DIRECTOR OF INFECTION PREVENTION & CONTROL REPORT
Period from Dec – Feb 2012
Outlined below are the current activities of Quarter 3 for Mental Health, Camden Provider Service and Hillingdon Community Health for Infection Prevention & Control. The infection control team for all of CNWL still has slight different reporting methods to CPS area, HCH area and MH area. CNWL has moved some way to reducing this anomaly and will continue to do so until we have the same reporting mechanisms. The Board should be assured that the required information is extracted from the three areas.
Acute hospitals were set a target for MRSA and C-Diff, aiming for a year on year reduction, and this did not apply to community or mental health services. In line with this, the Board of Directors agreed that the targets for the three areas of CNWL will be year on year reduction, and set our own target (self target) and this is reflected in the table below.
- Alert Organism Surveillance
ALERT ORGANISM / Target / CPS / HCH / MH / CNWL Total
*MRSA Bacteraemia / 2010/2011 figures / 1 / 0 / 0 / 1
Self Target / 0 / 0 / 0 / 0
Current Quarterly Figure / 0 / 0 / 0 / 0
Running Total / 0 / 0 / 0 / 0
**Clostridium difficile. (Toxin positive) / 2010/2011 figures / 9 / 2 / 0 / 11
Self Target / 8 / 1 / 0 / 9
Quarterly figure / 1 / 0 / 0 / 1
Running Total 2011/2012 / 4 / 3 / 0 / 7
Other organisms / 0 / 0 / 0 / 0
*MRSA Bacteraemias – MRSA positive cultures where the patient was an ‘in patient’ the specimen date is on, or after, the third day of admission, where the day of admission is day 1.**Clostridium difficile infection- ; where the patient was an inpatient and the patient’s specimen date is on, or after the fourth day of the admission, where the day of admission is day 1. (Clostridium difficile antigen positive, toxin negative results are not part of mandatory surveillance and are therefore not recorded).
- Outbreaks and/or SUI
CPS / HCH / MH / CNWL Total
Norovirus / 0 / 0 / 1
(3 patients) / 1
Other Organisms / 0 / 0 / 0 / 0
Mandatory / Induction / CPS / HCH / MH / CNWL Total
Number of staff trained this Quarter / 75 (APPROX) / 75 / 275 / 425
12% / 12% / 12.7% / 36.7%
Running total of staff trained this financial year*
Annual Target 95% / 307 / 118 / 1208 / 1930
91% / 84% / 76% / 83.6%
*CNWL - Mandatory training target 95%
Total number of Mattress / CPS
(53 inpatient beds) / HCH
(22 inpatient beds) / Mental Health
(873 beds) / CNWL Total
Total mattress audited
Total mattresses passed / 53 / 22 / 449 / 524
51 / 22 / 407 / 480
% Total / 96% / 100% / 47% / 81%
Hand Hygiene / CPS / HCH / MH / Total
98% / 96% / 92% / 95%
Environmental (PEAT) / 1 Mock PEAT / 1 site (NPCU) audited / 14 sites
Clinical Environment / 8 sites / 16 sites inspected over 12 months / 3 sites
*Numbers cannot be comparable due to different audits undertaken in different areas
- Sharps/Inoculation Injuries
CPS / HCH / MH / CNWL Total
Number of sharps/inoculation injuries this Quarter / 2 / 6 / 2 / 10
Running total of sharps/inoculation injuries this Financial Year / 12 / 6 / 8 / 26
- Policy update
7.1 CNWL - The amalgamation of policies is planned over the forthcoming year; at which point a joint manual will be launched. In the interim, amended joint policies have been incorporated into the Infection Prevention and Control Policy Manual:
- Personal Protective Equipment
- Hand Hygiene
- Outbreak Management
- Notifiable Diseases
- Procedure for the management of sharps injuries and blood-exposure incidents
This is a policy which has been amended to have one format for all CNWL. The policy has been assessed as part of the NHSLA visit; subsequently minor revisions have been made to the Monitoring section.
Infection Control Training (including Hand Hygiene) this is a stand alone policy.
The Decontamination of medical devices (B2) and disinfection of equipment (B3) policies have been amended. The overarching Decontamination of Medical Devices Policy is for all CNWL and will be the reference point for staff.
A PGD; to improve administration of suppression therapy within 24 hours of positive result has been developed. Awaiting ratification and introduction into clinical practice by the clinical service lead.
- Risk Register
Top 10 Nil to report
All - NHSLA: The Inoculation Policy for NHSLA has been completed Dec 2011
Cleaning audits - will all go separately via their respective Clinical Governance Groups for the three areas within CNWL.
- Exception Report
None to report
The teams aim to improve the reporting format. All areas of CNWL will amalgamate all policies where possible. However, some policies do not lend themselves to cover all CNWL. Some of the policies will have to remain separate, reflecting the specialties that are provided in the three areas of CNWL.