United Bristol Healthcare NHS Trust

AGENDA ITEM 13

United Bristol Healthcare NHS Trust

Trust Board Report and Position Statement on Healthcare Associated Infections

November 2007

1.  MRSA Bacteraemia

1.1  Performance (see Graph 1)

In September 2007 there were four cases which took the Trust to one case above trajectory in the month, reported in the Integrated Performance Report this month. At the time of writing this report there had been three cases in October and if there are no more between that date and the end of October then the position would still be one above trajectory. It is unlikely that this will be the case but an updated position for October will be reported verbally to the Board on the 30th October.

Graph 1: MRSA bacteraemia cases. Year to date

1.2 Root Cause Analysis Process

All MRSA bacteraemia cases are notified to the Chief Nurse and Director of Governance, Health Protection Agency, Strategic Health Authority and Primary Care Trust on the day of identification. A root cause analysis is conducted which is reported in the same way within 5 working days.

The outcomes of all of these reviews are considered and reported as follows as of this month:

Ø  Individual cases fed back with learning points to the clinical team involved.

Ø  Collated divisional issues considered by the Division’s Clinical Governance Group and reported to the Divisional Board.

Ø  Collated trust issues considered by the Infection Control Committee quarterly and any issues fed to the Trust Board through the Assurance Framework.

Should any issue arise of concern or high risk in nature, they are recorded on the risk register and escalated to the Executive Team by the Chief Nurse and Director of Governance.

1.3 Outcomes April – September Root Cause Analyses

21 cases of MRSA bacteraemia

By Division: Medicine Division 13

Surgery Head and Neck Division 3

Women’s and Children 3

Specialised Services 2

The divisional pattern is what would be expected with most cases in the area treating the emergency patients. There has been concern expressed by the Strategic Health Authority about the cases in paediatrics, because this is not a pattern reflected in other tertiary paediatric centres. The Strategic Health Authority Infection Control lead has visited the Trust to review the paediatric cases and action has been agreed.

Four cases were in augmented care (Critical Care etc), two of which were the paediatric cases on Ward 37 (renal).

11 of the cases (52%) were pre-48 hours i.e. community acquired.

7 of the cases were known Intravenous Drug Users.

In response to this analysis the following actions are being taken in addition to the existing infection control programme for the year:

Ø  Implementing the Saving Lives programme for Renal Patients on Ward 37.

Ø  Speeding up the implementation of the new Saving Lives programme (2007) for intravenous cannulae and urinary catheters.

Ø  Meeting with the Primary Care Trust and Intravenous Drug User ‘involvement groups’ to discuss options for this group of patients.

Ø  Simplifying the protocol to ensure that topical treatments for a MRSA positive patient (identified on screening) are immediately administered and do not wait for prescription.

Ø  In depth review of the four wards which have had 2 or more cases.

2. Clostridium difficile

2.1 Performance (see Graph 2)

For the 65 years and over age group, for which the trajectory applies, the Trust was at 138 cases in September. This was 95 cases below trajectory. The target reduction in the trajectory was set locally by the Bristol Primary Care Trust at a 10% reduction for the year.

The number of cases for age groups 2 to 64 was 15 in September, the pattern in the year each month previously being 18, 11, 11, 10 and 6.

Graph 2: Clostridium difficile cases. Year to Date (aged 65 and over)

2.2 Root Cause Analysis Process

This financial year there has also been a requirement to introduce a root cause analysis process for all patients who have Clostridium difficile cited on their death certificate or for patients who require a colectomy (gastrointestinal surgery) and have a history of having had Clostridium difficile.

This process was harder to implement as it required new systems to be established to identify the cases for analysis. The Patient Affairs Office who oversees the issue of death certificates and the consultant gastrointestinal surgeons trigger the process. Notification to the Chief Nurse and Director of Governance, and Primary Care Trust is again immediate. A root cause analysis is done within 10 working days, the results of which are collated internally and reported monthly to the Primary Care Trust. The same reporting levels apply as with the MRSA bactereamias as of this month, with the addition for Clostridium difficile death certificate reports going to the divisional mortality meetings.

2.3 Outcomes April – September Root Cause Analyses

Due to the complexity of these reviews and reports it has not been possible so far to collate one report and a priority has not been placed on doing this due to the low numbers so far. However, the process and common issue analysis is taking place and will be considered at the Infection Control Committee in November.

The Chief Nurse and Director of Governance, and Infection Control Committee monitor the number of death certificate cases and would alert the Board if any adverse trends were identified or numbers rose.

3. Maidstone and Tunbridge Wells NHS Trust Report

3.1 Board members will be aware of the publication of this report by the Healthcare Commission week commencing 7th October. The Chief Nurse and Director of Governance has read the report and considered the recommendations in relation to the position at United Bristol Healthcare NHS Trust. David Nicholson wrote to all Chief Executives on the 15th October (Appendix One) requiring them to consider their position in relation to the recommendations in the report.

3.2 United Bristol Healthcare NHS Trust Position / Recommendations

The Chief Nurse and Director of Governance has considered the recommendations in the report and commented on this trust’s position in relation to each one (Appendix Two). The recommendation to the Board is that the position in the Trust is a relatively strong one, reflected in the good performance figures. It is however acknowledged that there is always room for improvement and therefore Appendix Two highlights some recommended action for the Trust to take in response to this report. This action is either strengthening existing plans or newly identified actions.

4. National Money for Control of Healthcare Associated Infections

The Trust has received this month £310,000 for expenditure in this area. The spending plans were consulted upon with front line staff. The plan has been approved by the Strategic Health Authority and covers the areas in Table 1 below, where the potential impact has been identified.

Expenditure Plan / Clostridium difficile / All infections
Releasing ward / department link practitioners infection control for 4 days up to March 2008 for activities in their area / √
Improvement Hand Hygiene Practice / √
Public Awareness / √
Steam cleaners trial / √
Dedicated monitoring equipment for isolation patients / √
Cleaning Equipment / √
New commodes / √
Replace 9 old sluice macerators / √
Mattress replacement / √

Lindsey Scott

Chief Nurse and Director of Governance

17th October 2007

Appendix One

David Nicholson Letter (email)

To: All Chief Executives at NHS Trusts in England

All Chief Executives at NHS Foundation Trusts in England

All Chief Executives at Primary Care Trusts in England

All Medical Directors at NHS Trusts in England

All Medical Directors at NHS Foundation Trusts in England

All Medical Directors at Primary Care Trusts in England

All Directors of Nursing at NHS Trusts in England

All Directors of Nursing at NHS Foundation Trusts in England

All Directors of Nursing at Primary Care Trusts in England

cc. All Chief Executives at Strategic Health Authorities in England

All Medical Directors at Strategic Health Authorities in England

All Directors of Nursing at Strategic Health Authorities in England

Monitor - Independent Regulator of NHS Foundation Trusts

Healthcare Commission report on Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust

You will all have seen the recent headlines covering the investigation of the outbreak of Clostridium difficile at Maidstone and Tunbridge Wells Hospitals NHS Trust.

The Healthcare Commission published a damning report on 11 October 2007 detailing significant failings in infection control and patient care at the trust. The report is available on-line at:

http://www.healthcarecommission.org.uk/_db/_documents/Maidstone_and_Tunbridge_Wells_investigation_report_Oct_2007.pdf

This is the second major report which the Healthcare Commission has published on Clostridium difficile, the first being the report at Stoke Mandeville in July 2006.

I want to ensure that everyone with leadership responsibility within every NHS organisation actively considers the Healthcare Commission report relating to the serious shortcomings at Maidstone and Tunbridge Wells NHS Trust, and what further action they need to take. I am clear that the failures highlights in the report must not be repeated. A copy of the report is appended to this letter.

Where senior management and trust boards fail to act to deliver good quality infection control they must and will be held accountable. Whilst infection control is everyone's concern, ultimate accountability lies with the trust board. Trust boards must drive local improvements and they have the tools and materials to do this. We have given the NHS comprehensive guidance on infection control, and I expect you to ensure that good practice in infection prevention and control is day to day core business.

This is what patients expect and what the NHS has a duty to deliver.

I expect you to ensure that progress on reducing the number of MRSA blood stream infections achieved in the SR04 period is sustained over the Comprehensive Spending Review period. The Department of Health has also included a target for an overall reduction in Clostridium difficile infections by 30% by 2011. Together these indicators will ensure better control of healthcare associated infections.

Finally, I would urge each of you to ensure that the recommendations laid out in this report are fully understood by your board and that any local actions necessary are implemented with immediate effect.

Yours sincerely

David Nicholson

NHS Chief Executive

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Appendix Two

United Bristol Healthcare NHS Trust Position V Maidstone Report Recommendations

Domain / Recommendation / Trust Position / Propose Action
1. Action by the Board / Trust Board to review leadership to ensure it is able to discharge its responsibilities to an acceptable standard / Ø  Chief Nurse and Director of Governance is Board lead, directly manages the Infection Control Team and chairs Infection Control Committee
Ø  There is a Director of Infection Prevention and Control
Ø  Divisional leads for infection control identified.
Ø  Chief Executive meets Director of Infection Prevention and Control bi-monthly
Ø  Integrated Performance Report on infection rates to the Trust Board monthly
Ø  Divisional Performance Reviews have infection rates as a standing item
Ø  Assurance Framework for core standard 4a reported to Audit and Assurance Committee quarterly.
Ø  Annual Reports and Annual Infection Control Programme / To strengthen the assurance to the Trust Board by moving to a quarterly Infection Control Report to the Board in the month following the quarterly Infection Control Committee meeting (new)
2. Clinical Governance and management or risk / Control of infection to be integral to clinical governance and a high priority / Ø  Infection Control Committee part of clinical governance structure and reports to the Clinical Risk Assurance Committee routinely
Ø  See position above regarding high priority of infection control / None
Improve management of risk via Serious Untoward Incident reporting, analysis of risks from incidents and complaints, including system to capture learning / Ø  Serious Untoward Incident Policy revised in August and to be implemented
Ø  Serious Untoward Incidents reported to and monitored by Governance and Risk Management Committee
Ø  Incidents and Complaints addressed by risk and learning individually only
Ø  Risk Register has a category for infection control / Ø  Implement revised Serious Incident Policy (existing)
Ø  Introduce complaint and incident trend analysis (new)
Domain / Recommendation / Trust Position / Propose Action
3. Action by board and managers / Trust board to give greater priority to control of infection and factors of environment, cleanliness, movement of patients, bed occupancy / Ø  See action under number 1 regarding proposed new board report quarterly
Ø  Environment and cleanliness monitored via the Assurance Framework and have been focused on by the Board and, the Audit and Assurance Committee during the quarterly review of the assurance framework.
Ø  The movement of patients is monitored and not done for those who are positive to Clostridium difficile. There is a cubicle tracker and patient tracker for these cases. The Trust does not have a formalised policy regarding the movement of patients in relation to infection control
Ø  Occupancy levels are monitored but not directly in relation to infection rates. This would only be done if there was an outbreak etc. / Agree the position regarding the movement of patients and define the policy to be applied (new)
Ensure effective isolation for patients who pose a potential or actual high risk of infection to others / Ø  Policies for high risk patients in place.
Ø  Cubicle tracker for Clostridium difficile identifies immediately if a positive patient can not be isolated
Ø  Cohort ward plan agreed in 2005/06 and reviewed in October 2007 with the Clinical Site Team / Further review Cohort Ward plan to ensure accuracy in light of ward changes (new)
Demonstrate that the infection control team is operating an appropriate system for surveillance / Ø  Clostridium difficile Infection Control Management Pack and cubicle tracker in place. Management pack currently under review.
Ø  MRSA Care Pathway in place and recently updated.
Ø  Direct and face-to-face intervention of Infection Control Team for all MRSA bacteraemias / Conduct review of Clostridium difficile Management Pack (revision)
Domain / Recommendation / Trust Position / Propose Action
3./ cont / Ensure standards of hygiene in relation to the cleaning and decontamination of equipment on wards is functioning properly / Ø  Recent ward cleaning specifications identified need for clarity on cleaning responsibilities for equipment and standards
Ø  Facilities equipment audit had poor results (trolleys and wheelchairs) – re. audit due in November
Ø  Decontamination Board exists and assurance framework for core standard 4c.
Ø  Spaces in between beds must be broadly in line with NHS Estates recommendations in 2002. It is very likely this is not able to be met e.g. Old Building and has been one of the factors in the Redevelopment Projects and the Trust Strategic Planning / Ø  Check cleaning specification equipment (existing)
Ø  Review facilities audit results (new)
Ø  Get Director of Facilities and Estates opinion regarding position on spaces between beds
Trust to publish criteria for the opening of escalation / overflow areas / An escalation policy exists / None
4. Standards of Care / Diagnosis of Clostridium difficile to be seen as a diagnosis and not secondary, with appropriate care and treatment / Management Pack in place and Clostridium difficile treated as a diagnosis / See action under 3 Management Pack earlier
Adherence to the Management Pack and guidance must be monitored / Ø  This is monitored by the Infection Control Team informally on ward visits
Ø  Formal monitoring via Root Cause Analysis of patients with Clostridium difficile on their death certificate
Ø  Adherence to antibiotic prescribing guidelines is audited / None
Prescribing of antibiotics follows good practice and for shortest possible period / Ø  Guidelines in place and audited
Ø  Trust does not have policy for default of 5 day intravenous prescriptions then switch to oral / To clarify 5 day intravenous to oral policy (new)
Domain / Recommendation / Trust Position / Propose Action
4./ cont / Standards of nursing care to be improved to ensure call bells answered, privacy and dignity respected and single sex accommodation / Ø  Complaints monitored for trends of concern on all these aspects
Ø  Assurance framework monitors privacy and dignity
Ø  Privacy and Dignity work extended in 2007 with trust wide audit of issues over and above single sex ward ones
Ø  Trust meets Department of Health standards on single sex wards / None
5. Staffing levels and training / Ensure recruitment in place to minimise vacancies / Ø  Vacancies and bank / agency use monitored at Trust Board level
Ø  2007 risk with too many vacancies held in summer for new recruits leading to bank and agency unable to fill needs / Ø  Recruit to existing vacancies (existing)
Ø  New system to coordinate vacancies better across divisions (existing)
Monitor nurse staffing levels and ensure comparable to other trusts / Ø  Nursing Key Information Sheet monitors levels
Ø  Nurse Dependency System in place for monitoring
Ø  Acuity to be added to above in 2008
Ø  Extensive benchmarking between 1999 and 2005 / None
All staff have control of infection training / Ø  Mandatory training needs matrix
Ø  Monitoring of above at trust and divisional level and by Infection Control Committee / None

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