2008/09
Infection Control Annual Report
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Contents:
1. Executive Summary 1.1 CCO 1.2 National Context 1.3 Infection Control Programme of Work 1.4 Key achievements 2. Infection Control Arrangements 2.1 Organisational arrangements 2.2 Responsibilities 2.3 Committees 2.4 Links to Clinical Governance 3. HCAI statistics MRSA bacteraemia C Difficile Outbreaks 4. Hand Hygiene 4.1 Cleanyourhands campaign 5. Decontamination 5.1 Arrangements 6. Cleaning services 6.1 Arrangements 6.2 Monitoring (PEAG) 6.3 Internal PEAT inspections 6.4 Annual PEAT inspection 7. Audit 7.1 Audit programme 8. Training 8.1 Training provision to Trust 8.2 Training undertaken by infection control team 9. Policy Review 10. Assurance framework 11. Pandemic flu 12. Patient Feedback 13. Freedom of information requests 14. Infection Control Objectives for 2009/10
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Executive Summary 1.1 CCO CLATTERBRIDGE CENTRE FOR ONCOLOGY NHS FOUNDATION TRUST INFECTION CONTROL POLICY STATEMENT The Board has collective responsibility for minimising the risks of infection and the general means by which it prevents and controls such risks. As such it is committed to a strategy, which minimises risks through a comprehensive system of internal controls whilst maximising potential for innovation and best practice. The Board acknowledges that the contribution of its staff is fundamental to achieving this. The Trust will support and help its employees in providing services that are safe for patients. This will require that all staff recognise that Infection Control is everyone’s business. The annual report for infection control has been produced for the period of 1st April 2008 to 31st March 2009. The report outlines the activities that have taken place throughout the year to ensure that the management of infection prevention and control is constantly reviewed. Infection prevention and control is an essential tool in ensuring a safe environment for patients, staff and visitors and to ensure the stability and reputation of the organisation. This report sets out the Trust’s infection control activities and performance throughout the year. 1.2 National Context Throughout 2008/09 there has continued to be a high national profile surrounding reduction of healthcare associate infection. Key activities have included: The revision of the Hygiene Code and the subsequent requirement for Trusts to apply to the Care Quality Commission for registration based on compliance with the new Hygiene Code (and amended legal framework). The Trust submitted its application in January and was informed in March that it had registration with no conditions. The Healthcare Commission continued its round of inspections relating to compliance with the Hygiene Code. The Trust underwent its first inspection in September 2008. The subsequent report identified: Duty 2: The trust must have in place appropriate management systems for infection prevention and control: no breach identified. Duty 4: The trust must provide and maintain a clean and appropriate environment for healthcare: breach of hygiene code identified Duty 8: The trust must provide adequate isolation facilities: no breach identified The specific breach in Duty 4 was in relation to: 3
Duty 4 (sub-duty e) – The trust should ensure that it assesses it provision for handwashing facilities and provides alcohol hand rub at the delivery point of the care of patients, to reduce the risks of the spread of infection. Duty 4 (sub-duty f) – The trust should ensure that all patient equipment is decontaminated between use to reduce the risk of HCAI. The Healthcare Commission indicated that in six months' time they check that the trust has made these improvements. All required improvements were put in place in time for the Trust to declare full compliance in its application for registration. The Trust was also required to declare its compliance against Standards for Better Health for 2008/09. The Trust declared full compliance against all infection related standards in particular: C4a: infection control C4c: decontamination C21: premises: maintenance and cleanliness
1.3 Infection Control Programme of Work The infection control programme of work, linked to the infection control strategy continued to be delivered against throughout the year with progress being monitored by the Infection Control Committee 1.4 Key achievements and changes to practice A number of initiatives were put into place throughout the year. Key activities included: Education: ¾ Programme of awareness through the use of the light box within clinical areas ¾ Adult treatment of infection guidelines & poster in clinical areas ¾ SHO training set up ¾ Clinical Champions training Governance: ¾ Establishment of antibiotic stewardship group ¾ Review of all CCO medicine stock lists for antibiotics ¾ Revised root cause analysis form developed
Surveillance: ¾ 3 monthly point prevalence surveys
Changes in practice: ¾ Use of actichlor plus as part of the deep clean programme and the management of outbreaks / infected patients ¾ Change in alcohol gel to one which is active against norovirus ¾ Review of the NPSA notice on alcohol gel and action plan developed and completed.
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Design: 他 Physical changes to the ward areas including improved clean and dirty stores and increased sink provision 他 Change to the style and number of waste bins 他 Integration with the Productive Ward programme 他 Involvement in building projects including the satellite radiotherapy centre and the designs for Sulby Ward
2 Infection Control Arrangements 2.1 Organisational arrangements and responsibilities Within the organisation key individuals / groups have specific defined responsibilities for the management of infection and for providing assurance on the Trusts Infection Control arrangements. These arrangements aim to ensure optimal clinical care for patients and occupational health for staff. The Director of Nursing and Quality has executive responsibility for infection control and is the designated Director of Infection Prevention and Control (as defined in Winning Ways). The Assistant Director of Nursing: Matron supports the Director of Nursing and Quality in the implementation of infection control practices throughout the Trust. Specific responsibilities include delivery of the Cleanyourhands Campaign and the Matrons Charter together with ensuring that the Cleaning SLA with Wirral NHS Trust is managed. Infection Prevention and Control Nurse In June 09 CCO employed an Infection Prevention and Control nurse at 32hrs per week. In October 2008 this post became full time. Specialist advice and support is available. This post is over and above the Service Level Agreement from Wirral University Teaching Hospital (WUTH) Infection Control Team (ICT) Antimicrobial Pharmacist. In July 08 the part time antimicrobial pharmacist increased to a full time position. Wirral Infection Control Team. Specialist advice and support is provided by the Wirral Infection Control team via the SLA. This includes a consultant Microbiologist, infection control nurse and pathology services. An infection control nurse is specifically designated to CCO. Heads of department have local responsibility for infection control within their department including ensuring that all relevant staff access infection control and hand hygiene training. Link Staff (nurses and radiographers) are responsible for participating in the Infection Control Committee and for disseminating information to their department and senior manager for implementation. All staff are responsible for their own infection control practices. Staff attend bi monthly infection control meetings. Patients and Visitors Patients and visitors play an important part in controlling infection by ensuring that they act in a way to minimise the spread of infection. This includes use of alcohol gels and basic 5
good hygiene. They are supported by the provision of information leaflets / notices and by information from clinical staff. 2.2 Committees The Trust Board received the following information and assurances regarding infection control: ¾ Quarterly matrons report ¾ Monthly compliance balanced scorecard report re: MRSA and C Diff targets. ¾ Capital programme (ward refurbishment plans including increase in single rooms) ¾ Infection Control Annual report The Integrated Governance Committee, as a formal committee of the Board, has overarching responsibility for the infection control agenda.
The Integrated Governance Board committee received infection control information at each of its quarterly meetings. Key information included: ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾
MRSA C Diff RCA training Hospital cleanliness Saving Lives assessment Saving Lives HIIs MRSA RCA Infection control strategy Infection control audits PEAT assessments
The executive team received: ¾ Weekly performance reports on MRSA and C Diff (including root cause analysis’)
The Director of Nursing and Quality (DIPC) attends all above meetings Local Infection control committee This meeting constitutes: ¾ Director of Nursing and Quality (CCO) ¾ Assistant Director of Patient Services: Nursing (CCO) ¾ Consultant microbiologist (WUTH) ¾ Infection Control Nurse WUTH ¾ Infection control nurse (WUTH). ¾ Antibiotic pharmacist ¾ Infection control link staff / champions ¾ Technical services representative Each meeting is minuted. Terms of reference To provide a forum for information dissemination between the Infection Control Team (WUTH) and Clatterbridge Centre for Oncology ¾ To monitor infection outbreaks. ¾ To agree local changes in practice 6
¾ ¾ ¾ ¾ ¾
To ensure adequate provision of infection control training To monitor the SLA with WUTH To respond to external requirements e.g. legislation / Department of Health. To provide a link with estates To develop and deliver the Infection Control Strategy including delivery and monitoring of the Saving Lives High Impact Changes audit programme. ¾ Prepare an annual report for infection control The Infection control committee reports to the Risk management committee via the Director of Nursing and Quality. Environmental / microbial hazards working party. CCO is represented on the WUHT infection control committee membership. Attendance is by a technical services representative. The Director of Nursing and Quality also attends the Wirral C Diff monitoring and target setting meeting.
2.3 Links to Clinical Governance In July 2008 the Trust approved its Quality Strategy. Within this strategy are clear links to infection control in relation to: ¾ C diff ¾ MRSA ¾ Use of the global trigger tool ¾ High impact interventions ¾ Patient survey metrics 3 HCAI statistics For 2008/09 the Trust had two Healthcare Commission mandated targets: C Diff : no more than 19 attributable cases. The Trust had 7 cases during the year attributable to the Trust. MRSA: The Trust has a target of no more than 2 bacteraemias in year. The Trust had no attributable cases during the year.
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C-Diff cases within and after 48 hrs of admission 16
14
12
10 Total All cum.after 48 hours cum. within 48 hours no after 48 hours no within 48 hours
8
6
4
2
0 Apr-08
May-08
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Outbreaks: The Trust had one outbreak of Norovirus in May 08.The affected ward was closed to admissions for 6 days This was a considerable achievement as the surrounding health economy had many cases throughout the winter. 4 Hand Hygiene 4.1 Cleanyourhands campaign Cleanyourhands Campaign The Trust continued to participate in the CleanyourHands Campaign. Activities included: 他 Use of the Cleanyour hands promotional posters and information 他 Infection Control Roadshow 他 Hand hygiene audits (appendix 1) 他 5 moments of hand hygiene 5 Decontamination 5.1 Arrangements The Trust has continued to purchase its decvontamiation service for re-usable medical equipment from Sterilplus and remains compliant with the Standards for better Health requirements. 6 Cleaning services 6.1 Arrangements 8
Cleaning services continue to be provided via an SLA with Wirral Hospital Trust. The contract is monitored at 3 monthly Hotel Services meetings. 6.2 Monitoring (PEAG) The Trust receives at the PEAG results at its regular review meetings. The scores remain consistently high (see appendix 2) 6.3 Internal PEAT inspections Internal Director led PEAT inspections are done every month with the Assistant Director of Nursing leading the reporting of issues and feedback to departments with requests for action plans to be developed. Wider issues identified in this process have been fed into the new estates strategy. Inspection team representation includes: ¾ ¾ ¾ ¾ ¾ ¾
Executive director Senior managers Technical services Patient / public Domestic services Infection control.
Key areas covered included infection control, cleanliness, food, estates, Caldicott, DDA compliance.
6.4 Annual PEAT inspection The annual PEAT assessment was completed in March 2008. The self assessment scored ‘green’. An external assessor was including in the inspection team
7 Audit 7.1 Audit programme The audit programme for 2008/09 has included: Infection Control Policy (NHSLA policy audit) Care pathway Bin audit: ¾ Action: new bins purchased Sharps Soaps Macerators ¾ Action: new macerators purchased Hand gel Mattresses and chairs ¾ Awaiting action plan Commodes ICNA: ¾ Actions: minor changes in practice 9
High Impact Interventions The Trust participates in the Saving Lives High Impact Interventions. The programme is managed by the Infection Control nurse at CCO and WUTH with involvement with from the Assistant Director of Nursing at CCO. IT support is gained from WUTH. High Impact Intervention surveillance. We are compliant with observations in all relevant areas such as: ¾ Central venous care ¾ Peripheral intravenous cannula care ¾ Urinary catheter care clostridium difficile. Problems highlighted during the year relate to data interpretation and ownership by the wards. 8 Training 8.1 Training provision to Trust Infection control training delivered in year has included: ¾ Mandatory training for all staff ¾ Trust induction ¾ Clostridium difficile roadshow ¾ Hand hygiene training ¾ Actichlor plus training ¾ Pandemic flu training ¾ Face fit testing 8.2 Training undertaken by infection control team The ICN has attended a Cleanyourhands workshop. 9 Policy Review During 2008/2009 the Trust reviewed its corporate documents relating to infection control. CCO utilises WUTH Infection Control manual. List policies reviewed and amended ¾ Neutropenic sepsis pathway ¾ Aminoglycosides ¾ Antibiotic policy developed ¾ Clostridium difficile associated disease policy ¾ Isolation of infectious patients ¾ MRSA ¾ Outbreak control contingency planning ¾ Closure of wards, departments and premises to new admissions. ¾ Infeciton control policy Strategy The Trusts infection control strategy was approved by the Trust Board in September 2007. This brings together a range of planned developments ensuring full compliance with all relevant national guidance documents and legislation into a work plan monitored by the infection control committee. The work plan is refreshed at least annually.
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10 Assurance framework The Trust has an assurance framework in place to manage the risks associated with healthcare associated infections. ¾ The principle objectives for HCAI are contained within the Infection Control Strategy ¾ The principle risks are contained within an infection control risk assessment which has been reviewed and updated quarterly throughout the year. ¾ Key controls and assurances are contained within both the infection control strategy and the risk assessment / risk register ¾ A clear reporting mechanism to the Trust Board, Integrated Governance, Risk Management Committee and the Infection Control Committee are in place.
11 Pandemic flu During 2008/09 the Trust participated in a regional audit of its pandemic flu planning arrangements. The revised Pandemic Flu plan was approved by the Trust Board in December 2008. An external review by the SHA was undertaken. The methodology used considered the affirmative answers to the National Audit (this is how the Department of Health will consider the responses) and converted this to a % figure. Using a RAG status, organisations with under 70% were considered ‘Red’, 71-85 % ‘Amber’, and 86 -100 % were considered ‘Green’. CCO scored 87% and therefore given a RAG status of Green. The Trust also participated in exercise Rising Tide, a regional test of pandemic flu planning arrangements. 12. Patient Feedback Care Quality Commission annual patient survey The Trust scored in the top 20% for the following infection control related questions: ¾ In your opinion, how clean was the hospital room or ward that you were in? ¾ How clean were the toilets and bathrooms that you used in hospital? ¾ As far as you know, did doctors wash or clean their hands between touching patients? CCO scores the top score As far as you know, did nurses wash or clean their hands between touching patients? CCO were 1 away from top score The Trust received no formal complaints relating to infection control. 13. Freedom of Information Requests 38/08 42/08 96-08 103/08 128/08 130/08
Decontamination of Surgical Instruments Deep Cleaning Cleaning Services Financial Targets for CDiff Financial Targets for CDiff CDiff Capital Change Fund
2009 09/09 27/09
Hospital Acquired MRSA CDiff and MRSA Health Protection Figures 11
14. Infection Control Objectives for 2009/10 In addition to the current infection control programme of work key objectives for 2009/10 include: ¾ Review of new Hygiene Code and development of action plan to ensure ongoing full compliance ¾ Review of Clostridium Difficile infection: how to deal with the problem (DH) and development of action plan to ensure ongoing full compliance ¾ Amendment to current infection control SLA to then appoint an additional ‘CCO’ infection control nurse: band 8a, leaving the medical and pathology element covered by the Wirral SLA. ¾ Further development of High Impact Interventions programme using the Saving Lives website ¾ Isolation education ¾ Further policy development ensuring ongoing compliance with the Health Act ¾ Development of the hand hygiene policy ¾ Further development of the audit and surveillance programme.
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Appendix 1: Weekly hand hygiene audits in all clinical areas. Incorporated in this are audits looking at bare below the elbows. Weekly Hand Decontamination Report Running Performance 2008 CCO
04/08
11/08
18/08
25/08
90
100
100
100
100
100
100
100
100
100
100
100
100
100
100
90
100
100
Conway Delamere Diagnostic Imaging Mersey
90
OPD
80 NR
100 100
100 NR
1/9
100 NR
8/9
15/9
100 NR
90
22/9
29/9
6/10
13/10
20/10
27/10
100
80
100
100
100
100
100
100
80
90
100
3/11
10/11
17/11
24/11
80
100
100
100
80
100
100
100
100
60
100
100
80
90
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
90
100
100
100
100
100
NR
NR
Radiotherapy Sulby
100
100
100
100
100
100 2009
CCO
01/12
08/12
15/12
22/12
29/12
5/01
12/01
19/01
26/01
02/02
09/02
16/02
23/02
02/03
09/03
16/03
23/03
Conway
100
100
100
100
100
100
90
100
100
100
100
100
100
100
100
100
90
Delamere Diagnostic Imaging
100
100
100
100
90
100
100
100
100
100
100
100
100
100
100
100
100
90
100
90
70
90
100
100
100
100
100
100
100
100
100
90
Mersey
100
100
90
100
100
100
100
100
100
100
100
100
100
100
100
100
100
OPD
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
100
NR
NR
Radiotherapy Sulby
40 100
100
100
100
100
100
100
100
Planning
100
100
100
100
100
100
100
100 100
Key =
100%
=
80 - 90%
=
Below 80%
N/R
=
No results received
CLO
=
Ward closed
N/S
=
10 Observations not carried out
13
100
National Cleaning Standards Scoring Matrix 2008-2009 Audits 12
Clatterbridge Centre of Oncology NHS Foundation Trust 2008
C.C.O. Functional Area Conway Ward Delemere Ward Mersey Ward Snaefell Ward Sulby Ward Cyclotron C.T Scann O.P.D. Foyers / core area Gamma J.K.Douglas Physics M.V. / V 6 R.T.6 Med rec / Portercabi Mould up & down M.R.I R.T.School.C.T.Plan Theatre Dee Ward
QMM MMcG MMcG MMcG MMcG MMcG MMcG MMcG MMcG MMcG MMcG MMcG MMcG MMcG MMcG MMcG MMcG MMcG MMcG MMcG (Closed)
Supervisor JF JF JF JF JF JF JF CK CK CK CK CK CK KG CK JF CK CK KG
Weighting 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 7
Apl 98 98 98 98 93 95 98 98 98 98 95 98 98 98 95 93 95 95 95
Page 8 of 8 Date : 08.04.09
2009 May 95 98 98 98 93 98 98 98 98 98 95 95 95 95 95 93 95 98 98
Jun 98 98 95 98 90 98 98 98 90 98 95 95 98 98 98 95 95 98 98
July 95 98 95 98 93 98 95 98 95 98 95 93 95 95 96 95 95 94 98
Aug 95 98 95 98 93 98 98 98 98 98 98 95 98 98 98 95 98 94 98
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Sept 95 98 95 98 93 95 98 98 95 98 95 95 98 98 96 93 98 95 98
Oct 95 98 98 98 98 95 98 98 95 98 95 95 98 98 96 95 95 96 98
Nov 95 98 98 98 95 98 95 98 95 98 95 98 98 98 98 93 98 95 98
Dec 95 98 98 98 95 98 98 98 98 98 95 95 98 98 95 93 98 98 98
Jan 98 98 98 98 98 98 98 98 95 98 95 98 95 98 98 93 98 98 98
Feb 95 98 98 98 95 95 98 98 98 98 95 98 97 98 97 93 95 98 98
Mar 98 98 98 98 98 98 95 98 98 95 95 98 95 98 97 95 95 98 98
Total 1152 1176 1164 1176 1134 1164 1167 1176 1153 1173 1143 1153 1163 1170 1159 1126 1155 1157 1173
Average x weighting 4608 4704 4656 4704 4536 4656 4668 4704 4612 4692 4572 4612 4652 4680 4636 4504 4620 4628 8211
.
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