The Health and Social Care Act infection

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					Attachment Y

                                  Trust Board Meeting
                                   27th January 2010

Title of document                               Paper No: Attachment Y
DIPC Update on Infection Prevention and

Submitted on behalf of
Mr Rob Evans

Aims / summary
Present compliance with Code of Practice, Health and Social Care Act, for prevention
and control of infection.
Update progress against IP&C projects

Action required from the meeting
Document owners to ensure updated.
Clinical Units to prioritise activity for IP&C, especially audit

Contribution to the delivery of NHS / Trust strategies and plans
Contribution towards zero harm

Financial implications

Legal issues
Legal requirement to be registered with CQC and comply with Code.

Who needs to be / has been consulted about the proposals in the paper (staff,
commissioners, children and families) and what consultation is planned/has
taken place?

Who needs to be told about any decision

Who is responsible for implementing the proposals / project and anticipated
All staff, especially CUs

Who is accountable for the implementation of the proposal / project
DIPC, CUs, Medical Director, Other units
Author and date
J C Hartley 20/1/2010
Attachment Y

Update Report on Infection Prevention and Control at GOSH
Jan 2009
Author: Dr John Hartley, Director of Infection Prevention and Control

Thank you for the opportunity to give this regular update, my first since taking up the
role of DIPC from Ms Susan Macqueen, Lead CNS Infection Prevention and Control,
following her official retirement at the end of July 2009. Susan is currently working 3
days a week with us as the Lead CNS, pending the commencement of her
replacement, Ms Enfys Mercieca, in March

In this report I will focus on the three areas, compliance with the Code of Practice
and some areas of process and outcome audit.

1. Health and Social Care Act 2008 Code of Practice for health and adult social
care on the prevention and control of infections and related guidelines
Update version published 16 Dec 2009

Registration with the Care Quality Commission is a legal requirement. Compliance
with the Code of Practice is a necessary requirement to maintain registration. There
are 10 Compliance Criteria

Compliance What a service provider will need to demonstrate
1          Systems to manage and monitor the prevention and control of
           infection. These systems use risk assessments and consider how
           susceptible service users are and any risks that their environment and
           other users may pose to them.
2          Provide and maintain a clean and appropriate environment in managed
           premises that facilitates the prevention and control of infections.
3          Provide suitable accurate information on infections to service users
           and their visitors.
4          Provide suitable accurate information on infections to any person
           concerned with providing further support or nursing/medical care in a
           timely fashion.
5          Ensure that people who have or develop an infection are identified
           promptly and receive the appropriate treatment and care to reduce the
           risk of passing on the infection to other people.
6          Ensure that all staff and those employed to provide care in all settings
           are fully involved in the process of preventing and controlling infection.
7          Provide or secure adequate isolation facilities.
8          Secure adequate access to laboratory support as appropriate.
9          Have and adhere to policies, designed for the individual’s care and
           provider organisations, that will help to prevent and control infections.
10         Ensure, so far as is reasonably practicable, that care workers are free
           of and are protected from exposure to infections that can be caught at
           work and that all staff are suitably educated in the prevention and
           control of infection associated with the provision of health and social

Detailed analysis of the compliance guidance has been performed and
documentation is available, or in preparation, to demonstrate compliance. A huge
amount, of often unseen, activity underpins this. However, some policies have not
been completed or updated at expected time and this is a priority. Not all required
reporting to Board occurs.
Attachment Y

a.All document owners to ensure regular review and update of policies.
b. Need to address compliance point 1.5 on IP&C activity, requiring quarterly
reporting to Board by clinical directors and modern matrons.

Endoscope decontamination was an area of focus at the previous Health Care
Commission visit. This has been addressed. Investment of space and money is likely
to be necessary to maintain Decontamination Services en site and respond to the
concerns regarding vCJD control.

Action: Decontamination Strategy options, being developed, will need to consider

2. Infection Prevention and Control Process Audit – Link Practioners

A large range of audit is performed in relation to the policies and procedures
highlighted through compliance with the Code of Practice. In this report I would like to
comment on the schedule of Infection Prevention and Control process audits that are
required (these include areas such as hand hygiene and central venous line care
bundle compliance).

Feed back of data has been facilitated by development of Dashboards, through the
work of the Transformation team. As demonstrated previously in November Zero
Harm Report.

Completion of audit cycles: The audits are performed by the team of Link
Practioners. Completion of audits is not 100% and this must be addressed.
Discussion with staff suggest that performance of routine clinical care does not leave
adequate time to complete the audits.

Action: All clinical units need to ensure adequate time and staff are available to
ensure timely performance of Infection Prevention and Control Audit.

3. Infection Prevention and Control Outcome Data

A. KPI mandatory data

i. MRSA Bacteraemia Data
Financial year  06/07                 07/08           08/09             09/10 to Jan
Episodes        5                     2               8                 1

New ‘MRSA Objective’ for 10/11 is 2 or less (previously 4 or less). See ‘Risk’ below.

ii. Trust assigned C. difficile infection
Financial year     06/07                07/08         08/09             09/10 to Jan
Episodes                                11            10                8

Risk of non-compliance: Small numbers of cases and new criteria raise risk GOSH
will not meet MRSA and C. difficile targets simply through ‘statistical’ variation.
Action: Meeting with Lead Commissioning PCT arranged.
Attachment Y

B. Transformation supported Infection Projects

                The Transformation Infection
     Elimination of avoidable
     • Central venous line associated infection
     • Ventilator associated pneumonia
     • Surgical site infection

     Combination of
     - implementation of best practice through care bundles
     - with surveillance to detect a problem and demonstrate

                                  CVL infections
 CVL infections – unavoidable base line or stuck?
                                                                                                    - Modify hand
 2% Chlorhexidine/70% Alcohol                                                  Practical Annual
       Hub Disinfection                                                     IV competency Update    hygiene and
                                      Introduction of annual                                        line care
                                       IC audit programme                                           bundle audit
                                                                       CVL Care Bundle

                                                                                                    -Target areas

                                                                                                70% Alcohol
                                                                                              Skin Disinfection

   Ventilator associated pneumonia
 Pilot surveillance
 (accepted for publication JHI)                                PICU   One year surveillance shows
 Establishing Nurse-Led                                               1. VAP is rare – one case in
 Ventilator-Associated                                                Sept 2009. To change to
 Pneumonia Surveillance                                               - ‘Days since last case’
 In Paediatric Intensive Care
 M Richardson (1), S Hines (1), G Dixon (2),                          2. Care bundle compliance
 L Highe (1), J Brierley (1)
 (1) Paediatric and Neonatal Intensive Care Unit
                                                                      rose from 6.5% to 91%.
 (2) Microbiology Department                                          Routine care.
                                                                      Reduce frequency necessary.
 3 cases over 4 months
                                Introduction of Care Bundle and surveillance
                                - Modified over coming year

 July 2007                                  Oct 2008                            Dec 2009               Jan 2010

                                                                        NICU – pilot underway
Attachment Y

                   Surgical site infections
                                  GOSH Surgical site infection
     Clinical speciality surveillance:             surveillance team (Special Trustee
     Spinal – Oct 08 – Jun 09.                     funded)
     Local team, with support and                  Mr Garner (tissue viability CNS)
     encouragement, working to HPA                 would lead the group, based
     standard with post discharge                  within IP&C
     component (but not sustained).                4 new staff for 3 years:
                                                   - Data manager (Started Nov 09)
     Urology – May 08 - integrated a               - 2 clinical support workers (first
     system within newly developed local           started Nov 09)
     audit data base.
                                                          Working in parallel with
     Neurosurgery – continuous audit data                 A new practice educator
     base (but not continuous output)                     to work on care bundle
                                                          side (Starting today)

                                                   Nov 09   Jan 10

Action: Reinforce audit and compliance with care bundles and root cause analysis.
Look forward to working with surgical specialities on overall IP&C action plans, with
assistance on surveillance and implementation of care bundles.

Additional data -

C.        MRSA acquisition in GOSH

               Year - 06             07            08                09
First detection       127            128           158               162
Possible acquisition  19             5             11                11
Action: Continue extensive screening (remaining compliant with national screening
requirement) and implement isolation policy.

D.       All S. aureus bacteraemia

              GOSH S.aureus bacteraemia –
                   patient episodes
                                                             S. aureus




                 Q2       Q3       Q4        Q1     Q2       Q3       Q4
                2001     2002     2003      2005   2006     2007     2008

Action: Achieving steady decline but not eliminated avoidable. All CUs asked to
support staff in RCA process. Consider decolonisation for MRSA or sensitive strains.

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