Infection Prevention and Control Annual Report April 2015

Infection Prevention and Control Annual Report 2015/16 Page 1 of 33

Infection Prevention and Control Annual Report

April 2015-March 2016


Agenda Item No 12

Meeting Infection Prevention and Control Committee

Date 14/10/16

Title Infection Prevention and Control Annual Report

Executive Summary

This report provides a summary of the activities of the Infection Prevention and Control Team (IPCT) for the year 2015/16. It includes key issues such as; meticillin resistant Staphylococcus aureus (MRSA) bacteraemia and Clostridium difficile figures, Carbapenemase Producing Enterobactericae (CPE) activity, audit activities and adverse incidents.

Next steps/future actions Clearly identify what will follow the Board decision

The Trust Board are asked to note this report

Discuss Receive

Approve Note

Assurance to be provided by:

Key metrics tracked through the Trust IPC Committee (bi-monthly)

Strategy Financial Implications

Performance Legal Implications

Quality Regulatory

Workforce Stakeholder implications

NHS constitution rights and pledges

Equality Impact Assessed

For Information Confidential

Prepared by

Richard Catlin, Assistant Director of Infection, Prevention and Control

Presented by

Trish Armstrong-Child, Director of Nursing and Director of Infection Prevention and Control


Contents Page Number

1. Executive Summary 3

2. Team Structure – Acute and community 5

3. Healthcare Associated Infections (HCAI) performance 7

4. Infection Prevention and Control Governance 14

5. Flu Campaign 18

6. Community IPC 19

7. Environmental Sampling 20

8. VRE/CPE Screening in ICU 20

9. Emerging Issues 20

10. Cleaning and Decontamination 22

11. Ongoing Developments 24

12. Education and Training Activities 24

13. Objectives for 2015/16 25

14. Appendix 1: Bristol Stool Chart 30

15. Appendix 2: Principles of SIGHT 31


EXECUTIVE SUMMARY This report is intended to give a concise overview of key activities in the Trust related to infection prevention and control (IPC), healthcare associated infections (HCAI) and antibiotic stewardship. IPC remains critical to the Trust as it is a core component in the delivery of clean, safe care; failures in IPC can lead to adverse outcomes for patients and a poor patient experience. Antimicrobial stewardship has increasingly been identified as a challenge for the UK and presents a legitimate risk of the widespread dissemination of multi-drug resistant organisms and is therefore reflected in this report and future plans. The Trust has IPC and HCAI objectives set by NHS England related to Clostridium difficile1 and meticillin resistant Staphylococcus aureus (MRSA)2. The Trust also has key IPC/HCAI objectives commissioned by Bolton CCG. Fig. 1: Summary table of performance of HCAI as reported as part of the mandatory surveillance scheme

Organism Cases Reported

All Cases Trust Cases3

MRSA bacteraemias 11 6 Trust assigned

Clostridium difficile toxin cases

83 28 Trust apportioned

22 Performance cases4

Meticillin Sensitive Staphylococcus aureus (MSSA) bacteraemias

66 15

Escherichia coli (E. coli) bacteraemias

253 NA

MRSA Bacteraemia NHS England now adopts a zero tolerance to MRSA bacteraemias with an expectation that acute providers will have no avoidable MRSA cases. There were six Trust assigned MRSA cases in 2015/16 compared with five cases in the previous year. Clostridium difficile NHS England sets the annual Clostridium difficile objectives. The objective for 2015/16 was no more than 19 Trust apportioned cases; there were 28 Trust apportioned cases in total, of which 22 counted towards performance. Six cases were discussed with Bolton CCG and it was agreed that they should not count towards performance as there were no identified lapses in care. There were 20 Trust apportioned cases in 2014/15.

1 https://www.england.nhs.uk/patientsafety/associated-infections/clostridium-difficile/

2 https://www.england.nhs.uk/patientsafety/associated-infections/

3 As determined by Department of Health definitions

4 As agreed with Bolton CCG in line with agreed performance criteria

https://www.england.nhs.uk/patientsafety/associated-infections/clostridium-difficile/

https://www.england.nhs.uk/patientsafety/associated-infections/


Meticillin Sensitive Staphylococcus aureus (MSSA) Bacteraemia There are no national objectives for MSSA cases but these are a good proxy for the delivery of safe care, in particular related to line and wound care which are frequently the root cause of these infections. In 2015/16, there were 15 Trust apportioned cases compared with 18 cases in the previous year. Escherichia coli (E. coli) Bacteraemia There are no national objectives for E. coli cases and emerging studies suggest that cause and effect related to E. coli bacteraemias and healthcare is unclear. There were 253 cases in 2015/16 compared with 219 cases in the previous year. Carbapenemase Producing Enterobactericae (CPE) CPE are an emerging group of multidrug resistant organisms. They have come to the fore in the past five years and the North West generally and Greater Manchester in particular have become hotspots for CPE. At Bolton, two clinical departments – E3 and E4 – had been affected by the cross-transmission of CPE; the last case of concern was identified 14/06/15. Fig. 2: CPE cases across Greater Manchester 2015/165

In 2015/16 there were 22 identified CPE cases. Of these, 15 cases were identified through screens, the other seven identified from clinical samples.

5 Based on information provided by Public Health England


The Trust has now rolled out targeted screening in line with national guidance with additional screening in departments such as E3, E4, HDU and ICU. SYSTEMS TO MANAGE AND MONITOR THE PREVENTION AND CONTROL OF INFECTION Acute Services The IPCT remains largely unchanged in 2016 from the structure amended in the previous year. The IPC functions continue to be split between the acute team who serve the Trust’s acute services and the community team who serve the Trust’s community functions as well as the Bolton Council. Outline of the Acute IPC Team Structure

The Director of Infection Prevention and Control (DIPC) retains overarching responsibility for IPC and reports directly to the Board. The Assistant DIPC (ADIPC) oversees the development and implementation of IPC strategy and policies for the acute and

DIPC

IPC Doctor

Microbiology Consultant (1 WTE)

Microbiology Consultant

(0.6 WTE)

Assistant DIPC

Acute IPC Team

IPC Matron

(0.8 WTE)

Band 7 IPC Nurse

(2.55 WTE)

Band 6 IPC Nurse

(3.25 WTE)

Clerical & Admin

(1 WTE)

Community IPC Team

Band 7 Team Leader ( 1WTE)

Band 6 IPC Nurse (2 WTE)

Clerical & Admin

(1 WTE)


community teams, reporting directly to the DIPC. The ADIPC works in conjunction with the IPC doctor and the rest of the IPC team and key staff such as the antimicrobial pharmacist to develop strategy related to IPC and HCAI. The IPC matron has primary operational responsibility for day-to-day IPC management, management of the IPC team and oversight of key quality standards. Community Services In 2014/15, Bolton Council commissioned Bolton Foundation Trust to provide community IPC services for their areas of accountability and the community services provided by Bolton FT. Prior to this there had been discrete IPC service for Bolton primary care or local authority for two years. The team covers such services as care, homes, Bolton hospice, schools, district nursing, podiatry and community loan stores as examples. The team has demonstrated a proactive approach to providing IPC across the community sector in Bolton and has far surpassed the expectations of the local authority at the commissioning phase. They provide an informative, open, and knowledgeable service working cross organisationally to promote safe and effective infection prevention and control practices. The team has forged relationships with partners, including all of the Bolton Care Homes with services commissioned by Bolton Council. In 2015 the team hosted an initial launch event in for care home staff to introduce the team and to roll out a programme of audit and education across the care homes and hospice to promote the basics and principles of infection prevention and control to reduce the risks to our elderly residents. When the service commenced, several of these care homes were RAG rated 'Red', and with support, audit and education have now improved substantially - reaching 'Amber' or 'Green' status. Fig. 3: Care home audits

Red (<50% compliance with

standards)

Amber (51-95% compliance with

standards)

Green (≥95% compliance with

standards)

Baseline audit 8.9% 79.5% 11.5%

End of year 0% 67.5% 32.5%

The team regularly liaise with partners within the CQC and local authority to feedback critical findings and to share information in both directions. The team have worked with care homes, schools and nurseries around the importance of reporting and appropriately managing outbreaks of infection - including diarrhoea and vomiting, and influenza. They have visited schools and carried out education sessions with the smallest of children, and also liaised with the local authority neighbourhood teams to encourage the 'Making Every Contact Count' approach to infection prevention and control with a view to this message being shared with the wider community. The team has also worked closely with community action groups in Bolton such as the Bolton Community of Mosques to discuss specific IPC and infection issues identified in


their communities prevented or treated appropriately if identified and reported to GP without hesitation or embarrassment. Surveillance has identified a number of infections caused by MRSA and Panton-Valentine Leukocidin (PVL producing strains of Staphylococcus aureus (some infections that are MSSA and others that are MRSA). An agreement has been drawn up between the Trust and the CCG to allow the team to provide suppression therapy treatment for patients identified to be colonised with MRSA or PVL and deemed to be high risk of developing a clinical infection. There are now separate bi-monthly link meetings for both FT community staff and care home staff which serve as an educational and informative forum for staff to feed back to their areas of work. The team also carries out mandatory training for our community staff, and have made time to visit several individual teams at their request, including podiatry and respiratory services, to carry out more 'tailor made' training for staff. There is now a programme of audit for the Trust Health Centres and with this is a commitment to closer working with close colleagues such as the Integrated Neighbourhood Teams to bridge knowledge gaps and infection control practices across the FT and LA staff. This has included liaising with the education team at Castle Hill and their team leader attending our training session to ensure they are up to date with current infection prevention and control practices to feed back to council employees in mandatory training. The team also liaise directly with patients where necessary to ensure they are receiving the correct treatment and have a good understanding of their infection. This might include an initial conversation (by phone or in person) and it often followed up by a home visit to ensure correct practices and treatment are in place. This usually involves communication and close liaison with other teams - including district nurses, Children's Community Nursing Team, tissue viability service, podiatry and GPs amongst others. The service have now developed patient information leaflets around some of the common infections, which are now available to all staff on the FT intranet. Microbiology Services The provision of microbiology services also remains unchanged with three consultant microbiology posts (2.6 WTE). The team continue to provide advice by phone, regular antimicrobial ward rounds for the review of patients with complex or prolonged antibiotic treatment and has recently established a weekly ward round to review Clostridium difficile toxin positive patients. The team also provide planned and prospective support for the critical care departments such as ICU and NICU. Out of hours IPC advice continues to be provided by the microbiology service although a shared IPC nurse and microbiology model will be finalised in 16/17. The microbiology service also provides IPC advice Greater Manchester West Mental Health Trust under a service level agreement and a limited service for GPs.


The microbiology laboratory continues to provide a seven-day service for the diagnosis of Clostridium difficile toxin, Meticillin resistant Staphylococcus aureus (MRSA), and Norovirus infections. Budget allocation to infection control activities The total staffing budget allocated to Infection Prevention and Control is £446,869 (acute care team) and £154,972. Healthcare Associated Infection (HCAI) System The IPCT makes use of ICNet; a proprietary system for the management of HCAI. The system extracts data from the Trust laboratory system and Patient Administration System. It uses this information to alert the IPCT to these results in real time and is also the electronic patient record for the IPCT. The system allows epidemiological information to be used from historical data. The system also allows the acute and community team to function collaboratively and independently with each able to access each other’s notes and to alert the opposing team to new information e.g. a patient of interest can be flagged prior to or on discharge for follow-up in the community. The system is operated on in a licensed fashion with an annual fee for licenses. 3. Healthcare Associated Infections (HCAI) performance The Trust participates in the mandatory HCAI programmes. The following conditions are reported to the Department of Health (DH) via the Public Health England (PHE) Data Collection System (DCS): 1. MRSA positive blood cultures 2. Clostridium difficile toxin positive results 3. MSSA positive blood cultures 4. E. coli positive blood cultures 5. Surgical Site Infections 3.1 MRSA Bacteraemia From April 2014 changes were made to the process by which MRSA cases are reviewed and reported for performance and epidemiology purposes. Cases are now assigned to organisations in a three-step fashion:

1. The case is apportioned to a Trust or CCG based on when the blood cultures were collected. Cases are apportioned to the CCG or transferring Trust if specimens are collected on the day of admission or the day after. These are non-Trust apportioned cases and have traditionally been referred to in the Trust as “Pre” cases. Any case where blood cultures were taken after this are apportioned to the Trust. These are Trust apportioned cases and have traditionally been referred to in the Trust as “Post” cases.

2. The second step is to undertake a post-infection review of the case using root cause analysis methodology. Ideally this should be done in a collaborative fashion between the Trust and CCG for both Trust and non-Trust apportioned cases for shared learning and determining the right outcome. The post-infection review should identify any lapses in care or learning points to improve care.


3. The third step is to attribute a final assignment for the case for which there are three options:

i. CCG assigned; when there is evidence of lapses in care delivered by services commissioned directly by the CCG that led or contributed to an MRSA infection

ii. Trust assigned: when there is evidence of lapses in care delivered by the acute provider that led or contributed to an MRSA infection. If the Post-infection review determined that the result was a contaminant, the case is automatically assigned to the organisation that collected the blood cultures as they are able to take the learning from the incident

iii. Third party assigned: third party assignment was introduced for when there might be a specific third party (another Trust, non-NHS services, healthcare providers outside of England) that may have been responsible for lapses in care that led or contributed to an MRSA infection. This assignment can also be used when there were no lapses identified and the CCG and Trust agree that it would not be appropriate to finally assign the case to either organisation

For the purposes of apportioning cases, any part of a day – no matter how small – is considered a full day. The DH apportions cases to acute Trusts based on date of specimen collection. If blood cultures are collected on the day of admission or the following day then the case is automatically apportioned to the Clinical Commissioning Group (CCG). Specimens collected after this period are automatically apportioned to the Trust. In the event that the CCG and Trust cannot reach an agreement, the case is taken to an arbitration panel with NHS North appointing an arbitrator. All third party cases are automatically subject to a review by a regional arbitration panel. This surveillance only covers MRSA positive blood cultures and excludes results from screening and other clinical sites. Fig. 4: MRSA cases

2013/14 2014/15 2015/16

Trust Assigned Cases 2 1 6

CCG Assigned 5 5 4

Third Party Assigned 0 0 0

0

1

2

3

4

5

6

7

8

9

10

MRSA Cases 2011-15


3.1.1 Trust Assigned Cases NHS England has set a zero tolerance policy for MRSA bloodstream infections so every acute provider has a trajectory of zero cases every year. During 2014/15 there was one Trust apportioned MRSA bacteraemia. During the calendar years of 2014 and 2015 there was a 366 day period where there were no MRSA cases (January 3rd 2014-January 4th 2015). The case was reviewed using PIR methodology. The key issue noted from the review of the case was:

Inconsistent documentation of line care This information has been incorporated into local and Trustwide IPC training sessions. Root Causes: Fig. 5: Summary of MRSA bacteraemia root causes

Case Number

Department Root Cause Performance Case

1 Ward D3 Determined to be a peripheral line related infection. Typing of the organism confirmed that there had been cross-transmission with case 3

Yes

2 Ward D3 Confirmed continuing infection. The patient had been confirmed as MRSA positive from a blood culture collected on admission with the case assigned to the CCG. The second blood cultures were collected as part of the clinical management of the patient but collected two days outside of the de-duplication6 period

No

3 Ward D3 Determined to be a peripheral line related infection. Typing of the organism confirmed that there had been cross-transmission with case 1

Yes

4 Ward E3 Blood culture contaminant No

5 A&E Blood culture contaminant No

6 A&E Blood culture contaminant No

As evidenced above, the major root cause of MRSA bacteraemias in the year was blood culture contaminants. A blood culture is determined to be a contaminant if key organisms are grown in the cultures – such as coagulase negative Staphylococci (CNS) which are (usually) harmlessly colonise the skin. This is suggestive that the skin has not been adequately decontaminated prior to taking the sample and the result is due to bacteria from the skin being collected at the same time as the blood cultures. A sample may also be considered a contaminant if the patient’s condition has improved significantly with no antibiotics or antibiotics that would have had no therapeutic value for treating MRSA. Blood culture contaminant rates are now being tracked as part of an extended IPC dashboard presented to the IPC committee. The target for blood culture contaminants is

6 As repeated blood cultures may be part of the plan in managing a patient with a significant infection to

evaluate their response to treatment, there is an allowance that MRSA positive blood cultures collected within 14 days of the first sample do not need to be declared as a new case


for the prevalence to be less than 3% based on clinical evidence. The Trust was regularly over this figure in 2015/16 with the assessment areas (A&E, CDU, D1, D2 and F3) having particularly high rates of contaminants: Fig. 6: Blood culture contaminant rates Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Average

Trust average

4.36%

5.16%

2.84%

5.85%

3% 6.57%

4.95%

6.13%

5.17%

4.18%

4.90%

4.97%

4.84%

Trust average excluding assessment areas

3.81%

3.55%

2.69%

4.79%

2.06%

3.56%

3.49%

3.05%

2.40%

3.39%

2.95%

4.31%

3.34%

Assessment area avareage

6.24%

4.60%

3.84%

7.25%

5.30%

6.31%

4.74%

6.27%

16.95%

7.81%

12.79%

9.11%

7.60%

There is now a working group reviewing blood culture contaminants focussing initially on the assessment areas. 3.1.2 Non-Trust Apportioned Cases In 2014/15 there were five non-Trust apportioned cases. These cases have also been reviewed using PIR methodology. In year, the support by Bolton FT for the CCG to undertake these reviews has been strengthened to improve shared learning. Although there were no clear themes from the reviews, the reviews have identified the need for there to be a more sophisticated approach to managing MRSA patients post-discharge. The Trust has followed national guidance regarding discontinuing MRSA suppression therapy after discharge but the review of cases of infections has identified that some patients determined as being at particular risk of developing an infection post-discharge, should continue (or in some cases, start) suppression therapy post-discharge. Bolton FT is working with Bolton CCG on a post-discharge pathway for the management of MRSA positive patients in the community following discharge from the Trust. 3.1.3 Post Infection Review (PIR) of MRSA Bacteraemia Cases The Trust follows the mandated NHS England PIR process7 in conjunction with the CCG. This requires for a case to be reviewed and fed back to a joint Trust/CCG group to agree apportionment. 3.1.4 MRSA Screening The Trust has maintained a universal policy to MRSA screening with all elective and non-elective admissions being screened for MRSA on admission to the Trust. Additional screening is undertaken in the critical care departments of the Trust where patients are

7 http://www.england.nhs.uk/wp-content/uploads/2014/04/mrsa-pir-guid-april14.pdf

http://www.england.nhs.uk/wp-content/uploads/2014/04/mrsa-pir-guid-april14.pdf


screened on admission to the relevant unit and on a weekly basis. Elective patients may also be screened as part of their pre-admission pathway to maximise safety prior to surgery or other invasive procedures. 3.2 Clostridium difficile The DH apportions cases to acute Trusts based on date of specimen collection. If a stool specimen is collected on the day of admission, the following day or the day after that, then the case is automatically apportioned to the Clinical Commissioning Group (CCG). Specimens collected after this period are automatically apportioned to the Trust. There is no agreed process for apportionment to be re-allocated, but there is now an agreement with the CCG on acceptable standards of care for patients with possible Clostridium difficile infection. If the Trust can demonstrate that there have been no lapses of care then the CCG has agreed to consider these cases as not counting to performance. The Trust remains complaint follows the Department of Health guidelines for C. difficile testing8. These guidelines stipulate that all stool specimens type 5-7 on the Bristol Stool Chart (BSC) should be tested if there is no other clear cause of diarrhoea. All samples submitted to the lab from the acute services in patients older than two years that meet this definition should always be tested for CDT in the laboratory, additional to any other test request. Any sample in a patient over the age of 65 from community patients should be tested for CDT additional to any other tests requested. The test should be undertaken using a two step algorithm with a sensitive screening test; step one using glutamate dehydrogenase enzyme immunoassay (GDH EIA) or Clostridium difficile toxin polymerase chain reaction (CDT PCR). Step two using CDT EIA. It is only the CDT EIA positive cases that are mandated for reporting. Bolton FT uses GDH EIA followed by CDT EIA.

8 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215135/dh_133016.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215135/dh_133016.pdf


Fig. 6: CDT cases

3.2.1 Trust Apportioned Cases The objective for Bolton FT by NHS England was no more than 19 Trust apportioned cases. The Trust ended the year on 28 Trust apportioned cases. Six cases were discussed with Bolton CCG due to their being no identified lapses in care which was agreed and so of the 28 cases, only 22 counted towards the year end target of 19. 3.2.1.1 Trust apportioned cases are subject to a review which is undertaken using a guided root cause analysis approach. The purpose of these is to review the care provided and assess whether the care delivered was safe and appropriate. They are reviewed to establish whether care might have contributed to the risk of the patient developing a CDT infection and if this is the case, whether the corresponding policy was followed. The clinical teams are responsible for the review. On the day of the result, the ward/department management team (patient consultant, ward manager and matron) are notified and given a date for the case to be fed back. The review should be multidisciplinary and it has been agreed with the Divisional Heads of Division that the patient’s consultant will be ultimately responsible for the review. The review should be undertaken using a multidisciplinary approach and should be fed back (as a minimum) by a senior doctor and a senior nurse from the department. The case is fed back to a panel consisting of:

DIPC or ADIPC (chair) IPC Doctor or Consultant Microbiologist Medical Director Antimicrobial pharmacist

The themes that have emerged from reviews of cases in 2015/16 are:

Samples not being collected in a timely fashion. There were a small number of cases where patients had loose stool from admission but samples weren’t collected immediately. This delay led to the case being apportioned to the Trust

2011/12 2012/13 2013/14 2014/15 2015/16

Trust Cases 21 62 38 20 28

Non-Trust Cases 18 49 67 72 55

Objective 28 48 19

Performance 22

0

10

20

30

40

50

60

70

80

CDT Cases 2011-15


Patients not being isolated in a timely fashion. There were a number of cases where samples were sent but the patient wasn’t isolated

Inconsistent use of stool charts. There a number of cases where stool charts weren’t commenced when symptoms started, stool chats weren’t completed consistently or the use of Bristol Stool Chart terminology (see Appendix 1) wasn’t used

These deficits are being targeted by a reviewed Diarrhoea Management Plan developed in conjunction with the Trust Gastroenterology Consultant Nurse, Gastroenterology Consultants and service users. The IPC team will be rolling out the principles of SIGHT (see Appendix 2) in line with the DH (2012)9 guidelines and reinforcing this at regular points during the year. The Trust stool chart has been reviewed and replaced in conjunction with clinical staff using a PDSA approach. Antibiotic prescribing is covered elsewhere in this report. 3.2.1.2 Outbreaks There were no outbreaks Clostridium difficile infection in 2015/16. 3.3 MSSA Bacteraemia There are no national targets for MSSA cases. The DH apportions cases to acute Trusts based on date of specimen collection in the same way it does for MRSA. If blood cultures are collected on the day of admission or the following day then the case is automatically apportioned to the Clinical Commissioning Group (CCG). Specimens collected after this period are automatically apportioned to the Trust. This surveillance only covers MSSA positive blood cultures and excludes results from screening and other clinical sites. Fig. 7: MSSA cases

9 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215135/dh_133016.pdf

2011/12 2012/13 2013/14 2014/15 2015/16

Trust Cases 17 20 16 18 15

Non-Trust Cases 52 50 56 51 51

0

10

20

30

40

50

60

MSSA Cases

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215135/dh_133016.pdf


The risks associated with MRSA infections apply to MSSA cases; infections are predominantly linked to wound and line infections. Efforts to reduce the risk of MRSA infections will also reduce the likelihood of MSSA infections. 3.4 E. coli Bacteraemia There are currently no national targets for E. coli cases with no suggestions that this is likely to occur in the immediate future. Mandatory surveillance has helped understanding of E. coli infections and it is clear that these are much more complex than MRSA or MSSA infections and much less likely to attributed only to healthcare provision. To this end, the DH does not apportion these cases to acute care providers specifically in the same way that MRSA, MSSA and Clostridium difficile infections are. Fig. 8: E. coli cases

The trend locally is rising and this matched on a national level with the trajectories being broadly similar.

2011/12 2012/13 2013/14 2014/15 2015/16

Cases 220 244 246 219 253

200

210

220

230

240

250

260

E. coli


Healthcare providers do increase the likelihood of patients developing avoidable E. coli infections when they have indwelling urinary catheters. The IPCT continues to work closely with clinical staff to maintain best practice in regards to urinary catheter care. The IPC matron chairs a urinary catheter expert advisory group. It is the intention for 2016/17 to increase the scrutiny applied to urinary catheter care generally. 3.5 Glycopeptide Resistant Enterococcus (GRE) Bacteraemia

There were no cases of GRE bacteraemia in the Trust in 2015/16. There continues to be very small numbers of cases (one or two cases/year) and no particular concerns regarding GRE. 3.6 Surgical Site Infection Surveillance (SSIS) Every Trust that provides orthopaedic surgery is required by mandate to undertake SSIS. The minimum commitment for a Trust is one quarter of the year of at least total knee or hip replacements. At Bolton, the orthopaedic team ordinarily undertake ongoing surveillance (all quarters of every year) of total knee and total hip replacements as well as repairs of neck of femur resulting from fractures. This gives the Trust an excellent oversight of both elective and non-elective orthopaedic surgery. There were senior nursing capacity issues in year and the team were only able to undertake surveillance in the final quarter hence the small sample sizes. This has now been resolved, and the team intends to continue its commitment to continuous surveillance.

Total Knee Replacement

Total Hip Replacement

Repair of Neck of Femur

RBH National Average10

RBH National Average


No. of procedures

60 119788 56 117623 105 63628

10

The national comparison is against reported figures without patient questionnaires completed for a like for like comparison

2011/12 2012/13 2013/14 2014/15 2015/16

Cases (Bolton) 220 244 246 219 253

Cases (nationally) 26717 32309 34286 35793 38232

200

210

220

230

240

250

260

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

E. coli - UK (left axis) v BFT (right axis)


Total Knee Replacement

Total Hip Replacement

Repair of Neck of Femur

RBH National Average10



No. of infections

0 1004 1 1051 0 934

Incidence of infection

0% 0.8% 1.8% 0.9% 0% 1.5%

Although at face value this places the Trust above the national average for hip replacements, in context, this relates to 1 case out of 56 procedures. 4. Infection Prevention and Control Governance IPC assurance continues to be provided by the following:

The IPC Committee was reviewed for 2015/16 and has strengthened the strategic role of the committee in line with other groups such as Clinical Governance and Quality. Accordingly, the IPC operational group has also been reviewed to take more of the developmental and operational role for IPC. 4.1 Infection Prevention Control Committee (IPCC) The committee continues to meet bi-monthly and is chaired by the DIPC (the ADIPC in the DIPC’s absence). This committee provides assurance to the DIPC to be reported to the Board where required and provides a strategic direction for the provision of IPC. The committee covers the following on a regular basis plus other topics by exception:

HCAI surveillance Outbreaks/periods of increased incidence Antimicrobial stewardship Policy approval Emerging issues Divisional concerns Feedback from the whole health economy

Membership includes the following:

DIPC (chair) ADIPC Medical Director IPC Doctor Community IPCT Team Leader HOD for each clinical division DND for each clinical division

IPC Committee

IPC Operational Group

Water Safety Group

Antimicrobial Stewardship Committee


Antimicrobial pharmacist Estates and facilities Representatives from:

o Greater Manchester West o Bolton CCG o Public Health England

The revised Terms of Reference are available on request. 4.2 Infection Control Operational Group This group also meets on a bi-monthly basis alternating with the IPC committee. The purpose of this group is much more operational and covers agenda items such as:

IPC audits Operational impact of emerging issues HCAI performance and corresponding feedback from RCAs

Membership includes the following:

ADIPC (chair) Consultant microbiologist Acute IPC nurses Community IPC nurses Matrons Ward managers IPC link nurses

The revised Terms of Reference are available on request. 4.3 Water Safety Group

Estates and facilities are responsible for water safety. There are regular meetings during

the year covering all aspects of water safety.

From an IPC perspective, this includes Legionella and Pseudomonas aeruginosa which

are particularly related to ill health in inpatient settings. There have been no concerns in

2015/16 related to IPC and water safety. Issues related to water safety are fed into the

IPC committee by exception as well as being reported to the Health and Safety

Committee.

4.4 Antibiotic Stewardship Committee (ASC) The antimicrobial stewardship committee is chaired by the IPC doctor and includes representation from each of the clinical divisions. The remits of the group are to provide assurance on the following:

Ensuring the relevant policies are in date and evidence based Provide assurance that key antibiotic prescribing policies are audited and that the

audits are fed back The Trust has a strategy for providing safe and effective care related to antibiotic

prescribing and use


The committee oversees the audit of antibiotic prescribing against the standards set out in the DH Start Smart Then Focus11. There are five auditable standard:

1. Compliance with Trust Antibiotic Guidelines (including prescription in line with

culture and sensitivity testing and/or microbiology recommendation).

2. Indication for treatment written in the patient case notes at the point of antibiotic

initiation.

3. Indication for treatment written in the antibiotic section of the prescription chart.

4. Stop date or a review clearly documented in the case notes by 48 hrs.

5. Stop or review date clearly documented on the prescription chart by 48 hrs.

Trustwide Compliance with Each Standard: The set the Trust an objective of at least 75% compliance with all five standards for

2015/16. More challenging targets have been set for the coming years; 85% for 2016/17

and 95% for 2017/18.

Quarter Compliance

Quarter 1 76%

Quarter 2 74%

Quarter 3 81%

Quarter 4 78%

Total 77.25%

32% of patients included in the audit were on at least one antibiotic - 38% in Q1, 40% in

Q2, 34% in Q3. This is in keeping with the national average of 1 in 3 and is lower than Q1,

Q2 and Q3.

Compliance for Each Standard by Division

STANDARD 1: Compliance with Trust Antibiotic Guidelines (including prescription in line

with culture and sensitivity testing and/or microbiology recommendation).

11

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/417032/Start_Smart_Then_Focus_FINAL.PDF

92 91 85 89 96 97 90 94 94 91 100 95 96 78 87 87 0

20

40

60

80

100

Acute Adult Elective Care Family Care TRUST AVERAGE

Q1 Q2 Q3 Q4




STANDARD 2: Indication for treatment written in the patient case notes at the point of

antibiotic initiation.

STANDARD 3: Indication for treatment written in the antibiotic section of the prescription

chart.

STANDARD 4: Stop date or a review clearly documented in case notes by 72 hours

STANDARD 5: Stop or review date clearly documented on the wardex by 72 hours

97 81 85 88 92 97 93 94 93 94 86 91 92 78 92 87 0

20

40

60

80

100


Q1 Q2 Q3 Q4

81 47 56 61 70 57 69 65 52 59 38 49 59 54 41 51 0

20

40

60

80

100


Q1 Q2 Q3 Q4

91 63 100 85 74 82.5 67 74.5 80 88 100 89 74 94 92 86 0

20

40

60

80

100


Q1 Q2 Q3 Q4

64 33 78 58 74 38 17 43 82 90 85 85 72 82 80 78 0

20

40

60

80

100


Q1 Q2 Q3 Q4


The full evaluation is available on request. 4.5 Representation at other Trust wide groups Members of the IPCT represent the service at a number of Trust wide groups such as the medical devices group, Professional Advisory Group (PAG), Trust Health and Safety Committee and is invited into other Trustwide groups such as building projects as required. The IPCT also represent the Trust at external meetings including the Greater Manchester West Mental Health Trust IPCC, North West Infection Control (NORWIC) and the NHS North IPC collaborative group. 5. Flu Campaign The IPCT led on the staff flu vaccination programme for frontline staff in 2015/1612. Uptake in the Trust for frontline healthcare staff was 44%; 1934 out of 4388 frontline staff took up the offer of the seasonal flu vaccine.

Staff Group Total Staff Frontline Staff Vaccinated

% Staff Vaccinated

Doctors 375 143 38.9%

Qualified Nurses 1899 657 34.6%

Registered Healthcare Professionals 460 184 40%

Support Staff to Clinical Staff 1128 428 38%

Total 4235 1558 36.8%

Following the flu season there were a number of listening events hosted by the Staff Engagement Lead for the Trust to understand why uptake was poor. The following themes emerged:

The myths related to the effectiveness of the flu vaccine persists The myths related to the potential adverse effects of the flu vaccine persists There was wide media coverage regarding vaccine failure during this flu period.

There had been significant mutation in the circulating viruses which meant that efficacy against one of the specific strains included in the vaccine was poor

The campaign was too low-key Staff felt that the campaign was to directorial and not positive and inclusive There were capacity issues in local flu vaccine provision

A debrief meeting was held and these issues have been considered and addressed for the 2016 flu campaign. The IPC and communication teams have reviewed the campaigns

12

Frontline staff are classified by the DH as: doctors, GPs, qualified nurses, other registered healthcare professionals and support staff to clinical staff


from trusts that were more successful with flu campaigns in the past year or so and these lessons will be incorporated into the campaign for 2016. 6. Community IPC The community team functions directly under a contract from Bolton Council. This contract covers all of the health and social care commitments of Bolton Council and Bolton FT’s community services. In the first phase of the commissioned service, this has focussed on areas of key risk – closed communities such as care homes and maintaining training for clinical staff in the community. They have also managed and dealt with outbreaks of infection in care homes and schools and worked as key liaisons with GPs in managing IPC issues in the community. 6.1 Care Homes In the baseline audits of care homes undertaken from May 2015, the average compliance was 71% compliance with a RAG rating of:

0-50% Fail 51-91% Partial Compliance 92-100% Compliant

Each audit has a support bundle of feedback and training built into it as a process and compliance dictates the frequency and timing of re-audit. By the end of the year, average compliance had risen to 86%.

Standard Baseline End of Year

Average audit score 71% 86 % (+15%)

Lowest score 30% 74% (+44%)

Highest score 99% 97% (-2%)

% Fail 8.8% 0%

% Partial Compliant 79.5% 69.5%

% Compliant

11.8% 30.5%

6.2 Training On top of delivering mandatory training for community staff related to IPC, the IPC team delivered training for more than 820 staff in care homes alone across 59 sessions in the year. 6.3 Outbreaks The team dealt with 57 outbreaks in 15/16:

Care Home Outbreaks (including Laburnum

Lodge and Bolton Hospice)

School Outbreaks Cause

31 (54.5%) 23 (45.5%) Gastroenteritis – 44 (77.2%) Scabies – 5 (8.8%) Flu-like symptoms – 3 (5.2%) Scarlet Fever – 2 (3.5%)


Foot, hand and mouth – 1 (1.75%) Chicken pox – 1 (1.75%)

6.4 Other Functions The team also take queries by phone, contribute to RCAs of Trust and non-Trust related infections. 7. Environmental Sampling The IPCT continues to monitor ongoing sampling such as weekly rinse water testing from the washer-disinfectors, settle plates from HSDU and water sampling from recommended points in the Trust. Any abnormal results are acted upon as soon as possible. There have been no specific issues in year. Further environmental sampling maybe carried out if indicated by an incident or following building work. 7.1 Rinse Waters Weekly testing of rinse waters from washer-disinfectors has continued for all baths in both Endoscopy and Urology. The IPCT monitor the results that have been put into a spreadsheet along with subsequent advice given to staff in both units. As above, there has been nothing of note to report. 8. VRE/CPE Screening on ICU The IPCT have instigated screening of patients to ICU for VRE and CPE in the light of recent increase in number of cases seen in critical care. Patients are screened on admission and on a weekly basis. 9. Emerging Issues 9.1 Carbapenemase Producing Enterobactericae (CPE) CPE are an emerging group of multidrug resistant organisms. They have come to the fore in the past five years and there are a number of established “hotspots”. Globally these are: Bangladesh India North Africa (all) South/Central

America The Balkans Ireland Malta China Israel Middle East (all) Turkey Cyprus Italy Pakistan Taiwan Greece Japan South East Asia USA Nationally, all London healthcare providers are considered high-risk. Regionally the established hotspots are:

Central Manchester and Manchester Children’s University Hospital Foundation NHS Trust

University Hospital South Manchester Foundation NHS Trust Royal Liverpool and Broadgreen University Hospital Trust


Countess of Chester NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust

There have been a relatively small number of CPE cases identified at Bolton FT, predominantly as the result of screening.

In 2015/16 there were 15 identified CPE cases. Of these, eight cases were identified through screens, the other seven identified from clinical samples. These are frequently endogenous infections (infections caused by the individuals own bacteria). CPE screening at Bolton FT continues on ICU, HDU, E3 and E4. These are admission screens (for all patients) and weekly screens (for all patients). The last ‘hospital acquired’ case in E3 or E4 where concerns had been raised in the previous year was 14/06/15. Outside of these specialist areas, the CPE policy at Bolton FT outlines the needs to consider the following groups as high-risk in line with the national toolkit:

Patients who have had healthcare admissions overseas in the past 12-months Patients who have been inpatients in a known high-risk hospital (as above) in the

past 12-months Patients with a known history of CPE

These patients should be isolated from admission and screened for CPE. As CPE can be difficult to identify, three consecutive screens are required at least 48-hours apart to confirm a patient’s negative status. 10. Cleaning and Decontamination 10.1 Decontamination across the Trust The Infection Prevention and Control team is continues to provide decontamination advice throughout the Trust. The IPCT are available to give specialist advice on policies, procedures and the purchase of equipment in relation to decontamination.

CPE (all) CPE (clinical) CPE (screens)

14/15 17 4 13

15/16 15 7 8

0

2

4

6

8

10

12

14

16

18

CPE Cases


10.2 Cleaning Service Domestic services continues to be delivered by ISS Mediclean under contract from the Trust. Standards are monitored on a continuous basis:

Internal audit by ISS Mediclean Assurance audits by the Estates and Facilities department

Audits are undertaken using national standards. The audits are visual inspections incorporating 41 standards. Departments are considered to be high-risk (for example, complex care) or very high-risk (for example, ICU). The same standards are monitored, but a successful audit in a high-risk area is 95% compliance with the audit whereas the required compliance in a very high-risk area is 98%.

Cleaning Score Nat Standards Of Cleaning Target

Performance Score 98%

Ave

rag

e

Sc

ore

Trust Very High Risk Green = pass Amber = Fail

Red = Fail - Poor

April 99.56%

May 99.56%

June 99.40%

July 99.43%

August 98.96%

September 99.50%

October 99.55%

November 99.45%

December 99.18%

January 98.81%

February 98.93%

March 99.00%

Cleaning Score Nat Standards Of Cleaning Target

Performance Score 95%

Ave

rag

e

Sc

ore

Trust High Risk Score

Green = pass Amber = Fail

Red = Fail - Poor

April 98.29%

May 97.90%

June 97.61%

July 96.97%

August 97.04%

September 96.91%

October 96.87%

November 97.69%

December 97.34%

January 97.20%

February 97.29%

March 97.51%

The facilities team now audit the cleanliness of near patient equipment. This equipment is the responsibility of the nursing team to clean and the results from these audits are fed back to the department manager.


Patient Equipment Cleanliness Target Performance Score 95%

Ave

rag

e

Sc

ore

Trust Team Audit Score 95%

April 98.05%

May 98.63%

June 97.65%

July 95.24%

August 97.99%

September 99.06%

October 98.61%

November 97.80%

December 97.41%

January 98.68%

February 98.58%

March 98.90%

All cleaning performance is reviewed and discussed at the Trust IPC Committee and the IPC Operational Group. Scores are reviewed monthly by the IPC team and area with consistently low scores or scores that generate a specific concern are discussed with the relevant managers. At the intermediate care facilities there is local authority in-house cleaning staff. Darley Court’s cleanliness is now assessed exactly the same as any other inpatient department in the Trust and reviewed with the same processes. All community healthcare facilities perform a 3 monthly audit which checks the standards of cleanliness and identifies any building fabric or building concerns. The audits are returned to the management team to progress any actions. In the new build health centres the cleaning is performed by Eric Wright associates and is performed to a high standard they perform monthly environmental/cleaning audits which are reported to the relevant management teams. 10.3 Infection Control audits The IPCT carry out audits of practice and adherence to key IPC standards on at least an annual basis. High risk areas (listed below) are audited at least twice yearly:

ICU HDU A&E Dept Ward D1 Ward D2 CDU NICU Main Theatres

The audits are planned in advance and carried out by a member of the IPCT with a member of the ward staff; ideally the ward manager or IPC link nurse. An action plans are completed by the ward staff and returned to the IPCT and the results are fed back at the IPC operational group. The group is attended by representatives from


estates and facilities to assist if there are environmental issues that the ward staff cannot resolve them themselves. If the initial audit is unsatisfactory then a re-audit is required and if there are significant concerns, the issue may be escalated to the senior management team for support. 10.7 Hand Hygiene Audits Hand hygiene audits are completed by nominated departmental staff continue and are inputted into secure applications. All grades of all types of staff are included in the audit and up to five members of staff are observed to check that hand washing before and after patient contact is taking place. Managers are able to generate reports for feed back to their team/department. 11. Ongoing Developments

11.1 Updated Policies The IPC team continues to review IPC policies in line with new or revised guidance. Revised policies are shared with key stakeholders for comment before being reviewed at the IPC committee. New policies follow the same route but require final review by the executive team.

11.2 Infection Control webpage The IPC webpage is continually updated to ensure that the advice and supportive information is current and fit for purpose. Organism specific information and key documents are available here for staff to review and access. The website also links to key external sites such as Public Health England advice pages. 12. Education and Training Activities The delivery of training remains a core component of the IPC service. The IPCT provides training for the Trust on the corporate induction and day 2 of the induction for clinical staff. There is now an e-learning module for clinical and non-clinical mandatory training for acute staff although this training is still face-to-face with community staff. It is anticipated that there will be an e-learning package for community staff available in 16/17. The IPCT increasingly deliver training on an ad hoc basis as required and in response to incidents. More time is being devoted to training on a one-to-one basis or in small groups in the work setting as this is known to be an effective way of training staff. The IPC team provide core training for cascade trainers – for example for cascade trainers for fit testing or aseptic non-touch technique (ANTT). An important part of the development of the Trust IPC link nurses is also teaching, training and information sharing. 12.1 Student Nurse Placements The IPCT is a spoke placement area for both student nurses and qualified staff. During their placement the student/staff are given an insight into the daily working of the team which includes ward and patient visits, training, audits, community aspects and reviewing microbiology results. Visiting staff are given an information package which includes the


names and contact details of the IPCT/microbiology team and the key roles and responsibilities in relation to infection prevention and control of all staff within the Trust. They are also given an opportunity to undergo a brief training session to discuss the fundamental aspects of infection control. 12.2 IPC Link Meetings The link group meetings have now been split into two discreet groups: acute staff link nurses and community staff link nurses. Each group is held bi-monthly and held mid-afternoon to facilitate maximum attendance. The meetings generally incorporate a short presentation or demonstration related to an aspect of IPC. This is followed by the team giving the group up to date information on recent events, new initiatives, key priorities and educational opportunities. The purpose of the meeting is for the attendees to disseminate the information to their clinical areas. The ‘Link Champion’ trophy is presented to a link person who has shown initiative in their area. The link person is presented with a trophy and a certificate. A certificate is also given to the ward/department to display on their achievement board. 13. Objectives for 2016/17

During the next 12 months the IPCT aims to ensure a high quality and effective service across the whole Trust. The IPCT will adopt a zero tolerance approach to avoidable HCAI’s and ensure that all staff in the Trust are aware of their responsibilities in relation to infection prevention and control.

The trajectories set by NHS England remain challenging:

MRSA Bacteraemia: zero no avoidable cases of MRSA bacteraemia CDT cases: no more than 19 Trust apportioned cases

There are also two national CQUINS linked to IPC/HCAI/Infectious disease management:

1. Antimicrobial stewardship. This is split into two parts: i. Reduction in antibiotic consumption per 1,000 admissions. 1% reduction in

total antibiotic consumption with consumption in 13/14 as the baseline. 1% reduction in the consumption of tazobactam/piperacillin with consumption in 13/14 as the baseline. 1% reduction in the consumption of carbapenems with consumption in 13/14 as the baseline

ii. Empiric review of antibiotic prescriptions. Evidence of review of antibiotic prescribing at 72 hours.

There are two critical priorities for the coming year to significantly improve patient safety, care and to reduce the Trust risk of avoidable HCAI:

1. Making ANTT more robust 2. Reducing blood culture contaminants

13.1 ANTT ANTT training is currently provided using a cascade training system; individuals are trained an assessed as being competent to train staff to use ANTT by the IPC team. These staff then cascade the training to staff in their own department although this is


largely restricted to nursing or AHP staff who work permanently in the department. There is often a lack of capacity to train medical staff. Training records are fragmented and held locally. It is imposiible for the Trust as a whole to understand staff compliance with ANTT as the data is not easily available and denominator information is not easily available. Currently ANTT processes concentrates on training with an element of competency in a non-clinical setting. There is currently no competency assessment when delivering ANTT practice in real setting. The priority is to get Trust agreement that ANTT should be mandatory for the following staff groups:

Medical staff Nursing staff (qualified and unqualified) Allied health professionals in specific roles

Mandatory sessions can generate Trustwide compliance and encourages staff to seek out training as staff are unable to qualify for increments or apply for study leave if they are not compliant with their mandatory training. This will have a forcing function and should incentivise staff to seek out ANTT training if they are not currently compliant. There should be a move to a focus on competence rather than training. The Trust would gain much more assurance should staff be able to show evidence of demonstrating competence with ANTT rather than merely having received training. 13.2 Blood Culture Contaminants In 2015/16 there three MRSA bacteraemias with a root cause of the blood cultures being contaminated. This does not inspire confidence in the ability of staff to provide clean, safe care. Current literature suggests that acute care providers should be aiming for a blood culture contaminant rate of ~3%; Bolton FT currently had an average rate of 4.84% for 2015/16. However, the assessment areas (A&E, CDU, D1, D2 and F3) when taken together have a much higher rate of contaminant – an average of 7.6%. As these are departments that take a sizeable proportion of blood cultures, they skew the Trust figure considerably; without the assessment areas, the average rate of contaminant would be only 3.34%.

Blood Culture Contaminant Rates

The whole Trust excluding the assessment areas

The assessment areas The Trust average with assessment areas

3.34% 7.6% 4.84%


Blood culture contaminants have the capacity to influence clinical teams to commence treatment that is inappropriate and often not required at all, impacts negatively on length of stay as patients wait to finish treatment and are also a poor use of resource. 13.3 Surveillance The team will continue to carry out mandatory HCAI surveillance as required for the following:

MRSA bacteraemia Clostridium difficile toxin positive cases MSSA bacteraemia E. coli bacteraemia GRE bacteraemia SSI

Additionally, the Trust will actively surveil the following alert organisms:

CPE Mycobacterium tuberculosis Resistant Gram negative organisms (e.g. ESBL and AmpC producing organisms) Streptococcus pyogenes (Group A Streptococcus) Haemophilus influenza Legionella spp. Neisseria spp. Salmonella spp. Shigella spp. Campylobacter spp. Verotoxin producing E. coli (e.g. E. coli 0157) Rotavirus Norovirus Respiratory syncytial virus Varicella zoster Rubella Parvovirus

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

Trust average

Minus assess. Areas

Assess. Areas

Benchmark


Measles These organisms are reported to the IPC team either by the ICNet (the IPC team surveillance system and electronic patient record) or by the laboratory on suspicion or confirmation. The Trust will need a particular focus on Training in the coming 12-months

IPC mandatory training will be more closely monitored and plans to get compliance to or above 95% (currently at 93.8%)

In line with this and to widen training access, e-learning and targeted local training are being considered

A system for monitoring of compliance with ANTT training for all relevant staff types needs to be developed

Departments or groups with poor compliance will be identified and supported This will include medical staff

An IPC/HCAI reduction plan will be produced in a format to be designed to be used on an ongoing basis for monitoring through the IPC Committee and IPC Operational Group. It will be matched against the 10 core standards in the Code of Practice and NICE guidance and will be much more action and outcome focussed than the previous plan.

Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance (updated 2012)

NICE (2011) Quality

Improvement Guide for HCAI

Criterion The registered Provider is required to demonstrate Quality Improvement

Statement

1 Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider how susceptible service users are and any risks that their environment and other users may pose to them

1

2 Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections

2

3 Provide suitable accurate information on infections to service users and their visitors

4 Provide suitable accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion

4

5 Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people

5

6 Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection

6

7 Provide or secure adequate isolation facilities 7

8 Secure adequate access to laboratory support appropriate 8

9 Have and adhere to polices, designed for the individual’s care and provider organisations. That will help to prevent and control infections

9

10 Ensure so far as is reasonably practicable, that care workers are free of and are protected from exposure to infections that can be caught at work and that staff are suitably educated in the prevention and control of infection associated with provision of health and social care

10


Documents

Infection Prevention and Control Annual Report April 2015