Agenda Item 7.3
CENTRAL MANCHESTER AND MANCHESTER CHILDREN'S
UNIVERSITY HOSPITALS NHS TRUST
Report of:
Paper prepared by:
Date of paper:
Subject:
Purpose of paper:
Director of Patient Services/Chief Nurse/Director of Infection
Prevention & Control
Nurse Consultant Infection Control
30th June 2008
Annual Report of Infection Prevention and Control Team
To inform the Trust Board of the activities and progress of the
infection prevention and control team for 2007/08
EXECUTIVE SUMMARY
2007/08 was an intensive year of action for infection prevention and control within the Trust which
has resulted in significant achievements in meeting performance standards as set out by the
Department of Health, The Health Care Commission and the requirements set out in the Hygiene
Code in the Health Act of 2006.
Key Achievements
The Infection Control Team expanded to meet the demands of the service. The Trust was
successful with a bid to the Commissioners of Manchester PCT for funding to undertake extended
screening for MRSA amongst all elective admissions.
The actual number of incidents of MRSA bacteraemia for the year was 21 against a target of 24.
CMMC was the only acute teaching hospital within the North West Region successful in achieving
fewer incidents of MRSA bacteraemia than the set target. This was attributable to efforts to
improve performance in key clinical procedures, particularly hand hygiene and Aseptic Non-Touch
Technique (ANTT) and a clear accountability process.
Against a background trend of 16% annual increase in the rate of Clostridium difficile (CDT)
diarrhoea in patients over 65 years, the Trust agreed a zero increase for 2007/8 (i.e. 300 cases)
with the Commissioners of Manchester PCT. The actual number of incidents of CDT diarrhoea
was 266. This achievement was facilitated by a revised Antibiotic Prescribing Policy and other
infection preventions/interventions.
The Trust activity was maintained despite a loss of 401 bed days in outbreaks and subsequent
ward closures due to Noro-like virus.
The Cleanyourhands Campaign is now in its third year. Large vibrant coloured mats were
installed at the entrance to all clinical areas to increase awareness of the important of hand
hygiene.
ANTT was implemented for a wide range of clinical procedures across the Trust and has had a
significant impact on rates of infection, particularly due to MRSA bacteraemia. This success was
recognised by the Department of Health ANTT Team and representatives from the Trust were
subsequently invited to address national conferences later this year.
Current arrangements for Sterile Services comply with national guidelines.
1
Agenda Item 7.3
The annual Patient Environment Action Team (PEAT) assessment scores for the environment
were rated good for all sites except MRI and REH where the scores were acceptable. The Trust
also participated in the Deep Clean Initiative during which a range of cleaning tasks and
improvements were undertaken to improve the environment and uphold public confidence
The focus of the Infection Prevention & Control Audit Programmes for this year concentrated on
policies that reduce the risk of infection to patients through direct patient care. These included
monthly audit of hand hygiene practice, ANTT and antibiotic prescribing. The results of these
audits showed an improvement in performance.
The Trust declared compliance with the Health Act 2006, and reviewed its current position in
preparation for the Health Care Commission visit. Following on from the first visit in 2006 the DoH
Review Team re-visited CMMC in October 2007. The DoH team were confident that the Trust
had demonstrated a serious commitment to preventing and controlling HCAI and signed over
monitoring measures to the PCT.
The Trust was also selected to be the Show Case Hospital for the North West Region. This
project is part of the DoH Technology Innovation Programme aimed at reducing Health Care
Associated Infections.
Future Work Programme
The Trust continues to strive towards a zero tolerance for Hospital acquired Infections and has set
out a challenging work programme for 08/09 in the report.
Conclusion
This was a mile-stone year for Infection Prevention & Control activities within CMMC. The Board
is asked to note the report and the work plan for 2008/09.
2
Agenda Item 7.3
CONTENTS
SECTION 1: Executive Summary
5
SECTION 2: Infection Prevention & Control Arrangements
7
2.1 The Director of Infection Prevention & Control
7
2.2 The Infection Prevention & Control Team
7
2.3 The Winning Ways Committee
7
2.4 Infection Prevention & Control Structure Within the Divisions
7
2.5 The Infection Prevention & Control Link Practitioners
SECTION 3: Budget Allocation to Infection Prevention & Control Activities
Error! Bookmark not defined.
Error! Bookmark not defined.
3.1 Funding for Infection Prevention & Control
8
3.2 Extended Screening for MRSA
8
SECTION 4: HEALTHCARE ASSCOCIATED INFECTION
8
4.1 Methicillin Resistant Staphylococcus aureus Bacteraemias
8
4.2 Clostridium difficile Toxin Associated Diarhhoea (CDT)
9
4.3 Glycopeptide (vancomycin) resistant Enterococci (GRE)
10
4.4 Mandatory Surgical Site Infection (SSI) Surveillance for Joint Replacement
11
4.5 Report on a Cluster of Pseudomonas aeruginosa on ICU During November 2007
11
4.6 Report on Outbreak of Respiratory Syncitial Virus (RSV) on the Neonatal Unit December 2007
12
4.8 Outbreaks of Noro-Like Virus (Viral Gastroenteritis)
12
SECTION 5: Hand Hygiene and Aseptic Non Touch Technique
13
5.1 Raising Awareness and Increasing Compliance with Hand Hygiene Policy Across the Trust
13
5.2 Additional Actions Within the Children's Division
13
5.2 Additional Actions Within the Children's Division
13
5.3 Dress Code Policy
13
5.4 Implentation of Aseptic Non Touch Technique
13
5.5 Visit to the Trust by the Department of Health National ANTT Team
14
5.6 Challenges for the Future
14
SECTION 6: Decontamination Services
6.1 Review of Usage of Intubation Equipment (Laryngoscopes)
6.2 Review of Local Re-Processing of Endoscopes
SECTION 7: Cleaning Services
14
14
Error! Bookmark not defined.
Error! Bookmark not defined.
7.1 Current Management Arrangements for Cleaning Services
15
7.2 Transfer of Domestic Services to Sodexho
15
7.3 Annual Patient Environment Assessment Team (PEAT) Assessment 2007/8
15
7.5 Annual PEAT Inspections 2008/9
15
7.6 Deep Clean Initiative
15
3
Agenda Item 7.3
SECTION 8: Audit
16
8.1 Hand Hygiene Frequency Audit
16
8.2 Aseptic Non Touch Technique (ANTT) Audit
16
8.3 Audit of Compliance Rate to ANTT Principles
17
8.4 Audit of Peripheral Cannulae September 2007
17
8.5 Saving Lives High Impact Interventions (HII's)O
17
8.6 Antibiotic Policy / Prescribing Guidelines
18
8.7 Audit of Antibiotic Prescribing Guidelines
18
8.8 Additional Antibiotic Audits
18
8.9 The Infection Control Nurses Association (ICNA) Audit Tool
18
8.10 Trust-Wide Screening Audit
20
SECTION 9: TRAINING ACTIVITIES
20
SECTION 10: TARGETS AND OUTCOMES
21
10.1 The Health Act 2006
21
10.2 The Annual Plan for Infection Prevention & Control
21
10.3 Review by Department of Health Improvement Review Team
21
10.4 Showcase Hospital Project
21
10.5 Trust and TrusTECH Project Group
21
SECTION 11: Conclusion
APPENDICES
Error! Bookmark not defined.
23
Appendix 1: Infection Prevention & Control Organisational Structure
23
Appendix 2: Infection Prevention & Control Team Structure
24
Appendix 3:
25
Appendix 4: Trust Training Figures 2007/2008
30
Appendix 5
31
4
Agenda Item 7.3
EXECUTIVE SUMMARY
This was a very intensive year of action for infection prevention and control within the Trust which
has resulted in significant achievements in meeting performance standards as set out by the
Department of Health, The Health Care Commission and the requirements set out in the Hygiene
Code in the Health Act of 2006.
Key Achievements
The Infection Control Team expanded to meet the demands of the service. The Trust was
successful with a bid to the Commissioners of Manchester PCT for funding to undertake extended
screening for MRSA amongst all elective admissions.
The actual number of incidents of MRSA bacteraemia for the year was 21 against a target of 24.
CMMC was the only acute teaching hospital within the North West Region successful in achieving
fewer incidents of MRSA bacteraemia than the set target. This was attributable to efforts to
improve performance in key clinical procedures, particularly hand hygiene and Aseptic Non-Touch
Technique (ANTT) and a clear accountability process.
Against a background trend of 16% annual increase in the rate of Clostridium difficile (CDT)
diarrhoea in patients over 65 years, the Trust agreed a zero increase for 2007/8 (i.e. 300 cases)
with the Commissioners of Manchester PCT. The actual number of incidents of CDT diarrhoea
was 266. This achievement was facilitated by a revised Antibiotic Prescribing Policy and other
infection preventions/interventions.
The Trust activity was maintained despite a loss of 401 bed days in outbreaks and subsequent
ward closures due to Noro-like virus.
The Cleanyourhands Campaign is now in its third year. Large vibrant coloured mats were
installed at the entrance to all clinical areas to increase awareness of the important of hand
hygiene.
ANTT was implemented for a wide range of clinical procedures across the Trust and has had a
significant impact on rates of infection, particularly due to MRSA bacteraemia. This success was
recognised by the Department of Health ANTT Team and representatives from the Trust were
subsequently invited to address national conferences later this year.
Current arrangements for Sterile Services comply with national guidelines.
The annual Patient Environment Action Team (PEAT) assessment scores for the environment
were rated good for all sites except MRI and REH where the scores were acceptable. The Trust
also participated in the Deep Clean Initiative during which a range of cleaning tasks and
improvements were undertaken to improve the environment and uphold public confidence
The focus of the Infection Prevention & Control Audit Programmes for this year concentrated on
policies that reduce the risk of infection to patients through direct patient care. These included
monthly audit of hand hygiene practice, ANTT and antibiotic prescribing. The results of these
audits showed an improvement in performance.
The Infection Prevention & Control Team delivered training on basic infection prevention & control
at mandatory training sessions. Attendance figures were; corporate mandatory 61% (target 80%):
clinical mandatory 57% (target 80%): corporate induction 85% (target 98%)
5
Agenda Item 7.3
The Trust declared compliance with the Health Act 2006, and reviewed its current position in
preparation for the Health Care Commission visit. Following on from the first visit in 2006 the DoH
Review Team re-visited CMMC in October 2007. The DoH team were confident that the Trust
had demonstrated a serious commitment to preventing and controlling HCAI and signed over
monitoring measures to the PCT.
The Trust was also been selected to be the Show Case Hospital for the North West Region. This
project is part of the DoH Technology Innovation Programme aimed at reducing HCAI rates.
Future Work Programme
The Trust continues to strive towards a zero tolerance for Hospital acquired Infections and has set
out a challenging work programme for 08/09 in the report
Conclusion
The work and commitment from every level of the organisation is demonstrated within this report.
Key factors to our success have been a clear accountability framework, effective leadership,
improvements in clinical practice and performance and a clearer focus on the environment of
care. The prevention and control of infection continues to be a high priority for the Trust and is
core to ensuring public confidence in our services. The Trust has demonstrated a zero tolerance
approach to health care acquired Infections and will continue to work in partnership with
colleagues across the health economy to maximise the health benefit for the communities we
serve. Our challenge is to sustain and improve on, our achievements during 07/08 which is
reflected in the work plan for 08/09
6
Agenda Item 7.3
SECTION 2: INFECTION PREVENTION & CONTROL ARRANGEMENTS
2.1
The Director of Infection Prevention and Control (DIPC)
Mrs Gill Heaton, Director of Patient Services/Chief Nurse is the DIPC for the Trust.
2.2
The Infection Prevention & Control Team
Within the last twelve months there have been changes and additions to enhance and strengthen
the structure of the Infection Prevention & Control Team. The team now comprises of the
following personnel (full time equivalent (FTE) unless otherwise stated):
•
Dr Andrew Dodgson, Microbiologist and Infection Prevention & Control Doctor (Central
Site)
•
Dr Bobby Sanyal, Microbiologist and Infection Prevention & Control Doctor (Children’s
Hospitals)
•
Mrs Julie Cawthorne Nurse Consultant, Infection Prevention & Control
•
Mrs Jo Rothwell, Lead Nurse, Infection Prevention & Control
•
Ms Jo Clubb (0.93 FTE) Infection Prevention & Control Nurse Specialist.
•
Miss Janice Streets Infection Prevention & Control Nurse Specialist.
•
Mrs Michelle Worsley Infection Prevention & Control Nurse Specialist.
•
Mr Federico Tabios Junior (0.6 FTE) Infection Prevention & Control Nurse Specialist
•
Dr Kirsty Dodgson, Clinical Scientist, Microbiology
•
Ms Ann France Secretary
In addition to the above there is funding available to make two further full-time appointments, one
Infection Prevention & Control Nurse Specialist, and a Surveillance Officer.
Once all personnel are in post, the Infection Prevention & Control Nursing Team will review their
working hours per week to include a week-end and evening service.
2.3
The Winning Ways Committee
The Winning Ways Committee is chaired by the DIPC and meets every two months. The
Committee has corporate responsibility for all Infection Prevention & Control issues and
monitoring the implementation of the annual Infection Prevention & Control plan. The Committee
has the following sub-committees:
•
Infection Prevention & Control Expert Group
•
Medical Devices Committee
•
Modern Matron Facilities Committee
•
Medicines Management (Antibiotics) Committee
The Winning ways Committee is to be reviewed and re-named to reflect recent updates that have
occurred within the provision of an infection prevention service. A schematic to describe Infection
Prevention & Control arrangements within the Trust and structure of the Infection Prevention &
Control Team can be found in appendix 1 & 2 respectively..
2.4
Infection Prevention & Control Structure within the Divisions
Each Division addresses Infection Prevention & Control issues either as a standing item on the
Divisional Clinical Governance Meeting or, through a separate Divisional Infection Prevention &
Control Committee/Group.
2.5
The Infection Prevention & Control Link Practitioners (ICLP’s)
There are ICLP’s across all the Divisions within the Trust who act as a conduit from the Infection
Prevention & Control Team to the clinical environment. The ICLP’s receive regular education and
training on issues pertinent to Infection Prevention & Control and in return undertake audits and
local training, for example, hand hygiene in their areas.
7
Agenda Item 7.3
SECTION 3: BUDGET ALLOCATION TO INFECTION PREVENTION & CONTROL
ACTIVITIES
3.1
Funding for Infection Prevention & Control
•
The Infection Prevention & Control Nursing team and the Medical Microbiologists are
funded by the Division of Clinical and Scientific Services.
•
Funding for Microbiology laboratory services (including outbreaks of infection) is covered
by the Service Level Agreement (SLA) between the Trust and the Health Protection
Agency.
•
Funding for outbreaks of infection (excluding laboratory costs) are funded locally by the
Divisions.
•
The Service Level Agreement (SLA) with the Manchester Mental Health and Social Care
Trust (MMH&SC) remains in place. This equates to 0.4 (FTE) Band 7. The SLA includes
all key Infection Prevention & Control activities for services based at the Central site.
•
Internal funding and funding from the former Greater Manchester Strategic Health
Authority was used to install ICNet (electronic Infection Prevention & Control surveillance
database). The annual recurring costs will be met from the Divisions.
3.2
Extended Screening for MRSA
A detailed business case which encapsulated all shortfalls for the Infection Prevention & Control
programme was submitted to the Commissioners of Manchester PCT for 2008/9. This bid has
been part funded and will include resources to undertake extended screening for MRSA amongst
all elective admissions
SECTION 4: HEALTHCARE ASSOCIATED INFECTION
4.1
Methicillin Resistant Staphylococcus aureus Bacteraemias
The Department of Health gave all acute trusts a target to reduce the incidence of MRSA
bacteraemias by 60% over a three year period (April 2005 – March 2008). The annual targets and
actual results for CMMC can be seen below:
MRSA Bacteraemias April 2007 to March 2008
Actual vs Target
30
20
Target
10
Actual
0
Apr- Ma Jun-Jul- Au Se Oct-Nov- De Jan- Fe Ma
Target
2
4
6
8
10 12 14 16 18 20 22 24
Actual
2
6
6
9
11 11 12 13 15 17 19 21
Overview of results of MRSA bacteraemia
Each incident of MRSA bacteraemia is investigated using a Root Cause Analysis (RCA) tool, and
presented to the weekly Infection Prevention & Control meeting, chaired by the DIPC. A summary
of the 21 incidents of MRSA bacteraemia for this year can be found below.
8
Agenda Item 7.3
Incidents of MRSA bacteraemia by speciality in which they occurred
Augmented
care*
General
Medicine
Clinical
Cardiology
Haematology
Paediatrics
Total
Year End
Trajectory
6
8
2
4
21
24
1
* includes High Dependency Units and Renal Medicine
Likely Root Cause of MRSA bacteraemia Incidents
Line
Infection
Contaminated None
unavoidable other
Blood Culture adherence to
policy/procedure
None
found
Total
9
2
2
21
4
1
3
Key factors in the achievement of the Target
The Trust was the only acute teaching hospital within the North West Region successful in
achieving fewer incidents of MRSA bacteraemia than their annual target. This was probably
attributable to improvements in key clinical procedures.
Target for 2008/2009
The target for the next year to reduce the MRSA bacteraemia rate is yet to be agreed. This will
continue to be a real challenge and will require a sustained effort and programme of intervention.
Department of Health Review Team
In November 2007, the Department of Health Cleaner Hospitals Review Team returned to the
Trust to assess progress of implementation of an action plan to reduce the incidents of MRSA
bacteraemia. A summary of their findings can be found in section 10.3
Extended Screening for MRSA
To comply with the Department’s guidelines the Trust will extend its current screening programme
for MRSA to include all elective admissions by March 2009. (see section 3.2 for details of
funding). Most patients will be screened at pre-admission clinics however, there are some inpatient services where this is not applicable. The Trust will need to explore this further with the
PCT.
4.2
Clostridium difficile Toxin Associated Diarrhoea (CDT)
Against a background trend of 16% annual increase in the rate of CDT diarrhoea in patients over
65 years, the Trust agreed with the commissioners of Manchester PCT a zero increase for
2007/08 (i.e. 300 cases) The actual number of incidents of CDT was 266 (see the graph below).
9
Agenda Item 7.3
CDT Trajectory
350
300
CDT numbers
250
200
Target
Actual
150
100
50
0
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Target
25
50
75
100
125
150
175
200
225
250
275
300
Actual
33
62
78
99
120
141
168
181
196
227
241
266
Month
Key factors to reduce the Incidence of CDT
Reducing the incidence of CDT is dependant on controlling the use of antibiotic therapy, reducing
the number of environmental spores by appropriate cleaning of the environment/patient shared
equipment and isolation/cohorting of infected patients.
•
•
•
Following the Department of Health recommendations to limit the prescribing of extended
spectrum cephalosporins and fluoroquinolone antibiotics the guidelines were revised and
updated. These were launched in August 2007. A trust wide audit of the guidelines was
undertaken in December 2007 (see section 8.7 for results)
In line with national recommendations the use of a chlorine based disinfectant for cleaning
patient shared equipment/the environment has been rolled out across all wards that have
a high incidence of CDT diarrhoea amongst patients.
As in other acute hospital services the Trust has a limited number of isolation facilities
(single side rooms), available and competing bed pressures. The Infection Prevention &
Control team have introduced a care pathway for patients who develop diarrhoea due to
known/suspected infection. This tool facilitates prompt implementation of Infection
Prevention & Control measures.
Target for 2008/9
The Department of Health have set a target reduction for all acute Trusts of 30% by March
2011.Continued success will require co-operation from the PCT particularly in relation to antibiotic
prescribing within the community setting.
4.3
Glycopeptide (Vancomycin) resistant Enterococci (GRE)
At present no target has been set in relation to GRE however, the Trust reports all incidents of
GRE bacteraemia to the Health Protection Agency. The total number of incidents for this year was
13, a considerable reduction on the number of incidents from previous years. These incidents
were scattered across the Trust
10
Agenda Item 7.3
GRE Bacteraemias by Division April
2007 to March 2008
10
Total
8
6
4
2
0
Medicine
Surgery
CSS
SMH
GRE Bacteraemias 2003 – 2007
2003-2004
20
20042005
27
2005-2006
2006-2007
49
2007-2008
32
13
4.4
Mandatory Surgical Site Infection (SSI) Surveillance for Joint Replacement
The Trust participated in the above surveillance scheme for knee replacement surgery. Although
participation is mandatory for a minimum of one quarter per year, the Surgical Unit completed
three quarters.
Period
Apr to Jun
Jul to Sep
Oct to Dec
Jan
to
March
Total
Total No. of
records
submitted
(including SSI’s)
63
50
46
N/A
Number of
Surgical site
infections
159
4 (2.5%)
1
0
3
N/A
All four patients with infections reported had satisfactory outcomes.
4.5
Report on a cluster of cases of Pseudomonas aeruginosa on ICU during November
2007
Between 23rd – 28th November Pseudomonas aeruginosa resistant to
meropenem was isolated from six patients on the ICU/CICU. Five of these isolates had the
same/similar sensitivity to antibiotics and one, subsequently discounted as part of the cluster, had
a different sensitivity pattern. Two of the patients in the same cluster died from other causes.
•
The incident was managed according to the Trust Outbreak Policy, actions were
implemented and no further isolates were identified.
11
Agenda Item 7.3
•
Samples were taken from patients and the environment for typing to establish if cross
transmission had occurred. The results identified several different strains of Pseudomonas
aeruginosa. The same strain however, was identified in two patients and another separate
strain was identified from a further two patients and from environmental sites. This
indicated that limited cross infection had occurred though the outbreak was not of the
scale originally anticipated.
4.6
Report on Outbreak of Respiratory Syncitial Virus (RSV) on the Neonatal Unit
December 2007
RSV was detected in a total of 5 babies on the Neonatal Surgical Unit between 5th and 20th
December 2007.
Four babies had either been born in the Trust or admitted to the Trust on the day of birth and one
was transferred to the Trust at three days old. All babies were found to be positive following a
minimum of 19 days in hospital and whilst it was unclear how the index case became infected,
there is some evidence that in the other cases, cross transmission may have occurred.
• The Unit was closed on 5th December 2007
• The outbreak was managed according to the Trust Outbreak Policy
• It was initially decided that the ward remain closed until all babies who were RSV positive
were negative on testing on 2 consecutive days.
• The ward was re-opened on the 20th December when there had been no new cases for
10 days.
• A total of 31 bed days were lost.
4.7
Outbreaks of Noro-Like Virus (Viral Gastroenteritis)
This season the Health Protection Agency reported an increase in the number of Noro- Like virus
cases, almost double the number reported for the same period last year. Below is a summary of
the outbreaks of confirmed/suspected Noro-Like Virus that occurred in CMMC
Ward
Dates of closure
Number of
patients
affected
Number of
staff affected
Bed days
lost
Wrigley
22.10.07 – 28.10.07
24
81
AM4
19.11.07 – 23.11.07
6 (plus 8
relatives)
11
5
21
AM4
07.12.07 – 16.12.07
11
3
38
15
19.12.07 – 30.12.07
11
1
101
33
28.12.07 – 03.01.08
10
6
5
AM1
03.01.08 – 12.01.08
15
0
29
15
07.01.08 – 08.01.08
7
0
2
15
29.01.08 – 05.02.08
9
0
34
Ashby
20.01.08 – 27.01.08
7
9
39
15
22.02.08 – 28.02.08
12
0
31
12
Agenda Item 7.3
15
12.03.08 – 13.03.08
11
0
0
Ashby
18.03.08 – 21.03.08
7 ( plus1
relative)
132 (plus 9)
0
10
49
401
Total
Comments
•
The activity of throughput of patients was maintained despite a total of 12 outbreaks and
subsequent ward closures.
•
There were a number of factors that contributed to the high number of outbreaks that
occurred on ward 15 for example there were limited hand wash facilities, (this issue has
subsequently been addressed with the installation of three additional clinical hand wash
basins to the ward).
SECTION 5: HAND HYGIENE AND ASEPTIC NON TOUCH TECHNIQUE
5.1
•
•
•
Raising Awareness and increasing compliance with Hand Hygiene Policy across the
Trust
The Trust continues to implement the national Cleanyourhands campaign.
Large vibrant coloured mats have been installed at the entrance to all wards and
departments to indicate the location and encourage usage of alcohol hand gel
All clinical areas undertake monthly audits of hand hygiene opportunity and frequency (see
section 8.1).
5.2
•
Additional Actions within the Children’s Division
The Children’s Division have identified Clinical champions for hand hygiene in each of the
Directorates. The Clinical champions are charged with addressing key issues from the
findings of audit from their areas with the ward managers.
•
Scores from the hand hygiene audit have been colour coded red, amber and green. Those
areas who fail to submit or who are red (i.e. less than 75%), are asked by the Clinical
Director for an explanation and action to be taken.
•
There were difficulties associated with the interpretation of the audit tool, as a result the
guidelines for measurement were made more explicit. The new guidelines are currently
being piloted within the Division, and will be rolled out to the rest of the Trust if successful.
5.3
Dress Code Policy
The Trust is currently developing a Trust wide Dress Code Policy that will support the
implementation of ‘Bare Below the Elbows’ in accordance with The Health Act.
5.4
Implementation of Aseptic Non Touch Technique (ANTT)
The foundations for the implementation for ANTT for all invasive procedures began in October
2006. These have included;
•
Developing a range of clinical practice guidelines for key invasive procedures.
•
Individual assessment of staff in each ANTT procedure applicable to their practice.
•
Audit of practice (September 2007 & June 2007 (see section 8.2). Results of audit and
implementation of actions to address areas of non-compliance were fed back to ward
managers. Re-audit is planned for May 2008
•
Trial of trolleys that facilitate compliance with national guidelines for near side disposal of
sharps during ANTT procedure.
13
Agenda Item 7.3
Review of procedure for blood culture sampling (January 2008). This has led to a
reduction in the number of blood cultures that are positive due to contamination (See
graph below).
1200
16
14
1000
12
800
10
600
8
6
400
4
200
2
0
% Contamination
Total peripheral blood
cultures taken in adults
•
Total BCs taken
% Contamination
0
May-08
Feb-08
Nov-07
Aug-07
May-07
Feb-07
Nov-06
Aug-06
May-06
Feb-06
Nov-05
Aug-05
May-05
Month
5.5
Visit to the Trust by the Department of Health National ANTT Team.
Earlier this year the Trust was visited by the above and has subsequently been identified as a
centre of excellence with regard to ANTT procedures. As a consequence, representatives from
the Trust have been invited to present at two separate national conferences to be held in
September 2008.
5.6
•
•
Challenges for the Future
The implementation of ANTT has so far been focused on nursing staff. This year the Trust
will train and assess all new doctors starting in August.
The implementation of ANTT will also be enhanced by an in-house DVD which will support
training.
SECTION 6: DECONTAMINATION SERVICES
•
The Trust appointed Lead for Decontamination is David Pearson, Acting Director for
Clinical and Scientific Services.
•
Re-processing of instruments continues within Decontamination and Sterilization
Department (DSD) at St Mary’s Hospital and Booth Hall Children’s Hospital. Both units are
fully compliant with ISO9001/2000 ENISO 13485.
•
The DSD will be moving to a new purpose built facility in the summer 2008
6.1
Review of Usage of Intubation Equipment (Laryngoscopes)
The Trust is currently reviewing two options with regard to the issue of decontamination of
laryngoscope blades
1. Switch to single patient use.
2. Purchase enough re-useable laryngoscopes to enable instruments to be re-processed
through DSD between each patient use.
A range of trials of disposable largyngoscope blades are currently in progress in key areas.
14
Agenda Item 7.3
SECTION 7: CLEANING SERVICES
7.1
Current management arrangements for Cleaning Services
The Trust directly manages the cleaning services at the Central site.
The domestic services report to the Head of Facilities, who in turn reports direct to the Director of
Nursing (Adults).
The Facilities Directorate is also responsible for the monitoring arrangements.
At the Royal Manchester Children’s Hospital and Booth Hall Children’s Hospital the domestic
services are contracted out to Medirest Compass Group. This service is monitored by the
Facilities Directorate at monthly review meetings.
7.2
Transfer of Domestic Services to Sodexho
In accordance with the PFI contractual term and conditions, domestic services will transfer from
the Trust to Sodexho, as per the project timetable described below;
•
The Domestic Services for MRI, SMH, REH and the Dental Hospital will transfer to
Sodexho during 2008 / 2009.
•
The Domestic Services arrangement for both Children’s sites will transfer to Sodexho
during 2009 / 2010.
There is a range of meetings taking place with Sodexho, involving all key stake holders including
the Infection Prevention & Control team and Matrons, regarding a common contractual
undertaking in regard to provision of service, product approval, work schedules, performance
agreement standards, compliance with standards and Sodexho fault monitoring arrangements.
•
•
•
A Trust Monitoring Team has been agreed and details of the Trust monitoring
arrangements will shortly be confirmed.
A further objective is the production of a Facilities Monthly Assurance Report that would be
available for Trust Committees.
Patient satisfaction surveys will also be undertaken.
7.3
Annual Patient Environment Assessment Team (PEAT) Assessment 2007 / 2008
An annual PEAT Assessment, in compliance with Department of Health requirements was
undertaken in March 2008, for the six hospital sites at Central Manchester and Manchester
Children’s University Hospitals NHS Trust. The assessments on the environment are;
•
Booth Hall - Good
•
Royal Manchester Children’s Hospital - Good
•
St Mary’s - Good
•
Manchester Royal Infirmary and the Royal Eye Hospital - Acceptable.
7.4
Hospital Standard Assessments (Mini PEAT)
The Modern Matrons undertake a quarterly Hospital Standards Assessment Any area generating
an unsatisfactory outcome now automatically generates a performance management corrective
action plan.
7.5
Annual PEAT Inspections 2008 / 2009.
In addition to replicating the 2007 / 2008 PEAT Audits, it is proposed to undertake;
•
an additional formal audit inspection (October / November 2008). Adverse outcomes of
this specific audit will provide an action plan for completion before the Department of
Health Annual PEAT (March 2009) Audit.
•
PEAT performance Management arrangements will be maintained by the Trust.
7.6
Deep Clean Initiative
The CMMC bid for £450,000 non recurrent from the Department of Health Deep Clean Initiative
was successful. (December 2008)
15
Agenda Item 7.3
A wide range of cleaning tasks and improvements were undertaken to inspire confidence in our
patients, visitors and staff. Extra emphasis and attention was given to the Children’s Hospitals, St.
Mary’s and the Royal Eye Hospital to demonstrate the commitment to maintain environmental
standards for benefit of patients and staff for these short life hospitals.
SECTION 8: AUDIT
The Infection Prevention & Control audit programme for this year was driven by the need to focus
on reducing the risks of infection to patients acquired through direct patient care particularly
clinical procedures and antibiotic therapy.
8.1
Hand Hygiene Frequency Audit
Hand hygiene is the single most important method of preventing cross infection and is
fundamental to all clinical procedures. All clinical areas undertake monthly hand hygiene
frequency audits. The audit results are discussed at the Infection Prevention & Control KPI
meeting, this helps to maintain the profile of the importance of hand hygiene. The results for the
year 2007/2008 can be seen below
Average HH Compliance by Designation
Nurses
Medics
HCAs
Others
100%
95%
90%
85%
94%
90%
88%
87%
85%
84%
80%
75%
70%
72%
70%
65%
60%
55%
Apr-07
May-07
Jun-07
Jul-07
Aug-07
Sep-07
Oct-07
Nov-07
Dec-07
Jan-08
Feb-08
Mar-08
Comments
•
Findings are inconclusive although there does appear to be a slight upward trend. It is
important that the audits continue on a monthly basis to keep the emphasis on this high
priority intervention. results of these audits must be reviewed and addressed at Divisional
Infection Prevention & Control meetings
•
There has been some ambiguity expressed about the definitions of hand hygiene
opportunities (see section 5, additional actions within the Children’s Division). These
issues have now been addressed.
8.2
Aseptic Non Touch Technique (ANTT) Audit
Root Cause Analysis undertaken as a result of each incident of MRSA bacteraemia indicates line
infection as the likely root cause in 43% of incidents (see section 4). The risk of infection to the
patient is minimized when procedures involving line insertion and maintenance are undertaken
using the principles of asepsis.
16
Agenda Item 7.3
ANTT was implemented within the Trust from October 2006 and included a range of clinical
practice guidelines for key invasive procedures. The first audit was undertaken in June 2007 and
repeated in September 2007. The results from both audits are shown below.
8.3
Audit of Compliance Rate to ANTT Principles. (The following analysis is based on a
sample 459).
100%
94%
97%
95%
92%
91%
90%
84%
83%
86%
81%
80%
77%
80%
72%
68%
70%
65%
60%
Original Audit
Re-Audit
50%
40%
30%
20%
10%
0%
Children's
MREH/Dental
Surgery
CSS
St Mary's
Medicine
Total
Comments
•
There was a significant improvement in practice across all Divisions
•
The challenge for the future is maintain the same level of priority on ANTT and to ensure
that the principles of ANTT are incorporated into the practice of all appropriate health care
personnel including medical staff and Allied Health Care Professionals. To facilitate this
process all new medical staff starting with the Trust in August will be trained and assessed
in ANTT during induction.
8.4
Audit of Peripheral Cannulae September 2007.
As a result of local findings from Root Cause Analysis undertaken for MRSA bacteraemia a Trust
wide audit of peripheral intravenous cannulae was undertaken in October 2006. A re-audit was
undertaken in September 2007, the results showed:
•
•
•
Poor documentation in terms of insertion details and ongoing monitoring of the cannula
site.
Good compliance with the policy in the length of time the cannula remains in situ.
Good compliance in using the appropriate dressing designed to reduce infection rates and
allow for visibility of the exit site – this was an improvement on the previous audit in 2006.
Comments
As a result of the audit:
• Education on completing documentation (VIP chart), is now included in the training for
intravenous access
• Point prevalence survey (planned for June 2008).
8.5
Saving Lives High Impact Interventions (HII’s)
The Trust has set up a Saving Lives High Impact Interventions group that includes appropriate
specialists who advise on or manage areas where there are significant risks of infection from high
impact interventions. The focus of this group has been to review current policies and undertake
audit of procedures. A full list of these audits for 2007/8 and results can be obtained from the
Infection Prevention & Control Team. (Please see Infection Prevention & Control programme
2008/9 appendix 3 for audit calendar)
17
Agenda Item 7.3
The work of this group has led the way forward to introducing the use of high impact intervention
tools in appropriate clinical settings in the future.
8.6
Antibiotic Policy / Prescribing Guidelines
Following the Department of Health recommendations to limit the prescribing of extended
spectrum cephalosporins and fluoroquinolone antibiotics the guidelines were revised and
updated. These were launched in August 2007.
The Medicines Policy has been updated to include principles of antibiotic prescribing. The
indication for antibiotic therapy and intended duration of treatment / a review date must be
documented on the prescription. Allergy status must also be documented. These will be included
in the Trust wide audit.
8.7
Audit of Antibiotic Prescribing Guidelines
The Trust wide (Central and Children’s sites) point prevalence audit was performed in December
2007 to assess compliance with the antibiotic guidelines. (1031 inpatients were reviewed).
The results of the 2007 audit are compared with results from the 2006 audit in the table shown
below;
2006 audit (Central site)
2007 audit (Trust wide)
Compliant
56%
79%
Non Compliant but Justified
7%
4%
Non-Complaint
21%
9%
Compliance N/A
16%
8%
Comments
• Compliance with the guidelines had improved significantly since the 2006 audit where 21%
of prescriptions were non-compliant.
8.8
Additional antibiotic audits
• An audit of ciprofloxacin prescribing was performed to assess the appropriateness of
therapy. (September 2007)
• An audit of antibiotic surgical prophylaxis was carried out in August 2007. 49% of
prescriptions were compliant with the guidelines in relation to all aspects assessed – drug,
dose, timing of prophylaxis and post operative doses. The surgical prophylaxis guidelines
are currently under review. Following dissemination the audit will be repeated.
8.9
The Infection Control Nurses Association (ICNA) Audit Tool
The ICNA tool, comprising of 10 elements, was used across 131 wards and departments to
assess compliance with general infection control standards.
18
Agenda Item 7.3
The results are shown below (Fig 1). All areas that fell into partial or minimal compliance were reaudited (Fig 2).
Figure 1
Trust Compliance Levels: Breakdown of ICNA Tool Elements
Full
Partial
Minimal
120
100
No
80
60
40
20
0
Ward
Enviroment
Ward Kitchen
Handling of
Linen
Dept Waste
Sharps
Patient
Equipment
General
Patient
Equipment
Specialist
Hand
Hygiene
Personal
Protective
Equipment
Isolation
Procedures
Element
Figure 2
Compliance Improved
Trust-Wide ICNA Re-Audit: Improvement
Compliance unchanged
Compliance decreased
45
40
35
30
25
20
15
10
5
0
Ward
Enviroment
Ward Kitchen
Handling of
Linen
Dept Waste
Sharps
Audit Elements
Patient
Equipment
General
Hand Hygiene
Personal
Protective
Equipment
Comments:
• Compliance in many areas improved, or improved significantly, upon re-audit
• Action plans were received from wards and actions followed through by the Modern
Matrons Facilities Working Group.
• Decreased compliance on re-audit may have been influenced by subjective tool questions.
• There are difficulties associated with the ICNA audit tool:
• Some questions are ambiguous or open to subjective interpretation
• The size of the audit tool renders it difficult to provide timely and meaningful
feedback to clinical areas.
19
Agenda Item 7.3
•
•
In some cases the tool repeats work being done in other audits.
The tool is several years old and is currently being updated by the ICNA
In view of the problems identified above this tool will no longer be used across the Trust and will
be replaced with smaller alternate tools that are more applicable to current standards (see audit
programme in the Annual Plan appendix 3)
8.10 Trust–Wide Screening Audit
This project measured adherence with the screening criteria set by the Trust’s MRSA
management policy. Please see graph below for results (sample size = 210)
Compliance: Screening within 24hrs in Med/High
Risk Areas
57
27%
153
73%
Compliant
Non-Compliant
Comments
This sample was from a cross section of patients from unidentified areas within the Trust. In the
future re-audit will include a break down of specific areas of non compliance and thus enable a
focus fortraining in those areas.
SECTION 9: TRAINING ACTIVITIES
•
•
•
•
The Infection Prevention & Control Team (ICT) deliver training on the key principles of
Infection Prevention & Control at corporate induction and corporate clinical and non-clinical
mandatory training (see Appendix 4 for numbers trained). The content of the training is in
accordance with the core care policies identified within the Health Act
The Team have also undertaken additional, separate training for domestic staff. Discussion
between the ICT and Sodexho is currently taking place to establish how domestic and other
PFI managed staff will be trained in the principles of Infection Prevention & Control when
services are transferred.
There is an increasing interest in Infection Prevention & Control training and updates from
groups of medical staff for example, anaesthetists and paediatricians. In August of this year all
new medical staff will receive Infection Prevention & Control training during induction.
The team are working with colleagues to develop an ‘e’ learning package to facilitate access
to mandatory training. The Trust is also developing a DVD for ANTT training
20
Agenda Item 7.3
SECTION 10: TARGETS AND OUTCOMES
10.1
The Health Act 2006: Code of Practice for the Prevention and Control of Healthcare
Associated Infections
The Healthcare Commission are to visit all acute trusts in England between April 2008 and March
2009 to assess compliance with the Health Act 2006. The Trust is compliant with the Health Act
and has documented a body of evidence in preparation for the visit. (See appendix 5 for review of
compliance).
10.2 The Annual Plan for infection Prevention and Control
The Annual Plan for infection Prevention and Control for 2008 -9 can be found in appendix 3
10.3 Review by Department of Health Improvement Review Team
The Department of Health Improvement Review Team visited the Trust in November 2006 as
CMMC were one of a number of Trust’s nationally who were above the trajectory set by the DoH
to reduce the number of MRSA bacteraemia by March 2008. The review team issued a final
report to the Trust in January 2007 which included an agreed recovery plan. A follow up visit
occurred in October 2007 from which the Trust received the following feedback;
•
They were assured that the Trust has systems in place to prevent and control infection
•
Confident that the performance management approach developed had contributed to a
culture of zero tolerance for hospital acquired infection.
•
Evidence presented demonstrated a continuous improvement in the management and
control of infections.
•
Suggest that the PCT work closely with the Trust to manage high risk patient groups,
specifically those who have frequent in patient episodes.
•
Support the further development of teaching and training for medical staff groups in
infection prevention and control practice including management of antibiotic prescribing.
The review team were confident that the Trust had demonstrated how seriously it takes its duties
and responsibilities to prevent and control hospital infections and signed over the monitoring of
infection prevention and control measures to the PCT.
10.4 Show Case Hospital Project
The Showcase Hospital Project is a part of the Department of Health’s Technology Innovation
Programme aimed at reducing hospital acquired infection (HCAI) rates. CMMC has been selected
as one of only seven English hospitals to take part in the project.
The first year of the project, which is being coordinated by the NHS Purchasing and Supply
Agency, involves implementing and evaluating six technologically advanced products and
developing evidence of clinical effectiveness, implementation guides and sample business cases
that other hospitals can use to support the implementation of these products across the NHS. We
will also be hosting visits from front line practitioners from other North West hospitals to enable
them to see the new products in use and examine how we achieved successful implementation.
10.5 Trust and TrusTECH Project Group
There are a multitude of novel products available to aid in the prevention of HCAI, however whilst
they mostly have evidence on their laboratory or theoretical efficacy, their utility in the NHS setting
often remains unproven. The infection control team is at the heart of a multi-disciplinary group
formed to look at these new products in the infection control arena. The group consists of
representatives from TrusTECH, nursing staff, domestics, management and health and safety as
well as the ICT. The first project to be developed by this group, a trial of a novel disinfectant is due
to start in late June. The trial is fully funded by the product manufacturer.
The work of this group is independent from but complimentary to the work with the Show Case
Hospital Project
21
Agenda Item 7.3
SECTION 11: CONCLUSION
The work and commitment from every level of the organisation is demonstrated within this report.
Key factors to our success have been a clear accountability framework, effective leadership,
improvements in clinical practice and performance and a clearer focus on the environment of
care. The prevention and control of infection continues to be a high priority for the Trust and is
core to ensuring public confidence in our services. The Trust has demonstrated a zero tolerance
approach to health care acquired Infections and will continue to work in partnership with
colleagues across the health economy to maximise the health benefit for the communities we
serve. Our challenge is to sustain and improve on, our achievements during 07/08 which is
reflected in the work plan for 08/09
22
Agenda Item 7.3
APPENDIX 1
INFECTION PREVENTION & CONTROL ORGANISATIONAL STRUCTURE
CLINICAL EFFECTIVENESS COMMITTEE
WINNING WAYS COMMITTEE
(Chair – Mrs Gill Heaton
Director of Infection Prevention &
Control)
Expert Group
Lead Name:
Dr Andrew Dodgson
• Education
• Surveillance
• Outbreaks
• Infection control
policies
• Controls assurance /
CNST
• Research &
development
• Audit
• Risk Management
Medical Devices Group
Lead Name:
Mr Dave Pearson
• Decontamination
• Invasive devices
(catheters/lines)
Modern Matrons &
Facilities Working
Group
Lead Name:
Mr Walter Tann
• Peat visits
• Isolation
• Bed
management
• Kitchens
• Hand washing
• Patient
information
• Ward
housekeepers
• Ward
Medicines
Management
(Antibiotics)
Subgroup
Lead Name:
Dr Ahmed
Qamruddin
• Antibiotic policy
• Audit of practice
23
Agenda Item 7.3
Appendix 2
Infection Prevention & Control Team Structure
Director Infection Prevention &
Control
Director of Nursing
(Adult/Children’s)
Divisional Director
Clinical Scientific Services
Clinical Director Lab Medicine
Divisional Manager Lab Medicine
Managerial Accountability
Professional Accountability
Infection Control Doctors
Consultant Nurse
Infection Control
Lead Nurse, Infection
Secretary
Infection Prevention &
Control Nurse
Prevention & Control
Infection Prevention &
Control Nurse
Infection Prevention &
Control Nurse
Infection Prevention &
Control Nurse
Infection Prevention &
Control Nurse
24
Agenda Item 7.3
APPENDIX 3
Infection Prevention & Control Annual Plan 2008/9
OBJECTIVE
ACTION
LEAD
To update Infection Control Policy
•
•
Nurse
Consultant
Infection
Control
•
Lead Nurse
Infection
Control
March 2009
Review current Policy to incorporate Core Duties
identified within the Health Act.
o
Continue systematic update of core care
protocols (as identified in Infection Control Policy
Manual)
REVIEW
DATE
July 2008
To standardize corporate image of
Staff working within the Trust to
increase public confidence
•
Develop Dress Code Policy and implement across the
organization
•
Human
Resources
October 2008
To review local re-processing of
re-useable medical devices used
for
•
Intubation
•
Endoscopy
•
Standardize use of laryngoscopes to single use or
sufficient numbers to enable re-processing through DSD
•
Medical
Devices coordinator
October 2008
•
Standardize Policy re-processing of Endoscopes
•
Nurse
Consultant
Infection
Control
To Implement MRSA screening for
all elective admissions
•
Agree terms of elective screening programme with
Commissioners of Manchester PCT
•
Director of
Nursing
(Adults)
January 2009
July 2008
June 2008
•
All Elective admissions who attend pre-assessment
clinics to be included by June 2008.
•
Divisional
Managers
March 2009
•
All other elective admissions to include by March 2009.
•
Divisional
Managers
25
Agenda Item 7.3
July 2008
CDT diarrhoea disease
•
Update MRSA Policy to incorporate extended screening
•
Nurse
Consultant
Infection
Control/Infecti
on Control
Doctor
•
Improve the monitoring and clinical follow-up of patients
who develop CDT diarrhoea
Root Cause Analysis for all deaths associated with CDT
diarrhoea
•
Infection
Control
Doctor
September
2008
•
Feedback of Alert organism surveillance data to
Divisions
•
Consultant
Clinical
Scientist
Microbiology
September
2008
•
Finalise target for reduction in incidents of CDT
diarrhoea & MRSA bacteraemia with PCT
•
Director of
Nursing
(Adults)
July 2008
•
Implement Surgical site infection surveillance amongst
cardiac surgery patients
•
Cardio
thoracic
Surgeon
January 2008
•
Implement mandatory SSI for joint replacement surgery
•
Clinical Nurse
Lead,
Orthopaedics
September
2008
•
Recruit surveillance officer to ICT
•
Lead Nurse
Infection
Control
Infection
Control
Nurse
Specialist
October 2008
•
To develop Surveillance Policy
To Develop Infection Control Website
Undertake gap analysis of
•
Information for patients and public on HCAI
•
January 2009
26
Agenda Item 7.3
To ensure all staff groups within
the Trust access training in
infection control core policies
To extend Saving Lives High
Impact Intervention
•
Availability and accessibility of infection prevention and
control information for all Trust staff including Policies,
audit tools/results, surveillance results
•
Lead Nurse
Infection
Control
January 2009
•
All junior doctors to receive IC training during their
induction in August 2008.
•
Nurse
Consultant
Infection
Control
August 2008
•
ICT to deliver training at Trust Induction and Mandatory
Training sessions
•
Lead Nurse
Infection
Control
March 2008
•
Agree programme of training and monitoring of PFI staff
with Sodexho
•
Nurse
Consultant
Infection
Control
November
2008
•
Develop an ‘e’ learning package
•
Infection
Control
Nurse
Specialist
August 2008
•
IC training for Medical Consultant groups (TBA)
•
Infection
Control
Doctor
March 2009
•
DVD on ANTT training for consultant staff
•
Consultant
Anaesthetist
August 2008
•
Training for junior medical staff on antibiotic therapy
•
Antibiotic
pharmacist
September
2008
•
Care bundles to be implemented across the Trust in
relevant clinical areas
•
Nurse
Consultant
Infection
Control
October 2008
27
Agenda Item 7.3
To enhance the role and function of
ICLP
•
•
Increase numbers of ICLP to include more AHP’s
Update Role specification and training programme
•
Infection
Control Nurse
Specialist
December
2008
Infection Prevention & Control Audit Programme 2008/9
Audit
Frequency
Location
Lead responsibility
Date of Completion
Hand Hygiene Frequency
Monthly
Trust Wide
Ward managers
Quarterly Report to Expert
Group
Hand Hygiene facilities
Annual
Phase 2
ICT
September 2008
Cleanliness of
Environment
Monthly
Trust wide
Lead Nurses/CNL’s
Quarterly Report to Expert
Group
Audit of handling and safe
disposal of Sharps
Every Six Months
Trust wide
ICT
July 2008/January 2009
Audit of Antibiotic Policy
Annual
Trust wide
Antibiotic pharmacist
October 2008
Audit of integrated Care
pathway for MRSA
Annual
Trust wide
ICT
September 2008
Audit of integrated Care
pathway for management
of patients with
known/suspected CDT
diarrhoea
Annual
Central Site
ICT
October 2008
28
Agenda Item 7.3
Additional Audits from Saving Lives High Impact Interventions Audit Calendar
Urinary Catheterization
Annual Adults
Annual Children’s
Adult services
Children’s services
Peripheral Cannulae
Annual
Trust wide
Ventilator Care Bundles
Annual
ANTT
CVC
Renal Dialysis ANTT
Urology Nurse Practitioner
March 08
June 08
Lead Nurse Infection
Control
June 08
Adult services
Lead nurse Critical Care
April 08
Annual
Trust wide
July 2008
Annual
Annual
Trust wide
Renal Unit (adults)
Assistant director of
Nursing (Adults)
Lead Nurse Critical Care
Nurse Consultant Renal
Services
August 2008
March 2009
29
Agenda Item 7.3
APPENDIX 4
TRUST TRAINING FIGURES 2007 – 2008
Corporate Mandatory for April 2007 – March 2008 attendees
Total
Attended
Apr 07 mar 08
Division
Childrens
869
CSS
640
Eye
188
Dental
121
Medicine
844
St Mary’s
685
Surgery
350
Corporate
355
Facilities
214
Trust
4266
total
No. with
over 12
months
service
1390
1003
305
188
1548
922
557
510
610
Outstanding Percentage
521
63%
363
64%
117
62%
67
64%
704
55%
237
74%
207
63%
155
70%
396
35%
7033
61%
2767
Target
80%
80%
80%
80%
80%
80%
80%
80%
80%
80%
Staff who have attended Clinical Mandatory Training (April 2007 – March 2008)
Division
Total
Childrens
CSS
Eye
Dental
Medicine
SMH
Surgery
Trust
589
248
100
66
617
420
255
2295
Total
who
should
attend
829
378
232
141
1331
701
423
4035
Outstanding Percentage
240
130
132
75
714
281
168
1740
71%
66%
43%
47%
46%
60%
60%
57%
Target
80%
80%
80%
80%
80%
80%
80%
80%
Corporate Inductions for the Financial Year to Date (April 2007 to March 2008)
Division
Children's
Surgery
Medicine
Eye
Dental
SMH
CSS
Corporate
Facilities
Total Trust
New
Inductions
Outstanding Percentage Target
Starters
277
239
38
86%
98%
135
121
14
90%
98%
332
275
57
83%
98%
60
56
4
93%
98%
51
35
16
69%
98%
181
144
37
80%
98%
178
136
42
76%
98%
187
164
23
88%
98%
93
77
16
83%
98%
1494
1247
247
83%
98%
30
Agenda Item 7.3
APPENDIX 5
HEALTH ACT 2006
CODE OF PRACTICE FOR THE PREVENTION AND CONTROL OF HEALTH CARE ASSOCIATED INFECTIONS – UPDATE
MANAGEMENT, ORGANISATION &
THE ENVIRONMENT
EVIDENCE
SUPPLEMENTARY EVIDENCE
ANNEX 1
1. General duty to protect patients staff and
others from HCAI.
Evidence portfolio SfBH/Risk
management/clinical governance/winning
ways/clinical protocols
Processes, practices and procedures
2. Duty to have in place appropriate
management systems for infection
prevention and control.
1. Board level agreement outlining its
collective responsibility for minimising the
risks of infection and the general means by
which it prevents and controls such risks.
2. Designation of an individual as DIPC
accountable directly to board.
3. Appropriate assurance framework,
infection control programme and infection
control infrastructure
•
•
•
•
•
•
•
•
•
•
•
DIPC appointed, executive director of the
Trust (JD for DIPC)
•
Organogram of IC Team, Appendix 1 Annual
Report
Infection control work programme, Appendix 2
Annual Report
•
4. Relevant staff contractors and other
persons receive suitable and sufficient
Infection Control Annual Report
Infection Control Overarching Policy
Declaration on SfBH
Current Internal audit
Summary of visit from MRSA Cleaner Hospital
and presentation
Infection Control Annual Report
Infection Control Overarching Policy
Terms of Reference of Winning ways and
associated committees: expert group, medical
devices, medicines management
Risk compliance report
Board reports - minutes
31
training information and supervision on
measures required to prevent and control
risks of infection.
•
•
•
•
•
5. Programme of audit
6. Policy addressing relevant admission
transfer, discharge and movement of patients
between departments and within and between
health care facilities
•
•
Annual programme of audit in annual report.
Saving Lives HII incorporated into above.
•
Bed Management policy
•
Transfer policy – transfer forms (appendix 1) in
place.
Advice sheet for bed managers/co-ordinators –
adults and paediatrics
•
3. Duty to assess risks of acquiring HCAI
and to take action to reduce or control such
risks
1. Risk assessment to patients in receipt of
health care
2. Identify steps taken to reduce or control
such risks recorded and implemented above
Agenda Item 7.3
Education and training programmes in place
corporate induction & corporate mandatory
training, clinical mandatory
See training needs analysis (Training)
See annual report for numbers trained
(Training)
Education and training programmes in place for
PFI partners (Training)
All staff have access to policies through intranet
http://intranet.cmht.nwest.nhs.uk/navigation/def
ault.asp and hard copies on all the wards.
•
•
•
•
•
•
MRSA policy
ICP’s for alert organisms (MRSA and C diff)
MRSA / C diff admission tool adults
MRSA admission tool paediatrics
Policies for alert organism/condition
isolation policy
outbreak policy
•
•
KPI meetings
Infection control audits
32
•
•
•
3. Methods in place to monitor risks to
reduce or control HCAI
Duty to provide and maintain a clean and
appropriate environment for health care.
•
Agenda Item 7.3
MMFWG Minutes and Terms of Reference
Hospital standards
MRSA RCA
•
Divisional infection control groups/Clinical
Gov ToR and Minutes
Improvement and action plans
Outbreak Reports
Incident reporting
Cleaning schedules, Sodexho Service
Directory)
Mobilisation Plan
Legionellae policy
Water Quality Plan
Waste Management Policy
Pest Control
MMFWG (minutes)
Trust Water Quality meeting June , July ,
March
Theatre Group
•
•
Decontamination lead in place (JD)
Lead Manager for Facilities
3. Premises are suitable for purpose and
clean and maintained in good
physical repair
•
•
•
PEAT assessment scores
ICNA audits
Reports from Sodexho, evidence of PPM
4. Cleaning arrangements detail
•
Cleaning Schedules, Sodexho Service Directory
1. Policies for the environment which
make provision for liaison between
members of infection control team
and the person with the overall
management responsibility of
facilities
2. Designates lead managers for
cleaning and decontamination of
equipment
•
•
•
•
•
•
•
•
•
•
•
33
Agenda Item 7.3
standards and schedules – publicly
available
Duty to provide Information on HCAI to
patients and the public
5. Adequate hand wash facilities &
antibacterial rub
•
•
•
Cleanyourhands campaign
Floormats
Audit of facilities in Children’s Division
6. Effective arrangements for
decontamination instruments and
equipment
•
•
DSD compliant with ISO 9001, ISO 13485,
Directive 93/42/EEC
Medical devices co-ordinator currently
reviewing provision of Laryngoscopes, minutes
of meetings
7. Supply of linen and laundry reflects
health service guidance (HSG(95)18)
•
Laundry facilities compliant with HSG(95)18
8. Clothing worn by staff including
uniforms is clean and fit for purpose
• Draft Policy for Dress Code
• Uniform policy for nurses
• Uniform policies for AHP’s
• Information available on internet site.
http://intranet.cmht.nwest.nhs.uk/navigation/de
fault.asp .
• Patient information leaflets – MRSA, C diff
• Patient information leaflet – general infection
control advice.
• Productive ward boards showing infection
rates.
• Antibiotic advice leaflet (TIG group)
• MRSA advice around screening and treatment
• Norovirus advice given to patients and
relatives in an outbreak.
1. Information available to patients and
public:
a. organisations systems for
prevention and control of
infection
b.any particular considerations re
risks and nature of any HCAI
relevant to their care
c. any preventative measures pt
ought to take after discharge
34
Agenda Item 7.3
•
Duty to provide information when a patient
moves from the care of one health care body
to another
Record of infection status
Duty to ensure co-operation
Staff and contractors must enable the
Trust to meet its obligations under the
Code
Must provide or secure provision of
adequate isolation facilities for patients to
prevent or minimise the spread of HCAI
Duty to provide adequate isolation facilities
Duty to ensure adequate laboratory support
Laboratory must have in place
appropriate protocols according to the
standards required for CPA (UK) ltd
Major Outbreak Policy
•
Transfer policy – transfer forms (appendix 1) in
place.
• Letter from Medical Director to all trusts re.
MRSA patients transferred in to Trust.
• Part of SLA and contracts,see mobilisation
programme).
• Copy of Trust employee standard in all JD’s
• There are policies & practices in place that
enable risk assessments to take place to isolate /
cohort nursing to manage client groups:
Bed management policy
Information for bed managers / co-ordinators –
adults, paeds.
MRSA ICP with details of isolation
C Diff ICP with details of isolation
• New designs include additional isolation
facilities, eg. ICU/Ward 18 at Trafford.
• The new hospital will provide additional
isolation facilities in line with building
regulations.
• CPA accredited
• MMMP accreditation
Clinical Care Protocols
Annex 2
Duty to adhere to policies & protocols
applicable to infection prevention and control
1. Standard universal IC precautions
2. Aseptic technique
3. Major outbreaks of communicable
diseases
•
•
•
•
•
Hand hygiene policy
PPE’s policy
ANTT policy
Outbreak policy
Outbreak distribution list
•
Isolation of patients policy
35
Agenda Item 7.3
4. Isolation of patients
•
Bed Management Policy
•
Occupational exposure to BBV’s, including
sharps
5. Safe handling and disposal of sharps
6. Prevention of occupational exposure
to blood borne viruses (BBV’s)
including prevention of sharps
injuries
7. Management of occupational
exposure to BBV’s
8. Closure of wards /dept to new
admissions
Outbreak policy
9. Disinfection policy
10. Antimicrobial prescribing
•
•
Decontamination of Equipment policy
Environmental audit tool
• Antibiotic policy:
Adults
Paediatric / neonates
11. Reporting to HPU / SHA
12. Alert organisms – MRSA, CDT, TSE,
TB
•
•
All c diffs reported to the HPU/SHA
All MRSA bacteraemias reported weekly and
monthly to HPU/SHA
•
•
•
•
•
•
GRE
MRSA policy
CDT policy
TSE policy
TB policy
Draft policies Viral Haemorrhagic Fever
36
Agenda Item 7.3
Health Care Workers
Duty to ensure in so far as reasonably
practicable, that health care workers are free
of and 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
Annex 3
1. Access to OH Services
2. OH policies for prevention and
management of communicable
infections in health care workers
3. Induction and training for all staff
4. Education for existing staff inc
agency locum and staff provided by
contractors
5. Updating staff and records of
attendance
6. Responsibilities are clear in job
description and PDP
•
•
•
•
Occupational policies and procedures and
access to information on intranet site
Occupational exposure to BBV’s, including
sharps
See section 2 above for training information
Generic job description for all staff
37