BOD 76/2012
BOARD OF DIRECTORS
Annual Infection Prevention & Control Report
For the Period April 2011 – March 2012.
This report provides an update on Infection Prevention & Control activities and
information on actions in place to provide assurance to the Board of compliance
with Health & Social Care Act and Associated Code of Practice for the Prevention
& Control of Healthcare associated Infections
RESPONSIBLE DIRECTOR: Peter Walsh Director of Infection Prevention &
Control
DATE: July 2012
1
Contents
Page
1
2
Introduction
Executive Summary
6
7
3
4
5
6
7
8
9
10
Specific Achievements
Reporting Structures
Key Objective 2012-13
CNWL Demographical Information
Infection Prevention and Control Structure
Infection Prevention & Control Team
Continued Professional Development Activities of IPC Team
Committee/Groups attended by the Infection Prevention & Control
Team
Infection Prevention & Control Committee
Reporting Arrangements
Director of Infection Prevention & Control Reports to the Board of
Directors
Infection Prevention & Control Link Practitioners Group
Infection Surveillance & Data Reporting
Alert Organism Summary
MRSA Bacteraemia Surveillance
Clostridium Difficile Surveillance
Incidents
Norovirus
TB Incident at Mortimer Market
Staff Survey
Decontamination
Decontamination Clinical Environments
Decontamination of Medical Devices
Decontamination of Dental Devices
Multi-disciplinary team working
Estates & Facilities
Facilities, Cleaning & Catering Services
Facilities, Laundry & Linen Service
Health & Safety
Clinical Risk Management
NHSLA Risk Management Standards
Governance Reporting
Occupational Health
IPC Related Audits & Other Projects
Current Practice in CPS, OHS
Training & Education
Annual Mandatory Training
Policies and Procedures
Individual policies under development and review by IPCT
7
8
8
9
9
9
10
10
11
12
13
14
15
16
17
18
19
19.1
19.2
20
21
21.1
21.2
21.3
22
22.1
22.2
22.3
23
24
25
26
27
27.2
27.3
28
28.1
29
29.1
11
11
11
11
12
12
13
13
13
15
15
16
17
17
18
18
18
19
20
2
30
31
31.2
31.3
31.4
31.5
31.6
31.7
32
33
34
35
36
37
38
Infection Prevention & Control website and intranet
Audit
Hand Hygiene Audits
Clinical Environment Audits (PEAT)
Commode Audit
Mattress Audit
Glove Audit
Antibiotic Prescribing Audits
Antimicrobial Stewardship
Needle Stick Injuries
Audit Plan for 2011-2012
Work plan for 2011 -2012
Summary
Conclusion
References
20
20
23
23
24
24
24
24
26
Appendices
Appendix 1 Work Plans for MH, CPS & HCH Services 2011-2012
Appendix 2 PEAT Scores
Appendix 3 IPCT Structure
Appendix 4 IPCT Budget Statement
Appendix 5 Needle Stick Exception Report
Appendix 6 Annual IPCT Audit Plans
3
List of Abbreviations
AAT
ANTT
Adopt Adapt Transform
Aseptic Non Touch Technique
BBV
Blood Borne Virus
BBW
Balfour Beatty Workforce
BOD
Board of Directors
CNWL
Central North West London NHS Foundation Trust
CD4
Cluster of Differentiation 4 (blood cell count)
C Diff
Clostridium Difficile
CPS
Camden Provider Services
CQC
Care Quality Commission
DIPC
Director of Infection Prevention & Control
DoH
Department of Health
EHS
Eastbourne Hospital Services
HCAI’s
Health Care Associated Infections
HCH
Hillingdon Community Healthcare
HIV
Human Immunodeficiency virus
HPA
Health Protection Agency
HST
Health and Safety Team
HQ
Headquarters
IGRAs
IR1
IPCD
IPCLPs
IPC
Interferon Gamma Release Assays
Incident Report Form 1
Infection Prevention & Control Doctor
Infection Prevention & Control Link Practitioners
Infection Prevention & Control
IPCC
Infection Prevention & Control Committee
IPCN
Infection Prevention & Control Nurse
IPCT
Infection Prevention & Control Team
MH & AS
MRSA
Mental Health & Allied Services
Methicillin Resistant Staphylococcus Aureus
4
NHS
National Health Service
NHSLA
National Health Service Litigation Authority
NPCU
Northwick and Pinner Community Unit
NPSA
National Patient Safety Agency
OCS
One Complete Solution
OHS
Occupational Health Services
PEAT
Patient Environment Action Team
PCT
Primary Care Trust
SUI
Serious Untoward Incident
THH
The Hillingdon Hospital
UWL
University of West London
VIP
WHO
Visual Infusion Phlebitis Score
World Health Organisation
5
1. Introduction
1.1 This is the 7th Annual Report of the Director of Infection Prevention & Control (DIPC)
and the 1st report to include information following the merger of Central and North West
London (CNWL) NHS Foundation Trust, Mental Health and Allied Services (MH & AS)
with Camden Provider Services (CPS) and Hillingdon Community Health (HCH)
Services. This report provides an overview of the Infection Prevention and Control
(IPC) activities throughout the Trust over the last 12 months. The Infection Prevention
and Control Team (IPCT) took the Adopt, Adapt and Transform (AAT) approach and
has progressed in a number of areas as detailed in this 2011/2012 Annual Report.
1.2 The DIPC reports quarterly to the Trust Board of Directors. This Annual Report is
part of the process that tracks and monitors the Trust’s performance against regulatory
requirements using the Hygiene Code 2008. The IPCT work plans focus on
implementing systems that embed IPC into the everyday practice of all CNWL staff.
1.3 This report confirms compliance with the regulatory requirements of the Health &
Social Care Act (2008) Regulation 12, detailed in the Code of Practice for the
prevention & control of infections, otherwise known as the Hygiene Code. Compliance
with these requirements is monitored by the Care Quality Commission as Outcome 8,
Cleanliness and Infection Control. Work to ensure compliance with regulatory
requirements will also demonstrate compliance with National Health Service Litigation
Risk Management Standards (NHSLA 2010)
1.4 This annual report provides information on the progress and achievements of the
IPCT over the past financial year, and focuses on overall Trust wide IPCT activity.
Where required it provides particular information relating to MH & AS, CPS and HCH
services.
1.5 Infection Prevention & Control remains a key priority within the patient safety and
quality agenda. Patient surveys and public opinion polls, year on year demonstrate that
cleanliness and the prevention of infections within healthcare settings remains a top
concern from a patient’s perspective.
1.6 The DIPC would like to clarify to the BOD that although this report covers all of
CNWL it is useful to highlight that with a number of different providers coming together,
this has necessitated a change in the presentation of the Annual Report from previous
ones.
1.7 CNWL provides joined up clinical services however, we need to recognise that
many of these services are unique and that it is the responsibility of the IPCT & DIPC to
6
acknowledge these and to be well placed to take advantage if the increasingly diverse
services CNWL now provides.
1.8 Service provision across CWNL varies and some examples include
 HCH manages the only Dental Service within CNWL;
 CPS has one of, if not the largest, sexual health service in the UK ;
 Offender Care presents unique challenges in that they are completely closed
environments.
2. Executive Summary
2.1 At Central and North West London NHS Foundation Trust (CNWL) we pride
ourselves in our dedication to safe and effective Infection Prevention & Control practices
and we provide a service that meets the needs of our patients, service users, carers
and staff.
2.2 To reduce Health Care Associated Infections (HCAI’s) there are requirements to
have in place effective systems to prevent, manage and control the risk of infection.
These systems must incorporate national guidance and good practice, engage staff and
make infection prevention and control “everyone’s business”. Evidence of compliance
and good practice is demonstrated through the Work Plans (Appendix 1) to meet the
requirements of the Hygiene Code (Department of Health, 2008).
2.3 The work plans provide assurance to service users, staff and the public through this
annual report that every effort is being made to minimise risks associated with HCAI’s in
a culture of zero tolerance to avoidable infections.
2.4 Despite many challenges for the IPCT we have again maintained an effective and
dynamic service this past 12 months.
2.5 The ongoing integration of CNWL means there will be further work to bring together
the IPC policies and processes throughout 2012-2013.
3. Specific Achievements
3.1 The surveillance and recording of alert organisms has been integrated into the
inpatient service making it a more sustainable and robust system. The number of
Clostridium difficile (C.diff) and Meticillin Resistant Staphylococcus Aureus (MRSA)
infections, are reported in section 18 (page 13).
3.2 The role of the Infection Prevention & Control Link Practitioners (ICLP) continues to
be further developed across all of CNWL. This role at ward/department level requires
full backing from senior staff and is essential in maintaining the vital role link nurses
provide.
3.3 The Infection Prevention & Control Team (IPCT) provide onsite post outbreak
training for staff to optimise infection prevention and control of future outbreaks.
7
3.4 An additional full time MH & AS IPC Nurse Advisor post was recruited which led to
an increase in training attendance figures as referenced in Section 28 (page 19).
3.5 HCH Have continued their emphasis on increasing the awareness of excellent hand
hygiene practices across the Trust. Public events have occurred in shopping centres,
health clinics and local libraries to encourage the public to realise the importance of
hand hygiene, along with additional staff initiatives that have also been delivered.
3.6 Also in HCH services the Aseptic Non Touch Technique (ANTT) pilot project was
launched with the link practitioner group in March 2012. Effective prevention and control
of infection, needs to be embedded in everyday practice. ANTT is a framework to both
‘standardise and raise clinical standards whilst undertaking aseptic clinical procedures’
(Rowley, 2000) which includes wound care and the management of invasive devices,
e.g. urinary catheters.
3.7 Within CPS, a project was delivered on Practical Infection Control Training which
was selected for the finals of the Nursing Times Award 2011- 12.
Additional achievements include the following:
 Standardisation of all soaps and hand gels across services
 Policy development and introduction of non latex gloves
 Introduction of VIP scores and care plans for all intravenous medical devices
 Specialised training/ local procedures for contraceptive services on infection
control practices and aseptic techniques.
3.8 The results of the Patient Environment Action Team (PEAT) Audit outcomes for
2011-12 were “Good” across CNWL, MH&AS, CPS and HCH (Appendix 2).
4. Reporting Structures
4.1 Reporting structures have not yet been fully aligned across CNWL in 2011/2012.
This was an intentional decision by the IPCT during the AAT period. The three different
reporting structures used within MH&AS, HCH and CPS will be reviewed in order that
the 2012/2013 reporting process uses the most effective system offering a common
template for all services.
5. Key Objectives 2012/2013 are:





All of CNWL must be compliant with using retractable syringes by May 2013 –
this is a statutory requirement;
Ensure a “zero tolerance” approach to poor IPC practices is in operation;
Hand washing training to remain a priority for all CNWL;
Ensuring point of care testing across the Trust;
To continue and strengthen collaborative working within CNWL.
8
6. CNWL Demographical Information
6.1 Up until 31st January 2011 CNWL was one of the largest specialist NHS Mental
Health Trusts in England with over 3300 employees serving more than 100 sites. HCH
joined CNWL in February 2011, followed shortly in April 2011 by CPS. The total
number of employees is now approximately 4500.
6.2 The Trust provides a very diverse range of service lines working across twelve
London Boroughs and a unit in Epsom, Surrey. These range from specialist services
such as Addictions & Offender Care, Community Health, Dental Services, Learning
Disability, Rehabilitation and Sexual Health.
7. Infection Prevention and Control Structure
The Director of Infection Prevention & Control (DIPC) and the IPCT currently provide
advice and support for the MH&AS, CPS and HCH Services provided by CNWL. The
IPCT Structure is shown in Appendix 3.
8. Infection Prevention & Control Team
8.1 The Infection Control Doctor (IPCD), DIPC and IPCT provide infection prevention
and control advice 24 hours a day, 7 days a week .
Director of Infection Prevention & Control
(DIPC)
MH & AS -Senior Infection Prevention and
Control Nurse
CPS- Senior Infection Prevention and
Control Nurse
HCH- Senior Infection Prevention and
Control Nurse
MH & AS Infection Prevention & Control
Nurse Advisor
MH & AS Infection Prevention & Control
Nurse Advisor
HCH Infection Prevention & Control Nurse
Advisor
Administration support (CPS)
Consultant Medical Microbiologist Infection
Control Doctor - MH and Allied Services
Consultant Medical Microbiologist Infection
Control Doctor - CPS
Consultant Medical Microbiologist Infection
Control Doctor - HCH
WTE 0.2
WTE 1.00
WTE 1.00
WTE 0.50
WTE 1.00
WTE 0.50 (temporarily funded by the
Older People & Healthy Ageing Service)
WTE 0.50
WTE 1.00
WTE 0.1
WTE
WTE
9
8.2 The three IPCT budget lines are currently managed separately; therefore they are
set independent of each other. The plan is to bring them together in 2012/2013. The
details of the budget statement for the IPCT services is presented in Appendix 4.
9. Continued Professional Development Activities of IPC Team
Members of the team have undertaken a wide range of professional development
activities ranging from attending mandatory training updates, to undertaking graduate
and postgraduate qualifications in infection prevention and control and profession
related conferences.
10. Committee/Groups attended by members of the Infection Prevention &
Control Team
The team members attend a range of safety and quality meetings to ensure Infection
Prevention & Control issues are addressed effectively.
These include:
Corporate Meetings (All)







Board of Directors Meeting
Infection Prevention & Control Committee
Corporate Risk/Health & Safety Group
Nursing, Estates and Facilities Business Meeting
DIPC London Committee
Chelsea & Westminster Infection Control Committee (Super Tuesday) Meetings
North West London Sector Infection Control Nurses Meeting
Local Groups in MH & AS










Clinical Safety Group
OCS Contract & Site Management Meetings
Medical Devices Group
Matrons Meeting
Blood Borne Virus Meeting
Physical Health Care, Infection Prevention & Control & Medical Devices Meeting
Clinical Quality Group
Nursing Directorate Leads Meeting
Trust Senior Nurse Away Day
Nursing Directorate Senior Nurse Planning Day
Local groups in CPS
 Health & Safety
 IPC sub Committee
 Clinical Standards
10




IPCN Leads Group SW
District Nurses Leads
Contraceptive & Sexual Health Service Meeting
Medical Devices Working Group
Local groups in HCH



HCH Providers Service Meeting
Quality Governance Meetings - including Risk Register, Medicines Management,
Audits, Policies
Northwood & Pinner Community Unit (NPCU) Monthly Meetings
11. Infection Prevention & Control Committee (IPCC)
11.1 The IPCC, chaired by the DIPC meets quarterly and comprises of representatives
from a wide range of clinical, non-clinical teams and support services across CNWL.
The overall purpose of the committee is to provide both strategic and operational
leadership to all services and teams in relation to IPC measures and standards.
The role of the members is to support the Trust in achieving the regulatory requirements
as referred to on page 6 of this report, and in providing assurance to the Board of
Directors.
11.2 The committee members are also responsible for effectively disseminating
information to their relevant teams and for bringing to the committee key information
aimed at improving and sustaining high standards of IPCC.
12. Reporting Arrangements
As this report has already highlighted, the IPCT senior nurses each report to different
immediate local line managers. The day-to-day operational management of IPC issues
is dealt with by the three IPC Senior Nurses within their own areas, with medical support
and advice from the IPC Doctors and the DIPC as and when required. In 2012/2013
this will change in that the Infection Control Nurse will all report to the Deputy DIPC.
13. Director of Infection Prevention & Control Reports to the Board of Directors
The DIPC reports to the Trust Board of Directors (BOD) who meet four times each year.
The DIPC produces three quarterly reports and an annual report with the IPCT activity.
These reports track and monitor the Trust’s performance against the Hygiene Code.
The DIPC reports to Chief Executive and the Board and through no other Officers.
14. Infection Prevention & Control Link Practitioners Group
The Infection Prevention & Control Link Practitioners (IPCLP’s) continue to drive IPC
initiatives at a local level and support the delivery of IPC programmes under the
guidance of the IPCT. These are staff members identified in all clinical sites and teams,
with members drawn from a variety of disciplines. A requirement of the role is to act as
11
a resource and role model in their work area, address IPC issues and participate in IPC
projects and audits.
15. Infection Surveillance & Data Reporting
The Department of Health instigated mandatory surveillance systems of key infections
from 2001. This now includes MRSA bacteraemia, C difficile, MSSA and E coli
bacteraemia. These infections are reported to the HPA by Microbiology Laboratories.
Additionally, CNWL monitors and reports other infections which occur in our patients to
the BOD.
16. Alert Organism Summary
Across the whole of the NHS, Monitor have set targets for MRSA bacteraemia and C
diff. The table below demonstrates the alert organism surveillance across the Trust.
Alert Organism Surveillance
ALERT
ORGANISM
Target
CPS
HCH
MH
CNWL Total
Year
2009/2010
MRSA
Bacteraemia
CPS and HCH not
part of CNWL
0
Cases not
disaggregated from
acute and PCT
services
Cases not
disaggregated from
acute and PCT
services
0
**Clostridium
difficile. (Toxin
positive)
CPS and HCH not
part of CNWL
1
MRSA
Bacteraemia
CPS and HCH not
part of CNWL
1
Cases not
disaggregated from
acute and PCT
services
Cases not
disaggregated form
Acute and PCT
services
0
**Clostridium
difficile. (Toxin
positive)
CPS and HCH not
part of CNWL
9
Self Target
7
7
2
16
Self Target
0
7
0
7
0
2
0
16
Actual Total
4
3
0
7
0
Year
2010/2011
0
Year
2011/2012
*MRSA
Bacteraemia
Actual Total
**Clostridium
difficile. (Toxin
positive)
12
The targets in the table for 2011/2012 were in place within CNWL prior to the merger
between MH & AS, CPS and HCH.
17. MRSA Bacteraemia Surveillance1
There have been no cases of this infection reported in CNWL during 2011/2012.
18. Clostridium difficile Surveillance2
18.1 The cumulative total number of cases of C. diff for CNWL during 2011/2012 is
seven. As part of the Monitor compliance framework the maximum number of cases
permitted annually is sixteen. The number of cases reported by CNWL the previous
year was nine.
18.2 Monitor, in their compliance framework, have stated that they do not want Trust’s
to be reporting on six C. diff cases or less, meaning that seven or more would be
reported on. Therefore under Monitor’s guidance, CNWL as a whole would be expected
to have only one total target figure of seven C. diff cases. The DIPC recommends that
the three services should continue to report separately and that the self target figures
should remain at seven for each of the community providers and two for MH & AS.
18.3 Over the past few years MH & AS have not been required to report C. diff cases
and, in fact, have not had any actual cases within the Trust to report. It is for that
reason that the DIPC advises the BOD to agree that MH & AS continue to have a lower
target than community services.
19. Incidents
19.1 Norovirus
During 2011/12 there were three outbreaks of presumed/confirmed Norovirus that
caused wards to be closed to admissions in MH & AS. These outbreaks were during a
period where Norovirus was circulating widely in the local community and many local
care homes and hospital wards were also affected.
MRSA Bacteraemias – MRSA positive cultures where the patient was an ‘in patient’ the specimen date is on, or
after, the third day of admission, where the day of admission is day 1.
1
Clostridium difficile infection- ; where the patient was an inpatient and the patient’s specimen date is on, or after the
fourth day of the admission, where the day of admission is day 1. (Clostridium difficile I’ve taken this out as the
guidance on this is for this year not last.Based on HPA acute trust mandatory surveillance data caveats.
2
13
Presumed/Confirmed Norovirus Outbreaks
Date
Location
Organism Type
of
Unit
Affected
13.04.11 Coombe
Confirmed Coombe
Wood
Norovirus Wood
Ward
–
Ward
–
Park Royal
Park Royal
Hospital
Hospital
No. of Duration of
staff
outbreak
affected
4 staff
Ward
closed for 9
days
18.04.11 Fearnley
Ward
–
Northwick
Park
30.01.12 Butterworth
Centre
(Older
Adults)
No staff
Ward
closed for 4
days
1 staff
Ward kept
under close
observation
for 3 days
Confirmed
Norovirus
No
diagnosis
confirmed
No.
of
patients
affected
Diarrhoea
and
vomiting 4
mothers,
3 babies
affected.
Fearnley
Diarrhoea
Ward
– and
Northwick
vomiting 5
Park
patients.
Butterworth Diarrhoea
Centre
and
(Older
vomiting 3
Adults)
patients.
There were no outbreaks in the community provider services.
19.2 TB incident at Mortimer Market: An HIV positive patient presented with chest
symptoms and a productive cough. The results were consistent with a diagnosis of
Tuberculosis, (sputum smear positive for acid fast bacilli, and a positive PCR for
Mycobacterium TB). The patient attended the Bloomsbury clinic and/or the onsite
pharmacy a total of nine times whilst symptomatic. (1st November 2010– 31st March
2011). In response, an incident team was convened in April 2011, the risks assessed
and a “look back” exercise and screening criteria agreed. In response, an incident
team was convened in April, the risks assessed and a “look back” exercise and
screening criteria agreed.
19.2.1 Using these criteria, a total of 201 HIV positive patients attended the Bloomsbury
clinic and or pharmacy during this period. 19 patients attended GUM and 21 attended
HTD.
Outcome: Overall 114 attended a screening clinic.
Screening results Interferon-Gamma Release Assays (IGRA) chest x-ray (CXR)
103 had a negative IGRA, 11 had a positive IGRA (one or both tests positive).
19.2.2 A medical expert reviewed 8 of the 11. The majority of those testing positive had
a history of previous exposure/history of TB. Most patients opted for a “watch a wait”
policy rather than taking prophylaxis treatment.
19.2.3 Further follow up for individuals with a low CD4 count and negative IGRAs, was
in line with NICE guidance.
14
20. Staff Survey
20.1 The NHS staff survey is undertaken every year. Infection control and hygiene is
included in this and indications are that the majority of staff are satisfied with the
facilities made available to them.
20.2 The IPC lead in CPS identified that clinicians working in the community and
Mortimer Market Centre had the least level of satisfaction and targeting these areas will
have a positive impact on patient care. This has been added to the CPS IPC Work
Programme.
21. Decontamination
As the services are continuing to come together the DIPC will be the interim
Decontamination Lead for all of CNWL, supported by the current leads for MH&AS,
CPS and HCH. As this position is not sustainable in the long term, a Decontamination
Lead will be appointed for all CNWL who will report to the DIPC.
There is an identified Dental Consultant Decontamination Lead for HCH.
21.1 Decontamination Clinical Environments
This is described under Audit (Section 31).
21.2 Decontamination of Medical Devices
The Trust has a Decontamination Policy which is devised and updated by members of
the Medical Devices Group as required by changes and development in infection control
practice.
21.3 Decontamination of Dental Devices
Dental services are provided by HCH. The Dental Service Lead developed the HCH
Dental Decontamination Policy in 2011. This policy provides guidance to ensure that
decontamination processes used within the HCH Community Dental Service are robust,
reflect best practice, and comply with NHS requirements and legislation. It is a specific
requirement of the Health and Social Care Act, 2008: code of practice for the prevention
and control of healthcare associated infections that the Trust has a clear policy for
decontamination of dental equipment.
The aim of this policy is to identify and describe the responsibilities of staff in line with
Health Technical Memorandum 01-05: Decontamination in primary care dental practices
for the community dental service. All members of the dental team will use and refer to
the policy.

This policy sets out the procedure for the safe and effective decontamination of
medical devices and equipment, laboratory work disinfection and staff
responsibilities throughout these processes.
15

It sets out clearly the difference between single use, single patient use and
general reusable medical devices.

It highlights the various methods of decontamination process and when they
should be used.

It sets out the procedures for the safe and appropriate disposal of medical
devices and equipment.

It sets out the procedures for the safe and appropriate disposal of dental clinical
waste requirements.

It sets out the testing requirements and audit on decontamination processes.
22. Multi disciplinary team working
22.1 Estates & Facilities
The MH&AS IPCT has worked closely with the Estates & Facilities department on the
following refurbishment projects to ensure IPC requirements are met and in place.
 South Kensington & Chelsea – Vincent Square clinic relocation
 Warwick Road – service line redesign
 Chelsea Chambers – service line redesign
 Hillingdon Hospital– Colne Ward internal alterations
 South Kensington & Chelsea – reception redesign
 St Charles Hospital – internal redesign
And the following capital projects
 Environmental improvement programme:
o Kingswood Centre
o Horton Haven – Westfield & Rushett House
o Roxbourne Complex
o Rosedale
o Park Royal – Coombe Wood

CPS IPC have been involved in the review of a number of projects, these
included developments for South Wing, Mortimer Market, Clash and a number
sexual health and contraceptive services outreach programmes.

A new provider of Estates and Facilities services Balfour Beatty Workforce
(BBW) has been commissioned in partnership with Camden and Islington
Foundation Trust. Compliance with the Health & Social Care Act 2008 is a
requirement of the new contract agreement, this is being drawn up. Processes to
monitor compliance with the Health & Social Care Act will have to be integrated
into the CPS infection control reporting mechanism (e.g. Legionella testing),
these are being developed within CPS by the Head of Administration.
16
At HCH a number of work projects have been carried out to improve the environment in
Northwood and Pinner, including a long standing problem with the mixer taps.
22.2 Facilities Cleaning & Catering Services
One Complete Solution (OCS) is the main contractor for the provision of these services
to MH&AS. The contract is four years into its five year term, with an option available to
extend a further two years, which is currently be negotiated with direct input from the
IPCT.
The contract has a high specification relating to Infection Control and is monitored by
the Facilities & Patient Environment Manager with Trust and OCS staff on a monthly
basis. A member of the IPCT attends the monthly contract meetings at HQ and the local
review meetings on a rotational basis. Audits are undertaken – these are explained in
Section 31.
Balfour Beatty Workforce provide cleaning & catering services for CPS and Hillingdon
Hospital (Acute) provide cleaning & catering services for HCH.
22.3 Facilities Laundry & Linen Service
This service is provided to the CNWL MH&AS services by Eastbourne Hospital Services
(EHS), which is a part of East Sussex Hospitals NHS Trust. The contract commenced
on 1st October 2009 and is now two and a half years into a five year term, with an option
available to extend a further two years.
All linen sent for laundering with EHS is treated as “infected” and as such delivers a
high standard of infection control. The contract continues to run very smoothly and is
monitored by Estates & Facilities with the involvement of the IPCNs.
Balfour Beatty Workforce provide linen services for CPS and Hillingdon Hospital (Acute)
provide linen services for HCH
23. Health & Safety
The Infection Prevention and Control team work closely with the Trust’s Health & Safety
Team who provide advice and support particularly in the area of risk assessment.
With the implementation of Datix Web (electronic incident reporting) the IPCT now
receive alerts for all relevant incidents enabling timely follow up and investigation.
24. Clinical Risk Management
The IPCT continue to work closely with the Clinical Risk Management Team on a range
of issues for example reviewing relevant policies.
17
25. NHSLA Risk Management Standards
25.1 CNWL will be formally assessed by the NHS Litigation Authority against their Risk
Management Standards on the 28th and 29th of June 2012 at Level 1. The IPCT has
been actively engaged in this work stream by ensuring that relevant infection control
policies are in line with NHSLA Standards.
25.2 Four IPC policies and procedural documents have been reviewed to ensure that
they meet required standard and are ready for assessment. These include:




Hand Hygiene Training (Part of Training Policy)
CPS Inoculation Procedures
MHLD Inoculation Procedures
HCH Inoculation Procedures
25.3 At the time of reporting, all these documents were deemed to be ready for
assessment.
Ongoing work to merge CNWL and Allied Services policies will include ensuring NHSA
standards are met.
26. Governance and Reporting
26.1 Infection Control remains a standing agenda item at each meeting of the Trust’s
Clinical Safety Group. The Clinical Safety Group maintains an overview of clinical safety
issues within the Trust including Infection and Prevention Control issues.
26.2 The Group also overseas the dissemination and implementation of all NPSA
Patient Safety Alerts and action plans in the organisation. The group reports directly to
the Quality and Performance Management Group.
27. Occupational Health Services
27.1 During 2011/2012 Occupational Health Services (OHS) within CNWL were
delivered via a range of providers. Over the coming year this service will be integrating
under one internal provider, namely Camden OHS.
27.1.1 The internal OHS is working closely with infection control colleagues regarding
the introduction of the usage of “Safer Devices” across the Trust, as well as improving
the quality of the data regarding OH activity that is provided.
27.1.2 The internal service is already starting to plan for the delivery of a robust staff
seasonal flu vaccination programme across CNWL and the IPCT will assist in the
delivery of this campaign.
18
27.2 Infection Prevention & Control Related Audits and other Projects
Work continues in respect of the EU Directive on the prevention injuries and infections
to healthcare worker from sharp objects such as needles, lancets and intravenous
catheters. The new Directive must be translated into national Law by May 2013.
27.3 Current practice in CPS OHS
27.3.1 Staff new to CPS are seen by Occupational Health to have their immunisation
status assessed and updated where required.
27.3.2 Verbal and written information is provided regarding the prevention of body fluid
exposure and how to report these.
27.3.3 Policies are in place on the managing of these incidents and documented in
section D of the Infection Control Manual.
27.3.4 Ten of sixteen (62.5%) body fluid exposure in the past year was caused by used
sharps medical devices and could have been prevented with the use of sharp safe
equipment.
27.3.5 Further work is being undertaken by the Infection Control and OH teams to
encourage the introduction of safer devices across CPS. Suppliers and devices have
been researched and devices are being indentified for trial in various clinical
environments across CPS. A cost comparison is also being undertaken at the time of
this report.
27.3.6 An audit of the OHS compliance with national guidance around the care of staff
who are HIV positive was undertaken in this financial year. Findings confirmed good
compliance and an action plan for further general improvements to services are being
developed.
28. Training & Education
28.1 Annual Mandatory Training
IPC mandatory
training compliance
figures
MH & AS
CPS
HCH
2011/2012
Cumulative over 2 years
Cumulative over 2 years
36%
86%
86%
The staff survey carried out this year within CNWL showed that 67% of staff reported
that they were trained in the past 12 months, showing an increase of 18% on the
previous year. Those that said that they had been trained in the past two years totalled
91%.
19
The DIPC believes that a major contribution to an increase in training numbers in the
MH&S from 27% in 2010/2011 to 36% in 2011/2012 is due to the appointment of a full
time IPC trainer. Unfortunately this member of staff was off sick for a prolonged period
of time and this will be reflected in the training figures for the end of the year.
29. Policies and Procedures
29.1 Procedures are essential to ensure all staff have access to evidence based
information, aimed at ensuring high standards of IPC are practiced Trust wide.
29.1.1 The MH&AS continue to use the agreed in date IPC Manual (previously referred
to as IPC policies).
29.2 Individual Policies under Development/Review by IPCT
The amalgamation of policies between CPS and HCH is planned over the forthcoming
year; at which point a joint manual will be launched. The joint policies below are now in
use in HCH and CPS and can be found on the Trust intranet.
 Personal Protective Equipment
 Hand Hygiene
 Outbreak Management
 Spillage
 Isolation
 Notification of diseases reportable to the Health Protection Agency.
 Procedure for the management of sharps injuries and blood-exposure incident. This
is a policy which has been amended in line with the CNWL format and has been
assessed as part of the NHSLA visit; subsequently minor revisions have been made
to the monitoring section.
 Infection Control Training (including Hand Hygiene). This is a stand alone policy that
has been amended.
 The Decontamination of medical devices (B2) and disinfection of equipment (B3)
policies have been removed from the CPS Infection Prevention and Control Policy
Manual. The overarching Decontamination of Medical Devices Policy produced by
CNWL will, in the future be the reference point for staff. Where necessary, services
are to develop local decontamination of medical devices procedures.
 Dental decontamination Policy (applies to HCH only).
30. Infection Prevention & Control website and Intranet
30.1 The Trust intranet pages are maintained and updated regularly to ensure the
information is available and reflects current practice.
30.2 On the CNWL public website there is a statement describing the purpose of the
IPCT and what we expect patients and staff to be aware of.
20
31. Audit
31.1.1 Due to the large number of audits either undertaken or monitored by the IPC
across CNWL, the IPCT has prioritised some of those audits to offer information in this
report. The reported audits are Hand Hygiene Audits, Clinical Environment Audits
(PEAT), Commode Audit, Mattresses, Glove Audit, Antibiotic Prescribing Audits and
due to a recent spike in the number of needlestick cases, an exception report detailing
all known needlestick injuries. As these incidents are potentially life threatening, the
IPCT has had to re-focus its use of resources and pulled together a detailed audit of the
type and of needlestick injuries and have completed an exception report attached
(Appendix 5).
31.1.2 The Health & Social Care Act (2008) Code of Practice for the Prevention and
Control of Health Care Associated Infections requires that health care providers have in
place a programme of audit to ensure that key policies and practices are being
implemented appropriately. The audits allow the identification of areas of poor practice,
provide valuable feedback opportunities and can lead to a review of best working
practices, policy compliance and current awareness. Equally, good practice can be
highlighted and shared across services (Appendix 6).
31.2 Hand Hygiene Audits
31.2.1 CNWL MH&AS, CPS and HCH participated in the CleanYourHands campaign
and received the final delivery of promotional material in February 2011. This was
circulated to the clinical areas and information disseminated to staff to ensure continued
attention is maintained in this area.
31.2.2 The audit results indicate that CPS (52 beds) and HCH (22 beds) have achieved
100% of hand hygiene audits within their in-patient areas. The MH and Allied services
(870+ beds) audit results have been much lower and 35% were carried out over the
past year. The IPCT view the Service Lines development as a very positive move,
however, this has resulted in not insignificant disruption in reporting mechanisms from
the services that is being addressed through IPCLPs and Matrons.
31.3 Clinical Environment Audits (PEAT)
The IPCT are an integral part of these visits alongside the Estates and Facilities
Departments.
The results for 2011-12 were “Good” across CNWL.
31.4 Commode Audit
Inadequately cleaned commodes are a well-known source of cross infection of infective
diarrhoeal illnesses in healthcare. The condition of commodes is regularly monitored
and recommendations and advice made to staff on cleaning and operation to prevent
21
any transmission of infection. In MH&AS new commodes that lend themselves to more
effective cleaning have now replaced out of date models.
31.5 Mattress Audit
Mattress audits are undertaken regularly throughout the Trust to ensure they are fit for
purpose in relation to tissue viability, infection control and fire safety.
All condemned mattresses are replaced where identified. The main cause of mattress
failure is cigarette burn.
31.6 Glove Audit
In CPS the objective was to reduce exposure of staff and patients to latex by introducing
new glove types. As part of a project CPS trialled Nitrile and Nitrile sensitive gloves
throughout its services to test their performance and establish whether the sensitive or
standard are better suited for different areas. The majority of staff were satisfied with
these results and therefore following this success HCH and MH&AS will look towards
adopting Nitrile and Nitrile sensitive gloves.
31.7 Antibiotic Prescribing Audits
The results below summarise the four individual quality indicators assessed via the
antibiotic audit tool, along with overall compliance to all indicators (overall compliance is
only met if all four indicators are deemed compliant for a given prescription). There has
been clear improvement in documentation of allergy status and selection of therapy
according to guidelines within the Trust, however there has been a reduced compliance
in documentation of duration of therapy and in selection of appropriate course length.
These observed reductions have been fed back to the relevant teams. Further work is
underway to develop local antibiotic prescribing guidelines and to provide tailored
teaching to specific staff groups to sustain this prudent antimicrobial prescribing.
All Directorates (excl. Older Adults)
Allergy Documentation
Application of a prescription stop date
Appropriate Course Length prescribed
Appropriate selection of Treatment
Overall Compliance
2010 - 11
(N= 417)
2011 - 12
(N= 509)
94%
87%
85%
80%
61%
98%
=86%
=84%
85%
72%
2010 - 11
(N= 171)
2011 - 12
(N= 223)
Older Adults
22
Allergy Documentation
Application of a prescription stop date
Appropriate Course Length prescribed
Appropriate selection of Treatment
Overall Compliance
93%
91%
84%
83%
66%
100%
79%
73%
87%
60%
32. Antimicrobial Stewardship
32.1 CNWL employ an antimicrobial pharmacist for two days a month. This year has
seen further development and roll out of an antimicrobial prescribing tool which has
been developed to monitor antimicrobial prescribing quality indicators in order to guide
training and development, identification of common prescribing patterns and unusual
practices and to demonstrate compliance with the Trust Antimicrobial Prescribing Policy
and the Health and Social Care Act 2008.
32.2 Antimicrobial prescribing is monitored at ward level by the CNWL pharmacists on
an on-going basis and is reviewed by the antimicrobial pharmacist, summarised and fed
back to the Trust with areas/topics identified for further improvement. The antimicrobial
pharmacist has also provided advice to CNWL pharmacists and teaching sessions to
the infection control link professionals and pharmacists.
33. Needlestick Injuries
33.1 Due to the increase in recently reported needlestick injuries the DIPC has
presented two exception reports to the (MH&AS) Clinical Governance Group. Incident
reporting data from April 2011 to April 2012 shows a consistent 1, 2 or 3 needle/sharps
related incidents reported per month until May 2012 when this increases to 4 reported
incidents suggesting a rise in needlestick injury.
33.2 However, when April 2011 and April 2012 data is compared there is no rise in
actual needlestick injury (2/2) and only a slight rise in all needle/sharps reporting (2/3).
33.3 When May 2011 and May 2012 data is compared it does show a significant rise in
both actual needlestick injury (0/3) and all needle/sharps reporting (0/4). It should be
noted however that in May 2011 there were no reported incidents of any kind at all
therefore skewing the perceived increase in reporting.
33.4 In the immediate future it is too early to establish whether this perceived trend is
set to continue to rise beyond May 2012.
33.5 Looking at the data from a historical perspective over the past 6 years the incident
data appears to have reduced during the period of ‘masking’ of non-safety devices and
then increased somewhat when ‘masking’ was relaxed. Needlestick exception report
available in Appendix 5.
23
34. Audit Plan for 2011/2012
Audits plans for 2011/2012 are detailed in Appendix 6.
35. Work plan for 2011/2012
Work plans for 2011/2012 were prepared separately by MH&AS, CPS and HCH.
Work plans were followed by the IPCT in 2011/2012. Progress against these plans is
reported through IP&C frameworks and into the Board of Directors quarterly via the
DIPC reports. An integrated work plan for all services within CNWL is planned for
2012/2013.
36. Summary
36.1 Last year proved to be both challenging and inspiring with increased opportunities
for learning by the coming together of three services. The DIPC has been well placed
to take advantage of the best of the IPCT Services from across CNWL, drawing on
expertise and developments to provide a better service for our patients, carers and staff.
36.2 In the coming year CNWL is even better placed to further enhance a closer
working relationship with the IPCT Services bringing these together in order to utilise
the learning opportunities that have occurred during the year 2010/2011. The three
services, as would be expected, operated differently in terms of reporting formats and
methods of working. Order to ensure safe services were maintained the last year
consisted largely of the AAT Approach.
37. Conclusion
37.1 The DIPC is pleased to report that he can give assurance to the Board of Directors
that safe practices have been maintained during this period of change. With the
introduction of Service Lines this adds to the changes required to meet the needs of
CNWL. Infection Control has maintained its safe practices throughout.
37.2 As mentioned earlier many of the changes have proved to be an excellent
opportunity for the services to learn from each other and provide mutual support to each
other for posts that can often be one person on their own within the infection control
speciality. Another benefit is that services that had no immediate resource to call on for
unforeseen peaks ie; infectious outbreak, now have colleagues to work with or are
contactable by telephone to give advice and moral support.
37.3 There are many positives to be taken from last year with an increase in IPC
training. This was due to in no small part to the appointment of a fulltime trainer in
infection prevention and control.
24
37.4 The BBV Group continues its excellent work and the Gordon Hospital is the pilot
site for opt out rather than opt in blood borne virus (BBV) testing. This has led to the
discovery of patients who have an undiagnosed BBV. The reason this is so important is
that it reduces the accidental infection of others and enables early treatment which can
increase life expectancy and quality of life.
37.5 The Sexual Health Clinic run by CNWL has again improved the treatment options
and learning for all staff in the treatment and care off those suffering from HIV and other
BBV’s. This has assisted in the treatment of patients with secondary infections such as
TB which is not an uncommon diagnosis of patients with HIV.
37.6 Every year London suffers from outbreaks of Norovirus (winter flu) and this year
has been no exception with many acute hospitals having to close ward for days or
weeks. CNWL had three outbreaks this year, much lower than previously reported. We
may not be able to stop patients, carers and staff being infected by this virus but we can
manage the outbreaks. The staff on the wards, in particular nursing staff, have done an
excellent job at minimising the severity and duration of outbreaks. Even though London
reported an increase in Norvirus outbreaks last year CNWL was able to report a
reduction and for those areas that had an outbreak the duration was short.
37.7 Overall the DIPC is pleased with the standards of infection control services
provided in particular to our patients, in what had the potential to be a very difficult
period with all the changes that were occurring, standards were maintained.
37.8 The IPCT must not be complacent and strive to improve services year on year. It
is satisfying to report that in spite of the current finical climate, the changes that the
NHS and CNWL are going through, the IPCT has not only maintained it’s standards but
has improved upon them.
37.9 This report sets out the activity within the Trust during 2011/2012 in relation to the
prevention and control of infection and demonstrates assurance of the commitment to
meet the required regulatory standards to ensure the effective and safe care of patients.
25
38. References:
Care Quality Commission (2009) Registration.
http://www.cqc.org.uk/guidanceforprofessionals/nhsTrusts/registration.cfm
Care Quality Commission (CQC) registration requirement for cleanliness and infection
control (CQC Guidance about Compliance, Outcome 8)
Department of Health (2003) Winning Ways: Working Together to Reduce Healthcare
Associated Infections in England. http://www.dh.gov.uk
Department of Health (2008) The Health and Social Care Act 2008 Code of Practice for
health and adult social care on the prevention and control of infections
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGu
idance/DH_110288
Department of Health (2009) Decontamination Health Technical Memorandum 01-05:
Decontamination in primary care dental practices HTM 01-05
Pratt, R.J. et al (2007) Epic 2: National Evidence-Based Guidelines for Preventing
Healthcare-Associated Infections in NHS Hospitals in England Journal of Hospital
Infection (2007) 65S, S1–S64
EU (2010) Directive 2010/32/EU - prevention from sharp injuries in the hospital and
healthcare sector
http://osha.europa.eu/en/legislation/directives/sector-specific-and-worker-relatedprovisions/osh-directives/council-directive-2010-32-eu-prevention-from-sharp-injuries-inthe-hospital-and-healthcare-sector
HMSO (2007) The Medical Devices (Amendment) Regulations
NHS Litigation Authority, Risk Management Standards, acute, community, mental
health and learning disability and independent sector standards 2011 - 2012 Infection
control, Hand hygiene training standards 2.8
National Institute Clinical Excellence, NICE Guidance (2003), Prevention of HealthcareAssociated Infections in Primary and Community Care.
26
Appendices
Appendix 1 Work Plans for MH, CPS & HCH Services 2011-2012
Appendix 2 PEAT Scores
Appendix 3 IPCT Structure
Appendix 4 IPCT Budget Statement
Appendix 5 Needle Stick Exception Report
Appendix 6 Annual IPCT Audit Plans
27
Appendix 1
Work plans for services 2011-2012
CNWL INFECTION PREVENTION & CONTROL ANNUAL WORK PLAN 2011-2012 - MH
1
2
3
4
5
6
Requirement
The Board of Directors
(BOD) need assurance that
Infection Control practice @
CNWL is compliant with the
Hygiene Code for Care
Quality Commission (CQC)
purposes
Significant changes are
occurring in the Infection
Prevention & Control Team
(IPCT), these need to be
communicated regularly to
all staff Trust wide
All Infection Prevention &
Control Policies will need
reviewing alongside HCH
and CPS IPC policies
All staff (clinical and nonclinical, contractors and
agency) must have annual
mandatory Hand Hygiene
and Infection Control
All patient and areas must
have a minimum of one
Environmental Audit every
six months
Annual Patient Environment
Action Team (PEAT) visits
are required
Action
To write and present a
quarterly exception report
and an Annual Report for
BOD – both to include
Mandatory reporting of alert
organisms. To undertake
and maintain gap analysis
against current Hygiene
Code
All updates to team to be
added to weekly news on
Trustnet, a quarterly IPCT
Newsletter will be produced
Accountability
Director of Infection
Prevention & Control
(DIPC) and Senior
Infection Control Nurse
(SICN)
Timescale
Quarterly and
Annually for
Board Reports,
Quarterly for the
Hygiene Code
March 2012
Progress/Comments
Board Reports due August &
November 2011, February
2012. Annual Report 2012 to
be confirmed BOD May 2012.
Gap analysis included in Board
Reports and reported in
Annual Report
IPCT/Communications
Dept/
Quarterly –
commencing late
2011
Quarterly newsletters to
commence by year end 2011
To update IPC Manual as
appropriate
IPCT
As required
To be discussed at quarterly
ICG meetings
To rewrite and present all
powerpoint presentations (for
clinical, non-clinical and
mandatory training).
Compile IPC e-learning
package
Using the icat audit tool all
inpatient areas will be
audited
IPCT
Ongoing
IPCT
March 2012
The IPCT will participate in
PEAT as and when required
PEAT team
November 2011
(mock) February
2012 (actual visit)
A significant improvement in
attendance for training is
needed – relaunched the IPC
training. E-learning package
under development by
Learning & Development
iCAT tool under review in order
to make it more user friendly
and appropriate for mental
health settings
PEAT visits planned,
Environmental audits can be
performed at the same time
28
7
8
9
10
11
12
13
14
Requirement
Infection Prevention &
Control Link Practitioners
are required in all Clinical
areas
Action
IC Links need to be
identified, fully trained and
regularly updated
Accountability
IPCT/All Clinical areas
Other audits;
 Hand Hygiene
 Policy
 Mattress
 Indwelling urinary
catheters
All actual/potential
infections or outbreaks
must be promptly reported
via IR1 forms
The IPC webpage needs to
be maintained on Trustnet
and the public facing
internet
The Trust is required to
have quarterly IPCG
meetings attended by
representatives from each
Clinical area
The Trust needs update
patient information/leaflets
relating to Infection
Prevention and Control for
patients, staff and visitors
IPCT participation in the
CNWL Nursing Conference
2011
A rolling programme of
annual audits as listed
IPCT/All Clinical areas
All infections and outbreaks
will notified to Risk
Management/IPCT ASAP
All areas
Monthly
Monitor database monthly
Admin staff to assist and set
up and maintain IC webpage
Administrator/IPCT
October 2011
Book all meetings for 20112012
IPCT
Quarterly
March 2012
Initial webpage set up on
public facing website March
2011 – further development
required
All arranged
ToR reviewed and agreed
Review and update
information provision
IPCT/IPCG/Patient
Involvement
Completed
6 IPCT information have been
produced and are available to
download on Trustnet
IPCT to have a stand
focusing on hand hygiene
and other key IPC issues at
this years Nursing
Conference
Plan and deliver IPC
activities during this time
IPCT/Conference
organisers
Completed
IPCT
October 2011
The IPCT had a very good
attendance for the Hand
Hygiene practical session
undertaken at the IPCT stand
at the Nursing Conference
To be arranged
Participate in National
Infection Control week
Timeframe
First meeting
20.07.11 &
quarterly
thereafter
Progress/Comments
Identify where the gaps are,
engage managers to identify
IPCLP’s, review training
package and plan training
dates
Audits planned
August 2011
September 2011
May 2011
tbc
29
CPS Work Plan 2011-2012
The Infection Prevention and Control annual programme for 2011-2012 will be further developed with
the Infection Control Leads at CNWL and Hillingdon PCT. Core priorities will be worked on primarily to
progress the merging of the individual services. Alongside this plan a local CPS programme will be
developed to meet specific organisational and service needs.
Task
Detail / Process
Indicator
Lead
1. Advise on the
following policies.
Advise on policies developed by other services
where IC is relevant
(i) Policies to be developed in collaboration with
E&F
 Building and Renovation policy
 Food Hygiene Policy
 Policy on Management of potable and nonpotable water supplies
 Cleaning Policy – arrangements,
standards, frequency schedule
 Waste management policy (to comply with
HTM 07-01)
 Terminal clean/ disinfection policy
 Legionella policy
 Air Handling Systems Policy
 Pest control Policy
 Planned preventive maintenance
 Laundry Policy
 Decontamination of the environment policy
including disinfection and terminal clean
Decontamination of medical devices
Monitoring of policy implementation
via audit results
Head of
administration
and facilities
E&F
RCA to be carried out for cases of MRSA
bacteraemia, infection, E. coli bacteraemia and
toxin producing C. difficile
RCA findings and action plan to address
issue
Report outbreaks / incidents (SUIs / STIES)
Incident report
Maintain Assurance Framework Document,
(incorporating Gap analysis and action plan for
health & Social care Act 2008)
Reports to ICC as appropriate
lead / assist in the Investigation of and incident
- outbreaks of infection
Minutes of outbreak committee meetings
2. Risk management
Compliance with national requirements &
standards
ICT
Audit management of complex medical
devices (Oct)
Relevant multidisciplinary
team and ICT /
Microbiologist.
ICT
30
Audit
Reports to be
presented at IPC
sub Group.
Outcomes to be
disseminated to
staff via IC training
and via local team
meetings.
Policy audit to ensure that selected IC policies
from CPS, CNWL and Hillingdon PCT) are
assimilated Audit compliance - adherence to
standard precautions
Policy Manual
Audit results demonstrating level of
compliance with policy/good practice.
Regular review of cleaning standards
IPCC minutes
Audit of urinary catheter care – and
establish baseline for CQUIN
Catheter care Audits
High impact interventions / essential steps in
community setting
Essential Steps to clean safe care Audit
results demonstrating level of compliance
with policy/good practice
Audit results demonstrating level of
compliance with policy/good practice
Outcomes and
results to feed into
work plan.
4.Promote
compliance with
hand hygiene
amongst clinical
staff and visitors
Audit of hand hygiene in clinical practice –
including WHO’s 5 moments for hand hygiene
& bare below the elbows, review hand hygiene
audits.
Display 6 step hand decontamination poster at
all handwash basins and at all alcohol hand gel
stations
Examine reasons for below safety metric
scores for staff survey around hand hygiene
equipment.
5.Promote
prevention of HCAI’s
through training,
media and
campaigns
6. Provision of
advice and review
and report adverse
incidents
7. Practice
Development
Infection control training ,an ongoing
programme of updates is available to all
provider staff and Infection Control included in
each induction session
ICT
Service Leads
Head of
administration
and facilities
& E&F
ICT with L&D &
clinical leads
ICT & E&F
Audit results demonstrating level of
compliance with policy/good practice
Increased hand hygiene compliance on
re-audit
ICT
Attendance record
Evidence of education and work
undertaken.
Progress towards recommendation,
reviewed at IPCsC
Training Policy & Programme
ICT and Site
managers
ICT
L&D / ICT
Seasonal Influenza campaign, new approached
to improve uptake amongst staff
Uptake of vaccination report
OH
Dissemination of information and raising
awareness of infection control issues and good
practice through intranet
New staff aware of IC Team and IC
policies and how to access IC team
ICT
Target is 95% clinical staff to be trained
Increased awareness of infection control
policies procedures improvement in
clinical audit results Reductions in HCAI.
L&D / ICT
Provide advice and maintain accurate record of
advice given. Develop way to identify & monitor
trends.
Annual advice/incident log summary
report to ICC
Governance
ICT
review reports for, and provide specialist
information at e.g. waste , H&S committees,
decontamination of medical devices, as
required
Introduction of core care plans/ care pathways
- adult community nursing
Committee minutes
Training Policy & Programme /
Reductions in HCAI.
L&D / ICT/
service leads
Extend audit to include urinary catheter care
Training & Policy Reductions in HCAI.
L&D / ICT/
service leads
Ensure all EPIC and NICE guidance is in
place, in particular invasive medical device
management and aseptic technique.
Training & Policy
ICT
Estates and
Administration
lead
L&D / ICT/
service leads
31
Decontamination is integrated into the
management of medical devices.
Introduction of safety devices across all
services. EU Directive
All clinical staff are compliant with catheter
insertion and Aseptic Technique.
Procurement checklists completed.
Risk, facilities
and
administration/
service leads
ICT.
L&D / ICT/
service leads
Bold = priority action.
32
CNWL, HCH, NHS Hillingdon, Independent Providers and Contractors.
Infection Prevention and Control Work Plans from April 2011 –2012
Issue
Recommendations
Actions
Exec Lead
Operational
Lead
Timeframe
RAG
Comments
HCH work plans 2011-2012
Northwood and Pinner Community Unit (NPCU) 22 Bedded Unit based at Mount Vernon Hospital
1
1.1
Hand Hygiene
WHO audit (5
moments) tool
Clean indicator
tape for
decontaminated
equipment at
NPCU
Consistency in
application of clean
indicator tape
following
decontamination of
commodes, hoists,
wheelchairs and bedframes.
1,2
Hand hygiene
audit in NPCU
form a visitors
perspective.
1.3
Legionella: risk
management at
NPCU
To audit hand
hygiene from a
visitors perspective at
the NPCU 22 bedded
unit
Provide evidence of
testing/flushing of
taps
Link Nurse practitioner to
undertake hand hygiene
audits weekly Send the
audit results to the IPCT.
Ad hoc IPCT to undertake
“spot checks”
Instruct all staff to write
name, date and time on
clean indicator tape and
attach to equipment after
decontamination of any
equipment
Specific and ad hoc
training in the unit to be
recorded by the IPCT.
Ad hoc inspections by the
IPCT.
Training for night/bank
staff to be arranged.
Audit tool to be designed
and implemented.
All staff to receive
instructions to flush taps
weekly (done in 2010).
PW
HW
UD
GC
PW
Ongoing
Ongoing
HW
UD
GC
AD
PW
HW
UD
PW
HW
CE
AD
Aug 2011
Thereafter
yearly.
33
Log book to be signed and
dated by staff undertaking
flushing of taps.
IPCT Check log book six
monthly
Instruct staff to unzip and
inspect mattresses
weekly.
Audit compliance.
Complete action plan for
2011/2012 inspection
1.4
Mattresses
inspection at
NPCU
Monitor schedule for
inspecting mattresses
weekly
1.5
Patient
Environment
Action Team
(PEAT)
Undertake
assessment as
required nationally
1.6
MRSA Screening
on admission to
Unit
Compliance with
MRSA screening
To ensure compliance with
the “MRSA screening of
patients on admission
policy to the NPCU policy”
Submit data on MRSA
positive patients to the
IPCT administrative staff.
To audit patients
records to ensure that
protocols for MRSA
eradication are being
followed t
IPCT to audit
Yearly hand hygiene
audit across all
services to ensure
that compliance to
policy is being
IPCT to undertake yearly
Ad hoc “spot check”
across all HCH services at
regular intervals.
2
HCH Mandatory
hand hygiene
audit for
clinicians
UD
GC
PW
PW
PW
CE
HW
AD
GC
UD
HW
AD
CE
UD
Sodexo
(THH estates)
AD
CE
UD
GC
Ward Manager
Yearly
Yearly
Monthly
Six monthly
PW
HW
UD
GC
Quality
Governance
April 2011
Since last
ICC
34
followed.
3
Patient
experience of
hand hygiene
4
Policies
Outstanding
2011 for HCH
Policies to be
updated in
partnership with
CNWL and CPS
ANTT
competencies
4.1
5
Undertake this audit
within the specified
time
Inform the District Nurses
of the audit in order to
encourage patient
participation.
Undertake audit
Action plan on results
PW
HW
UD
GC
Quality
Governance
CF
SB
October 2011
Meet with IC leads to
prioritise and agree
Discussed with the DIPC
at CNWL regarding
integration of policies and
future planning on policies
IPCT to provide training to
the Link Nurse
Practitioners in order that
they will disseminate to
clinical teams
Monitor dissemination
To contribute as required
at the HIA steering group
PW
HW
UD
GC
On-going for
2012-2013
PW
HW
UD
GC
Feb 2012
PW
HW
JY
UD
As per HIA
plan
To contribute as required.
PW
UD
Yearly
Undertake audit
PW
HW
UD
GC
OH
Feb 2012
Submit data to IC Lead
quarterly
PW
UD
OH
Quarterly
IPCT to provide ANTT
training.
6
High Impact
Actions
Implement high
impact action plans
on catheter care.
7
CNWL IC
Annual Report
Needle stick
injury audit
Contribute to the
annual report
Audit to be
undertaken to
establish staff
awareness and
management in the
event of a needlestick
injury.
Collate data and
information on
8
9
Occupational
Health
35
needlestick injuries.
To support the IPCT
To complete an
annual link nurse
work plan
10
Infection
Prevention and
Control link
practitioners
11
Mandatory
Training
Mandatory training
compliance to be 95%
across HCH,
12
Outbreak
Management
Compliance with
policy
13
CNWL ICC
meetings
To represent HCH
14
EU Directive on
sharps
To comply with EU
legislation
Undertake link nurse
action plan
PW
HW
GC
Yearly
Staff to attend mandatory
training for IPC to ensure
compliance with good IPC
practices.
Audit compliance post
each outbreak and report
to ICC
Undertake action as
required by CNWL
PW
Service leads
Reported
monthly
PW
HPA
HW
UD
GC
UD
GC
Ongoing
Ensure systems and
processes are in place to
meet compliance
PW
UD
GC
LZ
May 2013
PW
Quarterly
Independent Providers and Contractors
15
General
Practitioners
Audit
Complete remaining
GP audits over 20112012 Rolling
programme over
three years to audit
GP premises
16
General Dental
Practitioners
General dental
Practitioners to self
assess in accordance
with guidance from
the HTM 01 from April
2011 and the CQC
regulatory body.
17
Independent
To offer advise and
ICT to co ordinate, audit,
evaluate and make
recommendations to
improve practice in
preparation for CQC
registration 2012
Report to DIPC, Primary
Care, ICC
IPCT to provide advice
and support.
Agree with dental
commissioners CB
priorities for 2011-2012
DIPC
UD
GC
DIPC
CB
UD
GC
Continue with e – network
DIPC
UD
2011 -2012
Ongoing
36
18
Nursing Homes
and Hospices
support in minimising
risks associated with
HCAI’s
and information
dissemination
Continue to offer advice
and guidance to homes
and support training.
Healthcare
Estates
Inspect audit and
NHS Hillingdon
Health Care buildings
in order to minimise
potential risks of
infection associated
with the healthcare
environment.
IPCT to audit PCT health
centres to address any
infection control issues.
Environmental
cleaning
19
Antibiotic
Prescribing
Prudent antimicrobial
prescribing for
General practitioners
20
Clostridium
difficile
associated
diarrhoea
(CDAD)
21
Health Care
Acquired
Infections
(HCAI’s)
Report to the
pharmaceutical
advisors in the event
of CDAD and also
when advised of pre
48hrs clostridium
difficile
Ensure accurate
surveillance of HCAI’s
in conjunction with the
HPU.
Work with clinic
supervisors in
implementing remedial
action if required following
site cleaning audits.
Compliance of prudent
prescribing demonstrated
by prescribers across
HCH and NHS Hillingdon.
GC
Ongoing
CNWL
Estates
PW
CNWL
UD /GC
ICC
Clinical
Supervisors
West London
Estates
LD
Ongoing
DIPC
Pharmaceutical
Service Leads
Advisors
Medicines
Management
Team
UC/GC
Pharmaceutical
Advisors
UD /GC
ICC
Quarterly
Immediately
Ongoing
ICCUD /GC
/THH /HPU
Monthly
Ongoing
Pharmaceutical advisors
and ICT to investigate and
inform antibiotic
prescribers.
Vasundra
Tailor
Monitor the number of
HCAI’s – MRSA’s
bacteraemias and C.Diff
acquired in THH and in the
DIPC
37
22
PCT.
Report to IPC
Root Cause Analysis
(RCA) for pre 48hr MRSA
bacteraemias in
partnership with THH.
NPSA tools to be used for
the RCA
Pre 48hr MRSA
and C.diff
bacteraemias
Root cause
Analysis
THH to inform the
PCT of any pre 48 hrs
MRSA and C.Diff
bacteraemias by use
of protocols
Target for 2011 IS 9
FOR MRSA
90 C.Diff
Report to IPC
23
Collaborative
working with
The Hillingdon
Hospital (THH)
To raise the profile of
infection prevention
and control profile
across the health
economy
Programme of joint work
with THH/CNWL/HCH
Marie Batey
(THH)
PW
DIPC
HW
UD
GC
IPC
FL (THH)
24
NHS Hillingdon
ICC
Represent
HCH,CNWL
Attend or send
representation
UD
GC
25
THH ICC
Represent HCH,
CNWL
Attend or send
representation
26
Annual Plan
Contribute as
required
Complete contributions
required by DIPC
DIPC (NHS
Hillingdon)
DIPC (THH)
DIPC (NHS
Hillingdon)
DIPC (THH)
DIPC
PW
DIPC
UD
GC
Quality
governance
Act
Immediately
Report to be
written within
10 days and
submitted to
the clinical
governance
group and to
CNWL and
NHS
Hillingdon and
THH IPC
Ongoing
UD
GC
Ongoing
DIPC
UD
GC
Ongoing
38
Appendix 2
Environment
Privacy and Dignity
Food and Hydration
PEAT 2012
2011
2012
2011
2012
2011
2012
Park Royal
St Charles MHU
3 Beatrice Place
SK&C
Gordon Hospital
Horton Haven
Roxbourne Complex
Rosedale Court
Northwick Park
7a Woodfield Road
Hillingdon
Kingswood Centre
1a Beatrice Place
Fairlight Avenue
Butterworth Centre
Max Glatt Unit
Enfield LD
Northwood & Pinner CU
92.0%
94.9%
90.5%
92.0%
93.1%
93.5%
90.2%
86.6%
93.9%
93.8%
91.8%
90.9%
98.3%
87.7%
96.2%
89.4%
96.2%
89.9%
91.9%
94.1%
94.2%
96.2%
95.5%
91.4%
85.2%
83.0%
97.0%
93.3%
89.9%
90.1%
98.5%
86.9%
93.3%
87.6%
96.3%
96.2%
100.0%
97.8%
97.1%
96.9%
100.0%
100.0%
100.0%
93.3%
100.0%
100.0%
98.9%
100.0%
100.0%
100.0%
98.5%
91.1%
97.8%
96.0%
97.8%
97.3%
100.0%
100.0%
98.5%
98.5%
96.9%
94.3%
100.0%
100.0%
99.1%
100.0%
100.0%
100.0%
100.0%
96.9%
100.0%
100.0%
98.6%
95.7%
95.7%
98.6%
94.2%
98.6%
95.7%
95.7%
92.8%
94.2%
95.7%
91.3%
100.0%
N/A
89.9%
87.0%
94.2%
92.8%
98.4%
96.7%
95.1%
96.7%
95.1%
98.4%
95.1%
90.2%
96.7%
98.4%
90.2%
93.4%
98.4%
N/A
88.5%
86.9%
98.4%
96.7%
St Pancras - South Wing
79.9%
90.2%
84.0%
100.0%
100.0%
93.1%
91.6%
92.2%
97.4%
98.9%
95.0%
94.8%
2011
2012
2011
2012
2011
2012
Excellent
3
5
16
18
13
12
Trust Total
Good
16
14
3
1
5
6
Acceptable
0
0
0
0
0
0
Poor/Unacceptable
0
0
0
0
0
0
Total
19
19
19
19
18
18
39
Appendix 3 Budget
555812
Infection
Control
HCH
Account
Code
2813
2823
72110
72720
78850
Account Code Description
Nursing Band 8a - Una Dunne
Nursing Band 7 - Gilbert Chinjekure
Total Pay
Staff Travel
Regular Car User Allowance
Childcare Vouchers
Non-Pay Total
Infection Control Total
403017
Infection
Control
CNWL
Account
Code
2813
2823
2843
WTE Budget
1
1
Account Code Description
Nursing Band 8a - Jeanette Bennett
Nursing Band 7 - Zoe Zawariya
Nursing Band 5 - Jeanette Fayers
YTD Actuals
(£)
61,133
44,666
105,799
1,312
0
16
1,328
2
107,127
WTE Budget
1
1
0.50
YTD Actuals
(£)
59,069
44,818
0
Total Pay
PAY
Nursing Band 8b - Rebecca Stretch
Nursing Band 8a - Una Dunne
Nursing Band 7 - Gilbert Chinjekure
Nursing Band 5 - Jeanette Fayers
Admin And Clerical Band 2 - Vacant
Agency Admin And Clerical
Funded by Older Adults Service Line (under review)
103,,887
TOTAL PAY
47090
55380
70100
78410
78860
Room Hire
Contract Non-Nhs H/Care Services
CRB-Criminal Records Checks
Staff Christmas Activities
Hospitality
Non-Pay Total
Infection Control Total
660
20,000
44
20
30
20,754
3
124,641
NON-PAY
Staff Travel
Regular Car User Allowance
Childcare Vouchers
Room Hire
Contract Non-NHS H/Care Services
CRB-Criminal Records Checks
CP1RAM Specialist
Community
Services
CPS
Account
Code
2803
4183
Account Code Description
Nursing Band 8b - Rebecca Stretch
Admin And Clerical Band 2 Vacant
WTE Budget
1
YTD Actuals
(£)
65,857
1
22.284
Total Pay
78.141
Staff Christmas Activities
Hospitality
Internal Recharge
TOTAL NON PAY 6,277
CP1RBV Infection
Control
71020
72110
Telephone - Calls
Staff Travel
147
0
78750
78940
Training
Internal Recharge
Non-Pay Total
130
6,000
6,277
Account
Code
55400
Account Code Description
Nhs Contract Services
Non-Pay Total
WTE Budget
Uclh Infection Control Total
Checks
Estates
Pay
Non-Pay
Total
Total
Grand Total
GRAND
TOTAL
107,127
14,247
124,641
YTD Actuals
(£)
14,247
14,247
14,247
7
78.141
14.247
92.388
150.000
479.156
41
79,095
Appendix 4
IPC Governance Structure
Board of Directors
CNWL Infection
Prevention & Control
Committee
Hillingdon
Infection Prevention &
Control
Mental Health Act
Other Groups
including Clinical
Safety Group
Camden
Infection Prevention &
Control
42
Appendix 5
Appendix 6 Mental Health - Audit Calendar
Community
Nursing
Inpatient, Offender Care & Rehab
Site
Audit
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Hand Hygiene
Monthly
Mattress Audit
Monthly
Commode Audit
Policy Audit
Environmental
Audits
Rolling 6/12 programme of inpatient sites
Adhoc as
requested
Dates may be revised.
44
Mar
Appendix 6
Camden Provider Services - Audit Calendar
In-patient Rehabilitation
Hand Hygiene
Monthly
HII7 Clostridium
difficile
MRSA screening
Transfer Policy
Peripheral
Cannulae
Adult
Comm
unity
Nursin
g
Urinary Catheter
Health
Clinics
All service Lines
Urinary Catheter
Essential Steps
to safe, clean care
Hand Hygiene
Decontamination
Environmental
Audits
Dates may be revised.
45
Appendix 6
Hillingdon Community Health – Audit Calendar – 2011-2012
Number
1
Name of Audit
Mandatory Hand Hygiene
2
3
Hand Hygiene Audit at NPCU
Clinical Environmental
Inspection
Patient environment Action
Team (PEAT)
Cleaning Audit by Sodexo
Antimicrobial Prescribing
Audit
C.difficile surveillance/audit
MRSA bacteraemia
surveillance/audit
Norovirus monitoring
Mattresses
Commodes
4
5
6
7
8
9
10
11
12
Location
Across HCH
Services
NPCU
NPCU
Frequency
Annually
NPCU
Annually
NPCU
NPCU
Monthly
6 monthly
NPCU
NPCU
Ongoing
Ongoing
NPCU
NPCU
NPCU
Ongoing
Weekly
Monthly – but inspected
weekly.
When a patient is found
to be positive for MRSA
post screening.
Monthly
Weekly
Weekly
NPCU
14
MRSA compliance to
eradication treatment – not
bacteraemias
Hand hygiene audit
undertaken by link
practitioners
Cleaning in Health Centres
15
Sharps Injuries
HCH
Weekly –results sent to
the Infection Prevention &
Control Team on a
monthly basis.
Quarterly
16
Mandatory Infection
Prevention & Control Training
Hand Hygiene – patient
experience
HCH
Quarterly
Community
Annually
13
17
HCH Health
Centre
Clinics
Across HCH
46
Appendix 7
EXCEPTION REPORT
NEEDLE STICK INJURY
DAVINA WILSON
30th MAY 2012
SUBJECT
AUTHOR
DATE
*NOTE THAT THIS REPORT DOES NOT INCLUDE DATA FROM CPS AND HCH
PURPOSE
This Exception Report has been produced to notify Super Tuesday Meeting members of a
perceived increase in needle stick injury over recent months and to explore the validity of
this perceived increase.
Over the first two months of the financial year there have been seven needle related
incidents reported. This was a cause for concern as it appeared to be an increase in relation
to previous months.
DESCRIPTION OF THE EXCEPTION/APRIL 2011-MAY 2012
Incident reporting data shows that during April/May 2012 there were 7 reports of needle
related incidents which was in contrast to only 2 reported incidents in April/May 2011.
In order to further explore the validity of this perceived increase incident reports were
examined over a 14 month period (see below) from April 2011-May 2012 inclusive:
INCIDENTS BY INCIDENT DATE AND SERVICE LINE (Month and Year)
Acute Addictions CAMHS CMCOMP Community Eating
Learning Offender OPHA Total
Inpatient
Recovery Disorders Disability
Care
2011
04
2011
06
2011
07
2011
08
2011
11
2011
12
2012
01
2012
02
2012
03
2012
04
2012
05
Totals:
1
0
0
1
0
0
0
0
0
2
0
0
0
1
0
0
0
0
0
1
0
0
0
0
0
0
0
1
1
2
3
0
0
0
0
0
0
0
0
3
1
0
0
0
1
0
0
0
0
2
0
0
0
0
1
1
0
0
1
3
0
0
0
0
2
0
0
0
0
2
1
0
0
0
0
0
0
0
0
1
1
0
0
0
0
0
1
0
0
2
0
1
1
0
0
0
0
0
1
3
0
1
0
0
1
0
0
0
2
4
7
2
1
2
5
1
1
1
5
25
47
Between April 2011 and April 2012 the data suggests a consistent 1, 2 or 3 needle related
incidents reported per month – this increased in May 2012 to 4 incidents reported.
Of the 25 DATIX reports examined between April 2011-May 2012:16
- actual needle stick injuries
8
- inappropriate sharps disposal
1
- cut from broken glass vial
Furthermore of the actual needle stick injuries:5
- insulin related
5
- lancet related
2
- depot related
2
- blood taking related
1
- re-sheathing related
1
- clozapine related
FURTHER OBSERVATIONS/HISTORY
Following a decision made in 2008, retractable needle devices for injectable medicines
were implemented. The purpose of this was to further reduce the risk of needle/sharps
related incidents.
Summary of needle/sharps incidents reported over the last 6 years:Year
No. of Needle/Sharps
Incidents
2006/2007
17
2007/2008
10
2008/2009
10
2009/2010
16
2010/2011
16
2011/2012
18
Breakdown by financial quarter for last 2 years:No. of Needle/
Sharps
Incidents
Q1
Q2
Q3
Q4
Total
2010/2011
7
7
1
1
16
2011/2012
3
5
5
5
18
2012/2013
(Apr/May only)
7
During 2010/2011 Q2 a spike in the number of incidents was identified, further
investigation at that time indicated that services were still ordering non-safety devices and
that clinical staff were using these instead of the approved safety devices. As a
consequence all non safety devices were ‘masked’ on the procurement order form to
48
prevent them from being ordered. There was then a large reduction in the number of
incidents reported in 2010/2011 Q’s 3 and 4.
However in April and June 2011 a number of non-safety devices were ‘unmasked’ due to
the needs of CPS and HCH.
The Quarterly incident data then appears to increase.
CONCLUSIONS
Incident reporting data from April 2011 to April 2012 shows a consistent 1, 2 or 3
needle/sharps related incidents reported per month until May 2012 when this increases to
4 reported incidents suggesting
a rise in needle stick injury.
However, when April 2011 and April 2012 data is compared there is no rise in actual
needle stick injury (2/2) and only a slight rise in all needle/sharps reporting (2/3).
When May 2011 and May 2012 data is compared it does show a significant rise in both
actual needle stick injury (0/3) and all needle/sharps reporting (0/4). It should be noted
however that in May 2011 there were no reported incidents of any kind at all therefore
skewing the perceived increase in reporting.
In the immediate future it is too early to establish whether this perceived trend is set to
continue to rise beyond May 2012.
Looking at the data from a historical perspective over the past 6 years the incident data
appears to have reduced during the period of ‘masking’ of non-safety devices and then
increased somewhat when ‘masking’ was relaxed.
AVAILABLE OPTIONS
 Deeper trend analysis (to include procurement and training)
 Continue to monitor monthly to see if increased trend continues
 Develop a system for gathering more detailed information for increased
monitoring of incidents
 Develop an alert system to respond when more than x incidents in any one month
 Investigate each needle/sharps related incident
 Training needs analysis for areas of higher incidence
 Training needs analysis for all areas
 To include needle/sharps related incidents from HCH and CPS
 Do nothing
RECOMMENDATIONS
Short term
 Continue to monitor monthly to see if increased trend continues
 Develop an alert system to respond when more than x incidents in any one month
 Investigate each needle/sharps related incident
49
Medium term (if trend persists)
 Deeper trend analysis (to include procurement and training)
 Develop a system for gathering more detailed information for increased
monitoring of incidents
 To include needle/sharps related incidents from HCH and CPS
 Training needs analysis for areas of higher incidence
Longer term
 Training needs analysis for all areas
AGREED DECISION
50