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Infection Prevention & Control Strategy 2013-2015

Helen O’Connor Nurse Consultant /ADIPC June 2013 1

EAST & NORTH HERTFORDSHIRE NHS TRUST INFECTION PREVENTION & CONTROL STRATEGY Introduction This strategy aims to support the reduction and control of hospital acquired infections. Whilst healthcare associated infections continue to reduce in number nationally from 8.2% in 2006 to 6.4% in 2011 locally there is always an opportunity for improvement with the aim that ‘No person is harmed by a preventable infection’ (Infection Prevention Society mission statement 2013). The Trust Infection Prevention Assurance Framework and Annual Plan of work have been developed in response Infection & Control Strategy and developed in response to the Health & Social Care Act (2008), regulation 12 which focus requirements for registration against standards of cleanliness and infection control. Compliance with the code is monitored by the Care Quality Commission. There are 10 compliance criteria which the Trust as a provider is required to meet these are cited in the appendices. Our strategy embodies the strategic aims of the trust “To continuously improve the quality of our services in order to provide the best care and optimise health outcomes for each and every individual accessing the Trust’s services and to excel at customer service, achieving outstanding levels of communication and patient, carer and GP satisfaction. Background Unfortunately the treatment and care of patients in hospital may sometimes be complicated by the development of infection. The factors critical to the control of infection and reduction of infections include sound hygiene practices, environmental cleanliness, effective methods of disinfection and sterilisation, good antimicrobial stewardship, systems in place to manage and monitor infection, provision of accurate and relevant information systems to patients, visitors and staff at all times. Incorporation of these elements into clinical practice must be supported by the continued education and training of staff to ensure good practice. A robust audit and surveillance programme to monitor, assess the burden and impact of infection, inform and ensure programmes are in place to reduce or eradicate as appropriate. It is also vital that infection control specialists with responsibility for helping to develop Trust strategy are supported by and support the relevant Management teams. Trust Management will have responsibility for ensuring that adequate resources are provided to enable the efficient and timely delivery of infection prevention & control service. Infection Prevention & Control is therefore acknowledged as a major priority for the Trust. Strategic aims 1. “To continuously improve the quality of our services in order to provide the best care and optimise health outcomes for each and every individual accessing the Trust’s services. 2. To excel at customer service, achieving outstanding levels of communication and patient, carer and GP satisfaction. Infection Prevention & Control Strategic Objectives All staff will understand the impact of infection and infection control practices to enable them to discharge their personal responsibilities to patients, other staff, visitors and themselves. In recent years the Trust has experienced an increased number of Norovirus outbreaks as this infection has lingered in the community in to the summer months. This in turn has impacted on the Trusts availability of a decant ward required to support and facilitate the deep clean programme. This strategy will endeavour to 2

minimize the number of outbreaks and ward closure through prompt identification of symptomatic cases, and strict adherence to IP&C measures. Supported by a robust deep cleaning programme which includes hydrogen peroxide fogging. During the past year the Trust has identified an increased incidence of Vancomycin resistant enterococci (VRE) within the renal patient population. This strategy aims to provide care for all patients in physical environments that minimise the risk of infection. This includes the ability to regularly decant and deep clean the ward followed by hydrogen peroxide fogging. A review of the cause of staphylococcus aureus related bacteraemias identified 3 cases related to contaminated samples at the time of taking. The Trust currently competency assesses all junior training grades whoever this strategy embraces all senior training grades (registrars) and new consultants to the Trust who undertake this clinical procedure. Infection Control plans must be supported by adequately resourced specialist infection control staff with sufficient skill mix to meet the needs of the Trust’s infection prevention and control annual plan. To continually improve upon the surgical site infection rate in trauma and orthopaedics the Trust will adopt comprehensive surveillance and audit programmes to monitor and direct their infection control plans. Plans will be based upon local needs as directed by the overarching annual Trust Infection Prevention and Control Plan of work, but will adopt national programmes as they are developed and directed by the Department of Health. Reduction in avoidable infection rates will form part of Trust plans and strategies. This will be embedded within overall Trust Management scheme for example, performance management and the ‘floodlight’ score care to meet the Trust’s strategic objective “To continuously improve the quality of our services in order to provide the best care and optimise health outcomes for each and every individual accessing the Trust’s services”. The Trust will continue to develop and enhance systems to ensure effective recording, analysis, sharing and access to their own data, and access to information sources appropriate to their needs for managing infection in the Trust. How these Strategic Objectives will be achieved National policy and guidelines that are up-to-date and evidence based will be adopted to ensure consistent and effective infection prevention & control practice across the Trust. Infection prevention will be embedded as a core item of the management agenda and accountabilities of all staff and managers (as appropriate to their function). Information analyst support will be available to the Trust Infection Prevention & Control Team as required, to support the local infection control plan. Effective training schemes will be available to meet the needs of all staff. The training will cover foundation grade doctors, all medical trainees, students nurses and trainees in all professions allied to nursing, all in-service NHS and non NHS, post registration, and include continuing professional development. A zero-tolerance approach to avoidable healthcare acquired infection will be maintained. MRSA bacteraemias will continue to be considered a local ‘never-event’ and an aspirational target for Meticillin Sensitive Staphlylococcus aureus of a 20% reduction on the previous year. 3

All healthcare associated bacteraemias will be investigated using a route cause analysis approach include Post Infection Reviews and all learning will be implemented, monitored and shared across wider health economy at the Clinical Commissioning group. The Trust wide deep clean programme and fogging will continue including hydrogen peroxide fogging. A competency based programme will commence for senior training grades and new consultants to the Trust who perform blood culture taking on patients. Structure of the Strategy The strategy builds on the achievements and challenges of the previous year and aims to support the reduction in healthcare associated infection. The strategy focuses on 6 main areas: Organisational Arrangements and Infrastructure Information Technology and Communication Training and Education Surveillance and Audit Environment of Care Report Monitoring External Reporting Strategic Intent Infection prevention & control must be everyone’s responsibility, from clinicians, cleaners and ancillary staff to patients and relatives. A key challenge for the prevention and control of healthcare associated infection is to ensure that procedures in place to reduce the risk of acquiring such infections are strictly adhered to by all. One purpose of this strategy is to provide clarity regarding the leadership and direction of the management of the Trust’s Infection Prevention and Control agenda which ultimately aims for the reduction of healthcare associated infection in particular hospital acquired infection (HAI) rates. This strategy should be considered along side Trust strategies, in particular, the Clinical Governance and Risk Management strategies. This strategy will: Provide direction for staff Identify priorities for improvement within a framework of clinical governance Provide the foundation for Infection Prevention & Control Annual Plan and Assurance Framework Identify challenges, constraints and offer solutions Support the reporting and accountability process The ARC programme will continue to compliment the strategy in putting patients first, working as a team across divisions and continually striving for improvement and excellence. Accountability and Responsibilities The Chief Executive is accountable for ensuring that systems are in place for monitoring the quality and clinical practice and for ensuring the Trust Board that care is being delivered to patients safely and effectively. This accountability is encompassed in the Trust Patient Safety and Clinical Governance strategies. Within the current organisational structure, the Chief Executive delegates responsibility for particular elements of the infection prevention agenda to the following Executive Directors: 4

The Director of Nursing/DIPC supported by the Assistant DIPC are responsible for driving the implementation of Infection Prevention Strategy, Infection Prevention & Control Annual Plan of work and the Assurance Framework. The Company Secretary is responsible for corporate assurance, relating to healthcare on regulation both internal and external to the organisation. The Medical Director is responsible for clinical leadership, and as Chair of the Trust Clinical Governance and Patient Safety Committees is responsible for driving forward infection prevention issues. All staff employed by the Trust are responsible for the delivery of safe clean care and reducing harms to patients by preventing and reducing infection healthcare associated infection as a clinical priority. Organisational Arrangements-Corporate The Trust board is ultimately responsible for ensuring that patients receive safe standards of care and that clinical quality is achieved. The Trust has a well established Infection Control Committee (TIPCC) chaired by the Director of Infection Prevention (DIPC). The role of the Committee includes advising the Trust on the ways of providing a managed environment that focuses on reducing healthcare associated infection rates across the Trust. In addition the Committee is responsible for overseeing the Infection Prevention and Control Strategy and Assurance Framework and Annual Plan. The Assistant DIPC currently chairs monthly divisional infection prevention & control meetings. The TIPCC currently meets 11 months of the year. The Infection Prevention & Control Committee reports directly to the Risk & Quality Committee and forms part of the Patient Safety Report to the Trust Board. Trust Board (Patient Safety Report) ↑ Risk & Quality Committee ↑ Trust Infection Control Committee (Chair DIPC) ↑ Joint Infection Prevention & Control Committee Committee (Chair ADIPC)

Trust Decontamination

(Chair ADIPC)

Divisional Infection Prevention & Control Committees (Chair ADIPC) Organisational Arrangements-Divisional Each of the five Divisional Chairs has a least two representatives on the Trust Infection Control Committee. The Divisions have both a clinical lead consultant and divisional nursing services manager with responsibility for ensuring that the infection control agenda is prioritised and managed effectively at an operational level. Divisions will achieve accountability for Infection Prevention by contributing to the TIPCC monthly escalating key divisional issues and communicating actions monthly rather than submitting a quarterly

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report as in previous years. The Divisional IP&C Consultants will support local management and ensure standardisation across the Trust: 1. Where appropriate and in parallel with corporate priorities the Infection Control Committee will identify and agree Divisional priorities from the Trust Infection Prevention & Control Assurance Framework. 2. Accountability will be further strengthened by Infection Prevention & Control being a key feature of Divisional performance reviews. Organisational Arrangements-Infection Prevention & Control Team The Trust Infection Prevention and Control Team (IPCT) has primary responsibility for advising on aspects of the surveillance, prevention and control of infection in hospitals, satellite units, special schools (and 3 hospices, the Surgicentre and Mental Health Trust SLA agreements). The IPCT for the Trust comprises of one Infection Control Doctor and four point four Infection Prevention & Control Nurses. In addition 2 further Consultant Microbiologists and one Consultant Nurse who provide infection control advice as require on a day to day basis. The Consultant Nurse is also the Assistant Director Infection Prevention and the Trust Decontamination Lead. The Team is responsible for advising on the development, implementation and monitoring of all aspects of infection prevention and control. This is managed through the Annual plan of work, which is approved and monitored quarterly by the Trust Infection Prevention & Control Committee (TIPCC). The Infection Control Team is supported by the microbiology laboratories at the Lister Hospital for Lister, QEII Hospital and affiliated sites. The Hillingdon Hospital NHS Foundation Trust laboratories support Mount Vernon Cancer Centre and Luton & Dunstable NHS Foundation Trust supports the Luton Renal Satellite Unit. Director Infection Prevention & Control

Assistant Director Infection Prevention & Control

Infection Control Doctor Consultant Microbiologists

Lead Nurse (IP&C) IP&C Nurses Surgical Site Surveillance Nurse

Information Technology and Communication Good information management support is essential for efficient working in infection prevention and control. The Trust will undertake a baseline assessment of current information systems to support the following:Gathering, recording, analysing and dissemination data for surveillance purposes; Improving access to clinical information Outbreak Management Tracking patients inter-ward moves and frequency of moves Monitoring compliance with isolation policy and escalation standards Assessing the impact of staff activity on infection outcomes Deriving proxies for the effectiveness of infection control management Dissemination/availability of results 6

Monitoring antimicrobial resistance Monitoring antimicrobial prescribing practices Facilitating communication and making available updates on policies and guidelines: Developing an intranet adhoc targeted training topic forums as required Timely and accurate information remains a key factor in the success of any team. Whilst in recent years this has improved through the use of ICnet, support from the Trust Infomatics department and the development of BIMS system the IP&CT remain challenged in respect of data on patient inter-ward movements and isolation practices. Whilst embedding the change process is challenging this newly revised strategy will allow the Divisions to fully embrace infection prevention and control issues and allow ownership and direction of issues identified. It is recognised that improved information technology and communication will support the Trust vision ‘to be amongst the best’. Training and Education The Care Quality Commission places strong emphasis on the need for all health care staff to understand and discharge their roles and responsibilities in relation to infection prevention and control within the clinical governance and risk management framework. Ensuring effective training schemes to support the objectives contained within the various policy documents is critical for achieving success. In order to support the implementation of the Trust’s Strategy and to comply with the Health & Social Care Act, criterion six IP&C training is aimed at developing infection control expertise to all levels and groups of staff remains a key priority for the Trust. The focus of the programme will be to ensure responsibility for in-service training arrangements, record keeping, monitoring, and feedback to divisions of attendance is documented and acted upon, this will include blood culture training for all medical and nursing staff who undertake the procedure. Surveillance and Audit Good accurate and meaningful information and data to plan service delivery evaluate progress and demonstrate improvements is an essential requirement of the infection prevention and control agenda. Infection control surveillance data plays a central role in providing the information needed to underpin strategic objectives as well as informing priorities and focus for day to day operations. Infection reduction programmes can only be demonstrated as being effective if accurate rates of infection are known. Incorporation of an effective surveillance programme with regular feedback of results to clinical staff is recognised as crucial to the development of action plans to facilitate reductions in the incidence of healthcare associated infections. Clinical Divisions, in partnership with the IPCT will continue to decide upon appropriate non-mandatory surveillance programs. The Divisions will be responsible for the implementation of some of this non-mandatory surveillance with close collaboration and support from the IPCT. Adequate staffing and good management arrangements will be needed to ensure success and the Trust will review the resources available to support the surveillance programme. The IPCT will, alongside the Divisional Leads for Infection Prevention & Control, review the results of the surveillance programs on a regular basis, presenting findings to divisional educational governance meetings presenting action plans aimed at reducing the level of hospital acquired infections. The Trust Informatics Department provides an important resource to monitor the implementation of policies and operational performance. It could also provide insight in to problems highlighted by surveillance. The role in surveillance by the Clinical Audit Department will need to be strengthened. 7

The IPCT will continue to work closely with the divisions to advise and agree on the topics and priorities for audit. Current Mandatory Surveillance: MRSA and MSSA bacteraemias, Clostridium difficile toxin positive cases, Glycopeptide resistant enterococci, Vancomycin resistant enterococci, Eschericia coli and surgical site wound infections relating to orthopaedic implants (hip, knee and fracture neck of femur). This strategy is proposing to expand the non mandatory surveillance programme working with the divisions in our drive to achieve the Trust vision of ‘being amongst the best’. Environment of Care There is clear evidence of the relationship between hospital cleanliness and infection. The Trust has implemented the revised National Standards of Cleanliness in to all clinical areas and has maintained the Department of Health Deep Clean initiative (2008).In recent years this has proved to be very challenging in part due to the activity around Our Changing Hospital initiative and pressures on bed capacity. Decanting of wards has been more difficult and creative use of empty bed spaces and bays has been deployed. The responsibility for managing the environment of care to ensure high standards of hygiene and maintenance is achieved by the key role of the Senior Ward Sister/Charge Nurse or Department Manager. Support from Corporate Divisions e.g. Estates, Facilities, and Quality Control Department is essential for ensuring that the fabric of the environment is suitable for meeting the needs of the patients, visitors and staff. The Assistant Director of Infection Prevention & Control is responsible for the planning and implementation of the Trust Deep Clean Programme working with the Directors of Operations and Nursing to achieve the maximum use of decanting facilities available to achieve the programme. Focus will continue on medical devices in the environment in particular bed frames and their mattresses. It is essential that the audits of ward cleanliness are reviewed with the IPCT and that the IPCT audit independently on a regular basis. Independent audits will continue to be undertaken by members of the Trust Executive Team with the Director/Assistant Director of Infection Prevention & Control on a regular basis. Report Monitoring The achievement of measurable improvements in infection rates will need to be underpinned by setting, implementing and monitoring national, local and aspirational targets. In order to focus activities to improve practices health professionals, support staff, managers and the public need to know how they are doing against the ceiling targets. Robust divisional comparable information on infection rates and patient outcomes developed during the recent past will be built upon to include costs in relation to outbreak management. Divisional specific Infection Prevention & Control performance Indicators in the form of compliance indicators will be reported on monthly to the divisions and agreement will be sought to achieve improvement where required. These will continue to be reported to and monitored by the Trust Executive Committee, Risk and Quality Committee and Trust Board. Monthly reports specific to the divisions of medicine and surgery will be provided to each divisional board to ensure high level engagement. External Reporting Progress on the implementation of this Strategy, Assurance Framework and Annual Plan of work will be reported to: Clinical Commissioning Group NHS Trust Development Authority Care Quality Commissions Regulators

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Implementation of this Strategy This strategy will be implemented through the Infection Prevention Annual Plan of work and managed through the Trust Infection Prevention & Control Assurance Framework. Objectives and time-scales are included within each section of the programme and assurance framework which is aligned to the criteria set out as a requirement for registration in the code of Practice for health and adult social care on the prevention & control of infections 2008. In order for this strategy to be implemented it is essential for it to be owned by all staff. Good clinical and managerial leadership at all levels, clarity of roles and responsibilities and multidisciplinary team working will be the key to success. Some objectives will be dependant on resources and will therefore need to be priorities against competing objectives. Others may be achieved by changing working practices as part of the quality, innovation, productivity and performance (QIPP) initiative.

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