Infection Prevention and Control Annual Report April 2007 March 2008 Bolton Hospitals NHS Trust
Contents ANNUAL REPORT Page Number 1. Executive summary overview of infection control 4 activities in the Trust 2. Infection control arrangements 4 3. DIPC reports to the Trust Board summary 5 4. HCC Vist/DH Support Team Visit 6 5. Budget allocation to infection control activities 6 6. HCAI statistics 6 7. Deep Clean 12 8. Audit & Training activities 13 9. National Guidance/Requirements 13 10. Conclusion 14 Appendices 1. The integrated HCAI prevention and control action plan 15-22 2. Action plan following HCC visit 23-25 3. Quarterly report from Winning Ways Group 26 4. Infection Control Training 27-28 2
1. Executive summary overview of infection control activities in the Trust Infection prevention and control is an essential component of care and is deservedly high on the agenda for everyone, it promotes safe and effective practice. The public quite rightly expects the hospital to have the highest standards to reduce the spread of healthcare associated infections (HCAI). The Infection Prevention and Control Team (IPCT), have a key role in providing a dynamic and comprehensive infection prevention and control service. Over the last year the profile of infection control nationally has been raised considerably, with challenging targets and priorities being introduced. The Trust has an integrated HCAI prevention and control action plan, which has been developed based on internal and external review. The plan relates to improvements being made in relation to HCAI s, and sets out identified actions against priorities alongside the associated action, and progress being made (Appendix 1). The following analysis is a summary of the activity and progress that has been made around infection prevention and control across the Trust. 2. Infection control arrangements The IPC team consists of: Current structure WTE Comments Consultant Microbiologist 1.0 Consultant Microbiologist 0.5 Retires March 31st Nurse Consultant, Infection Prevention & Control 1 Infection Prevention & Control Nurse 1 works over 4½ days Infection Prevention & Control Nurse 0.5 works over 2½ days Infection Prevention & Control Nurse 0.4 works over 2 days works over 4 Infection Prevention & Control Nurse 0.8 Infection Prevention & Control Support Nurse 0.4 days works over 2 days The team are increasingly working proactively with the infection prevention control team at Bolton PCT to better address infection control issues across the health economy. 3
2.1. Representation at Trust wide groups The Consultant Microbiologist is a member of a number of key strategic groups, including the Clinical Governance and Drugs & Therapeutics Committee. Members of the ICT represent the service and have a voice at a number of Trust wide groups, including the Decontamination, Risk Assessment Sub Group, Laboratory Medicine Health & Safety, Nutrition Advisory, Tissue Viability, Hydrotherapy Pool Management, Medical Devices, Waste Management, National Standards of Cleanliness, Pandemic Influenza, Clinical Risk Management Committee, Group and the Trust Health & Safety Committee. 2.2. Microbiology support New working arrangements were established within the Microbiology department to facilitate seven day testing and reporting for Clostridium difficile Toxin and Methicillin resistant Staphylococcus aureus (MRSA). Whilst in the early stages of being embedded, it is anticipated that this will have a significant impact for ward teams, in ensuring they are given real time information about Alert Organisms so that they are more able to respond and initiate appropriate treatment in a timely fashion. The microbiology team are working towards improving already established relationships with the IPC team to utilise and respond to epidemiology and surveillance information more effectively. 2.3. Infection Control Committee (ICC) The Trust Infection Control Committee continues to meet quarterly and oversees the work programme for infection control, operationalised by the Winning Ways group, which reports directly to the committee. The ICC receives regular updates including monitoring of progress of the integrated action plan, surveillance and use of data, as well as ensuring estates/ facilities current guidance and surveillance including response to any newly published guidance/recommendations., The group is chaired by the Director of infection Prevention and Control (DIPC) and its membership draws from representatives from key service areas from across the Trust as well as outside agencies such as Bolton Primary Care Trust and the Health Protection Agency 3. DIPC reports to the Trust Board summary The DIPC has executive authority and responsibility for implementation of strategies to prevent HCAI s at the organisational level. The DIPC is the public face of infection prevention and control. The DIPC provided the trust board with a comprehensive review of all infection control practices following the publication of the Healthcare Commission report of Maidstone and Kent, that raised significant concerns about the management of patients with Clostridium difficile. In addition the DIPC has provided briefings to the overview and scrutiny committee as well as a review of the trusts outbreak management policy for isolation and care of patients during an outbreak. 4
As part of the routine monthly and quarterly reporting and monitoring systems; in addition to the DIPC reports, the Trust Board also received the Improving Health & Best Possible Care Report which provided the Trust s overall position and trajectory for Healthcare Acquired Infections (HCAI), 2007/08). 4. HCC Visit/DH Support Team Visit 4.1. Healthcare Commission-Unannounced Visit The DIPC provided a report to the board following the Healthcare Commission s (HCC) unannounced visit in January 2008, where an inspection was conducted against the Trusts compliance with the hygiene code. Following this a number of actions were taken in response to the findings (Appendix 2). The Trust was compliant with the Health Act. 4.2. DH Support Team Visit The DIPC invited the DH MRSA Improvement team and the Health Protection Agency to the Trust to review its action plan and to provide further advice on continuing to improve performance. This took place in May 2007. Further assurance was sought from the SHA quality team. The trust focused attention on working on its improvement plan, based on the findings from the visits, as well as ongoing internal reviews. 5. Budget allocation to infection control activities Infection Control is essential as a core component of patient care and has an annual budget of over 285,000. The majority being allocated to staffing of the IPC team, with approximately 12,000 spent on materials to support education, training, and surveillance activities. 6. Healthcare associated Infections Statistics 6.1. MRSA Bacteraemia Based on previous numbers of reported cases, the Department of Health (DH) set a trajectory for cases of MRSA bacteraemia as 16 from April 2007 to March 2008. In this period the trust reported 31 cases, which was 15 above its trajectory. 6.2. Reporting structures introduced A reporting system was introduced in January 2008, lead nurses and medical staff with IPC nurse, report to the head of clinical practice, the following morning of any new cases of MRSA bacteraemia. The purpose of the meeting is to provide an urgent review of the case, against policies and practices. The group then attend the next executive directors meeting to brief them about the case. The RCA findings are then reported to the head of clinical practice the following week, so that learning can be shared through the Winning ways group. At the same time a number of other activities were implemented which are summarised in the Winning Ways report, including implementation of the high impact interventions, root cause analysis training and more. improved compliance with hand hygiene audits (Appendix 3). The Microbiology department commenced evaluation of rapid, nucleic acid testing method for MRSA, in September 2007, the new method is more sensitive and reduces the time to detection from 24hrs to 3hrs. At this time Bolton was the only hospital trust in Greater Manchester to have introduced this technology. 5
A ticking clock indicating the number of days since an avoidable MRSA bacteraemia was added onto the Intranet home page in March 2008. In the last three months, it can be seen that improvements were started to be seen in the number of cases, with no cases occurring in March 2008. Performance tracking for MRSA is set out in the next page: 6
Performance tracking for MRSA Bacteraemia April 2007 - March 2008 Monthly 2007/08 Detectio ns APR 4 MAY 4 JUN 2 JUL 3 AUG 2 SEP 1 OCT 2 NOV 2 DEC 6 JAN 3 FEB 2 MAR 0 7
Cumulative MRSA Detections vs MRSA Trajectory Trajectory Actual 2007/08 Trajector Actual y Q1 6 10 Apr 4 2 Q2 4 6 May 8 4 Q3 3 10 Jun 10 6 Q4 3 5 Jul 13 8 Aug 15 9 Sep 16 10 Oct 18 11 Nov 20 12 Dec 26 13 Jan 29 14 Feb 31 15 Mar 31 16 8
6.3. Clostridium difficile (CDT) Clostridium dificile (CDT) is a healthcare-associated infection that can cause diarrhoea, sometimes more serious conditions and occasionally death. Certain groups of patients are particularly at risk of developing an infection with Clostridium difficile, older people and those who have undergone surgery, and people with serious underlying disease, usually in association with recent antibiotic use. The difficulty in restricting the use of broad-spectrum antibiotics, and the lack of facilities for isolation represent the greatest challenges for the trust as well as many other acute trusts in controlling this infection. There is a mandatory surveillance programme that requires all NHS trusts to report to the Health Protection Agency (HPA) the number of cases of infection caused by Clostridium difficile diagnosed in patients 65 years of age and older. The marker for this infection is the presence of Clostridium difficile toxin. From November 2007 we commenced testing of all diarrhoeal samples from patients above the age of 2years, which became reportable from 1 January 2008 and this is reflected in the increased detection shown in the following graph. During 2007/08 the Trust saw a 33% reduction in Clostridium. difficile rates following the introduction of a new antibiotic policy. Alongside the fact that the Trust is testing far more samples in comparison with last year, this will make the target for the coming year all the more challenging. 9
2007/08 7.4 Performance tracking for Clostridium difficile toxin (CDT) detection Bolton PCT (pre-48hrs) CDT detections Bolton Hospitals (post- 48hrs) CDT detections Apr 5 42 47 May 3 27 30 Jun 5 25 30 Jul 5 25 30 Aug 2 18 20 Sep 2 14 16 Oct 4 21 25 Nov 5 14 19 Dec 6 23 29 Jan 5 29 34 Feb 6 23 29 Mar 7 33 40 Total 55 294 301 Bolton Health Community CDT detections 10
6.4. ICNET The ICNET surveillance package was installed in late of Summer 2007. All records on patients with an alert organism or condition are now kept and updated electronically. The positive microbiology results are sent automatically to ICNET from the laboratory computer system as soon as the department has validated the results, and at set periods during the day for the IPCT to action. This has meant results are available to ward staff in a timely manner. For example most Clostridium difficile results received in the laboratory in the morning are reported by the laboratory the same day and these are now available on the ICPT computers that day for action. Currently the ICNET system is not linked to the Patient Information Management System (PIMS) which means all admission and movement data has to be added manually. It is envisaged in 2008 that the link will be made which will facilitate reporting. 6.5. Outbreaks Gastrointestinal infection (infectious intestinal disease) is highly contagious, caused by a variety of communicable infections, Norovirus being the most common cause of gastroenteritis in England and Wales, affecting as many as 1 in 5 members of the population each year. Increasingly Norovirus is no longer confined to previously seen winter months but all year round, with the HPA reporting an increase of cases over the last year. Despite the hospital treating a number of patients who have been admitted with vomiting and diarrhea, it has seen a relatively low number of ward closures in comparison with other trust over the same period. Management of these outbreaks was in line with and consistent with infection control policies. 7. Deep Clean The DH announced in November 2007 that each NHS Trust had to have in place a deep clean programme by March 2008, as well as an increase in Matrons. As the trust already had in place a schedule of Deep cleans across the trust, a bid was put forward that focused on replacement of furniture and fittings that were difficult to clean, and replacement of carpets for more suitable flooring. The Trust was already planning to increase its Matron workforce, so surpassing the target that had been set. In March 2007 there were sixteen Matrons in post. 7.1. Cleaning Domestic supervisors have responsibility for ensuring cleaners maintain high standards and cover all cleaning tasks, which includes formal monitoring of these standards. High risk areas such as Intensive care and neonatal unit are monitored weekly, with wards and departments being monitored on a monthly basis. The criterion follows the National Standards of Cleanliness that requires a set of 41 standards to be checked. 11
On a day to day basis, the ward managers and matrons play a role in ensuring these standards are being met, with a number of inspections talking place jointly. These have been organised on a monthly basis with representation from facilities and infection control, joining the domestic supervisor and Matron. This is in addition to the Patient environment Action Team (PEAT) inspections that are carried out on a yearly basis. 8. Audit and Training activities The IPCT support a host of training and education programmes as well as conducting regular audits looking at compliance against policies and environmental cleanliness. Training activities over the period are listed in appendix 4. Environmental audits are carried out on a regular basis, with outcomes reported to ward teams for actions. An extensive programme of hand hygiene audit was introduced, and is supported by the Clinical Effectiveness team. This audit covers all wards and it is anticipated it will be extended to all parts of the hospital in incremental process. Results of compliance and non returns are reported on a monthly basis to all wards and divisions by the Clinical Effectiveness team. This has proved powerful in ensuring hand hygiene is kept high on agenda s and recognised as a key procedure that is known to have an impact on reducing the spread of infection. 9. National Guidance/ Requirements 9.1. The Health Care Act 2006 The code [revised in January 2008] supports Trusts to plan and implement how they can prevent and control health care associated infections. It sets out criteria by which organisations can ensure that patients are cared for in a clean environment and where the risk of health care associated infections is kept as low as possible. It includes: Management, organisation and the environment Clinical care policies Health care workers The trust had an unannounced visit in January 2008 that looked at the trusts compliance against a number of the section of the code (section 5.1). 9.2. Clean safe care-reducing infections and saving lives (DH) The document was published in January and provided the basis for the infection control work programme. It draws together recent initiatives to tackle healthcare associated infections and improve cleanliness and details new areas where the NHS should consider investing to ensure that patients receive clean and safe treatment whenever and wherever they are treated by the NHS. The trust completes an annual evaluation against the elements set out in the document, this is incorporated in the integrated action plan (appendix 1). 9.3. PL/CMO/2007/8 Healthcare associated infections and death certification The Chief Medical Officer issued a letter reminding doctors of their responsibility in ensuring accurate completion of death certificates, this was as a result over concerns over the possible under-reporting of HCAI as a cause of death. For a period from December to March death certificates were reviewed to determine the accuracy of this information. 12
9.4. Ongoing Developments Programmes of work will remain as well as be responsive to RCA reviews and; continued update and review of Policies targeted education based on RCA findings focus on screening and compliance with policies replacement of carpets in clinical areas review of hand washing facilities isolation practices ongoing implementation of High Impact Interventions and hand hygiene audits 10. Conclusion In summary the trust has seen a continued focus on reducing the number of HCAI s, with continued reinforcement of key infection prevention and control policies. These are fundamental to the trusts focus on patient safety, linked into the both governance and board assurance frameworks. However, we recognise the importance of maintaining this as a significant priority on all agendas, with the need to continue to strengthen compliance with key policies in being able to further reduce the incidence of avoidable infections. 13
APPENDIX 1 Bolton Hospitals NHS Trust MRSA/HCAI Action Plan Based on External and Internal Reviews Update Nov 5th 2007 1.4 Suggested Target Milestones from DH Round Table Review Team Top 3 priorities with target milestones Focus on hot-spot areas 1 implement High Impact Interventions in Critical Care and General Medicine and commence weekly audit 2 raise the profile and follow through training in Root Cause Analysis 3 Identify Link Nurse and ICP Clinical Champion in Critical Care By Date End Sept 07 Actions Milestones Trust Progress Achieve monthly run rate or less and remain below yearly trajectory 1. Actioned. Rolling programme commenced. Monthly Reports to ICT and Divisional Boards & and winning Ways group 2.Training sessions planned CS. (Nov 07) 3. Actioned Further priority actions: 1 roll out High Impact Interventions in all areas and departments including theatre. 2 establish a regular audit cycle to monitor sustainability of initial improvements and attendance and uptake for training and link meetings, publish compliance and uptake locally 3work closely with PCT s and whole health economy to further reduce the numbers of pre 48hr bacteraemia By Date January 08 Achieve monthly run rate or less and remain below yearly trajectory Reduce gap and create headroom to achieve 2008 target 1. In progress-schedule developed for Trust and being taken to Winning Ways Group. MS-Oct 07 2. Audit tools and schedule developed. For agreement and endorsement at winning ways group. MS Oct 07 Maintain register of attendance at training and link meetings-report to Matrons for gaps/ action. In progress> CS meeting with PCT leads on regular basis 14
Actions Milestones Trust Progress 3.4 Suggested Target Milestones Flagged on PIMs. Data Start collecting data on the number of patients admitted who have been flagged with previous hospital exposure and these should be recorded. available from ICNET and accessed by ICT Report cases of MRSA to the infection control team, as well as the ward following a positive result, as this will ensure that the specific control plan is put into action Engage the information team in high level meetings to ensure that the right message is communicated. Question as to whether the wards would like to receive more data on their MRSA C.difficile status Liaise with infection control team to ensure data on risk factors is reported in the mess data and within the trust ICT need to become involved in the RCAs and auditing of outcomes need to be followed up, so that they can improve and change behaviour The laboratory send out a a daily alert organism report, however, further work into the display traffic lighting may help highlight problems and hotspots Immediate action Immediate action Immediate action Immediate action Immediate action Actioned-Notification process of patients transferred from outside the local area. CS Liaising with Head of Communications Done. Daily alerts sent to all wards. Divisional Nurses receive and distribute to wards and depts. Wards to liaise with infection control teams and carry out risk assessments on high risk patients ICT Now involved in RCA s. Pull out key themes and close loop. Actioned 15
Internal Trust actions and targets Recommendations made 2.2.2.People-Medical staff engagement Actions to be taken and progress By When Lead person Introduce a medical competency based training package for interventional treatment using agreed techniques that will be standard across the Divisions Then Audit High profile launch of screening prophylaxis and eradication policies launch planned Deliver both multidisciplinary & junior doctor procedure training and the audit to give local ownership and harvest maximum gain 2.2.3. People-Directorate responsibilities IV group now established, responsible for introduction of training package. New skills trainer, once appointed will be involved in delivering this to staff. Study days rolling out. Policy complete and high profile Part of IV group remit. Skills trainer role Ongoing Nov 07 Nov 07 Ongoing CS CS CS CS Recommendations Actions to be taken By When focused objectives for all members of Each ward now has 2 link Done the division including AMD s clinical practitioners, one of whom is the leads. Matrons and ward managers ward manager. More formal training planned for links and ward managers. 2.3.1 Performance-Board Level Assurance Recommendations Actions to be taken By When Each directorate to have a tolerance Agreed target of no avoidable Next target set for MRSA & MSSA MRSA s and MSSA s. This now quality bacteraemias each month against needs sign up in Divisions and board which their performance should be monitoring through quality boards. meeting measured 2.3.2.a Performance- Information & Feedback Lead person CS Lead Person MS Recommendations Actions to be taken By When Lead person Audit compliance with policies and practices. Report to appropriate person/ committee and implement actions immediately Link practitioners completing regular audits including HII. Reporting to wards and part of action plan involves capturing trust wide data. In process MS 16
2.3.3 Performance- audit Recommendations Actions to be taken By When Lead person Establish a mechanism for sharing/spreading good practice and learning across the Trust Through Winning Ways Group. Divisional reports to group identifying areas of good practice Ongoing MS Link the results of audit into future induction/education and training, personal development plans and performance monitoring frameworks Increase the frequency of audit to heighten awareness and give more focus to a particular area of infection control linked to the trust priorities to reduce MRSA bacteraemias 2.3.4 Performance-Performance framework ownership and or improvement ICT feed audit results into training PDP s done at ward level and part of Job descriptions. Establish timetable and calendar of Audit. And process of feedback from Divisions Done Ongoing October CS Divisional Nurses Recommendations Actions to be taken By When Lead person Measurable outcomes will enable Linked to MRSA targets. Zero Ongoing MS/CS objectives to be focused and incorporated within the performance management outcomes for the directorate tolerance. Divisions reporting to Winning Ways Group 2.4.1 Processes- Policies Recommendations Actions to be taken By When Lead person Develop a schedule for audit of compliance to key policies Policies now launched. Audit calendar drafted and Ongoing CS/MS Audit compliance with policies and practices. Report to appropriate person/committee and implement actions immediately Share good practice and learning 2.4.2 Processes-Cleaning agreement at WWG Annual programme of Audit of Policies and practices. Implemented through Infection control team and link practitioners. Through Winning Ways Group- In progress MS CS/MS Recommendations Actions to be taken By When Lead person Resolve the issue of cleaning to reduce risk to patients, utilise new ways of Cleaning schedule in place, monitor compliance-spot checks Ongoing Anne Finlay working to reduce cost and increase output and audit across ward areas on monthly basis Recommendations Actions to be taken By When Lead person Where cleaning is not available and is Risk assessment training Ongoing MS 17
required carry out risk assessment and report risk appropriately Introduce specific guidance on when and who cleans shared equipment 2.5.1 Practice-Hand Hygiene underway for all staff. Matrons monitoring that assessments are completed Medical Devices Policy Launched Done Shirley Ryan/MS Recommendations Actions to be taken By When Lead person Restate the message to all staff that improved compliance with hand hygiene is a priority for the Trust and set a target for compliance of 95% across the Trust. Ensure all relevant staff understand the rationale behind the need to use gloves, when to wash hands, and when to use gel or rub. Audit through the HII and performance manage to ensure all staff, whether touching a patient or not, decontaminate their hands on entry and exit to clinical areas and always at the point of care Standard now embedded into all Job descriptions Flyer outlining expectations of all staff sent out with wage slips Part of weekly hand washing Audit Actioned Actioned Ongoing LED LED CS Increase the frequency of hand hygiene audits to be undertaken by identified individuals, publish the results and take any appropriate action. Promote the use of alcohol hand rub as the gold standard for routine hand hygiene when appropriate Escalate the education and awareness, training and auditing, particularly in areas identified by the RCA as the main areas of focus All clinical staff to have the blood sampling technique shared with them junior doctors competency to be assured Frequency of audits increased to weekly until compliance greater than 95% Evidence of audit results Learning from RCA s as feedback goes into Audit and Action Plan following any RCA, which is fed back into ward meetings. Regular item on Divisional Board and part of Quality board. Quarterly reports to Winning Ways Group to ensure improved communication At induction competency assessed. Taking of blood cultures part of that assessment. New guidance circulated Actioned and ongoing Immediate CS CS/S In progress CS 18
2.5.2 Practice-High Impact Interventions Recommendations Actions to be taken By When Lead Undertake audit of the implementation of the HIIs for relevant areas accordingly Ensure the utilisation of the HIIs are owned by the divisions, with clear responsibility and accountability and linked to governance and performance. Ensure the Trust guidelines are implemented for the insertion and management of PVC s and CVCs. Audit documentation and performance manage Observational audit at point of insertion should become everyday practice. Review and target the training programme, link audits to individual development programmes 2.5.3 Practice-Screening/ decolonization person Actioned. In progress Ongoing CS Meeting set up with Quality managers to agree process, key responsibilities and accountability including mechanism. Part of HII audit cycle which is now in process across all the wards Nov/Dec07 Ongoing MS/CS Recommendations Actions to be taken By When Lead person Use national evidence and the forthcoming DH guidance to review and re-launch the screening and decolonisation policies. Provide consistent clarification to staff in relation to screening of all high risk patients (surgery, critical care, elderly care, regular or repeat admissions and admissions from nursing home/residential care homes) as recommended in national guidance (Guidelines for the Control and Prevention of MRSA in Healthcare Facilities by BSAC, HIS, ICNA working party on MRSA) Actioned: Part of the Trusts MRSA Policy High risk protocols developed for screening of elective patients. Protocols in development for emergency admissions Relaunch planned Complete Oct 07 CS CS/MS Consider using Patient Group Directives (PGD) for decolonisation of MRSA positive patients PGD s signed off in orthopoedics. For rollout in Medical division. To be taken through Drugs and Therapeutic committee. Nov 07 CS Linda Woods 19
Recommendations Actions to be taken By When Lead person Ensure the policies are interpreted and adhered to appropriately and audit compliance. Performance manage and feed back to directorates/departments Part of Audit programme Working with PCT to agree consistent process of screening Ongoing Vicky Welsby 2.5.4 Practice-Antibiotics Recommendations Actions to be taken By When Lead Expedite a relaunch of the antibiotic strategy and policy. Ensure availability, accessibility and performance manage. Consider providing a pocket sized version of the guidance as well as internet access. Link to clinical governance, performance and education and training. Gain further engagement of clinicians in reviewing their antimicrobial prescribing data. Change management in prescribing will impact not only on HCAI, but also on patient outcomes, operational performance and the financial position of the Trust Now in use. Looking at Gastro intestinal section. Ratified at Drugs & Therapeutic Committee. Antiobiotic Policy re launched Simple guidance for Junior medical staff to be produced Training and education reviewed. Auditing of Antibiotic policies Done In Progress person BS BS/CS/MS AI/BS Review the current induction and training for junior doctors and design to ensure staff are fit to practice. Audit compliance In progress ICT involved in induction programme Nov 07 Malcolm Brown/ Ron Hopkins 20
2.5.5 Practice-Root cause analysis Recommendations Actions to be taken By When Lead person Review the rationale and importance of RCA and roles, responsibilities and accountabilities within the Trust and communicate to the Trust Board Policy gone to Clinical Governance & Trust Board. WWG responsible for strengthening clinical involvement and engagement part of Ongoing MS/CS/ ML Review current RCA approach used and develop a more robust approach. The Trust is using the newly developed NPSA RCA tool and will be able to identify trends in individuals, teams, environmental issues, sources, case mix issues, collective training and development needs, etc Assign responsibility for undertaking RCA to an individual within the relevant division who has the skills and status to investigate, action and follow-up all cases supported by infection control/dipc and the risk management team. Medical staff must be involved. Performance manage and monitor and ensure interventions are targeted Each relevant consultant to report to their divisional leads and ICT on the findings of RCA and action taken to support learning. Performance manage through existing governance structures actions for group Training to be provided on Root cause Analysis All Root cause analysis must be clinician led who has received training on Root Cause Analysis. The RCA must involve all key staff involved in the patients journey Part of training programme and clinical engagement (as above) Coordinate through quality managers, able to make assessments of outcomes. Feeds through Divisional Boards. ICT get report from RCA. Set up process to receive action plans, so teams can monitor progress and share learning Divisional Board- Standing item. Starts Nov 07 Ongoing Ongoing Ongoing CS RH/CS/ MS Divisional Nurses/ Matrons CS/MS 21
APPENDIX 2 HEALTHCARE COMMISSION HYGIENE CODE VISIT FEBRUARY 2008 IMMEDIATE IMPROVEMENTS MADE Sub Duty 4c AREAS FOR IMMEDIATE ACTION ACTION TAKEN BY WHEN RESPONSIBILITY MONITORING ARRNAGEMENTS Focused improvements to current cleaning regimens a) Arrangements for the frequency & standard of cleaning of patient trolleys Arrangements made for trolleys to be Deep cleaned, including base and wheels. Trolleys colour tagged to ensure they are cleaned weekly as part of a rolling schedule. Schedule devised to ensure all trolleys are deep cleaned (power cleaned) on a monthly programme. Actioned Feb 08 Actioned Actioned Actioned Actioned Anne Finlay, Site Services manager/ Matron Infection, prevention & control team Anne Finlay/Carol Christie, Domestic Supervisor Anne Finlay Matron/ IPCT Matron quality checks & IPCT spot checks Monitored as part of Matron quality checks Matron Quality Checks Quality Checks by Matron & IPCT Spot Checks by Matron & IPCT Cleaning checklist devised to monitor compliance and provide evidence of completion. Disposable tags, which are dated and signed to be used to indicate trolleys [and commodes] have been cleaned in between patients 22
FURTHER RECOMMENDATIONS AND ACTIONS BEING TAKEN DUTY 4: Duty to provide and maintain a clean and appropriate environment for health care Areas for Action: Action taken By When Sub Duty 4c D1: Ward now decanted State of decoration into another area to and repair of D1 enable work to be and Accident carried out. &Emergency dept. Entire area being redecorated Additional sinks being installed Floor coverings being replaced General improvements to other areas i.e. lighting Sub section 4c Review the Policy for cleaning and disinfection of equipment to ensure that it reflects current guidance and accurately details the cleaning and disinfecting products currently in use within the Trust A&E: Flooring on Quadrangle now replaced Department part of a rolling programme for decoration work, escalated as a priority area. Other general improvement work to the environment ongoing Policy being reviewed in line with guidance from Code of Practice, 2006 Ward decanted and work commenced on 23 rd April 08. Due for completion by 3 rd June 2008 Flooring Replaced Feb 08. Decoration to be complete by September 08 May 2008 By Whom Nigel Palmer, Divisional Manager /Anne Cleary, Divisional Nurse Nigel Palmer, Warren Millington, Matron & Anne Cleary Christine Sweeney, Consultant Nurse IPC Monitoring Progress reports & updates by Anne Cleary & Nigel Palmer Progress reports & updates by Anne Cleary & Nigel Palmer Through ratification process 23
Duty 8: Duty to provide adequate isolation facilities Areas for Action: Sub Duty 4c Review all IPCT policies relating to the isolation of patients to ensure they reflect the consideration of the need for special ventilated isolation facilities Continue to monitor the availability of isolation facilities to ensure they are adequate for the needs of its inpatient population Display schedule of cleaning frequencies Action All relevant Policies reviewed IPCT attend corporate bed management meetings. To be included on EXTRAMED bed management system to support decision making in allocating isolation facilities to appropriate patients. Schedules to be put on Trust Internet. Schedule to be displayed in each ward/dept area By When May 08 Action immediate:jan 24 th 08 May 2008 In progress due for completion May 08 By Whom Christine Sweeney, Consultant Nurse IPC/ Maria Sinfield, Head of Clinical Practice. As above Kate Lewis, Matron for Patient Flow Anne Finlay/ Maria Sinfield Follow up Through ratification process IPCT/ Infection, Prevention and Control Committee Anne Cleary Matron Quality Checks 24
APPENDIX 3 Report populated from Divisional Feedback Reports. This Report will go to Clinical Governance & Quality Committee. BOLTON ROYAL HOSPITALS NHS TRUST QUARTERLY CORPORATE REVIEW WINNING WAYS GROUP CORPORATE REVIEW QUARTER 4: Jan 08-Mar 08 PERSON COMPLETING REPORT: Maria Sinfield Key objectives of last quarter: Provide training on completing Root Cause Analysis (RCA s) Improve compliance with hand hygiene tool. All ward areas to continue to carry out hand washing observations on weekly basis unless >95% compliance. Key Infection Control Policies to be reviewed and updated. Issues/Themes: Poor documentation regarding insertion and care of peripheral lines and recording of insertions and VIP scores. Need to improve compliance of screening patients who meet criteria. Eradication therapy not always prescribed and or administered correctly Progress/improvements/good practice RCA Training carried out, and will continue as a rolling programme. In depth review conducted by head of clinical practice with ward team, following any cases of MRSA Bacteraemia (divisional nurse and ICT also present). Meet again in a week to review and log actions from completed RCA. Improve % completion and return of hand hygiene tool Hand hygiene up to average of 80.6% compliance Patient information leaflet updated and cascaded Introduction of Chloroprep for cannulation Key Deliverables over next quarter: Target training and surveillance on hand washing technique Roll out Aseptic non touch technique (ANTT) across the Trust MRSA eradication treatment PGD and MRSA Care Pathway to be cascaded Trust wide Improve compliance with recording VIP scores Performance MRSA Bacteraemia 2007 2008 Jan Feb Mar Total C.Diff Jan Feb Mar TOTAL Pre 48 2007 72 42 46 160 Post 48 4 3 3 10 2008 29 23 33 85 Pre 48 Post 48 3 2 0 No of MRSA over Quarter 5 TOTAL 3 2 0 5 No of C.Diff over Quarter : 85 25
Appendix 4 Infection Control Training Date Group Presenter 04/05/2007 Mandatory training for Breast Unit KL/AF 23/05/2007 Orthoptics Mandatory training AF 30/05/2007 ICU Development day KL 17/08/2007 Mandatory training for Endoscopy KL 28/08/2007 Mandatory training for paediatric medical staff CD/KL 6/09/2007 Paediatric IV Therapy CFJ 13/09/2007 Link Group IPCT 18/09/2007 New starters clinical induction KL 19/09/2007 New starters clinical induction CFJ 25/09/2007 Mass induction for HCA s DL 4/10/2007 Infection Control for Pathology staff CFJ 11/10/2007 Infection Control for Pathology staff CD 16/10/2007 New starters Induction AF 23/10/2007 Infection Control for Pathology staff CD 24/10/2007 Infection Control for Pathology staff CFJ 24/10/2007 Medical staff Mandatory training KL 25/10/2007 Grapevine launch of MRSA policy CFJ + CS 29/10/2007 Infection Control for Audiology staff AF 30/10/2007 Infection Control for Audiology staff AF 06/11/2007 New starters Induction AF 15/11/2007 Root Cause Analysis Training CS 16/11/2007 Infection Control for transport staff CD 20/11/2007 Link Group IPCT 20/11/2007 Root Cause Analysis Training CS 22/11/2007 Root Cause Analysis Training CS 27/11/2007 New starters Induction AF 30/11/2007 Outbreak management Training CS 04/12/2007 Outbreak management Training CS 04/12/2007 New starters Induction AF 17/12/2007 Infection Control for Pathology staff CD 18/12/2007 New starters Induction AF 07/01/2008 Outbreaks for phlebotomy staff KL 08/01/2008 New starters Induction AF 16/01/2008 Link Group IPCT 17/01/2008 HII for radiology KL 22/01/2008 New Starters Induction CD 05/02/2008 New Starters Induction AF 05/02/2008 Theatre audit meeting training on ANTT and KL/SW peripheral line H.I.I 06/02/2008 Junior Doctors Induction JD 07/02/2008 Student Training CFJ 19/02/2008 New Starters Induction AF 20/02/2008 Mandatory Training Maternity Staff JD 22/02/2008 Infection Control General Outpatient staff CD 26
04/03/2008 New Starters Induction AF 05/03/2008 Link Group IPCT 06/03/2008 A/E Training CFJ 11/03/2008 New Starters Induction DL 19/03/2008 Newly qualified staff induction KL 20/03/2008 Mandatory Training Maternity Staff CD 26/03/2008 New Starters Induction CD 27/03/2008 Mandatory Training ENT Staff KL KL = Kath Lee CD = Chris Dawe CS = Christine Sweeney AF = Alison Foster CFJ = Catriona Fraser-Jones IPCT = Infection Prevention Control Team DL = Denise Lilley (Training Dept) SW = Sam Westwell 27