WRIGHTINGTON, WIGAN & LEIGH NHS TRUST DIRECTOR OF INFECTION PREVENTION AND CONTROL ANNUAL REPORT 2007/8

WRIGHTINGTON, WIGAN & LEIGH NHS TRUST DIRECTOR OF INFECTION PREVENTION AND CONTROL ANNUAL REPORT 2007/8 Author: Gill Harris, Director of Infection Prevention and Control Date: April 2008 DIPC 2007-8 ANNUAL REPORT final 2 Page 2 of 51

1 EXECUTIVE SUMMARY This is the fourth Director of Infection Prevention and Control s (DIPC) report, covering the period April 2007 to March 2008. The DIPC Report is produced on an annual basis and incorporates the annual Infection Control Report. The DIPC Report consists of an overview and progress report on the Infection Control management arrangements (including budgetary control), together with other Infection Control activities. This document also provides summary reports on the following:- Description of Infection Control Team Arrangements Infection Control Budgetary allocation Healthcare Associated Infection statistics Decontamination Cleaning Services Audit Targets and Outcomes 2 DESCRIPTION OF INFECTION CONTROL TEAM ARRANGEMENTS See Annex A, Wrightington, Wigan and Leigh NHS Trust: Infection Control Policy and Infection Control Committee Terms of Reference. 3 DIPC REPORTS TO THE TRUST BOARD The Director of Infection Prevention and Control has presented the Trust Board with the following agenda items on Infection Control in 2007/2008. The DIPC Annual Report 2006/2007 endorsed. Infection Control Committee Annual Programme 2007-2008 endorsed. Quarterly Infection Control minutes highlighting outbreaks and areas of concern and progress. The Trust MRSA Bacteraemia trajectory progress and areas of concern. The Trust Clostridium difficile trajectory progress and areas of concern. Initial report from Department of Health s Infection Control Inspection Team, November 2007. Issues identified as relevant to the Trust in the Health Care Commission s report on the Clostridium difficile outbreak at Maidstone NHS Trust. The Director of Infection Prevention and Control acts as the liaison between the Trust Board, Infection Control Committee and Infection Control Team. 4 DEPARTMENT OF HEALTH INFECTION CONTROL INSPECTION VISIT The Trust underwent a two-day inspection by the Department of Health Team in November 2007. A number of recommendations were given for immediate action and the full report can be found in Annex B. 5 BUDGET ALLOCATION TO INFECTION CONTROL ACTIVITIES The Infection Control budget for 2007 2008 is 211,663 (non-pay = 3,539). DIPC 2007-8 ANNUAL REPORT final 2 Page 3 of 51

The Microbiology budget for 2007 2008 is 1,191,207 (non-pay = 319,066). Infection Control staff: = 4.5 WTE (4.5 2.0 WTE in post during the period of the report). Secretarial support = 0.7 WTE. Infection Control Doctor 0.5 WTE. Consultant Microbiologist 1.5 WTE. Infection Control Annual Programme 2007-2008 and review of progress see Annex C 6 HEALTH CARE ASSOCIATED INFECTION STATISTICS Results of Mandatory Reporting of Health Care Associated Infection See Table One. Trends in Health Care Associated Infection Statistics MRSA bacteraemia See Graphs One and Two. Clostridium difficile diarrhoea See Graph Three and Four. 7 UNTOWARD INCIDENTS (INCLUDING OUTBREAKS) 2007 - Second Quarter A possible case of measles had attended the Accident and Emergency Department. This resulted in 14 staff members being screened for measles immunity and a number received MMR vaccination to provide protection against infection. Action was taken in line with Trust Measles Policy. The business case for routine vaccination of non-immune staff to measles was resubmitted for consideration. The Trust was part of a look-back exercise for a Hepatitis C infected Healthcare Worker employed for a two-week period in 1984. Thirteen patients were found to have been exposed to risk of infection. All were subsequently offered testing and none was found to be infected with the virus. This exercise was undertaken in conjunction with the Health Protection Agency. A possible outbreak amongst staff members at Wrightington Hospital was investigated. Food consumed by staff members was investigated but there was no indication that this was likely to be the source and indeed symptoms were relatively minor and possibly unrelated to each other. 2007 Third Quarter Five confirmed cases of measles within an extended family had all attended the Accident and Emergency Department over the course of some days. Implementation of the Trust Measles Guidelines had prevented any transmission to patients or staff members. The business case for measles vaccination of nonimmune staff members was accepted. This would significantly reduce the risk of transmission and simplify future management of such occurrences. Nine cases of Clostridium difficile diarrhoea were investigated on an orthopaedic ward. Antibiotic prescribing habits were reviewed and feedback on appropriate prescribing given to the clinical staff. The ward underwent a deep clean and some related issues were dealt with. A significant fall in numbers was observed following this intervention. DIPC 2007-8 ANNUAL REPORT final 2 Page 4 of 51

An increase in the number of patents colonised with a multi-resistant strain of Pseudomonas was detected on the ICU. A review of Infection Control practices and possible sources was undertaken. Routine audit detected that blood spills within the theatre environment were not being dealt with using disinfectant agents. This was rapidly remedied and the need to use chlorine based disinfectants reinforced throughout the Trust. 2007 Fourth Quarter Five wards had been affected by norovirus related gastroenteritis. All wards had been closed until symptoms resolved and had undergone a deep clean and a terminal clean before reopening. Norovirus appeared to be widely distributed within the region also causing outbreaks in schools and nursing homes. An increase in acquisitions of MRSA was detected on an orthopeadic ward. The ward was closed, underwent a terminal clean and additional Infection Control precautions were implemented. The number of acquisitions fell significantly following this action. Further cases of multi-resistant pseudomonas were detected on the ICU. A joint review of the Unit was undertaken in conjunction with the Health Protection Agency and a detailed action plan formulated. This remains under regular review and Infection Control standards are monitored regularly. A dedicated cohort ward for the management of Clostridium difficile diarrhoea cases was opened in late November 2007. All patients from the RAEI site with a positive Clostridium difficile toxin test were moved immediately to the cohort for specialist management. This has contributed to a fall in the total number of monthly Clostridium difficile cases detected within the Trust. 2008 First Quarter Sporadic episodes of Norovirus gastroenteritis were detected. However, these were rapidly controlled and there were no significant outbreaks within the hospital environment. Three further episodes of multi-resistant pseudomonas were detected on ICU. All were colonisation rather than infection. Further Infection Control measures including water sampling were undertaken. However, no specific source was detected. Antimicrobial Resistance 26% of Staphylococcus aureus isolates from blood cultures within the Trust were resistant to Methicillin in 2007/2008 (i.e. MRSA). 8 DECONTAMINATION Decontamination continued to be performed in-house at the Hospital Sterilisation and Disinfection Unit, Leigh Infirmary. Work has continued with the Joint-venture Decontamination programme throughout the year. Work has been undertaken at a number of sites to accommodate the expected changes in transport arrangements necessitated by sending instruments off-site for decontamination. DIPC 2007-8 ANNUAL REPORT final 2 Page 5 of 51

Incidents A small number of endoscopes were reprocessed in the Gastroenterology Unit without the use of appropriate disinfectant agents. A review of medical notes is being performed to determine risk to patients. Additional controls on the addition and testing of disinfectants to endoscope processing machinery were introduced to prevent recurrence. 9 CLEANING SERVICES The Management arrangements for the domestic provision is as follows: Associate Director of Estates & Facilities Assistant Estates & Facilities Manager Facilities Manager Hotel Services Manager Deputy Hotel Services Manager Domestic Supervisors Domestic Assistants The Domestic Assistants/Supervisors work to planned rotas that are site specific, but have the agreement to transfer to the Trust s other sites to undertake cleaning duties if required. The Deputy Hotel Services Manager has the management responsibility for designated sites and reports to the Hotel Services Manager whom in turn manages the services operationally Trust-wide. The Facilities Manager has the overall management responsibility for the services provided strategically implementing initiatives and guidelines, monitoring the National Cleaning standards promoting a proactive service meeting the needs of the Trust and in turn reporting to the Assistant Estates & Facilities Manager. The Trust holds a cleaning services forum chaired by the Deputy Director of Nursing and Governance. It comprises of members from multi disciplinary backgrounds and a patient representative (formerly the chair of the patient forum.) This group s remit is to improve the domestic provision and associated services delivered to the Trust. It also Implements quality measures and innovations. Examples include: it was highlighted in audits that additional training was required to standardise the role of the housekeeper training sessions were designed and delivered to the staff group DIPC 2007-8 ANNUAL REPORT final 2 Page 6 of 51

offering an expansion to the remit of the housekeeper s role to provide continuity across the divisions within the clinical environment the domestic department has standardised its procedures, protocols and products across the sites The forum recommended the adoption of the safer practice notice from which the Trust implemented the National colour coding scheme The Trust maintains the National Cleaning Standards code and monitors its standards using the Maximiser system. The domestic supervisors audit the clinical areas on a monthly basis, which is supported by the Ward Manager accompanying the Domestic Supervisor to assess the levels of hygiene and environmental standards. The Matrons accompany the Deputy Hotel Services Manager on a quarterly basis ensuring that areas maintain a high standard. The Trust score for its clinical areas is 92.5% and its external verification was good to excellent. The PEAT submission was good for patient environment. The senior team who agree the score is once again a multi- disciplinary team with a patient representative. The budget allocation is 3,247.732 (pay) and 261,550 (non-pay) totalling 3,509.282. The Trust has taken the decision not to incur a cost improvement saving on the domestic services department this year. Additional Domestic Assistant posts have been recruited to implement the 24hr cleans on A&E and to improve the response to terminal cleans of bed spaces. The Trust has achieved the government initiative of the deep cleaning of the wards. This deep cleaning exercise comprised of the restoration of surfaces, the cleaning of lighting and ventilation equipment cleaning and steam sanitising of the patient environment and equipment. The department has improved its financial performance by the reduction of office cleans Trust-wide. The hours saved were transferred into additional cleaning of the patient environment. The department undertakes satisfaction surveys. The supervisors regularly meet with the patients to discuss ways of improving the domestic services. The Domestic Supervisors also undertake planned environmental audits. The Director of Nursing provides the clinical responsibility for the domestic services provision, engaging in regular meetings with the Associate Director of Estates and Facilities. The Facilities Manager is provided clinical access through the matrons meetings and regular meetings with the Infection Control Manager. 10 AUDIT The following audits have been undertaken: Antimicrobial prescribing multi-ward audit of antimicrobial prescribing using the Trust Antibiotic Treatment Guidelines as the standard. Hand washing audit compliance with hand washing guidelines performed on all clinical areas within Trust. DIPC 2007-8 ANNUAL REPORT final 2 Page 7 of 51

11 TARGETS AND OUTCOMES MRSA Bacteraemia Nineteen episodes were recorded in 2007/2008. This was 1.6 times the MRSA reduction target of 12 episodes set by the Strategic Health Authority. However, this compares with thirty five episodes recorded in 2006/2007 and represents a 46% fall. Each episode of MRSA bacteraemia is subject to detailed root-cause analysis and an action plan is prepared and implemented, based on the findings. MRSA Bacteraemia - Divisional Performance Division/Area Apr-07 May June July Aug Sept Oct Nov Dec Jan-08 Feb March Total Medicine Wards 2 1 2 1 1 1 1 1 1 11 Coronary Care 0 Cardiology 0 Surgery Wards 1 1 1 1 4 ITU 1 1 2 Musculoskeletal Wards 1 1 2 MONTHLY TOTAL 3 1 2 3 1 2 1 1 1 2 1 1 19 TRUST CUMULATIVE TOTAL 3 4 6 9 10 12 13 14 15 17 18 19 19 Green Amber Red On target Caution required - exceeding cumulative monthly target currently - recovery possible Total allocated target exceeded Clostridium difficile Diarrhoea Four hundred and seventy-one episodes of Clostridium difficile diarrhoea were reported via the Mandatory Surveillance System in 2007/2008. This includes both hospital and community patients. 2007/2008 is the first year in which standardised data was collected under the Mandatory Surveillance System, making accurate comparison with 2006/2007 difficult. Using data from the Trust database for inpatients only gives a total of 373 cases compared to 358 in 2006/2007. Comparison of monthly totals for 2007/2008 against 2006/2007 indicate a significant fall in numbers in the last quarter of 2007/2008. The local target of achieving an 8% reduction in total cases in 2007/2008 compared to 2006/2007 was not achieved. DIPC 2007-8 ANNUAL REPORT final 2 Page 8 of 51

Health Care Commission Annual Health Check 2007/2008 The Trust was rated Fair for quality of services. 12 TRAINING ACTIVITIES Induction All staff, including medical staff, had Infection Control training included within their induction sessions. This includes instruction on handwashing, use of Infection Control Guidance and accessing Infection Control advice. In addition, medical staff received instruction on antimicrobial prescribing. CPD for all Staff Annual updates on Infection Control are mandatory for all staff and are delivered via the electronic mandatory training system. Compliance is monitored regularly. Junior medical staff receive educational sessions on Infection Control and prudent antimicrobial prescribing as part of their educational programme. A presentation of Clostridium difficile was given to clinical staff in December 2007. Training for Infection Control Specialists Infection Control Doctor is fully up to date with CPD requirements. Infection Control Team members attended national and local courses and updates as required. Training for the DIPC Attended Department of Health meetings/updates as required. Training for Matrons and Ward Managers Matrons and Ward Managers attend the University of Central Lancashire s Principals of Infection Control Course. 13 CONCLUSION Addressing the challenge of Healthcare Acquired Infections remains a key priority of the Trust, its Board members and the senior Divisional teams, understanding the accountability for infection control lies with each and every employee raising awareness with our visitors, patients and their relatives. The Trust is compliant with the Hygiene Code in terms of policy and the Key Core Standards of the Healthcare Commission, has completed a robust Deep Clean Programme, and is increasing the number of matrons in line with the DH guidance. The Trust received an unannounced visit from the Healthcare Commission during April which gave some positive feedback on the progress made to date. We have made DIPC 2007-8 ANNUAL REPORT final 2 Page 9 of 51

significant improvements in the final quarter of 2007/8; however, this does not mean to say the Trust is complacent or that we cannot improve further. 14 RECOMMENDATION The Trust Board is asked to note the contents of this report and approve the forward programme. DIPC 2007-8 ANNUAL REPORT final 2 Page 10 of 51

2007-1 2007-2 2007-3 2007-4 2008-1 2006-2 2006-3 2006-4 14 12 10 8 6 4 2 0 Graph 1 - Trends in MRSA Bacteraemia 2003-3 2003-4 2004-1 2004-2 2004-3 2004-4 2005-1 2005-2 2005-3 2005-4 2006-1 2003-2 2002-4 2003-1 2001-4 2002-1 2002-2 2002-3 2001-2 2001-3 Episodes

TABLE 1 RESULTS OF MANDATORY REPORTING INDIVIDUAL CASES YEAR 2007 2008 Quarter 2 3 4 1 MRSA Bacteraemia (cases) Glycopeptide resistant Enterococci bacteraemia (cases) Clostridium difficile (cases)* 6 6 3 4 0 0 0 0 154 159 102 56 Orthopaedic surgical site infection Not performed Not performed Not performed # * The mandatory return data includes all patients positive within the community and those symptomatic on arrival at hospital. As such it differs from the Trust local trajectory figures # Results awaited from the Department of Health. DIPC 2007-8 ANNUAL REPORT final 2 Page 12 of 51

Graph 2 - MRSA Bacteremia - Cumulative Totals 2006/2007 versus 2007/2008 40 35 30 25 20 15 10 5 0 2006/7 2007/8 Cumulative Episodes APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH DIPC 2007-8 ANNUAL REPORT final 2 Page 13 of 51

Graph 3 - Trends in Total Clostridium difficile Diarrhoea Cases 180 160 140 120 Number of Cases 100 80 60 40 20 0 2004-1 2004-2 2004-3 2004-4 2005-1 2005-2 2005-3 2005-4 2006-1 2006-2 2006-3 2006-4 2007-1 2007-2 2007-3 2007-4 2008-1 DIPC 2007-8 ANNUAL REPORT final 2 Page 14 of 51

Graph 4 - Clostridium difficile - Inpatient Episodes 2006/2007 versus 2007/2008 Cases 50 45 40 35 30 25 20 15 10 5 2006/7 2007/8 0 April May June July August September October November December January February March DIPC 2007-8 ANNUAL REPORT final 2 Page 15 of 51

ANNEX A INFECTION CONTROL POLICY WRIGHTINGTON WIGAN AND LEIGH HEALTH SERVICES NHS TRUST DEPARTMENT OF INFECTION CONTROL INFECTION CONTROL POLICY Authors : Dr R Nelson, Ms L Barkess-Jones Date of Acceptance : October 2000 Date of Last Review : May 2006 Date of Next Review : May 2008 DIPC 2007-8 ANNUAL REPORT final 2 Page 16 of 51

INFECTION CONTROL POLICY Wrightington, Wigan and Leigh NHS Trust aims to control and minimise the risk of acquiring infection whilst in Trust premises. This applies to patients, visitors and staff members. The responsibility for controlling infection risks lies with all Trust employees. In addition, the Trust has an Infection Control Team and Infection Control Committee (see below) which produce and execute an Annual Infection Control Programme. Written guidance on all aspects of Infection Control is available to all staff members via the Trust Intranet. THE INFECTION CONTROL TEAM (I.C.T.) The I.C.T exists to provide advice, training and information on all aspects of Infection Control within the Trust. It has the responsibility for formulating, implementing, reviewing and auditing the Trust s Infection Control Guidance. Membership of the Team consists of: Director of Infection Prevention and Control. Infection Control Doctor (also known as the Infection Control Officer) Consultant Microbiologist Senior Infection Control Nurse Specialist Infection Control Nurse Specialists Members of the ICT are available for consultation 24 hours a day, seven days per week. THE INFECTION CONTROL NURSES OFFICE IS LOCATED AT: The Elms Royal Albert Edward Infirmary Wigan Lane Wigan WN1 2NN Telephone: 01942 822035 (or ext. 2035) Page: 6063/6035/8099/8035/6064 THE INFECTION CONTROL DOCTOR IS LOCATED AT: Department of Microbiology Royal Albert Edward Infirmary Wigan Lane Wigan WN1 2NN Telephone: 01942 822131 (ext. 2131) or 822943 (ext. 2943) DIPC 2007-8 ANNUAL REPORT final 2 Page 17 of 51

OUT OF WORKING HOURS ADVICE: Is available from the on-call ICN and Consultant Microbiologist via the RAEI switchboard on: 01942 244000. However, to maintain efficient use of available resources, the guidance contained within the Infection Control Guidelines should be consulted for information in the first instance. THE INFECTION CONTROL COMMITTEE (ICC) The function of the ICC is to approve of, and advise on, the functioning of the ICT. It acts as a bridge between the ICT, Trust Executive and members of staff within the Trust, facilitating communication on all Infection Control matters. The ICC consists of the members of the ICT plus representation from: The Chief Executive PCT Public Health Department The Occupational Health Department Senior Medical Staff Senior Nursing Staff PCT Staff Estates and Facilities Trust Directorates Greater Manchester Health Protection Unit Lancashire and Cumbria Health Protection Unit The structure and function of the ICC complies with current guidance 1, 2 and is detailed in the Infection Control Committee Terms of Reference copies available from members of the Infection Control Team on request. INFECTION CONTROL GUIDELINES The Infection Control Guidelines contain comprehensive guidance on all aspects of Infection Control. They are available via the Infection Control site on the Trust Intranet and should be consulted in the first instance for all Infection Control problems. Staff should also take time to familiarise themselves with the contents, in particular the Guidelines on hand washing. REFERENCES: 1. Hospital Infection Control, Guidance on the Control of Infection in Hospitals. PHLS/DH 1995. Controls Assurance Standard Infection Control. NHS Estates Rev. 04 October 2003. DIPC 2007-8 ANNUAL REPORT final 2 Page 18 of 51

WRIGHTINGTON WIGAN AND LEIGH HEALTH SERVICES NHS TRUST THE INFECTION CONTROL COMMITTEE TERMS OF REFERENCE Authors : Dr R Nelson, Mrs L Barkess-Jones Date of Acceptance : June 2000 Date of Last Review : Dec 2003 DIPC 2007-8 ANNUAL REPORT final 2 Page 19 of 51

WRIGHTINGTON, WIGAN & LEIGH NHS TRUST INFECTION CONTROL COMMITTEE TERMS OF REFERENCE The Infection Control Committee (ICC) is a Sub Committee of the Trust Clinical Governance Sub Committee. It acts in an advisory capacity. However, the Infection Control Team (ICT) may exercise executive powers under the auspices of the Director of Nursing on a day to day basis. Functions of the Infection Control Committee The functions of the Infection Control Committee are: To advise and support the Infection Control Team. Draw the attention of the Chief Executive, through the ICT and Director of Nursing, to any serious problems or hazards relating to infection control and their resolution. Consider reports on infections, infection control problems/adverse incidents and make appropriate recommendations to the Clinical Governance Sub Committee. Discuss and endorse the annual infection control programme (including annual audit programme), review the progress of the programme, assist in its effective implementation and review the final results. To discuss and review data on the surveillance of infection and make appropriate recommendations to the Clinical Governance Sub Committee. Advise the Management Board on the most effective use of resources available for the implementation of the programme and contingency requirements. Approve infection control policies and review their implementation. Promote and facilitate the education of all grades of Trust staff in infection control procedures. Committee members to communicate information on infection control to all members of their Directorate as appropriate. Implement official Guidance on Infection Control as appropriate. DIPC 2007-8 ANNUAL REPORT final 2 Page 20 of 51

Membership of the Infection Control Committee The membership will include where available: Infection Control Doctor. Infection Control Nurse(s). Consultant Microbiologist. Public Health Representative(s) (PCT). Public Health Representative(s) (Health Protection Agency). Occupational Health Physician. Occupational Health Nurse. Senior Representatives from Trust Divisions. Director of Nursing (Representative of the Chief Executive). Clinical Risk Co-ordinator. Estates and Facilities Representative. Other members may be co-opted as appropriate. For example: Pharmacy Manager C.S.S.D Manager Catering Manager Environmental Health Officer Current Membership List See Appendix A Operational Aspects of the Infection Control Committee The committee will meet quarterly. The intended duration of meetings will be ninety minutes. A quorum will consist of one quarter of the current membership or more. If the meeting is not quorate, it will be adjourned. The meeting will be chaired by the Infection Control Doctor, or his/her nominated representative. Accurate minutes will be taken and circulated as below. DIPC 2007-8 ANNUAL REPORT final 2 Page 21 of 51

Accountability Arrangements These are given in chart form in Appendix B. Communication Arrangements These are given in chart form in Appendix C. Circulation of Minutes Minutes of the Infection Control Committee meeting will be circulated to all those detailed on the circulation list (see Appendix D). It is the duty of the Divisional Infection Control Committee members who receive copies of the Committee s minutes to ensure that minutes are made known to other divisional staff. Minutes should be circulated using the divisional circulation structure. This will ensure a two-way flow of information to the Division and back to the Committee. References Hospital Infection Working Group. Hospital Infection Control Guidance on the control of Infection in Hospitals. Department of Health/PHLS 1995. Anon. Controls Assurance Standard. Infection Control Rev. 03 (October 2002). Department of Health 2002. DIPC 2007-8 ANNUAL REPORT final 2 Page 22 of 51

Appendix A: Membership of the Infection Control Committee INFECTION CONTROL COMMITTEE MEMBERSHIP LIST MARCH 2008 INFECTION CONTROL TEAM: Dr R Nelson Dr C Faris Mrs L Barkess-Jones Ms T Cawley Mr P Huxley DIPC/D.O.N. Mrs G Harris MEDICAL DIRECTOR: Mr C Chandler NON EXECUTIVE DIRECTOR: Ms L Barnes SURGICAL REPRESENTATIVES: Dr R Saad, Consultant Anaesthetist Mr J Mosley, Consultant Surgeon Ms A Kelly, Head of Nursing Ms D Swindlehurst, Head of Midwifery MEDICINE: Dr I O Connell, Consultant Physician Ms L Smyth, Head of Nursing Ms M Jolley, Associate General Manager CLINICAL SUPPORT: Dr T Hiwot, Consultant Biochemist MUSCULO-SKELETAL: Mr T Clough, Consultant Orthopaedic Surgeon Ms A Kelly/replacement, Head of Nursing DIPC 2007-8 ANNUAL REPORT final 2 Page 23 of 51

OCCUPATIONAL HEALTH: Dr S Kumar, Consultant Occupational Health Physician Mrs P Cash, Occupational Health Nurse ESTATES AND FACILITIES: Mr N Surrell, Deputy Estates and Facilities Manager TB NURSE: Ms J Miller, TB Nurse PATIENT REPRESENTATIVE: Mr G Baron PCT INFECTION CONTROL NURSE: Mr K Park FIVE BOROUGHS INFECTION CONTROL NURSE: Ms L Rosbottom PCT: Ms C Whittaker, General Manager, Clinical Services HPU: Dr J Chaloner, Consultant in Communicable Disease Control, Greater Manchester Dr K Lamden, Consultant in Communicable Disease Control, Cumbria and Lancashire CLINICAL RISK: Ms P O Brien DIPC 2007-8 ANNUAL REPORT final 2 Page 24 of 51

Appendix B: Infection Control Accountability Arrangements: Wrightington, Wigan and Leigh NHS Trust CHIEF EXECUTIVE CLINICAL GOVERNANCE SUB-COMMITTEE (via Director of Nursing and Quality) RISK MANAGEMENT COMMITTEE INFECTION CONTROL COMMITTEE INFECTION CONTROL TEAM (Led by Infection Control Doctor) TRUST STAFF DIPC 2007-8 ANNUAL REPORT final 2 Page 25 of 51

Appendix C Communication Arrangements for the Infection Control Committee Education/Guidance Infection Control Team Guidance/ Actions Policies/documents/data/reports/agenda items Infection Control Committee Members Feedback Dissemination Input Findings/ Actions INFECTION CONTROL COMMITTEE Dissemination Division/Directorate Improvement Teams Division Meetings Sisters Meetings Via minutes/ annual report Via Director of Nursing Feedback/ minutes Via minutes Feedback Dissemination Clinical Governance Sub Committee Trust Board/CEO Those on distribution list (appendix D) Staff Members DIPC 2007-8 ANNUAL REPORT final 2 Page 26 of 51

APPENDIX D: MUSCULO-SKELETAL DIVISION DISEMINATION OF INFECTION CONTROL MINUTES Ann Armstrong General Manager (Member, ICC) Head of Nursing & Patients Services Consultant Staff General Managers Associate Rheum Patient Admin. Matron Matron Governance General Manager Services Manager (Ortho & rheum) (trauma) Implementation Co-ordinator Manager Conf Centre JCW Directorate Med Social Clerical Specialist Ward Practice Ward Manager Support Secs Work staff Nurses Sisters Development Sisters Staff Secs Nurse DIPC 2007-8 ANNUAL REPORT final 2 Page 27 of 51

DIPC 2007-8 ANNUAL REPORT final 2 Dr Nelson, Mrs L Barkess-Jones 07/05/2008 Page 28 of 51 Appendix D: Circulation List for Minutes of ICC Meetings CHIEF EXECUTIVE Andrew Foster Les Higgins Chief Executive Trust Chairman EXECUTIVE TRUST DIRECTORS Tony Chambers Director of Operations NON EXECUTIVE DIRECTORS Albert Mandall Louise Barnes Robert Collinson Geoff Bean Pamela McCann Robert Armstrong OTHER Divisional Chairs General Managers DIPC 2007-8 ANNUAL REPORT final 2 Page 28 of 51

DIPC 2007-8 ANNUAL REPORT final 2 Dr Nelson, Mrs L Barkess-Jones 07/05/2008 Page 29 of 51 ANNEX B DEPARTMENT OF HEALTH INSPECTION TEAM REPORT Following Trust visit, November 2007 - Not yet received (22/04/2008) DIPC 2007-8 ANNUAL REPORT final 2 Page 29 of 51

DIPC 2007-8 ANNUAL REPORT final 2 Dr Nelson, Mrs L Barkess-Jones 07/05/2008 Page 30 of 51 ANNEX C WRIGHTINGTON WIGAN AND LEIGH NHS TRUST INFECTION CONTROL PROGRAMME OCTOBER 2007 MARCH 2008 Progress Report 5 th March 2008 Author Dr R Nelson, Mrs L Barkess-Jones Date September 2007 Approving Committee Date Review Date Manager responsible for review Infection Control Committee Dr R Nelson, Mrs L Barkess-Jones DIPC 2007-8 ANNUAL REPORT final 2 Page 30 of 51

Code of Practice Point Programme of Work 2007/8 By Whom (lead) Achievement Progress/Outco me 1 General duty to protect patients and staff from health care associated infection. Covered in points 2 to 11. 2 Duty to have in place appropriate management systems for Infection Prevention and Control. RN, LBJ, DIPC March 08 a) Infection Control Programme to be expanded. Programmed actions to involve all staff members and Directorates, not solely those of those members of the Infection Control Team. Expanded Ic programme produced Oct 07. Progress reviewed within this document b) Adjust Infection Control Annual Programme period to align with the DIPC Annual Report (April to March). RN March 08 Achieved October 07 c) DIPC Annual Report to incorporate Progress Report on the Annual Infection Control Programme. Separate Infection Control Report to be abolished. RN, LBJ, DIPC March 08 Achieved March 08 d) Quarterly DIPC Report to Trust Board on Infection Control issues to replace the IC component of the Risk Management Quarterly Report. RN, LBJ, DIPC Oct 07 Commenced Oct 07 e) DIPC to present the DIPC Report for 2006/7 to the Trust Board. DIPC Oct 07 Presented Nov 08 f) DIPC to present the Infection Control Programme for October 2007 March 2008, to the Trust Board. DIPC Oct 07 Presented Nov 08 g) Infection Control Committee to continue to meet quarterly with representatives from all Divisions attending each meeting. RN All Divisional Representatives Meet quarterly in 2007/8 Met Quarterly in 2007/08. Membership currently under review. 3 Duty to assess risk of acquiring healthcare associated infection and to take action to reduce or control such risks. a) Maintain continuous surveillance of MRSA and Clostridium difficile diarrhoea cases. Data to be fed back monthly to wards, General Managers and DIPC. Microbiology Consultants Infection Control Nurses Ongoing Monthly reports produced Oct 07 Feb 08 DIPC 2007-8 ANNUAL REPORT final 2 Page 31 of 51

DIPC 2007-8 ANNUAL REPORT final 2 Dr Nelson, Mrs L Barkess-Jones 07/05/2008 Page 32 of 51 b) Monthly statistical process control charts to be produced for Clostridium difficile and MRSA cases. RN Ongoing Monthly reports produced Oct 07 Feb 08 c) Monthly charts detailing progress against MRSA bacteraemia and Clostridium difficile targets, to be produced. RN, LBJ Ongoing Monthly reports produced Oct 07 Feb 08 d) Progress against MRSA bacteraemia and Clostridium difficile reduction targets to be monitored monthly. DIPC, Trust Board Ongoing Summary circulated monthly to DIPC and Trust Board e) Update and distribute data on the Divisions progress against MRSA target after each episode of MRSA bacteraemia. LBJ As each episode occurs Circulated after each new episode f) Maintain alert organism and alert condition surveillance for other organisms/conditions. Microbiologists IC Nurses Ongoing Maintained g) Three-month block of Mandatory Orthopaedic Wound surveillance to be undertaken during 2007/8. Musculo-skeletal Division April 2008 Undertaken Jan to March 2008 h) Investigate prospective wound surveillance in surgical patients. Surgical Division April 2008 Surveillance Nurse to be employed in 2008/09 4 Duty to provide and maintain a clean and appropriate environment for healthcare (including environmental hygiene, medical a) Continue implementation of the Cleanyourhands campaign and adhere to recommendations. Infection Control Team and all clinical staff Ongoing Maintained throughout period of report DIPC 2007-8 ANNUAL REPORT final 2 Page 32 of 51

DIPC 2007-8 ANNUAL REPORT final 2 Dr Nelson, Mrs L Barkess-Jones 07/05/2008 Page 33 of 51 device decontamination and clinical hygiene). b) Monitor the transfer of Patient Line cleaning from the supplier to Trust. Estates & Facilities and Infection Control Team Ongoing Transfer suspended following legal advice c) Monitor decontamination standards during the changeover from in-house decontamination to decontamination super centre. Infection Control Team, Estates & Facilities As changeover occurs See above d) Revised Legionella Policy to be implemented Trust wide. Estates and Facilities Nov 07 December 07 5 Duty to provide information on healthcare associated infections to patients and public. 6 Duty to provide information when a patient moves from the care of one healthcare body to another. 7 Duty to ensure cooperation. Each NHS body, so far that is reasonably practical, ensures its staff, contractors and others included in provision of healthcare cooperate with each other to meet obligations of code. e) Maintain Infection Control input into new developments including Theatre 8 at Wrightington, Pharmacy extension RAEI, new Paediatric Ward RAEI. a) DIPC Annual Report for 2006/2007 to be published. a) Ward staff to ensure that patient and appropriate carers are aware of their HCAI status on discharge. a) Maintain the quarterly meetings with PCT Infection Control Team. b) Investigate joint working with the PCT on issues such as urinary catheter care identified as an issue by MRSA bacteraemia root cause analysis. c) Monitor contractors adherence to Infection Control precautions during development work taking place on Trust premises. ICT in conjunction with Estates and Facilities As developments occur All developments had IC input DIPC Oct 07 Published Oct 07 All clinical staff Ongoing Ongoing DIPC DIPC/Infection Control Team Estates and Facilities, ICT Ongoing Ongoing Ongoing Maintained. Frequency increased to monthly Maintained via monthly meeting Progress monitored by ICT during all recent developments DIPC 2007-8 ANNUAL REPORT final 2 Page 33 of 51

DIPC 2007-8 ANNUAL REPORT final 2 Dr Nelson, Mrs L Barkess-Jones 07/05/2008 Page 34 of 51 8 Duty to provide isolation facilities, adequate to need. a) Continue with side room building programme. Estates and Facilities, Infection Control Team, DIPC April 08 Two additional rooms completed February 08 b) Assess impact of side room loss should hospital sites close. Infection Control Team, DIPC As required No site closures as yet c) Bed management procedures to comprehensively incorporate Infection Control assessment and the need for isolation. 9 Duty to ensure adequate laboratory support. a) Review of MRSA screening provision. Bed Managers with assistance from Infection Control Team DIPC, RN, IC Committee March 08 Ongoing Bed management policy under revision to incorporate this March 2008 Review document published Nov 07 b) Develop business plans for increased screening if implementation is judged necessary. DIPC, RN As required Screening requirements under review March 2008 10 Duty to adhere to all clinical policies and protocols applicable to infection prevention and control. c) Laboratory to undergo full CPA assessment in January 2008. a) All staff to adhere to such documents b) Update of Infection Control Guidance as necessary or on expiry. Pathology All staff RN, LBJ Jan 08 Ongoing Ongoing Completed Jan 08 Awaits audit data All guidance within date, March 2008 c) Update Occupational Health Guidance maintained on Infection Control Intranet site SK Ongoing All guidance within date, DIPC 2007-8 ANNUAL REPORT final 2 Page 34 of 51

DIPC 2007-8 ANNUAL REPORT final 2 Dr Nelson, Mrs L Barkess-Jones 07/05/2008 Page 35 of 51 11 Duty to ensure that healthcare workers are free of and are protected from exposure to communicable disease during the course of their work and are educated in infection prevention and control. d) Monitor adherence to new Antibiotic Treatment Guidelines. a) Occupational Health services in place and to be maintained. b) Infection Control and antibiotic use to be in all induction and update programmes both manual and electronic. Pharmacy, Microbiologists SK, DIPC LBJ, RN, HR Dept Ongoing Ongoing April 08 March 2008 Adherence Audits performed monthly Maintained In place for induction and E-mandatory training, Oct 07 c) The requirement to adhere to all Infection Control Guidance included in all Agenda for Change job plans. LBJ, HR Dept April 08 Work in progress, not yet complete Responsible people: LBJ Mrs Lynda Barkess-Jones RN Dr Robert Nelson SK Dr S Kumar HR Human Resources DIPC Director of Infection Prevention and Control. DIPC 2007-8 ANNUAL REPORT final 2 Page 35 of 51

Annex D Infection Control Annual Programme 2006/2007 WRIGHTINGTON, WIGAN AND LEIGH HEALTH SERVICES NHS TRUST INFECTION CONTROL ANNUAL REPORT SEPTEMBER 2006 AUGUST 2007 Author(s): Dr R Nelson, Mrs L Barkess-Jones, September 2007 Accepted by the Infection Control Committee: DIPC 2007-8 ANNUAL REPORT final 2 Page 36 of 51

DIPC 2007-8 ANNUAL REPORT final 2 Dr Nelson, Mrs L Barkess-Jones 07/05/2008 Page 37 of 51 INTRODUCTION Publication of this document marks the completion of the Trust s seventh Annual Infection Control Programme. The report covers the twelve month period October 2006 to September 2007. This report details the Infection Control Team s progress against the Infection Control Programme for 2006 to 2007. It also provides information on events that cannot be programmed for, such as outbreaks and adverse incidents. STRUCTURE AND STAFFING OF THE INFECTION CONTROL TEAM Mrs D Jones left her post as Infection Control Nurse in January 2007. Mrs J Spendlove left her post as Infection Control Nurse in April 2007. Currently the Infection Control Nursing Team has 2.5 WTE in post. The structure is currently being revised following the departure of the two Infection Control trainees. The Infection Control Nursing Team moved from the Clinical Support Directorate to the Nursing Division in June 2007. INFECTION CONTROL GUIDANCE All existing guidelines were maintained and updated in accordance with the Annual Infection Control Programme. New guidance was produced on: Respiratory Viral Infection. Diarrhoea. Single-use Equipment. Respiratory Protective Equipment. Measles. Disposal of Sharps. DIPC 2007-8 ANNUAL REPORT final 2 Page 37 of 51

DIPC 2007-8 ANNUAL REPORT final 2 Dr Nelson, Mrs L Barkess-Jones 07/05/2008 Page 38 of 51 SURVEILLANCE Mandatory Surveillance Schemes The Microbiology Laboratory continues to provide data for the following mandatory surveillance schemes: MRSA bacteraemia. Vancomycin-resistant enterococcal bacteraemia. Clostridium difficile diarrhoea. The Infection Control Team assisted the Musculo-skeletal Directorate with the collation of data for the Mandatory Orthopaedic Wound Surveillance block for January to March 2007. Mandatory National Surveillance Results The Trust s position with regard to the most recently published Mandatory Surveillance data is as follows: MRSA bacteraemia (April 2006 March 2007) = 1.48 cases per 10,000 bed days. NHS average = 1.59 cases per 10,000 bed days. Clostridium difficile diarrhoea (January 2006 December 2006) rate = 2.28 cases per 1,000 bed days. NHS average = 2.39 cases per 1,000 bed days. Progress Against MRSA Reduction Targets (see Figures 1 and 2) Figure one outlines Trust progress against the MRSA reduction trajectory for 2006/7. The trajectory set by the Strategic Health Authority was originally to achieve fourteen or fewer episodes during the twelve-month period. This was revised by the Strategic Health Authority at the mid point of the year to a total of 27 episodes or fewer. The Trust had 35 episodes during the twelve-month period. Figure two outlines progress against the 2007/2008 trajectory target. Currently (September 2007) the Trust has had eleven episodes of MRSA bacteraemia. The target is twelve episodes or fewer and is therefore going to be difficult to achieve. Considerable work has been undertaken by the Infection Control Team and many other members of the Trust staff to reduce the bacteraemia rate. Developments include: Introduction of Root Cause Analysis for every episode of MRSA bacteraemia. Close liaison with PCT Infection Control Team for episodes occurring within 48 hours of admission to Trust premises. DIPC 2007-8 ANNUAL REPORT final 2 Page 38 of 51

DIPC 2007-8 ANNUAL REPORT final 2 Dr Nelson, Mrs L Barkess-Jones 07/05/2008 Page 39 of 51 Training and standardisation around central venous catheter insertion and management. Regular feedback to Ward Managers of current MRSA situation. Ongoing implementation of the Saving Lives and Cleanyourhands programmes. Education on the taking of blood cultures. Figure three summarises the totals by ward of MRSA colonisation, MRSA bacteraemia and Clostridium difficile diarrhoea. Local Surveillance Schemes Alert organism and alert condition schemes are continuously operated within the Trust. Particular emphasis is placed upon the collection of data for MRSA colonisations and Clostridium difficile diarrhoea cases. The data are distributed on a monthly basis in graphical format to Ward Managers and other senior staff members within the Trust. Figure four (MRSA process control graph). This graph summarises the whole Trust MRSA colonisation on a monthly basis in a process control format. Warning and action lines are provided to indicate where outbreaks may be occurring. It has been possible to revise the average number of cases downwards due to a general overall drop in MRSA colonisations throughout the Trust. The number of new colonisations remained below the action line at all times apart from January 2007. An increase in colonisation was detected in January 2007 and this was thought to be related to ongoing outbreaks of viral gastroenteritis increasing staff workload. Intervention rapidly brought the MRSA rate back towards the mean. Figure five illustrates the total number of Clostridium difficile diarrhoea cases detected within in-patients for 2006/2007. There has been a slow but steady increase in the number of cases over the preceding 12 months. It is not clear if any single factor accounts for this. A number of interventions are being made to control case numbers. These include: Revised Antibiotic Policy, removing cephalosporins and quinolones from use. Re-design of drug chart to restrict length of antibiotic prescriptions Antibiotic education of junior medical staff at dedicated teaching sessions. Antibiotic prescribing included in e-mandatory update training. Monitoring of bed space cleaning schedules. Promotion of hand washing with soap and water in Clostridium difficile cases. HANDWASHING The Infection Control Team continues with its implementation of the National Patients Safety Agency s Cleanyourhands campaign. DIPC 2007-8 ANNUAL REPORT final 2 Page 39 of 51

DIPC 2007-8 ANNUAL REPORT final 2 Dr Nelson, Mrs L Barkess-Jones 07/05/2008 Page 40 of 51 THE HOSPITAL ENVIRONMENT The demolition of the old Accident and Emergency block was concluded without any evidence of related infection occurring within hospital in-patients. This was thanks to the infection control measures implemented by staff on adjacent ward areas. The cleanliness of Patient Line patient bedside telephone and television equipment has been continuously monitored. Failings have regularly been brought to the attention of the Patient Line line management team. This has subsequently resulted in the Trust taking over the cleaning of these units to ensure standards are met. ADVERSE INCIDENTS/OUTBREAKS 2006 Fourth Quarter Investigations by the Infection Control Team suggest that reuse of items intended for single-use only continued in certain Departments. This placed patient at increased risk of infection and device failure as they cannot be adequately decontaminated. This also breaches the Medical Devices Agency s Guidelines on this topic. The Infection Control Committee through Dr Nelson has brought this issue to the appropriate Departments attention with a request to cease immediately. Two patients with multi-resistant Acinetobacter organisms were admitted to the Trust. Cases were unrelated, one coming from the USA and the other from Iraq. Both patients have now been discharged and the organism has been successfully contained to date. One episode of MRSA colonisation on the Neonatal Unit. Typing revealed this to be a different strain from past episodes and no evidence of spread was detected. Beginning in November 2006, an increase in reports of gastroenteritis symptoms was detected by the Team. Five wards had significant numbers of staff and patients affected and were closed for short periods. In addition, six other wards reported small numbers of cases and were monitored without closure. The outbreak was at an end by mid December 2006. A similar increase was noted in the community, reflecting the general increase in viral gastroenteritis activity throughout the region. Our Trust was significantly less affected by the virus than neighbouring Trusts. This reflects the high degree of compliance with infection control precautions. 2007 - First Quarter A new strain of MRSA carrying the PVL toxin was isolated from a number of patients within the community. This organism is unusual in that it causes infections within families rather than in hospital patients. There is no evidence of the organism being present within the Trust. The issue has been brought to the attention of the Health Protection Agency and the PCT. A meeting to discuss the management of further cases was held and a management policy developed. DIPC 2007-8 ANNUAL REPORT final 2 Page 40 of 51

DIPC 2007-8 ANNUAL REPORT final 2 Dr Nelson, Mrs L Barkess-Jones 07/05/2008 Page 41 of 51 A number of wards were affected by viral gastroenteritis during February and March 2007. A number of staff were also affected as often occurs in such events. A number of wards required short-term closure to contain spread of the virus. The shortage of acute medical beds around this time also contributed to the difficulties in managing the situation. All wards were terminally cleaned and they opened by early April 2007. 2007 Second Quarter A possible measles case had attended in Accident and Emergency. Fourteen staff members had been identified as contacts and had received MMR vaccine in accordance with Trust Policy. The diagnosis of measles could not be confirmed as it proved impossible to obtain a second serum sample from the index case. A possible outbreak of food borne diarrhoea and vomiting amongst staff at Wrightington Hospital was investigated. This was performed in conjunction with Environmental Health and the Estates Department. The final conclusion was that symptoms were non specific and were not related to food served at a function at Wrightington. Investigations revealed excellent record keeping by the Catering Department and high standards of food preparation and storage throughout the supply chain. The lookback exercise for thirteen patients exposed to a staff member infected with the Hepatitis C virus was performed. The staff member was employed for a two week period in 1984. A helpline and counselling service was set up for patients involved in the exercise. No patient was found to be infected with the Hepatitis C virus. This exercise was performed in conjunction with the Health Protection Agency and all data were forwarded to them to assist in a final national report. 2007 Third Quarter Measles infection was confirmed in a number of members of an extended family in the Wigan area. All either attended the Accident and Emergency Department or the Leigh Walk-in Centre. This led to considerable staff exposure to the measles virus. The Trust Measles Policy was implemented and MMR vaccine was offered to all identified staff contacts. Close liaison with the Health Protection Agency and the PCT successfully brought this episode to a close. There has been no evidence of further spread to staff members or other patients, indicating that the Trust Measles Policy works successfully in such situations. The business case for ensuring routine immunity to measles amongst all staff members has been progressed following this episode. Area 3 reported an increase in Clostridium difficile diarrhoea cases. A review of cleaning standards and antibiotic prescribing was carried out by Infection Control, Microbiology and Pharmacy. Some deficiencies were noted in the ward environment and excessive antibiotic course lengths were noted in a number of cases. These issues have been raised with appropriate managers together with advice on how to achieve control. Numbers of cases fell away rapidly after implementation of these controls. DIPC 2007-8 ANNUAL REPORT final 2 Page 41 of 51