Download DIPC report 2010/11

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
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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.
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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
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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.
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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%
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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.
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Assistant matron for infection prevention and control Debra Jenkins and ward manager
Pauline Jiggins
19
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