Infection Prevention & Control

Annual Report 2007/08(2008/09 update) Dr Patricia O’Neill

Director of Infection Prevention & Control 25th September 2008

• Major change in our approach to Healthcare Associated Infections

• Huge investment of time and resource by all staff• Working with partners in PCT and external

experts• MRSA bacteraemia target was not achieved but

25% reduction on previous year’s figure• C difficile target was achieved• On target to achieve both in 2008/09

Overview

Change of approach to HCAI

Classic StyleInfection Control team responsible for HCAISeen as experts who advised on policy and gave education and sorted out problemsImportance of HCAI recognised by trust but lack of ownership at ward levelSurveillance and audit carried out by ICT but small number of audits and not empowered to make change happen Emphasis was on dealing with problems ie CONTROL

New StyleEmphasis on PREVENTION not ControlIdentify risks and take action to prevent themOwnership from “Board to Ward” – high profileResponsibility for action now with Divisions not IPCT – monitored

through clinical governanceAudits of hand hygiene and other interventions now done by ward

staff and massively increased in numberIPC team still experts, writing policies and educating - but more

time spent assessing risks and monitoring performance of othersWeekly multidisciplinary operational groupMonthly Infection Control Committee chaired by CEO

MRSA Bacteraemia 2007/08

Target was to have no more than 23 cases Challenging target60% reduction from 2003/04 baseline of 58SaTH had 36 cases in 2007/08 so did not achieve target but

25% reduction on 06/07 (48 cases) and 14 were pre 48Rate per 1000 bed days was 0.12 – national averageAverage for large acute trusts in West Midlands 0.18Of 19 trusts in West Midlands only 5 achieved MRSA targetOf these 4 were single specialty trusts

MRSA Bacteraemia 2007/08MRSA Bacteraemia Cases 07-08

0

5

10

15

20

25

30

35

40

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

Cases per monthCumulative totalProfile

What have we done? – risk assessmentSpecialty Source

Medical 11 Central Lines 8

General Surgery 11 Urinary Tract Infection

5

Urology 4 Peripheral lines 4

Renal Unit 3 Surgical Wound 3

Oncology 3 Endocarditis 3

Cardiothoracic Surgery

2 (Surgery in North Staffs)

Percutaneous feeding tube

1

Vascular Surgery

2 Skin & Soft Tissue 2

TOTAL 36 Respiratory 2

Time sample taken after admission Contaminants 4

Unknown 4

<48 hours 14

>48 hours 22 TOTAL 36

C L I N I C A L R I S K A L E R T

T O A L L C L I N I C A L S T A F F

A n y p a t i e n t w i t h

A h i s t o r y o f M R S A i n u r i n e a n d h a s a T r a u m a t i c i n s e r t i o n / r e m o v a l o f u r e t h r a l / s u p r a p u b i c c a t h e t e r o r b l o c k e d c a t h e t e r .

1 . S t a r t I V v a n c o m y c i n ( 1 5 m g / K g b d ) 2 . S e n d a u r i n e s a m p l e f o r c u l t u r e s

3 . R e v i e w w i t h m i c r o b i o l o g y o n r e c e i v i n g t e s t r e s u l t

B r e n d a M a x t o n , C l i n i c a l R i s k A d v i s o r , E x t : - 1 4 4 8 C h r i s B e a c o c k

R o d W a r r e n

J u l y 2 0 0 7

C r i t e r i a f o r t r a u m a t i c c a t h e t e r i z a t i o n a n y o n e o f t h e f o l l o w i n g o M o r e t h a n 2 a t t e m p t s a t c a t h e t e r i s a t i o n o A n y i n s t r u m e n t a t i o n o H a e m a t u r i a o R e m o v a l o f c a t h e t e r w i t h b a l l o o n i n f l a t e d

What have we done? – actions

• Strengthening of Root Cause Analysis on each case of MRSA bacteraemia, led by the clinical team involved

• Focus on reducing MRSA bacteraemia in augmented care (ie ITU and the Renal Unit) – particularly intravenous line infections

• Increased MRSA screening • Introduction of a cohort ward for isolation of patients with MRSA• Introduction of twice daily visual inspection of all intravenous line sites

to monitor for development of phlebitis• Expansion of “High Impact Intervention” audits so that all wards are

auditing their insertion and care of intravenous lines• Introduction of a Care Pathway for patients with MRSA • Increased Hand Hygiene audits

MRSA Bacteraemia 2008/09

0

5

10

15

20

25

Cases per month 0 0 2 2 1

Cumulative total 0 0 2 4 5

Target 2 4 6 8 10 12 14 16 18 20 22 23

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

C difficile >65 yrs Shropshire Health Economy 2007/08

0

50

100

150

200

250

300

350

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

Cases PerMonth ShropsCumulativeCases ShropsTarget

What have we done?

Introduction of increased cleaning, including use of chlorine based disinfectants, the Deep Clean Programme and refurbishment of bathrooms, and purchase of new beds and commodes

Improved diagnosis with the introduction of rapid testing available 7 days a week

Tighter antibiotic controlImproved care of patients with C difficile with an updated

management protocol and care pathwayRapid isolation of patients with diarrhoeaIncrease in hand hygiene audits and emphasis on the need to use

soap and water, not hand gel, with C difficile

C difficile cases and recurrences over 2yrs old 2008/09 - SATH Responsible

0

50

100

150

200

250

Cases per month 7 9 16 7 6 0 0 0 0 0 0 0

Cumulative 7 16 32 39 45

Target 19 38 57 76 95 114 133 152 171 189 207 225

Apr May J un J ul Aug Sep Oct Nov Dec J an Feb Mar

Hand Hygiene

Probably most important single step in preventing HCAIPreviously audited by IPC teamIn June 2007 wards started to do their own audits Number of “observations” increased from 10 to 1000 per

month By March 08 compliance was 88% - now 95%Taking part in “cleanyourhands” and “It’s OK to ask”“Bare below the elbows” introducedHand Hygiene education and road shows continue

SATH Hand Hygiene Compliance

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

J un-07 J ul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 J an-08 Feb-08 Mar-08 Apr-08 May-08 J un-08 J ul-08 Aug-08

High Impact Intervention Audits

“Saving Lives” gives advice on key steps in prevention of infection for 7 common interventions, including intravenous line care, urethral catheter care, dialysis etc

Also contains tools so that staff can audit against the standard advice – High Impact Intervention Audits

In 2007/08 we rolled out use of these audits by ward staff concentrating on intravenous line audits

Helped pick up issues we were not aware ofNow extending programme to other audits

Insertion of Central Lines

Central Line Insertion Audit SATH 2007-08

0%

20%

40%

60%

80%

100%

120%

May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08

Environment

A Deep Clean of all wards and clinical areas ward carried out between November 2007 and March 2008

Refurbishment of bathrooms and purchase of new beds and commodesIntroduction of chlorine based products for disinfection of the

environment for C difficileNew colour coding system for cleaning equipment introduced in line with

new national standardsRoll out of ”Productive Ward” continued. Additional DH monies for prevention of HCAI were bid against

successfully to enable the funding of a Rapid Response Cleaning Team, steam cleaners, placement of additional hand wash basins and improved signage for hand gel stations

Environment Inspections

PEAT – RSH and PRH awarded “Excellent” by NPSA in areas of Environment, Food, Privacy and Dignity

Health Care Commission Inspection Jan 08 – reported July Management GreenEnvironment AmberIsolation Green

Areas for improvement included need for upgrade of CSSD, cleaning checklists, care of linen, and documentation of training – now addressed

2008/09 ICP Programme• Sustainability is key• Review new implementations – streamline if possible• Further strengthen ICP team and management systems• Roll out other components of High Impact Intervention

Audits• Repeat Deep Clean and continue refurbishment programme• Empower Modern Matrons to control cleanliness • Continue plan to commission new CSSD with other partners• Continue to work with PCTs

0

5

10

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25

30

35

40

Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08

MRSA Bacteraemia

Cdiff

March 08▲RSH MRSA screening of emergency admission.▲17/3/08 Cohort ward opened RSH▲Clinical site meetings with Infection Control team ▲MRSA and C.diff care pathways introduced▲Chloraprep introduced▲ Introduction of data packs from Consultant M icrobiologist▲Central venous catheter ongoing care▲Renal catheterisation audit

Dec 07▲Introduced Tristel for terminal/daily cleaning▲Peripheral line audits

A pril 08▲Introduce Tristel cleaning of toilets and bathrooms daily.Weekly Consultant Microbiologist treatment review of cdiff patient RSH & PRH.▲Antibiotic pharmacist PRH started 1/4/08

J an 08▲Launch of Yr3 CleanYourHands ▲Deep Clean carried out across the Trust

May 08▲Daily review of C.diff patients at RSH by Ward 22C doctorFeb 08

▲New beds & commodes ▲Antibiotic pharmacist 2 afternoons a week RSH. ▲Productive ward programme

Oct 07▲7 day testing for C.dff▲Wards responsible for Route Cause Analysis on bacteraemia

J uly 07▲Clinell wipes introduced

Aug 07▲Hand hygiene audits

May07▲Central line insertion audits

Nov 07▲C.diff HII audit

Aug/Sept 08▲SMART cycler for rapid MRSA testing ▲Matron appointed for Infection, Prevention and Control ▲Service Improvement Manager in postSept 07

▲MRSA screening introduced for emergency admissions and elective inpatient surgey at PRH