INFECTION PREVENTION AND CONTROL ANNUAL REPORT 2008-9

INFECTION PREVENTION AND

CONTROL

ANNUAL REPORT 2008-9

Based upon guidance from the Department of Health Inspector of Microbiology

Report Title Infection prevention and control Annual Report 2008-9

Report Date 18 December 2009

Author Noel Scanlon

Author’s Job Title Chief Nurse / Director of Infection Prevention & Control

Department Infection prevention and control, Nursing Directorate

Owner Noel Scanlon

Owner’s Job Title Chief Nurse / Director of Infection Prevention and Control

18 December 2009 The Queen Elizabeth Hospital King’s Lynn NHS Trust

Annual report Infection prevention & control 2008/9 Page 2 of 101

Table of contents

page

EXECUTIVE SUMMARY AN OVERVIEW OF INFECTION CONTROL ACTIVITIES IN THE TRUST ................................................................4

INTRODUCTION............................................................................................................................................................................................9

INFECTION CONTROL ARRANGEMENTS...................................................................................................................................................10

GOVERNANCE ARRANGEMENTS FOR INFECTION CONTROL................................................................................................................................10 MEMBERSHIP OF THE INFECTION CONTROL TEAM ...........................................................................................................................................10 MEMBERSHIP OF THE INFECTION CONTROL COMMITTEE ..................................................................................................................................10 LINKS TO OTHER COMMITTEES ......................................................................................................................................................................10 REPORTING ARRANGEMENTS: .......................................................................................................................................................................11

THE HEALTH ACT 2006 AND THE HYGIENE CODE...................................................................................................................................11

RESOURCE ALLOCATION TO INFECTION CONTROL ACTIVITIES: ............................................................................................................12

MEDICINE ..................................................................................................................................................................................................12 NURSING ...................................................................................................................................................................................................13 PHARMACY................................................................................................................................................................................................13 ADMINISTRATIVE SUPPORT...........................................................................................................................................................................13 MICROBIOLOGY LABORATORY .....................................................................................................................................................................13 IT SUPPORT ................................................................................................................................................................................................14

ENVIRONMENTAL IMPACTS UPON HCAI..................................................................................................................................................15

ENVIRONMENTAL RISK ASSESSMENT AUDITS ...................................................................................................................................................15 DEEP CLEANING..........................................................................................................................................................................................16 ISOLATION CAPACITY...................................................................................................................................................................................16 TEMPORARY STAFFING ................................................................................................................................................................................17 FAILURE TO ISOLATE PATIENTS, ESCALATION AND PATIENT TRANSFER ................................................................................................................17

DIRECTORATE REPORTS ............................................................................................................................................................................17

EMERGENCY CARE & MEDICINE....................................................................................................................................................................17 External review of the cluster of C.difficile cases between 20th August and 2nd September 2008 on Oxborough ward at QEKL Hospital...............................................................................................................................................................................................18 Independent Review of Infection control practices within Oxborough and Necton Wards.........................................................20

ACCIDENT & EMERGENCY MEDICINE.............................................................................................................................................................21 ELECTIVE CARE ...........................................................................................................................................................................................21 OBSTETRICS AND GYNAECOLOGY .................................................................................................................................................................22

Overview of service............................................................................................................................................................................22 Out-patient services ...........................................................................................................................................................................22 MRSA screening .................................................................................................................................................................................22 HII audits.............................................................................................................................................................................................22 Environmental issues .........................................................................................................................................................................23 New developments ............................................................................................................................................................................23 Future plans........................................................................................................................................................................................23

ANAESTHETICS AND CRITICAL CARE...............................................................................................................................................................23 CHILD HEALTH ...........................................................................................................................................................................................24

Neonatology.......................................................................................................................................................................................24 Rudham ..............................................................................................................................................................................................24

RADIOLOGY ...............................................................................................................................................................................................24

HEALTHCARE ASSOCIATED INFECTION....................................................................................................................................................25

MANDATORY SURVEILLANCE........................................................................................................................................................................25 METICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) .............................................................................................................................25 MRSA SCREENING......................................................................................................................................................................................26 CLOSTRIDIUM DIFFICILE................................................................................................................................................................................27

Root cause analyses and learning ....................................................................................................................................................28 GLYCOPEPTIDE RESISTANT ENTEROCOCCAL BACTERAEMIA...............................................................................................................................29 SURGICAL SITE SURVEILLANCE.......................................................................................................................................................................29

Introduction .......................................................................................................................................................................................29 Reporting............................................................................................................................................................................................30

SERIOUS UNTOWARD INCIDENTS – OUTBREAKS (SUIS) REPORTED TO REGION .....................................................................................................34 MULTI-RESISTANT ORGANISMS .....................................................................................................................................................................37 ANTIBIOTIC THERAPY ..................................................................................................................................................................................37



Table of contents (contd.)

page

HAND HYGIENE AND ASEPTIC PROTOCOLS ............................................................................................................................................39

‘CLEANYOURHANDS’CAMPAIGN ..................................................................................................................................................................39 IV LINES AND URINARY CATHETERS ...............................................................................................................................................................41 LAUNCH OF CHLORAPREP SKIN PREPARATION (2% CHLOROHEXIDINE AND 70% ALCOHOL) ................................................................................41 DECONTAMINATION....................................................................................................................................................................................41

Mattress breach..................................................................................................................................................................................42 CLEANING SERVICES ....................................................................................................................................................................................43 AUDITS......................................................................................................................................................................................................44

Hand Hygiene.....................................................................................................................................................................................44 Environment.......................................................................................................................................................................................44 Peripheral Cannulation Audit ...........................................................................................................................................................45 Sharps Audit .......................................................................................................................................................................................46

CARE BUNDLES (HIGH IMPACT INTERVENTIONS (SAVING LIVES(2005)) ..............................................................................................................46 CARE BUNDLES /LEADING IMPROVEMENT IN PATIENT SAFETY (LIPS)..................................................................................................................49

Performance scorecard ......................................................................................................................................................................49

INFECTION CONTROL POLICIES .................................................................................................................................................................52

HEALTHCARE COMMISSION HYGIENE CODE INSPECTION .....................................................................................................................53

HEALTH ACT 2006 (HYGIENE CODE) .............................................................................................................................................................53 HEALTHCARE ASSOCIATED INFECTION (HCAI) PROGRAMME OF INSPECTIONS ....................................................................................................53

Recommendations of the health care commission ..........................................................................................................................54 IMMEDIATE ACTIONS TAKEN ........................................................................................................................................................................56 STATUTORY DECLARATION OF COMPLIANCE WITH THE HYGIENE CODE ..............................................................................................................58

ACTION PLANNING ....................................................................................................................................................................................59

TRAINING ACTIVITIES ................................................................................................................................................................................59

INDUCTION.............................................................................................................................................................................................59 MANDATORY INFECTION AND CONTROL UPDATE..............................................................................................................................59 ADDITIONAL TRAINING .........................................................................................................................................................................59

EVALUATION OF THE INFECTION CONTROL ACTION PLAN APRIL 2008 – MARCH 2009 ......................................................................60

EVALUATION OF ANNUAL INFECTION CONTROL PROGRAMME 2008/2009.......................................................................................61

APPENDIX 1: HYGIENE CODE ACTION PLAN 2008/9: ..............................................................................................................................71

APPENDIX 1A: OXBOROUGH ACTION PLAN ( AS AT JUNE 1, 2009).......................................................................................................90

APPENDIX 2: STATISTICAL PROCESS CONTROL CHART MRSA & C DIFF INCIDENCE V. INSTITUTION OF CONTROL MEASURES .......97

CONCLUSION..............................................................................................................................................................................................99



Infection prevention and control Annual Report 2008-9 Based upon guidance from the Department of Health Inspector of Microbiology

Executive Summary

An Overview of infection control activities in the Trust

Introduction The annual report of infection control activities in the Trust is drawn up by the Director of Infection Prevention & Control following guidance issued by the Inspector of Microbiology for the Department of Health. This report relates to the period April 1st, 2008 – March 31st, 2009 and all performance, external inspections and recommendations therein. It will necessarily include action plans which are incomplete at year end as the Queen Elizabeth Hospital King’s Lynn is committed to continuous improvement of service irrespective of when in the calendar weaknesses are identified.

Performance The incidence of MRSA bacteraemia in year 2007/08 was 8 cases against a trajectory of 12 – static performance following a 67% reduction in the MRSA bacteraemia rate between 2004/5 and 2007/08.

The Trust recorded 68 cases of Clostridium difficile in the 2008/9 following 12 consecutive months of under trajectory performance. In all there was a 58% reduction on performance between the years 2007/8 and 2008/9.

The Infection Control Committee, Clinical Governance Committee, Health care governance Committee and Board itself monitors this performance on a monthly basis as well as reviewing the outcomes of root cause analyses for MRSA bacteraemia and audits of all Clostridium difficile cases not just those that relate to colectomies, intensive care admissions and deaths. Monthly monitoring of compliance rates against the care bundles based on Department of Health High Impact interventions are also reviewed at each of these meetings.

Quarterly compliance against these measures have shown sustained improvements:

• MRSA screening rates across the Trust have improved from 58% to 82% in the fourth quarter.

• Hand Hygiene compliance achieved a mean of 91% across the year which is a 15% increase on the year 2007/2008. The monitoring of patient environment and clinical safety through cleanliness, environment, and sharp safety tools in the fourth quarter has improved from 96% to 98%.

• The Surgical site infection care bundle has shown improvements in compliance across every ward and theatre environment from 85% to 100%.

• The Urinary catheter care bundle had levels of improvement from 95% to 99%.

• The central venous catheter care bundle, has yielded compliance rates through quarterly monitoring from 96% in the first quarter to 86% in the fourth.

• The care bundle for ventilated patients (prevention of ventilator associated pneumonia) has very high rates of compliance which have now been monitored less stringently at between 98% and 97% in the final quarter of the year.

• Compliance with the Peripheral line care bundle has varied between 90% and 95%.



• The weekly monitoring of sharp incident reports have shown between 6 and 9 cases per month, with a peak during the winter months, whilst at the same time the proportion of very low incidents by grade has increased and no high risk incidents have occurred since April 2008.

Patient environment and control measures Reference to this statistical process control chart for MRSA bacteraemia and Clostridium-difficile incidence between 2004 and 2008 (see Appendix 2), demonstrates dramatic improvements in these infections brought about through prudent antibiotic prescribing, the interventions recommended through previous performance improvement visits for C.difficile infections, and the Trusts own infection control action plans. The introduction of root cause analysis, progressive refinements in antibiotic policy, audits of hand washing compliance and the opening of the Clostridium difficile isolation ward in February 2008, as well as the introduction of the Clostridium-difficile care bundle and other high impact interventions can clearly be seen to have had a dramatic impact of reducing the incidence of health care associated infections within the Trust.

Root cause analyses and learning In 2008/2009 the Trust had 8 MRSA bacteraemias. The IPACS under took a root cause analysis on each of these cases. The general issues identified on undertaking a RCA on these patients identified poor documentation, firstly of the insertion/removal of the intravenous cannula present in each case and secondly the recording of the Visual Infusion Phlebitis (VIP) scores, which look for the signs of inflammation of the site/s. This had been a general problem for some time.

IPACS instigated the use of 2% Chlorhexidine and 70% Alcohol for the preparation of skin prior to cannulation early 2009. The Trust approved of the change of practice, as this was in line with EPIC 2 Guidelines and Saving Lives (see previous section on 2% Chlorhexidine and 70% Alcohol). However, the last MRSA bacteraemia proved on investigation to be probably avoidable, if the VIP scoring was undertaken regularly and documented. The patient had a cannula or cannulas in situ for two weeks and only one VIP score was documented. A multi disciplinary working party was set up to review the documentation and the use of a cannula pack for venous access. A review of the documentation is hoped to make the documentation for the recording of the VIP scores more easily accessible and clearer. The introduction of a cannula pack will focus the staff cannulating that the process must be undertaken in a clean non touch technique. The Practice Development Nurses have been asked West Anglia College Media department to undertake a media project, and film various aseptic techniques, including a clean non touch technique of cannulation. This DVD will be used to train doctors and nurses.

Root cause analysis for Clostridium Difficile continues to highlight the over use of prolonged courses of broad spectrum antibiotics and the use of proton pump inhibitors as potential contributors to the incidence and spread of this iatrogenic infection. The Trust appointed an antimicrobial pharmacist in 2008, who is working along side our Consultant Microbiologist in reviewing the use of the antimicrobials that select for Clostridium difficile.

The opening of the isolation unit for the management of patients with Clostridium difficile on Stanhoe ward, contributed to the reduction of this infection within the Trust this year. In previous years there had been issues with the non-compliance or delayed isolation of patients in side rooms who had been diagnosed with the infection, causing the potential for spread. Since the opening of the unit, C Diff. patients are transferred within two hours of when the ward is informed.

External inspection The Trust received an unannounced annual inspection against compliance with the hygiene code on 9th and 10th December 2008. The inspection assessed the Trust’s compliance against Duty 2 (management systems), Duty 4: (clean and appropriate environment), Duty 8 (adequate isolation facilities), Duty 10j (adhere to antimicrobial prescribing policies).



The assessment was in depth - assessing the knowledge of staff through to checking whether wards and bathrooms have been cleaned properly. The inspection included looking at the environment as well as practices and procedures; for example looking at hand-washing, procedures for isolating patients and the cleaning of equipment.

On February 3rd the Trust received the final recommendations following the inspection.The report indicated that whilst there were a number of areas of good practice and was complimentary to the Trust in relation to governance, delivery, accountability and support, a number of weaknesses were identified. These included:

• Intelligence gathering

• Hand hygiene facilities

• Training of some staff groups

• Back log maintenance

• Some inconsistencies around linen and waste disposal

• Business planning and risk registers

• Workforce infrastructure to support IP&C

• Incidence / prevalence of C. Diff on a specific ward

• Two breaches within duty 2 – Duty to have in place appropriate management systems for infection

prevention and control

• Three breaches within duty 4 – Duty to provide and maintain a clean and appropriate environment for

health care – HCC indicated that there was also a material failing in sub duty 4f. However this did not

result in an improvement notice.

In response, the trust has created an action plan which addresses not just the points made in the report, but also incorporates the three action plans currently in place so that there is one action plan which schedules a series of measures against the duties of the code (Appendix 2). Each item of which has a lead member of senior staff who will take responsibility for compliance against the assurance statement relevant to that specific duty and will monitor progress on a regular basis and identify a timeframe. This action plan can then be “traffic lighted” for continuous performance monitoring at regular in some cases weekly periods thereafter. In relation to the specific issues raised the commission found as follows. Duty 2 Duty to have in place appropriate management systems for infection prevention and control.

Arrangements must include: Sub-duty 2c The mechanisms by which the board intends to ensure that adequate resources are available to secure

effective prevention and control of HCAI and should include implementing an infection control programme.

The Trust is currently reviewing the provision of infection prevention and control arrangements. An advertisement is currently out for the appointment of a second full-time Consultant Microbiologist. The current microbiologist will assume the responsibility of Infection control doctor in the interim. The nursing element of the Infection Prevention and Control Service nursing team will be enhanced in both quantity and grade mix. The overall intention is to ensure that the Service has adequate capacity and authority to affect and influence change in the delivery of clinical services in order to continuously improve the quality of practice and clinical outcomes for patients in relation to healthcare associated infection. Out of hours arrangements will be enhanced to ensure that a robust 24/7 mechanism is available to support clinicians where there is a case of suspected or proven infection. A programme of infection prevention and control activity has been devised and worked to by the Infection Prevention and Control Service. This comprises a series of policy development, educational programmes, campaigns and innovations, to ensure that all members of staff have the necessary competencies and capacities to deliver safe basic



nursing and medical care. The objectives for the infection prevention and control programme were contained in the 2008/9 Annual report and approved by the board at it’s publication in September last year. Sub-duty 2e A programme of audit to ensure that key policies and practices are being implemented appropriately. All Infection Prevention and Control policies and procedures have been inventorised indicating their scheduled dates for review. A programme of review and development has been put in place to ensure that all policies are current and represent a contemporaneous authoritative set of guidances based upon current evidence. This is in addition a Trust-wide programme of audit which is managed by the Clinical Audit department to ensure that key policies and practices are being implemented appropriately. The audit framework for the plan details responsibilities and highlights areas for continuous review on the basis of Patient Safety Incidents, National Guidance and individual service priorities. This forward plan is managed by the Clinical Audit department in close liaison with Associate Chief Nurses, Clinical Governance Leads and individual Clinician Managers. This includes a specific section of audit related to Infection prevention and control dictated by the prevalence and incidence of HCAI, compliance with high impact interventions, antibiotic usage and patient safety incidents. The trust can evidence action taken following audit outcomes and an audit trail to demonstrate that reco0mmendaitons are followed through to delivery. Duty 4 Duty to provide and maintain a clean and appropriate environment for health care. An NHS body

must, with a view to minimising the risk of HCAI, ensure that: Sub-duty 4a There are policies for the environment which make provision for liaison between the members of any

infection control team and the persons with overall responsibility for facilities management. Policies for the environment, which make provision for liaison between members of the Infection Prevention and Control Service and persons with overall responsibility for Facilities Management, are in place. These relate both to cleanliness, cleaning of medical equipment, estates design and provision of advice and support both in relation to education of all members of staff, but also specifically to outbreak control. Sub-duty 4e There is adequate provision of suitable hand wash facilities and antibacterial hand rubs. The Trust has reviewed the numbers of hand wash basins within the Trust, consider the lay-out of toilets, bathrooms and sinks during the review of clinical areas in line with the Department of Health’s ‘Eliminating mixed sex wards’ directive of 28th January 2009. There are presently specific issues in the end bay in three of the wards visited and these have been prioritised for estates refurbishment in the first quarter of this financial year, in order to ensure that every member of staff has access to hand hygiene facilities within their clinical place of work. Waste bins which obstruct access to hand wash basins have been removed and placed in alternative locations. Sub-duty 4f: An NHS body must, with a view to minimising the risk of HCAI, ensure that there are effective

arrangements for the appropriate decontamination of instruments and other equipment. This commentary specifically relates to the provision of mattresses, one of which was found to be soiled during the visit. Every mattress in the Trust has been inspected. Each Matron has been trained in the Mount Vernon mattress inspection technique and this has been cascaded to shift leaders and all registered nurses. This included the ‘fist’ method to measure the rebound capacity of the mattress itself, the integrity of the cover, the zip and the status of the foam. All covers were removed and the foam exposed to visual inspection. Every mattress was inspected and all those found to be defective have been scheduled for immediate replacement. All of these mattresses are being replaced under the terms of the lease agreement and additional capital has been put aside to ensure that every mattress is fit for purpose. The buffer store arrangements are being reviewed so that nursing staff can access available or replacement mattresses instantly they detect a fault. A new Mattress Policy has been established to ensure that mattresses are continuously inspected using the Mount Vernon method, both between patients and on a regular basis. This is validated by a six monthly mattress audit undertaken by the Tissue Viability, Back Care and Infection Prevention and Control Service. The trust is committed to the highest standards of infection prevention and control and will allocate sufficient resources to not only meet our obligations under the code but reduce the already very low incidence of health care associated infection in the trust. The staff and executive have responded to the very fair criticism of our current arrangements with zeal to immediately make the necessary improvements and a pride in our services we have come to expect of this organisation. The control of infection team has further evaluated compliance against the code by completing an assurance framework in order to assess capacity to meet each duty of the code not merely the duties which were assessed by the health care commission. This is appended at Appendix 3. The assurance framework has revealed the same themes as the HCC inspection and the action plans extant at the time of the visit out with duties 2.4.8 and 10j. However, the absence of CPA accreditation for the Microbiology laboratory is contained in the Pathology department business plan for 2009/10.



During the Healthcare Commission review the visiting team questioned the robustness of a recent investigation into a cluster of cases of Clostridium difficile on Oxborough ward as they considered that the Board was not fully aware of all the cases. The Trust responded positively to the comments by the HC and requested an external review of the management of the incident. The reviewers were the HCAI programme manager at the SHA and a Consultant Microbiologist from a neighbouring Trust. The review concluded that in the absence of ribotyping, (which is needed to identify if the cluster of cases were caused by the same or different strains of C.difficle) this could not be identified as an ‘outbreak’. It was agreed that only the four cases admitted to Oxborough ward were linked by time place and person. The key findings listed by the reviewers support the Healthcare Commission’s concerns as to the robustness of the investigation and therefore the ability of the Board to be fully aware of the cases. The reviewers recommended that:

• The DIPC review outbreak policy clarifying actions required and agreeing definition for an outbreak. Clarify route of communication of outbreak report to Board.

• Review C.difficile management policy – clarifying definition of an outbreak, agreeing clear objective criteria regarding time, place and person, establishing clear links to other policies e.g. cleaning, outbreak management.

These actions were implemented in full. Further, The Chief Nurse commissioned a second external review of the organization and delivery of nursing practice on Oxborough ward. An action plan was developed that has been revised and implemented beginning in March 2009. A new Ward Sister came into post shortly after. She has since implemented a number of changes to ensure key areas such as staffing levels, documentation and effective ways of working were addressed.

Governance In the period March – May 2009 the following has been achieved:

• Development of the Infection Control annual programme April 2007-March 2008

• Development of Trust Infection control assurance framework based on compliance against the Code of practice.

• Review of compliance against Code of practice (Trust position statement) and Trust preparation for external visits

• Creation of a Trust HCAI action plan and inclusion of actions identified as a result of HCC inspections and the code of practice review.

• Establishment of monthly Estates planning meetings with IPACs where all new projects must meet IP&C approval

• Trust wide review and retraining around equipment decontamination and routine regular mattress inspection and replacement in real time

• Establishment of weekly Meetings of IPACs chaired by the DIPC

• Review of ICT structure and resources

Workforce Concerns regarding the less than universal compliance with care bundles for peripheral lines were expressed in year. Re-launches are planned with the use of revised audit tools, peripheral line insertion packs and alternative antiseptic devices.

The Lead Nurse Innovation and practice has devised DVDs on aseptic technique, urinary catheterisation, blood culture drawing and peripheral line insertion. These training DVDs were launched for the new intake of house officers in August 2009.

Audit and dissemination The clinical audit programme comprises mandatory infection prevention and control elements.

The Trust’s new patient safety bulletin was launched in May 2009 and a new root cause analysis tool for Clostridium difficile to establish a process similar to the MRSA bacteraemia process for responsible consultants and the infection control doctor was piloted in April.



The Trust is also participating in the productive ward programme.

Summary In summary, a comprehensive programme of improvements in all aspects of Infection prevention and control have yielded sustained MRSA performance following a 67% reduction in the MRSA bacteraemia rate between 2004/5 and 2007/08; and a 58% reduction in Clostridium difficile incidence between the years 2007/8 and 2008/9.

Following the Health care commission hygiene code inspection the trust has embarked upon a comprehensive and far reaching action plan informed by and structured around the hygiene code, including changes to decontamination, mattress replacement and medical device management.

The trust is confident that as a consequence of all this effort and further hard work ahead that it will achieve less than the 61 case threshold of in hospital Clostridium difficile cases in 2009/10 defined in the operating framework and in achieving less than the MRSA target of 7 Bacteraemias in 2009/10.

Introduction

The annual report of infection control activities in the Trust is drawn up by the Director of Infection Prevention & Control following guidance issued by the Inspector of Microbiology for the Department of Health. This report relates to the period April 1st, 2008 – March 31st, 2009 and all performance, external inspections and recommendations therein. It will necessarily include action plans which are incomplete at year end as the Queen Elizabeth Hospital King’s Lynn is committed to continuous improvement

The report describes the current infection control arrangements within the Trust including the composition of the infection control team, the governance arrangements whereby healthcare associated infection rates are monitored, action plans devised, their effectiveness evaluated and reports escalated to the Board through its various sub-committees and to outside agencies such as the Consultant in Communicable Disease Control, Director of Public Health and the Health Protection Agency.

The capacity of the Trust to meet more exacting infection control targets is a function of the resources allocated to infection control activities. These comprise a Consultant Microbiologist, an infection control nursing team, attendant administrative and information technology support and crucially the commitment of every member of clinical and non-clinical staff within the Trust. To this end a comprehensive infection control programme (Appendix 3) builds on the achievements of the previous year and outlines a range of measures intended to address the seven action areas described in the Winning Ways report (CMO, December 2003). These measures relate to the reduction of infection risk, the introduction of care bundles (or high impact interventions as they are termed by the DH), the maintenance of high standards of hygiene in clinical practice and the prudent use of antibiotics.

The incidence of health care associated infection is described in the report with a particular emphasis upon Meticillin Resistant Staphylococcus Aureus (MRSA), Glycopeptide Resistant Enterococcus and Clostridium difficile as these are seen to be the major causes of infection outbreak and the most difficult to control. The report also describes the approach taken to reducing the risk at common portals of entry of infection such as surgical wounds and the management of infection outbreaks. Tuberculosis is an emergent public health problem with an increasing incidence in the community and the hospital population. Outbreaks of infection invariably lead to bed closures and significant impacts on the capacity of the Trust.

The single largest source of transmission of infection in hospital is the hands of health workers. Consequently the report describes the approach taken to hand hygiene, the development of aseptic protocols, the relationship between hospital acquired infection and invasive devices and the development of cleaning services.

The effectiveness of all of these interventions must be carefully appraised through the rigorous use of clinical audit and the implementation of action plans where weaknesses are identified. The appointment of



an anti-microbial pharmacist is one of the many innovations which will continue to improve the Trust’s performance in relation to infection control.

The capacity of the infection control team and the Trust’s staff to meet the infection control agenda is a function of the skills and capacity of its workforce. The training activities of the Infection prevention and control (IPACs) team itself is also described within the report.

The report also recognises that Healthcare associated infection knows no boundaries and the development of inter-agency and inter-Trust fora to manage the infection control agenda of the NHS is an important part of the network to prevent health care associated infection in hospitals and beyond.

Infection Control Arrangements

Governance arrangements for Infection Control

The Chief Nurse / Director of Infection Prevention and Control (DIPC) is the Executive Lead for Infection Control and is accountable to the Trust Board.

The DIPC and Infection Control Committee formally report in to the Clinical governance Committee which in turn reports to the Health care governance committee which is a sub-committee of the Trust Board.

Governance frameworks have been strengthened following the Healthcare Commission’s inspection against three duties of the Hygiene Code in December 2008. The development of an assurance framework for Infection Control will ensure the on-going measurement of compliance with the Hygiene Code and will be integrally linked to the Trust’s annual Infection Control programme and action plan.

Membership of the Infection Control Team

Gwyneth Wilson Director of Infection Prevention & Control / Chief Nurse ( - Nov 2008) Val Newton Director of Infection Prevention & Control / Chief Nurse (Nov 2008 - Feb 2009) Noel Scanlon Director of Infection Prevention & Control / Chief Nurse (from Feb 2009) Prof. Lynne Liebowitz Infection control Doctor/Consultant Microbiologist Lynne Roberts Lead Nurse Infection Control Elspeth Hardy Clinical Nurse Specialist Infection Control Helen Senior Infection Control Nurse Dr. Christianne Micaleff Antimicrobial pharmacist

Membership of the Infection Control Committee

Chair Mr Noel Scanlon (from Feb 2009) Mrs Val Newton (Dec. 2008- Jan. 2009) Gwyneth Wilson ( - Nov 2008) Infection Control Team As above Dr Chris Williams Consultant in Communicable Disease Control Dr Christianne Micaleff Antimicrobial Pharmacist Mrs Angela Hircock Assets and Facilities representative Mr Tony Webster Estates manager Mr Paul Rowley HSSD Manager Mrs Judith Levene Occupational Health Senior Nurse Advisor Dr. Sarda Elderly Medicine Dr. B. Piel Child Health

Links to other committees

Members of the Infection Control Team attend the following committees:

Mr N Scanlon .........................................................................................................Clinical Governance Committee ................................................................................................................................................ Trust Executive Board ................................................................................................................................... Decontamination Committee ...........................................................................................................................Pandemic Flu planning committee ............................................................................................. MRSA Screening For Elective Patients working party



.....................................................................................................................................................Executive Directors .................................................................................. Norfolk Health Protection and Infection Control Forum .......................................................................................................................Capacity & Infrastructure Committee .................................................................................................. Control of Infection Committee policy sub group .............................................................................................................Nursing & Midwifery Executive Committee ......................................................................................................................... Health care governance committee Prof. L. Liebowitz..................................................................... Control of Infection Committee policy sub group ............................................................................................. MRSA Screening For Elective Patients working party ................................................................................................................................... Decontamination Committee .............................................................................................................................. Emergency Planning Committee ...............................................................................................East of England Epidemiology Microbiology Forum ….……………………………………………………………………………Norfolk Health Protection Advisory Group

.………………………………………………….Norfolk Health Protection and Infection Control Forum ................................................................................................Chair, Trust Antimicrobial Stewardship Committee ..................................................................................................................................... Pandemic Flu working party Dr. C. Micaleff.................................................................................................Drugs and Therapeutics Committee .........................................................................................................Control of Infection Committee IC sub group ...........................................................................................................Trust Antimicrobial Stewardship Committee Mrs. L Roberts ........................................................................................................... Decontamination Committee .......................................................................................................................................... Patient safety committee

..................................... …...………………………………………Control of Infection Committee policy sub group .........................................................................................................Nursing and Midwifery Executive Committee .................................................................................. Norfolk Health Protection and Infection Control Forum ...........................................................................................................................Pandemic Flu planning committee ................................................................................................................................................... ICN Regional Group ....................................................................................................................................... Nutritional Steering Group ...............................................................................................................................................Specialist Nurse Group ............................................................................................. MRSA Screening For Elective Patients working party ...................................................................................................................................Health and Safety Committee ..........................................................................................................................................................Learning Forum ............................................................................................... Essential Care Services committee (Food, Cleaning)

Reporting arrangements:

The Director of Infection Prevention & Control presented the Annual Report for 2007/8 and accompanying Infection Control Action Plan to the Trust Board in September 2008, where the Annual Report was noted and the Action Plan approved.

Reports of Serious Untoward Incidents related to outbreaks of infection are presented to the Trust Board by the Chief Nurse / DIPC.

The Health Act 2006 and the hygiene code

The Health Act 2006 introduced a statutory duty on NHS organisations from October 1st 2006 to observe the provisions of the Code of Practice on Healthcare Associated Infections1. In August 2006 it was publicised that trusts' observance of the Code would form part of the Healthcare Commission's assessment and ratings process from April 2007.

In order that performance against the Code is taken into account in the 2007/ 8 annual health check, the Healthcare Commission required all trusts to:

• consider the extent to which they have been meeting the duties set out in the Code from October 1st 2006 in their declarations of performance against the core standards that were submitted on May 1st 2008. The Healthcare Commission has amended its criteria for standards C4a, C4c and C21 to include reference to the Code. Priority was also be given to the Code by including at least one of these standards in a Health care commission inspection visit that might take place to any trust from

1http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?

CONTENT_ID=4139336&chk=6oAPfi



the summer of 2007. The trust received such a visit in December 2008. A full report of this visit can be found later in this report.

• provide a short statement outlining whether the trust considers it has appropriate measures in place to ensure that the provisions of the Hygiene Code are being observed as at March 31st 2008. The trust submitted this statement using the declaration form for core and developmental standards. This statement did not directly contribute to a trust’s quality of services element of the rating, rather it sat alongside trusts’ declarations for the core and, where relevant, the developmental standards. This statement was also intended to provide assurance to patients and the public that trusts have taken due account of their new duties under the Code and to continue to support the protocols for the mandatory submission of data for the surveillance of MRSA bacteraemias and Clostridium difficile in order to allow for assessment of performance against the national target.

Resource allocation to infection control activities:

Medicine

Funding for medical staff is held by the Pathology Directorate. The Microbiology Department has one Consultant Microbiologists, Prof. Lynne Liebowitz acts as Lead Infection Control Doctor and Head of Department. Prof. Liebowitz works closely with the Infection Control Nurses on a day-to-day basis.

Prof. Liebowitz is involved in meetings and other interactions with senior management, the Primary Care Trust, the East of England Strategic Health Authority; and the Department of Health relating to the programme to control health-care-associated infection in England. Prof. Liebiwitz also acts as Chairman of the Trust’s Antibiotic Stewardship Committee responsible for the selection of antibiotics on the trust formulary, and the review of the Trust’s Antibiotics Guidelines and other guidelines that involve the use of antibiotics. All Consultants were involved in the development of the Trust Antibiotic Guidelines and the adaptation and implementation of the Saving Lives Care Bundles. The guidelines are updated annually. Any case where an antibiotic is requested that is not in the antibiotic guidelines has to be approved by a Consultant Microbiologist, thus involving close liaison with Pharmacists.

Prof. Liebowitz contributed to the teaching programmes for doctors and nurses regarding Infection Control issues and the appropriate use of antimicrobials. In addition, the Trust Antibiotics Stewardship Committee provides regular reviews of different guidelines that involve the use of antibiotics, such as the neutropenic sepsis guidelines, guidelines for the use of antibiotics in general practice and some Directorate specific guidelines for the use of antibiotics, e.g. Obstetrics and Paediatrics..

Prof. Liebowitz serves on several Trust committees dealing with infection control issues such as decontamination and MRSA. Prof Liebowitz also advises the Sterile Supply Department on microbiological issues. The root cause analysis of each case of MRSA bacteraemia involves a meeting, which includes a Microbiology Consultant, IPACs, DIPC , CEO and the Consultant and senior nursing staff caring for the affected patient.

Professor Liebowitz has regular ward rounds in Intensive Care and High Dependency Units, and heamatology. Consultants are also attempting to understand the root causes of each case of Clostridium difficile associated disease that occurs in the QEH. Professor Liebowitz has also contributed to the development of other Trust guidelines and policies with infection control implications referred to later in this report.

The opening of isolation ward in March 2008 for the management of patients with Clostridium difficile associated diarrhoea was fully supported by the Consultant Microbiologist, and every multi-disciplinary meeting has Consultant Microbiologist input.

Professor Liebowitz interacts with colleagues in the local Health Protection Unit regularly to ensure effective reporting of infection control risks in the community.



Nursing

The clinical demands on the team have continued to increase substantially due to increased training, environmental audits have been extended to new departments, requests for statistical data, continued development and implementation of care bundle packages, complete review of all infection control policies to meet the demands of the hygiene code as well as routine surveillance and outbreak control. This involved establishing five brand new policies in addition to the existing policies that were revised. Additional work in preparation to meet NHSLA requirements level two, an increase in estates advice work on refurbishment and new build and development of clinical areas changing needs.

The drive upon rigid adherence to the MRSA screening risk assessment has led to an three fold increase in screening. The increase in screening patients for MRSA has increased the clinical workload in terms of following up patients who either present an infection control risk on admission or develop one later, not least in terms of supporting ward based staff in ensuring patients are fully informed of the needs for isolation and understand the approach taken to their care.

The Trust has continued to experience outbreaks of Norovirus and clusters of MRSA this year all of which take time to gather information for the meetings, minute take and follow up on actions, write reports and hold debriefs which generate the development of action plans, as well as educate and support ward staff.

Pharmacy

Effective antimicrobial stewardship, combined with the High Impact Interventions for clinical procedures, is an important contribution to the control and prevention HCAI caused by antibiotic resistant organisms. There is evidence that suggests an association between total antimicrobial use and MRSA prevalence. A higher MRSA prevalence is associated with some groups of antibiotics, such, quinolones and second and third generation cephalosporins. Furthermore, there is now a large body of evidence to support the hypothesis that the use of broad-spectrum antibiotics (such as quinolones and cephalosporins) is a major factor in inducing Clostridium difficile associated disease.

In March 2008, an antimicrobial pharmacist was appointed (1WTE on most occasions- in March 2009 this changed to 0.6WTE).DR. Christianne Micallef has Produced an Antibiotic Prescribing policy and helped update and initiate other antimicrobial guidelines, conducted clinical ward-based antibiotic audits, produced quarterly antibiotic consumption data, regularly participated in Trust Meetings (including Control of Infection, Infection Control Policy sub-group, Pandemic Flu, Antibiotic Stewardship Committee and Drugs and Therapeutics Committee). Dr. Micalleff has also drafted and implemented a Trust-wide Antimicrobial Prescribing Audit Programme, attended daily consultant-led Clostridium difficile infected patient ward rounds and is founder and editor of PHARMAlinked, The QEH Pharmacy Department Newsletter (with regular updates on antibiotic audits conducted as well as antimicrobial therapy issues).

Administrative support

The Infection Prevention and Control currently receives 7 hours of administrative support per week. This support is supplied from the Pathology department. The member of staff compiles the weekly data for MRSA and Clostridium difficile and distributes the data to the relevant Consultants, Divisional managers, Associate Chief Nurses and Ward managers. Within the 7 hours she supports the IPACS team with clerical duties such as, writing up minutes (including Link Nurse minutes), environmental reports and additional reports required, arranging room bookings for training and diary entries. Also included is maintaining the filing of IPACS paper records of MRSA and Clostridium difficile patients in the Trust. Although the 7 hours of clerical support is invaluable and but only relieves the some pressure off the IPACS team to allow them to undertake their role in the clinical area and for training etc.

Microbiology Laboratory

The laboratory has had to handle significantly more samples over the course of the year relating to HCAI risks. The bulk of the requests are MRSA Screens where increased surveillance has seen an increase of over 6,000 specimens from 2007-08. In addition Routine Pre-admission for all electives was introduced in April 2009 and preliminary figures for the first 6 months of 2009-10 indicate that this will generate up to a



further 15,000 specimens in a full year. Full admission screening, due to be implemented from April 2010 is likely to add up to another 20,000 specimens. (See graph below)

In addition there have been several other HCAI pressures on the laboratory. There has been an increase in the numbers of specimens tested for enteric pathogens, Cl difficile testing up 35% and Norovirus testing up 47% since 2006-07.

Serology testing has also seen a sharp rise, with increasing numbers of requests for staff testing of VZ, Measles, Mumps and Hepatitis.

This increased testing requires the budgetary consequences of consumables, equipment and staff resources to be monitored carefully.

Figure 1: Volume of Microbiology MRSA screens 2005/6 – 2008/9

8681 9625

15402

21756

34534

55000

0

10000

20000

30000

40000

50000

60000

2005-06 2006-07 2007-08 2008-09 2009-10 (Proj) 2010-11 (Proj)

IT support

The healthcare commission noted weaknesses around the detection of trends in infection outbreaks, clusters of alert organisms and timely communication of microbiological findings and advice (see p.45). An infection control software programme to allow microbiology data to be downloaded electronically, negating the need for manual input and to assist in the preparation of graphs and appropriate other tools to feedback infection control statistics to clinical directorates is now to be purchased in 2009/10. The Health Protection Agency has compared three systems and reported on these in 2005. The IT department were asked to review these and assist in the development of a business case for their procurement. £50,000 was put aside by the board for this purpose in 2009.

The infection control and IT team considered various surveillance systems and have identified a solution provided by ICNet that offers the functionality required and is compatible with existing systems and equipment. ICNet is offered by a well-established company able to provide good technical support and development. The system has been fully evaluated by the Health Protection Agency on behalf of the Department of Health and is supported by our IT department.

The procurement of a tried and tested surveillance package will add value to the existing infection prevention and control service by providing effective data management and enabling skilled personnel to access and interpret high quality information to inform and target practice improvements and developments.



This system has now been procured and in the process of being implemented to support the Trust in delivering a comprehensive infection prevention and control programme that provides effective surveillance and assures compliance with standards set in Winning Ways 2003, Saving Lives 2005, and the NHS Litigation authority for Trusts 2008 (NHSLA) Level 3.

The principle objective for this project is to implement the ICNet infection control surveillance system to:

• Interface with our Laboratory System

• Enable the prompt notification of “alert organisms” and “alert conditions” to the infection control team.

• Facilitate effective real time communication of notifications to clinical teams to ensure appropriate precautions are initiated, reviewed and evaluated.

• Plan and track the movement of patients with infection or at risk of infection

• However this is dependant upon a Patient administration system (PAS) interface. The time frame for this has not

been agreed. The New PAS application is due to go live in 2010.

• Promptly identify outbreaks of infection.

• Inform the planning and implementation of control measures.

• Identify trends and support Root Cause Analysis and the implementation of a Hazard Analysis and Critical Control Point (HACCP) management systems.

• Enable wireless communication between infection prevention and control staff and the laboratory when

wireless systems are introduced in 2011 or so.

• Optimise data management to generate timely and meaningful reports to inform strategic development.

• Minimise duplication The IT Department have also taken further steps to raise awareness of Infection Control within the Trust. For example, through publishing IC screen savers trust-wide aimed at providing another channel for informing and educating all staff of potential IC threats.

Environmental impacts upon HCAI

Environmental risk assessment audits

The Infection Prevention and Control Team undertake annually environmental audits based on The Infection Control Nurse Association (now The Infection Prevention Society) Environmental audit tools. The elements of which are Waste disposal, Hand washing, Disinfection, Medical Equipment, Isolation Precautions, the Environment and Practice.

Only one area (Endoscopy) was omitted in 2008/09 due to work pressures of IPCAS and workload of the Endoscopy Department. They were scheduled to be audited as soon as possible in 2009/10.

An average score of 85% was accepted as the minimum required. Five of the 39 Wards/Departments audited did not achieve a minimum of 85%. The average was 92%. The Wards and Departments are requested to submit to the IPACS an action plan which will address issues identified in their audit. Where necessary IPACS re-audit areas where compliance has been poor.

The Infection Prevention Service is assessing the suitability of an electronic audit programme, similar to that used by Hotel Services to undertake the cleaning audits. There have been issues with the software, which the company is addressing. It is hoped to implement this system in 2009/10.



Deep cleaning

The Deep Clean Programme is a Department of Health action plan to reduce healthcare associated infection rates. Deep Cleaning is a systematic approach throughout the Trust of decluttering, cleaning and disinfecting wards and departments.

The Annual Deep Clean programme runs from April through to March and includes:

• The removal of all radiators followed by steam cleaning of the complete patient area then disinfection with a chlorine releasing agent.

• All curtains are changed at this time. There is also a programme of changing all curtains 4 times a year.

There has been some discussion as to whether deep cleaning can take place in a ward occupied by patients. Ideally terminal cleaning should take place in a ward that is empty of patients and is therefore much more time consuming in partially empty wards where patients are rotated between clean and dirty bays until the ward is entirely clean

As the Trust has no facility for a ward to be decanted to allow for deep cleaning to take place the cleaning has been very difficult to complete, but the domestic staff work with the ward staff to ensure compliance. Although a programme is set for the whole year it has to be movable as areas become available to clean. If there are two bays empty at one time on any given ward then this ward will be cleaned as this allows for the clean to take place with less inconvenience to the patient population or stress to the staff.

Out patient areas are also included in the deep cleaning programme and this work is carried out in the evenings by the evening/night cleaning team.

In the year of 2008-09 all wards and departments including all outpatient areas were successfully deep cleaned. No extra funding has been given to allow for completion of this task or the increase in curtain changing.

Isolation capacity

There is a great demand for isolation beds within the Trust, making the present low establishment a problem both from a bed management / bed density perspective and Infection control.

The Trusts Infection Control policies for MRSA, C. difficile, Norovirus and Diarrhoea of unknown origin put a daily strain on our Isolation capacity - all patients presenting with a suspected or confirmed diagnosis must be isolated on admission. To alleviate this problem if suspected MRSA carriers is “isolated” in the bays, bed spaces 1 or 6 if no side room is available. Staff must then generate a clinical incident form to highlight the inability to adhere to policy. This is not an ideal situation and may lead to cross infection.

In March 2008 a Clostridium difficile (C. diff) isolation unit was formed by dividing Stanhoe ward, giving 10 side rooms over to C. diff plus one 5 bedded bay for the asymptomatic patients prior to being discharged from the unit. The unit was locked down with only swipe access and a separate nurse team was allocated. Through a combination of strict isolation, strict antibiotic regime and a dedicated gastro-enterologist and nursing team, the number of C. diff patients gradually reduced allowing for the bay and 2 side rooms to be given back to Stanhoe ward.

With the outbreak of Norovirus in January 2009 the isolation capacity was found to be inadequate to nurse all diarrhoeal admissions and the C. diff numbers were down so a plastic temporary barrier was erected to allow for 3 side rooms to be given back to Stanhoe ward allowing for the isolation of diarrhoea of unknown origin admissions.

It was soon evident that a ‘swing’ capacity was required so 2 sets of swipe access doors were put between a pair of side rooms on each side of the ward, allowing for these to swing between being Cdiff isolation rooms or standard isolation. This allowed 4 side rooms to be added or subtracted on demand. At times the



nursing staff capacity was also stretched as rooms were required to be vacated and cleaned several times in any one day.

Temporary staffing

Within the Trust, nursing sickness and absence is covered by bank staff as required, after the need for this is assessed by the ward sister. From October 2008 – September 2009 113,456 hrs of bank shifts were requested and of these were and 21739 hrs were unfilled. It is especially difficult to fill shifts during school holidays and this can impact of the numbers of staff available and the increased workload on remaining staff on duty. During a period of high maternity and vacancy levels the Trust used bank and agency staff to fill shifts during summer months and early autumn. Temporary nursing staff tend to work shorter shifts and usually move to other ward areas within a working week, often working in 2 or more shift a short period of time. This increases the number of patient contacts per nurse and thus increases the potential to spread bacteria. It should be noted that bank staff are expected to undertake annual mandatory training which incorporates an infection control element and agency staff are advised of Trust practices re : infection control when they commence within the Trust

Failure to isolate patients, escalation and patient transfer

The Trusts’ infection prevention and control policies states that have been are confirmed as carrying alert microorganisms must be isolated in side rooms. The monitoring of compliance with isolation has not been routinely audited by the IPACS. This is due to lack of recourses within the service, IPACS review on a daily basis the patients in side rooms in the wards. Ward staff are requested to complete an incident form when they have been unable to isolate a patient in a side room. Clinical audit reports to the Infection Control Committee the number of incident forms they have received, relating to infection prevention and control, including failure to isolate patients. The numbers of forms received fall way below the numbers of incidents of failure to isolate that IPACS are aware of. IPACS has compiled a business plan to employ a Band 3 support worker to monitor isolation of patients on a daily basis and undertake a compliance audit.

On the establishment of Stanhoe Isolation Unit for Clostridium difficile March 2008, the time span for transfer from the ward to the unit was set at two hours from the time the ward was informed of the diagnosis. This was incorporated in the Operational plan for the unit. IPACS complete a route cause analysis on each acquisition of Clostridium difficile and record the time the ward was informed and when the patient was admitted into the unit. In an audit undertaken by IPACS in March/April 2009 the compliance was 98%. One patient was transferred from another Trust with Clostridium difficile but the receiving ward was not informed, although they did isolate the patient and send a specimen.

Directorate reports

Emergency care & Medicine

The directorate of Emergency care & Medicine (comprising ICU, A&E, MAU, Emergency and Elderly Medicine) are responsible for over half of the trusts 500 in-patients. They are also the most vulnerable and at high risk of HCAI. The service aims to provide optimal quality of clinical care and infection control practices at all times. The nature and needs of the patients’ pose a great challenge to all staff in the Directorate, especially in areas which have a high turnover (i.e. A&E & MAU) or where the bed density of the patients is very high (elderly care wards).

Following a a hygiene code visit by the Health Care Commission in December 2009, an elderly care ward, (Oxborough ward) was identified to have higher than expected levels of C. diff . Following the HCC visit an external review of the ward was undertaken to assess if there were any working practices that might have contributed to the rates of C. Diff, an action plan was developed that has been revised and implemented beginning in March 2009. A new Ward Sister came into post shortly after. She has since implemented a number of changes to ensure key areas such as staffing levels, documentation and effective ways of working were addressed.



The division now has two lead nurses to cover the 9 medical wards within the division and as part of their role they visit the clinical areas within their responsibility, to support good practice, maintain standards and assess high impact intervention audit results.

Several wards within the division have undertaken the productive ward project (Releasing time to care) which allows wards to display rates of MRSA and C. Diff rates and encourages staff to engage in ways of reducing infection rates.

As part of the national directive for MRSA screening, the division has commenced screening of all elective admissions in April 2009 and are currently reviewing the inclusion of all emergency admissions within this screening from April 2010.

External review of the cluster of C.difficile cases between 20th August and 2nd September 2008 on Oxborough ward at QEKL Hospital. During the last Healthcare Commission review the visiting team questioned the robustness of a recent investigation into a cluster of cases of Clostridium difficile on Oxborough ward as they considered that the Board was not fully aware of all the cases. The Trust responded positively to the comments by the HC and requested an external review of the management of the incident. The reviewers were the HCAI programme manager at the SHA (Rosie Readman) and a Consultant Microbiologist (Dr Caroline Barker) from a neighbouring Trust. The external review took place on the morning of 23rd January 2009.

The cluster commented on by Dr Siva consisted of 6 cases however two of these had not been to Oxborough ward and so were discounted from the cluster. The cluster of cases consisted of 4 patients all nursed on Oxborough ward for differing lengths of time between the 19th August and the 2nd September. All were transferred to Stanhoe isolation unit when confirmed as Clostridium difficile toxin positive.

• Patient 1 had diarrhoea on admission and was identified as CDT positive with in 24hrs and transferred to Stanhoe on 20.08.08

• Patient 2 spent 6 days on Oxborough in a main bay and was identified CDT positive and transferred to Stanhoe on 25.08.08

• Patient 3 was admitted one day after Patient 1 and was identified as CDT positive and transferred to Stanhoe on 01.09.08. This patient was never exposed to antimicrobials*

• Patient 4 was admitted to Oxborough on 13.08.09 and was transferred to side room on 02.09.08 and then to Stanhoe on 03.09.08 when identified as CDT positive. This patient had a previous history of intermittent diarrhoea with 5 previous CDT negative results in June during a previous admission.

The 4 patients were never nursed in the same bays or under the care of the same nursing teams. In the absence of ribotying of cases this review refers to the incident as a ‘cluster’ of cases.

Review process:

The following information was provided and reviewed:

• An internal letter from Dr Siva (Locum Consultant Gastroenterology and Medicine) to Professor Liebowitz (Consultant Microbiologist)

• An internal letter in response to Dr Siva’s letter from the Deputy Chief Executive/Chief Nurse

• ‘outbreak report’ written by Helen Senior

• Oxborough ward environmental audit report August 08

• The trust Clostridium difficile policy ratified March 08

• Data for all toxin positive Clostridium difficile results within QEKL



• A timeline for the 4 cases on Oxborough

• Oxborough ward hand hygiene audit results

• The inpatient notes for the 4 patients

Further information was requested:

• HCC written comments re outbreak – these were not yet available

• Board comments re ‘outbreak’ – comment on the cluster could not be found in the Board minutes for September and October (draft).

• Cleaning scores for Oxborough – we were told these were consistently at 100%. We suggest that compliance is jointly monitored (matron and contractors as recommended by SHA and DH) to confirm the sustained high standard.

• Action plans for Oxborough in response to below target hand hygiene audit results in July (84%) and September (81%) with the 5 moments at 71% compliance (we noted the improvement in October and November to 100%).

Key Findings:

Listed below are the key findings that were considered by the reviewers to have led to the Healthcare Commissioning drawing the conclusion that the Trust Board had not been fully aware of all the case details.

• The Trusts policy for the management of patients with C. difficile gives no indication of objective criteria for declaring an outbreak leading to inconsistency of approach.

• Lack of clarity and consistency on the definition of an ‘outbreak’

• Chief Nurse Letter ‘ an outbreak is two or more patients on the same ward

• Trusts Policy for the Management of patients with C.diffiicle definition of an outbreak 6.1 ‘ a risk assessment is required when the number of C.difficile cases on a ward exceeds three patients, or when the cases of C.difficile are not related to antimicrobial therapy*’

• The four cases were subject to review using the trusts C.difficile data collection sheet but were not subject to a full root cause analysis. There was no evidence of a robust report to the Board or of Board knowledge of the event. Evidence of robust reviews provides evidence of and information for organisational learning and action planning. The Trust may wish to consider the approach used by Dr Barker’s Trust, where all Clostridium difficile cases are reviewed together at a monthly RCA meeting with expert clinical clinician input.

• The Trust needs to agree with clinicians when ribotyping will be undertaken for C.difficile cases. Other trusts in the region do ribotype clusters of cases as part of their C.diffiicile management strategy. In the absence of ribotyping confirmation of an outbreak will always be subjective.

• We were unable to see evidence of an assurance process at all levels of the organisation that monitors compliance with all high impact interventions including hand hygiene.

• We were advised that only the bed space is cleaned when a symptomatic patient is transferred from a shared bay. There is no explicit cleaning activity identified in the policy on transfer of a symptomatic patient. There is no link to the trusts cleaning policy in the C.difficile management policy although there is mention of the disinfection policy.

• We were only able to identify a clear bowel management history and the consistent use of the Bristol stool chart in the one patient admitted with diarrhoea when we reviewed the nursing notes.



• Absence of organisational learning at a clinical and strategic level from the actions taken in response to the cluster of cases

• The ICT collates data monthly and so this cluster was not given the importance that it required as all cases were identified with 2 weeks of each other. This meant that the overlap of cases in time and place was identified by Dr Siva as the lead consultant for the Isolation unit. Our understanding is that the infection control team have no data analyst support neither is there an electronic reporting system in the trust.

• High impact interventions are implemented on a 3 month rolling programme irrespective of high risk areas. The trust may wish to consider the use of High impact intervention 7 more frequently in wards know to have a higher number of cases.

Conclusion:

The review concluded that in the absence of ribotyping, (which is needed to identify if the cluster of cases were caused by the same or different strains of C.difficile) this could not be identified as an ‘outbreak’. It was agreed that only the four cases admitted to Oxborough ward were linked by time place and person. The key findings listed by the reviewers support the Healthcare Commission’s concerns as to the robustness of the investigation and therefore the ability of the Board to be fully aware of the cases.

Suggested actions:

• Review outbreak policy clarifying actions required and agreeing definition for an outbreak. Clarify route of communication of outbreak report to Board.

• Review C.difficile management policy – clarifying definition of an outbreak, agreeing clear objective criteria regarding time, place and person, establishing clear links to other policies e.g. cleaning, outbreak management.

These actions were implemented in full. Further, The Chief Nurse commissioned a second external review of the organization and delivery of nursing practice on Oxborough ward.

Independent Review of Infection control practices within Oxborough and Necton Wards The Independent Review assessed current practice in relation to infection prevention and control within Oxborough Ward. This included the practice of all nursing, medical and Allied Health Professionals who work within this area. The review identified any practice that may impact on compliance with Infection prevention and control and made recommendations where required, for changes to practice, systems or processes. The review also looked at general ward management, leadership and culture identifying the impact this has on compliance. Background Information The Trust received an unannounced annual inspection against compliance with the hygiene code on 9th and 10th December 2008. The inspection assessed the Trust’s compliance against Duty 2 (management systems), Duty 4: (clean and appropriate environment), Duty 8 (adequate isolation facilities), Duty 10j (adhere to antimicrobial prescribing policies). Mandy Burton, Linda Dempster and Sarah Bellars undertook the inspection. Information seen during the inspection clearly indicated a recurring incidence of Clostridium Difficile in one clinical area namely Oxborough Ward. The Infection Control programme manager from the East of England and a Consultant Microbiologist from the West Suffolk Hospital NHS Trust undertook an independent review of the cluster of cases on the 23rd January 2009. This confirmed a link between four cases. Noel Scanlon, Chief Nurse/Deputy Chief Executive, requested an independent review of infection control practices within this area by an experienced senior nurse from outside of the Trust. The review took place on Oxborough and Necton Ward. Necton ward was used for comparison purposes. The two wards are comparable in size, patient group, and establishment. The independent reviewer was authorised to recommend any changes to practice; and had delegated authority to access all policies and procedures relating to infection control and all other documentation relating to ward management on the two identified wards.



Specific Issues to be addressed The Independent Reviewer assessed individual staff groups knowledge of policies and and how each staff group would monitor compliance of infection control policies and assess their ability to challenge incorrect practice. She reviewed compliance with Trust training requirements in relation to infection control and prevention; numbers of staff who have attended mandatory infection control and prevention training in the past 12 months; benchmarked existing staffing levels on Oxborough and Necton against Regional Care of The Elderly wards identifying any gaps in the skill mix; reviewed compliance with Trust isolation policy to include:

• Isolation guidance displayed • Documentation in relation to infection control issues • Observation of use of PPE in practice • Monitoring of infection control practice in relation to staff and visitors presence on the wards

Methodology included Observations of practice - to assess key aspects of shift management to include: • Communication – is there a culture of shared information? • Direction and organisation of staff – are staff guided and supported throughout the shift? • Monitoring compliance with infections control standards – is there evidence of this happening

throughout the shift? The Independent Reviewer made recommendations for:

• Changes to infection prevention and control practice on the wards • Recording or reporting system improvements; • New ways of working. • Any additional training needs • Changes to delivery and organisation of clinical care • Competency & capacity of clinical teams • and provided a detailed report to the Chief Nurse/ Deputy Chief Executive by May 5th, 2009.

For purposes of completeness the action plans to both of these reviews were consolidated and are presented in process as Appendix up to June 1st, 2009.

Accident & Emergency Medicine

Within the Accident and emergency department the practice development nurse has undertaken hand hygiene assessments, and fit testing in order to ensure key personnel within the department are prepared to be able to assess patients suspected of carrying high risk airborne infections, such as pandemic influenza. The division has developed a pandemic flu plan for Medicine, A&E and critical care. The new cannula assessment tool is being used within the Accident and emergency department and cites the insertion of a cannula by paramedics teams to ensure that staff can assess cannulae sited by staff prior to admission to accident and emergency.

Elective care

The Elective Care Division includes five wards, seven operating theatres, main outpatient department and a stand alone four theatre day surgery unit. Specialties include trauma, orthopedics, ear, nose, throat, ophthalmology, general surgery, breast, colorectal and urology. The division delivers around 16,000 theatre procedures and sees 17,000 out patient attendance’s.

Any patient known to have MRSA is nursed where possible in a side room, or in bed 1 or 6 in a bay, as per hospital policy. Staff endeavor to complete an incident form as per hospital policy for each MRSA positive patient and undertake weekly screening according to the guidance issued.

All elective admissions are screened at pre-assessment, however, if this has not been possible specific screening clinics are held for patients to attend to enable an MRSA screen to occur prior to admission and in the extremely rare occasions when this has not occurred (patients have not attended the screening clinic or in an extreme urgency) the patient will be screened as soon as they arrive for their procedure or admission.

Elective care have recorded their compliance rates against the guidance issued and to date have achieved 98%. Of these only 3% have been confirmed as positive and all have been able to commence decolonization treatment prior to their procedure or admission.



Within surgery there have been two cases of C-Diff that that have resulted in death although neither of these cases had C-Diff on part one of their death certificate. Although it is not standard practice, elective care undertake a root cause analysis on any patient that has been diagnosed with C-Diff to ensure that any lessons are learnt, the impact reduced and hopefully not repeated. Both root cause analyses undertaken this year have identified that stool charts must be introduced sooner. Work continues to raise the profile of infection control issues.

A very positive audit on surgical site infections (SSI’s) has also been produced and the department is well below the national average for SSI’s (see p.23).

Obstetrics and Gynaecology

Overview of service The maternity and gynaecology services for the QEH consist of both inpatient and outpatient services. A 22 bed combined ante-natal / post-natal ward, a delivery suite and out-patient / ante-natal clinic with in-patient gynaecology beds within the low dependency surgical Elm ward. The Appleton Clinic provides early pregnancy assessment services as well as clinic provision for women requesting termination of pregnancy. Innovations to the service include an increased fertility service with a nurse specialist and expansion of ambulatory gynaecology therapies are being developed at the time of this report to include ambulatory hysteroscopy and increased provision of the uro-gynaecology service in addition to the colposcopy delivered from the outpatient clinic.

Out-patient services This increase in outpatient treatments has required review of infection control procedures and equipment sterilisation and tracking within the clinic area. Estates work has been undertaken to make the area fit for purpose and allow for appropriate waste disposal. The development of the Versapoint hysteroscopy service has required review of the sterilization for the equipment and correct care and processing to ensure infection control compliance.

MRSA screening MRSA screening for all gynaecology surgery has been established using pre-admission clinics in accordance with Trust policy. In-patient gynaecology is reviewed under Elective Care.

The Obstetric department has also undertaken MRSA screening in accordance with Trust policy. All elective caesarean sections, women receiving intravenous Venofer therapy and any women who have had several admissions to a hospital within the previous 12months are all to be screened. Assurance has been received that elective section women are all screened but compliance has been less robust for the other categories. The Ward Manager has developed an action plan to achieve full compliance and this is being monitored monthly. The screening for Venofer treatment is maintained with similar criteria to all patients who require frequent IV access. The effectiveness of Venofer therapy has been marked and the use of this therapy is increasing.

It is noteworthy that the department has had 4 positive MRSA results since commencing screening and a cohort of 3 women was identified. An investigation by both IPACs and the clinical governance midwife revealed no common connection to link the 3 women.

HII audits The High Impact Intervention audits (HII) are undertaken across the department with variable levels of compliance. It has appeared that there have been some inconsistencies with both undertaking the audits and the recording of the results but assurance is now received from all areas that these audits are undertaken. The caseload of the area is different from other areas in that the women are generally well and the rapid transfer from the hospital to home and the timely recovery from any surgical intervention results in a limited scope for audit. Hand hygiene audits are undertaken led by the Senior Support Workers who challenge all staff who are non-compliant.



Environmental issues Environmental audit results for the O&G department are excellent. The stability of the cleaning staff to the areas enhances the quality of the cleaning standards delivered. The recent refurbishment of Delivery Suite has identified a shortfall in the amount of cleaning time now required to maintain the bathroom facilities to the required standards. This is under discussion with Hotel Services.

Castleacre Ward also has excellent environmental audit results for cleaning but the quality of the décor and bathroom facilities is less than ideal. The need for refurbishment of the whole ward area is evident. The Division has identified the area for refurbishment as part of the Capital programme although a date for this to commence has not been identified.

One of the main infection and health and safety risks for Castleacre ward is the anomaly of the sluice area being outside of the ward doors which are security access only. The need for staff to negotiate through a swipe access to dispose of bedpans etc cannot be resolved unless the ward doors are moved to incorporate the sluice area into the main ward. Discussions to incorporate this change within capital works in 2009/10 are ongoing.

New developments For women aged 15 – 24 the Chlamydia screening programme has been instigated by NHS Norfolk using a voluntary self screening process. Take up of the screening is increasing but this has only been in place for 2 months and results have not been audited as yet as to the effectiveness of this programme.

Future plans • It is anticipated that the Chlamydia screening programme will increase in take up and effectiveness.

• The department will be required to look at universal screening for MRSA for all pregnant women.

• 100% compliance with HII audits and MRSA screening of all high risk women

• Upgrading of the fabric of Castleacre Ward and the resolution of the sluice doors location

Anaesthetics and Critical care

There was no reported MRSA Bacteraemias in Critical Care in 2008/9. A high proportion of critical care patients require central venous or arterial catheterization making this a primary source of concern as the most prevalent portal of entry for bacteraemia. The proposed introduction of peripherally inserted central lines (PICS) will help to continue to reduce infections related to Central lines. Aseptic training in the care of lines as well as a review and creation of new care bundles in the management of femoral venous catheters and arterial catheters have been developed by the specialty in 2007. Hand hygiene and cleanliness of the environment where this very vulnerable patient population is nursed, features heavily in mandatory in-service training and constant enforcement amongst visiting clinicians as well as the clinical staff of the

critical care department itself. Consequently monitoring places great emphasis upon central venous catheter care

bundle compliance, hand hygiene and the care of ventilated patients.

The Critical Care team is supported by the regular attendance of the Consultant Microbiologist on the ward rounds. This ensures that the Trustwide plan for antibiotic stewardship is followed in these difficult patients and decisions where the policy cannot be followed are taken after careful consideration. The low resistance rates are a testament to the success of this. The prevention of ventilator associated pneumonia (VAP) is a key target within Critical Care, and to this end an innovative endotracheal tube has been developed and marketed by consultants in the unit. A recent review of the incidence of in patients treated in the QE with this tube has shown no VAPs in 53 patients2. This is consistent with previous work demonstrating the eradication of liquid aspiration with this tube. The

2 Fletcher et al. Critical Care 2009; 13: P295



overall VAP rate within critical care is below 5%, compared with the implied target of 10% in the NICE recommendations.

Child Health

Neonatology The Neonatal unit has a very small footprint and has extremely limited storage facilities which have led to issues of storage being raised at environmental audits. In addition the space between each cot is also insufficient and the sluice requires updating .These issues should be solved with the refurbishment of the unit which is likely to take place next year.

NICU deep clean the nurseries at least 4 times a year and the cleaning standard is high – the department is frequently commended on PEAT inspections for the cleanliness of the unit.

The high impact audit results for NICU are good and it is impressed on families how important hand washing and the use of hand gel is to prevent infection on the unit.

NICU is important in supporting Rudham ward within a pandemic (human swine influenza) – especially for babies under 6 months that require ventilation and the likelihood of increased preterm deliveries within a pandemic is high- both of these issues are reflected in the Divisional Pandemic plans.

Rudham The HII audits are improving from a position where many non paediatric clinical teams visit the ward area as well as a high visitor rate with families and siblings visiting frequently.

The Swine flu policy and presentations have been widely disseminated within the department and also Trust wide; furthermore the Practice development nurse and Senior sister have liaised with areas such as Day surgery and ITU to ensure training of staff and the organisation of paediatric supplies and equipment.

During the winter months the lack of isolation facilities does prove problematic - as in most paediatric wards, due to the incidence of Respiratory syncitial virus (RSV) and Rotavirus. In 2008/9 there were 59 cases of Rotavirus and 47 cases of RSV which was high in comparison to recent years. In addition to this, the likelihood for a second wave of swine flu does provide concern regarding capacity but contingencies are in place to help manage these issues.

The environmental cleaning standards for Rudham are extremely high, even though the ward has not only patients but many parents and siblings visiting and using the facilities

There have been no cases of MRSA bacteraemia and MRSA Screening pathways for NICU and Paediatrics –both emergency and elective cases have been developed as part of the Trust plan.

Radiology

Radiology is a service department to most specialties and does not have a direct role to play in the surveillance or screening of MRSA. However it does have an overall responsibility in the prevention of acquired infection whilst patients are in the department. The department relies on the clinical information on the request forms. When alerted special arrangements are made with the ward and for any out-patient referrals (including Community Hospitals and Nursing homes). Those staff working in clinical areas are aware of aseptic techniques for IV access. Mandatory training is monitored to ensure all staff are aware of current practice. Where there is any concern arrangements are made to discuss and if necessary arrange further training with the Trust specialists.



Healthcare associated infection

Mandatory surveillance

Every case of MRSA bacteraemia, isolates of glycopeptides-resistant enterococci and C. difficile associated diarrhoea is reported on the HCAI Data Capture System and regularly audited against laboratory data.

Meticillin resistant staphylococcus aureus (MRSA)

The incidence of MRSA bacteraemia in year 2008/9 was 8 cases against a trajectory of 12 – the same incidence as 2007/8. Performance for the previous 4 years shows a 67% reduction incidence of MRSA bacteraemia in the QEH KL.

Figure 2: MRSA bacteraemia incidence 2008/9 v. performance trajectory

The Trust had been set a target by the PCT to reduce the number of MRSA bacteraemias to 8 in the year 2008/9. The graph above shows the bacteraemia data from the inception of mandatory reporting.

The baseline set by the Department of Health for each acute Trust is the total number of MRSA bacteraemias recorded in 2003/04. The Target set is a 60% reduction on 2003/04 down to 12 cases a year by March 2008; a 20% p.a. reduction from year ending March 2006 and recurrently below 12 cases pa target from March 2008 onwards.

MRSA Bacteraemia v Performance threshold 2003/4 to 2008/9

0

10

20

30

40

50

60

Year

MR

SA B

acte

raem

ias MRSA Bacteraemia

Threshold

MRSA Bacteraemia 37 32 36 30 52 24 12 8 8

Threshold 30 38 34 25 12 12

2000/1 2001/2 2002/3 2003/4 2004/5 2005/6 2006/7 2007/8 2008/9



The table below identifies the origin of MRSA positive blood culture specimens by ward and department.

Reported MRSA Bacteraemias 2008-09

QEH Episodes - Specimens taken >= 2days post admission

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

Necton Ward 0 0 0 0 0 0 0 0 0 1 0 0 1

Pentney Ward 0 0 0 0 0 0 1 0 0 0 0 1 2

West Raynham Ward 1 0 0 0 0 0 0 0 0 0 0 0 1

Total 1 0 0 0 0 0 1 0 0 1 0 1 4

QEH Episodes - Specimens taken <2 days post admission

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

A&E QEH 0 0 0 0 0 2 0 0 0 0 0 1 3

MAU 0 0 0 0 0 1 0 0 0 0 0 0 1

All locations 0 0 0 0 0 3 0 0 0 0 0 1 4

Total Episodes

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

Grand Total 1 0 0 0 0 3 1 0 0 1 0 2 8

MRSA Screening

The Trust’s policy includes the screening on admission, of those patients that are considered high risks in view of the local population. The policy follows the Guidelines for the Control and prevention of Meticillin-Resistant Staphylococcus aureus (2006)3.

The criteria are as follows

• All patients in High risk areas on admission and discharge e.g. CCU and NICU • All patients who are transferred from Medical wards to surgical wards e.g. outliers • Patients who have been positive MRSA in the past. • Patients who have been transferred from other hospitals • Patients who have been admitted from a Residential or nursing care facility • Patients who have had two or more hospital admissions in the previous 12 months • Patients who are immuno-suppressed • Patients from Institutes e.g. Prisons, learning disability homes etc • Patients who are carers of known MRSA carriers • Patients who are healthcare workers and are inpatients • Patients who are IV drug users or known HIV • Oncology patients

The Trust also screens those patients on the medical and surgical wards, who have been in hospital for more than two weeks, every weekend there after. This surveillance is carried out to identify any hospital acquisition of MRSA during their admission. The identification of MRSA will firstly reduce the risk to the patient of infection due to their own colonisation. Secondly, to reduce the reservoir of MRSA within the hospital. If a patient has been screen and identified as a carrier of MRSA, they are then prescribed decolonisation treatment. Patients who are admitted into the high risk areas of Critical Care and NICU are

3 Coia et al (2006) Guidelines for the control and prevention of Meticillin- resistant Staphylococcus aureus (MRSA) in Healthcare facilities. Journal of Hospital Infection. 63 Suppl: (1): page S1-44



screened on admission and every weekend there after. All MRSA positive patients with the Trust have their notes marked with an alert sticker and it is also identified on the Patient administration (PAS) system.

The Department of Health Gateway reference number 11123 stated that Trusts were to comply with the recommendations, that all elective admissions are screened prior to admission by April 1st 2009. The Trust has put in place measures to comply by the said date, by identifying pathways to ensure screening is undertaken and business cases secured for additional resources.

Clostridium difficile

In February 2008 the national target for Clostridium difficile was set at 30% reduction in the number of hospital acquired infections by 2010/11 compared with a 2007/8 baseline. The East of England Health authority determined that this target should be met in one year. The Trust recorded 68 cases of Clostridium difficile in the 2008/9 following 12 consecutive months of under trajectory performance. These are hospital in-patient specimens detected 2 or more days after admission. Cases observed prior to this 2 day point are deemed community acquired. In all there was a 58% reduction on incidence between the years 2007/8 and 2008/9.

Figure 3: Clostridium difficile incidence 2005/6 to 2008/9 v targets 2007/8 and 2008/9

* specimens taken in 2005/6 and 2006/7 include those taken within 2 days of admission

Clostridium difficile incidence v performance trajectory 2005/6 to 2008/9

0

50

100

150

200

250

300

350

400

450

Year

C.

Dif

f in

cid

ence

C Diff

Threshold

C Diff 393 298 160 68

Threshold 257 199

2005/6* 2006/7* 2007/8 2008/9



As can be seen from the table below the Trust’s incidence of Clostridium difficile infection was below trajectory for the year up to March 2009.

QEH Episodes - Specimens taken > 2days post admission

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

Oxborough Ward 0 2 1 1 2 2 2 3 1 0 2 2 18

Stanhoe Ward 1 1 0 3 0 1 0 1 1 0 0 0 8

Pentney Ward 0 1 3 0 1 1 0 0 0 1 0 1 8

Necton Ward 1 0 0 0 1 2 0 0 2 0 0 2 8

West Raynham Ward 0 2 1 0 0 1 1 0 0 0 0 0 5

Marham Ward 0 0 0 0 0 0 0 0 1 0 3 0 4

Shouldham Ward 0 0 0 1 0 0 0 0 0 1 1 0 3

Denver Ward 0 0 0 0 0 0 0 0 2 0 0 0 2

Critical Care Unit 0 1 0 1 0 0 0 0 0 0 0 0 2

Leverington Ward 1 0 0 1 0 0 0 0 0 0 0 0 2

Terrington Ward 0 1 1 0 0 0 0 0 0 0 0 0 2

Feltwell Ward 0 0 1 0 0 0 0 0 0 1 0 0 2

Gayton Ward 0 0 0 0 0 0 0 0 0 0 1 0 1

Terrington Ward 0 0 0 0 0 0 0 0 0 1 0 0 1

Elm Ward 0 0 0 0 0 0 0 0 1 0 0 0 1

West Newton Ward 0 1 0 0 0 0 0 0 0 0 0 0 1

QEH Total 3 9 7 7 4 7 3 4 8 4 7 5 68

A challenge for the Trust is to identify the root causes for the cases of Clostridium difficile infections. The DOH requires a root cause analysis for all cases where a patients death certificate states that CDI was the direct or contributory cause of death. However, route cause analysis has been undertaken on all cases of Clostridium difficile to gain potential learning.

An Isolation ward was opened in February 2008. A dramatic decrease in Clostridium difficile infections followed.

Root cause analyses and learning In 2008/2009 the Trust had 8 MRSA bacteraemias. The IPACS under took a root cause analysis on each of these cases. Where links with the community were evident, the PCT Infection Control Teams contributed. Out of the 8 MRSA bacteraemias, 4 were identified two days after admission. All 4 of these patients had an IV cannula in situ at one stage, for a number of days. Two patients showed signs of phlebitis associated with the cannula. The general issues identified on undertaking a RCA on these patients showed a strong theme. That was of poor documentation, firstly of the insertion/removal of the cannula and secondly the recording of the Visual Infusion Phlebitis (VIP) scores, which look for the signs of inflammation of the site/s. This had been a general problem for some time.

IPACS instigated the use of 2% Chlorhexidine and 70% Alcohol for the preparation of skin prior to cannulation early 2009. The Trust approved of the change of practice, as this was in line with EPIC 2 Guidelines and Saving Lives (see previous section on 2% Chlorhexidine and 70% Alcohol). However, the last MRSA bacteraemia proved on investigation as probably avoidable, if the VIP scoring was undertaken regularly and documented. The patient had a cannula or cannulas in situ for two weeks and only one VIP score was documented. A multi disciplinary working party was set up to review the documentation and the use of a cannula pack



for venous access. A review of the documentation is hoped to make the documentation for the recording of the VIP scores more easily accessible and clearer. The introduction of a cannula pack will emphasise to staff cannulating that the process must be undertaken in a clean non touch technique. The Practice Development Nurses have enlisted the support of West Anglia College, who are happy to undertake a media project, and film various aseptic techniques, including a clean non touch technique of cannulation. This DVD will be used to train doctors and nurse.

Root cause analysis for Clostridium Difficile continues to highlight the over use of prolonged courses of broad spectrum antibiotics and the use of proton pump inhibitors as potential contributors to the incidence and spread of this iatrogenic infection. The Trust appointed an antimicrobial pharmacist in 2008, who is working along side the Consultant Microbiologist in reviewing the use of the antimicrobials that select for Clostridium difficile.

The opening of the isolation unit for the management of patients with Clostridium difficile on Stanhoe ward, contributed to the reduction of the infection within the Trust this year. In previous years there had been issues with the non-compliance or delayed isolation of patients in side rooms who had been diagnosed with the infection, causing the potential for spread. Since the opening of the unit, patients are transferred within a two hour time slot from when the ward is informed.

Glycopeptide Resistant Enterococcal bacteraemia

The Glycopeptide resistant enterococcal bacteraemias arise predominantly in renal patients, who represent a high risk group for such infections due to the frequent use of Glycopeptide antibiotics required for the treatment of infections due to Gram positive organisms. Consequently this is not a major problem in the QEH which does not have a Renal in patient department. Glycopeptide resistant enterococcal infections occur rarely as a cause of urinary tract infections. Indeed, there was only one case in 2008/9, which was in fact more a mixed enteric flora. In October 2008 a surgical patient post laparotomy and ileostomy for Bowel Cancer produced a Specimen which grew Escherichia coli from both bottles and a Glycopeptide resistant Enterococcus faecium from one bottle only. The patient recovered from this infection and was discharged home on November 17th , 2008.

Surgical site surveillance

Introduction The estimated cost to the NHS hospitals of caring of patients that acquire a healthcare associated infection is over £1 billion per year (Plowman et al 1999). The Third Prevalence Surveillance of Health Acquired Infections in Acute Hospitals in England (2006) found that surgical site infections account for 20 percent of all hospital acquired infections.

A national surveillance system for surgical Site Infections (SSI) was established in 1997 and eventually evolved into the Surgical Site Infection Surveillance Service (SSISS). Surveillance of SSI in Orthopaedic surgery became mandatory for all NHS Trust in England in April 2004.

The aim of SSISS is to enhance the quality of patient care by encouraging hospital to use data obtained from surveillance to compare their rates of SSI over time and against a benchmark rate, and to use this information to review and guide clinical practice. Each trust is required to participate for a minimum of one surveillance period (three months). Most Trusts choose to undertake the total hip and knee prosthesis category. The number of participating Trusts have increased year on year.

The Queen Elizabeth Hospital has participated in the mandatory reporting of Total Hip replacements, Hip Hemi-arthroplasty, Knee Replacement prosthesis and also contributed to surveillance Large Bowel Surgery surgical site infections from April 2004 to March 2008. The collection and reporting of this data has been undertaken by the Clinical Audit and Effectiveness department, using the Health Protection Agency (HPA) Surgical Site Infection System. The annual results have been reported to the Trust Board through the Infection Prevention and Control Annual Report.



Reporting

National Orthopaedic infection rates. The HPA Fourth Report of mandatory Surveillance of Surgical Site Infection in Orthopaedic Surgery: April 2004 to March 2008 was published in November 2008. Table 1 shows the total number of Trusts participating in Year 4, their combined totals for 4 years of procedures, number of infection and percentage that were infected.

Table 1; Participation in mandatory surveillance of SSI in Hip prosthesis for Year 4 April 2007 - March 2008

Total no. Trusts No of Procedures No. SSI % Infected Year 4 4 Years

combined Year 4 4 Years

combined Year 4

4 Years combined

Year 4 4 Years combined

Total 155 161 69200 226008 418 2154 0.6 1.0

Hip Prosthesis 119 147 28510 92697 145 723 0.5 0.8

Hip

hemiarthropalsy

66 104 6333 24766 151 805 2.4 3.3

Knee prosthesis 110 136 30605 95064 87 412 0.3 0.4

Year 1 2004-2005, Year 2 2005-2006, Year 3 2006-2007, Year4 2007-2008

The Queen Elizabeth Hospital NHS Trust infection rates The infection rates for Total Hip replacements, Hip Hemi-arthroplasty, Knee Replacement prosthesis and Large Bowel Surgery are listed in the table below. This Trust did not submit surveillance data for these procedures since in quarter 3 of 2008 (October to December0 due to staffing levels in Clinical Audit and Effectiveness.

Apr 08 – Mar 09

The Queen Elizabeth Hospital NHS Trust All Hospitals

Procedure Operations Apr 08 – Mar 09 % Infected % Infected

Total Hip Replacement 108 0.0 1.3

Hip Hemiarthroplasty 28 0.0 3.9

Knee Replacement 98 0.0 1.0

Large Bowel Surgery 36 0.0 10.6

Apr 07 – Mar 08







Apr 06 – Mar 07







Apr 05 – Mar 06




Procedure Operations

Apr 05 – Mar 06

% Infected % Infected





The Queen Elizabeth Hospital NHS Trust infection rates in comparison to national rates. This Trust has submitted surveillance data since April 2005. The Trust’s infection rates have consistently been below the national average for all three orthopaedic infection rates and for the large bowel infection rates. The grafts below demonstrate the infection rates for all four procedures in comparison to the national average.

Surgical Site InfectionsTotal Hip Replacement

0.9% 0.9%

0.0% 0.0%

1.7%

2.0%

1.6%

1.3%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

Apr 05 - Mar 06 Apr 06 - Mar 07 Apr 07 Mar 08 Apr 08 - Mar 09

Surveillance Period

% In

fect

ed

Queen Elizabeth Hospital All Hospitals % Infected



Surgical Site InfectionsHip Hemiarthroplasty

0.8%1.3%

0.6%

0.0%

4.4%4.8%

4.3%3.9%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%


Surveillance Period

% In

fect

ed


Surgical Site InfectionsKnee Replacement

0.0% 0.0% 0.0% 0.0%

0.9%

1.3%

1.1%1.0%

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%


Surveillance Period

% In

fect

ed




Surgical Site InfectionsLarge Bowel Surgery

3.1%

1.3%0.6%

0.0%

9.1%9.7%

10.3% 10.6%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%


Surveillance Period

% In

fect

ions


Future surveillance The Clinical Audit and Effectiveness Department have increased the staffing which will allow for future submission of data to the surveillance system. The data for April 2009 to June 2009 is currently being analysed.

Summary The Queen Elizabeth Hospital NHS Trust has participated in the Surveillance of Surgical Site infections from April 2004 until December 2008. The infection rates in the three orthopaedic procedures and large bowel surgery have consistently been below the national average. Although the Trust was unable to contribute to all four quarters in 2008 to 2009, the issues have now been addressed in Clinical Audit and Effectiveness to allow future submission of data for all quarters.



Serious untoward incidents – outbreaks (SUIs) reported to Region

We have seen an increase in outbreaks and SUIs year on year with a total of four for 2008-9.

Date of report

Organism/incident Comment

29.11.08 Norovirus Continued until 07.01.09. Total of 10 wards affected (3 surgical wards and 7 medical). 105 patients with symptoms, of which 30 were positive Norovirus and a total of 86 staff. Hospital closed to visitors for most of this period, although visiting was allowed over the Christmas period.

28.01.09 Norovirus Continued until 13.02.09. Medical ward. 5 patients became symptomatic in a 24 hour period. Total of 13 patients, with 1 patient positive.

02.03.09 Norovirus Continued until 09.03.09. Two medical wards, 9 patients on one ward and 2 on the other. Four patients positive.

11.03.09 Norovirus Continued until 05.05.09. In total 10 wards were affected, with 105 patients experiencing symptoms, of which 30 were positive. There was 86 staff reported sick. Only the affected wards closed totally to visitors on this occasion, and not the hospital. The issues which arose during the outbreak were the removal of the radiators covers for cleaning, the breaches of policy and the lack of domestic cleaning cupboards. The radiator covers are now routinely taken off for all deep cleans. Additional training has been scheduled for next autumn prior to the winter. The lack of cleaning cupboards is being reviewed.

These SUIs led to root cause analysis inquiries and debriefing sessions, identification of contributory factors, presentation of recommendations and implementation of an action plan to minimise the likelihood of a recurrence.

With each outbreak, an outbreak committee was convened and an investigation into the possible source of transmission commenced which included screening of potentially exposed patients and staff, suspension of service and decontamination of the environment.

Further Improved adherence to infection control policy and procedure was observed. The cumulative action plan for these outbreaks is as follows:



No Issue/Key findings Actions Measurable Outcomes

Accountab-ility

Status

Time Frame

1 Dust behind radiators being a reservoir for infection. Radiators covers on Terrington and MAU different type to rest of hospital and had never been removed for cleaning, presented problem for Domestic staff and Estates

At end of out break on Terrington the bays were sealed and radiators cleaned for the first time by Estates staff wearing appropriate PPE. Subsequent cleans were carried out by Domestic staff. Sealing of bays was not required and normal PPE precautions were in place.

Radiators on Terrington and MAU are cleaned after every outbreak/cluster and during scheduled routine deep cleaning

Ward manager/ Domestic Supervisor and Estates

G 01.04.09

The opportunity arose in MAU, when they had limited patients, to clean their radiators. This was arranged with Hotel Service and Estates. All the radiators had their initial cleaning.

Ward manager/ Domestic Supervisor and Estates

G 01.04.09

Arrangements are now in place for Hotel Services to arrange with Estates when the radiators on Terrington and MAU are required to be removed for future cleaning

Cleaning of radiators of all wards are schedule as part of routine deep cleaning and after every outbreak/cluster

Ward manage/Domestic Supervisor and Estates

G 01.04.09

2 Cleaning of a bay is delayed whilst Domestic staff wait for Estates to be available to remove the radiators covers prior to cleaning. This can delay the opening of the bay or ward and the releasing of closed beds

Flexibility of Estates to be available to remove the radiator covers for cleaning

Radiator covers are removed timely to enable the bay/ward to opened as quickly as possible to release closed beds

DIPC/ Manager of Estates

R 01.05.09

3 Testing staff who have gone off sick for Norovirus.

Occupational Health will monitor staff who persistently report symptoms

Reduction of staff reporting genuine symptoms

Occupat’l Health Manager

G 11.05.09

4 Ward staff not aware of all the patients with symptoms and Daily record sheet not completed for collection by IPACS leading to a delay in obtain relevant information

Associated Chief Nurses and Lead Nurse to remind wards to obtain the relevant information and complete daily record sheets

Completed record sheets are available for collection for IPACS by 8 am each morning

Associate Chief Nurse/Lead Nurses

G 31.05.09

IPACS to undertake Norovirus sessions prior to next winter, reminding staff of policy and procedures etc.

Staff are aware of Trust policies and procedures and are familiar with all relevant paper work

Lead IPACS A 30.09.09

5 Outbreak packs not returned to Op Centre therefore not available for other wards when required

Associate Nurses and Lead Nurses to remind wards that packs have to be returned to Op centre so they can be replenished by IPACS

Outbreak packs are replenished and available for all wards

Associate Nurse and Lead Nurses

G 31.05.09

5 Adequate supply of scrubs for wards.

Emergency supplies are available in emergency trolleys out side Linen room. A check list of items and measures to be put in place complied for each ward when on outbreak or cluster is declared on their ward.

There is adequate supplies for wards

DIPC/ Deputy DIPC

A 31.5.09

6 Use of a chlorine releasing agent e.g. Actichlor in other areas to prevent the spread of Norovirus during the season

All toilets and bathrooms are routinely cleaned with a chlorine releasing agent e.g. Actichlor. Additional cleaning three times per day of MAU will be initiated in discussion with Domestic Supervisor at the onset of the outbreak

Reduction of a potential spread of Norovirus within and from MAU during an outbreak

G 11.05.09

7 Adequate information leaflets available for visitors during outbreak

Information leaflets being produced at the onset of the outbreak season and replenished by Op centre

Information leaflets readily available for visitors

Lead Nurse Emergency Access

A 30.09.09



8 Domestic Cleaning cupboards have been removed to use for other purposes. There are insufficient numbers leading to wards sharing Domestic cleaning cupboards. There is no sound evidence that this is indicated in and outbreak, but proves difficult to manage when one ward is closed and not the other. Many of the cupboards are too small for the purpose and do not have hand hygiene facilities

Issue to be raised at the next Infection Control Committee

Each ward has a cupboard which is suitable to house a Domestic cleaning cupboard with hand hygiene facilities, which allows cleaning to be managed more effectively during outbreaks

DIPC/Deputy DIPC

A 12.06.09

9 Effective management of patients who are Noro positive and require surgery

Protocol to be identified in Norovirus policy

No patient is cancelled and risk of spread of Norovirus is prevented


10 Hotel service staff cleaning wards and working in kitchen that evening leading to a risk of spread via staff from ward to kitchen and food

Business case to be put forward for a designated cleaning team, which would provide designated staff to prevent cross contamination

Designated staff for cleaning and no cross over to catering

Manager for Hotel Services

A 03.07.2009

11 Domestic staffing numbers do not allow for cleaning a ward in the time frame requested. Domestic staff rushing to complete and not cleaning as effectively as required

Business case to be put forward for a designated cleaning team, which would provide designated staff to prevent cross contamination

Dedicated team allows for effective cleaning in a time that will allow earliest release of closed beds, and the prevention of further out breaks in that area

Manager of Hotel Services

A 03.07.2009

12 Domestics staff starting cleaning ward before checking with IPACS or bleep holder at weekend, which may be inappropriate if there have been patients with symptoms. Protocol has been for Domestic Supervisor to liaise with IPACS during normal working hours or relevant bleep holder outside normal hours.

Protocol to be stated in Norovirus policy

Ward cleaning is commence when appropriate


13 Hotel Service Assistants clean and serve drinks, which could lead to spread of infections

Due to staff shortages Hotel Service Assistants are required to serve the drinks due to staff shortage. Precautions are in place to minimise risk. E.g. aprons and hand hygiene

Incidence of infections spread via this route

Hotel Services Manager/ Assoc. Chief Nurses/Lead Nurse/Ward Managers

A 31.05.09

14 Volunteers washing glasses on ward

Educate volunteers to desist from same & use central kitchen to wash eating utensils and vessels

Cross contamination via drinking vessels prevented

Associate Chief Nurses/Lead Nurse/Ward managers

A 31.05.09

15 Closing hospital to visiting during outbreak - Impact on reducing infection and welfare of patients

Chief Nurse present to board a paper on the effect of closure to visitors on the reduction of spread of outbreak and the impact of the closure on the welfare of the patients

Prevention of spread of infection and maintaining the welfare of the patients

Chief Nurse A 27.04.09

Sub group to be arranged to look at visiting

Prevention of spread of infection and maintaining the welfare of the patients

Associate Chief Nurse for Surgery

A 31.05.09

16 Communication to staff at weekends and out of hours is reduced

Information available on the Intranet for staff out of hours. To be discussed with Communications Officer

Staff are aware of ward closures and relevant information at all times

PA to Chief Nurse

A 31.05.09



17 Gaps in knowledge of identifying potential infectious diarrhoea, policy and practices in all grades of staff

Put in place Norovirus sessions prior to the winter months. Ensure sessions are made available to Medical staff

Staff aware of and comply with policy and practice.

Lead IPACS Specialist Nurse

A

30.11.09

18 Lack of escalation capacity and a clear pathway for D&V admissions since the opening of Stanhoe C.diff Isolation Ward meant D&V admissions were admitted to side rooms throughout the Trust, leading to the potential of spread and the potential for cleaning and opening wards early.

Review of escalation facilities and pathway for D&V admissions

Mangement of D&V admission patients do not lead to spread of Norovirus

Chief Nurse, Associate Chief Nurses, Division managers, Lead IPACS specialist Nurse

R

30.11.09

19 Lack of staff led to movement of staff from infected wards to other wards to ensure safety of patients.

Increase staffing levels Adequate staffing levels to ensure safe care for patients and prevent unneccessary spread if infections.

Chief Nurse, Associate Chief Nurses and Division managers

R

30.11.09

Multi-resistant organisms

This Trust, in common with most acute Trusts, is identifying increasing numbers of multi-resistant Gram negative organisms, some causing infections but others just colonising patients. Such patients are isolated whenever possible to reduce cross-infection risks and treated appropriately. The Department of Health is aware of this national issue and is working closely with the Health Protection Agency to monitor the situation. Within the Trust, the Antibiotic Stewardship Committee has issued new Antibiotics Guidelines to reduce overuse of antibiotics and encourage prudent prescribing, thereby reducing the selective pressure on micro-organisms to develop resistance. Multi-resistant Gram negative organisms can be spread on hands in a dirty environment, so the emphasis must also remain on encouraging hand washing and maintaining a clean environment as part of the overall infection control approach to reducing risks to patients. The resistant organisms encountered include ciprofloxacin-resistant coliforms, extended spectrum beta-lactamase-producing organisms (ESBLs), and a few glycopeptides-resistant enterococci.

In the wider community, one of the types of infection that may be caused by resistant Gram negative is community acquired urinary tract infections, especially in elderly patients. Many of these infections are caused by bacteria that are resistant to all of the first line oral antibiotics (leaving only parenteral choices). Managing these infections can be problematic in the primary care set-up and many patients end up in the hospital for parenteral therapy or as a result of complications following failure of oral antibiotics.

Antibiotic therapy

In March 2008, an antimicrobial pharmacist was appointed (1WTE on most occasions- in March 2009 this changed to 0.6WTE). One of the initial tasks was to implement and co-ordinate an antimicrobial prescribing audit programme, together with the Consultant Medical Microbiologist for the Trust. Initially, retrospective audits were conducted quarterly, using WHO/ATC DDD Methodology, as Total DDD/1000 occupied beddays, on a number of target antibiotics (all penicillins, cephalosporins, quinolones, macrolides, tetracyclines and glycopeptides). This data is routinely presented to the Antimicrobial Stewardship and Control of Infection committees (Fig 1 and Fig 2).

From March 2008 to September 2009, a number of other initiatives were also taken and these included: ward-based antimicrobial prescribing audits (in addition to the retrospective audit data collection and analysis), an Antimicrobial Prescribing Policy, Adult Gentamicin Monitoring Form, Pharmacy Department Pandemic Flu Policy, active contribution towards the revision of Trust and PCT antimicrobial guidelines e.g. Women and Children Department, New Splenectomy guidelines, an electronic/hardcopy database of significant patient cases handled was generated, daily attendance to the multi-disciplinary CDI ward round, a CDI- Dear Doctor letter for the Trust was drafted and implemented, a Medicines Management newsletter with periodic updates on antimicrobial-related issues, as well as audit results, PHARMAlinked was launched in June 2008 and produced bi-monthly, participation at Infection Prevention and Control Nurse Study days, participation in the induction for doctors, nurses and pharmacists and contributing to a multi-disciplinary



research role, specialising in the relationship between multi-drug resistant pathogens and antimicrobial prescribing.

Clinical pharmacists and pharmacy technicians are actively involved in ensuring compliance to antimicrobial guidelines and where problems arise, these cases are referred directly to the antimicrobial pharmacist (or Chief/Deputy Chief Pharmacist) who, in close collaboration with the Consultant Medical Microbiologist addresses them. A record is kept of all significant cases dealt with.

In January 2009, ward-based audits were initiated and these have revealed a consistent 100% compliance to guidelines, except for one surgery (Urology) ward which scored 70%. Currently both surgical and medical wards are being audited and reports on performance issued to respective departments.

In August 2009, the QEH was chosen as a trial site for a new Department of Health, High Impact Intervention-Antimicrobial Prescribing, intended as an easy-to-use audit tool for use by doctors, pharmacists and nurses. Results are currently being generated. When the new guidance is officially in place, the QEH will include this as an additional High Impact Intervention which wards would be requested to produce, at least once every month, in collaboration with the Clinical Audit department.

A number of ‘snap-shot’ audits were also conducted during 2008-2009. In November 2008, a month`s audit of all cephalosporin and quinolone usage was performed (total medications dispensed during this period totalled 8373 items) and results showed that compliance to guidelines was 60%. Only 0.7% of all items dispensed were in fact cephalosporins and/or quinolones. This result was largely due to the fact that urologists use ciprofloxacin as a first-line option for prostatitis (rather than second-line as recommended in June 2008 guidelines). Also, in some cases, cephalosporins and quinolones were indicated where patients had multiple antibiotic allergies or directly recommended by the Consultant Medical Microbiologist. In August 2009, a two-day prospective audit on treatment of lower respiratory tract infections (LRTIs) on patients admitted in MAU was conducted. Overall, 49 patients were admitted with different ailments and only 5 were found to be suffering from LRTIs. Compliance rate with guidelines was 100% and no cephalosporins or quinolones were prescribed for LRTIs.

The Antimicrobial Stewardship Committee has recently approved (August 2009) a form for the Supply of Restricted Antimicrobials, which is due to be launched, after consultation with by Drugs and Therapeutics Committee (23rd September 2009). This would need to be filled in by the prescriber and held in Pharmacy for regular auditing. In addition, new Antifungal Guidelines are being produced for the Trust and a gentamicin prescribing audit is planned for this month. In addition, an audit of 100 CDI patients admitted to the CDI Isolation ward since March 2008, will also be concluded in the next few months.

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Hand Hygiene and Aseptic protocols

‘CleanYourHands’campaign

Although the 4th quarter shows slightly less adherence, Hand Hygiene compliance achieved a mean of 91% across the year which is a 15% increase on the year 2007/2008.

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Hand hygiene performance showed an average 2% diminution per month compounded between December and February for each aspect of the audit. IPACs had applied further support in order to improve compliance. This has led to some improvement however this has not been sustained.

The Chief Nurse / DIPC has reviewed practice, analysed local and organisational hand hygiene data and examined literature in this field in order to arrive at a set of hypotheses regarding non adherence from which a multi-factorial plan of action has been developed. This can be recommended to stakeholders and the board as forming the basis of a recovery plan for effecting and sustaining lasting improvement in hand hygiene compliance across the trust. This review will involve the Nursing and midwifery executive committee, trust executive board and hospital staff management committee.

High workload was associated with non adherence. Conversely, easy access to hand hygiene in the form of the immediate availability of a hand-rub solution at the time of patient contact and hand washing stations strongly predicted physician adherence. Of note, physician performance varied strongly among specialties, independent of other risk factors for adherence. Junior staff and students who were taught to hand wash abandoned their habit when others, especially more senior staff, did not bother4. Furthermore, because nurses have higher adherence rates than physicians and because poor physician adherence to hand hygiene is among the reported reasons by nurses for the difficulty in ensuring sustained adherence, improvement in physician compliance might improve overall adherence among all health care staff. There are multiple factors which determine compliance, making tackling non-compliance a complex problem. The solution requires introducing and sustaining behaviour change which will affect the whole system. Parts of the system need to be redesigned, and both internal and external drivers for change are necessary at a number of levels. While we continue to promote the need for hand washing at a sink when hands are visibly soiled, the hand rubs, available at the point of care, are critical to increasing the likelihood that staff will clean their hands at the right time, and more often. To promote their use, and prompt the behaviour, the refreshed campaign will also include a range of marketing materials; infrastructural resources; and a patient engagement element.

The review suggests that this is sometimes a low priority area in our hospital and that patient engagement, using the hand hygiene leaflets as a prompt, is patchily or poorly executed. The role of the lead nurse (the modern matron role has not been adopted in this trust) in hand hygiene improvement is hugely significant. Where clinical leaders within each directorate or department actively champion the campaign it is more likely to succeed.

The hands of healthcare staff are the single biggest source of transmission of infection in hospitals and whilst, hand hygiene procedures are simple, their routine and consistent application to healthcare workers, is a complex phenomenon which is not easily explained or changed.

4 Larson E, McGinley KJ, Grove GL, Leyden JJ, Talbot GH. Physiologic, microbiologic, and seasonal effects of handwashing on the skin of health care personnel. Am J Infect Control. 1986;14:51-9. [PMID: 3635374]



This paper has identified a number of obstacles to adherence, within the Queen Elizabeth Hospital. From experience, feedback and evaluation of the literature in similar settings - where the adoption of national hand hygiene campaigns over several years, have dramatically improved compliance but not sustained it at a level of 95% or more, across every clinical setting in the organisation. In particular, features of high workload, easy access to hand hygiene facilities and variation in physician performance between specialities, compounded by positive and negative role modelling from senior to junior staff, has prompted actions around workload, capacity, demand, behaviour, education and performance monitoring.

This plan attempts to make sense of the problem and create a context for good practice which is seen to be the easiest option; reinforced by the expectation and feedback of patients and sustained through a change in both the culture and context in which care is given, demonstrating the impact of these changes through consistent, clear and easily accessible feedback.

The dissemination of good practice and the selective use of sanction where performance has been observed to dip against a previously agreed baseline, will be amongst the measures taken to improve compliance. Many of the previous approaches will be refreshed and rejuvenated. Educational media will be replaced and overhauled in order to make a high impact in communicating the right message. This will involve both personal communication, the identification of champions, the adoption of new educational media and the development of a dashboard to monitor compliance, feedback and integrate into the organisation. The notion that consistently high performance in hand hygiene is part of the way in which we deliver care in this Trust to every patient, every time they receive care and treatment needs to be inculcated in all our staff.

The board has considered the review of the supposed contributing factors to mixed inconsistent and unsustained staff hand hygiene compliance in all clinical settings of the trust and asked the DIPC to convene a working party to develop a multi factorial recovery plan.

IV lines and urinary catheters

The presence of peripheral and central IV lines and indwelling urinary catheters increase the risk to patients of acquiring an infection. Following the introduction of the DH Saving Lives programme, care bundles have been developed and launched for the management of peripheral lines, central venous catheters and urinary catheters (see below). The Infection Control Nurses continue to teach on the Trust intravenous drug administration day and Trust cannulation and venepuncture study sessions for nurses.

Launch of Chloraprep skin preparation (2% Chlorohexidine and 70% alcohol)

The launch of the above product for cleaning skin prior to venous access commenced on 9th March 2009. The clinical educators from the company Enturia trained 421 clinical staff during their visits to clinical areas to demonstrate the correct method of application.

They visited all the clinical areas in a 6 day period and demonstrated to all the staff available, the use of the product. In the feed back from the Clinical Educator they have signature of attendance from 115 doctors out of 319 on the electronic register (36%). This was the highest number of doctors they have had in one Trust.

They also trained 183 nurses out of 1079 (17%), Phlebotomists 9 out of 15 (60%). Others included X-ray, pharmacy and Operating department staff 99 in all. The total of 421 staff comprised of all those that were on duty at the time the clinical educator visited their department and who cannulate.

Enturia assure IPACS that these figures are above average attendance for a Trust this size. They were very pleased to have seen so many medical staff.

Decontamination

The newly formed decontamination committee will enable the trust to have a mechanism to:



• Endorse all Decontamination policies, procedures, and guidance on the cleaning and sterilization of medical devices provide advice and support on the implementation of policies, monitors the progress of the annual Decontamination programme;

• Review the age, condition and fitness for purpose of decontamination facilities and equipment and record any actions being taken to address any issues of immediate potential risk to patients and staff;

• Undertake a comprehensive review of all aspects of the overall process of decontamination, and use this to complete a baseline self-assessment and develop an action plan against the controls assurance decontamination standard;

• Undertake to work with PCT Chief Executives and Clinical Governance leads where appropriate, ensure that independent contractors;

• Obtain a picture of decontamination provision across the trust to inform medium-term action plans. This will include effective management control systems;

• Review decontamination processes to ensure they remain fit for purpose. The overall decontamination process includes purchasing and acquisition , cleaning and disinfection , packaging , sterilization, transport, storage and disposal;

• Scope a number of health and safety issues associated with decontamination; Undertake a comprehensive review of decontamination processes;

• Ensure that traceability systems are in place to allow sets of surgical instruments to be tracked through decontamination processes in order to ensure that the processes have been carried out effectively. Systems should also be implemented to enable the identification of patients on whom instrument sets have been used.

The Sterile Services Department has been certificated since May 2007 with a registered body – Lloyds register Quality Assurance group (LRQA) to the standards: ISO 13485:2003 and MDD 93/42/EEC., with the next surveillance and certificate renewal planning visit planned for November 2009.

The department has a structured training program is in place which includes operator training to the relevant HTM standards, Instruments recognition, knowledge and understanding of all departments quality policies and procedures, and completion of training manuals. Trainee technicians undertake a minimum of two year’s training prior to an assessment and attaining the qualifications necessary to become a qualified Technician. All Technicians have completed the NHS Estates e-learning in Decontamination.

All staff attended relevant mandatory training including infection control training and hand hygiene.

The Sterile services department is still waiting to Implement the IMS (instrument Management System ) supported by CSC and connecting for health to have an electronic tracking and traceability system to track trays of Instruments , this is hoped to go live at the latter part of 2009.

Mattress breach A visit by the Healthcare Commission on December 3rd, 2008 resulted in identification of a soiled foam mattress core in use on Stanhoe ward. The ward manager when questioned identified that it was not policy to check the foam core or inside cover of mattresses between patients. The Trust responded by a snap inspection of all the foam mattresses in the Trust on the 4/5th of February. 153 mattresses were found to be defective, either due to ‘bottoming out’ of the foam or breaches in the outer cover resulting in staining and soiling of the inside cover or foam. 26 mattresses were replaced by Huntleigh Healthcare on the 9th March. Huntleigh was not prepared to replace further mattresses until they had inspected them for themselves, so a joint audit of the Trust’s defective foam mattresses was carried out on the 17th April. 75 defective mattresses were tested and it was agreed that 54 required replacing. The 54 mattresses have been subsequently replaced. A further joint audit of all the Trust’s foam mattresses is planned for 6th and 7th of October, 2009.



A mattress policy was developed and agreed by the Trust in February. This is on the Trust’s internet, has been widely broadcast so that all ward managers are aware of the policy, and is included in the Trust’s Induction for nurses as well as being included in all Pressure Ulcer Update Sessions which are held twice monthly. The policy includes directions for correct cleaning of foam and dynamic mattresses and requires that all foam mattresses are checked for damage to the foam and cover after ever patient discharge or every three months, which ever is sooner. Any mattress that fails this testing is condemned.

The Trust has purchased 25 new foam mattresses to act as a buffer stock, and these are being used to replace condemned mattresses, prior to a representative from Huntleigh checking and agreeing the condemned status and providing replacements. The Trust also now has a stock of mattresses covers, so that foam mattresses that sustain damage to the cover can be immediately replaced before the foam becomes contaminated and the entire mattress requires condemning.

The Trust has advertised for a full time Band 6 Tissue Viability Nurse, part of whose role will be ensuring correct decontamination of foam and dynamic mattresses. Money has also been designated for decontamination and management of the dynamic mattresses in combination with an equipment library to ensure correct and safe use of dynamic mattresses. Further money has been put aside to purchase Trace™ to monitor use of dynamic mattresses as well as funding for an onsite technician to ensure that the Trust’s own

Cleaning Services

During the past year the Domestic Services department have been working closely with the Infection Prevention & Control team, nursing staff and the Estates team in order to ensure the Trust meets the needs and expectations of the patients, public and staff in terms of cleanliness of the hospital. To achieve this, these departments have been looking at ways of improving the environment, as well as monitoring systems to ensure the required high quality cleaning standards are met at all times.

There have been occasions when the Domestic Services Department have not been consulted when considering plans to refurbish / redesign areas within the hospital, and this has created additional stress within the department. Without building a cleaning programme into these projects extra work is eventually required on completion, and this adds pressure to the actual service as well as the budget.

The official PEAT inspection was conducted in January 2009, and the overall score for the Trust’s environment (which includes cleanliness) was recorded as “Good”. We continually strive to attain an “Excellent” score, and there are many areas that do achieve the excellent score rating of 5. These areas are generally those that have been refurbished as they are easier to keep clean due to the quality of flooring, protection of the walls and upgraded toilets and wet rooms.

We also undertake 3 additional internal PEAT inspections throughout the year, as this provides us with the opportunity to continually monitor the Trust’s standards and prepares us more effectively for the official inspections.

The new NPSA cleaning manual suggests that the cleaning service quality reports should be submitted to the Trust Board, and it has been agreed that this will now take place; with the first one being ready in December 2009.

There has been a 23% increase in requests for IC terminal cleans in comparison to last year. Many of these types of cleans are being carried out in the evenings or during the night within A&E by the Night Cleaner.

The Trust has committed to continue with the deep clean programme into 2009/10. This programme has to be planned in conjunction with the Estates Department, as it involves removing all radiator covers in order to clean behind them.

The availability of domestic cupboards is still an issue. Not all wards have their own dedicated cupboard, but we are actively working to resolve this with Estates management and the ward staff.



Norovirus outbreak continues to put additional pressure on the Domestic Services Department, but it is hoped that the introduction of afternoon cleaning in October will go some way to alleviate this as there will be more staff working throughout the day.

A business case for introducing a deep clean team is currently being constructed; with the idea being that the team will assist in achieving a quicker turnaround of opening wards following an outbreak.

Audits

Hand Hygiene Please also see ‘CleanYourHands’ section above

Each ward / department within the Trust takes part in the audit of standards of compliance with hand hygiene on a monthly basis.

Results are fed back locally to the DIPC and disseminated to all Clinical areas in the form of an electronic ‘clinical dashboard’ which is sited on the Clinical Audit & Effectiveness Intranet website and available for any members of the Trust to view. Results are also shared within the Infection control committee and Clinical Governance Committee on a monthly retrospective basis.

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The above graph indicates that although the 4th quarter shows slightly less adherence, Hand Hygiene compliance achieved a mean of 91% across the year which is a 15% increase on the year 2007/2008.

Environment All clinical areas have under gone environmental audits, patient equipment audits and kitchen audits. All of these areas have either submitted or are in the process of submitting action plans in response to the



audits. In addition to this all areas have had sluice audits which involved the macerators and state of commodes.

An audit schedule comprising the following audits is in place:

• Ward/departmental kitchens - 17:26 audited were compliant

• Management of patient equipment – 22:28 were compliant

• Environment – 18:38 were compliant

Re-audit is based on compliance. Wards achieving compliance at 85-100% are audited 12 monthly, partial compliance at 76-84% audited 6 monthly and those deemed non compliant at below 75% audited 4 monthly. The main issues that need to be addressed involve levels of dust in treatment rooms especially, cleaning of equipment that is not clearly either the responsibility of ISS or nurses, cluttered wards due to lack of storage space available. In addition to focusing on the environment: practice audits have been carried out in the following areas: peripheral cannulation audit and a sharps audit.

Peripheral Cannulation Audit In April 2008 a Trust-wide observational audit took place looking at peripheral line management in all wards. In total 44 wards were visited and 147 peripheral cannulae observed. Audit findings demonstrated a variety of IV dressings in use as well as inappropriate dressings being used on peripheral lines i.e. central line dressings, micropore etc. In addition many secondary bandages were being used which hinders visualisation of the cannula entry site. Results also demonstrated a lack of awareness of documenting the date of insertion on the cannula on the IV dressing (10%). Visual Infection Phlebitis (VIP) scoring was noted to be haphazard and ineffective; 6 patients having a VIP score greater than 1 (1 patient had a VIP score of 3). 2 patients were observed with peripheral cannula that had been in-situ for 6 & 8 days respectively.

Following this the practice development team in conjunction with the IP&C team undertook a series of updates for nursing and midwifery staff to raise awareness of current practice and to improve the use of VIP scoring within the Trust. A venous Access Group chaired by the Lead Nurse - practice and innovation was reconvened in May 2009 to organise the introduction of cannulation packs, cannulae assessment records and to revise the cannulation and venepuncture policy, all of which were introduced within the Trust in August 2008.

The Health Act 2006 requires all NHS Trusts to examine their working practice with regard to infection prevention and control issues. The introduction of the ‘Saving Lives: reducing infection, delivering clean and safe care’ has provided a solid foundation on which Trusts can assess their performance in terms of measuring compliance with Trust policies.

Action Area Two of the Winning Ways document introduced by the Department of Health in 2003 focused on ‘Reducing the risk of infection from the use of catheters, tubes, cannulae, instruments and other devices’. Root cause analysis carried out on patients identified as having a hospital acquired infection highlighted that in some cases a cannula was inserted and not used which may have been a contributing factor in the development of an infection.

The care of peripheral cannulae is included as one element of the monthly ward audit requirement and relies on observation at insertion. The Infection Prevention and Control Service carried out a ‘Snap shot’ Audit of all inpatients who had a peripheral cannula insitu on a specific date in April 2008 which focused on documentation, insertion site and dressings. The audit highlighted poor or no documentation and that many cannulae were inserted and not used or left in longer than 72 hours.

The action plan following the audit focused on training for all nursing staff and junior doctors who had responsibility for insertion and care and covered documentation, visual infusion phlebitis (VIP) scoring and care.

A re-audit in January 2009 focused on exactly the same issues as the first and again was a ‘snap shot’ audit. It again highlighted poor documentation of insertion, removal or change of cannula.



The action plan focused on implementing new observation record chart with colour coded VIP scoring. The need to introduce cannulation packs as standard practice through out Trust and to look at the possibility of a dedicated Cannulation team within Trust. The work is ongoing due to the poor results as tabled below.

Comparison of April 2008 and January 2009 Standard Jan-09 Apr-08 Variance =/- 1. Insertion details relating to the cannulae have been documented on the fluid balance chart 100% 19% 11% 8% 2.Details of cannulae removal/change are documented 100% 32% 31% 1% 3.Cannula has been used in the last 24 hours 100% 80% 80% 0% 4.Cannula to be used in the next 24 hours 100% 75% 72% 3%

5. Daily check of cannula site documented 100% 35% 19% 16%

6. Removal of cannula documented 100% 16% 9% 7%

7. Resite of cannula documented 100% 18% 10% 8%

8. Dressing opaque 100% 100% 99% 1%

9. Dressing intact 100% 98% 100% -2%

10. Dressing clean and dry – no obvious moisture 100% 84% 80% 4%

11. IV Site appears healthy 100% 85% 94% -9%

12. Current VIP score present 100% 32% 14% 18%

13. Action taken in line with VIP score 100% 79% 95% -16%

Sharps Audit 80 Sharps and blood/body fluid exposure incidents/ injuries were reported to Occupational Health in 2008/9. 76 were clinical staff across all disciplines, 4 were non clinical staff but ward based.

This continues to highlight the importance of effective education in this area and the need to ensure appropriate disposal facilities are available in all wards and departments. The infection control nursing team continues to work collaboratively with the occupational health team on this issue. Within the Trust we have the Sharp smart system allowing for uniformity through out the Trust, and is a system which when used correctly should greatly reduce sharps injuries. The cartsmart trolleys allow the sharps bin to be wheeled to the point of care also to reduce misuse of sharps. There is resistance to theses trolley’s in that they are large and the tray holder does not work well with the Trusts injection tray. Both of these issues are being worked on by IPACS and hope to be rectified as soon as possible.

Care bundles (High impact interventions (Saving lives(2005))

Saving Lives (2005) was a delivery programme introduced by the Department of Health to reduce Healthcare Associated Infections including MRSA and was revised in 2007. This delivery programme centers on a series of High Impact Interventions (HII), which are techniques to improve the reliability of clinical processes. Safety and reliability are described by Bion and Heffner (2004) are the most important components of quality in healthcare. The interventions will assist clinical governance to ensure that all patients receive a consistent quality of care, by minimizing unwarranted variation in delivery of clinical care.

The High Impact Interventions are based on an approach by the NHS Modernisation Agency (MA), where evidence based “care bundles” link this evidence with a measuring tool and provides a strategy for improving the clinical process to ensure the delivery of evidence based safe practice. They incorporate a series of elements which, when performed regularly improve the patients outcomes. They also provide a basis for continuing education and rapid assessment of the evidence associated with each element.

The HII audits comprise:

HII No 1. Central Venous catheter care

This care bundle evaluates the insertion and ongoing care of central venous lines. The third national prevalence study (Smyth 2006) identified 42.3% of all blood stream infections were central line related. It looks at the insertion, skin preparation aseptic technique and ongoing care. The issue of this care bundle that affects the results has been the unavailability in the Trust of 2% Chlorohexidine and 70% alcohol to



clean skin prior to insertion and the ongoing care of hubs and ports. March 2008 the Trust saw the introduction of 2% Chlorohexidine and 70% alcohol for cleaning skin for all venous access procedures. Once the use of this product has been embedded in practice, it is planned to introduce the use of a wipe which impregnated with 2% Chlorohexidine and 70% alcohol but not licensed to clean skin to clean hubs and ports. The hand hygiene element of this care bundle has been incorporated in a specific hand hygiene care bundle complied by IPACS and included in the QEH results as such.

HII No 2. Peripheral intravenous cannula care

This care bundle evaluates the insertion and ongoing care of peripheral intravenous cannula. In a Hospital Infection Society survey in 2003 show and infection rate of cannula as being 0.2 per 1,000 intravenous cannula days. It looks at similar issues as peripheral cannula and has the same issue affecting the results are the same as for central venous catheters. In March 2009 the Trust launched a Venous Access Group to look at issues around venous cannulation within the Trust. The initial projects were to improve the practices around cannulation and prevent infection, by the introduction of a cannulation pack and revamping the documentation to ensure compliance with a clean non touch technique and correct documentation and audit trail. The hand hygiene element has been included in the Hand Hygiene care bundle.

In addition to the care bundle documentation, the use of a dedicated IV insertion pack containing standardised skin preparation, IV dressing and a peel off IV insertion record for patients’ medical notes has finally become available through NHS Logistics in May 2008. This will promote best practice in aseptic insertion; with all wards and departments having this as a top-up item on their stock list.

A review of the care bundle documentation including insertion, continuing care and local audit process is currently taking place. It is envisaged that peer observation of insertion practice as the method of audit will follow on from this review.

HII No 3. Renal dialysis catheter

The Renal Dialysis Unit is a satellite of Addenbrooke’s hospital and does not come under the umbrella of Infection prevention and control at QEH. Therefore this HII care bundle is not included in the QEH results.

HII No 4. Prevention of surgical site infection

This care bundle comprises of a preoperative section involving MRSA screening and decontamination. The QEH as compiles a specific care bundle around MRSA screening and decolonisation for all the Trust. HII No 4 also includes a peri-operative section looking at hair removal, prophylactic antimicrobials, normothermia and glucose control which can contribute to the patient acquiring a surgical site infection based on evidence, Only Theatre and Days Surgery Unit undertake this audit.

HII No 5. Ventilated patients

This care bundle looks at the regular observations and the ongoing care of patients on ventilators. Ventilated associated infections account for 45% of all infections in intensive care units. The care bundle looks at head of bed elevation, sedation holding, deep vein thrombosis and gastric ulcer prophylaxis. They are undertaken in Critical Care Unit and NICU.

HII No 6. Urinary catheter care

This care bundle looks at the insertion and ongoing care of urinary catheters including whether the catheter is required, aseptic technique, sampling and drainage bag technique. Urinary tract infections are the second largest single group of all healthcare-associated infections at 19.7% (Smyth 2006).

HII No 7. Reduce the risk from Clostridium difficile

The Health Protection Agency reported from January to December 2006 that the number of patients in England over the age of 65 with Clostridium difficile associated disease in acute Trusts was 55,681(HPA 2007). This adds an average stay of an extra 21 days and at a cost of an estimated £4,000 plus per case (Wilcox 1996). This care bundle looks at antibiotic prescribing, decontamination of environment, personal



equipment and isolation. From March 2008 this Trust opened a C.difficle isolation unit. As soon as a patient is diagnosed with C.difficile they are transferred to Stanhoe isolation Unit, therefore this care bundle only applies to that area.

Isolating patients with healthcare-associated infection

This care bundle is a summary of best practice. Isolating patients with healthcare-associated infection is incorporated into all policies within the Trust.

Screening for meticillin-resistant Staphylococcus aureus

This care bundle is a summary of best practice for screening of MRSA colonization. The Trust screens high risk groups of patients on admission e.g. all patients admitted into CCU and NICU. All patients who are an inpatient for 2 weeks are routinely screened every weekend. The Trust compiled a care bundle around the Trust MRSA policy for screening. The Trust is also working toward the compliance for pre elective screening of surgical patients as per the Department of Health guidance Gateway 11123. Date of required compliance is April 1st 2009.

Taking blood for blood cultures

This care bundle looks at the procedure of taking blood for blood culture. The aim is to improve the quality of blood culture investigation and reduce the risk of blood sample contamination. 2 % Chlorohexidine and 70% alcohol for skin preparation was introduced into the Trust march 2009 to ensure recommended guidelines were followed and to reduce contamination of patients own skin flora and of the person taking the blood for blood culture.

Additional Audits

The Trust also devised an additional audit for Decontamination of Patient Equipment based on the Trust decontamination policy.

Summary

The IPACS, Clinical Audit and Effectiveness and Nursing, Midwifery Executive Committee are reviewing the process of auditing and feed back of the High Impact Intervention audits, the compliance and the reliability of these audits. Thus ensure that these audits provide a tool for measuring the safe delivery of care to the patients, by delivering a consistent quality of care and reviewing the processes to improve the patients outcome. Initiative include, cross auditing, reviewing the format of audit tool and creating a dashboard reporting system on the Clinical audit and Effectiveness website for easy access of results.

References Bion, J and Heffner J.E. (2004) Challenges in care of the critically ill. Lancet. 363. 970-977 Collignon P (1994) Intravenous catheter associated sepsis: a common problem. The Australian study on intravascular catheter associated sepsis. Medical Journal of Australia. 161: page 374-378 Department of Health (2007). Saving Lives: reducing infection, delivering clean and safe care. DH Publications. London McLaws ML and Taylor PC. (2003) The hospital infection Standardized Surveillance (HISS) Programme: analysis of a two-year pilot. Journal of Hospital Infection. 53 : 259-267 Smyth ETM (2006). The third prevalence study of healthcare associated infection in acute hospitals. Hospital Infection Society. Wilcox MH et al. (1996). Financial burden of hospital-acquired Clostridium difficile infections. Journal of Hospital Infection. 34: 23-30



Care bundles /Leading improvement in patient safety (LIPS)

Following work undertaken by the Deputy Director of Governance and the practice development nurse – emergency care and access, on the NHS Institute of innovation and improvement (NHSI) LIPS programme, during the past 12 months, it was agreed that the PDN’s would start this process within the clinical areas. This was undertaken by the implementation of small audits of practice, by observing specific procedures prior to the sisters and charge nurses in each area starting to assess practice. These audits are part of a PDSA (Plan,do,Study,Act) cycle of audits which have been demonstrated by the NHSI to improve practice.

These were agreed in the first instance as:

• Administration of IV medications

• BM procedure

• Venepuncture

• Cannulation

• Theatre check list – theatre only

• Flushing enteral tubes

Each PDN / PDM discussed the process with their Associate Chief Nurses and Lead Nurses, prior to explaining the process at individual sisters/ charge nurse meetings.

Each PDN / PDM discussed the process with a sister / charge nurse, in the clinical areas where these procedures are carried out and then one procedure was selected (see below) per day for a week and then practice was reviewed . Results of the observation were then fedback to the nurse observed and ward sister on the day of the observation and then audit form was sent to clinical audit to analyse and to formulate a ‘run chart’ that can be displayed within the ward so that staff are aware of practice within their own area. These results did not contain the names of the nurse observed.

This process commenced in July 2009 and then results discussed at the Patient Safety following each month audits undertaken, once process in place and a robust system is in place to be discussed at the NMEC meetings on a monthly basis.

5 observations of a procedure is undertaken in each area during a month. Plan for the July – November as follows.

• Administration of IV medications -July 2009

• Venepuncture

• Cannulation

• BM procedure

• Enteral feeding

• Theatre check list C

Performance scorecard A simple audit tool is used to record whether an element of the clinical process has been performed; the measurement is by recording yes or no. Each ward / area should return data to the Clinical Audit department by the end of the month to enable data to be analysed and reported prior to Trust Board. Over the year 2008/09, ward / area returns have increased returns rate from around 50% to 74% of wards / areas returning data.



Compliance with an element of the clinical process is judged by the ratio between the numbers of occasions when the elements were performed compared to the total number of occasions when they should have been carried out.

Figure: Care bundle compliance by quarter April 2008 to March 2009

Central Venous Catheter Care

9397 96

86

80859095

100

1st Quarter2008/09

2nd Quarter2008/09

3rd Quarter2008/09

4th Quarter2008/09

Urinary Catheter Care

95 98 98 99

020406080

100120

1st Quarter2008/09

2nd Quarter2008/09

3rd Quarter2008/09

4th Quarter2008/09

Care of Ventilated Patients

98 96 100 97

0

50

100

150

1st Quarter2008/09

2nd Quarter2008/09

3rd Quarter2008/09

4th Quarter2008/09

Peripheral Lines

90 95 95 91

0

50

100

150

1st Quarter2008/09

2nd Quarter2008/09

3rd Quarter2008/09

4th Quarter2008/09

MRSA Screening

58 7093 82

020406080

100

1st Quarter2008/09

2nd Quarter2008/09

3rd Quarter2008/09

4th Quarter2008/09

Hand Rub

97 96 97 93

0

50

100

150

1st Quarter2008/09

2nd Quarter2008/09

3rd Quarter2008/09

4th Quarter2008/09

Prevention of SSI

85 8960

100

050

100150

1st Quarter2008/09

2nd Quarter2008/09

3rd Quarter2008/09

4th Quarter2008/09

Clostridium Difficile

99 97 100 99

0

50

100

150

1st Quarter2008/09

2nd Quarter2008/09

3rd Quarter2008/09

4th Quarter2008/09



Decontamination of Patient Equipment

96 97 98 97

0

50

100

150

1st Quarter2008/09

2nd Quarter2008/09

3rd Quarter2008/09

4th Quarter2008/09

Blood Culture Sample Collection

98 95 95 97

0

50

100

150

1st Quarter2008/09

2nd Quarter2008/09

3rd Quarter2008/09

4th Quarter2008/09

This process is carried out on a random sample of ten patients in every ward / department every month and collated using a spreadsheet or scorecard which is evaluated by the modern matron, general manager, IC lead, DIPC, CEO and Director of Operations. This enables particular weaknesses in areas or with certain interventions to be highlighted and troubleshooted as well as becoming the focus of performance review in every directorate, at Senior management team, Nursing executive and board every month. Ward, trust and directorate 6 week rolling trend charts are published the following week.

An overview of performance in these high impact interventions, hand hygiene compliance, MRSA screening, environment and safety audits and sharps injuries since the full roll out of the programme and the inception of the later tools for Renal dialysis patients, the re launch of the Ventilated care bundle and the development of weekly assessments of the patients environment is contained here.

NEEDLESTICK INJURIES (CLINICAL STAFF) 1.4.08 - 31.3.09

0

2

4

6

8

10

12

LowModerateHigh

Low 5 1 5 3 1 3 3 5 8 6 3 7

Moderate 0 1 2 1 2 1 1 4 2 3 4 0

High 1 0 0 0 0 0 0 0 0 0 0 0

2008 04

2008 05

2008 06

2008 07

2008 08

2008 09

2008 10

2008 11

2008 12

2009 01

2009 02

2009 03

Sustainable improvement in HCAI requires Trusts to have an organisation-wide action plan which embeds infection prevention and control across the entire organisation. The plan incorporates national guidance and good practice, engages staff and make this everyone’s business.

Figure: Sharps injury by month April, 2008 – March 2009 by frequency and grade



Infection control policies

The Infection Control manual comprises of 47 policies. They can also be accessed via the Trust intranet. The

renewal and updating of these is ongoing in light of analysis of contemporary evidence, to ensure the

effectiveness of clinical practice. There were two major policies that required review during 2008/09, in light of

new evidence and published guidelines; these were MRSA and Clostridium difficile. The introduction of

screening for all elective patients commencing 1st April 2009 require the MRSA policy to reflect the new guidance

and practice. The establishment of the Clostridium difficile Isolation Unit on Stanhoe Ward and the new

guidelines published by DH January 2009 required changes to the policy and new guidance for the Isolation Unit.

Two policies are outstanding, Decontamination and Transmissible Spongiform Encephalopathy (TSE). Work is

being undertaken in the Trust to assure compliance with decontamination and auditing and the policy will reflect

the measures implemented. Also, new guidelines on TSE are expected to be published in 2009.

CONTENTS PAGE POLICY TITLE REVIEW DATE 1 Infection Prevention and Control Policy Statement May 2009 2 Infection Prevention & Control Policy September 2010 3 Hand Hygiene Guidelines for Healthcare Workers September 2009 4 Standard Infection Control and Disease Specific Precautions December 2009 5 Acinetobacter SPP October 2010 6 Antibiotic Prescribing Policy October 2010 7 Avian flu (Bird Flu) June 2010 8 Chickenpox (Varicella Zoster) Screening and Immunisation June 2010 9 Clostridium Difficile associated diarrhoea March 2009

10 Commode and bed pan guidelines February 2010 11 Discharge and Ward Cleaning – Hotel Services and Infection Control October 2008 12 Disinfection of Equipment and the environment December 2011 13 Employee Infection Screening and Immunisation Policy May 2010 14 Food Safety for Ward Pantries February 2010 15 Gastro-enteritis or diarrhoea of unknown aetiology October 2010 16 Hepatitis B infected healthcare workers June 2010 17 Hepatitis C infected healthcare workers June 2010 18 Herpes Simplex Virus infections September 2009 19 HIV Infected Healthcare Workers October 2010 20 Human Infestation Policy September 2009 21 Inclusion of IPACS within building development, change and development February 2011 22 Isolation Nursing September 2010 23 Isolation Unit Operational Policy March 2009 24 Laundry Disposal February 2010 25 Legionella (Legionnaire’s Disease) Legionellosis September 2011 26 Major Hospital Outbreak Plan December 2011 27 Measles infections October 2011 28 Meningococcal Chemoprophylaxis in Health Care Workers June 2010 29 MRSA December 2009 30 Multiple Resistant Gram Negative Bacteria (ESBL’s) October 2009 31 Mumps October 2011 32 Norovirus Winter Vomiting Disease (SRSV) June 2009 33 Notification of Infectious Diseases, Food Poisoning and Isolation October 2009 34 Pandemic Flu – a summary of guidance for infection control in healthcare settings June 2010 35 Pandemic Influenza March 2009 36 Pre-operative Hair Removal August 2009 37 Pulmonary Tuberculosis (TB) December 2009 38 Respiratory Viruses April 2009 39 Scabies Policy September 2009 40 Severe Acute Respiratory Syndrome (SARS) February 2010 41 Sharps injuries & accidents involving exposure to blood and body fluids August 2009 42 Standards for the Ophthalmic Service at St George’s Medical Centre, Littleport December 2010 43 Surveillance Policy September 2009 44 Transmissible Spongiform Encephalopathy (TSE) September 2008 45 Vancomycin Resistant Enterococci (VRE) April 2009 46 Viral Haemorrhagic fevers February 2011 47 Waste Management Policy November 2010



Healthcare Commission hygiene code inspection

Health act 2006 (Hygiene code)

On 4 June 2007 the Healthcare Commission (Commission) announced that it was to carry out unannounced inspections of 120 NHS trusts over the coming year (10 trusts per month) in the biggest ever programme relating to healthcare-associated infection. Inspections check compliance with the Government Hygiene Code – The Health Act, Code of Practice for the Prevention and Control of Health Care Associated Infections published October 2006, which outlines 11 compulsory duties to prevent and manage healthcare-associated infections such as MRSA and clostridium difficile.

Healthcare Associated Infection (HCAI) Programme of Inspections5

The purpose of the hygiene code is to help NHS bodies plan and implement how they can prevent and control healthcare-associated infection (HCAI). It sets out criteria by which managers of NHS organisations are to ensure that patients are cared for in a clean environment, where the risk of HCAI is kept as low as possible. Failure to observe the code may result in the Healthcare Commission making recommendations for improvements at the trust. If there is a material failing to observe the Code, the Healthcare Commission may serve an improvement notice.

The Trust received an unannounced annual inspection against compliance with the hygiene code on 9th and 10th December 2008. The inspection assessed the Trust’s compliance against Duty 2 (management systems), Duty 4: (clean and appropriate environment), Duty 8 (adequate isolation facilities), Duty 10j (adhere to antimicrobial prescribing policies).

The assessment was in depth - assessing the knowledge of staff through to checking whether wards and bathrooms have been cleaned properly. The inspection included looking at the environment as well as practices and procedures; for example looking at hand-washing, procedures for isolating patients and the cleaning of equipment.

The Healthcare Commission has carried out inspections at 120 trusts to check compliance with the hygiene code in 2008/9. The visits are unannounced to allow assessment managers to see the hospital as a patient or visitor would see it.

The Trust received a draft report in early January 2009 that was checked for accuracy and was then re-submitted by the Trust to the Health Care Commission on 23rd January 2009. On 3rd February the Trust received the final recommendations following the inspection.

The report indicated that whilst there were a number of areas of good practice and was complimentary to the Trust in relation to governance, delivery, accountability and support, a number of weaknesses were identified. These included:

• Intelligence gathering

• Hand hygiene facilities

• Training of some staff groups

• Back log maintenance

• Some inconsistencies around linen and waste disposal

• Business planning and risk registers

5 HEALTH AND SOCIAL CARE (COMMUNITY HEALTH AND STANDARDS) ACT 2003 as amended by the Health Act 2006



• Workforce infrastructure to support IP&C

• Incidence / prevalence of C. Diff on a specific ward

• Two breaches within duty 2 – Duty to have in place appropriate management systems for infection

prevention and control

• Three breaches within duty 4 – Duty to provide and maintain a clean and appropriate environment for

health care – HCC indicated that there was also a material failing in sub duty 4f. However this did not

result in an improvement notice.

The trust had an opportunity to comment upon the factual accuracy of the report. Amendments were made and a revised report submitted to the trust on February 25th. Every inspection report is subject to a robust quality assurance process. As part of this, a national panel reviews all reports and evaluates the findings made by assessors. The panel's role is to benchmark assessments to ensure that the commission is applying similar standards consistently across the country. A summary report was produced, which was published on the Healthcare Commission website on March 2nd.

Recommendations of the health care commission The health care commission wrote to the trust on February 24th indicating:





The full report is available upon request from the Trust secretary or at:

http://2008ratings.cqc.org.uk/_db/_documents/RCX_Queen_Elizabeth_Hosp_King's_Lynn_HC_IR_08-09.pdf .

Immediate Actions taken

Statement on measures to meet the hygiene code. The trust recorded 8 MRSA Bacteraemias in 2008/9 against a target of 12. There were recorded 98 cases of Clostridium difficile in the hospital against a target of119. A reduction of 57% against 2007/8. The trust is able to evidence compliance against the hygiene code. The Health care commission undertook a visit on 9th and 10th December, which inspected the Trust’s compliance against Duties 4, 8 and 10j of the Hygiene Code. An action plan has been created which addresses not just the points made in the report, but also incorporates the three action plans currently in place so that there is one action plan which schedules a series of measures against the duties of the code (Appendix 2). Each item of which has a lead member of senior staff who will take responsibility for compliance against the assurance statement relevant to that specific duty and will monitor progress on a regular basis and identify a timeframe. This action plan can then be “traffic lighted” for continuous performance monitoring at regular in some cases weekly periods thereafter. In relation to the specific issues raised the commission found as follows. Duty 2 Duty to have in place appropriate management systems for infection prevention and control.

Arrangements must include: Sub-duty 2c The mechanisms by which the board intends to ensure that adequate resources are available to secure

effective prevention and control of HCAI and should include implementing an infection control programme.



The Trust is currently reviewing the provision of infection prevention and control arrangements. An advertisement is currently out for the appointment of a second full-time Consultant Microbiologist. The current microbiologist will assume the responsibility of Infection control doctor in the interim. The nursing element of the Infection Prevention and Control Service nursing team will be enhanced in both quantity and grade mix. The overall intention is to ensure that the Service has adequate capacity and authority to affect and influence change in the delivery of clinical services in order to continuously improve the quality of practice and clinical outcomes for patients in relation to healthcare associated infection. Out of hours arrangements will be enhanced to ensure that a robust 24/7 mechanism is available to support clinicians where there is a case of suspected or proven infection. A programme of infection prevention and control activity has been devised and worked to by the Infection Prevention and Control Service. This comprises a series of policy development, educational programmes, campaigns and innovations, to ensure that all members of staff have the necessary competencies and capacities to deliver safe basic nursing and medical care. The objectives for the infection prevention and control programme were contained in the 2008/9 Annual report and approved by the board at it’s publication in September last year. Sub-duty 2e A programme of audit to ensure that key policies and practices are being implemented appropriately. All Infection Prevention and Control policies and procedures have been inventorised indicating their scheduled dates for review. A programme of review and development has been put in place to ensure that all policies are current and represent a contemporaneous authoritative set of guidances based upon current evidence. This is in addition a Trust-wide programme of audit which is managed by the Clinical Audit department to ensure that key policies and practices are being implemented appropriately. The audit framework for the plan details responsibilities and highlights areas for continuous review on the basis of Patient Safety Incidents, National Guidance and individual service priorities. This forward plan is managed by the Clinical Audit department in close liaison with Associate Chief Nurses, Clinical Governance Leads and individual Clinician Managers. This includes a specific section of audit related to Infection prevention and control dictated by the prevalence and incidence of HCAI, compliance with high impact interventions, antibiotic usage and patient safety incidents. The trust can evidence action taken following audit outcomes and an audit trail to demonstrate that reco0mmendaitons are followed through to delivery. Duty 4 Duty to provide and maintain a clean and appropriate environment for health care. An NHS body

must, with a view to minimising the risk of HCAI, ensure that: Sub-duty 4a There are policies for the environment which make provision for liaison between the members of any

infection control team and the persons with overall responsibility for facilities management. Policies for the environment, which make provision for liaison between members of the Infection Prevention and Control Service and persons with overall responsibility for Facilities Management, are in place. These relate both to cleanliness, cleaning of medical equipment, estates design and provision of advice and support both in relation to education of all members of staff, but also specifically to outbreak control. Sub-duty 4e There is adequate provision of suitable hand wash facilities and antibacterial hand rubs. The Trust has reviewed the numbers of hand wash basins within the Trust, consider the lay-out of toilets, bathrooms and sinks during the review of clinical areas in line with the Department of Health’s ‘Eliminating mixed sex wards’ directive of 28th January 2009. There are presently specific issues in the end bay in three of the wards visited and these have been prioritised for estates refurbishment in the first quarter of this financial year, in order to ensure that every member of staff has access to hand hygiene facilities within their clinical place of work. Waste bins which obstruct access to hand wash basins have been removed and placed in alternative locations. Sub-duty 4f: An NHS body must, with a view to minimising the risk of HCAI, ensure that there are effective

arrangements for the appropriate decontamination of instruments and other equipment. This commentary specifically relates to the provision of mattresses, one of which was found to be soiled during the visit. Every mattress in the Trust has been inspected. Each Matron has been trained in the Mount Vernon mattress inspection technique and this has been cascaded to shift leaders and all registered nurses. This included the ‘fist’ method to measure the rebound capacity of the mattress itself, the integrity of the cover, the zip and the status of the foam. All covers were removed and the foam exposed to visual inspection. Every mattress was inspected and all those found to be defective have been scheduled for immediate replacement. All of these mattresses are being replaced under the terms of the lease agreement and additional capital has been put aside to ensure that every mattress is fit for purpose. The buffer store arrangements are being reviewed so that nursing staff can access available or replacement mattresses instantly they detect a fault. A new Mattress Policy has been established to ensure that mattresses are continuously



inspected using the Mount Vernon method, both between patients and on a regular basis. This is validated by a six monthly mattress audit undertaken by the Tissue Viability, Back Care and Infection Prevention and Control Service. The trust is committed to the highest standards of infection prevention and control and will allocate sufficient resources to not only meet our obligations under the code but reduce the already very low incidence of health care associated infection in the trust. The staff and executive have responded to the very fair criticism of our current arrangements with zeal to immediately make the necessary improvements and a pride in our services we have come to expect of this organisation. The control of infection team has further evaluated compliance against the code by completing an assurance framework in order to assess capacity to meet each duty of the code not merely the duties which were assessed by the health care commission. This is appended at Appendix 3. The assurance framework has revealed the same themes as the HCC inspection and the action plans extant at the time of the visit out with duties 2.4.8 and 10j. However, the absence of CPA accreditation for the Microbiology laboratory is contained in the Pathology department business plan for 2009/10.

Statutory declaration of compliance with the Hygiene code

On July 2nd, 2009 he Board is asked to made the following declaration: Having addressed all of these recommendations Queen Elizabeth Hospital King’s Lynn NHS trust is pleased to provide the Healthcare Commission with assurance that the trust is providing a clean and a safe environment for patients and that

appropriate systems are in place to address all aspects of the Hygiene Code6. 6 The Hygiene Code came into force on 1 October 2006. The Code has 3 headings which form the basic Code and under which sit 11 duties: Management, organisation and the environment 1 General duty to protect patients, staff and others from health care associated inspection (HCAI) 2 Duty to have in place appropriate management systems for infection prevention and control 3 Duty to assess risks of acquiring HCAI to take action to reduce or control such risks 4 Duty to provide and maintain a clean and appropriate environment for health care 5 Duty to provide information on HCAI to patients and the public 6 Duty to provide information when a patient moves from the care of one health body to another 7 Duty to ensure co-operation 8 Duty to provide adequate isolation facilities 9 Duty to ensure adequate laboratory support Clinical care protocols 10 Duty to adhere to policies and protocols applicable to infection prevention and control Health care workers 11 Duty to endure, so far as reasonable practicable, that health care workers are free of and are protected from exposure to communicable infections during the course of their work, and that all staff are suitably educated in the prevention and control of HCAI Considerable detail is provided under each of the 11 duties together with further reading and guidance. Where breaches are identified trusts must produce an action plan to rectify problems within a specific timescale and failure to achieve this will result in the Commission publicly issuing an “improvement notice”. This is a new legal power given to the Commission under the Health Act 2006 to enforce the Hygiene Code. If the improvement notice is not properly responded to the Commission can ask the secretary of state to impose special measures and oversee a programme of improvements within the trust. Compliance will be an automatic part of all inspections carried out as part of the 2006/07 annual assessment of NHS trusts. This is a review of about 20% per year of all trusts to ensure they meet the core standards for better health: three of these standards relate to the Code: C4a C4c and C21. The systems for the prevention and control of HCAI are expected to address: �Management arrangements to include access to accredited microbiology services; �Clinical leadership; �Application of evidence based protocols and practices for both patients and staff; �The design and maintenance of the environment and medical devices; and �Education, information and communication. All provisions of the basic Code applies to an Acute Trust. An Acute Trust includes all NHS foundation trusts or any trust which is not established as a Mental Health Trust or an Ambulance Service Trust all or most of whose hospitals, establishments and facilities are situated in England. Provisions of the basic Code apply in part to other bodies i.e. Mental Health Trust, Ambulance Service Trust, NHS Blood and Transplant and any Primary Care Trust (PCT). Each section of the basic Code has supporting guidance / publications that are intended to inform policy development and which all NHS bodies must take account of. When commissioning services an NHS body must satisfy itself that contractors have appropriate systems in place to keep patients, staff and visitors safe from HCAI, as far as reasonably practicable.



Action planning

In response to each of this inspections, recommendations were made and an action plan produced. This was revised following input from stakeholders and the output from the Infection control assurance framework and weekly meetings followed to review progress with implementation. The DIPC has taken the view that all of these recommendations and action plans should be consolidated into one action plan aligned with the duties of the Hygiene code in order to assure the board and provide a single reliable and comprehensive reference for the infection prevention and control work of the trust over the remainder of the financial year. This single hygiene code action plan first created on February 15, 2009, updated, traffic light risk assessed each week and the version evaluated on March 31, 2009 can be found in the action planning section of this report.

Training Activities

INDUCTION

All new permanent members of staff, including doctors, attend induction which includes infection prevention and control. All staff (excluding doctors) attends core induction scenarios which include infection prevention and control. All clinical staff attends hand hygiene session during introduction, with nursing staff attend further infection prevention and control sessions. Doctors attend a separate scheduled induction, which includes hand hygiene and infection prevention and control.

MANDATORY INFECTION AND CONTROL UPDATE

Mandatory infection prevention and control update sessions are grouped in two levels for those who come into contact with patients and have hands on care. Level 2 and 3 are face to face sessions facilitated by the IPAC team. The levels are outlined in the Infection Prevention Training Needs Analysis published on the intranet. Level 1 mandatory infection control training is for the staff that does not have patient contact and is achieved by reading the MANTRA. IPACS also undertake mandatory training for groups that have specific requirements in the clinical areas, due to their roles of by the nature of their department and their availability to attend sessions. Attendance is recorded on the ESR.

Attendance with mandatory training has been variable throughout the year, reflecting staff shortages and outbreaks.

ADDITIONAL TRAINING

Additional training was undertaken by IPACS where required or requested. e.g. The setting up of Stanhoe Clostridium difficile Isolation Unit required additional training for new staff and an update for existing staff on C.diff.

IPACS continued with the rolling programme of Norovirus, C.diff and MRSA drop in sessions scheduled during the late summer months.

The annual IPAC Link Nurse Study day was held in September 2008, with 22 out of the 33 Link Nurses attending. The day was sponsored by a company and included sessions by our Consultant Microbiologist and Antimicrobial Pharmacist and the IPAC Nurse specialist from Mental Health and UEA.

The three members of the IPACS team attended a number of external educational training sessions, which included The Annual Infection Prevention Society Congress, The Aseptic Non Touch Technique Study Day (ANTT), ChloroPrep Study Day, Clean your Hands Workshop, HPA Epidemiology Training Day and Infection 09 Training Day.

In addition Noel Scanlon, DIPC attended the Infection 09 study day, London and is also undertaking the Post graduate diploma in Planning buildings for health at London South Bank University.



Evaluation of the Infection Control Action plan April 2008 – March 2009

The Trust annual Infection Prevention and Control action plan outlined the key activities and priorities for Queen Elizabeth Hospital Kings Lynn NHS Trust for the year 2008-2009. This plan supported the Infection Prevention and Control Strategy and was integral to the Trust’s Infection Prevention and Control assurance framework to enable compliance with the Health Act (2006). This programme outlined details of how the Infection Prevention and Control Service together with Directorates and the Board assisted the Trust to meet its objectives and was approved by the Trust Infection Control Committee (ICC).

Progress has been made against each duty of the Hygiene Code. These include the Board receiving monthly reports of risks associated to infection prevention and control e.g. a route cause analysis (RCA) summary of the Trust’s Clostridium difficile associate diarrhoea cases.

The increased attendance of mandatory Infection prevention and control annual training of medical staff, through additional training sessions.

The implementation of MRSA screening of all elective admissions to the Trust by 1st April 2009.

RCA’s of MRSA’s undertaken in a shorter time scale, to ensure actions are taken promptly and promote shared learning, to reduce future incidence.

Compliance with hand hygiene improved, through additional training, targeting new members of staff and improved compliance with submission of Saving Lives, High Impact Intervention hand hygiene audits.

Regular liaisons meetings established with Hotel Services and Estates, to ensure continued infection prevention and control input.

An assurance frame work was developed to provide evidence to supporting the compliance with Standards for better health and the Health Act.

The opening of the Clostridium difficile Isolation Unit on Stanhoe ward has contributed to the effective management and decreased of cases and deaths of patients with in the Trust. However, as the numbers have decreased, the capacity issue of the unit is under review.

To improve the efficiency of a small IPAC Team, a business case has been put forward for a software package that will enhance surveillance, by providing near time surveillance information and promote a comprehensive reporting and tracking system.

Through the RCA reporting of the Trust’s MRSA Bacteraemia’s, issues have been identifies with the practices around venous access. Skin preparation that complies with national guidance was introduce and a multidisciplinary group was set up to look at the introduction of cannulation packets and practices, to reduce the risks of infection. Also, to look at the documentation related to cannulation, which will provide evidence for tacking purposes. The group has expanded their remit from their original purpose, by looking at safety needles and cleaning of hubs and ports.

Minimising antibiotic resistance by appropriate prescribing continues to be monitored through audit under taken by the IPACS/Antimicrobial Pharmacist and reported to the IC Committee.

Policies continue to be updated and ratified by IC Committee. The Trusts Pandemic flu policy continues to be reviewed and amended appropriately in accordance with government guidelines.

The infection prevention and control programme for 2008/09 is attached to this report.



EVALUATION OF ANNUAL INFECTION CONTROL PROGRAMME 2008/2009

1. Summary: Queen Elizabeth Hospital Kings Lynn NHS Trust (QEH KL) is committed to eliminating all avoidable healthcare associated infections (HCAI’s). Achieving this vision requires planning and a systematic approach to actions to bring about a culture change in Infection Prevention and Control. Although the Infection Control Team have a pivotal role in supporting QEH KL to achieving its aims, the Trust acknowledges that every member of staff needs to be involved in the process and clear on both individual and team/directorate accountability and responsibility.

The Trust annual Infection Prevention and Control programme outlines the key activities and priorities for QEH KL for the year 2008-2009. This programme supports the Infection Control Strategy and is integral to the Trust’s Infection Control assurance framework to enable compliance with the Health Act (2006). This programme outlines details of how the ICT together with Directorates and the Board will assist the Trust to meet its objectives and will be approved by the Trust Infection Control Committee (ICC). Specific details on local actions can be found within the Trust’s HCAI action plan. Other key personal and corporate responsibilities for Infection Prevention and Control are outlined in the Infection Control strategy to support delivery of this programme of activity.

It is acknowledged that the achievement of the programme is dependent on adequate resourcing of the Infection Control Team across the Trust. Prioritisation of activities will be undertaken via the Director of Infection Prevention and Control if resources are insufficient to meet the requirements of the programme. Each objective has been developed with an associated risk assessment in order to clarify the impact and anticipated risk consequences should they not be achieved. A review of each risk statement and progress against the programme will be presented to ICC on a quarterly basis in order to monitor progress.



2. Aim of QEH KL Infection Control Programme 2008-09

To reduce preventable healthcare-associated infections within the activity of QEH KL and ensure compliance with national policies and guidance by a process of: • Surveillance / Incident reporting • Promotional Campaigns

• Development, review and implementation of Infection Control Policies. • Response to local / regional / national initiatives

• Education / Training for all clinical and support staff • Research

• Audit of infection prevention and control practice • Compliance with the Code of Practice for Prevention and Control of Infection.

• Continued development and monitoring of compliance with saving lives care bundles

• Communication of learning following incidents/outbreaks of infection

• Maintenance of the expertise of Infection Control specialist staff who will provide guidance on Infection Control measures

3. Identified targets for the Trust • Reduction of MRSA bacteraemias in line with SHA target (21 for year 2008-09) • Reduction in rates of Clostridium difficile in line with SHA target (183 for year 2008-09)

4. Identified targets for Directorates

• Compliance with local Directorate targets for avoidable MRSA bacteraemia and C. difficile cases • Quarterly reporting to ICC in line with Board to Ward reporting framework • Identification and management of Red Risks related to Infection Prevention and Control on risk registers • Root Cause Analysis of MRSA Bacteraemias undertaken and forms returned within 5 working days of notification of Bacteraemia • Learning from RCA’s and incidents/outbreaks implemented fully • Appropriate use of antibiotics and other antimicrobial agents and compliance with antibiotic audits

5. The Infection Prevention and Control Programme 2008/09 has been developed using the following Department of Health guidance.

• Winning Ways: working together to reduce Healthcare Associated Infection in England December 2003 • Saving Lives: a delivery programme to reduce Healthcare Associated Infection including MRSA June 2005 • NHSLA Standards • Standards for Better Health • Code of Practice for Infection Prevention and Control • Clean, Safe Care

The purpose of this programme is to identify all key work streams required to ensure all appropriate actions are being taken by QEH KL to minimise the risk of healthcare associated infections within QEH KL.



Trust Board Objectives Actions Lead Timescales Update Ongoing update

by IPACS • The Board will receive Infection Control updates at each

Public part of the Board Meeting. DIPC Monthly Feb 09: In place – evidenced Board mins

• The Board will receive the Annual Report. DIPC July 08 Feb 09: Completed, agreed at Sept BAC, to be presented to Sept Board

• The Board will receive reports and risks associated with IPC via the ICC and Clinical governance and Health care governance committees

DIPC On-going Feb 09: In place – escalation reporting in place – evidenced in minutes and on escalation reports

Board takes an active part in ensuring that Trust-acquired infections are reduced to a minimum.

• The Board will receive information relating to assurance on compliance with the Code of Practice and standards for better health and key indicator targets via the HCG and challenge concerns in relation to compliance

DIPC

To be implemented April – May 09

Assurance framework in development Feb 09

Assessment of Risk: Feb 09 Potential Risk: Board does not take an active part in this issue Likelihood = 1 Impact = 2

2 → Green (Controls Adequate)

Directorates Objectives Actions Lead Timescales Update On going update

by IPACS • Each Directorate will table an Infection Control Report

quarterly to the ICC IC leads Quarterly on-

going Feb 09 : Board to ward reporting in place–evidenced in ICC mins

• Directorates will participate in the Infection Prevention Performance Monitoring framework

Clinician Manager

On-going Feb 09: Performance Monitoring review in place

• IC risks are fed into Directorate Risk Registers and reviewed monthly.

Clinician Manager

July 08 Feb 09: Process being reviewed and strengthened inline with new Divisions

• All staff attend induction and mandatory annual update sessions

Clinician Manager

On-going Feb 09:Training programme in place; need to address SpRs

To ensure that reduction of Trust-acquired infections are a priority for Directorates to enable a reduction in HCAI’s and the Trust to meet its objectives.

• Lessons from IC SUI’s/incidents/outbreaks are reviewed regularly and acted upon.

Clinician Manager

Ongoing Feb 09: Evidenced in reports, action plans, ICC, CIRC

• Monitoring of Directorate Infection Control associated audits e.g. antibiotic compliance

Clinician Manager

Monthly Feb 09: Commenced, & to be developed further & monitored

Assessment of Risk: Feb 09 Potential Risk: irectorates do not make this a priority and therefore infections are not reduced

Likelihood = 1 Impact = 2

2 →

Green



Infection Control Team in liaison with others The role of the Infection Control Team is to limit the acquisition and spread of pathogenic microorganisms by using scientifically based knowledge, thorough planning, surveillance, education, advice, support and leadership.

Objectives Actions Lead Timescales Update On going update by IPACS

Provision of Infection Control service o Provide reactive service to meet needs of incidents/enquiries/outbreaks

o Work collaboratively with the Mental Health Trust and meets external SLA requirements

o Work proactively with multi-disciplinary staff and dept’s to reduce risk of HCAI

o Identify and inform ICC of any risks associated with IC resources and ability to provide service

HOC

On-going

Feb 09: Ongoing.

Assessment of Risk: Feb 09 Potential Risk: Advice and support not given to clinical areas resulting in inappropriate management and the spread of infection


1 →

Green

Surveillance The Trust will develop and enhance its local alert organism surveillance systems during 2008-09 to enable web-based availability of ward/directorate data. Prompt action is taken when required following feedback of surveillance data.

Continue mandatory Surveillance of:

• MRSA Bacteraemias • C. difficile • Glycopeptide resistant enterococci • Orthopaedic surgery wound infections. (formerly NINSS)

Undertake a review of and implement voluntary surveillance of:

• C. difficile (daily reporting) • MRSA non-bacteraemias

Undertake other ad-hoc surveillance as required.

ICD ICD ICD CD Ortho. ICT

Ongoing Aug 08

Sept 08: Ongoing and reported to ICC Daily reporting to DIPC, CEO (C.Diff) Database in place, monthly reports shared with Directorates (MRSA non bact)

Business case being undertaken for ICNet – surveillance software for IPACS 31/3/09: IPACS meet with computer services to review Panasonic hand held tablet.

Assessment of Risk: Feb 09 Potential Risk: Enhanced local surveillance is not undertaken and targeted interventions are not taken resulting in continuing infection problems


1 ↓

Green



• Review process and ensure that all employees (including

locum bank staff and contractors) receive infection control induction training at commencement of employment.

Dir HR

Commence June 08

Feb 09: IC Information leaflet developed. To be rolled out

• ICT undertake requirements of IPC education and training: - Input into staff inductions and annual mandatory updates - Pre and post registration nurse training - Skills training – IV cannulation and drug administration/venepuncture/blood culture technique

Lead ICN Feb 09: Training programme in place

Clinical Educators from Enturia launched an education package for Chloraprep skin preparation for venous cannulation 9.3.09

• Undertake gap analysis of all mandatory and skills training and associated record keeping including IPC elements

Dir HR

Commence July 08 Feb 09: Gap analysis completed – uptake of mandatory <70%

Education Ensure that all Trust employees have a programme of education and training on the prevention and control of infection in order to understand their responsibility for infection control and the actions they must personally take.

• Ensure all relevant staff receives training in aseptic techniques and are assessed as competent.

Chief Nurse/MD

Ongoing Ongoing

Assessment of Risk: Feb 09 Potential Risk: Staff do not take up training and therefore do not understand their responsibilities resulting in greater infection risks


6 → Amber – mandatory training issue



Policies are updated in line with review dates Ongoing Policies

The Trust has appropriate policies in place in relation to preventing and controlling the risks of HCAIs and meets the requirements of Duty 10 of the Code of practice. • Policies/guidelines to be revised –

Priority o Waste Disposal o Safe disposal of sharps o Purchase of equipment o Infection Control glossary o Clostridium difficile o Central vascular catheters o Urinary catheter care o Glove use o Isolation o Multi-resistant gram negative bacteria o Notifiable diseases o Funding for outbreaks of infection o Surveillance

Others: o Chickenpox and Shingles o Meningococcal infection o SARS o Human Infestations o Nasendoscope decontamination o Tonometer head cleaning and disinfection o Patient transfer o Linen o Patients with absent or dysfunctional spleen o Infection Control issues for staff health o Glossary

ICT ICT

Feb 09: On going programme of reviews. Five policies currently awaiting ratification (MRSA – new guidance) will be ratified and published by 31 Mar

28/ 2/09: Clostridium difficile policy being reviewed to incorporate recommendations by the Health care commission. i.e. definition of Outbreak and cluster 31/3/09: Blood culture policy being reviewed to include Chloraprep and procedure for paediatrics Norovirus policy to be reviewed at end of outbreak

Assessment of Risk: Feb 09 Potential Risk: Staff will not be able to undertake correct practice if they do not have access to up to date/correct information


4 → Yellow

Audit of Policies Compliance with key policies is ensured through the implementation of high impact interventions and monitored through audit. Additional policies are audited on an as needs basis.

Planned policies to be audited – • Purchase of equipment • MRSA • MRSA suppression therapy prescription to treatment time • Decontamination • Sharps management • Hand hygiene (6 monthly) • Peripheral cannulation

Medical Devices Committee ICT ICT ICT ICT ICT ICT

Feb 09: In progress 28/3/09: Peripheral cannulation audit undertaken, awaiting report Medical Devices Committee to be established April 09

Assess standards of practice through audit of High Impact Interventions.

See separate Audit Programme

Ongoing Feb 09: In progress



Assessment of Risk: Feb 09 Potential Risk: Incorrect practice will not be identified and rectified resulting in increased infection risks


4 → Yellow

• Audits of antibiotic prescribing to be undertaken monthly • Develop Trust Antibiotic intranet web-site.

Antibiotic pharmacist Antibiotic pharmacist

Ongoing Ongoing

Feb 09: In progress, and currently reviewing audit tool & presentation of information

Antibiotic Prescribing Minimise antibiotic resistance by appropriate prescribing.

• Ensure education on antibiotic prescribing to all doctors, updated annually.

• Directorates to comply with mandatory antibiotic audits as set out in Trust annual audit programme

Medical Director Clinician Managers

Ongoing Feb 09: ink to above

Assessment of Risk: Feb 09 Potential Risk: Possible increase in antibiotic resistance resulting in difficulty in treating infections and an increasing reservoir of resistant organisms. Poor antibiotic stewardship may cause C. difficile to occur

Likelihood = 1 Severity = 2

2 → Yellow



Environmental audits Ensure environmental standards are maintained.

• Ensure audits are carried out annually. • Environment • Patient equipment • Kitchen • Sluice • Participate in PEAT process and assist taking forward

of lessons identified.

ICT with Ward/ Department Managers/Audit Dept/Matrons/Facilities Dept/ISS

Ongoing

28/2/09: Action plans completed but Evaluation of delivery sometimes lacking

• Matrons to monitor through rounds, Environment and facilities risk meetings, Domestic Service review meetings

Assessment of Risk: Feb 09 Potential Risk: Environmental issues are not identified and appropriate action taken


3 →

Yellow

MRSA Screening Compliance with Health Act requirements for MRSA screening.

• Ensure MRSA screening of all elective admissions is in place and process to move to screening all admissions is implemented as soon as possible

DIPC March 09 Feb 09: Business plan approved. Working Party meeting weekly.

28/2/09: MRSA Policy currently being reviewed to incorporate MRSA screening for elective admissions as per DH guidance by Apr 1. 31/3/09: MRSA Policy signed off and published on INTERNT and INTRANET

Assessment of Risk: Feb 09 Potential Risk: Potential for sanctions if the Trust does not comply with the requirements of the health act.


3 → Yellow To publish & evaluate new policy

MRSA Bacteraemias Improve MRSA bacteraemia rates though identification of root causes, corrective action and sharing of learning.

• Ensure timescales for RCA reporting are met and corrective actions/learning shared across Directorates.

• Report root causes and action to ICC and Trust Board. • Implementation of ‘coroners court’ process following

MRSA bacteraemia RCA is considered and investigated.

Infection Control Leads. DIPC CEO/ICT

Ongoing Ongoing

Feb 09: On going – RCA’s in place & agreed actions. Reported to ICC, BAC, Board. Currently above trajectory.

28/2/09: RCAs not always undertaken in a timely manner 28/2/09: National Patient safety RCA Tool now being used for all RCA’s undertaken

Assessment of Risk: Feb 09 Potential Risk: Bacteraemia rates will not improve resulting in adverse patient outcomes and scrutiny of the Trust by DH, SHA etc


6 → Orange Learning not always out quick enough



• Formal training on peripheral line insertion/aseptic

technique and ongoing management to be included in Education/training review

Dir HR Feb 09: Cannulation training in place

28/2/09: Chloraprep introduction & training Mar 7- 21 31/3/09: Compliance audit arranged with Enturia for May

• Continue to monitor care bundle compliance On-going May 08 On going

Reduce IV line-associated infections.

• Review care bundle tool ICT Aug 08 Care bundle revised, agreed & piloted. For re-launch 22 Sept.

Assessment of Risk: Feb 09 Potential Risk: IV line associated infections will not reduce resulting in increase risk of litigation, scrutiny by DH, SHA etc.


3 → Orange

Reduce needle stick injuries Implement inclusion of NSI data in performance review process. Evaluate pilot introduction of safety cannulae across Trust.

OH/DIPC/ICT On-going Feb 09: Safety cannulae implemented across trust Aug/Sept 08.

Assessment of Risk: Feb 09 Potential Risk: Needle stick injuries will not reduce resulting in continuing risk of infection to staff and litigation for the Trust


6 → Orange

Continue to make progress with: Development of Link Practitioner Programme

• Continue to develop this Trust-wide. • Continue to build on existing programme

incorporating new initiatives as required: • Annual updates • Quarterly meetings

ICT Ongoing Feb 09: Ongoing 28/2/09: Struggling to keep up with turnover of new link practitioners Bi monthly updates introduced Jan 09

Assessment of Risk: Feb 09 Potential Risk: Link Practitioners will not be adequately supported /developed to undertake the role.


3 → Yellow

Hand Hygiene

• Monitor results of care bundle compliance and audits • Continue with ‘Clean your hands’ campaign • Ensure clinical staff comply with ‘Bare below the

Elbows’.

ICT CD

Ongoing On-going

Feb 09: Ongoing

15/3/09: Improved Sept – Dec 08 Rates fallen by 6% Dec-Feb 09 31/3/09: Action plan to address fall in compliance of hand hygiene currently being complied

Assessment of Risk: Feb 09 Potential Risk: Risk of cross infection if staff do not comply with hand hygiene initiatives


6 →

Orange

Emergency Planning Participate in Trust’s emergency planning Specifically for:

• Pandemic Influenza

DIPC Ongoing

Feb 09: Ongoing involvement with Trust emergency planning

Policy to be approved Mar 26

Assessment of Risk: Feb 09 Potential Risk: Trust will not be adequately prepared Likelihood = 1 Impact = 2

2 →

Green

Building development and Cleaning issues

• Continue input into building developments and refurbishments

ICT

Ongoing

Feb 09: Ongoing 28/2/09: Refurbs less consistent & timely approach 31/3/09: Regular meetings set up with IPACS and Hotel Service and with Estates to ensure IPACS include in all decision making



Assessment of Risk: Feb 09 Potential Risk: Buildings will not be built, maintained and cleaned to facilitate good infection control practice


6 →

Orange

Standards for better health

• To ensure compliance with S4BH C4a (Infection Control) is maintained and ensure compliance with Compliance with, C21 (environment), C4c (decontamination), C4e (waste)

• Embedding Infection Control elements of level 2 NHSLA and planning for level 3.

• Evidence to support compliance with Standards for better health and the Health Act is identifiable and readily available

ICT

Ongoing

Feb 09: Compliance reports completed year to date against all standards – compliant; quarterly review. Active membership of NHSLA level 3 action plan group

28/2/09: Infection Prevention and Control Assurance Framework currently being developed 31/3/09: Claire Roberts and Lynne Roberts in discussion with Klarient re software

Assessment of Risk: Feb 09 Potential Risk: Trust cannot provide adequate assurance of basic standards resulting in poor annual health check, adverse media attention and risk visits by the HCC


1 →

Green

Development of Trust’s Web-site

This will be developed to include information on Infection Control

ICT

From June 08

Feb 09: Information reviewed; website to be checked to ensure actioned

Assessment of Risk: Feb 09 Potential Risk: Inability to be able to provide patients and the public with information on infection control as required in the heath act


4 → Yellow

Ensuring that all employees adhere to their responsibilities in relation to Infection Control

IC will be included in all appraisals and PDPs Dir HR Feb 09: Work in progress to ensure all staff have an appraisal +PDPs

28/2/09: Appraisal rate <75%

Assessment of Risk: Feb 09 Potential Risk: Inability to demonstrate compliance with the requirements of the health act in respect of performance and development of staff


4 → Yellow



Appendix 1: Hygiene code Action plan 2008/9:

Action plan for the delivery of sustainable adherence to the Code of Practice for the Prevention and Control of Infection

DUTY

Duty Assurance Statements Issue Action Measurable Outcomes

Accountability / Responsibility

Monit. Ctee. Status Time

Frame Evalua

tion

2a 2a. A Board level agreement outlining its collective responsibility for minimizing the risks of infection and the general means by which it prevents and controls such risks.

Monitoring, review and action to improve clinical practice and prevent and control HCAI is part of the routine business of every service area/clinical division / Trust Board

The Health Care Commission could not find evidence of a formal collective agreement, although the Board was presented with the annual report in Sept 2008 by the Dipc at which point an acknowledgment was made of the Trust’s commitment to reducing HCA1’s as part of the reporting process. It was reported that a review of this was being undertaken on the risk register & the process of scoring as some inconsistencies had been evident in the scoring which had the potential to prevent Board members getting a true picture of the level of risks.

No recommendation was made by the HCC, re: the provision of evidence of collective agreement, however the Trust has recognised this issue and plans are in place to address this matter. Terms of reference for all governance committees currently under review. A review of the scoring of the risk register is in progress.

New Terms of reference from each of the Governance committeess ( Health care governance, Clinical Governance, Resoruce Governance, Environmental Governance ) . Introduction of a new scoring system for the risk register.

Director of Performance & Informatics Company secretary Health care Governance - Carol Townend, Clinical governance - Martin Rimmer, Environmenatal Governance - Barbara Cmmings, Resource Governance - Jeremy Cook

HCG

CG

RG

EG

A

01/04/2009

01/04/2009



2c 2c. The mechanisms by which the Board intends to ensure that adequate resources are available to secure effective prevention and control of HCAI. These should include implementing an appropriate assurance framework, infection control programme and infection control infrastructure.

Responsibility and accountability for infection control is clearly allocated in each clinical area (e.g. to the manager of that area).

The IP&C service were unable to present the Annual infection control programme on the day of the visit.

A programme of infection prevention and control activity has been devised and worked to by the Infection Prevention and Control Service. This comprises a series of policy development, educational programmes, campaigns and innovations, to ensure that all members of staff have the necessary competencies and capacities to deliver safe basic nursing and medical care. The objectives for the infection prevention and control programme were contained in the 2008/9 Annual report and approved by the board at it’s publication in September last year. This is also appended hereto.

Board Reports wil contain refrence to delivery of the Annual programme as well asa review of delivery within the 2008/9 Annual IP&C report.

Lead Nurse, IPAC Chief Nurse / Deputy Chief Executive (DIPC)

COI

BOARD

G

31/03/2009

31/03/2009



Information given to the Board re; performance reports about infection control rates was not broken down by ward to allow the board to allow them to identify patterns or trends in specific areas. There was evidence that information had been collected and collated but not presented to the Board.

New reporting system commenced to the Board in January 2009 – includes a break down of incidences of C.diff to ward level to allow the identification of trends and inclusive of hand hygiene audit results.

Board Reports contain monthly Cdiff figures per ward with infromation about previous months performance to enable the Board to be aware of trends.

Lead Nurse, IPAC Chief Nurse / Deputy Chief Executive (DIPC)

BOARD

G

31/03/2009

31/03/2009





Information seen during the inspection clearly indicated a recurring incidence of clostridium difficile in one clinical area – Board members spoken to including Chief Executive were unaware of this information.

On receiving information regarding the reoccurring incidences of clostridium difficile in one specific clinical area an independent review of the cluster of cases in September 2008 was undertaken on 23rd January 2009 by the Infection Control programme manager from the East of England and a Consultant Microbiologist from the West Suffolk Hospital NHS Trust. The report will be actioned and copy sent to the Board.

Investigation by Rosie Readman (SHA) and Dr Barker (West Suffolk Hospitals NHS Trust) undertaken 23rd Jan 2009. Report re : review of Cluster of C diff ( august -September 2008) reported to 23rd February 2009.

Chief Nurse / Deputy Chief Executive (DIPC)

COI

BOARD

G

01/03/2009

01/03/2009



Information seen during the inspection clearly indicated a recurring incidence of clostridium difficile in one clinical area – Board members spoken to including Chief Executive were unaware of this information.

On receiving information regarding the reoccurring incidences of clostridium difficile in one specific clinical area, Chief Nurse has commissioned a review of Nursing practice in this area by an experienced senior nurse from outside of the Trust – due to undertaken in April 2009 ( with results of the review to be actioned and sent to the Trust Board).

Terms of reference for Nursing review drawn up by Head of Nursing - emergency care and access and Lead Nurse - Practice and Innovation. Nursing review to be undertaken April 2009 and report sent to the next avaialable Trust Board

Chief Nurse / Deputy Chief Executive (DIPC)

NMEC

BOARD

A

30/04/2009

17/03/2009





During observation the Health care commission established a short fall in the provision of hand washing facilities in some areas – Board members indicated that this was on the Trust’s risk register, however evidence given by the Trust did not include this information.

Audit of hand washing facilities undertaken in January 2009 and will be placed on risk register once results obtained and audit will be actioned February 2009.

Completed audit of Hand washing facilities - Completed Jan 2009 Action Plan agreed following audit and changes to envionment implemented following audit results

Head of Estates / Lead Nurse Practice and Innovation

COI

NMEC

BOARD

R

30/04/2009

31/03/2009


Personal responsibility for compliance with infection control policy and procedures is identified in the job description of all staff who work in clinical areas.

Health Care commision aware that there had between some inconsistencies evident within the scoring which has had the potential to prevent board members getting a ‘true’ picture of the level of risks.

Review of risk register in progress - data cleansing and review of scoring by corporate risk manager

Risk Register changed to inmprove scoring and to reduce inconsistencies

Corporate risk Manager

HCG

CG

RG

EG

G

31/03/2009

31/03/2009




Defined governance and performance outcomes and reporting frameworks are identified at a directorate/divisional level

Plan developed in March 2008 to reduce HCAI’s had not been updated to inform of progress made against the plan.

Action plan to reduce HCAI’s to be updated with progress made against plan – February / March 2009

Action plan - updated and all aspects actioned as appropriate

chief Nurse / Deputy chief Executive / Lead Nurse Practice and Innovation

COI

BOARD

G

31/03/2009

31/03/2009



The Health care commission team were unable to determine who had ownership for the progression of these action plans the three plans are listed below:- 1. An action plan following the SHA celan hospital visit in may 2007, 2. an intial action plan was developed from issuea arising as part of the visit and had continued to be updated An action plan to determine compliance with the 6 recommendations from ‘winning ways ‘ guidelines.

This action plan has been created which addresses not just the points made in the report, but also incorporates the three action plans currently in place so that there is one action plan which schedules a series of measures against the duties of the code. Each item of which has a lead member of senior staff who will take responsibility for compliance against the assurance statement relevant to that specific duty and will monitor progress on a regular basis and identify a timeframe. This action plan can then be “traffic lighted” for continuous performance monitoring at regular in some cases weekly periods thereafter.

Action plans to be reviewed, agreed and action taken

Chief Nurse/ Deputy Chief Executive/ Head of nursing/ Lead / IC&PT

COI

BOARD

G

23/02/2009

23/02/2009





The Trust does not have a designated infection control doctor, but is supported by an antimicrobial pharmacist and a consultant microbiologist.

The Consultant Microbiologist has responsibility for infection control within her job description. The Trust is currently reviewing the provision of infection prevention and control arrangements. A Business Plan has been prepared for the appointment of a second full-time Consultant Microbiologist. This will be approved in the next few weeks as part of the trusts business planning cycle for 2009/10. The current microbiologist will assume the responsibility of Infection control doctor in the interim. Out of hours arrangements and on-call needs will form part of this review in order to ensure that a robust 24/7 consultancy both within hospital & community.

The Trust are satisfied with provison of medical cover within the IP&CT

Medical Director Divisional Chair, Path & Support services DIPC / Chief Nurse / Deputy Chief Executive

ED

COI

A

31/03/2009

31/03/2009





The Trust does not have a designated infection control doctor, but is supported by an antimicrobial pharmacist and a consultant microbiologist.

The nursing element of the Infection Prevention and Control Service is currently under review with the likelihood that the nursing team will be enhanced in both quantity and grade mix. The overall intention is to ensure that the Service has adequate capacity and authority to affect and influence change in the delivery of clinical services in order to continuously improve the quality of practice and clinical outcomes for patients in relation to healthcare associated infection.

The Trust are satisfied with provison of nursing cover within the IP&CT

DIPC / Chief Nurse / Deputy Chief Executive

ED

COI

A

31/03/2009

31/03/2009



There are no electronic systems for surveillience

The Trust is in discussion re the purchase of ICnet and will develop a business plan to obtain an electronic surveillance system by 31/3/09

The Trust has Icnet in place

Lead Nurse IPACs / Lead Nurse Practice and Innovation DIPC / Chief nurse / Deputy chief Executive

COI

A

31/03/2009

31/03/2009




Infection prevention and control l give clinical advise as required

The are no on-call arrangements for the IPAC nurses but they do answer on call requests over week ends on an informal basis. The Consultant Microbiologist also provides cover out of hours but this is not a formal arrangement.

To review the current system of IP&C advise and support out of hours and review on call needs.

IP&CT support and advice ia available out of hours

Medical Director Divisional Chair, Path & Support services DIPC / Chief Nurse / Deputy Chief Executive

ED

COI

A

31/03/2009

31/03/2009


Infection prevention and control is included in the personal appraisal & development plans of all staff

The Infection Prevention and Control team were unable to identify a specific programme of activity of infection prevention and control but made reference to 3 action plans they were working to which wee subject to ongoing review by the team. E learning not used for IC within the Trust

Infection control Nurses and Dipc to agree a programme for Infection control and prevention to include E learning

Infection control Programme in evidence and adequate learning for infection control and prevention are in place

Lead Nurse IPACs and Chief nurse / Deputy chief Executive (Dipc)

COI

G

23/02/2009

23/02/2009



2d 2d. Ensuring that relevant staff, contractors and other persons whose normal duties are directly or indirectly concerned with patient care receive suitable and sufficient training, information and supervision on the measures required to prevent and control risks of infection.

Infection control updates available to all staff

Clinical staff during the inspection indicated that they had not received their mandatory infection control updates due to staffing issues, but indicated that this would be addressed following recruitment into vacant posts.

To ensure all staff attend mandatory annual infection control updates.

Electronic record indicates all staff have attended approriate level of IC training

Director of HR Lead Nurse IPACs DIPC / Chief nurse / Deputy chief executive Lead Nurse practice and Innovation

HR&OD ctee.

COI

R

31/03/2009

31/03/2009


Peat inspections undertaken

Records of audit undertaken in June 2008 on MAU – areas for action identified, but detail was not included of action to be taken. Flooring in Mau very worn and in a poor state, identified in IPAC environmental audit, but unclear re: action taken.

Head of Nursing for emergency care and access to ensure flooring in MAU replaced.

Flooring in MAU is fit for purpose

Head of Nursing - emergecny care and access

EMERG

CARE DIV.

COI

G

31/03/2009

11/03/2009




During observation the Health Care Commission saw information on display in a cleaning room with out of date, information of cleaning procedures and colour coding was not consistent with the standards required for current practice.

All areas to ensure current information re cleaning and colour coding is up to date.

All areas display correct cleaning information and colour coding system

Head of Hotel services Heads of Nursing/ Lead nurses Lead Nurse IPACs

EG

NMEC

G

31/03/2009

16/03/2009


Infection control updates avaialbe to all staff

At the time of inspection (December 2009) 559 of 2374 staff has received their mandatory training leaving a significant number of staff to receive their mandatory infection control training between December 2008 – March 2009. The Trust could not provide evidence that there was sufficient capacity within the IP&C team to deliver within the dates provided.

To review current system of mandatory infection control updates with IP&C team and Dipc and to review the use of e-learning. Implement a training programme which ensures that sufficient time is made available to ensure that all staff receive suitable and sufficient training on infection prevention & control each year.

Robust infection control programme in place

Lead Nurse IPACs and Chief nurse / Deputy chief Executive (Dipc) Director of HR

COI

HR&OD ctee.

R

31/03/2009

31/03/2009



2e 2e. A programme of audit to ensure that key policies and practices are being implemented appropriately.

Directorates review the results of compliance audits, and incorporate these into their plans for continuing improvement.

The Trust has an annual programe for audit. However ther was insufficient evidence to show that there are systems to ensure that appropriate action is taken by the Trust in response to audit outcomes. This is in addition to a Trust-wide programme of audit which is managed by the Clinical Audit department to ensure that key policies and practices are being implemented appropriately. The audit framework for the plan details responsibilities and highlights area for continuous review on the basis of Patient Safety Incidents, National Guidance and individual service priorities.

All Infection Prevention and Control policies and procedures have been inventorised indicating their scheduled dates for review. A programme of review and development has been put in place to ensure that all policies are current and represent a contemporaneous authoritative set of guidances based upon current evidence. This is also appended. Action is taken following audit outcomes which demonstrates - through an evidence trail - that actions identified are monitored through to completion. All Heads of Nursing to ensure that all audits are actioned and action plan sent to them for personal review. The forward plan is managed by the Clinical Audit department in close liaison with Associate Chief Nurses, Clinical Governance Leads and individual Clinician Managers.

Action plans produced at the end of all audits An evidence trail demonstrates that actions identified are monitored through to completion.

Lead Nurse IPACs DIPC / Chief nurse / Deputy chief Executive Heads of Nursing Lead Nurses

COI

NMEC

G

09/02/2009

09/02/2009



During observation the Health care observed some non-compliance with Trust’s policies and procedures.

All ward managers to ensure compliance with policies and procedures.

Evidence of compliance with all policies and procedures evident

Heads of Nursing/ Lead nurses

EMERG

CARE DIV.

SURG. DIV. W&C DIV.

NMEC COI

G

28/02/2009

28/02/2009





One area identified as having as 2 or more incidences of clostridium difficile from August to December 2008, and although the Trust’s definition of an outbreak indicated that these cases constituted an outbreak, the Health Care Commission could not find any evidence that this was treated as an outbreak in accordance with the policy.

Full review of cluster of Clostridium difficile in specific clinical area reviewed January 23rd 2009 and review of nursing practice to be undertaken in April 2009. see point 2c

Reports from both reviews sent to the Board and action plans developed.

Lead Nurse IPACs Lead Nurse, Innovation & Practice DIPC / Chief nurse / Deputy chief Executive

COI

EMERG.

CARE DIV.

NMEC

BOAR

D

A

30/04/2009

07/03/2009



Audit of isolation policy undertaken September 2007 indicated compliance at 58% - no evidence of action taken as a result of these findings.

To undertake a repeat audit of compliance with isolation policy and action findings.

completed audit of complaince with isolation policy

Lead Nurse IPACs COI

A

09/03/2009

9/3//09

4a 4a. There are policies for the environment which make provision for liaison between the members of any infection control team (“the ICT”) and the persons with overall responsibility for facilities management.

ICT & Estates policies for the environment which make provision for liaison between the members of any infection control team (“the ICT”) and the persons with overall responsibility for facilities management.

Backlog of maintenance identified – priority of works determined as part of a risk assessment undertaken by the estates department and had not included the IP&C team.

Policies for the environment, which make provision for liaison between members of the Infection Prevention and Control Service and persons with overall responsibility for Facilities Management, are in place. These relate both to cleanliness, cleaning of medical equipment and provision of advice and support both in relation to education of all members of staff, but also specifically outbreak control. Maintenance programme to re viewed and to include IP&C team when review priority of work in relation to infection control issues.

all maintainence undertaken is referred to the IP&CT for advice re priority with regards to infection control issues

Head of Facilities / Lead Nurse IPACs

EG

COI

A

28/02/2009

28/02/2009



4a 4a. There are policies for the environment which make provision for liaison between the members of any infection control team (“the ICT”) and the persons with overall responsibility for facilities management.

All wards & dept.s clean, tidy & fit for purpose with adequate storage, decontaminated equipment & safe working environment

Several areas observed to have overflowing linen and stacked linen awaiting collection.

Hotel services to review current system for the collation of used linen to prevent the build up of used line awaiting collection.

Soiled linen collected in a timely manner

Head of Facilities / IP&CT

EG

RR

28/02/2009

28/02/2009

4c 4c. All parts of the premises in which it provides health care are suitable for the purpose, are kept clean and are maintained in good physical repair and condition.


Trust has failed to demonstrate that it has made provision within it's envionmental policies for liaison between members of IPACs and the person with overall responsibilty for facilities management

Create envionmental policies for liaison between members of IPACs and the person with overall responsibilty for facilities management Create structures, commitees and governance arrangments which formalise the relationship, provide mechanisms for monitoring and feedback and demonstrates liaison between IPACs and Facilities management, e.g. Basic care services - Catering, Housekeeping, Estates, Nursing - addressing environmental, nutrition, cleanliness and IP&C issues of common concern

Policies for liaison between members of IPACs and the person with overall responsibilty for facilities management created. Regular meetings to review estate plans. New structures, commitees and governance arrangements formalise the relationship, provide mechanisms for monitoring and feedback and demonstrates liaison between IPACs and Facilities management, e.g. Basic care services - Catering, Housekeeping, Estates, Nursing - addressing environmental, nutrition, cleanliness and IP&C issues

Head of Facilities Lead Nurse, Practice innovation Lead Nurse, IPACs

EG

COI

G

30/04/2009

10/03/2009





Business case put forward for increased cleaning in the afternoon and for additional high dusting some confusion of where in the business case process this was.

Business case for afternoon cleaning and high dusting has now been has now been agreed.

Rota of staff available to clean durign outbreaks and system for high dusting devised

Head of Facilities EG

G

28/02/2009

28/02/2009


The estates strategy includes an agreed and resourced programme for PPM.

Backlog of maintenance work due to financial constraints plan to paint 4 wards per year on hold at present time.

Review of timescales for maintenance progamme - Trust Board to consider costs involved.

Maintaince throughout the hospital is to a good standard

Director of Performance & Informatics Head of Estates Chief Excutive Director of Finance

EG

RR

30/04/2009

310/4/09



4e 4e. There is adequate provision of suitable hand wash facilities and antibacterial hand rubs.

Hand hygiene facilities are available at the point of care.

No hand wash basins accessible to the end bay in 3 of the wards visited / no hand washing facilities in the cleaners room in one ward/ access to hand basin blocked in one ward by waste bins.

The Trust will, during the course of the next month, review the numbers of hand wash basins within the Trust, consider the lay-out of toilets, bathrooms and sinks during the review of clinical areas in line with the Department of Health’s ‘Eliminating mixed sex wards’ directive of 28th January 2009. There are presently specific issues in the end bay in three of the wards visited and these have been prioritised for estates refurbishment in the first quarter of the next financial year, in order to ensure that every member of staff has access to hand hygiene facilities within their clinical place of work. Waste bins which obstruct access to hand wash basins have been removed and placed in alternative locations.

Sinks available outside all bays

Head of Estates Lead Nurse, Pracitce & Innovation DIPC / Chief Nurse / Deputy Chief Executive

EG

COI

NMEC

R

01/06/2009

01/06/2009



Programme for grouting around sinks had been deferred.

To review the programme for grouting within bathrooms.

Grouting in bathrooms to a good standard

Head of Estates EG

R

31/05/2009

31/03/2009



The Trust had not undertaken an audit of hand-washing facilities to assess the needs of the service.

Audit of hand washing facilities undertaken in January 2009 and will be actioned in February 2009.

audit of Hand Washing facilties undertaken and changes made in accordance with this

Chief Nurse / Deputy chief Executive ( Dipc) - Lead nurse Practice and Innovation

EG

COI A

31/03/2009

31/03/2009




Audit of hand hygiene compliance meets agreed locally defined compliance rates, and are monitored and reported by directorates/divisions.

IP&C team and Estates indicated that the Trust is not compliant with standards for the provision of hand washing facilities, although no risk assessment had been done to demonstrate this

Risk assessment to be undertaken of hand-washing facilities within the Trust.

Audit of Hand Washing facilties undertaken and changes made in accordance with this as above see above

Chief Nurse / Deputy chief Executive ( Dipc) - Lead nurse Practice and Innovation

EG COI

A

31/03/2009

31/03/2009

4f 4f. The Trust must ensure that there is effective arrangements for appropriate decontaimnation of equipment4f. The Trust must ensure that there is effective arrangements for appropriate decontamination of equipment

Annual mattress audit Mattresses not unzipped and checked after use – during observation mattresses unzipped and found to be contaminated – ward manager said that it is not usual practice to unzip mattresses and to check of internal foam. - mattress removed and destroyed on day of inspection - full mattress inpesction audit carried out of all mattresses in the Trust on 5/2/09 and action plan agreed. Policy for the cleaning of mattresses devised and ratifed 5/2/09

Audit of all mattresses undertaken 4/5th Feb and arrangments made to replace any mattresses that fail inspection. Each Matron has been trained in the Mount Vernon mattress inspection technique and this has been cascaded to shift leaders and all registered nurses. This included the ‘fist’ method to measure the rebound capacity of the mattress itself, the integrity of the cover, the zip and the status of the foam. All covers were removed and the foam exposed to visual inspection. Every mattress was inspected and all those found to be defective have been scheduled for immediate replacement. We are in discussion with the manufacturers to replace all of these mattresses in the next week or so under the terms of the lease agreement and additional capital has been put aside to ensure that every mattress is fit for purpose. The buffer store arrangements are being reviewed so that nursing staff can access available or replacement mattresses instantly they detect a fault.

Audit results of all mattresses within Trust / policy for the cleaning of mattresses

Lead Nurse, Tissue viabilty Lead Nurse, Pracitce & Innovation DIPC / Chief Nurse / Deputy Chief Executive

BEDS &

MATTRS GP

NMEC

COI

DECONTAM CTEE.

A

30/04/2008

31/03/2009



A new Mattress Policy has been established to ensure that mattresses are continuously inspected using the Mount Vernon method, both between patients and on a regular basis. This is validated by a six monthly mattress audit undertaken by the Tissue Viability, Back Care and Infection Prevention and Control Service.

4f 4f. The Trust must ensure that there is effective arrangements for appropriate decontaimnation of equipment4f. The Trust must ensure that there is effective arrangements for appropriate decontamination of equipment

All medical equipment has procedures for cleaning after use

The trust does not have a separate decontamination group

To formulate a separate decontamination group

Trust has a separate decontamination group

Director of Operations Director of Performance & Informatics DIPC / Chief Nurse / Deputy Chief Executive

DECONTAM. CTEE.

R

15/03/2009

15/03/2009



4f 4f. The Trust must ensure that there is effective arrangements for appropriate decontamination of equipment

All medical equipment has procedures for cleaning / discarding after use after use

Issues with potential reuse of single use items e.g sterile scissors

Devised policies and procedures to ensure that all re useable equipment is decontaimnated after use and can be evidenced as such by any user, All equipment is examined before patient use, any condemned equipment is clearly labelled, removed from use and disposed of, all equipment for single item use are discarded after use

All re useable equipment is decontaimnated after use and can be evidenced as such by any user, All equipment is examined before patient use, any condemned equipment is clearly labelled, removed from use and disposed of, all equipment for single item use are discarded after use

DIPC / Chief Executive / Deputy Chief Executive Lead Nurse IPACs, Lead Nurse, Practice & Innovation Lead Nurse, Tissue viability Heads of Nursing/ Lead nurses Director of Operations Director of Performance & Informatics Divisional manager, Surgery Asst Director of Governance

DECONTAM. CTEE.

COI

R

01/04/2009

01/04/2009

4f 4f. The Trust must ensure that there is effective arrangements for appropriate decontamination of equipment

Trust instructions on the use of chlorine releasing substances

Chlorine releasing solution made up for the cleaning of commodes but not labeled and dated with time solution made.

All staff to use chlorine releasing soluiton in line with manufacturers guidance

Chlorine releasing soluion used correctly at all times

Heads of nursing Lead Nurse, IPAcs

EG

G

09/02/2009

0/02/09

8a 8a. Definition An NHS body/Health Care provider providing in-patient care must ensure that it is able to provide or secure the provision of adequate isolation facilities for patients sufficient to prevent or minimise the spread of HCAI.

The infection control team are integral to the planning of facilities including the provision of isolation facilities

Doors left open within the isolation unit – due to patient safety issues.

All clinical staff reminded of infection control isolation procedures and to undertake a risk assessment if this has to be done.

Staff comply with isolation policy

Heads of nursing/ Lead nurses

COI

G

09/02/2009

09/02/2009



8a 8a. Definition An NHS body/Health Care provider providing in-patient care must ensure that it is able to provide or secure the provision of adequate isolation facilities for patients sufficient to prevent or minimise the spread of HCAI.

There is a policy based on a local risk assessment which addreses the need for isolation and defines the criteria for isolating / cohorting patients. The policy identifies resources for implementation and the mechanisms for monitoring compliance across all relevant wards/department/clinical areas

Some ward areas that are accessed by a central corridor to two wards with no door separating each ward.- business cases developed for this due to fire safety issues rather than infection control.

·To instigate the fixation of doors to the clinical ward areas

All ward areas have doors at end of ward and between the neighbouring wards

Head of Estates Director of Operations DIPC / Chief Nurse / Deputy Chief Executive

EG

G

31/03/2009

31/03/2009

10j 10j. Antimicrobial prescribing.

Policy implementation & application is monitored via the organisations Clinical Governance system.

There is no system to verify that junior doctors receive a copy of the antibiotic g guidelines on induction.

Signature list of doctors who have received antibiotics guidelines to be held by post graduate department.

Evidence of antibiotic guidelines being given to doctors

Infection control Dr. Medical Director Lead Nurse IPACs

COI

G

06/04/2009

06/04/2009



Appendix 1a: Oxborough Action plan ( as at June 1, 2009)

No. Issue / Key findings Action Measurable Outcomes Accountability / Responsibility Status Time Frame Evaluation

Lynn Roberts – Lead Nurse IP&C and

c.diff policy clearly identifies the criteria

Lynne Roberts

C. diff policy revised and will be sent to the IC subcommittee on 21

april 2009 Prof Liebowitz to discuss required changes to C diff policy and change accordingly. for decision to declare an

outbreak

Lead Nurse – IP&C

A

1 The Trust’s policy for the management of patients with C. difficile gives no indication of objective criteria for declaring an outbreak leading to inconsistency of approach.

Lyn Liebowitz – Consultant Microbiologist

Complete by 28th February 2009

c. diff policy amended to meet this

Lynne Roberts

requirement

Lead Nurse – IP&C

agreed if a cluster is identified the bay will be cleaned - led by the IP&C team - see above time of polciy changes

to be agreed

Lyn Liebowitz – Consultant Microbiologist

A

2 Only the bed space is cleaned when a symptomatic patient is transferred from a shared bay. There is no explicit cleaning activity identified in the policy on transfer of a symptomatic patient. There is no link to the trusts cleaning policy in the C.difficile management policy although there is mention of the disinfection policy.

Lynn Roberts – Lead Nurse IP&C and Prof Liebowitz and Hotel Services manager to discuss required changes to C. diff policy and change accordingly

Angela Hircock – Hotel Services Manager

Complete by28th February 2009

Lack of clarity and consistency on the definition of an ‘outbreak’

Trust to review the purchase of electronic surveillance

c. diff policy amended to reflect

Noel Scanlon – Deputy CEO / Chief nurse

3

Chief Nurse Letter ‘ an outbreak is two or more patients on the same ward

Meeting with ICnet on 23rd February 2009

consistency of definations of an

Val Newton

Decision made to purchase electronic surveillance system by 31st March 2009 policy amended -

awaiting review at sub committee see above



Trusts Policy for the Management of patients with C.diffiicle definition of an outbreak 6.1 ‘ a risk assessment is required when the number of C.difficile cases on a ward exceeds three patients, or when the cases of C.difficile are not related to antimicrobial therapy

Final decision to be made by Trust Board re ; purchase and then business case to be developed

outbreak or cluster

Lynne Roberts

A

No ‘real time‘ trend analysis

Lyn Liebowitz, Graham Rogerson

The four cases were subject to review using the trusts C.difficile data collection sheet but were not subject to a full root cause analysis. There was no evidence of a robust report to the Board or of Board knowledge of the event.

New reporting system commenced to the Board in January 2009 – includes a break down of incidences of C.diff to ward level to allow the identification of trends and inclusive of hand hygiene audit results.

Noel Scanlon – Deputy CEO / chief nurse

G

New reporting system commenced in January 2009

Chief Nurse to discuss use of audit tool all CAI & HAI c diff cases with IP&C - to trial from 1st

may 2009

4

Evidence of robust reviews provides evidence of and information for organisational learning and action planning.

To consider: reviewing all Clostridium difficile cases are at a monthly RCA meeting with expert clinical clinician input. – to check with Chief nurse / Dipc

Lynne Roberts

Decision re ; review of all C diff cases by March 31 2009

When a cluster is identified the following to be undertaken:

ribotyping will be undertaken in


IPAc service and Prof Liebowitz and chief

nurse agreed to work within definition by the

DH

Formal meeting is called with Lyn Liebowitz – Consultant Microbiologist

accordance with DH guidleines

Lynne Roberts

G

5 The Trust needs to agree with clinicians when ribotyping will be undertaken for C.difficile cases. Other trusts in the region do ribotype clusters of cases as part of their C.diffiicile management strategy. In the absence of ribotyping confirmation of an outbreak will always be subjective.

Deputy Chief Executive / Chief Nurse ( Dipc) and relevant Consultants and minutes taken of decisions made whether to send specimens for ribotyping and decisions actioned

Lyn Liebowitz, Graham Rogerson, Designated consultant physician / surgeon

February 2009 and ongoing

6 No evidence of an assurance process at all levels of the organisation that monitors compliance with all high impact interventions including hand hygiene.

Heads of Nursing / midwifery / Lead Nurses to take responsibility for ensuring compliance and to ensure following audits, action is taken to address any issues and to communicate this formally to the IP&CT

Heads of Nursing / Midwifery

A

28th February and ongoing HON to devise audit

and to action feedback in reponse monthly HII



Lead Nurses

Emergency Division - All action plans uploaded

onto shared intranet file and reviewed by HON . Formal meeting with Lead Nurse to review

plans.


Lead Nurses G

7 Poor documentation of bowel management history and the use of the Bristol stool chart.

All nursing staff to ensure all documentation re : bowel function is completed using Bristol Stool Chart

28th February and ongoing

Noel Scanlon – Deputy CEO / chief nurse G

Lynne Roberts



8 Absence of organisational learning at a clinical and strategic level from the actions taken in response to the cluster of cases.

All cluster cases to be formally investigated and action plans developed and results taken to Trust Board and action plans implemented Trust wide

Lead Nurses

28th February 2009 and ongoing

The ICT collates data monthly and so this cluster was not given the importance that it required as all cases were identified with 2 weeks of each other. This meant that the overlap of cases in time and place was identified by Dr Siva as the lead consultant for the Isolation unit.

Trust to review the purchase of electronic surveillance

surveilliance system in place to identify


Icnet infromation reviewed by mike west 6/ 4/09 - business case in progress interface issues

clinisys/ ICNet / Isoft / Anglia unclear for

further review VN 19.5.09: Business

Case for ICNet completed and sent to

Deputy CEO / chief Nurse 18/5/09 - await

approval

9

Meeting with ICnet Feb 09

information using real time data

Lynne Roberts

R

31st March 2009 and ongoing



The infection control team have no data analyst support neither is there an electronic reporting system in the trust.

Final decision to be made by Trust Board re ; purchase and then business case to be developed


Scope revised PAS interface deerred

Buisiness case now developed - to be taken

to Board 27/5/09

To review the data analyst support required to ensure secure surveillance and allocate appropriate resources to maintain good practice.

complaince with audit and improved


G

a working partly has been convened to review HII , first meeting 17 /4/09

audit results

Lynne Roberts

Lead Nurse – IP&C

10 1. High impact interventions are implemented on a 3 month rolling programme irrespective of high risk areas.

Chief nurse / Dipc to review frequency of the all High Impact Interventions and especially HII – 7 C.diff

Lyn Liebowitz –

31st March 2009 and ongoing

11 During Verbal feedback of the review it was commented on that cleaning reports not given to the Board

Deputy Chief Executive Chief Nurse / Dipc to review whether cleaning reports are required to go to the Board or if this is to be actioned by Heads of Nursing / midwifery / lead nurses

Noel Scanlon – Deputy CEO / Chief nurse

A

31st March 2009

Cleaning reports to come to COI meetings VN 19.5.09: Cleaning

reports to be discussed at the Essential Care Services meeting ( bi

monthly)

11

Nursing staff shortage

review current nursing establishment. identify shortfalls in staffing. vacancies to be advertised promptly. check off duty rota for study leave and annual leave levels . External reviewer to bencharck staffing levels/skill mix

daily check on staffing numbers on ward. Staffing levels/skill mix comparable to benchmarked wards

CN Pover, Acting Lead Nurse Jerry Green & Associate Chief Nurse Marion Collict G

01/03/2009 External review has now taken place and confirmed poor skill mix. New Ward Sister is reviewing rostering guidelines to ensure compliance with Trust policy.. Delays removed from recruitment process.

12

cluster of C.Diff patients identified by HCC

Monitor compliance with Infection Control Practices. Audits will be done by a member of staf form another ward. External rewiewer will observe and assess all aspects of infection prevention and control practice.

Full compliance with Infection Prevention and control policy and procedures. No further cluster/outbreak of C.Diff,

CN Pover, SR Apolarino & CN Tracey and ward medical teams. Lead Nurse. Associate Chief Nurse

G

Discussion and agreement for cross auditing has taken place. Lead Nurse to review compliance.



13 Junior Doctors to review patient’s blood results/complete TTO’s and discharge letters in timely manner, not at last minute.

Consultants to inform own team of this requirement, ward nursing staff to remind Doctors of their duties.

CN Pover, SR Apolarino & CN Tracey and ward medical teams

A

01/07/2009 New Ward Sister will monitor this and liaise with appropriate consultants if problems continue.

14 Ward Round -nursing staff to be identified to attend round

nursing staff to be identified on daily allocation sheets for ward rounds Staff breaks to be arranged around ward round times.Review shift pattern to allow for more staff continuity and improved communication on ward rounds. Shift leader to attend ward round if necessary. Brief nursing staff of the impostance of attendance on ward round. External reviewer to observe and inform on any communication issues impacting on service delivery.

Consultants and registrars on ward rounds feedback on improved information from staff.

CN Pover, Acting Lead Nurse Jerry Green & Associate Chief Nurse Marion Collict

A

01/07/2009 New Ward Sister is carrying out a full review of the current ward round practice to ensure there is no lap over of rounds and that there are sufficient staff to take part in the rounds.

15 staff are frequently moved to cover other wards leaving reduced levels on Oxborough .

the staff moves required to other wards are noted and reported to Marion Collict and Jerry Green. The effect of any period of "no staff moves" to be noted

reduction in the number of staff moved from Oxborough to elsewhere

Acting Lead Nurse Jerry Green & Associate Chief Nurse Marion Collict G

01/04/2009 Moves from Oxborough ward do not occurr any more frequently than any other ward. Staff are only moved following a risk assessmetn by the Bleep holder.

16 Incomplete nursing documentation especially stool charts.

new nurses handover sheet has been developed by Band 6 SR. To be checked by Senior CN then shared amongst staff for use. Review of compliance with documentation by Lead Nurse. External reviewer to audit compliance.

Compliance with nursing documentation standards. Reduction in incidents of missed care/medication, increased planning and awareness of patient needs

CN Pover, SR Apolarino & CN Tracey

A

01/07/2009 New Ward Ssiter has identified communication gaps and has met with HoN to discuss ways of improving this.

17 Ward meetings not attended by medical staff

planned dates to be shared with medical teams to ensure attendance

medical attendance at every ward meeting

CN Pover, Acting Lead Nurse Jerry Green & Ward Consultants. G

dates already set on year planner

Dates planned and medical staff are invited to attend.

18 Ward environment cluttered and in need of re-organising

New ward clerk area identified. New workstation and storage ordered. Second sluice to be installed.Long term plan for introduction of Productive ward on Oxborough.

Nurses station and work area organised and clutter free,. Productive ward initiative commenced on Oxborough ward.

CN Pover, Acting Lead Nurse Jerry Green & Associate Chief Nurse Marion Collict

A

01/07/2009 environment alterations are in progress. Application for Productive ward has been submitted. Decluttering of the ward has been organised.



19 Volunteers do not have access to mandatory training and are not included in staff MRSA screening.

Volunteer Manager to be contacted and level of training and update records confirmed.

All volunteers will take part in relevant mandatory training including infection prevention and control.

Marion Collict. Fran Monson

A

30/06/2009

20 Peer audit of High Impact Interventions Work with IPCN to set a programme of peer audit.

Monthly audits are undertaken by peers and completed in the specified time frame.

Associate Chief Nurses, Lead Nurses, Ward Sisters/Charge Nurses

A

30/06/2009

21 Inappropriate storage of Necton Cleaning trolley

Provide an alternative storage location for Necton cleaning trolley

Necton Cleaning trolley will be stored in an appropriate location within or in the immediate vicinity of the ward.

Marion Collict, Lead Nurse for Medicine, Estates Department. R

30/08/2009

22 There is no consistant approach to the monitoring of attendance at Mandatory Training.

Attendance at Mandatory Training monitoring to form part of performance meeting with senior nurses. Non attendance at mandatory training to be fed back to Associate Chief Nurses and Lead Nurses for follow up.

A robust system of monitoring mandatory training is in place.

Chief Nurse, Associate Chief Nurses, Lead Nurse. Ward Sister/Charge Nurses

R

30/08/2009

23 There is no system in place for the recording of decontamination of equipment between patient use.

All equipment is decontaminated between patients and can be evidenced.


R

30/08/2009

24 Poor documentation of HII in patient records by nursing and medical staff.

Associate Chief Nurses with Lead Nurses to develop a documentation audit programme that includes HII and all other aspects of dcoumentation

Full compliance with agreed documentation standards.


R

31/09/09

25 Ward establishments are under resourced and skill mix does not meet nation benchmarks

Full review of skill mix and staffing levels on both wards. Agree minimum staffing levels and escaltion plan when staffing levels fall below minimum agreed levels

Skill mix is in line with national benchmarks and each ward has agreed minimum staffing levels.

Associate Chief Nurse, Emergency Division, Lead Nurse, Medicine.

A

30/09/2009

26 Non compliance with Isolation policy - Isolation side room doors are not closed.

AssociateChief Nurse to meet with Ward Sisters/ Charge Nurses to re-enforce the need to adhere to this policy and to complete a risk assessment if not able to comply.

Patients requiring isolation are nursed in side rooms with the door closed.

Lead Nurses, Ward Sisters/Charge Nurses

A

30/06/2009

27 Ward environment is not suitable for the preparation of injections.

Provide a clinical preperation room/area on Oxborough Ward

Injections and Infusions are prepared in an appropriate area.

Associate Chief Nurse Emergency Division, Lead Nurse, Medicine, Estates Department

R

30/09/2009



28 There is no appropriate cleaning facitity in the ward kitchens to clean water jugs.

Review current practice with Hotel Services, IPCN's and consider installation of dish washers in ward pantry or the purchase of sufficient jugs and beakers to allow for them to be returned to the main kitchen for cleaning.

Water jugs and beakers are cleaned in accordance with cleaning regulations.

Angela Hircock – Hotel Services Manager, IPCN's

R

30/06/2009

29 Side rooms do not have en-suite facilities Any refurbishment of wards to consider the installation of en-suite facilities to side rooms

All side rooms used for isolation purposes have en-suite facilities

Chief Nurse, Estates Manager R

30/06/2009

30 The current standards for rostering does not identify skill mix and does not include adequate study leave allowance to cover mandatory training.

Develop a rostering policy that identifies competencies required for shifts and also revisit current study leave allowance in ward establishments

A Rostering policy is available that identifies skill kmix and leave allowance.

Chief Nurse, Associate Chief Nurses, Lead Nurse. R

30/08/2009

31 Fall risk, nutrition risk, hydration and safeguarding issues were not receiving such a high profile as may be expected on care of the elderly wards.

The role of the Lead Nurse for Older People should be to support and develop the ward staff to deliver the most appropriate care for older people in conjunction with the practice development team. A review of the role is required to enhance the knowledge and skills of the staff at ward level as outlined in the job description.

The Lead Nurse for Older People is recognised as a key person in the monitoring and development of practice in regards to falls, nutrition, hydration and safeguarding on Older People.

Associate Chief Nurse Emergency Division, Lead Nurse for Older People.

A

31/07/2009

32 Ward staff on Oxborough ward do not feel valued and often feel that they are viewed as a failing ward by other wards and management.

Associate Chief Nurse to set up team building exercises/time out for the staff to engage with the new sister and recognise that the organisation does value them.

Staff demonstrate a sense of being valued. The new Ward Sister has the full engagement of her staff.

Chief Nurse, Associate Chief Nurses, Lead Nurse. R

31/07/2009



Appendix 2: Statistical process control chart MRSA & C Diff incidence v. institution of control measures

MRSA Bacteraemia QEHKL

0

2

4

6

8

10

12

14

16

18

20

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3

2004 2005 2006 2007 2008 2009

Alcohol Gel Antibiotic

Guidance Hand Hygiene Audits

VIP scoringAudits Antibiotic

Audits



C.difficile QEHKL

0

20

40

60

80

100

120

140

160

180

200

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3

2004 2005 2006 2007 2008 2009

Change in antibiotic guidelines and

Opening of Isolation ward

Conclusion

Performance The incidence of MRSA bacteraemia in year 2007/08 was 8 cases against a trajectory of 12 – static performance following a 67% reduction in the MRSA bacteraemia rate between 2004/5 and 2007/08.

The Trust recorded 68 cases of Clostridium difficile in the 2008/9 following 12 consecutive months of under trajectory performance. In all there was a 58% reduction on performance between the years 2007/8 and 2008/9.

The Infection Control Committee, Clinical Governance Committee, Health care governance Committee and Board itself monitors this performance on a monthly basis as well as reviewing the outcomes of root cause analyses for MRSA bacteraemia and audits of all Clostridium difficile cases not just those that relate to colectomies, intensive care admissions and deaths. Monthly monitoring of compliance rates against the care bundles based on Department of Health High Impact interventions are also reviewed at each of these meetings.

Quarterly compliance against these measures have shown dramatic improvements:

• MRSA screening rates across the Trust have improved from 58% to 82% in the fourth quarter.

• Hand Hygiene compliance achieved a mean of 91% across the year which is a 15% increase on the year 2007/2008. The monitoring of patient environment and clinical safety through cleanliness, environment, and sharp safety tools in the fourth quarter has improved from 96% to 98%.

• The Surgical site infection care bundle has shown improvements in compliance across every ward and theatre environment from 85% to 100%.

• The Urinary catheter care bundle had levels of improvement from 95% to 99%.

• The central venous catheter care bundle, has yielded compliance rates through quarterly monitoring from 96% in the first quarter to 86% in the fourth.

• The care bundle for ventilated patients (prevention of ventilator associated pneumonia) has very high rates of compliance which have now been monitored less stringently at between 98% and 97% in the final quarter of the year.

• Compliance with the Peripheral line care bundle has varied between 90% and 95%.

• The weekly monitoring of sharp incident reports have shown between 6 and 9 cases per month, with a peak during the winter months, whilst at the same time the proportion of very low incidents by grade has increased and no high risk incidents have occurred since April 2008.

Patient environment and control measures Reference to this statistical process control chart for MRSA bacteraemia and Clostridium-difficile incidence between 2004 and 2008 (see Appendix 2), demonstrates dramatic improvements in these infections brought about through the interventions recommended through previous performance improvements visit and the Trusts own infection control action plans. A review of the staff dress code, the introduction of root cause analysis, progressive refinements in antibiotic policy, audits of hand washing compliance, a public awareness campaign, installation of hand hygiene stations and the opening of the Clostridium difficile isolation ward in February 2008, as well as the introduction of the Clostridium-difficile care bundle and other high impact interventions can clearly be seen to have had a dramatic impact of reducing the incidence of health care associated infections within the Trust.



Root cause analyses and learning In 2008/2009 the Trust had 8 MRSA bacteraemias. The IPACS under took a root cause analysis on each of these cases. The general issues identified on undertaking a RCA on these patients identified poor documentation, firstly of the insertion/removal of the intravenous cannula present in each case and secondly the recording of the Visual Infusion Phlebitis (VIP) scores, which look for the signs of inflammation of the site/s. This had been a general problem for some time.

IPACS instigated the use of 2% Chlorhexidine and 70% Alcohol for the preparation of skin prior to cannulation early 2009. The Trust approved of the change of practice, as this was in line with EPIC 2 Guidelines and Saving Lives (see previous section on 2% Chlorhexidine and 70% Alcohol). However, the last MRSA bacteraemia proved on investigation to be probably avoidable, if the VIP scoring was undertaken regularly and documented. The patient had a cannula or cannulas in situ for two weeks and only one VIP score was documented. A multi disciplinary working party was set up to review the documentation and the use of a cannula pack for venous access. A review of the documentation is hoped to make the documentation for the recording of the VIP scores more easily accessible and clearer. The introduction of a cannula pack will focus the staff cannulating that the process must be undertaken in a clean non touch technique. The Practice Development Nurses have been asked West Anglia College Media department to undertake a media project, and film various aseptic techniques, including a clean non touch technique of cannulation. This DVD will be used to train doctors and nurses.

Root cause analysis for Clostridium Difficile continues to highlight the over use of prolonged courses of broad spectrum antibiotics and the use of proton pump inhibitors as potential contributors to the incidence and spread of this iatrogenic infection. The Trust appointed an antimicrobial pharmacist in 2008, who is working along side our Consultant Microbiologist in reviewing the use of the antimicrobials that select for Clostridium difficile.

The opening of the isolation unit for the management of patients with Clostridium difficile on Stanhoe ward, contributed to the reduction of this infection within the Trust this year. In previous years there had been issues with the non-compliance or delayed isolation of patients in side rooms who had been diagnosed with the infection, causing the potential for spread. Since the opening of the unit, C Diff. patients are transferred within two hours of when the ward is informed.

Governance In the period March – May 2009 the following has been achieved:

• Development of the Infection Control annual programme April 2007-March 2008

• Development of Trust Infection control assurance framework based on compliance against the Code of practice.

• Review of compliance against Code of practice (Trust position statement) and Trust preparation for external visits

• Creation of a Trust HCAI action plan and inclusion of actions identified as a result of HCC inspections and the code of practice review.

• Establishment of monthly Estates planning meetings with IPACs where all new projects must meet IP&C approval

• Establishment of weekly Meetings of IPACs chaired by the DIPC

• Review of ICT structure and resources

Workforce Concerns regarding the less than universal compliance with care bundles for peripheral lines wewre expressed in year. Re-launches are planned with the use of revised audit tools, peripheral line insertion packs and alternative antiseptic devices.



The Lead Nurse Innovation and practice has devised DVDs on aseptic technique, urinary catheterisation, blood culture drawing and peripheral line insertion. These training DVDs were launched for the new intake of house officers in August 2009.

Audit and dissemination The clinical audit programme comprises mandatory infection prevention and control elements.

The Trust’s new patient safety bulletin was launched in May 2009 and a new root cause analysis tool for Clostridium difficile to establish a process similar to the MRSA bacteraemia process for responsible consultants and the infection control doctor was be piloted in April.

The Trust is also participating in the productive ward programme.

Summary In summary, a comprehensive programme of improvements in all aspects of Infection prevention and control have yielded sustained MRSA performance following a 67% reduction in the MRSA bacteraemia rate between 2004/5 and 2007/08; and a 58% reduction in Clostridium difficile incidence between the years 2007/8 and 2008/9.

Following the Health care commission hygiene code inspection the trust has embarked upon a comprehensive and far reaching action plan informed by and structured around the hygiene code.

The trust is confident that as a consequence of all this effort and further hard work ahead that it will achieve less than the 61 case threshold of in hospital Clostridium difficile cases in 2009/10 defined in the operating framework and less than the MRSA target of 7 Bacteraemias in 2009/10.

INFECTION PREVENTION AND CONTROL ANNUAL REPORT 2008-9

Documents