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Infection Control Report


									                        TRUST BOARD - SUMMARY REPORT

 Date of Board meeting:             26 June 2007

                                    Infection Control report to the Trust Board
 Name of Report:
                                    Dr Anne Uttley [Infection Control Doctor] and Karen
                                    Taylor [Asst Director of Nursing – Infection Control].

 Approved by (name of               Dr David Roy
 Executive member):
 Presented by:                      Dr Anne Uttley & Karen Taylor

Purpose of the report:
To present the Infection Control programme for 2007 – 2008
To outline activity of the Trust Infection Control service 2006 – 2007

Action required:
The Trust Board to ratify the Infection Control programme for 2007 – 2008

Recommendations to the Board:

Relationship with the Assurance Framework (Risks, Controls, and Assurance):

Summary of Financial and Legal Implications:

Equality & Diversity and Public & Patient Involvement Implications:
The Infection Control programme is developed to positively support diversity issues
                               1 June 2006 to 31 May 2007


The Infection Control Team (ICT) includes: Dr Anne Uttley, Infection Control Doctor and Karen Taylor,
Asst. Director of Nursing. Dr David Roy is the Director of Infection Prevention and Control for the
There is representation from Occupational Health [Kathy Baker], Catering [Paul Winter] and Health &
Safety Risk Management [Ron Moody] at the six weekly ICT operational meetings.
The programme was developed from the Infection Control Strategy [2006 – 2009] that outlines specific
targets. It ensures that that the ICT offers a high quality service to reduce the risk of infection to
patients, staff and visitors.
The programme has also been developed to ensure compliance with: The Health Act 2006
[incorporating: Standards for Better Health; Winning Ways; Saving Lives: A delivery programme to
reduce HAI including MRSA]
The programme will be altered to reflect new Government Statutory Regulations or any other infection
control issue deemed to be a priority by the ICT that may occur within the Trust in 2007/2008.
The ICT aims to embed good infection control prevention throughout the Trust and make Infection
Control Everybody‟s business.


                                                                            PERSONS          TARGET
                                                                           RESPONSIBLE         DATE
2.1 Policies and     Infection Control [IC] policies will be reviewed to        ICT           31/03/08
Procedures           reflect published professional guidance and
                     relevant legislation.
                     The Influenza and C.difficile policies will be             ICT           1/10/07
                     reviewed annually.
                     The IC web site will be updated on a regular               ICT           Ongoing
                     basis to provide: policies, product information,
                     educational material and appropriate links.

2.2 Education and    The IC education programme has been                        ICT           Ongoing
training             developed and will be used in:                          Education &
                          The marketplace induction for new                  Training
                             Nursing, Support and Contract staff             Department
                          Ongoing education for existing staff and
                             development of Knowledge & Skills
                             Framework indicators for IC for all staff
                          The National IC „e‟ learning programme                             Ongoing
                             will continue to be introduced
                             throughout the Trust.

                     The Trust will comply with the National „‟Clean            ICT           Ongoing
                     Your Hands‟‟ campaign to reinforce correct use
                     of alcohol hand gels in all inpatient units.
                     The „‟Squirt and Go‟‟ posters will be circulated.

                     The ICT will support the introduction of the new      ICT and Head of    Ongoing
                     hand wash solutions in all areas.                      Hotel Services

                     Educational leaflets, posters and the quarterly            ICT
                     newsletter will continue to be developed.
                     Circulation of the IC booklet to all Clinical staff        ICT
                     and inclusion in induction packs will continue.
                       Road shows as part of National Infection Control              ICT            10/07
                       week will be held in key areas of the Trust and
                       will include the Health Act.
2.3 Audit              A proposed strategy and programme have been                   ICT           31/03/08
                       developed [Appendix 1]. These will include
                       audits on:
                        Antibiotic prevalence
                        Ward kitchens throughout the Trust, in
                             collaboration with the Catering Manager
                        All inpatient areas with feedback to the Trust
                             Nurse Advisors & Modern Matrons
                        Capital Planning and Estates & Facilities
                        Additional standards when critical issues
                             have been identified

                       All audit tools reviewed and developed for                    ICT           Ongoing
                       specific areas, will link in with existing Trust risk
                       management and assessment tools.

2.4 Surveillance       A targeted surveillance programme of alert                    ICT           Ongoing
                       organisms with a feedback loop to relevant
                       clinicians will be developed with external
                       Pathology Laboratories.
                       Work will continue to ensure that results are
                       received by the ICT in a timely manner, e.g alert
                       organisms: MRSA. C. difficile.
2.5 Capital Planning   Advice from the ICT will be given, as part of the       Capital Planning   Ongoing
& service              Buildings and Engineering Services policy for             Department/
development            Capital Planning and Estates & Facilities [E &F]        E & F Managers
                       with reference to the following:
                        When preparing service specifications for
                            engineering and building services
                        When preparing tender processes for
                            building and commissioning.

                       The ICT will monitor Cleaning programmes and                  ICT          Ongoing
                       protocols in patient care areas to ensure high
                       standards of cleanliness.
                       As part of the Matrons Charter, the ICT will
                       continue to work with the Modern Matrons
                       The ICT will attend the Client Environment
                       Board and Patient Environmental Operational
                       Group meetings and give activity updates.

2.6 Hotel Services     The ICT will continue to be involved in all stages       ICT and Hotel      31/03/08
& Contracting          of the contracting process for hotel services and          Services
processes              other services that have implications for infection        Managers
                         Hotel services
                         Porter services
                         Laundry services
                         Clinical waste disposal.

2.7 Medical            The ICT will continue to attend the Medical                   ICT           Ongoing
Devices and            Devices Group meetings. Advice will be given
Equipment              on infection control risks associated with the
Management             purchase, lease or loan of medical devices and
                       other equipment used within the Trust.

                       The introduction of new safety devices e.g
                       butterflies will be monitored and staff training will         ICT
                       be sought from Product Representatives
Progress so far [programme April 2007 – March 2008]:


1.1   The following policies were developed to comply with the Health Act:
               Aseptic technique
               Clostridium difficile
               Enteral feeding
               Antibiotic prescribing

1.2   The IC web site is updated on a regular basis to provide: policies, product information and
      educational material.

1.3   A new Clostridium difficile leaflet has been developed and circulated to all MHOA wards.


2.1   The ICT continues to attend the Market-place in the more interactive induction for all new staff.

2.2   The ICT has launched the National Infection Control „e‟ learning programme in the MHOA
      wards in the Trust. Funding will be identified to enable the package will be launched to other
      inpatient areas.

2.3   The March edition of the IC newsletter featured information on the new National Patient Safety
      Agency‟s colour coding of hospital cleaning materials and equipment. This is contained on the
      IC website.

2.4   Ad hoc teaching sessions will be carried out throughout the Trust.

3.    AUDIT

3.1   The ICT has commenced the audit strategy for 2007/2008:

               Infection Control environmental audits

                 As part of the „‟Cleaner Hospitals and Lower Infection rates‟‟ document from the
                 Department of Health, the programme of audits on inpatient units continue.

               Ward Kitchen audits, Maudsley

                 A programme of audits will continue, in collaboration with the Trust Catering
                 Manager, on ward kitchens throughout the Trust. OT Kitchens will also be visited.

Progress on programme April 2006 – March 2007


1.1   Infection Control stands featuring the topics of hand hygiene and sharps disposal were set up
      at the Ward Managers & Team Leaders day throughout 2006. They were well attended.

1.2   The ICT attended the market- place on all induction days for new staff (nursing, PAMS and
      ancillary staff).

1.3   Hand wash products from Ecolab were introduced throughout the Trust. Site surveys were
      carried out by the ICT and a representative from Ecolab to review individual areas‟ needs. The
      new back plates housing the soap dispensers contain hand hygiene educational material.
1.4   Members of the Project team, involved with the „‟Clean Your Hands‟‟ campaign [for non acute
      Trusts] at the National Patient Safety Agency, have visited wards at York Clinic.

1.5   As part of the Health Act and the „‟Clean your Hands‟‟ campaign, information on the alcohol
      hand gel “Spirigel” and the importance of hand hygiene to prevent cross-infection was
      circulated to all community staff.

1.6   Road shows were held on the Maudsley and Bethlem sites at the beginning of November as
      part of National Infection Control week. The theme was hand hygiene. They were well

1.7   The infection control newsletter has been distributed quarterly via the Intranet. Topics featured
      include: Keeping the patient environment clean and tidy and National Infection Control week
      theme: „‟It‟s in Your Hands‟‟.

2.    AUDIT

      The ICT audit strategy for 2006/2007 was completed:

               Infection Control environmental audits
                As part of the „‟Cleaner Hospitals and Lower Infection rates‟‟ document from the
                Department of Health, the programme of audits on inpatient units commenced in
                September 2006:
                                 Maudsley – 2 wards
                                 Bethlem Royal Hospital – 7 wards
                                 Guys Hospital – 4 wards
                                 St Thomas Hospital – 1 ward
                                 Ladywell Unit, Lewisham – 6 wards
                                 Lambeth Hospital – 9 wards

                 The tool used includes standards on: waste management, sharps disposal and
                 cleanliness of clinical equipment e.g. catheter stands.
                 A report for each area with recommendations was prepared and forwarded to the
                 relevant Modern Matron and Nurse Advisor. The results indicate poor to good
                 compliance with the set standards. The critical issues identified were: Poor cleaning
                 practices [particularly at high level]; Poor waste management and untidy areas.

               Ward Kitchen audits

                 A number of audits were carried out, in collaboration with the Trust Catering
                 Manager, on ward kitchens throughout the Trust. Issues relating to hand hygiene,
                 temperature documentation & chilled storage were been identified.

               Antibiotic prevalence study

                 This audit was not carried out during 2006/2007 owing to staff shortages within the

      A site survey of all ward kitchens at the Ladywell unit was carried out to check compliance with
      food hygiene requirements for the environment. The findings were fedback prior to the
      programme of refurbishment programme.


      June 2006 – May 2007 [See Appendix 2]

       There have been no identified infections after reported injuries. Members of the ICT were
       involved in advising staff on the use of safety devices e.g. blood lancets and continuing with
       retractable needles.


       An order has been placed for the Influenza vaccine for both staff and patients. The delivery
       date will be in September 2007. Anti viral drugs [Tamiflu] are in stock in the Trust Pharmacy
       Department , to be used in the event of an outbreak of Influenza.


       Members of the ICT meet regularly with a senior Project manager in Capital Planning for an
       exchange of information on building schemes. Mandate forms on all projects have been
       forwarded to the ICT.


       The ICNs have attended the Client Environment Board [and the newly formed monthly sub
       committee: Patient Environment Operational Group] meetings to ensure compliance with Food
       Hygiene legislation and resolve cleanliness issues.
       The ICT meet regularly with the Trust Catering Manager.


       The ICNs continue to carry out testing of the drinking water supply during the commissioning of
       new buildings or in areas where there are concerns.


       The ICT is involved in overseeing the monitoring of the quality and treatment of the swimming
       pool at the Bethlem Hospital. Testing of the pool is carried out on a monthly basis. The team
       carry out inspections in collaboration with the Trust Health & Safety Risk Manager.


       As part of the Health Act, statements regarding adherence to all IC policies and procedures
       and the prevention of infection have been included in all new job descriptions.


       The ICT has attended the annual Infection Control Nurses‟ Association conference in Brighton.
       This included the themes of governance, anti-microbial resistance and innovations.
       The ICNs have attended conferences and study days relating to Infection Control issues

Report prepared by Karen Taylor & Aileen Jack – Infection Control Nurses.
5 June 2007
                                Surveillance - 1 June 2006 to 31 May 2007                                                             Appendix 1

MRSA:                  For the months of June 2006 – May 2007, there have been 21 clients colonised with MRSA (Maudsley Hospital - 5, St Thomas - 2,
                       Ladywell Unit - 3, Guys - 1, Bethlem - 5, and Community units - 4]. No secondary cases.
Hep C:                 For the months of June 2006 – May 2007, 15% [22 out of 150] of those screened at Bethlem & Maudsley for Hepatitis C antibody
                       were positive. The ICT liaised with Clinicians to ensure appropriate follow-up
Hep B:                 For the months of June 2006 – May 2007, 156 patients were tested at Bethlem & Maudsley for HepBsAg. Following further tests,
                       none were found to be HepBeAg positive.
HIV                    For the months of June 2006 – May 2007, 33 patients were tested at Bethlem & Maudsley for HIV, two were found to be positive.
                       No action was required by the ICT.
C. difficile           For the months of June 2006 – May 2007 – Nil cases

Antibiotic resistant   October 2006
infections e.g.        One case of an ESBL in a urine specimen from a patient on an Older Adults ward at Maudsley. The decision was taken not to
*ESBL, VRE, etc        treat as the patient was asymptomatic.

                       December 2006
                       One case of an ESBL in a urine specimen from a patient on a ward at the Lady well Unit. The decision was taken not to treat as
                       the patient was asymptomatic.
Pulmonary              November 2006
tuberculosis           A patient attending a community unit was found to have Pulmonary TB. The ICT liaised with the Consultant in Communicable in
                       Lambeth for the follow-up of staff contacts.

Other infections:
Headlice               August 2006
                       There have been two cases on two different wards on the Bethlem site. Advice was given on appropriate treatment and preventing

Scabies                June 2006
                       There has been one case of scabies at the Bethlem Hospital which was successfully treated.

                       February 2007
                       There has been a case of scabies on a ward at the Ladywell Unit. This was successfully treated.

                       In both cases, advice was given to prevent the spread of infection.
   Chickenpox             December 2006
                          There were seven cases in the Day Nursery on the Maudsley site. They were all excluded and advice was given regarding
   Shingles               June 2006
                          There has been a case in a patient on a ward at St Thomas‟ Hospital. All contacts were identified.

                          March 2007
                          There has been one case of shingles on a ward at the Bethlem Hospital. All staff and patient contacts were
                          In both cases, advice was given to care staff on the likelihood of spread.
   Diarrhoea and          July 2006
   Vomiting               Elderly Care Unit – Maudsley Hospital
                          Affected 4 patients over a 5 day period - commenced 14/7/06

                          October 2006
                          Addictions Detox Unit, BRH
                          Affected 6 patients and 5 staff over a 21 day period - commenced 2/10/06

                          Addictions Detox Unit, BRH
                          Affected 7 patients and 3 staff over a 14 day period - commenced 16/10/06

                          Staff Day Nursery, BRH
                          Affected 4 patients over a 5 day period - commenced 14/7/06
                          Three stool specimens were taken.

                          March 2007
                          Acute Psychiatric ward, Maudsley Hospital
                          Affected 6 patients and 4 staff over a 12 day period – commenced 25 March 2007

                          April 2007
                          Acute Psychiatric ward, Maudsley Hospital
                          Affected 10 patients and 1 member of staff over a 22 day period – commenced 4 April 2007

                          Elderly Care Unit – Guys Hospital
                          Affected 6 patients over a 19 day period – commenced 21 April 2007

                        In all cases, following investigation, food was not implicated.
*Extended spectrum beta-lactamases. Vancomycin resistant enterococcus


                                                                                                     MRSA TOTAL


                           ov 6

                             n- 6
                         O 06

                          Ju 06

                           ar 7
                             p- 6
                          ug 6

                           ay 7
                           ec 6

                           p 7

                         M b- 0
                         N t-0

                         Ja -0
                         Fe 0
                         D -0

                         A -0
                         Se -0
                         A l-0

                         M r-0


NB MRSA was identified in clients, the majority of whom were transferred into the Trust. There were no cases of infection and no
  secondary spread.

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