Infection Prevention and Control Annual Report

2011 – 2012

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Trust Values

Trust Strategic Goals

Our strategic goals are: To deliver high quality person centred models of care, throughout the organisation. To be at the centre of an integrated network of partnerships to provide holistic approach to care. To engage with our communities to ensure we deliver the services they require.

To be a dynamic organisation driven by innovation To be one of the most efficient providers

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Contents

Executive summary 4 Introduction 5 Assessment of compliance with the Health & Social Care Act 2008 6 Trust arrangements for Infection Prevention & Control 7 Assurance framework 8 Annual Programme of Work 9 Key documents 9 Mandatory reporting 10 Meticillin resistant & Meticillin sensitive Staphylococcus aureus 11 Escherichia coli 12 Clostridium difficile infections (CDI) 12 Resistant microorganisms 13 Serious incidents 14 Specialist advice 16 Hand Hygiene 16 Cleanliness 17 The Built Environment 19 Antimicrobial resistance 20 Seasonal Influenza Vaccine Campaign 21 Education and Training 22 Policy development and review 23 Quality Improvement 24 Information for members of the public 25 The Management of Medical Devices 26

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Summary of Achievements 28 Areas of further development 29 Summary and Conclusion 30 References 31 Appendix I Infection Prevention and Control Annual Programmes of Work 33 Appendix II The Management of Medical devices Annual Programme of Work 40 Appendix III Role of the Director of Infection Prevention andn Control (DIPC) 41

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Executive Summary Combined Healthcare NHS Trust has an excellent track record of sustaining year on year reductions in healthcare associated infection. Not all infections are preventable, and not all are healthcare associated, however, the organisation has a zero tolerance to avoidable infections and strives to care for patients in a safe environment protecting them from harm. The Director of Infection Prevention and Control is pleased to announce that the Trust has met the infection prevention and control objective for the period 2011/2012. There have been no Meticillin resistant Staphylococcus aureus (MRSA) blood stream infections since 2007 and one reported Clostridium difficile infection (CDI) during this year. In 2011 the requirements for mandatory reporting changed to include Meticillin sensitive Staphylococcus aureus (MSSA) and Escherichia coli (E.coli) blood stream infections. One MSSA and one E.coli blood stream infections have been reported for the period of this report. As this requirement is relatively new, there is no comparative data, this year therefore, will assist in providing a benchmark.

All organisations are increasingly aware that one of the greatest threats to patient safety is

antibiotic resistant bacteria. The World Health Organisation report that globally, the number

of infections due to resistant bacteria is growing. In November 2011, the Trust successfully

recruited an antimicrobial pharmacist and is now gaining an insight into prescribing practice

within the organisation.

The provision of high quality facilities and the application of evidence based design in the built environment underpins good infection prevention and control practice. The Trust can boast a high percentage of single rooms but has also made significant upgrades by installing additioinal “state of the art” electronic no touch hand washing facilities, increased the provision of single rooms with on-suite facilities and continued to promote the removal of carpets from clinical areas. A clean and well maintained environment supports a positive experience of care and the Trust is pleased to report excellent or good Patient Environment Action Team (PEAT) scores. Recognition and thanks is given to support services staff for their dedication and hard work, particularly those at Bucknall Hospital for maintaining consistently high standards. The annual report provides an opportunity for reflection and retrospective analysis on the previous year, to celebrate success and identify priorities to sustain and build on our achievements.

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Introduction This document produced on behalf of the Director of Infection Prevention and Control (DIPC) for Combined Healthcare NHS Trust, details the actions taken by the organisation to minimise the risk of infection during the period April 2011 to March 2012. The aim of this report is to summarise achievements in meeting national objectives, implementing published evidence based practice and compliance with key documents including The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance (Department of Health 2010). The text outlines progress measured against the planned work detailed in the published Annual Programme of Work and any emerging risks, unforeseen issues or responsive work which impacted upon this plan. Individual sections highlight the actions taken to strengthen compliance with the relevant criteria detailed in The Health and Social Care Act 2008 Code of Practice. This includes a summary of the key areas of work undertaken by and associated with infection prevention and control including –

Surveillance

MRSA admission screening

Outbreak prevention and management

Audit and quality improvement

Cleanliness

Policy development and review

Specialist advice

Training and education. The Health and Social Care Act 2008 Code of Practice requires the Trust to produce an annual report and release it publicly. This document also serves to inform senior management and the Board and supports the Trust’s assurance framework. A review of the previous year provides an opportunity to reflect on the Trust’s position and provides the mechanism to ensure that sufficient resources are available to secure effective prevention and control of infection within the organisation. This document is a summary report, further details can be obtained from the Trust Infection Prevention and Control Specialist Nurse or the respective service lead for support services, health and safety, estates, occupational health, or training and education. Information relating to communicable diseases in the wider community and public health issues are detailed in documents produced by the Health Protection Agency.

Data for the Staffordshire and Stoke-on-Trent Partnership Trust can be found in the DIPC annual report for that organisation.

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Assessment of compliance with the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance (Department of Health 2010) The Care Quality Commission (CQC) was established by the Health and Social Care Act

2008 as an independent regulator to ensure that care meets government standards of quality and safety. This applies to all providers of health and adult social care in England including those detained under the Mental Health Act. To become and stay registered, providers must meet the full range of registration requirements. The standards detailed below are the ten criteria against which a registered provider is judged. The Trust registered with the CQC and declared full compliance with the criteria detailed below.

Criterion What the registered provider will need to demonstrate

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

2 Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections.

3 Provide suitable accurate information on infections to service users and their visitors.

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

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

6 Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection.

7 Provide or secure adequate isolation facilities.

8 Secure adequate access to laboratory support as appropriate.

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

10 Ensure, so far as is reasonably practicable, that care workers are free of and are protected from exposure to infections that can be caught at work and that all staff are suitably educated in the prevention and control of infection associated with the provision of health and social care.

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Trust Arrangements for Infection Prevention & Control

Criterion 1: Systems to manage and monitor the prevention and control of infection. The Chief Executive (CE) has corporate responsibility for infection prevention and control and ensures that effective arrangements are in place throughout the Trust. The Chief Executive is Fiona Myers.

Dr Jorsh Dr Adeyemo The Director of Infection Prevention & Control (DIPC) is directly accountable to the CE and the Board and has the executive authority and responsibility for ensuring the implementation of strategies to prevent avoidable infection at all levels within the organisation. The role of DIPC transferred from Dr Jorsh, the Medical Director to Dr Adeyemo on 31st December 2011. Dr Jorsh and Dr Adeyemo ensure that members of Quality and Governance Committee and the Executive Directors receive regular updates. The Deputy Director of Infection Prevention and Control reports to the DIPC. The Deputy DIPC was Carole Goodwin until her retirement on 22nd December 2011. Infection Prevention and Control Specialist Nurse (IPCN) – The Trust employs one whole time Specialist Nurse who reports to the DIPC. During annual leave, the Staffordshire and Stoke-on-Trent Partnership Trust IPCNs provide cover for the recognition and management of outbreaks of infection or emergencies. The nominated Infection Prevention & Control Doctor (ICD) is the University Hospital of North Staffordshire Consultant Microbiologist Dr Vasile Laza Stanca. The IPCN has access to the nominated ICD and meets weekly with other infection prevention and control professionals working within North Staffordshire. Matrons, Ward Managers and Service Leads work closely with the Trust IPCN to ensure that infection prevention and control is embedded into everyday practice and applied consistently by all staff. Infection Prevention and Control is everone’s responsibility. The Trust actively promotes the message that infection prevention and control is the responsibililty of everyone working within and on behalf of the Trust. All policy and guidance documents and mandatory training refer to the collective responsibility and duties of all staff, whatever their role, in minimising the risk of infection.

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Assurance framework Infection Prevention and Control and the Management of Medical Devices Group This group meets four times a year and reports to the Trust Quality and Governance Committee (QGC). Summary reports, briefing papers, policy and guidance documents, surveillance data, outbreak, incident and root cause analysis reports are presented to members of the Infection Prevention and Control Group for discussion, agreement and approval prior to submission to QGC.

Membership of the Infection Prevention and Control and the Management of Medical Devices Group

Title Name

Director of Infection Prevention & Control (Chair) Dr Jorsh & Dr Adeyemo

Deputy Director of Infection Prevention & Control

Carole Goodwin

Infection Prevention & Control Specialist Nurse Sue Williams

Matron/s Jackie Wilshaw, Karen Livesley & Jackie Clowes

Head of Support Services/Support Services Advisor Susan Dale/Anne Melville/Janet Greener

Head of Estates Colin Plant

Senior Occupational Health Advisor Wendy Gould

Health & Safety Advisor Owen Myatt

Senior Management Assistant, Harplands Joanne Orlando

Clinical Governance Lead Dianne Morris

Head of Pharmacy/Antimicrobial Pharmacist Louise Jackson/Rachel Tarbuck

Resuscitation Officer Trevor Pegnall

Secretarial Support (until 1st February 2012) Fay Smallman

Co-opted members as appropriate

The Deputy DIPC, Carole Goodwin retired on 22nd December 2011 and Fay Smallman was tranferred on 1st February 2012.

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Annual Programme of Work The purpose of the Infection Prevention and Control Programme of Work is to –

Set objectives

Identify priorities for action

Provide evidence that policies have been implemented

Report progress against the objectives in the DIPC’s annual report The objectives detailed in the annual programme aim to sustain and strengthen the Trusts position in meeting the requirements of the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance (Department of Health 2010) and other key national documents. Progress, unanticipated and emerging risks or issues impacting upon the planned Annual Programme of Work are reported to the DIPC and members of the Infection Prevention and Control Group at each meeting. The Annual Programme for the period of this report is detailed in Appendix 1.

Key Documents Department of Health 2010 The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance www.dh.gov.uk Department of Health 2010 The Operating Framework for the NHS in England 2011/2012 www.dh.gov.uk NHS Litigation Authority. NHSLA Risk Management Standards for NHS Trusts providing Acute, Community or Mental Health and Learning Disability Services. www.nhsla.com/RiskManagement The Information Centre for health and social care 2011. Patient Environment Action Team Assessments 2012. www.ic.nhs.uk

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Mandatory reporting

Criterion 4: Provide suitable accurate information on infection to any person concerned with providing further support or care in a timely fashion. Criterion 8: Secure adequate access to laboratory support as appropriate. Clinical specimens are processed by the University Hospital of North Staffordshire Pathology Laboratory, a facility with Clinical Pathology Accreditation (CPA). Organisms of significance to infection prevention and control are reported via the ICNet system. ICNet The Trust subscribes to the web based infection control case management software ICNet. The University Hospital of North Staffordshire manage and administer the programme which is interfaced with laboratory systems and allows the rapid review of laboratory reports.

Surveillance Surveillance is defined as the systematic collection, collation, and analysis of data, followed by the prompt dissemination of the resulting information to those who need to know so that appropriate action can result (Hawker 2002). The IPCN undertakes daily surveillance using ICNet. Clinical teams are subsequently made aware of the appropriate control measures required for individual cases.

Extensions to mandatory surveillance The Department of Health requires the Trust to report some infections as part of the national mandatory reporting system including Meticillin resistant Staphylococcus aureus (MRSA) and Clostridium difficile infections (CDIs). Nationally there have been significant reductions in both (MRSA) bloodstream and CDIs (Department of Health 2011), however, in order to continue this progress the government extended mandatory reporting to include Meticillin sensitive Staphylococcus aureus (MSSA) infections on 1st January 2011 and Escherichia coli (E.coli) infections on 1st June 2011. MSSA and E.coli bloodstream infections may not always be healthcare associated, however, the increase in laboratory reports and antimicrobial resistance suggest that it is essential to obtain a more comprehensive picture to inform future strategy. The following information provides details of surveillance data summaries, trends and variances associated with mandatory reporting within the organisation.

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Meticillin sensitive Staphylococcus aureus (MSSA) Since the introduction of MSSA mandatory surveillance on 1st January 2011, one MSSA bacteraemia occurred in June at Bucknall Hospital. The detail of this complex case was subject to the root cause analysis process, the summary report concluded that the clinical team had taken all reasonable measures to prevent this infection.

Meticillin resistant Staphylococcus aureus (MRSA) A MRSA bacteraemia is defined as a positive blood sample test for MRSA on a patient (Operational Framework Technical Guidance 2011/2012). The Department of Health report a 41% reduction in MRSA bloodstream infections across the NHS in England since 2009/10. The national MRSA objective requires organisations with few MRSA cases to maintain current performance, the Trust has successfully achieved this objective and is pleased to announce that there have been no reported MRSA bacteraemias since September 2007.

MRSA Admission screening

In response to Operational Guidance published by the Department of Health (2008) the Trust implemented MRSA admission screening for all emergency and elective admissions to hospital inpatient beds in 2008. Subsequent guidance for mental health Trusts resulted in a change to selective MRSA admission screening for those patients meeting Department of Health criteria i.e. indiviuals who are -

Admitted following surgical procedures

Transferred from an Acute Trust

Intravenous drug users

Self harmers

Affected by chronic wounds such as leg ulcers and pressure sores

Living with long term indwelling devices such as enteral feeding tubes.

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MRSA admission screening is an integral part of the Trust risk assessments process to determine how susceptible service users are to the risk of infection. Individuals with MRSA positive admission screening swabs, who are colonised with MRSA are offered the five days decolonisation regime in accordance with national guidance and the Trust MRSA Policy. The Trust is pleased to report that the MRSA admission screening process is embedded into everyday practice in all hospital inpatient areas. The IPCN monitors weekly MRSA admission screening returns and forwards month end data to the Performance Department for inclusion in summary reports.

Escherichia coli (E.coli)

Following the introduction of E.coli mandatory surveillance on 1st June 2011, one E.coli bacteraemia occurred in January 2012 at Bucknall Hospital. The case was subject to a root cause anlysis investigation and an action plan developed to minimise further risk.

Clostridium difficile infections (CDIs) The document NHS 2010 – 2015: from good to great, preventative, people centred, productive (Department of Health 2009) challenges the NHS to deliver continued and sustainable reductions in C.difficile and to reflect the NHS’s move towards a culture of zero tolerance of preventable infections. The Department of Health report (May 2012) that there has been a 30% reduction in CDIs across the NHS in England since 2009/10. In comparison with the national picture, Combined Healthcare NHS Trust reported a 46% reduction in 2009/10, a 66% reduction in 2010/11 and a further 50% reduction for this period. The DIPC is pleased to report that the objective for 2011/2012 was met. One CDI occurred on Ward 5 at the Harplands Hospital, this coincided with an outbreak of diarrhoea and vomiting attributed to norovirus. The subsequent root cause anlysis investigation suggested that the infection was an incidental finding associated with the outbreak rather than a true CDI. The five year analysis detailed in the graph below demonstrates the sustained year on year reduction in Clostridium difficile infections.

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Laboratory testing In 2009 the NHS Centre for Evidence Based Purchasing raised concerns regarding the accuracy and effectiveness of C.difficile testing kits and the variations in testing regimes in laboratories in England. In 2010 The University Hospital of North Staffordshire Pathology Laboratory introduced a new test algorithm for the diagnosis of C.difficile specimens using a combination of two tests. Testing subjects stool samples to a Polymerase Chain Reaction (PCR) test for C. difficile toxin gene B on samples that are Glutamate Dehydrogenase Antigen (GDH) positive and

C.difficile toxin negative. All Trust stool specimens suspected of a C.difficile infection are subjected to this process. More rigorous and detailed testing may, however, result in the identification of additional cases in the future.

Resistant Microorganisms

Not all infections are reportable, however, some laboratory reports identifying resistant organisms are of significance and occur at intervals within the Trust. Specimens reported, but not emanating from the Harplands Hospital include extended spectrum beta lactamse (ESBL) producing organisms, Panton Valentine Leucocidin MRSA (PVL MRSA) and one report of Vancomycin resistant enterococci (VRE). Carbapenems are the treatment of choice for serious infections due to ESBL producing organisms, yet carbapenem resistant isolates have now been identified in England. Infections associated with highly resistant organisms considerably reduce treatment options.

0

5

10

15

20

25

30

35

2007-2008 2008-2009 2009-2010 2010-2011 2011-2012

No

.of

case

s

Period

No. of reported CDI cases

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Resistant microorganisms such as glycopeptide resistant enterococci (GRE) and carbapenemase producers have no respect for organisational or geographical boundaries and clearly in a closed hospital environment the potential for spread represents a significant and potential risk. The Health Protection Agency (2011) highlights the emerging risk and recommend that organisations be alerted to this position.

Serious Incidents

The table below provides a summary of reported outbreaks of infection within the Trust during the period April 2011 to March 2012 .

Location Date Closed

Date Reopened

Days Closed

Patients affected

Staff affected

Laboratory Reports

Dragon Square Bungalow 4/5

27.08.11 31.08.11 4 days 4 0 Nil

Ward 6 Harplands Hospital

16.11.11 & 24.11.11

21.01.11 & 28.11.11

9 days 6 10 Norovirus

Ward 7 Harplands Hospital

07.2.12 17.02.12 10 days 15 7 Norovirus

Ward 5 Harplands Hospital

09.03.12 & 17.03.12

14.03.12 & 23.03.12

12 days 11 2 Norovirus

Total 35 (Av 9 days)

36 19

Reported outbreaks affected three wards and one learning disability respite bungalow. The information and clinical picture reported by clinical teams resulted in all being managed as outbreaks of norovirus. Subsequent laboratory reports supported this approach in four of the five outbreaks. The rapid improvement of cases resulted in no stool specimens being submitted during the outbreak affecting Dragon Square. Diarrhoea and vomiting resulted in delays in admissions, discharges and transfers, all outbreaks, however, were successfully contained within the affected area. Outbreaks resulting in the temporary closure of wards and inpatient units are reported as a Serious Incident (SI) and are subject to a Root Cause Analysis (RCA) investigation. The aim of this process is to determine the index case and possible source of the outbreak. The subsequent report details lessons learned and actions taken to minimise further risk.

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Outbreaks of infection are managed in accordance with national guidance. The affected location will not re-open until there have been no new cases for seventy two hours, no symptomatic patients for forty eight hours and a terminal clean has been completed. The number of days closed is a function of these requirements.

The above table provides a five year trend analysis of reported outbreaks of infection within the Trust.

The above graph demonstrates that the Trust is, on average, affected by four to five outbreaks of norovirus every year. The RCA analysis process suggests that the index case is typically a patient asymptomatic on admission but incubating symptoms and subsequently develops a norovirus infection. Minimising the risk from norovirus is included in infection prevention and control mandatory training for all staff while information on norovirus is provided to members of the public in the Trust leaflet “Spread the word, not the germs”. Guidelines for the management of norovirus outbreaks in acute and community health and social care settings (2012) The norovirus working party (2012) report that during periods of high incidence norovirus is estimated to cost the NHS over £100 million a year. Recent guidance proposes a move away from complete ward closure to an escalatory system using single rooms and cohort nursing. A review of this guidance has been undertaken, however, a balance of risk approach will be used to determine the feasability of implementation in the forthcoming norovirus season.

6

4

3

5

4

0

1

2

3

4

5

6

7

2007-2008 2008-2009 2009-2010 2010-2011 2011-2012

Outbreaks of infection - 2007 - 2012

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Specialist advice Criterion 5: Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people. The infection prevention and control service includes specialist advice to staff working within clinical teams on the management of patients with an identified infection. Patient specific advice is provided in response to laboratory reports or following requests from clinical teams. A balance of risk is employed where a patient may be in the acute phase of a mental illness. Specialist advice may relate to –

The management of individual patients

Infection risks to staff

Refurbishment and redevelopment projects

The management of medical devices

Hand Hygiene

Criterion 2: There is adequate provision of suitable hand washing facilities and antimicrobial hand rubs.

Good hand hygiene is essential in preventing avoidable infection and the Department of

Health report that the decrease in MRSA and C. difficile has been achieved due to good

clinical practice including improved hand hygiene.

The Trust continues to demonstrate its ongoing commitment to hand hygiene through the

following measures –

Including hand hygine in corporate induction and mandatory training

Trust policy and the ongoing programme of audits

Upgrades to hand washing facilities during refurbishment and redevelopment

projects to ensure compliance with Health Technical Memorandum 64.

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Cleanliness Criterion 2: Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections. The national patient choice survey in 2008 found that hospital cleanliness and low rates of infection are selected most often by patients (74%) as an important factor when choosing a hospital (Department of Health 2011). High standards of cleanliness provide the right setting to promote public confidence and are an integral part of the Trust’s strategy for infection prevention and control. The independent regulator, The Care Quality Commission, use Patient Environment Action Team (PEAT) data to revew Quality Risk Profiles (QRPs) when monitoring essential standards of quality and safety within provider organisations such as Combined Healthcare. Trust standards are monitored through a documented quartely programme of announced cleanliness audits, assessed against the forty nine standards detailed in The National Specifications for cleanliness in the NHS (NPSA 2007). Assessments are undertaken by the Support Services Advisor, the Matron, a representative from the Clinical Team and where possible the housekeeper and the IPCN. For the Harplands Hospital, the Contract Monitoring Officer and a representative from Carillion would also be included in the team. In healthcare, matrons or persons of a similar standing have personal responsibility and accountability for delivering a safe and clean care environment, while the nurse in charge has direct responsibility for ensuring that cleanliness standards are maintained throughout that shift (Department of Health 2010).

Overall cleanliness scores for all Trust locations

Location Percentage overall performance

Bucknall

97.43%

Community Premises

95.99%

Harplands

91.63%

Learning Disabilities

96.13%

Mental Health Resouce Centres

95.38%

Total average 95.31%

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Learning Disability Premises Teams working in learning disability homes provide care to individuals with behavoural issues which may impact upon the integrity of the environment and cleaning frequency. High standards have been maintained resulting in an overall score in excess of 96%

PEAT Score Summary Chart

Site Name Environment

Score Food Score

Privacy & Dignity Score

Bucknall Hospital 5 excellent 5 excellent 5 excellent

Dragon Square Community Unit 5 excellent 5 excellent 5 excellent

Learning Disabilities Unit Hilton Road 4 good 5 excellent 4 good

The Bungalows, 1 - 6 Chebsey Close 5 excellent 5 excellent 5 excellent

Darwin - Clydesdale Centre 5 excellent 5 excellent 5 excellent

Harplands Hospital 5 excellent 5 excellent 5 excellent

The Publicly Available Specification (PAS) Provides a risk based framework for organisations to identify critical “must clean” areas, define cleaning frequencies and manage staff to maximum effect. An illustration of the process, for example, may be a toilet which carries a high risk, while offices carry a low risk. The Trust welcomed the opportunity of being part of the Department of Health pilot at Bucknall Hospital in 2010. The PAS system and associated documentation has been reviewed. Consideration is currently being given to the changes to systems and procedures required prior to adopting the system within the Trust. The Trust Commitment to High Standards of Cleanliness Support Services Advisors employed by the Trust are active members of the Association of Healthcare Cleaning Professsionals (AHCP) a body with a strong emphasis on training and maintaining competencies. Trust Support Services staff are qualified to NVQ Level 2 and 3 in Support Service or Cleaning Building and Interiors. The organisation recognises and commends the commitment and hard work of support services staff at Bucknall in sustaining excellent standards prior to the transfer or wards to the Harplands Hospital. Carillion staff should be commended on responding at short notice to requests for additonal cleaning during outbreaks of infection at the Harplands Hospital. Area of further devlopment

Raise the overall performance of cleanliness at the Harplands to 95%

Work towards implementing the PAS system

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The Built Environment Criterion 2: Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections. Criterion 7: Provide or secure adequate isolation facilities. The Head of Estates has considered infection prevention and control in all major refurbishment projects undertaken on behalf of the Trust. National guidance has been used to provide facilities which support best practice. Ward 6, Harplands Hospital The refurbishmet of Ward 6 included easily cleaned facilities, hard flooring and electronic hands free, Health Technical Memorandum (HTM) 64 compliant hand wash basins.

Lapped flooring has been used to facilitate thorough cleaning and the multicolour system assists patients with dementia and Alzheimers disease in locating doorways and entrances. No touch electronic hand hygine facilities support clinical teams in implementing good infection prevention and control practice. Staff prompt and assist patients with organic illness affecting memory and comprehension in maintaining personal hygiene. The Sutherland Centre The bungalow has been upgraded to include refurbished single bedrooms with on-suite facilities, HTM 64 compliant hand wash basins and hard flooring in clinical areas. Legionella Training In April 2011, the Head of Estates provided an update on the risks and required standards associated with Legionella. The potential for Pseudomonas aeruginosa infections from taps and water systems In response to the Department of Health Best Practice Guidance on Pseudomonas aeruginosa (2012), a Water Quality Group has been formed. The remit of the group will be to develop a Water Safety Plan and to ensure that essential systems and procedures are in place within the Trust.

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Antimicrobial resistance Criterion 9: Procedures should be in place to ensure prudent prescribing and antimicrobial stewardship. In 2002, the document Getting Ahead of the Curve identified antimicrobial resistance as a priority for action and recognised the role of pharmacists in monitoring and advising on prescribing practice. To date, however, the focus has largely been directed to the work of acute hospital Trusts. People with mental health issues are at increased risk of physical illness, including infections (Department of Health 2006) and injecting drug users are particularly vulnerable with one third reporting symptoms of bacterial infection at an injecting site in the past year (HPA 2010). There is, therefore, a role for the antimicrobial pharmacist in promoting prudent prescribing within a mental health organisation.

Antimicrobial Pharmacist

The Trust is pleased to report that a new member of staff was recruited into this role in

November 2011, allowing pharmacy to work proactively with clinical teams to promote

prudent antibiotic prescribing.

Prescribing trends during the period January to March indicate that 84 infections required

antibiotic treatment (excluding GP prescriptions in learning disability homes). Fifty five

percent of all antibiotic prescriptions were for the treatment of urinary tract infections,

followed by cellulitis and respiratory tract infections. These resulted in Trimethoprim,

Co-amoxiclav and Flucloxacillin being the most commonly prescribed antibiotics.

European antibioitic awareness day – 18th November

Antibiotic resistance is one of the most significant threats

to patient safety and the number of infections due to

antibiotic resistant bacteria is growing (Department of

Health 2011).

The aim of European Antibiotic Awareness day on 18th

November 2011 was to promote the responsible use of

antibiotics.

Trust events included a presentation to medical staff, an information stand placed in the

Harplands Hospital reception, and articles in Newsround and The Sentinel newspaper.

Area of further devlopment

Promote a zero tolerance to avoidable infections and continue to encourage prudent

antimicrobial prescribing.

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Seasonal Influenza Vaccine Campaign Criterion 10. “That health and social care workers are free of and are protected from exposure to infections that can be caught at work”.

Dr Jorsh receives the seasonal influenza vaccine from The Lead Occupational Health Nurse

The Trust committed to the national NHS Employers seasonal influenza campaign brief and promotional materials including leaflets, posters, stickers and magazines. The benefits of the vaccine were promoted in all infection prevention and control mandatory training sessions during the winter months. Seasonal influenza immunisation is provided to Trust frontline staff by the Shropshire Community Health NHS Trust Occupational Health Service in accordance with Department of Health guidance (DoH May 2011). Influenza vaccine sessions were delivered at varying times in a number of locations across North Staffordshire or by appointment in the Occupational Health Department in Fenton. A total of thirty two clinics were provided for Trust staff. The overall percentage uptake of the vaccine was 27%, this included 10 out of a total of 67 doctors and 107 out of a total of 552 nursing staff. Uptake for the equivalent period in the previous year was 14.9%. In comparison, uptake in the Staffordshire and Stoke-on-Trent Partnership Trust was reported to be 43.4% and in excess of 90% at the University Hospital of North Staffordshire. . The Trust Human Resources Department report that there were 493 episodes of staff absence due to Influenza Like Illness (ILI) which resulted in a total of 1,145.5 full time equivalent days lost. A staff questionnaire conducted during the vaccine campaign suggested that uptake may improve if the vaccine was taken to community teams. This valuable feedback will be used to prepare for the 2012/13 campaign. Area of further development

Improve uptake of the seasonal influenza vaccine

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Education & Training

Criterion 10: All staff are suitably educated in the prevention and control of infection. “The principles and practice of prevention and control of infection are included in induction and training programmes for new staff and there is appropriate ongoing education for existing staff”. “The responsibility of each member of staff for the prevention and control of infection are reflected in their job description and in any personal development plan or appraisal”. During the period of this report a total of forty four infection prevention and control training sessions were provided and one planned session was cancelled due to annual leave. Infection Prevention and Control is included in the Corporate Induction programme for new staff and in three yearly mandatory updates for all staff. The Learning Centre report that the Trust overall percentage compliance with infection prevention and control mandatory training to be 89% at the year end, this compares favourably with the reported 75% for the equivalent period in the previous year. The Trust employs in the region of 1,500 staff who receive training through a three yearly programme of mandatory updates, this represent a goal of 500 staff each year to achieve 100% compliance. Using the example of forty IPC sessions provided – 500 = 13.0 staff per session 40 Training records are constantly updated and amended, however, the identified gap in compliance with infection prevention and control mandatory training represents a potential risk for the Trust. Poor attendance due to conflicting priorities or staffing levels are thought to be the key contributing factors.

Area of further devlopment

Improve compliance with mandatory training to 95%.

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Policy Development and Review

Criterion 9: Have and adhere to policies, designed for the individual’s care and provider organisations that will help to prevent and control infections The following provides a summary of the Trust’s Infection Prevention and Control Policies

No Policy Title

1 Sources of Advice

2 Infection Prevention & Control Operational Policy

3 Policy for minimising the risk of infection through standard precautions

4a Hand Hygiene Policy

4b Policy for the use of Personal Protective Equipment (PPE) by Clinical Teams

5 Isolation Policy

6 Notifiable Diseases

7 Policy for the prevention of occupational exposure to blood borne viruses and the management of inoculation or splash injuries

8 Cleaning and Disinfection Policy

9 Food Safety Policy

10 Management of Pulmonary Tuberculosis Policy

11 Meticillin resistant Staphylococcus aureus (MRSA) policy

12 Policy for The Prevention and Management of Outbreaks of Infection

13 Management of Linen and Laundry Policy

14 Specimen Management Policy

15 Policy for the prevention and management of Clostridium difficile infection (CDI)

All policies are subject to a planned programme of review or will be revisited in response to changes in national guidance and published evidence based practice.

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The following polices have been revisited and updated during this period –

Management of Pulmonary Tuberculosis (June 2011)

Personal Protective Equipment (June 2011)

Notifiable Diseases (June 2011)

Standard Precautions (November 2011)

Clostridium difficile (November 2011)

Food Safety (November 2011)

Quality Improvement

Criterion 2: A programme of audit is in place to ensure that key policies and practices are being implemented appropriately. Infection Prevention and Control standards are monitored through a structured programme of regular audit. Nationally approved tools endorsed by the Department of Health and the Infection Prevention Society (previously known as the Infection Control Nurses Association) are used to monitor standards. Matrons and Ward Managers are required to undertake a quarterly programme of audit including hand hygiene, personal protective equipment, sharps, and patient equipment. Random unannounced visits and assessments are undertaken by the IPCN . A total of forty six infection prevention and cleanliness audits were completed by the IPCN during the period of this report. The Edward Myers Ward use the Department of Health High Impact Intervention tool to monitor practice associated with the management of peripheral lines.

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Information for members of the public Criterion 3: Provide suitable accurate information on infections to service users and their visitors. Information on infection prevention and control is displayed on notice boards and leaflet racks in the entrance areas of all wards at Bucknall and the Harplands Hospitals. The Patient Advice and Liaison (PALs) Service and members of the public have assisted in the development of a range of information leaflets. The Trust leaflet “spread the word, not the germs!” explains how members of the public can assist the Trust in preventing infections.

Ward Manager Lynne Birch-Machin directs patients to the infection prevention and control information board in the ward entrance area. Members of the public are provided with contact details, data trends and actions taken to minimise the risk of infection.

Area of further development

Update Trust leaflets on infection prevention and control.

Include questions on the Trust discharge questionnare concerning infection prevention and cleanliness.

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The Management of Medical Devices People who use services, work for, or visit the Trust should not be at risk or harmed from unsafe or usuitable equipment. Outcome 11, Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 refers to the Safety, availability and suitability of equipment and requires providers to ensure that equipment is –

Suitable for the purpose

Available

Properly maintained

Used correctly and safely

Promotes independence

Comfortable

The Trust provides services from over thirty sites in a variety of premises including small community learning disability bungalows, rehabilitation centres and two hospital sites. The spectrum of medical devices ranges from single use items to complex reusable mechanical and electrical equipment. Trust arrangements for the Management of Medical Devices have been outlined on Page 7 of this report, additional roles and responsibility are detailed below - The nominated Equipment Managers – Each clinical team has a nominated Equipment Manager. The role includes the safe management of medical devices, ensuring that staff receive appropriate training and have been assessed as proficient prior to using an item of equipment. The University Hospital of North Staffordshire Department of Clinical Technology – The Trust has a formal agreement with this Department for the maintenance and testing of most mechanical and electrical equipment. The Head of Estates – Ensures that contracts with external companies and suitably qualified in house engineers are available for the testing of all other mechanical and electrical equipment. The Resuscitation Officer provides help, support and training on the use of specialist equipment associated with Basic Life Support. The Shropshire Community Health NHS Trust Lead Occupational Health Nurse provides summary data on sharps injuries at each meeting.

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The Health and Safety Advisor reports on safety warnings, alerts, recalls, incidents and issues associated with medical devices. Reported Incidents. For this period, three incidents were reported, one associated with an ECG machine and three relating to needles and syringes. All incidents are reviewed and where necessary investigated. Annual Programme of Work The Trust prepares an Annual Programme of Work for the Management of Medical Devices. Progress and issues affecting planned work are reported to members of the Infection Prevention and Control and the Management of Medical Devices Group. The Annual Programme of Work for Medical Devices is detailed in Appendix II of this report. Planned, preventative maintenance programmes (PPM) The University Hospital of North Staffordshire Clinical Technology Department and the Estates Agency undertake comprehensive planned, preventative maintenance programmes to comply with Statutory and Mandatory requirements and manufacturer’s recommendations. University Hospital of North Staffordshire Clinical Technology Department Hold a database of all Trust Equipment requiring mechanical/electrical testing. The Service Level Agreement determines the Level of Support as follows – A. Full PPM, and repair provision B. Repairs only with no PPM provision

C. Equipment which appears on the database for asset management purposes only

All equipment in the PPM programme is labelled to indicate the test date and the subsequent date for retesting the following year. Equipment Managers take responsibility for monitoring the process and informing Clinical Technology if equipment has been decomissioned, transferred to another area, or is in need of attention. The Estates Agency The Estates Agency inspect and maintain hydraulic equipment such as beds. The Department also agrees and monitors contracts with external companies, for example Arjo, for the inspection and maintenance of hoists, hoist slings and specialised baths. Areas of further development

Update the Equipment Managers Workbook

Update the Trust asset register for medical devices

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Summary of Achievements

Supported the Director of Infection Prevention and Control

No reported MRSA infections since 2007

A further 50% reduction in Clostridium difficile infections (CDIs)

Successfully contained reported outbreaks in the affected area

Used the root cause anlysis process for outbreaks and other reportable infections to influence future planning and monitor progress

Sustained Excellent or Good PEAT scores

Provided forty four training sessions

Achieved 89% compliance with IPC mandatory training

Contributed to the Trust Corporate Induction Programme

Monitored standards through forty six infection prevention and cleanliness audits

Installed additional HTM 64 compliant hands free hand wash basins

Increased the number of hard floors in patient and clinical areas

Recruited an antimicrobial pharmacist

Provided specialist advice to clinical teams

Contributed to the Trust’s assurance framework

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Areas of further development

Increase compliance with mandatory training to 95%

Improve uptake of the seasonal influenza vaccine by frontline staff

Continue to promote prudent antibiotic prescribing

Raise the overall performance of cleanliness at the Harplands to 95%

Monitor and minimise the risk from emerging resistant micro-organisms

Work towards implementing the Publicly Available Specification (PAS) system

Update Trust leaflets on infection prevention and control

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Summary & Conclusion

The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance (2010) requires the DIPC to produce an annual report and release it publicly. The retrospective anlysis allows the Board an opportunity to reflect on Trust performance and to plan for the forthcoming year. This document also provides summary information for members of the public on healthcare associated infection, cleanliness and other indicators detailed in the Care Quality Commision Essential standards of quality and safety. The DIPC is pleased to report that the organisation has achieved the Trust objective for Clostridium difficile infections and sustained the position of no MRSA infections. The reported MSSA and E.coli bacteraemias will provide a benchmark for the forthcoming year and the Trust will continue to monitor the emerging and potential risk from resistant organisms. Cleanliness scores are excellent or good, a reflection of the ongoing commitment to high standards particularly at the Bucknall site and in learning disabililty homes. The Trusts commitment to learning is reflected in the number of training sessions provided at Corporate Induction and through the Mandatory Training programme, however, additional actions are required to achieve improved compliance. Standards are monitored through an ongoing programme of audit and quality improvement undertaken by clinical teams and the Trust Infection Prevention and Control Nurse. Uptake of the seasonal influenza vaccine has improved but further work is required in the forthcoming year to promote additional uptake by frontline staff. The appointment of an antimicrobial pharmacist will assist in continuing to promote prudent antibiotic prescribing. The Trust is pleased to announce a further year of sustained reductions in healthcare associated infection. In the context of patient safety, quality of care and improved outcomes, this provides a strong position in support of the organisation’s application for Foundation Trust. This report demonstrates that most of the objectives detailed in the annual programme of work have been met. Any outstanding actions or recognised areas for further development will be included in the programme or work for the forthcoming year.

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References

Care Quality Commission 2012 The essential standards of quality and safety. www.cqc.org.uk Department of Health 2006 Choosing Health: Supporting the physical health needs of people with servere mental illness www.dh.gov.uk/publications Department of Health 2008 Dear colleague letter Gateway reference 10324 MRSA screening operational guidance www.dh.gov.uk Department of Health 2009 Clostridium difficile infection: How to deal with the problem. www.dh.gov.uk/publications Department of Health 2009 NHS 2010 – 2015: from good to great preventative, people-centred, productive. The Stationery Office. www.tsoshop.co.uk Department of Health 2010 The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance. www.dh.gov.uk/publications

Department of Health 2010 The Operating Framework for the NHS in England 2011/2012 www.dh.gov.uk Department of Health 2010 Equity and excellence: Liberating the NHS. The Stationery Office. www.bookshop.parliament.uk Department of Health 2011 Dear Colleague letter. Gateway reference 15353. Extension to mandatory surveillance to Meticilllin Sensitive Staphylococcus aureus (MSSA) and update Healthcare Assoicated Infections clinical guidance ( “HCAI Compendium”) www.dh.gov.uk Department of Health 2011 Dear Colleague letter. Gateway reference 15980 Extension of mandatory surveillance to E.coli bloodstream infections – June 2011. www.dh.gov/uk Department of Health 2011 Dear Colleague letter Gateway reference 16066. Seasonal Flu Immunisation Programme 2011/12 (PL/CMO/2011/01. PL/CNO/2011/01) www.dh.gov/uk Department of Health 2012 Web page update on Tuesday 8th May. www.dh.gov/uk Department of Health 2012 Water Sources and potential Pseudomonas aeruginosa contamination of taps and water systems. Advice for augmented care units. www.dh.gov/uk

Hawker J, Begg N, Blair I, Reintjes R, Weinburg J. 2005 Communicable Disease Control Handbook. Blackwell Publishing

Health Protection Agency 2010 Shooting up. Infections among injecting drug users in the UK 2009 An update: November 2010 www.hpa,org.uk

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National Patient Safety Agency 2007 The national specifications for cleanliness in the NHS: a framework for setting and measuing performance outcomes. npsa.nhs.uk National Patient Safety Agency 2009 The revised healthcare Cleaning Manual npsa.nhs.uk NHS Litigation Authority 2011 NHSLA Risk Management Standards for NHS Trusts providing Acute, Community or Mental Health and Learning Disability Services. www.nshla.com/RiskManagement Norovirus Working Party 2012 Guidelines for the management of norovirus outbreaks in actue and community health and social care settings. Health Protection Agency; British Infection Association; Healthcare Infection Society; Infection Prevention Society; National Concern for Healthcare Infections; NHS Confederation www.hpa.org.uk

Appendix I

Infection Prevention & Control Annual Programme of Work for the period April 2011 – March 2012

The aim of this document is to minimise the risk of infection through a planned programme of work. This includes sustaining and strengthening the Trust’s position in achieving compliance with The Health & Social Care Act 2008 and other key Department of Health documents.

The infection prevention and control programme will set objectives, identify priorities for action, provide evidence that policies have been implemented and report progress in the DIPC’s annual report (DoH 2010)

Objective Actions Person/s Responsible Time scale & Priority

DIPC – Director of Infection Prevention & Control, Dr Jorsh Deputy DIPC – Carole Goodwin IPCN – Infection Prevention and Control Specialist Nurse, Sue Williams (For DIPC also read Deputy DIPC if the action has been transferred or request made to represent the organisation)

Criterion 1 Systems to manage and monitor the prevention and control of infection

Assurance framework Clinical and Information Governance Committee and the Board receive regular reports and presentations (quarterly as a minimum) from the Director of Infection Prevention and Control The DIPC will ensure the Board agree and approve the –

annual programme of work

annual report

policy, procedure and guidance documents

DIPC IPCN & DIPC

Quarters 1-4 Quarter 1 Quarter 2 Review date

Ensure that progress of the annual programme is monitored by Infection Control Committee (ICC) and any identified or emerging issues or responsive work affecting the programme is reported to the committee

IPCN

At each meeting

Make a suitable and sufficient assessment of the risks of HCAI and take action to minimise the risk.

Undertake alert organism surveillance. Using ICNet, review laboratory reports during periods of duty. Provide specialist advice to clinical teams on the management of individual patients Inform the DIPC of all MRSA, MSSA and E.coli bacteraemia’s, and C.difficile cases and initiate the root cause analysis process. Support clinical teams in complying with the Trust target of zero bacteraemia cases and C.difficile infections Support clinicians and matrons in undertaking timely root cause analysis investigations of all bacteraemia’s and C.difficile infections. Assist in the development of subsequent action plans. Facilitate selective MRSA admission screening in accordance with Department of Health guidance. Ensure that data is collected, collated and presented to ICC and Performance Management Data analysis Present data summaries to ICC. Discuss statistical trends and any corrective actions taken to minimise identified or emerging risks. Present data summaries in the infection control annual report outlining statistical trends and variances.

IPCN IPCN IPCN IPCN IPCN IPCN DIPC/IPCN

Daily during normal working hours On receipt of the lab. report As required Within 5 days Monthly and quarterly Quarterly update Year end

Surveillance Outbreaks

Undertake alert condition surveillance Respond to and investigate alert condition reports from clinical teams Respond to and advise on the management of outbreaks of infection Report all outbreaks of infection resulting in the closure of wards or units as a SI through the incident reporting system. Inform the DIPC, senior management, Performance Management and key individuals of the outbreak. Initiate the RCA process Prepare outbreak summary reports and submit to ICC, Quality and Governance Committee and the Board. Review to effectiveness of outbreak reporting system

IPCN IPCN IPCN IPCN DIPC DIPC/IPCN

Within 24 hours Within 24 hours Within 24 hours Within 5 days At the next meeting As above

Policy and Procedures (Criterion 9) Have and adhere to policies, designed for the individual’s care and provider

Ensure that existing policies with a review date falling within this period are revised and updated –

Tuberculosis

Personal Protective Equipment (June 2011)

Notifiable Diseases (June 2011)

IPCN IPCN IPCN

April 2011 May 2011 June 2011

organisations, that will help to prevent and control infections Ensure that policies and procedures are relevant to the regulated activity of the registered provider and reflect legislation, regulations and evidence based practice.

Standard Precautions (November 2011)

Clostridium difficile (November 2011)

IPCN IPCN

Sept 2011 October 2011

Education and training: (Criterion 10) Ensure that all staff are suitably education in the prevention and control of infection

Liaise with the Training Managers to ensure that all staff are suitably educated in the prevention and control of infection and contribute to the following -

Corporate induction

Mandatory training days

Scheduled programme of updates

IPCN/Training team

Timescale in accordance with documented programmes

Audit (Criterion 1) To ensure that key policies and practices are being

The infection control nurse will support service leads, matrons and ward managers in delivering the annual programme of audit using nationally agreed audit tools. The ICC will receive regular progress reports on audits and subsequent action plans

IPCN/matrons/ service leads Service leads /Matrons/IPCN

Quarterly Quarterly

implemented through a programme of audit

Incident reporting forms and the effectiveness of subsequent action plans will be reviewed Undertake a re-audit of hand washing facilities in hospital inpatient and day unit areas Undertake random audit of MRSA admission screening An IPCN timetable of quality improvement visits will be prepared following the release of IPS qualitly improvement tools

Risk manager/ IPCN IPCN IPCN

Documented schedule Random visits In accordance with documented programme

Performance management : To promote compliance with the requirements of performance management

Ensure that HCAI data is forwarded to the Performance Team Ensure that the Performance Team receive the information and data required to populate the Commissioners and performance reports

IPCN IPCN

Monthly Monthly

Specialist advice Duty to provide specialist advice and information: To provide information and specialist advice on the prevention and control of

Timely and responsive specialist advice will be provided to staff working within and on behalf of the Trust including - DIPC/Deputy DIPC Clinical teams Bed managers Estates Department

IPCN IPCN

As required

infection to staff and members of the public

Patients, relatives or members of the public Update the current range of leaflets and booklets including “Thank you for helping to prevent infection”

IPCN/ PALS

Quarter 1

Representation at key committees

Representation will be provided at key committee’s detailed below-

Infection control, medical devices and decontamination committee

Quality & Governance Committee

Health & Safety, Violence and Aggression Committee

Risk Review Group

New Build and refurbishment project groups

Education and Learning Group (ELG)

Strategic Infection Prevention & Control Committee

Weekly health economy surveillance meeting

Supplies flu preparedness group

IPCN/DIPC/ DIPC DIPC IPCN IPCN IPCN IPCN DIPC/IPCN IPCN IPCN

In accordance with agreed dates/schedules

Provide and maintain a clean and appropriate

Support the medical devices and decontamination lead in strengthening Trust systems and procedures for the safe management of re-usable medical devices including –

environment (Criterion 2)

Training and updating Equipment Managers

Liaising with University Hospital of North Staffordshire Clinical Technology Department

Undertaking random audits of re-usable medical devices

Actively contribute to cleanliness audits and PEAT inspections in accordance with the agreed programme

IPCN/ Deputy DIPC IPCN IPCN

Bi - annual As required Random Agreed programme

Prudent antimicrobial prescribing (Criterion 9)

Contribute to – The North Staffordshire health economy review of antimicrobial prescribing guidelines The review of antibiotic prescribing through the incident reporting system The annual audit of antimicrobial prescribing

Chief Pharmacist/IPCN As above As above

Agreed date Weekly Agreed date

Emergency Planning / Flu preparedness

Work with partner organisations to ensure that the Trust has systems and procedures which minimise the risk from emerging and resistant organisms including influenza

DIPC/IPCN

Timely response to information from the HPA

Appendix II

Medical Devices and Decontamination Annual Programme of Work for the period April 2011-March 2012

Objective Action

Persons/s Responsible

Time Scale

The aim of this document is to minimise risks associated with the management of medical devices and to ensure that patients “will not be harmed by unsafe or unsuitable equipment”.

The programme will set objectives, identify priorities for action, provide evidence that policies have been implemented and report progress to Infection Prevention and Control and the Management of Medical Devices Group

Assurance framework Criterion One: Appropriate management and monitoring arrangements

Clinical and Information Governance Committee and the Board receive regular reports (quarterly as a minimum) from the Medical Devices/Decontamination Lead Ensure the Board agree and approve the –

annual programme of work

policy and procedure documents Ensure that progress of the annual programme is monitored by Infection Prevention & Control and the Management of Medical Devicces Group Undertake a review of incidents and issues associated with medical devices/decontamination

Medical devices/ Decontamination Lead As above H&S Dept

Quarterly meetings May 2011 Review dates Quarterly meetings Quarterly meetings

To minimise the risks associated with the management of medical

Maintain the register of equipment managers for all clinical areas. Maintain the register of mechanical /electrical and other reusable

Operational lead Operational lead

As required

devices medical devices Support Equipment Managers in the implementation of actions relating to their responsibilities Respond to and advise on alert reports / issues relating to medical devices

IPCN and operational lead H&S Dept, Operational lead

Criterion 2: Policies

The decontamination lead should have responsibility for ensuring that policies

exist which take account of evidence based practice and national guidance

Policies: Update the Trust Medical Devices Policy (Review date April 2011)

Operational Lead

April 2011

Education and Training

Ensure that the Trust has a programme of education

and training for the management of medical devices as outlined in

“Equipped to Care: The safe use of medical

devices in the 21st century”

Provide a bi-annual update for Equipment Managers to ensure that staff are trained in how to manage equipment including cleaning and decontamination processes and hold appropriate competencies for their role

Operational Lead/IPCN

Quarter 2 & Quarter 4

Audit

To ensure that key policies and practices are being implemented through a

programme of audit

Monitor the implementation of the Equipment Managers Toolkit and compliance with Trust policy through a programme of regular audit

Operational lead / IPCN

Quarter 2

Performance Management

Provide an annual report on the Trusts position including compliance with key documents, issues and incidents

Operational lead / IPCN

Quarterly and

annually to complement the reports for IPC

Provide and maintain a clean and appropriate environment

Actively contribute to refurbishment and renovation projects to ensure that adequate facilities are available for the decontamination of reusable medical devices

Head of Estates/IPCN

All relevant projects

Appendix III Role of the Director of

Infection Prevention and Control

The role of the Director of Infection Prevention and Control is to :

Be accountable directly to the Chief Executive and to the Board (but no necessarily a member of the Board)

Be reponsible for the organisation’s infection prevention and control team (IPT) or infection control team (ICT)

Oversee local prevention and control of infection policies and their implementation

Be a full member of the ICT and regularly attend its infection prevention and control meetings

Report directly to the NHS Board and, in non NHS care settings the registered provider

Have the authority to challenge inappropriate practice and inappropriate antibiotic prescribing

Assess the impact of all existing and new policies on infections and make recommendations for change

Be an integral member of the organisation’s clinical governance and patient safety teams and structures

Produce an annual report and release it publicly as outlined in Winning Ways: working together to reduce healthcare associated infection in England.

Taken from the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance (Department of Health 2010)