INFECTION PREVENTION AND CONTROL …

1 INFECTION PREVENTION & CONTROL department INFECTION PREVENTION AND CONTROL department ANNUAL REPORT 2013/2014 Emma Dowling INFECTION PREVENTION & CONTROL Annual Report 2013/2014 Page 2 of 50 INFECTION PREVENTION & CONTROL Associate DIPC CONTENTS GLOSSARY .. 3 Executive Summary .. 4 Introduction .. 6 INFECTION PREVENTION and CONTROL Roles and Structures within the Trust .. 7 Out of hours INFECTION PREVENTION and CONTROL Service .. 8 The INFECTION PREVENTION and CONTROL Committee.

2 8 Reports to the Executive Team and Trust Board .. 8 INFECTION PREVENTION and CONTROL Risk Register .. 9 MRSA Bacteraemia (Blood stream infections ) .. 10 MRSA screening .. 11 Escherichia coli bacteraemia .. 14 Water Hygiene Report (prepared by Nick Kay Head of Health, Safety & Risk) .. 16 Clostridium difficile associated diarrhoea .. 22 Summary of main themes from the CDI RCA s .. 23 RCA findings .. 23 Clostridium difficile Ward Round .. 25 Other Resistant Bacteria .. 14 OUTBREAKS, WARD CLOSURES, PERIODS OF INCREASED INCIDENCE.

3 26 Norovirus outbreak .. 26 Summary of Ward Closures due to Norovirus .. 27 SURGICAL SITE INFECTION SURVEILLANCE .. 28 SAVING LIVES: HIGH IMPACT INTERVENTIONS .. 29 TRAINING AND EDUCATION .. 30 INFECTION PREVENTION Mandatory training .. 31 Teaching training 32 Alert Labels .. 32 Alert Sheets .. 33 INFECTION PREVENTION and CONTROL Link Nurses .. 34 COMPLIANCE WITH THE HEALTH AND SOCIAL CARE ACT 2008 .. 35 POLICIEIS, PROCEDURES & PROTOCOLS .. 37 INFECTION PREVENTION & CONTROL Annual Report 2013/2014 Page 3 of 50 INFECTION PREVENTION & CONTROL AUDIT.

4 38 Monthly Hand Hygiene Audit Compliance Scores .. 39 PATIENT LED ASSESSEMENTS OF THE CARE ENVIRONMENT -PLACE .. 39 Environmental audit .. 41 KEY ACTIONS / ACHIEVEMENTS IN INFECTION PREVENTION FOR 2013/14 . 42 Hand Decontamination -Hand Towels .. 43 OBJECTIVES AND WORK PLAN FOR 2014/15 .. 44 Appendix 1 INFECTION PREVENTION and CONTROL Programme for 2013/2014 .. 46 GLOSSARY ARHAI Advisory committee on Antimicrobial Resistance and Healthcare Associated INFECTION ADIPC Associate Director INFECTION PREVENTION and CONTROL CNS Clinical Nurse Specialist DoH department of Health DIPC Director of INFECTION , PREVENTION & CONTROL CCG Clinical Commissioning Group C.

5 Diff Clostridium difficile CDI Clostridium difficile INFECTION CQC Care Quality Commission GDH Glutamate Dehydrogenase GRE Glycopeptide resistant Enterococci HCAI Healthcare Associated INFECTION IPC INFECTION PREVENTION & CONTROL IPCN INFECTION PREVENTION & CONTROL Nurse INFECTION PREVENTION & CONTROL Annual Report 2013/2014 Page 4 of 50 INFECTION PREVENTION & CONTROL IPCT INFECTION PREVENTION & CONTROL Team KPI Key Performance Indicator MRSA Meticillin resistant Staphylococcus aureus MSSA Meticillin sensitive Staphylococcus aureus OPD Out patients department PPM Planned Programme of Maintenance PIR Post INFECTION Review Q A Quality Assurance RCA Root cause analysis SHA Strategic Health Authority SSI Surgical Site INFECTION SUHFT Southend University Hospital Foundation Trust Executive Summary This annual report fulfils the Trust s statutory requirement under section of the Health and Social Care Act 2008 for the Director of INFECTION

6 PREVENTION and CONTROL (DIPC) and Associate Director of INFECTION PREVENTION and CONTROL (ADIPC) to provide a report on INFECTION CONTROL activity across the organisation. In addition to the Trust s obligation, this report provides key information to the public, patients, staff, Trust Board, the CQC, Monitor and our Commissioners of the activity relating to INFECTION PREVENTION and CONTROL . This report covers the period from 1st April 2013 - 31st March 2014 and provides an assessment of performance against national targets for the year and includes key issues such as; Meticillin Resistant Staphylococcus Aureus (MRSA) bacteraemia figures INFECTION PREVENTION & CONTROL Annual Report 2013/2014 Page 5 of 50 INFECTION PREVENTION & CONTROL Clostridium difficile Toxin (CDT) rates, Audit activities and other key priorities for the year.

7 The Trust continued to have both patient safety and Health Care Associated infections (HCAI) as a priority within the organisation. 2013/14 has been another challenging year for both the organisation and INFECTION PREVENTION and CONTROL team (IPCT), as there is greater scrutiny and surveillance on HCAI as well as ever reducing ceilings for infections . The Trust sustained a clear focus and energy on the INFECTION PREVENTION and CONTROL agenda, sharing key learning and best practice in order to deliver on both HCAI national targets This year the Trust experienced a mixed level of attainment with regard to the Healthcare associated INFECTION (HCAI) objectives.

8 The Trust achieved the MRSA bacteraemia objective set by the DH at zero cases .This is the first time the Trust has reported 0 cases and it is great achievement for all concerned. Conversely, we were very disappointed to report that the objective for incidents of Clostridium difficile was breached at 31 cases against a very challenging ceiling of just 18 (see section for full details) In line with the INFECTION PREVENTION and CONTROL (IP&C) Strategy, work has continued to ensure that we maintain compliance with.

9 The Health and Social Care Act 2008 NHSLA Risk Management Standards for Acute Trusts The Care Quality Commission registration Outcome 8 The Trust emphasis on of Saving Lives continues and included the application of evidence based improvements in intravenous line care, isolation utilisation, antibiotic usage and the surgical site INFECTION bundle The Trust successfully achieved the overall target of 95% hand hygiene compliance with a total of Training in hand hygiene for all staff and improvements to hand hygiene facilities continued through the year.

10 INFECTION PREVENTION & CONTROL Annual Report 2013/2014 Page 6 of 50 INFECTION PREVENTION & CONTROL 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 using the new training record booklet ( see section ) There was just 1 ward closed during December 2013 due to suspected Norovirus. In total 12 bed days were lost due to the suspected Norovirus outbreak Introduction The term Healthcare Associated INFECTION (HCAI) encompasses any INFECTION by any infectious agent acquired as a consequence of treatment.