PENNINE ACUTE HOSPITALS NHS TRUST

HCAI RECOVERYVic Crumbleholme/Louise Dickinson

Associate Director of Nursing/Nurse Consultant Prevention & Control of Infection

PAHT MRSA bacteraemia 6 monthly figures and rates per 10,000 bed days, April 01-March 07

05

1015202530354045505560

Nu

mb

ers

0

0.5

1

1.5

2

2.5

3

3.5

Rat

es

Numbers Rates per 10,000 bed days Linear (Numbers) Linear (Rates per 10,000 bed days)

PAHT c. difficile Annual figures & rates per 1,000 bed days for patients 65 +

050

100150200250300350400450500550600

2004 2005 2006

Year

Nu

mb

ers

0

1

2

3

4

5

Rat

e

Numbers

Annual Rate per 1,000 bed days for patients 65 yrs & over NW

Annual Rate per 1,000 bed days for patients 65 yrs & over, Pennine Trust

Annual C. diff rate per 1000 bed days

2.16

1.83

2.89 2.282.62

0.84

2.74

2.11

1.06

1.89

0.83

1.55

1.98 1.78

2.33

0.00

2.79

0.890.89

2.33

2.59

1.66

1.51

1.242.27

2.82

1.45

1.62

2.28

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

Annual Rate per 1000 bed days 04 Annual Rate per 1000 bed days 05 Annual Rate per 1000 bed days 06

MRSA Bacteraemia Rates 10/04-03/07

1.20

1.911.711.49

0.63

0.91

2.16

1.142.02

1.24

0.35

0.98

0.94

1.120.82

1.75

0.28

1.76

1.36

1.310.58

0.76

2.12

1.62

1.711.591.45

0.93

1.32

-

2.00

4.00

6.00

8.00

10.00

12.00

14.00

Aint

ree

Hosp

itals

Bolto

nHo

spita

ls

Chris

tieHo

spita

l

Coun

tess

of

Ches

ter

East

Lanc

ashi

re

Live

rpoo

lW

omen

's

Mor

ecam

beBa

y Hos

pita

ls

North

Cum

bria

Acut

e Roya

lLi

verp

ool

Sout

hM

anch

este

r

St H

elen

's &

Know

sley

Tam

esid

e an

dGl

osso

p Ac

ute

The

Penn

ine

Acut

e

Traf

ford

Heal

thca

re

Wrig

htin

gton

,W

igan

& L

eigh

Oct06-Mar07

Apr06-Sep06

Oct05-Mar06

Apr05-Sep05

Oct04-Mar05

Why is PAHT in Recovery?MRSA Trajectory

0

10

20

30

40

50

60

April May June July Aug Sept Oct

Month

Nu

mb

ero

f M

RS

A b

acte

raem

ia

07-Aug trajectory Linear (07-Aug)

Recovery Plan• High Impact Interventions• Infection prevention moved into the corporate

domain/HCAI Board• DoH support• Managerial engagement• Clinical engagement• PCT support• Infection Prevention Performance Team• Forensic approach to Infection Prevention

High Impact Interventions• Hll 1 Central line Care • Hll 2 Peripheral Cannulae• HII 3 Renal Dialysis Catheter Care Bundle• Hll 4 Prevention of surgical site infection• HII 5 Ventilated patients or tracheostomy• HII 6 Urinary catheter• HII 7 Arrangements for managing C diff

Corporate Team• Chief Executive• Director of Infection Prevention & Control• Director of Nursing• Infection Prevention Nurse Consultant• Associate Director of Nursing• HAI Board• IPNs/IPPs• DNMs/Ward Managers

DoH Support

• Weekly monitoring

• Face to face contact

• Phone to phone contact

• Clinical/project support

• Critical review of progress

Managerial Engagement• Performance management “dashboard”

Managerial Engagement

Managerial Engagement

Managerial EngagementInstitutional FactorsActual ward establishment > or < HCC toolkit estimate

Antibiotic prescribing policy

Bed Occupancy >90%

Number of patient transfers including transfer from A&E

Was this an appropriate admission to this ward?

Ward/Local Infection Prevention FactorsEnvironmental issues - appropriate cleaning agents

Environmental issues - appropriate cleaning around beds

Environmental issues - appropriate cleaning between admissions

Environmental issues - availability of alcohol rub

Environmental issues - bed spacing

Environmental issues - call bells working

Environmental issues - clean linen stored appropriately

Environmental issues – cohorting

Environmental issues - dirty linen disposed of appropriately

Environmental issues - domestic cleaning score

Environmental issues - equipment available

Environmental issues - equipment working

Environmental issues - general ward cleanliness

Environmental issues - handwashing (1 basin per 6 beds)

Environmental issues – isolation

Environmental issues - kitchen cleanliness

Environmental issues - mixed sex

Environmental issues – storage

Environmental issues – waste

Equipment shared between patients

Staff adherence to dress code

Temporary staffing usage over past 3/12 - agency shifts

Temporary staffing usage over past 3/12 - bank shifts

Managerial EngagementResponse of IPC Nursing team Did last 10 complaints indicate any IC problems on ward

Response of Microbiologist Did last 10 incident reports indicate any IC problems on ward

% Registered Staff ANTT Competency Assessed Was this an unavoidable bacteraemia

% Unregistered Staff ANTT Competency Assessed Eradication treatment administered appropriately

All staff had all mandatory IC updates Eradication treatment prescribed appropriately

Antibiotic usage HII 3 Renal Dialysis Catheter Care Bundle (Renal Only)

Availability hard copies of IC policies on ward HII 5 Ventilated patients or tracheostomy - Record of care

Availability of IC/ ICNA audit data < 12 months HII 6 Urinary catheter INSERTION - Record of care, sticker

Availability of monthly monitoring returns HII 6 Urinary catheter ONGOING CARE - Record of care

Hll 1 Central line Care INSERTION HII 7 clostridium difficile - care pathway properly completed

Hll 1 Central line Care ONGOING CARE Hll 1 Central line Care INSERTION Number & technique

Hll 2 Peripheral Cannulae INSERTION Hll 1 Central line Care ONGOING CARE - Record of care

Hll 2 Peripheral Cannulae ONGOING CARE Hll 2 Peripheral Cannulae INSERTION Number, technique & sticker

HII 3 Renal Dialysis Catheter Care Bundle (Renal Only)Hll 2 Peripheral Cannulae ONGOING CARE - Record of care & VIP score

Hll 4 Prevention of surgical site infection Hll 4 Prevention of surgical site infection - preadmission screeningHII 5 Ventilated patients or tracheostomy Hll 4 Prevention of surgical site infection - prophylactic antibiotic use

HII 6 Urinary catheter INSERTION Isolation/barrier nursing arrangements

HII 6 Urinary catheter ONGOING CARE MRSA care pathway properly completed

HII 7 clostridium difficile Frequent admissions

Response of IPC Nursing team Flagged on PAS

Response of Microbiologist Previously colonised

Blood culture - contamination Profile of IC on ward (High, Medium or Low)

Blood culture - who took it Was patient on end of life pathway when bacteraemia detected

Blood culture - why taken

Factors at the Point of Patient Care

Clinical Engagement

• Handwashing week• ISS• ANTT awareness• HAI Board• Wider range of

communication• Backlog

maintenance

• Public health day• C difficile day• IP Summit• Handwashing stations• Screensaver• Pennine News• Series of meetings with

Consultant medics

PCT Support

• £550,000 of £50,000,000 Government help allocated to PAHT

• Contract incentives

• Clinical support

Infection Prevention Performance Team

• 5 sisters

• Site based

• Targeted support to clinically-based staff

• Corporate authority

• Specific role re. education, practice and to support specific projects (e.g., ChloraPrep)

• Monitoring support

• Audit/accreditation

Our Experience% Staff using hand rub at entrance to wards before (n=1540 observations) & after

(n=1385 observations) handwashing week

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

DOCTORS NURSES PATIENTS PORTERS OTHER MEDSTAFF

DOMESTICS VISITORS OTHER TOTAL

Before

After