Download 2011/12 Infection Control Annual Report

ANNUAL REPORT 2011/2012
Emma Dowling
Matron Infection Prevention & Control
Dr Stephen Barrett
Director of Infection Prevention & Control
INFECTION PREVENTION & CONTROL DEPARTMENT
INFECTION PREVENTION
AND CONTROL DEPARTMENT
CONTENTS
GLOSSARY .......................................................................................................................... 3
EXECUTIVE SUMMARY ........................................................................................... 4
2
BACKGROUND INCLUDING INFECTION PREVENTION AND CONTROL
ARRANGEMENTS ............................................................................................................... 5
3
REPORTING AND COMMUNICATION ..................................................................... 7
3.1
Out of hours service ............................................................................................ 7
3.2
Internal Reporting Arrangements ........................................................................ 7
4
REPORTS TO THE EXECUTIVE TEAM AND TRUST BOARD ................................ 8
4.2
MRSA Bacteraemia............................................................................................. 9
4.3
MRSA bacteraemia summary Root Cause Analysis (RCA) ................................ 9
4.4
MRSA screening ............................................................................................... 10
4.5
Meticillin Sensitive Staphylococcus aureus bacteraemia .................................. 11
4.6
Escherichia coli bacteraemia............................................................................. 12
4.7
Legionella .......................................................................................................... 12
4.8
Clostridium difficile associated diarrhoea .......................................................... 13
4.9
Other Resistant Bacteria ................................................................................... 17
5
OUTBREAKS, WARD CLOSURES, PERIODS OF INCREASED INCIDENCE ...... 17
5.1
Multidrug resistant Acinetobacter baumannii .................................................... 17
5.2
Norovirus outbreak April 2011- March 2012 ...................................................... 18
6
SURGICAL SITE INFECTION SURVEILLANCE..................................................... 18
7
SAVING LIVES: HIGH IMPACT INTERVENTIONS ................................................ 20
8
TRAINING AND EDUCATION ................................................................................. 21
8.1
Infection Prevention Mandatory training ............................................................ 21
8.2
Infection Prevention and Control Link Nurses ................................................... 22
9
COMPLIANCE AGAINST HYGIENE CODE ............................................................ 23
10
INFECTION PREVENTION AND CONTROL POLICIES......................................... 24
11
AUDIT ...................................................................................................................... 24
12
PATIENT ENVIRONMENTAL ACTION TEAM (PEAT) INSPECTION .................... 25
12.1
Environmental audit .......................................................................................... 26
13
KEY ACTIONS / ACHIEVEMENTS IN INFECTION PREVENTION FOR 2011/12 .. 27
14
OBJECTIVES AND WORK PLAN FOR 2011/12 .................................................... 27
Appendix 1
Infection Prevention and Control Programme for 2012/2013 .................. 28
Infection Prevention & Control Annual Report 2011/2012
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INFECTION PREVENTION & CONTROL
1
GLOSSARY
CNS
Advisory committee on Antimicrobial Resistance and
Healthcare Associated Infection
Clinical Nurse Specialist
DH
Department of Health
DIPC
Director of Infection, Prevention & Control
C diff
Clostridium difficile
CDI
Clostridium difficile infection
HCAI
Healthcare Associated Infection
IPC
Infection Prevention & Control
IPCN
Infection Prevention & Control Nurse
IPCT
Infection Prevention & Control Team
KPI
Key Performance Indicator
MRSA
Meticillin resistant Staphylococcus aureus
MSSA
Meticillin sensitive Staphylococcus aureus
OPD
Out patients Department
PCT
Primary Care Trust
RCA
Root cause analysis
SHA
Strategic Health Authority
SSI
Surgical Site Infection
SUHFT
Southend University Hospital Foundation Trust
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INFECTION PREVENTION & CONTROL
ARHAI
1 EXECUTIVE SUMMARY
All NHS organisations must ensure that they have effective systems in place to control
University Hospital NHS Foundation Trust’s overall risk management strategy.
The Trust puts infection prevention and control and basic hygiene at the heart of good
management and clinical practice, and is committed to ensuring that appropriate resources
are allocated for effective protection of patients, their relatives, staff and visiting members of
the public. In this, emphasis is given to the prevention of healthcare associated infection, the
reduction of antibiotic resistance and the sustained improvement of cleanliness in the
hospital.
This report outlines activity and events related to infection prevention and control for the
period from 1 April 2011 to 31 March 2012.

The Trust achieved the MRSA bacteraemia objective set by the DH, namely a single
MRSA bacteraemia was diagnosed against the ceiling of 1.

There were 32 Clostridium difficile cases against a ceiling of 26 (23% over target).

The Trust implementation of ‘Saving Lives’ continued and included the application of
evidence based improvements in intravenous line care, isolation utilisation, antibiotic
usage and the surgical site infection bundle.

Increased engagement and ownership of infection prevention and control continued,
and was enhanced by performance monitoring with feedback including the
surveillance of infections, hand hygiene compliance and the Trust-wide emphasis of
quality and safety.

The Trust achieved the overall target of 97% hand hygiene compliance during this
period and many areas achieved more. Training in hand hygiene for all staff and
improvements to hand hygiene facilities continued.

Training in infection prevention and control included outbreak management and was
delivered through staff induction, mandatory updates, link nurse sessions and ward
based update sessions.

There were three outbreaks during this period which were associated with norovirus.
In total 161 bed days were lost due to the norovirus outbreaks.

A period of increased incidence of multidrug resistant Acinetobacter baumannii
(MRAB) occurred, predominantly involving the Wound Management Unit and Kitty
Hubbard Ward.
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INFECTION PREVENTION & CONTROL
healthcare associated infection. The prevention and control of infection is part of Southend

The key risks during this period were predominantly associated with maintaining
standards of cleaning and the decontamination of equipment.

There were three HCAI’s during this period that were reported as Seroius Incidents
throught the IPCC and the Clinical Assurance Committee (CAC).
2 BACKGROUND INCLUDING INFECTION PREVENTION AND
CONTROL ARRANGEMENTS
The Infection Prevention & Control Department provides the infection prevention and control
service for Southend University Hospital NHS Foundation Trust. The work of the Infection
Prevention and Control Department supports the Trust in minimising the risk of healthcare
acquired infection to patients in accordance with and taking into account:

Winning ways (DH 2003)

Towards Cleaner Hospitals and lower rates of infection (DH 2004)

A matron’s charter: an action plan for cleaner hospitals (DH 2004)

Revised guidance on contracting for cleaning (DH 2004)

Saving Lives: A delivery program to reduce healthcare associated infection (HCAI)
including MRSA (DH 2005)

Going further faster: implementing the Saving Lives delivery program (DH 2006)

The national specifications for cleanliness in the NHS: a framework for setting and
measuring performance outcomes. (National Patient Safety Association 2007)

Essential steps to safe clean care (DH 2007)

Clean, safe care: reducing infections and saving lives (DH 2008)

Board to ward how to embed a culture of HCAI prevention in acute trusts (DH 2008)

The Health Act 2008 Code of Practice for the NHS on the prevention and control of
healthcare associated infections and related guidance (DH 2009).
Infection Prevention & Control Annual Report 2011/2012
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INFECTION PREVENTION & CONTROL
(SI’s).These were investigated and action plans implemented and monitored

Clostridium difficile infection: How to deal with the problem (Health Protection Agency
& DH 2009)
NHSLA (National Health Service Litigation Authority) Risk management standards

NICE - National Institiute for Health and Clinical Excellence (2011) Quality
Improvement Guide; Prevention and control of Healthcare Associated
Infections www.nice.org.uk
2.1 The infection prevention and control service is delivered and facilitated by an infection
control team which includes: 1 WTE Infection Prevention and Control Matron, 2 WTE
Infection Prevention and Control Nurse Specialists and 0.8 Personal Assistant.
2.2 The Director of Infection Prevention and Control (DIPC) is a Consultant Microbiologist.
The DIPC is directly accountable to the Chief Executive and has direct reporting lines to the
Director of Nursing and medical directors. The DIPC is responsible for the strategy, policies,
implementation and performance relating to infection control and ensuring an annual report is
produced. The DIPC attends the Trust board and other meetings as planned or required.
2.3 The core infection prevention service includes an infection control advisory service,
proactive infection prevention work and education and training throughout the organisation. It
also undertakes audit, policy formulation and advice, surveillance and epidemiology,
outbreak and control management.
2.4 The IPC team (IPCT) meets weekly formally to review infection control issues and
performance. A co-ordinated plan of work is agreed and disseminated. Minutes of this
meeting are available from the IPCT.
2.5 Infection control link-staff meet quarterly. The programme is facilitated by a member of
the IPCT (see 7.2)
2.6 The Trust infection prevention and control committee (IPCC) is chaired by the DIPC and
met monthly during 2011/12 with representatives from boards and key service areas. The
minutes are available from the IPCT. This committee reports to the Clincal Assurance
Committee (CAC)
2.7 The Infection Control Team 2011/12: The Trust has a proactive infection prevention and
control team that is very clear on the actions necessary to deliver and maintain patient safety.
Equally, it is recognised that infection prevention and control is the responsibility of every
member of staff and must remain a high priority for all to ensure the best outcome for
patients.
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INFECTION PREVENTION & CONTROL


Dr Stephen Barrett - Consultant Microbiologist and Director of Infection Prevention &
Control
Dr Marilyn Meyers - Consultant Microbiologist

Sue Hardy - Director of Nursing and Executive Lead for Infection Prevention & Control

Cheryl Schwarz - Associate Director of Nursing

Emma Dowling - Infection Prevention and Control Matron

Judith Holdsworth - CNS

Claire Whittington - CNS

Elaine Bibby - PA to Consultant Microbiologists & Administrator to Microbiology Dept

Laura Search – Personal Assistant to the Infection Control Team
3 REPORTING AND COMMUNICATION
The IPCN’s and Medical Microbiologists are in daily contact in relation to operational issues
and there is a planned and minuted weekly meeting. The Director of Infection Prevention
and Control may attend the Executive Team Meeting once a month to provide assurance
against trajectories and compliance against the Health and Social Care Act (2008) and an
update of any other relevant matters. In addition they meet regularly with the Executive Lead
for Infection Prevention and Control.
3.1
Out of hours service
The IPCN team provide 24 hours availability on call rota. The Consultant Microbiologists are
also available on a rota out of hours.
3.2
Internal Reporting Arrangements
The Infection Control Committee meets monthly. The IPCC is responsible for monitoring
implementation of the annual programme and the Care Quality Commissions outcome 8,and
the Health and Social Care Act (2008). It formally reports to the CAC. The committee is the
main forum for discussions concerning changes to policy or practice relating to infection
prevention and control. The membership of the committee is multi-disciplinary and includes
representation from all business units, senior management and external agencies such as
the HPA and PCT commissioners.
Infection Prevention & Control Annual Report 2011/2012
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INFECTION PREVENTION & CONTROL

3.3
CQC visit
In July 2011 the Trust had an unannounced visit from the CQC who looked at standards of
cleanliness and infection control. The Trust received a positive report, concluding: “People
reasonable protection against the risks of infection.”
4 REPORTS TO THE EXECUTIVE TEAM AND TRUST BOARD
Monthly assurance is provided to the Executive Team on MRSA, MSSA, Escherichia coli
bacteraemias and Clostridium difficile cases. The Executive Team also receives information
on the current position concerning MRSA hospital colonisation, MRSA screening compliance,
High Impact Interventions compliance and quarterly risk assessment for compliance with the
Code of Practice. Quarterly compliance reports are provided to the PCT electronically for
reporting to the SHA and via the Clinical Quality Review Group as direct reporting as KPI’s.
The Trust Board are kept informed on a monthly basis of all the mandatory surveillance
reports and updated in relation to the Infection Prevention Risk Register.
4.1
Infection Prevention and Control Risk Register
The following risks remain on the IPC Risk Register after review by the IPC Matron
ID
Risk Title
Existing
risk
level
37
Healthcare associated infection (MRSA bacteraemia) may LOW
lead to patient harm or morbidity
573
Outbreak (defined as 2 incidents over 2 weeks) of C.difficile LOW
may lead to patient harm
687
Failure of sluice washer disinfectors may lead to cross LOW
contamination and service disruption
1630
Healthcare associated infection (MRSA colonisation) may LOW
lead to patient harm
1631
Healthcare associated infection (Clostridium difficile) may LOW
lead to patient, staff and visitor harm
1647
Incorrect use or disposal of used sharps may lead to injury or LOW
ill health from exposure to blood-borne viruses
1731
Staff failure to adhere to ward visiting restrictions and LOW
infection
control
interventions,
during a
suspected or
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INFECTION PREVENTION & CONTROL
can be confident that they will receive treatment in a clean environment and will receive
confirmed
Norovirus
outbreak
may
lead
to
cross
contamination and further disruption to hospital services
1803
Failure to reduce rates of C.difficile in line with challenging HIGH
Monitor Governance rating
1823
Failure to meet challenging Trust performance target for HIGH
MRSA bacteraemia may impact on our reputation and
Monitor Governance rating
1816
Failure to maintain the negative pressure isolation rooms to LOW
the required standard may lead to cross contamination
4.2
MRSA Bacteraemia
For 2011/12 the Trust was set a trajectory of not more than one case of MRSA bacteraemia.
This was achieved with a single case diagnosed in October 2011:
Southend University Hospital NHS Foundation Trust
MRSA Information 2011-2012
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Specimens allocated to Acute Trust
0
0
0
0
0
0
1
0
0
0
0
0
Monthly objective ceiling
1
0
0
0
0
0
0
0
0
0
0
0
Year to date Acute Trust specimens
0
0
0
0
0
0
1
1
1
1
1
1
4.3
MRSA bacteraemia summary Root Cause Analysis (RCA)
RCAs are undertaken for any MRSA bacteraemia by the IPCN and Consultant managing the
patient. The RCAs are discussed at a meeting chaired by the Director of Infection Prevention
and Control with a remedial action plan developed with immediate effect. Details of the single
case diagnosed are as follows:
Date
received
October 2011
> 48 hours after
admission
Yes
Age
82 yrs (male)
Known MRSA
carrier
no
The RCA revealed poor documentation on the Invasive Device Tool (IDT) and therefore an
action plan was developed to improve completion of IDT by all Health Care Professionals
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INFECTION PREVENTION & CONTROL
Trust performance targets may impact on our reputation and
4.4
MRSA screening
The DH required all Trusts to screen all elective patients for MRSA starting on April 1st 2009,
and all other admissions as soon as possible thereafter, but no later than 2011. Patients at
referral at their OPD appointment. The IPCT receives confirmation of these results from the
Microbiology Department. All patients with a positive screen result are contacted informing
them of their result and a letter sent to the patient. Their GP receives a letter/fax advising on
the correct topical decontamination protocol to be prescribed for the patient and advice on
follow up screening.
The Trust has procedures in place to comply with requirements to screen all admissions
other than the exceptions defined by the DH.
Elective screening data
YTD
Total elective admissions
13621
Elective admissions screened
11661
% of elective Admissions screened
85.6%
Emergency screening data
Total emergency admissions
15447
Emergency admissions screened
14131
% of emergency admissions screened
91.5%
The large numbers of patients selected for pre-admission screening has been reflected in
very little transmission of MRSA within the hospital since most patients are detected and
decolonised before admission (Figs 1 and 2).
Infection Prevention & Control Annual Report 2011/2012
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INFECTION PREVENTION & CONTROL
Southend University Hospital NHS Foundation Trust are screened for MRSA at point of
Fig 1
New MRSA acquisitions
All directorates April 09– March 2012
INFECTION PREVENTION & CONTROL
MRSA Hospital Acquisition - April 2009 - to date
9
8
7
6
5
4
3
2
1
ec
-1
1
Fe
b12
D
ec
-1
0
Fe
b11
A
pr
-1
1
Ju
n11
A
ug
-1
1
O
ct
-1
1
D
-0
09
Fe
b10
A
pr
-1
0
Ju
n10
A
ug
-1
0
O
ct
-1
0
D
ec
-
9
9
O
ct
9
ug
-0
A
pr
A
Ju
n0
09
0
Fig 2
MRSA activity
(New hospital and community acquisition cases)
April 2009– March 2012
MRSA acquisition - April 2009 - to date
35
30
25
20
15
10
5
09
Fe
b10
A
pr
-1
0
Ju
n10
A
ug
-1
0
O
ct
-1
0
D
ec
-1
0
Fe
b11
A
pr
-1
1
Ju
n11
A
ug
-1
1
O
ct
-1
1
D
ec
-1
1
Fe
b12
ec
D
9
-0
9
O
ct
9
ug
-0
A
pr
A
Ju
n0
09
0
Hospital acquired pt
4.5
community acquired pt
Meticillin Sensitive Staphylococcus aureus bacteraemia
The DH extended mandatory surveillance to include MSSA bacteraemia from January 2011
in Gateway Reference 15353; the Trust had already been reporting MSSA bacteraemias
voluntarily since the beginning of 2010. Fig 3 shows MSSA bacteraemias detected during the
year and whether they were considered Community-acquired (<48 hours after admission), of
Hospital-acquired (>48 hours after admission).
Infection Prevention & Control Annual Report 2011/2012
Page 11 of 32
Fig 3
Total Meticillin Sensitive Staphylococcus aureus
(MSSA) bacteraemias by month April 10 –March 12
7
6
5
4
3
2
1
A
0
10
r
p-
lJu
10
0
t-1
Oc
1
n- 1
Ja
Ap
1
r-1
lJu
11
<48 hours
4.6
1
t-1
Oc
2
n- 1
Ja
>48 hours
Escherichia coli bacteraemia
The DH extended mandatory surveillance reporting to include bacteraemias due to this
organism from June 2011; the Trust has been collating this information since April 2010.
4.7
Legionella
Legionella bacteria, which cause legionellosis, are naturally widespread in water systems.
The Trust continues to take this responsibly very seriously and is aware of the risks inherent
in a multi building site with a number of older buildings.
Water samples are routinely taken across the organisation as part of a planned preventative
measure against legionellosis. Results from a number of samples taken prompted some
remedial housekeeping actions to be taken. Expert advice was sought from the Consultant of
Communicable Diseases (CCDC) at the HPA to ensure that best practice was followed and
the Trust Policy has been reviewed and updated accordingly. The Trust Health and Safety
and Infection Prevention and Control Committee receive regular and comprehensive reports
on legionella data.
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INFECTION PREVENTION & CONTROL
SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST
MSSA BACTERAEMIA APRIL 2010 - MARCH 2012
4.8
Clostridium difficile associated diarrhoea
The figures below demonstrate a month on month breach of the objective ceiling for the Trust
in relation to Clostridium difficile, with a final outturn of 6 cases over the objective ceiling of 26
There was significant scrutiny during October from the SHA, PCT, and Monitor as the Trust
experienced an unexpected rise in new hospital acquired cases of Clostridium difficile.
However despite intense investigation and a peer review undertaken by an independent
Consultant Microbiologist no specific cause was identified to account for this breach. Equally
all of the RCA’s undertaken between April 2011 and March 2012 did not reveal evidence of
specific concerns/causal factors to account for the month on month breaches.
Southend University Hospital NHS Foundation Trust
Clostridium difficile infections information 2011-2012 (Patients aged 2 and over)
Apr
Specimens allocated to Acute Trust
Monthly objective ceiling
Year to date Acute Trust specimens
Year to date Acute Trust objective ceiling
3
3
3
3
May Jun
2
1
5
4
Jul
3
2
8
6
Aug
5
1
13
7
3
2
16
9
Sep
Oct
1
3
17
12
Nov
9
3
26
15
2
2
28
17
Dec
2
2
30
19
Jan
Feb
1
2
31
21
1
2
32
23
Mar
0
3
32
26
Infection Prevention & Control Annual Report 2011/2012
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INFECTION PREVENTION & CONTROL
cases or 23% over target.
Hospital acquired
Clostridium difficile cases by month
April 2010 – March 2012
INFECTION PREVENTION & CONTROL
Hospital acquired C difficile 2010 - to date
10
9
8
7
6
5
4
3
2
1
Ap
r-1
Ma 0
y10
Ju
n10
Ju
l-1
Au 0
g1
Se 0
p10
Oc
t-1
0
No
v10
De
c10
Ja
n1
Fe 1
b11
Ma
r -1
1
Ap
r-1
Ma 1
y11
Ju
n11
Ju
l-1
Au 1
g1
Se 1
p11
Oc
t-1
1
No
v11
De
c11
Ja
n1
Fe 2
b12
Ma
r -1
2
0
NB: Dept of Health Gateway letter 15766 – 17th March 2011
Non clinically significant C. difficile infection is not required to be reported as HCAI infection.
Main themes from the CDI RCA’s
Main themes identified from RCA’s undertaken
Stool chart not commenced on admission
Poor documentation relating to reasons for obtaining stool specimen.
Poor documentation - incomplete records on Bristol Stool Chart
Delay in isolation at onset of symptoms
Stool specimen within 48 hours of having laxatives
Delay in sending stool specimen
Stool specimen taken within 24hrs of bowel preparation
Risk assessment should be completed if not safe to isolate patient
No verbal handover of history of loose stools on transfer to another ward
Failure to isolate symptomatic patient promptly - in accordance with Isolation Policy
Infection Prevention & Control Annual Report 2011/2012
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RCA findings
Quarters 1- 4 2011/12
17
57%
0
0%
0
0%
7
23%
0
1
2
3
10%
3
4
3
10%
5 or more
The RCA process has identified that in many cases patients presenting with CDI have more
than one risk factor. An increased number of risk factors a patient may increase the
predisposition for CDI. Risk factors comprise: multiple co morbidities, underlying bowel
disease, high risk medications, advanced age, multiple hospital admissions, bowel surgery
and immunosuppression.
Patients on
High Risk Medications
Quarters 1- 4 2011/12
83%
87%
Nutritional Supplements
PPIs
Steroids
Chemotherapy
Anti-motility
33%
57%
Laxatives
Anti-ulcer
63%
10%
17%
17%
Antibiotics
Studies confirm that antibiotics predispose to CDI and also indicate a potential link with
Proton Pump Inhibitors (PPI). In addition, laxatives, nutritional supplements and
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INFECTION PREVENTION & CONTROL
Number of Risk Factors per Case
chemotherapy are indicated as potential factors in CDI therefore all of these medications are
included in the RCA’S report.
Quarters 1- 4 2011/12
5
17%
17
56%
0 - 15
8
27%
16 - 29
30 - 64
65 - 77
78+
This graph demonstrates that a high proportion of cases at this Trust are in the 78+ group
Clostridium difficile toxin (CDT) positive versus Clostridium difficile infection (CDI):
Following publication of guidance from the DH that ‘All laboratory diagnostics results should
be considered alongside the clinical presentation of the patients’ symptoms’ – Gateway letter
15766 (dated 17 March 2011), an algorithm was developed by the Infection Prevention and
Control Matron to support the process of clinical review in SUHFT. This process is
undertaken with a view to exclusion from the mandatory system for acute cases that either
are found C. difficile toxin positive when some other more obvious cause for for diarrhiea was
present, or where C. difficile is not cultured when sent for ribotyping.
Updated Department of Health (DH)/ARHAI guidance:
The above algorithm has now been superseded by recently updated DH/ARHAI guidance
(February 2012) related to combination C. difficile testing kits to promote consistency of
results. Outputs from a study commissioned by the DH have been used by ARHAI to update
the guidance to healthcare providers ‘to promote more effective and consistent diagnosis,
testing and treatment of C. difficile infection (CDI)’. Guidance for interpretation of test results
is provided and identifies cases that will and will not require inclusion in mandatory reporting
to the HPA – it is significant to note that the guidance recommends clinical assessment in
conjunction with test results to support management choices acknowledging the fact that no
test or combination of tests is infallible. An algorithm for the management of patients with
unexplained diarrhoea – suspected Clostridium difficile infection is also included in the
Infection Prevention & Control Annual Report 2011/2012
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INFECTION PREVENTION & CONTROL
Age at time of Clostridium difficile diagnosis
guidance to support the process. The DH recommends that all healthcare providers move to
a diagnostic algorithm consistent with the advice set out in the guidance from April 2012. This
guidance provides an evidenced based way of improving the accuracy of testing for the
Clostridium difficile Ward Round
In response to the DH Guidelines the DIPC arranged for weekly multidisciplinary clinical
review of all inpatient C diff patients within the Trust. This commenced in June 2011.The
review
team
includes
an
infection
prevention
and
control
doctor,
Consultant
Gastroenterologist, antimicrobial pharmacist, IPCN, Microbiology Registrar and if possible the
patient’s own clinician. The objective of the ward round is to ensure that the infection is being
treated as a ‘condition in its own right’ to ensure optimum treatment and that the patient is
receiving all necessary supportive care.
4.9
Other Resistant Bacteria
The only in exceptional multi-antibiotic resistant bacterium noted in the Trust was multi-drugresistant Acinetobacter baumannii which continued to be detected at a low level, as
described below.
5 OUTBREAKS, WARD CLOSURES, PERIODS OF INCREASED
INCIDENCE
5.1
Multidrug resistant Acinetobacter baumannii
The Trust experienced a period of increased incidence (PII) of multi-resistant Acinetobacter
within Southend University Hospital NHS Foundation Trust, between 24.12.11 and 21.02.12,
affecting the Wound Management Unit, Kitty Hubbard Ward and the Surgical High
Dependency Unit.
Acquisition of MRAB is multifactorial related to environmental contamination and contact with
transiently colonised health care workers.
Control measures addressing these potential sources of MRAB were successful in
terminating this PII. On-going surveillance and continued attention to hand hygiene and
environmental cleaning are essential to prevent the reoccurrence patients becoming
colonised.
Infection Prevention & Control Annual Report 2011/2012
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INFECTION PREVENTION & CONTROL
infection, and delivering better patient management and care.
An examination of ward practices and enhanced environmental decontamination was
undertaken with continued promotion of good hand hygiene practices via IPC training .Also
the introduction and development of a ward based ‘cleaning champion’ on all wards Trust-
It should be noted that although exhibiting resistance to almost all antibiotics, Acinetobacter
baumannii is of very low virulence and no patients have been found suffering significant
sepsis attributable to the organism.External advice was sought from the HPA, but no further
action (s) were suggested.
5.2
Norovirus outbreak April 2011- March 2012
It was necessary to close three wards and one bay during the period April 2011 – March
2012 due to suspected Norovirus. The Trust has seen a smaller number of cases than last
year, but due to the prompt response from staff, the management successfully minimised the
impact on operational performance, safeguarding the quality of clinical care.
Summary of Ward Closures due to Norovirus
Date
Ward
April 2011
March 2012
March 2012
March 2012
Blenheim
Southbourne
Blenheim (1 bay)
Westcliff
Norovirus
confirmed
yes
yes
no
yes
Days
closed
7
7
4
5
Total
Bed days
lost
24
28
4
105
161
The key lesson learnt during this period:•
The importance of a robust communication plan for staff once the outbreak is declared
over in relation to the safe decanting of patients during the deep clean process.
6 SURGICAL SITE INFECTION SURVEILLANCE

Orthopaedic Surgery
The DH requires all hospitals performing orthopaedic surgical operations (joint
replacements and implants for fracture surgery) to monitor surgical site infections
(SSI) for a minimum three month period each year.
Infection Prevention & Control Annual Report 2011/2012
Page 18 of 32
INFECTION PREVENTION & CONTROL
wide is now under development.
Trust Surgical Site Surveillance programme 2011/2012:
Category
April – June 2011
Repair of neck of femur
Hip replacements
Amputations
Repair neck of femur
Hip replacement
Repair neck of femur
Hip replacement
Abdominal hysterectomy
Amputations
July – September 2011
October – December 2011
January – March 2012
Closing date for
data submission
30th September 2011
31st December 2011
31st March 2011
30th June 2012
Results obtained from the Health Protection Agency’s Surveillance of Surgical Site
Infections.
April – June 2011
Category
Repair neck of
femur
Hip replacement
Amputations
Total
number of
SUHFT
operations
Number of
SSI’s
75
98
16
SUHFT
(%infected)
Total no. of
operations
for all
hospitals
Total no. of
SSI’s for
all
hospitals
All
hospitals
(%
infected)
0
0.0%
44352
832
1.9%
1
1.0%
183040
2102
0
0.0%
2530
141
5.6%
1.1%
July – September 2011
Category
Repair neck of
femur
Hip replacement
Total
number of
SUHFT
operations
Number of
SSI’s
SUHFT
(%infected)
Total no. of
operations
for all
hospitals
Total no. of
SSI’s for
all
hospitals
All
hospitals
(%
infected)
50
2
4.0%
48265
896
1.9%
102
1
1.0%
188865
2147
1.1%
*Although figures indicate our infection rate for Repair repair of neck of femur for July –
Spetember was above that of all other hospitals, this involved only 2 patients with infections
at SUHFT. For the overall period April – December 2011, SUHFT’s repair of neck of femur
infection rate was below the national average.
Infection Prevention & Control Annual Report 2011/2012
Page 19 of 32
INFECTION PREVENTION & CONTROL
Period
Both infections were unlinked cases, isolated different organisms and were under different
consultants. There were no practice issues raised.
Our infection rate for total hip replacements was consistently inline with the national average
Category
Repair neck of
femur
Hip replacement
Abdominal
hysterectomy
Total
number of
SUHFT
operations
Number of
SSI’s
SUHFT
(%infected)
Total no. of
operations
for all
hospitals
Total no.
of SSI’s for
all
hospitals
All
hospitals
(%
infected)
38
0
0.0%
52397
959
1.8%
86
1
1.1%
193182
2206
1.1%
46
0
0.0%
6152
205
3.3%
During this surveillance period we reported nil SSI’s for Repair of neck of femur, and also for
total abdominal hysterectomy.
7
SAVING LIVES: HIGH IMPACT INTERVENTIONS
Saving Lives was introduced by the DH in June 2005.The High Impact Intervention tools are
based upon a ‘care bundle’ concept , integrating the latest evidence based guidelines and
providing a means for staff to measure compliance to key clinical procedures. High impact
interventions assist clinical governance by ensuring that all patients receive a consistently
high quality care.
During 2011/2012 audits were undertaken on the following care bundles.
Hand hygiene – Trust wide audited compliance percentage
HII 1: Central venous catheter care bundle – insertion
HII 1: Central venous catheter care bundle – on-going care
HII 2: Peripheral intravenous cannula care bundle – insertion
HII 2: Peripheral intravenous cannula care bundle – on-going care
HII 3: Renal dialysis catheter care bundle - insertion
HII 3: Renal dialysis catheter care bundle – on-going care
HII 4: Care bundle to prevent surgical site infection – pre-operative
HII 4: Care bundle to prevent surgical site infection – peri-operative
HII 5: Care bundle for ventilated patients
HII 6: Urinary catheter care bundle - insertion
HII 6: Urinary catheter care bundle – on-going care
HII 7: Prevention of spread of clostridium difficile
HII 8: To improve the cleaning and decontamination of clinical equipment
% achieved
97%
99.43%
98.03%
94.36%
95.23%
98.94%
97.6%
100%
96.6%
99%
97.66%
96.4%
100%
Nil data (see
11.1)
Infection Prevention & Control Annual Report 2011/2012
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INFECTION PREVENTION & CONTROL
October – December 2011
The results are presented monthly in graph format. Any compliance issues are addresses
through the Matrons and reported at the Infection Prevention and Control Committee.
Main teaching programme
Frequency
IPC induction for all staff (including medical)
Fortnightly
Facilities staff/Contractors
as required
Renal Unit
X 6 a year
NHS Professionals
as required
Newly qualified nurse development course
monthly
1 day IC workshop (all grades)
quarterly
IC awareness days
quarterly
Link Nurse Session
quarterly
HCA Induction (Bank)
6 times a year
Day stay theatre / Post-op
annually
Mandatory Infection Control
3x week
Junior doctors
biannually
(ARU) IC for student nurses
on request
Sharps Awareness day
Yearly
New education programmes are added as required.
8.1
Providers
IPCN/DIPC
IPCN
IPCN
IPCN
IPCN
IPCN/DIPC
IPCN/DIPC
IPCN
IPCN
IPCN
IPCN
DIPC
IPCN
IPCN
Infection Prevention Mandatory training
The IPCT continued to provide mandatory update sessions for all both clinical and non
clinical staff.
Business Units (BU)
Infection Prevention and Control
Target
Trained
%
Acute & Assessment - BU
Capital - BU
Clinical Support Services Diagnostic & Therapeutic - BU
Corporate Services
Facilities - BU
Medicine - BU
MSK Musculoskeletal - BU
Ophthalmology - BU
Reserves and Financing - BU
Surgery - BU
390 Womens & Children's - BU
647
17
803
1146
328
690
458
129
5
479
508
405
12
622
885
133
521
364
121
0
361
365
63%
71%
77%
77%
41%
76%
79%
94%
0%
75%
72%
Grand Total
5210
3789
73%
Infection Prevention & Control Annual Report 2011/2012
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INFECTION PREVENTION & CONTROL
8 TRAINING AND EDUCATION
8.2
Infection Prevention and Control Link Nurses
The IPCT continues to expand the Infection Prevention and Control Link Nurse programme.
Link Nurse Sessions are run quarterly and provide an education session, usually from a
included for example, hand hygiene, MRSA screening and outbreak management. The
sessions run for approximately two hours.
The aim of these sessions is to update on any new guidance / policies and to increase the
flow of Infection Prevention and Control communications.
Infection Prevention and Control Link Nurse Programme 2011 / 2012
Date
17.06.11
23.09.11
Guest Speaker
Discussion / Programme
Julie Coleman – Practice
Development Nurse
CQC in relation to infection control
Ruth Nicholls – Octenisan Rep
Feedback & discussion of Octenisan
Judy Holdsworth – IPCN
Quiz regarding assessment for isolation
Discussion/feedback of RCA’s undertaken & new or updated
policies
Q & A session
MRSA screening elective and emergencies -Q and A session
On line E learning programme up date
Preparation for oncoming Norovirus season-Red folders
Discussion/feedback of RCA’s undertaken & new or updated
policies
Q & A session
Compliance with Hand Hygiene Policy IC 009
MRSA screening discussion
Light box training.
Discussion/feedback of RCA’s undertaken & new or updated
policies
Q & A session
Acinetobacter up date
High Impact Intervention No 8 discussion regarding
decontamination- (Green labels)
Nursing equipment cleaning audits /cleaning register
Environmental cleaning audits
Domestic services
Introduction of Tristel
MRSA regimes /swabbing practice
Noro Virus
C diff targets update on situation-Poster When to take a stool
specimen
Claire Whittington – IPCN
Judy Holdsworth - IPCN
16.12.11
Judy Holdsworth – IPCN
08.02.12
Judy Holdsworth - IPCN
Infection Prevention & Control Annual Report 2011/2012
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INFECTION PREVENTION & CONTROL
guest speaker incorporated into the meeting. Numerous topics are covered and have
9 COMPLIANCE AGAINST HYGIENE CODE
The Health and Social Care Act 2008 Code of Practice for the prevention and control of
Healthcare Associated Infections (HCAI’s) became operational in April 2009 and revised April
sector ambulance providers.The Code of Practice outlines compliance criteria the Trust is
required to meet and supporting guidance for implementation. The Annual Work Plan and
GAP Analysis details the Trust’s compliance.
The GAP Analysis (i.e. analysis of areas where requirements are not completely met) shows
an increased compliance with the Hygiene Code. The 10 criteria and supporting evidence are
RAG (Red-Amber-Green) scored.
RED-Non –compliance based upon insufficient evidence
AMBER-Processes in place but requires development
GREEN-Evidence available to support compliance
This Trust has no red scores, which would indicate non-compliance. At the time of this report
there are now only 3-amber scores
Criterion
Compliance criteria point
1
Systems to manage and monitor the prevention and control of infection.
Those systems use risk assessments and consider how susceptible service
users are and any risks their environment and other users may pose to
them
Provide and maintains a clean and appropriate environment which
facilitates the prevention and control of HCAI.
2
3
4
5
7
8
9
10
Provide suitable accurate information on infections to service users and
their visitors. Patient information leaflets reviewed and updated
Provide suitable accurate information on infections to any person
concerned with providing further support or nursing / medical care in a
timely fashion.
Ensure that people who have or develop an infection are identified promptly
and receive the appropriate treatment are care to reduce the risk of passing
on the infection to other people.
Provide or secure adequate isolation facilities
Secure adequate access to laboratory support as appropriate
Have and adhere to policies, designed for the individual’s care and provider
organisations that will help to prevent and control infections.
Ensure, so far as reasonably practicable, that care workers are free of and
are protected from exposure to infections during the course of their work,
and that all staff are suitably educated in the prevention and control of
infection with the provision of health and social care.
Compliant
Comments
Labelling of
decontaminated
equipment needs
improvement
HII No 8
Decontamination of
Equipment Adudit
implemented March
2011
Interhealth Care
Transfer needs to
include Infection
staus
MRSA screening for
both elective and
emergency patients
not 100% compliant
European Union
directive. The
implementation of
sharp safety devices
by May 2013 .IPCT
in conjunction with
procurement to
develop a roll out
plan.
Infection Prevention & Control Annual Report 2011/2012
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INFECTION PREVENTION & CONTROL
2011.Known as the Hygiene Code it now includes primary dental care and independent
10 INFECTION PREVENTION AND CONTROL POLICIES
During 2011/12 the IPCT reviewed and updated many of the existing policies in line with
Care Act (2008) and NHSLA were being met. All Infection Prevention and Control policies are
on the Infection Control section of the Trust Intranet site. All policies are reviewed every two
years.
No.
Policy
ICN
Published
Date
02/12
Review
Date
02/14
IC007
MRSA Policy
ED
IC09
Hand Decontamination
02/12
02/14
12/11
12/13
HS 06
Prevention of Sharps Injury
ED
CW
ED
IC017
C difficile Policy
ED
01/12
01/14
IC019
Isolation Policy
ED
06/11
06/13
IC011
Surveillance Policy
ED
09/11
09/13
IC06
Control of Outbreaks Policy
ED
06/11
06/13
IC05
Infected Patients in the Operating Theatre
ED
07/11
07/13
IC014
Food Hygiene Policy
ED
AB
07/11
07/13
11 AUDIT
Code of practice for the prevention and control of Healthcare associated infections under the
Health and Social Care Act 2008 requires that all NHS organisations have in place an audit
programme to ensure key policies and practice are being implemented appropriately. This
table gives details of policies audited where practice and knowledge was examined and the
% results obtained. Nil re audit were required.
Infection Prevention & Control Annual Report 2011/2012
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INFECTION PREVENTION & CONTROL
national guidelines and best practice to ensure that the requirements of the Health and Social
Audit
C diff IC 0017
May 2011
Isolation Policy
June 2011
MRSA IC 007
C diff IC 017
July 2011
TB IC 002
Score
On-going data Audit June
97.5%
100%
99%
Nil in patient cases
On-going data collection
Oct
C diff IC 0017
August 2011
Hand Decontamination IC 009
94%
September 2011
MRSA IC 007
C diff IC 017
October 2011
99%
100%
MRSA IC 007
December 2011
January 2012
February 2012
March 2012
98%
C diff IC 0017
HINI ‘Swine Flu’ IC 023
Standard Precautions
IC 022
MRSA IC 007
99%
Nil flu patients
98%
96%
Monthly Hand Hygiene Audit Compliance Scores
Effective hand hygiene is the cornerstone of good infection prevention and control
practice.Hand hygiene is auited monthly using an observational audit.The results are
discussed at the IPCC.The colloated results are shown below.
Q1
92.5%
Q2
95.4%
Q3
99.9%
Q4
99.6%
12 PATIENT ENVIRONMENTAL ACTION TEAM (PEAT)
INSPECTION
The PEAT assessment is an annual compulsory environment audit requiring reports to be
submitted to the National Patient Safety agency for all inpatient healthcare facilities in
England with more than ten beds.
It is a benchmarking tool to ensure improvements are made in the non-clinical aspects of
patient care including environment, food, privacy and dignity, cleanliness and infection
control.
Infection Prevention & Control Annual Report 2011/2012
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INFECTION PREVENTION & CONTROL
Month
April 2011
The Trust undertook pre PEAT audits in preparation for the PEAT assessment. Element 7 of
the PEAT assessment relates to infection prevention and control. This element assesses
availability of alcohol gel, posters demonstrating hand washing technique, hand washing
Results
The table below details the PEAT assessments carried out over the past three years for
infection prevention and control (element 7).
Year
Excellent
2009
√
2010
√
2011
√
2012
√
Good
Acceptable
Poor
Unacceptable
12.1 Environmental audit
Environmental audits are carried out on a monthly basis. The audit team consist of,

Matron

Domestic supervisor

Member of the Quality Assurance Team

On a rota basis a member of the Infection Prevention and Control Team
This audit tool records the cleanliness, according to a visual check against the NHS National
Standards of Cleanliness 49 Elements. Elements include floors, walls, beds, sinks, baths and
medical equipment. The area being assessed is defined as a functional area according to the
designated risk factor.
An Audit is required to score 95% or above to pass. Audits below this score will require an
action plan and re-audit to be carried out within a specified period.
Cleanliness - % of compliance to NPSA cleanliness standards for the environment
Q1
94.9%
Q2
95.3%
Q3
95.9%
Q4
95.6%
Cleanliness - % of compliance for Patient/ Nursing Equipment standards
Q1
95.72%
Q2
93.38%
Q3
95.01%
Q4
94.24%
Infection Prevention & Control Annual Report 2011/2012
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INFECTION PREVENTION & CONTROL
facilities and that the Trust has an, update hand decontamination policy.
13 KEY ACTIONS / ACHIEVEMENTS IN INFECTION PREVENTION
FOR 2011/12
The IPCT has successfully continued to participate in the SSI surveillance programme

Improvement with compliance MRSA pre admission screening in accordance with The
DH requirements.

Achieved MRSA bacteraemia target

Infection Prevention Control Policies updated and reviewed

Fully implemented national guidance for Clostridium difficle

Infection Prevention and Control Patient information leaflets updated

‘When to take a stool specimen’ poster developed and introduced throughout the Trust

Noro virus care pathway developed and used during Noro virus outbreaks

Tristel jet introduced November 2011 for the decontamination of all commodes and
patient toilet areas

Business case produced for the curtain replacement project

Educational videos produced for mask wearing and the correct loading of the washer
disinfector bed pan washers

‘Tool box talk’ and certificate of attendance for contractors working at the Trust

Noro virus poster updated and distributed thought the Trust
14 OBJECTIVES AND WORK PLAN FOR 2011/12
The attached work programme underpins the detail of the work to be undertaken by the
infection prevention and control service to:

Implement effective systems to prevent and control Health Care Acquired Infections

Challenge and change culture, and educate all staff, patients, relatives and visitors of
the importance of all infection prevention and control procedures (including hand
decontamination)

Identify risks in infection control and work with colleagues to provide solutions to
reduce, control or eliminate those risks

Undertake audits of Infection Prevention Policies and the environment

Promote, improve the reliability of and monitor the clinical infection control practices

Provide clear, concise and evidence based policies and guidelines, which are
accessible to all staff group
Infection Prevention & Control Annual Report 2011/2012
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INFECTION PREVENTION & CONTROL

Appendix 1
Compliance criteria
point
1. Systems for the
prevention and
control of
infection. These
systems use risk
assessments and
consider how
susceptible
service users are
and any risks that
their environment
and other users
pose to them.
Infection Prevention and Control Programme for 2012/2013
Programme of work 2011/12
Quatlery Infection and Prevention report to the IPCC and PCT
commisioners
Continue to raise the profile of the Infection Prevention and Control
Team throught the Trust
Ensure Infection Prevention Team is represented in essential Trust
Committees
Present annual programme 2012/12 (including annual audit
programme) and Annual Report 2011/12 to Board of Directors
through the Quality Assurance Committee. Ensure report available to
the public. Additional briefing to Board of Directors at least yearly.
Review Healthcare associated infection risks identified on the Trust
Assurance Framework/Risk Register regularly (quarterly and when
required) and report to Board of Directors
Provide HCAI statistics for performance reporting at Board of
Directors and at the IPCC, including details of trends
Continue to undertake root cause analysis for HCAI (MRSA/MSSA
bacteraemia, Clostridium difficile).
Evidence of lessons learnt through the RCA process are shared and
agreed .Evidence of actions implemented produced.
Review all outbreaks of HCAI at the Infection Control Committee.
Assess new and existing policies with regard to infection prevention
and control and make recommendations for change
Plan and deliver a full education programme for all staff.
By whom (lead)
Evidence
Matron IPC
Report /
Date to be
achieved
ongoing
Director of Infection
Prevention Control
(DIPC) and IPCC
Matron
DON / ADN
/Matron IPC
ongoing
ongoing
DIPC / IPCC /
Matrons
Minutes / Risk
register/ Web Site
August 2012
IPC Matron
Minutes / Risk
register
Monthly /
Quarterly
DIPC
IPC Matron
DIPC, IPCT, Ward
Managers,
Matrons.
Minutes
DIPC,IPCT
IPCT
IPCT
Completed RCA
Tools. Minutes
Quarterly
Minutes. Annual
report
Update programme
with review dates
Programme /
emails /
attendance records
On going
On going
On going
Infection Prevention & Control Annual Report 2011 /2012
Page 28 of 32
INFECTION PREVENTION & CONTROL
2
Programme of work 2011/12
By whom (lead)
Evidence
Launch new e-learning module for clinical/non clinical
Commence and evaluate new style education for ongoing essential
training
 E-learning module
IPCT
Plan and deliver quarterly Link Nurse sessions.
IPCT
Review and up date Hand Hygiene audit toolContinue education and support for ward staff to undertake hand
hygiene compliance. Hand hygiene compliance to be monitored in all
in-patient areas monthly. Areas of non compliance to be discussed at
IPCC
High Impact Interventions Audits undertaken monthly. Provide
feedback at IPCC regarding progress and recommended actions.
IPCT
E learning
Programme /
presentation
material / records
of undertaking
Programme /
presentation
material / records
of attendance
Minutes
Quarterly
sessions
during
2012/2013
Aug 2012
Matrons
Graphs
On going
IPCT Matrons
Audit reports
minutes
ongoing
PEAT reports and
minutes
Evidence of sign
off of projects
As required
Update programme
with review dates
Web Site
On going
2. Provide and
maintain a clean
and appropriate
environment in
managed
premises that
facilitates the
prevention and
control of
infections.
Infection prevention input to environmental audits and report poor
compliance
Continued Infection Prevention and Control input /participation with
PEAT assessments.
Provide expert advice to all service developments to ensure infection
risks are considered and good infection prevention facilities/practices
built into the development.
In particular, ensure that infection prevention is considered in the built
environment through provision of infection prevention expertise to
capital projects from concept stages to commissioning, as well as
more minor refurbishment projects.
IPCT
3. Provide suitable
accurate
information on
infections to
service users and
Continue to produce and publish Public Information leaflets
IPCT
Update and review the contents and design of the Infection
Prevention and Control Web site
ICPT
IPCT
Date to be
achieved
July 2012
As required
ongoing
Infection Prevention & Control Annual Report 2011 /2012
Page 29 of 32
INFECTION PREVENTION & CONTROL
2
Compliance criteria
point
Programme of work 2011/12
By whom (lead)
Evidence
Date to be
achieved
4. Provide suitable
accurate
information on
infections to any
person
concerned with
providing further
support or
nursing/ medical
care in a timely
fashion
5 . Ensure that
people who have
or develop an
infection are
identified
promptly and
receive the
appropriate
treatment and
care to reduce
the risk of
passing on the
infection to other
people.
6. Ensure that all
staff and those
employed to
provide care in all
settings are fully
involved in the
process of
Review and update letters GP D/N in conjunction with PCT and local
GP’s
Audit of inter care transfer form to monitor compliance
IPCT + PCT ICN
Letters
As required
Discharge team
Audit Reports
Quarterly
Ensure evidence required by commissioners is presented to IPCC
IPCT
Minutes
On going
Continue to participate in the Surgical site Surveillance Schemes
IPCT
Programme of
categories with
collection dates.
Reports
On going
Monitor screening emergency and elective patients data and report to
IPCC and PCT-
IPCT
Develop the Infection Prevention and Control DASHBOARD
Ensure that anti-biotic compliance audit is presented to the IPCC
quarterly.This audit will monitor the general usage of antibiotcs in
adult in- patients,and this will provide compliance with the Department
of Health requirements for antimicrobial stewardship
Ongoing
Ongoing
Department of
pharmacy
Quarterly
See criterion 1 (programme of education, audit and monitoring of
practice)
Infection Prevention & Control Annual Report 2011 /2012
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INFECTION PREVENTION & CONTROL
2
Compliance criteria
point
their visitors.
Programme of work 2011/12
Provide specialist infection control advice to new build or
refurbishment projects such as bathroom facilities and isolation
facilities
By whom (lead)
Evidence
Date to be
achieved
IPCT
As required
8. Secure adequate
access to
laboratory
support as
appropriate.
Nil work issues for the IPCT
9. Have and adhere
to policies,
designed for the
individual’s care
and provider
organisations,
which will help to
prevent and
control
infections.
10.Ensure, so far as
is reasonably
practicable, that
care workers are
free of and are
protected from
Revise policies as per schedule or following publication of new
evidence/guidelines.
IPCT
As required
Continue with audit programme of IPC policies compliance with
Policies
IPCT
ongoing
Provide specialist infection prevention input to Occupational Health
policies as required.
IPCT
ongoing
Infection Prevention & Control Annual Report 2011 /2012
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INFECTION PREVENTION & CONTROL
2
Compliance criteria
point
preventing and
controlling
infection.
7.Provide or (
secures)
adequate
isolation facilities
Programme of work 2011/12
By whom (lead)
Support the Occupation Health Service Department in the importance
of staff having influenza vaccination.
IPCT
Evidence
Date to be
achieved
Infection Prevention & Control Annual Report 2011 /2012
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INFECTION PREVENTION & CONTROL
2
Compliance criteria
point
exposure to
infections that
can be caught at
work and that all
staff are suitably
educated in the
prevention and
control of
infection
associated with
the provision of
health and social
care.