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Infection prevention and control
ANNUAL REPORT
2014/2015
Authors:
Emma Dowling – DIPC/head nurse
Laura Search – PA/IPC data manager
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CONTENTS
GLOSSARY .................................................................................................................................................................... 4
1. Compliance criteria one ...................................................................................................................................... 7
1.1 Risk assessment ................................................................................................................................................ 7
1.2 Director of infection prevention & control (DIPC) ............................................................................................... 8
1.4 Assurance framework ........................................................................................................................................ 8
1.5 Infection prevention & control programme ......................................................................................................... 9
1.6 Infection prevention & control infrastructure ...................................................................................................... 9
1.7 Movements of patients ..................................................................................................................................... 10
2. Compliance criteria two .................................................................................................................................... 11
2.1 Cleaning services ............................................................................................................................................. 11
2.2 Deep clean programme ................................................................................................................................... 12
2.3 Monitoring arrangements ................................................................................................................................. 13
3. Compliance criteria three .................................................................................................................................. 14
4. Compliance criteria four .................................................................................................................................... 15
5. Compliance criteria five .................................................................................................................................... 15
6. Compliance criteria six ...................................................................................................................................... 16
7. Compliance criteria seven ................................................................................................................................ 17
8. Compliance criteria eight .................................................................................................................................. 17
8.1 Laboratory support ........................................................................................................................................... 17
9. Compliance criteria nine ................................................................................................................................... 18
9.1 Policy audits 2014/2015 ................................................................................................................................... 18
9.2 Hand hygiene audit .......................................................................................................................................... 19
9.3 High impact interventions audits ...................................................................................................................... 20
9.4 Antimicrobial stewardship ................................................................................................................................ 22
10. Compliance criteria ten ..................................................................................................................................... 23
10.1 Occupational health services ........................................................................................................................... 23
11. Education .......................................................................................................................................................... 24
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11.1 Induction, training programmes and on-going education ................................................................................ 24
11.2 Link nurse meetings ......................................................................................................................................... 25
12. Performance against national targets ............................................................................................................... 25
12.1 MRSA bacteraemias ........................................................................................................................................ 25
12.2 MRSA screening .............................................................................................................................................. 27
12.3 MSSA bacteraemias ........................................................................................................................................ 28
12.4 Clostridium difficile ........................................................................................................................................... 28
12.5 Surgical site infection surveillance ................................................................................................................... 33
13. Outbreaks ......................................................................................................................................................... 33
13.1 Norovirus .......................................................................................................................................................... 34
14. Ebola ................................................................................................................................................................. 34
15. Legionella and water quality monitoring ........................................................................................................... 36
15.1 Water hygiene .................................................................................................................................................. 36
16. Key actions/achievements in infection prevention and control for 2014/2015 ................................................. 42
17. Key objectives 2015/2016 – annual plan .......................................................................................................... 43
Appendix 1 work programme 2015/2016 ...................................................................................................................... 44
Appendix 2 .................................................................................................................................................................... 51
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GLOSSARY
ARHAI
Advisory committee on Antimicrobial Resistance and Healthcare Associated Infection
BICSc The British Institute of Cleaning Science
C. diff Clostridium difficile
CAC Clinical Assurance Committee
CCG
Clinical Commissioning Group
CDI Clostridium difficile infection
CNS Clinical nurse specialist
CQC
Care Quality Commission
DIPC Director of infection, prevention & control
DoH
Department of Health
GDH
Glutamate dehydrogenase
GRE
Glycopeptide resistant enterococci
HCAI Healthcare associated infection
HCPC Health and Care Professions Council
HII’s High impact interventions
IOSH Institute of Occupational Safety Health
IPC Infection prevention & control
IPCC Infection prevention and control committee
IPCN Infection prevention & control nurse
IPCT Infection prevention & control team
KPI Key performance indicator
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MRSA Meticillin resistant Staphylococcus aureus
MSSA Meticillin sensitive Staphylococcus aureus
NHSLA
National Health Service Litigation Authority
OPD Outpatients department
PHE Public Health England
PIR Post infection review
PLACE Patient led assessments of the care environment
PPM
Planned programme of maintenance
Q A Quality assurance
RCA Root cause analysis
SSI Surgical site infection
SUHFT Southend University Hospital Foundation Trust
TMV Thermostatic mixing valve
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The annual report of the director of infection prevention and control provides information on the
progress of all the infection control activities throughout the year 2014-15. The report seeks to
demonstrate a hospital-wide commitment to the prevention and control of Healthcare Associated
Infections (HCAIs).
For the year 2014-15, one case of MRSA bacteraemia was reported as the hospital apportioned
against a ceiling of zero set by the Department of Health. One further case was identified post 48
hours of admission but following investigation and post infection review (PIR) it was deemed that
the case was a contaminant.
The annual ceiling for Clostridium difficile was no more than 26 cases, the hospital reported 28.
All cases were thoroughly investigated via a root cause analysis (RCA), which concluded that all
appropriate care had been delivered.
During 2014-2015, only one bay on one ward in the hospital was required to be closed for a short
period of time due to Norovirus. In this respect we fared much better than all our neighbouring
acute trusts.
The infection prevention and control team have worked closely with the estates project team
on several major building projects including changes to critical care as part of the project to
install a lift, refurbish Westcliff Ward, development of a new paediatric A&E and clinical decision
unit, refurbishment of theatres 5 and 6 and development of a new foetal assessment unit.
The expert knowledge of team members is essential in ensuring the impact of building works on
patients, staff and hospital visitors is minimized and new builds are fit for purpose and use from
an infection control in the built environment viewpoint e.g. ventilation, impervious surfaces, clean
to dirty work flow etc. The team continues to be active in delivering teaching to all staff, both
clinical and non-clinical at induction, mandatory update and specific, tailored sessions for
individual departments/areas on request
Executive summary
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The trust board recognises its responsibilities for overseeing infection control arrangements
across the hospital guided by compliance criteria one. This includes the infection prevention and
control strategy which outlines individual and the trust’s collective responsibility for keeping to a
minimum the risks of infection and the general means by which it will prevent and control such
risks. The infection prevention and control strategy was reviewed in January 2015 to ensure that
encompassed all regulatory requirements.
1.1 Risk assessment
Infection prevention and control (IPC) is included in all executive objectives and individual
directors are identified as responsible for the implementation of specific areas of the IPC
strategy
Infection prevention and control performance data is continually monitored and reported
monthly. The trust board receives a report on the infection prevention and control
performance data at each bi-monthly trust board meeting; and quarterly reports updating
on compliance with the health act and infection prevention and control annual report are
provided.
Compliance with the Health Act (2008) and any action plans pertaining to infection
prevention and control are monitored through the Infection Prevention and Control
Committee (IPCC), Clinical Assurance Committee (CAC) and the trust board.
IPC performance is discussed at meetings with the DIPC and acting chief nurse and
monitored through the CAC.
The infection prevention and control team (IPCT) are actively involved in necessary risk
assessments to ensure risks involving infection prevention are identified and managed.
Those requiring risk assessment and subsequent entry on the trust risk register are
1. Compliance criteria one 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.
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monitored according to the risk score. Any risk that scores 15 and above is automatically
placed on the corporate risk register and is reviewed monthly and undergoes close
scrutiny by the DIPC, the executive and trust corporate management team.
1.2 Director of infection prevention & control (DIPC)
The head nurse for infection prevention and control is the director of infection prevention and
control, and this has been in the remit of the role since July 2014.
The DIPC’s job description and objectives reflect the responsibilities set out in Winning Ways:
working together to reduce Healthcare Associated Infections in England (DoH 2003).
The DIPC provides a report to the CAC on a monthly basis.
This is the first annual report presented by the head nurse for infection prevention and control in
the role of DIPC to the trust board. The report is also published on the Southend University
Hospital website and made available to the public.
1.3 The Infection Control Committee
IPCC is a key forum for the development and performance management of the infection control
agenda across the organisation. The committee meets bi-monthly and is chaired by the DIPC
with key representation from across the organisation. Membership includes the IPCT, a number
of senior management and senior nurses, the occupational health department, clinical
governance staff, pharmacy, estates and facilities staff and external bodies such as the local
Public Health England (PHE) Health Protection Unit and Clinical Commissioning Groups Infection
Control (CCG).
1.4 Assurance framework
The hospital has an infection prevention and control strategy. This sets out the clear objective for
the hospital of ensuring that patients’ safety in respect of IPC is delivered. This strategy was
reviewed and updated January 2015.
The DIPC provides a monthly performance report to the executive team on a number of infection
prevention and control measures. This includes the trust’s current position against Department of
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Health ceilings for MRSA bacteraemia and clostridium difficile infections. The trust board receives
a report on the incidence of MRSA bacteraemia and of clostridium difficile, and of learning and
practice changes instigated as a result of the outcome of root cause analysis and post infection
reviews (PIR).
Post infection reviews and root cause analysis are undertaken for all cases of clostridium difficile
and MRSA bacteraemias that are hospital apportioned. Any case not hospital apportioned is
investigated by the CCG to identify any links to the hospital or community issues.
The assurance process includes both internal and external measures. Internally the
accountability is exercised via the IPCC ensuring that there is robust scrutiny of compliance with
national standards, local policies, and clinical practice and following post infection reviews (PIR).
External assurance is obtained through the Care Quality Commission (CQC) registration and
unannounced visits, assessment by the National Health Service Litigation Authority (NHSLA)
against their standards for infection control and the Patient Led Assessments of the Care
Environment (PLACE).
1.5 Infection prevention & control programme
The infection prevention and control programme is published annually and areas of the
audit programme are monitored through the IPCC.
The annual programme for 2015-2016 is attached (appendix 1) and includes details of
audit and policy revision.
1.6 Infection prevention & control infrastructure
The infection prevention and control team structure (appendix 2).
The budget for infection control is held by the chief Nurse and managed by the head of infection control/DIPC.
From August 2014 to May 2015 there were two locum consultant microbiologists covering maternity leave.
The head nurse for infection prevention and control is the director of infection prevention and control.
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1.7 Movements of patients
The movement of patients is one of the most significant aspects of infection control management
particularly in an outbreak situation. A key daily activity is ensuring patient safety when allocating
beds or relocating patients.
The IPCT produce and disseminate to relevant personnel via the ‘Daily Patient Alert Report’. This
document comprises of patients that currently are either:
Positive MRSA carriage
Previously known MRSA carriage
C difficile infection
Previous C difficile infection
C difficile carrier
Multi drug resistant organisms
Pulmonary tuberculosis
Norovirus
Any other infection that may require isolation or IPCT input. The team also advises regarding
prioritisation of patients for isolation/single rooms. The IPCT ensure that all patients requiring
isolation are appropriately placed and prioritise isolation requirements through risk assessment
and the best use of those resources available.
During 2014/2015, the IPCN team provided 24 hours availability via ‘on call rota’. The consultant
microbiologists are also available on an on call rota out of hours.
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2.1 Cleaning services
The domestic service department underwent a managerial and operational restructuring process
to redesign how the department operates and implementing the appropriate management
structure to facilitate a better service delivery and maintain an excellent standard of cleanliness.
The aim of the restructuring was to ensure that the department was equipped to meet the ever
growing needs of this challenging environment. Since 9 June 2014, all cleaning duties in
Southend University Hospital Trusts main site and satellite areas are carried out to the agreed
NHS National Specification of Cleanliness 2007 standard.
To implement this standard, there has been a substantial investment in the domestic department
as regards to training, equipment procurement and allocated operational cleaning hours on each
ward/area. Each ward has been allocated 11 hours for daily operational cleaning duties with two
shift patterns to provide continuous cleaning on the wards. To enhance productivity, the
department procured new cleaning equipment (scrubber dryers, hand buffers, carpet machine,
and ride on machine, decontamination machine, steamer, flood machines and vacuum cleaners)
for wards and public areas.
The domestic manager, zone leaders and supervisors all have their licence to practice in BICSc,
an industry leading standard. Using this new skillset they are working closely with the facilities
training team in the training of the domestic staff, aiming for all staff to be in receipt of their
licence to practice BICSc by December 2016.
The domestic manager, zone leaders and supervisors have all completed additional training in
health and safety, obtaining their IOSH certificates in Managing Safely. This qualification along
2. Compliance criteria two
Provide and maintain a clean and appropriate environment which facilitates the prevention
and control of HCAI.
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with the additional knowledge from the BICSc training has developed the domestic management
team, supporting the implementation of a more efficient, effective delivery model of domestic
services across the trust.
A dedicated facilities training department has been created to facilitate any and all training in
relation to the domestic services department
2.2 Deep clean programme
The domestic department have a very well trained cleaning response team (CRT) who are
responsible for the following duties:
Terminal and c.diff daily cleaning – Terminal cleans are requested by ward areas and the CRT
carry out this enhanced cleaning of the room once vacated. When needed, these areas are
sanitised using specialised sterilisation equipment. Isolation rooms used for the care of patients
with clostridium difficile have daily cleans carried out as per the daily isolated patient list, once a
patient has been discharged, then a terminal clean is carried out and sanitization of the room
completed. Following any refurbishment or building works the CRT will carry out a deep clean of
that area prior to it being handed back to the service.
Detailing programme - The domestic department has a detailing programme in place for all
ward areas. Supervisors identify areas in need of attention to detail on wards and these are then
carried out by the CRT.
Ad hoc deep cleaning – The domestic department receives daily requests for deep cleaning,
including cleans required from post building works, major spillages etc. All of these requests are
coordinated via the domestic department and carried out by CRT.
Stripping and sealing programme – The domestic department receives requests for the
stripping and sealing of floors on ward areas, along with a programme already in place these
duties are carried out by CRT being coordinated by the domestic office.
Flood/spillage control – Emergency response of water suction is provided when needed for any
spillages/floods within the trust by CRT and deep cleaning of affected areas after incidents is
then carried out.
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Curtain hanging – There is a four monthly disposable curtain changing periodical in place
delivered by an external contactor on all ward/patient areas. However CRT hang/replace any ad
hoc curtain changes in between this periodical as and when these are requested by wards.
2.3 Monitoring arrangements
Unannounced audits are now in place and are being carried out by the quality assurance
department throughout the trust. Any audited areas that fails it’s expected pass mark, a senior
manager/DIPC will attend the re audit. Audit results are reviewed at the IPCC and reported to the
trust board
The score rating for the risk categories as per NHS 2007 Specification of Cleanliness is as
follows:
Very high 98%
High 95%
Significant 85%
Low 75%
Supervisor checks – Are conducted by the domestic management team on wards to identify
any attention to detail cleaning needed and to maintain the cleaning standards on wards.
Ward manager/matron logs - Are carried out weekly by domestic supervisors to ascertain the
views of the senior ward management in highlighting and rectifying issues as they happen and to
obtain feedback on their wards/areas cleanliness.
Domestics services cleaning patient survey – Are carried out to obtain patient views on the
cleanliness of their environment, allowing the domestic management team to use the information
to continually develop a more efficient domestic service.
Domestic cleaning technical audits - Are conducted on a daily basis on all ward areas by
domestic supervisors using a touch screen tablet to help maintain the cleanliness of the areas,
this information is then used to identify any attention to detail needed and a general view of the
standard of each individual area.
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The infection prevention and control policies are made available to all staff on the
hospital’s internal STAFFnet site as they are produced, reviewed and updated.
Infection prevention and control advice was available at all times including out of hours to
SUHFT staff.
Leaflets giving information and advice about specific infections are available as well as
general information about hand hygiene and not visiting relatives and friends if unwell
which is available on the hospital website.
Alcohol hand gel is available at the entrance to all departments and visitors and patients
are encouraged to use it by both posters and reception staff as appropriate.
In areas such as lavatories there are signs informing patients and their visitors of what to
do if they are dissatisfied with the cleanliness. These are also available in general clinical
areas.
In the case of an outbreak, signs are used to inform visitors of the problem and patients’
relatives are kept informed by telephone if visiting is suspended.
Each ward area has information displaying individual ward or department performance
HCAI’s and environmental cleanliness.
All information developed for patients or their visitors is agreed through the IPCC and
undergoes patient/user group review before publication.
3. Compliance criteria three Provide suitable accurate information on HCAI to the service users and their visitors.
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Information on infections specific to an individual patient is included in the patient’s
discharge summary. In addition the GPs of all patients identified as having Clostridium
difficile, MRSA are sent a letter at the time of the identification of the infection by the IPCT
Patients who may have been exposed to infections such as in a confirmed outbreak of
norovirus are not discharged to any other institutions until the end of the outbreak.
Patients with a significant infection will be seen by a member of the IPCT and will be given
information as well as the opportunity to ask questions, in a small number of instances this
information will be imparted by senior nursing/medical staff on behalf of the ICT.
All patients identified as either:
Positive MRSA carriage
Previously known MRSA carriage
C difficile infection
C difficile carrier
Any other multi-drug resistant organism
These alert organisms are “flagged” on the Medway electronic patient record system
by the IPCT. This ensures that these patients are easily identified to all staff on
subsequent admissions to facilitate their appropriate care.
Microbiology results are available to staff with access to the hospital’s pathology (ICE) system.
4. Compliance criteria four Provide suitable accurate information on infections to any person concerned with providing
further support or nursing/medical care in a timely fashion.
5. Compliance criteria five Ensure that patients 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.
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Policies regarding the management of patients with specific infections are available on the
hospital intranet to ensure that patients are managed appropriately to reduce the risk of
transmission to other patients and/or staff.
The placement of all patients identified as having, or of being suspected as having, an infection is
reviewed daily by one of the infection prevention and control nurses (IPCNs).
An important system which enables early identification of patients admitted with an infection
control alert is the ‘The Hospital Admissions Report’. This information is available to the Infection
prevention and control team, Monday to Friday. This is an important tool in the prevention and
control of transmission of intection.
All permanent and bank staff are required to attend an induction session which includes a
session on infection prevention and control.
Specific induction sessions are provided for locum medical staff.
Infection prevention and control is part of the annual mandatory training required by all
permanent and bank hospital staff and monitored through the mandatory training matrix.
Specific infection prevention e-learning has been developed as an alternative to attending
a face to face session.
All policies and guidelines are published on the intranet to which all staff and permanent
contractors have access.
Any external contractors undertaking temporary work (e.g. building or refurbishment) in the
hospital are required to produce method statements and are supervised by the estate and
6. Compliance criteria six Ensure that all staff and those employed to provide care in all settings are fully involved in
the process of preventing and controlling infection.
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facilities staff in line with the Managing Contractors Policy. They also receive an infection
control ‘tool box’ talk.
Patients who cannot be isolated due to lack of side rooms are formally risk assessed to ensure
that priority for the single room is given to the patient with the greatest need. On a daily basis the
infection control nurses review all patients requiring isolation.
The IPCT are available to provide guidance on single room prioritisation.
The IPCT are involved in capacity meeting at times of high capacity in the hospital to optimise the
use of isolation facilities within the hospital
8.1 Laboratory support
Pathology services at both Southend and Basildon hospital have implemented a joint venture
with Integrated Pathology Partnerships (iPP). The partnership with a private sector partner will
see investment of over £10m in modernising equipment and facilities to deliver a more efficient
and improved service.
The microbiology department provides a comprehensive laboratory and clinical service including
bacteriology, virology, mycology and parasitology. The laboratory has clinical pathology
accreditation and has been approved by the Institute of Biomedical Science for training
biomedical scientists to both HCPC registration and specialist level.
7. Compliance criteria seven Provide or secure adequate isolation facilities.
8. Compliance criteria eight Secure adequate access to laboratory support.
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Existing policies continue to be reviewed and updated systematically and several new policies
written/developed and ratified this year.
Policies
9.1 Policy audits 2014/2015
The Health and Social Care Act’s Code of Practice (2010) requires that all NHS organisations
have an audit programme in place to ensure that compliance with key polices and practice is
being implemented. The audit programme is place to acquire assurance of the understanding
and adherence to policies and in undertaken by the infection control team. Results are reviewed
at the IPCC.
9. Compliance criteria nine Have and adhere to appropriate policies, designed for the individual’s care and provider
organisations that will help to prevent and control infections.
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9.2 Hand hygiene audit
Hand hygiene is the single most important measure for reducing transmission of HCAIs in
hospital. To ensure that the profile of this vital precaution remains high, compliance with the hand
hygiene policy is audited monthly, based on the World Health Organisation’s “five moments for
hand hygiene”. The performance is recorded on the infection prevention dashboard and the
results for the year are shown below. In the hand hygiene audit, staff assess fellow staff
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members on their hand hygiene technique, knowledge of the hand hygiene policy, bare below the
elbow compliance and hand washing facilities. The average compliance for the year was 99.32%.
The IPCT also carries out ad-hoc hand hygiene audits. These results are sent to the Matrons’ for
dissemination.
9.3 High impact interventions audits
High Impact Interventions (HII’s) are based on the care bundle model and published by the
Department of Health as part of the Saving Lives, reducing infection, delivering clean and safe
care programme. The HII’s are specifically aimed at reducing the risks of acquitting a HCAI.
Currently the following seven HIIs are audited monthly and the hospital wide results are included
in the infection prevention and control monthly dashboard reports.
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HII1 Insertion and on-going care of central venous devices.
HII2 Insertion and on-going care of peripheral intravenous devices.
HII3 Insertion and on-going care of peripheral intravenous devices.
HII4 Preoperative and perioperative actions to prevent surgical site infection.
HII5 The reduction of ventilation – associated pneumonia.
HII6 Insertion and on-going care of urinary catheters.
HII7 Reducing the risk from clostridium difficile.
The HII7 (reducing the risk from clostridium difficile) audit is carried out on each patient confirmed
as having C difficile associated disease and every element of the care bundle has been carried
out on each case.
The high level of compliance with the HIIs is reflected in the performance against national targets.
For example, the invasive device tool (IDT) audits associated with the care of peripheral lines,
central lines and urinary catheters illustrates the high standard of care provided to patients with
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these invasive devices. This is likely to be one of the factors in reducing not only MRSA
bacteraemias but also those of meticillin sensitive staphylococcus aureus (MSSA).
9.4 Antimicrobial stewardship
Antimicrobial Stewardship is an essential element, recommended in both the ‘UK five year
Antimicrobial Resistance Strategy’ and 2011 Chief Medical Officer Report, to tackle the
growing challenges of antimicrobial resistance and to improve the safety and quality of
patient care.
A rolling audit and feedback programme continues across the various clinical directorates in the
trust to monitor antimicrobial prescribing standards, as recommended by the ‘Start Smart Then
Focus’ principles.
The majority of antimicrobials are prescribed in the Clinical Directorate of Medicine. The graph
below compares the audit outcomes in this directorate from September 2011 to October 2014.
The antimicrobial prescribing section of the drug chart was developed in late 2013. This was
to ensure prudent antimicrobial prescribing by prompting regular review of antimicrobials,
encouraging documentation of indication and promoting IV to oral switch where appropriate.
It was also expected to prevent inappropriate long duration, and facilitate monitoring of
restricted antimicrobials.
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The positive impact of the new chart was observed in the October 2014 audit. The audit
showed an increase of 20.9% in appropriateness of IV to oral switch when compared to the
pre-new chart audit of the same directorate in 2013. However, documentation of duration
was below expectation at the last audit. Duration was only documented in 43% of the
prescriptions. Improvement in documentation is expected with electronic prescribing.
European antibiotic awareness day (EAAD) was marked in the trust on the 18th of November,
to raise awareness of antimicrobial related issues. It provided an opportunity to showcase,
and promote prudent antimicrobial prescribing. Flyers, crosswords and quizzes were
distributed to the public and staff. Posters were also exhibited.
Electronic prescribing is now live and being rolled out across the trust. This will improve the
quality of antimicrobial prescribing. The choice of antimicrobials will be linked to the
indication, and both duration and indication will have mandatory fields. It will also allow real
time reports to be generated to support expert microbiology input in clinical decision making
around antimicrobial prescribing.
10.1 Occupational health services
The occupational health & wellbeing service is committed to providing a service that contributes
towards a safe environment and promotes health and wellbeing at work. This commitment is
supported by a range of operating procedures which complies with current legislation, policy and
best practice.
The service has achieved the Safe Effective Quality Occupational Health Service (SEQOHS)
accreditation which is an assessment of a set of standards which demonstrates a continuous
improvement in the quality of services provided and is evidence that the services provided are
robust, safe and effective.
10. Compliance criteria ten 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 all staff are suitably
educated in the prevention and control of infection associated with the provision of health
and social care.
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The occupational health department has also signed up to the public health responsibility deal
and updates progress against 10 pledges to the Department of Health annually.
The occupational health & wellbeing service works closely with other teams within the trust
including infection prevention and health and safety.
6,609 appointments were undertaken by the OH&WBS in 2014.
The seasonal influenza vaccination is offered to all staff to protect patients, staff and their
families, and the percentage of healthcare workers vaccinated in 2014/15 was 59.3%.
Attendance management referrals are one of the core activities undertaken by the OHD.
507 management referral appointments were held in 2014 following referrals from
managers and 173 members of staff self-referred themselves to the service.
11.1 Induction, training programmes and on-going education
The delivery of training throughout has continued to be recognised as of paramount importance
and is a key element of the infection prevention and control service. The IPCT provides training
for the trust, on the corporate induction, both clinical and non-clinical mandatory training
sessions, all grades of medical staff training and student nurse training. All educational sessions
delivered include the fundamental principles of infection prevention and control such as hand
hygiene, the wearing of personal protective equipment, cleaning of the environment and the
actions that the trust are taking to minimise the risk of transmission of infections. Any new
published national guidance or changes to current practices are integrated to all training. In
addition, the IPCT provides ad-hoc training for individual areas/groups of staff where the need is
identified or upon request.
External contractors undertaking temporary work (e.g. building or refurbishment) in the hospital
receive an infection control ‘tool box’ talk and certificate of attendance.
11. Education
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11.2 Link nurse meetings
The infection control link nurses meetings are held quarterly and held mid-day as this was
thought to be a more suitable time to allow more staff to attend.
The meeting involves a short presentation relating to an aspect of infection control, followed by
the IPCN giving the group up to date information on recent events such as RCA feedback, new
initiatives, key priorities and any other relevant information. The group are then expected to
disseminate the information to their clinical areas.
12.1 MRSA bacteraemia
Meticillin resistant staphylococcus aureus (MRSA) bacteraemia
Staphylococcus aureus is a bacterium commonly found colonising humans. Although most
people carry this organism harmlessly, it is capable of causing a wide range of infections from
minor boils to blood stream infections.
MRSA is a strain of staphylococcus aureus that is resistant to flucloxacillin and other antibiotics.
The Department of Health introduced mandatory surveillance and reporting of MRSA
bloodstream infections in 2001 and since April 2005 NHS acute trusts have been set annual
targets for reducing MRSA blood stream infections.
For the period April 2014 to March 2015, the trust target for MRSA blood stream infections was 0
acute trust apportioned cases. The trust did not achieve this target with two MRSA bloodstream
infections reported. This is extremely disappointing given previous years performances.
Both cases have been through the post infection review process (PIR).The first case was
identified as hospital acquired and the second case following investigation and post infection
review (PIR) was deemed to be a contaminant. Following the two bacteraemia cases a formal
review of the invasive device tool (IDT) was undertaken and completed February 2015 and
significant education in avoiding contaminated samples blood leading to false positive results.
12. Performance against national targets
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Post infection review (PIR) of MRSA bacteraemia cases
The trust undertakes a PIR following all cases of MRSA bacteraemia in order to identify any key
issues and themes. Action plans are then put into place to address any issues. The PIR is
completed by the clinicians and nursing teams involved in the care of the patient, a strategic
review of the PIR is undertaken by the microbiologist, antimicrobial pharmacist, public health,
infection control nurse and the director of infection prevention and control – the results of this
review are then fed back to the clinical teams.
The PIR is required to be uploaded onto a PHE database within seven days of notification of the bacteraemia. This was achieved in both cases.
MRSA bacteraemia – number of post 48 hour cases 0 Tolerance ceiling
Actual Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
1
0 0 1 0 0 0 0 0 0 0 0
MRSA bacteraemia pre and post 48 hours of admission
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12.2 MRSA screening
MRSA screening of elective admissions
The rationale for screening non-emergency patients is to identify MRSA carriers, enabling
application of topical decolonisation or suppression treatment either immediately prior to
admission or on admission and the use of appropriate systemic antimicrobial prophylaxis at time
of procedure, if this is appropriate.
Our local experience demonstrated that universal screening of all elective admissions was not of
benefit to many subsets of patients and a proposal to adopt a risk-based approach was approved
by the commissioners June 2014.
We have continued to screen elective patients in the following subsets:
All patients that are undergoing major abdominal surgery e.g. abdominal hysterectomy, major
orthopaedic or vascular procedures
Also patients that meet any of the following criteria will be screened:
From nursing/residential home
Is a previous MRSA carrier
Had an inpatient stay within last 6 months
Has any wounds
Has an existing dermatological condition including cellulitis and eczema
Has a urinary catheter
Is a healthcare worker
Have a spouse or partner who is MRSA positive
Have a spouse who is a healthcare worker
Screening rates are monitored monthly and a further improvement
MRSA screening of emergency admissions Work to achieve 95% screening on all emergency admissions continues. The DIPC and matrons
regularly review compliance levels and explore approaches to achieve the 95% target. On
analysis an increase in the levels of omissions tends to occur when the volume of patients
admitted is higher than usual or when staff are not substantive in that area. This has been
addressed with training and embedding screening as part of the admission procedure.
P a g e | 28
12.3 MSSA bacteraemia
MSSA bacteraemia The IPCT continue to report all meticillin sensitive staphylococcus aureus bacteraemia (MSSA)
cases via the MESS system on a monthly basis. It was anticipated that national trajectories would
be set for individual trusts for MSSA bacteraemia; however, to date that has not yet occurred.
For each post 48 hours of admission MSSA bacteraemia case, a review is undertaken by the
IPCT to identify any key themes which require actions.
12.4 Clostridium difficile
Clostridium difficile is a bacterium that releases a toxin which causes colitis (inflammation of the
colon), and symptoms range from mild diarrhoea to life threatening disease. Asymptomatic
carriage also occurs. Infection is often associated with healthcare, particularly the use of
antibiotics which can upset the bacterial balance in the bowel that normally protects against C.
P a g e | 29
difficile infection. Infection may be acquired in the community or hospital, but symptomatic
patients in hospital may be a source of infection for others.
Mandatory surveillance for C. difficile in over 65 year olds has been undertaken since 2004.
Since 2007 episodes of C. difficile in patients between the ages of 2 and 65 have also been
reportable.
Episodes (or cases) are reported via the Public Health England Data Capture System. An
episode consists of one or more C. difficile toxin positive stools during a 28 day period. Cases
that occur on or after day four of a hospital admission (with day one being the day of admission)
are apportioned to the acute trust with those identified on days 1-3 of admission likely to have
been community acquired and therefore not hospital apportioned.
Diarrhoeal stools submitted to the microbiology laboratory are examined for presence of
C.difficile toxin in accordance with the Department of Health updated guidance on diagnosis and
reporting which was published in March 2012 (DoH 2012) and implemented in April 2012.
This guidance requires that the appropriate samples are tested using a two stage test which
includes a glutamate dehydrogenase (GDH) enzyme immunoassay (EIA) and a sensitive toxin
EIA. Samples that are both GDH and toxin positive must be included in mandatory reporting.
Diarrhoeal stools submitted to the microbiology laboratory are examined for presence of
C.difficile toxin in accordance with the Department of Health updated guidance on diagnosis and
reporting which was published in March 2012 (Department of Health, 2012) and implemented in
April 2012.
All samples for patients who tested positive for the toxin more than 72 hours of admission (post
72 hours) are sent to reference facilities for strain typing to determine whether the cases
represent cross infection.
Strain typing is a specialised service provided by a reference laboratory. This is an indispensable
service which helps us to manage and minimise C. difficile. Strain typing is undertaken to identify
possible clusters of C. difficile cases. This year no linked cases were identified. In addition, there
were no predominant strains present in the trust.
The IPCT has done a large amount of education throughout the year on promoting the use
P a g e | 30
of the Bristol Stool Chart, the importance of rapid isolation of patients with diarrhoea and actions
that reduce the transmission of CDI in the clinical area. This has led to a 9% reduction in post 72
hour cases.
C .diff cases 2006-2014
The table below shows the hospitals performance during the year. The annual ceiling for
clostridium difficile was 26 cases. The hospital reported 28; all cases were thoroughly
investigated via a root cause analysis (RCA).
Clostridium difficile (toxin positive) - number of post 72 hour cases
Year total ceiling – 26
Actual
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
1
3 1 2 4 2 4 2 2 4 0 3
P a g e | 31
The root cause analysis (RCA) process is completed by the relevant ward manager and clinical
team for all hospital apportioned cases. The RCA is presented at the RCA meeting and reviewed
by the infection control team, clinician, consultant microbiologist, anti-biotic pharmacist and ccg
infection control nurse.
The RCA process is required to identify direct lapses in care which may have resulted in C diff
infection. This information is scrutinised by the Clinical Commissioning Group (CCG). Of the 28
hospital acquired C diff infections this year only one lapse of care contributing to infection was
identified in quarter two. (Delay in obtaining a stool sample identified). Learning/actions are fed
back to the ward team, RCA findings are discussed by the DIPC at the Infection Prevention and
Control Committee and Clinical Assurance Committee.
If there are sufficient patients within the trust or patients requiring review there is a C diff ward
round involving consultant microbiologists, antimicrobial pharmacist, an infection control nurse
and the gastroenterologist. This ward round provides expert review and advice, when required,
on the treatment and management of the patient.
Other resistant bacteria
surveillance of glycopeptide resistant enterococci (GRE) bacteraemia
GRE are resistant to glycopeptides (antibiotics such as vancomycin) and have been nationally
reported since 2003. During 2014/15 the trust reported no cases, with the last reported case
being in 2010. Although the incidence remains low the ICT will continue to monitor and report
cases.
Escherichia coli (E coli) bacteraemia
E coli is a species of bacteria commonly found in the intestines of humans and animals. There
are many different types of E. coli, and while some live in the intestine quite harmlessly, others
may cause disease. There is no objective or target associated with this bacteraemia and it is not
included in our performance data. However E coli bacteraemia contribute to a high number of
blood stream infections and the significant effect on both the patient and burden on the health
P a g e | 32
economy should not be underestimated. In total there were 176 E coli blood stream infections for
2014/15 with the significant number of patients admitted with an established bacteraemia.
By using the same data definitions as MRSA and MSSA attributed cases, the trust has reported
the following cases as represented in the following graph. There appears to be a strong
association of urinary catheters with genitourinary related bacteraemia .There has been a lot of
work trust wide and within primary care in relation to reducing unnecessary urinary
catheterisation. This has included training and improved documentation.
Carbapenemase-producing enterobacteriaceae
Carbapenems (such as Meropenem) are a powerful group of broad-spectrum antibiotics which
are often the last effective defence against multi-resistant bacteria. Infections with Carbapenem-
resistant enterobacteria are an emerging threat. It is seen mainly in the Indian subcontinent but
has also been reported in the Mid-East, North Africa, Europe and the USA. In this country, less
than 100 cases have been identified by the Health Protection Agency (now PHE) with bacteria
that are Carbapenem-resistant. Many have been associated with patients who have received
P a g e | 33
prior treatment abroad, in India or Pakistan, but there are reports of a few incidents of cross
infection in the UK.
In December 2013, PHE issued the acute trust toolkit for the early detection, management and
control of Carbapenemase-Producing Enterobacteriaceae (CPE). The toolkit requires that the
trust should have a dedicated preprepared plan to prevent the spread of CPE. The toolkit
required that certain measures relating to screening, identifying, isolating and managing
suspected or confirmed cases are in place by the end of June 2014. The trust is compliant with
the toolkit and has a policy in place.
12.5 Surgical site infection surveillance
Surveillance of orthopaedic surgical site infection (SSI) was undertaken for both total knee
replacement and repair of fractured neck of femur in line with our mandatory requirements for
SSI. The IPCT would have ideally liked to have extended this surveillance with additional surgical
techniques; however this was not achievable in the last year within the resources available, due
to sickness levels within the IPC team.
An outbreak is defined as two or more cases of an organism or condition (such as diarrhoea and
vomiting) within a 48 hour period which is epidemiologically linked. Norovirus is a highly
contagious pathogen responsible for outbreaks in the community (e.g., schools, cruise ships,
13. Outbreaks
2.
P a g e | 34
residential homes, etc.). Norovirus outbreaks occurring in hospitals are normally acquired as a
result of increased activity in the community and the admission of a symptomatic patient from the
community. Nationally, Norovirus activity has been low in 2014/15. Public Health England (PHE)
observed that reports of outbreaks of diarrhoea and vomiting in hospitals continue to be reported
but at lower levels than in previous years.
13.1 Norovirus
The laboratory confirmed an outbreak of Norovirus was contained and resolved very quickly.
Ward Closed Reason Clean
started
Clean
completed
Balmoral Ward(6 bedded bay)18
bed days lost
20.02.15 Confirmed Norovirus – 2
confirmed cases
26.02.15 26.02.15
Since the initial outbreak of ebola (a viral haemorrhagic fever) in West Africa in 2014, and the
subsequent worldwide alert for potentially infected patients and the worried well reporting to
health care facilities for treatment in the UK, the decision was made nationally for NHS England
to assume strategic command and control, as part of their responsibilities; they sought assurance
from health care providers as to their capabilities to handle suspected cases until a definitive
diagnosis was obtained.
Southend hospital as part of that process sent four staff to undertake a ‘train the trainer’ course in
the instruction in the use of personal protective equipment, which was delivered by Public Health
England. Personal protective equipment was subsequently purchased in line with national
guidance
Detailed packs were constructed by the infection prevention
and control team, which contained a diagnostic algorithm,
these were placed in the key areas of the trust were patients
may self-present, these were as follows:
14. Ebola
3.
P a g e | 35
Emergency department
Acute medical units
Surgical assessment unit
Women and children’s
The information contained in the packs:
Algorithm to determine likelihood of infection, by use of both clinical and travel
information.
Required personal protection equipment
Patient flow chart whilst being assessed
Required blood samples and safe handling
Transfer of confirmed cases to national units
Waste management arrangements were put in place, in line with national guidance in order to
ensure compliance with legal requirements on the disposal and storage of contaminated waste.
A multi-agency table top exercise was held at the hospital in order to both strengthen and
determine the trusts knowledge and understanding of assessing and caring for potential infected
patient, and to identify shortfalls within our preparations. Since November 2014, the trust has
assessed four potential cases, who were all referred via other health care providers, none of the
patients was were found to be suffering from Ebola.
New cases of Ebola continue to be diagnosed in West Africa; however NHS England has
confirmed that it will be standing down from its operational response and that this will now be
managed through the emergency preparedness, resilience and response arrangements.
P a g e | 36
15.1 Water hygiene
Highlighted below is an outline of some of the measures which are in place to manage water
hygiene monitoring and control within Southend University Hospital NHS Foundation Trust and
satellite properties under the trust responsibility.
Legionella bacteria
Legionella is a waterborne bacterium. For it to grow and spread within the hot and cold water
systems it needs the presence of sludge, scale, algae, rust, and organic matter, and the ideal
temperature of 20 - 40 degrees C.
Current situation
Currently the trust has a contract with a specialist contractor who carry out a number of planned
preventative maintenance (ppm’s) tasks and other control measures in line with the current
guidance and legislation that is in place namely: HTM– 04 and the ACOP ‘Legionnaires’ disease -
the control of legionella bacteria in water systems (L8), and HSG274 - Legionnaires’ disease:
technical guidance part 2: the control of legionella bacteria in hot and cold water systems.
In addition to the PPMs carried out by the specialist contractor the trust also carries out regular
flushing of water outlets which are used less than twice a week, which increases the turnover of
water and prevents the bacteria forming in stagnant water.
An approved sampling regime is in place to sample water systems throughout the trust and in
satellite properties under the trust responsibility as below.
15. Legionella and water quality monitoring
4.
P a g e | 37
Once a legionella bacterium is detected from elevated sample results various engineering
controls are implemented to try and eliminate the risk of the bacteria reforming. This includes:
removal of flexible hoses if present, increasing temperature, changing or relocating thermostatic
mixing valves, descaling the outlets, daily flushing or chlorination of the complete water system.
Legionella Sampling - 6 Monthly
Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Phase 6
Apr-15 May-15 Mar-15 Jan-15 Feb-15 Mar-15
Tower Block
Prittlewell Wing
Hillborough Wing
Cardigan Wing
Education Centre
Pain Management
Palliative Care
Ladybird Nursery
The Lodge
Urology Outpatients
Churchfield 2
Diabetes & Endocrine Centre
Renal Unit
Carlingford Centre
Nightingale Centre
Neurology/EGG
Radiotherapy (Linac Building)
Facilities (Inc Mortuary)
Old Children's Centre
Main Boiler House Tank Room
Britannia Park
Lighthouse Centre
Canvey Island OPD
Ophthalmology (Eye Clinic)
P a g e | 38
Since 2013 rather than take water outlets out of use, therefore creating disruption to the wards or
departments, in most cases point of use water filters (shown below) are attached to the outlet.
These filters allow the outlet to continue to be used safely whilst engineering action is taken.
These filters ensure that patients and staff were not put at any risk from these elevated counts.
The filters last for up to 60 days. Point of use filters are also designed for showers.
A point of use filter
The graph below shows all the legionella sampling which has been under taken by out specialist
Contractor
P a g e | 39
Below shows the Legionella sample results taken over the last five years.
Year 2011 2012 2013 2014 2015
Taken 46 580 299 253 64
Positive 6 86 19 38 15
Clear 40 494 280 215 49
Percentage Positive 13% 15% 6% 15% 23%
Percentage Clear 87% 85% 93% 85% 76%
All outlets which have returned with elevated sample results are resampled once engineering
actions have been taken, and when results come back clear they are put on to the flushing
register for domestics to flush daily – as a precaution
Going forward a new sampling regime will be implemented which adheres to the relevant
legislation and will target outlets which have produced elevated counts previously.
This regime will be agreed by the Water Assurance Committee which is chaired by the director of
infection, prevention and control, with committee members comprising of the responsible person
for legionella control in water systems, their deputy, infection control matron, EFM quality
assurance and a member of unison.
Pseudomonas aeruginosa
Pseudomonas aeruginosa is a waterborne bacterium which was highlighted in the press in the
early part of 2012 which resulted in the death of four babies, one in Londonderry and three in
Belfast.
It is a tough bacterial strain, which is able to survive in harsh environments. It is found widely in
soil and stagnant water, and can infect humans and plants. It does not usually cause illness in
healthy people, but is described as an "opportunistic" organism, causing serious infection when
our normal defences are weakened. This means that it represents a genuine threat to the most
P a g e | 40
vulnerable hospital patients, most commonly intensive care patients, those with depleted immune
systems such as cancer patients, people with severe burns and premature babies in neonatal
units
In 2012 an interim document was produced advising action which needs to be taken to manage
Pseudomonas aeruginosa; this was superseded by the release of an HTM 04 Addendum in
2013.
To determine what areas within the hospital may possibly be affected all those which fell under
‘augmented care’ were included on a sampling regime in accordance with the HTM addendum
which was risk rated by the Water Assurance Committee with support from Evolution Water
Services as per the below.
Sampling began in the later part of 2012 and is still on-going and is being carried out on a six
month regime.
6 monthly Sampling Regime Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Phase 6
Pseudomonas Aeruginosa Sampling March April May June July Aug
SCBU
Central Delivery Suite
MB1
MB2
Neptune
Critical Care
Kitty Hubbard - HDU
Rochford Ward - ARU
Main Theatres - Post Op Area
Day Stay Theatres - Post Op Area
Eye Theatres - Post Op Area
Renal Unit
A&E
Elizabeth Loury Ward
P a g e | 41
0
20
40
60
80
100
120
140
160
180
200
Oct Dec Feb Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb Apr
2012 2013 2014 2015
Taken
Elevated
As highlighted above sampling has taken place from latter part of 2012 to April 2015, with the results as
shown on the graph below.
Unlike legionella sampling, pseudomonas aeruginosa sampling consists of both the hot and cold
water taps being sampled. Any elevated samples that are identified within the ward, are
investigated for any remediation works that maybe required which typically would include
investigation works, descaling of outlet, servicing of TMV valves, removal of any flexible hoses
and increased daily flushing.
It’s worth noting when initial sample results are received, prior to any engineering actions taking
place a further two samples are taken; one as soon as the outlet is opened (pre-flush), and a
second after water has flowed out of the outlet for two minutes (post-flush). This helps confirms if
the bacterium is in the outlet itself or further back in the water system. As with Legionella, until
the results have been returned as acceptable, as a precaution to protect the end user point of
use filters are installed, or in the case where the filters cannot be fitted, additional hand hygiene
measures are implemented and the outlets are flushed daily.
The first regime of sampling was set up by the Water Assurance Committee to gain a base line
for future sampling to ensure the correct areas are sampled. Going forward, the HTM Addendum
P a g e | 42
will be reviewed further and advice taken from Evolution Water Services as how to be in full
compliance with this new guidance.
The trust continues to take this responsibility very seriously and is aware of the risks inherent in a
multi building site with a number of older facilities. The trust has a Water Quality group which
meets regularly throughout the year monitoring trust performance for both Legionella and
Pseudomonas.
Actions Key Points
Infection prevention and control dashboard
Successfully up and running since 2012. The dashboard provides a system for matrons to upload their high impact intervention scores. The data manager has updated the dashboard and produced a simple guide for users.
IPC policy audits Annual rolling programme of infection prevention and control audits with timely feedback to clinical teams achieved.
MRSA screening for elective and emergency admissions
The ICPT provided support to ensure compliance with the target to help improve compliance with screening
Facilities and estates Successfully worked in conjunction with the trust estates and facilities management team to look at building work/projects/new legislation which require infection prevention and control advice the DIPC has produced a draft policy for the prevention of nosocomial invasive Aspergillosis during demolition /construction / renovation activities in conjunction the estates team.
Mandatory bi-annual updates for infection prevention and control for all staff groups
Continued to provide and support the trust programme at induction and mandatory training sessions – update bi-annually
Policies updated as per programme All IPC policies updated as required
New policies produced in line with current legislation
See section 9.1
Leaflets All IPC leaflets updated as required
16. Key actions/achievements in infection prevention and
control for 2014/2015
P a g e | 43
Surgical Site Surveillance The IPCT has continued to follow a rolling programme.
IPC Link Nurse Continuing work to develop link nurse role to enhance infection prevention & control throughout the trust.
A formal review of the Invasive Device Tool (IDT) was undertaken and completed February 2015.
The IDT’s including tools specific for ITU/HDU and SCBU were reviewed, updated and reformatted as required.
The infection prevention and control staff training record for ad hoc localised infection prevention training was developed and implemented across the trust May 2014
This complements the corporate training needs analysis for all grades of staff.
The production of the ‘antibiotic man’ poster – Ready for roll out April 2015
This has been designed or all clinical areas as an education tool.
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 HCAI’s and ensure that all staff
in the trust is aware of its responsibilities in relation to infection prevention and control.
The trajectories set by the DoH for MRSA and CDI for the forthcoming 12 months remain
challenging.
The team will continue to carry out enhanced surveillance in line with DoH guidance for the
following infections:
Meticillin Resistant Staphylococcus Aureus (MRSA) and
Clostridium difficile
MSSA bacteraemia E-coli bacteraemia
RCA’s action plans generated will be used to provide feedback to clinical directorates of any key
themes. The responsibility will lie with matrons to provide the IPCT with assurance regarding the
implementation of actions put into place to address issues raised. There will be greater focus and
emphasis on sharing lessons learnt within all clinical directorates.
17. Key Objectives 2015/2016 – Annual plan
P a g e | 44
Appendix 1 Work programme 2015/2016
Compliance criteria
points
Programme of work 2015/2016 By whom (lead) Evidence Date to be
achieved
1. Systems for 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 pose to them.
Quarterly infection and prevention reports to the IPCC and
CCG.
director of
infection prevention
& control (DIPC)
Report Quarterly
Continue to raise the profile of the infection prevention and
control team through the trust.
director of infection
prevention &
control (DIPC)
On-going
Ensure infection prevention team is represented in essential
trust committees, such as the health and safety.
DON / ADN DIPC Minutes On-going
Present annual programme 2015/16 (including annual audit
programme) and Annual Report 2015/16 to board of directors
through the Quality Assurance Committee. Ensure report
available to the public (Published on web site). Additional
briefing to board of directors at least yearly.
DIPC / IPC /
matrons
Minutes/risk register/
website
August 2015
Review healthcare associated infection risks identified on the
trust assurance framework/risk register regularly (monthly,
quarterly and as required) and report to board of directors.
DIPC
Minutes/risk register Monthly /
Quarterly
Provide HCAI statistics for performance reporting at board of
directors and at the ipcc, including details of trends.
DIPC Minutes Monthly
Continue to undertake root cause analysis and post infection DIPC, IPCT, ward
managers,
Completed RCA Quarterly
P a g e | 45
Compliance criteria
points
Programme of work 2015/2016 By whom (lead) Evidence Date to be
achieved
reviews for HCAI (MRSA bacteraemia, Clostridium difficile).
Evidence of lessons learnt through the RCA process are
shared and agreed. Evidence of actions implemented
produced an action plan.
matrons.
Tools. Minutes
Review all outbreaks and clusters of HCAI to the Infection
Control Committee.
DIPC,IPCT Minutes. Quarterly
Report Annual report
On-going
Assess new and existing policies with regard to infection
prevention and control and make recommendations for change
in line with current legislation.
IPCT Update programme
with review dates
On-going
Plan and deliver a full education programme for all staff. IPCT Programme / emails /
attendance records
On-going
Update and review the e-learning module for clinical/non
clinical staff.
Develop new methods of providing education for all staff.
IPCT E learning
Programme /
presentation material /
records of undertaking
On-going
Continue to deliver and develop quarterly Link Nurse sessions.
Sessions to include RCA and PIR feedback.
IPCT Programme /
presentation material /
records of attendance
Quarterly
sessions during
2015 / 2016
P a g e | 46
Compliance criteria
points
Programme of work 2015/2016 By whom (lead) Evidence Date to be
achieved
Continue education and support for ward staff to undertake
hand hygiene compliance. Hand hygiene compliance to be
monitored in all in-patient areas monthly. Areas of non-
compliance to be discussed at IPCC.
IPCT Minutes On-going
High Impact Interventions Audits undertaken monthly. Provide
feedback at IPCC regarding progress and recommended
actions.
Matrons Infection Prevention
Dashboard
On-going
2. Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections.
Infection prevention participation with environmental audits and
report poor compliance via the IPCC.
IPCT Matrons Audit reports minutes Bi-monthly
Continued infection prevention and control input /participation
with PLACE assessments.
IPCT PLACE reports and
minutes
As required
Provide expert advice to all service developments to ensure
infection risks are considered and good infection prevention
facilities/practices built into the development.
In particular, ensure that infection prevention is considered in
the built environment through provision of infection prevention
expertise to capital projects from concept stages to
commissioning, as well as more minor refurbishment projects.
IPCT Evidence of sign off of
projects
As required
P a g e | 47
Compliance criteria
points
Programme of work 2015/2016 By whom (lead) Evidence Date to be
achieved
3. Provide suitable accurate information on infections to service users and their visitors.
Continue to produce, update and publish public information
leaflets as required.
IPCT Update programme
with review dates
On-going
Update and review the contents and design of the Infection
Prevention and Control Website as and when required.
ICPT Website On-going
4. Provide suitable accurate information on infections to any person concerned with providing further support or nursing/ medical care in a timely fashion
Review and update letters as required - GP D/N in conjunction
with CCG and local GP’s.
IPCT + CCG ICN Letters On- going
Ensure evidence and data required by commissioners is
available and also presented to IPCC.
DIPC Minutes Bi-monthly
Sharing learning continues across the South Essex Area at
the quarterly IPC network meetings.
IPCT Minutes Quarterly
5 .Ensure that people who have or develop an infection are identified promptly and receive the
Continue to participate in the Surgical Site Surveillance
Schemes.
Reports circulated to relevant surgeons and SSI data reported
at IPCC.
DIPC +IPCT Programme of
categories with
collection dates.
Reports
Attend training
On-going
P a g e | 48
Compliance criteria
points
Programme of work 2015/2016 By whom (lead) Evidence Date to be
achieved
appropriate treatment and care to reduce the risk of passing on the infection to other people.
sessions
Monitor screening of emergency and elective patients’ data
and report to IPCC and CCG.
Continue to develop the infection prevention and control
dashboard.
Ensure that antibiotic compliance audit is presented to the
IPCC quarterly. This audit will monitor the general usage of
antibiotics in adult in-patients, and this will provide compliance
with the Department of Health requirements for antimicrobial
stewardship. DIPC to attend Antibiotic Group.
IPCT
IPCT
Department of
pharmacy
Data %
Audit data and
minutes
Monthly
On-going
Quarterly
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.
See criterion 1 (programme of education, audit and monitoring
of practice)
The continuing use of the infection prevention training record.
This provides staff of all grades with an up to date record of
their IPC training.
IPCT
IPCT
Training records
Training records
On-going
On-going
P a g e | 49
Compliance criteria
points
Programme of work 2015/2016 By whom (lead) Evidence Date to be
achieved
7.Provide or ( secures)
adequate isolation
facilities
Provide specialist infection prevention and control advice to
new build or refurbishment projects such as bathroom facilities,
isolation facilities and theatre maintenance.
IPCT Sign off sheets from
estates department
As required
8. Secure adequate
access to laboratory
support as
appropriate.
Nil work issues for the IPCT.
9. Have and adhere to
policies, designed
for the individual’s
care and provider
organisations, which
will help to prevent
and control
infections.
Revise policies as per schedule or following publication of new
evidence/guidelines.
Produce policy for the management of the patient with a PVL.
Produce a policy in relating to infection control in theatres.
DIPC/IPCT
DIPC
DIPC
Ratified at IPCC and
the procedural
As required
June 2015
May 2015
P a g e | 50
Compliance criteria
points
Programme of work 2015/2016 By whom (lead) Evidence Date to be
achieved
Continue with audit programme of ipc policies compliance with
policies.
DIPC /IPCT On-going
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 all staff are
suitably educated in
the prevention and
control of infection
associated with the
provision of health
and social care.
Provide specialist infection prevention input to occupational
health policies as required.
DIPC / IPCT
DIPC/ IPCT
As required
Support the occupational health service department in the
importance of staff having influenza vaccination.
P a g e | 51
Appendix 2
Emma Dowling Director Infection Prevention & Control /
Head Nurse Infection Prevention & Control
Laura Search PA - Infection Prevention &
Control / Data Manager
Nada ElhagConsultant
Microbiologist
Steve Barrett
Consultant Microbiologist
Claire Whittington Infection Prevention &
Control Nurse Specialist
Marilyn MeyersConsultant
Microbiologist
Judy Holdsworth Infection Prevention &
Control Nurse Specialist
Elaine Bibby PA to Microbiologists
