Director of Infection Prevention and Control (DIPC) Annual Report April 2011 to March 2012 The third DIPC annual report for Dudley and Walsall Mental Health NHS Partnership Trust AUTHORS: Alison Geeson Head of Nursing Angela Murray IPC Lead Nurse PREPARED ON BEHALF OF: Wendy Pugh Director of Operations and Nursing/Director of Infection Prevention and Control DATE: July 2012 DIPC Annual Report 2011/12 - Final July 2012 Page 1
Contents Section Page Number List of Abbreviations 3 List of Tables and Charts 5 Definitions/Key Information 6 1.0 Executive Summary 8 2.0 Introduction 9 3.0 Infection Prevention and Control Arrangements 9 4.0 The Work of the Infection Prevention and Control Committee 10 5.0 Surveillance 11 6.0 Outbreaks 13 7.0 Audit 13 8.0 Education and Training 22 9.0 International Infection Prevention and Control Week 22 10.0 Occupational Health Highlights 22 11.0 HCAI Incident Reporting 24 12.0 Policies 25 13.0 Showcasing Good Practice 25 14.0 What Would the DIPC Like Us to Achieve During 2012/13 26 15.0 Conclusion 27 DIPC Annual Report 2011/12 - Final July 2012 Page 2
List of Abbreviations C.diff CQC CQUIN CYHC DH DIPC DWMHPT EBE EIA ESR F2F GDH GQC GRE HCAI HoS HPA IPC IPCC ICNA IPCLN IPCT Clostridium difficile The Care Quality Commission the integrated regulator of health and adult social care Commission for Quality and Innovation Clean Your Hands Campaign Department of Health Director of Infection Prevention and Control. An individual with overall responsibility for infection control and accountable to the registered provider Dudley and Walsall Mental Health NHS Partnership Trust Expert By Experience Enzyme Immuno Assay Electronic Staff Records Face to Face Learning Glutamate Dehydrogenase Governance and Quality Committee Glycopeptide-Resistant Enterococci Health Care Associated Infections Heads of Service Health Protection Agency Infection Prevention and Control Infection Prevention and Control Committee Infection Control Nurse Association incorporating Infection Prevention and Control Lead Nurse Infection Prevention and Control Team DIPC Annual Report 2011/12 - Final July 2012 Page 3
IPS ISS IT MEXT MRSA MSSA NHSLA NSC OHD PEAT PPE QAA QIPPP SHA SI SLA WHO Infection Prevention Society Integrated Services Solutions Information Technology Management Executive Team Meticillin-resistant Staphylococcus aureus Meticillin-sensitive Staphylococcus aureus NHS Litigation Authority National Standards of Cleanliness Occupational Health Department Patient Environment Action Team Personal Protective Equipment Quality Assurance Assistant Quality, Improvement, Prevention, Productivity, Partnership Strategic Health Authority Serious Incidents Service Level Agreement World Health Organisation DIPC Annual Report 2011/12 - Final July 2012 Page 4
List of Tables and Figures Table Page Number 1 Health and Social Care Act 2008 - Code of Practice for 8 health and adult social care on the prevention and control of infections 2 Infection Prevention and Control Audit Programme for 2011/12 14 3 Variance of Trust compliance against previous year s audit data 15 4 Level of compliance (taken from the IPS Audit tool) 16 5 Performance of the mattresses against the audit criteria 18 6 Performance of the pillows against the audit criteria 18 7 Cleaning Standards for 2011/12 20 7.1 Cleaning Standards Compliance Levels 20 8 PEAT Scores 21 9 Infection control mandatory face to face training compliance for 22 clinical staff for April 11- March 12 10 Infection Control related incidents April 2011- March 2012 25 Chart 2.1 Overall level of compliance for each service line for Hand Hygiene 17 observational audits 2.2 Overall level of compliance for each service line for PPE 17 observational audits 2.3 Overall level of compliance for each service line for Sharps 18 observational audits 3 Trend Analysis: Contractor Domestic Services Self-Assessment 20 Scores - April 2011-March 2012 4 Summary of Flu Vaccines Given 2009-2012 23 5 Total Number of Incidents reported 2009/20010/2011 24 DIPC Annual Report 2011/12 - Final July 2012 Page 5
Definitions / Key Information HCAI Health Care Associated Infections HCAI s are infections acquired in hospitals or as a result of healthcare interventions. They are caused by a wide variety of micro organisms by bacteria that often live harmlessly in or on our body. Whilst people are most likely to acquire HCAI s during treatment in acute hospitals, they can also occur in GP surgeries, care homes, mental health trusts, ambulances and people s own homes. In fact anywhere that people are receiving clinical treatment. Although the majority of HCAI s cause minimal harm and can be treated like any infection, particular challenges are faced from MRSA and C.difficile. For those people with MRSA or C.difficile the consequences can be severe. In addition to the pain and suffering to patients and families there are also implications for NHS resources. Evidence suggests that patients with an MRSA bacteraemia spend on average an additional 10 days in hospital and for C.difficile the additional length of stay is 21 days. Infection can cost an organisation an extra 4,000-10,000 per patient. MSSA Bacteraemia Meticillin-Sensitive Staphylococcus aureus Staphylococcus aureus is a bacterium that commonly colonises human skin and mucosa (e.g. inside the nose) without causing any problems. It can also cause disease, particularly if there is an opportunity for the bacteria to enter the body, for example through broken skin or medical procedure. Most strains are sensitive to the more commonly used antibiotics, and infections can be effectively treated MRSA Bacteraemia Meticillin-Resistant Staphylococcus aureus MRSA is a strain of the Staphylococcus aureus bacteraemia which is resistant to commonly used antibiotics. About 30% of the population have some type of staphylococcus aureus bacteria living naturally on their skin or in their nose where it usually does them no harm. MRSA can be more difficult to treat and therefore infections may become more severe. MRSA can infect surgical wounds or ulcers and more seriously if it enters the blood stream it can cause bacteraemia. C.Difficile - Clostridium difficile Clostridium difficile is a bacteria that lives in the gut of about 3% of healthy adults in England. It is kept at bay by normal gut bacteria but if those bacteria are killed by antibiotics, C.difficile can proliferate. Toxins released by C.difficile cause diarrhoea which can occasionally be very severe and life threatening. In most cases the infection develops after cross infection from another patient. Over 80% of cases of C.difficile infection are in people over the age of 65. DIPC Annual Report 2011/12 - Final July 2012 Page 6
Norovirus Norovirus is the most common cause of gastroenteritis in hospital settings and outbreaks often lead to ward closure and major disruption in activity. Vomiting and short lived diarrhoea is the prominent symptom. During bouts of vomiting aerosol containing millions of live virus particles are released and are disseminated widely in the environment i.e. across several meters. Thorough environmental cleaning is an essential part of outbreak control management. Secondary cases therefore occur easily, both through exposure to an infectious individual and the contaminated environment. Secondary attack rates are commonly high and staff themselves may become infected. Glycopeptide Resistant Enterococci (GRE) Enterococci are bacteria that are commonly found in the bowel of normal healthy individuals. They can cause a range of illnesses including urinary tract infections, bacteraemia (blood stream infections) and wound infections. During the mid- 1980s enterococci with resistance to the glycopeptide antibiotics vancomycin and teicoplanin emerged; these are termed glycopeptide-resistant enterococci (GRE). DIPC Annual Report 2011/12 - Final July 2012 Page 7
1.0 Executive Summary This is the third DIPC report for DWMHPT and reflects an overview of all aspects of the organisation s infection prevention and control programme for 2011/12. This report is also a demonstration of assurance from the DIPC in relation to DWMHPT compliance with the Health and Social Care Act 2008 - Code of Practice for health and adult social care on the prevention and control of infection. The areas of compliance are demonstrated in Table 1. The prevention and control of healthcare-associated infection (HCAI) continues as a key priority for DWMHT and remains a high profile issue, not only for patients, and the wider community the Trust serves but also healthcare commissioners and regulators including the Department of Health (DH) Despite the challenges for the Trust i.e. Foundation Trust application and Service Transformation we have maintained an effective and dynamic IPC service this past 12 months. We have maintained continuing compliance in all areas of compliance criteria as detailed below: Table 1 - Health and Social Care Act 2008 - Code of Practice for health and adult social care on the prevention and control of infections Compliance What the registered provider will need to demonstrate criteria 1 Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider how susceptible service users are and any risks that their environment and other users may pose to them. 2 Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infection. 3 Provide suitable accurate information on infection to service users and their visitors. 4 Provide suitable accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion. 5 Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection of other people. 6 Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection 7 Provide or secure adequate isolation facilities 8 Secure adequate access to laboratory support as appropriate. 9 Have and adhere to policies, designed for the individual s care and provider organisations that will help to prevent and control infections. 10 Ensure, so far is reasonably practicable, that care workers are free of and are protected from exposure to infections that can be caught at work and that all staff are suitably educated in the prevention and control of infection associated with the provision of health and social care. DIPC Annual Report 2011/12 - Final July 2012 Page 8
2.0 Introduction The role of the Director of Infection Prevention & Control (DIPC) was first described in Winning ways: working together to reduce healthcare associated infection in England (DH 2003) and has continued to be seen as the public face of infection prevention and control. Within Dudley and Walsall Mental Health Partnership Trust (DWMHPT) the DIPC role is within the portfolio of the Director of Operations and Nursing. A key responsibility of the DIPC is to produce an annual report. 2011/12 has been a year of significant pace and the service transformation agenda has come a very long way as the Trust progresses it s desire to fulfil it s ambition of being better together as a mental health focused provider, coupled with the challenging dilemma of improving efficiency whilst driving up quality. Previous DIPC annual reports have comprehensively demonstrated a pro-active and productive journey of IPC service development and the opportunity for embedding best practice in IPC within a mental health provider organisation. It is a requirement of Health and Social Care Act 2008 that organisations give assurance that effective prevention and control of HCAI has to be embedded into everyday practice and be applied consistently by everyone. The Trust is formally registered with the Care Quality Commission (CQC) and declared as compliant with the Health and Social Care Act 2008 but acknowledges that ongoing work is required to ensure continued compliance and quality improvement. 3.0 Infection Prevention and Control Arrangements 2011/12 has been a year of change for Infection Prevention and Control. The Infection Prevention and Control Lead Nurse was appointed on 1 st July 2011 in order to build capacity into the current service already provided by Walsall Manor Hospital and NHS Dudley. Administration support to the post is provided by the PA to the Head of Nursing. Walsall NHS advised the Trust that the SLA for Infection Prevention and Control advice and support would not be renewed from 30 th June 2012 due to a revision in the services in Walsall. Dudley Public Health also advised the Trust that they would no longer be able to provide the same level of support as previously offered e.g. training and audit etc., due to a reorganisation in their service however there was no formal arrangement in place for this. At the time of producing this report we are in the processes of recruitment to an IPC Nurse band 6 post to work closely with the IPC Lead Nurse. This will allow in-house provision of IPC services and opportunities to review training and audit activity to ensure optimum use of resources. In addition to this there was an agreement to develop an SLA for 24 hour access to an infection control doctor in order to ensure continued compliance with the Hygiene Code and CQC Standards. DIPC Annual Report 2011/12 - Final July 2012 Page 9
4.0 The Work of the Infection Prevention and Control Committee (IPCC) The main purpose of the Infection Prevention and Control Committee (IPCC) is to oversee and monitor infection control policies, procedures and processes within the Trust, to ensure compliance with the Health and Social Care Act 2008 - Code of Practice for health and adult social care on the prevention and control of infection. The DIPC is an integral member of the IPCC which is chaired by the Head of Nursing and the Vice-Chair responsibility is with the IPC Lead Nurse. The committee has met on a monthly basis during 2011/12 and has an integrated membership of staff from all directorates and partnership organisations. The committee also has service user representation and having an Expert by Experience (EbE) as a member has enabled an enhanced opportunity to consider effective user-involvement in IPC matters at local level. Being a member of the IPCC has given me self-esteem. I have a good rapport and relationship with other members. My knowledge has gone from zero to much greater. I have a real feeling of involvement not just a tick box approach. I have seen the IPCC grow, the profile is raised and for me it has brought IPC to life for service users. Chris Roberts - EbE The expert contribution of infection control team representatives from Walsall and Dudley health economy has been crucial during the past year and despite a change to working relationships as a result of discontinuation of service specifications and local agreements, they will continue to be key members of the Committee with the emphasis on the importance of working across the whole health economy. The reporting arrangements for the IPCC of DWMHT are as follows: DWMHT Trust Board Governance and Quality Committee Infection Prevention & Control Committee DIPC Annual Report 2011/12 - Final July 2012 Page 10
5.0 Surveillance Surveillance is an essential component in the prevention and control of Infection within the Trust. It consists of the routine collection of data on infections among patients/clients or staff, so that appropriate action can be taken. The main objectives of surveillance are: The prevention and early detection of outbreaks in order to allow timely investigation and control. The assessment of infection levels over time in order to determine the need for and measure the effectiveness of prevention or control measures. The numbers of confirmed positive specimens are low in mental health however it is important not to become complacent as infections such as MRSA and Clostridium difficle are widely recognised as being issues across the whole health economy. The IPCLN developed a surveillance form which was successfully trialled with the intention of rollout to inpatient areas from April 2012. However, there are limitations as there are no electronic systems in place to review results therefore, the system is dependant on timely return of the forms and the Microbiologist reporting the result to either the ward or IPCN Lead. This has a consequential effect upon our ability to produce future comprehensive data analysis. This is an area for quality improvement during 2012/13 however, the report acknowledges the positive progress that the IPCLN has made with the local surveillance system. 5.1 MRSA and MSSA bacteraemia mandatory reporting In 2004 the Department of Health introduced mandatory surveillance for MRSA bacteraemia which was extended to include MSSA from January 2011. Surveillance of these infections is key to their control: we need to be able to measure them if we are to assess whether any impact has been made on controlling infection. DWMHT has had zero incidents during 2011/12, mainly due to the fact that very few intravenous cannulae are inserted in the mental health environment. 5.2 Clostridium difficile mandatory reporting In April 2007 the Department of Health introduced mandatory surveillance of Clostridium difficile infection in patients 2 years and over. Preventing and controlling the spread of Clostridium difficile is a vital part of the local and regional quality safety agenda. In March 2011 the Chief Nursing Officer and Inspector of Microbiology issued a letter giving advice to the NHS regarding the current guidance on the methods of testing available. DWMHPT currently sends its clinical specimens to 2 microbiology laboratories, i.e. Walsall Healthcare NHS Trust and the Dudley Group of Hospitals NHS DIPC Annual Report 2011/12 - Final July 2012 Page 11
Foundation Trust. During 2011/12 The Dudley Group tested using EIA technology, which has been used by the majority of laboratories for many years and has been considered the most convenient detection method. However following a successful business case Walsall commenced GDH testing (dual) on 1 st July 2011 which was recognised as a more sensitive way of testing specimens There were 2 cases of C diff identified using the new testing method in the Walsall locality however both were negative on the traditional testing method classing them as incidental findings. These cases were not classed as breaches of the Trusts objective of zero as they were only identified on the new testing method that was being trialled. As of April 2012 the Department of Health has issued new guidance to laboratories on the methods of testing to be used in order to ensure that nationally everyone is using the same testing kits. Both Dudley and Walsall microbiology laboratories will be using the same testing methods from April 2012. In order to raise awareness amongst staff a poster (SIGHT) was developed in line with national recommendations from the Health protection Agency and the Department of Health and circulated to inpatient areas on the management of patients with diarrhoea in inpatient settings. The first key recommendation was that all doctors and nurses should apply the following mnemonic protocol when managing suspected potentially infectious diarrhoea S Suspect that a case may be infective where there is no clear alternative cause for diarrhoea I Isolate the patient and consult with the infection control team (ICT) while determining the cause of the diarrhoea G Gloves and aprons must be used for all contacts with the patient and their environment H Hand washing with soap and water should be carried out before and after each contact with the patient and the patient s environment T Test the stool for toxin, by sending a specimen immediately A system was developed for placing a flag on OASIS by the lead infection prevention and control nurse to alert staff of patients previous c diff diagnosis in order to provide an early warning system if and when patients are readmitted. 5.3 Glycopeptide Resistant Enterococci (GRE) Along with MRSA bacteraemia and Clostridium difficile infections, all NHS Trusts must report their number of cases of Glycopeptide Resistant Enterococci (GRE) bacteraemia. This organism is highly resistant to antibiotics. Dudley and Walsall Mental Health Trust has had zero cases of GRE for this reporting period. DIPC Annual Report 2011/12 - Final July 2012 Page 12
6.0 Outbreaks An outbreak of infection can be described as: Two or more people with the same disease or symptoms or the same organism isolated from a diagnostic sample, who are linked through a common exposure, personal characteristics, time or location. A greater than expected rate of infection compared with the usual background rate for the particular place and time. A single case of a rare or serious disease such as diphtheria, polio, rabies, legionella etc. There have been no outbreaks of infectious diseases during this reporting period. The Outbreak Pack has been reviewed and updated in-line with national guidance. Within the pack is a helpful information leaflet for patients and visitors. A copy of the pack is available on the infection control page of the intranet. 7.0 Audit Audit is an important activity that assists Trusts and Infection Prevention and Control teams in monitoring practice and the environment. The annual audit programme for this reporting period is as below (2011/12). Table 2 below demonstrates that there is an intensive audit programme which is kept under continual quality review to ensure that the audit is meaningful and helpful in generating best practice. DIPC Annual Report 2011/12 - Final July 2012 Page 13
Table 2 Infection Prevention and Control Audit Programme for 2011/12 AUDIT AUDITOR FREQUENCY DATA ANALYSIS FEEDBACK TO RESULTS REPORTED TO NHS Dudley and Annual NHS Dudley and Walsall HOS IPCC Walsall Healthcare Programmed Healthcare NHS Trust Matron/Clinical Lead NHS Trust Infection determined by Infection Prevention & Ward Manager Prevention & Control relevant IPC Control teams Clinical Governance teams teams Lead Nurse Lead IPCN Infection Control (based on ICNA national audit tool) Hand Hygiene Environment Kitchen Waste Spillages PPE Sharps Linen Decontamination Hand Hygiene PPE Sharps Infection Control Link Workers (in-patient areas) Monthly Clinical Governance Assistant Heads of Service IPCC Mattress/Pillow audit Cleaning Audits 49 elements national tool Infection Control Link Workers (community based) Matrons/Clinical Leads/Ward Managers ISS Quarterly 6 monthly Clinical Governance Assistant Monthly inpatient areas Quarterly community areas ISS Actions taken by leads at time of audit to address identified issues IPCC 6 monthly IPCC quarterly DIPC Annual Report 2011/12 - Final July 2012 Page 14
During the reporting period the annual audit programme includes annual monitoring by our Commissioning Trusts, which is currently undertaken by the Infection Prevention and Control Teams located in NHS Dudley and NHS Walsall. 7.1 External Audits This external infection audit utilises the Infection Control Nurses Association Audit tools for monitoring infection control guidelines within the community setting 2005. The audit itself focuses on a number of key areas of infection prevention and control including: Hand Hygiene Environment Kitchen Disposal of Waste Spillage and contamination Personal Protective Equipment Sharps Linen Decontamination of Equipment 7.1.2 Understanding the audit findings The Infection Prevention and Control audit results for each in-patient clinical area audited is scored against the relevant criteria. Level of compliance is presented utilising the following weighting, and is colour coded to promote ease of understanding, as shown below in Table 3 and 4 :- Table 3 - Variance of Trust compliance against previous year s audit data 2009/10 2010/11 2011/12 Dif Total Total Total Hand Hygiene 87% 84% 87% 3% Environment 68% 77% 76% -1% Kitchen 83% 85% 86% 1% Disposal of Waste 86% 88% 94% 6% Spillage and contamination 83% 90% 88% -2% Personal Protective 90% 96% 95% -1% Equipment Sharps 89% 88% 90% 2% Linen 95% 91% 94% 3% Decontamination of Equipment 75% 81% 81% - DIPC Annual Report 2011/12 - Final July 2012 Page 15
Table 4 Level of compliance (taken from the IPS Audit tool) Level of Compliance Audit scoring Colour code Compliant 85% or above Green Partial compliance 76% to 84% Amber Minimal compliance 75% or below Red From this initial audit actions are then put in place and actions are recommended to resolve any issues highlighted. An example of an improvement following issues identified was the development of a cleaning checklist in order for staff to have a reference to what areas they should be checking within their environments. 7.2 Internal Audits These audits are carried out by the Link Workers in partnership with Team Managers supported by the Governance team. The observational audits are designed to give an overview of local practice in relation to infection control practices within the organisation. Within the audit process, if any immediate risk issues or concerns are highlighted, the Link Worker and Manager implement the necessary local action to manage the risk. Observational audits in relation to three key areas (PPE, Sharps and Hand Hygiene) are undertaken by each areas designated infection control link worker and are monitored on a quarterly basis by the Trusts Infection Control Committee. During the period 2010-11, the organisation reverted from reporting by locality to service line reporting, this method of reporting continues to be reflected within the 2011-12 data. 7.3 Observational Audits Charts 2.1 to 2.3 show the overall level of compliance for the thee types of Link Worker Observational Audit undertaken by the organisation during 2011-12 The minimal compliance rating is 95%. The information is broken down by service line and draws a direct comparison with the compliance levels for the period 2010-11. Chart 2.1 shows that the percentage compliance for the organisation in respect to Hand Hygiene observational audits increased in 2011-12 based upon the previous year 4 of the Trusts five service lines (Acute, Older Adults, Recovery and EI) showed increases, with Community showing a small decrease. However it should be noted that the level of compliance for Community Services remained in line with the Trusts other service lines DIPC Annual Report 2011/12 - Final July 2012 Page 16
Chart 2.1 - Overall level of compliance for each service line for Hand Hygiene observational audits 100% 98% 96% 94% 92% 90% Acute Older Adults Community Recovery Early Trust Average Intervention Older Early Acute Adults Community Recovery Intervention Trust Wide 2010-11 96.86% 96.33% 99.21% 97.54% 97.17% 97.42% 2011-12 98.54% 97.39% 98.04% 98.69% 100.00% 98.53% Chart 2.2 shows that the percentage compliance for the organisation in respect to PPE observational audits increased in 2011-12 compared to the previous year. 3 of the Trusts 5 service lines (Acute, Community and Recovery services) showed an increase, with Older Adults Services exhibiting a very slight decrease. There is no data available for Early Intervention Services as this audit was deemed as inappropriate to the services offered. It should be noted that 2 of the Trusts service lines (Community and Recovery) showed 100% compliance Chart 2.2 Overall level of compliance for each service line for PPE observational audits 100% 98% 96% 94% 92% 90% Acute Older Adults Community Recovery Early Trust Average Intervention Older Early Acute Adults Community Recovery Intervention Trust Wide 2010-11 97.67% 98.56% 94.74% 98.86% No Data 97.46% 2011-12 99.04% 98.50% 100.00% 100.00% No Data 99.40% Chart 2.3 shows that the percentage compliance for the organisation in respect to sharps observational audits increased in 2011-12 compared to the previous year. 3 of the Trusts 5 service lines showed an increase in compliance (Acute, Older Adults and Community Services). It should be noted that there was no data available from Early Intervention Services as this audit was deemed as inappropriate to the services offered. Recovery Services showed 100% compliance and was consistent with the previous years dataset. DIPC Annual Report 2011/12 - Final July 2012 Page 17
Chart 2.3 Overall level of compliance for each service line for Sharps observational audits 100% 98% 96% 94% 92% 90% Acute Older Adults Community Recovery Early Intervention Trust Wide 2010-11 98.89% 97.63% 99.46% 100.00% No Data 99.05% 2011-12 99.65% 100.00% 100.00% 100.00% No Data 99.91% 7.4 Mattress and pillow audits All inpatient areas are required to audit pillows and mattresses against set criteria in order to identify items for replacement to ensure continued standards of hygiene and reduce the risk of healthcare associated infections. Any mattresses and pillows that do not meet required standards are immediately replaced. Table 5 - Performance of the mattresses against the audit criteria Audit Criteria April-Sep 2011 Oct-March 2012 Was the mattress fitted with a cover? 100.0% 100.00% Was the mattress free of stains? 96.0% 94.29% Was the mattress free of tears or damage? 91.5% 98.30% Was the mattress free from any unpleasant smells? 97.7% 98.86% Is the mattress cover sound e.g. undamaged? 93.7% 96.59% Was the mattress free of any soiling that cleaning cannot 97.59% remove? 96.0% Was the mattress core dry? 99.4% 100.00% Did the mattress pass the bottoming out test? 97.7% 98.86% Did the mattress pass the water penetration test? 94.3% 98.86% Table 6 Performance of the pillows against the audit criteria Audit Criteria April-Sep 2011 Oct 2011- March 2012 Was the pillow fitted with a cover? 99.4% 97.54% Was the pillow free of stains? 98.9% 96.55% Was the pillow free of tears or damage? 93.1% 96.06% Was the pillow free from any unpleasant smells? 100.0% 99.01% Is the pillow cover sound e.g. undamaged? 95.3% 96.53% Was the pillow free of any soiling that cleaning cannot remove? 98.8% 98.03% Was the pillow core dry? 100.0% 100% DIPC Annual Report 2011/12 - Final July 2012 Page 18
It is should be noted that the number of both mattresses and pillows failing the tests as part of the audit decreased from September 2011 to January 2012. It should be noted that the number of mattresses and pillows that failed during the period 11-12 was broadly comparable with the previous 12 months (2010-11) with 8.4% of mattresses failing the assessment and 6.3% of pillows failing. This suggests that mattress and pillow auditing process provides a robust and ongoing means of auditing the quality of mattresses and pillows within the organisation. 7.5 Environmental Cleaning Audits Cleaning services fall within the remit of Facilities services. This service is currently provided by ISS Facilities Services Limited and is provisioned to all DWMHPT owned and leased sites. DWMHPT Estates and Facilities work closely with our contractor as well as operations staff to ensure the required standards of cleaning are achieved and maintained. As part of this work, our contractor operates a programme of self-monitoring based on the National Standard of Cleanliness (NSC). During 2011/2012 this process has been expanded to include a member of the operational staff within each area monitored in order to develop a joint approach between the cleaning monitoring and the clinical leadership team. DWMHPT have also introduced a process of internal over-monitoring through the introduction of a Quality Assurance Assistant (QAA) as required under CQC guidance. Working as part of Estates and Facilities, the QAA is responsible for monitoring the Trust environment, collating any issues arising and ensuring resolution of such issues. This process has been put in place to provide a proactive approach to managing our environment. Supported by our Link Workers we are developing the Trust s Estate to consistently meet the expectations of DWMHPT patients, staff and visitors. Whilst this process may bear some similarities with the PEAT audit as mentioned above this internal over-monitoring also covers our community sites, thus providing a pan-trust standard approach to the provision of a suitable environment from which the Trust may provide services to the community. Following on from the requirement identified in the 2010/2011 DIPC report the Estates and Facilities successfully procured a Decontamination Lead service provider. Work continues in the development of various policies to ensure we are compliant with NSC. A working group meets on a monthly basis to provide a dedicated resource to ensure that all related polices are delivered. The IPCC, the Director of Operations and Nursing and the Estates and Facilities team will support and contribute to this work. Finally, the appointment of the IPC Lead Nurse has created the essential link between IPC and Estates and Facilities, thus closing gaps and successfully progressing our joint approach to ensuring high standards of cleanliness and progress with Estates and Facilities/IPC related issues. DIPC Annual Report 2011/12 - Final July 2012 Page 19
Audit Scores Chart 3 Trend Analysis: Contractor Domestic Services Self-Assessment Scores - April 2011-March 2012 Contract Monitoring - Domestic Services Trend Analysis April 2011 - March 2012 100.00% 98.00% 96.00% 94.00% 92.00% 90.00% 88.00% Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Month of Audit The overall cleaning standard for the year can be calculated as detailed below in Tables 7 and 7.1: Table 7 - Cleaning Standards for 2011/12 Q1 Q2 Q3 Q4 Average 2011/12 93.6% 95.7% 96.8% 96.7% 95.7% Based on contract Contractor self assessment scores Note: the scores above are rated based on the recommendations in the NSC Table 7.1 Cleaning Standards Compliance Levels 95% - 100% no action required Between 90% and 94.9% Good minor discrepancy Less that 90% Poor immediate improvement required DIPC Annual Report 2011/12 - Final July 2012 Page 20
7.6 PEAT Scores (Patient Environment Action Team) There is a strong evidence to suggest that the environment within which mental health care is delivered has a significant impact on both patient experience and safety. This link becomes even more important for inpatient services and the Trust is committed to improving the quality of inpatient areas Every year, all healthcare facilities in England with more than 10 inpatient beds are inspected and rated using Patient Environment Assessment Team (PEAT) assessments. Each hospital is given an annual rating of excellent, good, acceptable, poor or unacceptable, based on levels of cleanliness, aspects of infection control, quality of environment (such as decoration, maintenance and lighting) and the standard of food offered to patients. The DWMHPT 2011/2012 PEAT assessment was carried out by multifaceted teams, made up of NHS staff (nurses, matrons, catering, domestic service managers and estates service managers) as well as patients and patient representatives, resulting in a comprehensive assessment, incorporating the views and opinions from both within and outside the Trust. These assessments were conducted on our three hospital sites and the process was managed by NHS Dudley Estates Department on behalf of DWMHPT. The scores below (Table 8) show the Trust s acute sites have either made progress or maintained their high standards in the vast majority of areas. In particular the food has improved and dignity has maintained an excellent rating across all three hospital sites. Table 8 PEAT Scores Site Name Year Environment Food Privacy and Dignity Bushey Fields 2009 2010 2011 2012 Good Acceptable Good Dorothy Pattison Bloxwich Hospital 2009 2010 2011 2012 2009 2010 2011 2012 Acceptable Good Good Good Good Good Good Good Good The PEAT results continue to be an integral component of the Estates and Facilities and IPCC agenda where relevant leads are requested to demonstrate their action plans to improve PEAT scores with a view to achieving total excellence for 2013. DIPC Annual Report 2011/12 - Final July 2012 Page 21
8.0 Education and Training Education and training in the prevention and control of infection remains a core mandatory requirement for all employees of Dudley and Walsall Mental Health Partnership NHS Trust. For this reporting period face to face training has been delivered by the Infection Prevention and Control Teams from NHS Dudley and Walsall Community Health. Future training will be delivered by the Infection Prevention and Control Team employed by the Trust. Mandatory training compliance is reported to GQC on a monthly basis and to the IPCC on a quarterly basis. HoS are required to present risks/exceptions relating to staff compliance to the IPCC on a quarterly basis The infection control mandatory face to face training compliance for clinical staff for April 2011 to March 2012 is illustrated below in Table 9. Table 9 - Infection control mandatory face to face training compliance for clinical staff for April 11- March 12 March March March March 2009 2010 2011 2012 Infection Control F2F (Clinical) 39% 74% 84% 100% The opportunity of in-house provision IPC services will enable a robust review of training resources and the development of a quality programme of IPC training for 2012/13. 9.0 International Infection Prevention and Control Week International Infection Prevention and Control Week was an international initiative that ran for the week of 17 th -21 st October 2011. The Trust participated in this initiative and used the opportunity to highlight the importance of the prevention of infection. Link workers played a pivotal role during this week and a number of displays and initiatives were led by them. The Trust intranet was used to publicise interesting fact of the day to all staff and there was prize for the winner of a word search puzzle based on information about Clostridium difficile. 10.0 Occupational Health Highlights The Occupational Health Department (OHD) contribution has continued to be invaluable during 2011/12. The Occupational Health Manager will continue to play a key role in driving quality improvement within the areas of risk based preemployment screening, management/treatment of sharps injuries and uptake of seasonal flu vaccination programme DIPC Annual Report 2011/12 - Final July 2012 Page 22
10.1 Seasonal Influenza Vaccine Uptake The Occupational Health Department worked closely with senior managers, Human Resources and Corporate Communications to promote the 2011/2012 seasonal flu campaign. The Department of Health wanted to increase the number of Front Line Health Care Workers receiving the flu vaccine, however, the DH decided not to have a national campaign. The OHD in previous years had tried a number of different approaches, and had found that taking the vaccine to staff did work. Therefore the team chose to continue to offer site visits in conjunction with communications from the Trust on the importance of all staff attending for vaccination. Chart 4 below demonstrates the number of seasonal flu vaccines given not only during the 2011/12 season, but it also compares the number given during the previous two seasons. Chart 4 Summary of Flu Vaccines Given 2009-2012 10.2 Injuries Reported to Occupational Health in Compliance with the Management of Sharps Injury Policy For 2011/12 there have been nine injuries reported by staff to Occ. Health under the Management of Sharps Injury Policy. Five of which all relate to the same patient. Chart 5 below provides a comparison of injuries reported to Occ. Health for 2009/10, 2010/11 and 2011/12. DIPC Annual Report 2011/12 - Final July 2012 Page 23
Chart 5 Total Number of Incidents reported 2009/20010/2011 11.0 HCAI Incident Reporting During the past year we have continued to review incident reporting categories and ensure learning is embedded throughout our services following incidents. Data from the Trust incident reporting system is collated centrally, formatted and presented on a quarterly basis to the IPCC by the Governance Department. Incident data continues to be analysed by service line providing a robust means of noting trends in incident data. Work is in progress through taking a collaborative approach between HoS, Governance Department and the IPCC to further develop meaningful incident reporting structures through which to further improve the Trusts processes for the sharing and embedding of lessons within day to day practice. 11.1 Key Highlights of Incident Activity As outlined within sections 5.1-5.3 the Trust had zero reportable instances of MRSA, MSSA and GRE Bacteremia and zero cases of C.Difficile during 2011/12, there were also no reported outbreaks of infection (including Norovirus) during the same period. During the period there has been much awareness raising undertaken within the organisation around the timely reporting of infection control related incidents. During this reporting period there has been development and refinement of the Trusts incident reporting categories and cause groups in order to ensure that they meet the needs of the organisation in providing both statistics and intelligence for making appropriate decisions. Owing to the refinements to the Trusts incident reporting system it is therefore difficult to offer a direct comparison with the previous years figures. Table 10 below illustrates the incidents for this reporting period. DIPC Annual Report 2011/12 - Final July 2012 Page 24
Table 10 - Infection Control related incidents April 2011- March 2012 Infection Control Acute Older services Adults Total Sickness & Diarrhoea (Untested) 3 3 Scabies 1 1 2 Total Infection Control Incidents 4 1 5 There have been five Infection Control related incidents across the Trust, three of which related to cases of sickness and diarrhoea within Acute Services, there were also two further cases of scabies reported, one within Acute Inpatients and the other within Older Adults 12.0 Policies The IPC Lead Nurse has played a major role in facilitating the policy development work programme, resulting in the ratification and implementation of key IPC policies. The following policies were ratified during 2011-12 Clinical Specimens Policy Policy for the Prevention and Control of Clostridium difficile MRSA Prevention and Control (including screening) Outbreaks of infectious diseases Management Policy Standard Precautions for the Prevention and Control of Infection Glove policy The IPCC have noted the extensive policy work during 2011/12 resulting in a much better position from an IPC perspective and in line to aspiring to NHSLA Level 2 accreditation. 13.0 Showcasing Good Practice Within the Quality Accounts 2011/12 the following summary is noted: Infection Control The Trust has continued to build on best practice standards in complying with the Code of Hygiene within our care environments and is proud of its approach to ensuring that Infection Prevention and Control is everyone s responsibility. For example, the Infection Control Committee is now well established and next year the Trust anticipates involvement and membership from expert service users. It is anticipated that these solid foundations will support continued improvements such as the broader involvement of service users and carers as the Trust strives to prevent and control infection and to deliver excellent standards of compliance with the Code of Hygiene. During 2011/12 there were no MRSA or Clostridium Difficile breaches in the Trust. DIPC Annual Report 2011/12 - Final July 2012 Page 25
13.1 West Midlands Quality Peer Review During 2011/12 the Trust was reviewed as part of the West Midlands Quality Peer Review Programme. The review identified several areas of best practice which were showcased across the region, including Infection Control Link Workers. The IPC Link Worker workforce continues to grow and make positive contributions to local practice. 13.2 Examples of Local Best Practice During IPC International Awareness Week, IPC Link Workers from Ambleside Ward arranged a visual display and generally promoted awareness of hand hygiene in the reception of DPH. The Link Workers involved wore t-shirts which incorporated our local message Bugs are Mean, Keep your Hands Clean. The event involved staff, service users and visitors to the hospital and was a fantastic example of dynamic link working in practice. The Bloxwich Hospital team including IPC Link Workers arranged a community event Gimme 5, where children from local primary schools were educated as to healthy eating and the importance of hand hygiene. The children were invited to design a poster reflecting How Clean Are Your Hands? The posters were amazing and generated a wonderful display at Bloxwich Hospital, which was admired by many. This event was also profiled in the local press and many of the children went home that night and advised their families how to wash their hands correctly! 14.0 What Would the DIPC Like Us to Achieve During 2012/13? 1. Continuing compliance and demonstration of best practice with regard to the Health and Social Care Act 2008 Code of Practice for health and adult social care on the prevention and control of infections. 2. In-line with patient safety, to achieve the quality goal of maintaining and improving the cleanliness of the Trust hospitals and community facilities. 3. The embedding of in-house IPC Service provision and a progressive impact of our new arrangements on delivering continual quality improvements. 4. The continuation of healthy relationships and working partnerships across the local health economy. 5. The progression of user involvement within IPC areas building upon the excellent contribution of EbE s. DIPC Annual Report 2011/12 - Final July 2012 Page 26
15.0 Conclusion The third DIPC annual report has intended to give an overview of infection prevention and control activity during 2010/11. DWMHPT has progressed another year of industrious activity in relation to the vast arena of infection prevention and control. As an organisation, we have been assessed as fully compliant by the CQC in meeting best practice standards with infection prevention and control. 15.1 The DIPC in final summary concludes: Another very industrious year which demonstrates a positive journey. As DIPC I am proud that amidst our rapid Service Transformation programme and journey towards Foundation Trust status, we have successfully achieved a healthy level of compliance with infection prevention and control standards. We have a fine array of good practice examples and need to continuing developing our profile as a centre of excellence. The amount of work that we have needed to progress during the past three years to get to the stage of IPC development that we are at now cannot be underestimated. However, this industrious approach needs to continue and there is no room for complacency. As DIPC I would like to say thank you to all staff for their hard work and contribution to the infection prevention and control agenda as we now move forward during 2012/13 to being even better together in making our services cleaner and safer for everyone. DIPC Annual Report 2011/12 - Final July 2012 Page 27