INFECTION PREVENTION AND CONTROL ANNUAL REPORT 2010/2011

Transcription

1 INFECTION PREVENTION AND CONTROL ANNUAL REPORT 2010/2011 INFECTION PREVENTION AND CONTROL COMMITTEE 1

2 Contents Page 1. Executive Summary 3 2. Pennine Care Infection Prevention & Control Strategy Roles and Responsibilities Policies 9 5. Service Level Agreements Care Quality Commission Visit Audits Incidents Training Health Care Associated Infections (HCAI) - MRSA, Clostridium Difficile, ESBL (Surveillance) and Outbreaks Antibiotic Prescribing Cleaning and Decontamination procedure Planning and Refurbishment Flu Vaccination programme References 19 Appendix A Board Level Agreement Appendix B Appendix C Appendix D Infection Prevention and Control Completed Action Plan April 2010 to March 2011 Infection Prevention and Control Environmental Audit Plan April March 2011 Infection Prevention and Control Action Plan April 2011 to March Appendix E Cleanliness Monitoring April 2010 to March

3 1. Executive Summary Pennine Care NHS Foundation Trust provides specialist mental health services in a variety of community and inpatient settings across Bury, Rochdale, Oldham, Stockport, Tameside and Glossop. As an NHS organisation the Trust is committed to reducing the incidence of Health Care Associated Infections (HCAIs). The report is for the period April 2010 to March It also includes the Infection Prevention and Control (IPC) plans which include the audit and training planned for April 2011 to March The report outlines the accountability arrangements for IPC in the trust. The text outlines the activities of the Trust relating to IPC that aim to minimise the risk of HCAIs including surveillance, audit, quality accounts, antimicrobial stewardship, policy development and review, incident reporting, education and training and the prevention and management of outbreaks. The trust has implemented a programme of activities to embrace new national initiatives and effectively prevent and control HCAIs across the trust. The Health and Social Care Act 2008 outlines a clear code of practice for IPC. Pennine Care strives to achieve excellence in all aspects of the code. The Trust registered with the Care Quality Commission against the code of practice for Safeguarding and Safety Outcome 8: Cleanliness and IPC. The Trust is also assessed against risk management standards set by the National Health Service Litigation Authority (NHSLA) at level 1. The successful management, prevention and control of infection is recognised by the Trust as a key factor in the quality and safety of care of inpatients/service users as well as ensuring a clean and well maintained environment which the Modern Matrons enforce in inpatient units, drug and alcohol and Child Adolescence Mental Health Service (CAMHS). The Board receives regular reports in relation to IPC via the medical Director who is the Director of IPC (DIPC) and the chair of the IPC Committee. There is a Board Level Agreement signed by the Chairman and Chief Executive (Appendix A). IPC incidents are reported via the risk management reporting system and root cause analysis is undertaken when cases of new MRSA, Clostridium Difficile or an outbreak occurs, these are reviewed and any action plans agreed and monitored by the Trusts Committees. 3

4 2. Pennine Care Infection Prevention and Control Strategy 2.1 Aim Introduction The Department of Health has published a number of guidance documents to help NHS trusts to plan and implement how they can prevent and control HCAIs. Winning Ways: Working together to reduce Healthcare Associated Infection in England (2003) and The Health and Social Care Act 2008 Code of Practice for the Prevention and Control of Health Care Associated Infections. Good management and organisation is crucial to establishing high standards of IPC. The systems for the prevention and control of infections associated with healthcare have to address leadership, management arrangements, design and maintenance of the environment and devices, provide application of evidence based protocols and practices for both users and staff and provide education, training, information and communication. Effective prevention and control of HCAI has to be embedded into everyday practice and applied consistently by everyone. Pennine Care is committed to reducing the risk of infections to a minimum through effective IPC practice. IPC will be embedded in everyday practice across the organisation. 2.2 Scope The IPC Strategy is concerned with the prevention of avoidable risks of infection and the control and management of all unavoidable risks of infection to patients, service users, visitors and staff. 2.3 Objectives To ensure that IPC is an integral part of the service delivery. To ensure that HCAIs are reduced to a minimum. To maintain compliance with all requirements of the Health and Social Care Act To ensure Pennine Care have policies and procedures in place to fulfil the requirements and comply to the Code of Practice for the prevention and control of HCAIs as outlined in the Health and Social Care Act (2008). To ensure compliance with risk management standards as part of NHSLA. 4

5 To work with other stakeholders to improve surveillance and to strengthen prevention and control of infection and communicable disease processes. To ensure information is available to patients and the public about the organisations general processes and arrangements for preventing and controlling HCAI (Health & Social Care Act 2008). To ensure decontamination across the Trust meets all the National mandatory requirements. To provide education and training on prevention and control of infection to ensure staff understand their responsibilities. To ensure prudent antimicrobial prescribing and reduce inappropriate prescribing of antimicrobials which can result in the spread of resistance. To ensure appropriate information is communicated relating to infection risk and outbreaks to all relevant parties. To work with the local Health Protection Agency (HPA) to ensure good IPC practices across the trust. To completed all Assurance frame work documentation to ensure compliance against the Health and Social care Act Roles and Responsibilities The Pennine Care Board and ultimately the Chief Executive carries responsibility for IPC. For day to day management this is delegated to the Medical Director who is the Director of IPC (DIPC). All managers and clinicians must ensure that the management of IPC risks are one of the fundamental duties. Every clinical member of staff must demonstrate commitment to reducing the risk of infection through good IPC practice. This will be implemented, monitored and evaluated through staff IPDR processes. Role of Director of Infection Prevention & Control (DIPC) The DIPC is responsible for monitoring and overseeing IPC policies and reports directly to the Chief Executive Officer and the Board. Role of Deputy Director Nursing & Integrated Governance The Deputy Director of Nursing & Integrated Governance deputises for the DIPC and manages the Clinical Nurse Specialists: IPC/Physical Health. 5

6 Role of Clinical Nurse Specialist: Infection Prevention & Control Nurse/Physical Health (IPCN). The IPCN provides a clinical service for the prevention, surveillance investigation and control of infection for Pennine Care. The IPCN will: Ensure timely advice on IPC is available to Pennine Care staff, Committees and the Board. Liaise with the Health Protection Agency (in collaboration with acute trust nurse) when dealing with Outbreaks. Be responsible for coordinating IPC audits, education and training, policy and strategy development and the production of relevant IPC reports and data such as the Assurance Framework for use within the Pennine Care to monitor and promote improvements in practice. Role of Infection Prevention & Control Champions The IPC Champions are responsible for promoting good IPC practice in their work area with their colleagues, patients/service users, relatives and the environment. Role of Matrons and Ward/ Service Managers Matrons and Ward / Service Managers are responsible for the environment ensuring that the day to day cleaning is being implemented to the highest standard and they have the authority to address issues directly with cleaning teams. Matrons / managers report into there local environmental meeting. It is the Matrons responsibility to report into the Trust Environment meeting and IPC Committee (IPCC). Weekly checklists must be kept by the ward managers. The Matrons and ward/service managers are responsible for ensuring the Champions are supported and performing their role, and have the appropriate time and resources to do this effectively. Role of the Infection Prevention & Control Committee The committee members are responsible for providing strategic advice and support to the directors, managers, clinicians and all staff on the implementation of IPC. The Committee monitors the progress of the annual IPC programme and strategy, IPC policies, procedures, guidance and Service Level Agreements (SLA), audit, cleanliness, education and root cause analysis. The committee develops and monitors action plans 6

7 and reviews the Environment and Cleanliness meeting reports from the Trust Boroughs. Role of Estates Management and Domestic Services Estates Managers and Domestic Services Managers should ensure that the environment and equipment they are responsible for are maintained to required standards in order to promote good IPC practice and ensure easy cleaning of clinical areas. The estates maintenance and facilities manager and domestic monitoring staff attend the monthly environment and cleanliness meeting with the estates facilities manager also reporting into the IPCC. Role of Service Directors/Service Managers Service Directors & Service Managers liaise closely with the IPCN to ensure IPC policies are effectively implemented and maintained. They should ensure: All staff understand clearly their responsibilities in respect of the IPC Policies. New staff are adequately inducted in respect of IPC procedures including decontamination of equipment relevant to their work base and their role. The required time is allocated for staff to attend IPC education sessions through the mandatory training program and other training sessions. All IPC risks are systematically assessed and any necessary improvements prioritized. Policies, procedures and guidance are readily available to staff. IPCN are consulted on IPC issues, including specialized advice i.e. purchasing of equipment and building projects. IPC is discussed as part of the staff individual personal development review. Promote IPC by leading by example therefore providing a safe environment for patients, visitors and staff. Role of the Learning and Development Team The Learning and Development Department ensure IPC is part of all induction and mandatory training programmes for staff. 7

8 Arrangements are in place for staff training to be effectively recorded and maintained in staff records. A system is in place for informing managers of their staff s noncompliance and non-attendance at mandatory training sessions. Role of Health Protection Agency (HPA) The HPA will provide services to support and enable Pennine Care to fulfill their health protection responsibilities. The HPA team will work with Pennine Care to advise and support IPC in IPC matters and attend the Trust IPC Committee (IPCC). Role of the Risk Management Team The risk management team will ensure IPC incidents are reported and recorded on the appropriate documentation and to the IPC Nurses. A robust system of risk management is in place with action and follow up to any incident occurring, reporting through the IPCC and the Risk and Clinical Governance Committee. All Staff All staff are responsible for ensuring that they follow good IPC practice at all times and that they are familiar with IPC policies, procedures and guidance relevant to their area of work. Staff have a duty to report breaches in good practice and take correct action as appropriate. Table 1. Membership of the IPC Committee Director of IPC (DIPC) Deputy Director of Nursing and Integrated Governance (Deputy Chair) CNS : IPC Patient Safety and Clinical Risk Manager Antimicrobial Pharmacist IPC nursing representative from Pennine Acute trust, Tameside & Glossop Foundation Trust and Stockport Foundation Trust. Estates Representation Medical Representation Lead Borough Representation Health Protection Agency Representation Matrons Representation Governance Manager Representation Lead Commissioning PCT IPC nurse representation 8

9 4. Policies The Core IPC Policy CL4 contains: Standard Precautions Education and Training Roles and Responsibilities Assurance Framework Information Available to Patients and Public Occupational Health Services Surveillance Audit & Monitoring IPC Guidance on Patients Who Have Died Notifiable Diseases Decontamination of Linen Definition & Explanation of Terms Other IPC Policies and Policies linked to IPC Hand Hygiene CL 69 Management of Scabies CL80 MRSA CL70 Clostridium Difficile CL71 Sharps Management and Inoculation Injuries CL77 Personal Protective Equipment CL76 Vaccination Storage CL79 Pandemic Flu CL34 Medical Devices Management CO16 Aseptic Technique CL78 Waste Management CO45 Isolation and Barrier Nursing Outbreaks CL75 Management and Prevention of Head, Body and Pubic Lice CL74 Specimens CL73 Flowers and Plants in IPC CL72 Venepuncture CL27 Dress & Uniform Policy HR24 Cleaning Policy CO69 Death of a Patient CL65 Medicines Policy CL15 Food Safety CO37 COSHH CO32 Health & Safety CO9 Latex CL30 Cleaning, maintenance, audit and replacement mattress policy CL86 The specific IPC policies were updated and approved by the board in September

10 5. Service Level Agreements (SLA) The service level agreements continue with the 3 Acute Hospital Trusts Pennine Acute NHS Trust provides specialist IPC services at Birch Hill Hospital in Rochdale, the Royal Oldham Hospital, and Fairfield General Hospital in Bury. Tameside & Glossop Foundation NHS Trust provide specialist IPC services at Tameside General Hospital. Stockport Foundation Trust provides specialist IPC services at Stepping Hill Hospital and the Meadows in Stockport. The service is provided by IPC Teams based at each hospital site, comprising of Microbiologists and Specialist IPC Nurses. Under the SLA s the team should provided the following range of services to Pennine Care staff and patients. All wards and departments have contact information for IPC Teams in there area (e.g. office address, names & contact numbers and pager numbers). Telephone advice, to facilitate safe working practices in relation to IPC. Training and Education in all aspects of IPC. Induction Training for all new Pennine Care staff within Pennine Care Corporate Induction Programmes, usually provided by Pennine Care IPCN. Clinical Outbreak Management. Patient management of infections as notified by the microbiology laboratory. Monitoring and reporting HCAIs. Including MRSA, Extended Spectrum Beta Lactase (ESBL) and Clostridium Difficile. Staff management of infections as notified by the microbiology laboratory in conjunction with the Occupational Health Department Ward Auditing is undertaken by Pennine Care. Access to Acute Trust Policies 10

11 Literature (Posters, Leaflets etc) currently provided by Pennine Care IPCN. 6. Care Quality Commission Visit An inspection took place on 16 th and 17 th December 2009 in relation to the Trusts compliance against the Code of practice on Health Care Associated Infection s. Of the 15 measures inspected. No area of concern was seen in 12 and 3 needed improvement. The findings included: The need to audit the cleanliness of equipment. The need to ensure that staff are trained to clean equipment effectively. Review the use and organisation of store rooms. The Trust was re-visited in relation to IPC by the Care Quality Commission in February 2010 and given a clean bill of health. During the last 12 months there has been an improvement in all areas of the Trust regarding cleanliness and the environment and IPC. Incidents are down, last years we had 22 sharps injuries which was similar to other Mental Health trusts this year we had 9. Cleanliness scores now all average over 90% which is compliant with environment and equipment standards set in the assurance framework. The Trust PEAT scores for the environment have shown an improvement with five areas now scoring excellent. Infection rates have remained stable. All wards now have cleaning schedules for clinical areas and equipment, which are monitored by the ward/ service managers, and staff have a greater understanding of the importance of IPC. Estates HCAI action plan has meant wards have had flooring changed, new furniture, mattresses, bedding and curtains making the ward and clinic areas easier to maintain the high standards now set. The Deputy Director of Nursing & Integrated Governance along with the IPCN has done spot checks on wards in the Trust over the last 12 months. Staff and patients are asked about the environment and if anything can be improved. A verbal report is fed back to the nurse in charge of the ward and service manager if available on the day of the visit. A written report is sent to the ward manager and matron with audit feedback and any actions picked up from the visit. This is an ongoing programme and visits are planned for the next 12 months to include patient representation and other directors. The action plan for IPC for was reviewed at each IPC Committee and was completed by March 2011 see Appendix B. 11

12 7. Audits The environment audits are completed on inpatient units every 6 months. See audit plan for the year, Appendix C. The audit report for July deemed all wards compliant with a rating of over 85% following the national scoring tool. In the audit plan, wards not audited in July had not opened and the day hospitals are audited once a year following national standards. Action plans were completed by ward managers and after 3 months these were reviewed by the IPCN and the Matrons and this was reported back to the IPC Committee. The audit was repeated in January by the Matrons to cover the depleted IPC team. The audit plan for the next 12 months is contained in the IPC action plan Appendix D Hand Hygiene Audits Hand hygiene audits have been completed every three months in accordance with the Assurance Framework and PEAT assessments. The audits follow the World Health Organisation 5 moments for hand hygiene and compliance has been good with 98% staff compliance. Mattress Audits Mattresses are checked and cleaned every time a patient is discharged from a ward then every 6 months the mattresses are unzipped and the inside of the mattress checked the results are reported, any damaged or stained covers are changed and any stained inner mattress is replaced. Many areas have received new mattresses in the last 12 months. Antimicrobial Audits These are completed every 3 months by the pharmacists and the compliance rate reported in the Assurance Framework the results are reported through the IPC Committee and the Drug and Therapeutic Committee. The new antimicrobial pharmacist is reviewing the audit tool. The IPCN and Antimicrobial pharmacist plan to do joint audits to look at the treatment of the infection and offer training to reduce the use of antibiotics Deloitte Independent Assurance Report on IPC The Trust commissioned an independent assurance report on IPC. The report gave substantial assurance to the Trust. 12

13 8. Incidents During the last 12 months sharps awareness and training on the safe use of sharps has been a high priority. The introduction of needle safety devices throughout the Trust has highlighted the need for safe practice. Incidents involving sharps and IPC have reduced considerably over the last year from 52 down to 26 Cause Code Apr 09 - Mar 10 Apr 10 - Mar IPC Incident Needlestick Injury Sharps - Disposal Sharps - Misc Spillages 1 0 Total Directorate Apr 09 - Mar 10 Apr 10 - Mar 11 Bury 4 1 Oldham 7 6 Rehabilitation & High Support 12 4 Rochdale 8 4 Specialist Services CAMHS 3 2 Specialist Services D&A 4 1 Stockport 8 3 Tameside & Glossop 6 5 Total Bury Oldham Rehabilitation & High Support Rochdale Specialist Services CAMHS Specialist Services D&A Stockport Tameside & Glossop Apr 09 - Mar 10 Apr 09 - Mar 11 IPC/Sharps/Needlestick Incidents By Directorate 13

14 9. Training Pennine Care continues to be a member of the NPSA Clean Your Hands Campaign, this has contributed to the increased staff awareness regarding the importance of hand washing and annual training. All areas display the posters. The number of Pennine Care NHS Foundation Trust staff who have attended IPC training : Induction Mandatory Total The training plan for IPC is contained in the Action plan Appendix D 10. HCAIs MRSA, ESBL s & Clostridium Difficile (Surveillance) The Department of Health requires mandatory surveillance and reporting of some types of infection, including MRSA bacteraemia, Clostridium Difficile and Extended Spectrum Beta Lactamase (ESBL) Producing E. Coli. Pennine Care is complying with this requirement through Service Level Agreements with 3 General Acute Trusts, who provide monitoring and reporting of all Health Care Associated Infections (HCAI) affecting patients in Pennine Care inpatient services. Pennine Care have had no MRSA Bacteraemias for April 2010 March Since January 2010 MSSA Bacteraemias now have to be reported the Trust have had none. All new MRSA skin infections, ESBL and Clostridium Difficile cases have a Root Cause Analysis performed by the IPC Nurses who then reported this to the IPC Committee. MRSA and Clostridium Difficile have individual policies to make it easier for staff to follow the correct procedure and staff are updated on standard precautions and cleaning of equipment to reduce the risk of cross infection. MRSA (skin colonisation) Borough No of new cases Last Year Bury 0 0 Oldham 0 0 Rochdale 1 2 Tameside 0 0 Stockport 0 1 Specialist Services Rehabilitation & High Support 1 0 Total

15 Clostridium Borough No of new Last Year cases Bury 1 1 Oldham 0 0 Rochdale 0 0 Tameside 1 0 Stockport 0 1 Specialist Services Rehabilitation & High Support 0 0 Total 2 2 ESBL Borough No of new cases Last Year Bury 0 0 Oldham 0 0 Rochdale 0 0 Tameside 0 0 Stockport 0 1 Specialist Services Rehabilitation & High Support 0 0 Total Other Infections - Which the IPCN was involved in advice Campylobacter -1 case reported in Rochdale Ramsey Hunt 1 case in Stockport Scabies 1 case in Rochdale. Lice 2 cases in Stockport. Tuberculosis 1 case in Rochdale 10.2 Outbreaks The following outbreaks of Diarrhoea & Vomiting were reported in Pennine Care inpatient facilities over the period 01 April March All outbreaks have a root cause analysis recorded they are then discussed at the IPC Committee. Pennine Care report Norovirus outbreaks to the Health Protection Agency via the web site. 15

16 BOROUGH No of new cases Last Year Bury 0 2 Oldham 1 1 Rochdale 2 3 Tameside 1 2 Stockport 3 2 Specialist Services Rehabilitation & High Support 2 1 Total Antibiotic Prescribing The Medical Director chairs the Drugs & Therapeutic Committee, which monitors the use of medicines across the Trust. Membership of the Committee includes colleagues from the Acute and Primary Care Trusts, ensuring that Pennine Care works collaboratively with partner organizations, and that agreed standards are applied consistently across the health economy. All prescribing of antibiotics within Pennine Care complies with standards of good practice observed within Primary Care and Acute Trusts. Antibiotic auditing has been implemented every 3 months to monitor the policies and guidelines for antibiotic prescribing is being followed. A new antimicrobial pharmacist was appointed at the end of last year and will be working closely with the IPCN. The auditing has shown there may be improvements that can be made and the IPCN and antimicrobial pharmacist are starting to look at improving the audit and improving practice. 12. Cleaning the Environment and Decontamination Procedure As Pennine Care is a Mental Health Trust, there is very little usage of invasive medical equipment, which would require decontamination through sterilization before reuse. The few exceptions to this would be equipment contained in emergency resuscitation, e.g. Laryngoscope blade. When required, decontamination is provided via service levels agreements with the Acute Trusts. However all equipment used for patient care must be cleaned and disinfected appropriately if it is not single patient use. Guidance on cleaning and decontamination procedures is included in the Trust Medical Devices Management Policy and the Cleaning Policy. In specific areas there has been an increase in domestic input to improve standards of cleanliness and Pennine Care has introduced our 16

17 own cleaning staff. These cleaners receive IPC training and report to the Estates Department. The Trust has an ongoing programme of cleanliness monitoring checks and all inpatient areas are checked on a monthly basis. A cleanliness report goes to the IPC Committee and any problems are highlighted and actions taken, to ensure a high standard of cleanliness continues. (See Appendix F) The IPCNs meet monthly with the Estates Maintenance and Facilities Managers, Modern Matrons and Domestic Monitoring Officer to discuss any cleanliness and environmental issues. The Matrons are on the wards regularly and walk around to assess the cleanliness and ward environment. The Matrons monitor the ward environments on a monthly basis with the Domestic Monitoring Officer. New procedures were introduced for monitoring cleanliness from March 2010 but it took until June to bed these procedures and processes in place. April and May scores were excluded from the PEAT assessment changing the average for this assessment. The cleanliness monitoring report does show a marked improvement by nursing staff in the cleaning and decontamination of medical devices/equipment. (Appendix F) 12.1 Deep Cleaning The deep cleaning programme is led by the Estates Department. All wards were deep over the last 12 months and any extra requests or wards following an outbreak of Diarrhoea and Vomiting received a deep clean Patient Environment Action Teams (PEAT Assessments) The assessments were undertaken in February 2011 and March The IPC nurse was part of the assessment team. PEAT Score 2011 Environment Score Food Score Privacy & Dignity Score Site Name Fairfield General Hospital Excellent Excellent Excellent Tameside General Hospital Excellent Excellent Excellent Royal Oldham Hospital Good Excellent Good Birch Hill Hospital Excellent Excellent Excellent Stepping Hill Hospital Good Excellent Excellent The Meadows (Old Age Psychiatry Unit) Excellent Excellent Excellent Heathfield House Excellent Excellent Excellent Stansfield Place Good Excellent Excellent 17

18 PEAT Score 2010 Environment Score Food Score Privacy & Dignity Score Site Name Fairfield General Hospital Good Excellent Excellent Tameside General Hospital Good Good Excellent Royal Oldham Hospital Good Excellent Good Birch Hill Hospital Good Excellent Excellent Stepping Hill Hospital Good Good Excellent The Meadows (Old Age Psychiatry Unit) Excellent Excellent Excellent Heathfield House Good Excellent Good Stansfield Place Good Excellent Excellent 13. Planning and Refurbishment During the last year a lot of the trusts buildings have been renovated and updated. The CNS: IPC/Physical Health is available for advice reequipment and the new building Infection Control in the Built Environment (NHS Estates 2001) is used regarding advice. 14. Flu Vaccination programme As part of our winter planning arrangements, Pennine Care undertook a programme of Flu vaccinations. Flu vaccinations were offered to all inpatients over 65 years who were not able to access this from their GP due to being in hospital, and also inpatient service users under 65 years who were considered to be at high risk, due to physical health problems. Flu vaccination was also promoted for residents of long stay Forensic & High Support Units. In most cases this was accessed via GP services. The Trust also promoted the uptake of Flu vaccinations for all relevant service users and staff across all community services areas. Anaphylaxis training was also offered to staff in each borough, as administration of a vaccine could not be given without this. 18

19 15. References Department of Health (2009) The Health Act 2008 Code of Practice for the NHS on the prevention and control of HCAIs and related guidance Care Quality Commission (2009) Practice Alert September 2009: Mattresses Department of Health (2003) Winning Ways- Working Together to Reduce Healthcare Associated Infection in England IPC Nurses Association (2004) Audit Tools for Monitoring IPC Standards Department of Health (2006) Essential Steps to Safe Clean Care Department of Health (2007) Essential Steps to Safe Clean Care. Inter healthcare patient infection risk assessment form Department of Health (2007) Saving Lives: reducing infection, delivering clean safe care. Isolating patients with healthcare associated infection. A summary of best practice Health Care Commission (October 2007) Investigation into outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS National Patient Safety Agency (2007) Cleanyourhands Campaign National Patient Safety Agency (2007) National Colour Coding Scheme for cleaning materials and equipment National Patient Safety Agency (2008) Patient Environment Action Teams Assessments National Patient Safety Agency (2008) Clean Hands Save Lives, Patient Safety Alert Second Edition 2nd September 2008 IPC Policies and Guidance Pratt R J et al (2006) epic2: National Evidence Based Guidelines for Preventing HCAIs in NHS Hospitals in England. Journal of Hospital Infection (2007) 65 (Supplement) S1- S6 Department of Health (2002) Infection Control in the built environment 19

20 Appendix A Infection Prevention & Control Board Level Agreement The Board of Pennine Care NHS Foundation Trust takes the prevention and control of HCAIs very seriously and the Trust has implemented a programme of activities to embrace new national initiatives and effectively prevent and control HCAIs. The Board is committed to comply with The Health and Social Care Act 2008 (Code of Practice for the NHS on the prevention and control of HCAIs and related guidance) Board Responsibilities All Executive Directors have clear IPC responsibilities in their job descriptions. The Medical Director is the Executive Director of IPC (DIPC). Lead Nurse IPC/Physical Health This role is established in the Trust. The job description identifies clear roles and responsibilities. The Lead Nurse: IPC/Physical Health reports to the Deputy Director of Nursing. The Lead Nurse: IPC/Physical Health reports directly to the DIPC and Executive Director of Operations and Nursing if significant infections such as MRSA, Clostridium Difficile and outbreaks arise. Committees IPC is included in the agenda for each monthly meeting of the Trust s Board of Directors. The IPC Committee take place every two months, chaired by the DIPC. The deputy chair of the committee is the Deputy Director of Nursing. The Risk and Clinical Governance Committee meets monthly and IPC is on the agenda. This meeting is chaired by the Deputy Director of Nursing. Reports The Governance Department publishes monthly and quarterly dashboard reports, which identify current IPC information. 20

21 An Annual Report and Annual Programmes are presented to the IPC Committee and monitored by the Board of Directors. These reports are sent to the DIPC and the annual programme is updated at the IPC Committee. The PCT Assurance Framework document is completed monthly and signed off by the DIPC. Resources The Board has set up SLA s with all relevant acute Trusts. There is an identified DIPC. There is a Director of Capital Investment. Cleaning contracts are agreed and managed within the Capital Investment Department. Should there be a need to increase resources such as domestic staff following an outbreak, the Board is committed to funding additional resources as and when necessary to ensure highest possible standards of IPC. Audits There is a rolling programme of IPC audits and the results are reported via the IPC Committee and to the Trust s Board of Directors. Education There is a rolling programme of education. All staff attend IPC training as part of their induction and mandatory training. Additional training is also undertaken if outbreaks occur or incidents occur. Board members have received IPC training i.e. Hand Hygiene and the prevention and control of HCAI using RCA. Signed on behalf of the Board: Signed by John Schofield, Chairman Date Signed by John Archer, Chief Executive Date CF/FS/KH

22 Action complete Confident task will be complete Reasonably confident task will be completed Task not completed Appendix B Infection Prevention and Control Completed Action Plan April 2010 to March 2011 Action Lead Target Date R/A/G Comments NPSA Clean Your Hands Campaign IPCN Ongoing All wards and departments have clean your hands campaign posters Maintain evidence collection for NHSLA, CQC, Health & Social Care IPCN Ongoing Evidence collected and kept on Planning and Modernisation data base Act & Assurance Framework Provide IPC reports for the Board IPCN Monthly IPC reports taken to the Board by the DIPC Develop the IPC Champions Role IPCN May 2010 All champions trained and updated this year Provide an IPC Annual Report for the IPCN June 2010 Annual report completed IPC Committee & Board Contribute to the PEAT Assessment Head of Estates March 2011 Assisted with all dates for the PEAT inspections Update IPC Policies in line with new IPCN May 2010 Policies all updated guidelines. Ensure service Users Receive Flu IPCN October 2010 Flu vaccination of service users Vaccinations as appropriate Undertake Hand hygiene audits in line with Essential Steps Audit Tool & 5 Moments Undertake IPC Education as part of Mandatory and Induction training including hand hygiene. encouraged as appropriate IPCN On-going Hand hygiene audits completed every 3 months IPCN /Modern Matrons/Education and Training Department On-going On-going training programmes continue to be rolled out across the Trust. Mandatory training and Induction training continue 22

23 All wards have an Environmental Audits carried out 6 monthly. IPCN/Audit Department July 2010 & January 2011 October-November Audits completed Undertake IPC Environmental Audits IPCN /Audit Community audits completed across all Community Settings Department 2010 Audits of the ward environment are Matrons To Commence Monthly checks carried out by the carried out monthly and reported to the May 2010 matrons IPC Committee Keep IPC Web Page Up to date IPCN Ongoing Web page up to date Needle Safety devices to be implemented across the trust Unannounced visits to all inpatient areas annually IPCN September 2010 All areas now aware of needle safety devices Deputy Director of Ongoing The deputy director of nursing and Nursing & IG infection prevention nurse have visited all areas this year IPCN May 2010 Patient, visitor and staff leaflets designed /Communications and available on the web page. Patient and visitors leaflets to be designed and posted on IPC web page To investigate IPC incidents IPCN On Going All IPC incidents investigated. To investigate all MRSA, Clostridium IPCN On Going RCA used to investigate all outbreaks and Difficile, ESBL and outbreaks of infections such as MRSA, ESBL and Infection using RCA Clostridium difficile. Contribute to new building plans regarding IPC Maintain monthly meetings with estates, matrons and domestic supervisors IPCN/Estates On Going The infection prevention nurses have been involved in all new plans IPCN /Estates, On Going Monthly environment meetings continue. Matrons & Domestic supervisors 23

24 Infection Prevention and Control Environmental Audit Plan April 2010 to March 2011 Appendix C Location Ward Audit date By whom Audit date By whom Tameside Whittaker Day July 2010 CF Hospital Ward Ward 35 July 2010 FS January 2011 JS Ward 36 July 2010 FS January 2011 JS Assessment and July 2010 CF January 2011 JM Engagement Recovery July 2010 CF January 2011 JM Social inclusion July 2010 CF January 2011 JM Summers July 2010 CF January 2011 FP Saxon July 2010 FS January 2011 FP Hague January 2011 JM Hurst January 2011 JM Rhodes Inpatient Unit July 2010 CF January 2011 JM Place Stepping Hill Hospital Cobden July 2010 CF January 2011 VC Bevan July 2010 CF January 2011 VC Arden July 2010 CF January 2011 JS Norbury July 2010 CF January 2011 JS Davenport July 2010 CF January 2011 FP Saffron July 2010 CF/FP January 2011 FP Rosewood July 2010 CF/FP January 2011 FP The Meadows, Stockport Linden Day July 2010 CF/FP Heathfield House, Stockport Royal Oldham Hospital Birch Hill Hospital Fairfield General, Bury Stansfield Place Inpatient Unit July 2010 CF January 2011 JM Rowan July 2010 FS January 2011 GS/AK Cedars July 2010 FS January 2011 GS/AK Northside July 2010 FS January 2011 GS/AK Southside July 2010 FS January 2011 GS/AK Hollingworth July 2010 FS January 2011 GS/AK Moorside July 2010 FS January 2011 GS/AK Hazel July 2010 FS January 2011 GS/AK Beech July 2010 FS January 2011 GS/AK North July 2010 FS January 2011 GS/AK South July 2010 FS January 2011 GS/AK Hope July 2010 FS January 2011 FC Horizons July 2010 January 2011 FC Ramsbottom July 2010 FS January 2011 GS/AK Inpatient Unit July 2010 CF January 2011 JM 24

25 Action complete Confident task will be complete Reasonably confident task will be completed Task not completed *Deloitte Recomm endations 1 To Prevent Health Care Acquired Infections Infection Prevention & Control Plan 2011/2012 Lead Appendix D 1.1 Maintain evidence collection for NHSLA, CQC, Health & Social Care Act & Assurance Framework CF/AA Monthly 1.2 Provide IPC reports for the Board CF/AA Monthly 1.3 Provide an IPC Annual Report for the IPC Committee & Board CF/AA June Executive led awareness campaign including safety walkabouts to provide snap-shot assurance CF/AA Monthly 1.5 Improve professional links with microbiology services and be included in feedback loops (attend Acute Trust ICC) CF/AA Nov 11 2 To Demonstrate compliance with IPC policies 2.1 Ensure policies are reviewed and/or revised on receipt of new guidance or as appropriate CF/AA March Review of the RCA tool and process AA Dec Review antibiotic usage, report trends and audit adherence to antimicrobial formulary CF/Arifa August 11 Establish the delivery and recording of ANTT training for all relevant nursing/medical staff undertaking clinical 2.4 procedures. Prevalence survey to identify sites administrating Injections/taking blood and wound dressings AA March Establish procurement list for all cleaning/ipc products used in trust CF March Update Gastroenteritis outbreak form/signage/leaflets and Gastroenteritis checklist tool AA April Promote the introduction of sharp safe devices in the Trust CF/AA March Ensure service Users Receive Flu Vaccinations as appropriate CF/LS October Introduce IPC Pledge for all staff to buy in. Deliver at Trust Induction AA April 11 3 To provide IPC Education and Training for all staff 3.1 Ensure and promote all relevant staff receive Induction and annual mandatory IPC training CF/AA 6 Monthly Monthly review of staff attendance by staff group to enable a targeted approach and increased attendance to training CF/AA Sept Annual evaluation of all IPC teaching sessions including Induction and update as appropriate CF/AA June Promote the use of the E-Learning package with support of the training department AA Sept Quarterly IPC Champion Meetings over the 5 Boroughs (April, July, October and January) CF/AA 3 Monthly Target Date R/A/G 25

26 4 To provide a clean, safe environment and patient shared equipment for healthcare 4.1 Work closely with our PFI partners to ensure the patient environment is maintained appropriately to promote a clean and safe environment. CF/AA Monthly 4.2 Maintain monthly meetings with estates, matrons and domestic supervisors CF/AA Monthly 4.3 Contribute to new building plans regarding IPC CF/AA On request 4.4 Contribute to the PEAT Assessment CF/AA March Review the provision of social Hand washing sinks and/or Alco gel at the entrance to all wards and departments. AA June Promote Clinell labelling CF/AA Monthly 4.7 Fans are used in the ward environment. Ensure cleaning maintained or decommission CF/AA 6 Monthly 5 To promote responsibility and awareness for IPC at all levels of the organisation Utilise a variety of media messages to heighten Trust-wide awareness on key IPC issues (poster, electronic info boards, 5.1 ward boards, flash cards, floor mats, IPC week in October) AA 3 Monthly 5.2 Distribute quarterly IPC newsletters AA April Continued development of the IPC website AA Monthly 5.4 Develop the Champions role AA 3 Monthly Develop a senior leader s resource pack for undertaking service areas visits. Ensuring there is an emphasis on patient AA 5.5 experience and IPC observations October 11 6 A Programme of audit of IPC policies in line with the Health Act (2006) and 'Saving Lives' recommendations 6.1 Review of all audit tools by the IPC Team for suitability. CF July Undertake Hand hygiene audits in line with Essential Steps Audit Tool & 5 Moments CF 3 Monthly 6.3 All wards have an Environmental Audits carried out 6 monthly. CF/AA Jul11/Jan IPC Audit all community Buildings with Pennine care service users utilising the building CF/AA Jan Audit sharps equipment, practice and knowledge Daniels June Audit patient information leaflets CF/AA Feb Audit specimen collection technique CF October Antimicrobial Prescribing Audit AA/CF/AA 3 Monthly 6.9 Mattress Audit Huntleigh April PPE Audit (Gloves, aprons & Masks) Medisavers April Survey or snap-shot of staff feedback on uniform wearing CF/HR Dec

27 92% + Excellent 87% - 91% Good 74% - 86% Acceptable < 73% Poor Cleanliness Monitoring April 2010 to March 2011 APPENDIX E INPATIENT SITE Service Provider Team April May June July August Sept Oct Nov Dec Jan Feb March Birch Hill Hospital Hazel Pennine Care Cleaning 97% 94% 94% 98% 97% 99% 98% 100% 100% 100% 99% 100% Estates 100% 100% 95% 100% 88% 100% 100% 100% 100% 100% 100% 100% Nursing 60% 78% 84% 82% 88% 88% 88% 100% 100% 100% 88% 96% TOTAL 92% 94% 95% 96% 91% 95% 95% 100% 100% 100% 95% 98% Beech Pennine Care Cleaning 97% 95% 95% 96% 94% 98% 96% 95% 96% 100% 98% 100% Estates 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Nursing 73% 80% 87% 91% 92% 96% 80% 96% 88% 100% 92% 100% TOTAL 94% 95% 95% 96% 95% 98% 91% 97% 94% 100% 96% 100% Hollingworth Pennine Care Cleaning 93% 95% 92% 96% 91% 96% 96% 94% 97% 99% 100% 91% Estates 92% 100% 95% 100% 100% 100% 96% 96% 100% 96% 100% 96% Nursing 71% 85% 87% 96% 88% 92% 88% 84% 92% 100% 100% 100% TOTAL 91% 94% 92% 97% 93% 96% 93% 91% 96% 98% 100% 95% Moorside Pennine Care Cleaning 95% 95% 96% 95% 88% 98% 94% 91% 97% 98% 96% 97% Estates 100% 100% 90% 95% 88% 92% 92% 88% 88% 96% 100% 96% Nursing 56% 75% 85% 100% 88% 96% 88% 100% 96% 100% 92% 100% TOTAL 91% 94% 94% 97% 88% 95% 91% 93% 93% 98% 96% 97% Fairfield General North Ward ISS Mediclean Cleaning 91% 94% 92% 89% Unable 84% 97% 94% 96% 92% 96% 98% Estates 93% 91% 87% 71% to audit 84% 88% 88% 96% 88% 96% 96% Nursing 82% 89% 89% 100% 96% 92% 100% 100% 96% 96% 100% TOTAL 91% 93% 92% 89% 88% 92% 94% 97% 92% 96% 98% South Ward ISS Mediclean Cleaning 93% 95% 92% 96% Unable 93% 97% 100% 100% 97% 99% 100% Estates 88% 89% 94% 86% to audit 96% 100% 100% 100% 100% 100% 100% Nursing 81% 90% 88% 91% 96% 96% 100% 100% 100% 100% 100% TOTAL 89% 93% 92% 95% 95% 97% 100% 100% 99% 99% 100% Hope Unit ISS Mediclean Cleaning 90% 92% 93% 90% 97% 91% 85% 97% 88% 91% 95% 94% Estates 93% 89% 90% 95% 96% 96% 96% 96% 96% 100% 100% 100% Nursing 70% 81% 87% 87% 92% 84% 92% 100% 100% 100% 96% 96% TOTAL 88% 92% 92% 91% 95% 90% 90% 97% 94% 97% 97% 96% Horizon Unit ISS Mediclean Cleaning 96% 99% 100% 99% 100% 100% Estates 100% 100% 100% 100% 100% 100% 27

28 Nursing 96% 100% 92% 100% 100% 100% TOTAL 97% 99% 97% 99% 100% 100% Ramsbottom Ward ISS Mediclean Cleaning 90% 93% 92% 97% 93% 96% 98% 97% 96% 93% 100% 97% Estates 92% 90% 94% 100% 100% 96% 96% 96% 92% 100% 100% 100% Nursing 83% 89% 87% 100% 88% 100% 92% 100% 100% 96% 100% 100% TOTAL 89% 92% 92% 98% 93% 97% 95% 97% 96% 96% 100% 99% The Meadows Saffron Sodexo Cleaning 98% 96% 99% 98% 99% 100% 99% 97% 100% 98% 99% 95% Estates 93% 94% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% Nursing 94% 94% 88% 100% 100% 92% 88% 96% 96% 100% 92% 84% TOTAL 98% 96% 97% 99% 99% 94% 93% 97% 98% 99% 97% 93% Rosewood Sodexo Cleaning 98% 97% 99% 99% 97% 98% 98% 97% 97% 96% 97% 95% Estates 94% 98% 90% 95% 100% 100% 100% 100% 100% 100% 100% 100% Nursing 90% 91% 87% 96% 80% 100% 100% 100% 100% 96% 92% 100% TOTAL 98% 96% 97% 98% 92% 99% 99% 99% 99% 97% 96% 98% Stepping Hill Davenport Stockport FT Cleaning 89% 90% 90% 91% 84% 97% 92% 85% 83% 83% 80% 97% Estates 89% 91% 90% 90% 96% 100% 100% 100% 100% 100% 100% 100% Nursing 70% 57% 85% 96% 88% 100% 96% 100% 100% 100% 96% 100% TOTAL 80% 84% 90% 92% 89% 99% 96% 95% 94% 94% 92% 99% Arden Stockport FT Cleaning 84% 84% 92% 94% 89% 94% 93% 94% 87% 93% 97% 96% Estates 80% 73% 89% 100% 96% 96% 96% 100% 100% 88% 96% 96% Nursing 80% 58% 93% 96% 76% 100% 96% 92% 100% 96% 96% 96% TOTAL 80% 76% 92% 95% 87% 96% 95% 95% 95% 92% 96% 96% Norbury Stockport FT Cleaning 85% 84% 94% 94% 87% 94% 96% 97% 89% 89% 96% 92% Estates 73% 82% 90% 95% 96% 88% 96% 100% 100% 84% 92% 92% Nursing 70% 50% 93% 100% 100% 100% 100% 100% 96% 100% 100% 100% TOTAL 81% 77% 93% 95% 94% 94% 97% 99% 95% 91% 96% 94% Bevan Place Stockport FT Cleaning 94% 86% 94% 94% 93% 93% 96% 88% 97% 99% 97% Unable Estates 86% 90% 94% 100% 100% 100% 100% 100% 100% 100% 100% To Nursing 68% 53% 86% 79% 88% 96% 100% 100% 92% 100% 100% Audit TOTAL 89% 80% 92% 91% 93% 96% 98% 96% 96% 99% 99% Cobden Unit Stockport FT Cleaning 88% 87% 84% 91% 95% 93% 98% 90% 94% 95% 97% 92% Estates 74% 86% 89% 86% 100% 96% 100% 100% 88% 96% 96% 96% Nursing 68% 92% 88% 91% 100% 100% 100% 100% 100% 100% 100% 100% 28

29 Royal Oldham TOTAL 88% 88% 87% 91% 98% 96% 99% 96% 94% 97% 97% 96% Rowan Ward ISS Mediclean Cleaning 96% 93% 96% 87% 96% 96% 95% 98% 96% 95% 94% 96% Estates 100% 92% 95% 90% 92% 100% 96% 100% 96% 100% 96% 100% Nursing 100% 85% 100% 91% 100% 88% 100% 100% 96% 96% 100% 100% TOTAL 95% 91% 97% 90% 96% 94% 97% 99% 96% 97% 96% 98% Cedars Ward ISS Mediclean Cleaning 98% 99% 99% 96% 90% 96% 90% 97% 95% 95% 91% 90% Estates 100% 100% 98% 95% 96% 100% 100% 96% 100% 100% 96% 100% Nursing 100% 94% 98% 91% 84% 100% 100% 100% 96% 92% 100% 96% TOTAL 99% 98% 99% 96% 90% 98% 96% 97% 97% 95% 95% 95% Southside ISS Mediclean Cleaning 89% 86% 93% 84% 90% 77% 92% 96% 95% 90% 97% 90% Estates 92% 73% 84% 95% 100% 100% 96% 100% 96% 92% 96% 100% Nursing 42% 38% 86% 79% 96% 96% 96% 96% 100% 100% 92% 92% TOTAL 86% 73% 91% 87% 95% 91% 94% 97% 97% 93% 95% 94% Northside ISS Mediclean Cleaning 92% 84% 91% 95% 92% 96% 93% 96% 99% 95% 99% 95% Estates 78% 82% 89% 100% 96% 96% 96% 96% 100% 96% 96% 100% Nursing 55% 49% 88% 80% 96% 96% 92% 100% 100% 92% 92% 88% TOTAL 88% 77% 91% 94% 94% 96% 93% 97% 99% 94% 95% 94% Tameside General Summers Ward Pennine Care Cleaning 93% 94% 99% 100% 94% 100% 100% 100% 99% 100% 100% 100% Estates 100% 96% 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% Nursing 90% 91% 100% 100% 92% 100% 100% 100% 100% 100% 100% 100% TOTAL 92% 93% 100% 100% 95% 100% 100% 100% 99% 100% 100% 100% Saxon Ward Pennine Care Cleaning 89% 94% 97% 100% 92% 99% 96% 100% 97% 100% 100% 100% Estates 100% 98% 100% 100% 96% 100% 96% 100% 96% 100% 100% 100% Nursing 92% 91% 92% 100% 92% 100% 100% 100% 100% 100% 100% 100% TOTAL 91% 94% 97% 100% 93% 99% 97% 100% 97% 100% 100% 100% Ward 35 Pennine Care Cleaning 82% 87% 93% 95% 96% 98% 96% 94% 87% 97% 91% 93% Estates 92% 89% 95% 95% 100% 96% 96% 100% 96% 100% 100% 100% Nursing 60% 60% 87% 91% 100% 100% 96% 100% 96% 100% 100% 100% TOTAL 81% 81% 93% 95% 98% 98% 96% 98% 93% 99% 97% 97% Ward 36 Pennine Care Cleaning 95% 89% 91% 93% 93% 99% 99% 100% 91% 99% 92% 99% Estates 83% 81% 92% 100% 100% 100% 100% 100% 100% 100% 96% 100% Nursing 73% 68% 93% 100% 96% 100% 100% 100% 92% 100% 100% 100% TOTAL 91% 83% 92% 95% 96% 99% 99% 100% 94% 99% 96% 99% 29

30 Hurst Place Pennine Care Cleaning 93% 95% 96% 99% 97% 98% 99% 98% Estates 100% 100% 100% 100% 100% 100% 100% 100% Nursing 92% 100% 92% 96% 96% 96% 100% 92% TOTAL 95% 98% 96% 98% 97% 98% 99% 96% Hague Pennine Care Cleaning 95% 98% 90% 100% Unable 97% 97% 94% Estates 100% 100% 100% 100% to audit 96% 100% 96% Nursing 100% 100% 88% 100% 96% 100% 100% TOTAL 98% 99% 92% 100% 96% 99% 96% Social Inclusion Pennine Care Cleaning 96% 93% 91% 95% 93% 100% 96% 98% 93% 98% 97% 93% Estates 100% 90% 94% 100% 100% 100% 100% 100% 100% 100% 100% 100% Nursing 53% 75% 87% 77% 88% 100% 100% 100% 96% 96% 100% 92% TOTAL 91% 89% 91% 91% 93% 100% 98% 99% 96% 98% 99% 95% Recovery Pennine Care Cleaning 86% 89% 91% 96% 90% 96% 94% 98% 94% 98% 94% 98% Estates 78% 89% 91% 100% 100% 96% 96% 96% 100% 96% 100% 96% Nursing 53% 59% 86% 78% 96% 100% 92% 100% 96% 100% 96% 100% TOTAL 81% 86% 90% 94% 95% 97% 94% 98% 96% 98% 96% 98% Assessment Pennine Care Cleaning 89% 88% 91% 92% 92% 96% 92% 94% 93% 97% Unable 91% to Estates 67% 69% 94% 95% 100% 100% 96% 96% 96% 96% audit 96% Specialist Services Nursing 63% 74% 91% 79% 76% 92% 96% 96% 92% 100% 96% TOTAL 85% 81% 92% 90% 89% 96% 94% 95% 93% 97% 94% Rhodes Place Turning Point Cleaning 92% 93% 86% 87% 80% 75% 80% 84% 86% 79% 79% 85% Estates 73% 89% 94% 90% 100% 100% 96% 100% 96% 100% 100% 100% Nursing 98% 83% 93% 96% 100% 100% 92% 92% 100% 96% 96% 100% TOTAL 92% 91% 92% 90% 93% 91% 89% 92% 94% 91% 91% 95% Stansfield Place Pennine Care Cleaning 86% 97% 97% 98% 94% 95% 90% 81% 88% 97% 95% 87% Estates 73% 84% 91% 100% 96% 96% 96% 92% 96% 100% 100% 92% Nursing 50% 76% 92% 100% 88% 100% 92% 92% 96% 100% 100% 96% TOTAL 82% 90% 96% 99% 91% 97% 92% 88% 93% 99% 98% 92% Heathfield House Pennine Care Cleaning 96% 93% 94% 97% 91% 98% 96% 99% 97% 89% 100% 98% Estates 88% 92% 90% 100% 96% 96% 100% 100% 100% 92% 100% 100% Nursing 89% 74% 87% 100% 100% 100% 100% 92% 100% 96% 100% 100% TOTAL 95% 89% 93% 98% 95% 98% 98% 97% 99% 92% 100% 99% 30