Royal United Hospital, Bath NHS Trust

Appendix 1

Director of Infection Prevention and Control Annual Report

2007-08

Contents

DIPC Annual Report 1 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008 Executive summary

1.0Introduction 4 2.0Infection Control Team 5 2.1 Team structure chart 2.2 Infection Control nurse establishment 6 2.3 Infection Control doctor and microbiologist establishment 7 2.4 Budget allocation for Infection Control 7

3.0Infection Prevention and Control Committee and reporting 9 3.1 Infection Prevention and Control Committee 10 3.2 Saving Lives Implementation Committee 10 3.3 Infection Prevention and Control Reports 10 3.4 Board Assurance 11 3.4.1 Infection Control Strategy 11 3.4.2 NHS Litigation Authority standards 11

4.0Health Care Associated Infection Surveillance 11 4.1 MRSA Bacteraemia–Targets, monitoring, root cause analysis and action plans 12 4.2 MRSA Root cause analysis 13 4.3 Department of Health-cleaner hospitals team review, December 2007 15 4.4 Clostridium difficile 16 4.5 Orthopaedic Surveillance 19 4.6 Legionella control 19

5.0Audit 5.1 Hand hygiene 19 5.2 Peripheral cannula 20 5.3 Management of MRSA positive wounds 21 5.4 Urethral catheters 22

6.0Infection Prevention and Control Policies 22 7.0Complaints 23

8.0Incidents 23

9.0Infection Control initiatives and communication 23 9.1Safer Hands 24 9.1.1 Infection Control week 24 9.1.2 Clean your hands campaign 24

10.0 Side Room Tool

11.0 Outbreak data for 2007/08 24 11.1 Vancomycin Resistant Enterococci (VRE) 24 11.2 Clostridium difficile 25 11.3 Diarrhoea and Vomiting 25

12.0 Tissue Viability 26 12.1 Aseptic Non-Touch Technique (ANTT) 26 DIPC Annual Report 2 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008 13.0 Decontamination 26 13.1 Endoscopy 26 13.2 ENT/Urology Outpatient Departments 27 13.3 Critical Care 27 13.4 Sterile Services Department 27

14.0 Building projects 27

15.0 Cleaning Services 28 15.1 Developments to meet National Cleaning Standards 28 15.1.1 Special Cleans Team 28 15.1.2 Cleaning Working Group 29 15.1.3 Strategic and operational cleaning plan 29 15.1.4 Deep clean programme 29 15.1.5 Weekly management cleaning inspections 29 15.2 Cleaning audits 29 15.3 Cleaner Hospitals PEAT assessment for 2007/08 29 15.4 Colour coded cleaning equipment 29

16.0 Standards for Better Health and the Hygiene Code 30 16.1 Standards for Better Health 30 16.2 The Hygiene Code 30

17.0 Training Activities 30

18.0 Training for Infection Control Specialists 31

19.0 Summary and key objectives for infection prevention and control for 2008/09 31

20.0 Conclusion 31

Appendix 1 Infection Control Audit Programme 32

Appendix 2 Antimicrobial audit programme 33

Executive summary DIPC Annual Report 3 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008 During 2007–2008 the focus upon infection prevention and control to reduce healthcare associated infection (HCAI) has continued to be a strategic priority for the Royal United Hospital, Bath NHS Trust. The Infection Control Team (ICT) is not alone in the task of preventing infection with considerable steps being taken to ensure that continuous and appropriate liaison between clinical and non-clinical staff is the way forward. Through the enhancement of existing programmes key targeted actions have enabled the trust to focus upon specific interventions to reduce HCAI and ensure it became part of ‘everyone’s business’. The trust has received support from the Department of health reducing HCAI delivery team to enhance existing work streams. A continued emphasis on reducing MRSA and Clostridium difficile has seen reductions in incidence of both infections during the year. In the spring of 2008 the trust successfully underwent assessment against three national standards for infection prevention and control: the NHSLA, Standards for Better Health and the Code of Practice – Hygiene Code. The coming year of 2008-09 will continue to see infection prevention at the forefront of trust business through challenging targets and the introduction of the patient choice agenda all of which contribute to patient and public confidence and through high standards of care and practice.

DIPC Annual Report 4 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008 1.0 Introduction This report provides  A summary of the key initiatives and activities  An assessment of performance against national targets and performance indicators  Detail of key successes and areas for future development  An overview of collaborative working both within and external to the organisation

Key successes:  Significant reduction in MRSA bacteraemias to get back on monthly trajectory in year  Continuation of the monthly ward based audit programme  Re-launch of year 3 of the ‘cleanyourhands’ campaign  Continued regular use of ‘glow and tell’ hand hygiene education boxes by all matrons and key managers in their areas of responsibility  Continuation of the deep cleaning team and programme of ward cleaning  Further enhancement of the root cause analysis and feedback mechanisms for MRSA bacteraemias  Refurbishment and opening of a small cohort ward for Clostridium difficile  Completion of an upgrade of Marlborough ward to increase ensuite side room provision  Procurement and installation of ICNet surveillance system  Improvements in hand hygiene practices and change in hand soap supplier  Sustained improvements in management of peripheral line care demonstrated  Additional funding form the strategic health authority for infection prevention and control initiatives  Additional funding for deep cleaning and environment  Inclusion of key HCAI targets within Corporate score card  Establishing the Saving Lives Implementation Committee to operationally be responsible for monitoring MRSA and targeting associated work streams  Producing Clostridium difficile board to ward action cards  Forging links with other local infection control teams in local Primary Care Trusts  Comprehensive deep cleaning programme undertaken throughout the hospital.

DIPC Annual Report 5 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008 2. Infection Control Team

2.1 Team Structure Chart

Michael Earp Director of Infection & Prevention Non Executive Director Francesca Thompson Director of Nursing

Dr Sarah Meisner Dr Sue Murray Dr Beverly Tracey Halladay Infection Control Consultant Clinical Palmer Senior Infection Control Nurse Doctor Scientist Consultant Microbiologist Microbiologist Microbiologist

Denise Meyers Susan Smith Julia Jackie Infection Control Infection Bloomfield Cosgrave Nurse Control Nurse Infection Project Control Nurse Nurse

Linda Saunders Personal & Information Assistant

Link Practitioners

2.2 Infection Control nurse establishment The team workload has continued to be challenging during 07/08 with the continued local and national focus on reducing HCAI. Throughout the year the service level agreements (SLAs) with local Primary Care Trusts (PCT) underwent review with notice being served by Bath & North East Somerset PCT to end their contract in December 07. Wiltshire PCT also indicated plans to recruit their own team of infection control nurses either by spring of 2008. During April 2007 the Great Western Ambulance Trust advertised for acute trusts to provide an infection control service for their recently formed organisation. A tender was submitted from the RUH to provide two days a week of a band 7 infection control nurse with associated on call and support, this was duly accepted with the SLA commencing in July 07. These changes and proposed reductions in hours from other staff enabled the team to review its skill mix and put in place a temporary structure until March 2008. Essentially

DIPC Annual Report 6 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008 this enabled the project nurse (Julia Bloomfield) to act up as an infection control nurse and for Jackie Cosgrave to be recruited on a 9 month contract as the project nurse. Further additions to the team are planned for 2008/09 as a result of funding being identified in the CSR and tariff uplifts. Business cases were submitted and approved for a full time surveillance analyst to replace the project nurse and an additional band 7 infection control nurse. Recruitment for these posts will commence in April and May 08.

2.3 Infection Control doctor and microbiologist establishment Following a review of the trust microbiology service in the autumn of 2006 funding was approved to increase the infection control doctor sessions from 2 to 5 per week and for a full time microbiologist position. While the additional infection control doctor sessions have been implemented unfortunately the trust has been unsuccessful in appointing to these posts and interim arrangements through use of locums have been in place. Recruitment for the permanent post will be ongoing.

2.4 Budget allocation for infection control  The infection control budget allocation is primarily for the salaries of the infection control nurses and secretarial support.  The Infection Control Doctor sessions are not included in the Infection Control budget.  Funding to purchase and install the ICNet surveillance system was secured via the capital challenge funds, however budget allocation for the ongoing costs of the system were not secured during 06/07 or 07/08 and have been resubmitted for 08/09 for which the outcome is awaited.  The ICT have been fortunate to receive excellent support from the clinical audit department, however this continues not to be formalised into allocated sessions with regular dedicated time.  There is an allocated budget for ICN training that is primarily used to support trainees in obtaining specialist education in infection control and enable the ICNs to attend study days and conferences  In order for the ICT staff to remain up to date attendance at National conferences and study days is essential. These specialist courses are the recognised route for training and updating as no specialist training is available within the trust. The value of learning from others experiences and networking has been evident in several of the initiatives undertaken by the team. Many of the relevant National conference and study days are not held locally and with fees of around £200 – £300 plus travel it is not possible for staff to attend more than one per year. This also has an impact on planning of allocation, as it is not always possible to predict the dates of relevant conferences at the beginning of a financial year.  There is no allocation within the budget for training for the Director of Infection Prevention and Control (DIPC).  There is no identified budget to cover any additional expenses for the control and management of outbreaks of infection within the Trust.  There is no specific allocation in the infection control budget for the ICT to undertake research activities.

Additional funding to reduce HCAI In September 2007 the secretary of health announced additional funding to support trusts in management of healthcare associated infection. The Southwest Strategic Health Authority (SHA) informed the trust that £220,00 had been allocated and requested a plan of how the money would be spent. The following were identified and approved for funding support:

DIPC Annual Report 7 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008 Proposal Funding requested Priority 1- Operational costs of Clostridium difficile cohort ward £126, 297 Priority 2 - Top up funding to recruit antibiotic pharmacist £20,490 ahead of planed time frame Priority 3 – Purchase of permanent isolation signs £4,000 Priority 4 – Home IV co-ordinator post £22,525 Priority 5 – Staff costs to release infection control link nurses £46,688 for 1.5 days per month £220,000

In January 2008 the Department of Health (DH) published Clean, Safe care which announced that the comprehensive spending review had provided an investment of £270 million per year across the NHS by 2010/11. This investment is targeted to enable trusts to recruit specialist staff and increase resources alongside implementing screening of all elective and emergency patients for MRSA in the next three years. . The RUH plans to allocate these funds as follows: Additional Band 7 infection control nurse Money to support ongoing operational cost of the C diff cohort ward Additional resources to implement MRSA screening in line with national policy by 2009 for elective admissions and 2011 for all emergency admissions

DIPC Annual Report 8 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008 3.0 Infection prevention and control committee and reporting The infection control team holds weekly meetings which are attended by the Director of Infection & Prevention Control.

Trust Board

Governance Committee

Operational Governance Committee

Infection Prevention and Control Committee

Saving Lives Implementation Clostridium difficile working group Committee

Infection Prevention & Control representation at trust committees & groups:  Water hygiene  Health & Safety  Operational Governance  Divisional board meetings  Emergency Planning  Senior Nurses meetings  Procurement groups  Decontamination group  Patient experience group  Ward managers meetings  Occupational health  Cleaning group

DIPC Annual Report 9 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008 3.1 Infection prevention and control committee The infection control committee (ICC) meets twice a year with representation from the Divisions, Facilities, the Health Protection Agency and PCT Infection Control leads. The minutes of the ICC are circulated to Governance Committee. The function of the committee is:  Advise, ratify and monitor the implementation of infection control policies, procedures and guidelines and recommend them to the appropriate committee for approval prior to Governance committee ratification  Agree objectives and priorities for targeted surveillance as outlined in the Annual Infection Control Programme and feedback analysis of surveillance to Divisions as appropriate.  Promote and facilitate education and the application of evidence base practice in relation to infection control  Approve and endorse the Annual Infection Control programme  Monitor progress of the Annual Infection Control Programme at each meeting  Approve and endorse the Annual Director of Infection Prevention and Control report

3.2 Saving Lives Implementation Committee The committee has continued to meet every two months as the operational arm of the infection prevention and control committee with responsibility for monitoring and review of the MRSA improvement programme and associated audit programme. Key activities of the committee during 07/08 have been:  Receive feedback on investigation and analysis of each MRSA bacteraemia  Plan targeted interventions in clinical areas in line with national Saving Lives guidance  To determine areas of practice to focus action from review of MRSA bacteraemias and other alert organism data  To receive reports on the regular audits related to infection control practice  Identify and recommend education and training requirements  To ensure feedback to Divisions on actions taken and work plan

The action plan identified a series of audits for urinary catheters, hand hygiene, central venous catheters and peripheral cannula. Clinical leads were identified to oversee the audits with support from the clinical audit department. The programme was reviewed and revised at regular intervals to ensure time frames were maintained, appendix 1.

3.3 Infection prevention and control reports The infection control team is integrated throughout the trust with representation on key groups and committees, with reports being submitted as follows:  MRSA and C diff data provided for the trust score card and performance monitoring  Data is provided for the quarterly divisional performance meetings.  The ICT has contributed to the quarterly governance committee report which includes detail of initiatives, outbreaks, policy ratification and other activities linked to the infection control annual programme.  The Trust board approved the Annual programme for 2007/08 and the 2006/07 Annual report.  Minutes of the ICC are reviewed at Governance committee quarterly  The director of nursing (DIPC) regularly submits reports to management and trust board specifically the MRSA and Clostridium difficile action plans and assessment for the Hygiene Code DIPC Annual Report 10 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008  A report detailing all MRSA bacteraemias and results of root cause analysis of cases is provided monthly to the management board and senior divisional managers

3.4 Board Assurance The board has a nominated infection prevention control lead non executive who is also the chair of the Governance Committee. He receives copies of all key infection prevention and control related committees and attends the Infection Control Committee. The trust board met in public every two months during 2007/08. An infection prevention control report is routinely presented to the board every month. The Director of Nursing has developed a matron’s balance score card and introduced regular matron reports to the trust board in line with national guidance.

The key performance indicators for 2007/08: Clostridium difficile 20% reduction in over 65 yrs: GREEN MRSA bacteraemia trajectory: RED PEAT assessment: GREEN C4 Standard: GREEN Code of Practice: GREEN Saving Lives assessment : AMBER 85% Hand hygiene compliance: AMBER

3.4.1 Infection Control Strategy It is a requirement of the hygiene code for the trust to approve an infection control strategy which set out the responsibilities and duties for key personnel including the infection control team, DIPC, Executive directors, Divisional chairs, matrons and assistant directors of nursing. The strategy also provides detail of infection prevention and control committees and the internal reporting mechanisms. The current strategy for 2007 – 2010 was approved by the Trust board.

3.4.2 NHS Litigation Authority standards As part of the risk management process and assurance framework each NHS trust must comply with one of three levels for the NHSLA. The RUH underwent an assessment against level one in March 2008 and was confirmed as compliant. The level one standard relates to the existence of policies including hand hygiene, management of exposure to blood borne viruses, the infection control strategy and education.

4.0 Health Care Associated Infection Surveillance The monitoring of infections is crucial in the early detection of outbreaks and for highlighting deviations from the expected level of alert organism infections and colonisation. Surveillance of infection is undertaken and reported externally to meet the DH mandatory reporting criteria and internally as part of the hospitals infection control programme. Additionally surveillance must be recognised as an element of clinical governance. Reports on MRSA bacteraemias and Clostridium difficile isolates are produced for the Infection Control committee, Trust divisional boards and the monthly performance report and trust score card. To enable this timely and robust reporting the infection control team must be supported by sufficient resources and technology. In January 08 an IT surveillance system called ICNet was installed for the ICT to use for receipt of new results and running of regular reports. Feedback from the team is that the system is extremely useful and provides a clear process of monitoring patients with infection throughout the hospital. Once a surveillance analyst has been appointed the team will be able to utilise the system further to produce data and monitor trends. . The system interfaces with the pathology system to provide regular

DIPC Annual Report 11 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008 reports of selected organisms and also provides the ICT with a facility to run reports that enable tracking of epidemiology to monitor trends of infection.

4.1 MRSA Bacteraemia – Targets, monitoring, root cause analysis and action plans The Department of Health target to reduce MRSA bacteraemias by 60% at March 2008 was in its final year for 2007/08. The RUH target has been 21 which has been exceeded with a total of 35 bacteraemias for the period. The target includes those MRSA identified either during a patients admission to hospital or in the 48 hour period prior to admission when the patient could have been in another healthcare facility or the community setting.

At the beginning of the year cases were above the monthly trajectory during April and May with a significant rise in June when there were 5 cases identified as pre 48hour and 3 post 48 hour. In response to these cases the SHA Director of Nursing and the HCAI lead visited the trust to review current actions and advice on further actions. The meeting was attended by the RUH Infection control team and representation from Banes PCT Director of Public Health. The ICT presented findings of the RCAs and results of audit programmes which demonstrated that progress was being made, the SHA team were satisfied that all required actions were in place and advised the PCT that more robust systems for infection prevention and control were advised particularly recruitment of an infection control nurse for the PCT.

The ICT provide data on MRSA bacteraemias for the balance scorecard via the performance team for internal reporting. Data is also provided to the Health Protection Agency (HPA) surveillance unit on a quarterly return. Reports on MRSA are presented to Trust Clinical Divisions demonstrating areas where MRSA bacteraemias have occurred and the likely source of the infection.

Recorded pre and post 48 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar hours Actual no of bacteraemia 3 4 8 2 4 0 6 1 2 1 2 2 per month

Monthly Trajectory 2 2 2 2 1 2 2 1 1 2 2 2

Monthly Difference between actual and +1 +2 + 6 0 + 3 - 2 + 4 0 +1 - 1 0 0 trajectory

Rolling total number of 3 7 15 17 21 21 27 28 30 31 33 35 MRSA

3 month rolling average 3.3 3.6 5.0 4.7 4.7 2.0 3.3 2.3 3 1.3 1.6 1.6 number of infections

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actual in month pre 48 1 1 5 1 1 0 3 1 1 1 0 1 hrs Actual in month post 48 2 3 3 1 2 0 2 0 1 0 2 1 hrs *= community related, BC positive 60hrs after admission with identified source on admission

DIPC Annual Report 12 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008 Table 2 Demonstrates trust progress against MRSA bacteraemias target April 2007 – March 2008

40 RUH actual

35 Community actual Cumulative actual 30 Trajectory

7 7 7 7 7 7 7 8 8 8 0 7 0 0 0 0 7 0 0 - -0 - l- - - -0 - -0 - -0 -0 r y n u g p t v c n b r p a u J u e c o e a e a A M J A S O N D J F M

4.2 MRSA Root cause analysis (RCA) and reporting procedures Root cause analysis of MRSA bacteraemia continues with the ICT coordinating the process and clinical teams leading on the investigation and production of detailed action plans. The NPSA proforma continues to be used to review cases and produce action plans. Since October monthly meetings have been held with the infection control leads in Banes and Wiltshire PCTs to discuss each RCA and outcomes. This has resulted in an agreement for a community wide approach focusing on key areas. percentage of Pre 48hours and Post 48hour MRSA Bacteraemias April 2007-March 2008

DIPC Annual Report 13 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008

Percentage of Pre 48hrs and Post 48Hrs Bacteraemias

Pre Post

The RUH team have collated all bacteraemia data into a spreadsheet that enables identification of key risk factors and whether compliance with policy has been demonstrated during the patient pathway. Findings from the RCA process have identified the following contributing factors:

Post 48 hrs • MRSA Screening Policy at point of admission to be implemented • Insertion of PVC documentation to be completed for all patients. • VIP scores and PVC care plans for every PVC must be completed on every shift. • Hand hygiene • Staff shortages • MRSA decolonisation • Improve standard of wound, PVC and urinary catheter care plans by completing on each shift. • Urinalysis to be performed on admission • Re-screen for MRSA at 2 weekly intervals for long-stay patients. • Provide additional training on urinary catheter management for nursing staff.

Pre 48 hrs • Ensure that Nursing Home staff are aware of the need to send specimens for culture and antibiotic sensitivities, if there is concern about urinary tract infection. • Improve standards of documentation at Nursing Homes

It is recognised that certain factors increase the risk of MRSA colonisation and bacteraemia. From review of the cases during the year the following factors are more commonly observed:  Diabetes  Long term urinary catheter  Long term wounds/ulcers  Previous admission to hospital

A meeting between district nurses, podiatrists, diabetic nurses and tissue viability nurses in the acute and PCT trusts is being set up during April to explore patient

DIPC Annual Report 14 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008 pathways and develop clear systems for communication and collaboration between all teams.

Source Bacteraemia Pre 48 Post 48 Figures hrs hrs Undeterminable 9 5 4 Wound 9 5 4 Hickman Line 2 2 0 Indwelling Urinary Catheter 7 4 3 Short Term Central Venous 2 0 2 Catheter Pneumonia 3 1 2 Psoas Abscess 1 0 1 PICC Line 1 0 1 Peripheral Vascular Catheter 1 0 1

4.3 Feedback from Department of Health on day visit December 2007 As part of ongoing support from the department of health cleaner hospitals team a one day review was held on December 11th. The DH team spent time with a range of staff from the infection control team, senior Divisional nursing and medical staff and also visited some clinical areas with the site team and matrons. The team felt very encouraged to see the progress that had been made since the first review in July 2006. They emphasised the need to reduce numbers of MRSA and C. difficile within the Health Community further and recommended intensified actions and further embedding of infection prevention principles during the last three months of 2007/08. The leadership from Francesca Thompson and the work of the Infection Control Nursing Team was praised for instilling a positive culture and appropriate behaviours for infection prevention across the organisation. The team made the following recommendations:

Root cause analysis The process should actively involve all of the following key individuals: lead clinician(s); matron; infection control nurse; microbiologist; ward sister; link nurse. Once the findings and the actions are agreed feedback should be widely disseminated and implementation of actions formally performance monitored. For pre-48 hour RCAs the Primary Care Trusts should adopt a similar approach and ensure that an action plan is generated, which can be shared across the health community.

MRSA screening Rapidly agree the process for screening of high risk patients for MRSA. Focus this initially in Medicine and consider decolonisation of those that have been screened whilst awaiting results. Compliance to the screening policy should be included in the monthly audits by Matrons once implementation has taken place. Also to consider screening of long stay patients fortnightly, again initially in Medicine.

Engagement of the Primary Care Trusts in supporting screening and decolonisation in the community should also be secured.

Other areas for improvement that should be considered for more medium term implementation are:

DIPC Annual Report 15 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008  Review of the antibiotic policy to consider further restrictions on cephalosporins;  Expedite the introduction of products that are supported in national guidelines e.g. silver catheters and Chloraprep by using rapid improvement cycle methodology rather than trials in practice;  Determine the level at which a C. difficile cluster is declared and becomes a SUI;  Consider including the number of new cases of MRSA on the ward level dashboard;  Ensure the maintenance of the side room management tool is led by the bed management team.

Progress has been made with approval of Chloraprep for central line care in March, plans for RCA training for matrons in April and implementation of MRSA screening in elective patients.

4.4 Clostridium difficile (C. diff) In line with national targets the RUH and Banes PCT have agreed a 20% reduction of Clostridium difficile cases for 2007 -08 which has been based on data for 2006/07. The monthly target for the RUH is therefore 36 cases for patients in the over 65 year age group as directed by the Department of Health. This data has been included in the trust corporate score card to enable monitoring at all levels throughout the trust. The trust has seen a reduction in cases since June 2007 which has been sustained throughout the autumn months. Widcombe ward has remained open as the C diff cohort ward has continued to enable prompt isolation of symptomatic positive patients. The ICNs review patients on the cohort ward daily and visit MAU in order to identify any new admissions that may be C diff positive and require isolation.

Ongoing factors contributing to the fall in cases of C difficile:  turn-around times for C difficile testing have continued to improve leading to more timely identification and commencement of treatment and isolation.  Use of Actichlor plus for routine ward cleaning has contributed to a fall in the  number of spores present in the environment  Adherence to the revised antibiotic guidelines

The rise in numbers of cases in January coincided with the period of high numbers of ward closures due to viral diarrhoea and vomiting. It is common to see this association due to increase numbers of specimens being taken and identification of patients who may have been C diff carriers experiencing viral symptoms. There were fewer outbreaks in February and cases have fallen slightly during this period.

DIPC Annual Report 16 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008 Table 3 Clostridium difficile data analysis from April 2007 – March 2008 = key target of 36 cases per month over course of year acheivedUpdated 14/04/08

Aged 65 years or more Aged under 65 years Month Total RUH PCT Total RUH PCT & GP & GP April 2007 58 35 23 15 13 2 May 2007 61 40 21 12 10 2 June 2007 22 13 9 6 4 2 July 2007 30 19 11 9 8 1 August 20007 26 15 11 10 8 2 September 21 9 12 1 0 1 2007 October 2007 27 18 9 6 3 3 November 40 30 10 9 7 2 2007 December 35 23 12 4 3 1 2007 Jan 2008 53 38 15 9 6 3 Feb 2008 44 29 15 5 5 0 March 2008 47 32 15 5 3 2 Total 464 301 163 91 70 21

DIPC Annual Report 17 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008 Clostridium Difficile figures for (all ages) RUH & PCT - March 2007 - March 2008

200 RUH PCT/GP 150

0 April May June July August Sept Oct Nov Dec Jan Feb March Total RUH 48 50 17 27 23 9 21 37 26 44 34 35 371 PCT/GP 25 23 11 12 13 13 12 12 13 18 15 17 184

DIPC Annual Report 18 2007/08 Author: Tracey Halladay/Yvonne Pritchard, Senior Infection Control Nurse May 2008 4.5 Orthopaedic Surveillance The Orthopaedic Department is responsible for undertaking the mandatory surveillance periods choosing total hip replacement for April – June. The data is stratified using the US National Nosocomial Infections Surveillance System risk index which combines three major risk factors; the American Society of Anaesthesiologists’ (ASA) score, which reflects the health of the patient at the time of surgery, the duration of the operation, and the degree of microbial contamination in the wound. Each operation has been scored from 0 to 3 according to how many of these factors were present at the time of surgery. This stratification allows a more reasonable intra- and inter- hospital comparison. The infection rate for the RUH is 0.2 for the last four periods compared to 0.8 for all periods of surveillance we have undertaken and an infection rate of 1.4 for all hospitals undertaking the same surveillance.

4.6 Legionella control Legionella control continues to be monitored and assessed by the Water Hygiene Committee which has representation from the senior infection control nurse, infection control doctor, Health and Safety Manager and key facilities managers and staff. The DIPC receives a copy of the minutes for information. The water hygiene group meets monthly to review progress against the risk assessments and action plan of work to the water systems throughout the RUH site. During 07/08 pipe work has been replaced on Marlborough ward and Helena ward. A program of water sampling has also continued alongside regular temperature checks. Any notifications of positive samples have been dealt with in line with L8 and positive sample meetings have DIPC attendance.

5. 0 Audit Programme During 2007/08 audit was undertaken initially in line with the annual programme (Appendix 1)

The infection control programme audits for 2007/08:  Hand hygiene  Peripheral cannula  Central line practice in ICU and other wards  Audit of commodes  Management of MRSA positive wounds  Management of patients with C diff

The programme is regularly reviewed throughout the year to take by the Saving Lives Committee.

5.1 Hand hygiene audits Hand hygiene audits have been completed every two months until Jan 2008, at this point a review and focus on those areas of poor compliance was undertaken as improvement had not significantly increased since Oct 07. Compliance is now monitored via the trust score card with data being proved by the ICT. The indicators are green 85% or above, amber 80% or above and red below 80%. There is near 100% compliance for the audit of hand hygiene facilities with the exception of:  Staff are not wearing wrist watches / stone rings or other wrist jewellery in only 70% of cases  All patients are offered hand hygiene facilities prior to meals in 71% of cases Compliance has remained improved for November to January with a significant increase in compliance of staff not wearing wrist jewellery.

19 A total of 868 opportunities to decontaminate hands were observed during January 2008. Hands were decontaminated using an acceptable technique in 727 (84%) cases.

Overall hand hygiene compliance (low, medium and high risk activities)

c 60 n a i l

p 50 m o c 40 %

0 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08

Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08

Trustwide 82 78 80 86 85 84

5.2 Peripheral cannula (PVC) Audits of PVC care and management were undertaken regularly throughout the year. During Oct and Dec there was a break where ward staff worked on targeted action plans relating to previous non compliance. The results of the audit undertaken in March 08 are not available at the time of this report. .

Results of the audits in Oct and Dec are as follows: Removal details of the previous cannula are not being consistently documented, although compliance has increased since October 2007. Removal details were documented in 29 of 52 (56%) cases for December 2007, compared to 39% of cases for October 2007. The new nursing care plan was in use in 87 of the remaining 116 (75%) cases. This is a slight decrease in the 83% compliance achieved for October 2007

Percentage of cases in which the peripheral venous cannula in situ was appropriate

20 100

e 80 c n

a Jun-07

i 60 l p Oct-07 m

c Dec-07

0 PVC in s itu is appropriate

Is there a PVC care plan in use solely for this cannula? 100

s Jun-07 e 60 s

a Oct-07 c 40

% Dec-07 20

0 The PVC care plan is in use

Documentation of at least daily observations and the VIP score on the nursing care plan

100 80

s Jun-07 e 60 s

a Oct-07 c 40

% Dec-07 20 0 There is documentation of at VIP score is documented daily least daily observations

5.3 Management of MRSA positive wounds The audit have been carried out twice in the year with January 2008 demonstrating that on the whole wounds are being managed appropriately with over 90% compliance in all but three of the standards that were assessed. Further improvement is required for:

 Dressings: These were dry in 87% of the cases that were assessed

 Care Plans: These were in use in 78% of the cases that were assessed

 Isolation of patients: Patients with MRSA positive wounds were nursed in side rooms in 2 of 4 (50%) cases. Side rooms were not available in the 2 cases where patients were not isolated.

21 5.4 Management of urinary catheters The audits have been carried out every 3 months with the latest in February 2008. Overall compliance remaining at a similar level for the management of urinary catheters since the last audit was carried out in November 2007

 Compliance remains good for the following:

 Documentation of date of insertion of catheter  Appropriateness of catheter in situ  The use of the indwelling care plan  Position of the drainage bag (above the floor but below bladder level)  The catheter in situ is still required

Further improvements are required for the following:

 Documentation of the name of the person inserting the device  Documentation of reason for insertion of the catheter  Documentation of informed consent  Recording a signature for every shift on the care plan

6. 0 Infection prevention and control policies The Annual infection control programme for 07/08 set out the policies for review and also those new policies which were required in line with National guidance. All polices are ratified by the infection prevention and control committee and Governance committee before being published on the intranet and trust website.

Table 4 - policies Policy 2007/08 Universal precautions Ratified Feb 08 Isolation Ratified Nov 07 Hand Hygiene Ratified Feb 08 Decontamination Ratified Feb 08 Blood borne viruses Ratified March 08 MRSA Under review at time of report MRSA Screening Ratified Aug 07 Staff Health Out for Comment at time of report Surveillance Ratified Aug 07 Deep clean Awaiting ratification April 08 Clostridium difficile Ratified Nov 07 Linen Under review April 08 CJD Awaiting Ratification April 08

7.0 Complaints

22 The ICT have received a number of complaints throughout 2007/08 some have been directly related to strategic issues and others requiring a response to individual patient’s complaints. The themes are shown in table 5 below

Complaint Response/Action  Regular hand hygiene audits Staff noted not washing hands on entry to  Re- launch of clean your hands campaign. wards  Awareness weeks in September and October Nursing staff seen wearing uniforms  Awareness of uniform policy using display outside of hospital during infection control weeks  Article in Grapevine newsletter Lack of communication when transferring  review of nursing discharge documentation patients to other hospitals Concern about required precautions for  revised patient information leaflet MRSA Policy for MRSA screening  new screening policy developed in line` with new DH guidance

8.0 Incidents The ICT receive notifications of incidents where there has been a breakdown in infection control practice or a lack of communication which has resulted in an increased risk of infection. The infection control team responds to the incidents reported and these are discussed with the appropriate personnel, investigated and issues addressed.

Table 6 provides a summary of incidents

Problems Identified included Examples include Pressure of Beds/ Lack of Isolation Inappropriate placement of patients. Rooms Wards being re-opened early following outbreaks

Problems relating to patients or staff Infected patients being transferred to other areas. Staff not adhering to uniform policy. Incorrect wearing of personal protective equipment Lack of Communication Receiving wards or departments not being informed of the status of infected patients

Equipment and cleaning problems Areas or equipment not being cleaned effectively addressed at ward level or when equipment being sent for repair

9.0 Infection Control Team initiatives and communication Throughout the year the ICT have held a number of events to provide information to staff and raise awareness of infection prevention and control issues and progress towards the MRSA and C diff targets. It is recognised that staff, patients and the public need to be informed through a variety of mediums. To achieve this the team work closely with the trust communication team to ensure that press releases are available and provide the local newspapers with relevant

23 information to ensure the public receive accurate and informative information. Presentations and articles have also been given at the following forums:  Open staff meetings  Sixth form conference  Grapevine trust newsletter  A notice board has been placed in the atrium which aims to provide examples of leaflets that are available to patients and visitors and other key messages

9.1 Safer hands The infection control team took part in the ‘safer hands week’ during September. The focus was around ‘hands up, sleeves up, thumbs up’ with staff being encouraged to remove hand and wrist jewellery and to have bare arms below the elbow. Other aspects of uniform were also highlighted such as medical staff not wearing white coats. A display was held in the Landsown Foyer and was supported by a representative from the national ‘cleanyourhands’ campaign as they are due to launch a new range of posters in the autumn. Attendance was good with around 100 staff from cleaners and porters to nurses and medical staff checking their hand hygiene technique and viewing the display of uniforms over the last 100 years.

9.1.1Infection Control Week In October the ICNs held their regular infection control week with this years focus being on C difficile. A display was available for staff and the public to increase their knowledge of how patients acquire C diff and the control measures required to prevent spread. Other activities included unseen florescent gel on pens which when handled was transferred to unsuspecting staff, and only seen when their hands were placed in the light box. The ‘Commode Challenge’ was a fun event with a serious message as thorough cleaning of equipment such as commodes between patients is key to prevention of cross infection. We aimed to prove that it’s much quicker than you think to take a commode apart and put it back together. A de-clutter day rounded off the week with the facilities staff filling 5 skips with a range of unwanted and broken items.

9.1.2 Clean your hands campaign Year three of the campaign commenced in the autumn, with new highly visible posters being distributed to clinical areas in December. Further high visibility products to promote hand hygiene were distributed during January to replace the previous materials.

10.0 Side room tool The infection control nurses have implemented the side room tool to enable themselves and the site and bed management teams to clearly see which side rooms are being used for patients with infections and those patients who may be moved to enable isolation of others. The tool contains all the side rooms and can be accessed by either team to update the patients in each side room. If a patient remains an infection risk they will be highlighted as red indicating that it would be inappropriate to move them. If a side room is highlighted as green this indicates that a patient could be moved to a bay area to enable isolation of another patient. Both teams are now working to ensure regular updating is undertaken and to also explore ways of developing the tool so that ward staff can fill in patient’s details.

11.0 Outbreaks and incidents of infection

11.1 Vancomycin Resistant Enterococci (VRE) During August it was noted that there had been a number of cases of VRE (vancomycin resistant enteroccoci) in a small number of patients. An incident meeting was convened with the infection control team providing advice on isolation of the patients, implementation of environmental

24 precautions and screening of those patients that had been in contact with the cases. The results of the screening demonstrated a large number of different strains. Indicating that the patients may have acquired the organism in the community, however there were some similarities which the infection control team will be investigating further along with reinforcing existing guidelines to minimise cross infection.

11.2 Clostridium difficile In early November 5 cases of C difficile were reported on a surgical ward. The ward was reviewed and closed to admissions. A series of outbreak meetings were held with the infection control team, ward staff, Director of Infection Prevention and Control (DIPIC), matron, consultant staff and microbiologist. The following actions were implemented: All patients were isolated  Symptoms being recorded and reviewed twice daily  Stool specimens sent for virology testing  Staff wearing scrub suits  Use of disposable wash bowls for patients  All patients commenced on stool charts  Encourage hand hygiene with soap and water  The consultant teams reviewed all the cases  Setting up of hand hygiene point at ward entrance  Ensuring provision of information to patients and relatives  Increased daily cleaning using Chlorine agent as per national guidelines  Stool specimens sent for typing to determine strains  Investigating patients movement and possible links within theatres  Informing the SHA and reporting the outbreak as a Serious Untoward Incident  Review of antibiotics prescribed In total there were eight cases linked to the outbreak although no source was clearly identified. The ward was reopened after 10 days and once a full deep clean had been undertaken. Cases have continued to be monitored with increased awareness of possible symptoms amongst nursing and medical staff to ensure diagnosis and early isolation is undertaken.

11.3 Diarrhoea and vomiting outbreaks In line with the onset of the ‘winter vomiting’ season the trust began to experience ward closures due to diarrhoea and vomiting from mid November. The outbreaks increased significantly during December, a pattern also experienced in neighbouring trusts and nationally and reflected with a higher than normal level of case reporting in the general community. The trust experienced ward closures on a continual basis with variations in numbers of wards from two to a peak of ten in early January. During this time the trust also saw an increase in emergency admissions some of which were patients being admitted to the hospital with viral diarrhoea and vomiting. In some instances relatives were also reported to have symptoms while visiting the wards and were thought to be the index case for two of the outbreaks. The infection control team liaised regularly with the hospital site and operational teams on a daily basis. The number of wards affected was unprecedented and had a significant impact on operational pressures. On a small number of occasions it was necessary to open some wards ahead of the normal time period of 72 hours. On these occasions all risks were discussed with senior managers and members of the infection control team, with patients only being admitted to clean areas in closed wards when absolutely necessary to maintain capacity for emergency admissions. Advice was sought from the Health Protection Agency, Consultant in Communicable Disease Control (CCDC) and the Director of Public health for Banes PCT, who recognised the unprecedented level of ward closures and were supportive of actions which were taken to maintain patient flow and enable the hospital to continue to admit emergency patients.

25 The outbreaks also affected the community hospitals in Banes and Wiltshire PCT where 6 inpatient wards were closed. Daily conference calls were held between all acute trust and PCT parties to ensure clear communications including to the ambulance trust and Social services Messages were relayed to visitors and the public via a range of media both written and verbal and visiting to closed wards was restricted.

The table below provides an overview of the volume of activity and overall incidence of ward/Bay closures related to viral diarrhoea and vomiting for each month between April 07 and March 08. d e

t s f c f y e a a f t f d s

No of s e t e t b n

ward c e t i e s

Total t closures f f a o

Month Duration A p L Causative organism April 07 5 24 12 34 44 None confirmed May 07 2 19 19 32 105 None confirmed June 07 5 51 32 41 128 Noro virus confirmed in 1 outbreak July 07 3 17 8 22 24 None confirmed August 07 1 11 4 10 35 None confirmed September 07 1 4 1 6 14 None confirmed October 07 1 7 0 14 23 None confirmed November 07 9 57 28 99 135 Noro virus confirmed in 6 outbreaks December 07 13 122 80 151 418 ++ Noro virus confirmed in 7 outbreaks January 08 14 101 53 130 484 ++ Noro virus confirmed in 3 outbreaks February 08 7 25 2 37 72++ Noro virus confirmed in 3 outbreaks March 08 11 67 31 78 290 Noro virus confirmed in 2 outbreaks

Noro virus confirmed in 22 TOTALS 72 505 270 654 1772+ outbreaks

12.0 Tissue Viability

12.1 Aseptic Non-Touch Technique (ANTT) Training and implementation of ANTT was commenced in March 2007. Ward sisters from all clinical areas were asked to ensure that representatives attended training sessions and that these staff would cascade training to others within their department. Departmental representatives did not attend from 19% of these areas. Implementation of ANTT in the clinical areas has been slow. To date only 19% have fully implemented ANTT, with 49% partially implemented.

13.0 Decontamination

13.1 Endoscopy The Endoscopy refurbishment project is ongoing at the time of writing this report. Contamination levels in the water produced by the newly installed reverse osmosis plant have been higher than the recommended level despite repeated disinfection of the system. Work to correct the problem is still being carried out. The BHT endoscope reprocessors have been successfully commissioned and are running regularly throughout each normal working day. The drying cabinet is of great benefit to the department; allowing for scopes to remain usable for up to 72 hours after decontamination.

26 The Steris System 1 machines are currently still in use; these do not comply with HTM 2030 but rinse water samples are tested on a weekly basis.

13.2 ENT/Urology Outpatients An option appraisal is due to be carried out to identify how best to provide compliant decontamination solutions in these departments. Both departments suffer from a lack of space to expand their inadequately sized facilities, making satisfactory refurbishments difficult to achieve. One solution would be to refurbish an area remote to both departments but one that could service all flexible scopes outside of Endoscopy and at the same time provide continuity should services or equipment in Endoscopy fail.

13.3 Critical Care Critical Care are considering the purchase of a drying cabinet to ensure the ready availability of decontaminated bronchoscopes for their patients.

13.4 Sterile Services Department The oldest washer/disinfectors in the department were replaced in March 2008 and a duplex reverse osmosis plant was developed. The plant will provide consistent production of water to both the washers and sterilizers. In future servicing and maintenance can be undertaken without a loss of production. Air condition ducts were also cleaned, followed by a deep clean of the packing room prior to re-commencement of normal working. An assessment by BSI is due in May 2008.

14.0 Building projects The ICT have again continued to be involved with a variety of building and refurbishment projects ranging from advising on initial and final design, requirements for precautions during building work, monitoring during the work and inspection of the finished project prior to reoccupation by staff and patients. Of note have been the major refurbishments of:

 Marlborough ward which included the creation of six en-suite side rooms. The ward environment has been much improved with both staff and patients giving positive feedback.

 Helena annex refurbishment involved fitting a new sluice, entry system, new curtains and the creation of a shared waste room and new domestic cupboard for Helena ward. Since opening in July the annex is now know as Widcombe ward.

 The Audiology department environment was identified as requiring attention following an infection control environment and subsequently a group of key staff worked together to plan and complete a full refurbishment of the department to ensure a safe and easy to maintain environment for staff and patients.

Other projects requiring IC input:  Design and planning of the equipment library  Minor refurbishments in MAU  Reorganization of the Respiratory outpatients  Redesign of the main Endospcopy unit

27 In 2006 the trust was awarded £300,000 Capital Challenge funds which were allocated to a range of projects which were completed during the spring of 2007.

Cost Total ICNet surveillance system £65,000 £65,000 (Identified on risk register) Creation of 6 side rooms with £165,000 £230, 000 ensuite facilities and associated upgrade Marlborough ward Upgrade of Helena annex to £48,000 £278,000 become a co hort ward Purchase of 40 new commodes £22, 000 £300,000 across all wards

15.0 Cleaning Services The Cleaning Team provides services to wards, departments and circulation areas, but excludes residences. The service provides for the following:  General daily cleaning  Weekly cleaning  Periodic cleaning such as stripping & resealing floors  Special & isolation cleans  Theatre cleaning  Circulation and heavy duty cleaning. The service operates as follows:

Specified area Cleaning hours Departments 06.00 – 21.00 Mon - Fri 07.00 – 13.30 Sat - Sun

Theatres 18.00 – 24.00 Mon- Sun

Circulatory areas 06.00 – 24.00 Mon - Fri 07.30 – 19.30 Sat – Sun

Wards 07.30 – 13.30 Mon -Sun 16.00 – 19.30 Mon- Sun

15.1 Developments to meet National Cleaning Standards

15.1.1 Special Clean Team The special clean team has worked very hard to meet the high demand for special cleans of infected areas on wards over the past year. There has also been an increase in the demand for special cleans after midnight. As there is not a 24 hour cleaning service these were often left until the morning. To overcome this, additional cleaning staff have now been employed to provide the special cleaning service throughout the night. Based in the emergency department the cleaners can be called upon by nursing staff to clean an infected area from 12.00 to 07.30am. This is a further development to ensure the efficient flow of patients through the hospital. .

28 15.1.2 Cleaning Working Group The cleaning working group continues to meet each month to closely monitor hospital cleanliness standards and operational procedures, organize the deep cleaning programme for clinical areas and regularly review cleaning policies and procedures. The group has also worked closely with the Estates department to improve the patient environment with easier to clean surfaces. The group were actively involved in the work to totally refurbish and deep clean the Audiology department.

15.1.3 Strategic and operational cleaning plan A strategic and operational cleaning plan detailing the trusts commitment to providing cleaning to meet national cleaning standards has been drawn up and ratified.

15.1.4 Deep Clean Programme Deep cleaning of wards and other clinical areas has been undertaken during the period May 2007 to March 2008. Many wards were deep cleaned bay by bay as they became available. Due to high activity it was not possible for a decant ward to be made available. A large volume of outbreak cleans were also undertaken by the deep clean team on wards in the second half of the year.

15.1.5 Weekly Management Cleanliness Inspections Weekly cleaning inspections are now undertaken by the Director of Nursing, Director of Facilities and the Cleaning Services Manager. Once a month they are joined by a member of the Patients Forum. In addition the Cleaning Services Manager and the Facilities Manager, Hotel Services complete documented inspections of ward cleanliness each week.

15.2 Cleaning Audits There is a regular programme of auditing cleaning standards within clinical and non clinical areas of the Trust. The Trust is required to have an independent verification of the audit scores annually. In April 2008 the verified average audit score for the Trust was 85%. The independent report noted that there was a backlog of environmental improvement works that hindered effective cleaning in some areas.

A programme of environment improvement works has now commenced including redecoration of ward side rooms, upgrades of ward toilets, showers and bathrooms areas with easy to clean surfaces, public toilet upgrades, replacing corridor flooring and redecoration in public areas.

15.3 Cleaner Hospitals PEAT assessment for 2007/08 The hospitals cleanliness and environment was assessed by the Trusts Patient Environment Action Group in February 2008. The group included Facilities Managers, Nursing Management, Matrons, Infection Control and three Patients Representatives. The team were satisfied with the standard of cleanliness with the majority of scores in the good category. The official PEAT score is expected in June 2008.

15.4 Colour coded cleaning equipment New national colour codings for cleaning equipment were recently introduced. The cleaning department has purchased a full range of colour coded equipment to ensure the trust complies. The new equipment helps to ensure that cross contamination is avoided when cleaning on wards.

29 16.0 Standards for Better Health and Hygiene Code

16.1 Standards for Better Health The infection control team has provided evidence for the Trust declaration for the Standards for Better Health assessment, this enabled the trust to declare compliance against the C4a standard: ‘ Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that the risk of healthcare acquired infection to patients is reduced, with particular emphasis on high standards of hygiene and cleanliness, achieving a year on year reduction in Methicillin-Resistant Staphylococcus Aureus (MRSA).’

16.2 The Hygiene Code The Trust has undertaken a detailed assessment of compliance with the 11 areas of both the original and revised versions of the Hygiene Code. Review of the required actions has been undertaken leading to an action plan for achievement. The action plan was submitted to the Trust Board for review and assurance.

The Trust underwent an unannounced inspection by the Healthcare Commission on 14th February 2008 to assess compliance against 3 of the duties of the Hygiene Code. The Healthcare Commission found no material breaches of the Code but made a number of recommendations to improve systems for infection prevention and control reporting. The recommendations were: To ensure that attendance at infection control training is monitored and include compliance as a key performance measure for infection prevention and control reporting. To finalise the Trust’s admission policy. To ensure that cleaning schedules are posted in areas that are easily accessible to patients and to visitors of the hospital. To implement a system to monitor the effectiveness of cleaning equipment that is frequently touched between each patient.

The Healthcare Commission will check that the improvements have been made in 6 months’ time following their report.

17.0 Infection Control education and training activities The team has continued to provide induction sessions for clinical and non clinical staff via the mandatory training programme. The team have also contributed regularly to sessions for student nurses, return to practice nurses, Healthcare assistants new to healthcare and pre-registration house officers.

The five day Link nurse course commenced in May 07 has seen 14 staff, 6 from the RUH and 6 local PCTs prepare to be the infection control link for their wards/departments undertaking the five day course.

The NHS e learning programme for infection prevention and control continues to be a useful way for staff to update their infection control knowledge as it can be accessed either at work or home.

In conjunction with Swindon college and led by ICN S Smith 50 staff from a range of roles undertook a distance learning module on MRSA. All completed the course and gave positive feedback.

Tracey Halladay has continued to be a co-tutor for an accredited Principles of Infection Control Course which is run collaboratively with North Bristol and UBHT infection control teams.

30 Dr Meisner has led on the infection control contribution to the newly established mandatory training session for senior medical staff which is delivered through scenario group work.

18.0 Training for Infection Control Specialists

Tracey Halladay Denise Meyers Susan Smith Julia Bloomfield HCAI master class National study day Oxford Brooks Principles of 2 day event on Clostridium infection control infection course difficile course 2 modules level 3, PGC leadership for quality Infection Prevention improvement Society annual programme conference

19.0 Summary and key objectives for infection prevention and control for 2008/09  Maintain the C diff cohort ward  Reduce C diff to 4.0 per 1000 admissions to 20 cases per month 2008/09 in line with target  Achieve 26 MRSA bacteraemia by March 2009 in line with national target  Continue with monthly practice audits and feedback of results  Ensure compliance with Hygiene Code  Continue to focus on key areas in line with Saving Lives programme  Further enhance the deep cleaning team  Establish robust monitoring and audit of cleaning standards  Improve provision of infection data to clinicians, ward managers and senior managers  Improve the hand hygiene audit programme  Appoint an antibiotic pharmacist  Appoint surveillance analyst  Appoint band 7 infection control nurse

20.0 Conclusion The DIPC would like to thank the infection prevention and control team and in particular Tracey Halladay, Senior Infection Control Nurse in the compilation of this report.

With regard to executive report the DIPC is strongly encouraged by colleague’s commitment to this agenda and in particular Michael Earp who rigorously applies his champion lead non executive role.

Through this support and encouragement the DIPC has been able to lead and achieve on behalf of the organisation in the area of infection prevention and control.

31 Appendix 1- Infection Control Audit Programme (2007/08) Revised Jan 2008 The audits are undertaken either locally within wards and departments using the monthly audit booklet or by the ICT as indicated

Audit Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Hand Y Y Y Y Y Hygiene Observation Hand hygiene OP depts Y Y Hand Hygiene Entry & Y Y Exit PVC Y Y ICT Y

Urinary Y Y Y Y Catheters CVC Y Y

Wounds Y Y

Vent Care Y Y

C. diff ICT ICT

MRSA Screening Y Y

Isolation Y

Surgical site Peri- Y Op Sharps Completed Nov 07 Commode Completed Oct 07 No for month 3 2 3 2 2 2 2 2 2 3 2 2 1-ICT 1-ICT 1-ICT

32 Appendix 2 Antimicrobial Audit Programme This is the proposed program for audit of antimicrobial prescribing for the next 12 months at the RUH. Delivery of this program will be more achievable with a dedicated antimicrobial pharmacist in post. Note: Antibiotic pharmacist post not in post (30-4-08). Interviews planned and if successful will not be in post until Sept 08 at earliest. Antimicrobial Responsibility Rationale Action Action Review date to completion April 2008 start date Respiratory Pharmacy & Identified in October Jan 2008 Audit underway. CAP & HAP Respiratory & previous Trust 2007 Due to be completed Microbiology wide antibiotic May 2008 audit Vancomycin Pharmacy & Identified in Oct 2007 March 2008 Audit due to start in IV and Oral Use Microbiology previous Trust May 2008 Trust Wide wide antibiotic Proposal form audit completed High use across 3 mths of data Trust collection Overuse introduces risk of increased vancomycin resistant organisms Cephalosporin Pharmacy and Driver of C diff. Nov 2007 April 2008 Due to start in July Trust Wide Microbiology 2008. IV & Oral To under take a Led by surgical full (Drug Usage pharmacists Evaluation(DUE) Ciprofloxacin Pharmacy and Driver of C diff. DUE Jan June 2008 Not planned IV and Oral Microbiology 2008 Trust Wide To under take a Audit full (Drug Usage March Evaluation(DUE) 2008 Clindamycin Pharmacy & Driver of C diff. DUE FEB June 2008 Not planned Trust wide Microbiology Used more 2008 IV and Oral To under take a often as result Audit April full (Drug Usage of new 2008 Evaluation(DUE) guidelines Meropenem/Tazocin Pharmacy & High Cost drug DUE May November Audit undertaken Trust Wide Microbiology for medicine 2008 2008 by Micro/Pharmacy To under take a Audit Sept Awaiting report full (Drug Usage 2008 Data collection Evaluation(DUE) completed Jan 08 Other areas for future audits: bacterial endocarditis, gentamicin, co- amoxiclav, teicoplanin, linezolid and tazocin.

Bina Mistry Principal Pharmacist Clinical Services & Clinical Economy, Rob Eliot Deputy Clinical Audit Manager, Dr Sarah Meisner Consultant Microbiologist