45
DIRECTOR OF INFECTION PREVENTION AND CONTROL ANNUAL REPORT APRIL 2017 - MARCH 2018
DIRECTOR OF INFECTION PREVENTION AND
CONTROL
ANNUAL REPORT APRIL 2017 - MARCH 2018
Page 2 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
Director of Infection Prevention and Control Annual Report
1.Executive summary – Overview of Infection Control activities in the Trust 3
Key achievements 4
On-going work 4
2. Description of Infection Control arrangements
Infection Control Team 5
Infection Control Team Activities 6
Infection Control Enquiries 7
Hospital Infection Control Committee 9
Organisational structure and reporting line to the Trust Board 10
3. DIPC reports to the Trust Board – summary
Number and Frequency 11
Outbreak Reports 11
Estates and Planning 12
Water Safety Management 12
4. Budget Allocation to IC Activities
Staff 14
Training for IP&C staff 15
Training requirements for the Team in the coming year 15
5. HCAI statistics
MRSA bacteraemia 15
Clostridium difficile 16
MSSA bacteraemia 18
CRO 18
E Coli bacteraemia 19
Surveillance 21
Surgical Site Infection Surveillance 21
6. Hand hygiene
Hand Hygiene 22
7. Cleaning Services
Management arrangements 22
Monitoring arrangements 23
PLACE 23
Environment - NPSA 24
8. Decontamination 28
9. Audit
Audit programme and outcomes 35
10. Targets and outcomes
Policies update 2017/18 38
11. Antibiotic Team Report 39
12. Training Activities
Induction for all staff 40
E-Learning 40
Link Nurses 40
General
13. IC Programme for 2017/18
Page 3 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
1. EXECUTIVE SUMMARY
Overview of Infection Control activities in the Trust The year has been challenging for Colchester Hospital University Foundation NHS Trust however there have also been a number of key opportunities and improvements. The year started with the Trust in Special Measures; however, following a CQC visit in July 2017, which included a close examination of the Trust’s Infection Prevention and Control measures, the Trust was taken out of Special Measures. The main focus of infection prevention and control activity was to continue the good work already established in maintaining the low levels of Clostridium difficile and MRSA colonisation acquired within the hospitals of the Trust in the face of workforce challenges throughout the hospital and within the Infection Prevention and Control team. We continued to use the Saving Lives High Impact Interventions and Hand Hygiene rates to monitor good infection prevention practice. These results were reported monthly to the board through a board sub-committee. The results are also discussed at local divisional governance groups and the Hospital Infection Control Committee. The Antibiotic Management Team continued to review antibiotic guidelines and audit their use. For European Antibiotic Awareness Day (18 November) the team ran a travelling educational stall through the main hospital site visiting most of the wards. The team were successful in achieving part of the antimicrobial prescribing CQUIN’s offered to Trusts in this financial year (100% of antimicrobial prescriptions reviewed at 72 hours). The guidance around the reporting and performance management of Clostridium difficile cases changed for this year. The total number of cases continued to be reported and only those in which there were breaches in policy were subject to performance management terms. Our objective for the latter group was 18 cases. As in previous years all cases were followed up with an internal investigation and discussion at the North Essex HCAI (Heath Care Associated Infection) Scrutiny Panel. Part of this process included a judgement as to whether any of the cases could have been managed better and thus possibly prevented; “were there breaches of policy or not?” There were 18 cases of hospital attributed Clostridium difficile disease; only one of these cases was associated with a breach in key policy, the other 17 cases received care with no breaches in policy. There were two cases of MRSA bacteraemia attributable to the hospital during the year; against a target of zero. Both were discussed with commissioning colleagues at a Post Infection Review. In one case there were minor suggestions as to how better care could have been provided but there were no breaches of major policy. The other was considered to be a consequence of contamination of blood cultures taken on admission to hospital. The Trust participated in the 5th Health Care Associated Infection Point Prevalence Study, a national study co-ordinated by the Department of Health and Hospital Infection Society. Preliminary results show that overall 7% of patients in hospital in the UK had a healthcare associated infection. For Trust patients, this figure was 4.85%. The Infection Prevention and Control Team (IP&CT) held another successful annual conference for local healthcare staff (doctors, nurses, healthcare scientists) with 68 delegates attending.
Page 4 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
KEY ACHIEVEMENTS
Performance – generally low levels of C difficile - 1 case deemed as avoidable against a trajectory of 18
‘Governance’ – evidence that Saving Lives and Hand Hygiene data is discussed and acted upon at divisional and departmental level.
Infection Prevention and Control policies and guidelines - Updated CRO policy all other standard IP&C policies current
Integrated computerised surveillance system – system continues to generate timely clinical reports
Mandatory IP&C updates for all staff – the uptake continues to increase year on year 94% as at March 2018
ON-GOING WORK
To continue the trend of minimal number of patients with MRSA and Clostridium difficile.
To introduce improved management of peripheral IV devices
To reduce the number of urinary catheterisations in the Trust
To continue to participate in the development of the catheter passport
To collect and continue to report data on bacteraemia caused by a sensitive “ordinary” Staph aureus (MSSA) and Escherichia coli to
PHE Klebsiella spp. and Pseudomonas aeruginosa to the HCAI Data Capture System (DCS) since April 2017. This is to support the government initiative to reduce Gram-negative bloodstream infections by 50% by financial year 2020/21
Governance – to continue to embed IP&C throughout the organisation working closely with Clinical Leads
Mandatory bi-annual updates for all Trust Staff
Dr Tony Elston
Director of Infection Prevention and Control /Consultant Microbiologist & Infection Control Doctor
Page 5 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
2. DESCRIPTION OF INFECTION CONTROL TEAM ARRANGEMENTS Dr Tony Elston Consultant Microbiologist/Director of Infection Prevention & Control
☎ 01206 747316
Dr Sima Jalili Consultant Microbiologist
☎ 01206 747313
Heather Dakin Head of Infection Prevention Control
☎ 01206 742706
Vicky Bywater Senior Infection Prevention and Control Nurse
☎ 01206 744265
Diosalyn Bote Infection Prevention and Control Audit/Surveillance Nurse
☎ 01206 742704
Jenny Lockerbie Infection Prevention and Control Nurse
☎ 01206 7424267
Gillian O’Sullivan Infection Prevention and Control Officer
☎ 01206 7424267
Ralph Nation Data Manager
☎ 01206 742708
Tracy Fairman Antimicrobial Team Secretary
☎ 01206 744268
Angela Heard Infection Prevention and Control Team Secretary
☎ 01206 744268
Page 6 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
INFECTION CONTROL TEAM ACTIVITIES Members of the team are involved in the following committees/meetings: Infection Control Team Meeting Hospital Infection Control Committee Medicine Management Committee Matron and Ward Sisters Meetings Risk Management Committee Senior Management Advisory Group Service review meetings for facilities management Trust Clinical Governance Committee PLACE inspection team/annual and monthly PLACE Operational Steering Group Meeting Quality and Patient Safety Committee Capital Planning Update Monthly Meeting The Director of Infection Prevention and Control attends and reports to the following; Trust Hospital Infection Control Committee, Quality and Patient Safety Assurance Committee, Turs Board (via Executive Lead) There is an active North East Essex HCAI Operational Group. The group includes representatives from ACE, SEPT, PROVIDE, CHUFT, PHE - Essex and Essex County Council Social Services. The remit is to review progress in HCAI prevention in each of the organisations and to monitor progress against a joint action plan. This will change in line with the reorganisation of the STP and the CCG realignment.
ENQUIRIES - COMPARISON BY ENQUIRY TYPE AND YEAR The number of enquiries to the IP&C team captured continues to increase year on year, (1240) some of these enquiries may be dealt with quickly whilst others can lead to a major piece of project work. The three main themes remain consistent MRSA, diarrhea and vomiting (D&V) and infectious diseases. The C. difficile enquiries were separated out from the diarrhea and vomiting category as there appears to be a significant increase in enquiries relating to this topic. This may well be related to the increased teaching relating to this subject as the Trust overall has seen a reduction in cases in 2017/18. However, testing in terms of C. difficile carriage without disease has increased as has awareness of C. difficile disease in the Trust. What must be remembered is that the data does not capture all of the enquiries and work generated within the Team; however, it does assist in focusing where and what is required to plan for teaching and support for the year ahead.
Page 8 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
Hospital Infection Control Committee Out of meetings held, attendance is given as follows:
NAME TITLE
MEETING DATES
09
.05
.17
11
.07
.17
12
.09
.17
14
.11
.17
18
.01
.18
Elston, Dr Tony Consultant Microbiologist (DIPC) Meeting Chairman
Cancelled Cancelled
Bazzali, Jane Public Health England Infection Control Nurse (PHE)
Cancelled Cancelled Apologies
Boyle, Sheila Head of Health and Wellbeing Cancelled Cancelled x
Cook, Terry Estates Project Manager Apologies Cancelled Cancelled x
Dakin, Heather Senior Infection Control Nurse Cancelled Cancelled
Holman, Chris Antimicrobial Pharmacist Apologies Cancelled Cancelled Apologies
Howlett, Chris Director of Estates and Facilities Apologies Apologies Cancelled Cancelled Apologies
Jackson, Shaun Estates Operational Manager Apologies Cancelled Cancelled
Jalili, Sima Consultant Microbiologist Cancelled Cancelled
Morgan, Catherine Director of Nursing Cancelled Cancelled
Tracey Oats Head of Nursing and Clinical Services Women, Children an d Clinical Support
Apologies Apologies Cancelled Cancelled Apologies
Notley, Lou ADoN Medicine Apologies Apologies Cancelled Cancelled x
Sparrow, Fiona Head of Facilities Apologies Cancelled Cancelled
Swanson, John Infection Prevention and Control Nurse Specialist , CCG
Apologies Cancelled Cancelled x
Thorpe, David ADoN Surgery and Cancer Services
Cancelled Cancelled
Tonkin, Jo ADoN Medicine and Urgent Care Cancelled Cancelled
Walker, Howard Decontamination Lead x Apologies Cancelled Cancelled Apologies
Wheatcroft, Barry Patient Governor x Cancelled Cancelled
Heard, Angela Team Secretary, Infection Prevention and Control Minute Taker
Cancelled Cancelled
√ indicates attendance. X non attendance and no apologies received It has proved a challenge particularly during periods of high clinical activity i.e. the autumn and winter months to gain appropriate attendance at HICC meetings.
Page 10 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
Organisational structure and reporting line to the Trust Board
Page 11 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
3. DIPC REPORTS TO THE TRUST BOARD – SUMMARY The DIPC reported monthly to the Quality and Patient Safety Assurance Committee, which itself reports monthly to the board
3.1 Outbreaks
Date Ward Number of bays, ward closed
Number of days ward affected
Cases confirmed by PCR
28/06/2017-03/07/2017
Birch Two bays one bay closed 5 days, one bay closed 3 days
Yes
08/07/2017-22/07/2017
Acute Cardiac Unit
Initially one bay, progressing to ward
closure
15 days Yes
09/07/2017 -17/07/2017
Langham Initially one bay, progressing to ward
closure
Ward closed 3 days, one bay closed 7 days, one bay closed 6 days
Yes
13/11/2017-14/11/2017
Brightlingsea One bay 2 days No
18/12/2017-28/12/2017
D'arcy Initially one bay, progressing to ward
closure
11 days Yes
22/12/2017-27/12/2017
Peldon Initially one bay progressing to ward
closure
6 days Yes
03/03/2018-06/03/2018
Birch One bay 4 days Yes
Influenza
Date Ward Number of bays, ward closed
Number of days ward affected
28/03/2018-04/04/2018
West Bergholt One bay 8 days
Actions taken
Wards visited daily by Infection Prevention and Control Nurse and daily management plan agreed with local team and Trust site team
Decision to close bay or Ward agreed by Infection Prevention and Control team
Increased and enhanced environmental and equipment cleaning was put into place
Cohort nursing/care managed as required
3.2 Carbapenem-resistant Organisms (CRO) increased incidence in a Surgical Ward
Multi-drug resistant Acinetobacter Baumannii
Date Ward Number of bays, ward closed
Number of days ward affected
09/08/2017-18/08/2017
Layer Marney Ward decanted. Fewer beds on decant Ward (28
10 days
Page 12 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
beds compared to 33 beds on Layer Marney)
There was an index case which was not identified as a risk for CRO upon admission having had treatment in a London Hospital. This led to the patient not being isolated and two subsequent patients whom were in the same bay being identified with the same organism. Whilst this has not led to infections in these patients there was a potential for this to happen. Actions taken
Ward was decanted and a deep clean performed
Trust admission document to highlight the need for appropriate questioning at the time of admission
Trust CRO policy updated in line with learning
Appropriate patient contacts were screened in compliance with national guidance.
Increased education – including but not exclusive to mandatory IP&C E–learning training updated and CRO information included; screensavers
All IP&C training sessions include CRO updates including E-learning 3.3 Estates and Planning The IP&C team have continued to support and provide advice relating building projects, and schemes to develop or create facilities and services, including two full ward refurbishments during the year.
The movement of services to the PCC building from Essex County
Gainsborough Clinics
A&E reconfiguration
Turner Diagnostic centre
New Elmstead Endoscopy decontamination unit The on-going collaborative work with the Estates and Facilities Division continues to improve monitoring and reporting on cleaning standards and maintenance and monitoring of the estate. 3.4 Water Safety Report 2017-2018
Overview The primary water safety risks affecting hospital sites with respect to Infection Control are colonisation of water supply pipework by Legionella and Pseudomonas bacteria. The Trust has a comprehensive management system in place to minimise these risks and to allow action to be taken when these bacteria are detected. This is delivered by the Water Safety Group (WSG) which meets quarterly and includes representation from Estates, Facilities and Infection Control. The WSG maintains the Trust’s Water Policy and implements the Water Safety Plan. The Trust’s Authorising Engineer (Water) attends and provides technical guidance as well as auditing the Group’s activities. A separate Operational Water Group meets every month and reports into the Water Safety Group.
Page 13 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
Control Measures
Temperature The primary control measure used against L. and P. is water temperature. Hot water at CHUFT sites is stored and distributed at a sufficiently high temperature to kill the bacteria while cold water is distributed at a suitably cold temperature to prevent significant multiplication. The Trust’s contractor Clearwater carries out a regime of temperature monitoring to ensure the correct temperatures are being maintained. Where temperatures are detected outside of the required limits (e.g. caused by a fault with a hot water cylinder), Estates jobs are raised to correct the issues and tracked via the concept job management system. Figures showing temperatures monitored per month and exceptions picked up are shown below:
Comment
The figures highlight an issue where the number of outlets being monitored per month
declined during Q2-Q3. This was addressed with the contractor in Feb and the extent of
monitoring has now increased
The recent increase in monitoring has turned the spotlight on a number of areas with out-
of-limit temperatures, which have now been addressed
Other control measures Other control measures include:
Flushing of little-used outlets to prevent stagnation. This is carried out twice-weekly
by Estates maintenance staff.
Annual inspection of cold water tanks. Cleaning and disinfection is then carried out
where required.
Annual cleaning of domestic hot water calorifiers
Shower head replacement. Shower heads and hoses are replaced every 3 months.
The colour is changed every quarter to allow easy visual checking
Page 14 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
Risk Assessments Water Risk Assessments have been carried out for all areas. The Trust has a programme for implementing remedial actions (e.g. removal of pipework dead-legs) to be carried out in 2018-2019.
Bacteriological Sampling Periodic sampling is carried out for Legionella and Pseudomonas in areas with high-risk / augmented care patients. The control measures outlined above should not allow L. and P. to proliferate in the system, but sampling provides assurance that the control measures are working.
No positive L. samples were detected in 2017-2018. 1 positive P. sample (low count) was detected in November, this was resampled in subsequent months and not detected again.
Comment
Very few incidences L. and P. were detected. This reflects effective controls in the areas
that were sampled.
However; since the most recent samples were taken, the list of sampling points has been
reviewed and extended. This is expected to reveal positive results which can then be
addressed
4. BUDGET ALLOCATION TO INFECTION CONTROL ACTIVITIES 4.1 Annual Budget There was an under-spend at year end of £47,000. The under-spend was primarily due to one long term staff sickness episode and vacancy factor. However, there was an opportunity to look at skill mix and create an Infection Control Practitioner position at a band 3 this post was recruited into. Staff
Month 1 Month 12
Budgeted Actual Budgeted Actual
Consultant
Infection Control Doctor
0.40 0.40 0.40 0.40
Nursing Band
8b 1.00 1.00 1.00 1.00
7 1.00 1.00 1.00 1.00
6 2.84 2.84 2.00 2.00
A&C Band
3 1.17 1.17 1.17 1.17
5 1.00 1.00 1.00 1.00
3 0.00 0,00 1.00 1.00
Page 15 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
* staffing allocation shown as whole time equivalents (wte)
4.2 Project monies were spent as below: Antimicrobial App Micro-guide Trial of IP&C friendly pillows in Oncology 4.3 Training and development opportunities for IP&C team 2017/18 Public Health England Surgical Site Infection Surveillance training programme – Colindale 4.4 Training requirements for the Team in the coming year 2018/2019 Education bids have been put forward to for 2 modules in MSc Biomedical Sciences – via Greenwich University – Distance learning in Healthcare Associated Infection and Antimicrobial Stewardship modules to support specialist knowledge for the training of the Infection Control Nurses within the team. The aim of this training is to support succession planning in the delivery of the service across the evolving organisation. Infection prevention and control specialists are difficult to find and it is important that the Trust develops its own team to high standards, this will support recruitment to the team and the Trust in the future.
5. HCAI STATISTICS
5.1 MRSA bacteraemia
MRSA bacteraemia cases apportioned to CHUFT 2017/18 and the learning from these cases
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Page 16 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
There were two cases of MRSA bacteraemia in 2017/18 apportioned to the Trust, both cases were identified in samples taken in December 2017.
There had been a period of 16 months without a case of MRSA bacteraemia
5.2 Clostridium difficile Clostridium difficile infection (CDI) remains an unpleasant, and potentially severe or fatal infection which occurs mainly in the elderly or other vulnerable groups especially those who have been exposed to antibiotic treatments. The Trust has made great strides in reducing the number of people affected by CDI, however, each case identified in the Trust is subject to post infection review. If all care and treatment is managed within nationally and locally recognised policy, the Clinical Commissioning Group (CCG) scrutiny panel may agree that it is deemed as ‘non trajectory’. (2015/16 onwards) 17 of the 18 C. difficile cases for Colchester have been agreed as non- trajectory 2017/18 following panel review and sign off by CCG.
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Cumulative C.diff Decisions
Cumul avoidable Cumul awaiting Cumul no lapses in care Ceiling
Month Apr May Jun July Aug Sept Oct Nov Dec Jan Feb Mar
Ceiling 2 3 5 7 8 9 11 12 14 16 17 18
Total C.diff cases 0 3 6 7 8 10 10 11 15 18 18 18
C.diff Cases In month 0 3 3 1 1 2 0 1 4 3 0 0
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Cumul avoidable 1 1 1 1 1 1 1 1 1 1 1 1
C.difficile
Page 17 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
Year Number of cases of Clostridium difficile apportioned to Colchester Hospital
Target No more than
2014/15 32 cases 20 cases
2015/16 24 cases – 14 non - trajectory 18 cases
2016/17 35 cases - 26 non-trajectory 18 cases
2017/18 18 cases – 17 non-trajectory 18 cases
Patients identified as carriers are monitored closely and managed in much the same
way as patients with CDI in terms of monitoring.
Work continues through scrutiny panel reviews with Clinical Commissioning Group to
identify areas which may impact on further reduction of cases. Including looking at
antimicrobial prescribing in the local health care economy.
Continue to investigate and invest in new cleaning technologies supporting best
practice and efficiency including the use of hydrogen peroxide vapour (HPV) fogging,
micro-fibre for example, Micro-fibre and UV technologies.
The importance of keeping the bio-burden of C difficile and other organisms in the
clinical environment remains high on the IP&C agenda
.
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SAN
DW
ELL
AN
D W
EST
BIR
MIN
GH
AM
…
JAM
ES
PA
GE
T U
NIV
ER
SIT
Y…
KET
TER
ING
GE
NE
RA
L H
OSP
ITA
L N
HS
…
SOU
TH W
AR
WIC
KS
HIR
E N
HS…
NO
RFO
LK A
ND
NO
RW
ICH
…
TH
E R
OY
AL
WO
LVE
RH
AM
PT
ON
NH
S…
UN
IVE
RSI
TY
HO
SPI
TALS
CO
VE
NT
RY
…
TH
E P
RIN
CES
S A
LEX
AN
DR
A H
OSP
ITA
L…
CO
LCH
ESTE
R H
OSP
ITA
L U
NIV
ER
SITY
…
NO
RTH
AM
PTO
N G
ENER
AL
HO
SPIT
AL…
BE
DFO
RD
HO
SPIT
AL
NH
S TR
UST
MIL
TO
N K
EYN
ES U
NIV
ERSI
TY…
CH
EST
ERFI
ELD
RO
YA
L H
OSP
ITA
L N
HS…
PA
PWO
RT
H H
OSP
ITA
L N
HS
…
GE
OR
GE
ELI
OT
HO
SPIT
AL
NH
S T
RU
ST
WA
LSA
LL H
EALT
HC
AR
E N
HS
TRU
ST
LUT
ON
AN
D D
UN
STA
BLE
UN
IVER
SIT
Y…
TH
E R
OY
AL
OR
TH
OP
AED
IC H
OSP
ITA
L…
BIR
MIN
GH
AM
WO
ME
N'S
AN
D…
TH
E R
OB
ERT
JO
NES
AN
D A
GN
ES…
C.diff yearly average 17/18 KH03 overnight occupied beds per 100.000, EOE Hospitals, Trust apportioned
Page 18 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
Meticillin Sensitive Staphylococcous aureus Bacteraemia 5.3 Staphylococcus aureus
Staphylococcus aureus (S. aureus) is a bacterium that commonly colonises human skin and mucosa without causing any problems. It can also cause disease, particularly if there is an opportunity for the bacteria to enter the body, for example through broken skin or a medical procedure. Most strains of S. aureus are sensitive to the more commonly used antibiotics, and infections can be effectively treated. Some S. aureus bacteria are more resistant. Those resistant to the antibiotic meticillin are termed meticillin resistant Staphylococcus aureus (MRSA) and often require different types of antibiotic to treat them. Those that are sensitive to meticillin are termed meticillin susceptible Staphylococcus aureus (MSSA). MRSA and MSSA only differ in their degree of antibiotic resistance: other than that there is no real difference between them. (PHE 2017) Nationally there has been a year on year increase in the number of cases of MSSA bacteraemia. Whilst there is no nationally agreed target reduction, there is an aim to look more closely at all cases locally. 5.4 Carbapenemase Resistant Organisms (CRO’s)
Carbapenemase-producing Enterobacteriaceae (sometimes abbreviated to CPE) are a type of bacteria which has become resistant to carbapenems, a group of powerful antibiotics. This resistance is helped by enzymes called carbapenemases, which are made by some strains of the bacteria and allows them to destroy carbapenem antibiotics. This means the bacteria can cause infections that are resistant to carbapenem antibiotics and many other antibiotics. Carbapenem antibiotics successfully treat certain complicated infections when other antibiotics have failed. The spread of these resistant bacteria can cause problems to
0
2
4
6
8
10
12
14
16
18
20
NO
TTI
NG
HA
M U
NIV
ER
SITY
…
PA
PWO
RT
H H
OSP
ITA
L N
HS
…
MIL
TO
N K
EYN
ES U
NIV
ERSI
TY…
UN
IVE
RSI
TY
HO
SPI
TALS
…
BIR
MIN
GH
AM
WO
ME
N'S
AN
D…
JAM
ES
PA
GE
T U
NIV
ER
SIT
Y…
UN
IVE
RSI
TY
HO
SPI
TALS
OF…
WYE
VA
LLE
Y N
HS
TR
UST
TH
E Q
UEE
N E
LIZA
BE
TH…
SHR
EWSB
UR
Y A
ND
TEL
FOR
D…
EA
ST A
ND
NO
RT
H…
MID
ES
SEX
HO
SPIT
AL
SER
VIC
ES…
HE
AR
T O
F E
NG
LAN
D N
HS…
IPSW
ICH
HO
SPIT
AL
NH
S T
RU
ST
UN
IVE
RSI
TY
HO
SPI
TALS
…
UN
IVE
RSI
TY
HO
SPI
TALS
OF…
CA
MB
RID
GE
UN
IVE
RSI
TY…
BA
SILD
ON
AN
D T
HU
RR
OC
K…
DE
RB
Y T
EA
CH
ING
HO
SPI
TALS
…
WES
T H
ER
TFO
RD
SHIR
E…
CO
LCH
ESTE
R H
OSP
ITA
L…
WES
T SU
FFO
LK N
HS…
SOU
TH W
AR
WIC
KS
HIR
E N
HS…
WO
RC
EST
ER
SHIR
E A
CU
TE…
CH
EST
ERFI
ELD
RO
YA
L H
OSP
ITA
L…
SHE
RW
OO
D F
OR
EST
HO
SPI
TALS
…
KET
TER
ING
GE
NE
RA
L H
OSP
ITA
L…
SOU
THE
ND
UN
IVER
SIT
Y…
NO
RTH
WE
ST A
NG
LIA
NH
S…
TH
E D
UD
LEY
GR
OU
P N
HS…
BU
RT
ON
HO
SPIT
ALS
NH
S…
SAN
DW
ELL
AN
D W
EST
…
NO
RFO
LK A
ND
NO
RW
ICH
…
TH
E R
OY
AL
WO
LVE
RH
AM
PT
ON
…
LUT
ON
AN
D D
UN
STA
BLE
…
WA
LSA
LL H
EALT
HC
AR
E N
HS
TRU
ST
GE
OR
GE
ELI
OT
HO
SPIT
AL
NH
S…
UN
ITE
D L
INC
OLN
SH
IRE…
BE
DFO
RD
HO
SPIT
AL
NH
S TR
UST
TH
E P
RIN
CES
S A
LEX
AN
DR
A…
NO
RTH
AM
PTO
N G
ENER
AL…
TH
E R
OB
ERT
JO
NES
AN
D A
GN
ES…
TH
E R
OY
AL
OR
TH
OP
AED
IC…
MSSA 17/18 yearly average KH03 overnight occupied beds per 100,000, EOE Hospitals, Hospital apportioned
Page 19 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
vulnerable patients in hospitals or other settings because there are so few antibiotics available to treat the infections they cause. In line with national guidance from PHE Carbapenemase Resistant Organism toolkit, this helped to manage the CRO outbreak as described in section 3.3 of this report. It also helped to inform and update local policies to incorporate all mechanisms by which Carbapenemase resistance is shared between organisms. 5.5 Escherichia coli (E coli) blood stream infections
11
20
2624
34
2826
20
1417
22 22
5
5
12
4
2
7
2
2
24
0
5
10
15
20
25
30
35
40
E.coli Cases comparison 17/18 Hospital and Community
Hospital cases of E.coli
Community Cases of E.coli
0
5
10
15
20
25
30
35
40
NO
TTI
NG
HA
M U
NIV
ER
SITY
…
CA
MB
RID
GE
UN
IVE
RSI
TY…
UN
IVE
RSI
TY
HO
SPI
TALS
…
KET
TER
ING
GE
NE
RA
L H
OSP
ITA
L…
UN
IVE
RSI
TY
HO
SPI
TALS
…
DE
RB
Y T
EA
CH
ING
HO
SPI
TALS
…
WO
RC
EST
ER
SHIR
E A
CU
TE…
TH
E Q
UEE
N E
LIZA
BE
TH…
BIR
MIN
GH
AM
WO
ME
N'S
AN
D…
JAM
ES
PA
GE
T U
NIV
ER
SIT
Y…
UN
IVE
RSI
TY
HO
SPI
TALS
OF…
HE
AR
T O
F E
NG
LAN
D N
HS…
BA
SILD
ON
AN
D T
HU
RR
OC
K…
SHE
RW
OO
D F
OR
EST
HO
SPI
TALS
…
CH
EST
ERFI
ELD
RO
YA
L H
OSP
ITA
L…
TH
E R
OY
AL
WO
LVE
RH
AM
PT
ON
…
NO
RTH
WE
ST A
NG
LIA
NH
S…
MIL
TO
N K
EYN
ES U
NIV
ERSI
TY…
WES
T H
ER
TFO
RD
SHIR
E…
UN
IVE
RSI
TY
HO
SPI
TALS
OF…
WA
LSA
LL H
EALT
HC
AR
E N
HS…
CO
LCH
ESTE
R H
OSP
ITA
L…
EA
ST A
ND
NO
RT
H…
SOU
THE
ND
UN
IVER
SIT
Y…
GE
OR
GE
ELI
OT
HO
SPIT
AL
NH
S…
SOU
TH W
AR
WIC
KS
HIR
E N
HS…
MID
ES
SEX
HO
SPIT
AL
SER
VIC
ES…
NO
RTH
AM
PTO
N G
ENER
AL…
NO
RFO
LK A
ND
NO
RW
ICH
…
WES
T SU
FFO
LK N
HS…
SHR
EWSB
UR
Y A
ND
TEL
FOR
D…
TH
E D
UD
LEY
GR
OU
P N
HS…
IPSW
ICH
HO
SPIT
AL
NH
S T
RU
ST
TH
E P
RIN
CES
S A
LEX
AN
DR
A…
BE
DFO
RD
HO
SPIT
AL
NH
S TR
UST
PA
PWO
RT
H H
OSP
ITA
L N
HS
…
SAN
DW
ELL
AN
D W
EST
…
LUT
ON
AN
D D
UN
STA
BLE
…
TH
E R
OB
ERT
JO
NES
AN
D A
GN
ES…
BU
RT
ON
HO
SPIT
ALS
NH
S…
UN
ITE
D L
INC
OLN
SH
IRE…
WYE
VA
LLE
Y N
HS
TR
UST
TH
E R
OY
AL
OR
TH
OP
AED
IC…
E.Coli yearly average 17/18 overnight occupied beds per 100,000 EOE Hospitals, Trust apportioned
Page 20 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
In November 2016, the Secretary of State for Health, Jeremy Hunt, announced Government plans to halve the number of gram-negative bloodstream infections by 2020. E coli infections represent 65% of these gram-negative infections. As approximately three-quarters of E. coli BSIs occur before people are admitted to hospital, reduction requires a whole health economy approach. E coli bacteraemia total cases for North East Essex CCG
2017/18 Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Total
Hospital 5 5 1 2 4 0 2 5 2 2 2 4 34
Community 11 20 26 24 34 28 26 22 14 17 22 22 266 NB: where an infection develops after 48 hours in hospital the case according to national guidelines is considered to be apportioned to the hospital in which the patient is an inpatient. If the infection develops prior to or within the first 48 hours of admission the case is apportioned to the Community.
Locally, it is recognised that the majority of E coli bacteraemia occur in the elderly population in the community setting who then present to our hospital. This is supported at a national level identifying 65 – 80% of cases; last year it was measured that 88% of the cases occurred in the community setting for CGH. In the past year North East, Mid and West Essex IP&C teams worked together with colleagues in the Clinical Commissioning Group and Essex County Council in order to deliver train the trainer sessions for Nursing and Residential Homes in order to increase awareness in relation to urinary catheter management, hygiene and hydration. It was hoped that this important education would support a reduction in the incidence of E coli bacteraemia in the local population.
0
5
10
15
20
25
30
35
40
NO
TTI
NG
HA
M U
NIV
ER
SITY
HO
SPIT
ALS
…
CA
MB
RID
GE
UN
IVE
RSI
TY H
OSP
ITA
LS N
HS…
UN
IVE
RSI
TY
HO
SPI
TALS
BIR
MIN
GH
AM
…
KET
TER
ING
GE
NE
RA
L H
OSP
ITA
L N
HS
…
UN
IVE
RSI
TY
HO
SPI
TALS
CO
VE
NT
RY
AN
D…
DE
RB
Y T
EA
CH
ING
HO
SPI
TALS
NH
S…
WO
RC
EST
ER
SHIR
E A
CU
TE H
OSP
ITA
LS…
TH
E Q
UEE
N E
LIZA
BE
TH H
OSP
ITA
L, K
ING
'S…
BIR
MIN
GH
AM
WO
ME
N'S
AN
D…
JAM
ES
PA
GE
T U
NIV
ER
SIT
Y H
OSP
ITA
LS…
UN
IVE
RSI
TY
HO
SPI
TALS
OF
NO
RT
H…
HE
AR
T O
F E
NG
LAN
D N
HS
FOU
ND
AT
ION
…
BA
SILD
ON
AN
D T
HU
RR
OC
K U
NIV
ER
SIT
Y…
SHE
RW
OO
D F
OR
EST
HO
SPI
TALS
NH
S…
CH
EST
ERFI
ELD
RO
YA
L H
OSP
ITA
L N
HS…
TH
E R
OY
AL
WO
LVE
RH
AM
PT
ON
NH
S T
RU
ST
NO
RTH
WE
ST A
NG
LIA
NH
S FO
UN
DA
TIO
N…
MIL
TO
N K
EYN
ES U
NIV
ERSI
TY H
OSP
ITA
L…
WES
T H
ER
TFO
RD
SHIR
E H
OSP
ITA
LS N
HS…
UN
IVE
RSI
TY
HO
SPI
TALS
OF
LEIC
EST
ER…
WA
LSA
LL H
EALT
HC
AR
E N
HS
TRU
ST
CO
LCH
ESTE
R H
OSP
ITA
L U
NIV
ER
SITY
NH
S…
EA
ST A
ND
NO
RT
H H
ER
TFO
RD
SHIR
E N
HS…
SOU
THE
ND
UN
IVER
SIT
Y H
OSP
ITA
L N
HS…
GE
OR
GE
ELI
OT
HO
SPIT
AL
NH
S T
RU
ST
SOU
TH W
AR
WIC
KS
HIR
E N
HS…
MID
ES
SEX
HO
SPIT
AL
SER
VIC
ES
NH
S T
RU
ST
NO
RTH
AM
PTO
N G
ENER
AL
HO
SPIT
AL
NH
S…
NO
RFO
LK A
ND
NO
RW
ICH
UN
IVE
RSI
TY…
WES
T SU
FFO
LK N
HS
FO
UN
DA
TIO
N T
RU
ST
SHR
EWSB
UR
Y A
ND
TEL
FOR
D H
OS
PITA
L…
TH
E D
UD
LEY
GR
OU
P N
HS
FOU
ND
ATI
ON
…
IPSW
ICH
HO
SPIT
AL
NH
S T
RU
ST
TH
E P
RIN
CES
S A
LEX
AN
DR
A H
OSP
ITA
L…
BE
DFO
RD
HO
SPIT
AL
NH
S TR
UST
PA
PWO
RT
H H
OSP
ITA
L N
HS
FO
UN
DA
TIO
N…
SAN
DW
ELL
AN
D W
EST
BIR
MIN
GH
AM
…
LUT
ON
AN
D D
UN
STA
BLE
UN
IVER
SIT
Y…
TH
E R
OB
ERT
JO
NES
AN
D A
GN
ES H
UN
T…
BU
RT
ON
HO
SPIT
ALS
NH
S F
OU
ND
ATI
ON
…
UN
ITE
D L
INC
OLN
SH
IRE
HO
SPIT
ALS
NH
S…
WYE
VA
LLE
Y N
HS
TR
UST
TH
E R
OY
AL
OR
TH
OP
AED
IC H
OSP
ITA
L N
HS…
Yearly rate
EOE average
Page 21 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
Surveillance 5.7 ICNet Surveillance System ICNet surveillance system was introduced to the Trust in 2007 and provides the Infection Prevention and control team and the Trust with tools to support the effective monitoring and management of HCAI’s. The system will require an upgrade in the next 12 months as the system will not be able to continue to be supported in its current version. The system provides 3 times a day imports of relevant microbiological results to all for the timely review of patients and appropriate interventions to be managed. The system is also starting to show value in supporting data production for antimicrobial resistance and stewardship reporting for CQUIN. The system supports the data required for reporting to relevant internal and external agencies. The continued investment in ICNet with the Link with Patient administration System –Portal going forward in the Transforming Pathology Partnership must not be lost and the value of this system for reporting and case management cannot be underestimated. The system is also in use in Ipswich Hospital which will be supportive as both organisations merge into one organisation going forward. 5.8 Surgical Site Infection Surveillance Surgical Site Infection Surveillance (SSIs)
2017 Large
Bowel Small Bowel
Vascular Abdominal Hysterectomy
Total Hip Knee Replacement
Repair of Neck of Femur
Jan-March 2017
N/A 1/22 4.54%
2/106 1.9%
N/A 1/144 0.69%
0/136 0%
2/120 1.7%
Apr-June 2017
N/A N/A 0/93 0%
N/A 0/97 0%
0/116 0%
1/144 0.7%
July-Sep 2017
N/A N/A 2/86 2.3%
N/A 0/101 0%
0/88 0%
2/133 1.5%
Oct-Dec 2017
N/A N/A 4/76 5.4%
0/28 0%
0/149 0%
0/131 0%
1/153 1.1%
National average
11.6% 8.0% 4.3% 4.4% 1.0% 1.3% 1.3%
NB: The national programme for surgical site surveillance suggests that at least 50 cases need to be surveyed in a three-month period in order to obtain good quality figures which are statistically significant.
NB: all participating hospitals % per period in brackets in bold.
It is a mandatory requirement by PHE for each Trust to complete surveillance in one module of orthopedic surgery for one quarter per financial year. This provides national data that can be used as a benchmark allowing individual hospitals to compare their rates of SSI with collective data from all hospitals participating in the service. The Trust has always been keen
Page 22 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
to be able to benchmark in more areas of surgery and plans to continue this in the coming year. The table above summarizes the data collected for SSI’s by the Trust for the year 2017. The infection rates in orthopedic surgery, small bowel surgery and abdominal hysterectomy has been consistently below the national average. Vascular surgery on the other hand, has a 5.4% infection rate in Oct-Dec 2017 quarter against the national average of 4.3%. The number of procedures and risk factors involved are considered. The data is communicated to the surgical teams involved and is discussed in surgical governance meetings. 6. HAND HYGIENE Hand hygiene compliance observations continue to be reported monthly from each clinical area averaging a score 95%+ each month overall. Where there are areas of reduced compliance education and increased awareness sessions are put in place.
Periodic PEER review audits are undertaken to continue to promote awareness. 7. CLEANING SERVICES 7.1 Management Arrangements
The Housekeeping service is an In-house service which is managed by the Facilities Department along with other non-clinical support services. It falls directly within the remit of the Patient Environment Manager who manages it on a day to day basis through the Hotel Services Management and Supervisory Team in order that there is ‘around the clock’ supervisory cover for the cleaning staff on duty. These arrangements enable cleaning requests to be carried out with the minimum of delay.
94.50%
95.00%
95.50%
96.00%
96.50%
97.00%
97.50%
98.00%
98.50%
99.00%
99.50%
Ap
ril
May
Jun
e
July
Au
gust
Sep
tem
be
r
Oct
ob
er
No
vem
be
r
De
cem
ber
Jan
uar
y
Feb
ruar
y
Mar
ch
Hand Hygiene Monthly Totals 2017/18
Monthly Percentage
Month April May June July August SeptemberOctober NovemberDecemberJanuary February March
Monthly Percentage 97.92% 95.98% 98.18% 97.93% 98.54% 98.80% 97.75% 97.82% 96.65% 98.35% 96.32% 98.21%
Page 23 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
7.2 Cleaning Schedules Cleaning schedules are available in all patient areas and updated as required to meet individual service needs with the Ward Sister/Department Manager. 7.3 Monitoring arrangements All wards and departments are audited and monitored against the National Specifications for Cleanliness (2007) using 55 Elements approved by the Lead Infection and Prevention Control Nurse, which includes the 49 detailed in the Specifications documentation. The audits are generally carried out by a Matron or Ward Sister/Department Manager in conjunction with a member of the Housekeeping Management Team who is experienced in the NPSA Audit process. The results of the audits are reported at both the Estates and Facilities Senior Management Team and the Hospital Infection Control Committee. 7.4 Patient Led Assessment of the Care Environment (PLACE) The Trust continues to perform well with regards to patient perception of the cleanliness of the environment,
National Average Colchester General
2017
Cleanliness 97.57% 99.13%
Food and Hydration 89.27% 90.61%
Privacy, Dignity and Wellbeing
87.21% 89.33%
Condition,
Appearance, Maintenance
90.11% 93.00%
Dementia 74.51% 66.09%
NB. Figures in green detail where the Trust scored higher than the national average and figures in red detail where the Trust scored lower than the national average.
The Trust also holds six PLACE ‘lite’ inspections throughout the year, and quarterly PLACE steering Group meetings to review and update the action plan.
Page 24 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
7.5 NPSA Audit Results Total NPSA Score for 2017/18
96.9%
97.4% 97.3%
97.2%
97.4%
96.5%
97.1% 97.0%97.0%
97.4%
97.7%97.8%
95.5%
96.0%
96.5%
97.0%
97.5%
98.0%
Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
Page 25 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
NPSA Cleaning Audit2017/18
Overall percentage score
Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Year Average
CHUFT Totals 96.9% 97.4% 97.3% 97.2% 97.4% 96.5% 97.1% 97.0% 97.0% 97.4% 97.7% 97.8% 97.2%
Overall percentage score by area of responsibility
Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Year Average
Cleaning 96.3% 97.0% 96.8% 96.1% 96.3% 94.7% 95.6% 95.7% 95.7% 96.0% 96.5% 96.3% 96.1%
Nursing 95.5% 96.9% 96.2% 97.7% 97.4% 97.1% 97.5% 97.4% 96.5% 98.5% 98.5% 99.0% 97.4%
Estates 98.8% 99.1% 98.8% 99.4% 99.7% 99.3% 99.5% 99.8% 99.6% 99.7% 99.6% 99.7% 99.4%
Page 26 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
NPSA Scores by Cleaning Specialty
Deep Cleaning
The Trust continues to support the process of environmental decontamination with hydrogen peroxide vapour (HPV) which is used as standard practice for deep cleaning as per the Trust policy and as directed by the Nursing or Infection Control Team and where upgrades or refurbishments take place. There is an arrangement with each clinical department to release a room and undertake deep cleaning of ward based equipment on a monthly basis. Estates and Planning The IP&C team have continued to support and provide advice relating building projects, and schemes to develop or create facilities and services, including two full ward refurbishments during the year.
The movement of services to the PCC building from Essex County
92.0%
93.0%
94.0%
95.0%
96.0%
97.0%
98.0%
99.0%
100.0%
101.0%
Cleaning
Nursing
Estates
Page 27 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
Gainsborough Clinics
A&E reconfiguration
Turner Diagnostic centre
New Elmstead Endoscopy decontamination unit The continued collaborative work with the Estates and Facilities Division continues to improve monitoring and reporting on cleaning standards and maintenance and monitoring of the estate.
Page 28 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
8. Decontamination
Procedures and Policies The standards of operation (SOP) or activities in SSU department were regulated in line with medical device direction 93/42/EEC as amended by 2012/47/EEC and the external annual auditing were undertaken by British Standards Institute (BSI) a Notified Body on behalf of the MHRA . In January 2018, SSU Colchester branch acquired compliance to the new standard EN ISO 13485:2016. All essential monitoring requirements in relation to Environment test, sterility test, quarterly and annual equipment tests were carried out and all test results conform to the right standards. (See figures on Appendix section) The Trust Decontamination Policy is in place. The Policy was developed to meet the ‘Essential Quality Requirements’ of both the Hospital Technical Memorandum (HTM) 01-01: Management and Decontamination of Surgical Instruments (Medical Devices) Used in Acute Care; and Hospital Technical Memorandum (HTM) 01-06: Management and Decontamination of Flexible Endoscope. The front of the Policy states that it was approved by the HICC in July 2017. However, minutes of the July 2017 and January 2018 HICC meetings explained that the approval for the Policy had been deferred due to the absence of the Decontamination Manager from the meetings. Members of the Trust decontamination committee were reviewed to define all of the personnel with particular responsibilities within the committee in order to maintain and monitor procedures in relation to infection control and managing decontamination issues. Project All the endoscope washer disinfectors within Trust have been replaced except Clacton and PCCT, the change is due to the removal from the market of the disinfectant used by these machines. New facility for centralisation of endoscopy decontamination will serve both Elmstead Endoscopy and Main theatre. The Decon project also includes replacement of the Flexible Endoscope Washer Disinfectors at Essex County hospital due to end of life of product and that has been completed, the project was carried out in line with the Technical Memorandum 01-06 for Flexible Endoscopes and the Joint Advisory Group (for Gastrointestinal Surgery) JAG to ensure that reassurance of best practice was provided. An internal audit was conducted and a report prepared by Mazars Public Sector Internal Audit Limited at the request of Colchester Hospital University NHS Foundation Trust to establish controls in place relating to Sterilisation of Equipment. Eric Miller the Trust AE (D) deferred his audit to embed the endoscopy unit, now the unit has been running for more than 6 months, arrangement has to be put in place for this audit to take place. Staff Training The introduction of new EWD from Cantel necessitated the need to provide training for all endoscopy users including sterile service technicians to ensure they understand the required procedures. Staff also received decontamination of reusable invasive medical device training via in house NHS training. Staff completed mandatory training, health and safety training, E-Learning courses as well as leadership to lead training. The training certificates are kept up to date as appropriate.
Page 29 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
Personal Protective Equipment The policy or work instruction in place highlighted the PPE that staff are required to wear in both SSU and Endoscopy Unit. When handling dirty endoscopes and surgical instrument, staff are required to wear aprons, gloves, arm protectors and a face visor. When handling decontaminated devices e.g. endoscopes from the EWDs, staff are required to wear an apron and gloves. Stocks of PPE were readily available for staff to wear when required. CJD/vCJD and Evaluation of Protein detection There is a local Creutzfeldt - Jakob disease (CJD) and Variant Creutzfeldt-Jacob Disease (vCJD) SOP in use to maintain and monitor TSE issues. This SOP's will continue to be reviewed to ensure compliance with best practice. In line with MD DB2000 (04) guidance on single use items, the Trust policy continues to prohibit the reuse of single use items. All reusable items were tracked with the use of independent monitoring systems for patience use and for decontamination processes. Part of last year achievement includes implementation of the use of disposable soft packs within some outpatient clinics/wards to promote quick turnaround of surgical sets for patient care; the wards/clinics involved include CDS (delivery), sexual clinics, Gynae outpatient, and Podiatry unit. To continue promoting good practice on infection control, SSU plans to introduce pre-sterilized single use guide-wires, small fragment screws, cannulated items that are difficult to clean or reprocess and use of dismantle Spinal Rongeur (Kerrison punch). SSU managed issues of protein residue via the use of suitable optimized washer disinfector and detergent systems by using process challenge device to evaluate washer efficacy. Management Review Meeting Periodic management meeting were held to discuss Progress of implementing good practice, health and safety, set objectives , maintenance of quality service to customers, monitor and implement corrective and preventive actions in the Unit. These meetings were attended by senior management, including the Head of Estates, Sterile service operational manager, quality coordinator and the Decontamination Manager. Discussions also included training requirements and risks involved with implementing and the continued operation of the Unit. Tracking of Items / Instrument Trays Track and trace of surgical instruments was affected after the cyber-attack. Data for processed sets within period of network breakdown were manually logged and re-logged into Fingerprint IMS. However cyber-attack setback was rectified by IT and Fingerprint to enable SSU meet their mandatory obligation to provide services to theatres. A fingerprint off line connection system was established or set up in SSU as solution that will mitigate against disruption of track and trace of surgical instruments should the cyber-attack issue occurs in the future. Equipment downtime SSU had high record of equipment down time last year compared to previous years. There were series of incidents when RO plant failed to produce purified water for steam production, there were high counts of downtime hours with the washer disinfectors and autoclaves. We also had issues with conductivity in relation with hard water for reprocessing surgical instruments. However all issues were rectified to enable SSU meet service obligation to customers.
Page 30 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
Fig 1 Equipment downtime 2017/2018.
Fig 2 Housekeeping results 2017/2018
Area Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
Equipment Downtime (hours) 1176 941.5 937.2 769.1 566.5 629 694 650.2 144 1560 149.2 1286.2
Housekeeping Results Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
Level of Housekeeping Compliance 91.1 95.5 98.7 97.5 98.2 97 98.24 98.18 98 98.2 98.5
N/B- No result for month July 2017 due to breakdown on
housekeeping IMS system
Page 31 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
FEW DECONTAMINATION RISK ISSUES: Instruments can go missing on occasions when they are not accounted properly by either SSU Staff or Theatre staff. CQC auditors identified and raised concerns in 2016/2017 audit about this. Theatres receive missing items reports on Monthly basis. Tray checklists
updated to aid post operational checks Fig. 4.Missing Instrument 2017/2018
Fig 5. Sharp incidents; graph shows high peak in 2017 (Theatre sets returned to SSU with sharps)
0
1
2
3
4
5
6
7
APR MAY JUN JLY AUG SEP OCT NOV DEC JAN FEB MAR
Nu
mb
er
of
mis
sin
g it
em
s
Months
2017
0
1
2
3
4
5
6
7
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
nu
mb
er
of
inci
de
nts
Months
2017
Page 32 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
Sample identification Feb-17 May-17 Aug-17 Nov-17
Fig 6 WATER SAMPLE ASSESSMENT 2017
TSA reading/100ml TSA reading/100ml TSA reading/100ml TSA reading/100ml
Remarks
SK1 Rinse RHS Hot
99.9 0.99 0.99 0.99
FEB. = Outlets for clean room gown interchange Mix and Decon H/W area needs to be sanitized
SK1 Wash LHS Cold 99.9 15 300 300
SK2 Rinse LHS Hot 99.9 0.99 0.99
Alert level: >5 x 103/ml Action limit : >10 x 103/ml
SK2 Wash RHS Cold 300 0.99 300
Contained Sink Spray 300 0.99 300 300
Clean room Change Mixer 13,400 151 113
Decon area Hand wash Mixer 6,300 0.99 0.99 0.99
Ultrasonic Mixer 100 2 123 123 Domestic Store
Mixer 99.9 27 0.99 0.99
-15000
-10000
-5000
0
5000
10000
15000
TSAreading/100ml
TSAreading/100ml
TSAreading/100ml
TSAreading/100ml
Feb-17 May-17 Aug-17 Nov-17
Water sample Assessment 2017
SK1 Rinse RHS Hot
SK1 Wash LHS Cold
SK2 Rinse LHS Hot
SK2 Wash RHS Cold
Contained Sink Spray
Clean room Change Mixer
Page 33 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
S/N Category Feb-17 Mar-17 May-17 Aug-17 Nov-17
1 Cannulated inst. 57 2 0.99 0.99 0.99
2 1 piece inst. 3 0.99 0.99 0.99 0.99 Fig. 7
3 complex multi piece inst 264 2 0.99 5 0.99 BIOBURDEN DATA 2017
4 2 piece Joint instr. 4.2 0.99 0.99 0.99 0.99
5 Miscellaneous 50.4 0 0 0.99 0.99
For month of May 2017 Presence of Gram positive Colonies (GPC) observed in few inst. But not within alert level All counts are within specified Limits
Warning Limits = 50CFU Action limits = 100CFU. Test Result= PASS. All sites within limits.
0
50
100
150
200
250
300
Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17
Sco
res/
read
ing
Months
1 Cannulated inst.
2 1 piece inst.
3 complex multi piece inst
4 2 piece Joint instr.
5 Miscellaneous
Page 34 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
In conclusion the management system/ processes on medical devices in SSU CHUFT Currently refers as Sterilization and Decontamination Services is currently compliant and certified to the requirements of ISO 13485:2016.
Page 35 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
9. Audit
Da
te A
ud
it c
om
ple
ted
Ha
nd
Hy
gie
ne
Te
ch
niq
ue
Sta
nd
ard
Pre
ca
uti
on
s
Clin
ica
l p
rac
tic
es
: S
urg
ica
l
ha
nd
pro
ce
du
re
Clin
ica
l p
rac
tic
es
: C
are
of
uri
na
ry c
ath
ete
r -
co
nti
nu
ing
ca
re
Clin
ica
l p
rac
tic
es
: C
are
of
uri
na
ry c
ath
ete
r in
se
rtio
n
Clin
ica
l p
rac
tic
es
: C
are
of
pe
rip
he
ralv
as
cu
lard
ev
ice
co
nti
nu
ing
ca
re
Clin
ica
l p
rac
tic
es
: C
are
of
pe
rip
he
ral v
as
cu
lar
de
vic
e
ins
ert
ion
Clin
ica
l p
rac
tic
es
: C
are
of
ce
ntr
al v
en
ou
s c
ath
ete
r
co
nti
nu
ing
ca
re
Clin
ica
l p
rac
tic
es
: C
are
of
ce
ntr
al v
en
ou
s in
se
rtio
n
Clin
ica
l p
rac
tic
es
: Is
ola
tio
n
pre
ca
uti
on
s
Clin
ica
l p
rac
tic
es
: O
pe
rati
ng
Th
ea
tre
As
ep
sis
Clin
ica
l p
rac
tic
es
: E
nte
rna
l
fee
din
g
Pt
Eq
uip
me
nt
En
vir
on
me
nt
Ov
era
ll S
co
re
2014/15 77% 77% 90% 83% 96% 82% 97% 89% 100% 89% 100% 83% 81% 73% 87%
2015/16 92% 84% 100% 88% 96% 87% 92% 95% 96% 95% 99% 91% 87% 75% 91%
2016/17 88% 84% 100% 90% 98% 86% 94% 96% 100% 95% 100% 95% 86% 72% 83%
2017/18 92% 82% 100% 94% 99% 95% 97% 98% 95% 97% 100% 98% 84% 69% 84%
0%
20%
40%
60%
80%
100%
120%
2014/15
2015/16
2016/17
2017/18
Page 36 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
Saving Lives monthly percentages
The annual infection prevention and control audit is completed in all clinical areas (58) on an annual basis by the IP&C team and the results have remained relatively consistent over the years. It is a good opportunity to support clinical teams in highlighting best practice and practices which could be improved upon. These audits provide evidence in order to support ward refurbishment risk assessments for instance. It proved a challenge to complete these independent in depth clinical practice and environment audits in all areas this year due to staffing issues in the IP&C team. These will be picked up in the early part of 2018/19. The Trust monthly hand hygiene observational audits have demonstrated an increase in compliance consistently above 95% and regularly 97%. There are between 3700 and 4500 observations documented per month. There is regular peer review to monitor results and support education at a local level in order to maintain awareness for best practice. Hand hygiene is seen as an integral part to patient safety within the Trust. Periodic hand hygiene awareness roadshows are supported by the Infection Control team.
Mo
nth
CV
C-In
seryio
n A
ction
s
CV
C - C
on
tinu
ing C
are
PV
C-In
seryio
n A
ction
s
PV
C - C
on
tinu
ing C
are
Re
nal D
ialysis Cath
ete
r -
Inse
rtion
Actio
ns
Re
nal D
ialysis Cath
ete
r -
Co
ntin
uin
g Care
Surgical Site
Infe
ction
-
Pe
riop
erative
Surgical Site
Infe
ction
-
Pre
op
erative
Ve
ntilate
d P
atien
ts -
Re
gular O
bse
rvation
s
Ve
ntilate
d P
atien
ts -
Co
ntin
uin
g Care
Urin
ary Cath
ete
r Care
-
Inse
rtion
Actio
ns
Urin
ary Cath
ete
r Care
-
Co
ntin
uin
g Care
C.diff - P
reve
ntio
n
C.diff - P
reve
ntio
n o
f
Spre
ad
Total
April 100.00% 100.00% 99.06% 95.98% 100.00% 100.00% 92.86% 100.00% 100.00% 99.21% 94.59% 100.00% 100.00% 98.59%
May 100.00% 100.00% 98.29% 96.14% 100.00% 72.88% 92.00% 100.00% 98.41% 97.73% 92.31% 95.25%
June 97.06% 95.24% 98.26% 94.66% 100.00% 76.92% 100.00% 100.00% 100.00% 100.00% 89.76% 100.00% 100.00% 96.30%
July 100.00% 100.00% 99.06% 95.98% 100.00% 100.00% 92.86% 100.00% 100.00% 99.21% 94.59% 100.00% 100.00% 98.59%
August 100.00% 100.00% 98.71% 98.60% 100.00% 94.64% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 78.26% 97.71%
September 100.00% 100.00% 98.91% 98.94% 100.00% 98.44% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 85.71% 98.62%
October 100.00% 100.00% 100.00% 100.00% 100.00% 98.31% 100.00% 100.00% 100.00% 97.94% 100.00% 95.22% 99.29%
November 100.00% 100.00% 99.23% 96.55% 100.00% 100.00% 100.00% 100.00% 100.00% 99.05% 100.00% 100.00% 99.57%
December 100.00% 100.00% 98.92% 98.37% 100.00% 100.00% 89.41% 100.00% 85.00% 100.00% 100.00% 98.98% 100.00% 66.67% 95.53%
January 100.00% 100.00% 98.94% 98.10% 100.00% 98.00% 100.00% 100.00% 100.00% 99.14% 97.65% 100.00% 53.85% 95.82%
February 100.00% 100.00% 99.25% 99.40% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 99.90%
March 100.00% 98.18% 98.69% 100.00% 100.00% 94.92% 100.00% 100.00% 100.00% 100.00% 100.00% 94.44% 100.00% 98.94%
Saving Lives Totals Monthly 2017/2018
High Impact Interventions
Page 37 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
ANNUAL PLAN 2018/19
Plan for 2018-19 Key points
Compliance with Hygiene Code (2008 updated 2015)
To review action plan against the code on a regular basis
Saving Lives audits Continue to support clinical teams in the education and use of the tools
ICT Data Manager continues to work with local teams to tailor reports to department
To target three ‘High Impact Interventions’
Appropriate use of urinary catheters
Appropriate use of Isolation Facilities for HCAI
Effective use of risk assessments for HCAI
To promote Peer review of audits to promote learning across the divisions
Introduce new tools and monitor output (2018)
Annual IC audits Continue with annual rolling programme of Infection control audits with timely feedback to clinical teams
Facilitate the MRSA screening To continue to assist Divisions in achieving compliance with MRSA emergency admission screening procedure
To support a robust system is in place to assure compliance with the target
To support the feedback of data to support this work
Facilities /Estates Project review To work with Trust Facilities Management team to look at current specifications and which require Infection Control advice support through NPSA auditing
Work with Projects team to manage IP&C from feasibility/design, build and handover
Promote e-learning programmed and audit uptake
Continue updating programmed annually
To audit uptake and report to HICC bi monthly/QPSC monthly
Mandatory updates for Infection Control and antimicrobial management for all staff groups
To continue to support the Trust programme at induction and mandatory update sessions – update annually
Programme available in e-learning format for induction
Antimicrobial e-learning package
Update IC policies Ongoing programme - aligning with IHT
IC manual update Ongoing updating on web based manual
ICNet surveillance system To continually evaluate effectiveness of the system
The system requires upgrading at a financial cost – look at joint link in with Ipswich Hospital
Continue with Surgical site surveillance
Continue with agreed rolling programme of modules in addition to the mandatory modules
Promote the adoption within the Trust of surveillance in areas such as caesarian sections as the new modules become available
Infection Control Link System
To continue to develop the link role into other healthcare disciplines
To further develop the role of the Link role to enhance local infection control Induction
Surveillance E coli bacteraemia RCA and reporting
MSSA bacteraemia RCA and reporting
MRSA bacteraemia RCA and reporting
Psuedomonas bacteraemia reporting
Klebsiella bacteraemia reporting
C diff RCA and reporting
CRO reporting and RCA
Alert Organism reporting and Management
Page 38 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
Policies
Policy No: Title ICN Lead Issue Date Expiry
Date
PP(17) 048 Prevention of Infection in Patients with an Absent or
Dysfunctional Spleen Guidelines
Tony Elston Jun -16 April -19
PP(17)90 Hand Hygiene Procedure Heather Dakin Feb-17 Feb-19
210 Infection Control Procedure Heather Dakin Jun-17 Dec-18
389 Creutzfeldt Jacob Disease (CJD) – Procedure for the
Management of Related Disorders in Hospital
Heather Dakin/
Vicky Bywater
Sep-15 Sep-17
PP(16)181 Control of Outbreaks of Infection in the Hospital
Setting Procedure
Heather Dakin Apr-16 Apr-18
PP(16)361 Isolation Procedure Heather Dakin Sep-16 Sep-18
PP(17)371 Viral Haemorrhagic Fever (VHF) Procedure Heather Dakin Feb-17 Feb-19
PP(17)343 Hydrogen Peroxide Vapour (HPV) Decontamination
Procedure
Heather Dakin Feb-17 Feb-19
PP(16)245 Clostridium difficile and Unexplained Diarrhoea
Procedure
Vicky Bywater Mar-16 Mar-19
PP(16)360 Procedure for the Management of Extended
Spectrum Beta-Lactamase (ESBL) Producing
Organisms and AmpC Producing Organisms and
Prevention of Spread
Heather Dakin Mar-16 Mar-19
PP(16)246 Management of Chickenpox and Shingles
Procedure, Including Immunisation for Healthcare
Workers (Replaces 81 and 155)
Heather Dakin Apr-16 Mar-19
PP(16)407 Policy & Procedure for the management of
Carbapenemase producing Enterobacteriace
Vicky Bywater Mar-19 Mar-19
PP(16)112 Methicillin-Resistant Staphylococcus Aureus
(MRSA) Procedure
Heather Dakin May-16 May-19
PP(16)410 Visiting Pets Procedure (extension requested to
allow for volunteer leader input - new post)
Heather Dakin May-16 Jul-19
PP(16)80 Tuberculosis (TB) Management Procedure Heather Dakin Sep-16 Sep-19
PP(16)407 Policy & Procedure for the Management of
Carbapenemase Producing Enterobacteriace
Head of
Infection Control
Mar-17 Mar-19
PP(16)378 Vascular Access Devices
(Peripheral and Central):
Insertion, Management and Removal Procedure
Heather Dakin Dec-16 Dec-19
Page 39 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
11. ANTIBIOTIC MANAGEMENT TEAM REPORT 2017/18 AMT meetings: The Antimicrobial Management Team (AMT) meets every two months to plan and monitor the Antimicrobial Stewardship (AMS) strategy within the Trust. The team is currently chaired by the Antimicrobials Stewardship Pharmacist on an interim basis. The core membership consists of a consultant microbiologist, a pharmacy representative, and an infection control nurse. A representative from ACE now attends the meetings, but we have been unsuccessful in attracting representatives from the clinical divisions. Staffing: The pharmacy members of the AMT are now established in post. Staffing changes over the past year:
The lead Consultant Microbiologist for AMS is now part-way through her secondment to
Ipswich Hospital. As this consultant was the chair of the AMT, this role has moved to the
Antimicrobials Stewardship Pharmacist on an interim basis. Backfill for this post is being
paid for by Ipswich Hospital NHS Trust and locum Consultant Microbiologists are used in
this post.
A new AMT secretary has been employed due to the retirement of the previous
secretary.
Joint working with Ipswich Hospital NHS Trust: The AMT have started joint working with counterparts from Ipswich Hospital NHS Trust. So far:
Rarely used antimicrobial stock holdings across both sites have been agreed and will
continue to be expanded upon. (Currently - Ipswich will hold Aztreonam injection and
Natamycin Eye drops, Colchester will hold Artenusate injection, Riamet tablets, and
Fosfomycin injection).
A joint app for antimicrobial guidelines has been agreed. Treatment Guidelines will
replace MicroGuide here at Colchester.
Work on a joint antimicrobial guideline has begun. The teams from both Trusts are
planning to meet every two weeks while this work is ongoing. This is a large piece of
work that may cause considerable change to practice at both sites. It is envisaged that
this will tie up a large amount of AMT time until this work is complete.
Attendance at each other’s AMT meetings has already commenced.
Antimicrobial Shortages: The past number of months has been notable for the number of shortages of antimicrobials. In addition to the national shortage of piperacillin/tazobactam injection, the team also had to manage shortages of gentamicin injection, clindamycin injection, aciclovir injection, and mupirocin nasal ointment (Bactroban). At the time of writing, the current situation is: Piperacillin/tazobactam – stock available, but only at approximately two thirds of historical supply. Managed by adjusting our antimicrobial guidelines and helped by thrice weekly microbiology rounds on EAU. Gentamicin injection – stock now available, but the trust’s allocation is 550 ampoules of 80mg/2mL strength per week. Clindamycin injection – the trust has a stock of injection, but cannot order any more until late March/early April to replace any that is issued. Currently being managed by guideline changes and all stock returned to pharmacy; only being issued on microbiology advice.
Page 40 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
Acyclovir injection – only small amounts of stock available. All stock returned to pharmacy. Only issued one day at a time, or enough for a weekend. Liaison with clinical teams as to diagnosis of encephalitis and to expedite diagnostic procedures (e.g. lumbar punctures). Mupirocin nasal ointment – managed by guideline changes. Antimicrobial incidents: Monthly trends on Datix (Trust electronic incident reporting system) are monitored as a regular agenda item by AMT. From identifying trends in incidents or near misses education can be enhanced and systems can be implemented to minimise the risks in the future. A recent mini-trend is the inappropriate omission of tobramycin and teicoplanin doses whilst awaiting a level to be reported. Levels for these agents are not tested on site and can take up to five days to be reported. A MITCH will be circulated to educate nursing staff about this. Audits: Regular monitoring through audit continues. A rolling programme of audit, looking at antibiotic prophylaxis during surgery, has been expanded and the following surgical specialties are monitored:
Vascular
Gastrointestinal
Urology
Orthopaedic
Breast
Gynaecology
Caesarean sections
Pacemaker
Interventional Radiology
12. TRAINING ACTIVITIES Induction and Mandatory update for all staff
The mandatory updates are delivered face to face and the Infection Control E-learning is reviewed and updated at least annually, The Trust achieved 94% compliance as of March 31st 2018.
Course Number of sessions
Attended/Completed
Corporate Induction 12 319 attended
Infection Control e-learning Clinical N/A 1655 successful attempts
Non-clinical N/A 1398 successful attempts
Infection Control Awareness/adhoc 12 320
Doctors Induction and Foundation Programme 2 79
Total 3452
Infection Prevention & Control link workers
There were 3 Infection Prevention and Control link worker meetings held during 2017/2018.
The topics covered included:
Page 41 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
Sharps Safety
UTI diagnosis & treatment
Norovirus outbreaks
Meningitis
Tuberculosis
Saving lives High impact interventions – the “new” tool
Influenza
Fit testing
Sepsis Screening
Gram-negative bloodstream infections
Antibiotic Resistance
The infection prevention and control link role continues to extend to representatives from all
staff groups.
Page 42 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
APPENDIX 1 - CHUFT HCAI Action Plan 2017/18
CHUFT HCAI Action Plan 2017/18
Health and Social Care Act 2008 (2015) Criterion
Action Update RAG
1. Systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider the susceptibility of service users and any risks that their environment and other users may pose to them.
IP&C and Microbiology service available 24/7 with Microbiology laboratory support available.
Isolation Procedure updated in 2016 following the closure of the Isolation Unit
IP&C e-learning is mandatory on a bi-annual basis
Monitoring of the training update is now easily accessible via Training Portal
CHUFT to host/manage Pathology services Partnership
New risk assessment stickers developed and promoted in ward areas e-learning is updated annually/or in line with new guidance/evidence Training compliance has increased since the introduction of the training portal
2. Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections.
IP&C involved in all Capital Building and service re-provision in the year ahead
NPSA Cleanliness audit programme in place with IP&C input and monitoring at HICC
Water Safety Committee which reports to HICC
Decontamination Committee in place and reports to HICC
IP&C involvement in Market testing strategy for Facilities services with closer working relationships with Ipswich.
Planned upgrade to endoscopy decontamination system planned for September 2017
Supporting procurement processes for equipment to support best practice in the decontamination between patient uses
3 ward refurbishments planned for this financial year: Lexden, Aldham and Fordham ward Redesign and refurbishments to Gainsborough Ground Floor to allow services from ECH to move onto CGH site by March 2018 Supporting Introduction of Micro-fibre cleaning system in June 2017 Working with Facilities Management Team relating to upgrade of Endoscopy decontamination processes to be completed by September 2017
Page 43 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
CHUFT HCAI Action Plan 2018/19
Health and Social Care Act 2008 (2015) Criterion
Action Update RAG
3. Ensure appropriate antimicrobial use to optimize patient outcomes and to reduce the risk of adverse events and antimicrobial resistance.
Antimicrobial team meets monthly
Antimicrobial team Ward rounds to promote best practice in antibiotic management and support education
Antimicrobial training available for all staff via e-learning and regular face to face sessions available
Antimicrobial Microguide App available to staff with up to date antimicrobial guidelines
Monthly reporting to DIPC who reports QPSC Work ongoing to make antimicrobial training mandatory for all clinical staff Updated Penicillin allergy cards made available for all clinical staff to carry to act as ad memoire Continue to work towards this being an issue for the whole trust
4. Provide suitable accurate information on infections to service users, their visitors and any person concerned with providing further support or nursing/medical care in a timely fashion.
Intranet and internet pages specific to IPC which are updated regularly
Policy and procedures available to all staff to inform best practice
IP&C team support Clinical and Facilities teams adhoc training
Information leaflets updated annually and the introduction of new leaflets as guidance changes (leaflets available on internet page)
SSI mandatory and non-mandatory data collection
Leaflets updates annually and available on the internet and intranet pages IP&C e-manual available on intranet IP&C policies/ procedures updated and available on Intranet Bug News topical Monthly IP&C newsletter available on Trust intranet.
ssiss.docx
Page 44 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
CHUFT HCAI Action Plan 2017/18
Health and Social Care Act 2008 (2015) Criterion
Action Update RAG
5. Ensure prompt identification of people who have or are at risk of developing an infection so that they receive timely and appropriate treatment to reduce the risk of transmitting infection to other people.
IP&C service available 24/7 with appropriately skilled clinicians available
IP&C have nursing/admin team which has responsibility to support all clinical teams in order to inform and advise on best IP&C practice in a timely way
Data collection and inputting to PHE mandatory surveillance system
ICNet surveillance system supports IP&C team to be alerted in a timely way of increased incidences of alert organisms
6. Systems to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the process of preventing and controlling infection.
IP&C e-learning is mandatory on a bi-annual basis for all clinical staff
IP&C e-learning is available for non-clinical groups of staff
Monitoring of the training update is now easily accessible via Training Portal
Facilities Contractors have local induction to include IP&C in place prior to commencing work on site
There is an information leaflet for volunteers relating to IP&C
IP&C team teach on Volunteer induction training as requested
All clinical staff IPC e-learning training is updates bi-annually or in light of new evidence/guidance and is following the National Core Learning standards ( last updated April 2017) Volunteer training monthly IP&C information leaflet updated annually for all staff (August 2017)
7. Provide or secure adequate isolation facilities.
114 side rooms available across the Trust to support IPC isolation needs
Flu plan as part of Major incident planning updated 2017
Isolation procedure PP (16) 361 with clear escalation procedure
Isolation policy has a clear escalation plan in order to support timely and appropriate isolation of at risk patients. There is not always the number of isolation rooms as required in peak periods of increased incidence.
Page 45 of 45
Created: March 2018
Review: 2019
Author: Dr Tony Elston (Director of Infection Prevention & Control/Consultant Microbiologist)
CHUFT HCAI Action Plan 2017/18
Health and Social Care Act 2008 (2015) Criterion
Action Update RAG
8. Secure adequate access to laboratory support as appropriate.
24/7 Consultant Microbiology availability
Accredited Microbiology laboratory support 24/7
Ordercoms system planned to be in use in relation to microbiology by the end of 2017
9. Have and adhere to policies, designed for the individual’s care and provider organisations that will help to prevent and control infections.
Annual Infection Prevention and Control Audit programme for all clinical areas in place
Policies in place with programme to update bi-annually at least and in light of new guidelines/ evidence
Policy and procedures updated appropriately and are in line with Hygiene Code as a minimum Policies have been introduced accommodating emerging resistant organisms such as CRO
polocies.docx
