UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS TRUST
TRUST BOARD MEETING
To be held on 25 APRIL 2007
Agenda No 11
Report of:
Dr David Telford
Director of Infection Prevention and Control
Paper Prepared by:
David Telford
Date of Paper:
April 2007
Subject:
Infection Control Annual Report
Standards for Better
Standards for Better Health. C4a,d,c,e; C11; C21;
D12b
Health Link:
Strategic Objectives 1 and 10
Assurance Framework Link:
principal Objectives 1.4 and 10.3
Background Papers:
In case of query, please
contact:
David Telford (3770)
Purpose of Paper:
This is the annual Board update on infection control within the Trust.
Key issues:
1. Creditable progress and outcome measures.
2. Loss of a key member of staff.
3. Constraints from capacity problems and the growing number of vulnerable patients.
The Board is asked to: :
1. Note the report and concerns.
2. Endorse the forward plan.
3. Support the reappointment of the Nurse Consultant.
Relevant guidance and standards:
“Getting ahead of the Curve”
“Winning Ways”
“Going Further Faster”
“Saving Lives”
Standards for Better Health. C4a,d,c,e; C11; C21; D12b
Code of Practice for the Prevention and Control of Healthcare Acquired Infections (The
Health Act 2006)
Clinical Negligence Scheme for Trusts
Infection Control Team
Annual Report 2006
University Hospitals of
Morecambe Bay
NHS
INTRODUCTION
This is my first annual report since retiring as Medical Director and it covers the period
from October 2005 December 2006 inclusive. It is produced in accordance with the
obligation imposed by the Code of Practice for the Prevention and Control of Health Care
Associated Infections, issued under the Health Act 2006. I have not adopted the national
template for this report, because I believe it would create a very bulky document with a lot
of unnecessary detail that would obscure the main issues. This report offers an overview
for board members; much of the detail can be found in other reports and documents.
There was a five year gap when I was away from front-line practice and I have noticed
some major changes. These are having a significant impact on our infection control team
and the job has become more complex and busy. With hindsight, these changes have
been developing for many years but the gap has thrown them into stark relief.
First is the growth in the number of vulnerable patients. This is true in the traditional areas
of opportunistic infection such as cancer and transplant surgery. The growth in medical
implants and intensive care carries its own burden of infection. But most dramatic of all is
the growth in the frail, elderly population. These people have multiple health needs and,
whilst modern medicine can preserve life, they are very vulnerable to infection and have
poor powers of recovery. They receive frequent antibiotic courses that set the scene for
the emergence of antibiotic resistance. This is precisely the group that acquire Clostridium
difficile and MRSA and much of the rise in these infections is due the growing at-risk
group.
Secondly, and consequently, there is more antimicrobial resistance so infection
management and antimicrobial choice have become much more sophisticated.
Finally, to compound matters, there is a lot of competition for space in the undergraduate
medical curriculum and microbiology does not figure as highly as it once did. Junior
doctors are now much less microbiologically literate than they used to be and they need
more support. Most know this and seek advice but some do not and infection
management and antibiotic prescribing need continuous vigilance.
So, the Infection Control Team has had a busy year. Carol Magee’s retirement in April
2006 left us without a key member of staff and replacement has been delayed by banding
issues. This now resolved and we will be recruiting another Nurse Consultant in the very
near future. Whilst we have maintained day to day operational cover, some of the more
strategic elements of Carol’s role have been neglected. We are maintaining compliance
with the mandatory surveillance requirements and with the support of the facilities director
we are keeping up with the burden of regulation and compliance. Ill health in another key
member of staff has compromised this but overall we believe our performance is very
creditable.
There are three elements to hospital acquired infection and they set the format for this
report. They are:
 Personal and environmental hygiene.
 Antimicrobial resistance.
 Patient vulnerability.
HYGIENE
This is central in clinical practice but its efficacy is a matter of conventional wisdom.
Surprisingly, there is little hard evidence to support the link between cleanliness and
infection but intuitively and aesthetically the principle is sound. High standards of
personal and environmental hygiene are foremost in clinical practice and hospital
management. Initiatives in the past year were:
Personal hygiene
We have continued the roll-out of the national “Clean Your Hands Campaign”. This Trust
was an early implementer under the leadership of Carol Magee. Implementation was
largely complete at her retirement and the Infection control team have kept up the pace
up. Hand hygiene has a high profile at medical school and it is gratifying to see the junior
doctors setting a good example to their senior colleagues. It is also good to see some
visitors using the alcohol gels available at ward entrances and this is a welcome sign of
increasing personal responsibility on the part of the general public.
Together with the Occupational Health Department we have introduced a Glove Policy.
Latex allergy gave the main impetus to this but we have used the opportunity to encourage
good practice in glove use. There have been some problems of implementation, mainly
around procurement issues and the need for surveillance of staff with skin problems. The
policy needs further work and it has been given an early review date. It could well be
extended into a more general Hand Care policy.
The Board started a stimulating debate on dress and uniform codes to which the team
contributed. In general we believe that all ward staff should wear washable cotton fatigues
like those worn in theatre and ITU and in many hospitals outside the UK. I form the
impression that this is a developing trend in this Trust but rigorous enforcement of this
practice would have significant implications for the provision of changing accommodation
and for the linen services contract. Most staff appear presentable, and inappropriate dress
and excesses in jewellery, makeup, cosmetics and hair style are best addressed on an
individual basis.
Environmental hygiene
This is a continuous struggle. Most clinical areas are also heavily used public areas and
the rigid environmental control policies one finds in industry are not feasible. There is a lot
of wear and tear so continual cleaning and fabric maintenance are essential and the hotel
services department do an excellent job. The occasional lapses and complaints are
quickly addressed. A significant benefit here is the overall impression created by a clean
well-managed environment. A new consultant who joined us recently remarked that our
clean and tidy hospitals, in contrast to the teaching hospitals he had left, were a significant
factor in his decision to join this hospital group.
Overarching all this are the regular ward hygiene audits performed by the modern matrons
under the oversight of the infection control team. These are largely successful and we are
able to document resulting improvements. The team is working with departments to
integrate the practice observations and improvements set out in the Saving Lives initiative
into this audit programme.
For external oversight we have the regular inspections by the Patient Environment Action
Team and the Patient Public Forum. These are largely complimentary.
Many microbiologists agree that Clostridium difficile is more worrying than MRSA. It
regularly appears on death certificates although it is often one contributing factor amongst
many in a very frail patient. The report on the outbreak at Stoke Mandeville report has set
an agenda for many trusts and is central in the ICT’s thoughts. The growth in the numbers
of hypertoxic strains and the greater potential for patient to patient spread is forcing a
review of isolation facilities. A small allocation of £300,000 from central funds has been
spent on completing the mattress replacement programme and expanding isolation
facilities at Furness General. There will be a need to improve provision at the RLI and the
medicine directorate are exploring options.
Decontamination
This is overseen by the Medical Devices Group and, since the appointment of Chris Lamb,
as medical devices manager the Trust has made great strides in the safety of medical
equipment. The infection control team play a full part in the work of this group. The
Facilities Directorate completed the refurbishment of the sterilising department at Furness
General and the closure of the department in Westmorland General. The Trust now has
one of the few fully accredited services in the North of England delivered to the
Department’s deadline of March 2007, a vindication of the Trust’s resistance to joining a
consortium to build a large centralised facility in Lancashire. After three years, the
consortium is still in the very early planning stages. The next phase of the
decontamination strategy is to raise the endoscope disinfection facilities to full compliance
with the guidance set out in HTM 2030. The Trust is broadly compliant with the major
aspects of HTM 2030 but further work is needed on the detail of daily and weekly checks
and maintenance.
Surveillance
Much of the guidance and the external assessments concentrates on process and
procedure. There is a danger here that we loose sight of the point and that is a reduction
in infection levels. Rates of hospital acquired infection are the ultimate arbiters of the
effectiveness of infection control policies. The Health Protection Agency leads a
programme to measure rates of surgical site infections (SSI’s or, more prosaically, wound
infections) and compare Trust rates to national figures. Participation in this scheme is
compulsory and, with support from Stuart Westbrook in the Surgical Directorate, we have
been monitoring rates for hip and knee replacement since January 2006. Stuart’s detailed
knowledge of orthopaedics makes him a highly effective information gatherer and, with the
help of the new theatre management system, data collection is relatively straightforward
and not too time consuming. There is little to report here because we have had no
infections (fig 1). This unremarkable because, as the national figures show, infection rates
Fig 1. SURGICAL SITE INFECTIONS
Quarter 3 2006 (Jul- Sep)
Cumulative Performance
TOTAL HIP REPLACEMENT
Hospital
RLI
FGH
WGH
Total
Operations
27
25
63
Wound
Infections
0
0
0
Period
Apr - Sep 06
Jul - Sep 06
Jan - Sep 06
Total
National Benchmark
Total
Operations
50
25
154
229
98379
Wound
Infections
0
0
0
0
1530
Total
Operations
Wound
Infections
51
0
28
0
124
0
203
87184
0
758
Percent
0.0%
1.6%
TOTAL KNEE REPLACEMENT
Hospital
Total
Operations
RLI
17
FGH
28
WGH
34
Wound
Infections
Apr - Sep
06
0
Jul - Sep 06
Jan - Sep
0
06
Total
National Benchmark
0
Percent
0.0%
0.9%
for these procedures are very low. The real problem in prosthetic orthopaedic surgery is
the development of deep infections around the joint because they are very debilitating and
difficult to manage and the current surveillance programme does not trap these because
they emerge some time after surgery.
The programme has been compromised by sickness absence but once our programme
has recovered we will consider different procedures. The operations for fractured neck of
femur, vascular procedures and colorectal surgery have higher infection rates and should
be more useful.
ANTIBIOTIC RESISTANCE
The link between the levels of antibiotic use and the emergence of resistance is well
documented and is an example of evolutionary adaptation. By international comparisons,
the UK has been relatively prudent in its use of antibiotics for many years and serious
antibiotic resistance problems have been slow to emerge. We continue to control this but
we cannot avoid antibiotics altogether – they are life saving drugs.
We have an Antibiotic Subcommittee of the Drugs and Therapeutics Committee. It meets
approximately annually to review and manage antimicrobial prescribing. It exercises
formulary control with levels of restriction ranging from those antibiotics that can be freely
prescribed by junior doctors and independent prescribers to those that are only availably
on the authority of a microbiologist. The Trust has adopted the consensus guidelines on
the management of common medical conditions that is produced by a consortium in the
Midlands. We are bringing recommendations on routine antimicrobial into this envelope.
Policies and guidelines have their place but they are very blunt instruments and, when
combined with the lack of microbiological literacy found in the trainees, they do not
encourage intelligent antibiotic use
Improving microbiological literacy is a long game. The microbiologists have scheduled
teaching sessions with undergraduates and postgraduates but they need more exposure
and this will be in competition with other important areas of practice. Medical students and
junior doctors are usually keen to seek advice about individual patients and these
consultations are used as learning opportunities. Microbiologists have a higher profile
nowadays and the role is becoming much more clinical and less laboratory-based than it
used to be. For many years the Trusts microbiology department has run a module for BSc
students at Lancaster University. This could easily be adapted for medical students and
we will be exploring this possibility with the new medical school. Junior doctors frequently
look to nurses for guidance on local prescribing practices and nurses can be a formative
influence here. The Drugs and Therapeutics Committee is developing independent
prescribing. We now have about 10 non medical prescribers with as many in the pipeline.
I believe that this agenda can be used to support sensible antibiotic prescribing.
Surveillance
Fig 2. Antibiotic Spend per Patient Day
Oral
Antibiotics
Blackpool
£9
East Lancashire
£8
Lancashire Teaching Hospitals
£9
Morecambe Bay Hospitals
£11
North Cumbria Hospitals
£2
Average
£8
Intravenous
Antibiotics
£25
£27
£27
£16
£25
£24
Total
£34
£35
£36
£27
£27
£32
Again, it is outcomes that matter. Last summer, the Strategic Health Authority produced
some interesting comparisons of antibiotic expenditure that are summarised above (Fig 2).
These indicate that antimicrobial consumption in these hospitals is relatively restrained
when compared with our neighbours.
Clostridium difficile and Methicillin Resistant Staphylococcus aureus (MRSA) are both
phenomena of antimicrobial resistance and their antimicrobial use is a major factor in their
emergence. We submit data to the mandatory surveillance programmes and the most
recent results are charted below (Fig 3). Again, they essay a creditable performance.
Unfortunately, the performance target is a 50% reduction, not absolute levels. This
penalises Trusts with very low levels where the costs of further reductions are
disproportionate to the gain in patient welfare. I have also included a historical trend of the
local figures indicating that, whilst our comparative results are good, there is no room for
complacency.
Fig 3.
MRSA Bacteraemia Rate vs Occupied Beds per Day
Clostridium difficile Rate vs Bed Occupancy
4.5
6
5
Cl difficile rate
MRSA Bacteraemia Rate
4
3.5
3
2.5
2
1.5
4
3
2
1
UHMB
1
0.5
UHMB
0
0
0
500
1000
1500
2000
0
50000
100000 150000 200000 250000 300000 350000 400000
Occupied Beds per Day
HES 2004 over-65 bed-days
250
W GH
FGH
Trust
Totals
© David Telford 2007
Number
200
RLI
150
100
50
06
20
05
20
04
20
03
20
20
02
0
Many microbiologists agree that Clostridium difficile is more worrying than MRSA. It
regularly appears on death certificates although it is often one contributing factor amongst
many in a very frail patient. The report on the outbreak at Stoke Mandeville report has set
an agenda for many trusts and is central in the ICT’s thoughts. The growth in the numbers
of hypertoxic strains and the greater potential for patient to patient spread is forcing a
review of isolation facilities.
PATIENT VULNERABILITY
Successful disease control rests on a sound understanding of epidemiology – the way
diseases behave at a population level. It is epidemiology that elucidated the health effects
of smoking, pollution, radiation and industrial diseases and was the scientific basis of the
control of many conditions. A significant factor in the epidemiology of any infection is the
proportion of the population who are vulnerable; high levels of susceptible people lead to
high levels of infection.
Increasing life expectancy and modern medical interventions are eminently desirable but
there are consequences. The octogenarian population has risen from 2.3 million in 1995
to 2.7 million today; an increase of 17%. Projections run at 4 million in the late 20’s and
6.5 million by 2050; by which time there will also be 1 million centenarians. Many of these
are frail and vulnerable to infection. They receive more antibiotics so are open to the
emergence of antibiotic resistance and a downward spiral of increasing antimicrobial
dependence, increasing resistance, restricted antibiotic choices and, ultimately, antibiotic
failure. Managing these “opportunistic infections” occupies a major part of the
microbiologist’s day.
I believe that this Trust is performing quite well in addressing hospital hygiene and
antimicrobial prescribing. However, the success these activities will be constrained by the
levels of vulnerable people, by their concentration, and by the length of time they remain
exposed to the hospital environment. This growth in the elderly population is probably the
single biggest factor in the rise in hospital acquired infections, the one over which we have
least control and the one that attracts the least public attention. It is also a significant
factor in the rise of “community” healthcare acquired infections. Twenty years ago most of
my antimicrobial resistance problems were on the long-stay elderly wards at the Lancaster
Moor. Those wards are long since closed but the patients have not gone away. They are
now dispersed in nursing and residential homes or, with support, in their own homes and
there are many more of them. The problems here are social cultural and ethical, going
well beyond the sphere of microbiology. This growth of the vulnerable population will
offset the effect of our other infection control activities.
OUTBREAKS
During the period the Trust has experienced the following clusters of infection (Fig 4).
Fig 4
FGH
RLI
WGH
Viral Gastroenteritis
16
14
6
MRSA
0
0
0
Clostridium difficile
3
0
0
It is sometimes difficult to define an outbreak. On an elderly ward, there may be 2-3
patients at one time with diarrhoea of non-infectious origin or there may be a couple of
patients with Clostridium difficile or MRSA who have acquired it in different ways. The
Infection Control Team adopt a flexible approach in their advice because it is important to
strike a balance between patient and staff welfare and the disruption to hospital activity
caused by control measures. Each outbreak therefore is managed differently according to
the precise circumstances. The Team spend some time explaining these apparent
inconsistencies. A noticeable feature recently has been the impact of bed reductions. The
initial scale of the outbreaks has not changed but, in Barrow in particular, the Team have
commented that the loss of flexibility has restricted options making the outbreaks more
difficult to control and they have proved more protracted than in the past. There has been
more frequent recourse to restrictions on admissions and transfers with a greater impact
on elective activity than in previous years.
As with clinical hygiene, the effect of service pressure on infection control is difficult to
measure. Perhaps some insight can be gained from international comparisons. Holland is
often held up as a model of infection control practice; they have some of the lowest rates
in the world. A Dutch colleague who has come to work in this country has compared his
hospital in Holland with the one in England. The hospitals are broadly similar in size with
some interesting differences in bed distribution. But the main difference is the pressure on
capacity with half as many admissions and much lower bed occupancy (Fig 5). Most
English microbiologists would contend that the differences in MRSA and Clostridium
difficile rates are no mere coincidence.
It makes sense intuitively; the less pressure staff are under, the more they can give
attention to detail, and it is high personal standards that are the bedrock of sound infection
control. Directors should to take this into account when considering further capacity
reductions and the infection control team would welcome some dialogue with the
turnaround team on this issue.
Fig 5. A Dutch Comparison
Beds
Bed Distribution
Single accommodation
Intensive Care Beds
Annual Admissions
Average Bed Occupancy
Average Length of Stay
MRSA bacteraemias
Clostridium difficile
NHS Hospital
Dutch Hospital
1200
Multi-occupancy bays
10%
39
78,780
97.4%
5.5 days
0.31 / 1000 bed days
1.48 / 1000 bed days
1237
2-4 bed bays
Haematology & Paediatrics only
28
34,547
71%
8.9 days
0
0.16 / 1000 bed days
INFECTION CONTROL STRUCTURE
The Infection Control Team sits at the centre of these activities. It comprises the two
microbiologists, the lead nurse and the three site nurses. The accountability
arrangements are set out in the appendix. We meet monthly to share experiences, review
work progress the infection control agenda. Others such as occupational health, risk
management and the Health Protection Agency attend from time to time. Notes are kept
from these meetings and are available for inspection. In the past, guidance has always
stressed the importance of the Control of Infection Committee but the team has always
been sceptical of that. We find it more effective to raise issues in the corporate or
departmental forums that already exist. We have had to robustly defend this position at
times but accreditation inspections have always accepted our position. Whilst he Trust
has a formal infection control committee, it never meets. It is interesting to note that the
new Code of Practice makes no mention of an Infection Control Committee, stressing
instead the central role of the Team.
The Team is supported by five secretarial and clerical staff (3WTE). One of the posts is
currently held in the vacancy freeze. The absence of a lead nurse has reduced secretarial
demand but recruitment to the post and the demands of surveillance will highlight this loss
and we will be seeking to reactivate the post.
The Team contribute to the mandatory training programme but this has been at the
expense of some of the more focussed departmental sessions.
There is an infection control budget line within Pathology but it is almost exclusively staff
costs. There is no contingency for outbreaks or unanticipated events. These are
absorbed as and when they occur.
Together with the Facilities Directorate we are assessing the trust’s control of infection
arrangements in relation to the Code of Practice for the Prevention and Control of
Healthcare Acquired Infections. We are broadly compliant with all the major aspects and
will be making a statement to this effect in our declaration at the end of April.
FORWARD PLAN
The absence of a lead nurse is now becoming critical. There is much to be done in
updating our documentation for the CNST assessment in December. The process is well
in hand and we anticipate placing an advertisement soon.
Our policies need bringing up to date for the CNST assessment. This is in December but
the paperwork is required by August.
I will be sixty at the end of this year. Whilst I am in no hurry to retire we need to start
succession planning. As with many other specialities, microbiologists are in short supply
and, if we cannot recruit, we might need to look at alternatives such as recruiting a public
health doctor or infectious disease specialist to the team.
We will maintain the programme of ward audits and embrace the Winning Ways initiative
in this envelope.
We will maintain our extensive programme of work on improving microbiological literacy
and antibiotic prescribing. This will help with the target for the reduction in MRSA
bacteraemias but we are firmly of the opinion that a trajectory for reduction from our
already low levels is microbiologically baseless.
We will review trust isolation facilities and make recommendations via the Planning Team.
The Medicine Directorate will finalise plans for improving isolation accommodation at the
RLI.
We will explore improvements to SSI and pursue ways of utilising Stuart Westbrook in this
capacity.
David Telford
Director of Infection Prevention and Control
April 2007
Appendix
Accountability Arrangements
for Infection Control 2007
University Hospitals
of Morecambe Bay
NHS
This diagram sets out the personal and corporate accountability arrangements for infection control
in the Trust. The Director of Infection Prevention and Control sits on the Governance
Subcommittee and produces an annual report for the Trust Board. The nurses also have a
professional accountability to the Director of Nursing through the Nurse Consultant.
Corporate
Accountability
Personal
Accountability
Trust Board and
Governance Subcommittee
(Strategic)
Infection
Control
Team
(Operational)
Chief
Executive
Director of
Nursing
Director of Infection
Prevention and Control
Consultant
Microbiologists
Nurse Consultant
in Infection Control
Infection Control
Nurse Specialists
Microbiology
Laboratories
Links with other groups
Outside the Trust
Primary Care Trusts
Environmental Health
Public Health Medicine
Health Protection Agency
Strategic Health Authority
Infection Control Structure Version 6 March 2007
Within the Trust
Clinical Divisions
Clinical Governance
Facilities
Drugs & Therapeutics
Health and Safety
Occupational Health