INFECTION PREVENTION AND CONTROL DEPARTMENT · INFECTION PREVENTION AND CONTROL DEPARTMENT ... staff working across the Trust to enhance and sustain their performance in infection

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INFECTION PREVENTION

AND CONTROL DEPARTMENT

ANNUAL REPORT 2013/2014

Emma Dowling

Infection Prevention & Control Annual Report 2013/2014 Page 2 of 50

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Associate DIPC

CONTENTS GLOSSARY ............................................................................................................................. 3

1.0 Executive Summary .................................................................................................. 4

2.0 Introduction ............................................................................................................... 6

3.0 Infection Prevention and Control Roles and Structures within the Trust ................... 7

3.1 Out of hours Infection Prevention and Control Service ............................................. 8

3.2 The Infection Prevention and Control Committee ...................................................... 8

3.3 Reports to the Executive Team and Trust Board ...................................................... 8

4.0 Infection Prevention and Control Risk Register ......................................................... 9

5.0 MRSA Bacteraemia (Blood stream infections) ........................................................ 10

5.1 MRSA screening ..................................................................................................... 11

5.2 Escherichia coli bacteraemia ................................................................................... 14

5.3 Water Hygiene Report (prepared by Nick Kay – Head of Health, Safety & Risk) .... 16

6.0 Clostridium difficile associated diarrhoea ................................................................ 22

6.1 Summary of main themes from the CDI RCA’s ....................................................... 23

6.2 RCA findings ........................................................................................................... 23

6.3 Clostridium difficile Ward Round ............................................................................. 25

6.4 Other Resistant Bacteria ......................................................................................... 14

7.0 OUTBREAKS, WARD CLOSURES, PERIODS OF INCREASED INCIDENCE ...... 26

7.1 Norovirus outbreak .................................................................................................. 26

7.2 Summary of Ward Closures due to Norovirus ......................................................... 27

8.0 SURGICAL SITE INFECTION SURVEILLANCE .................................................... 28

9.0 SAVING LIVES: HIGH IMPACT INTERVENTIONS ................................................ 29

10.0 TRAINING AND EDUCATION ................................................................................ 30

10.1 Infection Prevention Mandatory training .................................................................. 31

10.2 Teaching training record.......................................................................................... 32

10.3 Alert Labels ............................................................................................................. 32

10.4 Alert Sheets ............................................................................................................. 33

10.5 Infection Prevention and Control Link Nurses ......................................................... 34

11.0 COMPLIANCE WITH THE HEALTH AND SOCIAL CARE ACT 2008 .................... 35

12.0 POLICIEIS, PROCEDURES & PROTOCOLS ......................................................... 37


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13.0 AUDIT ..................................................................................................................... 38

13.1 Monthly Hand Hygiene Audit Compliance Scores ................................................... 39

14.0 PATIENT LED ASSESSEMENTS OF THE CARE ENVIRONMENT -PLACE ......... 39

14.1 Environmental audit ................................................................................................ 41

15.0 KEY ACTIONS / ACHIEVEMENTS IN INFECTION PREVENTION FOR 2013/14 . 42

15.1 Hand Decontamination -Hand Towels ..................................................................... 43

16.0 OBJECTIVES AND WORK PLAN FOR 2014/15 .................................................... 44

Appendix 1 Infection Prevention and Control Programme for

2013/2014 ............................................................................................................................ 46

GLOSSARY

ARHAI

Advisory committee on Antimicrobial Resistance and Healthcare Associated Infection

ADIPC Associate Director Infection Prevention and Control

CNS Clinical Nurse Specialist

DoH

Department of Health

DIPC Director of Infection, Prevention & Control

CCG

Clinical Commissioning Group

C. diff Clostridium difficile

CDI Clostridium difficile infection

CQC

Care Quality Commission

GDH

Glutamate Dehydrogenase

GRE

Glycopeptide resistant Enterococci

HCAI Healthcare Associated Infection

IPC Infection Prevention & Control

IPCN Infection Prevention & Control Nurse


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IPCT Infection Prevention & Control Team

KPI Key Performance Indicator

MRSA Meticillin resistant Staphylococcus aureus

MSSA Meticillin sensitive Staphylococcus aureus

OPD Out patients Department

PPM

Planned Programme of Maintenance

PIR Post Infection Review

Q A Quality Assurance

RCA Root cause analysis

SHA Strategic Health Authority

SSI Surgical Site Infection

SUHFT Southend University Hospital Foundation Trust

1.0 Executive Summary

This annual report fulfils the Trust’s statutory requirement under section 1.3 of the Health and

Social Care Act 2008 for the Director of Infection Prevention and Control (DIPC) and

Associate Director of Infection Prevention and Control (ADIPC) to provide a report on

infection control activity across the organisation. In addition to the Trust’s obligation, this

report provides key information to the public, patients, staff, Trust Board, the CQC, Monitor

and our Commissioners of the activity relating to infection prevention and control. This report

covers the period from 1st April 2013 - 31st March 2014 and provides an assessment of

performance against national targets for the year and includes key issues such as;

• Meticillin Resistant Staphylococcus Aureus (MRSA) bacteraemia figures


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• Clostridium difficile Toxin (CDT) rates,

• Audit activities and other key priorities for the year.

The Trust continued to have both patient safety and Health Care Associated Infections

(HCAI) as a priority within the organisation. 2013/14 has been another challenging year for

both the organisation and infection prevention and control team (IPCT), as there is greater

scrutiny and surveillance on HCAI as well as ever reducing ceilings for infections. The Trust

sustained a clear focus and energy on the infection prevention and control agenda, sharing

key learning and best practice in order to deliver on both HCAI national targets

This year the Trust experienced a mixed level of attainment with regard to the Healthcare

associated Infection (HCAI) objectives. The Trust achieved the MRSA bacteraemia objective

set by the DH at zero cases .This is the first time the Trust has reported 0 cases and it is

great achievement for all concerned.

Conversely, we were very disappointed to report that the objective for incidents of Clostridium

difficile was breached at 31 cases against a very challenging ceiling of just 18 – (see section

6.0 for full details)

In line with the Infection Prevention and Control (IP&C) Strategy, work has continued to

ensure that we maintain compliance with:

The Health and Social Care Act 2008

NHSLA Risk Management Standards for Acute Trusts

The Care Quality Commission registration Outcome 8

The Trust emphasis on of ‘Saving Lives’ continues and included the application of

evidence based improvements in intravenous line care, isolation utilisation, antibiotic

usage and the surgical site infection bundle

The Trust successfully achieved the overall target of 95% hand hygiene compliance

with a total of 95.87%. Training in hand hygiene for all staff and improvements to hand

hygiene facilities continued through the year.


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Training in infection prevention and control included outbreak management and was

delivered through staff induction, mandatory updates, link nurse sessions and ward

based update sessions using the new training record booklet ( see section 10.2)

There was just 1 ward closed during December 2013 due to suspected Norovirus. In

total 12 bed days were lost due to the suspected Norovirus outbreak

2.0 Introduction

The term Healthcare Associated Infection (HCAI) encompasses any infection by any

infectious agent acquired as a consequence of treatment. Micro-organisms (germs)

responsible for HCAI can be viruses, fungi, parasites and, more frequently, bacteria. HCAI

can be caused either by micro-organisms already present on the patient’s skin and mucosa

(endogenous) or by micro-organisms transmitted from another patient or health-care worker

or from the surrounding environment (exogenous).

The risk of transmission and potential harm applies at any time during health-care delivery,

especially to immuno-compromised or vulnerable patients and/or in the presence of

indwelling invasive devices (such as urinary catheter, intra-venous catheter, endotracheal

tube, drains).

Infection prevention and control clearly has a very important role to play in ensuring that

patients receive a high quality of care and have improved clinical outcomes. The infection

prevention & control agenda faces many challenges including the ever increasing threat from

antimicrobial resistant micro-organisms, the emergence of new human pathogens, growing

service developments, national guidelines and very strict targets.

Healthcare associated infection is of increasing media and political interest being seen as a

visible and unambiguous indicator of the quality and safety of patient care.

The foundations of infection control are built on a number of simple, well-established

precautions proven to be effective and widely appreciated. “Standard Precautions”

encompass the basic principles of infection control that are mandatory in all health-care

facilities. Their application extends to every patient receiving care, regardless of their


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diagnosis, risk factors and presumed infectious status, reducing the risk to patients and staff

of acquiring an infection. Hand hygiene is very much at the core of Standard Precautions and

is the undisputed single most effective infection prevention control measure.

The main essential elements of controlling and preventing infections related to health care

are:

Identifying risk factors and minimising their impact

Improving patients’ resistance to infection

Early identification and effective treatment of infections

Preventing transmission of micro-organisms from person to person

Maintaining a clean and fit for purpose environment including equipment with minimal

levels of microbial contamination

3.0 Infection Prevention and Control Roles and Structures within the Trust

The Infection Prevention and Control Team (IPCT) is an integral part of the organisation

providing advice, expertise, knowledge and support to encourage and enable members of

staff working across the Trust to enhance and sustain their performance in infection control

principles and practice. The IPCT shapes policy, educates and provides information to the

public, patients, staff and colleagues across the health economy undertake surveillance and

outbreak control management.

The Infection Prevention and Control Team Members consist of:

Dr Stephen Barrett - Consultant Microbiologist and Director of Infection Prevention &

Control

Dr Nada Elhag - Consultant Microbiologist and Director of Infection Prevention &

Control

Dr Marilyn Meyers - Consultant Microbiologist


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Sue Hardy –Chief Nurse/Deputy Chief Executive and Executive Lead for Infection

Prevention & Control

Cheryl Schwarz - Associate Director of Nursing

Emma Dowling - Infection Prevention and Control Matron /Associate Director of

Infection Prevention and Control

Judith Holdsworth - CNS

Claire Whittington - CNS

Laura Search – Personal Assistant to the Infection Control Team

Elaine Bibby - PA to Consultant Microbiologists & Administrator to Microbiology Dept.

3.1 Out of hours Infection Prevention and Control Service

The IPCN team provides 24 hours availability ‘on call rota’. The Consultant Microbiologists

are also available on a rota out of hours.

3.2 The Infection Prevention and Control Committee

The Infection Prevention and Control Committee (IPCC) is the main forum for monitoring and

delivery of the IPC Strategy as well as the development and implementation of a trust wide

annual HCAI action plan. It also monitors the delivery of the IPC strategy and holds to

account Business Units for performance in IPC using the Infection Control Dashboard,

Members include the Chief Nurse, Deputy Chief Nurse, ICT, Matrons, Occupational Health

Department, Pharmacy, Estates and Facilities, Sterile Services and external bodies such and

our Commissioners and Public Health England

The IPCC reports to the Clinical Assurance Committee (CAC) where an overview of the

Trust’s measures of Infection prevention and control with appropriate actions are shared.

3.3 Reports to the Executive Team and Trust Board

The IPCT 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


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Department of Health ceilings for MRSA bacteraemia and C difficile infections. The Trust

Board receives a report on the incidence of MRSA bacteraemia and of C.difficile, and of

learning and practice changes instigated as a result of the outcome of root cause analysis

and Post Infection Reviews (PIR).

4.0 Infection Prevention and Control Risk Register

The following risks remain on the IPC Risk Register after review by the IPC Matron

ID Risk Title Existing

risk level

37 Healthcare associated infection (MRSA bacteraemia) may lead to patient

harm or morbidity

LOW

573 Outbreak (defined as 2 incidents over 2 weeks) of C.difficile may lead to

patient harm

LOW

687 Failure of sluice washer disinfectors may lead to cross contamination and

service disruption

LOW

1630 Healthcare associated infection (MRSA colonisation) may lead to patient

harm

LOW

1631 Healthcare associated infection (Clostridium difficile) may lead to patient,

staff and visitor harm

LOW

1647 Incorrect use or disposal of used sharps may lead to injury or ill health from

exposure to blood-borne viruses

LOW

1731 Staff failure to adhere to ward visiting restrictions and infection control

interventions, during a suspected or confirmed Norovirus outbreak may lead

to cross contamination and further disruption to hospital services

LOW

1803 Failure to reduce rates of C.difficile in line with challenging Trust

performance targets may impact on our reputation and Monitor Governance

rating

HIGH

1823 Failure to meet challenging Trust performance target for MRSA bacteraemia

may impact on our reputation and Monitor Governance rating

HIGH

http://intranet/nursing/ars/rm/Documents/Risk%20Management/Risk%20Assessments/0%20-%20499/RA%20ID%2037%20Healthcare%20associated%20infection%20(MRSA%20Bacteraemia)%20may%20lead%20to%20patient%20harm%20or%20morbidity%2025-02-11.doc

http://intranet/nursing/ars/rm/Documents/Risk%20Management/Risk%20Assessments/500%20-%20999/RA%20ID%20573%20Outbreak%20of%20C%20difficile%20may%20lead%20to%20patient%20harm%2013-08-11.doc

http://intranet/nursing/ars/rm/Documents/Risk%20Management/Risk%20Assessments/500%20-%20999/RA%20ID%20687%20Failure%20of%20sluicer%20washer%20disinfectors%2010-03-11.doc

http://intranet/searchcenter/Pages/results.aspx?k=ra%20id%201629

http://intranet/nursing/ars/rm/Documents/Risk%20Management/Risk%20Assessments/1500%20-%201999/RA%20ID%201631%20Healthcare%20associated%20infection%20(Clostridium%20Difficile)%20may%20lead%20to%20patient%20harm%20or%20morbidity%2024-02-11.doc

http://intranet/nursing/ars/rm/Documents/Risk%20Management/Risk%20Assessments/1500%20-%201999/RA%20ID%201647%20Incorrect%20use%20or%20disposal%20of%20used%20sharps%20may%20lead%20to%20injury%20or%20ill%20health%2029-10-11.doc

http://intranet/nursing/ars/rm/Documents/Risk%20Management/Risk%20Assessments/1500%20-%201999/RA%20ID%201731%20Staff%20failure%20to%20adhere%20to%20ward%20visiting%20restrictions%20and%20%2009-04-11.doc

http://sohmos001/nursing/ars/rm/Documents/Risk%20Management/Risk%20Assessments/1500%20-%201999/RA%20ID%201794%20Unsecured%20medical%20gas%20cylinders%20including%20cylinders%20on%20trolleys%2017-03-12.doc


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1816 Failure to maintain the negative pressure isolation rooms to the required

standard may lead to cross contamination

LOW

5.0 MRSA Bacteraemia (Blood stream infections)

The Department of Health (DoH) commenced mandatory surveillance of MRSA bacteraemias

in 2001. This includes all bloodstream infections with MRSA to establish whether it was

acquired in the hospital or community and considered to be a contaminant or not.

In 2013/14 the Trust had a ceiling of zero MRSA bacteraemia cases for the financial year

2013/2014.Several factors have contributed to this success, including MRSA screening,

universal decolonisation, decreased blood culture contamination rate, improved cannula care

etc. However the ceiling is once again set at 0 which remains a challenge for the Trust.

Figure 1

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

Specimens allocated to the Acute Trust 0 0 0 0 0 0 0 0 0 0 0 0 0

Zero Tolerance

Figure 2.This graph demonstrates both Hospital and Community attributable MRSA Bacteraemias since 2009 to March 2014

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5.1 MRSA screening

Since April 2009, in line with the NHS Operating Framework 2008-2009, all patients admitted

to NHS hospitals are screened for MRSA.

Significant work continued over the past year to ensure that screening for MRSA was

undertaken for all elective and non-elective admissions

The mandatory MRSA screening guidance currently extends to a range of individuals

screened to include people at low risk of MRSA colonisation or infection, such as patients

without serious comorbidity. The Department of Health’s impact assessment of universal

screening assumes that everyone screened has an equal risk of colonisation.

At this Trust, in September 2010 it was agreed by the Infection Prevention and Control Team

and Director of Nursing as part of our measures to reduce Health Care Associated Infections


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(HCAI’s) that all patients despite being screened for MRSA carriage would benefit from

suppression therapy before their procedure to reduce their bacterial load.

The current screening practice within SUHFT is that all patients who attend surgical pre

assessment clinics are screened first and then provided with an anti-bacterial body wash and

instructed to use this on the 2 days prior to and on the day of their procedure. They continue

to use this product throughout their admission in an attempt to reduce skin bacterial load and

ultimately minimise the risk of possible surgical site infections. Patients with underlying skin

conditions or undergoing radiotherapy treatment are risk assessed on an individual basis to

determine their suitably to use the wash. In the event of a positive screen the patient is

managed as per Trust Policy IC007.

These measures have been shown to be effective in prevention and controlling MRSA, as is

evident from our bacteraemia and MRSA acquisition rates (figures 1, 2 3, 4, and 5).

Between January 2013 and December 2013 over 10,000 MRSA elective patient screens

were processed with a very low yield of new cases of MRSA carriage (48 positive screens).

The 48 positive screens were reviewed. These included previously known cases, care home

residents, health care workers, patients undergoing orthopaedic procedures and patients due

for vascular procedures, who would be identified as high risk and therefore would have met

the criteria for screening.

The proposal for 2014/2015 is to stop universal screening and re-introduce a check list

activated risk assessment for MRSA screening of elective patients, which was the policy

previously used in the Trust until 2009. The check list algorithm will be designed to highlight

high risk patients, for example previously known MRSA carriers, health care workers, care

home residents, patients undergoing orthopaedic or vascular procedures. It should be noted

that there has not been a Trust attributed MRSA bacteraemia since January 2013.

Dr Barrett (Director of Infection Prevention and Control) has had discussions with the

Department of Health recently in relation to MRSA screening; it appears that the forthcoming


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report to NHS England will recommend that MRSA screening now be limited to groups at

particular risk, namely:

• Patients previously identified as colonised with or infected by MRSA.

• Patients admitted to critical and intensive care units.

• Patients admitted to high risk specialties: - vascular, renal/dialysis, neurosurgery,

cardiothoracic surgery, orthopaedics/trauma haematology/oncology/bone marrow

transplant

Trusts will of course be at liberty to define further groups for screening according to local

circumstances.

We understand that a number of Trusts throughout the country are also planning to adopt this

limited screening policy in anticipation of the forthcoming report.

Figure 3

Elective screening data YTD

Total elective admissions 13,586

Elective admissions screened where screening was applicable 12,701

% of elective Admissions screened 93.5%

Emergency screening data YTD

Total emergency admissions 16,969

Emergency admissions screened 16,127

% of emergency admissions screened 95%

Figure 4 Hospital – Screen obtained post 48 hours of admission-Colonisations


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Figure 5 Community – Screen obtained Pre 48 hours of admission

Other antibiotic-resistant Ba


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cteria

Escherichia coli bacteraemia

The DoH extended mandatory surveillance reporting to include bacteraemia due to this

organism from June 2011; the Trust has been collating this information since April 2010. No

trajectories have been set by the DoH for these cases, monitoring by monthly cases will

continue to be recorded as shown in Figure 6.

Figure 6

5.3 Meticillin Sensitive Staphylococcus aureus bacteraemia

The Department of Health has not yet set reduction targets for MSSA bacteraemias, but for

the year 2013/2014 the Trust report 10 cases identified post 48 hours of admission.


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Fig 7 shows MSSA bacteraemias detected during the year and whether they were

considered Community-acquired (<48 hours after admission), of Hospital-acquired (>48

hours after admission).

Figure 7

5.4 Glycopeptide resistant Enterococci (GRE) bacteraemia.

Enterococci are bacteria that are commonly found in the bowels of most humans. Many GRE

are resistant to multiple other antibiotics and are most commonly seen in groups of patients


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in intensive care units, renal, liver or haemato-oncology units who have been given multiple

antibiotics. In 2013/14 there no Healthcare Acquired GRE bacteraemia.

5.5 Water Hygiene (prepared by Nick Kay – Head of Health, Safety & Risk)

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 which is present in the water that feeds the Trust. 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. It is

transferred via water droplet e.g. aerosols from showers

Current Situation

Currently the Trust has a contract with Evolution Water Services who are the specialist

contractor and 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 Evolution 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.


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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.

During the last 12 months 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, and fail safe by blocking

and stopping supply of water. Point of use filters are also designed for showers.


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The graph below shows all the legionella sampling which has taken place since Evolution

started their contract with the Trust.

Below shows the samples taken over the last four years. In 2014 the percentage clear was

reduced due to a problem with the energy centre which feeds the Education Centre, the

temperature of the hot water system fell to 40oC for a period of time long enough for

legionella bacterium to form in a majority of the outlets sampled. As soon as the elevated

samples were received both the hot and cold water systems were chlorinated overnight.

Annual Samples 2011 2012 2013 2014

Initial Samples Taken/Year 30 479 245 53

Elevated Samples 3 46 17 10

Clear Samples 27 433 228 43

These samples were from the Education Centre following problems with the energy centre


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Percentage Elevated 10.0 9.6 6.9 18.9

Percentage Clear 90 90.4 93.1 81.1

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 hit the press in the early part of

2012 which resulted in the death of 4 babies: 1 in Londonderry and 3 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 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.


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To determine what areas within the hospital may possibly be affected all those which fell

under ‘augmented care’ were included on a sampling regime which was risk rated by the

Water Assurance Committee with support from Evolution Water Services. Sampling began in

the later part of 2012 and finishing in March 2014.

As highlighted above sampling has taken place from latter part of 2012 to March

2014, with the results as shown on the graph below

In March 2014 a total of 110 samples were taken on one specific ward within the Trust. 26 of

the samples obtained returned with an elevated count. Unlike legionella sampling

Pseudomonas aeruginosa sampling consists of both the hot and cold water taps being

sampled.


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The elevated samples that were obtained were identified within a specific area of the ward

which, on investigation it was concluded that the elevated counts were due to the outlets only

being used sporadically. Also it was identified that there was a build-up of scale on the end of

the taps increasing risk of elevated counts.

Immediate actions were undertaken to prevent re-occurrence which were a daily flushing

programme, installation of self-flushing showers, all outlets descaled with a plan to implement

a planned programme of maintenance to include regular descaling of outlets.

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, and a second after

water has flowed out of the outlet for two minutes. This confirms if the bacterium is in the

outlet itself or in the water system. Until the results have been returned, 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 will be reviewed further and advice taken from Evolution Water Services as how

to be in full compliance with this new guidance.

6.0 Clostridium difficile associated diarrhoea

Acute Trusts in England are required to report cases of Clostridium difficile infection that are

considered to have been acquired in that Trust, defined as 72 hours post admission. The

ceiling set for hospital acquired cases at SUHFT in 2013/14 was just 18 cases. The total

number of cases for 2013/14 was 31 cases, 58% over trajectory.

2013 - 2014 C difficile Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Total

Specimens allocated to the Acute Trust 3 0 4 2 2 1 2 2 4 2 2 7 31


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6.1 Summary of main themes from the CDI RCA’s

Clostridium difficile is the main cause of antibiotic associated diarrhoea. As a HCAI these

cases are monitored by the DoH, through mandatory surveillance data supplied by on a

monthly basis by all Trusts.

Main themes identified from RCA’s undertaken

Not comprehensive documentation on Bristol Stool chart

Delay in sending stool specimen or isolating patient as other reasons for loose stools considered but not recorded /documented

Once positive stool culture result obtained- all patients isolated within 1 hour

No evidence of cross infection identified

All patients presented with multiple co morbidities and risk factors

30 out of 31 cases had been prescribed antibiotics

6.2 RCA findings

The RCA process has identified that in many cases patients presenting with CDI have more

than one risk factor. An increased number of risk factors in a patient may increase the

predisposition for CDI. Risk factors comprise: multiple comorbidities (Figure 8). Underlying

bowel disease, high risk medications (Figure 9), advanced age, multiple hospital admissions,

bowel surgery and immunosuppression

Figure 8


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310%

931%

828%

931%

Number of Risk Factors per Case(Annual data 2013-14)

0

1

2

3

4

5 or more

.

Figure 9


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Studies confirm that antibiotics predispose to CDI and also indicate a potential link with

Proton Pump Inhibitors (PPI). In addition, laxatives, nutritional supplements and

chemotherapy are indicated as potential factors in CDI therefore all of these medications are

included in the RCA reports.

Figure 10 This graph demonstrates the average age and the male female ratio of patients at this Trust.

6.3 Clostridium difficile Ward Round

In response to the DH Guidelines the weekly multidisciplinary clinical review of all inpatient C.

difficile patients within the Trust continues. The review team includes a Consultant

Microbiologist, DIPC, Consultant Gastroenterologist, antimicrobial pharmacist, IPCN,

Microbiology Registrar and if possible the patient’s own clinician. The objective of the ward

round is to ensure that the infection is being treated as a ‘condition in its own right’ to ensure

optimum treatment and that the patient is receiving all necessary supportive care. The C

difficile Ward Round sticker shown below which is completed on the ward round by the

Consultant Microbiologist on the ward round as a highly visual communication aide.


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7.0 OUTBREAKS, WARD CLOSURES, PERIODS OF INCREASED INCIDENCE

7.1 Norovirus outbreak

The IPCT have worked hard to reduce the impact of Norovirus outbreaks on the Trust. One

element of this work was teaching sessions aimed at all staff groups to assist with the early

recognition and isolation of suspected / confirmed cases. These sessions were delivered to

all wards/clinical areas from September 2013 through to December 2013. The IPCT have

worked collaboratively with the Control Room, Clinical Site Managers, Discharge

coordinators, Accident and Emergency, Domestic Services, and the Communications

Department.

Alcohol gel used throughout the Trust (B Braun) has anti-viral properties and effective against

Norovius.


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7.2 Summary of Ward Closures due to Outbreaks

There were two episodes of ward closure due to presumed infection as tabulated below.

Ward Closed Reason Clean started Clean completed

Estuary 13.12.13 Suspected Norovius due to 4

patients with unexplained symptoms of

vomiting and loose stools

15.12.13 16.12.13 OPENED

12 bed days lost

The key lesson learnt during this period:-

• The importance isolationing patients admitted from residential homes that are closed

due to suspected or confirmed outbreaks.

Ward Closed Reason Clean started Clean completed

Gordon Hopkins 1 x Bay closed to admissions for 48 hours

Influenza A 20.02.13 20.02.13

Influenza A outbreak on Gordon Hopkins Ward – type A H3. 4 Patients in male non acute bay

and 1 female in sideroom. Patients recovered well – 2 beds blocked to new admissions for 48

hours only. Nil impact on bed capacity. No staff members affected. It was noted that the

patients affected had not had their seasonal flu immunisation.


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8.0 SURGICAL SITE INFECTION SURVEILLANCE

Orthopaedic Surgery

The DH requires all hospitals performing orthopaedic surgical operations (joint

replacements and implants for fracture surgery) to monitor surgical site infections

(SSI) for a minimum three month period each year. Details of this surveillance

undertaken in the Trust are tabulated below. (Large and Small bowels count separate

categories)

Results obtained from the Health Protection Agency’s Surveillance of Surgical Site Infections.

April – June 2013

Category

Total number of

SUHFT operations

Number of SSI’s

SUHFT (%infected)

Total no. of operations

for all hospitals

Total no. of SSI’s for all

hospitals

All hospitals

(% infected)

Hip replacement

102 1 1.0% 216865 2666 1.2%

July – September 2013

Category Total Number SUHFT Total no. of Total no. All


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number of SUHFT

operations

of SSI’s (%infected) operations for all

hospitals

of SSI’s for all

hospitals

hospitals (%

infected)

Abdominal hysterectomies

26 2 7.7% 5564 232 4.2%

Please note. There were a total of 26 Abdominal hysterectomies undertaken during this period and only 2 infections reported. The 2 surgical teams concerned undertook a review of the patients concerned and it was concluded in both cases that despite best practice both developed post-operative wound infections. They noted that both cases were extremely complex due to the patients presenting with multiple comorbidities, multiple risk factors and complex surgical procedures. (Both patients had undergone chemotherapy and radiotherapy prior to their procedures)

October – December 2013

Category

Total number of

SUHFT operations

Number of SSI’s

SUHFT (%infected)

Total no. of operations

for all hospitals

Total no. of SSI’s for all

hospitals

All hospitals

(% infected)

Repair neck of femur

44 0 0% 82385 1407 1.7%

Amputations

4 0 0% 2217 100 4.5%

Accumulative data for previous 5 years for all hospitals (5 year benchmark)

9.0 SAVING LIVES: HIGH IMPACT INTERVENTIONS

Saving Lives was introduced by the DH in June 2005.The High Impact Intervention tools are

based upon a ‘care bundle’ concept, integrating the latest evidence based guidelines and

providing a means for staff to measure compliance to key clinical procedures. High impact

interventions assist clinical governance by ensuring that all patients receive a consistently

high quality care.

During 2013/2014 the following audits were undertaken on the following care bundles.

%


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compliance

achieved

Hand hygiene – Trust wide audited compliance percentage 95.87%

HII 1: Central venous catheter care bundle – insertion 99.1%

HII 1: Central venous catheter care bundle – on-going care 98.8%

HII 2: Peripheral intravenous cannula care bundle – insertion 98%

HII 2: Peripheral intravenous cannula care bundle – on-going care 96.8%

HII 3: Renal dialysis catheter care bundle - insertion 97.1%

HII 3: Renal dialysis catheter care bundle – on-going care 97.1%

HII 4: Care bundle to prevent surgical site infection – pre-operative 100%

HII 4: Care bundle to prevent surgical site infection – peri-operative 99.8%

HII 5: Care bundle for ventilated patients 99.8%

HII 6: Urinary catheter care bundle - insertion 98.9%

HII 6: Urinary catheter care bundle – on-going care 97.5%

HII 7: Prevention of spread of Clostridium difficile 100%

HII 8: To improve the cleaning and decontamination of clinical equipment 97.6%

The results are presented monthly in graph format and are also available via the Infection

Prevention and Control Dashboard. Any compliance issues are addressed through the

Matrons and reported at the Infection Prevention and Control Committee. Infection prevention

and control training and support at ward level with using the data collection tools and

uploading data has resulted in a marked improvement with our data when compared to last

year’s figures.

10.0 TRAINING AND EDUCATION

Main teaching programme Frequency Providers

IPC induction for all staff (including medical) Fortnightly IPCN/DIPC

Facilities staff/Contractors as required IPCN

Renal Unit X 6 a year IPCN

NHS Professionals as required IPCN

Newly qualified nurse development course twice a year IPCN


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1 day IC workshop (all grades) quarterly IPCN/DIPC

IC awareness days quarterly IPCN/DIPC

Link Nurse Session quarterly IPCN

HCA Induction monthly IPCN

Day stay theatre / Post-op annually IPCN

Mandatory Infection Control E learn IPCN

Junior doctors bi-annually DIPC

(ARU) IC for student nurses on request IPCN

Sharps Awareness day Yearly IPCN

++New education programmes are added as required++.

10.1 Infection Prevention Mandatory training

In order to ensure flexibility, Mandatory Infection Prevention and Control training was

introduced in February 2013 via E learn. This is available to all staff grades via the staff

Intranet. This course has to be undertaken biannually-. Staff members that do not have

access to a computer can book face to face training via the iLearn system. The proportion of

staff trained during the year is shown below.

.


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10.2 Teaching training record

A teaching training record was devised by the Infection Prevention and Control Team. This

booklet is provided to all Trust staff by their IPCN.When face to face training is delivered in

the clinical setting. Examples of subjects in the record are C diff, MRSA, isolation, obtaining

MRSA swabs and invasive device tool update, as shown below:

10.3 Alert Labels

Following the the move from (Patient Administration System) PAS to the Medway system in

January 2014, the Trust no longer used the previous CAT A alert system to identify patients

that had previously been identified as MRSA positive or C difficile positive or C difficile

carriers. For these patients we had previously placed an alert sticker CAT A sticker on the

clinical records (see below) .The IPCT amended the sticker to identify these at risk patients in

line with the Medway system.


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.

CATA label ALERT label

10.4 Alert Sheets

Following the introduction of ‘zero tolerance’ for MRSA bacteraemia and the challenging C

difficile ceiling set by the DoH, the IPCT wanted to ensure that all clinical and medical staff

were aware if a patient had previously been known to be MRSA, C diff, or C difficile carrier .A

simple alert sheet was developed that is placed in the front of patients’ medical records

on admission. This ensures that the relevant policies, pathways and precautions are

followed. The process is started in the A/E department. If an emergency admission is

identified from the Medway system with an Infection Control Alert, the relevant Alert Sheet is

placed in the patient’s clinical record. The Infection Prevention team will also check to ensure

that this sheet has been placed in the medical records when visiting their patients.


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10.5 Infection Prevention and Control Link Nurses

The IPCT continues to provide the Infection Prevention and Control Link Nurse programme.

Link Nurse sessions are run quarterly and provide an education session and, usually include

a guest speaker to support the nurses to maintain their enthusiasm and commitment.

Numerous topics are covered and have included for example, hand hygiene, MRSA

screening and outbreak management. The sessions run for approximately two hours.

The aim of these sessions is to update on any new guidance / policies and to increase the

flow of Infection Prevention and Control communications.


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Infection Prevention and Control Link Nurse Programme 2013/2014

Date Guest Speaker - ICN Agenda items

10.04.13 Claire Whittington Sam Ferrick Gamma Health Care

Use of Clinell wipes and decontamination ‘I am clean label’ update C diff RCA feedback Bed pan washers – reporting problems Hand Hygiene audit discussion

14.08.13 Judy Holdsworth

Stool Charts MRSA screening Invasive Device Tool update Deep clean request - discussion Sharps Safety issues C diff RCA feedback

18.12.13 Emma Dowling Norovius and outbreak management –red folders update Influenza update –Q and A session C diff RCA feedback White paper towels- hand decontamination

05.03.14 Judy Holdsworth C diff RCA feedback Update with HCAI ceilings When to take a stool sample discussion MRSA screening /regimes Anti-bacterial body wash – discussion

11.0 COMPLIANCE WITH THE HEALTH AND SOCIAL CARE ACT 2008

The Health and Social Care Act 2008 Code of Practice for the prevention and control of

Healthcare Associated Infections (HCAI’s) became operational in April 2009 and was revised

in April 2011. Known as the Hygiene Code, it now includes primary dental care and

independent sector ambulance providers. The Code of Practice outlines the compliance

criteria the Trust is required to meet and supporting guidance for implementation. The Annual

Work Plan and GAP Analysis details the Trust’s compliance.


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The GAP Analysis (i.e. analysis of areas where requirements are not completely met) shows

with the Hygiene Code. The 10 criteria and supporting evidence are RAG (Red-Amber-

Green) scored.

RED-Non –compliance based upon insufficient evidence

AMBER-Processes in place but requires development

GREEN-Evidence available to support compliance

AS shown in the table, this Trust has no red scores, which would indicate non-compliance. At

the time of this report there is now only one amber score

Criterion Compliance criteria point Compli

ant Comments

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

2 Provide and maintains a clean and appropriate environment which facilitates the prevention and control of HCAI.

Weekly spot check monitoring of cleanliness by the facilities Department. Monthly joint audits with input from Matrons and IPC (when available) Domestic Service QA Team monitor cleaning and audit in accordance with the National Standards of Cleanliness 2007.


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3 Provide suitable accurate information on infections to service users and their visitors. Patient information leaflets reviewed and updated

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

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

MRSA screening for both elective and emergency patients not 100% compliant

7 Provide or secure adequate isolation facilities

8 Secure adequate access to laboratory support as appropriate

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

10 Ensure, so far as reasonably practicable, that care workers are free of and are protected from exposure to infections during the course of their work, and that all staff are suitably educated in the prevention and control of infection with the provision of health and social care.

12.0 POLICIES, PROCEDURES & PROTOCOLS

In line with the Health and Social Care Act 2008 infection prevention and control policies,

procedures and protocols continue to be developed as required, reviewed and updated by

the IPCT, ensuring that practice and guidance is current and evidenced based.

All polices can be accessed via the Intranet site. Those reviewed during the last year are as

follows.

No. Policy Author Published Date

Review Date

IC005 Infectious Patient in the Operating Theatre

ED April 2013

April 2015

IC006 Plan of the Control of Outbreaks

ED

May 2013 May 2015

IC007 MRSA Policy ED February February 2016


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2014

IC011 Collection of Infection Control Surveillance Data

ED August 2013 August 2015

IC019 Isolation Policy ED June 2013 June 2015

HS06 Prevention of Sharps Injury ED July 2013 July 2015

IC031 Viral Haemorrhagic Fever –New Policy

ED July 2013 July 2015

IC032 Influenza –New Policy

ED April 2013 April 2015

13.0 AUDIT

The Code of practice for the prevention and control of Healthcare associated infections under

the Health and Social Care Act 2008 requires that all NHS organisations have in place an

audit programme to ensure key policies and practices are being implemented appropriately.

The following table gives details of policies audited where practice and knowledge were

examined and the % compliance results obtained. No repeat audits were required.

Month Audit

Score

April 2013

TB IC 002 No Patients to audit

May 2013

Isolation Policy IC 019 96.5%

June 2013

MRSA IC 007

C diff IC 0017 Quarter 1

98% 99.5%

July 2013

Prevention of Sharps Injury HS06 92%

August 2013

Hand Decontamination IC 009 100%

September 2013

MRSA IC 007


99.7% 98.2%

October 2013 Isolation Policy IC 019 100%


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November 2013

Diarrhoea and Vomiting IC025

Hand Decontamination IC 009

No D and V patients to audit 100%

December 2013

MRSA IC 007


99.7%

97.85%

January 2014 HINI ‘Swine Flu’ IC 023

Diarrhoea and Vomiting IC025

No Influenza patients to audit

February 2014 Standard Precautions IC 022

100%

March 2014 MRSA IC 007

C diff IC 0017- Q4

99.2%

97%

13.1 Monthly Hand Hygiene Audit Compliance Scores

Effective hand hygiene is the cornerstone of good infection prevention and control practice.

Hand hygiene is audited monthly using an observational audit. The results are discussed at

the IPCC. The collated results are shown below.

Q1 Q2 Q3 Q4 Average

99.5% 100% 93.5% 90.5% 95.87%

14.0 PATIENT-LED ASSESSEMENTS OF THE CARE ENVIRONMENT –“PLACE”

The Patient-Led Assessments of the Care Environment (PLACE) programme was introduced

in 2013 as a new system for assessing the quality of the care environment.

Our assessments were carried out in June, 2013. The table below indicates where we were

against the National Average for 2013.


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Feedback and improvements to the PLACE information system have enabled the HSCIC to

further develop their system reports in preparation for the 2014 assessments. As part of our

continual improvement this information will be available for the formulation of action plans.

Our 2014 assessments were carried out in March. All results will be final as of the 7th July;

whilst the Trust will be free to use these results for internal purposes, and to share them with

our Patient Assessors, the HSCIC ask that the Trust do not release them to the media, and

refrain from making any public statements until the 2014 results have been published by

them; this is scheduled for August 27th.

Graphic below is data from 2nd April – 21st June 2013:

The PLACE 2014 assessments were carried out in March 2014.

The purpose of the PLACE assessments continues to be to assess hospitals across a range

of environmental aspects against common guidelines. The assessments focus entirely on the

care environment and do not cover clinical care provision. The teams assessed how the

environment supports patient’s privacy and dignity, food, cleanliness and general building

maintenance.


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At least 50% of those involved in undertaking assessments must meet the definition of a

patient; namely anyone whose relationship with the hospital is as a user rather than as a

provider of services.

14.1 Environmental audit

Environmental audits are carried out on a monthly basis. The audit team consists of,

Matron

Domestic supervisor

Member of the Quality Assurance Team

On a rota basis, a member of the Infection Prevention and Control Team

This audit tool records the cleanliness, according to a visual check against the NHS National

Standards of Cleanliness 49 Elements. Elements include floors, walls, beds, sinks, baths and

medical equipment. The area being assessed is defined as a functional area according to the

designated risk factor.

Environmental audits are expressed as “Cleanliness standards”, as shown below. An Audit is

required to score 95% or above to pass. Audits below this score will require an action plan

and re-audit to be carried out within a specified period.

Cleanliness standards - % of compliance to National Standards of Cleanliness Audit

Q1 Q2 Q3 Q4 Average

93.7% 92.6% 91.83% 94.2% 93%

Any areas of concern are identified to the relevant Matron, who is required to ensure that the

remedial actions needed are carried out to improve those areas.


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15.0 KEY ACTIONS / ACHIEVEMENTS IN INFECTION PREVENTION FOR 2013/14

Actions Key Points

Achieving 0 cases of MRSA bacteraemia

0 cases of MRSA compared to 2012/13 of 3

cases

Infection Prevention and Control Dashboard

Successfully up and running for over 18 months.

The Dashboard provides a system for Matrons to

upload their High Impact Intervention Scores

IPC Policy Audits Annual rolling programme of Infection Prevention

& 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.

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 & Control advice

Continued use of the Infection Prevention and Control e-learning programme for all staff

Commenced Trust wide February 2013

Mandatory bi-annual updates for Infection Prevention & 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

Viral Haemorrhagic Policy published July 2013

Leaflets All IPC Leaflets updated as required


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Change from green to white paper hand towels

December 2013

Introduction of an Infection Control Alert for C diff / C diff carriers.

November 2013

Development and production of C diff Ward Round Sticker to provide highly visual documentation

June 2013

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

Infection Prevention and Control MRSA and C diff Alert Sheets developed and implemented

October 2013

15.1 Hand Decontamination -Hand Towels

Hand hygiene has always been a top priority at our Trust. A busy hospital needs effective

products that perform well and that are a high quality.The Infection Prevention Matron

received feedback from wards and departments that the green paper towels were not fit for

purpose and that there was a need for a more hygienic, efficient and cost effective hand

towel solution

Our Trust recognised the need to

reduce waste and make

procurement more cost

effective. Therefore in December

2013 the Trust moved from

using green to white paper hand

towels.


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16.0 OBJECTIVES, FUUTURE DEVELOPMENTS AND WORK PLAN FOR 2014/15

The attached work programme underpins the detail of the work to be undertaken by the infection prevention and control service to:

Implement effective systems to prevent and control Health Care Acquired Infections

Continue to promote a ‘zero tolerance’ culture, and educate all staff, patients, relatives and visitors of the importance of all infection prevention and control procedures (including hand decontamination)

Identify risks in infection control and work with colleagues to provide solutions to reduce, control or eliminate those risks

Continue to undertake audits of Infection Prevention Policies and the environment. Programme to include external Trust premises

Produce new policies as required- this to include an Infestation Policy

Produce an ‘Antibiotic man’ poster for all clinical areas as an education tool

Promote, improve the reliability of and monitor the clinical infection control practices


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Continue to provide clear, concise and evidence based policies and guidelines, which are accessible to all staff group

Undertake a formal review of the Invasive Device Too (IDT). Develop and introduce section within the tool for Epidural lines

Continue to educate staff in relation to an Infection Alerts on the new Medway system

Develop and produce an Infection Prevention and Control Training record ‘passport’ for ad hoc localised infection prevention training. This will complement the corporate training needs analysis

To network with other providers through the CCG Infection Prevention and Control network meetings

Improve pan Essex communication from lessons learned from the RCA /Post Infection review process

Please see Appendix 1 for Infection Prevention and Control Programme detailing the IPCT work programme for 2014/2015

2

Infection Prevention & Control Annual Report 2013-2014

Page 46 of 50

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Appendix 1 Infection Prevention and Control Programme for 2014/2015

Compliance criteria points

Programme of work 2013/14 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 report to the IPCC and CCG

Matron IPC Report / Quarterly

Continue to raise the profile of the Infection Prevention and Control Team through the Trust.

Director of Infection Prevention &

Control (DIPC) and IPC Matron, ADIPC

On-going

Ensure Infection Prevention Team is represented in essential Trust Committees, such as the Health and Safety

DON / ADN /Matron IPC ADIPC

On-going

Present annual programme 2014/15 (including annual audit programme) and Annual Report 2014/15 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/ Web Site

August 2014

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

IPC Matron

Minutes / Risk register

Monthly / Quarterly

Provide HCAI statistics for performance reporting at Board of Directors and at the IPCC, including details of trends

DIPC IPC Matron

Minutes Monthly

Continue to undertake root cause analysis and Post Infection 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.

DIPC, IPCT, Ward Managers, Matrons.

Completed RCA Tools. Minutes

Quarterly

Review all outbreaks and clusters of HCAI to the Infection Control Committee.

DIPC,IPCT

Minutes. 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 /

On-going

2


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attendance records

Update and review the e-learning module for clinical/non clinical Develop new styles 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

2014/2015

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 Graphs 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

3. Provide suitable accurate

Continue to produce, update and publish Public Information leaflets as required

IPCT

Update programme with review dates

On-going

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information on infections to service users and their visitors.

Update and review the contents and design of the Infection Prevention and Control Web site as and when required

ICPT Web Site 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 1ST July 2013

Audit of Discharge Policy care transfer form to monitor compliance relating to patients infection status

Discharge team Audit Reports Quarterly

Ensure evidence required by commissioners is presented to IPCC Sharing learning across South Essex at quarterly IPC network meetings

IPCT Minutes Bi-monthly

Quarterly

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

Continue to participate in the Surgical Site Surveillance Schemes Team. A formal review of categories collected to be undertaken by end of Q1. Reports circulated to relevant surgeons and SSI data reported at IPCC

ADIPC +IPCT Programme of categories with collection dates.

Reports Attend training

sessions

On-going

Monitor screening emergency and elective patients data and report to IPCC and CCG Review the Department of Health Guidance in relation to MRSA screen for elective patients. Produce formal risk assessment based screening MRSA programme for elective patients Continue to develop the Infection Prevention and Control DASHBOARD Ensure that anti-biotic compliance audit is presented to the IPCC

IPCT

ADIPC

IPCT

Monthly

On-going

On-going

Quarterly

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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

Department of pharmacy

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) Continue to roll out of the” Infection Prevention Training Record”. This will provide staff with an up to date record of their IPC training Share this Essex wide

IPCT Training records On-going

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 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,

Revise policies as per schedule or following publication of new evidence/guidelines Produce policy for the Management of the patient with an Infestation Produce a policy in relating to Air Sampling Theatres

IPCT

ADIPC

ADIPC

Ratified at IPCC and the Procedural Document Group

As required

October 2014 On-

going(almost complete)

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which will help to prevent and control infections.

Continue with audit programme of IPC policies compliance with Policies

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.

IPCT

IPCT

As required

Support the Occupational Health Service Department in the importance of staff having influenza vaccination.