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Board of Directors Meeting
Date: 27 June 2007
Agenda item: 8.3(i) Part I
Title: DIPC Annual Report
Prepared by: Judy Potter/Alaric Colville Directors Infection Prevention & Control
Presented by: Dr Vaughan Pearce Joint Medical Director
Action required: For Information
Monitoring Information Please specify HC standard
numbers and tick other boxes as
appropriate
Healthcare Standards – CORE C4a, C4c, C20, C21
Healthcare Standards – DEVELOPMENTAL Standard numbers
Monitor Finance
Service Development Strategy Performance Management
Local Delivery Plan Business Planning
Assurance Framework Complaints
Equality, diversity, human rights implications assessed
Other (please specify) Health Act 2006 - Code of Practice for the Prevention and Control of healthcare associated infection
Title of Paper: DIPC Annual Report Board Date: 27 June 2007
1. PURPOSE
1.1 The purpose of this report is to inform patients, public, staff, Trust Board and Commissioners of the infection control work undertaken in 2006/7, the management arrangements and the state of infection control within the Trust.
2. BACKGROUND
2.1 The Directors of Infection Prevention and Control are required to produce and make public an annual report on the infection control work undertaken in the Trust.
3. KEY ISSUES
• The Trust has achieved the planned infection control activities outlined in the annual programme 2006/7.
• The Trust was able to declare compliance with C4a of the Healthcare
standards • The Trust is compliant with the Health Act 2006 - Code for the Prevention and
Control of Health Care Associated Infection (the ‘Hygiene Code’) • There has been an overall reduction in new cases of MRSA although the 20%
reduction target for MRSA bacteraemias in 2006/7 has not been achieved. • Low levels of Clostridium difficile infection have been maintained. • The impact of Norovirus infection on the Trust has been significantly less this
year and this may, in part, be associated with the introduction of a rapid test for Norovirus detection.
• The results of surgical site infection surveillance in orthopaedics demonstrate
excellent standards with a zero % infection rate amongst patients undergoing hemiarthroplasty between July and September 2006.
• Standards of environmental cleanliness remain high in clinical areas. • A new food delivery system has required a reorganisation of both food and
cleaning services. The impact of these changes will need to be evaluated. • The main concerns remain:
♦ Hospital acquired infections due to Clostridium difficile ♦ Hospital acquired bacteraemia ♦ Viral gastro-enteritis due to Norovirus
Hospital and community acquired infections due to MRSA.
4. RECOMMENDATIONS
N/A
Title of Paper: DIPC Annual Report Board Date: 27 June 2007
INFECTION CONTR
APRIL 2006-
Dr. Alaric Colville a
Directors of Infection
OL ANNUAL REPORT
MARCH 2007 nd Mrs. Judy Potter
Prevention and Control
CONTENTS
Executive Summary
1. Introduction 2. Infection Control Arrangements 3. DIPC Reports to the Board 4. Budget Allocation 5. Healthcare Associated Infection Statistics 6. Hand Hygiene and Aseptic non-touch Protocols 7. Decontamination 8. Cleaning Services 9. Catering and Kitchens 10. Targets and Outcomes 11. Audit 12. Training Activities 13. Policies and Guidelines Appendix 1 Infection Control Annual Programme Appendix 2 Terms of Reference for Infection Control Committee Appendix 3 Governance Structure Appendix 4 Infection Control Committee Meeting Minutes Appendix 5 Infection Control Committee Decision Briefings Appendix 6 Outbreaks of Small Round Structured Virus (Norwalk) Appendix 7 Ward Closures due to D&V 05/06 versus 06/07 Appendix 8 Clostridium difficile Appendix 9 MRSA Bacteraemia occurring within and after
48hours of admission Appendix 10 New cases of MRSA - identified more than 3 days
after admission to RD&E Appendix 11 Total Number of New MRSA Incidences per Quarter
across the Whole Healthcare Community Appendix 12 Hand Hygiene Compliance Graphs Appendix 13 Hand hygiene TV screen saver Appendix 14 Monthly statistical process control chart for end point
MRSA infection target
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INFECTION CONTROL ANNUAL REPORT
Key Issues/Executive Summary
• The Trust has achieved the planned infection control activities outlined in the annual programme 2006/7.
• The Trust was able to declare compliance with C4a of the Healthcare
standards • The Trust is compliant with the Health Act 2006 - Code for the
Prevention and Control of Health Care Associated Infection (the ‘Hygiene Code’)
• There has been an overall reduction in new cases of MRSA although
the 20% reduction target for MRSA bacteraemias in 2006/7 has not been achieved.
• Low levels of Clostridium difficile infection have been maintained. • The impact of Norovirus infection on the Trust has been significantly
less this year and this may, in part, be associated with the introduction of a rapid test for Norovirus detection.
• The results of surgical site infection surveillance in orthopaedics
demonstrate excellent standards with a zero % infection rate amongst patients undergoing hemiarthroplasty between July and September 2006.
• Standards of environmental cleanliness remain high in clinical areas. • A new food delivery system has required a reorganisation of both food
and cleaning services. The impact of these changes will need to be evaluated.
• The main concerns remain:
♦ Hospital acquired infections due to Clostridium difficile ♦ Hospital acquired bacteraemia ♦ Viral gastro-enteritis due to Norovirus ♦ Hospital and community acquired infections due to MRSA
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1. Introduction This is the third annual report by the Directors of Infection Prevention and Control at the Royal Devon and Exeter NHS Foundation Trust (RD&E). The purpose of this report is to inform patients, public, staff, Trust Board and Commissioners of the infection control work undertaken in 2006/7, the management arrangements and the state of infection control within the Trust. The programme of infection control activities is determined annually. National issues and targets are taken into consideration as well as local needs. In this report, these can be found described in the annual programme for 2006/7 (Appendix 1). Additional activities have focused on strengthening our position in relation to the new Health Care Act 2006 – The Code of the Control and Prevention of Health Care Associated Infection (Hygiene Code).
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2. Infection Control Arrangements 2.1 Infection Control Team (ICT) The ICT consists of the following personnel: Lead Nurse 1.0 WTE Infection Control Nurse Specialists (clinical leads) 3.4 WTE Infection Control Nurse Specialists 4.6 WTE Audit and Surveillance Nurse 0.8 WTE Infection Control Doctor 4 sessions Office Manager 1.0 WTE Team secretary 1.0 WTE Despite national advertising, we have no appointable applicants for a vacant Infection Control Nurse Specialist (Band 7). An Infection Control Nurse Specialist (Band 6, 0.6 WTE) has been on maternity leave for the first 9 months of the year. An additional Band 6 nurse was appointed to help support the depleted team. The Team secretary position has also been vacant for most of the year but an appointment has now been made. The lead nurse is responsible for the infection control nursing service and the associated service level agreements. The team has service level agreements with Exeter, East Devon and Mid Devon PCTs, Devon Partnership Trust. 5 nurses are deployed in PCT and DPT activities. The Medical Microbiologists also play an active role in infection control and, for part of the year provide out of hours infection control advice via the microbiology on call service. However, a ‘seasonal’ nursing on call rota commenced in December 2007, as Norovirus activity increased. This service remains in place at the time of writing this report and the nurses continue to respond flexibly to this ‘seasonal’ requirement. 2.2 Director of Infection Prevention and Control The Infection Control Doctor and the Lead Nurse continue to share the role of Director of Infection Prevention and Control (DIPC), reporting directly to the Chief Executive. 2.3 Infection Control Committee (ICC) The Committee is chaired by the DIPC and meets quarterly. The terms of reference and membership (Appendix 2) have been reviewed this year and the membership enhanced to strengthen embedding responsibility for infection control within the Directorates.
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2.4 Reporting line to Trust Board The Ds IPC reports to the Board through the Chief Executive. The ICC reports to the Trust Board via the Governance Committee. Refer Appendix 3 for Governance Structure. 2.5 Links to Drug and Therapeutics Committee One of the Medical Microbiologists is a member of the Drug and Therapeutics Committee and provides the link between the Committees. 2.6 Links to Clinical Governance/Risk Management/Patient Safety The DIPCs are members of the Governance Committee, the Nursing and Midwifery Governance Committee and the Health and Safety Committee.
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3 DIPC Reports to the Board The DIPC is accountable directly to the Trust Chief Executive and reports to the Chief Executive and Board. Both the Infection Control Doctor and the Infection Control Lead Nurse who share the DIPC appointment are members of the Governance Committee. 3.1 Number and Frequency The Infection Control Committee (ICC) meets 4 times a year. The committee reports to the Trust Board, through the Governance Committee, which meets 8 times a year. (For an example of minutes, refer Appendix 4). The Governance Manager receives a copy of the minutes as do some other members of the Governance Committee in their respective roles. However, in addition, a “Decision Briefing” is prepared after each ICC meeting, and is included as a standing item in the next Governance Committee meeting (Refer Appendix 5). This ensures that the most important items from the ICC are noted by the Governance Committee and thus, brought to the attention of the Board. In addition to these routine reporting arrangements, performance against infection control targets are discussed at each Board meeting, presented by Elaine Hobson, Director of Operations. The DIPCs also presented a report at a Board strategy meeting in February 2007 to help inform the Trust three year strategy. Finally, a report on compliance against the Hygiene Code was prepared by the DIPC and presented to the Governance Committee. A summary has been prepared for presentation to the Board in April as part of the Annual Declaration of Compliance with Healthcare Standards and Targets 2006 -2007. 3.2 Annual Action Plan/Annual Programme An annual programme is prepared by the ICT, agreed each year by the ICC and approved by the Board. Currently these plans are derived from a long term action plan developed when the Winning Ways was published. The annual programme for 2006/7 runs from April to March and is prepared for the ICC meeting before April each year. Progress against the annual programme is monitored by the ICC. (Appendix 1) 3.3 Board Decisions The Board approves annual plans, policies and guidelines developed by the infection control team, both new policies and significant revisions of existing policies and guidelines. These and other issues are generally considered by the Governance Committee and other relevant committees first.
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3.4 Outbreak and Incident Reports The Infection Control Team recognises and responds to significant episodes, incidents and outbreaks of infectious conditions every year. Not all incidents turn out to be outbreaks or due to cross infection. It is not unusual to see variation in surveillance data, clusters of infection which may be due to chance. However the ICT has to be alert to all potential outbreaks, and investigate them accordingly. Incidents and outbreaks may be reported in several different ways. Many are recorded in the minutes of the weekly Infection Control Team Meeting. Some are included in Infection Control Committee minutes. Where an outbreak is considered significant because of its size or the lessons learnt in its management, a specific outbreak report is prepared. 3.4.1 Norovirus Outbreaks of viral gastro-enteritis due to Norovirus have occurred almost continuously over the winter months for the last five years, with sporadic ward outbreaks in the summer. As a result, a more pragmatic approach has been taken to reporting these events with a daily outbreak update made to the Chief Executive, other Executive Directors and the Chairman by email during periods of extreme activity. Verbal reports are also made daily at Bed Capacity Review Meetings, which are usually chaired by the Director of Operations or Director of Nursing and Service Improvement. Appendix 6 shows the number of outbreaks that occurred each month affecting whole wards and the number of outbreaks affecting single bays each year for last four years. During the summer of 2006 a meeting was held to explore the lessons learnt from previous years and plan for the winter. Based on these plans a multimodal approach has been taken to minimising the impact of Norovirus on the operations of the hospital. The approach included:
• Identifying patients with symptoms suggestive of norovirus infection on or prior to admission. A questionnaire about symptoms is used to assess emergency admissions both in the Emergency Medical Unit and in the Emergency Department.
• Designating isolation rooms on Torridge ward for medical admissions
with symptoms suggestive of, or confirmed as, Norovirus infection. • Introducing a rapid test for norovirus detection (Norovirus by PCR)
which if commenced in the morning provides a result in the afternoon of the same day. The test is funded for use Monday to Friday.
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This rapid test has proved extremely useful. If results are positive, it confirms that measures implemented on suspicion of Norovrus infection are appropriate and must be maintained. If negative, it enables isolation precautions to be lifted immediately. In previous years, the patient would have remained isolated until symptom free for 48 hours. Where the index case is already an in-patient in a multi bedded area, there are usually other patients who have been exposed and who may subsequently become infectious themselves. In this situation, restrictions on further admissions and transfers out of the area are put in place. Again the rapid test has helped the ICT to lift restrictions much earlier if the result is negative but also provides confirmation of the need for such restrictions, if positive. Appendix 7 shows the number and duration of ward closures along a time line from December 2005 through to March 2006 and December 2006 – March 2007. A clear reduction in number and duration of ward closures can be seen at a time where the rest of the UK and Europe have experienced an increase in outbreaks. 3.4.2 Clostridium difficile Clostridium difficile People may develop infection with Clostridium difficile after being prescribed antibiotics. Symptoms range from mild diarrhoea to life threatening colitis, which may require surgery as well as treatment with specific antibiotics. Infection may be acquired in the community or hospital, but symptomatic patients in hospital may be a source of infection for others. Control of C. difficile is taken very seriously in the RD&E. A serious outbreak with a strain of C. difficile known as 027 occurred in 2005. This was controlled and since then rates have been low (refer Appendix 8). However, continuous surveillance is in place using statistical process control methods to detect possible outbreaks. Any incident is investigated to ensure guidelines are being followed and to implement special measures if necessary. The provision of designated facilities for patients with symptomatic C.difficile infection are maintained within the Medical Directorate on Torridge ward. In November 2006, an increase of cases of C.difficile linked to patients attending the renal ward and haemodialysis unit was noted. Renal patients are at risk of C. difficile infection as a result of their condition and treatment. Control measures included a precautionary terminal clean of the unit, although hygiene was noted to be good, enhanced case finding and isolation, and education on antibiotic use. Typing of strains suggested that this was a cluster of mostly unrelated cases rather than cross infection or introduction of a virulent strain. Following interventions case numbers returned to baseline. No particular cause was found.
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In January 2007 an increase in C. difficile cases was noted on the Acute Stroke Unit. These patients are also particularly at risk of C. difficile infection, often frail, many have infection complicating their presenting condition, and require antibiotic treatment. Interventions similar to those on the renal unit were undertaken, including a terminal clean, and ensuring effective isolation. At the time of writing the report the results of typing investigations are awaited. However the numbers of cases have returned to baseline. 3.4.3 Haematology Unit Patients with haematological malignancies, such as leukaemia and myeloma are often highly immunosuppressed either as a result of there condition or because of chemotherapy. These patients are susceptible to infection especially with unusual organisms like fungi. At times of severe immunosuppression they are admitted to single rooms with positive pressure filtered ventilation for protective isolation. An investigation was initiated when it was noted that there had been an increase in the rate of patients thought to have significant fungal lung infections, (likely to be aspergillus) requiring antifungal therapy. These infections are difficult to confirm and are generally treated on clinical suspicion rather than laboratory confirmation. An incident meeting was held and likely causes considered. The function of the ventilation systems in protective isolation rooms was checked by engineers and air samples taken. No failures were found in ventilation, or source of fungal infection. No explanation for the increased rate was found, and numbers returned to normal. It is possible that infection occurred in the home environment prior to admission. Ongoing enhanced surveillance for fungal infection is underway with the haematology clinicians. A cluster of patients infected or colonised with Vancomycin Resistant Enterococci (VRE) was noted, through normal surveillance, in February 2007. These were typed, and two strains were identified. There was evidence of cross infection between 3 of 4 patients. Feedback was given of infection control measures, though it was unclear when cross infection might have occurred, either as an inpatient or as an outpatient. 3.4.4 Respiratory infections - Neonatal Unit The Neonatal Unit is one of the areas of the hospital where patients are highly susceptible to infection. Premature infants have poorly developed immune systems, and may require intensive care, with ventilation and central lines to provide drugs and nutrition. In November 2006 5 babies were affected with respiratory symptoms. Not all were particularly unwell (most had “snuffles”), but one required transfer to the high dependence part of the Unit. Precautions were taken to isolate affected
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and potentially exposed babies. As a precaution the unit was closed to routine admissions, although it remained open for ITU admissions. All babies recovered well. No infective cause was found despite extensive laboratory testing for suspected viral infection. Symptoms were first noted on 8th November, The unit was partially closed between 8th and 16th November. In December 2006 a further incident occurred when adenovirus was identified in 2 babies with respiratory symptoms. On this occasion cohort isolation of the affected babies was possible without closing the unit, and both recovered. It was considered that a parent of one of the babies was the likely source.
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4. Budget allocation a. Staff Budget allocation for staffing is in accordance with the grades of staff indicated in Section 1. b. Support (IT etc) N/A c. Training The infection control team has a small budget for training and also a charitable fund which can be used for educational purposes. However, the team are also able to apply to the Staff Development Fund for funding for post graduate specialist programmes of study. Two members of the team are currently studying with part funding from the Staff Development Fund.
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5. Healthcare Associated Infection Statistics 5.1 Mandatory Statistics Mandatory reports are made to the Health Protection Agency (HPA). Some reports are made on line monthly and others are quarterly. ♦ Staphylococcus aureus bacteraemia Staphylococcus aureus is a bacterium commonly found colonising humans. Although most people carry this organism harmlessly, it is capable of causing a wide range of infections from minor boils to serious wound infections and from food poisoning to toxic shock syndrome. In hospitals it can cause surgical wound infections and bloodstream infections. This has been reported since April 2001, so at the end of the year 2006/7 six full years of reports had been submitted. Data has been submitted monthly since October 2005. Reports from the RD&E consist of all Staph. aureus isolated from blood cultures processed by the RD&E Microbiology Department. These include all isolates, whether true infections or contaminated blood cultures; hospital acquired or community acquired infections. Although most blood cultures originate from the RD&E, specimens submitted from community hospitals and General Practitioners are also included in the returns. Results are expressed by the HPA as total episodes of Staph. aureus bacteraemia, and meticillin resistant Staph. aureus (MRSA) bacteraemia. Rates of bacteraemia episodes per 1000 bed days, are also calculated. In October 2005, an enhanced data set was introduced which allows the distinction to be made between bacteraemia occurring before admission or within 48 hours of admission and those that occur more than 48 hours after admission (Appendix 9). In early 2007 a further enhancement included more information on isolates that were linked to patients in renal units. This is because the risk of bacteria getting into the blood is increased during haemodialysis treatment for renal failure. Whilst the HPA report continues to attribute all MRSA bacteraemia, regardless of source, to the RD&E, internally we are able to monitor the impact of control measures on bacteraemia acquired within the hospital. ♦ Glycopeptide resistant enterococcal (GRE) bacteraemia Enterococci are normally found in the gut, and are part of the normal human gut flora. Although a common cause of urinary tract infections, enterococci can occasionally cause serious infections such as endocarditis. In immunocompromised patients for example haemodialysis patients and haematology patients, especially those with intravascular lines, enterococci may cause bacteraemia.
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Glycopeptide resistant enterococci are resistant to glycopeptide antibiotics such as vancomycin and teicoplanin. These have been reported to the HPA since July 2003. The same criteria for selection and denominators as Staph. aureus applies. The number of cases reported are low and cases are usually sporadic. Further information can be obtained from the Infection Control Team. ♦ Clostridium difficile Clostridium difficile is a bacterium that may grow in the bowel and cause diarrhoea and colitis which can be life threatening. It is mainly a complication of antibiotic therapy and particularly affects the frail and elderly who have been prescribed broad spectrum antibiotics. C. difficile is a healthcare associated infection (first recognised in 1977), and has been linked to serious outbreaks in hospitals. Mandatory surveillance for infection in over 65 year olds has been undertaken since 2004. For mandatory reporting purposes, all diarrhoeal stools submitted to the microbiology laboratory from people aged 65 or more are examined for C. difficile toxins. Episodes are reported. An episode consists of one or more C. difficile toxin positive stools during a 28 day period. Total number of stools examined for routine culture and C. difficile are also reported as denominators. ♦ Orthopaedic Surgical Site Infection In 2004 it became a mandatory requirement to conduct surveillance of orthopaedic surgical site infections, using the Surgical Site Infection Surveillance Service of the HPA. The data set collected is forwarded to the HPA for analysis and reporting. This system is controlled and validated to allow comparison between centres. The requirement is for a 3 month module of surveillance of one of the orthopaedic options, namely
• Open reduction of long bone fracture • Hip arthroplasty • Knee arthroplasty
Having already undertaken surveillance of the other two categories abd found very low rates of infection hip hemi-arthroplasty was the option chosen for the 3rd annual orthopaedic surveillance module in 2006. The infection rate was 0%. The full report can be obtained from the infection control department on request.
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5.2 Trends in Health Care Associated Infection In addition to mandatory statistics the infection control team conducts surveillance to monitor hospital infection in several areas. Some of the surveillance is ward based, such as surgical site infection, some is laboratory based. These include the following: ♦ Bacteraemia surveillance Hospital acquired bacteraemia for all organisms (not just Staph. aureus or MRSA) is undertaken routinely. This surveillance indicates the major risk factors for hospital acquired bacteraemia, defined as bacteraemia occurring after 48 hours in hospital. Major risk factors continue to be central and peripheral IV cannulae. This information has been used to direct action for the prevention of potentially avoidable bacteraemias. Procedures have been revised and education directed towards high risk areas, such as renal medicine where many patients require central venous lines. Reports are issued quarterly to all departments. Copies can be obtained from the Infection Control Department.
♦ Clostridium difficile toxin positive diarrhoea In addition to mandatory reporting, and Trust wide monitoring of Clostridium difficile infection which is reported to the Infection Control and Governance Committees, ward specific cases are monitored and feedback provided to individual wards in the form of statistical process control (SPC charts).
♦ MRSA Newly Identified The numbers of patients diagnosed as MRSA positive for the first time are collected from laboratory data. This includes people who are colonised ( i.e. carrying the organism without any sign of infection) and those who have an infection of any type i.e. not just blood stream infections. The number of new cases identified more than three days after admission continues to decrease. (Refer Appendix 10). The number of new cases across the whole local health community has plateaued and may also be decreasing (Appendix 11) However, this measures the rate new people become colonised or infected. Consequently, the total number of people in the community with MRSA colonisation or infection continues to rise.
5.3 Antimicrobial Resistance
Antimicrobial resistance is detected in the microbiology laboratory when bacterial isolates are routinely tested for antimicrobial sensitivities. However studies have shown that because of the bias present in the selection of samples sent for laboratory testing, rates of resistance measured in the
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laboratory do not reflect that truly present in the community. Resistance tends to be overestimated. Since 2005 the laboratory has tested all significant isolates of coliform organisms for the presence of extended spectrum beta-lactamase (ESBL) and AmpC enzymes. These enzymes when present in bacteria cause resistance to a wide range of penicillin and cephalosporin antibiotics. The number of ESBL and AmpC positive strains seem to be increasing, especially in the elderly. Because ESBL testing has only recently started no valid trends or rates have yet been established although close monitoring has commenced.
Staph. aureus rates of resistance to methicillin (MRSA) is routinely monitored.
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6. Hand hygiene and Aseptic no-touch protocols 6.1 Continuation of the NPSA ‘Cleanyourhands’ campaign. The campaign continues to involve four main components:
♦ Point of care alcohol hand rub ♦ Awareness and role model posters ♦ Patient involvement ♦ Audit of practice and feedback to wards/dept using run charts
(appendix 12 - examples). The patient involvement element has probably been the area which has been least successful because patients are reluctant to challenge staff and staff are sometimes uncomfortable about being challenged! Leaflets are available which encourage patient involvement but we have now put information on the bed side television screens as one of the screen savers (Appendix 13) which invite patients to remind staff to clean their hands. 6.2 Application of Aseptic Clinical Protocols The principles of asepsis are included on the Trust Induction Programme for new staff. Clean and aseptic technique principles are also provided as part of nursing and medical student education. 6.2.1 Saving Lives High Impact Interventions A steering group for the Saving Lives Initiative identified 4 subgroups to pilot the high impact interventions relating to reducing catheter associated urinary tract infection, surgical site infection, ventilator associated pneumonia, catheter related blood stream infection. Asepsis is a key component of these interventions. The pilot work is now complete. The full report of the steering group can be obtained from the Infection Control Team. Plans are being made to roll out an improvement tool throughout the Trust.
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7. Decontamination 7.1 Arrangements The Hospital Sterilisation & Decontamination Unit (HSDU) is fully compliant to the standard ISO9001/2000 ENISO 13485 and is working to the 93/42 EEC Directive after receiving accreditation on 14th July 2004. All surgical instruments are centrally re-processed and the withdrawal of the final 4 remaining bench top sterilisers within the Orthopaedic theatres will be removed in May 2007 once the new arthroscopes, which will then be centrally re-processed, are delivered. The Decontamination Task group is responsible for monitoring decontamination arrangements and compliance overall and reports directly to the Governance Committee. The Trust is participating with the National Decontamination Training programme and has extended this to a wider range of staff over 2006 – 07. The HSDU has introduced a Dot Matrix Tracking on theatre single packed instruments by bar-coding the instruments using a Dot pen marker, however the Trust is now looking at a new tracking and traceability system that will cover the whole process through HSDU and Theatres. The new system will allow full traceability of instruments to patients and complies with the CJD guidelines. A few of the benefits are as follows:-
• Records the instruments sets through each process stage of the decontamination cycle within HSDU
• Allows serialisation of sets • Able to track and trace instruments across theatres and HSDU • Tracks and Traces all procedures within theatres • Records items and implants used on patients • Provides manual backup if the system crashed allowing continuity of
tracking 7.2 Audit HSDU conduct internal audits to ensure their compliance with ISO9001/2000, ISO13485 and 94/32 EEC Directive and are externally audited twice a year by a notified body. An external audit and review intended to speed up the processes and movement of surgical instruments between Theatres and HSDU is planned for early 2007-08. 7.3 Incidents/Failures Investigated All incidents are reported to the Trust Risk Manager and are graded as minor, moderate or major. All incidents graded Moderate or above are fully
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investigated. If any learning outcomes are identified system changes are implemented.
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8. Cleaning Services 8.1 Management Arrangements (in-house or contracted) All cleaning services are managed in-house. 8.2 Monitoring Arrangements Monitoring is undertaken in accordance with the National Specification for Cleanliness in the NHS. Housekeeping Services use the NHS approved Credits for Cleaning (C4C) monitoring system which was successfully introduced during 2006. Dedicated monitoring officers (2.0 WTE) record technical monitoring on a weekly basis as required by the National Specification. Areas of cleaning failure are recorded on a rectification sheet which is given to the duty supervisor to action and follow up. All ward sisters / charge nurses are sent a printed list of the cleaning results at the time of audit so that if there are any nursing issues these can be noted and rectified. Matrons are now also sent a copy of any nursing issues identified Collated results of monitoring are e mailed to the Lead Nurses, Senior Matrons and Matrons on a monthly basis and show 3-month rolling results for wards and departments. In addition to this a Quarterly Management audit is undertaken by a multi-disciplinary team and the results of this are used to monitor the technical audits undertaken on a weekly basis. 8.3 Budget Allocation Rolling budget. Any additional requirements or new areas need to be funded by the directorate to which they relate. The Credits for Cleaning (C4C) programme has been implemented and a significant amount of data relating to current resources and the recommended minimum frequency of clean requirements has been recorded. The output data is currently being used in the re-design of Housekeeping Services and their delivery in order to meet the changing needs of the Trust. An example of this was the complete revision of all ward work schedules introduced in preparation for the introduction a cook-freeze patient meal service which requires ward level plating of meals. The impact of cook freeze service on cleaning activities will be monitored closely. C4C has also been used to re-design the work schedules and manpower required for the Centre for Women’s Health that opens in June 2007. This is effective in allowing the Lead Nurses more freedom to negotiate the delivery of cleaning services within their areas of responsibility whilst remaining within the set parameters.
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Call-off funding for a dedicated infection outbreak cleaning team was allocated in 2006/07 and has made a significant difference to the response times for organising terminal cleaning and re-opening a ward. 8.4 Clinical Responsibility Ultimately, this lies with nursing although training is given to cleaning staff regarding awareness of working in both clinical and non clinical environments 8.5 Clinical Access Access to the clinical areas is made during the day time in in-patient areas and in the evening or at night in outpatient or day case departments. This minimises disruption to patients and clinical staff. Cleaning is sometimes hindered by activity and particularly visitors around bed areas. Following patient consultation, restricted visiting hours have been introduced and this has led to improved access for cleaning. 8.6 User Satisfaction Measures ♦ A satisfaction survey of Ward Managers is undertaken quarterly ♦ Monthly meetings with Ward Sisters / Charge Nurses and Matrons and in
2007 we are introducing an audit tool so that visual inspections are recorded for actions as appropriate.
8.7 Patient Equipment Cleaning Following work undertaken by one of the Directorate Lead Nurses a definitive list of Patient Equipment has been established in order to identify responsibility, frequency and method of cleaning and there is now a Patient Equipment Cleaning policy. This has been implemented Trust wide.
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9. Catering and Kitchens 9.1 Audits of Ward Kitchens Ward kitchens have been inspected as part of the National Standard of Cleanliness Audits and PEAT inspections and, whilst maintained in a clean state, deficiencies in design have been noted. As a result a refurbishment programme was commenced four years ago. A further 3 kitchens have been fully refurbished this year, incorporating better storage and a dishwasher. Another two kitchens that did not require refurbishment have had dishwashers added. The inclusion of a dishwasher enables some dish washing to take place on the wards, rather than in central kitchens. 9.2 Main Kitchens HACCP and EHO reports The main kitchens and other food outlets, such as Fine Fillings, are inspected by the Environmental Health Officer once a year. Random food sampling is also undertaken by the EHO. An analysis of hazards and critical control points is undertaken annually. 9.3 Introduction of a Cook Freeze Food Service The implementation of cook freeze has been a major project over the last 18 months. The infection control team have provided input via the project steering group and have been particularly involved with ensuring that standards of food hygiene are adequate at ward level. Evaluation of the new system continues.
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10. Targets and Outcomes 10.1 MRSA Bacteraemia - A 60% reduction target has been set which the Trust is expected to achieve by 2007/8. Whilst statistically we remain on trajectory, the target for 2006/7 was breached. Refer Appendix 14 for progress. Since November 2006 an investigation of each MRSA bacteraemia has been undertaken using the NPSA action tool. Where applicable, an action plan is compiled and reported through the Directorate Governance Groups. 10.2 Cleaner hospitals (PEAT scores) PEAT inspections are undertaken annually by self assessment. The internal assessment score was 92% across the Trust. We are waiting to hear if this will be validated by an external inspection team. 10.2 Healthcare Standards – C4a Although several of the standards are related to infection control, core standard C4a is specifically relevant. Following assessment by the internal audit department the Trust has been able to declare compliance with this standard. 10.3 Compliance against the Hygiene Code Compliance with the Code was assessed in October 2006. An action plan was formulated to achieve full compliance by march 2006, much of which reflected work underway in response to the ‘Saving Lives’ self assessment tool. Full compliance has subsequently been achieved. 10.4 Local Targets Progress with the Infection Control Annual Programme has been monitored by the Infection Control Committee and, in general, planned activities have been completed (Appendix 1).
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11. Audit 11.1 Environmental Audit Due to public concern over environmental hygiene in the NHS, considerable effort has been spent on environmental audit, in conjunction with Housekeeping Services. The audits are undertaken monthly by the monitoring officer and are validated quarterly by a team which includes infection control nurses and Matrons. Reports are available on request from the Hotel Services Manager. Infection control nurses have also been involved in all the PEAT inspections. 11.2 Hand Hygiene Observational audit of hand hygiene practice has continued, using an adapted Lewisham Observational Audit tool. Observations are undertaken by link nurses who submit the data to the Infection Control Team. Feedback on compliance is provided in the form of a run chart. Examples of compliance charts which are included at Appendix 12. The minimum standard for wards to aim for is 70%. This standard will be raised in 2007/8. All compliance charts are available from the Infection Control Department on request. 11.3 Mupirocin Audit Patients receiving dialysis via a haemodialysis line should receive nasal bactroban on insertion of the line and thereafter a 5 day course once a month. This intervention was agreed to reduce the risk of Staph. aureus bacteramia in these high risk patients. An audit was undertaken to determine whether the intervention had been implemented effectively. The audit showed that the introduction of Mupirocin for patients requiring haemodialysis via central lines was hampered by national supply problems throughout 2006. In addition an initial attempt to audit the implementation of the introduction highlighted the fact that there was no formal documentation of what was occurring. The attempt at the initial audit showed that a documentation system needed to be established. A full report can be obtained from the Infection Control department on request 11.4 Peripheral Venous Cannulae (PVC) Inappropriate PVC care has been associated with increased phlebitis/infection risk. Factors which may increase the risk of phlebitis are many and may include: method and site of insertion, purpose of PVC, and dressing types used.
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This study focused on: • Dressing type, condition and application • Duration of PVC placement • Documentation • Regular assessment of PVC entry site for the early detection of
complications • Prompt removal of devices either not in use or exhibiting signs of
phlebitis Whilst this study provided evidence of good compliance with some Trust standards, poor compliance was demonstrated in other areas, including documentation of line insertion, documentation of ongoing assessment and VIP score, delayed removal of unused PVC, and date labelling of administration sets. A high phlebitis prevalence rate was recorded in this study, and whilst it is reassuring that the vast majority of patients did not develop severe stage phlebitis, it is significant that 16 patients were found to have early to mid stage phlebitis, with a PVC still in situ. A range of recommendations have been made, including review of the pvc device used in the Trust, in collaboration with the Peninsular Purchasing Alliance. The full report is available on request from the Infection Control Department. 11.5 Antibiotic Prescribing The RD&E appointed an antibiotic pharmacist in 2004. A substantial part of the antibiotic pharmacist’s role is to undertake surveillance and audit to improve antibiotic prescribing. Audits undertaken or completed in 2006 – 7 by the antibiotic pharmacist include
1. vancomycin prescribing and monitoring 2. a point prevalence survey of antimicrobial use in collaboration with
other pharmacy departments in the South West 3. antimicrobial prescribing, with relevance to switching to oral from iv
therapy 11.6 Other Audits The Infection control team work collaboratively with other specialists to audit clinical care, providing infection control, expertise and advice. In particular, as mentioned in Section 6, the Saving Lives High impact intervention monitoring tools have been piloted to audit care in relation to reducing risk of catheter associated urinary catheter care, surgical site infection, reducing ventilator associated infection, catheter related blood stream infection and Clostridium difficile infection.
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12. Training Activities 12.1 Induction for all Staff Infection control training is provided for all staff as part of the Trust Induction programme which runs weekly. 12.2 CPD for Clinical and Support Staff An extensive programme of continuing education is available for all groups of staff, provided by the Infection Control Team. In addition, this year an electronic training package has been used for the first time for senior medical staff. Details are available from the Infection Control Department. 12.3 For infection Control Specialists All members of the Infection Control Team are members of the Infection Control Nurses’ Association (ICNA) and attend regional meetings which provide the opportunity for update and networking. All receive specialist journals as a benefit of membership which also aids development. Three members of the team attended the ICNA Annual Conference in Brighton. The Lead Nurse attended in her role as Chairperson of the ICNA. Another member of the team applied for one of 10 ICNA funded places and was successful. The third member of the team was funded from the infection control teams’s charitable fund. Two of the infection control nurse specialists have commenced a Post Graduate Diploma in Infection Control, undertaking four modules this year and another progressed through the second year of same programme of study, completing in June. The programme of study is provided by Inverness College and is available on-line. The Lead Nurse continues a slow course of study leading to a MSc Infection Control. This is also an online course through Inverness College. The Infection Control Doctor is a member of the Royal College of Pathologists and participates in the College’s continuing professional development scheme. His annual CPD plan includes infection control. He is also a member of the ICNA. This year among other meetings with infection control educational content he attended the Hospital Infection Society international conference in Amsterdam. 12.4 For the Joint DIPCs The DIPC role is shared by the Infection Control Doctor and the Lead Nurse. As such, both already hold specialist qualifications and have considerable experience within the field of infection control. In addition to training undertaken as part of their personal development as Lead Nurse and Infection Control Doctor, the DIPCs have attended SW Peninsula IP&C Forum educational events.
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13. Policies and Guidelines The following existing policies and guidelines have been reviewed,updated where relevant and disseminated in 2006/7. Source Isolation Policy Clostridium difficile Legionella Control Policy Aseptic technique ESBLs and Amp Cs Guidance on Animals and Pets in Helath Care Facilities Major Outbreak Plan The following policies have been reviewed and are awaiting final approval and dissemination: Infection Control Policy Surveillance Policy MRSA Guidelines
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The Chief Medical Officers Report ‘Winning Ways’ identified seven key action areas to achieve a reduction in health care associated infection and provided long term direction for infection control activities within NHS Trusts. In response to ‘Winning Ways’, a local, long term, action plan was formulated within the RD&E. The local action plan informs the annual programme of infection control activities for the Infection Control Team and the Trust. The contents of the annual programme also reflect the work required to implement the Department of Health ‘Saving Lives’ programme. These activities are inextricably linked to achieving the MRSA reduction target of 60% reduction by 2007/8. However, there are additional key issues for the Trust over the next year which include influenza planning, maintaining low levels of Clostridium difficile infection and Norovirus outbreak management strategies. The annual programme of work is undertaken in addition to the routine work of the Infection Control Team, which includes the 24 hour provision of clinical advice, delivery of education to all groups of staff, policy review and updating, audit and surveillance.
APPENDIX 1
Infection Control Annual Programme
2006/7 1. Introduction
.
Infection Control Annual Programme 2006-2007 Approved Infection Control Committee – 18th May 2006 Approved Trust Board – 28th June 2006 Page 28 of 55
2. Planned programme based around the Winning Ways Action Areas Winning ways Action Area
Activity To be completed Progress at March 2007
Surveillance The ICT will: ♦ Continue to undertake the mandatory surveillance activities:
♦ Staphylococcus aureus bacteraemia (MRSA and MSSA) ♦ Glycopeptide resistant enterococcal bacteraemia ♦ Clostridium difficile disease
♦ Assist the Orthopaedic Directorate to undertake mandatory orthopaedic surgical site infection surveillance
♦ Continue Trustwide, ‘all organism’ bacteraemia surveillance with feedback to
clinicians ♦ Continue the alert organism and alert condition surveillance with feedback
by Directorate to Governance Committee on MRSA and Clostridium difficile infection.
♦ Two monthly MRSA and C.difficile SPC chart feedback will be provided to
each ward/inpatient unit. ♦ Participate in National Prevalence Study – collecting healthcare associated
infection data throughout the Trust NB This will be collected by most members of the ICT over a two week period. It will be very demanding but should result in Trust specific feedback by type of infection, specialty etc.
Ongoing September 2006 Ongoing Ongoing Ongoing May 2006
Completed Completed
Reducing the Infection risk from catheters, tubes, cannulae,
♦ A significant proportion of bloodstream infections are associated with the insertion and use of central venous catheters (CVC). CVC guidelines were approved and disseminated at the end of 2004-2005. Therefore, activity this year will focus on:
♦ Completing audit of CVC care in ITU with feedback and
April 2006
Completed
Infection Control Annual Programme 2006-2007 Approved Infection Control Committee – 18th May 2006 Approved Trust Board – 28th June 2006 Page 29 of 55
instruments and other devices
recommendations. ♦ Continue line audit and surveillance work in Renal unit
♦ Provide infection control expertise and clinical project leadership to the
Saving Lives Steering group ♦ Provide infection control expertise to the four subgroups of the ‘Saving
Lives’ Steering Group i.e. end of 2004-2005.
♦ Reducing the risk of catheter associated urinary tract infection ♦ Reducing the risk of central line associated blood stream infection ♦ Reducing the risk of ventilator associated pneumonia ♦ Reducing the risk of surgical site infection
♦ Repeat peripheral cannula audit in a selection of areas to determine
improvement since Trustwide audit last year.
♦ Considerable emphasis remains on improving decontamination practices and whilst considerable improvements have been made over the last few years further work is required:
♦ Specialist advice to the Endoscopy Dept when considering
developments to decontamination facilities and tracking systems (aligned to Treatment Centre planning)
♦ Amend procedures to deal with instruments used on a patient known or suspected to be infected with CJD in view of new risk groups.
Ongoing. Ongoing March 2006 October 2006 Ongoing June 2006
Completed Completed Draft - completion delayed due to new national guidance
Reducing Reservoirs of Infection
The ICT will: ♦ Work with health planners, architects and user groups to ensure that the
facilities provided within Phase 4 and Treatment Centre are designed to facilitate infection prevention and control.
♦ Participate in National Standards of Cleanliness audits on a quarterly basis
and advise on areas of concern
Ongoing Ongoing
Infection Control Annual Programme 2006-2007 Approved Infection Control Committee – 18th May 2006 Approved Trust Board – 28th June 2006 Page 30 of 55
♦ Participate in PEAT audits and advise on areas of concern. ♦ Regularly review the arrangements for managing C.difficile infection e.g.
cohort/isolation facility provision, in light of monthly surveillance data provision
March 2007 Ongoing
Completed
Hygiene in Clinical Practice
♦ Continued efforts are required to increase and maintain compliance with hand hygiene and make sure that all disciplines recognise this as their responsibility: To this end the following activities are required:
♦ Continue to collate observational audit results and provide feedback
to wards sisters, Matrons, Lead Nurses who in turn will share with other disciplines at Directorate Governance Group Meetings.
♦ Feedback on progress to Trust Governance Committee and Nursing and Midwifery Governance Committee
♦ Working with the Director of Nursing and Service Improvement and
Directorate Lead Nurses to ensure that responsibility for implementation of infection control improvement work sits with the Matrons and Ward Sisters/Charge Nurses,
♦ Plan and deliver an infection control study day for Matrons.
Ongoing Ongoing November 2006
Completed Completed
Prudent use of antibiotics
♦ Continue the revision cycle of the antibiotic formulary ♦ Surgical prophylaxis – finish revision of surgical prophylaxis section ♦ Contribute to the business case for retaining an antibiotic pharmacist ♦ Contribute to the business case for additional ward pharmacists ♦ In cooperation with pharmacy department develop surveillance of
antimicrobial consumption when enhanced IT systems are available.
ongoing July 2006 April 2006 April 2006 December 2006
Completed Completed Completed Completed No IT available
Management and
♦ Formalise reporting arrangements between DIPC and Executive Team through monthly 1:1’s and Quarterly Review process
April 2006
Completed
e 2006-2007 ittee – 18th May 2006
th June 2006 Page 31 of 55
Organisation ♦ Produce an annual report for 2005/6
June 2006
Completed
Research and Development
♦ Undertake project to determine whether pregnant women employed in health and social are more likely to be MRSA carriers than other pregnant women. Findings will influence whether this group of patients should be screened for MRSA carriage prior to delivery.
♦ Publish report on C.difficile 027 outbreak
March 2007 March2007
In progress Not completed, although presented at numerous conferences/seminars
3. Other issues Action area
Activity To be completed
Influenza planning
♦ Contribute to Trust and PCT strategic and operational influenza planning groups as required.
♦ Provide guidelines for infection control in relation to Avian and Pandemic Influenza
♦ Provide FFP3 respirator fit testing & PPE training for key personnel within the Trust and the PCTs
Completed Completed Completed
Norwalk outbreak management
♦ Set up a review meeting once Norwalk season has abated. ♦ Review impact on the Trust in 2004/5 and 2005/6 ♦ Consider alternative strategies that may be useful next year with particular
regard to: ♦ Assessment on admission ♦ Admission facilities ♦ Cleaning - routine and terminal ♦ Bay and ward closure ♦ Movement to Community Hospitals/ Care Homes/own homes with
care package.
June 2006 Completed Completed Completed
Infection Control Annual ProgrammApproved Infection Control CommApproved Trust Board – 28
Infection Control Annual Programme 2006-2007 Approved Infection Control Committee – 18th May 2006 Approved Trust Board – 28th June 2006 Page 32 of 55
4. Monitoring progress Progress with the annual programme will be monitored by the Infection Control Team and Infection Control Committee, which in turn reports to the Trust Governance Committee. Specific issues relating to the Saving Lives delivery programme will be reported via the Saving Lives Steering Group. The Joint DIPCs will produce an annual report for the Board which will be published on the Trust website.
APPENDIX 2
INFECTION CONTROL COMMITTEE
Terms of Reference
Healthcare Standards (CORE – C4a
Complaints
Healthcare Standards (DEV’T - please specify which standard)
Monitor
Service Development Strategy Finance Local Delivery Plan Performance Management Assurance Framework Business Planning Other (Please specify) Code of Practice
1. Accountability 1.1 The Committee is a subcommittee of the Board of the Royal Devon and
Exeter NHS Foundation Trust. It normally reports to the Chief Executive and the Board through the Governance Committee of which the Director of Infection Prevention and Control is a member.
2. Purpose 2.1 The Infection Control Committee is the forum for consultation between
the Trust’s Infection Control Team and all other Directorates and Departments of the Trust.
2.2 The Committee agrees and endorses the Infection Control Teams
Annual Programme, which it also supports and monitors. 3. Membership 3.1 The Members of the Committee shall be appointed by the Board of Directors. 3.2 The Director of Infection Prevention and Control is chairman of the Committee 3.3 The membership shall be:
• Infection Control Team
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• Director/s of Infection Prevention and Control • Chief Executive or a representative with delegated authority • Medical Director • Director of Nursing & Service Improvement or representative • Consultant in Communicable Disease Control • Occupational Health Physician or Nurse • Director of Facilities/Decontamination Lead • Directorate Infection Control Leads • Medical staff - clinical champions for infection control issues • Hotel Services Manager
3.2.1 This membership ensure that all disciplines and groups of staff are
represented on the committee 3.2.2 If necessary additional members may be co-opted or invited at the
discretion of the committee, for example if their skills are required to cover particular topics.
4. A Quorum 4.1 A quorum will consist of not less than five members of the Committee,
and shall include:
• A Director of Infection Prevention and Control • One of the following:
– Chief Executive (or representative), – Medical Director or Director of Nursing & Service Improvement
5. Procedures 5.1 The Infection Control Committee shall appoint a secretary to prepare
and distribute agendas, keep minutes and deal with any other matters concerning the administration of the Committee. The Secretary shall distribute unapproved minutes of the Committee’s meetings to all members of the committee and the Governance Committee Manager within one month of a meeting.
5.3 The Chairman will prepare a ‘decision briefings’ sheet after each
Committee meeting to be sent to the Governance Committee Manager within one month of a meeting.
5.4 Any member of staff may raise an issue with a member of the
Committee. The Chairman will decide whether or not the issue shall be included in the Committees business. The individual raising the matter may be invited to attend.
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6. Frequency of Meetings 6.1 There will be four meetings a year. The Committee’ annual cycle is the
accounting year. 6.2 An extra-ordinary meeting may be called by the Director of Infection
Prevention Control or at the request of the Chief Executive. 7. Duties and Responsibilities 7.1 Agree and monitor an annual programme of activity including
surveillance, audit and education programmes. 7.2 Advise and support the Infection Control Team on the most effective
use of available resources in delivering an annual programme to include audit surveillance and education.
7.3 Draw the attention of the Chief Executive and the Board to any serious
problems or hazards relating to infection control. 7.4 Review reports on hospital acquired infection and infection control
problems. 7.5 Commission, approve and review policies for all aspects of infection
control and monitor their implementation. 7.6 Draw up plans for management of outbreaks both in the hospital and
the hospital’s response to major outbreaks in the community. 7.7 Ensure that all relevant legislation, Health Service Guidelines etc is
reviewed and that appropriate amendments/additions are made to local policies and procedures.
7.8 Review the funding and resource implications of other infection control
issues such as provision of adequate hospital facilities and accommodation and make appropriate recommendations to the Trust Board.
7.9 Received the DIPC Annual Report. 8. Review 8.1 The Infection Control Committee will review its Terms of Reference
annually and make recommendations to the Governance Committee for any changes required to ensure that the Committee remains fit for purpose.
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9. References 9.1 Guidance on the functioning of the Infection Control Committee is
produced by the Department of Health, the Health Protection Agency and Professional Bodies and Societies such as the Infection Control Nurses Association, the Association of Medical Microbiologists and the Hospital Infection Society.
9.2 Relevant Documents include:
• Health Act. Code of Practice for the Prevention and Control of Health Care Associated Infections. DH 2006
• Standards in Infection Control in Hospitals AMM, HIS, ICNA, PHLS:1993
• Hospital Infection Control: Guidance on the Control of Infection in Hospitals (The Cooke Report) DH: 1995
• Guidance for Clinical Healthcare Workers Protection against blood borne viruses DH:1998
• Winning Ways DH: 2003
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APPENDIX 3
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APPENDIX 4
INFECTION CONTROL COMMITTEE Minutes of the Meeting
held on 9th November 2006 12.30 PM Committee Room
Present: Julie Bloom, Alaric Colville, Penny Criddle, Janet De’Witt,
Berni George, Linda Hall, Hazel Hedicker, Mark Kealy, Pam Matten, Heather Pellow, Judy Potter, Terry Riordan, Doerte Schneider, Peter Schranz, Mark Stott, Kate Underwood, Iain Wilson
In attendance Janet Oatley 1. Apologies for Absence
Julie Bennett, David Dalton, Jane Evans, Elaine Hobson, Carlton Kneil, Catharine Pym, Ann Rossiter, Nick Withers
2. Minutes of the last meeting held on 23rd August 2006
The minutes were accepted as a correct record.
3. Actions from the Last Minutes Meningococcal Flowchart
Judy Potter reported that following the last meeting lots of e-mails had been sent clarifying the agreement and communication is better now. Alaric Colville proposed that the Committee agreed the flowchart and that it should be circulated and approved for a further two years.
Action: Infection Control
Mark Kealy commented that an agreement has not yet been reached with the Walk-in-Centre. Terms of Reference Judy Potter confirmed that she had amended the Terms of Reference to include the Director of Facilities and the Directorate Infection Control leads. Alaric Colville asked for comments within the next 24 hrs otherwise the Terms of Reference will be taken as accepted. The footer requires amendment.
Action: Committee Members/Janet Oatley
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MMR Vaccination Judy Potter confirmed that the importance of MMR vaccination will be recommended to staff during mandatory training.
4. Any Other Matters Arising
There were no other matters arising.
5. National Prevalence Survey
Judy Potter reported that the results have been made available and the overall rate was 7.6% as opposed to 9% last time. The local Trust figures are due to be made available mid November. Judy Potter stated that urinary tract infections are the most common.
6. Saving Lives – Code of Practice
Judy Potter spoke about the Code of Practice for the Prevention and Control of Healthcare Associated Infections that became legislation on 2nd October, she handed round a paper outlining the elements of the Code of Practice and the areas where the Trust need to improve. The main gap is around education and recording of attendance. Accessing of Medical Staff is particularly difficult. However it has been agreed as part of Saving Lives that attending infection control training is to become part of the annual appraisal process for medical staff. More work needs to be done on this.
Action Alaric Colville
It was agreed that infection control input at audit meetings would be appropriate for this training. Mark Stott suggested highlighting the requirement for training at the directorate business meetings. Iain Wilson commented that it would be good to have a variety of ways of accessing training and Judy Potter agreed to investigate an e-learning package currently in use by UCL.
Action: Judy Potter
Judy Potter commented that there is a need to inform current members of staff of the need to attend mandatory infection control training, she had discussed this with Linda Hall and it is hoped to send a statement with payslips to highlight this requirement. Judy Potter spoke about a study day being held on Thursday 16th November where a representative from the Healthcare Commission will be speaking about how they will be ensuring Trusts comply with the Code of Practice.
7. Policies
Source Isolation This revised policy was approved by the Committee
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Guidance on Animals & Pets in Healthcare Facilities This new policy was approved by the Committee, it requires an impact assessment and will then be presented to the Governance Committee.
Action: Judy Potter
Extended Spectrum Beta-Lactamases (ESBLs) & Resistant Amp C type Beta-Lactamases (AMPCs) This new policy was approved by the Committee, it requires an impact assessment and will then be presented to the Governance Committee
Action: Judy Potter Protocol for Aseptic & Clean Techniques This policy has been produced as a requirement for the Code of Practice, comments were requested in the next 3 weeks.
Action: Committee Members
Revised Major Outbreak Plan This policy currently sits as an appendix to the major incident plan, Judy Potter plans for this to form part of the Infection Control manual. Comments were requested in the next 3 weeks.
Action: Committee Members MRSA Policy This has been widely circulated for comments and these need to be incorporated into the policy. Discussion took place about screening all patients admitted to Durbin, it was agreed this would be removed from the policy for the time being and discussed outside of this meeting. The policy will then go to the Governance Committee.
Action: Judy Potter
8. Report on MRSA and Clostridium difficile in the Trust
A graph showing the latest figures of ward acquired MRSAs was circulated prior to the meeting, this shows a downward trend. Judy Potter commented that October had seen an increase in MRSA bacteraemias. A graph showing the latest figures for C.difficle was also circulated this shows that the situation is controlled and there has been a sustained decline. Judy Potter commented that the Trust had been praised by the Regional epidemiologist. Judy Potter spoke of a requirement from the Department of Health to undertake root cause analysis for ward acquired MRSA bacteraemias. A briefing paper was presented to the OMG meeting on Monday and this will be circulated to lead nurses.
Action: Judy Potter
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ESBLs It was agreed that surveillance of ESBLs would become a standing agenda item.
Action: Janet Oatley 9. Hotel Services
Pest Control Report Hazel Hedicker reported that there is no longer a problem with seasonal pests e.g. ants, flies. Problems continue with seagulls and a trial of placing plastic hawk owls around the roof is planned. Cleaning Audit Scores Graphs were circulated with the agenda showing the audit scores for July to September 06. Hazel Hedicker reported recent problems with manpower resulting in a reduced service in most areas, this was partly due to a freeze on posts. As a result weekend service only had been available in several areas. The Committee agreed that this was potentially dangerous. A job advert is due to be placed shortly and it is planned that by January 2007 there will be an additional 24 WTE members of staff in post. Hazel Hedicker confirmed that she has secured funding for an agency outbreak cleaning team and these staff will be trained as soon as possible and used on the wards in the interim. Berni George commented that she had spoken with Linda Hall regarding the freezing of posts and been assured that this will be discussed with lead nurses and DIPCs before it is proposed for cleaning staff in the future in the future.
10. Other Surveillance/Audit
PVC Audit Judy Potter commented that this audit has been completed and a report is being written.
Action: Infection Control
Orthopaedic Surgical Site Infection Surveillance Judy Potter reported that the current surveillance had ended resulting in a 0% infection rate. Judy Potter and Pam Matten are due to meet regarding the next period of surveillance.
Action: Judy Potter/Pam Matten Hand Hygiene Judy Potter commented that the observational audits are being undertaken regularly, a standard of 70% has been set and most wards are achieving this level.
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Alaric Colville thanked Catharine Pym in her absence for her on-going work with surveillance. MRSA/MSSA Alaric Colville spoke of the new web based reporting of MRSA and MSSA bacteraemias. National Prevalence Survey Judy Potter commented that this will be published in November and will be an agenda item for the next meeting.
Action: Janet Oatley
11. Outbreaks & Incidents
Neonatal Unit Alaric Colville spoke of a current problem on the Neonatal unit of 5 babies with a respiratory tract problem which may be viral but is not RSV, 1 baby has been readmitted to intensive care and the unit has been closed to planned admissions. Norovirus Judy Potter spoke about a community unit in Honiton has recently been closed due to D&V. (Post meeting comment – this is confirmed norovirus activity.) Alaric Colville commented that the business case for the Norovirus PCR test is to go to the capital control group. One patient recently admitted via EMU to Torridge has tested positive for Norovirus. Hazel Hedicker asked for the infection control guidance re D&V for on-call managers to be sent to her electronically.
Action: Judy Potter
12. Any Other Business
Flu Vaccination Kate Underwood reported that the programme of flu vaccination began yesterday at the RD&E and 310 members of staff were vaccinated. Berni George commented that feedback regarding the occupational health nurses going onto wards to target staff had been very positive.
13. Date of Future Meetings
Thursday 22nd February Board Rm 12.30 – 2pm Wednesday 23rd May Board Rm 12.30 – 2pm Thursday 23rd August Board Rm 12.30 – 2pm Thursday 22nd November Board Rm 12.30 – 2pm
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APPENDIX 5 DECISION BRIEFINGS
Name of Committee Control Committee Governance Committee – Decision Briefings
Name of Committee: Control of Infection Committee Date of Meeting: 18th May 2006 Number Description of Decision
1
The DIPC annual report and the Infection Control Team’s 2006/7 annual programme will be presented to the Trust Board on June 28th
2
The ICT surveyed the whole hospital in March for the National Prevalence Survey of Hospital Infections. Results are Expected in October
3
To overcome the problem of prescribing prophylaxis in the hospital to contacts of meningococcal disease, PCTs could be charged for the service. This will be taken forward via the contracting meetings.
4
Pest problems due to Seagulls are increasing. Problems with fouling and patient complaints. There has been reluctance to cull because of previous objections. The need for control will be taken up with the Trust Executive and the Patients Forum.
5
Because of poor MMR vaccine coverage outbreaks of measles are being reported in the country and local cases admitted to RD&E. Non-immune staff are at risk of infection, and in line with Trust policy staff should be protected with 2 doses of MMR. An information campaign to inform staff will take place, with support of managers. High risk areas e.g. ED, EMU and paediatrics will be targeted particularly to obtain high coverage rates of staff. This needs high level enthusiastic support.
Date of Meeting: 23rd August 2006 Number Description of Decision
1
Mechanisms to provide contacts of meningococcal disease with prescriptions for prophylactic antibiotics in the RD&E have been clarified.
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2
Terms of Reference reviewed. Changes recommended to Committee composition, and Annual DIPC report is specified as annual report.
3
Updated policies on following agreed
• Clostridium difficile & Antibiotic Associated Colitis • Varicella Zoster (VZ) Virus, Chickenpox and Shingles • Legionella Control Policy
4
New policy on Guidance on Animals and Pets in Health Care Facilities agreed to be seen by disability equality action group before submitting to Governance Committee.
Date of Meeting: 9th November 2006 Number Description of Decision
1
The flowchart for prophylaxis for contacts of meningococcal disease has been agreed within the Trust and will be reviewed after 2 years. Mark Kealy CCDC still has to make progress with Walk in Centre for prescribing to contacts.
2
The CIC terms of reference have been reviewed and updated. The Director of Facilities and Directorate Infection Control Leads are included in membership now.
3
The Committee received reports that, because of a freeze on recruitment and manpower problems, domestic services in some areas had to be reduces to weekend levels of cover. The Committee was extremely concerned about this, and felt that the situation was potentially dangerous. In the present climate highlighting the importance of domestic hygiene it was very worrying that domestic posts could be frozen to lead to such a low level of service provision. Recruitment to overcome the situation is imminent. In addition any moves to limit recruitment into established post in the future will be discussed with lead nurses and DIPCs.
4
In future Extended Spectrum Beta Lactamase (ESBL) positive coliforms will be added to routine surveillance reports in the Trust. These resistant organisms have caused outbreaks in some parts of the country, and may well be the subject of statutory surveillance in the future.
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Date of Meeting: 23rd February 2007 Number Description of Decision
1. The following policies/guidance were approved: Infection Control Policy Surveillance and Reporting Policy Tuberculosis Management in a Hospital Setting
2. Agreed that Hibiscrub would be used as a substitute for Aquasept skin cleanser for MRSA decolonisation, until national supply issues had been rectified.
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APPENDIX 6
OUTBREAKS OF SUSPECTED OR CONFIRMED NOROVIRUS
No of Outbreaks Affecting Whole Wards
0
2
4
6
8
10
12
14
16
18
April
MayJu
ne July
Augus
tSep
tOct Nov Dec Ja
nFeb
March
2003/20042004/20052005/20062006/2007
No of Outbreaks Affecting Single Bays Only
0
5
10
15
20
25
30
April
MayJu
ne July
Augus
tSep
tOct Nov Dec Ja
nFeb
March
2003/20042004/20052005/20062006/2007
APPENDIX 7
Ward Closures due to D&V Dec 05 - March 06
0123456789
1011121314151617181920
13-D
ec17
-Dec
21-D
ec25
-Dec
29-D
ec2-J
an6-J
an10
-Jan
14-Ja
n18
-Jan
22-Ja
n26
-Jan
30-Ja
n4-F
eb8-F
eb12
-Feb16
-Feb20
-Feb24
-Feb28
-Feb4-M
ar8-M
ar12
-Mar
16-M
ar20
-Mar
24-M
ar28
-Mar
Date
War
d C
odes
Avon (1)
Bolham (2)Bovey (3)Clyst (4)
Creedy (5)
Culm (6)Culm (RHDU) (7)
Harbourne (8)
Kenn (9)
Okement (10)Taw (11)
Torridge (12)Dart (13)
Exe (14)Dinham (15)
Otter (16)
Tavy (17)
Knapp (18)Durbin (19)
Page 47 of 55
Ward Closure due to D&V Dec 06 - Mar 07
0
1
2
3
4
5
6
7
13-D
ec16
-Dec
19-D
ec22
-Dec
25-D
ec28
-Dec
31-D
ec3-J
an6-J
an9-J
an12
-Jan
15-Ja
n18
-Jan
21-Ja
n24
-Jan
27-Ja
n30
-Jan
3-Feb
6-Feb
9-Feb
12-Feb
15-Feb
18-Feb
21-Feb
24-Feb
27-Feb2-M
ar5-M
ar8-M
ar11
-Mar
14-M
ar17
-Mar
20-M
ar23
-Mar
26-M
ar29
-Mar
Dates
War
d C
odes
Bolham (1)Okement (2)Harbourne (3)Bovey (4)Dyball (5)Clyst (6)
Page 48 of 55
APPENDIX 8 New cases of Clostridium difficile infection
0
20
40
60
80
100
120Ja
nFe
bM
arA
prM
ayJu
nJu
lA
ug Sep Oct
Nov
Dec Jan
Feb
Mar
Apr
May
Jun
Jul
Aug Sep Oct
Nov
Dec Jan
Feb
Mar
Apr
May
Jun
Jul
Aug Sep Oct
Nov
Dec Jan
Feb
Mar
Apr
May
Jun
Jul
Aug Sep Oct
Nov
Dec Jan
Feb
Mar
2003 2004 2005 2006 2007
Date
Num
ber o
f epi
sode
sSurgical RDEMedical RDEWoman & ChildrenRD&E OPDComm. Hosp. & Rehab. GPOtherTotals
Page 49 of 55
APPENDIX 9
MRSA Bacteraemias
0
1
2
3
4
5
6
7
8
Aug
-03
Sep
-03
Oct
-03
Nov
-03
Dec
-03
Jan-
04
Feb-
04
Mar
-04
Apr
-04
May
-04
Jun-
04
Jul-0
4
Aug
-04
Sep
-04
Oct
-04
Nov
-04
Dec
-04
Jan-
05
Feb-
05
Mar
-05
Apr
-05
May
-05
Jun-
05
Jul-0
5
Aug
-05
Sep
-05
Oct
-05
Nov
-05
Dec
-05
Jan-
06
Feb-
06
Mar
-06
Apr
-06
May
-06
Jun-
06
Jul-0
6
Aug
-06
Sep
-06
Oct
-06
Nov
-06
Dec
-06
Jan-
07
Feb-
07
Mar
-07
Not R D & E AcquiredR D & E Acquired
Page 50 of 55
APPENDIX 10
New cases of MRSA - identified more than 3 days after admission to RD&E
0
5
10
15
20
25
30
35
40
Nov-03
Jan-0
4Mar-
04May
-04Ju
l-04
Sep-04
Nov-04
Jan-0
5Mar-
05May
-05Ju
l-05
Sep-05
Nov-05
Jan-0
6Mar-
06May
-06Ju
l-06
Sep-06
Nov-06
Jan-0
7Mar-
07
No ofMRSACL
UCL
LCL
Page 51 of 55
APPENDIX 11
Total Number of New MRSA Incidences per Quarter across the Whole Healthcare Community
0
50
100
150
200
250
300
Jan -March
03
April -June 03
July -Sept 03
Oct -Dec 03
Jan -March
04
April -June 04
July -Sept 04
Oct -Dec 04
Jan -March
05
April -June 05
July -Sept 05
Oct -Dec 05
Jan -March
06
Apr -June 06
July -Sept 06
Oct -Dec 06
Jan-March
07
Page 52 of 55
Page 53 of 55
APPENDIX 12
Hand Hygiene Compliance - Okement ward
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jun-06
Apr-05
May-05
Jun-05
Jul-05
Aug-05
Sep-05
Oct-05
Nov-05
Dec-05
Jan-06
Feb-06
Mar-06
Apr-06
May-06
Jul-06
Aug-06
Sep-06
Oct-06
Nov-06
Dec-06
Jan-07
Feb-07
Mar-07
Hand Hygiene Compliance - ITU
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Summer
03
Feb-04
May-04
Jul-0
4
Sep-04
Nov-04
Jan-0
5Apr-
05
May-05
Oct-05
Nov-05
Dec-05
Jan-0
6
Feb-06
Mar-06
May-06
Aug-06
Oct-06
Dec-06
Jan-0
7
Feb-07
Mar-07
APPENDIX 13
Clean Hands are Safe HandsClean Hands are Safe Hands
If you’re notsure if we’vecleaned our hands, please remind us.
Page 54 of 55
APPENDIX 14
Monthly Statistical process chart for end point MRSA infection target
0
2
4
6
8
10
12
14
16Ap
ril
May
June
July
Aug
ust
Sep
tem
ber
Oct
ober
Nov
embe
r
Dec
embe
r
Janu
ary
Febr
uary
Mar
ch
April
May
June
July
Aug
ust
Sep
tem
ber
Oct
ober
Nov
embe
r
Dec
embe
r
Janu
ary
Febr
uary
Mar
ch
April
May
June
July
Aug
ust
Sep
tem
ber
Oct
ober
Nov
embe
r
Dec
embe
r
Janu
ary
Febr
uary
Mar
ch
05/06 06/07 07/08
Mon
thly
MR
SA b
acte
raem
ia
Actual monthly figureTarget figureLOWER ACTION LIMITSUPPER ACTION LIMITSLOWER WARNING LIMITSUPPER WARNING LIMITS
Page 55 of 55
