ANNUAL REPORT

Transcription

1 INFECTION PREVENTION & CONTROL ANNUAL REPORT Date Produced: June 2010 Approved by Infection Prevention & Control Committee: June 2010 Approved by Governance Committee: 6 th July 2010 Presented to Trust Board: 27 th July 2010 Executive Director: Dr Jean O Driscoll Director of Infection Prevention & Control Written and Compiled by: Niamh Whittome Matron, Infection Prevention & Control June 2010

2 CONTENTS PAGE Executive Summary 2 Page No. Introduction 2 Infection Prevention & Control Arrangements and Budget Allocation 3 The Infection Prevention & Control Programme 3 Surveillance 4 Outbreak Reports 8 Care Quality Commission (CQC) 8 Saving Lives/Infection Prevention & Control Leads 9 Hand Hygiene 9 Link Practitioner Programme 10 Decontamination 10 Patient Environment Action Teams (PEAT) & Department of Health Deep Cleaning Initiative 10 Infection Control Manual 10 Educational Activities 11 Audit Activity 11 Antibiotic Review Group 11 Risk Management/Clinical Governance 12 Building Projects 12 Service Level Agreements 12 Committee/Group Membership 12 Other Activities 13 Appendices 1. Infection Prevention & Control Governance Structure Infection Control Programme 2009/ Draft Infection Control Programme 2010/ Surveillance Data Summary of Pandemic Influenza A H1N1 at BHT CQC Hygiene Code Inspection Oct 09 Gap Analysis Hand Hygiene Observation Audit Results Link Practitioner Programme Education Audit Reports Needlestick/sharps/splash injury Audit Apr 09-Mar Antibiotic Review Group 79 Page 1 of 81

3 EXECUTIVE SUMMARY This has been another challenging year for infection prevention and control. The Care Quality Commission (CQC) made an unannounced visit to the Wycombe site in October to check the Trust s compliance with The Health Act 2006, superseded in January 2009 by The Health and Social Care Act No breaches were found. Improvement was required in relation to one of the standards inspected (decontamination of patient equipment). A gap analysis was produced and appropriate actions taken and the CQC were reassured that we were fully compliant in January 2010, without the need for a follow-up visit. The advent of Swine Flu was another challenge. Dr Kathy Cann took a lead clinical role in minimising risk, and the Infection Control Nurses provided training in respirator mask fit-testing. The Trust detected twelve cases of MRSA bacteraemia in 2009/10. Of these, 3 were post-48 hour cases, ie attributable to BHT. The limit for 2009/10 was 14 cases. BHT continued its sustained reduction in Trust-apportioned C. difficile cases, with a total of 49 cases against a limit of 112 cases. We continue to be amongst the best-performing Trusts in the UK in regard to this infection. There was also a significant reduction in infections following orthopaedic surgery thanks to concerted multidisciplinary efforts. Regarding MRSA screening, we continued to screen all elective admissions during 09/10 and also achieved >100% screening of non-elective as well as elective admissions by the end of March Our excellent performance in maintaining low levels of infection are due to hard work at all levels of the organisation. Infection Control Link Practitioners play a key role at ward and departmental level, e.g. by undertaking the monthly Hand Hygiene observational audits. I was delighted that their commitment to patient safety was recognised by the awarding of a Group Staff Award recently. The Infection Control Leads ( Saving Lives ) also continue to play a key part in ensuring that High Impact Intervention Audits are undertaken and any remedial actions required taken. They also lead in updating the monthly Infection Control Balanced Scorecards and reviewing the ongoing SDU Work Programmes. Like most other Trusts in the UK, we experienced several Norovirus Outbreaks. We have had a debriefing meeting to reduce the impact in forthcoming years. On a personal level, I was pleased to be elected to the post of Honorary Secretary of the European Study Group on C difficile. Fiona Simpson (recently appointed Lead Infection Control Nurse at Bucks PCT) and I completed a Leadership in Infection Prevention and Control Course at Warwick University. As our project we looked at improving communication across the healthcare boundaries. With that in mind, we welcome the integration of Community Health Bucks and BHT and look forward to improving patient safety even more for our local population. Dr Jean O Driscoll INTRODUCTION The following report outlines the department s activities over the past 12 months. Commitment to preventing the spread of infection is essential from all staff in all departments and at all levels of management in order to maintain a high standard of infection prevention & control practice throughout the Trust. Page 2 of 81

4 Staff Changes Gladys Mhandu was welcomed to the team from April to July. In June we welcomed back Niamh Whittome from maternity leave. In August we said goodbye to our Matron Catherine Greaves who left to take up the lead Infection Control post for Berkshire East Community Health Services. In September Fiona Simpson was seconded for 6 months to Community Health Bucks to provide Infection Prevention cover. We welcomed Sharon Njanike in October to the team and Judy Watmough to the team in November until February who was seconded to provide cover for Fiona Simpson. FY1 & FY2 Doctors worked within Microbiology at Stoke Mandeville and undertook some Infection Prevention & Control audits. We also benefited from Registrars (ST3) on Oxford Rotations who worked on the Wycombe hospital site. INFECTION PREVENTION & CONTROL ARRANGEMENTS AND BUDGET ALLOCATION The Trust serves a population of approximately 500,000 people with inpatient beds at Stoke Mandeville, Wycombe and Amersham Hospitals. Dr O Driscoll has continued in her role as Director of Infection Prevention & Control and the infection prevention & control governance arrangements for the Trust are described in Appendix 1. The IPCT currently consists of the following staff: Dr Jean O Driscoll DIPC Dr Kathy Cann Consultant Microbiologist Dr Ruby Devi Consultant Microbiologist Dr David Waghorn Consultant Microbiologist Niamh Whittome- Matron IPC Amanda Adkins - ICN Lisa Andrews ICN Jackie Dalton ICN Sharon Njanike ICN Fiona Simpson - ICN Gail Cregan - Secretary Karen McIntosh Secretary Karleen Mulder Secretary Lorraine Shaw - Secretary In April 2009 the budget allocation was as follows: Microbiologists Infection Prevention & Control Nurses Administrative support 4.0 WTE 6.80 WTE (0.80 vacant, 1 WTE protected PCT 2.78 WTE full time from Oct 09-March 2010 The team were tasked with making a 10% savings from the budget. This was achieved by removing a 30 hour band 6 post. This post had been vacant. THE INFECTION PREVENTION & CONTROL PROGRAMME Appendix 2 shows the Infection Prevention & Control programme for the year The Programme clearly defines the priorities for the Trust in relation to infection prevention & control activities as agreed by the Trust Infection Prevention & Control Committee which will also monitor the progress on this programme. The following report details the programmes development and progress. Appendix 3 outlines the programme for Page 3 of 81

5 SURVEILLANCE (Mandatory & Voluntary) Clear case definitions for in house surveillance have been developed and applied to data reported in this report. These can be found in Appendix 4. Clostridium difficile We continue to participate in the mandatory reporting of C.difficile infection. BHT C difficile Trajectory 2009/ cumulative limit cumulative actual Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Tabled below are our reported cases from April March 2010 using the in house definitions in appendix 4: 2-64 years 65 + years Acquisition W&A SMH W&A SMH Total cases BHT acquired BHT associated Community *(a) (b) (c) 5 5 (d) N/A cases i.e. relapses Total cases Meticillin Resistant Staphylococcus Aureus (MRSA) Non-bacteraemias The number of Buckinghamshire Hospitals NHS Trust (acquired and associated) non bacteraemia MRSA cases detected by the laboratories from April 2009 to March 2010 are displayed in the table below: SMH W&A Total BHT acquired (category 1) BHT associated (category 2) Total MRSA non-bacteraemia *Ref to Appendix 4 for definitions Page 4 of 81

6 Meticillin Resistant Staphylococcus Aureus (MRSA) Bacteraemias Mandatory reporting of MRSA bacteraemias continues. The Trust reported 12 bacteraemias for the year , of these 9 were attributed to the community and 3 attributed to the Trust. All MRSA bacteraemias have a Root Cause Analysis (RCA) undertaken. Learning points from these are shared through the Infection Prevention & Control Leads and discussed at clinical governance meetings Apr- 09 MRSA Bacteraemia Cumulative Trajectory 2009/10 Limit: maximum of 14 cases at year end (Baseline: 03/04: 47 cases) May- 09 Cumulative trajectory Total cumulative cases Cumulative BHT cases Jun- 09 Jul-09 Aug- 09 Sep- 09 Oct- 09 Nov- 09 Dec- 09 Jan- 10 Feb- 10 Mar- 10 Summary of MRSA Bacteraemia Cases Detected at BHT April 09 March 10 Total no of cases: 12 Post-48 hour cases ( BHT-allocated ): 3 (In , 11 cases were detected; 6 of these were post-48 hour cases). BHT cases: Site: 2 were detected at WGH 1 was detected at SMH WGH cases: One was a patient transferred from SMH ITU to a Cardiology Ward at WGH. It is possible that this case was a contaminant as the patient had 3 negative screens for MRSA. Two other organisms were also grown from the blood culture set. The other patient s MRSA probably originated in an infected venflon site. Delays in screening the patient for MRSA on admission and starting suppression possibly contributed to the bacteraemia. SMH case: This was a patient transferred from an international ITU to SMH ITU. They were screened for MRSA on arrival and found to be colonised with MRSA in their nose. Suppression therapy was started promptly, but MRSA was detected in the bloodstream nine days after admission. It was felt that this bacteraemia could not have been prevented. Page 5 of 81

7 Community MRSA bacteraemia cases: Cases detected at SMH: Where patient was admitted from: Likely source of MRSA Comment NH* (H) Urine Not catheterised. Home Urine (catheterised)?district Nurse training an issue. Home Insect bite PVL strain. Home CONTAMINANT Recent plastic surgery at SMH. NH (L) Urine (catheterised) Poor communication of MRSA status across healthcare settings. Home Amputation stump Herts PCT case. Cases detected at WGH: Where patient was admitted from: Likely source of MRSA Comment NH (SL) CONTAMINANT Not clear why blood cultures were taken. Home Unknown Multiple abscesses (cerebellar, epidural, psoas and lung). RH* (WL) Urine (catheterised) * NH: Nursing (Care) Home; RH: Residential Home Glycopeptide Resistant Enterococci Bacteraemia The Trust reported 1 GREs under the mandatory surveillance scheme. Poor communication of MRSA status across healthcare settings. Extended Spectrum Beta Lactamase Producing Organisms (ESBLs) ESBL producing organisms (including strains of E. coli and Klebsiella sp.) confer resistance to a wide range of beta lactam antibiotics. They may also be resistant to other classes of antibiotics. Treatment options are therefore limited and prompt infection control precautions are required when ESBL isolates are detected The Trust laboratories have identified 246 new isolates in urine specimens (111 W&A, 132 SMH) from April 2009 March Of these 153 (76 W&A, 77 SMH) were specimens received from General Practitioners (179 in 2008/9) and 90 (35 W&A, 55 SMH) were from the acute Trust (97 in 2008/9). Page 6 of 81

8 Multi Resistant Acinetobacter Baumannii (MRAB) MRAB is a bacterium that is found commonly in the environment. Approximately 25% of people may carry Acinetobacter on their skin or in their bowels asymptomatically. The trust laboratories identified 8 new isolates of MRAB for 2009/10. Only 1 of these 8 patients acquired the MRAB at BHT. H1N1 This year saw the Trust respond to the Influenza Pandemic. We were involved operationally in a number of preparedness activities to include: Weekly clinical & operational meetings Designation of influenza isolation areas and escalation plans Protocols for management of admissions Isolation advice Provision of PPE and FFP3 mask fit test training Surveillance of admitted cases Communications with staff, patients and visitors Vaccination programme for staff Below are the details of confirmed H1N1 positive BHT admissions 64 confirmed cases Average age 20.8 years (Range: years) For a more detailed summary of the flu pandemic activity see Appendix 5. Delay in Isolation of Infected/Potentially Infected Patients Delayed Isolation data has continued to be collected per patient bed day, and permits a prospective audit of the Trust s Isolation Policy. This information however relies on data obtained via a variety of means (e.g. bed management team, IPCT, ward staff) and therefore reflects a trend, not necessarily accurate information. This information is now part of the Bed Management Governance Report which is reported monthly to the Risk Monitoring Group and Nursing and Midwifery Board to enable the Trust to identify risks associated with delayed isolation of patients. Orthopaedic Surgical Site Surveillance Since its formation in 2003, BHT has taken part in the national Surgical Site Infection Surveillance (SSIS) organised by the Health Protection Agency (HPA). The programme was established to encourage hospitals to use surveillance to improve the quality of patient care by enabling them to collect and analyse data on surgical site infections (SSI) using standardised methods. With Trusts feeding their data into a central agency i.e. the HPA, it has allowed individual hospitals to compare their rates of SSI with collective data from all hospitals participating in the service. There are 12 defined categories of surgical procedures within the national SSIS programme, but orthopaedic SSIS has been mandatory for all Trusts to perform since 2004/05. The figures are presented separately for Wycombe & Amersham (W&A) and SMH because they are analysed and reported separately by the Centre for Infection in Colindale. The figures below include or infections (in-patients, readmissions and post discharge) Page 7 of 81

9 Total number of procedures April 09 March 10 (W&A sites): Totals Infections (W&A) National Infection Rate Hip replacements (0.4%) 1.2% Knee replacements (1.6%) 1.1% Total number of procedures April 09 June 09 Totals Infections (SMH) National Infection Rate Repair of neck of femur 70 1 (1.4%) 2.0% You will note from the table there was an increase in knee infections reported compared to the national average. Infection Prevention & Control meetings were established with input from multi disciplinary teams to address the increase. These meeting resulted in assessing the patient pathway from the beginning of their journey to include pre-operative assessment, theatre, admission to ward and discharge home. There was no single identifiable factor contributing to the infection increase in this assessment, however a number of concerns were highlighted. An action plan was drawn up to address these concerns, which included skin preparation prior to admission and at the time of surgery, theatre discipline, correct decontamination of equipment within the theatres, laying up of the instruments under the laminar flow unit, removal of carpets, pre op screening for MSSA and the changes to antibiotic prophylaxis. The majority of concerns have now been addressed and the meetings are now bi- monthly. OUTBREAK REPORTS In January 2009, the Health Protection Agency (HPA) launched a national web-based scheme for the reporting of norovirus outbreaks occurring in Acute NHS Trust Hospitals. The data is entered by the Infection Prevention & control Team and quarterly reports are generated. Details required for reporting include patient and staff cases, ward closures and duration, bed days lost, and microbiology confirmation, below gives the details of the number we reported for A total of 13 outbreaks of confirmed viral gastroenteritis associated illness occurred between April March A further 5 were unconfirmed but resulted in ward closures. (For April 2008 March 2009 the Trust had reported 16 outbreaks) CARE QUALITY COMMISSION (CQC) INSPECTION In October the CQC made an unannounced visit to the Wycombe hospital site. The CQC monitor us against The Health Act 2006 A Code of practice for the prevention and control of healthcare associated infections. They found no evidence that the Trust had breached the regulation to protect patients, worker and others from the risks of acquiring a healthcare associated infection. 15 measures were inspected and they had no concerns about 14 of these. Improvement was needed around arrangements for the appropriate decontamination of instruments and other equipment. On the inspection they found patient equipment ready for use that was not cleaned to a satisfactory standard, this included commodes and bedpans. They also found some equipment in a poor condition. A gap analysis was produced to outline the actions that were required following the visit see appendix 6. In January the CQC contacted the Trust to gain assurance that we had implemented the recommendation and were happy that we had addressed the areas for improvement Page 8 of 81

10 SAVING LIVES/INFECTION PREVENTION & CONTROL LEADS The IPCT have continued to work with the nominated Infection Prevention & Control Leads, Matrons and Link Practitioners from each SDU. Each SDU has been required to write its annual infection prevention & control work programme for the year. This included two mandatory items, hand hygiene and IV lines, as these were considered to be significant infection risks for the Trust. Each SDU also has an Infection Prevention & Control Balanced Score Card to complete which includes the following items: Number of red and amber risks on the SDU risk register relating to infection prevention & control Hand Hygiene audit scores Number of MRSA bacteraemias RCA s of MRSA bacteraemias returned within 5 working days Number of C.difficile infections. This information is held on the Trust Scorecard drive. HAND HYGIENE The Trust s Hand Hygiene campaign continued throughout The Trust has continued to work with the National Patient Safety Agency (NPSA) as part of the national hand hygiene campaign and has utilised all resources made available by the NPSA to assist the local hand hygiene strategy. The hand hygiene strategy has continued to evolve as a result of local need and identified risks following incidents/audits. The Trust also signed up for the World Health Organisation (WHO) Global hand hygiene challenge. The following have been achieved during : Audit of hand hygiene continued as per the annual audit programme. Assessment of Bare Below the Elbows compliance was included within the hand hygiene audit tool. The focus of the audit tool was around the WHO 5 moments as part of the national clean your hands Campaign. A central hand hygiene drive was set up for the wards. Dissemination of the results to all staff groups and wards/departments was undertaken with Infection Prevention & Control Leads and Modern Matrons taking responsibility within their areas for local improvement. Areas with results below the compliance level of 90% must complete weekly audits until the compliance level is achieved (see appendix 7). Areas must produce an action plan to the address areas of low compliance. The results are also discussed at divisional board meetings. These audits will continue as per the new audit programme for Mandatory hand hygiene competency assessment is well established within the mandatory training programme, annually for clinical and bi-annually for non clinical staff. It is also included within the Trust Induction training for all new starters. Training for other groups e.g. University of Bedford students has also continued. A contract is now in place for the maintenance of hand hygiene floor signs. A section on hand hygiene was included in the Infection Control Knowledge Survey. The Trust was involved in the WHO Global Hand Hygiene Day (October 2009) which was aimed at children. Activities such as assessing hand hygiene compliance with the light boxes, hand printing and a poster for the children to colour in was taken up in various areas. Photographs were published in the local newspaper. Page 9 of 81

11 Infection Prevention & Control week (15 th -19 th October 2009) was aimed at support workers involvement in infection prevention & control practices. Photographs were taken of support workers (e.g. volunteers, Healthcare Support workers and Nursing students) and placed on notice boards in the main entrances. Also various information regarding the resources Infection Prevention & Control provide for support workers was displayed. LINK PRACTITONER PROGRAMME The Infection Prevention & Control Link Practitioner (ICLP) programme comprised three study days throughout the year as planned on both Wycombe Hospital and Stoke Mandeville Hospital sites. For the first time the fourth study day was held as a combined study day in the Floyd Auditorium. Once again the well attended study days were repeated across the sites to ensure all the ICLPs received the same information across the Trust and allowed individuals to attend the days on either site. ICLPs received an ongoing education building on the previous years work. The role of the ICLP includes taking part in the High Impact Intervention (HII) audits across the Trusts for their wards and departments. The Hand hygiene audit underwent changes so that the audit is now completed on a monthly basis. A particular highlight this year was the award received by the ICLPs in the Trust Staff Awards scheme, in which they were awarded second place in recognition for their continued work to ensure our patients are cared for in Clean & Safe Environment. Please refer to Appendix 8 for further details of the content of the programme. DECONTAMINATION The Trust continues to work towards the provision of a single site CSSD facility. It will be designed to service all of BHT's activity and current contract provisions and is expected that the new unit will come on line during the next financial year PATIENT ENVIRONMENT ACTION TEAMS (PEAT) The IPCT were involved in the annual PEAT inspections in February. The final report has not yet been received. INFECTION CONTROL MANUAL The infection control manual continues to be updated and new sections added as required. The following sections were updated in Clostridium difficile September Glycopeptide Resistant Enterococci including VRE November Pandemic Influenza February MRAB (Policy 100) September Central Venous Lines June Food Hygiene August Needlestick & Other Inoculation Injuries March Laundry March Surveillance of Infections March Decontamination of Equipment Prior to Service or Repair November Equipment Recommended Disinfection Procedures 4.4 Local Decontamination Page 10 of 81

12 One new section was added to the manual: 3.15 Guideline on Animals on Hospital Premises All sections of the manual were also uploaded onto the Trust intranet in addition to being distributed to be included in hard copies of the manual located in clinical areas. EDUCATIONAL ACTIVITIES During the year the IPCT delivered formal education sessions to both clinical and non-clinical staff. This included induction and mandatory training for Trust staff. See appendix 9 for more detailed information. The figures included here do not include preparation time which can be considerable particularly for external presentations. AUDIT ACTIVITY The audit programme for the year can be found in the Infection Prevention & Control Annual Programme see Appendix 2. The following audits were undertaken: Ward/Department Environmental Audits Patient equipment audits Ward kitchen audits HII Urinary Catheter Care audit HII Care Bundle for ventilated patients. HII Peripheral Line audit HII Surgical Site Infection audit HII Central Line Venous Catheter Care Ongoing Management Visual Infusion Phlebitis audit Hand hygiene observational audits Infection Control Knowledge Survey MRSA and Clostridium difficile policy audits Transfer Form audit Formal reports provided by Clinical Audit & Effectiveness Department All formal reports are disseminated to relevant wards, departments, committees to highlight key findings and recommendations for their action. See appendix 10. Work Place Health undertook a Needlestick/Sharps/Splash Injury Audit April 2009 to March 2010 see appendix 11 for the full report. ANTIBIOTIC REVIEW GROUP The group has continued to meet throughout the year. A report of activity can be found in Appendix 12. Page 11 of 81

13 RISK MANAGEMENT/CLINICAL GOVERNANCE Dr O Driscoll has represented Infection Prevention & Control at the Risk Monitoring Group (formerly Clinical Risk Review Panel) and is responsible for producing the Infection Prevention & Control Clinical Governance reports. Dr O Driscoll is also a member of the Healthcare Governance Committee and attends Trust Board meetings. She provided Infection Prevention & Control reports to each Board and has direct access to and monthly meetings with the Chief Executive. BUILDING PROJECTS The ICT continued to provide support with both minor and major building projects including new builds and refurbishments. This included: Endoscopy, WH Neonatal Intensive Care Unit, SMH Installation of Laparoscopic Theatre, WH Adolescent Unit within NSIC, SMH GP Led Clinic, WH Labour Ward, SMH Obstetric Theatres, SMH Burns & Plastics OPU, SMH Claydon Wing, SMH Paediatric Decisions Unit, SMH Children s Day Unit, WH Children s Nursery at Amersham SERVICE LEVEL AGREEMENTS The IPCT has continued to provide a service to Buckinghamshire PCT, this initially involved two days a week of protected IPCN time but was increased to full time in October. The PCT served notice on the SLA in September. See appendix 13 for CHB work programme. COMMITTEE/GROUP MEMBERSHIP Infection Prevention & Control Committee Trust wide Infection Prevention & Control Group Health and Safety at Work Committee Quality Standards Committee Risk Monitoring Group (formerly Clinical Risk Review Panel) Medical Devices Committee Medical Equipment Purchasing Committee Nursing and Midwifery Board Sisters Meetings The Domestic Services Review Group (SMH & W&A) County Environmental Health Committee Regional Professional Development Group (microbiologists) Decontamination Committee Buckinghamshire PCT Infection Prevention & Control Committee. Healthcare Governance Committee Critical Care Delivery Group Orthopaedic Infection Group SDU governance Meetings Divisional Board Meetings Tissue Viability Page 12 of 81

14 OTHER ACTIVITIES Infection Control Times The Infection Control Times newsletter has continued to be distributed monthly. Infection Prevention & Control Notice Boards Updated as necessary in response to global and national events i.e. H1N1 and WHO Global Hand Washing. Study Day Due to staffing issues within the Trust all non mandatory training was suspended therefore our annual study day was cancelled with the plan to have one next year. Research, Publications and Presentations Dr J O Driscoll Presentation on Combating C.difficile infection in the UK at the European Congress on Clinical Microbiology and Infectious Diseases, Helsinki Presentation on C.diff at HCAI Conference, Manchester European C.diff Steering Group meeting in Paris: Dr O Driscoll was elected honorary secretary Presentation at Hospital Infection Society Study Day in Birmingham Page 13 of 81

15 Appendix 1 INFECTION CONTROL GOVERNANCE STRUCTURE Chief Executive and Trust Board Director of Infection Prevention and Control Governance Committee Risk Monitoring Group Infection Control Committee Infection Prevention & Control Team Infection Control Leads Group Trust wide Infection Control Meeting SDU Governance Groups SDU Infection Control Leads Link Practitioners Wards/Departments Modern Matrons Page 14 of 81 Dr J O Driscoll Director of Infection Prevention and Control May 2008

16 Appendix 2 INFECTION PREVENTION AND CONTROL PROGRAMME 2009/ Summary: The Infection Prevention and Control Annual Programme will clearly define the priorities for the Trust in relation to infection prevention and control activities as agreed by the Trust Infection Control Committee (ICC) which will also monitor the progress. 2. Aim of the Buckinghamshire Hospitals NHS Trust Infection Control Programme To reduce preventable healthcare-associated infections within the activity of BH NHS Trust by a process of: Surveillance / Reporting Development, review and implementation of Infection Control Policies. Education / Training for clinical and support staff Promotional Campaigns Response to local / regional / national initiatives Research Audit of infection prevention and control practice Compliance with the Code of Practice for Prevention and Control of Healthcare Associated Infections. Implementation of Saving Lives High Impact Interventions. Maintenance of the expertise of Infection Control specialist staff who will provide guidance on Infection Control measures The programme has been risk assessed using the Trusts risk matrix. The risk of not completing the actions identified is stated and then scored. The severity of the risk will always remain the same. The likelihood of the risk occurring is stated as it is at the current time (refer to date given). When the programme is reviewed at each ICC the likelihood of that risk occurring will also be reviewed and adjusted accordingly. It is expected that all stakeholders will work through the aspects of the programme that requires their input in order to keep the associated risk to a minimum. The aim of risk assessing the programme is to enable the Trust to easily identify priorities if the need arises. 3. Identified targets for the Trust Reduction of MRSA bacteraemias to no more than 14 cases by 31 March 2009 (SHA target). Trajectory illustrated in Appendix A. Reduction in rates of Clostridium difficile (SHA target). Appendix B. 4. Identified targets for Divisions and Service Delivery Units (SDUs) Annual Infection Control environmental audits by wards and departments: 100% of wards to achieve at least 85% compliance. Monthly reporting of: o Hospital acquired infections (MRSA and C. difficile) o Infection prevention and control training Annual reporting of: Page 15 of 81

17 o Hand hygiene compliance Identification and management of Red Risks related to Infection Prevention and Control on risk registers Root Cause Analysis of MRSA Bacteraemias undertaken and forms returned within 5 working days of notification of Bacteraemia Implementation of the Saving Lives High Impact Interventions Appropriate use of antibiotics 5. The Infection Prevention and Control Programme 2009/10 has been developed using the following Department of Health guidance. Winning Ways: working together to reduce Healthcare Associated Infection in England December 2003 Saving Lives: a delivery programme to reduce Healthcare Associated Infection including MRSA June 2005 NHSLA Standards Standards for Better Health Code of Practice for Infection Prevention and Control (Health Act October 2006 updated January 08 replaced by Health and Social Care Act 2008) Clean, Safe Care January 08 The purpose of this programme is to identify all key work streams required to ensure all appropriate actions are being taken by Buckinghamshire Hospitals NHS Trust to minimise the risk of hospital acquired infections. Trust Board Objectives Actions Lead Timescales Comment Board takes an active part in The Board will receive Infection Control updates at each DIPC Bimonthly ensuring that Trust-acquired Public Meeting. infections are reduced to a The Board will receive the Annual Report. DIPC July 09 minimum. RAG rating* March 10 The Board will receive regular Reports from Divisions. DIPC Ongoing Not routine The Board s Communication Strategy will include the need to inform patients and the public on matters relating to IC. Ensure IPC is incorporated into all Executive Director job descriptions, with identified outcome measures. JB/SK July 09 SH Ongoing Amber *Green = completed Amber = in progress no obstacles to progress Red = not started or obstacles to progress. Page 16 of 81

18 Divisions Objectives Actions Lead Timescales Comment To ensure that reduction of Trust-acquired infections are a priority for Divisions and SDUs. RAG rating* March 10 IC information will be publicly displayed on wards including C diff numbers, MRSA numbers and compliance with hand hygiene and Saving Lives audits. Each SDU will table an Infection Report update at Infection Control Lead Meetings. SDUs will partake in the Infection Prevention Performance Monitoring (Appendix C). IC risks are fed into SDU/Divisional Risk Registers and reviewed monthly. Lessons from IC SUIs reviewed regularly and acted upon. ICLPs SDU Infection Control Leads SDU Infection Control Leads EH Divisional Chairs and Lead Nurses Monthly from May 09 Bimonthly Ongoing Ongoing Ongoing Not uniform Infection Control Team in liaison with others Objectives Actions Lead Timescales Comment Surveillance Prompt action is taken when required following feedback of surveillance data. Continue mandatory surveillance of: MRSA Bacteraemias C. difficile Glycopeptide resistant enterococci Orthopaedic surgery wound infections. (formerly NINSS) KC/ICT Ongoing Amber Continue voluntary surveillance: C. difficile (weekly reporting) MRSA (non-bacteraemias) ESBL Multi-resistant Acinetobacter baumannii Commence voluntary surveillance of blood culture contamination DIPC Monthly from April 09 *Green = completed Amber = in progress no obstacles to progress Red = not started or obstacles to progress. Other ad-hoc surveillance Page 17 of 81

19 Objectives Actions Lead Timescales Comment RAG rating* March 10 Green Education Ensure that all Trust employees have a programme of education and training on the prevention Ensure that all employees (including locum bank staff and contractors) receive infection control induction training at commencement of employment. Divisional Managers Ongoing and control of infection in order Ensure that all the above receive annual updates in Divisional Ongoing to understand their infection control including hand hygiene competency Managers responsibility for infection assessment. control and the actions they must personally take. Embed e-learning as a modality for annual updates. FS/JOD Oct 09 Being started Ensure all relevant staff receive training in aseptic techniques and are assessed as competent. SW-F/GL Ongoing Underway RAG rating* March 10 Amber Decontamination There are effective arrangements for the appropriate decontamination of instruments and other equipment Ensure Decontamination Programme is drawn up which quality assures Trust s decontamination process achieved through Decontamination Committee. Specifically to: i) Audit Decontamination policy and practices including training of staff. ii) Ensure compliance with HTM2030 and other relevant HTM documents. iii) Implement any relevant new guidance. Make recommendations about purchase of new equipment and changes to operating environment. IG April 09 and ongoing RAG rating* March 10 Policies The Trust has appropriate policies in place in relation to preventing and controlling the Circulate updated policies to ICT Policies ratified by ICC CG Ongoing Green *Green = completed Amber = in progress no obstacles to progress Red = not started or obstacles to progress. Page 18 of 81

20 Objectives Actions Lead Timescales Comment risks of HCAIs. New policies to be written o Microbiology Lab protocol for investigation of HCAI ICT April 09 and surveillance o Blood Culture Guidance RAG rating* March 10 Audit of Policies Compliance with key policies is ensured through the implementation of high impact interventions and monitored through audit. Assess standards of practice through audit of High Impact Interventions. RAG rating* March 10 Antibiotic Prescribing Minimise antibiotic resistance by appropriate prescribing. Policies to be revised: As required per rolling programme Policies to be audited MRSA C. difficile ICT ICT ICT ICT As required Nov 09 Sept 09 See separate Audit Programme (Appendix D) GC Ongoing Antibiotic Review Group to continue to update and merge relevant guidelines. Audits of antibiotic prescribing to be undertaken regularly and results acted upon. Monthly update of antibiotic usage graphs with feedback of unusual/inappropriate prescribing to Division. DW DW/BC BC/DIPC Ongoing Ongoing Ongoing Green Green RAG rating* March 10 Environmental audits Ensure environmental standards are maintained. Ensure education on antibiotic prescribing to all doctors as required by national guidelines. Ensure environmental audits are carried out annually. Matrons to monitor through rounds, Domestic Service review meetings. DIPC ICT/Ward/Depart ment Managers/Audit Dept Ongoing Ongoing Not systematic Amber *Green = completed Amber = in progress no obstacles to progress Red = not started or obstacles to progress. Page 19 of 81

21 Objectives Actions Lead Timescales Comment SWF/Matrons RAG rating* March 10 Green Hand Hygiene audits Ensure that hand hygiene practice is maintained. RAG rating* March 10 Ensure hand hygiene audits are carried out according to audit programme and identified actions are implemented. ICT/Ward/Depart ment Managers Ongoing Green MRSA Screening Compliance with Health Act requirements for MRSA screening. RAG rating* March 10 Ensure MRSA screening of all elective admissions. Develop a programme of MRSA screening of all emergency admissions. ICT From April 09 From Oct 09 Green MRSA Bacteraemias Improve MRSA bacteraemia rates though identification of root causes, corrective action and sharing of learning. Ensure timescales for RCA reporting are met and corrective actions/learning shared across Divisions. Report root causes and action to Governance Committee and Trust Board. Infection Control Leads. DIPC Ongoing Ongoing RAG rating* March 10 Reduce IV line-associated infections. RAG rating* March 10 Reduce needle stick injuries RAG rating* March 10 Green Formal training on peripheral line insertion and DIPC Ongoing ongoing management. Central Line Packs to be issued. BCh/ICT April 09 Monitoring of central line infections. DIPC Ongoing Monthly monitoring of peripheral line infections. DIPC Ongoing Green Audit NSIs, identify preventable causes and take appropriate April 09 action. Green Continue to make progress with: Development of Link Continue to build on existing programme incorporating LA Ongoing Page 20 of 81 *Green = completed Amber = in progress no obstacles to progress Red = not started or obstacles to progress.

22 Objectives Actions Lead Timescales Comment Practitioner Programme new initiatives as required. RAG rating* March 10 Hand Hygiene Monitor results of Patient Experience Tracker System Continue with Clean your hands campaign Ensure clinical staff comply with Bare below the Elbows Focus on patient and visitor hand hygiene ICT Ongoing Ongoing Green RAG rating* March 10 Emergency Planning RAG rating* March 10 Building development and Cleaning issues RAG rating* March 10 Reactive, core clinical roles Participate in Trust s emergency planning Specifically for: Pandemic Influenza (All relevant staff should undergo fit-testing of recommended masks) Deliberate release CBRN Ensure a cleaning strategy exists that is regularly monitored by the Board Continue input into building developments and refurbishments Check that Legionella Risk Assessments are carried out Trust-wide and any identified remedial actions required carried out Annual Joint Reviews with Contractors Annual cleaning update Minutes of Domestic Review Group to go to ICC Check there is an annual planned programme of operating theatre engineering checks Clinical advice/support to all areas: Management of infectious patients Investigation of outbreaks and clusters KC IG ICT IG/AM IG IG IG/AM ICT Ongoing Ongoing Ongoing April 09 Sept 09 Sept 09 From April 09 April 09 Ongoing Green Green Outstanding Amber *Green = completed Amber = in progress no obstacles to progress Red = not started or obstacles to progress. Page 21 of 81

23 Objectives Actions Lead Timescales Comment RAG rating* March 10 Green Standards for better health To ensure compliance with S4BH C4a is maintained. CG/ICT Ongoing Evidence to support compliance with C4a and the Health Act is identifiable and readily available RAG rating* March 10 Green Development of Trust s Website This will be developed further JB Ongoing RAG rating* March 10 Ensuring that all employees adhere to their responsibilities in relation to Infection Control RAG rating* March 10 Key to Leads: IC will be included in all appraisals and PDPs SH To be developed JOD Dr Jean O Driscoll, DIPC NH Nick Hulme BCh Bob Chevin JB Juliet Brown CG Catherine Greaves AM Anne Maguire SK Sam Knollys SW-F Sarah Watson-Fisher IG Ian Garlington EH Liz Hollman GL Dr Graz Luzzi SH Sandra Hatton KC Dr Kathy Cann DW Dr David Waghorn ICT Infection Control Team FS Fiona Simpson BC Breda Cronnolly OH Occupational Health Green Outstanding Amber *Green = completed Amber = in progress no obstacles to progress Red = not started or obstacles to progress. Page 22 of 81

24 Audit Programme 2009/10 Page 23 of 81 INFECTION CONTROL DEPARTMENT Month Audit details Undertaken by April ICNA Management of Patient Equipment Audit (over 2 months) ICN Kitchen Hand Hygiene Observational Audit including Phlebotomists May ICNA Management of Patient Equipment Audit (cont d) ICN HII - Urinary Catheter Care Audit (insertion & ongoing management) ITU, Spinal, Urology & Theatres HII Care Bundle for Ventilated Patients ITU & Spinal Hand Hygiene Observational Audit including Phlebotomists Housekeeper Ward Managers/Modern matrons/iclps Ward managers/iclps Ward Managers/ICLPs Ward Managers/Modern matrons/iclps June VIP Audit Ward Managers/Modern matrons/iclps HII Peripheral Line Audit Hand Hygiene Observational Audit including Phlebotomists Outbreak Policy Audit Ward manager/iclp Ward Managers/Modern Matrons/ICLPs DIPC/ICT July Hand Hygiene Observational Audit including Phlebotomists Ward Managers/Modern matrons/iclps August Hand Hygiene Observational Audit including Phlebotomists Ward Managers/Modern matrons/iclps September Infection Control Knowledge Survey Clinical Audit/ICNs IC Clostridium Difficile Policy Audit Hand Hygiene Observational Audit including Phlebotomists F1/ICT Ward Managers/Modern matrons/iclps October Environmental Audits (over 2 months) Ward Managers/ICLPs Hand Hygiene Observational Audit including Phlebotomists HII Surgical Site Infection HII Central Line Venous Catheter Care ongoing management ITU Ward Managers/Modern matrons/iclps Theatres & ICN Ward Managers/ICLPs

25 November Isolation Policy Audit ICT Hand Hygiene Observational Audit including Phlebotomists IC MRSA Policy Audit Environmental Audits (cont d) Ward Managers/Modern matrons/iclps F1/ICT Ward Managers/ICLPs December Hand Hygiene Observational Audit including Phlebotomists Ward Managers/Modern matrons/iclps January 2010 Hand Hygiene Observational Audit Including Phlebotomists Ward Managers/Modern matrons/iclps February Hand Hygiene Observational Audit Including Phlebotomists Ward Managers/Modern matrons/iclps March Hand Hygiene Observational Audit Including Phlebotomists Ward Managers/Modern matrons/iclps Transfer Form Audit The aim is to provide a focus on elements of the care process and a method for measuring the implementation of policies and procedures. NB Programme subject to change if new or re-audits are required. ICT Page 24 of 81

26 Appendix 3 Draft INFECTION PREVENTION AND CONTROL PROGRAMME 2010/ Summary: The Infection Prevention and Control Annual Programme will clearly define the priorities for the Trust in relation to infection prevention and control activities as agreed by the Trust Infection Control Committee (ICC) which will also monitor the progress. 2. Aim of the Buckinghamshire Hospitals NHS Trust Infection Control Programme To reduce preventable healthcare-associated infections within the activity of BH NHS Trust by a process of: Surveillance / Reporting Development, review and implementation of Infection Control Policies. Education / Training for clinical and support staff Audit of infection prevention and control practice Implementation of Saving Lives High Impact Interventions. Maintenance of the expertise of Infection Control specialist staff who will provide guidance on Infection Control measures Promotional Campaigns Response to local / regional / national initiatives Research Compliance with the Code of Practice for Prevention and Control of Healthcare Associated Infections. The programme has been risk assessed using the Trusts risk matrix. The risk of not completing the actions identified is stated and then scored. The severity of the risk will always remain the same. The likelihood of the risk occurring is stated as it is at the current time (refer to date given). When the programme is reviewed at each ICC the likelihood of that risk occurring will also be reviewed and adjusted accordingly. It is expected that all stakeholders will work through the aspects of the programme that requires their input in order to keep the associated risk to a minimum. The aim of risk assessing the programme is to enable the Trust to easily identify priorities if the need arises. 3. Identified targets for the Trust MRSA objective: No more than 5 cases of BHT-attributed (ie detected more than 48 hours after admission) MRSA Bacteraemias. Trajectory illustrated in Appendix A. Reduction in numbers of cases of Clostridium difficile (SHA target). Appendix B. 4. Identified targets for Divisions and Service Delivery Units (SDUs) Annual Infection Control environmental audits by wards and departments: 100% of wards to achieve at least 85% compliance. Page 25 of 81

27 Monthly reporting of: o Hospital acquired infections (MRSA and C. difficile) o Infection prevention and control training Annual reporting of: o Hand hygiene compliance Identification and management of Red and Amber Risks related to Infection Prevention and Control on Balanced Scorecards. Root Cause Analysis of MRSA Bacteraemias undertaken and forms returned within 5 working days of notification of Bacteraemia Implementation of the Saving Lives High Impact Interventions Appropriate use of antibiotics 5. The Infection Prevention and Control Programme 2010/11 has been developed using the following Department of Health guidance. Winning Ways: working together to reduce Healthcare Associated Infection in England December 2003 Saving Lives: a delivery programme to reduce Healthcare Associated Infection including MRSA June 2005 NHSLA Standards Standards for Better Health Code of Practice for Infection Prevention and Control (Health Act October 2006 updated January 08 replaced by Health and Social Care Act 2008) Clean, Safe Care January 08 NAO Audit The incorporation of Community Health Buckinghamshire (CHB) into BHT from 1 st April 2010 will provide challenges and opportunities for strengthening infection prevention and control for the local population. Priorities for 2010/11 include: - Streamlining Policies and Guidelines - Streamlining induction and annual training updates - Improving the care of in-dwelling urinary catheters across the healthcare boundaries - Improving the transfer of information about specific infection risks across the healthcare boundaries The purpose of this programme is to identify all key work streams required to ensure all appropriate actions are being taken by Buckinghamshire Hospitals NHS Trust to minimise the risk of hospital acquired infections. Page 26 of 81

28 Trust Board Objectives Actions Lead Time Board takes an active part in ensuring that Trust-acquired infections are reduced to a minimum. RAG rating* for 2010 June The Board will receive Infection Control updates at each Public Meeting. DIPC scales Bimonthly The Board will receive the Annual Report. DIPC July 10 The Healthcare Governance Committee will receive regular Reports from Divisions. Issues of concern will be highlighted to the Board. Ensure IPC is incorporated into all Executive Director job descriptions, with identified outcome measures. KG SH Ongoing Ongoing Divisions Objectives Actions Lead Time scales To ensure that reduction of Trust-acquired infections are a priority for Divisions and SDUs. IC information will be publicly displayed on wards including C diff numbers, MRSA numbers and compliance with hand hygiene and Saving Lives audits. Each SDU will table an Infection Report update at Infection Control Lead Meetings. SDUs will partake in the Infection Prevention Performance Monitoring (Appendix C). ICLPs SDU Infection Control Leads SDU Infection Control Leads Ongoing Bimonthly Ongoing Update Green Update RAG rating * June 2010 IC risks are fed into SDU/Divisional Risk Registers and reviewed monthly. Lessons from IC SUIs reviewed regularly and acted upon. EH Divisional Chairs and Lead Nurses Ongoing Ongoing Amber Page 27 of 81

29 Infection Control Team in liaison with others Objectives Actions Lead Time scales Education Ensure that all employees (including locum bank staff Divisional Ongoing Ensure that all Trust and contractors) receive infection control induction Managers employees have a training at commencement of employment. programme of education Ensure that all the above receive annual updates in Divisional Ongoing and training on the infection control including hand hygiene competency Managers prevention and control assessment. of infection in order to Embed e-learning as a modality for annual updates. NW/JOD August 10 understand their responsibility for Ensure all relevant staff receive training in aseptic Lead Ongoing infection control and the techniques and are assessed as competent. Nurse/GL actions they must personally take. Update RAG rating * June 10 Surveillance Prompt action is taken when required following feedback of surveillance data. Continue mandatory surveillance of: KC/ICT Ongoing MRSA Bacteraemias C difficile KC/ICT Ongoing Glycopeptide resistant enterococci KC/ICT Ongoing Orthopaedic surgery wound infections (formerly NINSS) KC/ICT Ongoing Continue voluntary surveillance: C difficile (weekly reporting) MRSA (non-bacteraemias) ESBL Multi-resistant Acinetobacter baumanii Commence voluntary surveillance: MSSA Bacteraemias DIPC Monthly from April 10 Line-associated infections Monthly DIPC from April 10 Page 28 of 81 Amber

30 Objectives Actions Lead Time scales Ventilator-associated pneumonia Monthly DIPC from April 10 Continue to participate in the Matching Michigan DIPC - Project (commenced Dec 09) RAG rating * June 10 Decontamination There are effective arrangements for the appropriate decontamination of instruments and other equipment RAG rating * June 2010 Ensure Decontamination Programme is drawn up which IG Ongoing quality assures Trust s decontamination process achieved through Decontamination Committee. Specifically to: iv) Audit Decontamination policy and practices including training of staff. v) Ensure compliance with HTM2030 and other relevant HTM documents. vi) Implement any relevant new guidance. Make recommendations about purchase of new equipment and changes to operating environment. Joint Policy with CHB required. NW/FS July 10 Update Amber Green Policies The Trust has appropriate policies in place in relation to preventing and controlling the risks of HCAIs. RAG rating *June 10 Audit of Policies Compliance with key policies is ensured through the implementation of high Circulate updated policies to ICC NW Ongoing Policies ratified by ICC NW Ongoing New policies to be written: Joint BHT/CHB Policies NW/FS Ongoing Policies to be revised: As required per rolling programme ICT As required Policies to be audited MRSA ICT Nov 10 C. difficile ICT Sept 10 Page 29 of 81 Green

31 Objectives Actions Lead Time scales impact interventions and monitored through audit. Update Assess standards of practice through audit of High Impact Interventions. RAG rating * June 10 Antibiotic Prescribing Minimise antibiotic resistance appropriate prescribing. RAG rating * June 10 Environmental audits Ensure environmental standards are maintained. RAG rating * June 10 by MRSA Screening Compliance with Health Act requirements for MRSA screening. RAG rating * June 10 See separate Audit Programme (Appendix D) AA Ongoing Antibiotic Review Group to continue to update and merge relevant guidelines. Audits of antibiotic prescribing to be undertaken regularly and results acted upon. Monthly update of antibiotic usage graphs with feedback of unusual/inappropriate prescribing to Division. Ensure education on antibiotic prescribing to all doctors as required by national guidelines. Ensure environmental audits are carried out annually. Matrons to monitor through rounds, Domestic Service review meetings. Review PEAT scores Continue to ensure that all eligible elective and emergency admissions are screened. Page 30 of 81 DW DW/BC BC/DIPC DIPC ICT/Ward/Depa rtment Managers/Audit Dept/Chief Nurse/ Matrons Director of Operations Ongoing Ongoing Ongoing Ongoing Ongoing Ongoing When available Ongoing Amber Some slippage from Programme Amber Green Green

32 Objectives Actions Lead Time scales MRSA and MSSA Ensure timescales for RCA reporting are met and Infection Ongoing Bacteraemias corrective actions/learning shared across Divisions. Control Leads. Improve MRSA and Report root causes and action to Governance DIPC Ongoing MSSA bacteraemia Committee and Trust Board. rates though identification of root causes, corrective action and sharing of learning. RAG rating * June 10 Update Green Reduce IV lineassociated infections. RAG rating * June 10 Formal training on peripheral and central line insertion DIPC Ongoing and ongoing management. Monitoring of central line infections. DIPC Ongoing Monthly monitoring of peripheral line infections. DIPC Ongoing Green Reduce needle stick injuries & preventable occupational infections. RAG rating * June 10 Audit NSIs, identify preventable causes and take appropriate action (BHT and CHB). Monitor and encourage uptake of staff vaccination, eg influenza, varicella and MMR. WPH WPH From 10 From 10 April April Amber Link Practitioner Programme RAG rating * June 10 Continue to build on existing programme incorporating new initiatives as required. LA Ongoing Green Hand Hygiene Monitor results of Patient Experience Tracker System ICT Ongoing Complete the audit of provision of hand hygiene FS July 10 facilities at CHB Continue with Clean your hands campaign ICT Ongoing Ensure all staff groups in all clinical SDUs achieve DC/DLNs Ongoing 90% or more compliance on monthly audits. Ensure clinical staff comply with Bare below the ICT Ongoing Elbows Page 31 of 81

33 Objectives Actions Lead Time scales Focus on patient and visitor hand hygiene ICT Ongoing Review the hand hygiene component of the Annual IPCT July 10 Staff Survey and take action to correct any deficiency highlighted. RAG rating * June 10 Update Green Objectives Actions Lead Timescales Update Emergency Planning Participate in Trust s emergency planning Specifically for: Pandemic Influenza (All relevant staff should undergo KC Ongoing fit-testing of recommended masks) Deliberate release CBRN KC Ongoing RAG rating * June 10 Green Building development and Cleaning issues RAG rating * June 10 Reactive, core clinical roles RAG rating * June 10 Ensure a cleaning strategy exists that is regularly IG Ongoing monitored by the Board Continue input into building developments and ICT Ongoing refurbishments Check that Legionella Risk Assessments are carried IG/AM April 10 out Trust-wide and any identified remedial actions required carried out Joint BHT/CHB Legionella Policy to be produced IG/AM Sept 10 Annual Joint Reviews with Contractors IG Sept 10 Annual cleaning update IG Sept 10 Minutes of Domestic Review Group to go to ICC From April 09 Check there is an annual planned programme of operating theatre engineering checks IG/AM July 10 Clinical advice/support to all areas: Management of infectious patients ICT Ongoing Investigation of outbreaks and clusters ICT Ongoing Page 32 of 81 Amber Green

34 Objectives Actions Lead Time scales Update Standards for better health RAG rating * June 10 To ensure compliance with S4BH C4a is maintained. Evidence to support compliance with C4a and the Health Act is identifiable and readily available NW/ICT Ongoing Green Provision of information for patients, relatives and staff: RAG rating * June 10 Ensuring that all employees adhere to their responsibilities in relation to Infection Control RAG rating * June 10 Development of Trust s website NW/FS Ongoing Provision of relevant leaflets. New leaflets to be produced NW/FS Ongoing as required. IC will be included in all appraisals and PDPs SH To be developed Green. Amber Key to Leads: JOD Dr Jean O Driscoll, AM Anne Maguire NW Niamh Whittome DIPC JB Juliet Brown IG Ian Garlington KG Keith Gilchrist SK Sam Knollys SH Sandra Hatton IPCT Infection Prevention & Control Team EH Liz Hollman GL Dr Graz Luzzi WPH Workplace Health KC Dr Kathy Cann DW Dr David Waghorn AA Amanda Adkins FS Fiona Simpson BC Breda Cronnolly Page 33 of 81

35 APPENDIX A MRSA BACTERAEMIA TRAJECTORY APRIL 2010 MARCH 2011 Target for total number of cases by March 2011: 5 Monthly Target for Trust: May- Aug- Sep- Nov- Dec- Feb- Mar- Apr Jun-10 Jul Oct Jan Limit Page 34 of 81

36 Appendix B Clostridium difficile TRAJECTORY for BHT APRIL 2010 MARCH 2011 Target for total number of cases by March 2011: 65 Monthly Target for Trust: BHT C difficile Trajectory 2010/11 Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Limit cumulative limit Page 35 of 81

37 Target for total number of cases by March 2011: 5 Monthly Target for CIC: Clostridium difficile TRAJECTORY for Community Integrated Care APRIL 2010 MARCH 2011 BHT C difficile Trajectory 2010/11 Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Limit cumulative limit Page 36 of 81

38 Draft Audit Programme 2010/11 Month Audit details Areas to complete Audit Undertaken by Return to April May June July ICNA Management of Patient Equipment Audit (over 2 months) Kitchen Hand Hygiene Observational Audit including Phlebotomists ICNA Management of Patient Equipment Audit (cont d) HII - Urinary Catheter Care Audit (insertion & ongoing management All wards/departments All wards/departments not Theatres All areas/departments Page 37 of 81 Infection Prevention Nurse (IPN) Housekeeper Ward Managers/Modern matrons/iclps All wards/departments IPN N/A ITU, Spinal, Theatres, Urology, Rothschild Ward managers/iclps HII Care Bundle for Ventilated Patients Spinal St Andrews, ITU Ward Managers/ICLPs Hand Hygiene Observational Audit including Phlebotomists VIP Audit All areas/departments All wards/departments including DSU, endoscopy, X-ray, Day stickers Ward Managers/Modern matrons/iclps Ward Managers/Modern matrons/iclps HII Peripheral Line Audit All clinical areas/departments Ward manager/iclp Hand Hygiene Observational Audit including Phlebotomists All areas/departments Ward Managers/Modern Matrons/ICLPs Transfer Form Audit ICT ICT N/A IC Department Entered onto Hand Hygiene drive Clinical Audit Department Clinical Audit Department Entered onto Hand Hygiene drive Clinical Audit Department Clinical Audit Dept. Entered onto Hand Hygiene drive HII Surgical site Infection Pre op section One speciality Trustwide F1/ICPT F1/ICPT Hand Hygiene Observational Audit including Phlebotomists All areas/departments Ward Managers/Modern matrons/iclps Entered onto Hand Hygiene drive

39 August HII Surgical Site Infection All pre-op departments, All theatres Theatres & ICN HII Surgical Site Infection Peri operative section Hand Hygiene Observational Audit including Phlebotomists All Theatres All areas/departments Page 38 of 81 Divisional Leads, Theatre Managers, ICLP s Ward Managers/Modern matrons/iclps September Infection Control Knowledge Survey Clinical Audit/IPNs October IC Clostridium Difficile Policy Audit F1/ICT ICT Hand Hygiene Observational Audit including Phlebotomists Hand Hygiene Observational Audit including Phlebotomists HII Central Line Venous Catheter Care ongoing management ITU All areas/departments All areas/departments All areas Ward Managers/Modern matrons/iclps Ward Managers/Modern matrons/iclps Ward Managers/ICLPs Clinical Audit Department Clinical Audit Entered onto Hand Hygiene drive Clinical Audit Department Entered onto Hand Hygiene drive Entered onto Hand Hygiene drive Clinical Audit Department HII Surgical Site Infection Pre op section One Speciality F1/IPCT F1/ICPT Hand Hygiene Observational Audit including Phlebotomists HII Surgical Site Infection Elective Hip & Knee replacements only HII Central Line Venous Catheter Care ongoing management All areas/departments Ward Managers/Modern matrons/iclps Entered onto Hand Hygiene drive Loakes Theatres & IPCN Loakes Theatres & IPCN Clinical Audit ITU, St Andrews. November Isolation Policy Audit ICT Hand Hygiene Observational Audit including Phlebotomists All areas/departments Ward Managers/Modern matrons/iclps IC MRSA Policy Audit F1/ICT ICT Entered onto Hand Hygiene drive

40 December January 2010 February March Environmental Audits All wards/departments Ward Managers/ICLPs IC Department HII Surgical Site Infection Elective Hip & Knee replacements only Hand Hygiene Observational Audit including Phlebotomists HII Surgical Site Infection Elective Hip & Knee replacements only Hand Hygiene Observational Audit Including Phlebotomists Loakes Theatres & IPCN Loakes Theatres & IPCN Clinical Audit All areas/departments Ward Managers/Modern matrons/iclps Entered onto Hand Hygiene drive Loakes Theatres & IPCN Loakes Theatres & IPCN Clinical Audit All areas/departments Ward Managers/Modern matrons/iclps Entered onto Hand Hygiene drive HII Surgical site Infection Pre op section One Speciality F1/ICPT F1/ICPT Hand Hygiene Observational Audit Including Phlebotomists Hand Hygiene Observational Audit Including Phlebotomists All areas/departments Ward Managers/Modern matrons/iclps Ward Managers/Modern matrons/iclps Outbreak Policy Audit DIPC/ICT N/A Entered onto Hand Hygiene drive TBC The aim is to provide a focus on elements of the care process and a method for measuring the implementation of policies and procedures. NB Programme subject to change if new or re-audits are required. Page 39 of 81

41 Appendix 4 SURVEILLANCE DATA DEFINITIONS OF HEALTH CARE ASSOCIATED INFECTIONS Case definitions MRSA Non Bacteraemias 1. Probable BHT acquired: BHT inpatients > 48hrs before diagnosis or inpatient at a BHT site within 48hrs of the diagnosis. 2. BHT associated acquisition: patients who have been inpatients <48hrs or in a community setting AND have been BHT inpatients or regularly attend BHT for therapeutic interventions >48hrs (add up attendances to see if total greater than 48 hours) and within the previous 3 months ago. 3. Non BHT acquired: a) home : BHT inpatient < 48 hrs but resident in own home b) nursing home /residential home BHT inpatient <48 hrs but resident in nursing/residential home c) community hospital: BHT inpatients < 48 hrs but resident in a community hospital and have not had an IP episode anywhere in the last 3 months. d) other acute Trust: BHT inpatients <48hrs and transferred from another acute Trust or had an in-patient episode in the other acute Trust in the last 3 months. e) another country: BHT inpatients < 48 hrs and transferred form another country or have been an IP in another country in the last 3 months f) private hospital: BHT inpatients <48 hours and transferred form a private hospital or been an inpatient in a private hospital in the last 3 months Case definitions MRSA Bacteraemias 1. BHT - Bacteraemia acquired during hospitalisation which was not present or incubating at the time of admission and was identified 48 hours or more after admission 2. BHT- associated:- Bacteraemia in outpatients OR Bacteraemia within 48hours of admission in patients who regularly attend BHT for therapeutic interventions e.g. haematology/renal. OR Bacteraemia occurring within 48hours of admission in patients admitted from the community who have been discharged from BHT within the past 90 days 3 Community a) Home Bacteraemia detected within 48 hours of admission in patients admitted from own home and no hospital stay in previous 90 days. b) Nursing / residential home Bacteraemia detected within 48 hours of admission in patients admitted from nursing/residential home and no hospital stay in previous 90 days. c) Other hospital Bacteraemia detected within 48 hours of admission in patients admitted from a hospital outside Bucks Hospitals Trust. Page 40 of 81

42 Clostridium Difficile Case definitions: 1. Probable BHT acquired: Patients are inpatients >72hrs at a BHT site before onset of symptoms and diagnosis OR Have been discharged and develop symptoms within 72hrs of discharge and positive result confirmed (i.e via GP, patient does not have to be an inpatient to be categorised as Cat1) 2. BHT associated acquisition: patients have been inpatients <72 hours or in a community setting AND have been BHT inpatient >72 hours ago and < 3 months ago. 3. Non BHT acquired - a) Home: BHT inpatients <72hours but resident in own home b) Nursing home/residential home: BHT inpatients <72hours but resident in a nursing home/residential home c) Community hospital: BHT inpatients <72hours but resident in one of the community settings listed. d) Other acute Trust: BHT inpatients <72hours and transferred from another acute Trust or been an inpatient at another acute Trust in the last 3 months e) another country: BHT inpatients <72hours and transferred form another country or been an inpatient in another country in the last 3 months f) private hospital: BHT inpatients <72hours and transferred form a private hospital or been an inpatient in a private hospital in the last 3 months 1 st December 2009 Page 41 of 81

43 Appendix 5 Summary of Pandemic Influenza A,H1N1 1. H1N1 History H1N1 first isolated from a pig in Iowa 1976 First human death from swine flu in a US marine, no pandemic is triggered 1977 Mild flu epidemic 2. Key dates in the Pandemic 27 th April first UK cases confirmed 1 st May First person-to-person transmission confirmed 11 th June WHO officially declares swine flu to be a pandemic 30 th June 6,000 cases confirmed in UK 23 rd July National Flu Line phone service goes live 21 st October - H1N1 vaccine programme underway 12 th January 13,938 confirmed swine flu related deaths worldwide 19 th January HPA discontinues weekly pandemic flu media update 11 th February National Flu Line phone service disbanded 3. Outline of National Activity 3. Figure 1 Estimated number of cases and deaths Ref: Donaldson et al:2009. Mortality from pandemic A/H1N influenza in England: public health survey. BMJ: 339:521. Page 42 of 81

44 3. Figure 2 GP consultation rates for flu-like illness: Ref: Donaldson et al:2009. Mortality from pandemic A/H1N Influenza in England: public health survey. BMJ:339: BHT operational response Weekly clinical and operational meetings Designation of influenza isolation areas (A&E, ward and ITU) and escalation plans Protocols for management of admissions Isolation advice and provision PPE including fit-testing of FFP3 masks Surveillance of admitted cases Vaccination programme for staff Communications with staff, patients and visitors 5. Confirmed H1N1 positive admissions to BHT 56 patients o 64 confirmed 8 sets of notes could not be obtained for inclusion in these results Between 24/6/09 and 9/1/10 Average age 20.8 years (Range: years) Page 43 of 81

45 5. Figure < Age range (Years) 29 female, 27 male 25 paediatric, 31 adult 5. Figure 4 Paediatric Adult 5.1 Admission summary 44 were admitted with possible H1N1 None were admitted to ICU/HDU 2 patients received non-invasive ventilation during admission 1 transfer to tertiary paediatric/picu care as a consequence of H1N1 55 discharges home Page 44 of 81

46 According to notes the average apparent interval between symptom onset and presentation to hospital was 3.2 days (Range: 0 14 days) Inpatient length of stay was of an average length of 2.9 days (Range: 0 14 days) Total acute Trust bed days were Risk factors and severity Patients with at least one chronic underlying disease comprised 57.1% of the admissions (32 patients) Multiple co-morbidity o 20 had one underlying chronic disease o 9 had two underlying chronic diseases o 2 had three underlying chronic diseases o 1 had four underlying chronic diseases Respiratory diseases: 4 with chronic disease 3 moderate / 1 severe Asthma: 14 with asthma 6 mild / 8 moderate Chronic heart disease: 8 with CHD 2 mild / 2 moderate / 4 severe Chronic renal disease 1 with severe renal disease Chronic liver disease 1 with severe liver disease Chronic neurological disease 5 with chronic disease 2 moderate / 3 severe Diabetes mellitus 5 with DM 4 mild (all type 2 diabetics) 1 moderate (young type 1 diabetic) Immuno-suppression 4 patients identified as immuno-suppressed All were on long/medium term steroids and severity was unclassified Obesity 3 patients were specifically identified as being clinically obese Pregnant 1 pregnant patient of 33 weeks gestation Complications 1 child was transferred to paediatric tertiary care for specialist ventilatory support 3 bacterial pneumonias stated by clinicians but no microbiological correlation and all had pre-existing diagnosis of H1N1 5.3 Anti-virals All but one patient were prescribed Osteltamivir (Zanamivir in one patient -?indication) 8.9% (5/56) of patients were prescribed an antiviral prior to admission Page 45 of 81

47 54.9% (28/51 excluding those prescribed anti-virals prior to presentation to secondary care) of patients were prescribed an antiviral either upon admission or during their stay The majority were given antivirals for 5 days The proportion of patients given concurrent antibacterials and antivirals was not determined in this survey 5.3 Figure 5 Days treatment prescribed by location Adults: 950 days treatment in total PCT A&E Inpatients May June July August September October November December 5.3 Figure 6 Days treatment prescribed by location Children 1040 days treatment in total PCT A&E Inpatients May June July August September October November December 6. Laboratory activity and Sampling GP samples = 297 (53 positive) Acute care samples = 313 (64 positive) 19.1% of samples sent from all sources were positive Page 46 of 81

48 6. Figure 7 GP v Inpatient Samples from 25th May 2009 to the end of Week 52 (27th December 2009) Week 22 Week 23 Week 24 Week 25 Week 26 Week 27 Week 28 Week 29 Week 30 Week 31 Week 32 Week 33 Week 34 Week 35 Week 36 Week 37 Week 38 Week 39 Week 40 Week 41 Week 42 Week 43 Week 44 Week 45 Week 46 Week 47 Week 48 Week 49 Week 50 Week 51 Week 52 GP No of Samples Inpatient No of samples 6. Figure 8 GP v Inpatient Positives From 25th May 2009 to the end of Week 52 (27th December 2009) Week 22 Week 23 Week 24 Week 25 Week 26 Week 27 Week 28 Week 29 Week 30 Week 31 Week 32 Week 33 Week 34 Week 35 Week 36 Week 37 Week 38 Week 39 Week 40 Week 41 Week 42 Week 43 Week 44 Week 45 Week 46 Week 47 Week 48 Week 49 Week 50 Week 51 Week 52 GP No of Positives Inpatient No of Positives 7. Vaccination uptake Overall - uptake approx 30%, similar to that of seasonal vaccine. Best uptake in obstetrics and paediatrics Kathryn Lang Kathryn Cann Page 47 of 81

49 Appendix 6 CQC Hygiene Code Inspection October 2009 Gap Analysis Area for review Current Activity COMPLIANCE CRITERION 2 The Environment: Gaps Responsible person to monitor Actions required Target date for completion Update 13/01/2010 Equipment: including commodes, drip stands, hoists Monitoring/ Replacement of equipment : e.g. slipper pans, bed pans, wash bowls, commodes, drip stands Cleaning is generally ad-hoc Poor monitoring/ replacement of damaged equipment, No system in place to identify a clean piece of equipment No monitoring system in place to identify damaged equipment Ward managers Matrons ICLP Ward managers Matrons ICLP Introduce a systematic method to identify clean equipment e.g. clean indicator labels. Ensure all staff are trained and are aware of responsibilities. Display relevant cleaning posters Introduce system to monitor/replace damaged equipment With immediate effect and continuous With immediate effect and continuous Clean Indicator labels in place Nov A-Z clean inventory being produced & to be available on all wards and form part of decontamination policy. How to clean commode poster distributed and displayed in all sluices by IP&C nurses in November 2009 The monitoring of this is to form part of the matrons round Highlighted at NMB and Sisters meeting. Audited as part of the ICNA Management of patient equipment audit annually and as part of monthly Matrons round Page 48 of 81

50 CLINICAL SUPPORT SERVICES ACCESS Appendix 7 INFECTION PREVENTION &CONTROL DEPARTMENT Ward/Departmental Hand Hygiene Audit Results Oct 09 Mar 10 Red = Non Participation Amber = Below 90% - Non compliant Divisional % 100% 99% 97% 99% 99% 98% Division Ward/Department Site Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 OPD SMH 100% 98% 95% 94% 97% 92% OPD WH 100% 97% 90% #DIV/0! 100% 100% OPD AH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! POA SMH 100% 100% 100% 100% 100% 100% POA WH/AH #DIV/0! #DIV/0! #DIV/0! #DIV/0! 100% 100% Divisional % 99% 100% 100% 98% 99% 100% Division Ward/Department Site Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Breast Screening SMH 100% 100% #DIV/0! 100% 100% 100% Breast Screening WH 100% 99% #DIV/0! 100% 100% 100% CCHU Cancer/ SMH Haemotology Care 100% 100% 100% 100% 100% 100% Clinical Photography SMH 100% 100% 100% 100% 100% 100% Clinical Photography WH 100% 100% 100% 100% 100% 100% Clinical Photography AH 100% 100% #DIV/0! 100% 100% 100% Dietetic Clinic SMH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Dietetic Clinic WH/AH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Orthotist SMH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Orthotist WH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Orthotist AH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Plastics OPD SMH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Radiology SMH 97% 100% 98% 97% 100% #DIV/0! Radiology WH 98% 98% 100% 96% 100% 98% Radiology AH 100% 100% #DIV/0! 98% 92% #DIV/0! SLT Clinic SMH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! SLT Clinic WH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! SLT Clinic AH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Sunrise Unit WH 100% 100% 100% #DIV/0! 100% 100% MSK SMH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! MSK WH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! MSK AH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Page 49 of 81

51 MEDICINE NSIC Divisional % 92% 93% 94% 95% 97% 94% Division Ward/Department Site Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 St Andrews SMH 84% 84% 92% #DIV/0! #DIV/0! 98% St David SMH 92% 96% 96% 94% 95% 97% St Francis SMH 98% 95% 97% 93% 98% 90% St George SMH 83% 91% 91% 97% 96% 92% St Josephs SMH 100% 100% 92% 97% 95% 99% St Patrick SMH 91% 86% #DIV/0! 95% 100% 95% Spinal Gym SMH #DIV/0! 94% 94% 92% #DIV/0! #DIV/0! Spinal OPD SMH 100% 98% 98% 97% 98% 96% Occupational Therapy SMH #DIV/0! 73% #DIV/0! 77% #DIV/0! #DIV/0! Cystoscopy SMH #DIV/0! #DIV/0! 100% #DIV/0! #DIV/0! #DIV/0! Hydrotherapy SMH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Divisional % 95% 94% 93% 95% 96% 94% Division Ward/Department Site Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 3B WH 90% 90% 91% 90% 91% #DIV/0! 4A WH 96% 97% 96% 92% 99% 96% 4B WH 98% 99% 98% 92% 98% 99% 5B (Stroke Unit) WH 92% 95% 95% 99% 98% 98% 6A escalation WH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 6B WH #DIV/0! 93% 94% 93% 94% 91% A & E SMH 100% 97% 95% 96% 97% 98% CCU (2A) WH 87% 94% 97% 94% 96% #DIV/0! Cardiac Day Unit & Lab WH 96% 85% 94% 100% 95% 88% Day Hospital SMH 95% 100% 100% 100% 97% 93% Dermatology OPD AH 96% 67% 83% 77% 100% 89% Drake Day Unit AH 100% 100% #DIV/0! 100% 100% 100% EAU (SMW10) SMH #DIV/0! 97% #DIV/0! #DIV/0! 88% 90% EMC WH 91% 78% 54% 84% 97% #DIV/0! Endoscopy SMH #DIV/0! 100% #DIV/0! 100% 100% #DIV/0! Endoscopy WH 98% 97% 99% 99% 99% #DIV/0! GUM Clinic (SHAW) WH #DIV/0! 100% #DIV/0! 100% 100% 100% Hayward Unit WH 100% 100% #DIV/0! 100% 100% #DIV/0! Heberden AH #DIV/0! #DIV/0! #DIV/0! #DIV/0! 97% 91% MAU WH 96% 98% 94% 94% 96% 88% SMW1 SMH 98% 98% 98% 96% 98% #DIV/0! SMW2 SMH 89% #DIV/0! 97% 94% 99% 98% SMW20 SMH 99% 91% 90% 97% 97% 94% SMW22 escalation SMH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! SMW5 SMH 96% 98% 99% 98% 98% 96% SMW8 SMH 100% #DIV/0! 100% 90% 96% 98% Wilkinson Ward AH 100% 97% 97% 99% #DIV/0! 100% Page 50 of 81

52 SURGERY WOMEN'S & CHILDREN'S Divisional % 98% 96% 96% 96% 97% 94% Division Ward/Department Site Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Ward 9 Gynaecology SMH #DIV/0! 88% #DIV/0! 93% 83% 97% Gynae OPD SMH 95% 97% 92% 100% 100% 100% Gynae OPD WH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Labour Ward SMH #DIV/0! 100% 99% 100% #DIV/0! #DIV/0! Aylesbury Birth Centre SMH 100% 100% 100% 100% 100% 100% Wycombe Birth Centre WH #DIV/0! #DIV/0! #DIV/0! #DIV/0! 100% 90% Antenatal Clinic SMH #DIV/0! 82% 84% 75% 94% 92% Antenatal & Gynae WH Clinic #DIV/0! 95% 94% 100% 96% #DIV/0! Rothschild Ward SMH #DIV/0! 96% 94% 97% 97% 96% NNU SMH 100% 100% 89% 99% 100% 92% Ward 3 Paediatrics SMH #DIV/0! 100% 95% 97% 97% 96% Childrens Day Unit WH #DIV/0! #DIV/0! 90% 94% 94% #DIV/0! Paediatric OP Clinic SMH #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Paediatric OP Clinic WH #DIV/0! #DIV/0! #DIV/0! #DIV/0! 96% 81% Divisional % 95% 94% 96% 97% 97% 97% Division Ward/Department Site Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 12A WH 98% 97% 99% 100% 96% 96% 12B WH 98% 99% 98% 99% 99% 98% Burns Unit (SMW11) SMH 87% 99% 99% 96% 100% 99% Burns OPD SMH 100% 97% 100% 100% 100% 96% Day Procedures Unit SMH 95% 95% 97% 97% 100% 97% Day Surgery Unit WH 96% 96% 91% 89% 98% 99% ENT Clinic OPD SMH 100% 100% 100% 100% 100% 100% ENT POA WH 100% 100% 100% 100% 100% 100% Gynae Recovery SMH 91% 87% 97% #DIV/0! #DIV/0! #DIV/0! Gynae Theatres SMH 94% 87% #DIV/0! 89% 84% 90% ITU SMH 100% 100% 100% 100% 98% 98% ITU WH 92% 90% 89% 90% 90% 90% Loakes Recovery WH 79% 100% 92% 88% #DIV/0! 90% Loakes Theatres WH 86% 94% 98% 94% 100% 94% Main Recovery WH 90% 92% 95% #DIV/0! #DIV/0! #DIV/0! Main Theatres WH #DIV/0! 97% #DIV/0! 100% #DIV/0! #DIV/0! New Wing Theatre SMH 93% #DIV/0! #DIV/0! 100% 84% 95% New Wing Recovery SMH 95% #DIV/0! #DIV/0! 75% 90% 76% Ophthalmic OPD SMH 97% 95% 94% 97% 98% 96% Ophthalmic Theatres SMH 95% 94% 96% 96% 91% 97% Oral Surgery AH 100% 100% 100% 99% #DIV/0! #DIV/0! Orthodontic OPD AH 100% 100% 100% 99% 100% 100% Orthodontic OPD SMH #DIV/0! 97% 100% 99% 100% 99% Page 51 of 81

53 Plaster Room WH 94% 97% 96% 97% 95% 97% Plaster Room SMH 99% 97% 97% 98% 96% 99% SAU (POD) WH 89% 79% 86% 91% 95% 98% SMW4 SMH 92% 90% 92% 98% 99% 92% SMW6 SMH 91% 94% 98% 88% 97% 95% SMW7 (Plastics) SMH 92% 91% 98% 100% 95% 95% Urology WH 100% 98% #DIV/0! 97% 100% 94% Page 52 of 81

54 Appendix 8 Infection Prevention & Control Link Practitioners Programme 2009 Study Day 1 Chesty Problems IC Update - Lisa Andrews, Infection Control Nurse Respiratory Viruses - Wendy Hudson, Senior Biomedical Scientist Pandemic Flu TALKBOARDS - Karyn Finch, Bucks Integrated Capacity Manager & Emergency Planning Officer Community Acquired Pneumonia - Dr Jean O Driscoll, Director of Infection Prevention &Control & Consultant Microbiologist HPA Nurse s Role and Environment - Lou Murrell, Health Protection Practitioner, Thames valley Health Protection Unit FIT Testing - David Hamilton, Rep, Shermond Surgical Supply Mycobacterium Tuberculosis - Dr Mitra Shahidi, Consultant, Chest & General Physician (1) Physio Exercises (2) Auscultation - Presented by 2 Physiotherapists Study Day 2 Wounds & Wound Care IC Update - Rose Gallagher, RCN ICN Nutrition & Wound Healing - Liz Evans, Nutrition Nurse Specialist Surgical Site Infections & Surveillance BHT - Amanda Adkins, Infection Control Nurse Plastics Case Presentation - Hilary Sayell, Trauma Coordinator, Plastics Wound Assessment - Janine Ashton, Lead Tissue Viability Nurse The Diabetic Foot - Julie Sturges, Tissue Viability Nurse Evaluation and Update - Lisa Andrews, Infection Control Nurse Study Day 3 Rashes IC Update - Lisa Andrews Infection Control Nurse Root Cause Analysis Training - Jacqueline Smith Patient Safety Manager RCA in Practice : Obstetric Cases Helen Pearce Matron (Maternity In-Patients and Clinical Governance Lead for W&C Division) Who is at Risk? Dr Jean O Driscoll Consultant Microbiologist & DIPC Page 53 of 81

55 Patients Clothing Bags - Susan Pletts Nurse Advisor, MonoSol Ltd Rashes in Pregnancy -Dr. Pushpa Maharajan, SpR in Obstetrics Combined Study Day - NSIC Patient ISC A Local Perspective - TRACEY GEDDIS Deputy Sister/Peripatetic Nurse, Spinal OPD, NSIC, Stoke Mandeville Hospital ESBL Early Stages of a Significant Problem? - DR DAVID WAGHORN Consultant Microbiologist, Wycombe Hospital Rehab Physiotherapy - DOT TUSSLER & SCOTT HAWTHORNE Physiotherapists, Physiotherapy Department, SMH VAP Minimising Risk for Ventilatory Support - PAUL SUBONG Deputy Staff Nurse, NSIC, SMH & JENNY RICKETTS Outreach Lead Nurse/Deputy Matron, ITU, WH Outreach Service - KATHRYN SHERRINGTON Feedback from Care Quality Commission s recent Visit to Wycombe - LISA ANDREWS Infection Control & Prevention Nurse A Spinal Patient s Experience - Former Spinal Patient Page 54 of 81

56 Appendix 9 Education Mandatory Infection Control Training Training Attended by Staff Groups from 1 st April 2009 to 31 st March 2010 Division Yearly Totals by Division Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Surgery Medicine NSIC Women s & Children s Clinical Support Services (CSS) Corporate (includes Access) Total Clinical Attendees for year Total Non-Clinical Attendees for year Total Monthly (all Divisions) TOTAL ATTENDANCE (Clinical & Non- Clinical) Page 55 of 81

57 Student Nurses A number of lectures were given during the year to pre-registration students. These included: Semester 1 Introduction to infection control Semester 1 Hand hygiene Semester 3 Health care associated infection Semester 4 Care of the immuno-compromised infection Semester 6 Care of the surgical patient Semester 9 Infection control management issues and IV lines Post Basic Nurse Education A variety of lectures were given for trained staff. These include: IV Therapy. Venepuncture & Cannulation. IV Therapy for District Nurses (Buckinghamshire PCT). Midwives Mandatory Training Staff Nurse Development Programme Part 1 Staff Nurse Development Programme Part 2 Return to Practice Page 56 of 81

58 NSIC CLINICAL SUPPORT SERVICES MEDICINE Appendix 10 Audit Reports Results of Patient Equipment Audit Undertaken April 09 - March 10 Division Ward/Department Site Results (%) 1A WH 88% 3B WH 83% 4A WH 98% 4B WH 95% 6B WH 89% A & E SMH 82% CCU (2A) WH 95% Day Hospital SMH Drake Day Unit WH EAU (SMW10) SMH EMC (A&E) WH 98% Endoscopy SMH 100% Endoscopy WH 100% Heberden AH MAU WH 87% SMW1 SMH 94% SMW2 SMH 95% SMW20 SMH 81% SMW22 SMH 81% SMW5 SMH 97% SMW8 SMH 89% Stroke Unit (5B) WH 86% Wilkinson AH Division Ward/Department Site Results (%) 5A WH CCHU SMH 93% Dermatology OPD AH OPD SMH OPD WH 81% OPD AH 86% Sunrise Unit WH X-Ray AH 81% X-Ray SMH 81% X-Ray WH 80% X-Ray Ultrasound SMH Division Ward/Department Site Results (%) Spinal Gym SMH Spinal OPD SMH St Andrews SMH St David SMH 97% St Francis SMH 95% St George SMH 92% St Josephs SMH 87% St Patrick SMH 82% Page 57 of 81

59 WOMENS & CHILDRENS SURGERY Division Ward/Department Site Results (%) 12A WH 90% 12B WH 92% 7 WH Burns Unit (SMW11) SMH 94% Day Surgery Unit SMH 100% Day Surgery Unit WH 90% ENT Pre-op Assessment on 3A WH Gynae Recovery WH Gynae Theatres WH 97% ITU SMH ITU WH 96% Loakes Recovery WH Loakes Theatres WH 97% Main Recovery WH Main Theatres WH 100% New Wing Theatre SMH Ophthalmic OPD SMH Ophthalmic Theatres & Recovery SMH 97% Ophthalmic Ward SMH 84% Oral Surgery AH Oral Surgery OPD SMH Plaster Room WH Pre-op Assessment (POA) AH Pre-op Assessment (POA) SMH Pre-op Assessment (POA) WH SAU (POD) WH SMW4 SMH 95% SMW6 SMH 91% SMW7 (Plastics) SMH 87% Urology WH 84% Division Ward/Department Site Results (%) 10 WH 7 WH 92% 9 WH 96% ANC (Antenatal Clinic) SMH 90% Antenatal/Gynae Clinic WH 86% Delivery Suite SMH 93% Labour Ward WH 91% NICU SMH 97% Rothschild SMH 89% SCBU WH 94% SMW3 (MPU) SMH 98% SMW9 SMH 85% WACU (11) WH 88% Page 58 of 81

60 NSIC CLINICAL SUPPORT SERVICES MEDICINE Results of Ward/Kitchen Audit Undertaken April March 2010 Division Ward/Department Site Results (%) 1A WH 3B WH 90% 4A WH 4B WH 62% 6B WH A & E SMH CCU (2A) WH 96% Day Hospital SMH Drake Day Unit WH EAU (SMW10) SMH 93% EMC (A&E) WH Endoscopy SMH N/A Endoscopy WH N/A Heberden AH 70% MAU WH SMW1 SMH 86% SMW2 SMH 81% SMW20 SMH 77% SMW22 SMH SMW5 SMH 83% SMW8 SMH 56% Stroke Unit (5B) WH 96% Wilkinson AH 83% Hayward Unit AH 83% Division Ward/Department Site Results (%) 5A WH CCHU SMH Dermatology OPD AH No Kitchen OPD SMH No Kitchen OPD WH No Kitchen OPD AH 72% Sunrise Unit WH X-Ray AH X-Ray SMH X-Ray WH No Kitchen X-Ray Ultrasound SMH Division Ward/Department Site Results (%) Spinal Gym SMH Spinal OPD SMH 93% St Andrews SMH 69% St David SMH 79% St Francis SMH St George SMH 82% St Josephs SMH St Patrick SMH 75% Page 59 of 81

61 WOMENS & CHILDRENS SURGERY Division Ward/Department Site Results (%) 12A WH 86% 12B WH 100% 7 WH Burns Unit (SMW11) SMH 81% Day Surgery Unit SMH Day Surgery Unit WH 79% ENT Pre-op Assessment on 3A WH Gynae Recovery WH N/A Gynae Theatres WH N/A ITU SMH 81% ITU WH 77% Loakes Recovery WH N/A Loakes Theatres WH Main Recovery WH N/A Main Theatres WH 54% New Wing Theatre SMH N/A Ophthalmic OPD SMH Ophthalmic Theatres & Recovery SMH 94% Ophthalmic Ward SMH 72% Oral Surgery AH Oral Surgery OPD SMH Plaster Room WH Pre-op Assessment (POA) AH Pre-op Assessment (POA) SMH Pre-op Assessment (POA) WH SAU (POD) WH SMW4 SMH SMW6 SMH 100% SMW7 (Plastics) SMH Urology WH 90% Division Ward/Department Site Results (%) 10 WH 7 WH 100% 9 WH 93% ANC (Antenatal Clinic) SMH N/A Antenatal/Gynae Clinic WH 62% Delivery Suite SMH N/A Labour Ward WH 97% NICU SMH 95% Rothschild SMH 87% SCBU WH 97% SMW3 (MPU) SMH 93% SMW9 SMH 56% WACU (11) WH 86% Page 60 of 81

62 Summary of Audit Results Hand Hygiene Observational Audit Report 2009/10 Conclusions & Discussions This report shows a change in the hand hygiene audit procedure and the new audit tool. The overall compliance level has improved from 90% in 2008/09 to 94% Bare below the Elbows compliance has also improved from 92% to 95%. There has been a great increase in the number of observations recorded from in 2008/09 to The hand hygiene compliance per division ranged from 90% to 99%. Even though the overall divisional scores and staff groups compliance reached the compliance level of 90%, the scores must be assessed by each ward/ department to address areas of low compliance. Recommendations Firstly, it is important that staff are congratulated on this achievement. This report must be discussed at local meetings, Directorate and Clinical Governance meetings. This report must be disseminated Trust wide via the Infection Prevention & Control Directorate Leads, Divisional Nurse Leads and Modern Matrons and fed back to all grades/groups of staff. There must be a system is place to show that ward staff have seen the audit report. If the month s compliance level is below the recommended level then weekly audits must be completed along with an action plan (Appendix 2). This must show how low compliance is being addressed. Even if the overall month s result are above the compliance level, staff who are responsible for the hand hygiene data must look at the month s data. If the data shows certain areas are below the compliance level a mini action plan must be completed to show how these issues are being addressed. All hand hygiene results must be displayed at ward level for public information. Urinary Catheter Care Audit Insertion & Ongoing Management - June 2009 Conclusions & Discussions The insertion part of the audit was based on a total of 40 observations. If at least 20 observations had been made per ward/department then a minimum of 120 observations should have been recorded for the number of wards/departments that submitted data for this audit. This number is significantly lower than the number of observations made in 2008 where a total of 92 observations were made. To achieve robust data from the audit a minimum of 20 observations should be recorded by participating areas. If this cannot be achieved in one audit session then the audit should be repeated on subsequent occasions until a total of 20 observations have been made. A month is given to achieve this number of observations. It is not clear as to why 2 wards on the NSIC submitted data for the first part of the audit and 2 different wards submitted data for the second part of the audit. Thus 4 wards on the NSIC submitted half the data required to complete the full audit. It is not clear as to why the remaining wards did not participate in this audit. Urology Ward only submitted data for the first part and none for the second part of the audit, i.e. no Continuing Care was completed. Loakes Theatres and the Main Theatres at Wycombe Hospital did not complete the audit at all. The reasons for non-participation are not known. Page 61 of 81

63 If an area is unable to participate in an audit a written response stating the reason for nonparticipation should be sent to the Clinical Audit Department to avoid areas being listed as not participating. This should only be done once every effort has been made to address the problem by the Matron and/or the Divisional Lead. Compliance for each element of the tool ranges from % for the Insertion part of the audit and there is 100% compliance for Continuing Care. Overall the data collected has shown high levels of compliance although this should be viewed with caution due to the low numbers of observations achieved. Compliance levels achieved for 2009 are higher compared to those for 2008, which is encouraging and demonstrates good compliance can be maintained and improved upon. All elements performed has shown an increase in the compliance levels for This is a good indicator for individual patient care. Recommendations This report should be discussed at local unit meetings, including Clinical Governance meetings. This report should be disseminated Trust wide via the Divisional Nurse Leads and Modern Matrons and fed back to all grades/groups of staff. Areas with low compliance or non participation must produce an action plan to show how they are addressing these issues and how they are monitoring compliance. The audit will be repeated as per the audit programme. Care Bundle for Ventilated Patients June 2009 Conclusions & Discussion This is the second time that a Trust wide audit for the Care of Ventilated Patients has been carried out. Regular Observations Compliance for individual elements by ward/area ranged from 0% to 100%. St Andrew s recorded 18 observations which could affect the robustness of their results. At least 20 observations per area were requested which is the minimum number of observations needed for a robust audit. A number of elements performed achieved audit results below the recommended 85% on St Andrew s Ward. In particular they recorded a 0% result for the sedation hold element, which led to a 0% result for all elements performed, which is of concern. Particularly as this is the same result as the ventilator audit for last year, indicating that there has been no improvement from last year s audit. However, the 0% compliance for sedation hold may be inaccurate; as the patients being nursed on St Andrew s may not need to be treated with sedation. This would mean that the section for sedation hold would become Not Applicable and should be marked on the audit sheet accordingly. If this is the case the all elements performed result for St Andrew s Ward would be 17%, still very low. An action plan must be created by St Andrew s to identify the areas for improvement. Overall, there was an improved score of 72% being achieved across the 3 areas, compared with 62% for the previous year, which can only be attributed to the improved audit result for the ITUs. Continuing Care Suctioning etc It is not clear as to why St Andrew s and also ITU on the Stoke Mandeville Site did not complete the continuing care-suctioning part of the audit. St George s did complete this section of the audit but did not complete the first part and no explanation for this was given. Page 62 of 81

64 If an area is unable to participate in an audit, a written response stating the reason for nonparticipation should be sent to the Clinical Audit Department to avoid areas being listed as not participating. This should only be done once every effort has been made to address the problem by the Matron and /or the Divisional Lead. Recommendations This report should be discussed at local unit meetings, including Directorate and Clinical Governance meetings. This report must be disseminated Trust wide via the Divisional Nurse Leads and Modern Matrons and fed back to all grades/groups of staff. Areas that have not achieved an 85% compliance level must undertake weekly ventilator audits for four weeks or produce an action plan on how they intend to achieve this. The audit will be repeated as per the audit programme. VIP Form Audit June 2009 Conclusions & Discussions The results of this audit are not comparable to the previous audit results due to the format of the results being different. The results are calculated and presented by division at their request. The VIP chart was introduced across the Trust to assist staff in documenting infection prevention and control aspects of care relating to IV devices. Factors influencing infection can be patient susceptibility, type of cannula, method of insertion, purpose of cannula and duration of Cannulation. Daycase VIP stickers are available for use with patients whose IV devices is going to be insitu less than 24 hours. Catheter Related Blood Stream Infections are a major cause of morbidity and mortality. Bloodstream infections associated with insertion and maintenance of IV access devices are among the most dangerous complications of healthcare that can occur. MRSA bacteraemia required investigation. The VIP chart is vital in gathering information relating to IV device insertion and evidence of whether devices were assessed daily or documented each time accessed. Overall 95% of patients with IV devices had VIP forms, with Divisions reaching a compliance level of 91% and above. This is an improvement on last year s figure of 85%; however we must achieve 100% compliance with this. All patients who have an IV device inserted should have a VIP chart. The VIP chart must be started by the person putting in the device. It is essential that accurate records of IV devices are maintained for all patients. The total number of observations was high and included a good representation of wards Trust wide. Please refer to section for areas that participated in the audit. Compliance regarding the documentation of the insertion of the IV device ranged from person inserting 74% to insertion documented 91%. Compliance with documenting date/time of insertion was 81%, a significant improvement from last year s figure of 44%. Date and time of insertion must be completed, as this determines how long the device is in and when it should be removed. Compliance for documenting type of cannula and position of cannula has reduced. Results for removal of IV device documented range from 70%, reason for removal, to 78%, removal documented. Only 63% were documented each time accessed, which was only 1% improvement on the previous audit. Overall 58% of IV giving sets were labelled. This is an improvement on last year s figure of 47%, however further improvement is required. All giving sets must be labelled as this allows staff to know when administration sets must be changed. Page 63 of 81

65 All applicable elements were performed in only 30% of the 526 cases. This is an improvement on last year s compliance of 14%. It is essential that all elements are performed to ensure the safe management of IV devices; therefore each Division must investigate the areas of low compliance. Recommendations As a result of this audit and analysis of the results the following recommendations have been made: The results of the audit should be disseminated to all areas of the Trust via Infection Control divisional leads, Head Nurses and Ward/Dept Managers. The audit report and associated recommendations should be discussed at all Ward/Unit meetings in addition to Clinical Governance and Head Nurse Meetings. The results of the audit are to be reviewed by Nurse Divisional Leads and an action made to address issues identified and areas of non-participation. This should then be forwarded to the Infection Control Divisional lead and progress monitored through the Clinical Governance Framework. Educational sessions must be updated to include information from the audit. Focus should be on areas on low compliance. All patients with an IV device in situ, including CVC lines and Hickman lines, must have a VIP chart commenced on insertion. All staff including medical and anaesthetists are to be reminded of their responsibilities regarding this. Day case stickers can be used for patients where it is known that the IV device is insitu for 24hours or less. A VIP form must be commenced if the IV device then stays insitu longer than 24 hours. Areas which use the day case sticker can participate in the documentation of insertion and removal of the IV device within the audit. VIP charts should be checked during Matrons rounds and areas of low compliance must be highlighted and feedback in real time to be addressed. Snap shot audits should be completed within Divisions/ wards to monitor compliance levels of areas highlighted. Peripheral Line Audit June 2009 Conclusions & Discussions Peripheral IV Line Insertion In total 226 observations were made from 32 wards/areas. This is a decrease of observations but an increase in wards/areas participating compare to the previous years audit (279 observations from 28 wards/areas. There continues to be an improvement year on year with a compliance level of 87% for all elements performed compared to 76% in June 2008; however with small numbers of observations and less wards/ areas participating it is not possible to draw any specific conclusions. Key acute wards within Medicine and Surgery did not participate. Please refer to section for these areas. On-going Management of IV Lines. There has been a decrease in observations from 437, in June 2008, to 253 with a similar number of wards/areas participating. The compliance level for all applicable elements performed has decreased with a level of 68% compared with 73% in June 2008; however with small numbers of observations recorded it is difficult to compare results. Key acute wards within Medicine and Surgery did not participate. Please refer to section for these areas. Page 64 of 81

66 The non-participation of some wards/areas and the participation of a very different selection of wards/areas in each audit causes problems when undertaking audits such as these. It is not possible to draw valid conclusions from data that isn t comparable. Concerns continue to be raised that the non-participation of some areas will not highlight areas of good practice or risks to be identified. Recommendations As a result of this audit and analysis of the results the following recommendations have been made: The results of the audit should be disseminated to all areas of the Trust via Infection Control divisional leads, Head Nurses and Ward/Dept Managers. The audit report and associated recommendations should be discussed at all Ward/Unit meetings in addition to Clinical Governance and Head Nurse Meetings. The results of audit are to reviewed by Nurse Divisional Leads and an action to address issues identified. This should then be forwarded to the Infection Control Divisional lead and progress monitored through the Clinical Governance Framework. When completing the audit more emphasis must be put on increasing the number of observations. A MINIMUM of 20 observations of practice must be undertaken for the audit to assist with data analysis. This may mean that the audit will need to be performed on more than one occasion, throughout the month. Head Nurses and IC Divisional leads must ascertain the reasons why areas have not participated in order to ensure that all areas participate in future audits where applicable. This will provide data that is more meaningful, reliable and comparable. Some areas may need to participate in insertion and/or on-going management. In future if an area is unable to participate in an audit, a formal response stating the reason for non participation must be sent to the Clinical Audit Department. This should only be done once every effort has been made to address the problem by the Modern Matron and Divisional Lead. The ICT should review the suitability of this audit to all departments and determine whether specific areas should be targeted where the number of peripheral lines is highest. Results of the audit should be included in the divisional IC performance template by IC divisional leads. Use of the VIP chart must continue to be promoted and its initiation on insertion and management of devices improved. This to be addressed through education sessions, i.e. IV therapy, venepuncture and cannulation and ward handover between staff. The Daycase Stickers are available to be used in areas such as haematology out-patients, radiology, day surgery etc. These areas should then participate in the Peripheral IV line Insertion elements. Information on the type of staff inserting lines must be included to assist analysis of data to identify where educational input may be required. All IV administration sets should be labelled using the recommended labels and changed in line with the IC policy section 2.2. Red emergency lines stickers should be used on all lines inserted in emergency situations and potentially non-aseptic conditions and are then replaced as soon as possible. All aspects of Peripheral IV line insertion and ongoing Management of IV lines must be included in education sessions such as IV therapy teaching sessions. It is not the responsibility of just the Link nurses to complete the observations. Many staff should be involved in completing the audits. They should be supported by the ward to ensure that observations are undertaken on as many occasions as possible (including night duty) and to share the workload and increase participation at ward level. Ward/dept managers and head nurses must ensure that all completed audits are returned to the Clinical Audit Department at the required time in order to assist prompt analysis of data and report dissemination. This enables provision of more meaningful data. This audit should be repeated as per the current Infection Control programme of audit. Page 65 of 81

67 Infection Control Knowledge Survey October 2009 Conclusion Infection Control mandatory training has been delivered since 2006, it was initially undertaken by an external agency called Infection Control Solutions, however in 2008 the Trust Infection Control Team took over the training and rewrote the sessions. We provide clinical and non-clinical mandatory training sessions. The return rate to this questionnaire was 39%, similar to last year. On reviewing the results of the audit the following areas need more emphasis in mandatory training: Alcohol hand gel is not appropriate after caring for patients with Norovirus. The appropriate use of alcohol hand gel after administering an injection and when caring for MRSA positive patients (the results were similar last year). The need to wear personal protective equipment (PPE) when clearing up blood spillages. A copy of the Infection Control Manual is in the library. A theatre mask must be worn when entering a patient s room with influenza when there are no aerosol generating procedures/risk of splash to eyes. On average a good proportion of staff feel confident to challenge staff about bare below elbows (BBE) and/or hand hygiene practice. 87% of staff have had infection control mandatory training in the last year and 66% of staff felt that, by having infection control training, this has changed their practice. 29% of staff felt training did not change their practice however from the comments made by some staff they felt they were already adhering to good infection control practice and it was a good revision session to raise awareness. The inclusion of the two questions asking whether infection control was included in appraisal and PDP (Personal Development Plan) is to demonstrate compliance with the Health Act. The audit showed that 46% had it included at appraisal and 39% in their PDP, a slight improvement on last years results. Free text comments received highlighted more general problems with lack of appraisal and understanding of what a PDP is. Recommendations Share the results of this survey to all wards and departments. Highlight key areas where there is poor understanding in the Infection Control Times. Use the results to focus the infection control mandatory training. Review audit tool prior to reuse to incorporate any additional items. The plan is for infection prevention & control to be delivered by E-Learning modules this coming year. Page 66 of 81

68 Action Plan Recommendations Planned Action Person Share the results of this survey to all wards and departments Highlight key areas where there is poor understanding in the Infection Control Times Use the results to focus the infection control mandatory training and the issues raised should also be worked into other sessions as appropriate (e.g. sessions for junior doctors and HCA induction) Review audit tool prior to reuse to incorporate any additional items Send copy of completed audit via to all relevant staff Responsible IPCT/DIPC Method of Monitoring Raise at Sisters meeting and N&MB Deadline for Completion End April to all users IPCT N/A May 2010 Review and update teaching sessions IPCT IPCT Repeat audit 2010 Pilot on a small sample of staff prior to re-audit June 2010 September 2010 August 2010 Infection Control Clostridium difficile Policy Audit October 2009 Conclusions The limitations of the audit are that it analyses only a small cohort of patients over a short time period. In spite of this it highlights the importance of identification of patients who might be at risk of C.difficile, starting appropriate treatment and ensuring that 3 rd parties who would be involved in the patient s care after the patient is discharged are informed. Perhaps this most important point which comes out of this audit is that in 43% of cases there was no mention of C.difficile infection in the discharge summary which goes out to general practitioners. Recommendations: Early isolation of patients into side rooms if they develop diarrhoea Early submission of stool samples to the lab (the lab offer a same day result if the sample arrives before 2pm) Providing patients or their relatives with leaflets of isolation and C.difficile infection and documenting this on the sticker in the notes. Stool chart monitoring with daily entry, even if there was no bowel movement Starting treatment of the day of diagnosis Filling in the C.difficile letters and sending them to the GP and ICT Indicating on the discharge letter that the patient had C.difficile and was treated for it in the hospital. Buckinghamshire Hospitals are doing their best to ensure that they reduce the risk of C.difficile in their patients. The microbiology department and infection control team do a weekly ward round to review these patients in the wards and give advice on how to improve their management. A weekly antibiotic ward round has also recently started in Stoke Mandeville Hospital where the consultant microbiologists review the antibiotic prescribing practises in different wards to help reduce the inappropriate use of antibiotics. Page 67 of 81

69 With this audit we have highlighted some areas for possible improvement which can be done to improve patient care. Action Plan Issue Findings Action Required Lead Target Date Time interval from onset of symptoms to submission of first stool sample. Only 20% of samples were sent on the same day. Ward staff to be reminded to send samples promptly from symptomatic DLNs ASAP Review March 2010 Interval from diagnosis or onset of symptoms to isolation. C diff sticker in notes. C diff information leaflet provision to patient documented in notes. 50% were only isolated on day after onset/diagnosis or later. Present in 100% (put in by IPCN). Documented in 40%. patients. Patients need to be isolated within 4 hours of onset of symptoms (Trust requirement). DLNs C diff sticker needs to be completed fully by clinical staff. DLNs/Divisional Chairs. ASAP Review March 2010 ASAP Review March 2010 Isolation leaflet provided to patient and documented in notes. Stool chart present and daily entry. C diff treatment started on day of diagnosis C diff should be mentioned on discharge documentation. Copy of C diff GP letter to be returned to IPCT. Documented in 50%. C diff sticker needs to be completed fully by clinical staff. 70% compliance. Ward staff to be reminded of importance of daily entry. 80% compliance. Medical staff to be reminded to start treatment promptly. 43% compliance. Medical staff to be reminded to mention this on Discharge Summary and complete C diff GP letter pro forma. 29% compliance. Ward staff to be reminded of this. DLNs/Divisional Chairs. DLNs Divisional Chairs. Divisional Chairs. DLNs ASAP Review March 2010 ASAP Review March 2010 ASAP Review March 2010 ASAP Review March 2010 ASAP Review March 2010 Page 68 of 81

70 MEDICINE CLINICAL SUPPORT SERVICES ACCESS Ward/Departmental Environmental Audit Results Undertaken 2009/2010 Division Ward/Department Site Results (%) Comments OPD SMH 73% OPD WH 94% OPD AH 69% POA SMH 95% POA WH 94% POA AH #DIV/0! Division Ward/Department Site Results (%) Comments 5A WH 98% Breast Screening SMH 100% Breast Screening WH 85% CCHU Haematology/ Cancer SMH 100% Care Clinical Photography SMH 98% Clinical Photography WH 90% Clinical Photography AH 90% Dietetic Clinic SMH #DIV/0! Dietetic Clinic WH #DIV/0! Dietetic Clinic AH #DIV/0! Orthotist SMH #DIV/0! Orthotist WH #DIV/0! Orthotist AH #DIV/0! Pharmacy SMH #DIV/0! Pharmacy WH #DIV/0! Pathology SMH #DIV/0! Pathology WH #DIV/0! Plastics OPD SMH #DIV/0! Radiology SMH 95% Radiology WH 98% Radiology AH 100% SLT Clinic SMH #DIV/0! SLT Clinic WH #DIV/0! SLT Clinic AH #DIV/0! Sunrise Unit WH 98% X3 MSK SMH #DIV/0! X3 MSK WH #DIV/0! X3 MSK AH #DIV/0! Division Ward/Department Site Results (%) Page 69 of 81 Comments 3B WH 94% 4A WH #DIV/0! 4B WH #DIV/0! 5B (Stroke Unit) WH #DIV/0! 6A WH 63% 6B WH 92% A & E SMH 92% CCU (2A) WH 85% Cardiac Day Unit & Lab WH #DIV/0! Day Hospital SMH #DIV/0! Dermatology OPD AH 95% Drake Day Unit AH #DIV/0! EAU (SMW10) SMH 100% EMC WH 89% Endoscopy SMH 100% Endoscopy WH #DIV/0! Relocated to be done in March

71 SURGERY NSIC GUM Clinic (SHAW) WH #DIV/0! Hayward Unit WH #DIV/0! Heberden AH 98% MAU WH 82% SMW1 SMH 100% SMW2 SMH 98% SMW20 SMH 98% SMW22 - escalation ward SMH #DIV/0! time audit due SMW5 SMH 94% SMW8 SMH 94% Wilkinson Ward AH 89% Division Ward/Department Site Results (%) St Andrews SMH 77% St David SMH 95% St Francis SMH 82% St George SMH 92% St Josephs SMH 97% St Patrick SMH 84% Spinal Gym SMH 90% Spinal OPD SMH #DIV/0! Occupational Therapy SMH 100% Cystoscopy SMH #DIV/0! Hydrotherapy SMH #DIV/0! Division Ward/Department Site Results (%) 12A WH 92% 12B WH 87% Burns Unit (SMW11) SMH 95% Burns OPD SMH 89% Day Procedures Unit SMH 84% Day Surgery Unit WH 94% Delivery Theatre SMH #DIV/0! ENT Clinic OPD SMH 95% ENT POA WH #DIV/0! Gynae Recovery SMH 91% Gynae Theatres SMH 100% ITU SMH 74% ITU WH 73% Loakes Recovery WH #DIV/0! Loakes Theatres WH 84% Main Recovery WH 95% Main Theatres WH 93% New Wing Theatre SMH 64% New Wing Recovery SMH #DIV/0! Ophthalmic OPD SMH 94% Ophthalmic Theatres SMH #DIV/0! Ophthalmic Ward SMH #DIV/0! Oral Surgery AH #DIV/0! Orthodontic OPD AH 97% Orthodontic OPD SMH 94% Orthodontic Theatres SMH #DIV/0! Plaster Room WH 98% Plaster Room SMH 100% SAU (POD) WH 94% SMW4 SMH 98% SMW6 SMH 100% Comments Comments Page 70 of 81

72 WOMEN'S & CHILDREN'S SMW7 (Plastics) SMH 95% Urology WH 95% Division Ward/Department Site Results (%) Antenatal Clinic SMH SMH 90% Antenatal & Gynae Clinic WH #DIV/0! WH Aylesbury Birth Centre SMH 100% Childrens Day Unit WH 68% Gynae OPD SMH SMH #DIV/0! Gynae OPD WH WH #DIV/0! Labour Ward SMH 98% NNU SMH 97% Rothschild Ward SMH 94% SMW3 Paediatrics SMH #DIV/0! SMW9 SMH 100% Paediatric OPD SMH #DIV/0! Paediatric OPD WH #DIV/0! Wycombe Birth Centre WH 77% Comments Preventing Surgical Site Infection Conclusions Pre- Operative component. There weren t any positive MRSA results during the period of the audit but Pre-operative Assessment should still be congratulated on the hard work put in to keep the process working. Peri Operative Component. Unfortunately this section was not completed as per the audit programme. This component should have been completed January to March 2010 but only February to March was submitted. The audit should have only included total hip and knee replacements (primary& revisions) and any resurfacing. Following discussions with theatres, other procedures had been included. Therefore, we are unable to ascertain how reliable the data is in relation to total hip and knee replacements. In some instances a No response was given when maybe Not applicable was more appropriate, e.g. o Hair removal 132 No s were documented, o Glucose monitoring 17 No s were documented In the section regarding antibiotic prophylaxis within 30 minutes 22 No s and 27 Not applicable s were submitted. All of the procedures mentioned above must have antibiotic prophylaxis unless it is a revision and samples are being taken. If this is the case it must be clearly documented on the audit form. All elements were performed correctly for only 117 patients (62%), which is lower than when the peri-operative section was completed in RECOMMENDATIONS The audit must be completed as per the audit programme. Other specialities will complete the audit quarterly over a period of a week. This will include the post operative and the peri-operative sections. Loakes theatres will complete the audit over the three month period (Oct to Dec 2010), hips and knees only. Page 71 of 81

73 When the audit is being completed staff must know the correct process. Training must be put in place if relevant. The issue of non-compliance must be discussed at all relevant meetings ( theatre meetings, clinical governance meetings etc). This report and the results and the issues highlighted must be disseminated to all relevant staff. Divisional Nurse Lead to complete an action plan to address the issues highlighted. All the action must be signed off by the Divisional Nurse Lead (Anne Walker) as completed. To liaise with the Infection Prevention and Control Nurse for any support or guidance in relation to completing this audit in the future. ACTION PLAN Issue Date 22 June 2010 Ward Surgery Division Action Taken All peri-operative components of audits responsibility of Matron to ensure completion. Planned Completion Date June 2010 Further Action Required Matrons to do daily checks audits are being completed. Audits to be collected weekly and checked for accuracy. Matrons to confirm to DLN weekly that audits have been completed. Matrons to request training/education for staff from infection control on audit completion if required/identified. Person Responsible J Eldridge D Panikkar J Benson Signature on Completion Information from audit including non compliance to be discussed at Clinical Governance and Divisional Meetings July 2010 Theatre Matrons to present at Clinical Governance Meeting. DLN to present at Divisional Board. Theatre Matrons Anne Walker Information from audits to be shared with staff during audit half day on all sites. August 2010 Presentation to all staff members to be managed by theatre matrons including impact of non compliance. J Eldridge D Panikkar J Benson Page 72 of 81

74 Central Venous Catheter Care October 2009 Conclusions & Discussion The staff on the Intensive Therapy Units (ITU) are to be congratulated in achieving a score of 100% in all elements and for achieving a significant improvement since the last central line audit in They have achieved a result based on 48 observations (ITU WH) and 21 observations (ITU at SMH), which is just above the minimum number of observations required to ensure robust data) Recommendations As a result of this audit and analysis of the results the following recommendations have been made: This report should be discussed at local unit meetings, including Directorate and Clinical Governance meetings. This report should be disseminated Trust wide via the Divisional Nurse Leads and Modern Matrons and fed back to all grades/groups of staff. Results of the audit should be included in the directorate IC performance template by IC directorate IC leads. Use of the VIP chart should continue on insertion and management of devices. This audit should be repeated as per the current Infection Control programme of audit. The results of this audit should be displayed to promote the very high quality of care provided by the ITU staff for their patients Infection Control MRSA Policy Audit January 2010 Conclusions: Of the 13 cases of MRSA diagnosed in November 2009, 7 fulfilled admission screening criteria and 5 were subsequently screened. The proportion of cases given suppression treatment once identified as MRSA carriers was less (10/13) than compared to our previous audit (22/23) but again we found there was minimal delay in starting therapy. There was generally poor documentation in the medical notes about the patient receiving an MRSA or isolation leaflet. In only 5/13 cases was the giving of an Isolation Leaflet documented in the notes. Although this is not specified in the MRSA Policy, it is good practice for all isolated patients, including those in MRSA cohort bays. In general, the documentation of informing patients, providing documentation and isolation was poor. Despite the provision of an MRSA sticker in the medical record in 11/13 patients notes, only 3/11 were fully completed. Important information is therefore missing in patient records. All cases were isolated and there were no undue delays in isolation (>1 day from date of diagnosis), this is a vast improvement on last year s audit in which the isolation of 6/18 cases at SMH were delayed; however, documentation of isolation in the medical notes was generally very poor. The labelling of patient notes with an Alert sticker (11/13) appeared to be as well done as in the previous audit (22/23) but we noted problems with labelling sets of notes subsequent to that documenting the time of the index event, this is especially important as patients with multiple sets of notes tend to have a more complicated medical history and be more at risk of exposure to and colonisation with MRSA. Good points noted: The electronic patient record was flagged for every case identified this is the best result yet shown in auditing our MRSA Policy compliance. There were no undue delays in isolating patients once found to be MRSA+. Page 73 of 81

75 Suppression therapy was started promptly in 12 cases, the one case in whom suppression therapy was not started had already been discharged by the time the result became known. Action Plan: MRSA Audit Action Plan Issue Action Who to do Target date for completion MRSA Sticker Isolation CRS Ensure this is completed within 2 days of being affixed. 1) Isolation of patient to be documented in the patient s notes. This should include the time of notification of the need for isolation and the time the patient was isolated. 2) Isolation should be recorded in the IPCN notes. Reasons for delayed isolation should be clearly documented. 3) Any delay in Isolation (>4 hrs) to be recorded as a Clinical Incident. Wards need to ensure that patient location is documented promptly and accurately Ward Sister April 10 Ward Staff April 10 IPCN April 10 Ward Staff April 10 Ward Managers April 10 Transfer Form Audit 2010 Conclusions & Discussion The Infection Control Transfer Form is rarely used when patients are transferred to a new environment across the trust. Infection Control information is communicated using a variety of forms. However the type and amount of information differs widely and the forms are often difficult to find, especially when the patient has been an in-patient for a long period and has had several transfers. Verbal handovers were often documented and it is possible that infection control information was transferred in this way but there was no written evidence of this. Recommendations Although infection control information is communicated in various ways using a variety of forms, only the Infection Control Transfer Form should be used with all patients on discharge or transfers for conveying information about any infection risk. Compliance needs to be improved. Wards should be made aware of the audit results and education needs met. This can be done by raising awareness at Head Nurses/Sisters meetings and cascading down. Page 74 of 81

76 Matrons/Sisters are responsible for implementing the use of the Infection Control Transfer Form within their areas and monitoring compliance. If discharge/ transfers packs are available then the Infection Control Transfer Form must be included within the pack. The importance of using the Infection Control Transfer Form should also be included in infection control study sessions. Pathways to communicate information with CHB and the BHT need to be developed. An action plan must be completed to address the issue of low compliance and returned to the relevant IPCN for each division. Re-audit in 6 months INFECTION CONTROL TRANSFER FORM AUDIT ACTION PLAN FINDING ACTIONS REQUIRED LEAD DUE DATE 1. Each ward to be aware of the Start immediately need to use this form on transfer Matron Re-audit June 2010 of any patient. IC Transfer Forms not being used on the transfer of a patient either within the Trust or to a Healthcare setting outside the Trust. 2. Each ward to learn how to obtain the form 3. Form used on patient transfer Ward Manager/Sister Ward Manager/Sister Start immediately Re-audit June 2010 Start immediately Re-audit June 2010 Page 75 of 81

77 Workplace Health Tel: Fax: Chichester House Lincoln s Inn Office Village Lincoln Road Cressex Business Park High Wycombe HP12 3RE 1. Summary Buckinghamshire Hospital Needlestick/Sharps/Splash Injury Audit April 2009 to March Needlestick/Sharps/Splash injuries were reported to Occupational Health within the period from 1/4/09 to 31/3/10, with 95% incidences occurring in Wycombe (WH) and Stoke Mandeville Hospitals (SMH). The data suggests that the departments and wards most at risk (with 4+ injuries) are Maternity (11); Theatres/Unknown (11); Accident & Emergency (7); Theatre/Plastics (6); Intensive Care Unit (5); Ward 7 SMH (4) and EMC WH (4). 2. Source of data The information below has been extracted from the Occupational Health Needlestick Injury Database, which is dependant on self reporting from the recipient of the injury. Thus consideration should be given when comparing departments/wards of the possibility that the higher incidences may be due to more diligent reporting as opposed to greater injuries. 3. Location of incident Distribution of incidents across the three hospital sites Within the period from April 2009 and March 2010, 144 needlestick/sharps/splash injuries were reported to Occupational Health. There was a significant higher incidence of injuries within Stoke Mandeville Hospital (43%) and Wycombe Hospital (52%) as compared to Amersham (5%) (see Table 1 below). It is unknown whether these figures are relative to staff numbers. Table 1: Distribution of Injuries within the three hospital sites Hospital Department Wards Amersham 1 6 Stoke Mandeville Hospital Wycombe Hospital The Trust is Smoke Free. Smoking is not permitted on any of our sites. Providing services from Amersham, Stoke Mandeville and Wycombe Hospitals Trust Headquarters: Amersham Hospital, Whielden Street, Amersham, Buckinghamshire HP7 0JD Chairman: Graham Ellis Chief Executive: Anne Eden