusts in England. No inspection was undertaken in 2012-2013 however it is imperative that infection prevention and control stays as a priority in the Trusts agenda.

The Director of Infection Prevention and Control (DIPC) meets regularly with the Chief Executive (CE), the Chief Nurse, and the Medical Director and is Chair of the Trust’s Infection Prevention and Control Committee. The DIPC and Assistant DIPC are also members of the Quality and Safety Improvement and Effectiveness Board. The DIPC attends the Clinical Governance Committee and the Trust board when required.

Over the past three years the Trust has seen significant reduction in Clostridium difficile (C. difficile) associated infection and have had zero MRSA bacteraemia for the last three years. Therefore all targets have been achieved consistently but maintaining the good performance will be challenging.

The annual PEAT inspection has been replaced with PLACE but indicates that the hospital continues to provide a clean safe environment to deliver care. However this is an ongoing process and the Trust will continue to strive for excellence. The IP&C team continues to work closely with Estates and Facilities in relation to cleanliness, environment and capital schemes. The management of Legionella prevention meets and exceeds legislation with enhanced surveillance included this year to include Pseudomonas aeroginosa control. The Sterile services department maintains all the required elements to provide sterile instruments and fulfill contractual obligations.

The IP&C team has continued to improve practice and facilitate change and have continued to promote ANTT (aseptic non touch technique), hand hygiene safer sharps and the principles of infection prevention & control


The team continues to teach both informally and formally and ensure that they also maintain their professional competencies. Most of the IP&C policies have been re written and are on the Trust policy warehouse and infection control intranet site.

Considerable work has been done to improve antimicrobial prescribing within the Trust and the Consultant Microbiologists undertake teaching sessions with the medical staff. The IP&C team has undertaken a number of audits and surveillance of surgical wound infections. The Trust remains above the national average for infections related to knee replacement and considerable work is being undertaken to address this issue.

The Trust continues to support the Saving Lives and Clean your Hands Campaign and has promoted infection prevention and control with an awareness week and a sharps prevention awareness week including the ‘Bug Herald’.

The clinical nurse specialists have been conducting ward based practical observations of clinical practice. Working along side ward staff facilitates closer working between the IP&C team and ward staff whilst allowing closer observation of clinical practice. This is proving to be very successful and effective.

The Trust had a number of cases of Norovirus infection, but managed to avoid ward closures.

A new IP&C strategy for 2013 -16 has been developed and approved. The Objectives for 2012/13 contain all the required elements of an annual infection control programme.

Heather Mcnair Dr Jyothi Rao Denise PotterChief Nurse DIPC Assistant DIPC


ANNUAL REPORT – INFECTION PREVENTION & CONTROL

1.0 Introduction

The term Healthcare Associated Infection (HCAI) encompasses any infection by any infectious agent acquired as a consequence of treatment. Micro-organisms (germs) responsible for HCAI can be viruses, fungi, parasites and, more frequently, bacteria. HCAI can be caused either by micro-organisms already present on the patient’s skin and mucosa (endogenous) or by micro-organisms transmitted from another patient or health-care worker or from the surrounding environment (exogenous).

The risk of transmission and potential harm applies at any time during health-care delivery, especially to immuno-compromised or vulnerable patients and/or in the presence of indwelling invasive devices (such as urinary catheter, intra-venous catheter, endotracheal tube, drains).

Infection prevention and control clearly has an important role to play in ensuring that patients receive a high quality of care and improved clinical outcomes. The infection prevention & control agenda faces many challenges including the ever increasing threat from antimicrobial resistant micro-organisms, the emergence of new human pathogens, growing service developments, national guidelines and very strict targets. Healthcare associated infection is of increasing media and political interest being seen as a visible and unambiguous indicator of the quality and safety of patient care.

The foundations of infection control are built on a number of simple, well-established precautions proven to be effective and widely appreciated. “Standard Precautions” encompass the basic principles of infection control that are mandatory in all health-care facilities. Their application extends to every patient receiving care, regardless of their diagnosis, risk factors and presumed infectious status, reducing the risk to patients and staff of acquiring an infection. Hand hygiene is very much at the core of Standard Precautions and is the undisputed single most effective infection prevention control measure.

The main essential elements of controlling and preventing infections related to health care are:

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 and fit for purpose environment including equipment with

minimal levels of microbial contamination

Department of Health (DH) has continued to place infection prevention and control and health care associated infection high on the agenda. The major standards and legislation against which infection control services are judged include:

1. CQC Essential Standards of Quality and Safety.


2. Saving lives.3. NHSLA.4. The Health & Social care Act 2008 and associated Code of practise for health

and adult social care on the prevention and control of infections and related guidance (revised 2010).

5. Clean Your Hands Champaign. 6. Health & Safety at work etc. Act 1974.7. COSHH 2002.

The Infection Prevention and Control Team (IPC&T) has worked hard to implement these initiatives within the Trust. The main priority this year being, delivering the IP&C strategy 2010-2013 and action plan, exceeding national and local targets for MRSA bacteraemia, Clostridium difficile infection reduction, Saving Lives and continued focus on Clean your hands Campaign.

Following an inspection by the CQC in May 2009 the Trust was found to be fully compliant and therefore in the top percentage of Trusts in England with a clear compliance with the Hygiene Code confirming our registration without conditions no further inspections relevant to the hygiene code have taken place. However, the annual PEAT inspection confirmed the Trust was a clean safe environment to deliver care. This is an ongoing process and the Trust will continue to strive for excellence. PEAT will be replaced by PLACE and be patient led in 2013/14.

This report informs on the progress made on the objectives set in last years Annual Report and also the Trusts progress in implementing national initiatives during the reporting period April 2012 to March 2013. The report also encompasses the annual programme for 2013/14 which reflects the Trusts strategic vision and commitment to the IPC agenda.

2.0 Infection Prevention & Control Arrangements

The infection control service is provided by an Infection Prevention and Control team, the Consultant Microbiologists continue to support SWYFT Community Services Unit and provide 5 sessions per week as the Infection Control Doctor. The team currently consists of;

1. Consultant Microbiologist/ DIPC / ICD 37.5 hrs weekly2. Consultant Microbiologist 37.5 hrs weekly 3. Assistant DIPC 37.5 hrs weekly4. 1 Specialist Infection Control Nurse 37.5 hrs weekly5. 2 Clinical Nurse, Specialists 56 hrs weekly6. 1 Data Analysts 37.5 hrs weekly 7. 1 Admin/Clerical support 37.5 hrs weekly8. 1 Apprentice 37.5 hrs weekly

Infection Control Resources


The team has a separate budget which includes the provision of patient and public information, maintenance of the infection control software, training, and other supportive material.

Reporting arrangements

The District Infection Control Committee Quarterly meetings The Trust Infection Prevention and Control Committee (IP&CC) bi monthly. The Infection Control Operational group meets bi-monthly. The DIPC meets regularly with the CEO, Chief Nurse and is Chair of the Trust

Infection Prevention & Control Committee. The DIPC also attends as required the Clinical Governance Committee and Trust board, and is a member of the Quality and Safety Improvement and Effectiveness Board.

The Matron and Clinical Director have been nominated as infection control leads within each CSU. Their main role is to deliver the IP&C Strategy, assist in delivery of the annual infection control programme and saving lives programme. The CSU’s are required to report and provide evidence of compliance with the hygiene code which is checked by the IP&CT. This year exception reports have been developed and are being evaluated

The DIPC produces a monthly report to CEO and Executive Team, and bi monthly reports to IP&CC, Quality and Safety Improvement and Effectiveness Board.

The Assistant DIPC is included in the senior nursing, health & safety structure and quality agenda, meeting regularly with the Chief Nurse, matrons and AND’s.

The Decontamination Group meets quarterly and reports to the Infection Prevention & Control Committee.

The Trust has a Legionella group which meets twice yearly and reports to both IP&CC and Health & Safety. The group has met more frequently in order to action safety reports on pseudomonas.

Current lines of accountability for infection prevention control are shown in appendix 1.

The Infection Prevention and Control team continue to have a strong link with the Community Infection Control team, ensuring smooth transition of care between Health and Social Care.

3.0 Saving Lives: A delivery programme to reduce Healthcare Associated Infection


The ‘Saving Lives’ programme launched by the Department of Health in June 2005 is designed to increase organisational focus on infection control and to reduce healthcare associated infections including MRSA. The overall aim of ‘Saving Lives’ is to ensure that all staff recognise how they can contribute to reducing infection rates and adopt best practice to achieve this.

The programme has high impact interventions which relate to specific clinical procedures which can increase the risk of infection if not performed appropriately. Each of these interventions has a simple evidence based tool that reinforces the actions that clinical staff need to undertake every time in order to significantly reduce infection, increasing reliability and reduce unwarranted variation in care delivery Each CSU is asked to provide exception reports where standards are less than 100% and account for the variance. The Trusts compliance with the high impact interventions are demonstrated in table1. Data is being fed in to the Governance structure via the Infection Prevention and Control Committee and back to the Ward staff, Matrons and Clinical Leads. With exception reporting to the Trust Board.

Table 1: Saving Lives - Compliance results

Intervention Apr - Jun 12

Jul - Sept 12

Oct - Dec 12

Jan - Mar 13

Central Venous CatheterInsertion 100% 100% 100% 100%

Ongoing 100% 100% 100% 100%

Peripheral Intravenous Catheter

Insertion 89% 90% 91% 91%

Ongoing 91% 96% 96% 95%

Surgical Site InfectionPre-op 100% 100% 97% 100%

Peri-op 100% 80% 90% 100%

Ventilated Patients

Regular observations 100% 100% 100% 100%

Ongoing Care 100% 100% 100% 100%

Urinary CatheterInsertion 100% 100% 100% 99%

Ongoing 98% 97% 99% 98%

4.0 The Health & Social Care Act 2008: Code of Practice for the control of Health care associated infection (Hygiene Code 2010)


The Health and Social Care Act 2008 and subsequent Hygiene code which was updated in 2010 focus’s on the prevention and control of infections and related guidance having ten overall duties which form the basis of the CQC infection control inspection and helps NHS bodies to plan and implement how they can prevent and control HCAI.

The Trust is legally required to be registered with the Care Quality Commission and legal action can be taken if Trusts are found to be breaching the requirement of their registration to protect patients, workers and others from infection. The Trust successfully achieved full unconditional registration on the last inspection which was conducted on the 15th May 2009. No inspections have been undertaken in 2012/13.

To help deliver the requirements of the Hygiene Code the Trust has an Infection Prevention & Control strategy. This strategy and action plan first produced in June 2007 and updated March 2013 provides the Trust with an overarching strategic framework. This not only encompasses the Hygiene Code requirements but seeks to ensure that the Trust will be recognised as being one of the top performing NHS organisations and seeks to be first choice for patients.

5.0 Policies and Procedures

The team introduced a system of yearly policy updates however this has been difficult to sustain therefore will follow the current Trust policy of every two years. Policies and procedures can be found on the Trust intranet site. The following policies and procedures have been introduced, reviewed and updated by the Infection Prevention and Control team.

Updated Procedures

ANTT.IV cannula flushing procedure.Infection Prevention and Control service profile Principles of care for Infectious patientsTaking of Adult blood cultures in relation to the new safety collection system.Updated ward HACCAPStandard (universal precautions) infection control precautionsPrinciples of care for patients with MRGN Diseases and infections A-ZControl of infections major outbreak plan Assistant dogs and pets as therapy Staff Infectious diseases guidelines Commode cleaning poster

Updated Policies


Legionella Adult Antimicrobial policyHand Hygiene policy Clostridium difficile policy Blood Bourne Virus Insertion and management of intravenous cannula care Safe handling and disposal of sharpsTB CJDDiarrhoea Infection control surveillance

6.0 Visits, Reports and Projects

The Clean Your Hand Campaign –Seventh Year

Promotional hand washing awareness campaigns have been undertaken in the Trust with every clinical area engaged with the campaign. The Clean your hands champions meet quarterly with the IP&CT and they continue to integrate the campaign into practice including participating in the delivery of hand washing training at local level and monitoring practise. The number of clean your hands champions increases year on year, as staff become more pro-active in the campaign. The importance of embedding efficient and effective hand hygiene into all elements of care delivery must be kept prominent within health care and will remain a priority for the Trust. This year has seen the introduction of a hand washing DVD which is being used to enhance training

The fundamental principle underpinning the campaign is the focus on the hand hygiene practises of healthcare staff. Due to the nature of their work moving between different patients and different care activities with the same patient, healthcare staff have the greatest potential to spread the microbes that cause infection. The campaign this year has highlighted in the infection control newspaper which was sent to each ward and department as well as quizzes and other promotional events Compliance with hand hygiene is monitored by direct weekly observation of health-care workers whilst delivering routine care. These are presented monthly at all the relevant committees and are displayed at ward and department level.

The Trust continues to promote “bare below the elbow” standard for all staff entering clinical environment. The compliance with this is audited regularly and reported to the Infection Prevention and Control Committee and the Trust Board.

Patient Environment Action Team (PEAT) now replaced by patient lead assessments of the care environment (PLACE)


The team work closely with Matrons, Senior Nurses and Facilities to promote cleanliness and other environmental issues. PEAT visits were regularly conducted by this team and additional environmental walkabouts have been undertaken with IPCT and Matrons. The team have also participated in the formal annual PLACE assessment process. A more detailed environmental inspection has been completed when two or more cases of Clostridium difficile were identified in one area within a 28 day period.

Kitchen Inspections

Standards for food hygiene within the main kitchen are regularly monitored by the facilities department and managers informed of any action required. In addition to the regular facilities inspections, infection control along with Environmental Health conduct regular kitchen inspections. Full inspection has taken place of the main and ward kitchens, a number of issues required attention and these have all been addressed. The ward HACCAP controls have been updated.

Flu

The team have been actively involved in the management and control of influenza and has seen a number of cases including a cluster of infections on ward 24. An extensive staff vaccination programme was also completed by the Occupational Health department and the Trust achieved 63% of all staff being vaccinated

Decontamination

The Sterile Service Department at BHNFT continues to provide an accredited and certified service against British and European Standards for decontamination. Endoscopy washer disinfectors are closely monitored with weekly water quality testing. The processing of scopes is being moved from endoscopy to the sterile service department and the infection control team along with others have visited other trusts to evaluate, design and choose the most up to date methods of decontamination. The project is expected to be completed in 2013/14.

Infection control and estates have audited and inspected the external cleaning decontamination unit that cleans the Trusts specialist mattresses. The decontamination group meets quarterly and reports to the IP&CC.

Risk Assessments

Risk assessments have been completed and new ones continue to be developed to reduce the risks of HCAI, The team have also focused on Sharps prevention and control risk assessments in order to comply with new legislation being introduced in May 2013. Infection control information is included on all intra/inter health-care transfer documentation and is included in the transfer & discharge policy.Inspections


A detailed review of infection control in medical imaging, nuclear medicine, surgical HDU has been undertaken with recommendations made to improve practise. Observational visits have been completed in theatres and a pace maker patient journey with recommendations for improvements made including changing the skin prep prior to pacemakers being inserted.

The Trust laundry supplier has been audited and regular temperature checks on the washing machines are monitored.

Theatre Forum

The infection Prevention & Control Team remain active members of the forum and infection prevention and control remains an agenda item with a particular focus on surgical site infections.

Cleaning/Deep Cleaning

During 2012/13 the Trust decanted and deep cleaned several wards, including using the hydrogen peroxide unit decontamination process. Wards completed include 35,36,22,23,17 & CCU . There have been improvements to the allocation of resources within the cleaning contract with a more equal distribution of resources across all wards. The provision of a steam cleaning team continues. The domestic contract is monitored by facilities with reports going to the IPCC. Infection control is also a member of the hotel services monthly monitoring contract meetings and has been involved with the review of the contract and new cleaning methods. All touch points, toys and some furniture have been protected with a Nano coating to facilitate cleaning. The Pest Control is monitored by Estates and quarterly reports go to the IP&CC.

Aseptic Non Touch Technique (ANTT)

ANTT was introduced by the IP&CT as part of the Trust’s drive to improve aseptic technique Over the last year ANTT has been imbedded in to practise, refresher training given and reinforced by the clinical skills facilitator and Infection Prevention and Control team. Initially for wound and cannulation insertion the programme has now been extended to include IV additives and fluid administration.

The intravenous ANTT program commenced in Sept 2012, with training sessions completed. When staff have completed the training they are expected to complete a competency statement confirming that a colleague has assessed them and deemed them competent in ANTT principles and practice. It is then the responsibility of each member of nursing staff to ensure that the competency statement is completed annually.


Observation of clinical practice

Ward / Department visited

Date Nurse Revisit needed Total Number of ward / Department visits

Ward 22 03/05/12 Sue Burns No 1Oral Facial Surgery & Orthodontics

31//05/12 Sue Burns No 2

Ward 36 28/06/12 Sue Burns No 3Ward 29 12/07/12 Sue Burns No 4Ward 33 Rehab 02/08/12 Sue Burns No 5Ward 27 30/08/12 Sue Burns Yes 6Ward 27 06/09/12 Sue Burns Yes 7Ward 30 17/07/12 Lynda Slater No 8Ward 27 13/09/12 Sue Burns yes 9Ward 28 20/09/12 Lynda Slater No 10Ward 34 MT 21/09/12 Sue Burns No 11Ward 27 27/09/12 Sue Burns No 12Ward 31 04/10/12 Sue Burns No 13SHDU 11/10/12 Sue Burns No 14Ward 34 E 17/10/12 Sue Burns No 15Ward 37 24/10/12 Sue Burns No 16Ward 18 09/11/12 Sue Burns No 17Gynae outpt’s 16/11/12 Sue Burns No 18Ward 36 06/12/12 Sue Burns No 19Cardiology 13/12/12 Lynda Slater No 20Ward 24 14/12/12 Sue Burns No 21Maternity 30/01/13 Lynda Slater No 22Ward 19 31/01/13 Sue Burns No 23Ward 20 06/02/13 Sue Burns No 24

During 12/13 the clinical nurse specialists have conducted 26 ward based practical observations of infection control clinical practice. Working along side ward or department staff facilitates closer working between the IPCT and clinical staff whilst allowing closer observation of clinical practice. This is proving to be very successful and effective. Each area observed is expected to respond in writing to the actions identified in the report. Observation of theatre practice has been undertaken.The patients’ journey whilst having an angiogram has been observed and recommendations made.

Practice Sharing visits April 2012-April 2013


Infection Control Software System

The system provides notifications of patients with positive alert organisms in order that appropriate patient care is initiated as quickly as possible thereby improving efficiency and reducing the risk of infection. The infection control patient record and documentation is completed on the system which is stored against the patient’s unit number for easy access. The system is currently been used by the IPCT, Matrons and Consultant Microbiologists. Over the last year bed mangers have been requested to use the system.

The Following reports have been built in order that up to the minute information can be gained:-

Aspergillus report. Blood Culture resulting in Staphylococcus aureus, Escherichia Coli and MRSA. Clostridium difficile report. Group A. Streptococcus report. Influenza B PCR Report. Influenza H1N1 Report. MRSA Positive (First Isolate) report. MRSA Screening Report. TB Culture Report. Case Management forms report.

Additional reports built over the last year include:

Bordetella pertussis Serology Faeces Culture Barnsley Hepatitis Report Legionella Report Meningococcal PCR Report Orthopaedic (Bone/Tissue) and extended culture positive results Vibrio cholorae

In addition the Lead Nurses have been added to the system in order that an e-mail alert can be sent to them if a patient has a positive result for MRSA or Clostridium difficile Toxin within their Ward areas.

Further work still continues with the Data Surveillance Analyst and the Software provider regarding development issues to improve the functionality of the system.

Urinary Catheter usage and Reduction in associated infection


The team have lead a district wide task and finish group to achieve the catheter insertion reduction and associated infection reduction CQUIN target for the last two years. Achievements have included a urinary catheter care pathway, extensive training on appropriate use of catheters and incontinence management, bowel management training and a catheter passport to be used across agency settings and the use of intermittent catheterisation has been improved. All targets were achieved (appendix 6).

7.0 Antimicrobial prescribing

There is growing concern about the increasing resistance of microorganism to antimicrobial agents. Considerable work has been done to improve antimicrobial prescribing within the Trust. The current antibiotic guideline places restrictions on the use of broad spectrum antibiotics. The microbiology department selectively report antibiotic susceptibility on clinical samples to guide appropriate choice of antibiotics. Pharmacists and microbiologist review the antibiotic prescribing on a daily basis.

Several audits been conducted and the results are fed back to the relevant clinical specialities (see under audit for detail). Overall antibiotic policy compliance rate is very good.

Each CSU receives monthly data on the antibiotic consumption and the use of cephalosporins has declined dramatically since its restriction in 2008. To improve the allergy status documentation each of the wards and the notes trolleys have Traffic light codes for antibiotics. Considerable work has been undertaken to improve the dose of antibiotics received during IV administration with loss in giving sets reduced to a minimal.

Chart 1: Demonstrates 2nd and 3rd generation cephalosporin usage


The Antibiotic share point helps the microbiologist to identify areas with inappropriate antibiotic use, who will then take necessary action to improve adherence to antibiotic guideline.

8.0 Audits

Whilst the saving lives audit tool is used to regularly monitor targeted clinical interventions the following audits have also been undertaken:

Hand Hygiene

The programme of hand hygiene observational audits of 10 per week per ward led by the matrons continues. Those areas where compliance rate is less than 100% are placed on special measures requiring daily monitoring. Results of these audits are disseminated by the matrons to the CSU’s

Chart 2a: Demonstrates hand washing compliance before and after procedures during April – September 2012


Chart 2b: Demonstrates hand washing compliance before and after procedures during October – March 2013

Cluster One Cluster TwoSurgery Elderly

Critical Care General Medicine

Theatres & Day Care Cardiology / Respiratory

Head & Neck ED/AMUTrauma &

Orthopaedics Therapy

Children’s PathologyWomen's Imaging

Outpatients

Clostridium difficile patient review

All inpatients testing positive for C. difficile have a daily review undertaken by the infection prevention and control team. Blood results, dietary and fluid intake, stool type and medications are reviewed and relevant actions taken. From 1st September 2012 patients were also included in an on going audit of the wards initial management of cases. To date, 18 patients have been included in the audit resulting in a total of 126 infection control ward visits to review daily management. 15 of the 18 patients were isolated at the time of diagnosis and had the correct barrier nursing signage displayed on the cubicle door. Stool charts were present in 100% of cases.

Environmental Audits


In addition to local PEAT inspections, the IP&CT and Matrons have undertaken local infection control audits and action plans formulated. Additional audits are also undertaken if two or more cases of Clostridium difficile are identified on a particular ward in a 28 day period.

MRSA Decolonisation Audit

Transmission of Meticillin Resistant Staphylococcus Aureus and the risk of MRSA infection can only be addressed effectively if measures are undertaken to identify MRSA carriers and then decolonise as required. This audit reviewed the screening and decolonisation of patients with MRSA in accordance with the trusts MRSA and MRSA screening policies. 94% of all patients were screened within 24 hours of admission, however subsequent screening, including post decolonisation screening showed poor compliance. This gave an overall compliance to the screening policy of only 51%. Decolonisation management was also poor. 38% of patients received sub optimal treatment and 39% of patients received decolonisation in excess of the prescribed source. Overall compliance with screening and decolonisation did not show any improvement from the audit undertaken the previous year. Actions have been taken following the audit a re-audit will be undertaken once actions have been embedded into practice. One such action was to undertake an audit on the MRSA care pathway. Training and education continues and a promotional campaign is planned for 2013/14 and a PGD to facilitate earlier compliance with decolonisation will be introduced.

MRSA Care Pathway Audit

The aim of this audit was to establish the accuracy of documentation in relation to the MRSA care pathway.Forty-nine patients requiring a care pathway were audited. 94% of the patients had a pathway, however most aspects of the pathway were poorly completed, particularly those relating to the monitoring of swabbing and subsequent MRSA result. Following this audit a full review of the MRSA care pathway is to be undertaken to encourage better utilisation of the documentation.

Intravenous Cannulae Audit

This re-audit was undertaken as part of the Infection Prevention and Control work programme. A point prevalence audit was undertaken involving 182 patients. All aspects of the invasive connection record were audited.

Only 83% of the patients with cannulae had an invasive devices record, and of these only 54% were completed correctly. This is a significant reduction in compliance to the audit undertaken in 2011, where 93% of patients had an invasive devices record of which 66% were completed correctly. 4% of cannulae audited were found to have local signs of infection, an increase of 2% from the previous audit.


Improvements are required in the care and management of cannulae and therefore cannulation audits are currently undertaken weekly by the lead nurses.

Sharps Audit – January 2013

Daniels Health Care representatives conducted a site survey with the aim of assessing practice and raising sharps awareness. All the wards and departments were audited. Seventy wards/ depts. were visited a total of 637 sharps containers were inspected overall the result was very good with only 8 being over 2/3rds full and none not properly assembled. No containers had protruding objects however 22 were not appropriately labelled and 9 had inappropriate contents e.g. gloves, this is an improvement on last years audit, information has been fed back to local teams for action.

Data entered into the Incident reporting system was audited and recommendations have been made for improving the investigation

Medical Equipment Audit

The Lead Nurses and medical devices co-ordinators have undertaken a number of equipment decontamination audits including:-

The cleanliness of medical devices including syringe drivers, defibrillators, tympanic thermometers

The audit of decontamination of equipment returned to medical equipment library

The storage of medical equipment The cleanliness and integrity of mattresses and trolley coverings has taken

place with a number of mattresses condemned and the procedure for checking has been re-launched.

Additionally all audits undertaken with relation to medical devices have a decontamination aspect included. The bi weekly PEAT visits and infection control observational visits also include an element of medical devices cleanliness. All areas for improvement have been reported to the clinical areas.

The Use and Management of antibiotics

The pharmacy department has undertaken a two point prevalence audit of antibiotic usage. Results are overall favourable and have been presented to IP&C committee and also to the prescribers through clinical audit meetings. Audit of antibiotic prophylaxis in breast and general surgery was also carried out this year with the help of audit department and the results were fed back to the department. Also Trust has participated in the National Point prevalence survey conducted by the HPA.


9.0 Surveillance

The IP&C team continues to give a high priority to surveillance. In addition to the mandatory national surveillance scheme a regular cycle of other surgical intervention is monitored. The IPCT also undertake targeted and alert organism surveillance. Meticillin Resistant Staphylococcus Aureus (MRSA)

Each new case of MRSA is followed up by the IPCT who visit all new MRSA inpatients advising on decolonisation regimes and supporting the patients, relatives and staff, including stamping the patients prescription sheet for medical staff to sign for the decolonisation regime.

All patients (elective and emergency) admitted to the Trust continue to be screened for MRSA colonisation in line with the national initiative. The number of new MRSA isolates at BHNFT, remains stable. MRSA screening is monitored and non compliance fed back to clinical teams for checking. An audit has identified that sometimes samples are not taken at appropriate times and decolonisation is often delayed or incomplete new documentation and a nursing PGD is expected to improve this.

Chart 3: Number of District figures for new cases of MRSA infection colonisation by location:


Chart 4: Number of new cases of MRSA infection colonisation: District figures

Mandatory surveillance of MRSA bacteraemia

Since 2001 it has been mandatory for Trusts to report MRSA bacteraemia figures to Department of Health. Results are published as MRSA bacteraemia per 100,000 occupied bed days.

The Trust and PCO had a target of 0 MRSA bacteraemia cases for the financial year 2012/13. The actual number of MRSA bacteraemia cases for the year was 1 which was attributed to the Community. Several factors have contributed this success, including universal MRSA screening, improved decolonisation, decreased blood culture contamination rate, improved cannula care etc. However this sets the target for the coming year at 0 again which remains a challenge for the Trust.

Table 2: MRSA bacteraemia rate per 100,000 bed days.No of MRSA bacteraemia

BHNFT

Community

Target

Rate per 100,000 be days (Hospital attributable cases).

Rate per 100,000 bed days (Total Cases)

2005/06 17 13 4 19 - 11.6

2006/07 16 8 8 16 - 10.7

2007/08 12 6 6 12 - 7.9

2008/09 8 3 5 11 1.3 5.1

2009/10 2 1 1 8 0.7 1.3

2010/11 0 0 0 1 0.0 0.0

2011/12 1 0 1 0 0.0 0.7

2012/13 0 0 1 0 0.0 -


Chart 5: Total number of MRSA Bacteraemia District Figures

Chart 6: Trust MRSA bacteraemia compared with Regional data.


Chart 7: Monthly MRSA bacteraemia April 12 to March 13

Meticillin Sensitive Staphylococcus aureus (MSSA) Bacteraemia


As from January 2010 it has been a requirement to report nationally all MSSA. It is expected that in future a target will be set to reduce the rates of MSSA bacteraemia. Out of 31 MSSA bacteraemias, 7 were hospital acquired (post 48 hr admission). The sources of these 7 bacteraemias are given in table 4. Only 4 of these bacteraemias are directly related to the health care intervention within this hospital and hence potentially avoidable. Root Cause analysis has been conducted for each of these cases and action plan has been produced.

Table 3: To Identify the numbers of MSSA Bacteraemia by Month

Staphylococcus aureus Bacteraemia - Monthly Surveillance 2012/13Month Total No. Hospital Community MVH MRSAApril 2 0 2 0 0May 1 0 1 0 0June 4 1 3 0 0July 2 0 2 0 0

August 2 0 1 1 0September 3 0 3 0 0

October 3 0 3 0 0November 0 0 0 0 0December 4 0 4 0 0January 4 2 2 0 0February 4 3 1 0 1

March 2 1 1 0 0Total 31 7 23 1 1

Hospital = Hospital acquired (identified more than 48 hr after admission.)

Community = Community Acquired (identified within 48hrs of admission and not been an inpatient in the last 8 weeks.)

Chart 8: Demonstrates the numbers of Staphylococcus aureus bacteraemia by Month


Table 4: MSSA bacteraemia RCA findings

Case Source of MSSA Bacteraemia1 PVC-infection2 Wound infection3 Central line4 Long line5 Endocarditis6 Endocarditis7 Central line

Clostridium difficile Since 2004 the reporting of C. difficile infection has become mandatory. All NHS Trusts are required to test diarrhoeal stool samples from patients over 65 years and above reporting all positive results to the HPA (now Public Health England). Since 2007 this has been changed to report all positive Clostridium difficile cases >2 years of age. Data is expressed as the rate per 100,000 bed days. This year two stage testing approach was introduced to comply with the DoH guideline on diagnosis of C.difficile infection. This consists of GDH EIA for antigen detection as a screening test followed by GDH EIA for toxin detection. This is likely to produce more accurate results and also will detect carriers. GP letters have been reviewed and updated. The end of year 2012/13 position was 22 positive cases against a trajectory of 31 therefore targets were achieved. (table 5)

Table 5: Clostridium difficile National Surveillance Figures (All age groups)

Year Number of cases (Total PCO)

Number of cases (Trust apportioned)

Rate per 100,000 bed days (Trust


apportioned cases)2007/08 297 148 107.72008/09 194 105 73.22009/10 121 52 34.32010/11 131 49 35.22011/12 83 28 20.12012/13 64 22 N/a

Chart 9: Total number of Clostridium difficile cases by location – District figures

Chart 10: Monthly new Clostridium difficile episodes against agreed trajectory

Chart 11: Trust Clostridium difficile cases compared with Regional data.


RCA has been undertaken for all cases of C. difficile by the IPCT or Matron and an exception report is produced mainly concentrating on environmental cleanliness, if 2 or more cases are identified in a particular ward within 28 days. Antibiotic use is also monitored by the pharmacist. Actions are taken based on the results of the RCA and exception reports.

A RCA Overview Panel has been established since September 2008 involving representatives from SWYFT Commissioning, Public health and BHNFT continued to meet every month during 12/13 and is instrumental in trouble shooting and action planning as a health economy. Findings from these are presented to District and local IP&C committee.

Glycopeptide Resistant Enterococci (GRE):

The IPCT also monitor the number of cases of GRE. There were no cases of GRE infection /colonisation (table 6).

Table 6: Total Numbers of GRE cases by year

Year BHNFT GP KERES. KHB MVH TOTAL2005 4 0 0 0 0 42006 1 0 0 0 0 12007 2 0 0 0 0 22008 1 0 0 0 0 1

2009/10 0 0 0 0 0 0


2010/11 0 0 0 0 0 02011/12 3 0 0 0 0 32012/13 0 0 0 0 0 0

Surveillance of Escherichia coli Bacteraemia

Since April 2011, it has become mandatory to report all cases of E.coli bacteraemia into the national database. There is no national benchmark available to compare the rate at the current time.Table 7: Total numbers Escherichia coli Bacteraemia by Month

E Coli Bacteraemia - Monthly Surveillance 2012/13.Month Total No. Hospital Community MVH ESBLApril 8 2 6 0 1May 6 0 5 1 0June 6 1 5 0 0July 9 4 5 0 1

August 16 2 14 0 2September 19 4 15 0 4

October 7 2 5 0 0November 8 4 4 0 2December 11 2 9 0 0January 17 2 14 1 2February 13 4 9 0 1

March 10 4 6 0 4Total 130 31 97 2 17

Chart 12: Demonstrates the numbers of Escherichia coli Bacteraemia by Month

Surveillance of blood culture contaminants

Since the introduction of monthly surveillance of blood culture contamination rates there has been significant improvement in the rate of contamination of blood culture, thus


avoiding unnecessary antibiotic use and also the cost. The continued and reinforced use of ANTT to all staff saw a further reduction in the rate of contamination. Further work has been undertaken to reduce the rate down even further by the introduction of a new safety blood culture collection system it is expected to see improvements in 2013/14.

Chart 13: Total blood culture contaminants by month

Surgical Site Surveillance

Orthopaedic surgical site surveillance:

The Trust is participating in the mandatory Orthopaedic wound surveillance and has been since 2001. Even though Trusts are required only to collect data on one type of orthopaedic procedure for a 3 month period, BHNFT has elected to undertake consistent surveillance of hip, knee and hip hemi-arthroplasty wound infection. The percentage of wound infections for all periods of collection are as follows: Knees 1.4% infection, Hip replacement 2.0%, Repair of neck of femur 1.2%. More detailed results of this surveillance are shown in appendix 2.

Public Health England regard the trust as an outlier for Knee infection and a separate group have been meeting to address this issue an action plan is in place. One external review of theatres has been undertaken and a further one arranged for May 2013. IP&CT have been spending more time in theatres and estates have completed some minor works. Further work is ongoing to assure compliance and the numbers involved are very small.


Post discharge surveillance continues on patients undergoing hip and knee replacement and hemi arthroplasty surgery these figures are not included above.

This remains a high priorty on the Trust agenda and every effort is being made to improve the patient outcome.

Breast Surgery Surveillance

Breast Surgery surveillance was completed for period January – March 2013 which included post discharge surveillance also. Out of the 82 operations where data had been submitted there were no Surgical Site Infections found for inpatient / readmission. No Surgical Site Infections were identified by patient’s completing the post discharge questionnaire.

For Surgical Site Infections identified as inpatients / readmission, the current infection rate is 0.0% against the National Benchmark of 1.0%.More detailed results of this surveillance are shown in appendix 2.

Large Bowel Surgery surveillance

Large bowel surgical site surveillance was completed for the period October – December 2012 which included post discharge surveillance also. 6 wound infections were identified during this period out of 45 operations giving a percentage of 13.3%, against a national target of 10.3%. Additionally 1 patient reported cases were identified through the post discharge questionnaire. More detailed results of this surveillance are shown in appendix 2.

Caesarean Section Surveillance

Caesarean section wound surveillance (including post discharge surveillance) was carried out during April – June 2012. 20 Surgical Site Infections were reported giving a percentage of 14%. Four of the infections were detected while inpatient and 16 were patient reported. 19 infections were classed as superficial infections and 1 as deep incisional (table 8)

Table 8: The number of section operations and infections in 2010 to 2012

April – June 2010 April – June 2011 April - June 2012

No. of operations 128 139 140No. of SSI 13 22 20

% Operations infection 10% 16% 14%% of Deep Infection 0% 0.0% 0.7%

Chart 14: Demonstrates Number of Caesarean Section Wound Infections


Alert organism and alert conditions surveillance

Chart 15 gives the number of alert organisms identified in the laboratory. Alert organisms are those organisms that have infection control implications.

Chart 15: Laboratory Alert organism’s surveillance

Clusters/Outbreaks

Table 9: Details of BHNFT clusters / outbreaks

Date of Closure

Ward No. of days closed

No. of patients affected

No. of staff affected

Disease Organism Isolated

March 2013 24 48 hours 5 4 Influenza Influenza ADecember 19 N/A 4 0 Gastroenteritis Norovirus


2012 x1December 2012

35 N/A 8 0 Gastroenteritis Norovirus x1

December 2012

28 N/A1 bed blocked for 48 hours

6 2 Gastroenteritis Norovirus x1

November 2012

35 N/A 7 1 Gastroenteritis Norovirus x1

October 2012

19 N/A1 bed blocked for 48 hours

16 1 Gastroenteritis Norovirus x5

October 2012

31 N/A 3 0 Gastroenteritis Non found

October 2012

20 N/A 5 7 Gastroenteritis Non found

May 2012 21 N/A 7 3 Gastroenteritis Norovirus x7

May 2012 19 N/A 7 3 Gastroenteritis Norovirus x2

Also in addition to the above clusters a further 5 wards were reviewed by the Infection Prevention and Control Team following alerts by the ward staff. An increase in patients with Aspergillus in the previous year has resulted in a close monitoring of this alert organism with potential sources identified.

11.0 Complaints

The team have assisted CSU’s to answer three relevant complaints which required extensive patient follow up.


12.0 Serious incidents

Only one serious incident has been recorded and investigated

13.0 Patient Assessment

The team continue to support patients with infections, providing ongoing support for healthcare providers, carers, relatives and others. The team aim to visit all patients with alert conditions or alert organisms, providing individual assessments on care management and control of infection as well as providing information to patients and relatives. If the patient is unable to communicate, the team leave a compliment slip advising of the visit and our availability to relatives. Additionally the team conduct daily Clostridium difficile ward rounds visiting patients with CDAD evaluating and monitoring their progress. The microbiology consultants conduct significant micro-organism isolate ward rounds in addition to daily visits to ITU.

The Control of Infection relies on the prompt identification and management of infectious patients. Therefore the response times of the Infection Control Team are a vital element in the process to controlling risks associated with the transmission of human pathogens. The IPCT have set the following 2 target indicators against which they are performance managed.

Indicator 1 - Percentage of verbal advice within 30 minutes on notification of alert organism and alert conditions. (Target 99% of in patients)

Indicator 2 – Percentage of visits to the area within 2 working days. (Target 98% of inpatients) Summary of the results:

Indicator 1- 2796 in patient episodes of alert organism have been notified by the Infection Control team to clinical staff and verbal advice has been given. In 99.5 % of cases this was achieved within 30 minutes.

Indicator 2- 1174 initial visits have been conducted, 100% of which were done within 2 working days. The full report can be seen in appendix 3.

The team have strong working relationships with the bed management team including formal weekly meetings. Daily cubicle use continues to be monitored by the bed management and Infection Prevention and Control teams.

14.0 Educational Initiatives

The ongoing education of all staff remains a high priority for the team however; problems releasing staff continue to be experienced. The team have been actively involved in updating the corporate curriculum. E learning is available for both non clinical and clinical staff the non clinical E learning pack has been reviewed and update.


A blood borne virus study day is provided five times a year with a site specific 2½ hour update run frequently throughout the year.

The team participate in the induction programmes for new medical staff and have achieved 100% compliance with the provision of this service. The microbiologists continue to undertake targeted education of medical staff.

The team participate in the mandatory training & induction programmes for all other staff and have achieved 100% compliance with provision of this service.

The team have continued to train the clean your hands champions who in turn monitor and check the hand washing technique at clinical level.

A training package has been developed for external contractors providing basic infection prevention and control advice with several sessions having been conducted and well attended.

A DVD has been introduced for the training related to urinary catheter insertion and maintenance.

Antibiotic stewardship awareness has been added to the IV additive training

Training records can be seen in appendix 5.

14.1 Professional Development of the Infection Control Nurses

All the Infection Prevention and Control Nurses are required to provide evidence of continuing professional development as part of the requirements of the Nursing and Midwifery Council to maintain their nursing registration. Above this basic requirement there is on-going academic study and attendance at regional and national conferences to enable the nurses not only to develop professionally but also to ensure that they are able to provide the most up-to-date advice to prevent and control infection.

In the last 12 months, three Infection Control Nurses had day attendance at the National Infection Control Nurses Annual Conference and the team have attended various training days to update their knowledge. The team has continued to support and attend various committees e.g. Health & Safety, Medical Devices, COSHH and Waste, Procedures group and Senior Nurses Forum, Drugs and Therapeutics Committee, Hotel Services Forum, CQC leads, Decontamination, Legionella, Sharps Prevention, QSIEB

Additionally the team lead and chair the Infection Control Forum, the Sharps Prevention group, the urinary catheter CQUIN and the Clean Your Hands Champion meeting.

The Consultants continue to undertake CPD requirements and have attended professional study days.


15.0 Research

The team continues to evaluate current research and apply appropriately to practise.

16.0 Health Promotion (PPI/Special Projects)

The Infection Prevention & Control Team recognise the importance of working with the public to reduce healthcare associated infections and have encouraged the public to see this issue as a partnership. The team have promoted the principles of infection control to the general public at special events:

Items in the local press. Sharps prevention week Infection Control week Stand in OPD to promote Hand Hygiene for staff and visitors and general

infection prevention and control advice. Promotion of patient and public involvement including promotional events like

Penistone show.

The team continue to lead the sharps prevention strategy actively promoting the safe use and disposal of sharps. With the introduction of EH legislation and subsequent Health and Safety legislation in relation to the use and management of sharps, a number of safety devices have been trialled and implemented. A sharps awareness week was held in April 2012.

In November the team held Infection Prevention & Control week when a number of activities to raise awareness took place including poster displays, the Bug Herald was updated and reintroduced, educational stands were displayed in the dining room, education centre and outpatients with staff from disciplines other than nursing e.g. Estates and Facilities, Healthcare initial were available at the stands for advice. Infection Prevention and Control advice leaflets were also distributed to patients attending Outpatients, Medical Imaging and the Emergency Department.

17.0 Capital Schemes/Estates/Equipment.

The Infection Prevention & Control Team’s advice must be sought by the Trust for all service development activity including capital/building schemes, equipment procurement and contracting for services, which have implications for infection control. The Assistant DIPC and the Head of Estates (operational) have regular meetings to assist with communication and involvement. Over the last year involvement has included the Women’s and Children’s scheme, Window replacements, floor replacements main reception and general areas, ED and physiotherapy, roofing, acute medical admissions unit and Endoscopy decontamination relocation.

A detailed risk assessment and evaluation of risk from pseudomonas in water resulted in some taps being replaced and the use of hand washing sinks being restricted


18.0 External Inspections

No Hygiene code inspections have taken place this year however an internal audit was completed on the infection control service with some recommendations which have been actioned. An external verification of the data has also confirmed the accuracy of our statistics.

19.0 National & Regional Work

The team continues to forge national links and has represented the Trust at other regional meetings

20.0 OBJECTIVES FOR 2012/13

In addition to the core activities these are the specific objectives to be addressed in the year 12/13. The objectives listed below are a summary and more detailed breakdown has been issued separately.

Policies and Procedures

Policies and infection control procedures/guidelines will be reviewed.

Write Panton-Valentine Leukocidin (PVL) guidelines

Develop Group A Streptococcus policy

Audit of Policies and Procedures

Hand Washing Observational Audit All wards/clinical areas

Audit the clinical environment and equipment

Audit the cleanliness of equipment

Use and Management of Sharps Containers

Audit compliance with MRSA decolonisation and screening

Audit care of Clostridium difficile patients including monitoring clinical care

Audit compliance with the correct use of cannulae and maintenance of correct records

Audit compliance with providing hand-washing opportunities for patients

Audit compliance with correct isolation procedures


Audit compliance with the care of central and long intravenous lines

Antibiotic stewardship and management

Education

Review training content & conduct sessions to comply with corporate curriculum

Respond to adhoc training as required

Focus on training for aseptic technique /ANTT

Educate the patients and general public providing up to date and relevant information

Projects

Clean your Hands Campaign.

Clean your Hands Focused Campaign for Theatres to be maintained

Continue to develop information for the patients and the public.

Review risk assessments relating to infection control.

Improve and maintain the saving lives programme integrating in to practise new Saving Lives procedures

Promote Annual Infection Control week

Promote Annual Sharps Control week

Targeted Theatre infection prevention and control focus

Monitor the use of skin antiseptic for orthopaedic and caesarean sections

Develop an MRSA decolonisation awareness programme

Clostridium Difficile target reduction intervention programme

Surveillance

The routine surveillance of alert organisms, alert conditions, antibiotic resistance patterns and monitoring of all positive isolates will continue.


MSSA bacteraemia surveillance will be introduced and RCA of all hospital acquired cases will be undertaken.

MRSA bacteraemia surveillance will continue with root cause analysis of all cases.

GRE surveillance continues.

Surveillance of other resistant organisms e.g. ESBL’s.

Targeted surveillance of hips knees and neck of femur repair will continue.Including post discharge surveillance

Conduct 3 months surveillance of caesarean section infections including post discharge surveillance.

Conduct 3 months surveillance of Large Bowel surgery infections including post discharge surveillance.

Continue surveillance of E. coli bacteraemias and introduce RCA.

Conduct 3 months breast surgery wound surveillance including post discharge surveillance.

Clostridium difficile report monitoring continues and the root cause analysis will continue to be completed on all Clostridium difficile cases including action during a period of increased incidence or same ribotype.

Environment

Participate in new development and capital schemes.

Participate in the monitoring of the cleaning contract.

Upgrade treatment rooms to new drugs suites in line with the estates strategy.

All equipment and environment will be thoroughly decontaminated and cleanliness maintained to the highest level in all clinical areas according to infection prevention and control policies and procedures.

On discharge of all patients thorough terminal cleaning of the room will be completed.

Other

The Infection Prevention and Control Team will be aware of and incorporate additional activity as required to meet local and national requirements as resource will allow.


Promote BHNFT Nationally

Performance Management

Ensure compliance with infection control programme and hygiene code at CSU level

Produce and monitor infection control data e.g.

Positive and contaminated blood cultures Clostridium difficile positives MRSA positives MSSA positives


Committee Structures Lines of Communication and Accountability Appendix 1

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District Control of Infection Committee

BHNFT Board of Directors

Clinical Governance

Public Health England CCG

BHNFT Infection Control Operational

Group

CSU’s & Departments

Infection Prevention & Control Committee

Decontamination Group

Non-Clinical Governance Committee

Surgical Site Infection Surveillance Appendix 2

KNEE REPLACEMENT SURVEILLANCE2012 and Previous periods

BHNFT All HospitalsLast Period

October – December 2012Last 4 periods

January – December 2012 Last 5 Years

Risk Index No. Operations

No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

0 55 1 1.8% 221 3 1.4% 152495 643 0.4%1 22 0 0.0% 103 1 1.0% 47362 420 0.9%2 1 0 0.0% 10 1 10.0% 4791 88 1.8%3 0 0 0.0% 0 0 0.0% 20 2 10.0%

Unknown 6 0 0.0% 18 0 0.0% 16473 81 0.5%Total 84 1 1.2% 352 5 1.4% 221141 1234 0.6%

REPAIR NECK OF FEMUR SURVEILLANCE2012 and Previous periods





No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

0 10 0 0.0% 36 1 2.8% 16924 190 1.1%1 24 0 0.0% 104 2 1.9% 36866 581 1.6%2 20 0 0.0% 52 0 0.0% 7094 199 2.8%3 0 0 0.0% 0 0 0.0% 20 0 0.0%

Unknown 14 0 0.0% 51 0 0.0% 8992 124 1.4%Total 68 0 0.0% 243 3 1.2% 69896 1094 1.6%

TOTAL HIP REPLACEMENT SURVEILLANCE2012 and Previous periods





No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

0 22 0 0.0% 107 3 2.8% 139626 613 0.4%1 15 0 0.0% 64 0 0.0% 46760 488 1.0%2 2 0 0.0% 15 0 0.0% 7140 130 1.8%3 0 0 0.0% 0 0 0.0% 50 1 2.0%

Unknown 4 1 25.0% 16 1 6.3% 16006 132 0.8%Total 43 1 2.3% 202 4 2.0% 209582 1364 0.7%

LARGE BOWEL SURGERY2012 and Previous periods


October – December 2012 Last 4 periods Last 5 Years


No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

0 11 0 0.0% 49 2 4.1% 4761 329 6.9%1 18 3 16.7% 70 7 10.0% 7059 742 10.5%2 7 0 0.0% 27 1 3.7% 3043 438 14.4%3 1 0 0.0% 2 0 0.0% 414 97 23.4%

Unknown 8 3 37.5% 22 4 18.2% 1872 161 8.6%Total 45 6 13.3% 170 14 8.2 17149 1767 10.3%

43

BREAST SURGERY2012 and Previous periods


January – March 2013Last 3 periods

January 2011 – March 2013 Last 5 Years


No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

0 66 0 0.0% 154 0 0.0% 3775 30 0.8%1 10 0 0.0% 23 0 0.0% 798 15 1.9%2 0 0 0.0% 0 0 0.0% 30 3 10.0%3 0 0 0.0% 0 0 0.0% 0 0 0.0%

Unknown 6 0 0.0% 35 0 0.0% 421 4 1.0%Total 82 0 0.0% 212 0 0.0% 5024 52 1.0%

Risk Index Definition

A Risk Index comprising data obtained from three factors – ASA score, wound classification and duration of operation – is used to assign a risk score between 0 and 3 to each operation. Operations with a risk index score of 3 have a higher risk of developing SSI than those with a score of 0. This score is used to stratify operations and enable rates of SSI to be adjusted by these risk factors.

44

Performance Indicators Appendix 3

PERFORMANCE INDICATOR 1 = 99.5%Total number of referrals seen/not seen by Infection Prevention & Control

Breakdown of Total No. of referrals seen by Infection Control at BHNFT (Please note the table relates to original referral criteria not necessarily confirmed cases)

Month Received in a month

Achieved Target + Not

AchievedAchieved

Target Exceeds 30 Mins

Percentage Compliant

April 247 247 243 4 98.4%May 248 248 247 1 99.6%June 237 237 236 1 99.6%July 207 207 207 0 100.0%August 209 209 209 0 100.0%September 225 225 223 2 99.1%October 268 268 267 1 99.6%November 255 255 253 2 99.2%December 243 243 241 2 99.2%January 228 228 228 0 100.0%February 214 214 214 0 100.0%March 215 215 215 0 100.0%

Total 2796 2796 2783 13 99.5%

45

PERFORMANCE INDICATOR 2Total number of referrals seen/not seen within 2 working days of notification by Infection Prevention & Control

Month Number of

Assessments Total Within 48

Hrs Total Exceeding 48

HrsPercentage Compliant

April 104 104 0 100.0%May 115 115 0 100.0%June 96 96 0 100.0%July 75 75 0 100.0%

August 94 94 0 100.0%September 109 109 0 100.0%

October 108 108 0 100.0%November 102 102 0 100.0%December 90 90 0 100.0%January 89 88 0 100.0%February 104 104 0 100.0%

March 89 89 0 100.0%

Total 1175 1175 0 100.0%

100% Overall for the financial year April 2012 – March 2013

PERFORMANCE INDICATOR 2 Type of Patient Alert Organism Seen

Additional Patient reviews

INFECTION :BHNFT April 12 – March 13

MRSA 920Clostridium difficile Toxin 26Other 229Total 1175

Type of review April 12 – March 13

Clostridium difficile Ward round 28Diarrhoea Ward round 251Total 279

Appendix 4

46

Training data – 01.04.2012 – 31.03.2013

Type of session Number of sessions

No of attendees

Mandatory 96 813Train the trainers 11 34Hand Hygiene, by champions 64 256ANTT 25 46Corporate Induction 16 265Doctors Inductions 2 104HIV and BBV awareness day 3 19HIV and BBV update 7 31Student Inductions 15 137Contractors Induction 7 41Medical Nursing Induction 3 29ICE Medical Students 1 29

Appendix 5

47

Total number of Catheterised patient's Sharepoint Maternity Total

Total number of patients who have had a primary Catheterisation 2,410 899 3,309 90%Total number of patients who have had a Re-catheterisation 353 0 353 10%Total number of Catheterised patient's 2,763 899 3,662

Total number of Catheterised patient's that were in the exclusion category Sharepoint Maternity Total

Total number of patients who have had a primary Catheterisation and were in the exclusion category 2,256 899 3,155 90%Total number of patients who have had a Re-catheterisation and were in the exclusion category 333 0 333 10%Total number of Catheterised patient's that were in the exclusion category 2,589 899 3,488 95%

Total number of Catheterised patient's that were not included in the exclusion category Sharepoint Maternity Total

Total number of patients who have had a primary Catheterisation but not included in the exclusion category 154 0 154 89%Total number of patients who have had a Re-catheterisation but not included in the exclusion category 20 0 20 11%Total number of Catheterised patient's that were not included in the exclusion category 174 0 174 5%

Sharepoint Maternity Total Total number of Catheterised Inpatients who develop a UTI 0 1 1

Indicator 1 Numerator 1 Total number of Catheterised Inpatients after exclusions 174 0.11%Denominator 1 Total number of occupied bed days / 10,000 155181

Indicator 2 Numerator 2 Total number of Catheterised Inpatients who develop a UTI 1 0.03%Denominator 2 Total number of catheterised inpatient's 3,662

Catheterisation CQUIN

April 2012 – March 2013

Appendix 6

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