Infection Prevention and Control

Infection Prevention and Control Annual Report 2011/12 Presented by: Director of Infection Prevention and Control Written and Compiled by: Lead Nurse, Infection Prevention and Control Contributors: Hotel Services Manager Infection Prevention and Control Team Executive Lead: Director of Nursing and Patient Services/Director of Infection Prevention and Control

Contents Executive Summary 5 Infection Control Arrangements 6 Results of mandatory reporting 7 Meticillin resistant Staphylococcus aureus bacteraemia 8 Meticillin sensitive Staphylococcus aureus bacteraemia 8 Escherichia coli bacteraemia 10 Clostridium difficile 11 Surgical Site Infection 13 Untoward incidents including outbreaks 16 Hand hygiene 16 Antibiotic Stewardship 17 Cleaning services 20 Training Activities 25 Care Quality Commission Compliance 26 NHS Litigation Authority Standard and Assessment 27 Safety Thermometer 28 Appendix One Annual Programme for 2012/13 References 2

Executive Summary Infection prevention and control continues to be a high priority nationally and locally. Bedford Hospital NHS Trust has continued to reduce MRSA blood infections (bacteraemias) and Clostridium difficile (C diff) infections to their lowest level since mandatory reporting began. The hospital recognises however that any avoidable infection is too many and pledges to continue to work towards reducing infection in hospital. This report is the annual report from the Director of Infection Prevention and Control. It details the key work of the hospital with regard to infection prevention and control during 2011/12, and the associated statistics. The programme of work for 2012/13 is also included. 3

Infection Control Arrangements Trust Board Chief Executive Executive Management Board Quality Board Hospital Infection Prevention and Control Committee Environmental Cleanliness Decontamintion Committee Water Quality Management Committee 4

Director of Infection Prevention and Control (No defined hours) Infection Control Doctor (from March 2012) No defined PAs Lead Nurse Infection Prevention and Control and Tissue Viability (WTE 1.0 to cover both services) Antimicrobial Pharmacist (WTE 0.1) Service Administrator (WTE 1.0 to cover IPC, TV and some corporate nursing) Senior Nurse Infection Prevention and Control (WTE 1.0) Invasive Devices Nurse (WTE 0.6) Infection Prevention and Control Practitioner (WTE 1.0) The budget allocation for 2011/12 covered the salaries of the nurses and administrator, as well as a small stationery budget. Results of mandatory reporting Staphylococcus aureus is a common coloniser of human skin and mucosa, but can cause disease, particularly if there is an opportunity for the bacteria to enter the body. Meticillin-resistant S. aureus (MRSA) are a subset of S. aureus resistant to most β-lactam antibiotics such as flucloxacillin that are normally used to treat S. aureus infections. Most patients who are colonised with MRSA do not go on to develop an infection, but colonisation is a known risk factor. Reporting of 5

MRSA bacteraemia by NHS Trusts has been mandatory in England since April 2001 (Health Protection Agency, 2012). Meticillin sensitive Staphylococcus aureus bacteraemia Meticillin-sensitive S. aureus (MSSA) is sensitive to β-lactamase-stable antibiotics, such as flucloxacillin. Due to the relatively low rate of decline in MSSA compared to that of MRSA bacteraemia reports, mandatory reporting of MSSA bacteraemia was introduced in January 2011. With the collection of enhanced surveillance data, it is possible to apportion data into the groups Trust apportioned and non-trust apportioned reports (Health Protection Agency, 2012). There is no current target associated with reduction of MSSA bacteraemia. 7 Meticillin Sensitive Staphylococcus aureus Bacteraemias 2011/12 6 5 4 3 Non-acute Trust apportioned Acute Trust apportioned 2 1 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Meticillin resistant Staphylococcus aureus bacteraemia 2011/12 was the best year s performance since mandatory reporting and reduction targets were introduced for MRSA bacteraemia. One bacteraemia was identified, in April 2011. This was judged to be unavoidable using the root cause analysis process. The patient did not suffer any long-term harm from this infection. 6

7 6 5 4 Hospital-apportioned MRSA bacteraemia last five years 6 4 3 2 1 2 2 1 0 2007/8 2008/9 2009/10 2010/11 2011/12 Bedford Hospital NHS Trust position within other hospitals in the East of England 2011/12 Rank Name of NHS Trust Number Rate 1 Mid Essex Hospital Services 0 0.00 2 Southend University Hospital 1 0.05 3 West Hertfordshire Hospitals 1 0.05 4 Peterborough & Stamford Hospitals 1 0.05 5 Princess Alexandra Hospital 1 0.06 6 The Queen Elizabeth Hospital King's Lynn 1 0.06 7 West Suffolk Hospitals 1 0.07 8 Bedford Hospital 1 0.08 9 Ipswich Hospital 2 0.10 10 Luton & Dunstable Hospital 2 0.10 11 Hinchinbrooke Health care 1 0.11 12 East & North Hertfordshire 3 0.12 13 James Paget University Hospitals 2 0.13 14 Cambridge University Hospitals 5 0.14 15 Papworth Hospital 1 0.15 16 Basildon & Thurrock University Hospitals 4 0.17 17 Norfolk & Norwich University Hospitals 9 0.28 7

Funnel chart showing BedfordHospital's (in red) position amongst other hospitals in East of England for MRSA bacteraemia rates (blood stream infections per 10,000 occupied bed days) 0.5 0.4 0.3 0.2 0.1 0-0.1 0 50000 100000 150000 200000 250000 300000 350000 400000 Rate Mean 3sd 2sd -0.2-0.3 Source of data: HPA published data derived from MRSA and C difficile Mandatory Surveillance Website Escherichia coli bacteraemia Escherichia coli (E. coli) are Gram-negative, rod-shaped bacteria that form part of the normal lower intestinal tract microflora of humans and other warm-blooded animals. Most E. coli are harmless but they are frequently found as the cause of urinary tract infections, which although generally easily resolved can lead to serious complications such as bacteraemia. E. coli bacteraemia can also result from infections in other sites such as bile ducts infections and abdominal infections. Some E. coli serotypes have been linked to serious food poisoning outbreaks but this is rarely in conjunction with a bacteraemia. E. coli are mostly susceptible to antibiotics, however antibiotic resistant E. coli clones and plasmids harbouring antibiotic resistant genes are known to be circulating in the UK. Although the mandatory surveillance does not actively collect antibiotic susceptibility data, it is intended that the mandatory records will be linked to databases holding the susceptibility data to give a picture of national trends. Mandatory surveillance was extended to E. coli bacteraemia in June 2011 because there has been a year-on-year increase in E. coli bacteraemia reports made to the voluntary surveillance system while Staphylococcal bacteraemia reports are declining (Health Protection Agency, 2012). There is no current reduction target associated with this surveillance. 8

6/105 (5.7%) of the E. coli bacteraemias were found to be extended spectrum β lactamase (ESBL) producers. 11/105 (10.5%) of the E. coli bacteraemias were identified after the patient had been in hospital for more than 48 hours. 14 Escherichia coli Bacteraemias 2011/12 12 10 8 6 4 2 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Clostridium difficile Clostridium difficile infection (CDI) is the predominant cause of antibioticassociated diarrhoea among hospitalised patients, and is of great importance as a healthcare associated infection. Acquisition of C. difficile may manifest as asymptomatic colonisation of the intestine, or as an infection ranging in severity from mild diarrhoea through to severe disease in the forms of pseudomembranous colitis and toxic megacolon, both of which can lead to death. The risk of infection is higher in the healthcare setting due to a combination of risk factors including a predominantly elderly population, antibiotic use, and the possibility of cross-infection. Since 2004 it has been a mandatory requirement to report all CDI in NHS acute Trusts in patients aged 65 years and over. In April 2007 enhanced surveillance for CDI was introduced and it became mandatory to report all CDI in patients aged 2 years and older (Health Protection Agency, 2012). 9

250 200 206 Clostridium difficile last five years 150 100 94 75 50 30 27 0 2007/8 2008/9 2009/10 2010/11 2011/12 Bedford Hospital NHS Trust position within other hospitals in the East of England 2011/12. Reducing Clostridium difficile remains a priority for Bedford Hospital NHS Trust in 2012/13. Actions to improve the Trust position form a major part of the infection control annual programme of work for 2012/13 and specifically focus on strengthening antimicrobial stewardship, improving hand hygiene and improving time to isolation (for patients with potentially infectious diarrhoea). Rank Name of NHS Trust Number Rate 1 East & North Hertfordshire 11 0.04 2 Hinchinbrooke Healthcare 7 0.08 3 West Hertfordshire Hospitals 17 0.09 4 Princess Alexandra Hospital 16 0.10 5 Mid Essex Hospital Services 20 0.10 6 Papworth Hospital 8 0.12 7 Basildon & Thurrock University Hospitals 27 0.12 8 Cambridge University Hospitals 48 0.14 9 Southend University Hospital 31 0.14 10 Peterborough & Stamford Hospitals 30 0.16 11 West Suffolk Hospitals 23 0.16 12 Ipswich Hospital 29 0.17 13 Norfolk & Norwich University Hospitals 56 0.18 14 James Paget University Hospitals 28 0.19 15 Luton & Dunstable Hospital 35 0.19 16 Bedford Hospital 27 0.23 17 The Queen Elizabeth Hospital King's Lynn 41 0.25 10

Funnel chart showing Bedford Hospital's (in red) position amongst other hospitals in East of England for C. difficile rates (C difficile infections per 1000 occupied bed days) 0.3 0.25 0.2 0.15 0.1 0.05 Rate Mean 3sd 2sd 0 0 50000 100000 150000 200000 250000 300000 350000 400000 Surgical Site Infection Surgical site infections account for approximately 14% of hospital acquired infections (HAI), are estimated to double the length of post operative stay in hospital and significantly increase the cost of care (Surgical Site Infection Surveillance Service, 2011). Bedford Hospital NHS Trust has participated in the Health Protection Agency (HPA) Surgical Site Surveillance Service for more than 8 years using a systematic method of identifying surgical site infections during the inpatient stay and on readmission with the objective to produce data to inform preventative strategies within healthcare. Standardised post discharge surveillance methods were introduced by the HPA with the intention to provide more complete data on SSI s that develop post discharge. The aim of this pilot was to gain improved clinical effectiveness and improved patient experience through the strengthening of the current surgical site infection surveillance service in line with trust and infection control objectives through compliance review, options appraisal and implementation of a clinician led post discharge surveillance process, patient involvement, and patient experience. 11

Methodology Outcome A review of the current surgical site infection surveillance process was carried out resulting in the design and implementation of an effective post discharge surveillance data capture method. All patients undergoing surgery for total knee replacements were included as part of one of the chosen categories of Bedford Hospital NHS surgical site surveillance for the current quarter. The surveillance included surgical wound surveillance during inpatient stay; readmission and outpatient department follow up appointments. In addition, all suitable patients admitted to Howard ward for total knee replacement were invited to take part in post discharge surveillance through completion of a surgical wound healing post discharge questionnaire during a postoperative visit by a member of the infection control team. The wishes of all patients who did not want to take part in the post discharge surveillance were respected. At the end of the pilot, the Infection Control Team using the data contained in the pilot summary to determine the most efficient method of post discharge surveillance for the trust carried out an evaluation of the process. The evaluation revealed the following issues: Percentage of patients who expressed a wish not to take part or were unsuitable candidates for completing a questionnaire was very low at 5%. 11% of patients did not receive a postoperative visit due to a member of the infection control team not being available because of annual leave and other commitments. 72% of those patients who had a post discharge questionnaire sent to them by post were returned. 23% of posted questionnaires required a follow up letter as opposed to 67% of patients who received their questionnaires at their OPD follow up appointments. 20% of patients reviewed in OPD had no accessible electronic record available. A refined method of post discharge surveillance and distribution of patient information leaflets was designed following the evaluation, and adopted across all surveillance categories for a further three months from 1st October to the 31st December 2011 once agreement by all affected stakeholders and key partnerships had been achieved. The percentage return of the reviewed process was then revaluated and validated with the HPA SSISS Report with the following outcomes. 12

Category Hip Replacement Knee Replacement Large bowel surgery Total patients % Returned PDQ Patient reported infections 50 83.3% 3 6% 60 78% 2 3.3% 37 64.5% 4 10% % Overall 147 75.3% 9 6.36% Table 2.Table to show the percentage of PDQs returned and captured infections by specialty. Conclusion The feedback from patients and high return of PDQs provided evidence to suggest that patients valued the opportunity to be involved in their care and responded positively to information that was contained in the patient information leaflet. The capture of surgical site infections that presented post discharge strengthened the feedback from the current process thus enabling the infection control team to provide the clinical business units with a higher value of quality metrics, through the existing HPA reporting, in order for clinicians to embed evidence based practice to improve quality of care and patient safety. The pilot evaluation revealed that the patients involvement in their care had been improved resulting in a heightened level of positive patient experience. The positive benefits of providing patients with a contact name and direct phone number of the hospital infection control team in a patient leaflet were revealed through the number of calls received and the type of questions that were raised by the patients. Although many queries raised by the patients were not related to the healing of their wounds and were therefore were not measured as part of the pilot, this contact provided many patients with the opportunity to discuss any other concerns they had regarding their recovery. It was also concluded that further analysis may suggest that post discharge surveillance could have a potential to prevent a patient s condition deteriorating 13

Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar resulting in reduced readmission rates.(this potential would require further study to measure the actual impact on readmissions, as it was not included in the pilot scope). Untoward incidents including outbreaks Serious Incidents 2011/12 There were 2 MRSA clusters and 1 MRSA bacteraemia reported and investigated 5 were gastrointestinal outbreaks resulting in closed wards 2 Service Provision - AERs in endoscopy, sterility of a surgical set Hand Hygiene 100 95 90 95 96 96 96 93 95 99 98 99 99 96 98 85 80 75 70 65 60 Actual Figure Target Figure Promotion of effective hand hygiene remains a priority in 2012/13. 14

Antimicrobial Stewardship National Guidance The Department of Health published guidance for antimicrobial stewardship in hospitals in November 2011 entitled Antimicrobial stewardship: start smart then focus. This guidance highlights that an antimicrobial stewardship programme is a key component in the reduction of healthcare associated infections (HCAI) and contributes to slowing the development of antimicrobial resistance. A start smart then focus approach is recommended for all antibiotic prescriptions. The start smart - then focus approach is: START SMART Do not start antibiotics in the absence of clinical evidence of bacterial infection If there is evidence/suspicion of infection, use local guidelines to initiate prompt effective antibiotic treatment Document on the drug chart and in the medical notes: clinical indication, duration or review date, route and dose Obtain cultures first THEN FOCUS Review the clinical diagnosis and the continuing need for antibiotics by 48 hours and make a clear plan of action the Antimicrobial Prescribing Decision The five Antimicrobial Prescribing Decision options are: Stop, Switch IV to Oral, Change, Continue and OPAT It is essential that the review and subsequent decision is clearly documented in the medical notes The guidance also discusses the importance of the antimicrobial stewardship committee, antimicrobial ward rounds, evidence based antimicrobial prescribing guidelines and auditing of antimicrobial prescribing. This strategy was presented, along with the point prevalence audit results, at the clinical governance meetings to all clinical business units in January 2012 by the antibiotic pharmacist. Antibiotic Policy A revised antibiotic treatment guideline has been written and approved by the Antibiotic stewardship group and this is now available on the intranet having been approved by DTC and Quality Board. 15

Antibiotic usage (DDD's) / 1000 bed days) Antibiotic Usage Usage of restricted and commonly prescribed antibiotics are reported below. Seasonal variation is observed with clarithromycin and co-amoxiclav due to increased numbers of LRTI in the winter months. The use of meropenem has been seen to be increasing and this was highlighted at the clinical governance meetings in January to all clinicians as there is concern from the HPA over the emergence of resistant organisms. Total inpatient issues of Co-amoxiclav 500 450 400 350 300 250 200 150 Co-amoxiclav oral Co-amoxiclav IV Co-amoxiclav total 100 50 0 16

Antibiotic usage (DDD's / 1000 bed days) Antibiotic usage (DDD's /1000 bed days) 250 Total inpatient issues of Tazocin, Meropenem and Clarithromycin 200 150 100 Tazocin IV Meropenem IV Clarithromycin (IV / PO) 50 0 40 Total inpatient issues of Ciprofloxacin 35 30 25 20 15 10 Ciprofloxacin oral Ciprofloxacin IV Ciprofloxacin total 5 0 17

Antimicrobials Point Prevalence Audit December 2011 An audit of all available drug charts across the hospital was carried out by the infection control team on the 5 th -9 th December 2011. This audit was carried out soon after the introduction by the Department of Health of the start smart and then focus campaign for antibiotic prescribing and aimed to assess the Trusts compliance with some of the areas highlighted. All patients on antibiotics were recorded and the prescribed antimicrobial and documented indication were noted. The table below outlines the basic findings of this audit. No of patients surveyed 333 % of patients on antimicrobials 31% % of antimicrobials prescribedoral % of antimicrobials prescribed- IV 46% 54% Compliance to guidelines 91% Stop/review date documented on drug chart 34% The most commonly prescribed antimicrobials prescribed and their relative frequencies on the audit days are documented below: Antibacterial No. of prescriptions % of total Co-amoxiclav 41 27.52 Clarithromycin 17 11.41 Flucloxacillin 14 9.40 Meropenem 13 8.72 Piperacillin / Tazobactam 13 8.72 Metronidazole 12 8.05 These results are similar to those seen in previous year s audits of this nature apart from the increase in meropenem use as previously mentioned. Cleaning Services Management arrangements Cleaning services are 'in-house' and are part of Operational Support Services. The standard and frequency of cleaning is broadly in accordance with the NPSA 18

'49 steps' as detailed in their National Specification for Cleanliness in the NHS (2007). The department also provides several other services to improve environmental cleanliness as follows: Special Cleans team for terminal cleans of wards, bays, bed-spaces and side rooms after occupation by patients with known infections. This team also clean pressure mattresses and pumps thus facilitating a quicker turnaround of this equipment than if it had to be sent away for cleaning. Bed cleaning through the use of a bed washing machine which is also used for other items of equipment such as trolleys from wards, theatres and SSD. The Domestic Services Department employs a Clinical Equipment Cleaning Team to help ward nursing staff by releasing their time for direct patient care. Items such as blood pressure monitors, scales and drip stands are cleaned on a regular basis using a sporicidal cleaning solution. Environmental Cleanliness Group This group meets fortnightly, is chaired by the Director of Operational Support Services and has representation from the Matrons, Maintenance, Estates, Infection Control, Equipment Procurement and Domestic Services. The group addresses environmental issues that can enhance or detract from positive patient experiences. Topics such as monitoring scores and subsequent action plans, service changes, PEAT results, waste management, equipment storage plus new products all feature on the ECG agendas. Upward reporting is to the HIPCC (Hospital Infection and Prevention Control Committee). Monitoring arrangements Cleaning standards are monitored by the Domestic Services department against the NPSA 49 Steps. In December 2011 a revised 4 week monitoring schedule was introduced to include wards, theatres public and out-patient areas. Each area is monitored in accordance with the NHS National Standards of Cleanliness (2007). Individual areas are monitored for cleanliness in as many of the 49 Steps as are present e.g. toilets, high surfaces, internal glass, bed frames and chairs. The percentage score for each area monitored indicates how many of the 49 Steps present were of a satisfactory standard of cleanliness. The graph below shows our performance against these standards over the year 2011-2012: 19

100 90 80 70 60 50 40 30 20 10 Domestic Services Department Cleaning Monitoring Scores % Compliance with NPSA '49 Steps' 2011-2012 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Series1 97.1 97.32 94.35 92.22 92.66 90.18 90.92 94.37 92.34 94.95 94.94 94.44 Budget allocation 2011-2012 Cost element Pay 2,209,286 Non-pay e.g. cleaning materials, disposables, waste bags etc 278,236 Training All 133 domestic staff receive basic infection control training from the Infection Control Team. Staff are also issued with a pocket card illustrating essential infection control points such as the correct colour code for mops, buckets and gloves for particular areas, which waste disposal bags to use and key hand washing circumstances. 20

PEAT 2012 (Patient Environment Action Team) PEAT is an annual assessment of inpatient healthcare sites in England with more than ten beds. PEAT is self-assessed and inspects standards across a range of services including food, maintenance and repairs, cleanliness, infection control, and patient environment (including bathroom areas, décor, lighting, floors, and patient areas). The assessment was established in 2000 (managed by the NPSA since 2006) and is a benchmarking tool to ensure improvements are made in the non-clinical aspects of a patient s healthcare experience. PEAT highlights areas for improvement and shares best practice across the NHS. NHS organisations are each given scores from 1 (unacceptable) to 5 (excellent) for standards of privacy and dignity, environment, and food within their buildings. The NPSA publish these results every year to all NHS organisations, as well as stakeholders, the media and the public. The annual PEAT assessment was carried out on 3rd February 2012. Team members included matrons, ward managers, the maintenance manager, the lead nurse for infection control, the catering manager, the voluntary services manager, the director of support services and the hotel services manager. Mr. Peter Metherall (NHS East of England Patient Champion) and Mr. Max Coleman (Chair Bedfordshire LINk) kindly joined us as patient representatives. The teams were also joined by Mr. Andy Powell, Deputy Director of Facilities from the University of Leicester Hospitals NHS Trust, in his capacity as a validator. Areas visited included Accident and Emergency, Acute Assessment Unit, Critical Care Complex, Riverbank Ward, Elizabeth Ward, Howard Ward, Tavistock Day Surgery, Harpur Ward, Breast and Bowel OPD Clinics, Orchard Ward plus bereavement facilities, and public areas. PEAT Assessment Scores Summary Year Environment 2012 Excellent 2011 Good 2010 Good 2009 Good 2008 Good 2007 Excellent 21

The Environmental Cleanliness Group has an action plan to deal with items noted during the course of the PEAT assessment and this is reviewed at ECG meetings. User Satisfaction Each month patients are given the opportunity to complete a simple questionnaire and make comments on the cleaning service in the ward where they are an in-patient. The current survey includes the following questions: 1. What is your overall impression of the cleanliness of the hospital? 2. How do you rate the general level of cleanliness in the ward? 3. Is your bedside area cleaned each day? 4. Are the showers cleaned regularly? 5. Are the ward toilets kept clean? Are you very satisfied, satisfied or not satisfied..with our service? The graph below shows our performance of levels of patient satisfaction for 2011-2012: 90 80 70 60 50 Domestic Services Department Patient % Satisfaction Survey 2011-2012 40 30 20 10 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Very satisfied 62 83 64 64 57 66 61 67 64 63 84 74 Satisfied 34 17 35 34 41 33 36 33 32 36 16 25 Not satisfied 4 1 0 1 2 1 3 0 0 0 0 1 Very satisfied Satisfied Not satisfied 22

Training Activities The Infection Control team provides a comprehensive training service, including formal and informal opportunities, as well as day-to-day counsel. The hospital s mandatory training requirements are for clinical staff groups to attend update training annually and other staff groups every three years. The two tables below show the percentage of staff in each staff group who attended the mandatory training in 2011/12. Annual Staff Group % Trained Consultants 41% Specialist Registrars, Senior House Officers and 39% House Officers Foundation Year One and Two Doctors 100% Nurses 42% Clinical Support Workers 50% Allied Health Professionals 61% Every three years Staff Group % Trained Admin & Clerical 47% Domestics 97% Porters 24% Add Prof Scientific and Technical 79% 23

Clinical Infection Control Training April 2011 - March 2012 140 129 120 112 100 80 60 40 34 85 51 60 77 97 47 82 88 61 20 0 Care Quality Commission (CQC) Compliance The Care Quality Commission inspected the hospital as part of their routine inspection schedule in October 2011. Their report of that visit is as follows: What people who use the service experienced and told us Patients we spoke with during the visit were very complimentary about the standard of cleanliness. They made comments like they are wonderful, they keep the place very clean, they wipe the tops of cupboards and get right under the beds. One patient commented how clean the ward was and how often the cleaning staff returned to the same area. Another person in the outpatient department told us that because of the number of people using the area, particularly the toilets; they would have expected it to be less clean than it actually was. Other evidence In all the areas we visited there was plenty of appropriate hand washing facilities. We also saw clear signage requesting all visitors to use hand gel before entering the wards. Staff used the hand gel on a regular basis, especially when moving from one patient to the next and there were sufficient gloves and aprons available for staff. In many areas of the hospital we met a lead nurse responsible for infection control and this included auditing hygiene processes and practices and the results of hygiene audits were displayed in most visitor areas. These indicated that staff were committed to good hand hygiene procedures in an effort 24

to prevent the transmission of infection. In the maternity department we saw that rooms were labelled when a patient was discharged alerting the cleaner to the need to clean, once this had been completed the room was then labelled by the cleaning staff as ready for use. Where barrier nursing was in operation there were clear signs alerting staff and visitors to this and the precautions that they needed to take. It is the hospital s policy to swab all patients upon admissions for the presence of meticillin resistant Staphylococcus aureus (MRSA), the most well-known Healthcare Associated Infection. This process is audited regularly and the results inform the government targets for infection control. The Trust was considered to be in line with national targets. The hospital won the Cleanest Hospital award in the Healthcare Excellence and Leadership (HEAL) awards 2010, as voted for by patients and healthcare workers. In each department or ward we visited we saw individual cleaning rotas where staff recorded when they have carried out specific cleaning tasks. Domestic staff were aware of the importance of keeping the hospital clean and ensuring areas were free of infection. We found single use equipment such as oxygen masks, aprons, gloves and diabetic testing equipment in all departments that we visited, and where sterilisation processes were required we noted that equipment was clearly labelled as clean and ready for use. Since April 2011, the hospital has built a new high specification decontamination unit and all staff have been trained in the new system. Our judgement The Trust was compliant with this outcome. The hospital was clean and tidy throughout and regular auditing of the cleaning processes ensured that the risk of infection spreading was minimal. NHS Litigation Authority (NHSLA) Standard and Assessment A key function for the NHSLA is to contribute to the incentives for reducing the number of negligent or preventable incidents. This is achieved through an extensive risk management programme. The core of the risk management programme is provided by a range of NHSLA standards and assessments. Most healthcare organisations are regularly assessed against these risk management standards that have been specifically developed to reflect issues which arise in the negligence claims reported to the NHSLA. There is a set of risk management standards for each type of healthcare organisation incorporating organisational, clinical, and health & safety risks. 25

The level one assessment against Hand Hygiene Training Risk Management Standard (2.8) Passed with no recommendations/conditions. Safety Thermometer The NHS Safety Thermometer is a local improvement tool for measuring, monitoring, and analysing patient harm and harm free care. Bedford Hospital NHS Trust was a pilot site for 2011/12. The Safety Thermometer is a national CQUIN for 2012/13. The tool measures four high-volume patient safety issues (pressure ulcers, falls in care, urinary infection (in patients with a catheter) and treatment for venous thromboembolism). One hundred and sixty-seven patients were surveyed for the pilot study during 2011/12 - seven patients were receiving treatment for a urinary tract infection with a catheter in situ (4.1%) This constitutes a harm event on the thermometer. This monitoring will continue on a monthly basis during 2012/13. 26

Appendix One Annual Programme for 2012/13 Criterion Action Responsibility Timescale Comments Trust Objective/s a. Develop business case for Chief 30th September 1.0 WTE antimicrobial Pharmacist 2012 pharmacist 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 them b. Review other human resource needs in the IPC team c. Launch revised IPC governance f. Quarterly report to the Trust Board g. Appoint deputy DIPC HIPCC h. Publish annual programme of work (this document) a. Review Matrons' environment policy DIPC 30th June 2012 DIPC 14th June 2012 DIPC 31st July 2012 DIPC Matrons 18th September 2012 18th September 2012 30th September 2012 Business case approved for a new WTE1.0 band 6 post Revised policy to Quarter 1 HIPCC To HIPCC Q2 To HIPCC Q2 To HIPCC Q2 Patient Safety Clinical Effectiveness Patient Experience External Targets 2. Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections b. Develop Estates department policies e.g. pseudomonas in taps c. Develop food services policy Head of Estates Head of Support Services 31st March 2013 30th September 2012 To HIPCC Q2 Patient Safety Clinical Effectiveness Patient Experience External Targets Estate d. Review Special Cleans Team service Head of Support Services 30th September 2012 To HIPCC Q2

3. Provide suitable accurate information on infections to service users and their visitors a. Revise and develop information for hospital users DIPC 31st March 2013 To HIPCC Q4 Patient Experience External Targets 4. Provide suitable accurate information on infections to any persons concerned with providing further support or nursing/medical care in a timely fashion a. Audit discharge letters - medical and nursing DIPC 30th September 2012 To HIPCC Q3 Patient Safety Clinical Effectiveness Patient Experience 5. Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people Review all infection prevention and control pathways and supporting documentation DIPC 31st March 2013 To HIPCC Q4 Patient Safety Clinical Effectiveness Patient Experience External Targets 6. Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection a. Audit job descriptions DIPC b. Audit ANTT DIPC c. Lead CAUTI element of harm-free care DIPC 30th September 2012 31st December 2012 31st March 2013 To HIPCC Q2 To HIPCC Q4 Patient Safety Clinical Effectiveness Patient Experience External Targets 7. Provide or secure adequate isolation facilities a. Audit isolation facilities post bed reconfiguration DIPC 30th September 2012 To HIPCC Q3 Patient Safety Clinical Effectiveness Patient Experience External Targets 2

8. Secure adequate access to laboratory support as appropriate a. Develop laboratory policy for the investigation and surveillance of HCAI DIPC 31st December 2012 To HIPCC Q3 Patient Safety Clinical Effectiveness Patient Experience External Targets 9. Have and adhere to policies, designed for the individual's care and provider organisations that will help to prevent and control infections a. Review all infection prevention and control policies b. Audit all policies over two year rolling programme DIPC DIPC 31st December 2012 31st March 2014 Patient Safety Clinical Effectiveness Patient Experience External Targets 10. Ensure, as far as is reasonably practicable, that care workers are free of and are protected from exposure to infections that can be caught at work and that all staff are educated in the prevention and control of infection associated with the provision of health and social care a. Finalise new education programme DIPC 31st March 2013 Patient Safety Clinical Effectiveness Patient Experience External Targets 3

References Health Protection Agency (2012) Quarterly Epidemiological Commentary: Mandatory MRSA, MSSA and E. coli bacteraemia, and C. difficile infection data (up to January March 2012). London. Health Protection Agency. Antimicrobial Stewardship Start Smart then Focus, Department of Health access at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digita lasset/dh_131181.pdf Department of Health (2008) (rev 2010) The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance. [online] Available at: http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicy AndGuidance/DH_122604 (accessed 10th May 2012)