REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT · Infection Prevention & Control Annual Report 2011/12 and Objectives 2012/13 The Infection Prevention and Control (IP&C) Annual Report

REF: 12/07/P/5

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT

S:\Board\2012 Meetings\07 July\5_IPC_1.doc

SUBJECT: INFECTION PREVENTION & CONTROL ANNUAL REPORT

DATE: JULY 2012

PURPOSE: This paper presents the Infection Prevention and Control Annual report and objectives 2012/13 for approval.

RECOMMENDATIONS: Accept and approve the annual Infection Prevention and Control Report (2011/12) prior to submission to the District Infection Committee and subsequent publication on the hospital website.

AUTHOR: Heather Mcnair, Chief Nurse

CORE IMPLICATIONS

i) Business Plan Objectives Patient focus.

ii) Public and Patient Involvement Patient and public involvement is key to supporting the IP&C agenda and an area of increasing public interest and awareness.

iii) Communication And Reputation This report provides an opportunity to highlight areas of good practice and further strengthen the reputation of the Trust. Non-compliance is a significant reputation risk to the hospital.

iv) Risk Issues The impact of the ongoing operational and clinical pressures continues to challenge the capacity of the team.

v) Equality and Diversity Inherent in the delivery of all workstreams.

vi) Sustainability This programme of work has evolved in line with Department of Health requirements and is, and continues to be, sustainable.

vii) Legal Compliance with all aspects of the Hygiene Code is a legal requirement.

viii) Resources No additional resources required.

Subject: Infection Prevention & Control Annual Report Ref: 12/07/P/5

1. INTRODUCTION

1.1 The Annual Infection Prevention and Control (IP&C) report details progress, workstreams and achievements delivered by the IP&C team and the hospital. The Annual Report is a summary of all the year’s activities. Within the Health & Social Care Act 2008, the hygiene code (updated 2010) requires that the Board acknowledge and receive this report. Following the Board’s acceptance this report must be publically released.

1.2 Following approval by the Board the report will be provided to the District Infection Control Committee and then published on the Hospital website.

2. 2011/12 PERFORMANCE TARGETS/WORKPLAN

2.1 The Trust was set an extremely challenging performance target for Clostridium Difficile (C.Diff) in 2011/12. The annual target of 31 and a zero target for MRSA bacteraemia continue to be considered high risks for the Trust. The focus continues to be to identify whether each case of C.Diff is avoidable or unavoidable with the subsequent attention focused on all cases of avoidable infection. The Director of Infection Prevention and Control’s (DIPC’s) report details the Trust’s rate in line with this definition. To support this, and following agreement at the District IP&C Committee, any episodes of two or more C.Diff cases due to cross infection will be treated as a Serious Incident and reported and managed in line with that.

2.2 In addition internally all cases of defined ‘avoidable C.Diff’ will result in formal meetings with the Chief Nurse and the clinical team led by the consultant, to fully understand how the situation occurred and to ensure lessons learnt and appropriate actions taken. This action is with immediate effect.

3. CONCLUSION

3.1 This report provides ongoing assurance to the Board of the IP&C activity and the actions being taken to manage and minimise the risks inherent within IP&C.

4. APPENDICES

Appendix 1 – Infection Prevention & Control Annual Report

Director of Infection Prevention and Control Infection Control Annual Report 2011/2012

And Objectives for 2012/13

The Infection Prevention & Control Team 11/12

Dr J Rao Consultant Microbiologist/DIPC Dr Y Pang Consultant Microbiologist Denise Potter Assistant Director of Infection Prev ention and Control Christine Fisher Specialist Nurse Susan Burns Clinical Nurse Specialist Lynda Slater Clinical Nurse Specialist Simon Watson Data Analyst Deborah Elliott Data Analyst (PCT) Sue Todd PA Louise Scorah Clerical Assistant

Barnsley Hospital NHS Foundation Trust


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CONTENTS PAGE

Executive Summary 4 1.0 Introduction 6 2.0 Infection Prevention & Control Arrangements 7 3.0 Saving Lives 9 4.0 Health and Social Care Act 2008 (revised 2010) 10 5.0 Policies & Procedures 10 6.0 Visits, Reports and Projects 11 7.0 Antimicrobial Prescribing 14 8.0 Audits 15 9.0 Surveillance 18 10.0 Clusters/Outbreaks 28 11.0 Complaints 30 12.0 Serious Incidents 30 13.0 Patient Assessment 30 14.0 Educational Initiatives 31 15.0 Research 32 16.0 Health Promotion 32 17.0 Capital Schemes/Estates/Equipment 32 18.0 External Visits 33 19.0 National & Regional Work 33 20.0 Objectives 33 Appendices

Appendix 1 Lines of Communication and Accountability Appendix 2 Surgical site infection surveillance Appendix 3 Control of Infection Performance indicators Appendix 4 Training


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ABBREVIATIONS • IPCT Infection Prevention & Control Team • HCAI Health Care Associated Infection • NHSLA National Health Service Litigation Authority • MRSA Meticillin Resistant Staphylococcus Aureus • DIPC Director of Infection Prevention & Control • ICN Infection Control Nurse • CMT Corporate Management Team • DICC District Infection Control Committee • CEO Chief Executive Officer • CQC Care Quality Commission • RCA Root Cause Analysis • PEAT Patient Environment Action Team • HBV Hepatitis B Virus • CVP Central Venous Pressure • DH Department of Health • IPC Infection Prevention & Control • SWYPFT South West Yorkshire Partnership Foundation Trust • ICD Infection Control Doctor • HCCP Hazard Analysis of Critical Care Points • SHA Strategic Health Authority • PPE Personal Protective Equipment • NNU Neonatal Unit • ITU Intensive Care Unit • PAS Patient Administration System • IPCC Infection Prevention & Control Committee • COSHH Control of Substances Hazardous to Health • C diff Clostridium Difficile • C.diff Toxin Clostridium Difficile Toxin • C.diff Antigen Clostridium Difficile Antigen • CDAD Clostridium Difficile Associated Diarrhoea • CIP Cost Improvement Programme


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EXECUTIVE SUMMARY

Infection Prevention & Control Annual Report 2011/1 2 and Objectives 2012/13

The Infection Prevention and Control (IP&C) Annual Report provides a summary of all the IP&C activities and outputs across the Hospital for the year of 2011-2012. Within the Health and Social Care Act of 2008 the Hygiene Code (updated 2010) requires all NHS Boards to receive and acknowledge such annual reports prior to publically releasing them.

Healthcare associated infection is of increasing media and political interest being seen as a visible and unambiguous indicator of the quality and safety of patient care. The infection prevention and control agenda faces many challenges including the ever increasing threat from antimicrobial resistant micro-organisms, the emergence of new human pathogens, growing service developments, national guidelines and targets.

Following an unannounced inspection by the Care Quality Commission (CQC) in May 2009 the Trust was found to be fully compliant against all of the duties laid down within the Hygiene Code confirming our registration without conditions. This placed the Trust within the top percentage of Trusts in England. No inspection was undertaken in 2010/11.

The Director of Infection Prevention and Control (DIPC) meets regularly with the Chief Executive (CE), the Chief Nurse, and the Medical Director and is Chair of the Trust’s Infection Prevention and Control Committee. The DIPC and Assistant DIPC are also members of the Quality and Safety Improvement and Effectiveness Board. The DIPC attends the board on a quarterly basis to provide written and verbal feedback on Infection Prevention & Control activities. Since the new governance structure the DIPC attends the Clinical Governance Committee when required with other members of the team attending divisional governance meetings.

Over the past couple of years the Trust has seen significant reduction in Clostridium difficile (C difficile) associated infection and we have had zero MRSA bacteraemia for the last two years. Therefore all targets have been achieved but maintaining the good performance will be challenging.

The annual PEAT inspection indicates that the hospital continues to provide a clean safe environment to deliver care. However this is an ongoing process and the Trust will continue to strive for excellence. The IP&C team continues to work closely with Estates and Facilities in relation to cleanliness, environment and capital schemes. The management of Legionella prevention has been enhanced with considerable work from estates including exchange of calorifiers to plate heat exchanges. The Sterile services department maintains all the required elements to provide sterile instruments and fulfill contractual obligations.

The IP&C team has faced and managed a reduction in resources which has required a review of service provision. However the team have continued to improve practice and facilitate change e.g. introduction of new surgical wound dressing, improvements in cannulation practice by introduction of a cannulation pack increased education including the introduction and continued programme of ANTT (aseptic non touch technique)


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The team continues to teach both informally and formally and ensure that they also maintain their professional competencies. Most of the IP&C policies have been re written and are on the Trust policy warehouse intranet site.

Considerable work has been done to improve antimicrobial prescribing within the Trust and the Consultant Microbiologists undertake teaching sessions with the medical staff. The IP&C team has undertaken a number of audits and surveillance of surgical wound infections. The Trust remains above the national average for infections related to knee replacement but has recorded good results for breast, large bowel and abdominal hysterectomy.

The Trust continues to support the Saving Lives and Clean your Hands Campaign and has promoted infection prevention and control with an awareness week and a sharps prevention awareness week including the ‘Bug Herald’.

The clinical nurse specialists have been conducting ward based practical observations of clinical practice. Working along side ward staff facilitates closer working between the IP&C team and ward staff whilst allowing closer observation of clinical practice. This is proving to be very successful and effective.

The Trust had a number of cases of Norovirus infection, but managed to avoid ward closures.

The IP&C strategy for 2010 -13 continues to be on target despite the severe challenges of the winter months. The Objectives for 2012/13 contain all the required elements of an annual infection control programme. Heather Mcnair Dr Jyothi Rao Denise Potter Chief Nurse DIPC Assistant DIPC


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ANNUAL REPORT – INFECTION PREVENTION & CONTROL

1.0 Introduction The term Healthcare Associated Infection (HCAI) encompasses any infection by any infectious agent acquired as a consequence of treatment. Micro-organisms (germs) responsible for HCAI can be viruses, fungi, parasites and, more frequently, bacteria. HCAI can be caused either by micro-organisms already present on the patient’s skin and mucosa (endogenous) or by micro-organisms transmitted from another patient or health-care worker or from the surrounding environment (exogenous). The risk of transmission and potential harm applies at any time during health-care delivery, especially to immuno-compromised or vulnerable patients and/or in the presence of indwelling invasive devices (such as urinary catheter, intra-venous catheter, endotracheal tube, drains). Infection prevention and control clearly has an important role to play in ensuring that patients receive a high quality of care and improved clinical outcomes. The infection prevention & control agenda faces many challenges including the ever increasing threat from antimicrobial resistant micro-organisms, the emergence of new human pathogens, growing service developments, national guidelines and very strict targets. Healthcare associated infection is of increasing media and political interest being seen as a visible and unambiguous indicator of the quality and safety of patient care. The foundations of infection control are built on a number of simple, well-established precautions proven to be effective and widely appreciated. “Standard Precautions” encompass the basic principles of infection control that are mandatory in all health-care facilities. Their application extends to every patient receiving care, regardless of their diagnosis, risk factors and presumed infectious status, reducing the risk to patients and staff of acquiring an infection. Hand hygiene is very much at the core of Standard Precautions and is the undisputed single most effective infection prevention control measure. The main essential elements of controlling and preventing infections related to health care are:

• Identifying risk factors and minimising their impact • Improving patients’ resistance to infection • Early identification and effective treatment of infections • Preventing transmission of micro-organisms from person to person • Maintaining a clean and fit for purpose environment including equipment with

minimal levels of microbial contamination Department of Health (DH) has continued to place infection prevention and control and health care associated infection high on the agenda. The major standards and legislation against which infection control services are judged include:

1. CQC Essential Standards of Quality and Safety. 2. Saving lives.


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3. NHSLA. 4. The Health & Social care Act 2008 and associated Code of practise for health

and adult social care on the prevention and control of infections and related guidance (revised 2010).

5. Clean Your Hands Champaign. 6. Health & Safety at work etc Act 1974. 7. COSHH 2002.

New Government initiatives this year include;

• Mandatory reporting of MSSA Bacteraemia. • Mandatory reporting of Ecoli Bacteraemia.

The Infection Prevention and Control Team (IPC&T) has worked hard to implement these initiatives within the Trust. The main priority this year being, delivering the IP&C strategy 2010-2013 and action plan, exceeding national and local targets for MRSA Bacteraemia, Clostridium difficile infection reduction, Saving Lives and continued focus on Clean your hands Campaign. Following an inspection by the CQC in May 09 the Trust was found to be fully compliant and therefore in the top percentage of Trusts in England with a clear compliance with the Hygiene Code confirming our registration without conditions no further inspections relevant to the hygiene code have taken place. However, the annual PEAT inspection confirmed the Trust was a clean safe environment to deliver care. This is an ongoing process and the Trust will continue to strive for excellence. This report informs on the progress made on the objectives set in last years Annual Report and also the Trusts progress in implementing national initiatives during the reporting period April 2011 March 2012. The report also encompasses the annual programme for 2012/13 which reflects the Trusts strategic vision and commitment to the IPC agenda. 2.0 Infection Prevention & Control Arrangements The infection control service is provided by an Infection Prevention and Control team, the Consultant Microbiologists continue to support SWYPFT Community Services Unit and provide 5 sessions per week as the Infection Control Doctor. The Team has lost one 37.5 band 7 nurse as a CIP The team currently consists of;

1. Consultant Microbiologist/ DIPC / ICD 37.5 hrs weekly 2. Consultant Microbiologist 37.5 hrs weekly 3. Assistant DIPC 37.5 hrs weekly 4. 1 Specialist Infection Control Nurse 37.5 hrs weekly 5. 2 Clinical Nurse, Specialists 56 hrs weekly 6. 2 Data Analysts 37.5 hrs weekly BHNFT 18.5 hrs contracted to SWYPFT 7. 2 Admin/Clerical support 75 hrs weekly


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Infection Control Resources

The team has a separate budget which includes the provision of patient and public information, maintenance of the infection control software, training, and other supportive material. Reporting arrangements:

• The District Infection Control Committee bi-monthly changed to quarterly from July 2011.

• The Trust Infection Prevention and Control Committee (IP&CC) meets monthly

changed to bi monthly from January 2012.

• The Infection Control Forum meets bi-monthly.

• The DIPC meets regularly with the CEO, Chief Nurse and is Chair of the Trust Infection Prevention & Control Committee. The DIPC also attends as required the Clinical Governance Committee, and is a member of the Quality and Safety Improvement and Effectiveness Board. The DIPC attends the Trust Board on a quarterly basis to provide written and verbal feedback on Infection Prevention & Control activities.

• The Matron and Divisional Director have been nominated as infection control

leads within each Directorate. Their main role is to deliver the IP&C Strategy, assist in delivery of the annual infection control programme and saving lives programme. The divisions are required to report and provide evidence of compliance with the hygiene code which is checked by the IP&CT.

• The DIPC produces a monthly report to CEO and Executive Team, and bi

monthly reports to IP&CC, Quality and Safety Improvement and Effectiveness Board.

• The Assistant DIPC is included in the senior nursing, health & safety structure

and quality agenda, meeting regularly with the Chief Nurse & matrons.

• The Decontamination Group meets quarterly and reports to the Infection Prevention & Control Committee.

• The Trust has a Legionella group which meets twice yearly and reports to both

IP&CC and Health & Safety. Current lines of accountability for infection prevention control are shown in appendix 1. The Infection Prevention and Control team continue to have a strong link with the Community Infection Control team, ensuring smooth transition of care between Health and Social Care.


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3.0 Saving Lives: A delivery programme to reduce Health care Associated

Infection The ‘Saving Lives’ programme launched by the Department of Health in June 2005 is designed to increase organisational focus on infection control and to reduce healthcare associated infections including MRSA. The overall aim of ‘Saving Lives’ is to ensure that all staff recognise how they can contribute to reducing infection rates and adopt best practice to achieve this. The programme has high impact interventions which relate to specific clinical procedures which can increase the risk of infection if not performed appropriately. Each of these interventions has a simple evidence based tool that reinforces the actions that clinical staff need to undertake every time in order to significantly reduce infection, increasing reliability and reduce unwarranted variation in care delivery The Trusts compliance with the high impact interventions are demonstrated in table. Data is being fed in to the Governance structure via the Infection Prevention and Control Committee and back to the Ward staff, Matrons and Clinical Leads. With exception reporting to the Trust Board Table 1: Saving Lives - Compliance results

Intervention Apr- Jun 11

Jul - Sept 11

Oct - Dec 11

Jan - Mar 12

Insertion 100% 81% 100% 100% Central Venous Catheter

Ongoing 100% 67% 100% 100%

Insertion 95% 93% 90% 92% Peripheral Intravenous Catheter

Ongoing 98% 94% 89% 89%

Pre-op 100% 100% 100% 100% Surgical Site Infection

Peri-op 100% 90% 100% 100%

Regular observations 100% 100% 100% 100% Ventilated Patients

Ongoing care 100% 100% 100% 100%

Insertion 99% 100% 100% 100% Urinary Catheter

Ongoing 100% 97% 94% 99%


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4.0 The Health & Social Care Act 2008: Code of Practice for the control of Health care associated infection (Hygiene Code):

The Health and Social Care Act 2008 was updated in 2010 This code of practise for health and adult social care on the prevention and control of infections and related guidance has ten overall duties which form the basis of the CQC infection control inspection and helps NHS bodies to plan and implement how they can prevent and control HCAI. The Trust is legally required to be registered with the Care Quality Commission and legal action can be taken if Trusts are found to be breaching the requirement of their registration to protect patients, workers and others from infection. The Trust successfully achieved full unconditional registration on the last inspection which was conducted on the 15th May 2009. No inspections have been undertaken in 2011/12. To help deliver the requirements of the Hygiene Code the Trust has an Infection Prevention & Control strategy. This strategy and action plan first produced in June 2007 and updated February 2010 provides the Trust with an overarching strategic framework. This not only encompasses the Hygiene Code requirements but seeks to ensure that the Trust will be recognised as being one of the top performing NHS organisations and seeks to be first choice for patients. 5.0 Policies and Procedures : The team have introduced a system of yearly policy update on the Trust intranet. The following policies and procedures have been introduced, reviewed and updated by the Infection Prevention and Control team. Updated Procedures Barrier Nursing Blood Spillage Catheter specimen of urine Management of sharps Faeces specimen Mid Stream Urine Throat swab Hand Hygiene Urine spillage Body fluid spillage Decontamination of Laryngosope blades Principles of care for Infectious patients Infection Prevention and Control service profile Assistant Dogs and Pets as Therapy Updated Policies GRE Policy Isolation Policy MRSA Screening Policy


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Decontamination Policy Prevention & Control of MRSA Hand Hygiene Policy Clostridium difficile Policy 6.0 Visits, Reports and Projects: National Point Prevalence Survey The team participated in the National Point Prevalence Survey on Healthcare associated infection (HCAI) and antibiotic usage. This involved the examination of each patient’s notes on a given day to evaluate if an HCAI had been acquired and if antibiotic therapy was given and what was used. A national report is expected soon and local statistics will be available. The Trust can then benchmark against national results. The Clean Your Hand Campaign –Sixth Year Promotional hand washing awareness campaigns have been undertaken in the Trust with every clinical area engaged with the campaign. The Clean your hands champions meet quarterly with the IP&CT and they continue to integrate the campaign into practice including participating in the delivery of hand washing training at local level and monitoring practise. The number of clean your hands champions increases year on year, as staff become more pro-active in the campaign. The importance of embedding efficient and effective hand hygiene into all elements of care delivery must be kept prominent within health care and will remain a priority for the Trust. This year has seen the introduction of a hand washing DVD which is being used to enhance training The fundamental principle underpinning the campaign is the focus on the hand hygiene practises of healthcare staff. Due to the nature of their work moving between different patients and different care activities with the same patient, healthcare staff have the greatest potential to spread the microbes that cause infection. The campaign this year has highlighted in the infection control newspaper which was sent to each ward and department as well as quizzes and other promotional events Compliance with hand hygiene is monitored by direct weekly observation of health-care workers whilst delivering routine care. These are presented monthly at all the relevant committees and are displayed at ward and department level. The Trust continues to promote “bare below the elbow” standard for all staff entering clinical environment. The compliance with this is audited regularly and reported to the Infection Prevention and Control Committee and the Trust Board. Patient Environment Action Team (PEAT) The team work closely with Matrons, Senior Nurses and Facilities to promote cleanliness and other environmental issues. PEAT visits are regularly conducted by this team and additional environmental walkabouts have been undertaken with IPCT and Matrons. The team have also participated in the formal annual PEAT assessment process. The team are also involved in assessments of other Trusts as external


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validators. A more detailed environmental inspection is completed if two or more cases of Clostridium difficile are identified in one area within a 28 day period. Kitchen Inspections Standards for food hygiene are regularly monitored by the facilities department and managers informed of any action required. In addition to the regular facilities inspections, infection control along with Environmental Health conduct regular kitchen inspections, however none have taken place within the last reporting period. Full inspection has taken place of the coffee shops and the HACCAP controls have been updated. Flu The team have been actively involved in the management and control of influenza. An extensive staff vaccination programme was also completed. Decontamination The Sterile Service Department at BHNFT continues to provide an accredited and certified service against British and European Standards for decontamination. Endoscopy washer disinfectors are closely monitored with weekly water quality testing. The Trust has introduced a new sporicidal wipe for the cleaning of commodes and a new general cleaning wipe that has additional decontamination properties from the basic wipe that was in use Monitoring of equipment cleanliness takes place regularly as part of environmental audits, PEAT inspections and targeted audits. Infection control and estates have visited and inspected the external cleaning decontamination unit that cleans the Trusts specialist mattresses. The decontamination group meets quarterly and reports to the IP&CC. Risk Assessments Risk assessments have been completed and new ones continue to be developed to reduce the risks of HCAI, including the risk assessment of all admissions across all service areas. Infection control information is included on all intra/inter health-care transfer documentation and is included in the transfer & discharge policy. Inspections A detailed review of infection control in medical imaging, nuclear medicine, surgical HDU has been undertaken. Observational visits have been completed in theatres and a pace maker patient journey with recommendations for improvements made including changing the skin prep prior to pacemakers being inserted.


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Theatre Forum The infection Prevention & Control Team remain active members of the forum. NICE Surgical Site guidelines The IPCT in conjunction with theatre staff are pursuing the introduction of the NICE recommended pre operative skin prep with trials commenced in Orthopaedic surgery. Cleaning/Deep Cleaning During 2011/12 the Trust decanted and deep cleaned several wards, including using the hydrogen peroxide unit decontamination process. Wards completed include ITU, 31/32, 17/18, 27/28 and Paediatrics. There have been improvements to the allocation of resources within the cleaning contract with a more equal distribution of resources across all wards. The provision of a steam cleaning team continues. The domestic contract is monitored by facilities with reports going to the IPCC. Infection control is now a member of the hotel services monthly monitoring contract meetings and has been involved with the review of the contract and new cleaning methods. The Pest Control is monitored by Estates and quarterly reports go to the IP&CC. Aseptic Non Touch Technique (ANTT) As part of the Trust’s drive to improve wound care, the IPCT have introduced ANTT and other general improvements to aseptic technique. Over the last year ANTT has been imbedded in to practise, refresher training given and reinforced by the clinical skills facilitator. New wound dressing packs have been introduced Trust wide Observation of clinical practice During 11/12 the clinical nurse specialists have conducted 26 ward based practical observations of infection control clinical practice. Working along side ward or department staff facilitates closer working between the IPCT and clinical staff whilst allowing closer observation of clinical practice. This is proving to be very successful and effective. Infection Control Software System. The Infection Control Software System (ACMEice) received an upgrade to a new interface at the beginning of October 2010. This has resulted in improved data being received from the laboratory system. The system provides notifications of patients with positive alert organisms in order that appropriate patient care is initiated as quickly as possible thereby improving efficiency and reducing the risk of infection. The infection control patient record and documentation is completed on the system which is stored against the patient’s unit number for easy access.


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The system is currently been used by the IPCT, Matrons and Consultant Microbiologists. The Following reports have been built in order that up to the minute information can be gained:-

• Aspergillus report. • Blood Culture resulting in Staphylococcus aureus, Escherichia Coli and MRSA. • Clostridium Difficile report. • Group A. Streptococcus report. • Influenza B PCR Report. • Influenza H1N1 Report. • MRSA Positive (First Isolate) report. • MRSA Screening Report. • TB Culture Report. • Case Management forms report.

Further work still continues with the Data Surveillance Analyst and the Software provider regarding development issues to improve the functionality of the system. Cannulation Packs Intravenous cannulation remains a high risk intervention and can result in bacteraemias. Therefore, the IPCT have designed, developed and coordinated the trust wide introduction of cannulation packs. This will also have impact on reduction of needle stick injuries. Education on its use continues and this links with the infection control programme of enforcing ANTT. 7.0 Antimicrobial prescribing There is growing concern about the increasing resistance of microorganism to antimicrobial agents. Considerable work has been done to improve antimicrobial prescribing within the Trust. The current antibiotic guideline places restrictions on the use of broad spectrum antibiotics. The microbiology department selectively report antibiotic susceptibility on clinical samples to guide appropriate choice of antibiotics. Pharmacists and microbiologist review the antibiotic prescribing on a daily basis. Several audits been conducted and the results are fed back to the relevant clinical specialities (see under audit for detail). Overall antibiotic policy compliance rate is very good. Each division receives monthly data on the antibiotic consumption and the use of cephalosporins has declined dramatically since its restriction in 2008. To improve the allergy status documentation each of the wards and the notes trolleys have Traffic light codes for antibiotics.


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Chart 1: Demonstrates 2nd and 3rd generation cephalosporin usage

Cephalosporin Usage

0

5000

10000

15000

20000

25000

30000

35000

07-08 08-09 09-10 10-11 11-12

Year

Uni

ts is

sued

The Antibiotic share point helps the microbiologist to identify areas with inappropriate antibiotic use, who will then take necessary action to improve adherence to antibiotic guideline. 8.0 Audits Whilst the saving lives audit tool is used to regularly monitor targeted clinical interventions the following audits have also been undertaken:

Hand Hygiene The programme of hand hygiene observational audits of 10 per week per ward led by the matrons with the support of clinical audit continues. Those areas where compliance rate is less than100% are placed on special measures requiring daily monitoring. Results of these audits are disseminated by the matrons to the division as well as the IPCC. A web based tool developed by clinical audit for hand hygiene data collection has resulted in significant improvement in data quality.


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Chart 2: Demonstrates hand washing compliance before and after procedures

Trust Wide Hand Washing Results April 2011 - March 2012

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec -11 Jan-12 Feb-12 Mar-12

Integrated Medicine Surgical Women's, Children's, Outpatients & Diagnostics Overall Trust Wide (99.6%)

Environmental Audits In addition to local PEAT inspections, the IP&CT and Matrons have undertaken infection control audits. Additional audits are also undertaken if two or more cases of Clostridium difficile are identified on a particular ward in a 28 day period. Patient Opportunities for Hand Washing – July to August 2011 This audit was undertaken to ensure that those patients requiring assistance with toileting were offered hand hygiene facilities. 92% of patients were offered some form of hand hygiene (a 12% increase on the last audit), against a standard of 100%. The majority of patients (80%) were offered patient wipes. MRSA Decolonisation Audit Prompt screening and effective decolonisation of positive patients for MRSA and reduce the risk of MRSA bacteraemia. This audit reviewed the screening, decolonisation and promptness of initiating the MRSA care pathway in accordance with the Trusts MRSA and MRSA screening policies. Admission screening for MRSA has improved since the last audit, on average it takes less than 1 day from admission to screening of the patient. Improvements were also seen with regard to promptness in prescribing decolonisation, however only 62% of patients received decolonisation correctly. Posters have since been distributed to all inpatient areas advising on the correct use of decolonisation and all inpatients requiring decolonisation all receive information on its correct application.


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Intravenous Cannula Audit – October to November 2011 The aims of this audit were to assess adherence of the Saving Lives, High Impact Intervention No.2 (Peripheral Intravenous cannula care bundle) and to assess usage of the Invasive Devices Record. Compliance with using the Invasive Devices Record increased from 68% in the previous audit to 93% however only 66% were completed correctly. Although compliance is below the standard of 100% a 33% increase was identified since the last audit. The use of intravenous cannula packs following a successful business case may have attributed to this improvement. General management of the cannula had also improved since the previous audit; 75% of cannulas were in place for 72 hours or less. Sharps Audit – January 2012 Daniels Health Care representatives conducted a site survey with the aim of assessing practice and raising sharps awareness. All the wards and departments were audited. Overall results were good. 606 sharps containers were sighted, none were found to have protruding sharps and all were correctly assembled. Seven (7) that were not properly assembled, (these were immediately assembled properly and staff were informed that sharps containers which were not assembled properly could lead to the lids coming off if dropped or during transportation) and Twelve (12) that were more than three quarters full, (staff were advised to only fill to the line). Cannula Pack Compliance Audit – August – September 2011 Cannulation packs were introduced in 2011 with an aim to aid in the reduction of cannula infections, blood stream infections, and comply fully with NICE guidelines in relation to skin preparation. The audit was undertaken to evaluate usage of the cannulation packs and was carried out by staff on the Surgical Decisions Area in conjunction with the Infection Prevention and Control Team. 145 staff members were observed cannulating, of these 141 (97%) used the cannulation pack when undertaking cannulation. Trends on ordering packs were also monitored over a 5 month period; comparing the total number of cannulas and the total number of cannulation packs ordered. A discrepancy was identified between cannula and pack ordering and although failed cannulation attempts would represent a proportion of this discrepancy, this may require further investigation and audit. Whilst good practice in regard to cannula pack usage was observed on the SDA, it appears from the trend analysis that this is not consistent throughout the Trust. Promotion and education with regard to use of the cannulation packs continues.


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Medical Equipment Audit The Lead Nurses have undertaken a number of equipment decontamination audits including:- • The cleanliness of medical devices • The audit of decontamination of equipment returned to medical equipment library • The storage of medical equipment Additionally all audits undertaken with relation to medical devices have a decontamination aspect included. All areas for improvement have been reported to the clinical areas. The Use and management of antibiotics: The pharmacy department has undertaken a two point prevalence audit of antibiotic usage. Results are overall favourable and have been presented to IP&C committee and also to the prescribers through clinical audit meetings. Also Trust has participated in the National Point prevalence survey conducted by the HPA. 9.0 Surveillance The IP&C team continues to give a high priority to surveillance. In addition to the mandatory national surveillance scheme a regular cycle of other surgical intervention is monitored. The IPCT also undertake targeted and alert organism surveillance. Meticillin Resistant Staphylococcus Aureus (MRSA) Each new case of MRSA is followed up by the IPCT who visit all new MRSA inpatients advising on decolonisation regimes and supporting the patients, relatives and staff, including stamping the patients prescription sheet for medical staff to sign for the decolonisation regime. All patients (elective and emergency) admitted to the Trust continue to be screened for MRSA colonisation in line with the national initiative. The number of new MRSA isolates at BHNFT, remains stable. MRSA screening is monitored and non compliance fed back to clinical teams for checking.


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Chart 3: Number of new cases of MRSA infection colonisation by location: District figures

MRSA Patients (New Positives)

219

330

245 255

110 104 104 10512 16 8 12

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150

200

250

300

350

2008/09 2009/10 2010/11 2011/12Year

BHNFT Community Mount Vernon

Chart 4: Number of new cases of MRSA infection colonisation: District figures

MRSA Positives (New Patients)

341

452

357 373

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100

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2008/09 2009/10 2010/11 2011/12

Year

Mandatory surveillance of MRSA bacteraemia Since 2001 it has been mandatory for Trusts to report MRSA bacteraemia figures to Department of Health. Results are published as MRSA bacteraemia per 10,000 occupied bed days. The Trust had a target of 0 MRSA bacteraemia cases for the financial year 2011/12. The actual number of MRSA bacteraemia cases for the year was 0. Several factors have contributed this success, including universal MRSA screening, improved decolonisation, decreased blood culture contamination rate, improved cannula care etc. However this sets the target for the coming year at 0 again which remains a challenge for the Trust.


20

Table 2: MRSA bacteraemia rate per 10,000 bed days.

Chart 5: Total number of MRSA Bacteraemia District Figures

No. of MRSA Bacteraemia

02468

101214161820

2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

BHNFT Community Target

Chart 6: Trust MRSA bacteraemia compared with Regional data.

Chart 7: Monthly MRSA bacteraemia April 11 to March 12

No of MRSA bacteraemia BHNFT Community Target Rate per 10,000 bed days

2005/06 17 13 4 19 1.16 2006/07 16 8 8 16 1.07 2007/08 12 6 6 12 0.79 2008/09 8 3 5 11 0.53 2009/10 2 1 1 8 0.13 2010/11 0 0 0 1 0.00 2011/12 1 0 1 0 0.00


21

Monthly BHNFT MRSA Bacteraemia

0

2

4

6

8

10

Apr-11

May-1

1

Jun-11Ju

l-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-1

2

Feb-12

Mar-12

Month

No

of M

RS

A b

acte

raem

ia

Target Actual Cumulative actual

Meticillin Sensitive Staphylococcus Aureus (MSSA) Bacteraemia As from January 2010 it has been a requirement to report nationally all MSSA. It is expected that in future a target will be set to reduce the rates of MSSA bacteraemia. Out of 33 MSSA bacteraemias, 9 were hospital acquired (post 48 hr admission).and two of the community acquired (pre 48hr admission) were health care associated bacteraemias. The sources of these 11 bacteraemias are given in table 4. Only 4 of these bacteraemias are directly related to the health care intervention within this hospital and hence potentially avoidable. Root Cause analysis has been conducted for each of these cases and action plan has been produced.

Table 3: To Identify the numbers of MSSA Bacteraemia by Month

Staphylococcus aureus Bacteraemia - Monthly Surveil lance 2011/12

Month Total No. Hospital Community MVH MRSA April 1 0 1* 0 0 May 1 0 1* 0 0 June 0 0 0 0 0 July 2 1 1 0 0

August 1 1 0 0 0 September 4 1 3 0 0

October 4 0 4 0 1 November 5 1 3 1 0 December 5 1 4 0 0 January 5 1 3 1 0 February 3 2 1 0 0

March 3 1 2 0 0 Total 34 9 23 2 1


22

• Hospital = Hospital acquired (identified more than 48 hr after admission.) • * HCAI = Health Care Associated Infection (identified within 48 hrs of admission and had been an

inpatient in the previous 8 weeks) • Community = Community Acquired (identified within 48hrs of admission and not been an inpatient

in the last 8 weeks.)

Chart 8: Demonstrates the numbers of Staphylococcus Aureus bacteraemia by Month

Staphylococcus aureus Bacteraemia - Monthly Surveil lance 2011/12

0

1

2

3

4

5

6

Ap

ril

May

June

July

Aug

ust

Sep

tem

ber

Oct

ober

Nov

embe

r

Dec

embe

r

Janu

ary

Feb

ruar

y

Mar

ch

Month

Cou

nt

Hospital Community MVH

Table 4: MSSA bacteraemia RCA findings Case Source of MSSA Bacteraemia

1 Catheter related 2 Central Line 3 Septic arthritis of sternoclavicular joint 4 Skin and soft tissue infection 5 Peripheral cannula infection 6 Discitis 7 Central line 8 septic arthritis 9 Hip septic arthritis

*10 Haematoma following angiogram. *11 Haemodialysis fistula

Clostridium difficile: Since 2004 the reporting of C. difficile infection has become mandatory. All NHS Trusts are required to test diarrhoeal stool samples from patients over 65 years and above reporting all positive results to the HPA. Since 2007 this has been changed to report all positive Clostridium difficile cases >2 years of age. Data is expressed as the rate per 100,000 bed days. The end of year 2011/12 position was 28 positive cases against a trajectory of 31 therefore targets were met.


23

Table 5: Clostridium difficile National Surveillance Figures (All age groups)

Year Number of cases Rate per 100,000 bed days

2007/08 297 107.7 2008/09 194 73.2 2009/10 121 34.3 2010/11 131 32.9 2011/12 83 N/a

Chart 9: Total number of Clostridium difficile cases by location – District figures

Total number of Clostridium Difficile cases by location

148105

52 4928

149

89

69 8255

196

145

65

276

217

171

31

87

0

50

100

150

200

250

300

350

2007/08 2008/09 2009/10 2010/11 2011/12

BHNFT Primary Care Organisation BHNFT Target PCT Target

Chart 10: Monthly new Clostridium difficile episodes against agreed trajectory

BHNFT Clostridium Difficile Performance 2011 / 2012 .

0

1

2

3

4

5

6

7

Apr-11

May-1

1

Jun-

11Ju

l-11

Aug-1

1

Sep-1

1

Oct-11

Nov-1

1

Dec-1

1

Jan-

12

Feb-12

Mar-12

No. of Cases

SHA target Actual Number BHNFT apportioned


24

Chart 11: Trust Clostridium Difficile cases compared with Regional data.

RCA has been undertaken for all cases of C difficile by the IPCT or Matron and an exception report is produced mainly concentrating on environmental cleanliness, if 2 more cases are identified in a particular ward within 28 days. Antibiotic use is also monitored by the Pharmacist. Actions are taken based on the results of the RCA and exception reports.

A RCA Overview Panel has been established since September 2008 involving representatives from SWYPFT Commissioning, Public health and BHNFT continues to meet every month, and is instrumental in trouble shooting and action planning as a health economy. Findings from these are presented to District and local IP&C committee. Glycopeptide Resistant Enterococci (GRE): The IPCT also monitor the number of cases of GRE. There were 3 cases of GRE infection /colonisation see table 5. Table 6: Total Numbers of GRE cases by year Year BHNFT GP KERES.

KHB

MVH

TOTAL

2005 4 0 0 0 0 4 2006 1 0 0 0 0 1 2007 2 0 0 0 0 2 2008 1 0 0 0 0 1 2009/10 0 0 0 0 0 0 2010/11 0 0 0 0 0 0 2011/12 3 0 0 0 0 3


25

Surveillance of Escherichia Coli Bacteraemia Since April 2011, it has become mandatory to report all cases of E.coli bacteraemia into the national database. There is no national benchmark available to compare the rate at the current time. Table 7: Total numbers Escherichia Coli Bacteraemia by Month

E Coli Bacteraemia - Monthly Surveillance 2011/12.

Month Total No. Hospital Community MVH ESBL April 10 1 9 0 2 May 4 0 3 1 0 June 18 6 12 0 2 July 15 4 11 0 3 August 15 4 11 0 1 September 9 1 8 0 2 October 12 0 11 1 3 November 12 0 12 0 2 December 19 4 14 1 1 January 9 1 8 0 1 February 14 2 12 0 3 March 13 1 11 1 1 Total 150 24 122 4 21

Chart 12: Demonstrates the numbers of Escherichia Coli Bacteraemia by Month

E. Coli Bacteraemia - Monthly Surveillance 2011/12.

02468

101214161820

Apr

il

May

June

July

Aug

ust

Sep

tem

ber

Oct

ober

Nov

embe

r

Dec

embe

r

Janu

ary

Feb

ruar

y

Mar

ch

Month

Cou

nt

Hospital Community MVH ESBL


26

Surveillance of blood culture contaminants: Since the introduction of monthly surveillance of blood culture contamination rates there has been significant improvement in the rate of contamination of blood culture, thus avoiding unnecessary antibiotic use and also the cost. The continued and reinforced use of ANTT to all staff saw a further reduction in the rate of contamination.

Chart 13: Total blood culture contaminants by month

% Contaminant

0

1

2

3

4

5

6

7

8

Apr

-11

May

-11

Jun-

11

Jul-1

1

Aug

-11

Sep

-11

Oct

-11

Nov

-11

Dec

-11

Jan-

12

Feb

-12

Mar

-12

%contamination

Surgical site surveillance Orthopaedic surgical site surveillance: The Trust is participating in the mandatory Orthopaedic wound surveillance and has been since 2001. Even though Trusts are required only to collect data on one type of orthopaedic procedure for a 3 month period, BHNFT has elected to undertake consistent surveillance of hip, knee and hip hemi-arthroplasty wound infection. The percentage of wound infections for all periods of collection are as follows: Knees 2.6% infection Hip replacement 1.0% Repair of neck of femur 0.8%. More detailed results of this surveillance are shown in appendix 2. Post discharge surveillance has commenced on patients undergoing hip and knee replacement and hemi arthroplasty surgery. Breast Surgery Surveillance Breast Surgery surveillance was completed for period January – March 2012 which included post discharge surveillance also. Out of the 70 operations where data had been submitted there were no Surgical Site Infections found for inpatient / readmission. 1 Surgical Site Infection was identified by patient’s completing the post discharge questionnaire.


27

For Surgical Site Infections identified as inpatients / readmission, the current infection rate is 0.0% against the National Benchmark of 1.0%. Large bowel surgery surveillance: Large bowel surgical site surveillance was completed for the period October – December 2011 which included post discharge surveillance also. 4 wound infections were identified during this period out off 38 operations giving a percentage of 10.5%, against a national target of 9.9%. An additional 3 patient reported cases were identified through the post discharge questionnaire and 1 further case identified upon patient review, which gives a rate of 21.1% against national average 11.9% See appendix 2 Caesarean Section Surveillance Caesarean section wound surveillance (including post discharge surveillance) was carried out during April – June 2011. 22 Surgical Site Infections were reported giving a percentage of 16%. All these were superficial infections. This is an increase of 6% from the previous surveillance completed in 2010; Table 8: The number of section operations and infections in 2008 to 2011

March – June 2008 April – June 2010 April – June 2011 No. of operations 148 128 139

No. of SSI 5 13 22 % Operations infection 3% 10% 16% Chart 14: Demonstrates Number of Caesarean Section Wound Infections

Caesarean Section Surgical Site Surveillance

1

4

00

13

01

13

8

0

2

4

6

8

10

12

14

During Admission Patient Reported Other Post Discha rge

March - June 2008 April - June 2010 April - June 2011


28

Alert organism and alert conditions surveillance: Chart 14 gives the number of alert organisms identified in the laboratory. Alert organisms are those organisms that have infection control implications.

Chart 15: Alert organism’s surveillance

Total No. of Alert Organisms identified by the labo ratory within Barnsley April 2011 - March 2012

39

6

388

16

153

282

7

4

1

1

0

38

113

0 50 100 150 200 250 300 350 400 450

Salmo ne lla

Shige lla

C ampylo bacter

E. co li 0157

R o tavirus

Strepto co ccus Gp A

M yco bacterium T uberculo s is

N eisseria M eningit idis

V . cho le rae (no n to xigenic)

Legio ne lla

H epat it is 'A '

H epat it is 'B '

H epat it is 'C '

10. Clusters/Outbreaks

Table 9: Details of BHNFT clusters / outbreaks

Date of Closure

Ward No. of days

closed

No. of patients affected

No. of staff affected

Disease

Organism Isolated

28.05.11 28 1 13 1 Gastroenteritis Norovirus

10.07.11 22 1 11 0 Gastroenteritis Non-identified

N/A October

19 0 13 4 Gastroenteritis Norovirus

N/A October


N/A October


N/A December

22 0 18 0 Gastroenteritis Non-identified

N/A January


N/A January


N/A January


N/A January



29

N/A January


N/A January

19 0 8 0 Gastroenteritis Norovirus x 2

N/A February


N/A February

24 0 1 bed blocked for 24 hrs

3 4 Gastroenteritis Norovirus x 1

N/A February

CCU 0 3 4 Gastroenteritis Norovirus x 2

N/A February

21 0 Room 10, 1 bed blocked 4 days Room 16, 2 beds blocked


N/A February


N/A February

35 0 2 bed blocked <24 hrs

4

0

Gastroenteritis Norovirus x 1

N/A February

35 0 1 bed blocked <24 hrs

6 0 Non-Identified Non-Identified

N/A February

22 0 2 beds blocked for 5 days


N/A March

27 0 3 beds blocked for 5 days


N/A March

21 0 3 0 Non-identified Non-indentified

N/A March

36 0 3 beds blocked for <24 hours

8

0 Gastroenteritis Norovirus x 1

N/A March


N/A March

35 0 Room 12, 1 bed blocked 3 days Room 16, 2 beds blocked 3 day

7 0 Non-Identified Non-Identified

N/A March

17 0 1 bed blocked for 24 hours



30

Also in addition to the above cluster a further 5 wards were reviewed by the Infection Prevention and Control Team following alerts by the ward staff. An increase in the number of patients with Clostridium difficile on ward 21 was also identified. As a result an action plan was produced and initiated. An increase in patients with Aspergillus was also identified on the Intensive Care Unit. An action plan was produced which included environmental sampling for Aspergillus species, deep cleaning of the unit and monitoring for increased isolates of Aspergillus. This work included close cooperation with Estates

11.0 Complaints The team have assisted divisions to answer relevant complaints. 12.0 Serious incidents : Only one serious incident has been recorded and investigated 13.0 Patient Assessment The team continue to support patients with infections, providing ongoing support for healthcare providers, carers, relatives and others. The team attempt to visit all patients with alert conditions or alert organisms, providing individual assessments on care management and control of infection as well as providing information to patients and relatives. If the patient is unable to communicate, the team leave a compliment slip advising of the visit and our availability to relatives. Additionally the team conduct Clostridium difficile ward rounds visiting patients with CDAD evaluating and monitoring their progress. The microbiology consultants conduct significant micro-organism isolate ward rounds in addition to daily visits to ITU. The Control of Infection relies on the prompt identification and management of infectious patients. Therefore the response times of the Infection Control Team are a vital element in the process to controlling risks associated with the transmission of human pathogens. The IPCT have set the following 2 target indicators against which they are performance managed.

Indicator 1 - Percentage of verbal advice within 30 minutes on notification of alert organism and alert conditions. (Target 99% of in patients)

Indicator 2 – Percentage of visits to the area within 2 working days. (Target 98% of

inpatients) Summary of the results:

Indicator 1- 2538 in patient episodes of alert organism have been notified by the Infection Control team to clinical staff and verbal advice has been given. In 99 % of cases this was achieved within 30 minutes. Indicator 2- 1084 initial visits have been conducted, 99.1% of which were done within 2 working days. The full report can be seen in appendix 3.


31

The team have strong working relationships with the bed management team including formal weekly meetings. Daily cubicle use continues to be monitored by the bed management team and the Infection Prevention and Control team. 14.0 Educational Initiatives

The ongoing education of all staff remains a high priority for the team however; problems releasing staff continue to be experienced. The team have been actively involved in updating the corporate curriculum. E learning is available for both non clinical and clinical staff whilst the medical staff package is still under development.

A blood borne virus study day is provided bimonthly with a site specific 2½ hour update run frequently throughout the year. The team participate in the induction programmes for new medical staff and have achieved 100% compliance with provision of this service. The microbiologists continue to undertake targeted education of medical staff.

The team participate in the mandatory training & induction programmes for all other staff and have achieved 100% compliance with provision of this service. A stand is included in all Dr’s Inductions. Additionally mandatory training has been reviewed and updated.

A new hand washing DVD has been completed and is used in training. The team have continued to train the clean your hands champions who in turn monitor and check the hand washing technique at clinical level. A training package has been developed for external contractors providing basic infection prevention and control advice with several sessions having been conducted and well attended. Training records can be seen in appendix 5. Professional Development of the Infection Control Nurses All the Infection Prevention and Control Nurses are required to provide evidence of continuing professional development as part of the requirements of the Nursing and Midwifery Council to maintain their nursing registration. Above this basic requirement there is ongoing academic study and attendance at regional and national conferences to enable the nurses not only to develop professionally but also to ensure that they are able to provide the most up-to-date advice to prevent and control infection. In the last 12 months, three Infection Control Nurses have attended the National Infection Control Nurses Annual Conference in Harrogate. Over the year the team have attended various training days to update their knowledge. The team has continued to support and attend various committees e.g. Health & Safety, Medical Devices, COSHH and Waste, Procedures group and Senior Nurses Forum, Drugs and Therapeutics Committee, Hotel Services Forum, CQC leads, Decontamination, Legionella, Sharps Prevention, Divisional Governance groups .


32

Additionally the team lead and chair the Infection Control Forum, the Sharps Prevention group and the Clean Your Hands Champion meeting. The Consultants continue to undertake CPD requirements 15.0 Research The team continues to evaluate current research and apply appropriately to practise. 16.0 Health Promotion (PPI/Special Projects) The infection prevention & control team recognise the importance of working with the public to reduce healthcare associated infections and have encouraged the public to see this issue as a partnership. The team have promoted the principles of infection control to the general public at special events:

• Local radio interviews. • Items in the local press. • Sharps prevention week • Infection Control week • Hand hygiene reminder labels on toilet doors for patients • Stand in the Education Centre – July to promote MRSA for visitors and staff • Stand in OPD to promote Hand Hygiene for staff and visitors • Promotion of patient and public involvement with the CE, Directors and Trust

board including attendance at a Working Men’s club , and a stand at the Core and Barnsley College

The team continue to lead the sharps prevention strategy actively promoting the safe use and disposal of sharps. A sharps awareness week was held in April 11. In November the team held Infection Prevention & Control week when a number of activities to raise awareness took place including poster displays, the launch of the Bug Herald, handing out infection prevention advise to all out patients and A&E attendees The team promoted awareness of MRSA during a promotional week in September including: • A stand in the Education Centre • A stand in OPD – aimed at visitors and patients • Drop in session with representatives from ConvaTec, BSN medical, Systagenix,

Smith and Nephew, Schulke, Advancis medical. There was also representation from Infection Control, Tissue Viability and Materials Management.

17.0 Capital Schemes/Estates/Equipment. The Infection Prevention & Control Team’s advice must be sought by the Trust for all service development activity including capital/building schemes, equipment procurement and contracting for services, which have implications for infection control.


33

The Assistant DIPC and the Head of Estates (operational) have regular meetings to assist with communication and involvement. Over the last year involvement has included the Women’s and Children’s scheme, Window replacements,, Main Barriers and Paving, Mortuary Compressors, Roads and Paving scheme and Floor replacements main reception and general areas 18.0 External Visits No Hygiene code inspections have taken place this year.

19.0 National & Regional Work The Assistant DIPC continues to forge national links and has represented the regional Infection prevention society (IPS) at national meetings. The Team has represented the Trust at other regional/national meetings including Assistant DIPC being an external PEAT validator. 20.0 OBJECTIVES FOR 2012/13

In addition to the core activities these are the specific objectives to be addressed in the year 12/13. The objectives listed below are a summary and more detailed breakdown has been issued separately.

Policies and Procedures Policies and infection control procedures/guidelines will be reviewed.

Maintain the Infection control intranet site.

Audit of Policies and Procedures Hand Washing Observational Audit All wards/clinical areas

Audit the clinical environment and equipment

Audit the cleanliness of equipment

Use and Management of Sharps Containers Audit compliance with MRSA decolonisation and screening Audit care of Clostridium Difficile patients including monitoring clinical care Audit compliance with the correct use of cannula and maintenance of correct records Audit compliance of Antibiotic policy


34

Education

Review training content & conduct sessions to comply with corporate curriculum

Respond to adhoc training as required

Focus on training for aseptic technique /ANTT Projects

Re-launch and refresh the General Clean your Hands Campaign. Develop a Clean your Hands Focused Campaign for Theatres. Continue to develop information for the patients and the public including surveillance results and pre admission information. Continue to develop the central data base of risk assessments relating to infection control. Review and Improve Saving Lives procedures. Continue to respond to planning arrangements for Influenza. Improve the infection control software system. Promote Annual Infection Control week. Promote Annual Sharps Control week. Coordinate the CAUTI CQUIN. Update the Infection Prevention and Control Strategy. Introduce the use of Hibiscrub for pre-operative skin prep for orthopaedic surgery. Introduce the use of Chloraprep skin antiseptic for orthopaedic and caesarean sections.

Surveillance

The routine surveillance of alert organisms, alert conditions, antibiotic resistance patterns and monitoring of all positive isolates will continue.

MSSA Bacteraemia surveillance will be introduced and RCA of all hospital acquired cases will be undertaken. MRSA bacteraemia surveillance will continue with root cause analysis of all cases. GRE surveillance continues.


35

Surveillance of other resistant organisms e.g. ESBL’s.

Targeted surveillance of hips knees and neck of femur repair will continue. Including post discharge surveillance Conduct 3 months surveillance of Caesarean section infections including post discharge surveillance. Conduct 3 months surveillance of Large Bowel surgery infections including post discharge surveillance. Continue surveillance of E coli bacteraemias and introduce RCA. Conduct 3 months Breast Surgery wound surveillance including post discharge surveillance. Clostridium Difficile report monitoring continues and the root cause analysis will continue to be completed on all Clostridium Difficile cases including action during a period of increased incidence or same ribotype. Environment Participate in new development and capital schemes. Participate in the monitoring of the cleaning contract. Upgrade treatment rooms.

All equipment and environment will be thoroughly decontaminated and cleanliness maintained to the highest level in all clinical areas according to infection prevention and control policies and procedures. On discharge of all patients thorough terminal cleaning of the room will be completed. Antibiotic

The Adult antibiotic policy will be reviewed.

MRSA Review and update MRSA care pathway.

Other The Infection Control Team will be aware of and incorporate additional activity as required to meet local and national requirements as resource will allow. Promote BHNFT Nationally


36

Performance Management To review and ensure compliance with infection control Programme at CSU level. Produce and monitor infection control data e.g. Positive and contaminated Blood Cultures Clostridium difficile positives MRSA positives MSSA positives

37

Committee Structures

Lines of Communication and Accountability

District Control of Infection Committee

BHNFT Board of Directors

Clinical Governance

Commissioning

BHNFT Infection Control Forum

Divisions & Departments

Infection Prevention & Control Committee

Decontamination Group

Non-Clinical Governance Committee

Appendix 1

38

Surgical Site Infection Surveillance Appendix 2

KNEE REPLACEMENT SURVEILLANCE

2011 and Previous periods

BHNFT All Hospitals Last Period

October – December 2011 Last 4 periods

January – December 2011 Last 5 Years

Risk Index

No. Operations

No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

0 73 2 2.7% 211 6 2.8% 135776 576 0.4% 1 24 0 0.0% 81 2 2.5% 43230 359 0.8% 2 3 0 0.0% 5 0 0.0% 4324 59 1.4% 3 0 0 0.0% 0 0 0.0% 23 3 13.0%

Unknown 3 0 0.0% 49 1 2.0% 20559 103 0.5% Total 103 2 1.9% 346 9 2.6% 203912 1100 0.5%

REPAIR NECK OF FEMUR SURVEILLANCE





Risk Index

No. Operations

No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

0 9 0 0.0% 42 1 2.4% 12708 147 1.2% 1 28 0 0.0% 109 0 0.0% 26886 440 1.6% 2 9 0 0.0% 34 0 0.0% 5236 160 3.1% 3 0 0 0.0% 0 0 0.0% 11 0 0.0%

Unknown 16 0 0.0% 67 1 1.5% 7725 105 1.4% Total 62 0 0.0% 252 2 0.8% 52566 852 1.6%

TOTAL HIP REPLACEMENT SURVEILLANCE





Risk Index

No. Operations

No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

0 26 0 0.0% 88 1 1.1% 123841 567 0.5% 1 22 0 0.0% 60 0 0.0% 42843 439 1.0% 2 0 0 0.0% 6 1 16.7% 6390 136 2.1% 3 0 0 0.0% 0 0 0.0% 51 1 1.8%

Unknown 3 0 0.0% 42 0 0.0% 20022 161 0.8% Total 51 0 0.0% 196 2 1.0% 193147 1304 0.7%

39

LARGE BOWEL SURGERY 2011 and Previous periods

BHNFT All Hospitals

Last Period October – December 2011

Last 4 periods January – December 2011

Last 5 Years

Risk Index

No. Operations

No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

0 13 2 15.4% 53 2 3.8% 4297 277 6.4% 1 12 1 8.3% 63 4 6.3% 6030 618 10.2% 2 11 1 9.1% 22 1 4.5% 2659 380 14.3% 3 1 0 0.0% 1 0 0.0% 382 90 23.6%

Unknown 1 0 0.0% 35 1 2.9% 2131 174 8.2% Total 38 4 10.5% 174 8 4.6% 15499 1539 9.9%

BREAST SURGERY



January – March 2012 Last 2 periods

January 2011 – March 2012 Last 5 Years

Risk Index

No. Operations

No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

No. Operations

No. SSI’s

% Infected

0 50 0 0.0% 88 0 0.0% 2222 20 0.9% 1 7 0 0.0% 7 0 0.0% 516 7 1.4% 2 0 0 0.0% 0 0 0.0% 23 0 0.0% 3 0 0 0.0% 0 0 0.0% 0 0 0.0%

Unknown 13 0 0.0% 13 0 0.0% 354 4 1.0% Total 70 0 0.0% 130 0 0.0% 3115 31 1.0%

Risk Index Definition A Risk Index comprising data obtained from three factors – ASA score, wound classification and duration of operation – is used to assign a risk score between 0 and 3 to each operation. Operations with a risk index score of 3 have a higher risk of developing SSI than those with a score of 0. This score is used to stratify operations and enable rates of SSI to be adjusted by these risk factors.

40

Performance Indicators Appendix 3 PERFORMANCE INDICATOR 1 = 98.8% Total number of referrals seen/not seen by Infectio n Prevention & Control Breakdown of Total No. of referrals seen by Infecti on Control at BHNFT (Please note the table relates to original referral criteria not necessarily confirmed cases)

Month Received in a month

N/A Achieved Target

Exceeded 30 minute time limit

30-1H 1-2 H 2-3 H Excess of 3 H

Average % Notified within 30 minutes

Reason for delay

April

146

55

90

1

1

0

0

0

98.9%

Rang several times, no

answer at ward level

May

192

36

154

2

1

1

0

0

98.7%



June

176

52

123

1

0

0

0

1

99.2%



July

142

28

114

0

0

0

0

0

100%

N/A

August

162

60

102

0

0

0

0

0

100%

N/A

September

164

39

120

5

1

3

0

1

96.0%

Rang several times , no


October

251

n/a

247

4

n/a

n/a

n/a

n/a

98.4%

Not known

November

264

n/a

260

4

n/a

n/a

n/a

n/a

98.5%

Not known

December

236

n/a

232

4

n/a

n/a

n/a

n/a

98.3%

Not known

January

291

n/a

290

1

n/a

n/a

n/a

n/a

99.7%

Not known

February

260

n/a

257

3

n/a

n/a

n/a

n/a

98.7%

Not known

March

254

n/a

252

2

n/a

n/a

n/a

n/a

99.2%

Not known

41

PERFORMANCE INDICATOR 2 Total number of referrals seen/not seen by Infectio n Prevention & Control

99.9% Overall for the financial year April 2010 – March 2011 PERFORMANCE INDICATOR 3

* OTHER mainly includes Diarrhoea and suspected infections including swine flu

Number of assessments April 2010 – March 2011

TOTAL

WITHIN 48

HOURS

EXCESS 48

HOURS

April – June 2010 295 295 0

July – September 2010 250 250 0

October – December 2010 313 312 1

January – March 2011 250 250 0

INFECTION : BHNFT

April 11 – March 12

MRSA 695 Previous MRSA 1 CLOSTRIDIUM DIFFICILE TOXIN 31 CLOSTRIDIUM DIFFICILE Antigen (GDH) +

4

Previous Clostridium Difficile 3 CAMPYLOBACTER 18 HEPATITIS B/C 1 MENINGITIS 0 EXTENDED SPECTRUM BETA LACTAMASE (ESBL)

0

GROUP A STREP 0 SHIGELLA 0 SCABIES 3 SALMONELLA 2 SHINGLES 8 INFLUENZA 3 E COLI 18 OTHER* 240 TOTAL 1027

Appendix 4

42

Training data – 01.04.2011 – 31.03.2012

Type of session Number of sessions

No of attendees

Mandatory 111 1338 Train the trainers 16 36 Hand Hygiene, by champions 103 268 ANTT 17 70 Contractors Inductions 3 18 Doctors Inductions 1 86 HIV and BBV awareness day 3 34 HIV and BBV update 3 8 Student Inductions 12 127 Food hygiene 1 5 MRSA training 2 9 Cannulae pack training 2 15 MRSA road show 1 24 Governors Hand Hygiene 1 11

Appendix 5

Documents

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT · Infection Prevention & Control Annual Report 2011/12 and Objectives 2012/13 The Infection Prevention and Control (IP&C) Annual Report