United Bristol Healthcare NHS Trust
Infection Control Report May 2008
1. Performance
1.1 Summary 2007/08 Performance
1.1.1 MRSA Bacteraemia
The trajectory was for 34 cases and the Trust underachieved by 12 (Figure 1). The run rate was re-established from December / January.
Figure 1: MRSA Bacteraemia Trajectory Full Year 2007/08
The number of pre-48 hour cases was 19 (41%), 25 post-48hr (54%) and 2 unknown.
1.1.2 Clostridium difficile
The trajectory and target in this year was for cases in the 65+ age groups only. The Trust achieved this trajectory of 471 with a 385 out-turn (Figure 2). This comprised of 337 trust and 48 GP cases.
Figure 2: Clostridium difficile Trajectory 65yrs+ 2007/08
The total number of cases in the 2+ years was as defined in Figure 3, which is relevant to our targets for the coming year.
1.1.3 Hand Hygiene
Routine Hand Hygiene Audit results have been reported corporately since December 2007 and the results are now consistently good at the required minimum of 95% (Appendix One).
1.2 April 2008 Activity
1.2.1` MRSA Bacteraemia
At the time of writing this report on the 29th April there had been 3 bacteraemia cases, two pre 48hr and one post 48hr.
1.2.2 Clostridium difficile
The numbers in April remained high and were in the 60-69 range, but the reported out-turn will not be confirmed until the second week of May when the data is cleaned and GP cases removed. Not withstanding that the numbers remain of significant concern and urgent action is already in place as defined in the action plan for 08/09.
1.2.3 Norovirus
On the 25th April there was a clear re emergency of the Norovirus resulting in the closure of four wards. 42 patients and 11 staff had been affected at that time. Outbreak action was immediately instigated. At the time of writing this report on the 2nd May two wards were closed, one to reopen 3rd May and the other possibly 5th May.
1.3 Targets 2008/09
1.3.1 MRSA Bacteraemia
The level set for 2008/09 is 23 post-48hr cases and the Trust internal target remains a zero tolerance of these cases.
1.3.2 Clostridium difficile
The proposed interim target to be used until confirmed by the Strategic Health Authority at the end of quarter one is as follows:
Baseline Clostridium difficile cases (all cases0 538
% of community acquired 12%
Number attributable to Trust 473
2008/09 Trajectory 390
2009/10 Trajectory 307
2010/11 Trajectory 224
The 390 2008/09 target has been extrapolated into divisional targets against which they will be monitored, using the percentage out-turn in divisions in 2007/08. This is summarised as follows:
Division / % 2007/08 cases / Target of Cases 2008/09 (of 390) / Monthly run rateMedicine / 54 / 210.6 / 17
Specialised Services / 10 / 39 / 3
Surgery Head + Neck / 28 / 109.2 / 9
Women’s + Children / 8 / 31.2 / 2
1.3.3 MRSA Screening
Targets and thresholds in relation to MRSA screening are to be agreed locally for 2008/09. An indicative penalty of £200 for each patient not screened where the Trust is responsible for the screening has been proposed by Bristol Primary Care Trust, although this depends on local delivery mechanisms to deliver national trajectories. Our current policy meets the national requirements and the fines are not planned to be applied until Quarter 3.
2. Action Plans 2008/09
At the Board meeting on the 29th April the Board approved the Infection Prevention and Control Programme for 2008/09, in three sections:
i. Universal Action Plan
ii. MRSA Action Plan
iii. Clostridium difficile Action Plan.
From the May meeting the Board will receive a report on progress with the delivery of the actions to be tracked alongside performance, and notification of new actions which have been added in the previous month.
3. General
3.1 Director of Infection Control and Prevention
Chris Perry has returned to the Trust after her secondment to NHS South West to assist in the delivery of the infection prevention and control programme in the region. She will return to her role as Director of Infection Prevention and Control, but not to her Nurse Consultant role. The role requirements for the former have been updated by the Department of Health and Christine’s new Job Description will be amended accordingly.
3.2 Department of Health
3.2.1 Unannounced Visits 2008/09
Anna Walker, Chief Executive of the Healthcare Commission, emailed NHS Trust Chief Executives on the 23rd April to remind trusts of the intention to conduct unannounced inspection visits in all trusts during the coming year, in relation to arrangements in relation to infection prevention and control. Some guidance was given as to the nature of what would be defined as material failings and breaches, very much related to the nature and extent of the risk to patients. In 2007/08 there were 120 such visits with 3 improvement notices issued, two of the latter relating to decontamination. The Decontamination Board will be asked therefore to focus activity in quarter one to identify any risks and concerns.
Trusts will be notified if they are to be visited in the forthcoming quarter and documentation requested, but the actual date of the visit in that quarter will not be known to the Trust. We there know that we are not on the list for a visit in quarter one. Chris Perry has experience working on these inspection teams and will prepare for us a file of documentation that will need to be available and an operating procedure for the day of the visit, which will be kept in Trust HQ.
3.2.2 Trust December 2007 Visit
An updated action plan was sent to the Department in April (Appendix Two). Most of the actions have been completed or are on track. We have received feedback that the Department is satisfied with progress and no longer requires monthly progress reports. They will hold monthly telephone call conversations with Christine Perry to track progress.
3.3 Winter 2007/08 Norovirus Outbreak Health Community Review
Irene Scott and I attended a meeting on the 4 April to debrief on the February / March outbreak. One of aims was to clarify with collegues the position regarding ‘cohorting’ due to the negative communications that had taken place during the outbreak when we were under pressure to take the same actions as other trusts. There was acceptance that ‘cohorting’ was possible at different levels with Norovirus and that the decision had to be based on local circumstances and risk assessments. This trust had based all of its decisions on a clear and transparent risk assessment model which was shared with Bristol Primary Care Trust.
The two actions for us from the meeting were:
i. To work with neighbouring acute trusts over the summer to plan for specialist areas such as coronary care being closed.
ii. For North Bristol and our selves to lead in September on the instigation of planning for winter 2008/09, applying learning from this last experience.
3.4 Infection Control Committee
The Trust Executive Group has requested a review of the Terms of Reference of the Infection Control Committee, now that the ownership of operational issues around infection prevention and control are fully embedded in the divisions. I will work with the Chief Operating Officer in clarifying the roles of the Committee, the Divisions and the Trust Operational Group. Roles will be defined in terms of operational delivery, performance management, national targets, assurance and strategy / policy.
4 Recommendations
The Trust Board is asked to received and discuss this report, ratifying the actions being taken.
Presented by Lindsey Scott, Chief Nurse and Director of Governance
Prepared by:
Lindsey Scott Chief Nurse and Director of Governance
Christine Perry Director of Infection Control and Prevention / Assistant Director of Nursing
2nd May 2008
Appendix One
Hand Hygiene Audits to March 2008
Chart 1: % areas required to do an audit that did
Chart 2: Overall % Compliance with Hand Hygiene Policy
Chart 3: Overall % compliance by profession (excluded Diagnostic and Therapies)
Department of Health Visit 10th December 2007: ACTION PLAN
Department of Health Issue / Status / Comment at Time of Report / Residual Action / Timescales1. Immediately review the Root Cause Analysis process for every MRSA bacteraemia to identify themes and identify where to focus effort over the few remaining months (Immediate Priority). Strive to better understand what Root Cause Analyses are suggesting to be the cause by drilling down further and disseminating the learning in a more systematic way. / Jan 08
The Trust had been doing this review and looking for trends since the Root Cause Analysis process commenced earlier in 2007. However, they were all reviewed again to ensure that any key issues and themes were not missed. In addition the last 12 cases were reviewed in more detail and reported to the Trust Executive Group on the 23rd January.
From late December the clinical teams have been required to present the findings of the analysis to a Board executive and a Divisional Board representative, to identify their learning. Heads of Division give feedback to the Trust Executive Group. The Root Cause Analysis process has been strengthened accordingly.
An infection control message is the number one item in weekly newsbeat now, where possible taking the opportunity to spread learning.
11 Feb 08
Medical Director and Chief Nurse and Director of Governance agreed to weekly trust wide safety briefing for implementation prioritising Infection Control issues.
Infection Control Committee agreed to further refine the actual RCA process through application of lean thinking.
11 March 08
RCA review meeting planned for April / Ø Report any further Root Cause Analysis findings in addition to new themes to the Trust Executive Group. √ Achieved
Ø Consider the implementation of a trust wide safety briefing on a weekly basis following the Safer Patient Initiative template for daily briefings in clinical areas. √ Achieved
Ø Lean Thinking Seminar of overall RCA process – On track and planned for week commencing 28 April √ / Ø When required
Ø End Mar
Ø End April
2. Adopt a zero tolerance message that signals to the organisation this is different and as high a priority as all other national targets and standards (Immediate Priority). Step up the zero tolerance message and clearly signal this is a different approach to infections (Area for Improvement). / Jan 08
The Trust Executive Group agreed in December to adopt zero tolerance of any post-48 hour case of bacteraemia.
The Chief Executive wrote to all staff on this topic in January via the payslips.
A process for managing non-compliance with policies has been agreed, leading through to the disciplinary process.
Entrance notices emphasing this message have been established.
March 08
New Hand Hygiene notices for ward entrances agreed and procurement sorted. Process started for replacement but won’t finish due to size of trust until April. Format of new leaflet for patients agreed. / Ø Renew hand hygiene notices at clinical entrances. The format is agreed, the supplier identified and implementation began on the 1 April.
Ø Issue revised patient and visitor information leaflet. √ Achieved
Ø Develop process for Balanced Score Card and expanded key performance indicators for wards + departments. / Ø End Apr
Ø End Feb
Ø End Jun
3. Take action that will get the Trust back on to monthly run rate as a minimum (Immediate Priority). / Jan 08
By definition the immediate response to the verbal feedback which began to implement actions prior to the receipt of the final report, represented this action.
In addition 2% chlorhexidine was introduced for cleaning wipes prior to interventional devices being used and for central line insertion. / None - Achieved
4. Improve the current assurance framework on compliance with policies at divisional and clinical level (Immediate Priority). / Jan 08
The Chief Nurse and Director of Governance required infection control to be presented to monthly to all Divisional Boards.
Patient Safety Walkarounds by the Executive Directors were expanded to include senior managers and focused on infection control only from January.
Feb 08
Letters issued to all Clinical Staff w/c 21 Jan / Ø Review divisional board agendas for infection control focus monthly.
The review has been completed and results to be reported to Trust Executive Group in May
Ø Check returns from clinical staff acceptance policies. This is work in progress and is taking some time due to the scale of the data file (5,048 staff). When completed it will be reported to Trust Executive Group
Ø Report Hand Hygiene Audit results to divisional boards and Trust Board √ Achieved / Ø End Mar
Ø End Mar
Ø From Feb
5. The commitment at Board level needs to also be reflected at ward level. / Jan 08
This is being addressed via the following:
Ø Clinical Teams feeding back their Root Cause Analysis to executive directors.
Ø Safety Walkarounds,
Ø Hand Hygiene Audits. / Achieved
6. Complete and focus the review of the screening policy to ensure that it includes areas of highest concern (general medicine). / Jan 08
The Trust moved to implement screening for elective patients in April 2007, in advance of the national requirement to start this by April 2008. The review was completed in December and highlighted some gaps in compliance for practical reasons for elective patients e.g. patients who do not have pre-operative assessment. The review had also added in additional requirements in response to the issues in general medicine i.e. screening of Intravenous Drug Users and all transfers to the Bristol General Hospital. The Trust Executive Group reviewed the screening policy on 23rd January and agreed to move to immediate treatment for the Intravenous Drug Users and a plan for identifying any gaps in compliance with the plan.
Feb 08
Infection Control Committee felt approach too complex for staff and to consider quickly if we should just move to screen all patients.
March08
Costings for full move to screening nearly complete. Trust Executive Group to consider 19th March. / Ø Identify any gaps in compliance with the plan.
Ø Cost move to 100% Screening