Director of Infection Prevention & Control (DIPC) Annual Report for 20/07 Tracey Nutter DIPC May 2007
1. Introduction Each year the Director of Infection Prevention & Control (DIPC) is responsible for producing an annual report. The purpose of this report is to inform the Trust Board of the progress being made to reduce healthcare associated infections (HCAI) and to agree the Action Plan for sustained reduction and improvements in infection control practices for 2007/08 (Appendix 1). The Action Plan for 2007/2008 will focus on The Health Act 20: Code of Practice for the Prevention and Control of Health Care Associated Infections, which identifies criteria to ensure that patients are cared for in a clean environment, where the risk of HCAI is kept as low as possible. This document includes references to other National Strategy documents for infection control including Winning Ways: working together to reduce health care associated infection in England Saving Lives: a delivery programme to reduce health care associated infection, including MRSA Essential Steps to Safe Clean Care: reducing health care associated infection Failure to observe the Code may either result in an Improvement Notice being issued to the NHS body by the Healthcare Commission or in it being reported for significant failings and placed on special measures. All NHS organisations must be able to demonstrate that they are complying with the Code. A report has been completed which outlines how the Trust is complying with the Code and provides actions which are being implemented to ensure full compliance. These are included in the Annual Action Plan for 2007/08. The report provides an annual update of progress against the 20/07 Action Plan. 2. Overview and Action Plan Since April 2005, the Infection Control Team (ICT) has worked on achieving improvements to the seven action areas identified in Winning Ways. The following review of the Annual Action Plan 20/07 provides details of progress towards achieving the Infection Control objectives over the last twelve months. Annual Action Plan Review 20/07 No Objective Key Actions Who Update 1. Active Surveillance & Investigation Continue implementation of mandatory surveillance programme for HCAI. Continue implementation of alert organism & alert condition system. VC DIPC/ Team Programme in place. Policy implemented & to be reviewed July 2007. Continue implementation of root cause analysis (RCA) relating to HCAI. ICD/DIPC System well established. Use comparative data on HCAI & microbial resistance to reduce incidence & prevalence. DIPC/All Implementation via Antibiotic Reference Group (ARG). 2
Promote liaison with the HPA for effective management & control of HCAI. ICD HPA representative on IPCC. 2. Reduce Infection Risk from the use of Catheters, Tubes, Cannulae, Instruments & other Devices Implement audit programme of devices & lead recommendations. Implement Decontamination strategy. IC Senior Nurse Decontamination Group/ICT Programme established. Central line, cannula & urinary catheter audits complete. Strategy in place, policy reviewed. 3. Reduce the Reservoirs of Infection Ensure maintenance of high standards of cleanliness. Audit effectiveness of Escalation Policy. DIPC/ Head of Facilities Emergency Care Lead Ongoing. Reviewed & policy written. Continue ICT involvement in overseeing all plans for construction & renovation. Continue equipment audits & lead recommendations. Deputy DIPC ICT Continued involvement in Laundry & New Build. Results to IPCC. 4. High Standards of Hygiene in Clinical practice Introduce scrubs (Smart suits) to replace traditional uniform across the Trust. Implement MRSA Action Plan. DIPC DIPC/All September 2007. Completed & plan reviewed, but will continue to monitor 07/08. Continue programmes of infection control education for all staff via induction & ongoing education. ICT Continuous. Continue to prove high levels of compliance with hand decontamination by all staff via data collection & audit. ICT Audit results to IPCC. Maintain the role of the Link Professionals in clinical areas. ICT Monthly reports to DIPC. Continue promotion of infection control education for all staff via the computer based learning system by all groups of staff. ICT Continuous. Reports to Trust Board. Promote inclusion of infection DIPC Ongoing. 3
control as part of PDPs for all staff. 5. Prudent use of Antibiotics Continue implementation of the MRSA Pathway. IC Senior Nurse Pathway implemented & audit complete. Ensure effective performance of the Antibiotic Reference Group. Chief Pharmacist/ICD Report to Drugs & Therapeutics Committee. 6. Management & Organisation Promote the role of the DIPC in the prevention & control of HCAI. Chief Executive Role established. Establish the DIPC as an integral member of the Trust s Clinical Governance & risk structures. Chief Executive Complete. Lead infection prevention & control in the Trust & provide a six monthly public report to the Trust Board. DIPC Report established & complete. Ensure the system of Root Cause Analysis is used to review risks relating to infection prevention & control. Ensure a programme is in place to systematically monitor & review policies & guidelines relating to infection prevention & control. DIPC/Risk Manager DIPC/ IPCC System in place - complete. Continues to be used to review all MRSA bacteraemias. Programme in place - complete. Monitored via IPCC. 7. Research & Development Maintain membership of the SHA Steering Group, working on national research & development issues. DIPC Quarterly. Ensure epidemiological techniques are up-to-date. ICD Ongoing. Continue evaluations of measures that may prevent & control HCAI. ICT Annual Programme. 3. Infection Control Arrangements A comprehensive Infection Prevention and Control service is provided Trust wide. The ICT provides a ward liaison and telephone consultation service with on-call arrangements for emergency assistance and advice. 4
The ICT comprises 3.6 whole time equivalent (w.t.e) Infection Control Nurses (ICN) and 0.6 w.t.e secretary. Two new ICN s joined the team, one commenced in post July 20, and the second at the end of October 20. The team has successfully appointed a secretary, due to commence April 2007. The Infection Control Doctor (ICD) provides microbiological support. The organisational charts (Appendices 2 & 3) depict the structure of the team and the reporting structure in the Trust. 4. DIPC reports to the Board The DIPC Report and annual programme action plan is presented to the Trust Board bi-annually. The Infection Prevention and Control Committee (IPCC) monitors the action plan on behalf of the Trust Board. The IPCC also provides regular progress reports to the Clinical Governance Committee (CGC). 5. Budget Allocation The total budget for Infection Prevention & Control is 150.5K comprising: Staff Nursing 110K Administrative 17K Medical (2 PA s/week) 20.5K Support Non-pay 3K Training Training budgets are held centrally in the Trust. 6. HCAI Statistics 6.1 Outbreak Management The investigation and management of communicable and nosocomial infections in the hospital environment is the role that is most often associated with Infection Control and this is certainly an important and visible function of the service. Some areas in which the ICT have been particularly involved in the last twelve months include: Tuberculosis Tuberculosis (TB), is a disease caused by a germ (called the tubercle bacterium or Mycobacterium tuberculosis). TB usually causes disease in the lungs (pulmonary), but can also affect other parts of the body (extra-pulmonary). Only the pulmonary form of TB disease is infectious. Transmission occurs through coughing of infectious droplets, and usually requires prolonged close contact with an infectious case. TB is curable with a combination of specific antibiotics, but treatment must be continued for at least six months. Four patients have been admitted during this twelve month period with suspected symptoms of Tuberculosis (TB); three patients to the Medical Unit and one to the Oncology Unit. (One of the medical patients unfortunately failed to produce any sputum samples whilst an inpatient). A diagnosis was confirmed from test results for the other two medical patients and the oncology patient. The ICT followed advice from the HPA and liaised with the Respiratory Nursing Team. The patients were nursed in isolation following the diagnosis, and the Respiratory Nursing Team followed up inpatient contacts and family members. All contact patients who had been discharged 5
were followed up by their General Practitioners (GP), and inpatient Consultants as appropriate. Contact tracing of staff by the Occupational Health (OH) Department. High Count of Legionella There was an incidence of a high count of legionella (over the 1000 threshold) on one of the three monthly samples taken, from Estates Technical Services (ETS) stores and Beatrice 1, in June 20. An emergency meeting of the Legionella Outbreak Committee was convened and was attended by ICD and the Senior Nurse. The system was pasteurised and a round of new samples obtained, which were all negative. Extended Spectrum Beta Lactamase One of the most common ways that bacteria become resistant to antibiotics is by the production of enzymes. The most common enzymes produced are beta-lactamases, which breakdown betalactam antibiotics, such as penicillin and cephalosporins. Gram-negative micro-organisms have now started to produce extended spectrum beta lactamases (ESBLs), spread by hand contact, contaminated items or the faecal oral route. A few cases of ESBL have been isolated in some clinical areas. The significance of this is that ESBL is only responsive to a small number of antibiotics, so strict contact precautions are taken. Viral Gastro-enteritis Noroviruses are the group of viruses formerly known as Norwalk-like viruses (NLV) or small round structured viruses (SRSV). These viruses have long been associated with outbreaks of a relatively short-lived form of gastroenteritis, often referred to as winter vomiting disease. Hospital outbreaks can result in major disruption to normal activity and the ICT adheres to national guidance for the management of these situations. Key actions required in the control of these outbreaks include prevention of patient and staff movements to other clinical areas, hand hygiene and environmental decontamination. The ICT monitors these outbreaks closely and agreed communication links with clinical staff, clinical site team and Trust management are in place. There has been an outbreak of norovirus during quarter 4 (January March), with seven confirmed cases across the medical directorate, requiring partial or complete closure of wards. Clostridium difficile (C.difficile) Clostridium difficile is a spore forming bacterium, which is present as one of the 'normal'bacteria in the gut of up to 3% of healthy adults. It is much more common in babies - up to two thirds of infants may have C.difficile in the gut, where it rarely causes problems. People over the age of 65 years are more susceptible to contracting infection. C.difficile can cause illness when certain antibiotics disturb the balance of 'normal'bacteria in the gut. Its effects can range from nothing in some cases to diarrhoea of varying severity, which may resolve once antibiotic treatment is stopped, through to severe inflammation of the bowel which can sometimes be life threatening. It is possible for the infection to spread from person to person because those suffering from C.difficile -associated disease shed spores in their faeces. Spores can survive for a very long time in the environment and can be transported on the hands of health care personnel who have direct contact with infected patients or with environmental surfaces (floors, bedpans, toilets etc.) contaminated with C.difficle. During quarter 4 (January March), a total of sixteen patients were diagnosed as C.difficile positive on the Elderly Care Assessment Unit, and of these patients twelve were diagnosed on or after the 19 th of February. The unit was closed on the 20 th of February, and full outbreak status was declared. A post outbreak exercise is planned for the following quarter (May 2007) and a full report will be compiled and feedback to the Infection Prevention & Control Working Group (IPCWG) and Infection Prevention & Control Committee (IPCC). 6
Respiratory Syncytial Virus Respiratory Syncytial Virus (RSV) is a major cause of respiratory illness in babies and young children and is prevalent during the winter months. There have been no cases or outbreaks reported on the Paediatric Ward or Neonatal Intensive Care Unit (NICU) during the last twelve months. Chicken Pox (Varicella Zoster) Chicken pox is a common illness, which does not normally cause complications in children. The likelihood of complications can increase in adults and especially if they are immunosupressed because of disease (e.g. leukaemia), and having high doses of steroids or chemotherapy. Non-immune women in the early or late stages of pregnancy are also potentially at risk. There have been no cases of chickenpox during the last twelve months. 6.2 Surveillance The ICT collects alert organism and alert condition surveillance data within the Trust and this data is used in the detection of outbreaks and monitoring of trends. The Surveillance Practitioner co-ordinates data collection for the National Surgical Site Infection Surveillance (NSSIS) Programme. Within this programme, there are twelve surgical procedures that are applicable to the Trust. Data on Vascular Surgery has been submitted and surveillance on total hip replacement (THR), hemi-arthroplasty surgery and large bowel surgery has been completed. In April 20 surveillance commenced in two further categories of abdominal hysterectomy and breast surgery as per the Trust's Surveillance Plan 20/07 (Appendix 4). Abdominal hysterectomy surgery data collection finished on the 31 st of December 20. Breast surgery is being undertaken independent of mandatory HPA surveillance. In October 20, open reduction of long bone fracture surgery commenced and continued until 31 st of March 2007, to achieve a cohort of fifty cases. Methicillin Resistant Staphylococcus aureus (MRSA) The Department of Health (DoH) mandatory MRSA Bacteraemia Surveillance scheme has been used to measure the effectiveness of Infection Prevention & Control practices in all NHS Trusts. The rationale behind this scheme is that it is sometimes difficult to distinguish between colonisation and true infection caused by MRSA, but culture of the bacterium from blood almost always represents significant infection. The results from this scheme are as given in the summary below. Table 1 MRSA Bacteraemias April 20 March 2007 Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 0 0 1 3 3 3 1 0 1 0 4 0 The Trust's MRSA reduction trajectory for 20/07 is 13 cases, down from 17 in 2005/. As can be seen from Table 1, the total reported for this twelve month period is 16 (1 case is a result identified from a repeat blood culture sample taken and 2 are community acquired), which is a reduction of 4 cases from the previous year 2005/. The Annual Programme and MRSA Action Plan (Appendix 5) are key to achieving the planned reduction to a maximum of 12 cases in 2007/08. A root cause analysis (RCA) is performed to evaluate the incident of an identified MRSA Bacteraemia, using an adaptation of the National Patient Safety Agency (NPSA) infection control incident investigation tool. This offers the ICT a valuable approach for analysing and learning from these incidents and to ensure areas for improvements or recommendations for changes in practice are identified and implemented. 7
The process starts with timelines being produced of each individual bacteraemia, which includes clinical care interventions amongst admission details. The format consists of a multi-disciplinary approach, with all key personnel included in the process. The RCA process has been performed for all sixteen cases. Key points from investigations: 2 patients - previous MRSA isolates one had no intravascular devices but had a pre-existing skin condition (repeat blood culture taken third identified bacteraemia). one had complex medical needs, long term carers. 1 readmission from long stay on medical unit/elderly care, with sepsis. 1 readmission to medical unit/elderly care from residential home (multiple admissions). 1 transferred from another hospital to Spinal Unit, complex medical needs. 4 clinical haematology patients admitted within a three-month period to the oncology unit one clinically unwell on admision, treated for pre-existing infections in community (multiple admissions). one transferred from another hospital to oncology unit, with neutropenic sepsis. two clinically unwell with sepsis on admission, one admitted with an infected line All these patients had multiple admissions to the oncology day unit and continuous ongoing treatments. 1 patient admitted from a nursing home, clinically unwell. Not screened on admission. 2 medical patients (which included one elderly care patient) admitted with sepsis. 1 orthopaedic patient with suspected osteomyelitis, established wound infection. 2 patients positive blood culture within 48 hours of admission to hospital (community acquired). Clostridium difficile (C. difficile) The control of this infection has been through the combination of sound infection control practices and prudent antibiotic prescribing. C.difficile is reported to the HPA on patients of 65 years and over, but from April 2007, all patients over the age of two will be included for mandatory reporting. It is important therefore to emphasis that due to the increased reporting we do expect Trust figures to be higher. Table 2 Clostridium difficile in patients of 65 years and over April 20 March 2007 Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar In patient 15 9 3 6 9 5 2 5 10 5 12 16 Other 1 1 0 1 0 0 0 1 0 2 0 0 Other = GP, outpatient and community hospital patients. These are numbers of positive episodes. In a single patient, a positive test occurring after a previous positive test is considered a new episode only after 28 days. Following the Health Care Commission investigation into outbreaks of C.difficile type 027 at Stoke Mandeville Hospital, the IPCC were asked to review the published report and lessons for other trusts, considering practices and how we could inform patients about it. Key areas identified in the report: Rapid isolation of patients with diarrhoea Restricting the movement of infected patients between wards Rapid identification and notification of outbreaks Establishment of multi-disciplinary outbreak committee which meets regularly Rapid institution of recommended changes 8
Close monitoring of all components of the management of outbreaks including cleanliness, the environment for patients Communication with patients, staff and outside agencies In addition to these practices, which are performed within the Trust, the DIPC report was identified as a further means to convey information to patients and the public. Trends in HCAI statistics The Department of Health (DH) has announced its intention to halve the MRSA infection rates by 2008. Over the longer term, they will be developing a broader based approach to reducing HCAI and promoting a zero tolerance of poor infection prevention & control. As a Trust we are ranked in the top third of all Trust hospitals, indicating good infection control practices. However, further work is required, as we need to reduce our total MRSA bacteraemia incidences from the 2005/ figures of 20 to no more than 12 cases per year by 2008. Appendix 9 provides additional information. The MRSA Action Plan at Appendix 5 summarises how the Trust will reach this target and breaks down the problem into three parts: 1. Minimising the risk of MRSA acquisition (points 1 to 9) 2. Minimising the risk of bacteraemia (point 10) 3. Maximising administrative arrangements for infection prevention and control (points 11 to 12) All actions have been reviewed for 20/07 and are in place as per plan and policy. The ICT are currently reviewing the Clinical Management of MRSA Policy and considering options regarding: Screening management in identified low risk areas Guidance for clearance of MRSA positive/isolated patients 7. Hand Hygiene The Trust successfully applied to be included in Phase 3 of the cleanyourhands campaign launched by the National Patient Safety Agency (NPSA). The Trust officially launched the campaign in early 2005, aimed at improving compliance with hand hygiene. The Trust used the cleanyourhands campaign as a launch pad to improve patient safety by reducing the risk of infection with further promotion of hand hygiene including staff, patients and visitors. This features prominently in the 20/07 Action Plan and audit programme, and will continue as we commence year three of the campaign. 8. Decontamination The Trust Decontamination group continues to meet quarterly. National Infection Control Monies National capital monies has been received by the Trust to support the decontamination strategy. The Oral Surgery instruments are currently being purchased which will enable the benchtop steriliser to be removed in line with the guidance. A project team is being set up to progress purchase of a tray tracking system across the Trust. The nasendoscopes and cystoscopes will be purchased as part of the scope review being led by the Medical Devices Department. 9
Progress Against Decontamination Strategy The Decontamination Strategy remains in place with key objectives reviewed at each meeting but unchanged, as they are all still relevant. A risk assessment has recently been completed for outstanding areas of non compliance. Progress against these objectives is as follows: Ensure fully compliant decontamination practice Trust-wide by March 2007 The Decontamination Leads are currently undertaking audits of departments undertaking decontamination practices. Audits have been completed so far in Endoscopy, Main Theatres and Day Surgery Unit (DSU), and a number of issues have arisen for further action to ensure compliance. DSU have now disposed of their local benchtop steriliser. It is anticipated that the Oral Surgery benchtop steriliser will now be removed by July 2007 subject to receipt of the additional instruments above. An operational policy for the benchtop sterilsers in Main Theatres has been drafted but this will be incorporated within the revised Decontamination Policy which is being undertaken currently. These machines are very rarely used, but have been retained for emergency need to clean dropped instruments that are essential to complete a procedure only. However, recent audits have shown that some areas may not be following this policy. The Trust Decontamintion policy has had an annual review however, a full review of the whole policy and related policies/protocols is underway and should be completed within the next few months. Action is ongoing to reduce the number of difficult to clean items and replace them with single-use items whenever possible. All departments/directorates must be reminded of the need to complete risk assessments for such items and where, exceptionally, single-use items are re-used. The national IT training package has full uptake within Sterilization & Disinfection Unit (SDU), and will be rolled out across the Trust supported by a seconded team leader from SDU from January 2007. It is hoped that tray tracking software will be implemented during the calendar year, although a timetable is uncertain until clarity is received on the ability to link to ipms. Complete Phase I spending plan by March 20 All the planned purchasing for this Trust is complete and this part of the strategy is now achieved. Any future purchasing will be for developments or changes in practice to ensure continued compliance with national standards. Ensure all endoscope decontamination takes place in fully compliant washers and is in line with MDS DB2002 (05) by March 2007 A further options paper is being worked up to provide more details costings against risks/benefits for the centralisation of flexible endoscope decontamination. This will include fuller consideration of the implications of centralisation to the Endoscopy Unit or to the SDU. Maintain a fully complaint SDU until at least 2017 The SDU here in Salisbury continues to maintain its compliance and accreditation to the latest standards in Sterile Services. The Trust is committed to maintaining this service and not a super centre. Marketing the Salisbury SDU services to increase the external customer base This is an ongoing piece of work with any opportunities taken to expand our customer network and income channels. There is additional interest from existing customers to extend their contract with us and also from some GP practices that need to improve their decontamination practice. We already have contracts with some South Wiltshire GP practices to decontaminate their minor ops 10
instrumentation. We are awaiting the out come of a decontamination service for the PCT Podiatry Service The Decontamination group continues its work to ensure all these objectives are met. 9. Cleaning Services Post Infection Cleans The Housekeeping department routinely records post infection cleaning undertaken as part of the Trusts management and control of infection. During 2005/, 3120 post infection cleans were undertaken, during 20/07 this reduced by 21.8% to 2440 cleans. The opening of the clinical extension in May 20 resulted in an immediate reduction in the number of post infection cleans. Tidy Tuesday The Trust s clean up campaign entitled Tidy Tuesday, launched in March 2005 continues to support the cleaning process by the removal of unwanted items and by addressing excessive and inappropriate storage. On the last Tuesday of each month items are collected from around 15 different wards and departments with around 15 hours of portering time each month dedicated to the initiative. This initiative has been embodied within the Trusts culture and is now regarded as an integral part of our Clean Hospitals campaign. Other Trusts have expressed an interest in this proactive initiative to further support their cleaning programmes. Patient Environment Action Team (PEAT) The Trusts formal PEAT assessment was undertaken on 21st February 2007 the assessment team included representatives from the Trusts Patient and Public Involvement (PPI) Forum, Age Concern, Ward Leaders and Infection Prevention and Control. The Trust was assessed in accordance with the criteria specified by the National Patient Safety Agency. The 2007 PEAT audit criteria has changed, PEAT audit scores are now weighted using the National Standards of Cleanliness (NSC) score. Further details on how the PEAT scores are to be weighted have not yet been published. For 2007 the Trusts NSC score was 91%, an increase from last years score of 86%. In the 20 PEAT assessment the Trust received the highest rating of Excellent for cleanliness. The Department of Health will confirm the weighted PEAT scores for individual Trusts in July. In-house PEAT audits are undertaken throughout the year, the audit teams include representatives from wards and departments, Infection Prevention and Control, Housekeeping and Estates Technical Services (ETS) Department. In-house PEAT audit reports are reported to the Trust's Patient Environment Action Group (PEAG), which meets quarterly. Housekeeping Services User Guide Following extensive consultation with ward leaders and departmental heads an updated Housekeeping User Guide has been published (November 20), and is available on the Trusts Intranet site. The document has been presented to both the Trusts PEAG and PPI Forum. National Patient Safety Agency (NPSA) Colour Code Following the publication of the NPSA Safer Practice Notice (Number 15) in January 2007, an action plan to implement the national colour coding for cleaning materials is due to be tabled to the Clinical Risk Group in April 2007. In accordance with this notice, it is proposed that the Trust will transfer to the new colour coding by October 2007. Under the Safer Practice Notice, Trusts are required to amend local policies and use the National Colour Code for cleaning materials and equipment by March 2008. 11
Micro Fibre Cleaning System In January 2007, trials of the Micro Fibre cleaning system commenced on a plastic surgery ward, and following positive feedback from both ward and Housekeeping staff, a further trial is planned for the medical admissions unit (MAU) to commence in May 2007. Housekeeping Auditing System A new auditing system has been purchased for the Housekeeping Department. This new audit software uses the National Standards of Cleanliness to identify frequency of audits and measures the Trust against these standards. Over the next 6 months room data will be collected and training undertaken. The new auditing system will replace current arrangements in October 2007. Training Housekeeping staff are currently piloting Computer Based Learning (CBL) packages available on the Managed Learning Environment (MLE) within the Trust. This increased access to training and flexible approach has increased the quantity of training undertaken by Housekeeping staff and is supporting the collection of Knowledge and Skills Framework (KSF) portfolio evidence. 10. Audit The extent of the Infection Prevention & Control Audit Plan is illustrated in the Audit programme (Appendix 6). This programme ensures audit is clinically focused and targeted at improving infection control practices for all disciplines across the Trust. Key achievements and progress of the programme over the last twelve months include: Commencement of active surveillance and investigation in key clinical areas. Completion of equipment cleanliness and Trust wide hand hygiene audits. Implementation of planned policy and guideline review, which has included undertaking audits. Completion of identified Saving Lives Programme audits, which has focused on the delivery of care for lines, including management in reducing the acquisition of HCAI - (High Impact Intervention (HII) No: 1 Preventing the risk of microbial contamination, HII No: 2b Peripheral Line Care and a re-audit of HII No: 2 Central Venous Catheter (CVC) Care). Policy audit Hand Hygiene, MRSA Treatment Pathway and Uniform/Dress Code. Antibiotic audit in relation to C.difficile outbreak. Environmental audits (in relation to clinical standards and infection control practices). Audit recommendations are reviewed by the IPCWG and agreed by the IPCC. 10.1. Changes and Benefit as a Result of Audit There is an increased awareness of the effects of poor hand hygiene and increased compliance with good hand hygiene practices. Audits of clinical areas led by Link Professionals have led to significant improvements in infection prevention and control e.g. increased hand hygiene/decontamination compliance, e.g. better strategic placement of gel dispensers, and use of personal protective equipment, e.g. disposable aprons and gloves. Following the initial HII No: 2 Central Venous Catheter (CVC) Care audit undertaken from the Saving Lives programme on the Intensive Care Unit, changes in practice were identified and implemented. This included reviewing techniques and cleaning solutions (skin preparations/antiseptics) used when accessing the catheter ports. A re-audit was performed during quarter 4 and a report will be completed and reviewed by the IPCWG. 10.2. Antibiotic Prescribing The Antibiotic Reference Group (ARG) is a sub group of the Drugs and Therapeutics Committee (DTC) and provides a focus for all work linked with antibiotics, advising and promoting good 12
practice and optimal antibiotic prescribing across the Trust. The work of the ARG is aimed at delivering the Government agenda to minimise the development of anti-microbial resistance and to reduce healthcare associated infection as set out in the Winning Ways document. Key work areas for 20/7 have included: 1. Improving the prescribing of high-risk anti-microbial treatments is one of the key targets for the ARG. This has included the introduction of an educational Penicillin Allergy traffic light poster, repeated educational bulletins and training sessions. There has been a reduction in the number of intervention reports received from 17 to 9 by the Pharmacy Intervention Reporting System in 20. New guidelines for high dose 5mg/kg Gentamicin, which included a prescription sticker were launched in March 20. Results from a recently conducted audit to assess the reduction in high dose gentamicin prescribing errors is expected mid 2007. Education and monitoring of prescribing errors is ongoing to ensure steps are taken to improve the safe prescribing of anti-microbials across the Trust. 2. The Lead Anti-microbial Pharmacist conducts anti-microbial point prevalence audits every 6 months. This provides a one-day snapshot of antibiotic use and provides data relating to the quality and appropriateness of antibiotic prescribing across the Trust. Initial baseline data collected in 20 has helped to identify problem areas within the Trust and steps have been taken to resolve any problems. 3. Empiric guidelines are being developed for each clinical area. 4. In response to the recent C.difficile outbreak the Empiric Anti-microbial Guidelines for Respiratory and for Medicine were reviewed. This was to ensure the avoidance of cephalosporins and to minimise exposure to ciprofloxacin in the over 70 year old group of at risk patients. Following approval by the DTC these reviewed guidelines are now in use across the Trust. Compliance with these guidelines and the effect on C.difficile rates will be audited in the future. 11. Training Activities It is widely recognised that on-going education activity in infection control is required in order to improve health care worker compliance with infection prevention and control practices. The Infection Prevention & Control Team undertakes a large number of induction and educational updates to a wide range of key staff within the Trust. The ICT keeps attendance data from these sessions and supports the Trust in its delivery of mandatory education for all staff (Appendices 7 & 8). These activities include: Orientation Programme for all new staff In-Service Education Lectures Computer Based Learning (CBL) Continuing Professional Development (CPD) for all staff The ICNs have contributed to informal teaching sessions within clinical areas and other Trust departments, and also to study days organised by the Practice Education Team (PET), Intensive Care Unit (ICU), Maternity Unit, Spinal Unit and Emergency Department. The ICT have 72 Link Professionals within the Trust, who meet formally every month, with the opportunity to discuss infection control matters, in relation to their area and Trust wide, including 13
specific sessions on outbreak prevention management for norovirus and C.difficile infections. Attendance is monitored and reported to the Directorate Senior Nurses and the DIPC. Attendance has been variable and the team have commenced an audit of the Link Professional role in quarter 4, which is due for completion (May 2007). The ICT also produce a newsletter bi-monthly, which is distributed across the Trust and Wiltshire area (including GP practices/surgeries). Regular items on the newsletter include educational and training information, which will continue and be edited by the team secretary. The Trust are currently reviewing mandatory training and education methods. A new Infection Control CBL is being developed, enabling the team to ensure non-participants are followed up according to National Health Service Litigation Agency (NHSLA) standards. Completion of the programme is expected by end of quarter 1 (May 2007). 12. Summary This annual report has provided the Trust Board with evidence of improvements in Infection Control practices across the Trust. Continued implementation of the Infection Prevention and Control Annual Programme Action Plan and the MRSA Action Plan 2007/08 (Appendices 1 & 5) are key to ensuring a reduction in MRSA bacteraemia rates and to maintain widespread sound practice in the prevention and control of infection. 14
Infection Prevention & Control Appendix 1 Annual Action Plan 2007/2008 No Objectives Key Actions Who When 1. Management & Organisation 2. Active Surveillance & Investigation 3. Reduce Infection Risk from the use of intravascular lines (peripheral & central), indwelling devices, instruments & other devices Continue to promote the role of the DIPC in the prevention & control of HCAI. Maintain the role of DIPC as an integral member of the Trust s Clinical Governance & risk structures (including Assurance Framework). Lead infection prevention & control in the Trust and provide a six monthly public report to the Trust Board. Ensure the system of Root Cause Analysis (RCA) is used to review risks relating to infection prevention & control. Ensure a programme of audit is in place to systematically monitor & review policies & guidelines relating to infection prevention & control, and appropriately reported. Continue implementation of mandatory Surveillance Plan for HCAI & produce quarterly reports for ICC. Review implementation of alert organism & alert condition system. Continue implementation of Root Cause Analysis (RCA) investigations relating to HCAI and implementation of resultant recommendations. Use comparative data on HCAI & microbial resistance to reduce incidence & prevalence. Promote liaison with the HPA for effective management & control of HCAI. Implement Saving Lives programme. Implement audit programme of all devices & lead recommendations. Implement decontamination strategy & review progress. Chief Executive Chief Executive DIPC DIPC/LW IPCWG/IPCC VC DDIPC/ICT DIPC/ICD DIPC/ICT ALL ICT ICT Decontamination Group/ICT Continuous Ongoing Six monthly Continuous Quarterly Quarterly Ongoing Ongoing Continuous Ongoing Ongoing Ongoing April 2007 15
4. Maintain a clean & appropriate environment & reduce the reservoirs of infection 4. Maintain high standards of hygiene in clinical practice Ensure maintenance and monitoring of high standards of cleanliness. Ensure adequate provision of suitable hand washing facilities and continued implementation of CleanYourHands Campaign. Continue ICT involvement in overseeing all plans for construction & renovation. Continue equipment audits & lead recommendations. Continue implementation of MRSA Action Plan and monitor progress. Introduce Smart Suit uniforms for clinical nursing staff, to replace traditional uniform across the Trust and develop a Uniform & Personal Appearance policy for all staff. Continue programmes of infection control education for all staff via induction and on-going education. Continue to prove high levels of compliance with hand decontamination by all staff via data collection & audit. Maintain the role of the Link Professionals in all clinical areas and monitor effectiveness. Continue promotion of infection control education for all staff via the Computer Based Learning (CBL) system by all groups of staff. Promote inclusion of infection control as part of PDPs for all staff. DIPC/IR/SS DDIPC/PC/ICT ICT ICT DIPC/ICT DDIPC ICT ICT DIPC/ICT ICT DIPC Quarterly Ongoing Ongoing 6 monthly Continuous Autumn 2007 Continuous Quarterly Continuous Continuous Ongoing 5. Maintain prudent use of antibiotics 6. Research & Development Monitor & audit implementation of Clinical Management of MRSA policy & Treatment Pathway. Ensure effective performance of the Antibiotic Reference Group (ARG). Monitor & audit implementation of Clostridium difficile policy. Maintain membership of the SHA Steering Group, working on national research & development issues. Ensure epidemiological techniques are up-to-date. Continue evaluations of measures that may prevent & control HCAI. FM Chief Pharmacist ICD/ICT DIPC ICD ICT Ongoing Ongoing & annual review Ongoing Ongoing Ongoing 16
Infection Prevention & Control Appendix 2 Infection Control Doctor Director of Infection Prevention & Control Deputy Director of Infection Prevention & Control Senior Nurse Infection Control Infection Control Nurse Education & Audit Lead Infection Control Nurse Clinical Practice Lead Infection Control Nurse Surveillance Lead Infection Control Secretary 17
Appendix 3 Trust Reporting Structure Trust Board Clinical Governance Committee Audit Committee Joint Board of Directors Infection Prevention & Control Committee Clinical Risk Group Clinical Governance Operational Group Clinical Management Board Health & Safety Committee Operational Management Board Infection Prevention & Control Working Group Infection Prevention & Control Committee Health Protection Agency Antibiotic Reference Group Building & Works Group Infection Control Team Facilities Working Group Decontamination Working Group 18
Appendix 4 Surveillance Plan 2007/08 April - June 2007 (Quarter 1) ORIF Long bone fracture July - Sept 2007 (Quarter 2) Oct - Dec 2007 (Quarter 3) Total Knee Replacement (TKR) Limb Amputation Jan - Mar 2008 (Quarter 4) Total Hip Replacement (THR) Vascular 19
MRSA Action Plan 2007/08 Appendix 5 No Strategy Intervention 1. Reduce entry of MRSA into the Trust Pre-admission screening of elective high-risk surgical patients for MRSA. Pre-admission MRSA topical eradication treatment for elective high-risk surgery patients as per policy. 2. Early detection of MRSA in in-patients Admission screening of patients for MRSA. 3. Early eradication of MRSA from in- MRSA topical eradication treatment for patients 4. MRSA detection throughout admission 5. Reduce contact with MRSA positive in-patients 6. Reduce likelihood of MRSA acquisition from healthcare workers 7. Reduce likelihood of MRSA acquisition from the environment 8. Design hospital environment to reduce risk of MRSA acquisition 9. Minimise practice likely to promote MRSA emergence by strict antibiotic stewardship identified MRSA positive patients. MRSA screen triggered by specific events at any time during admission. Screening of contacts in response to MRSA detection in clinical specimen from index case. Isolate MRSA colonised/infected patient to side room/cohort bay. Adherence to Hand Hygiene Policy following audit programme. Ensure efficiency of cleaning in clinical areas and decontamination of equipment according to Trust policy. Ensure high proportion of single rooms in new build. Ensure facilities for hand hygiene are available in every clinical area. Prudent use of antibiotics monitored by the Antibiotic Reference Group (ARG). 10. Reduce the risk of MRSA bacteraemia Target minimising risk of bacteraemia by adherence to: Annual Programme MRSA Action Plan Audit Programme Policy Development & Review Programme Saving Lives Health Care Act 11. Promote effective directorate ownership of infection prevention & control 12. Promote senior management overview of Trust infection prevention & control practice Determine methodology via directorate 3:3 meetings to manage directorate specific infection issues in conjunction with the DIPC and the Infection Prevention and Control service. Monthly IP&C Working Group meetings and quarterly IPCC meetings Infection Prevention & Control review is a regular agenda item at Trust Board meetings (bi-annual DIPC report). 20
Appendix 6 Annual Audit Programme 2007/08 No Aim Audit Who 1. Active Surveillance & Investigation. Reduction of infection risk from the use of Catheters, Tubes, Cannulae, Instruments & other Devices 2. Reduce the Reservoirs of Infection 3. High Standards of Hygiene in Clinical practice 4. High Standards of Hygiene in Clinical practice 5. Prudent use of Antibiotics 6. Management & organisation Intravascular cannulation Surgical site infections Non-surgical site infected skin lesions Urinary tract Respiratory tract Use in immuno-compromised patients Environmental & equipment cleanliness (6 monthly). Hand hygiene/decontamination (quarterly) CleanYourHands campaign. Inclusion of infection control as part of personal development programme (PDP) for all staff. Strict antibiotic prescribing and usage. Policy/guideline development & review programme Clostridium difficile Clinical management of MRSA Infection Control - Construction & Renovation Isolation Outbreak Management of Norovirus Respiratory Syncitial Virus (RSV) Standard Precautions Surveillance Tuberculosis IC Senior Nurse IC Education Lead/ Link Professionals IC Education Lead/ Link Professionals/ DIPC Chief Pharmacist Deputy DIPC 21
Appendix 7 In Service Education Attendance 140 Numbers of Staff 120 100 80 60 40 20 IC Roles Standard Precautions Hand Decontamination Laundry Management Sharps Mgmt of MRSA Isolation Precautions 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan 07 Feb 07 Mar 07 Months 22
Appendix 8 IPC Computer Based Learning 120 Numbers of Staff 100 80 60 40 20 Decontamination Hands Waste Management Linen Management Sharps MRSA Isolation 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan 07 Feb 07 Mar 07 Months 23
Appendix 9 FREQUENTLY ASKED QUESTIONS Clostridium difficile Q. What is Clostridium difficile? C. difficile is a spore forming bacterium which is present as one of the 'normal'bacteria in the gut of up to 3% of healthy adults. It is much more common in babies - up to two thirds of infants may have C. difficile in the gut, where it rarely causes problems. People over the age of 65 years are more susceptible to contracting infection. Q. How do you catch it? C. difficile can cause illness when certain antibiotics disturb the balance of 'normal'bacteria in the gut. Its effects can range from nothing in some cases to diarrhoea of varying severity, which may resolve once antibiotic treatment is stopped, through to severe inflammation of the bowel which can sometimes be life threatening. It is possible for the infection to spread from person to person because those suffering from C. difficile -associated disease shed spores in their faeces. Spores can survive for a very long time in the environment and can be transported on the hands of health care personnel who have direct contact with infected patients or with environmental surfaces (floors, bedpans, toilets etc.) contaminated with C. difficile. Q. What are the symptoms of C. difficile infection? The effects of C. difficile can vary from nothing to diarrhoea of varying severity and much more unusually to severe inflammation of the bowel. Other symptoms can include fever, loss of appetite, nausea and abdominal pain or tenderness. Q. How do doctors diagnose C. difficile infection? It is difficult to diagnose C. difficile infection on the basis of its symptoms alone, therefore the infection is normally diagnosed by carrying out laboratory testing which shows the presence of the C. difficile toxins in the patient's faecal sample. Q. Who does it affect? Are some people more at risk? The elderly are most at risk, over 80% of cases are reported in the over 65-age group. Immunocompromised patients are also at risk. Children under the age of 2 years are not usually affected. Repeated enemas and/or gut surgery increase a person's risk of developing the disease. C. difficile infection occurs when the normal gut flora is altered, allowing C. difficile to flourish and produce a toxin that causes a watery diarrhoea. Antibiotics may also alter the normal gut flora and increase the risk of developing C. difficile diarrhoea. Q. How can it be treated? C. difficile can be treated with specific antibiotics. There is a risk of relapse in 20-30% of patients and other treatments may be tried, including pro-biotic (good bacteria) treatments, with the aim of re-establishing the balance of flora in the gut. Most cases of C.difficile diarrhoea make a full recovery. However, elderly patients with other underlying conditions may have a more severe course. Occasionally, infection in these circumstances may be life threatening. Q. What should I do to prevent the spread of C. difficile to others? If you are infected you can spread the disease to others. However, only people that are hospitalised or on antibiotics are likely to become ill. In order to reduce the chance of spreading the infection to others: it is advisable to wash hands with soap and water, especially after using the restroom and before eating; keeping surfaces in bathrooms, kitchens and other areas clean and cleaning these on a regular basis with household detergent/disinfectants. 24
Q. How can hospitals prevent the spread of C. difficile? Unfortunately patients with diarrhoea, especially if severe or accompanied by incontinence, may unintentionally spread the infection to other patients, which may lead to outbreaks of C. difficile in hospitals. In addition, the ability of this bacterium to form spores enables it to survive for long periods in the environment (e.g. on floors and around toilets) and disseminate in the air e.g. during bed making. Staff should wear disposable gloves and aprons when caring for infected patients and affected patients may be segregated from others. Rigorous cleaning with warm water and detergent is probably the most effective means of removing spores from the contaminated environment, whilst staff should observe good hand washing practice. Alcohol gels should be used routinely by healthcare staff between treating patients, but only if their hands are not visibly soiled. When hands are visibly soiled, they must always be washed with soap and water first. In an outbreak situation, the Infection Control Team may introduce special measures for staff, patients and visitors to follow. Q. I have heard that some patients are at increased risk for Clostridium difficile - associated disease. Is that true? That is true the risk for disease increases in patients with the following: antibiotic exposure gastrointestinal surgery/manipulation long length of stay in healthcare settings a serious underlying illness immunocompromising conditions advanced age Q. Has a new type of C. difficile infection been detected recently? The HPA has initiated a sampling scheme to detect new types of C.difficile infection. A new type of C.difficile closely related to one previously found in North America has recently been detected in the UK, including at Stoke Mandeville Hospital. Q. How common is this strain in the UK? It is not possible to make an assessment of how prevalent this is in the UK because data have not been collected in sufficient quantities to give us a true picture of the current position. Q. Is this strain more difficult to treat? This strain of C.difficile can be treated with antibiotics, in the same way as other types. Q. Is this hospital infection caused by C. difficile any more difficult to remove from the environment than other hospital infections? C.difficile are types of bacteria that produce resistant spores that are able to persist in the environment longer than other bacteria. Although they will not be killed by alcohol hand gels, they can be removed with soap and water. Staff, patients and visitors need to wash hands with soap and water in addition to using alcohol hand gels. Disinfectants containing bleach need to be used on surfaces and floors to ensure that the spread of infection is controlled. Staphylococcus aureus Q. What is Staphylococcus aureus? Staphylococcus aureus is a bacterium that is commonly found on human skin and mucosa (lining of mouth, nose etc). The bacterium lives completely harmlessly on the skin and in the nose of about one third of normal healthy people. This is called colonisation or carriage. Staphylococcus aureus can cause actual infection and disease, particularly if there is an opportunity for the bacteria to enter the body e.g. via a cut or an abrasion. Q. What illnesses are caused by Staphylococcus aureus? Staphylococcus aureus causes abscesses, boils, and it can infect wounds - both accidental wounds such as grazes and deliberate wounds such as those made when inserting an 25