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Trust Board
7th July 2016
Title of the paper: Infection Prevention and Control Annual report 2015/16
Agenda item: 17/39
Lead Executive: Tracey Carter, Chief Nurse and Director of Infection, Prevention Control
Author: Nyarayi Mukombe, Assistant Director of Infection, Prevention Control
Trust aims : Double click on the box to mark as appropriate:
To deliver the best quality care for our patients
To be a great place to work and learn
To improve our finances
To develop a strategy for the future
Purpose: The aim of this paper is to inform the Trust Board of the infection prevention and control programme of work undertaken and performance targets in April 2015 to March 2016.
Link to Board Assurance Framework (BAF)
PR1 Failure to provide safe, effective, high quality care (insufficiently robust and embedded quality governance and risk management)
Previously discussed:
Committee Date
Safety & Quality 24th May 2016
Benefits to patients and patient safety implications A clear governance framework exists to manage infection, Prevention Control to maintain the safety of patients in the care of the Trust.
Recommendations This report is for information, assurance and approval for publication
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Annual Report 2015-2016
INFECTION PREVENTION & CONTROL
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FOREWORD BY THE CHIEF NURSE AND DIRECTOR OF INFECTION PREVENTION AND CONTROL: Healthcare associated infection (HCAIs) remains a top priority for the Trust, public,
patients and staff. HCAIs increase the patient stay in hospital and thereby increase in the
cost of the patient`s care. The reduction of avoidable HCAIs is a priority for our
organisation.
This year we have invested in the development of the team to work in partnership with
clinicians across the Trust. Supporting our development of frontline leaders and new
recruits to deliver and progress the infection prevention and control agenda
I would like to thank all staff for their efforts and hard work in ensuring the stabilisation of
our infection prevention and control agenda. It is worth recalling that in 2010/11 we had 5
cases of MRSA bacteraemia and 54 cases of Clostridium difficile Infection. In the past
year we had 1 cases of MRSA bacteraemia and 28 cases of Clostridium difficile Infection.
Compared to 2007/08 we have reduced our CDI cases by 93%, this is worth celebrating.
Our continued goal is to deliver „Harm Free Care‟ and not a single preventable infection
should be allowed to develop in our hospitals.
Tracey Carter Director of Infection Prevention & Control/Chief Nurse
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EXECUTIVE SUMMARY This was another busy year for the Infection Prevention and Control Team (IPCT) who continued to maintain high visibility and engagement in the clinical areas. A Clinical Nurse Specialist for Vascular Access joined the team in February 2016. The IPCT still faces a challenge due to lack of dedicated electronic Infection Control Surveillance software, using paper system which is time consuming.
We reported 28 Clostridium difficile Infection (CDI) cases against a trajectory of 23. We
breached our trajectory by 5 cases. Our rate of CDI was 13.27 per 100,000 bed days. The
average rate for East of England was 14.93 per 100,000 bed days. We reported 6 cases of
CDI in November 2015, there was no evidence of any links in the 6 cases, as all had
different ribotypes and were not related to time and place, therefore no evidence cross
infection.
In January 2016, there was a Period of Increased Incidences of Clostridium difficile
infections on Stroke ward. All of the 3 WHHT apportioned cases on Stroke ward had
different ribotypes hence no evidence cross infection. The team in July implemented
weekly Clostridium difficile ward rounds
We reported 1 case of MRSA bacteraemia, which was the same as the previous year. Our
rate of MRSA bacteraemia was 0.47 per 100,000 bed days while the East of England
average rate was 0.7 per 100,000 bed days and that of England was 0.69. Our rates for
MRSA bacteraemia are lower compared to national and regional (East of England)
We continue to report MSSA (Methicillin Sensitive Staphylococcus aureus) and E.coli (Escherichia coli) Bacteraemia as part of mandatory surveillance. Our rate of MSSA bacteraemia was 0.23 per 100,000 bed days, the East of England average rate was 6.45 per 100,000 bed days and that of England was 6.74 per 100,000 bed days. Our rates were low compared to regional and national. Trust wide continuous total hip and knee replacement surveillance was undertaken.
There was confirmed Norovirus outbreak on 3 wards during February and March 2016, the
outbreaks were well contained, following lessons learnt from the 2014/15 Norovirus
Outbreaks. A Flu outbreak was reported on a respiratory ward and sporadic cases on
several wards, which were well contained.
Wet surfaces on SCBU were replaced, however there were sporadic cases of
pseudomonas in Special Care Baby Unit in March 2016
The team participated international and national IPC activities, delivered extra IPC mandatory training to improve training uptake, there was high uptake in “Power Training”. There were external visits from the CQC (planned inspection) in April 2015, Trust
Development Authority (TDA) HCAI review visit July, October and December 2015
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Future Priorities & Direction - 2016/17
Participate in the NHS Improvement `s IPC Collaborative 90 Day Improvement
Programme, focus on environmental and equipment cleanliness with the aim of
rolling this trust wide by the end of the 2016/17 financial year.
IPC mandatory training will be available face to face and via e-learning, this should
improve the uptake of mandatory training.
IPCT to maintain high visibility and engagement in the clinical areas.
Continue to raise awareness amongst staff regarding the importance of hand
decontamination in the prevention and control of infection in all educational
sessions and on routine visits to clinical areas
Deliver the IPC single study days and six day program.
Improve support to IPC Link Practitioners by undertaking Code of Practice
checklists in conjunction with them to improve understanding of IPC in the clinical
area,
Training on the use of the IPC admission risk assessment to ensue appropriate
management of patients.
To get an electronic IC software system; this would make the IC Surveillance more
proactive.
Urinary catheter CQUIN and Antimicrobial CQUIN.
Continue to improve the newly introduced local epidemiology surveillance programme and relate the findings to the trust antibiotic guidelines in line with the national recommendations to ensure effective use of antibiotics.
Monitor antibiotic consumption
Continue to improve OPAT service to meet the national standards for OPAT.
Improve diagnostics and introducing new technology to microbiology laboratory including rapid molecular diagnosis of viral infections enabling better antimicrobial stewardship
Better use of IT technology for data collection and processing of antimicrobial stewardship and antimicrobial prescribing
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Contents
FOREWORD BY THE CHIEF NURSE AND DIRECTOR OF INFECTION PREVENTION AND CONTROL: .............................................................................................................. 4
EXECUTIVE SUMMARY ................................................................................................. 5
1. INTRODUCTION ....................................................................................................... 9
2. INFECTION PREVENTION AND CONTROL ARRANGEMENTS ............................. 9
3 INFECTION PREVENTION AND CONTROL TEAM (IPCT) .................................... 10
4. IPC ANNUAL PROGRAMME .................................................................................. 10
5. MANDATORY SURVEILLANCE REPORTING OF HCAI ........................................ 10
5.1 Trust Apportioned MRSA Bacteraemia ................................................................. 11
5.2 Methicillin Sensitive Staphylococcus Aureus (MSSA) Bacteraemia ..................... 13
5.3 Escherichia Coli Bacteraemia ............................................................................... 13
5.4 Clostridium Difficile Infection (CDI) Performance .................................................. 14
5.5 Root Cause Analysis ............................................................................................ 14
5.6 MRSA Screening Compliance .............................................................................. 17
5.7 Surgical Site Infection Surveillance Programme (SSISS) ..................................... 18
5.8 Activities undertaken in 2015/16 ........................................................................... 19
5.9 SSISS Quarter 2 (April to June 2015) ................................................................... 19
5.10 SSISS Quarter 3 (July to September 2015) ........................................................ 19
6. SYSTEMS TO MANAGE AND MONITOR THE PREVENTION AND CONTROL OF INFECTION .................................................................................................................... 21
6.1 The Infection Prevention and Control Panel (IPCP) ............................................. 21
6.2 Local Health Care Associated Infection Group ..................................................... 22
6.3 Water Safety Group (WSG) .................................................................................. 22
6.4. Surgical Site Infection Surveillance Panel ........................................................... 22
6.5 Joint IPCT meetings ............................................................................................. 22
6.6 Divisional Governance Meetings .......................................................................... 22
7. INCIDENTS AND OUTBREAKS OF INFECTION ..................................................... 22
7.1 Outbreaks of infection ........................................................................................... 22
7.2 Incidents ............................................................................................................... 23
8. THE INFECTION PREVENTION AND CONTROL „DASHBOARD‟ ........................... 27
8.1 Environmental Cleanliness Monitoring ................................................................. 27
8.2 Deep Clean Programme ....................................................................................... 29
8.3 Audits:................................................................................................................... 29
8.4 Hand Hygiene Audits Compliance ........................................................................ 29
8.5 Training Activities ................................................................................................. 32
8.6 IPC Promotional Activities .................................................................................... 33
9. POLICIES AND PROCEDURES ................................................................................ 35
10. FLU VACCINATION ................................................................................................ 35
10.1 Fit Mask Testing ................................................................................................. 35
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11 ANTIMICROBIAL STEWARDSHIP ACTIVITIES ....................................................... 36
11.1 The trust Antimicrobial committee (AMC) ........................................................... 36
11.2 Local epidemiology surveillance programme ...................................................... 36
11.3 Outpatient intravenous antimicrobial Therapy (OPAT) ....................................... 36
11.4 Ward rounds ....................................................................................................... 36
11.5 Audits .................................................................................................................. 36
11.6 Guidelines ........................................................................................................... 37
11.7 Education ............................................................................................................ 37
11.8 Laboratory diagnosis and antimicrobial stewardship .......................................... 38
12 EXTERNAL VISITS ................................................................................................... 38
12.1 CQC visit ............................................................................................................ 38
12.2 NHS Trust Development Authority ...................................................................... 38
12.3 NHS Improvement (Formerly TDA) Infection Prevention and Control 90 Day Collaborative Improvement Programme ..................................................................... 39
13 RECOMMENDATION ............................................................................................... 39
APPENDIX 1: IPCP TERMS OF REFERENCE ............................................................. 40
APPENDIX 2: TDA LETTER TO THE DIPC................................................................... 44
APPENDIX 3: TRUST COMPLIANCE WITH THE CODE OF PRACTICE: .................... 46
APPENDIX 4: REDUCTION OF CLOSTRIDIUM DIFFICILE ACTION PLAN................. 62
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1. INTRODUCTION
The purpose of this report is to provide assurance of the Trusts compliance with the Health
and Social Care Act 2008 (DH, 2015), The Hygiene Code during 2015/16.
To keep the Trust Board informed of IPC performance over the year. This is in
addition to the monthly Integrated Performance Report.
To highlight the key areas of focus for 2016/17.
2. INFECTION PREVENTION AND CONTROL ARRANGEMENTS
Infection Prevention and Control is everyone `s responsibility within the organisation, as
healthcare workers we all play a role in ensuring that our patient are safe from acquiring a
preventable HCAI.
The Chief Executive accepts on behalf of the Trust Board responsibility for all aspects of
Infection Prevention and Control (IPC) within the Trust. This responsibility is delegated to
the Chief Nurse (CN) as Director of Infection Prevention and Control.
The Chief Nurse as the designated executive lead for IPC, reports directly to the
Chief Executive and the Board, and is chair of the Trust Infection Prevention and
Control Panel
As the Executive Director with responsibility for IPC the CN delegates operational
responsibility at Divisional level to the senior triumvirate teams which include the
Heads of Nursing/Midwifery and Divisional General Managers and Directors.
The CN/DIPC leads, and is accountable for the review and communication of the
strategy, assessment of milestones and ensures that appropriate planning takes
place in order to deliver the objectives.
The CN/DIPC works in close collaboration with the Infection Control Doctor (ICD)
and Assistant Director Infection Prevention and Control (ADIPC) (who is an
infection prevention and control nurse specialist) incorporating national guidance
into local policy, monitoring key performance indicators (KPIs) and compliance
with the Hygiene Code.
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3 INFECTION PREVENTION AND CONTROL TEAM (IPCT)
24hr IPC advise: A comprehensive IPC service is provided Trust-wide. The IPCT provides a ward liaison and telephone consultation service with on-call arrangements. This on call is undertaken by a consultant microbiologist for emergency assistance and advice.
4. IPC ANNUAL PROGRAMME The annual programme is prepared by the IPCT and agreed by the IPCP and ratified by
the QSG. The programme is mapped to the duties of the Hygiene Code, and is monitored
by the IPCP. The Health and Social Care Act 2008 provides Trusts with a code of practice
for the prevention and control of healthcare associated infections (HCAI‟s) and makes
clear their statutory responsibilities. Each Trust is expected to have sufficient systems in
place to apply evidence-based protocols and to comply with the relevant provisions of the
Act so as to minimise risk of infection to patients, staff and visitors. (See appendix 3 for the
programme and update for 2015/16.)
5. MANDATORY SURVEILLANCE REPORTING OF HCAI
The Department of Health (DH) requires mandatory surveillance of specific categories of
HCAI. This allows national trends to be identified and can be used as a measure of
progress within a Trust and an indicator of standards.
The Trust is required to report on the alert organisms indicated below:
MRSA bacteraemia
INFECTION PREVENTION AND CONTROL TEAM REPORTING & ACCOUNTABILITY STRUCTURE ~ MARCH 2016
Interim Chief Executive Jac Kelly
Ext 8211/8209
IPC Doctor/ Consultant Microbiologist
Dr Prema Singh
Ext. 7595 (Mob. 07702 616965)
Infection Prevention & Control Nurse
Elaine White Bleep: 1069
Ext. 8374
Consultant Microbiologist Dr Hala Kandil
Ext. 8285 (Tel. 01923 436825)
Deputy Chief Nurse Maxine McVey
Ext. 7311 (Mob. 07747865638)
Consultant Microbiologist Post covered by locum
Senior Infection Prevention & Control Nurse
Vishal Sookhoo Bleep: 1151
Ext. 7700
IPC Administrator/P.A Naz Zafar Ext. 8376
IV Specialist/Vascular Access Nurse
Julia Awad Bleep 1154
Ext. 7169
Data Administrator Dean Panks
Ext. 7309
Assistant DIPC Nyarayi Mukombe
Ext.8376 (Mob: 07584521262)
DIPC/Chief Nurse Tracey Carter
Ext. 8228
Infection Prevention & Control Support
Cheryl Atkins Bleep: 2968
Ext. 7700
Infection Prevention & Control Nurse
Lucy Ewers Bleep: 2900
Ext.8374
Lead Nurse Infection Prevention & Control
Jiovanna Foley
Ext. 8376 (Mob: 07825403019)
SSI Surveillance Nurse
Vacant
Antimicrobial Pharmacist Tejal Vaghela
Ext. 7368
Bleep. 1298
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Clostridium difficile infection (CDI).
Escherichia coli (E.coli) bacteraemia
MSSA (Methicillin sensitive staphylococcus aureus) bacteraemia
National mandatory reporting for these organisms is co-ordinated by the Public Health England (PHE) using a Data Capture System (DCS).
The IPC nursing team perform a daily review of all alert organisms and report any alert
organisms and conditions that are identified. There is no dedicated electronic Infection
Control surveillance software. With the IPCT using a paper system which is time
consuming. The surveillance system is of prime concern. It allows the IPCT to identify and
assess all the infected patients in the hospital and is essential to the hospitals infection
control management. The IPCT are working with CGI to progress the requirements with
the aim to build and match with other IC Surveillance software
5.1 Trust Apportioned MRSA Bacteraemia The DH began mandatory surveillance of MRSA bacteraemia in April 2004. The trajectory
set for this financial year 2015/2016 by NHS England was zero tolerance on MRSA
bloodstream infections for all Trusts. For all cases of MRSA bacteraemia a Post Infection
Review (PIR) is carried out. The purpose of the PIR is to investigate how a case of MRSA
bloodstream infection occurred and to identify actions that will prevent it reoccurring
In October 2015, we reported 1 MRSA bacteraemia on Acute Admission Unit. The PIR
was attended by the representatives from all the organisations involved in the patient `s
care pathway that was the patient`s General Practitioner (GP), Herts Valley Clinical
Commission Group (Head of IPC), IPCT and the clinical teams looking after the patient.
Issues/learning identified:
Improvement in documentation; wound management and visual infusion phlebitis (VIP) scores.
Education and training for nurses and doctors on the technique for collecting blood cultures.
Improve IPC training compliance to 95%.
Leg dressings not taken down in A and E on admission.
Following this, IPCNs focussed training (“Power Training” – training in the clinical areas)
on documentation, and MRSA. A vascular access nurse started in February 2016, who is
now supporting the management of vascular access devices. The learning from the PIR
was also discussed at the Unscheduled Care divisional Governance meeting in November
2015 and also the Joint Medicine and Unscheduled Care governance meeting in January
2016.
Prior to the MRSA bacteraemia in October 2015, the last MRSA bacteraemia had been in May 2014.
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Figure 1a, illustrates the MRSA bacteraemia from 2007 to March 2015. Figure 1 a
Figure 1 b The graph below (Figure1b) illustrates the number of MRSA bacteraemia per trust in East of England. Our rate of MRSA bacteraemia was 0.47 per 100,000 bed days, the East of England average rate was 0.7 per 100,000 bed days and that of England was 0.69. The trajectory for all Trust is zero avoidable.
0
5
10
15
20
25
30
35
40
2007-2008 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
MRSA BACTERAEMIA April 2007- March 2016
0
1
2
3
4
5
6
Total
Trajectory
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5.2 Methicillin Sensitive Staphylococcus Aureus (MSSA) Bacteraemia
Reporting of MSSA bacteraemia has been mandatory since January 2011. There is no
trajectory set for MSSA. In 2015/16 there were 4 WHHT apportioned MSSA bacteraemia.
This is an improvement from last year where we reported 13 cases of MSSA.
Below Table 1 is comparison with the previous year 2014/15. This year showed a decrease in the MSSA bacteraemia.
MSSA Quarter 1 Quarter 2 Quarter 3 Quarter 4
Apri May Jun July Aug Sep Oct Nov Dec Jan Feb Mar Total
2014/15 1 0 0 2 0 2 2 0 2 0 3 0 13
2015/16 0 0 1 0 1 0 0 0 0 0 1 1 4
The graph above illustrates the number of MSSA bacteraemia per trust in East of England. Our rate of MSSA bacteraemia was 0.23 per 100,000 bed days, the East of England average rate was 6.45 per 100,000 bed days and that of England was 6.74 per 100,000 bed days. Our rates were low compared to regional and national.
Our rates of MSSA bacteraemia were low compared to regional and national per 100,000 bed days.
5.3 Escherichia Coli Bacteraemia The reporting of Escherichia coli bacteraemia became mandatory in June 2011. Currently
there are no targets set for this condition. 33 Escherichia coli bacteraemia have been
identified as WHHT apportioned (that is 48 hours post admission) for April 2015 - March
2016 which is a increase from previous year which was 25. Common theme for the E. Coli
bacteraemia is a catheter associated urinary tract infection.
0
5
10
15
20
25
MSSA Bacteramia per Trust in EoE
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Table 2
E.coli Quarter 1 Quarter 2 Quarter 3 Quarter 4
April Ma Jun July Aug Sep Oct Nov Dec Jan Feb Mar Total
2014/15 1 2 3 2 4 2 3 0 3 1 1 3 25
2015/16 3 3 2 3 2 1 2 2 5 0 3 7 33
The increase in Escherichia coli bacteraemia is reflected regionally and national, there has been an increase in the counts and rates of Escherichia coli bacteraemia. 5.4 Clostridium Difficile Infection (CDI) Performance Reporting for CDI in patients aged 65 and over has been mandatory since 2004 and in 2007 this was extended to include all episodes in patients aged 2 years and over. The trust trajectory for this financial year was 23. Our monthly trajectory for CDI was higher at the end of the financial year than at the beginning; this has meant that throughout the year we were over trajectory on our monthly figures. 5.5 Root Cause Analysis (RCA): All WHHT apportioned CDI cases (post day 3 cases) are investigated using the RCA
process. The expectation is that the RCAs are completed within 14 working days of the
notification. Currently this is not always being achieved in the divisions due to various
clinical commitments.
The RCAs are robust; they involve the IPCT (IPC nurse and or Assistant Director of IPC
and consultant microbiologist or Infection Control Doctor and antimicrobial pharmacist;
Clinical team looking after the patient; Consultant, Head of Nursing or matron and ward
manager and the Head of IPC Herts Valley CCG.
The responsibility for completion of the RCA rests with the relevant division and must be
completed collectively by the relevant teams. The RCA is discussed and an action plan
created.
Each RCA, including the associated action plan was presented and monitored at the bi
weekly LHCAI meetings, however since July these are being discussed at the Divisional
Governance meetings, facilitating the sharing and learning across the organisation. As
from July the IPCT have been attending the Divisional Clinical Governance meeting. IPC
is a standing item on the agenda of these meetings. This is where the progress of the
action plan from the RCA will be monitored and progressed.
Below is the Clostridium difficile graph (figure 2) comparing the last 3 financial years April
2013 to March 2016.
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In November 2015 we reported six cases of Clostridium difficile, as illustrated in the graph
above, all the cases were on different wards and also had different ribotypes, therefore
there was no link in the cases, which demonstrated no transmission between the cases.
Figure 3: WHHT apportioned Clostridium difficile April 2007 to March 2016
This graph illustrates a 93% decrease to date compared to 2007/2008.
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2013-2014 2 4 2 2 2 3 2 5 0 2 0 4
2014-2015 2 2 1 1 6 4 1 1 1 1 1 2
2015-2016 1 3 3 2 2 3 2 6 1 1 2 2
Monthly Trajectory 2015 1 1 1 1 1 2 2 2 3 3 3 3
0123456789
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WHHT apportioned C.difficile
2007-2008
2008-2009
2009-2010
2010-2011
2011-2012
2012-2013
2013-2014
2014-2015
2015-2016
Number of Infections 396 98 91 54 17 46 28 23 28
0
50
100
150
200
250
300
350
400
450
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Figure 4: WHHT Clostridium difficile cases per Division 2015-2016
The graph above demostrates that 61% of the CDI cases were from Medicine division. Figure 5: WHHT apportioned Clostridium difficile cases per Ward
This demonstrates that there were more cases reported on Cassio wad. Cassio ward is our Gastroenteritis ward, most patients will have diarrhoea and increased sampling and also Flaunden ward which a colorectal ward.
The IPCT implemented a weekly Clostridium difficile ward rounds
0
1
2
3
4
5
Monthly Divisional Clostridium difficile 2015-2016
Medicine
Unscheduled care
Surgery
WACS
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
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Figure 6: WHHT C.difficile compared with other trust in East of England in 2015/16
Our rate of CDI was 13.27 per 100,000 bed days, the East of England average rate
14.93 per 100,000 bed days.
5.6 MRSA Screening Compliance In June 2014 the DH published the implementation of modified admission MRSA
screening guidance for NHS trusts, where trusts could implement selective screening for
MRSA. The Trust has continued to adopt MRSA screening for all planned and emergency
admissions with the exception of some low risk areas. The MRSA screening compliance is
monitored in the monthly IPCP meetings. Patients identified to be MRSA positive are
promptly isolated and commenced on the decolonisation protocol.
Below is the graph that shows MRSA screening compliance for both emergency and elective admission in the trust for 2015/16. Figure 7: MRSA Screening Compliance
0
10
20
30
40
50
60
Trajectory
Total
70
75
80
85
90
95
100
105
110
Co
mp
lian
ce %
MRSA Screening April 15- March 16
Emergency screening
Elective Screening
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Figure 8: MRSA Isolates April 2015 – March 2016 The graph below shows that the WHHT monthly acquired MRSA figures is less than those who are previously positive and community apportioned cases.
The graph above illustrates an increase of WHHT apportioned MRSA in August. This was due to an MRSA (colonisation) outbreak on Croxley ward. This will be discussed later in the paper in the section of outbreak and incidents.
The WHHT apportioned MRSA (colonisation) has been consistently lower than those that are positive on admission.
5.7 Surgical Site Infection Surveillance Programme (SSISS)
Orthopaedic Surgical Site Infection (SSI) surveillance is a mandatory requirement
introduced by the Department of Health in April 2004. The Public Health England (PHE)
healthcare associated infection and antimicrobial resistance department (HCAI & AMR)
run the surgical site infection surveillance service (SSISS). The data collected is forwarded
to the PHE for analysis and reporting. The system is controlled and validated to allow
comparisons between hospitals. There are 12 defined categories of surgical procedures
within the national SSIS programme, but orthopaedic SSIS has been mandatory for all
Trusts to perform since 2004/05. The requirement is for a three month module of
surveillance in one of the orthopaedic options namely:
Reduction of long bone fracture
Total hip replacement (THR)
Total knee replacement (TKR)
Repair of neck of femur
WHHT has been participating in continuous hip and knee prosthesis SSI surveillance
since July 2010 with the addition of other categories of surgery as agreed within the
Divisional SSI Surveillance Programme.
0
5
10
15
20
25
30
35
Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
MRSA WHHT acquired, Old +ve & Non WHHT acquired
WHHT Acquired Old/Known +ve Not WHHT acq
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5.8 Activities undertaken in 2015/16
There were monthly SSI Prevention Panel meetings, these were chaired by the
SSI Lead Surgeon for Orthopaedics
SSI Prevention Panel submitted its minutes to the IPCP, and issues that needed
escalation to the IPCP
There was Joint participation of the Microbiology Orthopaedic MDT.
A poster was accepted for publication at the EFORT Congress in May 2015
5.9 SSISS Quarter 2 (April to June 2015) Category of Surgical Procedure
Hip replacement
Knee replacement Saint albans City Hospital (SACH): the SACH Total Hip replacement (THR) and Total Knee replacement (TKR) SSISS results have been presenting below the national baseline since July 2014 and are not currently a cause for concern. Watford General Hospital (WGH): following a thirty three month period of zero reportable SSIs in TKR at WGH, 1 x SSI for Jan/Mar 15 in a combined (last 4 periods) study population of 84 operations elevated the trend in rate of infection to 1.2% against a national baseline of 0.7% (inpatient/readmission + without patient questionnaire). Nil SSIs were reported for Apr/Jun 15 therefore the rate declined to 1%. WHHT received PHE SSISS three separate high outlier notices for THR in July/September 2014, Octobe/December 2014 and April/June 2015 (incidence of SSI [inpatient and readmission] above the national 90th percentile in the previous four periods combined). The SSIPP, which has been actively reviewing trends in SSI rate since 2008, concluded that there was a known clinically significant rise in SSI incidence at WGH commencing January/December 2013. The actual number of SSIs in a relatively small study population increased the rate of infection to a peak of 10.3% in Oct/Dec 13 however PHE high outlier notices were not received at the time due to number volumes being less than the 100 threshold for 4 combined periods. A subsequent rise in study population numbers resulted in the first high outlier notice for Jul/Sep 14. It was felt during this time that, although the actual numbers were on the decline, the trend in SSI rate continued to be affected by the October/December 2013 surveillance period results. The downward trend continued to 0.9% in January/March 15 which was noted by the SSIPP as the lowest rate of SSI since Oct/Dec 12 (1.3%). 1 x SSI for April/June 2015 in a combined study population of 110 operations elevated the rate of infection to 1.8% against a national baseline of 0.8% (inpatient/readmission + without patient questionnaire(PQ)). 5.10 SSISS Quarter 3 (July to September 2015)
Category of Surgical Procedure
Hip replacement
Knee replacement
Large bowel surgery Findings SACH: THR and TKR SSISS results unchanged. Currently no cause for concern.
20
Findings WGH: decline in combined trend in rate of infection for THR to 0.8% against an amended national baseline of 0.7% (inpatient/readmission + without patient questionnaire). Rise in combined trend in rate of infection for TKR from 1% to 1.9% against an amended national baseline of 0.6% (inpatient/readmission + without patient questionnaire). Large bowel surgery surveillance in WHHT (WGH): Period July to September 2015
Selected period (inpatient/readmission) – study population of 85 patients, 6 SSIs identified: = 7.1%
Last 4 periods (inpatient/readmission) – study population of 253 x 31SSIs identified: = 12.25%
Last 4 periods (All SSIs) – study population of 253 patients x 33 SSIs identified: = 13% (addition of 2 x post-discharge confirmed SSIs for previous periods)
Inpatient/readmission national baseline (without PQ) = 12.1%
Key
6 = hip replacement,
7 = knee replacement,
15 =Repair of neck of femur Table 3 : Mandatory surveillance of SSIs following orthopaedic surgery - number of operations, infections and rates by surgical category from April 2014 to March 2015
NH
S T
rust
Cate
go
ry
Ye
ar
No.
su
rveill
an
ce
qu
art
ers
in
whic
h T
rust
pa
rtic
ipa
ted
Num
be
r of
op
era
tio
ns
Surgical Site Infections
Inpatient Inpatient and re-
admission
No. %
95%
LCI*
95%
UCI*
No. %
95%LCI*
95%LCI*
West Hertford
shire Hospitals NHS Trust
6 2014/1
5 4 464 0
0.0 0.0 0.8 3
0.7 0.1 1.9
7 2014/1
5 4 554 1
0.2 0.0 1.0 1
0.2 0.0 1.0
15 2014/1
5 1 81 2 2.5 0.3 8.6 2
2.5 0.3 8.6
A poster was accepted for publication at the EFORT Congress in May 2015
21
6. SYSTEMS TO MANAGE AND MONITOR THE PREVENTION AND CONTROL OF INFECTION The following explains the systems and processes that are in place in the Trust IPC BELOW IS THE IPC REPORTING ARRANGEMENTS.
6.1 The Infection Prevention and Control Panel (IPCP) The IPCP has an assurance and management role. Prior to August 2015 the group met
monthly, it now meets bi-monthly and the meeting is chaired by the DIPC. A patient
representative and the Head of IPC Herts Valley Clinical Commission Group (CCG) are
members of the IPCP. The IPCP reports to the Quality and Safety Group (QSG) and
Patient Safety Quality and Risk Committee (PSQR). The DIPC is a member of both the
QSG and PSQR. The Terms of Reference for the IPC Panel can be found in Appendix 1.
These are reviewed yearly. The IPC reports to the board via the quality and safety group
(QSG)
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The IPC Panel receive reports and minutes from the groups below: 6.2 Local Health Care Associated Infection Group This group met bi weekly and reported to the IPCP. Since July 2015, these meetings have been discontinued with the IPCT attending each Divisional Governance meetings where IPC is a standing item on the agenda. 6.3 Water Safety Group (WSG) The aim of the group is to ensure that risks associated with water systems are recognised, documented and action taken to minimise or control these risks and to ensure that the Trust is compliant with the Health and Social Care Act 2008 (2015) and DH legislation and guidance as they pertain to the safety of hot and cold water systems in Trust premises. The group meets monthly and the minutes of the meeting are tabled at the IPCP meetings. Any issues from the meeting are escalated to the QSG via the IPCP meetings. The meeting is chaired by the DIPC. There is also an external appointed independent water safety consultant who supports and advises the group. 6.4. Surgical Site Infection Surveillance Panel The group meets monthly and reports to the IPCP. 6.5 Joint IPCT meetings
This is a monthly meeting for the IPCT (antimicrobial pharmacist, consultant
microbiologist, ICD and the Infection prevention and Control nurses and support). This
meeting is chaired by the ADIPC. This group reviews IPC work plans and progress.
6.6 Divisional Governance Meetings
The IPCT attends the monthly divisional governance meetings, a report for the division is
presented by the IPCT with the Mandatory surveillance, IPC training compliance, results of
various audits, root cause analysis (RCA)s and any clinical issues are discussed.
7. INCIDENTS AND OUTBREAKS OF INFECTION
Outbreaks of infection continue to be the major cause of infection related incidents in any hospital in the United Kingdom. Outbreaks occur when there are two or more linked infections which may or may not be preventable. These events are recognised through surveillance, reporting or routine IPCT activities and are by definition unpredictable. 7.1 Outbreaks of infection 7.1.1 MRSA (colonisation) outbreak Croxley ward Croxley ward is a care of the elderly ward. There were 5 MRSA positive patients identified, all of which had been negative on admission. All cases were colonisation only, none were infections. The index case was a previous MRSA positive patient on admission. The patient was isolated on admission in AAU as per Trust policy, but not isolated on transfer to Croxley ward. The patient was high risk as suffered from Eczema.
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Outbreak meetings were convened and Head of IPC in Herts Valley CCG was also involved. Following the first meeting, whole ward was screened for MRSA. No further cases MRSA were identified; the outbreak was contained within the bay where the index case was and one other patient. The IPCN continued to maintain high visibility on Croxley ward, undertaking some support audits and providing some education and training. The Public Health England (PHE) reference laboratory typing confirmed that EMRSA-15 was isolated from all the five patients, four in a male bay and one in a female bay. There is evidence that there was some transmission. This outbreak was investigated internally. The learning from the outbreak has been shared in all the divisional governance meetings and final report presented to the IPCP. Key learning was:
Failure to isolate a previous MRSA positive patient who was considered high as the patient also suffered from eczema which would cause the sink to shed in the environment therefore leading to transmission.
7.1.2 Norovirus Outbreak Norovirus causes outbreaks of diarrhoea and vomiting. It is extremely infectious and spreads easily in any semi closed settings such as hospitals. Outbreak meetings were held according to policy and minutes generated. There were 4 confirmed Norovirus outbreaks, involving, Stroke unit, Gade and Heronsgate wards between end of January to March 2016. These outbreaks were well contained within those clinical areas. Following the end of the outbreak a deep clean and change of curtains were carried out before re admission of new patients.
The Norovirus outbreaks were well contained within the 3 clinical areas with an average closure of the ward being two weeks. Showing learning from outbreaks in 2014/15.
7.1.3 Flu Outbreak 26 were cases reported. These consisted of 6 cases on Aldenham which required ward closure for Aldenham from 25.02.16to 02.03.16. There were other sporadic cases, 3 cases on ITU. 1 on Gade, 1 on Cassio, 1 on Croxley, 3 on AAU Purple, 2 AAU 1 Blue, 1 AAU1 Purple, 5 Starfish and 1 on Delivery Suite. 7.2 Incidents
7.2.1 Period of Increased Incidences of Clostridium difficile infections
There was a period of Increased Incidences of Clostridium difficile infections in January on
Stroke ward; all of the 3 WHHT apportioned cases on Stroke ward had different ribotypes
hence no evidence of transmission.
6 cases of CDI reported in November 2015, there was no evidence of links in the 6 cases;
all were on different wards with different ribotypes.
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6 cases of CDI reported in November 2015, all were on different wards with different ribotypes. This confirmed no cross infection and links in these cases.
7.2.2 Carbapenemase-Producing Enterobacteriaceae (CPE) Carbapenems (such as Meropenem) are a powerful group of broad-spectrum antibiotics which are often the last effective defence against multi-resistant bacteria. Infections with Carbapenem-resistant enterobacteria are an emerging threat. It is seen mainly in the Indian subcontinent but has also been reported in the Mid-East, North Africa, Europe and the USA. In this country, less than 100 cases have been identified by the Health Protection Agency (now PHE) with bacteria that are Carbapenem-resistant. Many have been associated with patients who have received prior treatment abroad, in India or Pakistan, but there are reports of a few incidents of cross infection in the UK. In December 2013, PHE issued the “Acute trust toolkit for the early detection, management and control of Carbapenemase-Producing Enterobacteriaceae (CPE). The toolkit requires that the Trust should have a dedicated pre prepared plan to prevent the spread of CPE. The Trust has a CPE policy in place. Since April 2015 to March 2016 there have been three positive CPE cases identified. July:
A CPE positive case was identified in one of the London Hospital on transfer from Heronsgate ward/AAU.
23 contacts were identified.
„Alert‟ put in place on Clinicom/PAS.
Screening was undertaken for those who were still inpatients. August:
Patient on AAU 1 purple was found to be CPE positive following CPE screening as patient had been an inpatient in a hospital abroad.
5 contacts identified of which 3 remained inpatients and were followed up,
Alert‟ put in place on Clinicom/PAS for the discharged patients. September:
One patient on Aldenham ward was found to be positive for CPE positive in a clinical specimen. Patient had returned from abroad two weeks prior to WHHT admission.
11 contact patients were identified. All had CPE „alert‟s put on Clinicom/PAS system.
2 of the 11 contacts had been transferred to other health care institutions, the IPCT of these institutions were informed about the patients being contacts of a CPE positive patient.
Our policy stipulates that all patients that have been an inpatient in a hospital abroad, any London hospital and Manchester within the last year need to be isolated and screened for CPE on admission. This is monitored via the IPC dashboard at the bi- monthly IPCP meetings.
A patient Risk assessment document was launched in June 2015 with IPC section; this helps to support staff to identify patients that need screening for CPE on admission.
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7.2.3 Tuberculosis (TB): There were 2 unrelated Tuberculosis incidents on the Watford site. Incident 1: Index patient had a lymph node aspirate done end of May 2015, which was reported AAFB
positive on culture on 3rd July 2015. Subsequent sputum samples were reported AAFB
positive and confirmed as Mycobacterium tuberculosis (MTB).
The patient was an inpatient on Acute Admissions Unit (AAU) and Aldenham ward. They
were nursed in a bay with other patients; from 11th June to 16th June 2015. They were
discharged home from Watford General Hospital (WGH) on 16th June 2015 but continued
to receive intravenous drug therapy under the care of WGH. This patient was readmitted
to WGH from 28th June 2015 to AAU and transferred to Aldenham Ward on 3rd June 2015
where they remained in isolation until discharge on 25th July 2015.
Contact tracing On 12th August 2015, the Lead Respiratory consultant wrote a letter to the patients and their GP‟s explaining the incident. Contact tracing was undertaken relating to the patients hospital stay in June 2015 where they were nursed in open bays in Aldenham and AAU. This exercise identified 10 patient contacts. The screening of these ten contacts was co-ordinated and managed by the Respiratory team. Incident 2; A bronchoscopy procedure was undertaken as a day case at WGH Endoscopy Unit on 15th June 2015. On 18th June 2015 bronchial alveolar lavage washings, taken on 15th June 2015, were reported direct smear positive for AAFB and identified as Mycobacterium tuberculosis (MTB). The respiratory physician who performed the procedure highlighted their concern as „masks‟ were not worn during the bronchoscopy procedure. The members of staff who were in attendance at the bronchoscopy procedure for the patient were identified and referred by occupational health department at WGH to the TB nursing service for follow up. All screening was negative for MTB. Some of the actions taken following both incidents include:
More regular liaison between the Respiratory Nurse CNS and members of the IPCT
Sharing of relevant information & notification of possible/probable cases of TB as identified by the IPCN‟s on routine ward visits to Respiratory Nurse CNS.
Antimicrobial pharmacist notifying the IPCT of patients who have been commenced on medications used for TB treatment. This will trigger further review/follow up by the appropriate teams.
Early review of the organisations Management of TB Policy 7.2.4 Measles There has been 2 cases of confirmed measles. 2 siblings reported by PHE. At time of notification of this, it was too late to provide effective post exposure prophylactic MMR or Immunoglobulin. When results were confirmed contact tracing was undertaken for both
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staff and patients. There were no secondary cases, staff contacts were followed by Occupational Health. 7.2.5 Mumps 1 case confirmed elderly patient. Mumps is not common in the elderly population. 7.2.6 Pseudomonas Aeruginosa in SCBU
A total of 3 cases were reported. 1 was in February 2016. In March 2016 there were 2
other cases. A meeting was convened to discuss these cases. Screening all the contacts
of the 2 cases was undertaken and all were negative. To date, no new cases have been
identified. The water sampling results post refurbishments were reviewed at the meeting.
POU filters inserted. Water sampling was undertaken for all outlets in SCBU.
Subsequently results were satisfactory.
Typing results of the 2 cases were different; therefore there was no link to the 2 cases.
7.2.7 Water Safety The Trust Development Authority (TDA) Head of IPC has been on site the previous months and was informed of a number of repeat water sampling failures in PMOK Level 2. An update on the failures now showed negative results following a program of remedial works, of all affected outlets. Water safety risk is on the corporate risk register and is one of the highest risks.
7.2.8 Control of Legionella
Legionella had been identified in a number of outlets – these were being managed in the short term through fitting of point of use (POU) filters, flushing and a program of cleaning & chlorination
There were 2 clinical cases of legionella reported, however these were community cases. The cases have been discussed at the water safety group meetings (WSG). The recently published Public Health England (PHE) guidance on Responding to the detection of legionella in healthcare premises (PHE 2015) has been discussed and reviewed at the WSG and IPCP meetings.
Actions taken following failures
There is daily flushing and point of use (POU) filters were in place on affected outlets,
also on receipt of high counts disinfection and chlorination is undertaken, with re sampling
done 48hours post chlorination and disinfection of the affected out lets.
7.2.9 Wet services systems Wet services refers the infrastructure associated with providing hot, cold, treated and drinking water, that is pipe work, tanks, pumps, taps, valves, water softeners, treatment units. The wet services systems throughout the Trust, is a broad mix of building stock from 1900‟s builds, to modern construction, and the difficulties associated with the management of Water Safety within the Trust
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Works for SCBU to replace wet services A Capital scheme was in progress to replace all wet services on the Unit – planning the works had taken considerable time; this was as a result of the lack of appropriate services drawings. The work on SCBU was completed on the 5th December 2015; a deep clean was carried out. The patients moved back in the unit following the IPC checks on the 6th December 2015. Water sampling following the works was undertaken and all results for legionella have come back clear. IPC checks were done following the refurbishments.
The work on SCBU was completed on the 5th December 2015. TDA head of IPC has visited the unit on the 17th December 2015 and acknowledged the work that has been done. Improving water safety compliance and management.
Sampling regime The Trust currently undertakes 3 monthly water sampling for legionella and pseudomonas in both Intensive Care Unit and SCBU. The results are monitored via the water safety group.
8. THE INFECTION PREVENTION AND CONTROL ‘DASHBOARD’ This is presented at each IPCP meeting. “Red Exception reports” are produced by the
division/departments where areas of non-compliance are identified and discussed. The
dashboard has Hand hygiene compliance, Commode audits, IPC training compliance,
MRSA screening compliance, ward cleaning scores and high impact intervention audits.
The actions taken will be explained below under each key performance indicator. The
water flushing regimes and temperature are monitored and are available in the monthly
infection prevention and control dashboard which are also discussed at the monthly IPCP
meetings.
8.1 Environmental Cleanliness Monitoring In 2013 WHHT adopted BSI Standard - PAS 5748:2011 as the criteria for assessing
cleaning standards across its 3 hospital sites. PAS 5748:2011 is a Publicly Available
Specification (PAS) sponsored by the DH and National Patient Safety Agency and
provides a „Specification for the planning, application and measurement of cleanliness
services in hospitals‟.
PAS 5748:2011 is a risk-based system whose adoption is designed to provide evidence of
a Trust‟s intent to comply with the CQCs requirements for cleanliness and infection
control. The PAS is not prescriptive, but is based on local determination of the level of
service provision required, supported by an auditing programme to measure the standard
of cleanliness achieved. The audit is based on 50 scored elements that provide a
representative sample from which level of risk can be assessed.
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The current Trust Cleaning Policy does not reflect the adoption of PAS 5748:2011. The policy is being reviewed by the Facilities team and will be submitted to the IPCP in May 2016. Monitoring
Cleaning standards at WHHT are subject to formal and informal monitoring.
Formal Monitoring
By Medirest Quality Assurance Team. Medirest is bound within the contract to
provide internal quality assurance based on the agreed cleaning standards adopted
by the Trust. Under PAS 5748:2011 technical assurance audits are undertaken
weekly in all High risk areas, monthly in all Medium risk areas and quarterly / half-
yearly in Low risk areas. These audits are completed by the Medirest site
management teams and are discussed at the monthly performance review
meetings. Medirest also undertake an annual „external‟ company audit of
performance against cleaning standards. The results of this audit are presented to
the Trust.
By Trust Contract Monitoring Team. The Trust monitoring team conduct monthly
audits of all functional areas identified in the SLA. These audits are conducted in
accordance with the tjhe guidelines laid down in PAS 5748:2011, and result in a
PASS / FAIL score for each area. Results are presented at the monthly
performance review, circulated to Trust‟s senior nursing managers (including all
those with lead responsibility for a functional area), and presented at the bi-monthly
IPCP.
Informal Monitoring
Mock CQC Inspections. The Trust has a programme of „improvement‟ inspections
based on the mock-CQC inspection format. These visits assess, amongst other
things, cleaning standards, reporting back to Execs, and Director of Environment.
15 Steps / Exec Visits. A less formal programme of Exec-led visits includes
„cleaning standards‟ amongst the issues considered. Results reported back
through Execs.
Other. Monthly mock-PLACE visits are undertaken jointly by members of the
Facilities team and the Patients Panel. The visit focuses on the 5 PLACE domains,
including cleaning. A rolling PLACE action plan including issues identified on these
visits is maintained and managed by Facilities.
Action taken following failures The Trust, in conjunction with Medirest has put in place procedures to ensure that any „cleaning failures‟ encountered during the monitoring programme, or as a result of calls to the Environment Division Help desk or Medirest Help Desk, are acted on immediately. Areas that fail audits are re-audited within the audit period to confirm appropriate action has been taken. The areas that have failed are discussed at the IPCP with the Heads of nursing demonstrating what actions have been undertaken.
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8.2 Deep Clean Programme The Trust Cleaning Policy states that deep clean will be conducted throughout in-patient
clinical areas on a rolling 3 month programme. Where possible the Sterinis disinfection
process should be undertaken concurrent with the deep clean. Clinical areas make an
effort to make their areas available in accordance with the programme, where this not
possible alternative dates within the 3 month window should be agreed.
Operational pressures in the Trust has meant the programme has been conducted on a
bay-by-bay, room-by-room basis; and rarely with the opportunity to use the Sterinis
machine except in side rooms. As a result, as of mid-November 2015 almost 30% of
clinical areas are overdue a deep clean by at least one month, with almost 10% overdue
by 3 months. The Sterinis machine has only been used on about 30% of the areas in the
last 12 months. The associated Risk has been included on the Risk Register.
8.3 Audits: Table 6 Audits undertaken April 2015 - March 2016
Apr Mar
Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
HII8 44
5
50
21
49
35
44
18
47
12
48
16
16 page Environm
0
10
3
0
1
1
2
1
1
1
1
0
Hand Hygiene by IPCT
0
5
5
17
13
30
1
17
2
5
5
10
No. of Wards/De
pt audited
44
15
58
38
63
66
47
36
50
18
54
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Audit results are disseminated to departmental heads, infection prevention and control link persons and matrons for cascading within their clinical area. Actions to address area of unsatisfactory compliance are taken by the division. 8.4 Hand Hygiene Audits Compliance Effective hand hygiene remains the single most important intervention in the reduction of
HCAI. All inpatient and outpatient clinical areas are required to undertake monthly hand
hygiene audits. Compliance rates continue to be calculated, and individual tables for each
area within the divisions are produced by the IPCT. These are fed back direct to the
clinical leaders. The trust Hand hygiene compliance target is 95%. Compliance with hand
hygiene is monitored in the monthly IPCP meetings.
Areas of concern are visited by a member of the infection prevention and control nursing team. Repeated non-compliance is fed back to the relevant senior staff, the heads of nursing/midwifery include the work compliance in the divisional exception reports with action to complete.
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The Trust continues to participate in the yearly WHO international hand hygiene awareness day on the 5th of May with different activities undertaken by the IPCNs involving staff and members of the public.
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Figure 10 Hand Hygiene Audits - Overall Compliance per division April ’15 – March 16 The hand hygiene audit tool is based on the WHO`s “5 Moments of Hand Hygiene”. All auditors were trained in undertaking the hand hygiene audits to ensure that there are no variations.
Below is the hand hygiene compliance per division
80%
82%
84%
86%
88%
90%
92%
94%
96%
98%
100%
Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
Nurses 94% 90% 94% 92% 92% 96% 92% 97% 98% 96% 97% 97%
Doctors 90% 86% 87% 87% 89% 88% 88% 95% 94% 90% 96% 92%
Others 92% 88% 92% 91% 91% 94% 89% 96% 98% 96% 95% 98%
Hand Hygeine compliance-Staff Groups
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8.5 Training Activities Infection Prevention and Control training and education plays a key role in preventing
infections by making staff aware about infection control standards and requirements. It is
widely recognised that on-going education activity in Infection prevention and control is
required in order to improve healthcare worker compliance with infection prevention and
control practices.
Staff training has continued throughout the year, both formally and informally. The IPCNs
are involved in the mandatory and induction of all staff groups. Much of the education is
ad-hoc on a daily basis when IPCN‟s visit wards/departments and e-learning is also
available for bi-annual mandatory infection control training. The training data is included in
the figures in Table 5 below.
Table 5 Infection Prevention & Control Training compliance in WHHT The graph below shows the IPC training update from Apr 2015 – Mar 2016 In 2015/16 extra sessions were delivered with the aim to achieve the trust target of 95%. Compliance of the training is monitored via the monthly IPCP meetings, IPC Mandatory training currently is yearly, this sees staff falling out of compliancy quickly.
IPC Mandatory Training The IPCN‟s arranged additional IPC training sessions also known as „flexi sessions‟ in September, October, and November as it is recognised that the training and education of staff is the corner stone to the prevention & control of infection at the point of care. These extra sessions were not well attended by the divisions with the organisations‟ operational/capacity challenges having a significant impact on the ability of staff to undertake this.
70
80
90
100
Perc
en
tag
e o
f C
om
plian
ce
Apr-15
May-15
Jun-15
Jul-15Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Clinical 88 89 89 88 88 89 89 88 89 88 88 88
Trust Target 95 95 95 95 95 95 95 95 95 95 95 95
Non Clinical 80 81 82 81 81 80 80 79 81 80 81 80
IPC Mandatory Training Compliance
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Power Training Following the increased incidents of Clostridium difficile the IPCNs have undertaken power training where we visit clinical staff in their areas to deliver short and quick sessions lasting from 10 minutes to 20 minutes on sealing issues; various topics have been covered in Power training e.g. Clostridium difficile, MRSA and Norovirus.
There has also been a high uptake on the Power Training
During Q2 and Q3 the IPCNs also put in extra sessions to help support improve the training compliance.
The total amount of staff trained by the Infection, Prevention and Control team is: 3,910 for the year 2015-2016
One day IPC study days There have been 3 individual study days arranged and all have been very well attended and even oversubscribed. The main challenge in this organisation is finding suitable training facilities and the lack of availability has created issues in itself. However, the IPCT are intending to offer a comprehensive educational programme in the coming year commencing in April 2016. Support from the divisions is needed in order to ensure these are productive, successful and beneficial to both the attendees and the organisation in prevention and controlling the spread of infection. 8.6 IPC Promotional Activities 5th May 2015: WHO international hand hygiene day The trust observed the WHO international hand hygiene day on the 5th May 2015. There
was a stand at the main entrance of WGH. This was to ensure that the team engaged
members of the public and staff. There were also visits by the IPCNs to clinical areas to
raise awareness on the importance of hand hygiene to staff, patients and visitors. During
the visits the IPCNs encouraged patients to ask staff if they have washed their hands. The
IPCNs organised various competitions.
Some of the IPCN demonstrating the 5 moments of hand hygiene.
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Infection Prevention link practitioners: The IPCN invite representatives from all departments across the trust to the Infection Prevention Link Practitioners bimonthly meetings. These give an opportunity to discuss IPC matters, in relation to individual areas and trust wide, any new guidance. The expectation is that the link practitioners share the learning in their staff/team meetings within their areas or wards. To date the topics that have been discussed are:
Audits
Clostridium difficile Infection
MRSA care plans
MRSA screening and decolonisation
Decontamination of patient equipment
CPE and Screening
IPC Dashboard
Norovirus, MRSA , Clostridium difficile Infection and documentation
Dress Code and Infection Prevention and Control
Water Management and Flushing Infection Prevention and Control Awareness week IPC awareness week was held in the 3rd week of October 2015. A range of activities, various display stands. Various activities were under taken across the trust which included competitions, sluice room, linen room cleanliness, and best hand hygiene champion, with prizes which were presented by the DIPC.
MONDAY – Hand Hygiene Day, 5 MOMENTS here to stay
TUESDAY – DECONTAMINATION THEME
WEDNESDAY - I SPY SSI DAY
THURSDAY – Hip Hip Hurray the Theme is Products for the DAY
FRIDAY - ISOLATION DAY as the weekend comes our way!
The DIPC presented the Golden Commode Award to Langley and Ambulatory Care wards. Both wards had consistently scored 100% on their weekly commode audits ( in the last12 months) which are undertaken by the IPCT.
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Below are the winners of the Golden Commode Award:
IPCT continued to participate in international and national awareness activities.
9. POLICIES AND PROCEDURES The IPC team continued to review and revise the Trust‟s IPC policies during 2015-2016 in line with the review date. Policies reviewed this year were:
Hand hygiene
Isolation Policy
Management of Clostridium difficile
SARS
VRE
IPC policies are available on the Trust Intranet site. Compliance with these policies is monitored through audits, root cause analysis and surveillance. 10. FLU VACCINATION
The Flu campaign was launched on the 19th October 2015. The target set by the DH this year is 75% and the target set by the trust is 80%. 37.7% of staff has received the Flu vaccine which less than what we achieved in 2014/15 which was 79.6%. 10.1 Fit Mask Testing A programme has been facilitated to ensure compliance regarding Fit Testing (face masks
FFP3) across the Trust. Each department /area has nominated 2 or 3 members of staff to
attend a train the trainer session. They have completed 2 sessions to date with a further 4
planned for April 2016, this will enable approximately 70 members of staff to fit test staff
within own areas. All records of fit testing completed will be stored at local level and also
forwarded to the Health and Safety Department on a monthly basis. Any areas of non-
compliance will be escalated accordingly to the QSG.
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11 ANTIMICROBIAL STEWARDSHIP ACTIVITIES Antibiotic resistance is alarmingly increasing and our trust has implemented several measures to address this issue in line with published national recommendations and guidelines including The UK 5 year antimicrobial resistance strategy 2013-2018 and NICE guidelines for antimicrobial stewardship 2015. These activities are summarised as follows: 11.1 The trust Antimicrobial committee (AMC)
This committee is set up to provide a trust wide strategy to improve patient outcomes by promoting the safe and cost effective prescribing of antimicrobial agents. The committee is chaired by Lead microbiology consultant for antimicrobials and meets every two months.
The committee discuss matters related to Antimicrobial stewardship including audit reports, new guidelines and incidents and decide on actions taken forward to address non-compliance and incidents. This committee reports to Infection Control Panel and Medicines Use and Safety Panel (MUSP) 11.2 Local epidemiology surveillance programme This year marked the introduction of a local epidemiology surveillance programme. This programme was introduced to monitor the resistance pattern and prevalent organisms in different infection types. Knowledge of local resistance pattern supports the antimicrobial stewardship process. The programme will run on a yearly basis and an update will be feedback to prescribers and prescriber leads within the trust.
Introduction of a local epidemiology surveillance programme
11.3 Outpatient intravenous antimicrobial Therapy (OPAT) The trust runs an OPAT service successfully. This year we introduced some measures to improve and ensure safe provision of this service. This is a work in progress and will continue over the next years. These measures included the introduction of new guidance and virtual ward rounds where patients on OPAT are reviewed virtually by microbiology consultant on a weekly basis. An electronic OPAT database is underway for better monitoring of these patients and their outcomes. 11.4 Ward rounds Several ward rounds are running on a weekly basis to ensure effective use of antibiotics. This includes twice weekly Antimicrobial stewardship ward rounds, weekly orthopaedic rounds with the multidisciplinary orthopaedic team for both in patients and out-patients and regular clinical ward rounds 11.5 Audits These are carried out to monitor antibiotic consumption and compliance with Trust guidelines and with best practice based on Start Smart then Focus. The monthly antibiotic consumption audit reports are discussed in AMC and presented to the IPCP and MUSP, where any themes, areas of concerns are noted and taken forward, by the group and divisional representation at the meetings. Antimicrobial stewardship care bundles audits are carried out monthly in clinical areas. Any themes or areas of concerns are also feedback to the divisional management meeting every month.
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In addition to the above, this year, antimicrobial prophylaxis audits were carried out in gynaecology and obstetrics, Teicoplanin dosing audit, appropriateness of Piperacillin & Tazobactam usage audit and point prevalence survey on antimicrobials were undertaken and presented to all appropriate division and recommendations implemented. 11.6 Guidelines New guidelines were implemented this year including Teicoplanin dose banding and Sepsis treatment guidelines. Numerous other antimicrobial guidelines such as neutropenic sepsis, fungal and obstetrics & gynaecology guidelines were updated and implemented. We have also updated our microguide App to include renal dosing for antimicrobials to ensure safe prescribing of antibiotics in patients with impaired renal function.
We updated our microguide App to include renal dosing for antimicrobials to ensure safe prescribing of antibiotics in patients with impaired renal function.
11.7 Education A number of education sessions were delivered by the team to medical, nursing and
pharmacy staff. Education sessions include FY1 induction, FY2 and FY1 teaching session,
CMT teaching, Clinical Governance divisional meetings, Staff nurse development
programme and Grand rounds.
Numerous activities were undertaken by the microbiology, infection control and pharmacy
team to mark the EAAD and World Antibiotic Awareness Week in the Trust this year. 130
patients, 76 doctors, 135 nurses and 79 public were engaged in the various activities. The
team managed to get 34 antibiotic guardians signed up in this week. The team raised
antimicrobial awareness at the joint medicine and unscheduled care clinical governance
meeting which was attended by over 40 senior staff (consultants and senior nurses). A
teaching session was delivered on antimicrobial resistance to FY2 teaching session on the
18th November which was attended by 31 FY2 Trust doctors. The team also organised a
lunch time stand in the spice of life restaurant on the 18th November and had quizzes,
questionnaires and crosswords to raise awareness among staff and members of the
public. Over a hundred staff and public visited the stand. A level students from Watford
Grammar School visited the stand were they learned about antibiotic resistance from the
team. On the 20th November at the Grand Round local resistance data and antimicrobial
stewardship audit results were presented. The later part of the Grand round was devoted
to a very lively and entertaining quiz on “Weakest link in antimicrobial stewardship”. The
Grand round was attended by mainly medical and some pharmacists (80 attendees). The
medical team actively participated in the quiz. Certificate of achievement and gifts were
given to the top three winners. To end the week the team attended the Federation of
infection Societies Conference on 21st November in Glasgow on “Action on Resistance”
and presented 6 posters on Antimicrobial stewardship work.
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11.8 Laboratory diagnosis and antimicrobial stewardship Introduction of new technology to microbiology laboratory is an important aspect of
antimicrobial stewardship enabling the trust to make progress to implement actions
recommended in the UK 5 yr AMR strategy document. This year, our microbiology team
were successful at introducing a state-of-the-art technology (MALDI) which will provide
rapid identification of microorganisms from various samples, together with an automated
platform for antimicrobial susceptibility testing (Phenix). The acquisition of this technology
has significant impact on treatment of patients with Sepsis allowing earlier appropriate
antibiotic prescribing, antibiotic rationalisation and inform infection prevention control
decisions. This new technology is expected to go live early months of year 2016/17
12 EXTERNAL VISITS 12.1 CQC visit There was an announced inspection of all 3 WHHT hospital sits; Watford Hospital, St Albans Hospital and Hemel Hempstead Hospital between 14th and 17th April 2015 and on the 1st and 17th May at Watford General Hospital. The report was published in September 2015.There were no major IPC issues identified during the inspection.
12.2 NHS Trust Development Authority
We had several visits from the NHS Trust Development Authority (TDA) head of IPC on
the 29th and 30th July which was HCAI review visit for Watford site. Areas visited were ED,
AAU, Aldenham ward and theatres.
On the 9th October 2015: IPC Summit
An IPC Summit was held on the 9th October 2015, this involved the IPCT, Estates and
Facilities, divisional representation, the TDA and Herts Valley CCG. The summit focussed
on the trust`s compliance criterion 1, 2 and 4 of the Health and Social Care Act 2008
(2015). This was to give assurance to the trust board and the TDA that the trust has
systems in place to monitor the risks related to water safety, that the environment where
care is given is clean and appropriately maintained and also that the trust was providing
accurate information on infection risk. The issues discussed at the IPC summit have
already been covered earlier on in this paper.
The IPC summit paper was produced for the board and tabled on the QSG on 14th
December 2015.
On the 17th December 2015
The TDA head of IPC visited on the 17th December 2015 following the completion of the remedial works on SCBU. The CDI action plan, RCA trends, cleaning compliance and antibiotic prescribing, flu programme, was discussed. The extended team was commended for their hard work and improvement.
39
The extended team was commended for their hard work and improvement, see appendix 2 for the letter
12.3 NHS Improvement (Formerly TDA) Infection Prevention and Control 90 Day Collaborative Improvement Programme The WGH Theatres is the focus for the IPC improvement in collaboration with NHS Improvement. The aim is to improve IPC practices in Theatre 4 (General Surgery), with the focus to improve decontamination of equipment and environment and improve the waste flow by Sept 2016. Following on this will be rolled out to other theatres then trust wide. Future Priorities & Direction - 2016/17
IPC mandatory training will be available face to face and via e-learning.
IPCT will continue to provide IPC training for both induction and mandatory for all
disciplines of staff.
IPCT to maintain high visibility and engagement in the clinical areas.
Continue to raise awareness amongst staff regarding the importance of hand
decontamination in the prevention and control of infection in all educational
sessions and on routine visits to clinical areas
Continue to deliver the infection prevention and control single study days and six
day.
Participate in the 90 day IPC collaboration with NHS Improvement.
Improve support to Infection Prevention and Control Link Practitioners by
undertaking Code of Practice checklists in conjunction with them to improve
understanding of IPC in the clinical area, and to improve training on the use of the
infection prevention and control admission risk assessment.
Maintain a programme of audits to determine Trust compliance with key infection
control policies and procedure
To get an electronic IC software system; this will make the IC Surveillance more
proactive.
Continue to improve the newly introduced local epidemiology surveillance programme and relate the findings to the trust antibiotic guidelines in line with the national recommendations to ensure effective use of antibiotics.
Monitor antibiotic consumption
Continue to improve OPAT service to meet the national standards for OPAT.
Improve diagnostics and introducing new technology to microbiology laboratory including rapid molecular diagnosis of viral infections enabling better antimicrobial stewardship
Better use of IT technology for data collection and processing of antimicrobial stewardship and antimicrobial prescribing
13 RECOMMENDATION The Board is asked to: Take this report for information, assurance and approval for publication.
40
APPENDIX 1: IPCP TERMS OF REFERENCE
INFECTION PREVENTION & CONTROL PANEL TERMS OF REFERENCE
PURPOSE: The purpose of the Infection Prevention and Control Panel is to:
Strengthen the performance management of Health Care Associated Infections (HCAIs) and cleanliness across the whole of West Hertfordshire NHS Hospitals and to provide assurance to the Board of Directors that policy, process and operational delivery of infection prevention and control results in improved patient outcomes.
Making recommendations, as appropriate, on Infection and Prevention Control matters to the Board of Directors.
To assess and identify risks within the Infection and Prevention portfolio and escalate this as appropriate.
OBJECTIVES: West Hertfordshire Hospital NHS Trust is committed to Delivering Safe Clean Care by reducing the risk of harm to patients through pursuing a zero tolerance culture. The objectives of the Infection Prevention and Control Panel (IPCP) are:
To advise the Chief Executive and Trust Board on all aspects of infection prevention and control.
To provide assurance that the environment within the Trust is safe for patients, visitors and staff in terms of infection prevention and control.
To provide assurance that all appropriate measures are being taken to assist the Trust with achievement of national and local infection prevention and control targets.
To ensure corrective action has been initiated and managed where gaps are identified in relation to risks.
Agree and monitor the annual IPC work program The panel will receive reports on:
Mandatory surveillance figures
Occupational health
Water management
Decontamination
Cleaning monitoring
Building/Estates development
Audits undertaken and action plan progress
Incident reports and investigations DUTIES: In particular the Panel will provide assurance, raise concerns (if appropriate) and make recommendations to the Board of Directors in respect of : Infection Prevention and Control
41
The quarterly (Hygiene Code paper) Director of Infection Prevention and Control report to Trust Board.
Undertaking scrutiny and assurance on behalf of Trust Board in relation to infection prevention and control.
Monitoring exceptions in the infection prevention and control work plan.
Receiving information about national strategy and discuss how this will impact on the Trust and be operationalized.
Derive assurance that infection prevention and control strategy and performance is being delivered.
Formally review risks related to infection prevention and control and ensure risks are addressed and monitored and outcomes provide corporate assurance.
Monitor by exception Trust delivery plans to deliver targeted reduction and sustainable improvement of Health Care Associated Infections and cleanliness
Agree priorities for education and training of all grades and disciplines of staff to ensure reduction of Health Care Associated Infections
Review and monitor trust Health Care Associated Infections and compliance data IPC dashboard.
Review and monitor Trust performance against national and local targets and standards including MRSA blood stream infections and Clostridium difficile reduction.
Deliver a robust assurance programme that holds directorates to account and provide feedback to the Board of Directors.
To ensure that robust plans for the management of outbreaks of infection are in place and to monitor their effectiveness
MEMBERSHIP:
Chief Nurse/Director of Infection Prevention and Control (Chair)
Infection Prevention & Control Doctor (Deputy Chair)
Deputy Director of Nursing
Assistant Director Infection Prevention & Control/Infection Prevention and Control Nurse
Infection Prevention & Control Lead Nurse
Consultant Microbiologists
Occupational Health Manager
Clinical Champions (Doctors)
Heads of Nursing/Midwifery
Matron Representatives
Director of Estates & Facilities
Trust Decontamination Lead
Antimicrobial Pharmacist
Chief Pharmacist/Deputy
Patient & Public Panel Representative
Lead Nurse, Infection Prevention & Control – Herts Valley CCG
Head of operations
Senior Surgical Site Infection Prevention Nurse
Head of Information
Administrative support is provided by IPCNs PA
42
QUORUM:
The quorum necessary for the transaction of business shall be six members, one of which must be the DIPC or Deputy Chair/ICD. Infection Prevention & Control Nurse, and Divisional Representatives
RESPONSIBILITY OF MEMBERS AND ATTENDEES Members of the Panel have a responsibility to:
Attend at least 80% of meetings (or send appropriate representative) having read all papers beforehand;
Act as „champions‟, disseminating information and good practice as appropriate;
Identify agenda items, for consideration by the Chair, FREQUENCY Monthly AUTHORITY The Panel is authorised by the Board of Directors:
Monitor the compliance with The Health & Social Care Act, Code of Practice for the Prevention and Control of Health Care Associated Infections 2008 (2010) which outlines 10 compulsory duties to prevent and manage healthcare-associated infections
To investigate any activity within its terms of reference and produce an annual work program;
To approve or ratify (as appropriate) those policies and procedures for which it has responsibility
DECISION MAKING Wherever possible members of the Panel will seek to make decisions and recommendations based on consensus. REPORTING The Panel will have the following reporting responsibilities:
To ensure that the minutes of its meetings are formally recorded and submitted to the Board of Directors/Quality and Safety Group.
These minutes shall be accompanied by a summary prepared by the chair of the meeting outlining the key issues discussed at the meeting and those issues that need to be brought to the attention of the Board of Directors;
To produce those assurance and performance management reports listed in the IPC annual work programme which has been agreed with, and are required by, the Board of Directors including a quarterly DIPC report;
Any items of specific concern, or which require the Board of Directors approval, will be subject to a separate report;
To provide exception reports to the Board of Directors highlighting key developments / achievements or potential issues;
To produce an annual report for the Board of Directors setting out:
43
a. The role and the main responsibilities of the Panel
b. Membership of the Panel
c. Number of meetings and attendance
d. A description of the main activities during the year and the identification of any development needs for the Panel
REPORTING GROUPS
Local HCAI Meeting
Water Safety Group
Antibiotic Committee
SSIPP
Sepsis bundle work stream
The groups identified above will be required to submit the following information to the Panel:
Their terms of reference for formal approval and review;
The minutes of their meetings, together with a summary prepared by the Chair of that group outlining the key issues discussed at the meeting and those issues that need to be brought to the attention of this Panel;
Any report or briefing requested by this Panel. REVIEW: Terms of Reference will normally be reviewed annually Date Approved and issued Version Number: Version 1.0 Next Review: May 2016 To be reviewed by: Infection Prevention & Control Panel
44
APPENDIX 2: TDA LETTER TO THE DIPC SENT VIA EMAIL Tracey Carter Chief Nurse and Director of Infection Prevention and Control Trust Headquarters Watford General Hospital Vicarage Road Watford Hertfordshire WD18 0HB 23rd December 2015 Dear Tracey HCAI review: Remedial work SCBU Watford General Hospital Influenza Vaccination Uptake Progress against the CDI plan
Thank you to you and your team for arranging the meeting on the 17th December. We met
briefly to discuss the progress on the works undertaken and took the opportunity to
discuss the influenza vaccination programme within the Trust.
I met with Nyarayi Mukombe to discuss the progress against the CDI plan and we
discussed the trends from the RCA, including cleaning compliance and antibiotic
prescribing.
We did a walkabout of the unit which is so much better and the staffs working on the unit
are delighted with the refurbishment. The water flow is really good and now hot. The two
side rooms were open and being used.
There is just one seminar room outstanding to be completed and I suggested the ward
manager obtains a date for this to be completed rather than plastic sheeting across the
door.
The Legionella tests are awaited and Nyarayi will forward these on once they are
available.
The estates department have done this really well within the short timescale they planned.
I met with the Occupation Health Nurse lead to discuss the low uptake of vaccine within
the Trust, and why things have not gone as well as planned. She informed me they are
now undertaking a final push. I have received the response today from you relating to the
actions currently being undertaken, thank you.
In relation to CDI the Trust currently stand at 22 with an annual trajectory of 23. Nyarayi
demonstrated the newsletter on CDI to be distributed to all ward areas and the team are
supporting the clinical areas with short power training sessions of 20 minutes which is to
be commended. I was pleased to hear that the team had been awarded Team of the
Month for their input to the wards
We also discussed the annual IPC awards and shared photographs of the ceremony
which has gone a long way to raising morale with the front line staff. Despite the CDI
performance the Trust is undertaking so really good practice in relation to IPC.
Well done to all the extended team for their hard work and really impressive improvement.
45
I will review the CDI progress in January and perhaps we can book a call to review any
actions taken
Yours sincerely Gaynor Evans Head of Infection Prevention and Control (North)
46
APPENDIX 3: TRUST COMPLIANCE WITH THE CODE OF PRACTICE:
Infection Prevention & Control Annual Plan 2015-2016 (updated following revised Code) To comply with the Health and Social Care Act 2008 (updated 2015)
The purpose of the Infection Prevention & Control (IPC) annual plan is to set out the activities the organisation needs to do to ensure that safe quality care is provided. It will also provide assurance to the board that the programme of work if delivered will minimise any risks. The proposed activities of the IPC team, which will ensure that the service meets the statutory requirements. This programme is based around compliance with:
The Health and Social Care Act 2008 (updated 2015) – Code of Practice on the prevention and control of infections and related guidance also known as The Code.
The Hygiene Code is underpinned by ten compliance criteria, the programme of work is mapped to the compliance criteria, which will ensure that the Trust continues to maintain and strengthen its compliance. The annual plan is signed off by the Quality and Safety Group. Monitoring delivery of the program Progress against the programme will be monitored by the Infection Prevention and Control Panel (IPCP). Key:
GREEN (G) 100% Full compliance
AMBER (A) 71% - 99%
Action required
BROWN (B) 50% - 70%
Urgent action required
RED (R) =< 49%
Trust priority
47
Issue / Problem Progress/Assurance Lead Timeline RAG Progress/Assurance
Rating
Q1, Q2,Q£ and Q4
The Board will monitor the Trust compliance with the Health and Social Care Act
2008.
The TLEC, Quality and Safety Group (QSG) and Infection Prevention and Control Panel (IPCP) will receive the Annual IPC Report. 2014/2015
DIPC October
2015 G Completed
The Board will receive Infection Prevention & Control (IPC) updates and any key issues
Instant reporting of any emerging Healthcare Associated issues
MRSA BSI annual trajectory is 0
Clostridium difficile infection (CDI) annual trajectory is 23
DIPC Monthly G
Quality Safety Report
Monthly Assurance Board Report (IPR)
The Board will receive information relating to assurance on compliance with the Code of Practice, CQC outcome 8 and key indicator targets via the Quality and safety group and challenge concerns in relation to compliance via the DIPC`s Hygiene Code Paper
DIPC
6 monthly
G
Report discussed at the IPCP in November 2015, submitted to the QSG in
January 2016
Divisional objectives
All divisions to ensure that the
reduction of healthcare associated
infections is a priority.
Each Division will table clinical issues and exception reports for the Quality and Safety group actions to the IPCP
IPC leads/ HoN/ HoM
Monthly G
Each Division has submitted their exception reports and action plans monthly and bi monthly from August 2015.
All staff attend Trust induction and mandatory update sessions
Trust target for mandatory training is 95% IPC/
HoN/HoM Monthly B
Trust IPC training compliance
Averaging 81% to 89% The trust is not
achieving the 95% target agreed with the CCG. Extra sessions
48
delivered and monitoring through divisional reports at
Quality & Safety Group and divisional
performance reviews.
Lessons from IC SIs/outbreaks are reviewed monthly, reported to the IPCP and Quality and safety group and acted upon.
HoN/HoM Monthly G Exception reports to
IPCP submitted by the divisions
All High Impact interventions inc hand hygiene scoring less than 95% with formulate an action plan with evidence of actions taken and returned to IP&C Team, this which will be discussed at the Divisional Governance meetings
Ward/Dept Manager/ Hon/HoM
Monthly G
Completed action plans sent to IPCT. IPCT has
undertaken support audits to areas with
unsatisfactory compliance.
Any member of staff persistently not complying to hand hygiene policy or high impact intervention will be named on audits for review and escalation as required
Ward/Dept Manager/ HoN/HoM
Monthly G Captured in the exception reports and discussed at
the IPCP meetings
Participate in the Test Your Care (TYC) audits HoN/HoM Monthly G
All areas participating TYC Inpatient areas audited
Isolate patient with an infection e.g diarrhoea within two hours (DH) to reduce the risk of cross infection
Matron/ward manager
Ongoing
/monthly A
Monthly reports
Averaging 80%
For all new equipment to be purchased cleaning instruction for the equipment should be obtained from the manufacturer and these submitted to IPCT for approval before a purchase is agreed.
Hon/HoM Matron
As required
G
These are assessed by the IPCNs to ensure the equipment can be adequately decontaminated.
Patient equipment e.g Commodes, BP cuffs must be
cleaned in between each patient use
Ward/Dept Manager/
As required G
Captured in the monthly HII8 audits and weekly
49
Matron commode audits.
Bed space & equipment checklist verified through test your care audits
Patient isolated in side room for infection control reasons should have dedicated equipment for use e.g disposable BP cuffs, hoist slings.
Ward/Dept Manager/
Matron
As required
G Monitored via the HII8
Audits
Equipment decontamination /cleaning schedules that specifies cleaning standards for equipment such as commodes, BP cuffs are in place
Ward/Dept Manager/
Matron
Monthly /Ongoing G Test your care audits
6 monthly environmental audits to ensure that all ward areas are well maintained and appropriately managed to reduce the risk of infection (April/May and Oct/Nov)
Ward/Dept Manager/
Matron
6 monthly (April/May
and Oct/Nov)
G
All areas Undertook audits
Refurbishment program to be developed by each ward and in conjunction with estates
HoN/Head of estates
As required
G All divisions have
submitted list of work to the Estates team.
Divisions take ownership of RCA and are completed in a timely manner (within 14 days).
HoN As required
A
Monitored via the LHCAI meetings from July via the monthly
divisional governance meetings
Duty 1 and 2
Estates and Facilities; Operational
Assure quality of environmental cleanliness/ audit of the clinical areas
All areas should have a schedule of cleaning responsibilities, and frequency include an SLA
Head of Facility
Monthly On going
G
Cleaning monitoring officers undertake the audits
Monitored via monthly IPCP, from July
50
(meetings are now Bi monthly)
Ensure deep cleans are carried out as per schedule (every quarter and any estates work is carried out prior to the deep clean
Heads of Facilities &
Estates
As per Deep clean programme
B
The deep clean program is behind: A
paper was taken to the January IPCP then
QSG. This is on the risk register
Annual PLACE inspection
Head of Facilities
Yearly G
National PLACE audit May 2015
Mock PLACE are in place monthly.
Involve Infection Prevention and Control in all building works (from planning to finish of the building works)
Director of Estates
As required G
Involved in the Endoscopy, SCBU,
Theatres; Estates need to send the IPCT the
trust wide programme for all works.
Minutes and papers from the Water Safety Group meetings to be tabled at the IPCP
Water safety issues escalated to the Board via IPCP
Head of Engineering
Monthly G
All Monthly minutes have been tabled at the IPCP & issues escalated to the Quality and Safety group via IPCP; IPC summit paper, NNU Water Safety paper
Review Trust water safety plan Water
safety Group
September 2015
G
Water safety policy is in place and in date
Water Safety Plan went to January IPCP for ratification
51
Infection Prevention & Control Team Plan
Issue / Problem Actions Lead Timeline RAG Progress/Assurance
Q1, Q2,Q3 and Q4
1.
1.
Sy
ste
ms
to
ma
nag
e a
nd
mo
nit
or
the
pre
ven
tio
n a
nd
co
ntr
ol
of
infe
cti
on
. T
he
se
sy
ste
ms
use
ris
k a
sse
ssm
en
ts a
nd
co
ns
ide
r
ho
w s
usce
pti
bil
ity o
f s
erv
ice
us
ers
an
d a
ny r
isk
s t
hat
the
ir
en
vir
on
me
nt
an
d o
the
r u
se
rs m
ay
po
se
to
th
em
.
The IPCP will receive monthly information on:
Mandatory surveillance (MSSA, MRSA & E coli bacteraemia and CDI)
Audits
IPC Training compliance
Progress on action plans
Outbreaks & Incidents
Surveillance of other HCAIs
New publication relating to IPC/Microbiology ADIPC ICD
Monthly/ on going
G
Mandatory surveillance figures discussed at all IPCP meetings Enhanced surveillance of Carbapenemase producing- negative bacteria Briefing note on mycobacterium infections associated with heater cooler units. CDI increased incidents, May, June (action plan in place) Updated Health and Social care Act 2008 (2015) TB incidents MERS PHE, Legionella risk assessment
Provide reactive service to meet needs of incidents/enquiries/outbreaks
ADIPC As required G
Tuberculosis incidents Croxley MRSA (Colonisation ) outbreak August 2015 High legionella counts on SCBU October 2015
Work proactively with multi-disciplinary staff and departments to reduce risk of HCAI attend
ADIPC/Lead Nurse/ICD
Monthly G Q1 LHCAI meeting attendance
52
Divisional Governance meetings Q2 , Q3 and Q4 IPCT attended the Divisional Governance meetings
Work collaboratively with Clinical Commission Group, Trust Development Authority & the Hertfordshire HCAI reduction group
ADIPC Monthly /as required
G
Q1, Q2, &Q3 the ICD & ADIPC attended the monthly HCAI reduction group & bi monthly Herts Whole Economy ICC Group
Infection Surveillance software
ADIPC/CGI January 2016
A
Not compliant; Business case is being progressed, currently using the paper system.
Collate and submit alert organisms as directed by
the Public Health England onto the data capture
system. ADIPC Monthly G
Monthly submission in the PHE DCS, completed for Q1,Q2, Q3 & Q4
Work collaboratively with Operations teams,
matrons and ward managers:
review of side rooms
Appropriate placement of patients with a known or a
possible infection Lead Nurse IPC
As required G
IPCNs continue to review side rooms to ensure appropriate placement of patients by the operations team. Failure to isolate patients with 2 hours is datixed Monthly isolation report is produced by the IPCT for the clinical areas.
Issue / Problem Actions Lead Timeline
RAG
Progress/Assurance
53
2.
Pro
vid
e a
nd
ma
inta
in a
cle
an
an
d a
pp
rop
ria
te e
nvir
on
me
nt
in
ma
nag
ed
pre
mis
es
th
at
fac
ilit
ate
s t
he
pre
ve
nti
on
an
d c
on
tro
l o
f
infe
cti
on
s.
Audits by the Infection Prevention and Control nurses: Decontamination of patient equipment
(HII8) Personal Protective Equipment Management of Linen Isolation Precautions Management of sharps Test your care audits
Lead Nurse
As per audit schedule
G
Monthly test your care peer audits Monthly Decontamination of patient equipment (HII8) have been undertaken for Q1 , Q2, Q3 and Q4
Audit availability of hand hygiene facilities in the trust ADIPC
December 2015/January 2016
A Audit not completed; These will be audited in Q3.
Also refer to the estates & divisional action
Issue / Problem Actions Lead Timeline RAG Progress/Assurance
Q1, Q2,Q3 and Q4
54
3.
En
su
re a
pp
rop
ria
te a
nti
mic
rob
ial
us
e t
o o
pti
mis
e p
ati
en
t o
utc
om
es
an
d t
o r
ed
uce
th
e r
isk
of
ad
vers
e e
ve
nts
an
d a
nti
mic
rob
ial
res
ista
nc
e Educational sessions to Junior doctors, nursing
staff, pharmacy staff and other prescribers.
Regular feedback of audit data to various Divisional and governance meetings.
Public engagement activities e.g European Antibiotic Awareness day
Antimicrobial management team consisting of Microbiologists and antimicrobial pharmacist/Ward pharmacists
Antimicrobial Committee chaired by Consultant Microbiologist reporting to Drugs and therapeutics Committee and Infection Prevention Control Panel
(In progress) a mandatory training module on antimicrobial prescribing.
Evidence based guidelines on Trust intranet and App
Antimicrobial datix incidents reported on monthly antibiotic report and trends monitored and discuss at governance meeting as appropriate
Monitoring broad spectrum antimicrobial consumption monthly (Antibiotic report)
Antimicrobial stewardship strategy-updated annually
Antimicrobial stewardship audits
Surveillance of local resistance (microbiology)
Weekly antimicrobial stewardship rounds and C-diff rounds
OPAT pathways on antimicrobials
Weekly MDT –orthopaedics
Daily antimicrobial rounds on intensive care
Antimicrobial Pharmacist & Consultant Microbiologist
G
European Antibiotic Awareness day monthly antibiotic report and trends monitored and discuss at governance meeting as appropriate Weekly antimicrobial stewardship rounds and C-diff rounds Daily antimicrobial rounds on intensive care
Issue / Problem Actions Lead Timeline Progress/Assurance
Q1, Q2,Q3 and Q4
55
4.
Pro
vid
e s
uit
ab
le a
cc
ura
te
info
rma
tio
n o
n in
fec
tio
ns t
o
se
rvic
e u
se
rs, th
eir
vis
ito
rs a
nd
an
y p
ers
on
co
nce
rne
d w
ith
pro
vid
ing
fu
rth
er
su
pp
ort
or
nu
rsin
g/m
ed
ica
l c
are
in
a t
ime
ly f
as
hio
n
Maintain information leaflets for patients and visitors
Ensure all patient and public information leaflets are current and available on the Trust website
Lead Nurse IPC
As required
G Current leaf lets are in date.
Maintain information leaflets for contractors/volunteers/bank & locum staff
ADIPC January 2016
R Under review, to be completed by end of June 2016.
Participate in international Hand Hygiene Awareness Day.
Activities that include patients, visitors and staff – display stands
IPC Team May 2015 G
Activities that include patients, visitors and staff – display stands, competitions
Participate in international Infection Prevention and Control Week
Activities that include patients, visitors and staff – display stands
IPC Team October 2015
G
Display stands in the staff canteen, visits to clinical areas, talks with patients , staff and members of the public. Various competitions
Maintain up to date polices and guidelines for Infection Prevention on the Trust intranet.
ADIPC As required
A
Hand Hygiene
Policy
MRSA Policy
Isolation Policy
VRE
SARS; reviewed;
VHF and TB policy
under review
Staff information leaflets to be available
ADIPC/ Lead IP&C Nurse
As required
G Current leaflets are
in date.
56
Inform G.P. if patients are discharged before MRSA results are known and new MRSA
Lead IP&C Nurse
As required /daily
G IPCNS have continued to
send MRSA GP letters
Inform G.P of admitted patients indentified to have Clostridium difficile Lead IP&C
Nurse
As required /daily
G
IPCNS have continued to send Clostridium difficile GP letters
Flagging on Patient Administration System/ICE
information system for appropriate management.
Continue inserting information stickers for alert
organisms in the health records of patients.
IPCT As required/ daily
G
July August and September
2015,Alerts put in place for CPE
contacts following
identification of a CPE patient on various wards.
IPCT As required/ daily
G
IPCNs have continued to visit wards were patients have an alert organism to ensure appropriate
management and placement, this is also
documented in the patient’s notes/Kardex
Raise awareness on current IPC issues within the
Trust;
“Top Tips” IPCN news letter IPCT Bi Monthly G
Hand hygiene MRSA decolonisation
protocol Clostridium difficile
Infection
Issue / Problem Actions Lead Timeline Progress/Assurance
Q1 , Q2 ,Q3 and Q4
57
5.
En
su
re p
rom
pt
iden
tifi
ca
tio
n o
f p
eo
ple
wh
o h
av
e o
r
are
at
ris
k o
f d
ev
elo
pin
g a
n in
fec
tio
n s
o t
hat
they
rec
eiv
e t
ime
ly a
nd
ap
pro
pri
ate
tre
atm
en
t to
re
du
ce
the
ris
k o
f tr
an
sm
itti
ng
in
fec
tio
n t
o o
the
r p
eo
ple
.
All patient `s microbiological results are managed as a priority within the IP&C team.
Lead Nurse IPC
As required/ daily
G
Patients are visited on the wards and ward staff liaised with ensuring that staff understand and are
aware of the correct infection prevention &
control measures required for that
particular organism
Ensure timescales for RCA/PIRs reporting are met and corrective actions/learning shared across Divisions through Clinical governance meetings
IPCT/HoN As required/ monthly
A
RCA actions followed up in the LHCAI meeting and Divisional Governance meetings, timescale for completion are partially achieved.
Appropriate use of detection, management and isolation of diarrhoea flow chart for timely isolation of affected patients. IPCT/HoN
As required /daily
A
Isolation report, Failure to isolate within 2 hours
is datixed. Lack of adequate side room is on
the risk register.
Audit MRSA and Clostridium difficile care pathways and feedback results to clinical areas, HoN/HoM and IPCP
Lead Nurse/ ADIPC
Monthly G Done monthly though
Test your care
Mandatory update to includes outbreak management and isolation
Lead Nurse As required /daily
G
Mandatory update to includes outbreak management and
isolation included in the IPC Mandatory update
Inform bed management /ED staff of any outbreaks (e.g of Norovirus or any other infection) in local care home and NHS Trusts; Circulate report from SMH PHE
ADIPC/ Lead Nurse
As required /daily
G
Alerts from PHE were sent out to key staff, Bed
managers/operation team, HoN, ED and on
call managers
58
Issue / Problem Actions Lead Timeline Progress/Assurance
Q1, Q2,Q3 and Q4
6.
Sys
tem
s t
o e
nsu
re t
hat
all
ca
re w
ork
ers
(in
clu
din
g
co
ntr
ac
tors
an
d v
olu
nte
ers
) are
aw
are
of
an
d d
isc
ha
rge
th
eir
res
po
nsib
ilit
ies i
n t
he
pro
ces
s o
f p
rev
en
tin
g a
nd
co
ntr
oll
ing
infe
cti
on
. Review and update IPC Training schedule for all
Trust employees including contractors and volunteers : Mandatory, Induction; Ad hoc related to DH & local initiatives
Lead Nurse
April 2015 Annually and as required
G
Mandatory, Induction; Ad hoc related to DH & local initiatives training
slides have been reviewed and up to date with current guidance.
Review formal training on peripheral line insertion, CV/aseptic technique, ongoing management to be included in Education /training review; (Peripheral IV study day, Central IV study day, Venepuncture and Cannulation)
PDN
As required when new updates are published
G As required when new updates are published
Link Practitioner Educational meetings – maintaining records of attendance
Lead Nurse Bi- monthly G
Various topics discussed at the meetings: CDI;
MRSA,, CPE, Documentation
Infection Prevention is included in all Job descriptions (JD) and all new staff should attend Trust Induction (IPC is included in trust Induction for new staff.
Human Resources
As required G IPC is included in all new staff JD.
Issue / Problem Actions Lead Timeline Progress/Assurance
Q1, Q2,Q3 and Q4
7.
Pro
vid
e o
r
se
cu
re
ad
eq
ua
te
iso
lati
o
n
fac
ilit
ie
s
Ensure adequate isolation precautions and facilities as appropriate to prevent or minimise the spread of infections
IPCNs As required /daily
G
IPCNs review side room as required to ensure
appropriate placement of patients.
59
Ongoing review of capacity within isolation ward to meet clinical need.
Isolation Policy is audited by the IPCT annually
ADIPC/ Lead Nurse IP&C
January 2016
G
Due to be audited in January 2016; Policy was
reviewed, awaits ratification
Audit side room availability including rooms with both negative & positive ventilation
ADIPC/ Lead Nurse IP&C
As required A
The IPCT will provide advice and support on the
management of infectious patients during an
increased incidence of infection or outbreak to
contribute in the management of appropriate usage
of the side rooms.
ADIPC/Lead Nurse
As required/ daily
G Croxley MRSA outbreak,
TB incident
Issue / Problem Actions Lead Timeline Progress/Assurance
Q1, Q2, Q3 and Q4
8.
Sec
ure
ad
eq
ua
te a
cce
ss
to l
ab
ora
tory
su
pp
ort
as
ap
pro
pri
ate
Ensure the microbiology laboratory has appropriate protocols and standard operating procedures as required for accreditation by Clinical Pathology Accreditation (UK) Ltd.
ICD/ Consultant Microbiologist
As required G In Place
Issue / Problem Actions Lead Timeline Progress/Assurance
Q1, Q2,Q3 and Q4
9.
Hav
e
an
d
ad
her
e t
o
po
lic
i
es
,
des
ig
ned
for
the
ind
ivi
du
al’
s
ca
re
an
d
pro
vi
der
org
an
isa
tio
ns,
tha
t
wil
l
help
to
pre
ve
nt
an
d
co
ntr
ol
infe
ct
ion
s.
Com
p
lian
ce
with
ke
y
po
licie
s is
en
su
r
ed
thro
ug
h t
he
imp
le
me
nta
tio
n o
f
hig
h
imp
ac
t inte
rv
en
tion
s a
nd
mo
nit
ore
d
thro
ug
h
au
dit. Policies are updated with review dates and clearly marked up where they link to other policies both on the actual policy.
New policies/guidelines:
60
o Building and Renovation in hospital (NEW) ADIPC
February 2016
A Deferred to May 2016
o Purchase, trial and loan equipment (NEW) ADIPC
March 2016
A Deferred to May 2016
Issue / Problem Actions Lead Timeline Progress/Assurance
Q1, Q2 , Q3and Q4
10
. P
rov
ide
rs h
av
e a
sy
ste
m i
n
pla
ce
to
ma
nag
e t
he
occ
up
ati
on
al
he
alt
h n
ee
ds a
nd
ob
lig
ati
on
s o
f s
taff
in
re
lati
on
to i
nfe
cti
on
.
Annual Gap analysis of training needs for staff
Lead Nurse IPC
April 2015 Annually
G Completed
Review Annual training programme for all staff
including contractors, locums, volunteers, bank &
agency.
ADIPC/ Lead Nurse IPC
April 2015 G Completed
61
Related Occupational Health policies/procedures are in date:
management of occupational exposure to infection
a risk assessment and appropriate referral after
accidental occupational exposure to blood and body
fluids
having arrangements for identifying and managing
healthcare staff infected with hepatitis B or C or HIV
and advising about fitness for work and monitoring
as necessary
Occupational Health Manager/ Health and Safety Manager
As required G
Education on management of needle injuries. Policy for managing blood borne viruses for staff is in place and in date. Needle sticks injury reports taken to the Health and safety committee. These reports to be tabled at the IPCP as well.
Arrangements in place for regularly reviewing the immunisation status of care workers and providing vaccinations to staff as necessary in line with Immunisation against infectious disease („The Green Book‟)
Occupational Health Manager
On Going B
Not compliant: Mitigation, Immunisation status / vaccination history is recorded in staff member occupational health records. The risk number is 3046 Risk score is 12
Flu campaign and vaccination of Health Care Worker
Occupational Health Manager
October 2015
B To date 37.7% received the Flu vaccine;
62
APPENDIX 4: REDUCTION OF CLOSTRIDIUM DIFFICILE ACTION PLAN
WEST HERTFORDSHIRE HOSPITALS NHS TRUST – REDUCTION OF CLOSTRIDIUM DIFFICILE ACTION PLAN following Period of increased incident of CDI in May and June 2015.
Updated November 2015 This action plan is intended to:
Assist all clinical areas to focus on patients with diarrhoea and to assess their risk of Clostridium difficile.
Ensure all ward staff are familiar with Trust policy and action required for all patients with diarrhoea
PRIORITY ISSUE TO BE ADDRESED
ACTION REQUIRED TO ENABLE DELIVERY DATE
RESPONSIBLE OWNER
RAG PROGRESS UPDATE
Monitor of actions from the Root Cause Analysis (RCA) Leadership and clinical engagement in the process
IPCT to attend Divisional Clinical Governance meetings
July 2015 Tracey Carter DIPC
G
As from July 2015 the IPCT are now attending
the Divisional Governance meetings.
Reconvene LHCAI meetings to monitor actions from RCAs
30 November 2015
ADIPC G
This has now been implemented.
Ensure timescales for RCA reporting are met (14 days )
Immediate /ongoing
HoN/HoM
A
Currently not being achieved mainly by medicine division, the IPCNs are supporting.
Corrective actions/learning shared across Divisions
The medical division will share key learning points at their clinical governance from all the RCAs
August 2015 HoN/IPCT
G
Thematic review of the Q1 cases, these have been discussed at the Medicine Divisional Governance meeting.
End March 2016
HoN/IPCT
A Thematic review of all CDI cases, in progress , delay
63
incompletion of the RCA forms.
Surgery division to share key learning points at their clinical governance from all the RCAs
September 2015
HoN/IPCT
G
Thematic review of the Q1 cases, these have been discussed at the Surgery Divisional Governance meeting.
End March 2016
HoN/IPCT
A
Thematic review of all CDI cases, in progress, delay incompletion of the RCA forms.
Improve compliance to trust guideline for antimicrobial prescribing
Implement weekly review of CDI cases (in patients) on ward
August 2015
Antimicrobial pharmacist, IPCNs and Microbiologist
G
This has been implemented, with weekly rounds by the IPCT
Audit antimicrobial care bundle in clinical areas
Monthly Antimicrobial pharmacist
G Q1 Surgical wards done
Continue with antimicrobial stewardship rounds Raising awareness of prescribers for high risk antimicrobials
End March 2016
Antimicrobial pharmacist, and Microbiologist
G
Weekly, in place
Daily review of antibiotics on ward rounds by doctors
In Place
Clinical Directors Medical teams
G
Undertaken by medical teams, Compliance audits
undertaken by the antimicrobial pharmacist.
C-diff RCA analysis and on-going antimicrobial stewardship for FY1 and FY2
July and August 2015
Antimicrobial Pharmacist
G Completed Session delivered by antimicrobial pharmacist.
Reviewing the antimicrobial guidelines and introduce new
March 2016 Consultant Microbiologist
A
Guidelines completed. Use
64
guidelines for care of elderly of Temocillin not supported by Antibiotic Committee due to cost implication. (substituting tazocin with Temocillin lower risk for CDI but more expensive)
Use of proton pump inhibitors (PPI)
Reviewed daily by the medical team and stopped if possible as per Trust guidelines
In Place Clinical Directors Medical teams
G
PPI usage and Care bundle audits (PPI continued) reported in the monthly antibiotic report discussed at the bi monthly IPCP
Improve management of antigen positive patients
All antigen positive results will be flagged on the ICE system ( so that clinical team is aware of the need to discuss antibiotics with microbiology consultant if needed during current or subsequent admissions)
18 December 2015
Consultant Microbiologist/IPCN
G
Completed, All Antigen positives are reported on
ICE
Timely isolation of patients admitted with diarrhoea
Launch of Risk assessment booklet across the trust
August 2015 Quality Lead nurse
G
New documentation implemented. Audit of use of the IPC section was 64% for WGH. Plan to re-educate staff and re audit in June 2016, IPC section by IPCNs
65
Training and education to raise more awareness of CDI and its management
Targeted training (Power training) in clinical areas on Isolation, hand hygiene, decontamination of medical equipment, PPE, specimen labelling and sending them in timely manner
Immediate/ on going Review end of January 2016
ADIPC
G
For staff that are on permanent night duty, a Power training pack is available on the ward.
Support Hand hygiene audits on wards with a new WHHT apportioned C.diff
Immediate/on going
ADIPC
G
Compliance monitored via the IPCP On going until a target of >95% compliance is reached for 3 consecutive weeks
Continue with monthly audits for the decontamination of medical equipment (high impact intervention no.8)
Monthly ADIPC
G
Compliance monitored via the IPCP
Additional support audits for decontamination of medical equipment (HII No 8) on wards with a new WHHT apportioned C.diff
Immediate/on going
ADIPC
G
Compliance monitored via the IPCP On going until a target of >95% compliance is reached for 3 consecutive weeks
The June IPC newsletter issue of the monthly „Top Tips focuses on Clostridium difficile.
June 2015 ADIPC
G
Circulated to the Matrons, HoN, ward managers and IPC Link practitioners.
December IPC newsletter „Top Tips to focuses on Clostridium difficile.
December 2015
ADIPC
G
Circulated to the Matrons, HoN, ward managers and IPC Link practitioners.
66
Grand round to discuss CDT testing and guidelines
November 2015
Antimicrobial pharmacist, and Microbiologist
G
Completed Grand round in December discussed CDT testing and guidelines by Dr Kandil
Update to all staff and volunteers on our CDI cases and plans for improvement
Share themes identified from 2014/15 and Q1 CDI cases and prevention
July 2015 DIPC
G
E update sent to all staff and volunteers in July
2015
Inadequately cleaned commodes/toilet can be a source of cross infection
Nursing staff must clean commodes in between patient use; tag, date and sign them. Letter of concern is issued to staff that are non-compliant Toilets to be cleaned at least x2 daily & in addition upon request of ward staff. Cleaning sheets to be signed when facility cleaned/checked
In Place
HoN/HoM Medirest
G
Compliance monitored IPCP Compliance monitored by ward staff
Medical equipment can be a source of contamination and cause cross infection between patients
Continued emphases on the importance of dedicated patient equipment in side rooms to limit the potential risk of transmission of infection.
Immediate/on going
IPCT/HoN/HoM
G
Compliance audited by IPCN bi monthly through the HII8 audit
The nurse in charge to be sure that all discharged patients have their mattresses cleaned, checked
In Place HoN/HoM
G
This is audited through test your care in the 24 in patient areas and paediatrics
67
Standards of ward cleaning are paramount (assurance of quality of cleanliness)
Nurse in charge to check at the beginning of the early shift if this has taken place (daily quality ward checks )
Immediate/on going
HoN/HoM
A
Different daily quality checks have been developed for ward sisters
Monthly ward quality checks by matrons
Review end of March 2016
HoN/HoM
G
Monthly quality checks for matrons plan were revised,
Deep clean program to clinical areas
Review end of January 2016
Facilities Head of Compliance & Contracts A
Rolling programme is in place, challenges due to be capacity; 30% of areas are overdue a deep clean by at least 1 month. This in on the trust risk register
Wards become cluttered with patients belongings and the cleaners cannot do their job properly
Every shift the nurse in charge to allocate a member of staff to walk the ward and declutter.
In Place Ward manager
G
Test your care audits in the 24 in patient areas
Operational capacity issues affecting isolation of patients with diarrhoea (within 2 hours)
Ongoing review of capacity within isolation ward to meet clinical need.
In Place IPCN/Ward managers/Matrons
G
Daily side room reviews by the IPC nursing team
