Infection Prevention and Control Annual Report April 2017

Page 1 of 28 Annual report for Infection Prevention and Control 2017- 2018

Infection Prevention and Control Annual Report

April 2017 – March 2018

Jacqui Mains Infection Prevention & Control Manager

Date: 26th July 2018


Contents

Executive Summary ................................................................................................... 3

Key achievements in 2017/18 .................................................................................... 3

Key risks and mitigations: ........................................................................................... 4

Key priorities .............................................................................................................. 5

1. Introduction ............................................................................................................ 5

2. Background ............................................................................................................ 5

3. Corporate Responsibility ........................................................................................ 9

4. The Patient Safety Group (PSG) ............................................................................ 6

5. Education & Training ............................................................................................ 11

6. IPC Annual Audit Programme ................................................................................ 9

7. Service and Building Developments ..................................................................... 23

8. Serious Incidents and Complaints ........................................................................ 20

9. Key Achievements, Risks and Mitigations ............................................................ 20

10. Summary and Conclusion…………………………………………………………….25

Appendix A 2017 – 2018 IPC Audit Schedule Complaince Summary

Appendix B IPC Programme 2018 – 2019

Appendix C IPC Annual Audit Scheulde 2018 – 2019


Executive Summary

The purpose of this report is to inform the Trust of the progress made against the

Care Quality Commissions standards (Outcome 8, Regulation 12) and the

Department of Health ‘Health and Social Care Act’ 2008 (amended 2010) during the

period 1 April 2017 to 31 March 2018

An outline of the Infection Prevention and Control (IPC) Annual Work Programme for

2018/19 is appended to the report to illustrate the priorities for the forthcoming year

(Appendix B).The report provides information and evidence of the ongoing

commitment of the Trust to embed IPC principles and practices throughout the

organisation and shows the significant improvement the Trust has made in this

respect.

As a result of learning and improvement North East Ambulance Service (NEAS) has

a workforce that has the knowledge, skills and experience to appropriately minimise

infection risk for patients and staff, thereby improving patient safety and staff well-

being. The organisation is able to demonstrate compliance with infection prevention

and control standards and delivery of key strategic objectives including delivering on

NEAS Quality Strategy 2018 Infection Prevention & Control aims to maintain and

improve IPC practice, through robust audit, feedback and action.

Key Achievements in 2017/2018

The Care Quality Commission inspected NEAS in April 2016 against compliance

with the CQC Outcome 8 standards for cleanliness and infection prevention. NEAS

was overall rated “Good” and with Infection Prevention and Control no issues

identified.

The IPC Manager appointed in April 2017 has strove to achieve a high level of IPC

awareness through communications to staff in a variety of forums including; the IPC

dashboard, Patient Safety Group, the Summary, Clinical Care Manager (CCM) and

Scheduled Care Manager (SCM) team meetings.

IPC Monitoring included CCM’s completing 311 observational practice audits using

an electronic auditing tool which increased by 157 audits from the previous year.

Station Support Officer Cleanliness Audits increased by 145 audits from the previous

year and provides good assurance of cleanliness and clinical waste management.

The IPC manager conducted 77 station audits and visited 52 stations across the

trust.

Good communication with regional NHS Trusts and Public Health England continue

to be beneficial ensuring that timely information is shared across organisations with

regard to health care associated infections and infectious diseases.


The IPC Manager is part of Teesside Health & Social Care IPC Collaboration a North

East collaboration inclusive of multiple agencies aiming to reduce gram negative

bacteraemia this work is helping to shape the NEAS Antimicrobial Resistance (AMR)

Strategy being introduced in 2018.

The IPC Manager updated statutory and mandatory training in May 2017 and provided face to face sessions at induction for front line staff on appropriate PPE use and 263 staff received face to face training sessions on AMR.

The IPC Manager contributed to a AMR focus group held by Health Education

England recommending ambulance services and Advanced Practitioners should be

represented in future AMR learning materials.

There have been no formal complaints relating to infection prevention and control during 2017/18 this is taken to reflect positive patient experience.

The IPC manager has collaborated with the Academic Health Science Network North East and Cumbria and a local NHS Acute Foundation Trust to introduce a pressure ulcer risk assessment to paramedics. A pilot during October 2017 to January 2018 tested the risk assessment and a Pressure Ulcer Alert bracelet identifying patients with or at risk of pressure ulcer damage to emergency department staff on admission.

Key Risks and Mitigations:

The key risks from IPC associated issues include:

Infection Prevention & Control resources were identified as a risk due to the IPC

audit schedule and training work load. The IPC audit schedule for 2017 – 2018 was

not fully achieved with IPC vehicle verification audits not carried out.

Maintaining vehicles cleanliness with associated monitoring of cleaning processes

has been identified as a risk. Unscheduled Care Vehicle audits increased by 95

vehicles from the previous year, this was achieved by paramedics on alternative

duties completing audits. Scheduled Care Managers did not reach their IPC audit

trajectory with 99 less vehicle audits completed in 2017 – 2018 this could have been

due to Scheduled Care Managers being in a transitional period with role changes.

The IPC Schedule for 2018 – 2019 has taken into account the new structure and has

agreement with the Scheduled Care Manager and Clinical Care Managers.

The National threat of emerging infectious diseases and antimicrobial resistance is

being seen as a reality through increasing regional prevalence of resistance

organisms. NEAS is joining with local health and social care providers and working

with regional CCGs to help minimise the impact of AMR by ensuring good IPC

practices are embedded and commencing an AMR strategy.


Key priorities

The IPC Programme for 2018-19 can be seen in appendix B

Review of IPC Policies to be updated by March 2019.

IPC resources to be appropriate including IT / data repository resources to support

monitoring of quality assurance indicators including real time IPC dashboard.

High Impact Intervention Care Bundles for Hand Hygiene, Personal Protective

Equipment and Aseptic Non Touch Technique relating to Intra Vascular Devices are

embedded into practice and monitored through IPC Audit cycles.

AMR Strategy to be launched promoting antimicrobial stewardship. Advanced

Practitioners to be included in the IPC Audit Schedule will require support to

complete self and peer AMR audits.

All services that are provided in NEAS premises and vehicles demonstrate a high

level of cleanliness with robust monitoring processes.

Third Party Contractors - NEAS will re-establish links with all third party providers to

ensure that they are following all guidance in relation to IPC and National Standards

1. Introduction

This is the Infection Prevention and Control (IPC) Annual Report from the Director of

Quality and Safety, Director IPC (DIPC). The report is to inform the Board of the

progress made against the Care Quality Commissions standards (Outcome 8,

Regulation 12) and the Department Health ‘Health and Social Care Act’ 2008

(amended 2010) during the period 1 April 2017 to 31 March 2018.

An outline of the Infection Prevention and Control (IPC) Annual Work Programme for

2018/19 is appended to the report to illustrate the priorities for the forthcoming year

(Appendix B).

The report provides information and evidence of the ongoing commitment of the

Trust to embed IPC principles and practices throughout the organisation and shows

the significant improvement the Trust has made in this respect.

2. Background

Effective infection Prevention and Control practice requires ownership at every level

– from Board to frontline. Success depends on creating a managed environment that

minimises the risk of infection to patients, staff and the public and ensures

compliance with relevant national and local standards, guidance and policies.

Through personal accountability, skilled and competent staff, transparent and

integrated working practices and clear management processes a sustained

approach to IPC can be achieved.


2.1. The Health and Social Care Act 2008 (amended 2010): Code of Practice for

Health and Social Care on the Prevention and Control of Infections and related

guidance (Department Health).

Section 21 of the Health and Social Care Act (2008) enables the Secretary of

State for Health to issue a revised Code of Practice. The Code contains

statutory guidance about compliance with the registration requirement for

cleanliness and infection prevention and control. The Act states that the Code

must be taken into account by the Care Quality Commission (CQC) when

decisions are made regarding the cleanliness and infection control standards

required to achieve registration. The Code, revised in December 2010, focuses

on 10 areas which are captured within the work plan. (Appendix A)

3. Corporate Responsibility

In December 2003 the Department of Health published ‘Winning Ways: Working

Together to Reduce Healthcare Associated Infections’ which highlighted the

requirement for a Director of Infection Prevention and Control (DIPC). The Director of

Quality and Safety has been designated as the DIPC with lead responsibility within

the Trust for IPC. This post reports directly to the Chief Executive Officer and the

Trust Board. The Trust Board holds overall responsibility for ensuring that the Trust

is compliant with IPC national guidance.

4. The Patient Safety Group (PSG)

The aim of the PSG is to provide assurance to the Trust Board that all services are

provided in a clean and safe environment through the effective performance

monitoring of key performance indicators (KPIs). It provides a monthly forum for the

co-ordination of any IPC related projects ensuring a consistent approach throughout

the Trust. The PSG group is responsible for providing assurance to the Quality

Committee which is a sub-committee of the Board during 2017- 2018 met bi-monthly.

4.1. The Infection Prevention and Control Team

Director Infection Prevention and Control (DIPC)

The responsibilities of the DIPC are outlined in ‘Winning Ways’ (DH, 2003)

and include:

To be the responsible Executive Lead for IPC within the Trust

reporting directly to the Chief Executive

To ensure that pre-determined targets are met by overseeing the

IPC work programme and Annual IPC Inspection Programme

Present regular reports to the Trust Board


Head of Patient Safety

The responsibilities of the Head of Patient Safety include:

Ensuring Trust policies and procedures reflect the national and local

IPC requirements and are reviewed within timescales.

Overseeing the delivery of an effective performance monitoring

programme developed by the IPC manager and reporting through

the PSG Group to the Quality Governance Group.

Overseeing the delivery of an annual work programme developed

by the IPC manager focusing on improving and sustaining

compliance with the Health and Social Care Act (2008)

Oversee production of IPC annual report.

Contributing to the Quality Governance Report for submission to the

Trust Board.

IPC Manager

The responsibilities of the Infection Prevention and Control Manager include:

Provide specialist IPC advice for all areas of clinical practice

Develop IPC educational programmes including workbooks for

clinical and non-clinical staff for induction and mandatory training

Facilitating quality assurance monitoring and report compliance with

IPC policies to PSG on a monthly basis

Ensure there is a robust vehicle cleaning regime in place meeting

best practice and gain assurance monthly that this is being adhered

to and report to PSG

Review IPC policies and procedures ensuring they are up to date

and reflect best evidenced based practice

Monitor themes and trends from IPC incidents including needle

stick injuries and report to PSG monthly

Facilitate IPC Operational Champions network, supported via

newsletters and educational opportunities

Produce annual IPC report

Monitoring IPC training and report compliance for mandatory IPC

training in the annual report

Prepare IPC work plan for year ahead and facilitate delivery

Review and develop quality assurance integrated inspection tools to

ensure these are fit for purpose

Contribute to and support the AMR strategy


4.2 Policy Review and Development

All IPC policies and procedures were reviewed and ratified as appropriate in March

2016 in response to national guidance/ legislation. All policies and procedures are

available on the Trusts Q – Pulse policy system and the Trust intranet IPC page was

updated April 2016. As all IPC policies will require a review by March 2019 a

strategy to prioritise and review policies will be undertaken in 2018 – 2019.

5. Education & Training

Compliance with Mandatory Education & Training 2017 – 2018

Statutory Mandatory Training Compliance 2017 – 2018

IPC Level 1 Support Services 758 95%

IPC Level 2 Clinical Staff 1672 90%

Total 2430 91%

IPC Induction Compliance 2017 – 2018

IPC Induction Level 1 191 88%

IPC Induction Level 2 208 89%

Total 399 89%

One thousand, seven hundred and forty –six clinical staff 90% also received face

to face IPC training that incorporated applying standard precautions for

ambulance crew including appropriate glove use.

Two hundred and sixty three clinical staff 13% also received a face to face

Antimicrobial awareness session facilitated by the IPC Manager.

Compliance for IPC e-learning induction 2017 -2018 for operational staff:

Allied Health Professionals, eighty-one new starters: Seventy completed IPC e-

learning = 86% compliance.

Nursing & Midwifery twenty-one new starters: Eighteen completed IPC e-learning

= 86% compliance.

The Statutory and Mandatory training programme for 2018-2019 has been

agreed by the Trust IPC to be undertaken using the National e-learning modules

for all staff. Antimicrobial resistance (AMR) e-learning will be available for all

clinical staff and will be a specific requirement for Advanced Practitioners who

dispense antimicrobials using PGD’s to undertake this.


6. IPC Annual Audit Programme

6.1. Monitoring Systems A key risk identified is insufficient IPC staff resources to carry out comprehensive

monitoring. Previous IPC annual reports 2014 – 2016 reported incompletion of

planned audit schedules. IPC audit activity includes CCM’s conducting

observational audits on practice using an electronic application and Scheduled

Care managers conducting paper vehicle and bare below the elbow audits. The

process of embedding and reviewing IPC audits requires IPC resources. The

present IPC electronic audit application does not generate detailed reports from

the CCM observational audit and requires the IPC manager to analyse data,

this process is not sustainable and it also inhibits real time information and

feedback. Development of an IPC electronic application which generates

comprehensive reports is in progress with informatics. Station Support Officers

complete station cleanliness audits this has progressed from paper to an

electronic application this year.

2017 – 2018 IPC Audit Schedule with Compliance is given in Appendix A of this

report.

6.2 CCM Observational Audits CCM observational audits were introduced in April 2016 using an electronic

application that can be used on ride outs by CCM’s to undertake practice

audits on staff members. From April 2017 to March 2018 three hundred and

eleven observational audits were completed by 35 CCM’s an increase of one

hundred and fifty seven audits. The total score of the audits has remained

over 90% throughout the year.

CCM Observational Audits

Month Score Number

2017 Apr 97.4 17

May 92.8 27

Jun 95.1 36

Jul 96.4 52

Aug 95.7 49

Sep 94.5 30

Oct 98.8 24

Nov 98.4 13

Dec 100.0 1

2018 Jan 97.2 10

Feb 94.2 20

Mar 95.0 32

Total

94.5 311


CCM’s reported from South Divisions from the following clusters:

South Division CCM Observational Audits April 2017 – March 2018 by Cluster and Station

Cluster Station Score Audits

Bishop Cluster Barnard Castle 97.7 3

Bishop Auckland 94.4 5

Newton Aycliffe 96.5 4

Bishop Cluster Total 95.9 12

Coulby Cluster Carlin How 100.0 3

Coulby Newham 96.5 8

Middlesbrough 97.7 3

Redcar 94.8 4

Coulby Cluster Total 96.9 18

Hartlepool Cluster Fishburn 95.3 6

Hartlepool North 95.8 13

Peterlee 93.3 11

Ryhope 97.0 17

Seaham 96.3 11

Hartlepool Cluster Total 95.7 58

Lanchester Rd Cluster Chester-le-Street 100.0 8

Consett 98.8 23

Crook 100.0 5

Gilesgate 94.5 11

Stanley 98.3 16

Lanchester Road Cluster Total 98.2 63

Stockton Cluster Billingham 93.5 4

Darlington 100.0 3

Hartlepool South 94.7 9

Stockton 100.0 4

Stockton Cluster Total 96.3 20

South Division Total 171


CCM’s reported from North Divisions from the following clusters:

North Division CCM Observational Audits April 2017 – March 31st 2018 by Cluster and Station

Cluster Station Score Audits

Alnwick Cluster Alnwick 93.0 2

Amble 80.0 1

Belford 86.0 2

Berwick 97.2 5

Blyth 86.0 1

Alnwick Cluster Total 91.8 11

Backworth Cluster Backworth 93.0 1

Wallsend 80.0 1

Backworth Cluster Total 86.5 2

Blucher Cluster Blucher 99.5 13

Central 100.0 7

Haltwhistle 100.0 1

Hexham 99.0 7

Blucher Cluster Total 99.5 28

Monkton Cluster Gateshead 87.8 14

Monkton 100.0 7

Prudhoe 97.0 7

South Shields 95.8 13

Swalwell 96.5 8

Washington 100.0 6

Monkton Total 95.0 55

Pallion Cluster Pallion 96.8 15

Rainton Bridge 88.3 4

Pallion Cluster Total 95.0 19

Cramlington Cluster Ashington 90.5 8

Cramlington 91.5 8

Morpeth 93.0 2

Wideopen 81.6 7

Cramlington Cluster Total 88.5 25

North Division Total 140


6.3 Hand Hygiene Compliance

Hand hygiene compliance for Unscheduled Care staff has been monitored by the

CCM’s reporting the numbers of complaint staff and also using the World Health

Organisation’s 5 moments of hand hygiene model endorsed by NEAS Hand Hygiene

policy (2016).

Moment 1 is before patient contact

Moment 2 is before a clean / aseptic technique

Moment 3 is after body fluid exposure

Moment 4 is after touching a patient

Moment 5 is after touching patient surroundings

Hand Hygiene Compliance April 2017 – March 2018 Unscheduled Care Staff

Month Opportunities Taken / Compliance

Staff Compliance

April 97/101 18/20 96% 90% May 163/179 18/27 92% 67% June 181/192 28/35 94% 80% July 293/307 39/48 95% 81% August 300/317 40/48 95% 83% September 137/160 25/30 86% 83% October 100/101 23/24 99% 96% November 169/170 13/13 99% 100% December 4/4 1/1 100% 100% January 48/51 9/10 94% 90% February 79/84 18/20 94% 90% March 166/170 28/32 97% 87% Total

1735/1835

94%

260/308

84%


Hand Hygiene Compliance Un-Scheduled Care Staff April 2017 – March 2018

Compliance with Opportunities of 5 moments of Hand Hygiene2017 -2018

HH Moment

April 2017

May June July August Sept Oct Nov Dec Jan 2018

Feb March Annual Total

Before patient contact

22/24 31/38 41/47 66/71 70/75 31/33 21/22 35/36 1/1 10/11 18/20 41/42 387/420 92%

Amber

Before aseptic technique

16/17 32/32 32/32 51/52 60/63 24/31 21/21 35/35 1/1 10/10 12/12 29/30 323/336 96%

Green

After body fluids

13/13 32/32 22/22 57/57 41/43 24/31 24/24 24/24 8/9 11/11 13/13 269/279 96%

Green

After patient contact

24/24 36/38 43/46 65/68 63/68 30/33 17/17 35/35 1/1 11/11 17/20 43/45 385/406 95%

Green

After environment contact

22/23 32/39 43/45 54/59 66/68 28/32 17/17 40/40 1/1 9/10 21/21 40/40 373/395 94%

Amber

Total

97/101 163/179 181/192 293/307 300/317 137/160 100/101 169/170 4/4 48/51 79/84 166/170 1735/1835

Compliance 96% 92% 94% 95% 95% 86% 99% 99% 100% 94% 94% 97% 94%

RAG Green Amber Amber Green Green Red Green Green Green Amber Amber Green Amber

Staff Compliance

Staff 18/20 18/27 28/35 39/48 40/48 25/30 23/24 13/13 1/1 9/10 18/20 28/32 260/308

Compliance 90% 67% 80% 82% 83% 83% 96% 100% 100% 90% 90% 87% 84%

RAG Red Red Red Red Red Red Green Green Green Red Red Red Red

RAG: Red below 90% Amber 90% - 94% Green 95% - 100%


Overall annual compliance with the 5 moments of hand hygiene is reported at 94%

however when measuring staff compliance overall compliance is 84% that is 260

staff from 308 fully compliant. The observational audit provided evidence that CCM’s

discuss hand hygiene with non-compliant staff. Further breakdown of the 5

moments of hand hygiene compliance has been undertaken by the IPC Manager

which shows lowest compliance was with moment 1 before patient contact 92%.

6.4 Compliance with Bare Below the Elbow

Unscheduled Care and Scheduled Care staff combined reports 630 from 646 an

annual compliance of 97% being bare below the elbow. Compliance with

unscheduled care staff being bare below the elbow has improved over the year with

an overall compliance of 95% CCM’s also provided clear evidence that non-

compliant staff had been reminded of the BBE policy.

Unscheduled Care Staff Bare Below the Elbow Compliance April 2017 – March 31st 2018

April May June July Aug Sept Oct Nov Dec Jan Feb Mar Annual Total

20/20 31/33 33/35 47/51 47/49 29/30 24/24 24/24 1/1 10/10 18/20 30/32 314/329

100% 94% 88% 92% 96% 96% 100% 100% 100% 100% 90% 91% 95%

Scheduled Care Staff Bare Below the Elbow Compliance April 2017 – March 31st 2018

April May June July Aug Sept Oct Nov Dec Jan Feb Mar Annual Total

13/13 No data

12/12 11/12 26/26 41/41 42/42 32/32 37/37 42/42 42/42 18/18 316/317

100% 100% 92% 100% 100% 100% 100% 100% 100% 100% 100% 99%

6.5 Compliance with staff wearing alcohol gel

Alcohol gel use has been endorsed by NEAS since the 2008 aimed at increasing

hand hygiene compliance in health care workers. 2017 - 2018 compliance has

significantly improved from 87% in 2016 – 2017 to being reported at 96%

Unscheduled care staff reporting 94% and scheduled care staff 99%.


Personal Alcohol Gel Observed Compliance RAG

Unscheduled Care 308/328 94% Amber

Scheduled Care 315/317 99% Green

Total 623/645 96% Green

6.6 Aseptic Non Touch Technique (ANTT)

Patients having an intra vascular device inserted are at high risk of developing a

health care associated infection the procedures for insertion requires an ANTT

technique to help minimise the risk EPIC (2014). CCM’s audited ninety- two

paramedics inserting cannula during ride outs and all were reported as being 100%

using an ANTT providing assurance staff are adhering to IPC policy.

6.7 Personal Protective Equipment (PPE)

Glove Use

CCM’s have reported poor compliance with staff wearing personal protective

equipment including gloves and aprons. Infection Prevention & Control

responded to this and facilitated face to face sessions on basic PPE at

mandatory training during 2017 -2018. There was evidence provided by some

CCM’s that they are addressing this issue an example of a comment being:

“Gloves were being used unnecessarily by both crew members, also gloves in

cab area – removed gloves and discussed with both”. Appropriate glove use

indicated by changing gloves between procedures is reported as overall 90%

however the overall compliance drops when taken into consideration effective

IV cannulation compliance 2017 - 2018

Month Observed Compliant Percentage April 4 4 100% May 6 6 100% June 9 9 100% July 18 18 100% August 16 16 100% September 8 8 100% October 11 11 100% November 11 11 100% December 0 0 January 2 2 100% February 4 4 100% March 7 7 100% Total 92 92 100%


glove use by cleaning hands before and after glove use, reported as having an

overall compliance of 88%. The previous year 2016 – 2017 there was overall

compliance of 80% so although compliance has improved it is recognised this is

an area of concern that requires further improvement.

Glove Use April 2017 - March 31st 2018

Apr May Jun July Aug Sept Oct Nov Dec Jan Feb Mar Total

HH before glove use

16/19 22/23 21/27 46/50 38/47 24/28 21/22 12/13 1/1 8/10 11/16 17/27 237/283 83% RED

Gloves changed between procedure

14/16 26/30 24/25 39/44 33/38 15/20 21/21 8/8 No data

7/7 14/15 14/15 215/239 90% RED

HH after glove use

18/20 28/34 24/29 45/50 42/48 24/28 24/24 13/13 1/1 10/10 16/16 26/28 271/301 90% RED

Total 723/823 88% RED

Apron Use

Overall compliance with apron use is poor 77% requiring improvement and it is

identified that apron use has not been embedded into everyday practice by

ambulance crew which includes CCM’s who frequently report that apron use was

not applicable at the time of audit. There is some evidence that some CCM’s are

encouraging their staff to use aprons by comments made including from one

CCM: “discussed use of aprons from sluice when cleaning vehicles”. The

NASIPC Group has proposed a project to improve PPE is taken forward

nationally in 2018.

Apron Use April 2017 - March 31st 2018

Apr May June July August Sept Oct Nov Dec Jan Feb Mar Total

Aprons for cleaning

8/9 7/10 3/5 11/15 16/22 5/9 16/17 5/5 No data

1/2 2/4 5/8 79/106 74% RED

Aprons body fluid contact

6/6 5/8 3/4 11/16 14/14 5/8 16/17 6/6 No data

2/2 3/4 2/6 73/91 80% RED

Total 152/197 77% RED


6.8 Vehicle Audits Scheduled Care Service Three-hundred and fifty nine vehicles have been audited by scheduled care managers, which is ninety nine vehicles less than the previous year. Cleanliness compliance has been reported as high throughout the year (97% - 100%) and there is evidence that SCM’s who document poor compliance rectify this at the time of the audit. The highest item of non-compliance was eight vehicles not having an evidence of a clean sticker 98% and four vehicles were not segregating waste correctly. Overall compliance for scheduled care vehicles is 98% providing assurance vehicles are clean. As the audit results demonstrate excellent compliance a review of the volume of vehicle audits in scheduled care has been undertaken and this has been reduced to scheduled care vehicles being audited twice a year rather than quarterly. Scheduled Care Vehicle Cleanliness Audits 2017 –2018

Quarter Vehicles Compliance

Apr - June 37 99% July – Sept 79 98% Oct - Dec 125 98% Jan – March 118 98% Annual Total 359 99%

6.9 Vehicle Audits Unscheduled Care Services CCM’s carried out two hundred and forty-nine vehicle cleanliness audits ninety –five

more audits than the previous year when overall compliance with cleanliness was

reported as requiring improvement at 87%. The increase in audits carried out by

CCM’s gives assurance that CCM’s are checking vehicles cleanliness and with an

overall 95% score assurance is given that vehicles are clean.

CCM Vehicle Audits by month Score Number

2017 Apr 96.1 16

May 94.3% 18

Jun 97.1% 6

Jul 91.4% 12

Aug 95.5% 23

Sep 97.1% 19

Oct 95.3% 38

Nov 97.0% 44

Dec 97.0% 37

2018 Jan 91.9% 6

Feb 94.4% 13

Mar 95.4% 17

Total 95.2% 249


The five lowest compliance items reported were: EPCR/Tough book, cab area,

Styrker chair and evidence of a recent clean by crew, all other items were over 90%

compliance. Stryker chairs are being replaced in 2018.

CCM Vehicle Audits April 2017 – March 31st 2018

Lowest compliance item Score

EPCR 71.8%

Cab area is clear of gloves 85.1%

Stryker Chair 85.1%

Evidence of recent clean by crew 85.9%

6.10 Station Cleanliness Audits 2017-2018

There are currently fifty-two stations open at NEAS and a further two facilities that

crew use at Wooler and Rothbury. (April 2018). Station Support Officers (SSO’s)

carried out 451 station audits using the IPC electronic application that is an

increase of 145 audits from the previous year and a 24% increase with the audit

schedule. The IPC manager has worked with SSO’s to embed the IPC audit

schedule and the number of audits has increased in the 3rd and 4th quarter.

SSO’s are also ensuring clinical stock is rotated on stations and not left lying as

previously reported in first and second quarter of IPC manager verification audits.

SSO Station Cleanliness Audits 2017 – 2018

SSO Station Audits April 2017 – March 2018 Cluster Score Number

Alnwick Cluster 92.9% 26

Backworth Cluster 96.9% 40

Bishop Cluster 96.9% 47

Blucher Cluster 97.3% 34

Coulby Cluster 94.0% 31

Hartlepool Cluster 98.4% 69

Lanchester Road Cluster 97.8% 54

Monkton Cluster 96.6% 66

Pallion Cluster 97.1% 25

Stockton Cluster 97.7% 47

Cramlington Cluster 92.2% 12

Annual Total 96.8% 451 IPC Station Validation Audits

During 2017-2018 Seventy –seven audits were carried out by the IPC Manager

monitoring 49 ambulance stations and validating SSO Station audits. The

findings of the station audits carried out by the IPC manager were reported to


Operational Managers and local action plans instigated and included in bi-

monthly reports presented to PSG.

Green 95-100% 3 Stations

Amber 90-94% 22 Stations

Red 89% or below 24 Stations

IPC Station Validation Audits May 2017 – March 31st 2018

Trends in poor compliance from the station cleanliness audits identified clinical storerooms not being clean or not having evidence of a recent clean. This issue was partially due to domestics not being given access to store rooms that hold medicines. This was entered on the risk register and an action plan has been implemented to ensure cleaning of store rooms takes place. Although an increase in compliance has been reported in December 2017 (90%) it is still not embedded and is reliant on SSO’s signing evidence sheets/taking on cleaning duties if domestic services are not gaining access. Hospital laundry, mostly blankets being on stations is a reoccurring issue and Operational Managers have been asked to address this, a task and finish group has been set up to try and resolve this issue.

IPC & SSO Cleanliness Audits April 2017 – March 31st 2018 Lowest compliance item Total Score

There is evidence that the domestic has access to clean the floor / shelves (Store room2) 70.4%

There is evidence that the domestic has access to clean the floor / shelves (Store room1) 79.4%

The station is free of hospital laundry and personal blankets 81.0%

The sluice floor is clean and dry 88.4%

The microwave is clean 89.8%

86.2%

82.1%83.6%

91.5% 90.8% 90.6%93.0%

88.3% 88.4%

93.0%

0

2

4

6

8

10

12

14

16

18

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

May Jun Jul Aug Sep Oct Nov Jan Feb Mar

2017 2018

Sum of Score Number Trend


Mop buckets are clean ,dry and inverted 93.0%

Sluice walls are clean and free from contamination and splashes 93.2%

Ceilings are in good condition 94.1%

The floor is kept free of all stores 94.2%

Sharps containers are locked 94.3%

No inappropriate items are stored 94.5%

Sanitising wipes are available 94.6%

The fridge is clean 94.6%

6.9. The Annual IPC Audit Schedule 2018-2019

This can be found in in Appendix C

7. Service and Building Developments

The IPC Manager provided advice to ensure that design of new buildings or changes

to existing ones are fit for purpose and meet the required standards for IPC

legislation, guidance and best practice. The IPC manager provided IPC assurance in

support of the successful bid for 111 services.

The results of IPC premise and station audits have identified estates issues relating

to IPC non-compliances, these are reported and rectified as soon as possible by the

Estates and Facilities team.

8. Serious Incidents and Complaints

NEAS has reported no Serious Incidents related to IPC.

For 2017/18 there have been no IPC-related Formal Complaints/PALS

9. Key Achievements, Risks and Mitigations

Key achievements in 2017/18 include the increased use of the electronic auditing

application allowing access to more frequent data about the cleanliness of stations

and vehicles. CCM’s taking on their IPC Champion role is also being embedded as

shown in the increase of observational and vehicle audits.

Risks

Emerging infectious diseases remains a global threat with a potential to impact

upon the UK population. Middle Eastern Respiratory Syndrome (MERS) is still a

concern for people travelling from affected areas. Lessons learned from the

Ebola response were used to ensure all plans in place are tested and effective

and updated where required. Increasing antimicrobial resistance (AMR) that

impacts upon health care systems can be seen including the emergence of

Carbapenem resistance in the North East of England. An IPC risk assessment


tool for operational staff has been approved at PSG in May 2017 to help staff

assess patient’s infectious status and was included in staff induction and

mandatory training. This provides prompts to consider IPC issues when in direct

contact with all unscheduled patients. Relevant information would then from part

of the handover process.

AMR is identified in the 2018 Trusts Quality Strategy and governance will be

through the Medicines Optimising Group which commenced in March 2018 and

will be implementing an AMR Strategy in 2018 – 2019. AMR awareness training

has been introduced and 263 staff received face to face training sessions this will

be progressed through 2018 – 2019.

Tissue Viability – Pressure ulcer reduction collaborative

NEAS has been working closely with regional NHS partners across the North

East to see how they can effectively work more closely together towards earlier

identification of patients with suspected or actual pressure sores. NEAS is often

the first point of contact for many patients to the NHS; therefore they are often the

first to encounter patients who are susceptible to pressure area damage. A

pressure ulcer risk assessment tool was ratified by PSG in May 2017 and was

piloted October to December 2017 using Pallion, Ryhope and Monkton Clusters

and involved placing an pressure ulcer alert bracelet on patients at risk who were

being admitted to Sunderland Royal Hospital. An evaluation report of the pilot

recommends use of the pressure ulcer risk assessment and for staff to document

on the electronic patient clinical record. There is potential for the wider NHS

economy to benefit by minimising the risks of tissue damage and by using an

alert bracelet may be beneficial to patients. Discussions are currently ongoing

through the Directors of Nursing forums. Tissue Viability is on the Trusts Quality

Strategy with key indicators to take forward.

10. Summary and Conclusion

Patient safety remains a priority for the Trust and infection prevent and control is

integral to maintaining this. The Trust has shown its commitment to IPC by the

systems and processes implemented during 2017– 2018. The key achievements

over the year continue to be associated with embedding IPC standards firmly from

Board to frontline as demonstrated by audit results and the increase of audits

undertaken, by means of a comprehensive communication plan and joint working

between IPC and Operational staff. Key priorities for the coming year are to achieve

compliance across divisions and service lines with the audit schedule, including IPC

validation audits to ensure we can provide assurance for practice and environmental

domains. Although much has been done on all fronts to continue to drive quality IPC

standards to all NEAS staff, to move forward requires the continued support and

commitment from the Board to support the IPC team in the delivery of the work plan.


Appendix A: 2017 – 2018 Infection Prevention & Control Audit Schedule Compliance Summary

Audit Type Target to be achieved Auditor Assurance Compliance with Audit Schedule

Compliance with Policy

IPC Vehicle validation audit

200 vehicles Vehicle compliance 96%-100% Green 90% -95% Amber 89% and below Red

IPC Officer

Report compliance to PSG bi-monthly IPC Annual audit report

No vehicle audits were undertaken in 2017 – 2018 due to the vacant PC Officer post

Monitoring of scheduled vehicle cleans

All NEAS vehicles MW/GG

Report results to PSG IPC Annual audit report

Reported bi-monthly to PSG schedule on track

Unscheduled Care Vehicle Spot Check

147 DCA Vehicles (approx.) Initial target was to audit at the time of observational ride outs with staff however this was reduced for vehicles to be audited twice yearly = 294

CCMS Paramedics on alternative duties

Report compliance to PSG bi-monthly Annual Report

249 Unscheduled Care vehicles audited = 85%

Cleanliness compliance reported as year total 95%

Scheduled Care Vehicle Spot Check and Scheduled Care Bare Below the Elbow

PTS Vehicles 220 per quarter = 880 annual – This target was identified as unrealistic and reduced to vehicles being audited twice a year= 440

Scheduled Care Mangers

IPC Report to PSG Annual Report

359 schdueled care vehicles were audited achieving 81% compliance with audit schedule

Scheduled Care Vehicle cleanliness reported as 99%

Scheduled Care Staff reported as 99% complaint with BBE

Premise/Station Cleanliness

All stations/premises to be audited once per year Station Compliance Green 95% -100% Amber 90% - 94% Red below 90%

IPC Manager

IPC Report results to PSG IPC Annual report

77 station audits were completed representing 100% compliance with audit schedule

Complaince with IPC station cleanliness; 25 stations Green 18 staitons Amber 7 stations Red


Station Audits All stations 50 stations monthly 600 annually

SSO’s IPC Reports to PSG 451 SSO Station Audits have been completed 75% compliance with audit schedule

The overall year compliance with cleanliness is reported as 97 %

Premises/Station Cleanliness

All stations will have cleaning monitored in each quarter

Cordant Reporting to IPC monthly to PSG IPC Annual Report

Cordant have provided evidence of all stations monitored quarterly in 2017- 2018

Monitoring scores provided by Cordant are Green over 95%

Observational Audits of Practice including Hand Hygiene ANTT BBE PPE

All unscheduled care staff to be observed at least once per annum 1600

CCM’s

Reporting to IPC monthly to PSG IPC Annual Report

311 Observational Audits submitted by 35 CCM’s representing 19% of audit schedule

Hand Hygiene year total for staff compliance 85%

Compliance with 5 moments of HH 94%

ANTT reported as 100% compliance

BBE year total reported as 95%

Staff wearing alcohol gel 94%

PPE year total reported as 88 % Gloves 88% Aprons 77%

Sharps / Clinical Waste All stations audited monthly

SSO’s & IPC Reporting to CCMs IPC report results to PSG IPC Annual Report

Sharps and Clinical waste audits included in SSO’s and IPC Station Audits totals 528 audits completed in 2017 – 2018 representing 88%

Compliance with Clinical Waste policy identified from the station audits as compliant


compliance with audit schedule an increase of 29% from the previous year.

Appendix B: Infection Prevention & Control Programme 2018-19

The programme identifies the Infection Prevention Control (IPC) activities that the Team will focus on for the coming year.


Action Timescale Responsibility

1. IPC policies and procedures are up to date and available for staff.

Review IPC section on the intranet in line with current evidence base

Ongoing

IPC Manager

2 Infection Control Champions provide role model for staff

Embed communication channel for IPC Champions Provide up to date training materials for champions

April – July 2018 July – September 2018

IPC Manager Operational Clinical Service Managers

3. Education and Training To maintain and increase compliance of Mandatory & Statutory to over 95%. To increase compliance of Induction training to 95%

2018 – 2019

Infection Control Manager & Educational & Development team


Update IPC training materials Attend monthly meetings across divisions with Scheduled Care Managers and Unscheduled Care Managers

December 2018 Monthly

IPC Manager

4. Audits IPC Audits will monitor IPC policy and practice IPC Audits will monitor standards of cleanliness of equipment and environment Data collection / reporting to be electronic IPC Dashboard development

IPC Team CCMs SCM’s SSO’s Informatics /IPC Team

5. New builds and refurbishments

Estates and Facilities to ensure the Infection Control Team are informed of and involved in the

As required IPC Manager & Estates & Facilities Team


A

Audit Type Target to be achieved Auditor Assurance Vehicles validation audit at emergency departments

200 vehicles Infection Prevention Manager & IPC and Support Officer

Report results to PSG IPC Annual audit report

Scheduled Care Vehicle Cleanliness Audits

440 annually (Represents vehicles being audited twice a year)

Scheduled Care Mangers Report to PSG

Unscheduled Care Vehicle Cleanliness Audits

300 annually (Represents vehicles being audited twice a year)

CCM’s Report to PSG

development and planning to ensure all standards are met

6. Staff Health and Safety Increase compliance of point of use disposal of sharps through education and training. Respond to incidents with investigation.

Ongoing

IPC Manager & Risk Team

Appendix C: IPC Annual Audit Schedule 2018 - 2019


Monitoring of cleaning of Vehicles To agree % of vehicles monitored and 5 of vehicles ATP screened

M Woods Report to PSG

Premise/Station Cleanliness Validation Audit

All stations/premises to be audited once per year

Infection Prevention and Control team

IPC Report results to PSG

Station Cleanliness All stations will be audited once every month

SSO’s & IPC Team PSG

Premises/Station Cleanliness All stations will have cleaning monitored in each quarter

Cordant Reporting to IPC monthly to PSG IPC Annual Report

Observational Audits of Practice Hand Hygiene PPE ANTT Peripheral Cannulation

All unscheduled care staff observed at least twice per annum

Operational Mangers & CCM Reporting to IPC monthly PSG IPC Annual Report

AMR Audits To be decided dependent on IT support systems in place

Advanced Practitioners Medicines Optimising Group/PSG

BBE Alcohol gel use

All clinical staff observed twice a year

CCM’s & SCMs Reporting to IPC monthly PSG IPC Annual Report

Sharps / Clinical Waste All stations audited monthly SSO’s Reporting to CCMs IPC report results to PSG IPC Annual Report

Documents

Infection Prevention and Control Annual Report April 2017