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1.0 Summary
This report outlines activity and events related to infection control for 2005-06. Healthcare
Associated Infection continues to be an important issue for the Trust, not least because of
its impact on public perception of the Royal Free Hospital. There have been some
important changes in the arrangements for managing Infection Control. The period has
seen the implementation of ‘Saving lives’ as well as continuing work on ‘Winning Ways’
and the ‘cleanyourhands’ campaign

2.1 Description of infection control arrangements

Dr Adrian Tookman, Medical Director, took on the chair of the Infection Control
Committee (ICC) in April 2006. The ICC meets quarterly and has representation from
across the Trust. Reports from of Infection Control (IC) activity will be received from
directorates which now record IC activity as part of the clinical governance grid. Within the
Trust committee structure the ICC reports to the Clinical Risk Committee, which also has
the Medical Directors and Lead Infection Control Doctor as members.
The Consultant Microbiologist with Special Interest in Antimicrobial Prescribing and the
Antibiotic Pharmacist are members of the ICC and the Drugs and Therapeutics Committee
and act as a link between the two.
The Infection Control Team is headed by the Director for Infection Prevention and Control,
who is a board member and activity directed by the Lead Infection Control Doctor and
Lead Infection Control Nurse.
Membership and Terms of reference for the ICC are attached as Appendix 1.

2.2 Infection Control Team Staffing and Budget allocation to infection control

Medical Staff
Dr E. James          5PA appointed October 2005
Dr R Smith           3 PA appointed November 2005
Virology             1 PA

Nursing Staff
Ms Y Carter          Lead nurse                                FT
Ms Y. Barlow         Infection Control Nurse                   0.6 WTE
Ms D. Barry          Specialist Sister Infection Control       FT
Ms S. Allen          Specialist Sister Infection Control       FT
Mr S. Smith          Audit and Surveillance Nurse              FT
Mr R. Gotvassli      Patient Liaison – IC                      FT
                     (One year secondment sponsored by League of Friends)

Administrative Staff
A&C                  4 hours pw                             (currently vacant)
                     allocated from Microbiology Department


No separate budget allocation for work related to infection control, patient and
environmental screening samples currently funded from Microbiology Dept.

Renal Infection Control Nurse
A business case for the appointment of a renal Infection Control Nurse has been
supported and the post is currently out to advertisment, The role will be a particularly
important one for the trust. Patients receiving dialysis, especially through an indwelling
line, are at comparatively high risk of bacteraemia, especially that due th Staphylococcus
aureus including MRSA. In addition there are also risks of exposure to blood borne viruses
especially in patients returning from certain countries who have received dialysis there.
The dispersed nature of the satellite renal dialysis units, particularly with the recent
expansion of the workload has made it impossible to cover without this role

3.0 Untoward Incidents and outbreaks

A breakdown of incidents regarding infection control reported using the clinical incident
system is given in Appendix 2.
Transmission of certain HCAI pathogens including MRSA, glycopeptide resistant
enterococci (GRE) and multi-resistant acinetobacter (MRAB) occurs and is documented
further below. For GRE and MRAB in particular the focus of transmission remains in highly
dependent patients including ITU. There have been no outbreaks of Clostridium difficile
infection during the period covered by this report, although sporadic infection occurs.

The possibility of blood borne virus transmission in renal dialysis continues to be a risk for
the Trust with a lower frequency of surveillance testing performed than recommended
nationally, due to lack of funding. There remains also a problem of lack of funding for the
intensive surveillance of persons returning from a period of dialysis in high-risk settings
abroad, several of whom have been found to harbour newly acquired hepatitis viruses
upon return thus posing a risk to other patients
Exposure to infectious cases of tuberculosis has occurred intermittently, due to a delay in
recognition of possible tuberculosis or unexpected diagnosis. These have been managed
by the TB team in association with the ICT, and no cases of onward transmission have
been identified.

4.0 Activity within the Trust related to Infection Control

4.1 Policies

The following policies were reviewed by the Infection Control Committee and ratified.
Signs for isolation rooms
Staff health
Management of Outbreaks
Tetanus prophylaxis
Laundry policy
Surveillance programme

4.2 Pandemic „flu plan


A group has been convened by Richard Parker to develop a Trust Pandemic Influenza
plan as part of it business continuity plan. The work is ongoing.

4.3 Winning Ways
Action area 1. Surveillance and investigation.
Surgical site infection surveillance continues in orthopaedic surgery. In order to obtain a
broader picture of SSI in the trust surveillance of large bowel surgery was performed
during 2005, and since the beginning of 2006 surveillance of craniotomies has been
performed. No post discharge surveillance has been instituted as yet, mainly due to the
resource implications. Feedback of surveillance data now occurs at directorate or
specialty level. A root cause analysis tool for MRSA bacteraemia has been developed and
will be reviewed after use.
Action area 2 Reducing infection from invasive devices.
Saving lives High Impact Intervention Audits for CVC have been performed in many areas,
and the results are being reviewed in directorates. Audits in other HII areas are being
performed. A CVC care policy has been produced by the clinical care group and other
groups within the Trust have focussed attention in this area. Specific training for CVC
insertion to junior doctors will include a standard approach to aseptic technique.
Action area 3. Reducing reservoirs of infection.
The ICNs have continued to work closely with bed managers to optimise bed use,
although clinical reconfiguration has reduced the number of siderooms available to isolate
infectious patients. It is expected that the introduction of rapid molecular testing for MRSA
colonisation will help.
The ICT continues to be closely involved with the Projects department in ongoing building
work and refurbishment.
Action Area 4: High standards of hygiene in clinical practice
Work needs to be done within directorates and specialty groups to ensure appropriate
standards are met. The policy for teams visiting ITU has been relaunched. Infection
Control has yet to be included within PDPs.
Action Area 5: Prudent use of antibiotics
Antibiotic policies in line with the recommendations of this area have been published on
Freenet. Some audit of antibiotic usage has been carried out but needs to be extended.
Action areas 6 and 7 refer mainly to areas for DH or other national bodies to action.

4.4 „Saving Lives‟
A ‘Saving lives’ steering group met in January 2006 chaired by Dr Tookman to perform the
self-assessment. Appendix 3. The result of this was reported back to the steering group
and the infection control committee. ‘Saving lives’ actions have been included within the
infection control part of the governance grid. Initial audits have been oerformed in many
areas, especially with regard to CVC.

4.5 „cleanyourhands‟ campaign
The Trust is entering the second year of the ‘cleanyourhands’ campaign. Alcohol gel is
widely available within the Trust and recently bed-end holders for dispensers have been
distributed to wards. The performance of associated hand hygiene audit has been patchy
and ‘champions’ have yet to be found by directorates. The 2006 Action plan as appended
as Appendix 5.

4.6 Asepsis protocol


An asepsis protocol with associated clinical competencies is been developed by the Trust
with the involvement of the ICT.

5.0 Specific areas

5.1 Decontamination

A report from James Brown, Decontamination Manager is appended as appendix 4

5.2 Waste
The amount of clinical waste generated by the trust has been reduced by 200 tonnes per
year leading contributing to substantial savings. Almost all clinical waste bins have been
removed form patient areas. A revised policy taking account of the 2005 Hazardous
Waste Regulations is being prepared, awaiting further guidance from DH and Environment

5.3 Cleaning services

Cleaning services are managed in-house. The current budget allocation is £4,338,926 pa
Monitoring is performed using the Maximiser system, which is programmed to NHS
cleaning frequencies. Records are kept by the Domestic Department. Yearly audits are
done by local PEAT in conjunction with Infection Control.
To monitor user satisfaction the Domestic Department sends a ward questionnaire each
year, once collated a copy of the report is sent out to each ward, with any measures that
can be actioned recorded. The 2005 PEAT score was poor however the Patient Forum
score was 8/10.

6.0 Other issues

6.1 Reconfiguration of Clinical services
Local reconfiguration of services has led to a reduction in the number of siderooms
available for isolating potentially infectious patients. The impact of the transfer of Mount
Vernon plastic surgery services is currently being assessed and planned for. The
centralisation of renal services to the RFH has contributed to MRSA and MSSA

6.2 PMDU visit
Along with other trusts the RFH was visited by the Prime Minister’s Development Unit
because of comparatively high rates of MRSA bacteraemia in November 2005. General
feedback was obtained regarding the visits as a whole although no specific advice was

6.3 Performance Improvement Network
Team members joined the national Performance Improvement Network to learn and share
experience with teams from other trusts.

7.0 Audit
The audit schedule for infection prevention and control include was limited in 2005 due to
changes in staffing. It included:

Hand hygiene


Sharps management
The patient environment, specifically with PEAT and PPI Forum

Reports from all audits were reported back to the ICC and the trust board
8.0 Training activities
Infection control training of RFH staff
The infection control team continue to carry out a wide variety of programmed and adhoc
training to different types of staff. Infection control is included in the induction programme
for all staff including medical staff. Annual mandatory infection control training is not yet
happening for all staff. Difficulty in freeing staff from clinical duties to attend infection
control training sessions continues to be an obstacle.

Training of members of the infection control team
Shirley Allen and Deborah Barry are both starting the second year of the Hertford
University Infection Control Course

9.0 Public and patient involvement
Don’t pass the bug 18th November 2005
This was a day organised to highlight a number of issues to the general public related to
infection control, and included contributions from many departments within the Trust.
MRSA liaison nurse
A secondment was funded for one year to September 2006 by the League of Friends to
allow a nurse to focus on the patient experience with regard to MRSA. Funding has been
made available to continue this post and expand the role.
In addition the ICT have worked with the PPI on monitoring hospital hygiene and have
presented at a session outside the Trust.


10.0 Healthcare associated infection surveillance

10.1 Staphylococcus aureus bacteraemia including MRSA

Hospital acquired Staphylococcus aureus bacteraemia including that due to MRSA
continues to be an important infection control issue for the Trust, and has been made
even more important with the centralisation of renal services for the North Central Sector
here. The major contribution made by this area is clear from figure 3. A previous audit
suggests that at least half of these bacteraemias are related to IV lines. Therefore in the
prevention of these infections the insertion and care of lines is important, as well as
measures to prevent transmission of the organism between colonised patients. Effective
treatment of a bacteraemia, including early removal of an involved line is important to
prevent recurrent episodes.
Other specific measures introduced with the aim of reducing S. aureus bacteraemia are
the programme of screening dialysis patients with lines for nasal carriage and subsequent
decolonisation therapy, and exploring the role of decolonisation therapy for MRSA carriers
in ITU.
12 of 125 MSSA bacteraemias and 26 of 100 MRSA bacteraemias occurred in an ITU
Excluding Nephrology, where positive blood cultures occur frequently outside formal
admissions 34 MSSA bacteraemias were detected in the first 2 days of admission
compared with 14 MRSA bacteraemias

Figure 1. MRSA bacteraemia episodes by quarter 2003 – 2005.









       Apr - May 03

                      Jul - Sep 03

                                     Oct - Dec 03

                                                    Jan - Mar 04

                                                                   Apr - Jun 04

                                                                                  Jul - Sep 04

                                                                                                 Oct - Dec 04

                                                                                                                Jan - Mar 05

                                                                                                                               Apr - Jun 05

                                                                                                                                              Jul - Sep 05

                                                                                                                                                             Oct - Dec 05

                                                                                                                                                                            Jan -Mar 06

                                                                                                                                                                                          Apr - Jun 06

Figure 2. MRSA bacteraemia performance against target

                                                                                                                                   Number of MRSA bacteraemia reports





                                                                                Figure 3
                                                                                           Q             05
           General                                                                                         /0
                                                                                               rte              6
           surgery                                                                                     20
                                                                                           Q             05
                                                                                               rte              6
     Haematology &                                                                                r3
                                                                                           Q             05
       Oncology                                                                             ua             /0
                                                                                           Q             05
        Hepatology                                                                                         /0
                                                                                               rte              6
                                                                                           Q             06
                                                                                               rte              7
             HSEP                                                                                 r2
                                                                                           Q             06
                                                                                               rte              7
          Medicine                                                                         Q             06
                                                                                               rte              7
                                                                                           Q             06
        Nephrology                                                                          ua                  7

                                                                                           Q             07
                                                                                               rte              8

                                                specialty group
     Neurosciences                                                                                     20
                                                                                           Q             07
                                                                                               rte              8
         Surgical                                                                                      20
                                                                                           Q             07
        Specialties                                                                         ua
                                                                                               rte              8

                                    MSSA and MRSA bacteraemia RFH 2005 -06 by

                                                                                                                                                                                                                                     Actual Data
                                                                                                                                                                                                                Lower Action Limit
                                                                                                                                                                                           Upper Action Limit
                                                                                                                                                                     Lower Warning Limit
                                                                                                                                               Upper Warning Limit

10.2 Clostridium difficile

There continues to be a comparatively low though not insignificant rate of Clostridium
difficile associated diarrhoea at the RFH. Many areas of the hospital are affected notably
HSEP and Nephrology. Although the presence of additional virulence of the 027 strain
responsible for the reported Stoke Mandeville outbreak is uncertain, it was to some extent
reassuring that it was not found at the RFH during the programme of routine sampling by
the Health Protection Agency. The presence of clear antibiotic guidelines supported by
senior staff is probably important in controlling the infection here.

Figure 4

           Clostridium difficile episodes at RFH from April 2004

        Apr -  Jul -  Oct -  Jan -  Apr -  Jul -  Oct -  Jan -
       Jun 04 Sep 04 Dec 04 Mar 04 Jun 05 Sep 05 Dec 05 Mar 06

Figure 5

           Clostridium difficile episodes by specialty 2005-06




                                                       Haematology &



10.3 Glycopeptide - resistant Enterococcal (GRE) bacteraemia

As a tertiary referral hospital with renal, haematology and hepatology units and with
frequent use of glycopeptides, the RFH might be expected to have significant rates of
GRE bacteraemia. Recent relatively high rates have been mainly associated with stay on
ITU and are usually related to IV lines. While there is evidence of transmission of strains
other episodes appear to be sporadic. The pattern of involvement of different strains is
more complex than that seen with MRSA where the vast majority of infections are caused
by two principal strains and their variants.
Control will it is assumed be associated with similar measures employed for control of
MRSA bacteraemia, attention to insertion and care of IV lines and general measures to
reduce transmission including hand hygiene. Prudent use of glycopeptides is also

Figure 6

                Glycopeptide resistant enterococcal
                    bacteraemia from April 2003

        Apr Jul - Oct Jan Apr Jul - Oct Jan Apr Jul - Oct Jan Apr
       - Jul Sep -     -   - Sep -       -   - Sep -       -   -
        03 03 Dec Mar Jun 04 Dec Mar Jun 05 Dec Mar Jun
                  03 04 04          04 05 05          05 06 06


Figure 7

           Glycopeptide resistant Enterococcal bacteraemia
                 since April 2003 by patient location


10.4 Multi-resistant Acinetobacter

Multi-resistant Acinetobacter baumanii (MRAB) is defined by the HPA guidelines as those
isolates reistant to a third generation cephalosporin such as ceftriaxone and an
aminoglycoside such as gentamicin, Usually Acinetobacter sp. is a relatively avirulent part
of normal skin flora, however the acquisition of antibiotic resistance has led to some
strains becoming significant pathogens in highly dependent patients, usually in relation to
medical devices. The term MRAB-C refers to those strains also resistant to carbapenem
antibiotics such as meropenem, usually leaving colistin as the only licensed antibiotic
available to treat infections.
The RFH continues to experience both sporadic MRAB infections and those related to
transmission. Altough overall numbers of patients affected have declined compared to
previous years, the increasing number of MRAB-C cases causes concern.

Figure 8

        New cases of Multiresistant Acinetobacter at RFH
                          2003 to 2005

  100                                                       MRAB
   80                                                       MRAB-C
             2003-4         2004-5          2005-6


Figure 9

        New cases of Multi-resistant acinetobacter at RFH

   6                                                                         MRAB
       Apr- May- Jun-   Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar-
        05   05   05     05   05   05   05   05   05   06   06   06

Figure 10

             Location of new cases of Multi-resistant
               Acinetobacter at RFH 2003 to 2005

  50                                                                   ITU
  40                                                                   Medical
  30                                                                   Surgical
            2003-4              2004-5             2005-6


10.5 Surveillance of Surgical Site Infection

Orthopaedic surgery

Since April 2004 it has been mandatory for all NHS Trusts to perform one three-month
period of surveillance of one type of procedure. A recent rise in the number of infections
occurring in total hip replacements has been discussed with the orthopaedic department
and monitored.

                   RFH (% infected)       All hospitals (% infected)
                   Mar 05 –   All periods Since Oct 97
                   Mar 06
Total hip          3.6        2.5         1.7
Knee             0.0            0.0          0.9
Hip              3.3            4.2          4.4

Large Bowel Surgery

Surveillance of large bowel surgery will be repeated after audit of the relevant high impact
intervention on surgical site infection.

                 RFH (% infected)       All hospitals (% infected)
                 Jul 05 –   All periods Since Oct 97
                 Dec 05
Total            12.8       7.6         9.2

Appendix 1

                         ROYAL FREE HAMPSTEAD NHS TRUST


Reporting to:
Risk Committee (Clinical Governance structure January 2006)


The infection control committee reports to the risk committee, and in line with controls
assurance standard for infection control, is directly accountable to the chief executive and
trust board.

The infection control committee

   Provides advice and support on the formulation, implementation, review and audit of
    infection control policies, procedures and guidance, and as an expert panel ratifies
    these policies.

   Approves and monitors the formulation and progress of the annual infection control
    programme in consultation with the infection control team.

   Reviews audit and surveillance data relating to infection control in the trust, including
    compulsory surveillance as mandated by the department of health.

   Reviews current legislation and national guidelines relevant to the management of
    infection control within the trust.

   Ensures appropriate investigation and management of any outbreaks of transmissible
    disease or cross infection within the trust.

   Commissions and reviews reports from the relevant managers in the operations,
    works, projects and other trust directorates on infection control related issues.

   Liaises with the occupational health and safety unit on policies relating to infection
    control issues relevant to staff health and the working environment.

   Ensures a timely and effective contribution to the trust’s controls assurance and CNST


Medical director (Chair)
Director of Infection Prevention and Control
Infection control team:               Infection control doctors
                                      Lead nurse infection control
                                      Clinical nurse specialists
                                      Audit and surveillance nurse

Appendix 1

Director of nursing
Consultant in communicable disease control
Occupational health physician
Occupational health nurse/manager
Consultants in medical microbiology and virology
Infectious diseases representatives
Critical care representatives
Divisional representatives
Director of works operations
Domestic services manager
Head of operational facilities
AGM theatre services
Decontamination lead/manager
Community infection control nurses



Appendix 2

Reporting of Incidents related to Infection Control via Risk Management System

               1       2       3       4       5       6       7      8          9   10    Total
SAS            11      1               3                       1      1          1   1     19
Medical        11      1       3               2                                           17
W&C            1       10      4       1                                                   16
Cancer &       5                               1                                           6
Operational    1       1                                                                   2
RNTNE                                                  1                                   1
Total          29      13      7       4       3       1       1      1          1   1     61

1.Non-adherence to infection control policies
2. Other infection control issues
3. Breach of patient confidentiality related to infection control
4. Missed diagnosis of infectious disease ('look back')
5. Clinical waste issues - (e.g. inappropriate handling/storage etc)
6. No side rooms available
7. Cleaning/decontamination - non-adherence to protocols
8. Late recognition /action on infection status
9. Outbreaks - cross infection of 3 or more patients (non MRSA)
10. Transfer/admission to open bay / non-notified transfer of infected patient

Repeated issues arise regarding the recognition of patient’s MRSA status prior to being moved
into an open bay. Currently few incident reports relate to episodes of HCAI.

Appendix 3

                    Saving Lives: Reducing HCAI including MRSA
          Balanced Score Card: Self-assessment summary for infection control

                                    Royal Free Hampstead NHS Trust


         Challenge 1                        Challenge 2                       Challenge 3
Engage senior management            Appoint infection control         Implement          a       local
(clinical and non clinical) in      leaders at each level in the      surveillance programme in
order to secure the                 organisation to ensure the        order to identify in real time
implementation of best practice     promotion of good clinical        the       infection      status
in the prevention and control of    practice and challenge            throughout the Trust by the
infection.                          inappropriate behaviour           provision of reports to each
                                                                      ward/unit at least quarterly.

Score: 71.5%                        Score: 33%                        Score: 54.5%
         Challenge 4                        Challenge 5                       Challenge 6
Adopt national evidence based       Ensure the effective auditing     Ensure      that    all    Trust
guidance in order to ensure         of infection control practices    employees          have        a
that patients are treated           throughout the Trust through      programme of education and
according to best practice.         monitoring and                    training on the prevention and
                                    implementation.                   control of infection in order to
                                                                      understand their responsibility
                                                                      for infection control and the
                                                                      actions they must personally
Score: 69.5%                        Score: 36%                        Score: 71.4%

         Challenge 7                        Challenge 8                       Challenge 9
Review the patient journey for      Review the status of the built    Implement robust Trust-wide
emergency and planned               environment and the               policies for decontamination
patients in order to reduce the     effectiveness of the facilities   in order to ensure that
risk of transmission of infection   management services,              patients will not get infected
by minimising the movement of       including cleaning, in order to   by                inadequately
potentially infected patients.      provide a safe and clean          decontaminated       re-usable
                                    environment for patient care.     instruments,          including
                                                                      surgical   instruments     and
Score: 72%                          Score: 72%                        Score: 50%

                                          Overall Status

                                    100%                              Full compliance
                                    71% - 99%                         Review required
                                    = <70%                            Trust priority

Appendix 4

Decontamination 2005 – 06
James Brown

The focus this year has been on local areas which undertake decontamination. These being
mainly endoscopy units within the Trust and clinics, which use specialized equipment. The main
aim being a reduction of areas undertaking processing and modernisation of the areas remaining.

Process Changes

Replacement of old style decontamination methods within out patient areas has resulted in the
removal of glutaraldhyde based processes being replaced with chlorine dioxide wipes this did have
a cost associated however the replacement of the wipes in areas using single use sheaths for
scope protection made an overall saving. The two remaining areas using still using a glutaraldhyde
based disinfectant (paediatric endoscopy and RNTNE day surgery unit) will be scheduled for a
retro fit chorine dioxide system in 2006.

Day Surgery

The endoscope reprocessing unit (AER) within this area was over 15 years old and non compliant
with HTM or DoH standards was decommissioned and the items processed through this machine
were transferred to clinic 9.

Clinic 9

With the work load transfer from day surgery the existing AER within the area would have been
unable to sustain the throughput, therefore an agreement was made with Sterilox to supply free of
charge two new AER’s in return the trust would lease two super oxidised water generators to
supply the new AER’s with sterilant/disinfectant. This enabled the trust to remove the AER within
that unit, which was operating with a glutaraldhyde based product. This unit will be retro fitted to
enable it to use a chlorine dioxide based product and put into service as a replacement for a
current glutaraldhyde based machine.

Main Endoscopy

The new purpose built endoscopy unit opened with 3 new double safer machines and an
additional super oxidized water generator, enabling the unit to have a back up to the original
generator. Some operational difficulties have been experienced work is continuing to detect and
resolve the causes of these. As a resulted of this unit opening the Trust was able to transfer the
private work which was being carried out on the 12 floor into this unit resulting in the
commissioning of an old AER situated on that floor.


A substantial amount of surgical instrumentation has been purchased over the last year to enable
equipment to undergo reprocessing through the central Theatre Sterile Supply Unit (TSSU). The
podiatry unit now receives a complete service from the TSSU along with the out patient
departments. Theatres have also expanded their stock of equipment reducing pressure on both of
the units and are currently in the process of purchasing additional ophthalmic instrumentation to
centralise this service also.

 Appendix 5

                                                                 2006/7 Action Plan.
     Action plan collated from trust-wide Matron‟s workshop July 2006.

                                Action                                    Review       Responsible
                                                                           date           staff
Ensure that hand gel is always available at the point of care.
-Established ward/department staff to carry clip attached individual     September     Ward
bottle, (nursing, medical, surgical, clerical, domestic and              30th 2006.    Sister/Charge
housekeeping staff).                                                                   Nurse and
- Gel dispensers to be placed at the end of each bed.                                  Specialty group
- Clinics and non-inpatient departments to consider using dispensers                   Matrons
on trolleys.
- All dispensers (wall or bed mounted) to be checked weekly (patient                   Ward
environment checklist:PEC) to ensure they are clean and filled.                        Housekeeper

Lead by example. Photos of key members of the MDT to be placed
on Champion Posters.                                                     October       All members of
-Segregate Champion posters and do not display until they have a         31st 2006     each specialty
photo to display with them                                                             MDT
-Arrange within directorate/specialty group for photographs to be

“Cleanyourhands” campaign lead within each ward/department.
-Provide focal point for ensuring collection of CYH material from          September   Ward
Logistics top-up box each delivery.                                        30th 2006   Sister/Charge
-Ensure posters are displayed in strategic locations, with regard to                   Nurse and
wall decoration and integrity, staff visibility and rotational sequencing.             Specialty group
Ensure patient leaflets are available.                                                 Matrons

All staff to attend annual infection control (IC) up-date,
including hand hygiene training.                                         Annually      All line
- Infection control is a mandatory annual update session. Line                         managers and
managers and team leaders to contact IC team to arrange training                       team leaders.
for staff.
- Until staff are trained, there is inability to challenge appropriate
practice amongst colleagues and promote good practice with staff
and patients/visitors alike.
Engage with patients, service users and visitors.
- All staff have a responsibility to promote good practice with          September     All members of
colleagues, patients and visitors.                                       30th 2006     each specialty
- Ensure door signs are in place advising visitors of hand hygiene                     MDT
and visiting times.
- Discussion of CHY and all IC issues with PPI Forum and Panel of
Users.                                                                                 IC team.


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