director of infection prevention and · pdf filedirector of infection prevention and control...

2011-12

Susan Bowler

Executive Director of Nursing &

Quality,

Director of Infection Prevention and

Control

Sherwood Forest Hospitals NHS

Foundation Trust

Director of Infection Preventionand Control

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Index:

Section Page

Executive Summary 3

1 Purpose of report 4

1.1 Introduction 4

1.2 Compliance with annual programme of work 5

1.3 Annual programme of work 5

1.4 Compliance with the Code of Practice 5

1.5 Kettering Peer Review Visit 6

2 Key achievements 6

3 Description of Infection Prevention and Control arrangements 6

3.1 Infection Prevention and Control comprising of the following individuals 8

3.2 Clinical Librarian 8

3.3 Infection Prevention and Control Links 9

3.4 Healthcare Associated Infection Forum 9

3.5 Infection Prevention and Control Committee 9

3.6 Reports to the Trust Board 10

3.7 Budget allocation to infection prevention activities 10

3.8 Clinical Governance 10

4. Patient and Public engagement 10

4.1 Members event 12

4.2 Patient environment action team (PEAT) 12

5 Surveillance 13

5.1 Meticillin sensitive staphylococcus aureus bacteraemia 11

5.2 Meticillin resistant staphylococcus aureus bacteraemia 14

5.3 New clinical cases of MRSA 16

5.4 Glycopeptide resistant enterococcal bacteraemia 17

5.5 Clostridium difficile 18

5.6 Extended Spectrum β-lactamases Producers 20

5.7 Escherichia coli bacteraemia 21

5.8 Hospital acquired bacteraemia 22

5.9 Blood culture 22

5.10 Neonatal bacteraemia 23

5.11 Orthopaedic surgical site infection surveillance 23

5.12 Influenza 25

6. Commissioning for quality and innovation 25

7. Serious incident, periods of increased incident and outbreaks 27

7.1 Outbreaks of diarrhoea and vomiting 27

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7.2 Other infection related outbreaks 29

7.3 Serious incident 29

8 Antimicrobial management 29

8.1 Antimicrobial prescribing 29

9. Cleanliness 30

9.1 PEAT inspection 31

10. Design, construction, renovation and refurbishment programme 31

10.1 Theatre ventilation 31

10.2 Water management - Legionella 32

11. Decontamination 32

11.1 Decontamination of equipment 32

11.2 Decontamination of endoscopy 33

12. Partnership working 33

13. Policy review 33

14. Communication with staff, patients and relatives 34

15. Audits 34

15.1 Saving Lives 34

15.2 Clinical audits 34

15.3 Compliance with isolation precaution 35

15.4 Infection Prevention Society annual audit 35

15.5 Trust wide observation audit on hand hygiene techniques 36

15.6 Compliance with taking and recording blood culture 36

15.7 Commode and raised toilet seat audits 36

15.8 Additional audits 36

16. Education 37

16.1 Orientation training 37

16.2 Mandatory training 37

16.3 Bespoke training 38

17. Influenza planning 38

18. Infection Prevention and Control Nurse ward rounds 38

19. Hand hygiene 38

19.1 WHO awareness day 38

20. International Infection Prevention and Control week 38

21. Working with the wider health community 39

22. Conclusion and priorities for 2012 - 2013 39

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Director of Infection Prevention and Control Annual Report 2011/2012

Executive Summary

This annual report provides a summary of Trust performance against local and nationalInfection, Prevention and Control initiatives as outlined in the Infection, Prevention and ControlAnnual Programme 2011/2012.

Overall 2011/12 has been an extremely successful year for the Trust:

We experienced zero cases of hospital acquired MRSA bacteraemia for a periodexceeding 2 years, making us one of the best performing Trusts in the country

We saw a continual reduction in hospital acquired C. difficile infections and despitemissing our 2011/12 trajectory by 2 cases we saw a 17% reduction on 2010/11numbers

We saw a 31% reduction in urine catheter related bacteraemia Our mean ward closure time for wards closed due to epidemic gastroenteritis was

reduced to 8.5 days

The Trust was massively disappointed to have exceeded the C. difficile trajectory. There hasbeen significant scrutiny and assessment as to why this has arisen and whilst the Trust canreport a 17% reduction against the previous year’s figures it is committed to zero tolerance ofhospital acquired infection. In response to this, the Trust instigated an action plan whichdramatically reduced the monthly run rate from January onwards and has resulted in some ofthe lowest infection figures in the country during the last quarter.

Patient safety and tackling HCAI continues to be a key priority. This has been reflected withinthe organisation objectives, supported by strong, effective leadership and performancemanagement across the whole health economy. Infection prevention and control strategieshave been integrated into corporate risk, governance and quality frameworks. The appointmentof three Microbiologists and a Nurse Consultant has resulted in the formulation of an excellentteam to lead our zero tolerance of hospital acquired infection and support for a reduction incommunity acquired infections.

My thanks to the Infection, Prevention and Control Team for their continued hard work, passionand enthusiasm, not forgetting all staff who have demonstrated support and commitment to theHCAI reduction agenda.

I would like to thank Suzanne Morris, Liz Nicholas, Monica Marriott, Kay Theaker, StephenParks, Lee Radford, Theresa Kilduff and other members of the Infection Prevention and ControlTeam who have helped in compiling this Annual Report

Susan Bowler

Director of Infection Prevention and Control

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1. Purpose of reportThe Trust is committed to achieving the goal of no preventable healthcare associated infections (HCAIs).This report provides assurance to the Trust Board that Sherwood Forest Hospitals NHS Foundation Trust(Trust) is meeting its statutory and NHS obligations, which is a requirement of the Care QualityCommission (CQC), Annual Health Check and the revised Health and Social Care Act 2008.

This annual report provides a concise summary of the year on year reduction against Clostridium difficileand Meticillin Resistant Staphylococcus aureus (MRSA) bacteraemias trajectory, and other healthcareassociated infections (HCAI’s) including Meticillin Sensitive Staphylococcus aureus (MSSA) andEscherichia coli (E. coli) bacteraemias.

This annual report should be read in conjunction with the infection prevention and control annualprogramme of work, and quarterly reviews for the same period. This annual report has been compiledaccording to the guidelines issued by the Department of Health (DH) and will be presented to the TrustBoard in June 2012.

1. 1 IntroductionThe Trust is a medium sized acute hospital Trust with clinical services provided over four hospital sitesincluding King’s Mill Hospital, Mansfield Community Hospital, Ashfield Health Village and NewarkGeneral Hospital. The Trust is part of the Nottinghamshire County Health community and the servicesprovided by the Trust are commissioned principally by Nottinghamshire County PCT.

Infection prevention and control is central to the delivery of safe, cost effective healthcare. It impingesupon all aspects of healthcare delivery, and consequently has a unique place within the Trust. Sinceinfection prevention and control became number one priority for the Trust, there has been significantimprovements in the Trust performance and there has been a dramatic shift in the culture of the Trust,changing to one in which staff acknowledge and accept their personal responsibility for protecting allpatients, visitors and staff, from acquiring HCAI’s.

It is important to take account of the many components of effective infection prevention and controlpractices that contribute to the reduction in HCAIs; these include good hand hygiene, care of invasivedevices, providing a safe, clean environment and patient involvement in preventative hygiene measures.It is therefore important to focus the infection prevention and control programme of work for theforthcoming year on all these elements.

The assurance framework for infection prevention and control across the Trust is now well establishedand comprises of the following main components:

Healthcare associated infection integrated action plan Infection prevention and control annual programme of work Adverse events Internal audit Internal surveillance

Considerable amount of work has gone into meeting compliance with national guidelines and standards,including the Code of Practice for the Prevention and Control of Healthcare Associated Infections, theCQC NHS Provider Compliance Assessment Outcome 8 (Cleanliness and Infection Control) and theNational Health Service Litigation Authority (NHSLA).

There are two causes of HCAI that have external targets associated with them:

Meticillin Resistant Staphylococcus aureus (MRSA) bacteraemias Clostridium difficile infection (CDI)

To put this into context and demonstrate the scale of the improvements made, since the baseline targetyear 2003 – 2004; new clinical cases of MRSA has fallen dramatically. The Trust already has one of thelowest MRSA bacteraemia rates, and last year the Trust achieved a further year with no Trust attributedMRSA bacteraemias. In fact we are the only Trust in the East Midlands to have achieved this. This istruly an extraordinary accomplishment, which has only been possible by the commitment and hard workof all our staff. However, although this is a tremendous achievement, we must remember that MRSA isnot the only pathogen to cause HCAIs, and there is still much more work for us to do.

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The other infection prevention measure that has external targets associated with it is Clostridium difficileinfections (CDI). While momentous improvements have been seen since 2009, with an overall 68%reduction. Our performance against this measure for 2011 – 12 was not met; the Trust had 45 CDIagainst a target of 43.

Our internal measures of performance, catheter associated bacteraemias, MRSA acquisitions and MSSAbacteraemias saw a moderate improvement on the previous year’s figures. Strategies are required tohelp us deliver further and sustain these improvements and sustain these improvements.

Recurrent outbreaks of norovirus during the course of the year have reminded us all that there is noroom for complacency around infection prevention and control practices. New challenges are inevitableand old problems will recur despite the best efforts of everyone in the Trust, and close working acrossthe health economy must ensure that HCAI is never considered inevitable or acceptable.

The Trust can be justifiably proud of its achievements in reducing infection rates and improving clinicalpractice. It is the Trust staff members who are actually responsible for all these successes, through theircontinued commitment to compliance with infection prevention and control practices and protocols;including hand hygiene, cleaning, decontamination and antimicrobial prescribing practices. Thisdemonstrates how infection prevention and control is embedded into the Trust and is recognised asbeing “everybody’s business”. However, considerable Trust-wide effort is required to sustain theseimprovements and achieve the new challenging targets for further CDI reduction, as well as achievingzero tolerance of preventable HCAI’s.

1.2 Compliance with annual programme of workThe annual programme of work including surveillance and auditing was fully completed.

1.3 Annual programme of workThis has been informed by a gap analysis carried out on the requirements of the ‘Health and Social CareAct’ plus additional requirements specific to local needs and in response to the local health economystrategy for infection prevention and control.

1.4 Compliance with the Code of Practice /CQC Outcome 8The Health Act approved by Parliament in October 2006 contains a Code of Practice for the preventionand control of healthcare associated infections. The code places a statutory duty on the Trust to ‘ensurepatients are cared for in a clean environment, where risk of HCAI’s is kept as low as possible’. A revisedversion of the Code of Practice was published in 2008, which was updated in 2010.

All Trusts have to register with the Care Quality Commission (CQC); this body has the right to inspect theTrust compliance with the ‘Health and Social Care Act, Code of Practice’, which is a requirement for NHSProvider Compliance Assessment Outcome 8 (Cleanliness and Infection Control).

Under the Code of Practice, the Trust must ensure that: So far as reasonably practicable, patients, staff and other persons are protected against risks of

acquiring HCAI through the provision of appropriate care, in suitable facilities, consistent withgood clinical practice

Patients presenting with an infection or who acquire an infection during treatment are identifiedpromptly and managed according to good clinical practice for the purpose of treatment and toreduce the risk of transmission

The Trust is expected to have systems in place sufficient to apply evidence-based protocols and complywith the relevant provisions of the basic Code so as to minimise the risk of HCAI to patients, staff andvisitors. The systems for the prevention and control of HCAI are expected to address:

Management arrangements to include access to accredited microbiology services Clinical leadership Application of evidence based protocols and practices for both patients and staff The design and maintenance of the environment and medical devices Education, information and communication

Currently, the Trust has full unconditional registration with the CQC. The IPCT has collated documentaryevidence for the assessment of compliance for the infection prevention and control elements of the Codeof Practice/CQC Outcome 8 and these files are available for external assessment when required.

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For the forthcoming year; ongoing overall compliance will be reviewed bi-monthly by the Director ofInfection Prevention and Control and the Nurse Consultant, Infection Prevention and Control, complianceand/or deficits in compliance will be reported to the Infection Prevention and Control Committee (IPCC).To aid the IPCT to monitor the Trust compliance with the ten criteria’s related to infection prevention andcontrol in Outcome 8, it is recommended that the use of IT software is implemented, which would use adashboard approach in providing assurance of the Trust performance and compliance against Outcome8.

1.5 Kettering Peer Review VisitOn the 9

thMarch 2012 Dr. Manjula Natarajan, Consultant Microbiologist and DIPC, Pamela Howe, Lead

Infection Prevention and Control Nurse visited the Trust as part of a peer review and support visit. Thevisit was very useful from both sides to share experience, good practice and learn from past history.Open discussions led to a lot of suggestions and recommendations that would help focus leadership,organisational structure and enhance clinical ownership within the Trust.

2. Key achievementsProgress towards achieving key targets between April 2011 – March 2012 were as follows:

Maintain 2010 – 2011 MRSA bacteraemias achievement and ensure these are in line withagreed local and national targets: Target: less then 3 for the yearBetween April 2011 and March 2012, there were zero cases of MRSA bacteraemias

To reduce cases of Clostridium difficile in line with agreed local and national targets: Target:less than 43 cases for the yearBetween April 2011 and March 2012, there were 45 cases of Clostridium difficile infection

Maintain 2010 – 2011 MSSA bacteraemias achievement,Between April 2011 and March 2012, there were 22 cases of MSSA bacteraemias, although thisis a 10% increase compared to 2010/11 data, this is still a 27% reduction compared to 2009/10

To achieve a 10% reduction in urine catheter related bacteraemias.Between April 2011 and March 2012, there were 11 cases of urine catheter related bacteraemiaswhich equates to 31% reduction

To maintain the mean ward closure time due to epidemic gastroenteritis below 10 days.Between April 2011 and March 2012, there were 13 ward closures with a mean ward- closureperiod of 8.5 days

Full compliance with national legislation and guidance including the Health and Social Care Act(Code of Practice), NHS Litigation Authority (NHSLA), national guidance on the management ofMRSA and Clostridium difficile, and the Care Quality Commission (CQC) NHS ProviderCompliance Assessment Outcome 8 (Cleanliness and Infection Control).Compliance reviewed and evidence folders up dated

3. Description of Infection Prevention and Control arrangementsThe aim of the Infection Prevention and Control Team (IPCT) through the compilation and achievementof a robust annual programme of work is to devise, implement and evaluate strategies to reduce HCAI’sby working in collaboration with each Directorate. The IPCT act as key facilitators to the clinical team,they also now have a far more proactive approach, with a greater emphasis on clinical work and thedirect management of patients with HCAI’s. The IPCT is divided into two teams to effectively cover theDirectorates; this enhanced presence of the IPCT in the clinical environment has greatly increased theiraccessibility for guidance and advice and has improved the management of HCAI’s across the Trust.

The IPCT has worked hard to move towards providing a more clinically orientated service, with eachDirectorate having a designated Clinical Specialist Infection Prevention and Control Nurse (IPCN). Thissystem facilitates communication between the IPCT and Directorates and allows a bespoke service to bedeveloped for each area. The IPCT has worked closely with Heads of Nursing, Ward Leaders andsupport service staff to facilitate development of best practice, provided feedback and surveillance dataacross the Trust, thereby facilitating individual areas to develop ‘ownership’ of infection prevention andcontrol for their clinical area. This approach has been very successful in improving practice and reducingrates of hospital acquired infection.

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The IPCN perform a number of activities that minimise the risk of infection to patients, staff and visitorsincluding:

Providing advice on all aspects of infection prevention and control Actively involved in managing the risk of infection both to patients and staff Identifying risks of infection and advising of interventions likely to minimise or eliminate those

risks Managing outbreak of infection Conducting programmes of education Undertaking audit Undertaking targeted surveillance Formulating polices and procedures Interpreting and implementing national guidance at local level Involvement with refurbishment, new building and equipment projects

The IPCT also collaborates extensively with other Trusts across East Midlands and participate in theactivities of local and national groups (e.g. Infection Prevention Society, Nottinghamshire RCA reviewgroup), and the Consultant Microbiologist for antimicrobial stewardship is a member of the Drugs andTherapeutics Committee.

The team has remained stable during the year and was strengthened by the appointment of SuzanneMorris in her role as Nurse Consultant Infection Prevention and Control in November 2011. The keyunderpinning elements of her role will be to work closely with staff across the Trust to improve standardsacross the various disciplines within the Trust.

As from April 2012 she will be the Education Lead for the Trent Branch of the Infection PreventionSociety, and she also sits on the following committees within the Trust using these forums to feedbackadditional information to the wards and departments, and receives information to inform the priorities andactions of the IPCT:

Professional Advisory Group Water Safety Committee Strategic PEAT Estates Clinical Governance PFI meetings

All members of the Team received an Individual Performance and Development Reviews during 2011 –2012. Given the different training requirements, the personal development of individual team membersthis will remain a key priority and will be integrated into the Infection Prevention and Control AnnualProgramme of Work to develop ownership of Trust objectives and facilitate achievement of keyoutcomes.

Over the last year, Sally Palmer completed the ‘Healthcare associated infection prevention and control’module at Sheffield University, and is undertaking the RCN Leading for Quality Care course. Membersof the Team are actively involved with the Infection Prevention Society, with regular attendance at branchmeetings. Deborah Hamilton attended the Infection Prevention Society Conference in September 2011,

The Infection Prevention and Control Nurses meet on a daily basis to discuss current infection preventionand control issues and formulate the day-to-day working programme for the team. The IPCT meetsweekly to assess progress against targets, resolve problems, review surveillance data, monitorsprogress of control processes, as well as progress against objectives to ensure necessary informationincluding feedback from groups, committees and meetings attended is disseminated appropriately.

Members of the IPCT sit on the following meeting within the Trust: Emergency Planning Committee Relevant meetings of groups dealing with developments, procurement and commissioning when

appropriate CQUN: urine catheter related bacteraemia Medical equipment management Facility liaison Water management Endoscopy group County wide RCA meetings

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Dr S Ambalkar, the microbiology antimicrobial lead for the Trust, sits on the Medicines ManagementCommittee. The local antimicrobial prescribing policy was developed and launched in March 2012. Dr MTavodova and Dr S Ambalkar continue to work with Mrs M Marriott, Antimicrobial Pharmacist inmonitoring, auditing and educating on the use of antimicrobials. The Ward Pharmacists monitorantimicrobial use across the Trust

For the forthcoming year a Trust wide infection prevention and control programme of work has beendeveloped, this will be supported by the infection prevention and control links. Link staff play a criticalrole in clinical practice, providing the opportunity to develop knowledge and play a key component toclinical practice in influence and where necessary change practice.

3.1 IPCT comprising of the following individualsSessional Commitment to Infection Prevention:

Dr. S. Ambalkar (Head of Service) 0.5 Pas(from January 2012)

Dr. M. Tavodova (Infection Control Doctor) 2.5 Pas(from December 2012)

(A third full time Consultant Microbiologist has been appointed, who will be in post in November 2012)

Full Time Commitment to Infection Prevention and ControlMrs S Morris, Nurse Consultant 1.0 WTE(from November 2011)

Miss D Hamilton, Clinical Nurse Specialist 0.6 WTE

Mrs R Holmes, Clinical Nurse Specialist 1.0 WTE

Miss S Palmer, MRSA screening co-ordinator 0.5 WTEClinical Nurse Specialist 0.5 WTE

Mrs S Watson, Audit Officer 0.6 WTE

Mrs G Beaumont, Infection Prevention and ControlBiomedical Scientist 0.5 WTESurveillance Officer 0.5 WTE

Mrs M Marriott, Antimicrobial Pharmacist 0.8 WTE

Mrs S Gardner, Clinical Librarian 0.1 WTE(from January 2012)

Mrs. S Worthington, Clerical Support Assistance 0.4 WTE(Vacant since January 2012)

Mr E Masih, Education Lead 1.0 WTE(Temporary position till February 2012)

3.2 Clinical LibrarianSarah Gardner joined the team as Clinical Librarian (CL) in January 2012 with the objective of saving theteam time and providing high quality evidence to support their work. Primarily a CL responds toenquiries and literature search requests in a timely manner, offering summaries of evidence wheneverappropriate, with references to back them up. This type of response has the advantage of saving theIPCT member time, as they can see a reliable answer to their question without having to assemble itthemselves from a selection of abstracts of journal articles.

For some requests, however, a detailed analysis of a topic is required, along with the selection andsubmission of all relevant national guidance documents, for example research to inform the creation ofhospital policy.

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The high quality evidence found through literature searching can also support changes to hospitalpractice to improve patient care; importantly this often could also save the Trust money, as searches canbe performed to find the cost effectiveness of different interventions or equipment.

Another role of the CL is to provide a tailored current awareness service to the team, keeping themabreast of relevant new developments within the UK and internationally. The CL has searched for anddistributed news snippets to the team, and has plans for a broader and more comprehensive IP newsservice in the coming year.

A sample of topics covered Jan – March 2012 Background research to support the development of leaflets on infectious diseases for patients

and carers Research methodology - trial design Environmental audit – issues with decontamination of fabric noticeboards HPV for norovirus - efficacy Silver coated catheters – cost effectiveness MRSA decolonisation – policies and guidelines Research for policy writing – finding key national documents on CJD Decontamination of breast pumps – review of literature

3.3 Infection Prevention and Control LinksThe Infection Prevention and Control Link (IPCL) scheme continues to be an important aspect of theTrust approach to infection prevention and control and is an essential link between the IPCT and theWard/Departmental staff. IPCL’s are nominated by each clinical area, many have chosen to have morethan one staff member sharing the role. Currently there are 128 IPCL’s from a range of different clinicaldisciplines successfully reinforcing the message that infection prevention and control is everyone’sresponsibility. They place a key role in informing, educating and support their colleagues in the clinicalarea, they also undertake frequent audits of key aspects of clinical practice.

An IPCL study day is held quarterly, these serve both an educational purpose and as a means to keepthe IPCL’s updated with relevant issues. They also provide a forum for exchanging ideas and fordiscussion around key issues. Total attendance ranged from 59 to 68 attendees on each IPC Link studyday (255 in total throughout the year).

For the forthcoming year the IPCT plans to strengthen the role of the IPC link staff, underpinning theirrole, by developing their knowledge and skills ensuring that the fundamental elements of the role areclear, concise and effectively utilised within clinical areas.

3.4 Healthcare Associated Infection ForumSignificant infection prevention and control issues are also discussed at the bi-weekly HealthcareAssociated Infection (HCAI) forum, which is chaired by the DIPC. All MRSA, MSSA line related and allcatheter associated urine tract bacteraemias, as well as Clostridium difficile (C.difficile) and other seriousHCAI’s as well as recent audit results are reviewed at this meeting. The results of Root Cause Analysis(RCA) are reported, and appropriate recommendations made. Action plans arising from RCA’s arereviewed at subsequent meetings.

A key theme that has become the focus of the HCAI forum is the time taken to achieve isolation ofpatients with diarrhoea, particularly C. difficile. Recently published papers suggest that within a shortperiod of time following the onset of diarrhoea the surround environment can become contaminated.There is now a significant emphasis on isolating patients within 1 hour of the onset of diarrhoea forunknown cause, to reduce environmental contamination, thereby reducing the risk of cross infection.

3.5 Infection Prevention and Control CommitteeThe Infection Prevention and Control Committee (IPCC) meets bi-monthly and is chaired by the DIPC,and reports to the Clinical Governance Group (dates for 2001–2012 were: 10

thMay, 5

thJuly, 14

th

September, 29th

November, 24th

January and 13th

March). There is representation on the IPCC frommembers of each Directorate and senior management, as well as external groups such as the HealthProtection Agency (HPA), Primary Care Trust (PCT) and patient and public involvement groups.External links are well maintained with the Consultant for Communicable Disease Control (CCDC) forEast Midlands, who is also a member of the IPCC.

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The IPCC is a sub-committee of the Trust Clinical Governance Group with overall aim of supporting theTrust assurance structures. A separate Decontamination Committee which reports to the IPCC isplanned for the forthcoming year.

The IPCC receives reports on HCAI’s, HCAI associated deaths, relevant Root Cause Analysis (RCA)investigations and compliance with hand hygiene, the antimicrobial pharmacist reports the results of theantibiotics audits which have been conducted since December 2011, and the Nurse Consultant InfectionPrevention and Control will update the IPCC with progress against the annual programme of work.

The Department of Health document ‘Winning Ways’ states that the DIPC will ‘report directly to the ChiefExecutive and the Trust Board and not through any officer’. The DIPC meets regularly with the ChiefExecutive and reports to the Trust Board as required and is responsible for providing advice andassurance to the Trust Board regarding the management of hospital infection prevention and control, theinformation is then cascades directly to the Clinical Governance Committee and other relevantcommittees.

Trust wide reporting of HCAI’s is circulated to all clinical areas, Directorates and the Trust Board. Thisincludes surveillance and outbreak data, audit results, compliance with policy, link practitioner activity,and regular updates on other initiatives to improve infection prevention and control practices, as well asinformation on antimicrobial prescribing.

For the forthcoming year each Division will be required to develop an annual Healthcare AssociatedInfection Improvement plan; progress against these plans will be discussed at the HCAI Forum andreported to the IPCC by the Divisional Director of Nursing for the division. This will provide theopportunity to discuss the aspects of reducing infections that have been successful or challenging andprovide the forum for discussion to improve practice.

3.6 Reports to the Trust BoardAt every Trust Board the DIPC gives the Operational Performance Report for the Trust, which includesthe most recent infection prevention and control performance data. The presence of a Non-ExecutiveDirector on the IPCC means they are able to inform other Non-Executive Directors on a more timelybasis of the trends and details of issues the IPCT and the Trust are working on.

3.7 Budget allocation to infection prevention activitiesThe IPCT provides an infection prevention and control service for the Trust (761beds) and last year hadannual pay and non-pay budget of £221.800k and £28.400k respectively. The total pay budget for thenursing and secretarial support for the IPCT for the year was £221.800k. This figure includes a vacancyfactor of £4.000k

The non-pay budget to cover course fees, travelling expenses, printing and stationary plus computerswas £28.400k (includes £13.000k for computer hardware/software mainly for the ICNet subscription).

The infection prevention and control activities of the Consultant Microbiologist is not differentiated fromtheir general microbiology work in terms of pay costs, and as such it forms part of the Pathology budgetrather than that of Infection Prevention and Control.

3.7 Clinical GovernanceInfection prevention and control is a standing item on the agendas of most Directorate meeting. For theforthcoming year arrangements will be made to ensure the IPCT attend these meetings.

4 Patient and Public EngagementThe Trust is committed to seeking the support and engagement of patients and general public on mattersrelating to infection prevention and control. The Trust views this as a critical element of the strategy toensure that views and ideas submitted by patients and members of the community are incorporated intothe Infection Prevention and Control Annual Program of Work, and wider collaboration across thehealthcare economy.

4.1 Members EventThe IPCT participated in the ‘Members Event’ on the 3

rdMarch 2011. Topics covered during the event

included surveillance update, screening success, winter vomiting disease, improving hand hygiene anddevelopment in cleaning. The event was successful with 27 members of the public attending; feedbackfrom the members was positive and will be used to set the agenda for the 2012 Members Event.

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4.2 Patient Environment Action TeamThe Patient Environment Action Team (PEAT) undertook its annual assessment. The standards of thisassessment takes into account the patient experience in relation to food, cleanliness, infection controland the patient environment. The Trust is please to announce the improved scores against the stringentassessment undertaken in February 2012, excellent in 8 out of 9 assessment and good in the remainingassessment. The PEAT team has representatives from Head of Nursing, Infection Prevention andControl, Patient Representative and Facilities Service.

5. Healthcare Associated Infection SurveillanceSurveillance of infections is one of the most important components of infection prevention and controlpractice. The aim of surveillance is to produce timely information on infection rates and trends, detectoutbreaks, inform evaluations and changes to clinical practice and aid effective targeting of preventativeefforts

It can be difficult defining absolute points in time when infections are acquired. There are many factorsthat can influence how infections are defined as either hospital acquired or community acquired. Interms of MRSA bacteraemia, cases are defined as community acquired when the sample is taken within48 hours or prior to admission, for cases of C. difficile it is when the sample is taken within 72 hours of orprior to admission. However, these definitions are used for surveillance purposes, and setting targets forreductions in community and Trust settings.

Surveillance of HCAI’s can be defined as the systematic recording of infections using agreed definitions,with analysis, interpretation and dissemination of the results so that appropriate action can be taken.Surveillance is necessary to monitor trends in infection rates over time, detect outbreaks, and provideinformation for the planning of services and allocation of resources and to evaluate the impact of anyinterventions aimed at reducing infection risk. By targeting appropriate interventions surveillancecontributes significantly to reducing rates of infection and is recognised as an important contributor togood infection prevention and control practices.

In April 2001, a mandatory scheme for reporting Meticillin Resistant Staphylococcus Aureus (MRSA)bacteraemias commenced and the results of that surveillance is published regularly. In an attempt toaccount for variations in hospital activity, absolute numbers of MRSA bacteraemias are converted into arate using the bed availability and occupancy annual return. Since then the mandatory scheme has beenextended; in September 2003, bacteraemias due to Glycopeptide resistant enterococci (GRE), inJanuary 2004 Clostridium difficile, January 2011 Meticillin sensitive Staphylococcus aureus (MSSA)bacteraemias and in June 2011 Escherichia coli bacteraemias. The national surveillance scheme alsoincludes orthopaedic surgical site infections and the reporting of ‘serious incidents’ associated withinfection. The infection rates for the Trust are published in comparison with other acute Trusts nationally.

The Trust complies fully with the mandatory surveillance system for HCAI’s including staphylococcal(including MSSA and MRSA), E. coli and GRE bacteraemias, Clostridium difficile and orthopaedicsurgical site infections. All ‘serious incidents’ associated with infections are reported to the StrategicHealth Authority (SHA), PCT and the HPA. Monthly surveillance reports are circulated to all clinicalareas, Directorates and the Trust Board. The reports include surveillance and outbreak data, auditresults, compliance with policy and information on antimicrobial prescribing. As well as beingincorporated into the Trust Board performance management process, they are also reviewed at the HCAIforum, the IPCC and Divisional Clinical Governance Group.

For the forthcoming year the IPCT is planning an annual point prevalence audit/study, this will becomean annual one-day ‘snapshot’ audit of the data, which can be used to highlight areas of best practice andany deficits. In addition the IPCT will provide monthly reports, which includes surveillance data on newcases of MRSA (infection and/or colonisation), all hospital acquired bacteraemias, Clostridium difficile,gentamicin and quinolone resistant gram negative infections, GREs and ESBL producing coliforms andoutbreaks.

5.1 Meticillin Sensitive Staphylococcus aureus (MSSA) BacteraemiaStaphylococcus aureus is a common bacterium that commonly colonises the human skin. Like MeticillinResistant Staphylococcus Aureus (MRSA) it is a bacterium that causes a range of infections when thebacteria enter the body. The range of infections are from very minor (superficial skin infections) to lifethreatening infections of the heart valves, joint infections and blood stream infections.

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Table 1: Source of MSSA bacteraemiaSite confirmed 2009/10 2010/11 2011/12Septicaemia – febrile neurtropaenia - - 1Intra thoracic - - 1Arterial line 1 - -Hickman line 1 - -Non-tunnelled line 1 3 1PICC line - 2 -Peripheral line 6 1 3Central venous line 2 -Pneumonia 4 - -Bone 2 - -Bone with metal work 1 - -Bursitis 1 - -Joint 3 - -Abscess - 1 2Soft tissue 1 2 3UTI 1 1 -Vascular 2 - 1Source unclear 10 9 10Total 34 21 22

Table 2: Distribution of MSSA bacteraemiaWards 2009/10 2010/11 2011/12Cardiology 3 2 2Clinical haematology 1 0 1General medicine 14 7 11General surgery 4 1 2Care of the elderly medicine 6 2 0Paediatrics 1 2 0Rehabilitation 1 0 0Rheumatology 1 0 0Trauma and orthopaedics 3 0 3Endocrinology 0 0 1Neurology 0 1 1Urology 0 1 0Gastroenterology 0 5 1Total 34 21 22

Graph 1: demonstrates the percentage of cases of MSSA bacteraemias speciality between April 2011and March 2012, 49% occurred in General Medicine, with 13% in Trauma and orthopaedics, 9% inCardiology and General Surgery and 5% in remaining clinical speciality.

Graph 1: MSSA bacteraemia per speciality

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MSSA bacteraemia per speciality

Cardiology

Clinical haematologyEndocrinology

Neurology

Gastroenterology

Trauma and orthopaedics

General surgery

General medicine

Reporting MSSA bacteraemia became mandatory on 1st

January 2011, via the national mandatorysurveillance system (same as for MRSA). Between April 2010 and March 2011 the Trust reported 22hospital acquired MSSA bacteraemias, compared to 21 cases the previous year. Four cases of linerelated bacteraemias and ten cases of bacteraemias had no obvious source. Although there were threesoft tissue related bacteraemias, none of these were related to surgical site infections or secondaryurinary tract infections associated with an indwelling urinary catheter. Root Cause Analysis (RCA) areonly carried out on MSSA IV line related bacteraemia, which are undertaken by the clinical team caringfor the patient with support from the IPCT. The results are reported to the HCAI forum and series ofrecommendations made. Monitoring of actions arising from RCAs is also monitored by the IPCC. Thework which the Trust has undertaken to underpin the significant reduction in MRSA bacteraemiassupports prevention of MSSA, although patients are not routinely screened in the same way. However,in order to further reduce MSSA bacteraemias (both line and non-line related) the following strategies areplanned:

There will be continued effort to reduce the number of infections associated with medicaldevices, including intravascular and urinary catheters

The surveillance of post operative wound infections, for all elective and emergency Total Hip andTotal Knee Replacement procedures performed within the Trust

RCA will be performed on all MSSA bacteraemias, with the results of these investigations andtheir recommendations will be monitored by the HCAI forum

Multi-disciplinary discussion re: screening of cardiology patients prior to insertion of internalpacemaker devices

Graph 2: demonstrates that although the Trust had made a dramatic fall in the number of Trustapportioned MSSA bacteraemias in 2010-11; this has increased slightly in 2011-12.

Graph 2: Trust apportioned MSSA bacteraemia

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5.2 Meticillin Resistant Staphylococcus aureus (MRSA) BacteraemiaPrior to April 2010, MRSA bacteraemia reduction target was based on total numbers, since April 2010, aformal differentiation was made between MRSA bacteraemias acquired in the acute Trust and thoseadmitted with them. In view of this, and to reflect the performance in the previous year, a new target ofless than three MRSA bacteraemias was set for the Trust (cases occurring 48 hours or more afteradmission to the Trust). Between April 2011 and March 2012 the Trust reported zero MRSAbacteraemias. The Trust has had no Trust acquired MRSA bacteraemias since 18

thMarch 2010, and is

the only Trust within the East Midlands with this status. The annual MRSA bacteraemia totals since2003 are shown in Graph 3 and 4 as well as Table 3, it should be noted that the Trust reduction(trajectory) target was based on the Trust apportioned cases from April 2010.

Graph 3 and 4: demonstrates the downward trajectory and acquisition of MRSA bacteraemia since April2007.

Graph 3:

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Graph 4:

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Table 3: Number of cases against the trajectory set for each year since 2003.Year Trajectory Cases2011 – 2012 3 02010 – 2011 6 02009 – 2010 22 62008 – 2009 24 172007 – 2008 24 262006 – 2007 36 362005 – 2006 48 282004 – 2005 61 252003 – 2004 - 23

Graph 5: Trend of MRSA since 2007. Although there was a steady decrease in the number of MSSAbacteraemia from 2007, during quarter 1 of 2009, there was a significant rise in the number of Trustapportioned MSSA bacteraemia. Over the following 12 months the Trust saw a steady fall in the numberof Trust apportioned MSSA bacteraemia; however since October 2010 the rate has fluctuated.

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Trust apportioned MRSA and MSSA bacteraemia cases by quarter

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Graph 6: Demonstrates community acquired MRSA and MSSA bacteraemia is more erratic.

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5.3 New clinical cases of MRSAAs well as mandatory reporting of MRSA bacteraemias, all new cases of MRSA are also recorded, whichenabled the Trust to monitor the acquisition of MRSA in the Trust. These can be divided into ‘infection’where MRSA is isolated from clinical specimens and colonisation where MRSA is isolated fromscreening swabs. A patient is deemed to have acquired MRSA in hospital if their first MRSA isolate isfrom a sample taken more than 48 hours post admission.

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Patients admitted to the Trust who are known to be colonised with MRSA are identified by an alert ontheir electronic record (PAS) and in their clinical notes. These patients, as well as all newly identifiedinpatient cases, are visited by the IPCT who instigate appropriate infection prevention and controlmeasures and recommend topical MRSA eradication therapy.

In line with the ‘Code of Practice’, the Trust has worked to develop a systematic approach to screeningpatients for MRSA on admission and prior to admission. Capturing all relevant patients can provedifficult due to the complex pathways patients have for referral. During the year the Trust has monitoredrates of screening on an individual patient basis which can be onerous and also generates significantlaboratory work to process the samples. The DH directive to screen all adult patients has been debatedby many experts in the arena of infection prevention and control, viewed by many as not the most costeffective use of resources to prevent MRSA infections.

In May 2011 the Trust participated in the national one week prevalence audit of MRSA screening, whichwas commissioned by the Department of Health (DH) to review current practice around MRSA admissionscreening. Data was collected from infection control teams in English NHS acute trusts in order toassess the implementation of the DH guidance relating to MRSA screening, its impact on patients and itseffectiveness/cost effectiveness. The preliminary results indicated that 10% of Trusts screen alladmissions, and 70% of Trust screen in line with the DH guidance. The overall response rate to thequestionnaire was excellent with 86.2% of Trust returning the data required. The proportion of patientsscreened on admission were 61% emergency admission, 81% elective admission and 47% day caseadmission. The results did not establish the optimal screening strategy and further analyses are beingconducted to provide a full cost effectiveness evaluation and examine strategies in different settings, thefinal report should be publish in June 2012.

Table 4: Number of MRSA acquisitions has reduced compared to the previous year.Year Pre 48 hours Post 48 hours Total2010 - 2011 279 62 3412011 - 2012 133 52 185

Between April 2011 and March 2012 the total number of new MRSA isolates (those isolated from clinicaland screening samples) was 185, compared to 341 new MRSA isolates recorded for the previous year.The IPCT provided advice to 198 in-patients, this includes patients with multiple admissions, newacquisition and clinical samples (infection), this does not represent individual MRSA patients. For theforthcoming year the IPCT will be monitoring 21 day re-screening compliance, as this will be an internalmarker for cross infection.

5.4 Glycopeptide Resistant Enterococcal bacteraemiasGlycopeptide – resistant enterococci (GRE) bacteraemias occur mainly in specialist clinical areas,particularly transplantation, renal, haematological malignancy and critical care units. Between April 2011and March 2012 the Trust has reported zero cases of GRE bacteraemia, this compares to one case theprevious year. The number of GRE bacteraemias reported by any Trust is small and caution should beused when comparing individual Trusts.

Graph 7: shows the number of GRE bacteraemias since 2005.

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GRE bacteramias

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5.5 Clostridium difficileThe rate of Clostridium difficile (C. difficile) infection has continued to fall, but targets remain challenging.Graph 8 demonstrates that during 2011 - 2012 the Trust performance against the target of less then 43cases was missed by 2 cases; however the Trust has maintained a year on year reduction, and hasachieved an overall reduction of 16.6%. To view this in context, since 2008/09 there has been a year onyear reduction of C. difficile cases recorded (Graph 8 and Table 5) representing a reduction of 68% over4 years. This is a fantastic achievement and is likely to be due to the significant effects to reduce HCAIintroduced by the Trust in 2009.

In October 2011 the number of positive C. difficile had been above the annual trajectory for the Trust fortwo consecutive months. A trend analysis of the previous 21 cases of C. difficile was conducted and inNovember 2011 the Trust implemented significant efforts to reduce C. difficile including multidisciplinaryreview of all cases at the bed side, joint management with Gastroenterology, improved diagnosis,antibiotic prescribing audits, development and implementation of an antibiotic policy, C. difficileawareness training sessions, reinforcement of appropriate sample taking and bowel management.

Table 5: Total number of hospital acquired C. difficile cases against the trajectory for each year from2009 to 2012.

Year Trajectory Cases2011 – 2012 43 452010 – 2011 63 542009 – 2010 260 632008 – 2009 288 144

In March 2011, the DH published national guidance on the testing methodology for C. difficile. FromApril 2012, the Trust will be implementing the national guidance, which consists of conducting glutamatedehydrogenase (GDH) test first; if positive the sample will then be tested for C. difficile toxin. Testing willbe conducted for all samples that conform to the criteria received from inpatients over the age of 2 yearsautomatically.

Table 6: Total number of samples received in the microbiology laboratory requesting testing for CDI, andhow many were positive. It is of note that the policy for testing was changed in 2009 – 2010, thefollowing years of the period represented by this table highlighted that the number of samples testedeach year was in the order of 5000 per year, last year the Trust tested 4972 samples.

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Year No. ofsamples

Trajectory Cases

2011 – 2012 4972 43 452010 – 2011 5208 63 542009 – 2010 5130 260 632008 – 2009 3646 288 144

Graph 8: demonstrates that the Trust reached trajectory in September 2011 and had exceededtrajectory in October 2011. Following the implementation of a robust action plan the trend of positive C.difficile infections started to decrease. The Trust exceeded its end of year trajectory by 2 cases.

C difficile positives against reduction targets April 2011 - March 2012

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Graph 9: Percentage of cases of C. difficile cases by speciality between April 2011 and March 2012,40% occurred in General Medicine, with 16% in Healthcare of the Elderly, 13% Trauma andorthopaedics, 9% in General Surgery, 5% in Clinical Haematology and Cardiology, 4% in DiabeticMedicine and Gastroenterology, and 2% in Respiratory Medicine and Rehabilitation.

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Graph 10: Demonstrates the downward trend of Clostridium difficile against the Trust trajectory targetfrom 2008.

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It is clear that the Trust has to focus efforts on further reduction of cases of CDI in the forthcoming year.Patients admitted to elderly care are considered to be more at risk of acquiring CDI. This is in line withepidemiology of the infection whereby it is acknowledged that elderly debilitated patients are at increasedrisk of the disease. It is important to note, that although the target is based on the DH definitions ofattribution of infections, this does not take into account recent discharges from hospital and developsymptoms within 4 weeks of discharge, or of cases occurring within 72 hours of admission.

In order to further reduce CDI the following strategies are planned: Hospital acquired – community onset surveillance Targets for Divisions to reduce rates of CDI infections to be set for the forthcoming year It is important that Divisions focus upon these reductions as this infection can have serious

longer term complications for patients, result in increased length of stay and have beenestimated to have excess costs of £4000 per patient

Key target is to achieve early isolation of patients who develop unexplained diarrhoea, which isdifficult to achieve when the Trust is expected to operate with high occupancy rates, but must beseen as a critical control measure to prevent secondary cases that occur following exposure toindex cases

Monitor antimicrobial prescribing and administration RCA will be performed on all C. difficile (GDH positive and toxin positive), with the results of

these investigations and their recommendations being monitored by the HCAI forum

5.6 Extended spectrum β-Lactamases Producers (ESBLs) Since 2003, new highly resistant strains of Escherichia coli have become widespread in England andparts of Northern Ireland causing infections such as urinary tract infections, both in the acute hospital andthe community (HPA 2011). ESBL producing microbes are not new, first recognised in the 1980’s, butthe new strains produce a particular type of ESBL which is able to break down a wider range ofantibiotics. Table 7: Demonstrates the proportion of all ESBL identified from samples processes by theTrust. This reflects that urine is the most common body fluid to be either colonised or infected withESBL. It remains unknown where or how these organisms are arising and it should be noted that thepattern of infection seen with these organisms is being seen also nationally.

Specimen type No of specimen % rateUrine 652 90.1%Blood Culture 27 3.7%Swab 24 3.3%Sputum 13 1.7%

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Fluid 4 0.55%Tip 2 0.27%Tissue 1 0.13%

HCAI’s caused by ESBL producing gram negative bacteria complicate therapy and limit treatmentoptions; however the clinical significance of infections caused by ESBL producing bacteria is unclear.The true mode of transmission for ESBL is also unclear; it is thought to be very similar to the mode oftransmission for Vancomycin-Resistant Enterococci (VRE), faecal and skin colonisation, person toperson and transient contamination of the environment and hands of individuals.

5.7 Escherichia coli bacteraemiaSince June 2011 the Trust has participated in the national mandatory surveillance for recording cases ofEscherichia coli (E. coli) bacteraemias. This data is being captured by the HPA as there is concern thatrates of E. coli bacteraemias are increasing nationally, with a 5% increase in reported number of casesbetween 2009 and 2010. E. coli is the most common cause of bacteraemias, with the highest ratesbeing seen in those aged 64 years and older, the second most common group are those aged less than1 year old, with a higher incidence in males than females.

Between April 2011 and March 2012 the Trust recorded 244 cases of E. coli bacteraemias, 205 of thesecases were reported via the mandatory HPA national mandatory surveillance system (between June2011 and March 2012). Using the same criteria as for MRSA bacteraemia, 44 of these cases were Trustapportioned. Although there is no reduction target set nationally, however in order to reduce E. colibacteraemias the following strategies are planned:

There will be continued effort to reduce the number of infections associated with medicaldevices, including intravascular and urinary catheters

Graph 11: demonstrates that the Trust peaked in 2009 – 2010, with a downward trend since

5.8 Hospital acquired bacteraemiasDuring the year there has also been surveillance of all hospital acquired bacteraemias. Patients with abacteraemia were identified by daily review of all positive blood cultures, followed by clinical confirmationusing standard definitions. The main criterion for a bacteraemia to be recorded as hospital acquired isthat it was taken more than two days after admission. Information from patients with bacteraemia wasreviewed by a Consultant Microbiologist and included demographic, infection and risk factor data.

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Between April 2010 and March 2011 6831 blood culture sets were taken at the Trust. Once repeatisolates were removed, 123 patients were considered to have developed one or more episodes ofhospital acquired bacteraemia, which equates to 0.50 per 1,000 occupied bed days, which is equivalentto 2.4 patients per 1,000 admissions.

The majority of hospital acquired bacteraemias occurred in ITU, Ward 22 and Ward 23. This is likely toreflect factors that influence risk of bacteraemia such as severity of illness, immunosuppression andinvasive devices.

The underlying source for the majority of hospital acquired bacteraemias, urinary catheter being thecommonest source and intravenous lines being the second commonest source. There has been asignificant reduction in the number of bacteraemias secondary to intravenous lines, reflecting the workundertaken by the Trust to improve the management of these medical devices.

5.9 Blood CultureTable 8: Demonstrates the number of blood cultures taken between April 2011 and March 2012, thenumber of these which were positive and the number of these that were contaminated. The table alsohighlights the number and type of medical device for device related hospital acquired bacteraemia(DRHAB).

Table 8:Blood cultures 2011 - 12Blood cultures taken 6831Blood cultures positives 982Blood cultures significant 774Blood culture contaminants 208

Device related:Lines 25Urinary catheters 46Pacemaker 4Musculoskeletal – prosthetic joint 4Vascular graft 2

Table 9: Information on the causative agent (microorganism) for bacteraemia. The commonestindividual species was coagulase negative staphylococci, which accounted for 34% of positive bloodcultures and E. coil was responsible for a further 29% of positive blood cultures. Staphylococciaccounted for 45% of positive blood cultures, with 0.6% due to MRSA, 10.4% due to MSSA and 34% dueto coagulase negative staphylococci.

Table 9:Microorganism 2011-12

Coagulase negative staphylococci

Staph. epidermidis 4

Other ‘coagulase negative staph.’ 166

Staph. aureus

MSSA 51

MRSA 3

Esch. coli 144

Enterococcus sp. 23

Klebsiella sp. 42

Pseudomonas aeruginosa 17

Candida sp.Candida albicans 5Other Candida sp. 3

Other Enterobacteriaceae 29

Stenotrophomonas maltophilia 1

Acinetobacter sp. 4

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Other non-fermentative Gram negatives 3

Corynebacterium sp. 2

Table 10: Identifies the wards associated with device related hospital acquired bacteraemia, it should benoted that those wards which provided care for patients with the greatest number of medical devices arethe wards with the largest proportion of these forms of infection.

Table 10:

Ward 2011-12

ITU 6

Ward 23 3

Ward 24 3

Ward 25 1

Ward 32 1

Ward 34 1

Ward 35 1

Ward 34 1

Ward 35 1

Ward 42 1

Ward 43 2

Ward 51 2

Ward 53 1

5.10 Neonatal bacteraemiaDuring April 2011 and March 2012 there were 16 cases of bacteraemias within the neonatal unit, thecausative agent in 13% of cases were Beta-haemolytic streptococcus group B, 63 % were Coagulasenegative staphylococcus, 13% were Escherichia coli, 6% were Micrococcus and 6% were Viridansstreptococci. This is the first year these have been monitored, therefore unable to bench mark againstprevious years data.

5.11 Orthopaedic surgical site infection surveillanceThe Health Protection Agency surgical site infection surveillance service assesses speciality specificsurgical site infections on a quarterly basis. The Trust has participated in this surveillance since itsintroduction in 1997. Standard case definitions and surveillance methodology are provided to enablecomparable rates to be produced. The reporting of orthopaedic surgical site infections becamecompulsory in 2006, other components of the scheme remains voluntary.

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Although the Trust conforms to the requirements of the HPA Surgical Site Infection Surveillance byundertaking at least one major orthopaedic procedure for at least 3 months every year, the number ofprocedures is small. No surgical site surveillance was conducted between July and September 2011 asthe surveillance officer was conducting the national prevalence survey.

Table 11: Mandatory surveillance of surgical site infections following orthopaedic surgery – number ofoperations, infections and rates by surgical category April 2004 – March 2011 (HPA 2012).

Surgical Site infectionsInpatient Inpatient and readmission

Year Category No.surveillancequarters

No.operations

No % 95%LCI

95%UCI

No. % 95%LCI

95%UCI

6 4 166 2 1.2 0.1 4.3 2 1.2 0.1 4.32004/057 4 193 2 1.0 0.1 3.7 2 1.0 0.1 3.7

6 2 19 0 0.0 0 0.02005/067 2 87 0 0.0 0 0.0

6 1 73 1 1.4 1 1.42006/0713 2 87 2 2.3 0.3 8.1 2 2.3 0.3 8.1

2007/08 7 1 65 0 0.0 1 1.5

6 1 66 0 0.0 0 0.02008/097 2 162 0 0.0 0.0 2.3 2 1.2 0.1 4.4

15 1 95 1 1.05 0.03 5.73 1 1.05 0.03 5.732009/107 2 192 1 0.52 0.01 2.87 2 1.04 0.13 3.71

7 2 172 0 0.00 0.00 2.12 1 0.58 0.01 3.202010/116 2 120 1 0.83 0.02 4.56 1 0.83 0.02 4.56

Category:6 = Total hip replacement 7 = Total knee replacement 15 = repair neck of femur 13 =hip hemiarthroplasty

Table 11 demonstrates which Trauma/Orthopaedic modules were undertaken between April 2011 andMarch 2012:

Quarter Category No. ofoperations

No. ofinfections

Infection rate as a %

Trust NationalApril - June 6 68 1 1.5 1July – Sep No surveillance conductedOct - Dec 6 84 1 1.2 0.9Jan - Mar 7 78 4 5.12 -

July – September 2011 the Trust was participating in the European Prevalence Survey, therefore thesurgical site infection surveillance was not conducted. During 2011 -12 a total of 230 patients wereincluded in the surveillance:

78 patients had a Total Knee Replacement (TKR) 152 patients had Total Hip Replacement (THR)

Of the 230 patients included in the surveillance 4 patients developed post operative superficial woundinfection, 1 diagnosed post discharge, 2 diagnosed by the GP and 1 diagnosed on re-admission. Therewas also 1 deep infection diagnosed on re-admission. This represents an overall rate of 2.2% against anational rate that normally ranges form 1 – 1.5%. Data for January – March 2012 is not yet available.However this data should be interpreted with caution as we do not undertake post discharge surveillancewhen infections are more likely to be detected, and the Trust surveillance for in-patients is relatively small

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so may not be statistically comparable to the very large figures. There were no MRSA bacteraemiasassociated with surgical site infections.

To provide the Trust with assurance that the rate of infections related to surgical procedures, namelyTotal Hip and Total Knee Replacement are accurately detected, as well as establishing the number ofbacteraemias which may be attributable to a surgical site infections the following strategies are plannedfor the forthcoming year:

Infection Prevention and Control Surveillance Officer to work closely with the Orthopaedic Teamto develop a robust system of surveillance taking into account inpatient episode of care

Infection Prevention and Control Surveillance Officer, from April 2012 to conduct continuoussurgical site surveillance, for all elective and emergency total hip and total knee replacementthroughout the Trust

Infection Prevention and Control Surveillance Officer to work closely with the Orthopaedic Team,Physiotherapy and Community staff to establish appropriate systems to capture post dischargesurgical site infection

Due to short length of stay to conduct the 30 day follow up via post discharge surveillance usinga standard questionnaire, which should be returned 30 days after the procedure

Infection Prevention and Control Surveillance Officer to work closely with the Orthopaedic Teamto establish ‘telephone call follow up’ of selected cases post discharge

Feeding back infection data is a crucial component of a quality improvement programme and isknown to reduce post operative wound infection rates. Infection Prevention and ControlSurveillance Office to establish reporting framework. Reports to be produced and fed back tothe individual surgeons and Directorates on a quarterly basis

5.12 InfluenzaAlthough the Pandemic Influenza Planning Group has been stood down, the Trust Emergency Planningand Liaison Officer continues to oversee the monitoring of cases, review of response to date and thedevelopment of future arrangements.

Between December 2011 and March 2012 the IPCT were actively involved in supporting the co-ordination of the arrangements for patients admitted with ‘flu-like illness’, whilst ensuring that thepotential spread of infection was minimised. There were 7 confirmed cases of seasonal influenza (Flu A)reported to the IPCT (Ward 25 six cases, Ward 44 one case). Once the clinical teams reportedsuspected/confirmed influenza case to the IPCT, the wards were supported by an Infection Preventionand Control Nurse (IPCN), who visited regularly to provide advice on the infection control measurerequired, medical advice was provided by the Consultant Microbiologist. The IPCN attended the dailycapacity and flow meetings to provide information on the current in-patient situation in terms of numbersof suspected and/or confirmed cases and location within the Trust. This information was reported to theHPA on a daily basis.

For the forthcoming year, not all suspected cases of ‘flu like illness’ were reported directly to the IPCT,therefore the IPCT have utilised the Jonah database to help support clinical areas with suspected casesof influenza while waiting for confirmation laboratory results.

6. Commissioning for quality and innovationThe ‘Commissioning for Quality and Innovation’ (CQUIN) framework was introduced in April 2009 as anational framework for locally agreed quality improvement schemes. The framework aims to embedquality within commissioner-provider discussions and to create a culture of continuous qualityimprovements with stretching goals agreed in contracts on an annual basis.

One of the Trust CQUIN’s was to reduce the number of urethral catheter associated bacteraemias. Thehighest incidence of HCAI’s is associated with indwelling urethral catheters, catheterising patientsincreases the risk of them acquiring a urinary tract infection significantly; the longer a urethral catheter isin place, the greater the risk of acquiring an infection (NICE 2012). Up to 80% of urinary infections canbe traced back to an indwelling urethral catheter.

Between April 2011 and March 2012 the Trust reported 11 cases urethral catheter associatedbacteraemias. Since June 2011 a RCA was required to be completed for all cases of urethral catheterassociated bacteraemias (patients who are post 7 day admission)

There were two national criteria’s and one local criteria set for the Trust:1. On-going reason for a catheter was documented (national)

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2. The correct catheter should be used (national)3. Reduce the number of urethral catheter associated bacteraemias (local)

The two national criteria’s were met for all four quarters and practice has improved appreciably since thebaseline audit, which was conducted between April 2011 and June 2011. All wards, apart from Ward 51scored 100% in both criteria’s for the final month of quarter 4. This has been achieved by:

Quarterly action plans Multidisciplinary working between ward staff and IPCT Review and redesign of documentation Regular training Regular feedback to Ward Leaders and Head of Nursing Clinical audit and monitoring of performance

Graph 13: demonstrates for: Quarter 1 (April-June) the target of 50% was meet for both criteria’s Quarter 2: (July-September) the target of 75% was meet for both criteria’s Quarter 3: (October – December) the target of 88% was meet for both criteria’s Quarter 4: (January – march) the target of 95% was met for both criteria’s

Graph 14: demonstrates that the causative agent for the majority of urethral catheter associatedbacteraemias was E. coli.

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7. Serious Incidents, Periods of Increased Incident and outbreaksAny incident which meets the definition of a serious incident is reported via STEIS within 24 hours of theIPCT becoming aware of the event, which include the following:

All MRSA bacteraemia Clostridium difficile, classified as 1a or 1b on the death certificate where clostridium difficile has

made a significant contribution to the cause of death Outbreaks Infected healthcare worker or patient incidents necessitating consideration of look back

investigation Significant breakdown of infection control procedures with an actual or potential for cross

infection

7.1 Outbreaks of diarrhoea and vomitingBetween April 2011 and March 2012, 13 wards were closed due to outbreaks of vomiting and diarrhoeawithin the Trust, which were reported on Datix and to the PCT and HPA including the HPA voluntarynational reporting scheme.

Suspected or confirmed norovirus is considered the most infectious cause of diarrhoea in England andWales. Outbreaks are common in semi closed settings like hospitals, schools and Care Homes.Outbreaks of norovirus are essentially difficult to predict, and have a significant impact on the operationalservices of the Trust. When outbreaks occur on wards this impacts upon elective activity and correctplacement of patients on wards. Due to the sudden onset of symptoms there is frequently no prodromalperiod with awareness prior to the onset of vomiting/diarrhoea. The operational impact of this was wellmanaged and in contrast to other hospitals in the East Midlands there was relatively little disruption. TheIPCT worked with clinical staff to resolve 13 sporadic outbreaks of diarrhoea and vomiting, which wasgreatly facilitated by the use of rapid diagnostic technology, which enable the team to determine on thesame day whether norovirus is implicated or not.. The outbreaks were controlled by containment,enhanced infection control procedures, and environmental cleaning and decontamination. The followingcontrol measures were taken:

Outbreak meetings were convened and were generally attended by ‘key personnel’ includingrepresentatives from Medirest, FM Services Manager, affected wards, the operational team aswell as the IPCT. The IPCT regularly attends the daily capacity and flow (operational) meeting

Information was disseminated via the ‘Ward Closure’ and ‘Outbreak Update’ emails to relevantpersonnel

Symptomatic patients were isolated or cohorted Staff movements were restricted Visitors were restricted Enhanced infection control measures were implemented

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Symptomatic staff remained off work until 72 hours after their last symptoms Enhanced environmental cleaning and decontamination, using Hydrogen Peroxide Vapour

(HPV) was implemented in affected areas

The epidemiology of the outbreak is highly suggestive of multi-focal outbreaks with the virus beingbrought into the hospital on numerous occasions. Similar outbreaks were observed over the sameperiod in other Trusts within East Midlands and also within the community. In all episodes of proven orsuspected norovirus there was no evidence of spread of the virus within the Trust. This is testament tothe hard work of nursing and domestic staff in ensuring excellent infection prevention practices andeffective environmental cleaning in all affected areas. IPCT received reports that on several occasionsvisitors had suddenly developed vomiting during a visit, or had visited and then revealed when madeaware of the outbreak, that they have had symptoms in the preceding days. This makes the controlmechanisms very difficult to implement.

The following wards had single outbreaks: Ward 32, Lindhurst, Ward 41, Ward 51, Ward 52, Ward 24,Ward 23, Sconce, and Ward 42. A total of 132 patients and 80 staff were affected. Stool samples from12 wards were positive for norovirus. These outbreaks accounted for 111 ward closure days (defined asone ward closed for one day) with a mean period of ward closure of 8.5 days (range 3 - 13 Days).

During the year, there continued to be effective collaboration between the Operational Team and theIPCT which lead to prompt and successful containment. All wards which were closed or restricted wereclosed to discharge and/or admission as recommended by the IPCT.

Table 12: The following tables outline the ward closures and numbers of patients/staff on the affectedwards. The number of staff affected relates to numbers of staff working directly on the ward during theoutbreak and does not take account of other Trust staff. It is important to note that the table does notrepresent all incidences of norovirus when control measures are successfully put in place for exampleearly isolation of symptomatic patients, restricted access to ward/bays thereby preventing a wideroutbreak resulting in ward closure.

Month Ward Patients Staff Noroviruspositive

Days BedLost

May 33 14 4 Yes 13 116November 52 18 21 Yes 10 39November 41 10 11 Yes 10 12November 44 6 5 No 10 17December 42 9 8 Yes 11 27January Sconce 12 13 Yes 9 72February 23 2 1 Yes 5 4February 24 12 0 Yes 6 21February 52 14 2 Yes 13 26February 51 13 3 Yes 8 21February 41 12 6 Yes 7 28March Lindhurst 8 6 Yes 6 12March 32 2 0 Yes 3 6Total 132 80 111 401

Table 13: Mean period of ward closure has continued to be below the mean 9.1 days for 2009 – 2010, toa mean of 8.5 days in 2011 - 2012.

Year Wards Patients Staff Sample DaysNo. Mean No. Mean + ve - ve No. Mean

2008/09 12 172 14.3 41 3.4 73 26 102 8.52009/10 10 126 12.6 26 2.6 26 20 91 9.12010/11 13 128 9.8 77 5.9 52 19 107 8.22011/12 13 140 10.6 81 6.2 61 17 84 8.4(+ ve positive, - ve negative)

Information based on the national guidance was issued, and an Infection Prevention and Control Nurseattended the daily capacity and flow meetings to provide information on the current in-patient situation interms of numbers of suspected and/or confirmed cases and location within the Trust. This informationwas reported to the HPA on a daily basis.

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For the forthcoming year a norovirus tool kit will be developed and issued to all inpatients wards acrossthe Trust. Press statements, norovirus advice on the Trust web page, pull up posters at hospitalentrances and utilising the TV monitors across the Trust alerting members of the public to the potentialproblems associated with norovirus and visiting hospitals.

7.2 Other infection related outbreaksThere were 4 other infection related incidents dealt with by the IPCT between April 2011 and March2012, these are outlined in Table 14. All ward closures and other Serious Incidents are reportedinternally via Datix as well as to the HPA, PCT as part of the mandatory surveillance of HCAI. Reportson these incidents are available from the IPCT.

July 2011 Ward 44, 44 and 14: look back exercise forChickenpox

November 2011 Ward 12: PII Clostridium difficileDecember 2011 Ward 52: MumpsDecember 2011 Ward 33: PII Clostridium difficileFebruary 2012 Sconce Ward: PII Clostridium difficile* PII – Period of Increased Incident

7.3 Serious IncidentThe Trust is required to report to the commissioning PCT those incidents that fulfil the Serious Incident(SI) criteria; the following summarise these requirements:

There were no MRSA bacteraemias reported There were no classified as 1a or 1b on the death certificate where it is clear C. difficile had a

significant contribution to the cause of death reported There were no reports of infected healthcare worker or patient incident necessitating a look back

exercise There was one report of significant breakdown of infection control procedure with a potential risk

of cross infection (Refer to section 10.1) There were 13 SI completed for ward closure due to norovirus outbreaks (Refer to section 7.1)

8. Antimicrobial ManagementThe effective and proactive management of antimicrobial prescribing continued to be a high priority forthe IPCT. The Antimicrobial Pharmacist continues to be an active member of the IPCT and regularlyattends the Trust’s IPCC, and the multidisciplinary Trust HCAI meetings. The antimicrobial pharmacisthas been able to maintain and further develop the role as a focal point for the pharmacy input tomanagement of antimicrobials, working closely with the Consultant Microbiologists.

8.1 Antimicrobial Prescribing

Significant work continued in 2011/12 with regards to antimicrobial prescribing including: Maintenance of the intranet-based Trust Antimicrobial Prescribing Guidelines, ensuring that

guidance for treatment of infections and surgical prophylaxis regimes use the most appropriateantibiotics with regards to local resistance patterns and aim the minimise the use of high riskantibiotics with regards to Clostridium difficile infection. Examples of changes to guidance includethe removal of clindamycin for empirical treatment of cellulitis in penicillin allergic patients (tominimise risk of Clostridium difficile) and the change to Piperacillin/tazobactam for empiricaltreatment of uro-sepsis, biliary sepsis and sepsis of unknown origin (due to increased resistancerates of gram negative bacteria to amoxicillin and co-amoxiclav)

The Antimicrobial Prescribing Working Group (APWG) has been established and the ConsultantMicrobiologist has become more actively involved. This is a multi-disciplinary team consisting ofConsultant Microbiologists, the Antimicrobial Pharmacist, medical and nursing representation frommedicine and surgery. The purpose of this group is to promote safe, rational, effective andeconomical use of antimicrobial agents within the Trust

Since their appointment in December 2011 and January 2012, the Consultant Microbiologistconducts a twice-weekly microbiology ward round on ICCU

Introduction of weekly microbiology wards rounds across all wards at the King's Mill site, to reviewantimicrobial treatment of complex patients or those patients who treatment does not follow trustguidance. It is hoped that in 2012/13 these ward rounds could occur more frequently with theappointment of a third microbiologist

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Training and education on antimicrobial use to new doctors at induction, to staff at InfectionPrevention and Control Link study days, and to ward-based pharmacy staff (to enable proactivechallenges to prescribers on treatment durations and antibiotic choices) by the Antibiotic Pharmacist

Additional training has been provided to individual departments on specific subjects if required e.g.obs & Gynae and ED by the Consultant Microbiologist and Antibiotic Pharmacist

Presentation by the Consultant Microbiologist and Antibiotic Pharmacist of prescribing antibiotics andappropriate use at Ground Round

Consultant Microbiologist has provided training to FY1, ST1 and ST2 as well as medical students Active follow-up of ‘restricted’ antibiotic prescribing (including referral to Consultant Microbiologists

as necessary). Daily antibiotics reports are produced by the pharmacy dispensing system thatenables rapid identification of patients prescribed restricted antibiotics

Review of individual patients as part of the multidisciplinary MRSA/Clostridium difficile-associateddiarrhoea root cause analysis process

Establishment of a ward-based multi-disciplinary team to review all patients with Clostridium difficile-associated diarrhoea. This team consists of a Consultant Microbiologist, ConsultantGastroenterologist, antimicrobial pharmacist and infection control nurse. The MDT ensures patientsare receiving the appropriate treatment depending on the severity of the diarrhoea, and ensure thatall necessary infection controls measures are in place. It also provides an opportunity to educatemedical and nursing staff about the treatment of Clostridium difficile-associated diarrhoea

Feedback to prescribers on antibiotic-related incidents at ‘Incident of the Week’ sessions at GrandRounds

Bi-annual ‘point prevalence’ audits continue, where pharmacy staff documents all antibiotic use on aparticular day. This Trust data is then benchmarked against local Trusts through the East MidlandsAntimicrobial Pharmacists group (EMAP). Results to date show that the Trust has a similarconsumption of antimicrobial compared with other trusts, though we do use less quinolones thatsome hospitals possibly due to the nature of our patients (few haematology/oncology patients).Quinolone antibiotics are recognised as high-risk for the development of Clostridium difficile-associated diarrhoea

Regular feedback of selected antibiotic-related information, guidance and incidents via the TrustMedicines Newsletter

Maintenance of the Trust-wide antibiotic usage database (defined daily doses/occupied bed days)and summarised reports to the IPCC and directorates

Constant promotion of antibiotic duration/review date specification and conversion from IV to oralroutes of administration as per Trust guidelines

Implementation of an informal referral system between the Consultant Microbiologists and theAntimicrobial Pharmacist with regard to the management of complex cases. In 2012/13, it is hopedto develop an electronic referral system, which would also be accessible to doctors and nurse torefer patients

Review and rationalisation of antibiotics routinely available as ‘stock’ on wards to restrict someavailability and direct more prescribing to the Trust guidelines

The Consultant Microbiologists and Antimicrobial Pharmacist launched the Antimicrobial PrescribingPolicy, which states the standards to be followed by all prescribers of antibiotics and theexpectations of nursing staff and pharmacists in relation to administration and monitoring ofantimicrobials. Compliance with the prescribing standards in the policy is monitored on a weeklybasis using the “HAPPI Audit” (Hospital Antimicrobial Prudent Prescribing Indicators)

9. CleanlinessCleaning of Trust property is the responsibility of Medirest contracted by Central NottinghamshireHospitals PLC (CNH) as part of the PFI agreement. The monitoring of clinical areas are undertaken ona weekly/monthly basis following the National Standards of Cleanliness guidelines by Medirest,independent audits are also undertaken by Trust staff, which includes Heads of Nursing, InfectionPrevention and Control Team and Corporate Development staff. Further joint audits are undertaken inconjunction with Central Nottinghamshire Hospitals on an adhoc basis.

There have been significant improvements regarding consistent achievement of cleanliness targets. Dueto some technical difficulties being experienced with the Maximiser auditing tool and its subsequent lackof use, all Ward Housekeepers are being retrained to use the new electronic device and further trainingwill be offered to all Ward Leaders to ensure consistency of audits and an ability to compare results.

Cleanliness remains high on the Trust agenda and regular meetings continue to be held with Medirestand CNH and all levels of the organisation, to raise concerns and address issues that have arisen in this

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new partnership arrangement. The Facilities Liaison Group is an established forum for members of theorganisation to meet the service providers face to face to discuss and resolve operational issues.

The Trust is continuing with the Deep Clean programme of all clinical areas. Hydrogen peroxide vapourdecontamination (fogging) continues for the decontamination of areas that have been occupied bypatients with CDI. Hydrogen peroxide vapour has also been in use following cases of norovirus, with fullward ‘fogging’s’ being undertaken when able.

Medirest, the soft services provider, has undertaken patient satisfaction surveys for cleanliness andcatering across King’s Mill, Mansfield Community and Newark Hospital. The results of these surveys areshowing patients being very happy with the standards of cleanliness within their area and the hospitalgenerally as well as quality of the food presented and choices available.

All new areas now have disposable curtaining and the introduction of the Steamplicity catering systemhas further improved the perception of cleanliness at ward level on the King’s Mill site as catering andcleaning are now separated. In addition, the number of dedicated cleaning hours per day has increased.The new ward hostess role has been introduced at King’s Mill and on the Mansfield site. Work is inprogress for rolling this role out at Newark too. Microfibre cleaning system continues to be used acrossall wards. Joint audits are undertaken by infection prevention and control and the contract managementteam in conjunction with Medirest and demonstrate that a consistently high standard is being achieved.

9.1 PEAT inspectionOnce again the Trust participated in the national self assessment of Patient Environment using the PEATassessment tool. This annual audit measures the standards of cleanliness, environment, patient mealservice and privacy and dignity afforded to patients. The audit team consists of representatives fromInfection Prevention and Control, Facilities Services, Head of Nursing and also included a patientrepresentative. As the same team were involved in previous PEAT audits, they commented that this wasone of the best outcomes of the past 7 years of PEAT auditing, with standards at a very good levelacross the board. The validated scores are awaited but indicative scores are below, based on thefindings on the day. Excellent scores for environment, cleanliness and food service were recorded at allthree sites. Patient feedback was also very positive.

Table 16: performance comparison year on yearSite and Year Environment Food Privacy and

Dignity2010: King’s Mill 4 (Good) 5 (Good) 4 (Good)2010: Newark 4 (Good) 5 (Excellent) 5 (Excellent)2011: King’s Mill 4 (Good) 5 (Excellent) 4 (Good)2011: Newark 4 (Good) 4 (Good) 5 (Excellent)2012: King’s Mill 5 (Excellent) 5 (Excellent) 4 (Good)2012: Newark 5 (Excellent) 5 (Excellent) 5 (Excellent)2012: Mansfield 5 (Excellent) 5 (Excellent) 5 (Excellent)

10. Design, construction, renovation and refurbishment programme

The IPCT continues to contribute to the design, construction and renovation projects across the Trust,the IPCT were involved with the specification and risk assessment for the Renal Dialysis Unit, whichopened in November 2011.

10.1 Theatre VentilationUntil October 2005 the Trust managed its own Facilities Management Services. Following the signing ofthe PFI contract all Soft and Hard FM services were transferred to the Project Company, CNH plc.Skanska Facilities Services (SFS) managed the Hard FM Estates Services and Medirest managed theSoft FM Services such as cleaning, catering, parking etc. As part of the contractual obligations, SFSundertook the Planned Preventative Maintenance (PPM) of the hospital estate, which included thevalidation and maintenance of all operating Theatres. The Trust, through its Facilities ManagementEstates Team (SFS) is required to undertake validation/PPM of all operating Theatres across both sites(King’s Mill and Newark Hospitals). This is to ensure that all theatres are validated under the HTM 03-01regulations. The validation exercise in 2011 for theatres identified failures in Theatres 6 and 7. Thereports were analysed by the Trust’s Mechanical and Electrical Advisor and the following actions wereimmediately implemented:

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The theatres were taken out of use, resulting in cancellation and rescheduling of operating lists

The Trust met with SFS to understand the scope of work required to complete the works and

revalidated all failed theatres

To ensure Business continuity is maintained, a mobile ultra clean laminar flow unit was hired and

located into a designated alternative theatre to re-commence orthopaedic surgery lists. This was

available until the successful validation of Theatres with permanent laminar flow re-validated

A clinical review team was established to commence a clinical review to identify if patients had

been exposed and experienced adverse outcomes

Internal RCA was commenced by Corporate Development and SFS to investigate and analysis

previous validation data

Processes are being established to prevent recurrence and provide on-going board assurance

The Trust’s Clinical Review Team undertook a review of Orthopaedic Patients who had undergone majorsurgery in Theatre 6. The findings from the Team were that there is no statistically significant evidencethat any patients have been subjected to adverse outcomes directly attributable to the failure of thelaminar flow Theatre validation. It should be noted that the programme planned maintenance for thevalidation of Theatres for 2012 - 2013 has just commenced.

10.2 Water Management - LegionellaThe Trust’s overarching Control of Legionella Policy was ratified by the Trust Board in July 2011, sincethen the Trust, SFS and CNH have developed a tri-party approach to the control of Legionella across theTrust. The Trust has developed a Water Management Group which is a multidisciplinary groupresponsible for the safe management of water systems across the Trust. The annual Legionella testingprogramme has been developed and frequency of testing has been agreed which reflects the riskidentified to immuno-compromised patients. As part of the water flushing regime every effort is made toensure that each ward and department undertake a risk assessment of the water outlets and record thefindings and report any “risky” outlets to the Health and Safety Manager. A standard audit form is usedfor this purpose.

Corporate Development and the IPCT raised awareness via attending various meetings and trainingsessions. Shortly after the implementation of the policy it became clear that further support was requiredas the number of returned flushing records and risk assessments from the clinical areas were worryinglylow. During discussion with Ward Leaders and Heads of Nursing it became clear that clinical staff werenot aware that once they had completed the documentation, they were required to forward this to theHealth and Safety Officer.

For the forthcoming year it is recommended that the Health and Safety Officer attends the HCAI forummonthly and provides a monthly report on the Trust states in relation to flushing records and riskassessment from the clinical areas.

11. Decontamination

The basic principle of infection control is to prevent pathogens reaching a susceptible site in sufficientnumbers to cause an infection. Decontamination is the general term used for the destruction or removalof microbial contamination to render an item safe; this includes cleaning, disinfection and sterilisation asappropriate.

11.1 Decontamination of equipmentThe Sterile Services Department (SSD) based at King’s Mill Hospital is responsible for thedecontamination, packing and sterilisation of instrument sets and packs, single instruments andsupplementary packs for all user departments of the Trust in a clean and safe environment in order toreduce and control infections throughout the Trust. The department operates in pursuance of Article 12and Annex V of the European Directive 93/42/EEC, and continues to meet the requirements of ISO13485 2003 in connection with the reprocessing of medical devices.

The activities of the department are audited and certificated on a bi-annual basis to ensure that theappropriate measures identified in the Quality Manual and Standard Operating Procedures continue tomeet the required standard. The external audits over the past two years have resulted in no correctiveactions or observations being raised, therefore assurances that the department is continuing in meetingthe essential requirements of the appropriate standards.

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SSD is confident that it continues to meet all statutory requirements for placing medical devices onto theopen market, therefore having a positive impact on effective infection control during the year 2011/12.The equipment within SSD has now been fully upgraded having the Dekomed 2000 replaced by theDekomed D32 which is fully compliant with HTM 2030 and BS EN 15883 part 4.

In July 2011 a full decontamination audit was undertaken by Spencer Nickson, to establish the currentdecontamination status of the Trust, the findings of the report where submitted to the CommericalDirector for circulation. The report highlighted several areas for review:

Reprocessing of the nasal endoscopes both within ear, nose and throat outpatientdepartment (ENT OPD) and Newark

Re-processing of the flexible cholodoscope for theatres arrangements made viaChesterfield SSD. For these to be sterrad sterilised (low temperature, hydrogenperoxide gas plasma technology), so as to remove the risk from the PC&S risk register(as these were not being sterilised between decontamination processes)

The fabric and current location of SSD, awaiting further advice from Trust Board The environmental issues of endoscopy and the on going Total Viable Count (TVC)

failures. Quotes have been received from Environmental Water Services and Lancer,which are with the Medical Division awaiting further action

The equipment failures within endoscopy. Quotes have been received fromEnvironmental Water Services and Lancer, which are with the Medical Division awaitingfurther action

The Trust Decontamination Lead role and responsibility and highlighted in accordance with HTM 01-01,the requirement for this role to be at an Executive Director role or if delegated down within theorganisation that this person has direct communication to an Executive Director for support, authority andline management.

11.2 Decontamination endoscopyThere remains on going intermittent failures to the weekly TVC tests for endoscopy, which resulted in atotal shut down of the decontamination unit in November 2011. The resulting action plans were drawnup and agreed to identify the route cause of these issues as there are numerous variables to be resolvedto enable the true route cause to be established:

The Reverse Osmosis (RO) Unit sampling point is situated to the rear of the pipe work within theunit, therefore endoscopy personal have to introduce sterile tubing to the sample point in orderto obtain the sample to reduce the risk of contamination

Computer programme issues with the units, which have now been resolved with the updating ofthe software

Dead leg identified between the RO unit and the automated endoscope reprocessors (AER’s),which is not being sanitised. An action plan was implemented, together with Lancer andEnvironmental Water Systems to remedy this issue with costing, which has been submitted tothe medical division

Concerns with regards to the environmental controls with in the decontamination unit, inparticular to the air handling unit (AHU) i.e. number air exchanges being undertaken, ability toextract fumes from any chemical spills. Meetings have taken place to discuss and find a solutionto this problem. The Health and Safety Officer has reported back to Medical Division, awaitingfurther action

Evidence of cracking on the surface of the basins within the AERs, which were considered to bea possible cause of contamination during water testing and operational use, these have nowbeen replaced with stainless steel basins to all four AER’s. The replacement programme is nowbeing rolled out to the AER’s in the Newark endoscopy unit. All the basins within the AER’s atthe King’s Mill Hospital site have been replaced. A replacement programme has been agreed forreplacing the basins within the AER’s at the Newark site

Unit is currently performing dual sampling using two separated United Kingdom AccreditationService (UKAS) accredited laboratories. This was implemented on the back of the action planimplemented in November 2011 (the parallel testing has proven inconclusive). The watersample results are forwarded and analysed by the Trust Consultant Microbiologist,

12. Partnership workingAll cases of MSSA, MRSA bacteraemias and CDI acquired in the Trust are subjected to a RCAinvestigation. Joint regular review meetings are held, these are hosted by the Nottingham RCA Review

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Group to discuss the individual cases and to ensure that joint learning is shared across the healtheconomy.

13. Policy reviewThe Code of Practice requires the Trust to have in place core policies for the control and management ofinfection. A systematic programmed of work was implemented to review and revise infection preventionand control policies. The IPCT recognises the important of evidence based policies and procedures inensuring effective compliance with national infection prevention and control standards. All policiescomply with the Trust policy on policies and are available via the Trust intranet site. At renewal, allpolicies are examined to ensure compliance with the Trust Equality and Diversity Policy.

14. Communication with staff, patients and relatives

Communication with staff throughout the Trust is facilitated by a quarterly IPCT Newsletter. Duringoutbreaks communication of bay/ward closure is cascaded ‘outbreak email’ and attendance at thecapacity and flow meetings. The infection prevention and control policies and patient information leafletsare available on the Trust intranet site. Each ward/department is encouraged to have an infectionprevention and control notice board, which is changed on a regular basis and include education andsurveillance data.

15. Audit

The ‘Code of Practice’ requires the Trust to have in place a programme of audit to ensure that key policiesand practices are being implemented appropriately. The IPCT and the IPCL’s/Ward/Department Leadersensure that infection prevention and control audits are undertaken across the Trust as appropriate. Theaudits are planned on an annual basis, and are re-audited and additional audits are facilitated as required.

The Infection Prevention Society (IPS) audit tools for hospitals have been used. The tool is approved by anationally recognised organisation with a body of evidence based practice to validate its use. Wards areencouraged to display the results of their audits at their entrance or on a dedicated infection prevention andcontrol notice board.

Changes as a result of audit: Replacement of commode chairs not ‘fit for purpose’ Implementation of hand held steam cleaners at ward level Implementation of urinary catheter care documentation

15.1 Saving LivesA key strategy to reduce HCAI is to reduce the infection risk associated with the use of catheters, cannulaeand IV lines, instruments etc. ‘Saving Lives’ a delivery programme to reduce HCAI was published by the DHin 2005. The toolkit includes a self assessment tool and a series of High Impact Interventions (HII) whichwere designed to focus staff on core clinical elements that impacts on the reduction of HCAI. All clinical areascomplete the monthly audits, with close monitoring by the Heads of Nursing. Considerable improvements inthe management of these devices have occurred and there has been a reduction in the number of infectionsrelated complications associated with these devices.

The Trust continues to effectively use the High Impact Interventions (HII) to monitor, improve and sustainits high standards. The Saving Lives programme has been further adapted to include in-house tools forthe taking of Blood Cultures, MRSA screening/decolonisation and Hand Hygiene/bare below the elbowsobservations.

All areas within the Trust continue to self assess their performance using the key indicators, furtherenhanced by, Heads of Nursing, Training and Development and the Infection Prevention and ControlTeam. To maintain the trend of improvement continues, areas needing assistance are quickly identifiedand supported.

All results are disseminated on a weekly basis to Ward Leaders and Senior Management, which ensuresthe Trust, sustains and further improves. The Saving Lives Web page now includes an audit trail so thateach entry can be traced back to the clinician entering the observation. This information is also nowincluded on the weekly ward reports. During April 2011 and March 2012 detailed trend analysis reportshave been distributed at each month end, showing for each Ward and Departments their compliance %for each observation over the previous 6 month period, which helps wards/departments to monitor theirperformance.

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15.2 Clinical AuditsClinical audit is an important part of monitoring and evaluating of good clinical practice, establishingcompliance with good infection prevention and control practices, they are paramount to clinical improvementwithin infection prevention and control and the reduction of HCAI’s. These audits are a cyclical processinvolving impromptu observations audit, rapid feedback and appropriate action in response to the results.

The IPCT has worked closely with the Ward/Department Leaders and Heads of Nursing during the auditprocess, and feedback audit results to individual areas. Re-audits were undertaken when action planswere required following poor results.

The results of the following audits are available from the IPCT. The infection prevention and control auditprogramme for 2012 – 2013 is outlined in the annual programme of work. It is recommended that a morestructured approach is adopted in formulating the annual infection prevention and control auditprogramme for 2013/2014 by conducting a prevalence survey of HCAI in which all adult inpatient areaswill be surveyed to help ascertain the prevalence and type of HCAI within the Trust, this will take place inFebruary 2013

15.3 Compliance with isolation precautionsBetween April 2011 and March 2012 the Infection Prevention and Control Audit Officer monitored thecompliance of the isolation of an infected/suspected infectious patient. This advice is measured againstthe policies contained within the Infection Prevention and Control Manual. The auditor reviewed 234advice sheets, resulting in 83% compliance with the advice provide by the IPCT. 17% was non-compliant; the main rational for this was that patients had been discharged prior to isolation precautionsbeing implemented.

15.4 Infection Prevention Society Annual AuditBetween June and September 2011 the annual audit is performed using a standardised tool supplied bythe Infection Prevention Society. The Infection Prevention and Control Link Representatives from theWard/Department, with assistance from the Infection Prevention and Control Audit Office (if required),

completed the audit for their clinical area. The audit tool examines aspects of the environment, facilities,individual staff knowledge and clinical practice, as well has covering specific areas such as handhygiene, waste management. Scores were fed back to the Ward/Department Leader and Head ofNursing for dissemination, for these areas where a standard score was minimal compliance or belowwere requested to formulate an action plan, and to re-audit to check compliance with therecommendations.

Table: The results from this year’s audit concluded that there has been improvement on the wards anddepartments. Particular improvement should be noted for hand hygiene and patient equipment. 75% orless = Red (Minimal Compliance), 76-84% = Amber (Partial Compliance), 85% and above = Green(Compliance).

Handling anddisposal oflinen

Departmental Waste

Patientequipment

Handhygiene

Personalprotectiveequipment

MedicalEmergency Careand Medicine

83%

Planned Care andSurgery

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15.5 Trust wide observation audit on hand hygiene techniquesBetween April 2011 and March 2012 clinical areas conducted self-audits for hand hygiene compliance ona monthly basis. These were completed by ward/departmental staff utilising the Saving Lives HighImpact Intervention tool, as well as an observational audit based on the Lewisham tool.

The Lewisham observation tool involves observation of the frequency and quality of hand hygiene inclinical areas. The pass mark for hand hygiene audits is 95% and wards failing to achieve this areexpected to perform weekly audits until they consistently achieve this standard. The outcome from theobservations on the wards and departments reflects the high priority given to hand hygiene by staffmembers, as well as the impact of the WHO ‘Five Moments’ and other hand hygiene campaigns. Theobservation audits highlighted that the use of the alcohol based hand gel was the main approach utilisedby staff for hand decontamination. The staff group who were more complaint with conducting handhygiene appropriately were Healthcare Assistants.

For the forthcoming year each clinical area will also receive a qualitative audit that examines handwashing technique using the ‘Glow Box’. This activity will concentrate not so much on the ‘when’ toconduct hand hygiene, but on the ‘how. It will demonstrate in a very visual way just how effective anindividual applies hand gel and how effective their hand washing technique is. It will promote the ‘Alyffe’six-step technique. These sessions will also be used to raise staff awareness of contact dermatitis.Audit results will be reported back to medical and nursing staff working in the areas in order to improvepractice.

15.6 Compliance with taking and recording blood culturesBetween April 2011 and March 2012 blood letting for the purpose of blood culture was audited. The aimof this audit was to ensure wards/department were compliant with the Trust blood culture policy byobserving:

The procedure Completion of the relevant documentation Completion of the blood culture register

The results were not as encouraging as anticipated, in many cases the wards/departments wereinconsistent with the completion of the relevant documentation, and in some areas a method of recordingwas not in place. These findings were fed back to the relevant Ward/Department Leader and Head ofNursing for their information and action planning; the action plans were in place and acted on within 4-6weeks.

15.7 Commode and raised toilet seat auditsBetween April 2011 and March 2012 commode audits were carried out as ‘spot checks’ by the Head ofNursing for the clinical area weekly and where Clostridium difficile was identified. The audit tool lookedat the overall cleanliness and state of repair of each commode. The results highlighted that there was a

Clinical SupportServicesWomen &Children

UrethralCatheterManagement

EnteralFeeding

PeripheralIV Lines

Non-TunnelledCVC

IsolationPrecautions

Emergency Careand Medicine

Planned Careand SurgeryClinical SupportServices

No audits completed as not applicable

Women &Children

76%

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consistent level of good performance throughout the Trust for cleanliness, however many were replaceddue to poor state of repair.

15.8 Additional auditsBetween April 2011 and March 2012 many other audits were conducted with the relevant results beingdisseminated to the relevant Ward/Department Leaders/Head of Nursing by the Infection Prevention andControl Audit Officer. All actions identified have been addressed and a re-audit was conducted, or hasbeen scheduled for the 2012 -2013. Examples of these audits are:

The safe and correct use of personal protective equipment Environmental audits utilising the IPS and ATP reader Compliance with Sharps Policy MRSA admission screening compliance

16. EducationThe Trust has a statutory obligation to ensure that all staff receives appropriate education and training ininfection prevention and control. The ‘Code of Practice’ also requires that induction and trainingprogrammes for new staff and on-going education for existing staff should incorporate the principles andpractice of preventing and control of infection.

Training and education is essential to promoting safe practice, and is integral to the overall delivery ofan effective infection prevention and control service. An annual education programme is producedwhich outlines the Trust training programme, which includes an assessment of the training needs ofdifferent staff groups and is designed to meet local and national educational needs and requirements.

Infection prevention and control training continues to be embedded in many of the Trust’s training andeducation programmes. During April 2011 and March 2012, the Training Department improved themandatory update programme to include practical hand hygiene assessments which has helped toincrease the compliance rate of assessments as these were previously ward based. Training andeducation remains pivotal to the Trust’s approach to reducing infection control rates.

Infection prevention and control is an integral part of orientation, induction and mandatory updatetraining as well as the non-registration training days. The IPCT also advised on the content of educationsessions for Medirest and Skanska staff, with specific references to cleaning the environment, the use ofappropriate cleaning products and the impact of the building on infection prevention and controlpractices.

The IPCT also provided general infection prevention and control training, including hand hygieneutilising the ‘glow and box’ for the volunteer service.

Below is a table of infection prevention and control training undertaken during April 2011 and March2012:Table:

Staff attending mandatory update training 2810MRSA e-learning 75Infection control study days 65C. DIFF training 134ANTT 631Hand hygiene e-learning 214

The IPCT continues to provide education in different ways to meet the needs of the Trust, it is becomingincreasingly difficult for staff to be released from their duties and to this end the IPCT are increasinglydelivering training at ward/department level, in addition ad-hoc training for individual wards/departmentsis provided if that area has specific requirements i.e. Human Resource.

16.1 Orientation trainingThe training package was update for April 2011 and March 2012. All new staff to the Trust receivesbasic infection prevention and control training from the IPCT, including hand hygiene training as part oftheir induction to the Trust. New staff attend the orientation training, those who do not attend arechased up to ensure they attend at a later date

16.2 Mandatory training

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The training package was updated for April 2011 and March 2012. All clinical staff receives basicinfection prevention and control training from the IPCT, including hand hygiene training/compliance aspart of their mandatory update. Over 2810 clinical staff have attended the mandatory training; thosewho do not attend are chased up to ensure they attend at a later date.

A Trust review of mandatory training requirements is in progress, a new approach to blended learning isanticipated for April 2012 and March 2013 to reflect different learning styles and access.

16.3 Bespoke trainingThe IPCT worked closely with Medirest to develop a bespoke training programme to facilitate effectiverelevant training. This programme has been well received and staff report a greater understanding oftheir IPC responsibilities in relation to their practice

For the forthcoming year, the IPCT will work closely with other non-clinical areas in the development ofbespoke training programme for their area; this will include Little Miller Nursery, Human Resources, andVolunteers.

17. Influenza planningFollowing the emergence of the H1N1 Swine Flu Influenza Pandemic in 2009 the Trust was focussed onthe response to the new emerging virus along with other health care providers across the country. Asthe impact of the H1N1 virus has receded there has been an opportunity to reflect on the National andLocal Level response to the Pandemic. During 2011 a revision was completed to the Trusts PandemicInfluenza Plan which reflected the Trusts and National experiences during the Swine Flu pandemic. Asexpected following a national review of the response, the DH published the UK Influenza PandemicPreparedness Strategy 2011 in December and in April 2012 the DH Health & Social Care InfluenzaPandemic Preparedness & Response Guide 2012 was published. The Trust will now as a result need toreview its existing plans to ensure that they dovetail with the new national guidelines and plans.

18. Infection Prevention and Control Nurse ward roundsAll new patients with MRSA, C. difficile, norovirus, ESBL producing coliforms, Group A strep arereviewed individually by an Infection Prevention and Control Nurse (IPCN). This approach has improvedthe management of these patients as well as compliance with infection prevention and control practices.In addition, the enhanced presence of the IPCT in clinical areas greatly increased their availability foradvice and guidance and improved communication with staff, patients and relatives.

For the forthcoming year, the Nurse Consultant Infection Prevention and Control will join the ConsultantMicrobiologist and attend the twice weekly ITU ward rounds.

19. Hand hygieneThe National Patient Safety Agency (NPSA) (2010) announced their support for the World HealthOrganization (WHO) campaign ‘Five Moments’. This approach has been developed to reduceunnecessary hand hygiene, and to stress the importance of the correct location and time for handhygiene, thereby ensuring the chain of transmission is broken by appropriate hand hygiene and thusprevent the acquisition of infection. The ‘Five Moment’ is linked to the ‘CleanyourHands’ campaign in thefollowing ways:

The WHO guidelines on hand hygiene in healthcare formed the central clinical source for thecampaign

Within the campaign the ‘Five Moments’ approach to hand hygiene formed the framework forinforming staff when and why hand hygiene should be performed

This will ensure other information about how to perform hand hygiene for example, will have animpact on practice

The IPCT continue to deliver the message of the ‘Five Moments’ and ‘At the point of care’, and both areincorporated into the Trust Hand Hygiene policy and forms the template for the hand hygiene audit tool.

19.1 WHO awareness dayOn May 5

th2011, as part of patient engagement hand hygiene awareness event took place in the King’s

Treatment Centre, the aim of the event was to raise the awareness and importance of hand hygiene byrequesting members of staff and the public to have their hand hygiene practice assessed using the sixstage hand hygiene technique and the use of the ‘glow and tell’ box..

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20. International Infection Prevention and Control WeekInfection Control Week took place during October 2011. The topic for this year was influenza, generalknowledge in infection prevention and control including world wide issues. During this week members ofIPCT promoted awareness of IPC incorporating a public stand on KTC, Main Street, attended by staffand members of the public.

21. Working with the wider health communityThe Infection Prevention and Control Nurses from the local community have continued to work togetherand attend the Trust’s IPCC. Mechanisms for joint investigation of significant infections have beendeveloped and are working well and more detailed information is being shared with clinical teams as aresult. Trends when identified have been shared both locally and in the Trent Region. The MRSAscreening co-ordinator has regular meetings with the Quality and Safety Manager for Nottingham CountyPCT who has overall responsibility for the Infection Prevention and Control team in Nottingham CountyPCT. The RCA review group continues to meet to share information and common themes for RCA’scarried out in their area, this is based at Nottingham City Hospital.

22. Conclusion and priorities for 2012 - 2013The Trust considers the reduction of HCAI’s a key component of patient safety system and a criticalindicator of the quality of services provided by the organisation.

The infection prevention and control service at the Trust has made a significant progress and focus onreducing HCAI’s. The service offers and meets the challenging new agenda being set at both local andnational level. Infections due to C. difficile have fallen, and the Trust has seen its second year of noMRSA bacteraemias, however considerable Trust wide effort is required to maintain and continue theseimprovements, particularly if the Trust is to reach the C. difficile reduction targets of 36 for 2012-2013.

Norovirus outbreaks increased in line with reported increases in the community, and the HPA alertsystem. These outbreaks are difficult to prevent. Clinical staff and Medirest responded well to thedifficult task of managing and controlling the outbreak; along with promoting deep cleaning anddecontamination prior to the ward reopening.

The Trust had in place an escalation plan in place to aid in the management of a sudden influx ofpatients presenting to the Trust with influenza like illness, no outbreak of influenza like illness werereported.

The IPCT has changed the way it has worked in order to deliver a more clinically oriented and relevantservice. This approach has been effective in both improving clinical practice and reducing rates ofhealthcare associated infections. Assurance has been given to the Trust Board that the desiredoutcomes for the reduction of HCAI’s have been achieved.

Clinical Divisions need to maintain their engagement with the IPC programme of work in the forthcomingyear to ensure that practices to prevent HCAI are clear and that practice is consistent. The Trustremains committed to the provision of safe, clean and is proud of the achievements it has made during2011-2012.

Priorities for the following year include: Sustaining the MRSA bacteraemia trajectory of zero MRSA bacteraemias Continue to embed infection prevention and control at all levels across the Trust Achieve the local and national targets as outlined in the Annual Programme of Work (April 2012

– March 2013) Comply with current and new national mandatory surveillance requirements Extended surveillance for surgical site infection of all Total Hip and Total Knee Replacement

(elective and emergency) Ensure continued compliance with the Code of Practice/CQC Outcome 8 and other national

guidelines Revamp the Infection Prevention and Control web site, to provide up to date information Perform RCA on all serious HCAI’s Joint working with the Health Economy Review relevant policies Review of the Infection Prevention Model 1 and 2 for medical staff

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