Prepared by: Dr Peder Bo Nielsen, Director of infection Prevention & Control

Transcription

1 THE NORTH WEST LONDON HOSPITALS NHS TRUST Agenda Item TRUST BOARD Meeting on: 26 th July 2006 Paper Attachment Subject: Infection Control Annual Report Prepared by: Dr Peder Bo Nielsen, Director of infection Prevention & Control Summary: The year 2005/2006 has produced significant progress on the organisation and management of infection control albeit with modest impact on the mandatory performance indicators. The number of MRSA bacteraemia has been reduced from 58 to 56 cases, which is12 cases over the target. The laboratory has identified 318 patients with Clostridium difficile. It is the lowest number for three years for Clostridium difficile. The cleaning procedures have been reviewed and improved. The Trust has signed up for "Saving Lives" and an action plan is in place. Clinical Directors will implement it at departmental level. A comprehensive Surveillance Report will help Clinical Directors to identify areas for intervention. The Infection Control Team with additional manpower will increase their presence in clinical wards and every single MRSA bacteraemia will be investigated as a "serious incidence". It is expected that the new scheduled programme will provide the needed progress. Financial Implications: The increased demand on infection control and the additional cost cannot be accommodated by the existing infection control budget. The infection control team is in need of improved office and laboratory support. Risk Issues: Infection control is a key aspect of Clinical Governance and MRSA is one of the core performance indicators. 1

2 Recommendation: The Board is asked to: approve the annual infection control report with the given progress report and action plan for

3 NORTHWEST LONDON HOSPITALS NHS TRUST INFECTION CONTROL ANNUAL REPORT 2005 / 2006 By Dr Peder Bo Nielsen Director of Infection Prevention & Control 10 th July

4 1. Executive summary Overview of infection control activities in the Trust The year 2005/2006 has brought 0.4 WTE additional infection control nurse to the team and with replacement two new infection control nurses were appointed. They were both in place late spring The organisation of infection control at departmental level has changed in order to accommodate "Saving Lives" and "Winning Ways". The clinical directors have become responsible for local infection control and will report back to and receive support from the infection control team. The Trust has signed up for "Saving Lives" and conducted a self-assessment. An action plan has been developed that at the local level integrates infection control in everybody's job plan and personal development plan. This is already in place for the majority of departments. Programme for local audits using "Saving Lives'" audit tool is under development. A comprehensive "Surveillance Report on Multiresistant Bacteria & Clostridium difficile" has been produced enable clinical directors to make evidence based local interventions. The report includes MRSA, ESBL, GRE and Clostridium difficile with distribution of cases by wards. The time and place for MRSA bacteraemia are given together with mortality. The number of MRSA bacteraemia was down to 53 cases which is the lowest number in the last three years. However, the Trust did not meet the target of 44 cases. In the future all MRSA bacteraemia cases will be investigated as "serious incidence" and the infection control team will establish enhanced surveillance of all MRSA case. The financial consequences of introducing admission screening and 24 hours identification of MRSA seven days a week will need to be resolved. The Trust did not do well in a preliminary Clostridium difficile league table. In part it was due to reporting duplicates and cases younger than 65 years. We are now using the same criteria as other trusts. Last year the Trust has 318 cases which is still a high number. Over the year clinical and environmental audits of wards have given us valuable new information that have been used to improve the cleaning procedures and hand hygiene campaign. Again this year the PEAT score was excellent. IN CONCLUSION, the year 2005/2006 has produced significant progress on the organisation and management of infection control albeit with modest impact on the mandatory performance indicators. It is expected that the new scheduled programme will provide the needed progress. 4

5 2. Description of infection control arrangements Director of Infection Prevention and Control (DIPC) The Consultant Medical Microbiologist appointed 1st July 2004 is also the Director of Infection Prevention and Control. "Role of the Director of Infection Prevention and Control" is given in Winning Ways: Action Area Six and "Competencies for Directors of Infection Prevention and Control" in Department of Health document Gateway Reference The Director of Infection Prevention and Control may already be a member of the NHS Trust Board but this is not a requirement as the key phrase in Winning Ways is report directly to the Chief Executive and the Board and not through any other officer. The Director of Infection Prevention and Control will be an integral member of the organisation's clinical governance and patient safety teams and structures. The last year has shown progress in meeting the requirements of "Winning Ways". The DIPC has become member of key committees, such as Clinical Governance Patient Safety Committee However, the DIPC does not provide any professional input when Clinical Directors and/or Executives discuss or make decisions on infection control issues. The DIPC is reporting directly to the CEO and the Board and not through any other officer. Infection Control Team The team has been strengthened with another 0.4 WTE infection control nurse and within the last month the last of two newly appointed infection control nurses took up her position. The team consists now of 3.6 WTE infection control nurses supported by 0.5 WTE infection control administrator. The presence of the team in the clinical areas will be increased significantly. The microbiology laboratory support for infection control was until recently provided by a WTE technician. Unfortunately it has ceased as part of microbiology savings. Reporting line to the Trust Board and Links to Committees The Infection Control Team reports to and receives guidance from the Infection Control Committee. The latter reports to the Board via "Patients Safety Committee" and "Clinical Governance Committee". The DIPC is member of the above two committees plus Antibiotic Subcommittee Harrow PCT Infection Control Committee North West London DIPC committee under Strategic Health Authorities 5

6 The Infection Control Nurses are member of Lead Nurse Operational Group Cleaner Hospital Group Medical Device Committee Health and Safety Committee Waste Management Group Brent & Harrow TB Group Brent & Harrow MRSA Group 3. DIPC reports to the Trust Board summary Pathway of DIPC reports The DIPC has within the last year produced two quarterly reports and has presented the Annual Infection Control Report 2004/2005 for the Board. Annual Action Plan 2005/2006 The progress report is attached. The integration of infection control at board and senior manager level has progressed through out the year. The newly appointed Director of Nursing represent the Board and executives on a daily basis. The infection control is well integrated into the Trust structure giving DIPC membership of Clinical Governance Committee and Patient Safety Committee. Clinical Directors have taken on the infection control lead at departmental level and local infection control activities and audits as given in Saving Lives are being developed. The progress on the organisation and structure of infection control has been satisfactory. However, little impact has been seen on reduction of multiresistant bacteria, which can be read in the section for "Trend in HAI statistics". Outbreak Reports No outbreak reports have been presented to the Board. Change in monthly number of MRSA bacteraemia cases has been explained to the Board as seasonal variation. The Trust has a high number of Clostridium difficile cases. Only a part of it could be explained by reporting cases younger than 65 years as well as counting patients more than once within a four weeks period. The figures include isolates from PCT wards and GP surgeries. Several Trust and all PCT wards have been audited and screened for multiresistant bacteria. It has included clinical as well as environmental swabbing. The number of patients colonised/infected with multiresistant bacteria were surprisingly high as were the degree of environmental contamination. The reports have been sent to senior managers and clinical governance. 6

7 4. Budget allocation to infection control activities There has through the last few years been an increasing demand for infection control services. Unfortunately, the funding for especially MRSA admission screening of risk patients has not been sorted out. A programme for processing screening swabs overnight has been piloted. As the reading is done after 24 and 48 hours only specimens set up Monday, Tuesday and Wednesday are not delayed by no laboratory work during week-ends. Fast identification of MRSA seven days a week will be an essential step ahead in controlling the MRSA endemic. The " Turn Around Project" requires that microbiology laboratory makes savings. It has obviously consequences for the infection control support. Until recently, a WTE BMS was allocated exclusively for Infection control work. This has implication for the newly launched enhanced surveillance at the "Intestinal Failure Unit" that will be limited to MRSA. The other multiresistant bacteria, Clostridium difficile and the environmental component of the programme will not be implemented. The Trust wide programme will also be limited to MRSA. The admission screening and fast identification of MRSA are both new services for divisions, departments and PCTs. The additional cost need to be part of the budget. 5. HCAI statistics Results of Mandatory Reporting A separate surveillance report is attached. Surveillance of orthopaedic surgical site infections (SSI) has been running for a year. At Central Middlesex Hospital not a single infection has occurred. Well done! Northwick Park Hospital had five infections and even that they were superficial infections and the material consists of small numbers it is above the national average. The five cases are being investigated by the Orthopaedic Department. Nationally, MRSA bacteraemia is performance managed by Department of Health. The target for the Trust per 1 st April 2006 were 44 case. The Trust had 56 cases and therefore did not meet the target. An action plan has been produced and with more man power in the infection control team it should be possible to reduce the number of cases significantly. All new MRSA cases will on the day be attended to by the infection control team that will provide advice on appropriate treatment. All MRSA bacteraemia will be investigated as "a serious incidence". Quarterly surveillance report will be provided for Clinical Directors as support for departmental intervention. However, it may also depend on a successful implementation of "Saving Lives" and the fast overnight identification of MRSA seven days a week. The surveillance of Clostridium difficile has been set up to meet the requirements of Department of Health. In the past the ones reported to Health Protection Agency were also reported to Department of Health. That included too many repeat 7

8 isolates and patients less than 65 years old. Last year, the Trust had 318 cases, which is the lowest number ever but still too many. Trends in HCAI statistics This year it has been possible to include Extended Spectrum Beta-lactamase Producers (ESBL or multiresistant coliforms) in the statistics. Microbiology laboratory identified 786 isolates with ESBL. It includes specimens from the community and acute Trust. The statistics counts only one isolate per patient per month. We have included the location of the requestor in order to improve the feed back to the wards and departments. Location is therefore given for MRSA, ESBL and Clostridium difficile. The statistics includes all MRSA and not just bacteraemia. Untoward incidents including outbreaks In year 2004/2005 UK had a massive outbreak with Acinetobacter baumanii which also involved our Trust. We have seen no cases since February 2005 and it seems to have disappeared completely from UK. Over summer 2005 we had an investigation into a suspected Aspergillus cluster at Lister Unit. The outbreak could not be confirmed, but it resulted in a review of the functioning of ventilation and isolation rooms. Some improvements were done. In autumn 2005 we had several outbreak due to diarrhoea. They were all confined well and none of them were long lasting. This may be due to our newly established policy that includes daily monitoring of compliance with enteric precaution policy. Antimicrobial resistance Only surveillance of multiresistant organisms takes place. An audit at Neonatal Unit showed no problems with resistant organisms. Goals identified locally The goals are unchanged from last year. We need to learn how to extract routine data from the laboratory database and use it as guide for infection control interventions. 6. Hand hygiene and Aseptic protocols North West London Hospitals Trust joined the NPSA s cleanyourhands campaign in Feb It was launched at the Trust s Think Clean Day on 28 th February 2005 at both sites. Currently, all cleanyourhands posters and promotional materials received by named nurse /staff on each ward or department Trust-wide All materials received monthly direct from NPSA via NHS Logistics Cleanyourhands campaign monthly posters, badges Stop and use Alcohol Gel posters at every ward and department entrance and exit Alcohol gel dispensers at every ward and department entrance and exit Alcohol gel dispensers at every bed-end or wall mounted at head-end JohnsonDiversey - Stop, Wash, Go posters JohnsonDiversey six stage hand washing posters over hand wash basins 8

9 Infection Control Guidelines for all Staff leaflet redesigned Training handout given out at all training sessions Hand Hygiene leaflets distributed to all Trust employees and contracted staff by attaching to payslips Feb 2006 Hand Hygiene policy due for review in October 2009 Hand hygiene is contained in ALL infection control training sessions total of 1841 staff trained from April 2005 to end March 2006 Large boards installed in prominent positions in main entrances to Northwick Park, St Mark s and Central Middlesex Hospitals, and Maternity Dept, with alcohol gel dispensers and hand hygiene leaflets for patients, visitors and staff. Aseptic protocols addressed in Saving Lives programme. Action plans drawn up and include training and auditing of practice Saving Lives: 1. Aseptic procedures 2. care of IV and central venous cannulae 3. care of surgical wounds 4. care of ventilated patients 5. care of urinary catheters 7. Decontamination Currently, plans in progress for a sector-wide Super Centre for decontamination of equipment Trust lead is Head of Procurement Since Feb 06, Trust lead for decontamination is Head of Facilities. Decontamination and Sterilisation is organised as follows: Northwick Park and St Mark s Hospitals sterile supplies from Synergie Healthcare on site Production manager and theatre manager meet weekly Synergie keep all audit records Reported monthly to the Trust Any incidents/failures are reported to Clinical Risk and Head of Facilities Central Middlesex Hospitals sterile supplies from TSSU at CMH TSSU manager post vacant, but previously met weekly with theatre manager Reported monthly to the Trust Any incidents/failures reported to Clinical Risk and Head of Facilities 8. Cleaning services Close collaboration between Sodexho and infection control team has taken place over the year in order to improve the service. This has resulted in enhanced cleaning during outbreaks. 9

10 New technology for decontamination of wards is under investigation. All cleaning services contracted out. Monitored by Patient Environment Manager Monthly meetings of company s managers, PEM and Infection Control Nurses Northwick Park and St Marks Sodexho Central Middlesex - Target Healthcare Cleaning monitoring: Weekly by both companies using Maximiser Audit tool Annual programme of environmental cleaning audits by Infection Control nurse, ward manager and domestic manager/supervisor using Infection Control Nurses Association (ICNA) audit tool Areas currently audited: o Clinical environment o Kitchens o Safe handling and disposal of sharps in collaboration with Frontier representatives o Waste management o Handling and disposal of linen o Sluices in collaboration with Vernacare representatives o PEAT inspection improvement in early improvement for the second year running. Members of patient forum are part of inspection team. Staff attitude survey in 2005 highlighted concerns over hand washing facilities. 9. Audit ICNA's audit tools are currently in use: Environmental Audit D & V Policy Audits Hand Hygiene Audit Sluice / Commode Audit Sharps Audit The audits are scheduled and the results have been satisfactory. Microbiological audits of wards have shown massive contamination of wards with multiresistant microorganisms especially MRSA. The clinical significance of it and how to "decontaminate" wards are not clear. Deep cleaning has proved ineffective. A few weeks after deep cleaning the wards are just as contaminated as before. 10

11 10. Targets and outcomes The programme for Winning Ways and MRSA bacteraemia was launched last year and they are currently under review. Measured by PEAT score and MRSA league table the Trust's performances are acceptable. However, the requested reduction in MRSA bacteraemia was not met. An action plan to meet the requirements set by Clinical Negligence Scheme for Trusts has been in place for a while, and all infection control targets will be met. CPA of Microbiology Department will also ease the assessment. The Trust has signed up for "Saving Lives" and the self-assessment and action plan have been forwarded to SHA. As given under the organisation and management of infection control the essential parts of the action plan are Clinical Directors are infection control lead for their respective divisions Infection control is incorporated in all job plans and personal development plans Local audit of infection control issues will be launched Infection control link nurses will be key persons in local audits 11. Training activities Infection control training is provided in collaboration with The Training Department. Induction programme for all new staff clinical staff 2 hours twice monthly non-clinical staff 30 min twice monthly Mandatory training for existing staff annually Special programme for link nurses monthly meeting with the infection control team, and two annual whole day work shops The lead infection control nurse has over the year followed a university degree course. 11