North Tees and Hartlepool NHS Foundation Trust Director of Infection Prevention and Control Annual Report 2014-15
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Contents Page 1. Executive Summary 4 2. Infection prevention and control arrangements 5 3. Summary of performance 6 3.2 MRSA bacteraemia 6 3.3 Clostridium difficile diarrhoea 7 3.4 MSSA bacteraemia 8 3.5 E coli bacteraemia 9 3.6 Hand hygiene 9 3.7 Outbreaks 10 4. Policies 11 5. Antimicrobial stewardship 12 6. Environmental and equipment decontamination 13 7. Other significant issues 14 7.1 MRSA colonisation 14 7.2 Group A Streptococcus 14 7.3 Ebola 14 Appendix 1 IPC Annual programme 2015-16 16 3
1.0 Executive Summary 1.1 2014-15 was another successful year for the Trust with regard to Clostridium difficile infection (CDI) with a 33% reduction on the previous year and a final figure that was 50% under trajectory. Unfortunately the same improvements were not made for MRSA, MSSA and E coli bacteraemia (blood stream infection) all of which showed a slight increase on last year. A similar pattern has been seen in non-trust attributed cases of these infections, with a reduction in C difficile and increases in MSSA and E coli bacteraemia. 1.2 This has been a challenging year, and a particularly challenging winter with unanticipated levels of activity over an extended period leading to significant pressures on all parts of the Trust. The fact that we were still able to achieve such a reduction on CDI is testament to the hard work and commitment of all of our staff from ward to board. 1.3 The Trust puts infection prevention and control at the heart of good management and clinical practice, and remains committed to ensuring that appropriate resources are allocated for the effective protection of patients, visitors and staff. 1.4 There were 20 cases of Trust attributed CDI during this year against a trajectory of 40 cases. 1.5 There was one case of Trust attributed MRSA bacteraemia this year against a trajectory of zero. 1.6 There were 18 cases of MSSA bacteraemia and this means that the Trust s internal ambition to have less than 13 cases was not achieved. 1.7 The mean hand hygiene compliance score for the Trust was 92.97% for the year. and Director of Nursing, Patient Safety and Quality Cath Siddle 4
2.0 Infection Prevention and Control (IPC) Arrangements 2.1 The infection prevention and control department provides a service to the University Hospitals of North Tees and Hartlepool and to parts of Peterlee Community Hospital and One Life in Hartlepool. 2.2 The service is delivered and facilitated by a team which includes Infection Control Doctor/ Consultant Microbiologist Assistant Director of Nursing/ Infection prevention and Control Infection Prevention and Control Assistant Matrons Infection Prevention and Control Nurses Clerical Support 2.3 The team is supported by an Antimicrobial Pharmacist, Biomedical Scientist (link to pathology department) and Consultant Microbiologists and a group of link workers across all departments. 2.4 The is the Executive Director of Nursing, Patient Safety and Quality. 2.5 The ing arrangements for the Infection Prevention and Control Team (IPCT) are shown in Figure 1 below. The IPCT is also represented on various forums across the Trust including Patient Safety and Quality Standards Committee, Patient Safety Committee, Health and Safety Committee, Routine Cleaning Group, Uniform and Personal Appearance Committee, Drug and Therapeutics Committee, Estates Capital Projects Group and Decontamination Group. Fig 1 Reporting arrangements Trust Board Patient Safety & Quality Standards Committee IPCT Infection Control Committee C difficile assurance panel Operational Group 2.6 The IPCT has a budget which covers pay and non pay expenses. Additional costs relating to outbreaks and investigations requiring testing of samples at reference laboratories are separately funded. Service Level Agreements with local hospices, an independent hospital and a community network are in place and generate a small income. 2.7 The IPCT works to an annual programme to cover all aspects of the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance. The programme for 2015-16 can be found at Appendix 1. 5
3.0 Summary of Performance 3.1 The IPCT carries out a programme of surveillance to meet both mandatory and local requirements. The Department of Health requires mandatory surveillance of: Methicillin resistant Staphylococcus aureus (MRSA) bacteraemia (blood stream infection) Clostridium difficile diarrhoea Methicillin sensitive Staphylococcus aureus (MSSA) bacteraemia E coli bacteraemia 3.2 Methicillin resistant Staphylococcus aureus (MRSA) bacteraemia 3.2.1 MRSA is a strain of Staphylococcus aureus that is resistant to a number of antibiotics and is capable of causing a wide range of infections, including blood stream infections (bacteraemia). MRSA is carried on the skin or in the nose of a number of people without causing them any harm, but under the right circumstances the bacteria can enter the body and lead to infection. In previous years the Trust has been responsible for all MRSA bacteraemia regardless of whether they were hospital or community attributed. From April 2010 a new MRSA objective was introduced, with acute Trusts being responsible only for reducing those cases which were identified two or more days after the day of admission, whilst still being responsible for ing all cases processed by their laboratories. 3.2.2 In 2014-15 one case of MRSA bacteraemia attributable to the Trust was ed. This was disappointing as there has been a period of two years without a case, and even more disappointing because the sample was agreed as a contaminant, and therefore preventable. Each case is thoroughly investigated using the Post Infection Review (PIR) process introduced by the Department of Health in 2013 to ensure lessons are learned and errors are not repeated. The outcome of the PIR is shared with the Executive Team, directorate, commissioners and wider Trust staff. Table 1 shows the number of cases per year since 2007/8 and also the rate per 100,000 bed days. Figure 2 shows the cases per quarter since 2006 and demonstrates a significant improvement made overall. 3.2.3 The Trust is also required to any cases not attributed to the organisation. In 2014-15 there were 2 such cases, both of which were fully investigated in collaboration with commissioners. No learning for the Trust was identified from either case. Table 1. MRSA bacteraemia cases annual numbers and rates 6 Year 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 No of Trust 16 9 5 4 0 2 0 1 attributed cases ed Rate per 100,000 bed days 7.5 3.7 2.3 1.9 0.0 0.9 0.0 0.5
Fig.2 MRSA bacteraemia (Trust attributed cases) 2006-15 No of cases 10 9 8 7 6 5 4 3 2 1 0 Apr-Jun 06 Jul-Sep 06 Oct-Dec 06 Jan-Mar 07 Apr-Jun 07 Jul-Sep 07 Oct-Dec 07 Jan-Mar 08 Apr-Jun 08 Jul-Sep 08 Oct-Dec 08 Jan-Mar 09 Apr-Jun 09 Jul-Sep 09 Oct-Dec 09 Jan-Mar 10 Apr-Jun 10 Jul-Sep 10 Oct-Dec 10 Jan-Mar 11 Apr-Jun 11 Jul-Sep 11 Oct-Dec 11 Jan-Mar 12 Apr-Jun 12 Jul-Sep 12 Oct-Dec 12 Jan-Mar 13 Apr-Jun 13 Jul-Sep 13 Oct-Dec 13 Jan-Mar 14 Apr-Jun 14 Jul-Sep 14 Oct-Dec 14 Jan-Mar 15 3.3 Clostridium difficile diarrhoea 3.3.1 Clostridium difficile is an organism that causes diarrhoea, usually following antibiotic usage in vulnerable patients. This can cause complications such as pseudomembranous colitis which is a severe inflammation of the bowel, and can be life threatening. A reduction target/ objective for Clostridium difficile infection (CDI) has been in place since 2007. 3.3.2 2014-15 has been a very successful year in terms of reducing the number of Trust attributed CDI cases ed. Only 20 cases against a trajectory of 40 were ed. This represents a 33% reduction on the previous year and is the result of all the work carried out by staff in clinical areas to improve environmental and hand hygiene, antibiotic prescribing and general infection prevention practices. Patients who do develop the infection are closely managed and receive daily visits from an Infection Prevention and Control Nurse. Our patients are also followed up by telephone after discharge from hospital, to provide advice and support should symptoms recur. Table 2 shows the annual figures for CDI since 2007-8 and Figure 3 shows the cases by month since April 2012. 3.3.3 The Trust was shortlisted for the Infection Control category in the Nursing Times Awards 2014 for the multidisciplinary leadership approach to CDI. Although we were not successful in winning the category, to be shortlisted from such a high quality of applicants was an achievement in itself. Table 2. Clostridium difficile cases annual numbers and rates Year 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 No of Trust 210 158 136 53 68 61 30 20 attributed cases ed Rate per 100,000 bed days 99.3 66.3 60.5 25.9 35.0 29.9 15.2 9.8 7
Figure 3. Trust attributed CDI cases 2002-15 10 9 8 7 6 5 4 3 2 1 0 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sept-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sept-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sept-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 3.4 Methicillin sensitive Staphylococcus aureus (MSSA) bacteraemia 3.4.1 Staphylococcus aureus is a bacterium commonly found on human skin which can cause infection if there is an opportunity for the bacteria to enter the body. In serious cases it can cause blood stream infection. MSSA is a strain of these bacteria that can be effectively treated with many antibiotics. The Trust has been carrying out voluntary surveillance of MSSA bacteraemia cases since mid 2007 however the organism became part of the mandatory surveillance programme from April 2011. No reduction target is set for this infection. Root cause analysis is carried out for all Trust attributed cases. 3.4.2 In 2014-15 a total of 18 Trust attributed cases were ed showing an increase on the previous year. This is disappointing, however analysis of the investigations carried out into these cases and genetic typing performed for two suspected clusters of cases shows that they do not appear to have been linked and no common source or practice issues have been identified. The majority of cases had a source of infection that had been treated with appropriate antibiotics and therefore it is difficult to say that the bacteraemia could have been prevented. Table 3 shows the rate of cases per 100,000 bed days since 2008 and Figure 4 shows the monthly cases since January 2009. Table 3. MSSA bacteraemia numbers and rates 8 Year 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 No of Trust 20 11 10 9 11 13 18 attributed cases ed Rate per 100,000 bed days 8.3 5.1 4.9 4.6 5.4 6.5 8.8
Figure 4. Trust attributed MSSA bacteraemia cases 2008-15 4 3 2 1 0 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sept-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sept-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sept-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 3.5 E coli bacteraemia 3.5.1 Escherichia coli are a very common bacterium found in the human gut which can cause serious infections such as blood poisoning. From 1 June 2011 these bacteraemia cases became part of the national mandatory surveillance programme. We began our data collection in April 2011. Both hospital and community cases are entered into the data capture system following enhanced data collection. 3.5.2 A total of 204 cases were recorded during 2014-15, of which 28 were Trust attributed and 176 were acquired in the community based on the same criteria as are used for MRSA and MSSA bacteraemia. This is an increase on the previous year but root cause analysis has not identified any practice related issues in these cases, most of which appear to have been secondary to urinary tract infection in patients with no urinary catheter. There is no reduction target allocated to this infection. 3.6 Hand hygiene 9 3.6.1 Independent observations of hand hygiene practice are carried out in all wards by the Infection Prevention and Control team each month, utilising a tool to measure compliance with the World Health Organisation (WHO) 5 moments for hand hygiene. The information is ed to the Board of Directors at each meeting and is displayed on the Nursing and Midwifery dashboard. Table 4 shows the monthly Trust wide compliance. We believe that the independent observation adds rigour to the process and provides additional assurance. Wards with low compliance receive additional input from the IPCT and repeat observation within the month.
Table 4 Hand hygiene compliance 2014-15 Trust wide % compliance with hand hygiene 2014/15 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 84.97 89.44 95.66 92.00 94.97 92.52 91.61 93.81 94.98 94.09 95.23 96.38 3.7 Outbreaks 3.7.1 Each year there are a number of outbreaks of diarrhoea and/or vomiting which affect patients and staff in the community and in our hospitals. The cause of these outbreaks is usually Norovirus (also known as winter vomiting bug) and this reflects a similar picture in the community, in care homes, schools, nurseries and people s own homes. Outbreaks can have an adverse impact on the business of the Trust because wards can be closed for a number of days, reducing beds available for new patients to be admitted to. This is a serious concern for the Trust and a significant amount of work has gone into reducing the length of time that wards are closed, and providing a timelier and efficient post outbreak cleaning programme. Table 5 below shows the number of outbreaks and staff/patients affected in our Trust during 2014-15, which saw an increase in the number of outbreaks and the total number of patients involved. On a positive note fewer staff were affected despite the number of wards being involved being greater, which may indicate good compliance with hand hygiene and other IPC measures during the outbreaks. Table 5 Outbreaks 2008-15 Year 2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 No of outbreaks 22 21 14 25 22 13 20 No of patients 253 211 163 251 314 291 302 affected No of staff affected 56 51 51 110 79 89 63 10
4.0 Policies 4.1 The Trust has a programme for revision of core infection prevention and control policies as required by the Health and Social Care Act 2008. All policies are available on the Trust Intranet site. Key policies are available to the public on the Trust public website. Policies are audited where appropriate and overall compliance scores are shown in Table 6 below. A reduction in some compliance scores has been noted but this is due to the audits being taken over by the IPCT and therefore being more objective. Table 6. Policies Policy Code Policy Title Status Audit compliance and comparison with previous year IC1 Outbreak Policy For review December 2016 N/A IC2 Hand Hygiene Policy For review May 2016 93% ( 4%) IC3 Infection Control Policy For review May 2016 N/A IC5 CJD Policy Under review at time of N/A ing IC6 MRSA Policy For review July 2015 66% ( 3%) IC7 Management of Viral For review November 2017 N/A Haemorrhagic Fevers incl Ebola Policy IC11 Tuberculosis Policy Under review at time of N/A ing IC12 Local Decontamination of For review August 2016 N/A Medical Equipment Policy IC14 Clinical Specimen Policy For review in May 2016 N/A IC15 Patient Isolation Policy For review February 2017 88% ( ) IC17 Standard Precautions Policy For review April 2017 Standard prec 89 %( 8%) Environmental cleanliness 88%( 8%) IC18 Peripheral Cannulation Policy For review April 2017 Audit underway at time of ing IC19 Clostridium difficile Policy Under review at time of 95%( 7%) ing IC20 MRSA screening Policy For review March 2018 89%( 3%) IC21 Theatre Policy For review October 2015 N/A IC22 Management of Patients For review April 2017 N/A with Ectoparasitic Infestation Policy IC23 Infection Prevention and For review April 2017 N/A Control Surveillance Policy IC24 Management and Control of For review August 2017 N/A CPE Policy C56 Antibiotic Strategy For review April 2018 N/A 11
5.0 Antimicrobial stewardship 5.1 2014/15 has been a busy year in terms of ongoing work around antibiotic prescribing and new initiatives being introduced. 5.2 Antibiotic ward rounds have been expanded. Now, in addition to daily Critical Care ward rounds by the Consultant Microbiologist and Antibiotic Pharmacist, there are also weekly Orthopaedic and Haematology ward rounds. These ward rounds aim to ensure that antibiotic use is optimal at all times and also serves as a learning opportunity for junior doctors to improve their microbiology knowledge. As well as this formal approach to antibiotic review, there is also regular communication between clinicians and Consultant Microbiologists on an ad hoc basis regarding prescribing of appropriate antibiotics for patients both within the Trust and in primary care. As a further aid to antibiotic stewardship, the laboratory only release selected antibiotic sensitivity results, to ensure that only appropriate antibiotic choices are available for selection. Second and third line choices are suppressed, but available to the Consultant Microbiologists for selected patients if required. 5.3 Formal education sessions are also continuing, with additional sessions being provided for foundation doctors, on top of the annual induction sessions which all newly qualified doctors are required to attend. These sessions are multidisciplinary and have consisted of teaching given by the Consultant Microbiologists, Antibiotic Pharmacist and Senior Biomedical Scientists. 5.4 European Antibiotic Awareness Day (EAAD) took place again on 18 November 2014, with various promotional events carried out in the Trust. Stands were situated in the main concourse at both the University Hospital of North Tees (UHNT) and University Hospital of Hartlepool (UHH) (Figure 5), with an additional stand situated in the hospital canteen at UHNT over the lunchtime period to try and catch as many members of staff and the public as possible. Members of pharmacy and microbiology staff also visited the wards to hand out leaflets and pens to highlight to the nurses and doctors about the importance of good antibiotic stewardship. 5.5 To coincide with Antibiotic Awareness Day, a Consultant Microbiologist and the Antibiotic Pharmacist also presented at a Hartlepool and Stockton Clinical Commissioning Group (CCG) Time Out event, attended by GPs, Practice Nurses and Pharmacists and other members from the CCG. It was an opportunity to share our knowledge about the problems surrounding antibiotic prescribing and resistance and the role that primary care can play in helping us to overcome some of the issues. 12
Figure 5 EAAD display 5.6 The Trust Antibiotic guidelines are currently undergoing a full review, and should be available for use from June 2015. These reviews are important to enable us to update treatment in line with new evidence available and also to allow us to cycle our antibiotic use to help prevent resistance to regularly used antibiotics developing. 5.7 Consumption data in terms of defined daily doses (DDDs) continues to be ed, which allows us to monitor our overall use of antibiotics within the Trust. The pattern of use continues to be similar to last year, with higher prescribing of antibiotics over the winter months, which then returns to lower levels once the summer months arrive. Regular audits on appropriate antibiotic use are also ongoing, being carried out by both Pharmacy staff and junior doctors. 5.8 In September 2013, the UK Five Year Antimicrobial Resistance (AMR) Strategy was published by the Department of Health. It sets out actions to address the key challenges to antimicrobial resistance. The 7 key areas of the strategy include: 1. Improving infection prevention and control practices 2. Optimising prescribing practice 3. Improving professional education, training and public engagement 4. Developing new drugs, treatments and diagnostics 5. Better access to and use of surveillance data 6. Better identification and prioritisation of AMR research needs 7. Strengthened international collaboration 5.9 To assess whether prescribing is improving, changes in total prescribing will be measured, with an emphasis on whether inappropriate use of critically important antibiotics, such as carbapenems, is reducing. The initial objectives for 2014/15 were to measure total antibiotic consumption and total carbapenem antibiotic consumption in terms of DDDs per 1,000 beds days and per 1,000 admissions. 13
6.0 Environmental and equipment decontamination 6.1 Decontamination is a process which removes or destroys infectious agents from medical equipment. Cleaning is always the first step in this process, which is then usually followed by disinfection or sterilisation depending on the circumstances in which the equipment is used. The Trust provides an in-house sterile services department, reprocessing reusable medical devices. This is a fully validated and monitored service. Decontamination audits are carried out annually in departments where local decontamination is delivered, and the IPCT for part of the audit team. Disposable items are used wherever possible and efficient. 6.2 The endoscope (flexible tube used to look inside the body) decontamination facilities on the endoscopy units on both sites are fully compliant and providing a much improved service following a comprehensive modification programme to improve dosing and reduce failure rates. The Authorising Engineer (Decontamination) has validated the annual / re-commissioning s as suitable for service. In addition the Endoscope washer disinfectors within central sterile services department provide contingency support to the endoscopy unit facilities. 6.3 The provision of cleaning services is delivered by a combination of in house staff and external contractors (some community premises). Performance management systems are in place with monitoring staff making checks of the environment and patient equipment in line with national standards. The patient led assessments of the care environment (PLACE) inspection programme has been implemented and a team of clinical and facilities staff carry out the visits with patient representatives. The cleaning standards group meets monthly to review monitoring scores, with representation from IPCT and senior clinical matrons. A programme of cleaning and fogging with Hydrogen Peroxide Vapour (HPV) is in place on both Trust sites along with enhanced touch point cleaning whereby items of equipment that are frequently touched by staff and patients are subject to additional cleaning each day. 6.4 The Trust has made significant investment in an in-house mattress decontamination service where both static and alternating pressure mattresses and managed and decontaminated centrally. This has not only contributed to a reduction in the risk of infection but also to improved timeliness of deliver of alternating pressure mattresses to patients who require them. 14
7.0 Other significant issues 7.1 Routine screening and surveillance identified some wards with an increased MRSA colonisation rate in the latter part of 2014-15. In some areas staff and environmental screening was carried out and where staff carriers were identified a programme of decolonisation and enhanced IPC training were put into place. Each area had increased cleaning implemented and additional support and input from the IPCT. 7.2 A cluster of Group A Streptococcus cases was noted in the maternity unit in early 2014. Staff screening was carried out and any positive staff were excluded from clinical work while treatment was underway. No further clusters of cases have been ed. 7.3 Ebola Virus Disease caused a significant outbreak in West Africa in 2014-15 with some cases being noted in other countries, mostly among returning healthcare workers. National guidance was produced by Public Health England and all Trusts were required to ensure preparedness of their organisation to receive potential cases of this highly infectious haemorrhagic fever. The Trust revised its policy, implemented a programme of training for staff to ensure they were confident in donning and doffing of personal protective equipment (PPE), and carried out a number of exercises to test the policy. There was also an opportunity to test preparedness in a live situation when a potential patient was admitted. The patient was quickly proved not to be high risk but the situation provided useful learning for the internal preparedness working group. Work to maintain confidence and competence with PPE will continue in 2015-16. 15
Appendix North Tees and Hartlepool NHS Foundation Trust Infection Prevention and Control Department - Annual Programme 2015-2016 16 Health and Social Care Act Criteria 1: Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider how susceptible service users are, and any risks that their environment and other users may pose to them. Action planned Lead Target date/ review frequency 1.1 Assess infection prevention and control (IPC) risks, put controls in place to reduce or control these risks and monitor via the Trust risk register. 1.2 Produce an annual IPC for presentation to the Trust Board and publication on the Trust internet site. 1.3 Implementation of an IPC cleanliness programme comprising: De-clutter rolling programme. Touch point cleaning in high risk clinical areas. Rolling programme of deep cleaning, environmental maintenance and biodecontamination. Mattress decontamination programme Nursing and domestic equipment cleanliness monitoring. Staff & Patient Experience and Quality Standards (SPEQS)/PLACE visits IPC un-announced visits to clinical areas and community premises. 1.4 Review IPC training materials in line with national policy and guidance. Provide a robust programme of IPC training for all staff/volunteers at induction and in response to clusters/outbreaks of infection. 1.5 Develop and carry out an annual IPC audit programme of key IPC policies. 1.6 Reports to the Trust board on trend analysis for infections, antimicrobial resistance and antimicrobial prescribing and compliance with audit programmes. Review of statistics on incidence of alert organisms, outbreaks and serious untoward incidents. IPC Nurse (IPCN) Clinical teams DIPC IPCN Decontamination manager Decontamination manager Decontamination manager Associate Director (AD) Support Services DIPC / AD Support Services Assistant Matrons/ IPCNs IPCN Assistant Matrons DIPC/ Assistant DIPC From end March 2016 Progress
Health and Social Care Act Criteria 1: Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider how susceptible service users are, and any risks that their environment and other users may pose to them. Action planned Lead Target date/ review frequency 1.7 Joint working with other health care workers and health care providers/ organisations so that suitable and sufficient information on a service user s infection status is provided upon admission, when patients move between departments and organisations and upon discharge. IPCT/Care Home IPC Nurse/ Senior Clinical Matrons (SCMs)/ Clinical teams Progress Health and Social Care Act Criteria 2: Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections. Action planned Lead Target date/ review frequency 2.1 Monitor cleanliness standards and ensure that the environment is maintained in good physical repair and condition. 2.2 Hold/attend monthly cleaning standards group meetings and monitor cleaning scores. 2.3 Hold/attend and contribute to decontamination group meetings ensuring that decontamination policies are in place and monitored. Carry out/assist with decontamination audits. 2.4 Hold/attend and contribute to capital meetings. Contribute to all Estates Department new build and refurbishment projects in terms of giving IPC advice including new hospital project and any Community Provider Services developments. SCMs/Ward Matrons/ Domestic Managers/ Monitoring Officers/ Deputy Director Support Services Domestic manager IPCT/ Monitoring Officers Domestic Managers SCMs Sterile Services manager IPCT/ SCMs Sterile services manager IPCT Deputy Director (DD) Support services IPCN IPCN Progress 17
Health and Social Care Act Criteria 2: Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections. Action planned Lead Target date/ review frequency 2.5 Have systems in place for the safe management of: hand hygiene water and air hygiene pest control drinkable and non drinkable water supplies minimising the risk of Legionella minimising the risk of pseudomonas building and refurbishment planned preventative maintenance Cleaning services food service, including food hygiene laundry arrangements waste management 2.6 Approve pre-purchase procurement questionnaires for new equipment. IPCN )DD Support )Services ) ) ) ) ) ) ) ) AD Support Services/ Catering Linen Services manager Waste management advisor IPCN Progress 18 Health and Social Care Act Criteria 3: Ensure appropriate antibiotic use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance. Action planned Lead Target date/ review frequency 3.1 Consider the implementation of the principles of Start Smart Then Focus. 3.2 Manage the existing antibiotic stewardship programme. Report antimicrobial stewardship activities to the Board of Directors via Infection Control Committee 3.3 Review audit programme to include recommendation of Start Smart Then Focus where appropriate 3.4 Explore ability to local antibiotic susceptibility data and information on antimicrobial consumption 3.5 Provide induction and training in prudent antibiotic use to all prescribers Antibiotic lead/ Antimicrobial Pharmacist Antibiotic lead/ Antimicrobial Pharmacist/ DIPC Antibiotic lead/ Antimicrobial Pharmacist Antibiotic lead/ Antimicrobial Pharmacist Antibiotic lead/ Antimicrobial Pharmacist March 2016 October 2015 October 2015 March 2016 Progress
Health and Social Care Act Criteria 4: Provide suitable, accurate information on infections to service users, their visitors and any person concerned with providing further support or nursing/medical care in a timely fashion. Action planned Lead Target date/ review frequency 4.1 Provide accurate and up to date IPC patient IPCN and staff information leaflets and awareness posters. 4.2 Provide accurate and up to date information IPCT for patients, the public and staff on the Trust website. 4.3 Work collaboratively with Healthcare User IPCT Group, Healthwatch and PALs as required. 4.4 Where possible, locally resolve informal complaints about IPC related incidents and investigate IPC related complaints. 4.5 Work collaboratively with the patient survey lead and SCMs to improve the patient experience following results of the monthly MRSA patient survey. 4.6 Comply with national mandatory and voluntary surveillance programmes by ing CDI/iGAS/E-coli, GRE, MRSA, MSSA bacteraemia & Norovirus outbreaks. 4.7 Participate in awareness campaigns including: Antibiotic awareness day WHO hand hygiene day World Sepsis day European Antibiotic Awareness Week International Infection Control Week IPCN/ SCMs IPCN Assistant DIPC IPCT Antimicrobial Pharmacist Progress Health and Social Care Act Criteria 5: Ensure prompt identification of people who have or are at risk of developing an infection so that they receive timely and appropriate treatment to reduce the risk of transmitting infection to other people. Action planned Lead Target date/ review frequency 5.1 Work collaboratively with Public Health IPCT England North East in order to manage outbreaks and occurrences of serious infection. 5.2 Undertake daily alert and targeted surveillance IPCT and act on results accordingly. 5.3 Feed back infection rate statistics via the Nursing Dashboard and to Directorates via performance statistics. 5.4 Work collaboratively with Critical Care and Neo-Natal Unit staff to assist with the implementation of the principles and best practice from the Matching Michigan project to reduce line related bloodstream infections. IPCT IPCN/ Infection Control Doctor Progress 19
20 Health and Social Care Act Criteria 6: Systems to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the process of preventing and controlling infection. Action planned Lead Target date/ review frequency 6.1 Include IPC and cleanliness in: Induction programmes Job descriptions of all staff Annual performance reviews of all relevant staff 6.2 Provide staff with training and assessment in IPC procedures prior to them being carried out independently. 6.3 Co-ordinate the IPC link worker network and facilitate regular link worker study days. 6.4 Lead the post infection review for Trust attributed MRSA bacteraemias and participate in PIR of community acquired MRSA bacteraemias. Initiate/participate in Root Cause Analysis for Trust attributed Toxin positive Clostridium difficile cases/ MSSA bacteraemia cases/e colli bacteraemias/clostridium difficile related death. 6.5 Directorate representatives to attend ICC and present an IPC giving details of risks, actions taken and progress in reducing infections within their directorate. Health and Social Care Act Criteria 7: Provide or secure adequate isolation facilities. IPCT All Managers All Matrons IPCT/ Ward Matrons/ Clinical Educators IPCNs Assistant DIPC IPCN IPCNs Clinical teams General Manager, SCM, Clinical Director for each clinical directorate Mar 2016 Action planned Lead Target date/ review frequency 7.1 Work collaboratively with the Estates Department to increase, where possible, the availability of isolation facilities. 7.2 Undertake risk assessment of infectious cases to ensure optimal use of isolation facilities. DD Support Services IPCN IPCT All Matrons (AMs) SCMs Health and Social Care Act Criteria 8: Secure adequate access to laboratory support as appropriate. Progress Progress Action planned Lead Target date Progress 8.1 Work collaboratively with the Microbiology Laboratory staff in order to identify any shortfall in resources and escalate appropriately. Infection Control Doctor
Health and Social Care Act Criteria 9: Have, and adhere to, policies designed for the individual s care and provider organisations that will help to prevent and control infections. Action planned Lead Target date/ review frequency 9.1 Review all core IPC clinical policies by their review date. Policies to be available to all staff and the public. Infection Control Doctor/ Assistant DIPC Progress 9.2 Produce robust action plans in response to audit findings within the given timescale and review action plans to ensure that actions have been completed. SCMs 9.3 Standardise aseptic technique and carry out an audit to monitor compliance. AMs/IPCNs/ Clinical Educators/ Ward Matrons Health and Social Care Act Criteria 10: Providers have a system in place to manage the occupational health needs of staff in relation to infection. Action planned Lead Target date/ review frequency 10.1 Work collaboratively with the Occupational IPCT Health Department (OHD) in order to provide optimal advice on infection prevention and control related matters. 10.2 Monitor staff compliance with the Accidental exposure to bodily fluids policy and address instances of non compliance. 10.3 Risk manage mucous membrane exposure and sharps injuries and incidents. SCMs OHD Health & Safety OHD Progress 10.4 Manage cases of occupationally acquired Dermatitis by providing treatment and advice. OHD 10.5 Provide guidance on glove use via the latex policy. OHD 21
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