INFECTION PREVENTION AND CONTROL ANNUAL PROGRAMME APRIL 2017 MARCH 2018

Transcription

1 QUALITY COMMITTEE CHAIR REPORT BD/98/17 INFECTION PREVENTION AND CONTROL ANNUAL PROGRAMME APRIL 2017 MARCH 2018 Versin: 1 Ratified by: Date ratified: Name f riginatr/authr: Directr respnsible fr implementatin: Date issued: Infectin Preventin and Cntrl Cmmittee Dr Srinivasulu Reddy Infectin Preventin and Cntrl Dctr Paul Stevens Directr Infectin Preventin and Cntrl Valerie Harmn Deputy Directr Infectin Preventin and Cntrl Sally Smith, Chief Nurse and Directr f Quality

2 CONTENTS Sectin Page 1 Intrductin Aim f the Annual Prgramme Care Quality Cmmissin 3 2 The Infectin Preventin and Cntrl Team (IPCT) Infectin Preventin and Cntrl Team Activity 5 3 Develpment Prcess 6 4 Rles and Respnsibilities 6 5 The Infectin Preventin and Cntrl Cmmittee (IPCC) 6 6 Key Areas f Infectin Preventin and Cntrl Activity 7 7 Plicy/Guideline Develpment 7 8 Audit Activities 7 9 Surveillance Activities 8 10 Antibitic Management Audit The HOUDINI Prtcl Educatinal Activity Infectin Preventin and Cntrl Link Practitiners Hand Hygiene Campaign Leginella Management and Mnitring Hspital Hygiene New Builds, Site Develpment, Re-cnfiguratin f Clinical Services/Decant and Deep Clean Prgrammes The Duty f Candur Wrking with the CCGs Supprting the Wider Healthcare Ecnmy Prmtinal Campaign Wrk Service Cver and Business Cntinuity Management f Outbreaks f Infectin Respnse t Disease Threats Nrvirus Outbreaks 16 Appendices Appendix 1: EKHUFT Acute Trust Quality Metrics 17 V.1 Page 2 f 21 June 2017

3 1. Intrductin This Prgramme has been develped n behalf f East Kent Hspitals University NHS Fundatin Trust (EKHUFT) Infectin Preventin and Cntrl Cmmittee. The Infectin Preventin and Cntrl Prgramme exists t c-rdinate and mnitr the wrk f the Infectin Preventin and Cntrl Cmmittees and Teams in preventing and cntrlling infectin thrugh effective cmmunicatin, educatin, audit, surveillance, risk assessment, quality imprvement and develpment f plicies and prcedures. The Prgramme addresses the natinal and lcal pririties fr infectin preventin and cntrl and extends thrughut healthcare, health prtectin and health prmtin. Operatinal delivery f the prgramme is regularly mnitred and reviewed and reprted thrugh the detailed implementatin plan. The prgramme and assciated implementatin plan require all disciplines t wrk tgether t prmte gd infectin preventin and cntrl practice. Central t these effrts are the detailed wrk plans, gvernance systems, scrutiny and mnitring and reprting arrangements fr the effective preventin and cntrl f infectin acrss EKHUFT. Infectin preventin and cntrl clearly des nt rest slely within the dmains f ur Infectin Preventin and Cntrl Cmmittees and Teams. Everyne has infectin preventin and cntrl respnsibilities. Service users wh depend n EKHUFT require all f us t fllw best practice as described in the EKHUFT Infectin Preventin and Cntrl Manual. The Infectin Preventin and Cntrl Cmmittee and the Infectin Preventin and Cntrl Team (IPCT) with supprt f the link practitiners will c-rdinate delivery f this extensive bdy f wrk. All thse invlved in delivery f healthcare are participants in this prgramme by actively assisting thrugh each individual s infectin preventin and cntrl actins whether delivering r receiving care. 1.1 Aim f the Annual Prgramme The IPC Annual Prgramme fr is based n utilising perfrmance management systems t imprve patient safety, enhance quality f care and ensure cmpliance with the Cde f Practice with particular emphasis t prvide evidence based plicies t reducing the risks f acquisitin and spread f MRSA, C. difficile, antibitic resistant rganisms (i.e. CPO/GRE) and ther healthcare assciated infectins within the healthcare envirnments. 1.2 Care Quality Cmmissin The Health and Scial Care Act 2008 sets ut the verall framewrk fr the regulatin f health and scial care activities. Regulatins made under this Act describe the health and scial care activities that may nly be carried ut by prviders that are registered with the CQC. The Cde f Practice fr the preventin and cntrl f infectins (The Cde) states 10 criteria against which a registered prvider s cmpliance is mnitred and judged. Cmpliance criterin What the registered prvider will need t demnstrate 1 Systems t manage and mnitr the preventin and cntrl f infectin. These systems use risk assessments and cnsider hw susceptible service users are and any risks that their envirnment and ther users may pse t them. 2 Prvide and maintain a clean and apprpriate envirnment in managed premises that facilitates the preventin and cntrl f infectins. V.1 Page 3 f 21 June 2017

4 3 Ensure apprpriate antimicrbial use t ptimise patient utcmes and t reduce the risk f adverse events and antimicrbial resistance. 4 Prvide suitable accurate infrmatin n infectins t service users, their visitrs and any persn cncerned with prviding further supprt r nursing/medical care in a timely fashin. 5 Ensure prmpt identificatin f peple wh have r at risk f develping an infectin, s that they receive timely and apprpriate treatment and care t reduce the risk f transmitting infectin t ther peple. 6 Systems t ensure that all care wrkers (including cntractrs and vlunteers) are aware f and discharge their respnsibilities in the prcess f preventing and cntrlling infectin. 7 Prvide r secure adequate islatin facilities. 8 Secure adequate access t labratry supprt as apprpriate. 9 Have and adhere t plicies, designed fr the individual s care and prvider rganisatins that will help t prevent and cntrl infectins. 10 Prviders have a system in place t manage the ccupatinal health needs and bligatins f staff in relatin t infectin. 2. The Infectin Preventin and Cntrl Team (IPCT) The IPCT cnsists f medical and nursing infectin preventin and cntrl specialists respnsible fr mnitring and ensuring cmpliance with the standards and activities described within the Infectin Preventin and Cntrl Annual Prgramme. EKHUFT IPCT currently cnsists f: 3.5 Cnsultant Micrbilgists (f whm 3 hld the fllwing rles respectively: Clinical Directr (Labratry Medicine); Head f Service/Chair f the Antimicrbial Stewardship Cmmittee, and Infectin Preventin and Cntrl Dctr) The current status f the team is: ten Infectin Preventin and Cntrl persnnel - ne f whm is the Deputy Directr f Infectin Preventin and Cntrl, tw Infectin Preventin and Cntrl staff members and a Decntaminatin Lead. The prpsed team structure is under review and described in the fllwing table: Rle Wrking time DIPC DDIPC Mnday t Friday IPCD Mnday t Friday n call duties as per micr rtas 3 x IPC Clinical Nurse Specialists 37.5 hurs wrking every 3rd Saturday 3 x IPC Sisters 37.5 hurs wrking every 3rd Saturday 3 x IPC assistants 37.5 hurs wrking every 3rd Saturday 1 x IPCAA Mnday t Friday 1 x IPCDA Tuesday t Friday IPCLPs (infectin preventin and cntrl link practitiners) Designated time Ring fenced hurs t allw relevant activity in their areas f emplyment V.1 Page 4 f 21 June 2017

5 Secretarial/administratin supprt is prvided by 1 x full time secretary at the QEQM, and 1 x part time (24 hurs/week) Data Administratin Clerk at WHH Infectin Preventin and Cntrl Team Activity The IPCT meet regularly with attendance frm Micrbilgy, IPCD, Pharmacy, Decntaminatin Lead and members f the nursing teams (as deemed relevant and apprpriate) attend when pssible t discuss clinical issues. The regular agenda items fr meetings are: Clinical items: MRSA C. difficile Incidents and utbreaks Plicy review prgramme Audit prgramme Central line infectins Hspital acquired pneumnia s Surgical site infectin surveillance Implementatin f infectin preventin and cntrl initiatives AOB Issues discussed at the IPCT meetings may be included n the Infectin Preventin and Cntrl Cmmittee agenda as necessary. The DIPC prvides an update t the Bard quarterly. The IPCT: Prvides specialist advice, frmulates, mnitrs and evaluates the implementatin f plicies, including the Majr Outbreak Plicy. Ensures the use and incrpratin f evidence-based practice in the writing and reviewing f plicies. Are respnsible fr the daily management and advice n Infectin preventin and cntrl clinical cases and incidents. They advise EKHUFT at a strategic level n service and building develpments which will impact n infectin preventin and cntrl. Prvide educatin t all staff n infectin preventin and cntrl. Develp and cmplete a prgramme f audit relating t infectin preventin and cntrl. An Infectin Preventin and Cntrl Team Annual Plan is prduced by the DDIPC which includes educatinal, audit and surveillance activities. The DIPC Annual Reprt is circulated t all the members f the Infectin Preventin and Cntrl Cmmittee (IPCC). The IPCT will identify requirements fr additinal resurces t supprt and prmte infectin preventin and cntrl practices. The IPCT Terms f Reference will be reviewed annually by the Infectin Preventin and Cntrl Team. V.1 Page 5 f 21 June 2017

6 3. Develpment Prcess This Annual Prgramme has been develped by the DDIPC, and then distributed t all Members f the Infectin Preventin and Cntrl Cmmittee (Appendix 1). 4. Rles and Respnsibilities The Chief Executive Officer, the DIPC and the Bard have the ultimate and cllective respnsibility fr ensuring that the imprtance f the preventin and cntrl f infectin is engendered in all staff. They must ensure that the prcesses and necessary resurces are available t allw fr effective preventin and cntrl f Infectin. The DIPC advises n the measures necessary fr the preventin and cntrl f Healthcare Assciated Infectins. Clinical Directrs and prfessinal leads ensure that mnitring f clinical practice is relevant t the cntrl f all HCAIs and is undertaken rutinely, that results are mnitred and actin taken as apprpriate. They must als ensure that all staff within their teams attend training, cmply with infectin preventin and cntrl plicies and practices, and clinical areas participate in apprpriate audits as recmmended by the Infectin Preventin and Cntrl Team/Cmmittee. Clinical staff: t attend annual infectin preventin and cntrl cntinuing educatin sessins; t cmply with practice recmmendatins at all times. Nn clinical staff: t cmply with standard infectin preventin and cntrl practice recmmendatins at all times. Infectin Preventin and Cntrl Team: The Infectin Preventin and Cntrl Team are respnsible fr prducing and updating all IPC plicies. They are als respnsible fr prviding expert supprt and advice n infectin preventin and cntrl issues. The IPCT will ensure apprpriate training and supprt n infectin preventin and cntrl issues are available fr staff. They will als prvide training t enable clinical staff t carry ut relevant infectin preventin and cntrl audits in their clinical areas. Peridically the IPCT will als perfrm audits and/r surveys n the wards and ther clinical areas. If audits, surveys r rutine surveillance data identify any areas f cncern, the IPCT will feed these back t the lcal Infectin Preventin and Cntrl Lead and ther relevant staff. In the event f an utbreak, IPCT will set up an Outbreak Cmmittee and will advise n any additinal prcedures which are required. 5. The Infectin Preventin and Cntrl Cmmittee (IPCC) The EKHUFT Infectin Preventin and Cntrl Cmmittee (IPCC) is a multidisciplinary Trust cmmittee which includes Divisinal Infectin Preventin and Cntrl Leads and external representatin frm the Kent, Surrey and Sussex Public Health Team (Public Health England) and the Infectin Preventin and Cntrl Leads frm Canterbury, Ashfrd, Suth Kent Cast and Thanet Clinical Cmmissining Grups. The IPCC versees the activity f the IPCT, supervises the implementatin f the Infectin preventin and cntrl Annual Prgramme, reviews Divisinal cmpliance with the Key Perfrmance Indicatr Targets, and hlds the Divisins t accunt as required. Arrangements are currently being discussed t prmte greater medical engagement frm the Divisins. The IPCC will cntinue t meet bi-mnthly during , and will be chaired by the Chief Nurse. V.1 Page 6 f 21 June 2017

7 6. Key Areas f Infectin Preventin and Cntrl Activity The restructuring f the IPCT fcus is t assist, supprt and advise n measures that supprt the Trust cmpliance with the Cde f Practice (Health and Scial Care Act 2008) and t enhance the quality f care ffered t patients and demnstrate the reductin in the risks f acquiring HCAIs. Divisinal wnership and accuntability Perfrmance management in prmting Divisinal wnership and accuntability fr infectin preventin and cntrl will cntinue t be a key fcus during 2017/18. Divisinal Infectin Preventin and Cntrl Key Perfrmance Indicatr (KPI) primary fcus cntinues t be the management f C. difficile, MRSA and invasive devices, and CPOs as well as achieving full cmpliance with the requirements f the Cde f Practice. Mre Divisinal engagement will be required during 2017/18, particularly with regard t the RCA/PIR prcess fr cases f MRSA and C. difficile infectin. The IPCT have a high prfile in the clinical areas with regular visits t these areas t mnitr the cmpliance with effective islatin f patients, current practices and plicy implementatin. Daily - The IPCT react t ntificatins f infectins frm the labratry system thrugh VitalPAC. These are checked fr new and existing cases. On identificatin f new cases the IPCT cllect the demgraphic data n the patient and cmplete the apprpriate case infrmatin n the system. The clinical sites will be visited and/r phned (if a visit is nt pssible), cmmunicatin and advice given will be added t the patient electrnic recrd relating t prviding care pathways, patient infrmatin leaflets, islatin precautins and apprpriate treatment. Once per week The IPCT visit every inpatient area t review patients knwn t the service, prvide advice r infrmatin t staff n any existing patients nt knwn t the service. Once per mnth - the IPCT will liaise and wrk with the ICLPs incrprating educatinal sessins and review f audits which address lcalised Infectin preventin and cntrl issues. Once per year the IPCT will carry ut an envirnmental audit, write up the reprt, discuss real time cncerns and feedback timeline fr revisit where necessary; this is in additin t the envirnmental audits that are undertaken by the Senir Matrns. As required Telephne advice r visits t wards t deal with any clinical queries. This als includes the management f infectin preventin and cntrl incidents, perids f increased incidence (PII) and utbreaks. When required - the IPCT will discuss and advise n the apprpriate islatin f cases, supprt fr staff, cntact tracing, investigatin f surces/reasns fr utbreaks and planning f apprpriate actins. 7. Plicy/Guideline Develpment The plicies fr infectin preventin and cntrl underg regular review. The plicies are evaluated and up-dated fllwing risk assessment, and as new guidelines r evidence becme available, r alternatively every 2 years as stated in the Organisatins Plicy n Plicies, Standards, Prtcls and Guidelines. There is a planned prgramme fr the review f infectin preventin and cntrl plicies. Every clinical area has electrnic access t a cpy f the Infectin Preventin and Cntrl Manual cntaining the plicies. The IPCT are als invlved in advising departments n their individual plicies. 8. Audit Activities There is an annual audit prgramme f Infectin Preventin and Cntrl/Envirnmental audits in cnjunctin with the Husekeeping services, nursing and Allied staff. Every area is audited annually with a fllw up meeting arranged 6 weeks later t check n actin pints. V.1 Page 7 f 21 June 2017

8 There is an audit f cmpliance with key plicies/practice areas. The planned audit prgramme is part f the IPCT actin plan. An audit reprt and actin plan is prepared by the IPCT, presented t the IPCC n a quarterly basis and agreed with the cmmittee members - nce agreed this is then distributed t the key peple invlved. 9. Surveillance Activities Fr 2017/18 Surveillance f alert rganisms will cntinue and include the fllwing: Methicillin Resistant Staphylcccus aureus (MRSA) Methicillin Sensitive Staphylcccus aureus (MSSA) E. cli (E. cli) Streptcccus pygenes Mycbacterium tuberculsis Resistant Acinetbacter Glycpeptide Resistant Entercccus (GRE) Extended spectrum beta lactamase prducing Klebsiellae (ESBL s) Carbapenemase-prducing rganisms (CPO) All cases f MRSA bacteraemia will cntinue t be reprted internally via Datix. Mandatry surveillance f Staphylcccus aureus including Meticillin Resistant Staphylcccus aureus (MRSA) bacteraemia will cntinue. MRSA bacteraemia epidemilgical data will be reprted n a mnthly basis t all wards/departments as well as t the Executive Team, CCGs, Divisinal Infectin Preventin and Cntrl Leads, Matrns, Ward/Department Managers, Clinical Service Managers, Cnsultants and Junir Dctrs. The IPCT will cntinue t lead n all Pst Infectin Reviews (PIRs) (t be held within 14 wrking days f receipt f cnfirmatin f the prvisinal assignment frm PHE) regardless f whether the case has been prvisinally assigned t the Trust r ne f the CCGs. Greater engagement will be required frm the Divisins during 2017/18 with regard t cmpletin f the preliminary investigatin as part f the RCA and PIR prcess; this will be undertaken by the Ward Manager/Divisinal Matrn in cnjunctin with the IPCT. The Ward Manager/Divisinal Matrn must assist with arranging the PIR Meeting and will be required t present the case at the PIR meeting, which will be chaired by the site-based IPC Clinical Nurse Specialist. The PIR Meeting will be held within 14 wrking days f cnfirmatin f the bacteraemia and prvisinal assignment frm PHE. Attendees will be: the Ward Manager r Ward Sister/Charge Nurse Divisinal Matrn(s) Divisinal Head f Nursing the patient s Medical Cnsultant/Registrar Site based Cnsultant Micrbilgist CCG Head f Infectin Preventin and Cntrl Antimicrbial Pharmacist. Cmpletin f the PIR actin plan, ensuring that all actins are signed ff as cmplete within a specified time-frame, will be mnitred by the IPCT in cnjunctin with the Senir Divisinal Matrn and the Head f Nursing. V.1 Page 8 f 21 June 2017

9 The IPCT will review all PIRs undertaken fr cmpletin f actins verall; where these have nt been cmpleted, this will be escalated t the Divisinal Head f Nursing and Divisinal Medical Directr by the DIPC. The Ward Manager and Divisinal Matrn will be required t present the PIR at the IPCC. The Divisinal Head f Nursing and Divisinal Medical Directr will be required t ensure that learning frm PIRs is shared acrss the Divisin and that the PIR is reprted via the Divisinal gvernance framewrk. Reviews f individual MRSA clnised inpatients and review meetings fr any declaratin f an MRSA Perid f Increased Incidence (PII) where there are 2 r mre cases f MRSA acquisitin n a ward with a calendar mnth (patients with n previus histry f MRSA) - will be held in cnjunctin with the Ward Manager and the Divisinal Matrn. These Meetings will be reprted in the Infectin Preventin and Cntrl Mnthly Reprt t the Divisins and at the IPCC. Cmpliance with the management f invasive devices will cntinue t be reprted via the VitalPAC Indwelling Devices Reprt, which is submitted t the IPCC. The Clstridium difficile target fr 2017/18 is 46 cases. Rt Cause Analysis fr all cases f hspital acquired Clstridium difficile infectin will cntinue. Cases will cntinue t be deemed as avidable/unavidable and cmpliant/nn-cmpliant, and the justificatin fr these decisins will be clearly recrded. A prvisinal decisin as t whether r nt there has been a lapse f care will be made at the RCA, and frmally agreed at the CCG Task and Finish Grup, which meets bi-mnthly. Failure t apprpriately assess patients using the existing Diarrhea Assessment Tl has led t the IPCT develping and implementing a revised assessment Tl, and will supprt the Ward Managers and Matrns in ensuring that staff understand and are cmpetent with this prcedure. In additin t the abve, the IPCT will ensure that staff fully implement the C. difficile Patient Management Plan fr patients wh are diagnsed with GDH antigen r txin psitive C. difficile infectin. The IPCT will liaise with the CCGs and the IPCT fr Kent Cmmunity Health NHS Fundatin Trust regarding pre-72 hur cases f C. difficile as apprpriate if there are links t EKHUFT. The ward manager will carry ut cmpletin f a Datix Incident Reprt fr all > 72 hur C. difficile txin psitive cases. The Divisinal Matrn will be the nminated investigatr, supprted by IPCT. Once a mnth, the IPCT will identify whether any patients with knwn C. difficile infectin (pre and pst 72 hur cases) have died, and review the death certificate. Fr pst-72 hur cases, in the event that C. difficile is recrded n part 1a f the Death Certificate, the IPCT will liaise with the Clinical Risk Department regarding whether r nt this meets the criteria fr reprting n STEIS. Fr pre-72 hur cases, the IPCT will infrm the apprpriate CCG Chief Nurse and Quality Lead, wh will reprt the patient s death as apprpriate within their rganisatin. A Rt Cause Analysis meeting may be held, attended by the IPCT, if the patient was an inpatient within EKHUFT. A Perid f Increased Incidence will be declared in the fllwing circumstances: 2 r mre cases f C. difficile infectin ccurring > 72 hurs pst admissin n a ward within 28 days; where initial ribtyping identifies the same strain, a Serius Untward Incident (SUI) will be reprted pending enhanced finger printing. Shuld this then identify that the islates are indistinguishable, the IPCT will cnclude that crss-infectin has ccurred, and the incident will be reprted as an Outbreak as per DH guidelines (DH, 2008); 2 r mre cases f C. difficile infectin in patients with the same Cnsultant; V.1 Page 9 f 21 June 2017

10 2 r mre cases f GDH antigen acquisitin ccurring > 72 hurs pst admissin within 28 days; there is a burden f C. difficile infectin and GDH carriage at any time (these may be pre r pst 72 hur cases), which in itself increases the risk f a C. difficile cluster/utbreak; where a PII has been declared fr 2 r mre cases f C. difficile infectin ccurring > 72 hurs pst admissin within 28 days, the Ward Manager and the Divisinal Medical Lead, will be required t present the PII at the next Infectin Preventin and Cntrl Cmmittee meeting; ribtyping f C. difficile txin psitive islates will cntinue t be undertaken fr > 72 hur cases t distinguish between spradic cases and utbreaks; audit f antibitic prescribing in wards where there has been a PII t be requested by the DIPC; cleaning will be reviewed by the site-based IPCT as part f the RCA preliminary investigatin; envirnmental and clinical practice standards audits revisited by wards experiencing 2 r mre cases in a 28 day perid plus enhanced supprt frm the IPCT; the prgramme f actins fr individual cases f C. difficile will be carried ut by the IPCT as described in the revised Trust Plicy fr Preventin, Cntrl and Management f C. difficile. E. cli bld stream surveillance Mandatry surveillance f E. cli bld stream infectins cntinues t be undertaken within EKHUFT by the IPCT. MSSA bldstream surveillance RCAs will be undertaken in cnjunctin with the Divisins fr all cases f MSSA bacteraemia ccurring within 30 days f surgery, r where they are assciated with an intravascular access device. Internal surveillance reprting Mandatry surveillance f C. difficile will cntinue and C. difficile epidemilgical data will cntinue t be reprted n a mnthly basis t the Executive Team, all wards/departments, Matrns, Ward/Department Managers, Cnsultants and Junir Dctrs. An utbreak f C. difficile infectin will be called if there are 2 r mre cases caused by the same strain related in time and place, ver a defined perid that is based n the date f nset f the first case (DH, 2008), and reprted as Serius Untward Incidents via the Clinical Risk Department. The DIPC will cmpile a register f all deaths ccurring within 30 days f a C. difficile diagnsis and reprt the mrtality rate t the Patient Safety Bard. Any rise in mrtality in cmparisn with the baseline will require investigatin t rule ut acquisitin f a hypervirulent strain (e.g. O27) and ensure that apprpriate multi-disciplinary management has taken place. All NHS Trusts where rthpaedic surgical prcedures are perfrmed are expected t carry ut a minimum f three mnths surveillance in at least ne f the fur rthpaedic categries. Ttal hip replacements Knee replacements Hip hemiarthrplasties EKHUFT cmplete surveillance in the 3 categries. V.1 Page 10 f 21 June 2017

11 Systems will cntinue t be strengthened between the Trauma and Orthpaedic Divisin, particularly at WHH, and the IPCT t ensure that the surveillance results are used t maximum benefit with regard t service imprvement as apprpriate. 10. Antibitic Management The Antimicrbial Stewardship and Management are undertaken by the Lead Antimicrbial Pharmacist in cnjunctin with Micrbilgy, the Infectin Preventin and Cntrl Dctr and IPCT. Mnthly audit reprts f antibitic usage by each Divisin will be extracted frm the Pharmacy databases each mnth and sent t the mnthly Divisinal Gvernance Bard meeting. The Lead Antimicrbial Pharmacist will attend these meetings. Implementatin f the antimicrbial stewardship prgramme will incrprate and reprt n activity relating t: Educatin sessins fr medical staff Daily antimicrbial stewardship ward runds (review f all patients n restricted antibitics) Audit 3 day review f antibitics as per DH START SMART THEN FOCUS initiative Participatin in Eurpean Antibitic Awareness Day Submissin f Antibitic Stewardship CQUIN data t PHE. 11. Audit The Cde f Practice (2008) requires that there is a prgramme f audit t ensure that key plicies are being implemented apprpriately. The IPCT will undertake r cmmissin the fllwing audit prjects (with apprpriate supprt frm the Trust Clinical Audit Department and external agencies): Title Frequency LEAD Audit Areas Sharps management audit Annual IPCT Trust wide Fllw-up audit in rder Envirnmental and Clinical Practice Standards audits Undertaken within 6 mnths f the initial audit Wards will be audited annually; departments will be audited every 18 mnths IPCT in cnjunctin with Ward/ Department Managers r IC Link Practitiners T review areas where there were nncmpliances Trust wide Results f > 5 nncmpliances in ne r bth standards are entered nt an Infectin Preventin and Cntrl Risk Register. A letter is sent t the Divisinal Head f Nursing. Audits will be reprted at the IPCC. Ward/ Department Managers will be required t submit an actin plan addressing nncmpliance this must V.1 Page 11 f 21 June 2017

12 Cmmde audit Cmmde cleanliness audits (relevant wards/departments) Repeat audits Mattress/zipped item check (Mnthly) Annual Weekly As apprpriate if cncerns raised in annual audit Mnthly As apprpriate if cncerns raised in annual audit IPCT with Gama Healthcare IPC & Nursing Teams be mnitred by the Divisin Trust wide Cncerns will determine reaudit i.e. cnditin, cleanliness and mnitring f the replacement prgramme Trust wide Cncerns will determine reaudit i.e. cnditin, cleanliness and mnitring f the replacement prgram Cntinuus real time cmpliance mnitring will be carried ut n the fllwing: MRSA screening cmpliance within 24hrs f admissin/preassessment Mnthly Ward managers Trust wide as apprpriate Re-screening cmpliance fllwing MRSA declnisatin as per Trust plicy MRSA islatin/chrting as per Trust plicy Mnthly Ward managers Trust wide as apprpriate Mnthly Ward managers Trust wide as apprpriate Bare belw the elbw and hand hygiene cmpliance Implementatin f High Impact Interventins (DH 2005) (included in KPIs) - Peripheral intravenus cannula (insertin and cntinuing care) Central Venus Catheter insertin and cntinuing care Temprary dialysis catheter Insertin and cntinuing care Urinary catheter insertin and cntinuing care Cmpliance with antimicrbial prphylaxis prescribing in surgery frmal audit f prescribing Cmpliance with antimicrbial prescribing fr acute infectins in medicine Weekly Ward managers Trust wide On insertin and whilst in situ On prescribing On prescribing Ward managers Pharmacy/ Micrbilgy Pharmacy/ Micrbilgy Trust wide as apprpriate (VitalPAC Indwelling Device Reprt) The insertin and management/nging care f these devices will be recrded and mnitred thrugh VitalPAC Surgical Divisins Trust wide All Divisins Trust wide Antibitic stewardship runds Daily Micrbilgists and antimicrbial pharmacists Trust wide Pharmacy will prepare daily lists f restricted antibitic scripts fr review n stewardship runds V.1 Page 12 f 21 June 2017

13 12. The HOUDINI Prtcl The HOUDINI Prtcl, t reduce the incidence f urinary catheters within EKHUFT and the assciated risk t patients f develping a catheter-assciated urinary tract infectin (CAUTI), will be mnitred t ensure embedded acrss the Trust 2017/18 and includes: Use f the HOUDINI Prtcl fr the insertin and remval f urinary catheters, including all assciated dcumentatin (i.e. Urinary Catheter Guidelines; Bladder Scanning Prtcl; Trial withut Catheter Prtcl). Use f the Urinary Catheter Passprt fr all patients with a urinary catheter within EKHUFT. Urinary catheter care infrmatin will cntinue t be captured via VitalPAC 13. Educatinal Activity The Cde f Practice requires: that relevant staff, cntractrs and ther persns whse nrmal duties are directly r indirectly cncerned with prviding care, receive suitable and sufficient infrmatin n, and training and supervisin in, the measures required t prevent and cntrl the risks f infectin. All staff receive infectin preventin and cntrl educatin in the frmat f a mandatry e-learning package which incrprates evidence based infectin preventin and cntrl guidelines. Sft Facilities Management cntract staff and Estates staff are als required t undertake inductin and annual mandatry training including a cmpetency assessment, currently delivered by DVD. Trust wide cmpliance n mandatry training is reprted t the Trust Bard as part f the Quality and Patient Safety Reprt. All junir dctrs receive a shrt inductin sessin prvided by the IPCT. As part f inductin, all junir dctrs als underg mandatry training and assessment f cmpetence n the insertin f peripheral venus cannulae and phlebtmy skills including the taking f bld cultures (prvided by the Vascular Access Team in cnjunctin with the IPCT) and hand hygiene training. Participatin in the F1 Junir Dctrs prgramme includes antibitic prescribing and the rle f the micrbilgy labratry in the diagnsis f infectin. IPC Inductin fr medical students. Ad hc sessins fr the Divisins and departments. Infectin Preventin and Cntrl educatin fr newly qualified nurses attendance at the Preceptrship Cnference run by the Practice Develpment Nurses Management f the Acutely Ill Patient (as part f the in huse training curse). 14. Infectin Preventin and Cntrl Link Practitiners Cntinue t develp the Link Practitiner Prgramme thrugh educatin and supprt f the Link Practitiners. Prvide site-based educatin sessins/ipc Link Practitiner (IPCLP) Cntinue t invlve Link Practitiners in the annual IPC audits f Envirnmental and Clinical Practice Standards. V.1 Page 13 f 21 June 2017

14 Prmte/mnitr practical hand hygiene assessments f clinical healthcare wrkers, including medical staff, by Link Practitiners t ensure that all clinical health care wrkers have their hand hygiene cmpetency assessed annually. 15. Hand Hygiene Campaign The IPCT will cntinue t prmte effective hand hygiene: Include hand hygiene in all teaching sessins (inductin etc). The IPCT will prvide supprt, as required, t Divisins wh are underperfrming with regard t hand hygiene audit results. Prvide training sessins n undertaking hand hygiene audits apprpriately t relevant staff. Undertake annual practical hand hygiene assessments fr IPCLPs and issue them with an electrnic Certificate f Cmpetency, in rder that they can undertake practical hand hygiene training fr staff wrking within their clinical areas. Cmpliance is electrnically recrded. 16. Leginella Management and Mnitring The IPCC will mnitr cmpliance with Best Practice fr cntrl f Leginella as utlined in the HSE Apprved Cde f Practice fr cntrl f Leginella in healthcare premises (L8) and HTM 04. The IPCC verview f cmpliance will include: Quarterly reprt n cmpliance with the Trust Leginella Cntrl Plicy. Annual Review f the Leginella Risk assessments in cllabratin with Estates, fr each Hspital Site. Review f all Estates actins in respnse t psitive Leginella Cultures. Estates reprting f the mnitring ht and cld water systems supplying high risk patients fr Leginella clnisatin in accrdance with L Hspital Hygiene The IPCT will prvide supprt/advice t htel services/cntractrs as required as well as advising n dayt-day issues. 18. New Builds, Site Develpment, Re-cnfiguratin f Clinical Services/Decant and Deep Clean Prgrammes The IPCT will advise n all new develpments/recnfiguratin prjects relating t service and buildings within the Trust based n natinal guidelines and best practice. The IPCT will wrk with the Hspital and Facilities Managers n the develpment/implementatin f site-based decant prgrammes t facilitate refurbishment wrks and deep-cleans f wards. 19. The Duty f Candur The Duty f Candur Regulatins (CQC Regulatin 20) as they apply t IPCT fr C. difficile and MRSA bacteraemia cases, all ther incidents whereby a Datix wuld be raised are cntinuing. V.1 Page 14 f 21 June 2017

15 20. Wrking with the CCGs Supprting the Wider Healthcare Ecnmy The IPCT wrks clsely with the CCGs t supprt the preventin and cntrl f healthcare assciated infectins acrss the wider healthcare ecnmy as apprpriate. This includes active membership f the Kent-wide HCAI Assurance Panel and the HCAI Imprvement Frum. EKHUFT perfrmance with regard t HCAI preventin and cntrl will be mnitred by the Cmmissiners via cmpliance with IPC Quality Metrics (see Appendix 1). 21. Prmtinal Campaign Wrk The IPCT aim t raise staff awareness n infectin preventin and cntrl issues. This will be dne in varius ways: Hand hygiene awareness weeks (at least annually) Articles in the staff magazine Prductin f a web page and blg Cntinuus campaigns relating t the cncerns/issues and infectin/disease themes Presentatins t varius members f staff and public n infectin preventin and cntrl Flu vaccinatin mnth. Prmtinal and campaign wrk will be cnstantly under review by the IPCT in line with current clinical issues. The IPCT wrks with public and service users and expansin f this wrk is planned. Infrmatin available t the public in pre-assessment clinics and n admissin will be cntinually reviewed. One f the IPCLPs will be a member f the Patient Experience Grup and will wrk clsely with sme vlunteers frm the Patients Panel n patient infrmatin. 22. Service Cver and Business Cntinuity The DIPC and DDIPC plan leave, t ensure that ne staff member is always available fr service cver. The DIPC c-rdinates leave with the Micrbilgists t ensure that there is infectin preventin and cntrl dctr cver available at all times. The IPC Clinical Nurse Specialists leave is arranged t ensure that, there is n mre than ne f the team n annual leave at any ne time. A Business Cntinuity Plan has been develped t prvide a clear management prgramme in the event f any majr incident/pandemic situatin ccurring. 23. Management f Outbreaks f Infectin The IPCT will lead n the management f utbreaks f infectin/cntact tracing exercises where indicated (i.e. clusters/utbreaks f ESBL clifrm clnisatin/infectin; carbapenemase-prducing rganisms; mupircin-resistant MRSA; respiratry tuberculsis requiring cntact tracing f staff and patient cntacts). This will invlve clse wrking with the Divisinal Matrns, Heads f Nursing and Medical Directrs, as well as the lcal Public Health Team (Public Health England) and the Clinical Cmmissining Grups. Such incidents will be reprted as a clinical incident via Datix and will be reprted at the IPCC and in the Infectin Preventin and Cntrl Annual Reprt t the Trust Bard f Directrs. V.1 Page 15 f 21 June 2017

16 24. Respnse t Disease Threats The IPCT will respnd t lcal, natinal and internatinal guidance in relatin t emerging disease threats such as pandemic influenza and viral haemrrhagic fever ver the cming year, and wrk with the Emergency Departments t ensure that they are prepared. 25. Nrvirus Outbreaks The IPCT will cntinue t pay particular attentin t reducing the impact f Nrvirus utbreaks n the service by reviewing the plicy, embedding the prcess f aiding identificatin f Nrvirus and supprting staff in the management f cases. V.1 Page 16 f 21 June 2017

17 April 2015 March 2016 Appendix 1: EKHUFT Acute Trust Quality Metrics Ref. Lcal Requirement Reprted Health Care Assciated Infectins / Infectin Prtectin and Cntrl Reprting Perid Frmat Timing and Methd Gvernance Reprting Type 1.0 Infectin Preventin and Cntrl Annual Prgramme and Annual Reprt April 17- March 18 Annual IPCT Prgramme T be sent t the CCG fr review at the end f Q1. Quarterly update r exceptin reprts. Annual reprt t g t Bard June/July, Annual prgramme t be reviewed at each IPCC meeting as agenda item. Presenting at the CQRG Written reprt Trust wide HCAI imprvement plans (i.e. MRSA bacteraemia Actin Plan; C. difficile Actin Plan; PIR and RCA actin plans) MRSA screening f eligible patients in line with lcally agreed plicy (10 patients selected at randm frm 1 ward per hspital site per mnth) Pre 48 hr cases f MRSA bacteraemia t be reprted t the CCG the next wrking day the psitive result April 17 - March 18 Mnthly April 17 - March 18 Imprvement/ Actin plans Mnthly audit f cmpliance with MRSA Screening plicy (screening within 24 hurs f admissin / every 7 days) CCG t receive ntificatin f all incidence f MRSA (including HCAI DCS unique ID cde) the next wrking day via secure . T be sent t the CCG fr review at the end f Q1. Quarterly update r exceptin reprts. HCAI imprvement plan, C. diff actin plan, currently n frmal sign ff when cmplete. CCG t have sight ff the reviewed actin IPCC. Als detailed actin lgs frm PIR/RCAs t g t HCAI assurance panel / Task & Finish grup. Mnthly audit t be included in IPC Reprt Presenting at the CQRG Presenting at the CQRG Written reprt Written reprt As they ccur Presenting at the CQRG V.1 Page 17 f 21 August 2015

18 5.0 Pst 48 hr cases f MRSA bacteraemia t be reprted t the CCG within 2 wrking days f the psitive result April 17 - March 18 CCG t receive ntificatin f all incidence f MRSA (including HCAI DCS unique ID cde) within 2 wrking days via secure . As they ccur Presenting at the CQRG 6.0 CCG t be invited t all pst 48 hur MRSA PIR meetings. April 17 - March 18 Crss reference against HCAI natinal database. As they ccur Presenting at the CQRG 7.0 T reprt cases f MRSA bacteraemia n STEIS fllwing cmpletin f the Pst Infectin Review Mnthly/as they ccur STEIS reprting t demnstrate penness and Trust wide learning Mnthly within SI reprt t CCG Presenting at the CQRG Reprt 8.0 C-diff reprting f all cases (pre 72 hur and pst 72 hur) within 2 wrking days f identificatin April 17 - March 18 CCG t receive ntificatin f all incidence f C-diff (including HCAI DCS unique ID cde) within 2 wrking days via secure . As they ccur Presenting at the CQRG Pst 72 hur C-Diff Rt Cause Analysis (RCA) In cnjunctin with the CCG, undertake an assessment f every cnfirmed pst 72 hur case f C. diff t determine if lapses in care cntributed t infectin. April 17 - March 18 April 17 - March 18 RCA t be shared with the CCG within 28 wrking days f specimen date. Assurance prcess t be defined t review the evidence demnstrating the assessment prcess, lessns learnt and actins implemented (Assurance Panel, meeting between CCG and Acute Trust) As they ccur Presenting at the CQRG As they ccur Presenting at the CQRG Meeting V.1 Page 18 f 21 June 2017

19 11.0 Perids f increased incidence (PIIs) f C. diff are reprted t the CCG as they ccur April 17 - March 18 Mnthly submissin identifying any PIIs. Mnthly Reprt Presenting at the CQRG Cnfirmed utbreaks f HCAIs where there is evidence f transmissin t be reprted as an SI (with the exceptin f Nrvirus utbreaks, which will be reprted in the Mnthly Reprt) Quarterly Mnthly submissin f HCAIs where there is transmissin, t demnstrate penness, Trust wide learning. Mnthly Reprt Presenting at the CQRG Reprt 13 All cases f E. cli bacteraemia assciated with surgery within the last 30 days, and all cases f MSSA bacteraemia ccurring within 30 days f surgery r assciated with a vascular access device, which require Rt Cause Analysis, and therefre requiring RCA t be reprted t the CCG Mnthly Cmpleted dataset submissin in required timescale. Mnthly reprt Presenting at the CQRG Reprt 14 Outcmes f RCA fr all cases f E-cli and MSSA bacteraemia ccurring within 30 days f surgery and/r assciated with a vascular access device, t be reprted t the CCG Mnthly Mnthly reprt n all E. cli and MSSA RCAs, t include details f the investigatins and what actins the Organisatin is taking t reduce incidence and identify specific learning Mnthly reprt Presenting at the CQRG Reprt 15 Outbreaks (excluding Nrvirus) and incidents f ther infectius diseases (i.e. TB cntact tracing exercise), and t cmplete investigatin reprts and actin plans. Mnthly Quarterly exceptin reprt n utbreaks (excluding Nrvirus) incidents f infectius diseases, t include details f the investigatins and what actins the Organisatin is taking t reduce incidence. Mnthly reprt Presenting at the CQRG Reprt V.1 Page 19 f 21 June 2017

20 16 Cmpliance with lcal antibitic plicies Quarterly Audit f cmpliance with the antibitic prescribing plicy and actin plans fr imprvement Quarterly Presenting at the CQRG Reprt 17 The rganisatin participates in awareness-raising prgrammes t supprt best practice in antimicrbial prescribing including Eurpean antibitic awareness day (EAAD) Annually Evidence and detail f participatin in annual reprt. Ttal number f staff audited Annually Presenting at the CQRG Reprt 100% cmpliance with prviders internal hand hygiene plicy. Mnthly Ttal number f staff in each f the abve areas bserved as cmplying with hand hygiene cmpliance. Mnthly reprt- Embedded in mnthly reprt Presenting at the CQRG Reprt Hand Hygiene training Mnthly Reprt t be brken dwn t staff categry per ward T prvide data in relatin t % f all relevant staff wh have undertaken relevant hand hygiene training. Actins t imprve cmpliance and fllw-up nn-cmpliance t be incrprated int HCAI Organisatin Wide Actin Plan Mnthly reprt Reprted at IPCC meeting Presenting at the CQRG Reprt V.1 Page 20 f 21 June 2017

21 Lcal mandatry IPC training prgramme is delivered as per lcally agreed plan fr each staff grup Evidence f preparedness in the event f any infectin preventin threat (e.g. Ebla, Pandemic Influenza etc.) Mnthly April 17 - March 18 T prvide a quarterly reprt brken dwn by % cmpliance by staff grup Directrate T prvide in relatin t % f relevant staff wh have undertaken relevant training in hand hygiene. T prvide evidence f the plicies and prcesses that have been implemented in respnse t any CAS alerts Mnthly reprt Annually r if there are any changes t natinal guidance Annual Reprt Presenting at the CQRG Presenting at the CQRG Reprt Plicy V.1 Page 21 f 21 June 2017