ANNUAL REPORT INFECTION PREVENTION AND CONTROL
APRIL 2010 – MARCH 2011
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INFECTION PREVENTION AND CONTROL
ANNUAL REPORT 2010/2011
contents
1Introduction
2ROLE OF THE DIRECTOR OF INFECTION PREVENTION AND CONTOL
3THE HEALTH AND SOCIAL CARE ACT 2008
4 DEVELOPMENT OF IPAC SERVICES
5 INFORMATION TECHNOLOGY DEVELOPMENTS
6Audits
7 SURGICAL SITE INFECTIONS
8Methicillin-resistant staphylococcus Aureus
9CLOSTRIDIUM DIFFICILE ASSOCIATED DISEASE
10GLYCOPEPTIDE RESISTANT ENTEROCOCCI BacteraEmia
11NOROVIRUS
12 H1N1 InfluENZA
13 WIDER INFECTION CONTROL SERVICE
14THE ANNUAL JACKIE REES AWARD FOR INFECTION PREVENTION AND CONTROL PRACTICE AND INNOVATION
15 Antimicrobial Stewardship
16 Hand Hygiene Campaign
17 Estates and IPAC
18 Domestic Services and IPAC
19 DECONTAMINATION, STERILE SERVICES AND IPAC
20 Microbiology Lab and IPAC
21REFERENCES/USEFUL LINKS
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INFECTION PREVENTION AND CONTROL
ANNUAL REPORT 2010/2011
1Introduction
1.1This is the fifth annual report produced by the Director of Infection Prevention and Control at the Queen Elizabeth Hospital Kings Lynn (QEHKL) NHS Foundation Trust. The annual report is a public document and was first introduced following the publication of the Chief Medical Officer’s report entitled “Winning Ways” in 2004.
1.2 Healthcare associated infection remains a top priority for the public, patients and staff. Avoidable infections are not only potentially devastating for patients and healthcare staff, but consume valuable healthcare resources. Investment in infection prevention and control is therefore both necessary and cost effective. The resources committed by the QEHKL to infection prevention and control can be appreciated in the contents of this report.
1.3 The purpose of this report is to inform patients, public, staff, Trust Board and Commissioners of the infection control work undertaken in 2010-11, the management arrangements, the state of infection control within the QEHKL and progress against performance targets.
2ROLE OF THE DIRECTOR OF INFECTION PREVENTION AND CONTOL
2.1Every Trust must have a senior member of staff designated as the DIPC. The DIPC liaises with key staff at both board and ward level; this includesTrust Executives, all members of the Infection Control team, Consultant in Health Protection, clinical and nursing colleagues, DIPC’s of neighbouring organisations and the PCT.
2.2The DIPC holds corporate responsibility for infection prevention and control throughout the Trust, as delegated by the Chief Executive; is responsible for the development of strategies on infection prevention and control and is tasked with ensuring implementation and ongoing delivery of these to maintain compliance with the Health Act, 2008.
2.3The DIPC will oversee the local infection prevention and control policies and their implementation, and provide assurance to the Board that these policies remain fit for the purpose.
2.4The DIPC will monitor and report performance relating to infection prevention and control issues to the Trust, and report directly to the Chief Executive and the Trust Board.
2.5The DIPC has authority to challenge inappropriate clinical hygiene practice and antibiotic prescribing decisions, and is required to assess the impact of existing and new policies and plans on infection rates, and to make recommendations for change where necessary.
2.6The DIPC contributes to the organisation's clinical governance and patient safety teams and structures, and is responsible for producing an annual report on the state of healthcare associated infection in the organisation, which is released publicly.
2.7He/she must act on legislation, national policies and guidance, ensuring effective policies are put in place and audited; attend Board meetings to report on infection prevention and control issues and ensure infection prevention and control consideration in other operational and developmental decisions of the Board.
2.8The DIPC works with the decontamination lead to ensure that the requirements of decontamination guidance are in place and adhered to through the implementation of appropriate policies, and must lead the management of IPAC outbreaks, produce SUI reports and report to the SHA and PCT when appropriate, and ensure that the Trust remains below trajectory in its management of avoidable HCAI’s.
2.9A key role is to provide leadership to the Infection Prevention and Control Programme in order to ensure a high profile for infection prevention and control across the organisation, and manage and support the infection control team in all its activities to ensure delivery of the programme. The management of infection control is dependent upon a cohesive and committed team which, when functioning collectively, can impact significantly on patient safety and ensure that avoidable HCAI’s are kept to a minimum.
3THE HEALTH AND SOCIAL CARE ACT 2008
3.1In the financial year 2010/11, the Care Quality Commission (CQC) did not visit the Trust. The Assurance framework against the Health and Social Care Act, 2008, has been updated and ongoing status reported at monthly IPACS meetings, bi-monthly IC Committee meetings and quarterly Trust Board meetings.
4 DEVELOPMENT OF IPAC SERVICES
4.1The IPAC service consists of a multi-disciplinary team, which includes Consultants, nurses and a designated pharmacist. They are supported by an auditor and a secretary.
4.2 Additional Staff
4.2.1A Consultant Nurse post was approved, advertised and appointed in February, 2011. The post holder is expected to take up the post in May, 2011.
4.2.2The post facilitates the provision of interdisciplinary care for patients requiring infection prevention and control support within the Kings Lynn NHS Trust. Implicit in the role is the provision of specialist nursing expertise for patients, their families and care givers. The role will facilitate the liaison between primary and secondary health care teams. The post holder will be participating in effective educational activities in order to support competent clinical practice for all those health professionals involved in infection prevention and control support and will have specific responsibility for facilitating curriculum development and professional research activity.
4.2.3The Assistant Director of Infection Prevention and Control (ADIPC), is a key leader in the challenge to improve the profile of infection prevention and control (IPAC) throughout the Trust. The post holder will work in support of the Director of Infection Prevention and Control (DIPC) to ensure that the Trust continually improves its performance in reducing Healthcare Associated Infection (HAI) by developing systems that are evidence-based and grounded in best practice. With the DIPC, the post holder will lead on the development of infection prevention and control strategy, ensuring engagement of ALL groups of staff, patients and external organisations, where appropriate.
4.2.4 The Consultant Nurse will manage the existing team of Infection Prevention and Control Nurses and provide clinical and professional leadership at a strategic level to ensure the service meets the needs of the Trust. He/she will also work with professionals from a wide variety of disciplines to develop policy and protocols, and monitor infection prevention and control practice.
4.3 Educational Development of IPAC Team members
4.3.1Investment in the staff has included support for the two band 6 members of the team to study for a BSc degree in Infection Control at the University of Hertfordshire and a BSc in Nursing Studies at University of East Anglia. The Band 3 IPACS support worker has completed an NVQ 3 and commenced a foundation degree in Health Sciences at NorwichCityCollege,sponsored by the Trust. The band 8a undertook further study to enhance a senior nurse skills and knowledge.
5 INFORMATION TECHNOLOGY DEVELOPMENTS
5.1 Web-Based Surveillance Software for IPACS
5.1.1The IPACS Team require information in real time/near real time from the Microbiology Laboratory in order to avoid delays in management of infection control at ward level.
5.1.2ICNet was purchased and provided the IPAC team with near real time reporting, withan average of 5 imports of results per day instead of only one a day. The system has the capability of setting alerts to notify the IPAC team of any particular information, e.g. a cluster of a particular micro-organism identified In a particularclinical area, in a given period of time,such astwo or more patients identified with Clostridium difficile infection from the same ward.
5.1.3The system will eventually interface with PAS to provide admission/discharge information within the ICNet system. When the clinical areas within the Trust are Wi-Fi compliant, the IPAC Team will be able to access results from a portable tablet. The system is supported by a training and helpdesk package. The system went live on 1st June, 2010 without the PAS interface and has been working well and providing useful tools in outbreaks.
5.1.4However, the system does not currently interface with PAS. The purchase of the module was included in the original business case but, due to the IC infrastructure within the hospital being unable to support this module, it was not purchased. The infrastructure in the Trust has been changed and, in 2011, will be able to support the module. Another business case has been put forward to purchase the module as the original funding was no longer available and the cost of the product has increased. It is anticipated that the module will be in place in 2011. This will provide the IPACS team with additional tools to facilitate surveillance and eliminate the time spent transcribing demographic date from PAS to ICNet and the risk of transcription errors.
6Audits
6.1Audits provide a standardised method for monitoring evidence-based clinical practice, protocols, procedures and the environment. Feeding back the audit results enables a systematic identification of areas where improvement is needed to minimise infection risks and enhance the quality of patient care.
6.2High Impact Interventions (HII)- “Saving Lives”
6.2.1“Saving Lives”, a delivery programme to reduce healthcare associated infection, including MRSA, was launched by the Department of Health in 2005 and revised in 2007 (Saving Lives: Reducing Infection, Delivering Clean and Safe Care). This is a delivery programme centredon a series of clinical care bundles or high impact interventions. The care bundles or high impact interventions (HII) support HCAI improvement and form an essential part of an organisation’s plan to implement best practice, national guidance and the latest infection prevention and control policies.
6.2.2The HII’s relate to those key clinical procedures which can increase the risk of infection if not performed appropriately. They have been developed to provide a simple way of highlighting the critical elements of a particular procedure, the key actions required and a means of demonstrating reliability using compliance audit tools. The purpose of the HII’s is to minimise unwarranted variation in practice by providing a means to identify areas where compliance needs to be improved and a measure of how often all elements are performed for a given procedure. The tool is also the means by which results can be fed back to staff quickly and actions agreed and implemented. Progress of compliance can be tracked and shared to ensure that good practice is standardised and consistent.
6.2.3The HII audits comprise:
- HII No 1 - Central Venous Catheter Care
Areas where central venous catheter (CVC) care is predominant contribute to this audit. Elements of compliance relate to cleaning of the skin and ports when administering IV medication. 2% chlorhexidine and 70% alcohol wipes were introduced in summer of 2010 for cleaning hubs and ports for both CVC and PVC’s.
- HII No 2 - Peripheral Intravenous Cannula Care
Elements of compliance relate to cleaning of skin and ports when inserting IV medication. Ongoing work has been overseen by the Venous Access Group to review documentation and cannulation packs and ensure compliance with practice and completion of documentation.
- HII No 3 - Renal Dialysis Catheter
The Renal Dialysis Unit at the QEH is a satellite of Addenbrookes and does not come under the umbrella of IPACS; therefore it is not included in the HII at QEH.
- HII No 4 - Prevention of Surgical Site Infection
The elements of this HII are predominantly related to aspects of care specific to the Day Surgery Unit,main operating theatre and surgical wards. The QEH has very low surgical site infection rates, and currently monitors joint replacement and major bowel surgery(see also section 6 for greater detail). An updated care bundle has been published and the Trust audit tools amended accordingly.
- HII No 5 - Ventilated Patients
Critical Care and NICU undertake this HII, as ventilator-associated infections account for a high percentage of infections in intensive care units.
- HII No 6 - Urinary Catheter Care
Urinary catheter associated infections are one of the most common hospital associated infections. The correct size of catheter and sterility on insertion are the main elements of this HII.
- HII No 7 - Reduce the Risk of Clostridium difficile
C.diff remains a potential risk to the elderly person both in the community and acute setting. Within the QEH, this audit is only undertaken in the IsolationUnit on Stanhoe ward. A review of the Trust audit tool is being undertaken in relation to aspects of the audit across the Trust.
- HII No 8 - Cleaning and Decontamination of Clinical Equipment
The QEH policy on Cleaning and Disinfection reflect the guidance in this HII. Assessment of tracking the cleaning of equipment continues to be reviewed. Various methods of identifying clean equipment have been trialled. An overhaul of cleaning audits was completed in early 2011. Wards/departments now undertake daily audits, completed mainly by the Housekeepers, and Matrons undertake a monthly audit, which includes checking that the daily audits have been undertaken. The practice of identifying when an item has been cleaned has become well established throughout the last 12 months.
6.2.4The HII tool was updated and education commenced on how to use the tool, and launched on 25th October 2010. Matrons worked with ward teams to improve the audit process, to improve standards of care and achieve the expected compliance of above 95%. Data of incomplete documentation reported against practice compliance was now being reported separately. This is expected that this will give more weight to clinical teams as they can be assured that the results reflect practice.
6.2.5 After the launch there was an increase in correct reporting compared to previous months. A review of areas which have scored 100% for the past 4 months is planned both to see if any lessons for good practice can be shared and to validate this exceptional achievement. The standard of returns for HII continues to improve and overall scores increase.
6.2.6In early 2011, the dashboard reporting system was developed by the Clinical Audit Department to provide a means of sharing the results of HII audits, and can be accessed Trust wide via the Clinical Audit Department web page. Each area undertaking HII audits can view their month by month compliance against an expected compliance above 95%, and compare their results with similar areas, to ensure that a consistent quality of care is being delivered. The new dashboard incorporates a “RAG” system.
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Quarterly Divisional Infection Control Scorecard Jan - Mar 2011Indicators (percentage unless otherwise indicated) / Emergency Care / Clinical Support / Women & Children / Elective Care / Target / Trust % / Emergency / Clinical Support / Elective / Women & Children
% / No. / % / No. / % / No. / % / No. / Total Number of Incomplete Audits
HII 1. Central Venous Catheter Care Bundle Audit / 93 / NOTDUE / NOTDUE / NOTDUE / ≥ 95% / 93 / 0 / 0 / 0 / 0
HII 2. Care of Peripheral Cannula Care Bundle Audit / 84 / 72 / 96 / 87 / ≥ 95% / 85 / 3 / 0 / 0 / 3
HII 4a. Care Bundle to prevent Surgical Site Infection (Theatres & Day Surgery only) / 97 / ≥ 95% / 97 / 0 / 0 / 0 / 0
HII 4b. Patient MRSA Screening / N/A / CORPORATE BI-ANNUALLY / ≥ 95% / NOTDUE / 1 / 0 / 0 / 0
HII 5. Care of Ventilated Patients Audit Tool (CCU only) / 93 / N/A / N/A / ≥ 95% / 93 / 0 / 0 / 0 / 0
HII 6. Urinary Catheter Care Bundle Audit / 96 / N/A / N/A / 98 / ≥ 95% / 98 / 3 / 0 / 0 / 3
HII 7. Clostridium Difficile (Stanhoe Isolation only) / I / N/A / N/A / ≥ 95% / N/A / 3 / 0 / 0 / 0
HII 9. Blood Culture Sample Collection (MAU, A&E, SAU, CDU, CCU only) / 100 / N/A / I / ≥ 95% / 100 / 1 / 0 / 2 / 0
HII 10a/b. Hand Hygiene (5 moments) / 94 / 93 / 93 / 92 / ≥ 95% / 93 / 1 / 1 / 0 / 4
C Diff Positive specimens >2 days post admission / 6 / 0 / 0 / 0 / ≤38 / 6
MRSA Bacteraemias >2 days post admission / 0 / 0 / 0 / 0 / ≤3 / 0
MSSA Bacteraemias >2 days post admission / 2 / 0 / 0 / 1 / Monitor only / 3
Reported ESBL Bacteraemia / 0 / 0 / 0 / 0 / Monitor only / 0
Patient deaths associated with C Diff diarrhoea / 1 / 0 / 0 / 0 / Monitor only / 1
Infection Control related complaints / 2 / 0 / 1 / 0 / Nil / 3
Infection Control related incidents / 9 / 1 / 3 / 2 / Nil / 15
I = Incomplete Audit
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6.3 In 2010, four additional summaries of good practice were included:
- Antimicrobial Prescribing: a summary of best practice
Lead Antimicrobial Pharmacist undertakes audits to assess compliance with best practice.
- Taking Blood Cultures: a summary of best practice
The QEH has compiled a specific HII audit to comply with this best practice.
- Isolating Patients with Healthcare Associated Infections:a summary of good practice.
6.4 Environmental Risk Audits
6.4.1The annual Environmental Risk Assessment audits are undertaken by the IPAC team using a modified audit tool, based on the Infection Control Nurse Association - Audit Tool for Monitoring Infection Standards (2004). The audit includes cleanliness, decontamination procedure, hand hygiene facilities and practice, waste disposal, availability of personal protective equipment and practice.
6.4.2An audit was carried out on each ward and department, unless they were in the process of reconfiguration at the time of the scheduled audit, when an alternative date was scheduled.
6.4.3Each Ward/Department Manager, or nominated deputy, is expected to accompany the member of the IPAC team during the audit to ensure ownership of the audit and address urgent issues that may be identified. A report is sent to the Ward/Department Manager and Matron and an action plan of any issues identified is expected to be submitted to IPACS, stating actions undertaken and date completed.
6.5Other Audits
6.5.1Sluice and Commode Audit by External Company
An external company undertook an annual audit of the sluice and commodes in the ward areas. A full report was submitted and distributed to each ward area and an action plan requested to address any issues.