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Transcript
Director of Infection Prevention and Control Annual Report 2010-11 2 Domestic Ian McGuffog polishes the corridor floors Contents Page Foreword 4 1 5 Infection Prevention and Control Arrangements 2 Summary of Reports to The Board 6 3 Healthcare Associated Infection Statistics 6 MRSA bacteraemia GRE bacteraemia Clostridium difficile diarrhoea Surgical site infection MSSA bacteraemia Outbreaks 4 Infection Prevention and Control Initiatives cleanyourhands Saving Lives/Essential Steps MRSA screening Matching Michigan Infection Control Week Quality Review Panel Link Worker Programme 10 5 Policies 13 6 Infection Prevention and Control Incidents 14 Influenza Legionnaire’s disease Tuberculosis 7 Decontamination 15 8 Providing a clean and safe environment for our patients 15 Cleaning Survey Results Our New Hospital 9 Antimicrobial prescribing 17 10 Training 18 3 Director of Infection Prevention and Control Annual Report 2010-11 Foreword I am delighted to present the Director of Infection Prevention and Control’s annual report for 2010/11. Tackling infection, while a team effort, is a vital part of my portfolio as Director of Nursing and Patient Safety. Cleanliness and not taking away an infection you didn’t bring into the healthcare service are essential to the patient experience. In years gone by we had almost come to accept that picking up infections was almost an inevitable part of the healthcare experience. I hope when you read our achievements this year you will see our culture is that we most certainly do not accept this and we are relentless in our quest to eliminate the spread of infection. Since being appointed as Director of Nursing and about by cleaning your hands when you come in to Patient Safety and Director of Infection Prevention visit; if the gel dispenser is empty please tell us so and Control I am now in a position to report on we can get a refill, stay at home if you’re ill yourself three years of performance. It was pleasing to see an and please keep isolation doors closed. If we all work improvement between 2008/9 and 2009/10 but even together we can continue to fight against the spread better to see the dramatic fall in infection in the last of infection. year. I would like to thank everyone who has contributed In this trust we always say that behind every figure is to the results we have achieved this year. I commend a patient and even one avoidable infection is one too this report to you. many. To see the stark truth of the trust’s magnificent performance last year makes me proud not only of the medical and nursing team but the many, many people in front of and behind the scenes who understand that this is such a crucial aspect of care. While it is excellent to have an end of term report which shows the fantastic strides we have all made there is no room for complacency. We will not rest until we’re the best in terms of tackling infection. Good enough just isn’t good enough for us or, more importantly, for the patients we look after. Patients place their lives in our hands. We can and we will do everything humanly possible to protect patients from infection. However I would make one plea. We will play our part but we ask one thing of 4 those visiting and caring for patients; please play your part. Help and protect the person you care Sue Smith Director of Nursing and Patient Safety Director of Infection Prevention and Control 1 Infection prevention and control (IPC) arrangements Structure The Chief Executive holds overall responsibility for infection prevention and control in the trust. The Executive Director of Nursing and Patient Safety is the designated Director of Infection Prevention and Control (DIPC) for the trust and reports directly to the chief executive and board of directors. The Infection Prevention and Control Team (IPCT) provide specialist advice on matters relating to the identification, prevention and management of infections in the trust. The team works to an agreed annual programme approved by the Infection Control Committee which is chaired by a non executive director. The team includes a Consultant Microbiologist/Infection Control Doctor, Assistant Director of Infection Prevention and Control, Assistant Matrons, Infection Prevention and Control Nurses and clerical/data entry staff. The IPCT is supported by an antimicrobial pharmacist and a biomedical scientist link in the microbiology laboratory. The DIPC also works closely with the IPCT. Reporting arrangements The reporting arrangements for the IPCT are shown in Fig 1. The operational Group for IPC is the healthcare associated infection action group which meets bi-monthly and reports to the Infection Control Committee (ICC). The ICC meets quarterly and approves policies and receives audit reports and updates on the annual programme. The IPCT is also represented on various forums across the trust including Patient Safety and Quality Standards Committee, Patient Safety Forum, Health and Safety Committee, Routine Cleaning Group, Uniform and Personal Appearance Committee, Drug and Therapeutics Committee, Estates Capital Projects Group, Decontamination Group and Education/Training Operational Group.Fig 1 Reporting arrangements The IPCT has a budget which covers pay and non pay expenses. Additional costs relating to outbreaks and investigations requiring testing of samples at reference laboratories are separately funded. Service Level Agreements with local hospices and an independent hospital are in place and generate a modest income. 5 2 Summary of reports to the Board The DIPC provides a full report on IPC related matters at each Board meeting. Issues such as performance against mandatory surveillance targets, hand hygiene, audits, outbreaks and new initiatives or reporting requirements are included in the reports. 3 Healthcare Associated Infection Statistics The IPCT carries out a programme of surveillance to meet both mandatory and local requirements. The Department of Health requires mandatory surveillance of: • Methicillin resistant Staphylococcus aureus (MRSA) bacteraemia (blood stream infection) • Glycopeptide resistant enterococcus (GRE) bacteraemia • Clostridium difficile diarrhoea • Surgical site infection • Methicillin sensitive Staphylococcus aureus bacteraemia Methicillin resistant Staphylococcus aureus (MRSA) bacteraemia MRSA is a strain of Staphylococcus aureus that is resistant to a number of antibiotics and is capable of causing a wide range of infections, including blood stream infections (bacteraemia). MRSA is carried on the skin or in the nose of a number of people without causing them any harm, but under the right circumstances the bacteria can enter the body and lead to infection. In previous years the trust has been responsible for all MRSA bacteraemia regardless of whether they were hospital or community acquired. From April 2010 a new MRSA objective was introduced, with acute trusts being responsible only for reducing those cases which were identified two or more days after the day of admission, whilst still being responsible for reporting all cases processed by their laboratories. In 2010-11 the trust has performed well and reduced the number of hospital acquired cases by 20%, reporting 4 cases against a target of 6 (table 1). A total of 4 community acquired cases were also reported. Each case is thoroughly investigated to ensure lessons are learned and errors are not repeated. All cases of MRSA bacteraemia are presented to the trust executive team by the appropriate directorate leads. Table 1. MRSA bacteraemia cases annual numbers and rates Year No of bacteraemia reported 6 No of infections per 10,000 occupied bed days 2007/8 2008/9 2009/10 2010/11 28 (hospital and community attributed cases included) 12 (hospital and community attributed cases included) 11 (hospital and community attributed cases included) 4 (hospital attributed cases only) 1.32 ( rate 0.75 for hospital attributed cases only) 0.503 ( rate 0.37 for hospital attributed cases only) 0.489 ( rate 0.23 for hospital attributed cases only) 0.19 (hospital attributed cases only) Fig.2 MRSA bacteraemia (hospital acquired cases) 2007-11 5 no of cases 4 3 2 1 Feb-11 Dec-10 Oct-10 Aug-10 Jun-10 Apr-10 Feb-10 Dec-09 Oct-09 Aug-09 Jun-09 Apr-09 Feb-09 Dec-08 Oct-08 Aug-08 Jun-08 Apr-08 Feb-08 Dec-07 Oct-07 Aug-07 Jun-07 Apr-07 0 month/year Glycopeptide resistant enterococcus (GRE) bacteraemia The Trust is required as part of the mandatory surveillance programme to report bacteraemia cases where glycopeptide resistant enterococci (GRE) is isolated. Enterococci are a group of bacteria that are commonly found in the bowel of healthy people and can cause a range of infections, including blood stream infections. GRE is a type of enterococci which is resistant to a particular group of antibiotics, and is more of a risk to hospital patients who have procedures and invasive devices such as urinary catheters and intravenous lines. GRE does not spread easily but is more difficult to treat than other infections. In 2010-11 1 case of GRE bacteraemia was reported by the trust. There is no reduction target attached to this organism. Clostridium difficile diarrhoea Clostridium difficile is an organism that causes diarrhoea, usually following antibiotic usage in vulnerable patients. This can cause complications such as pseudomembranous colitis which is a severe inflammation of the bowel, and can be life threatening. A reduction target for Clostridium difficile infection (CDI) has been in place since 2007. In 2010-11 the trust has made significant reductions in the numbers of patients acquiring this infection in hospital, reporting 53 cases against a target of 127 (table 2). This is a 61% reduction on the previous year. This reduction has largely been due to a programme of enhanced decontamination supported by collaborative working between the facilities and nursing staff. Each hospital acquired case is subject to an in-depth investigation using root cause analysis, with findings and trends being reported quarterly at the ICC. 7 Table 2. Clostridium difficile cases annual numbers and rates Year 2007/8 2008/9 2009/10 2010/11 No of hospital attributed C difficile cases reported 210 158 136 53 No of infections per 10,000 occupied bed days 9.934 6.634 6.054 2.59 Fig. 3 Clostridium difficile diarrhoea (hospital acquired cases) 2007-11 35 30 no of cases 25 20 15 10 5 Ap r-0 Ju 7 nAu 07 g0 O 7 ct -0 De 7 c0 Fe 7 b0 Ap 8 r-0 Ju 8 nAu 08 g0 O 8 ct -0 De 8 c0 Fe 8 b0 Ap 9 r-0 Ju 9 nAu 09 g0 O 9 ct -0 De 9 c0 Fe 9 b1 Ap 0 r-1 Ju 0 nAu 10 g1 O 0 ct -1 De 0 c1 Fe 0 b11 0 month/year Surgical site infection The trust has participated in the mandatory surveillance of surgical site infections entering information in relation to humeral (shoulder) fractures, tibial (shin bone) fractures and fractured neck of femur (hip) cases. At the time of reporting, the Health Protection Agency has not published the data for 2010-11. Methicillin sensitive Staphylococcus aureus (MSSA) bacteraemia Staphylococcus aureus is a bacterium commonly found on human skin which can cause infection if there is an opportunity for the bacteria to enter the body. In serious cases it can cause blood stream infection. MSSA is a strain of these bacteria that can be effectively treated with many antibiotics. The trust has been carrying out voluntary surveillance of MSSA bacteraemia cases since mid 2007. In 2010-11 a local reduction of 10% in hospital acquired cases was agreed as part of the Commissioning for Quality and Innovation (CQUIN) arrangements. The total number of cases for 2010-11 was 10 which meant that the trust achieved the reduction. Table 3. MSSA bacteraemia numbers and rates 8 Year 2008/9 2009/10 2010/11 No of hospital attributed cases reported 20 11 10 No of infections per 10,000 occupied bed days 0.83 0.52 0.49 Fig 4 MSSA bacteraemia (hospital acquired) 2008-11 4 no of cases 3 2 1 Ap r-0 8 Ju n08 Au g08 O ct -0 8 De c08 Fe b09 Ap r-0 9 Ju n09 Au g09 O ct -0 9 De c09 Fe b10 Ap r-1 0 Ju n10 Au g10 O ct -1 0 De c10 Fe b11 0 month/year Outbreaks Every year there are a number of outbreaks of diarrhoea and/or vomiting which affect patients and staff in the community and in our hospitals. The cause of these outbreaks is usually Norovirus (also known as winter vomiting bug) and this reflects a similar picture in the community, in care homes, schools, nurseries and peoples own homes. Outbreaks can have an adverse impact on the business of the trust because wards can be closed for a number of days, reducing beds available for new patients to be admitted to. This is a serious concern for the trust and a significant amount of work has gone into reducing the length of time that wards are closed, and providing a timelier and more efficient outbreak cleaning programme. Table 4 below shows that the number of hospital patients and staff affected in 2010-11 has reduced along with the number of outbreaks reported since the previous year. Table 4 Outbreak numbers and rates Year 2008/9 2009/10 2010/11 No of outbreaks 22 21 14 No of patients affected 253 211 163 Rate per 10,000 occupied bed days 10.62 9.39 7.98 No of staff affected 56 51 51 Total number affected 309 262 214 9 4 Infection Prevention and Control Initiatives Cleanyourhands (cyh) The trust continues to participate in the National Patient Safety Agency (NPSA) campaign. The NPSA will cease to exist under the reorganisation of arms length bodies, however, we will continue to promote hand hygiene in the trust using the principles of cyh and utilising the tools provided by the World Health Organisation including the 5 moments for hand hygiene. Each year we hold a hand hygiene day on 5th May which is very successful and is supported by board directors and clinical staff. Staff are encouraged to carry out hand hygiene competency assessments and prizes are awarded to competition winners. Monthly observations of hand hygiene practice are carried out in all wards, departments and services as well as in community clinics. The trust has consistently achieved a score of over 90% compliance in self assessment reviews. In 2011 we will move to peer assessment of hand hygiene. We believe that this will add rigor to the process and provide additional assurance. We also aim to promote hand hygiene for visitors to our wards and departments in order to help us reduce opportunity for infection in our hospitals. Table 5 hand hygiene compliance Trust wide % self assessment compliance with hand hygiene 2010-11 10 Apr May June July Aug Sept Oct Nov Dec Jan Feb March 91.9% 94.4% 96.6% 95.5% 98.1% 96.3% 98.9% 99.3% 98.6% 98.8% 98.3% 97.5% Saving Lives/Essential Steps Saving Lives and Essential Steps are Department of Health initiatives that support trusts to audit best practice in relation to hand hygiene, use of personal protective equipment, safe handling of sharps, intravenous line care, urinary catheter care, surgical site infection, ventilator care and Clostridium difficile. The trust has continued to participate in the Saving Lives Programme in our hospitals and the Essential Steps Programme in our community settings. Audits are performed monthly and results reported to the Board in the regular DIPC reports. Results are also discussed and challenged at the Healthcare Associated Infection Action Group. A new Saving Lives tool was introduced in May 2010 to look at cleanliness of equipment and all clinical areas in the hospital are required to complete this assessment monthly. MRSA screening MRSA screening is a process where swabs are taken from people coming into hospital so that we know if they are carrying MRSA. Samples are taken from the nose and groin using a moist cotton bud. This is done before coming into hospital for people having an operation or procedure that has been booked beforehand or on admission for those people who come into hospital as an emergency. If the swab is positive the person is given a skin wash and nasal ointment that will reduce the number of MRSA bugs and reduce the risk of infection to them and to other people. We have been screening large numbers of our patients for MRSA for a number of years now. Compliance is monitored for both emergency and elective screening and is reported to the board of directors. NPSA Matching Michigan project Since May 2009, the Trust has been participating in the National Patient Safety Agency (NPSA) Matching Michigan project which aims to reduce the risk of patients acquiring central line related blood stream infections in critical care units. The project has been very successful during 2010-11. The working group has developed updated guidance on central line insertion and care, produced a procedure box to ensure all required equipment is immediately available, updated staff on correct practices and standardised equipment. Root cause analysis is carried out for all cases of central line related bacteraemia and the findings presented at the Infection Control Committee. Work is now underway to roll the project out to the neonatal unit. 11 Infection Control Week Once again infection control week was very successful with displays and competitions on both hospital sites and the One Life Centre. This year the theme for the week was sharps safety, featuring all aspects of the safe management of sharps, using national and local statistics, and management of norovirus, reinforcing to staff the key aspects of the outbreak policy such as early recognition of potential outbreaks. Patient Experience and Quality Standards (PEQS) panel Each month the senior nurses of the trust hold a PEQS panel to look at the patient environment, nursing documentation and patient experience. This is held in hospital and community settings and the assessment of the patient environment includes cleanliness of equipment, including commodes, compliance with ‘bare below the elbows’ and first impressions of the environment. Immediate feedback is given to the nurse in charge and each department/clinic lead receives a letter from the Director of Nursing and Patient Safety or Clinical Director of Community Services highlighting the positive aspects of the visit, any opportunities for improvement and offering support if needed. Link Worker Programme Our well established link worker programme has continued this year and there are in excess of 300 link workers across the organisation, including nurses, healthcare assistants, pharmacy technicians, physiotherapists, podiatrists, dieticians, speech therapists and care home staff. Link workers are responsible for audit, training and cascade of information in their own areas and the programme has been very successful. In July 2010 a study day focused on intravenous line care was well attended. In January 2011 a joint link worker meeting with representatives from hospital, community services, care homes and independent contractors was held and we now plan to make this an annual event 12 Chief executive of the Royal College of Nursing Peter Carter chats to associate practitioner Tammy Ann Saunders watched by senior clinical matron Pauline Townsend 5 Policies The trust has a programme for revision of core infection prevention and control policies as required by the Health and Social Care Act 2008. All policies are available on the Trust Intranet site. Key policies are available to the public on the trust public website. Policies are audited where appropriate and overall compliance scores are shown in the table below: Table 6. Policies Policy title Policy Code Status IC1 Outbreak Policy For review March 2014 IC2 Hand Hygiene Policy For review April 2013 Audit compliance and comparison with previous year N/A 96% IC3 Infection Control Policy For review April 2013 N/A IC5 CJD Policy Under review N/A IC6 MRSA Policy For review May 2014 63% IC7 Viral Haemorrhagic Fevers For review October 2013 N/A IC11 Tuberculosis Policy For review 2011 88% IC12 Disinfection and Sterilisation Policy For review October 2012 N/A IC13 Urethral Catheter Management Policy For review April 2012 N/A IC14 Clinical Specimen Policy For review December 2012 N/A IC15 Patient Isolation Policy For review November 2011 90% IC16 Scabies Policy For review March 2013 IC17 Standard Precautions Policy For review January 2012 IC18 Peripheral Cannulation Policy For review May 2014 N/A Sharps safety 97% Environmental cleanliness 93% PPE 97% 70% IC19 Clostridium difficile Policy For review 2011 IC 20 MRSA screening For review December 2013 IC21 Theatre Policy For review April 2012 N/A IC22 Surveillance Policy under development N/A C56 Antibiotic Strategy For review 2011 N/A 88% Elective 83% Emergency 87% 13 6 Infection Prevention and Control Incidents Influenza The increase in H1N1 influenza (swine flu) during winter 2010-11 had a significant impact on the trust in terms of increased admissions and dependency of patients, particularly in the critical care units. Pandemic preparedness plans were in place and regular meetings held to review effectiveness of the plans. The staff vaccination programme was delivered by the Occupational Health team supported by senior nurses. Overall 52% of staff were vaccinated. Legionnaires disease Legionnaires disease is a form of pneumonia. It is caused when people breathe in small droplets of infected water. There was a small number of cases of legionnaire’s disease during 2010-11. Each case was thoroughly investigated by the trust, working in collaboration with the health Protection Unit and Environmental Health. None of the cases were found to be hospital acquired but the increase in cases seen did provide an opportunity for review and strengthening of the trust legionnaire’s disease prevention plan. Tuberculosis Tuberculosis is an infectious disease that usually affects the lungs and can spread easily. There were a number of patients identified as having tuberculosis during 2010-11. In some cases this prompted contact tracing of patients and staff that had been in contact with cases prior to diagnosis. All contacts have either received information letters or been offered follow up appointments depending on the level of contact in each case. 14 7 Decontamination Decontamination is a process that removes or destroys infectious agents from medical equipment. Cleaning is always the first step in this process, which is then usually followed by disinfection or sterilisation depending on the circumstances in which the equipment is used. The trust provides an in house sterile services department, reprocessing reusable medical devices. This is a fully validated and monitored service. Decontamination audits are carried out annually in departments where local decontamination is delivered, and the IPCT form part of the audit team. The podiatry department moved away from reusable equipment several years ago and now have 100% disposable items. The endoscope (flexible tube used to look inside the body) decontamination facilities on the endoscopy units on both sites have been upgraded and are fully compliant and provide a much improved service following a comprehensive modification programme to improve dosing and reduce failure rates. The Authorising Engineer (decontamination) has validated the annual / re-commissioning reports as suitable for service, and a revised service contract has been agreed to better cover mandatory testing. In addition the Endoscope washer disinfectors within central sterile services department are coming on line, and will provide contingency support to the endoscopy unit facilities. 8 Providing a clean and safe environment for our patients Cleaning The provision of cleaning services continues to be delivered by in house staff and external contractors (some community premises). Performance management systems are in place with monitoring staff making checks in line with national standards. Both of our hospital sites achieved ‘excellent’ ratings for the environment in the 2010 Patient Environment Action Team (PEAT) assessment. The trust cleaning group meets monthly to review monitoring scores, with representation from IPCT and senior clinical matrons. Inpatient Survey results 2010 The trust results from the National Inpatient Survey for 2009 and 2010 show that the patient perceptions of cleanliness and hand hygiene continue to improve. Table 7 Inpatient survey results 2009 & 2010 Year 2009 2010 Score for general cleanliness 87 88 Score for bathroom and toilet cleanliness 83 86 Score for doctors hand hygiene 83 87 Score for nurses hand hygiene 86 87 15 Our new hospital A proposal for a single site hospital with a significant increase in ensuite single room accommodation is under development. This will provide a state of the art environment, designed to be safe and easy to clean. Until the new hospital is built there is a programme of refurbishment of trust premises to constantly improve the healthcare environment for our patients and staff. The IPCT are involved in all building and refurbishment projects and are represented at the Capital Projects Group. 16 9 Antibiotic prescribing Antibiotics are substances that kill or slow down the growth of bacteria. Junior doctors in each clinical directorate are required to carry out antibiotic prescribing audits every four months. These audits capture data such as whether stop and review dates are recorded at the time of prescribing, whether allergy boxes are completed, whether indication (reason for the antibiotic) is recorded on the prescription sheet and what the length of therapy has been. These results are then collated by the clinical effectiveness (audit) team and fed back to the directorates. Results for some directorates have improved dramatically, whilst others have been slower to improve. With increased education on the importance of these factors, we are planning to see further improvements over the next year. A weekly review meeting now takes place between the Consultant Microbiologist, Infection Prevention and Control Nurse (IPCN) and Antibiotic Pharmacist to discuss all current Clostridium difficile cases within the hospital. Any issues that are raised by the IPCN can then be actioned by either the Consultant Microbiologist or Antibiotic Pharmacist as appropriate. The Antibiotic Pharmacist also carries out antibiotic histories for the previous 3 months for any hospital acquired cases of Clostridium difficile within the hospital. These are then added to the analysis data and trends examined. New ‘Indicate Stop Date’ and ‘Review Switch to Oral’ stickers have been introduced for use by Pharmacists and Pharmacy Technicians whilst on the wards. These provide a clear and visible reminder to prescribers that a stop date is required for all oral antibiotic prescriptions, and the need to step down from intravenous to oral antibiotics as soon as possible. We have also introduced an annual induction session on antibiotic prescribing for all new trainee medical staff starting at the trust each August. It is delivered by the Consultant Microbiologist/ Antibiotic Pharmacist and covers the basics of antibiotic prescribing within the trust and what is expected of prescribers, including where they can find the guidelines and who to go to for help and advice. New guidance has been produced for the use of proton pump inhibitors (PPIs) and probiotics within the trust. The PPI guidance recommends that all PPIs prescribed for patients over 65 years of age and on antibiotics should be reviewed with a view to stopping altogether or at least omitting them whilst the patient is on antibiotics. This is due to the increasing evidence that PPI use may predispose a patient to Clostridium difficile infection by allowing the previously vegetative spores in the gut to thrive once the pH is raised by the use of the PPI. Antibiotic consumption data is now available in the form of daily defined dose (DDD) data. This is reported monthly on the Pharmacy intranet site and enables us to monitor usage of individual antibiotics and groups of antibiotics to note and act upon any changes seen. 17 10 Training The IPCT contribute to the trust mandatory training programme and have input into: • Weekly drop in sessions • Trust induction • Trainee medical staff induction • Blood culture sampling competency assessment • Five-yearly risk management programme • Student induction • Ward/department specific sessions Infection Prevention and Control training is a two yearly requirement for all trust staff and in 2010-11 the trust exceeded its 80% target for completion of training within two years. 18 Assistant matron for infection prevention and control Debra Jenkins and ward manager Pauline Jiggins 19 www.nth.nhs.uk