Infection Prevention & Control Report to the Infection Control Committee Quarter Two: July- September 2009 1.
Introduction This report is to provide NHS Kirklees Infection Control Committee an overview of the activity of the Infection Prevention & Control Team during the period from July 2009 up to and including September 2009.
Team Changes The Infection Prevention and Control Team has recently recruited an additional member of staff â€“ Tracey Singleton (Infection Prevention and Control Nurse) who will work under the direct guidance of Donna Roberts (Senior Infection Prevention and Control Nurse). Tracey has come from the Surgical Unit at Mid Yorkshire Acute Trust, and is keen to develop her skills and knowledge of infection prevention within the community. 3. MRSA Bacteraemia The total MRSA bacteraemia cases to date for Quarter 2 are shown below
MYHT Total CHFT
< 48hr > 48hr
< 48hr > 48hr
Total to date
Status to date
(NHS Kirklees cases in brackets, using the HPA definition of pre 48/post 48 hour cases)
NHS Kirklees RCA Investigation Learning Points Date 19/07/09 (CHFT)
Summary 79 year old male admitted to A&E with sepsis of unknown cause. Had bilateral leg ulcers; CRF and history of cardiac problems since 2001 with cardiac surgery in 2007. No
Key Learning Points â€˘Poor management of leg ulcers; dressings not available for two days post discharge, lack of swabbing when wounds appeared infected; lack of specialist tissue viability input
history of MRSA. Concordance issues Patient died
•Antibiotic prescribing in primary care sub optimal. Specimens and sensitivities rarely undertaken prior to commencing antibiotics. No request for Microbiology advice •Lack of PPE and uniform being worn by podiatrist •Excellent support from GP and substance misuse team • Lack of VIP and FRASE scores documented
39 year old male fell whilst out shopping. History of alcohol misuse and frequent falls. Lack of self care
65 year old female admitted to MAU via GP with sepsis unknown cause. History of CRF, IDDM, Charcot foot, osteoarthritis and chronic pain. Previously an in-patient February 2009in Leeds (LTHT) for management of chronic renal failure. Received care from Community Nurses and Podiatrist for dressings to leg ulcers. Received 9 lots of antibiotics since January 2009
•Review antibiotic prescribing with GP- prescribed without any sensitivities. No request for Microbiology advice •Wound management suspended for 2 weeks due to patient holiday. No alternative arrangements made •Good communication between Community nurses and podiatrist
4. Clostridium Difficile The table below shows c.difficile cases for Quarter 2
NHS Kirklees MYHT CHFT
Total to date
9 14 8
12 8 5
10 9 2
31 31 15
79 73 67
145 120 92
Status to date -65 -47 -25
Cases for NHS Kirklees occurred from both acute care providers, GP’s, HVMH and other Acute Trusts out of area. A root cause analysis investigation into the case at HVMH proved inconclusive. The only risk factor identified was that the patient had taken Proton pump inhibitors for the previous three years. The patient was isolated in a timely manner.
GP Audits 3 audits have been undertaken within GP Practices during quarter two. Main issues identified from these audits included : • • • • • • • • • •
Standards of cleaning and poor cleaning of equipment Cluttered clinical areas Presence of food and drink in clinical areas Presence of linen hand towels for drying Reusable instruments being available, although no longer in use Out of date policies Incorrect segregation of waste Equipment storage Management of the vaccines Compliance with COSHH regulations
Work is underway with the Governance Team to support the development of the Quality Matrix within General Practice. The audit is currently being reviewed by Sheena Kelly to provide a scoring system, as well as a self assessment tool for those practices that continue to make good progress with their infection prevention agenda. Four standards are to be included within the Quality Matrix which must achieve a RAG score of green to achieve compliance. These criteria relate to the Hygiene Code, and include; a clean environment; achievement of standards for minor surgery; management of the cold chain/ vaccine safety, and decontamination of equipment.
Work Within General Dental Practices (GDPs) Advice has been given to the contracting team to support Dentists with their 5 year plans to become compliant against the standards within the Department of Health document HTM 01-05, ‘Decontamination in primary care dental practices.’ Other advisory work within quarter 2 consisted of: • •
Visit to one practice to assesses the current decontamination standards and provide advice to promote compliance Reactive visit to a dentist following an informal complaint regarding the lack of use of face masks during practice
The Infection and Prevention Team have also sought to enhance their knowledge within dentistry to confidently undertake audits in the future. Linda Bussey (Infection Control Dental Nurse at Bradford PCT) has delivered a training session to the Team followed by a discussion session. Future training has been arranged to shadow the Dental Advisor in his Practice.
Essential Steps to Safe, Clean Care The database continues to be developed to record Essential Steps assessments. The tools have been reviewed and revised. Further information sessions have been delivered to improve awareness and hopefully completion of the forms. Assessments that have been returned from a total of 35 staff from HVMH; Fartown; Eddercliffe; Speech and Language Services; Dewsbury Health Centre; Contraceptive and Sexual Health; 61 responses were in respect of â€˜preventing infection/ application of standard precautionsâ€™; all 19 respondents identified compliance when inserting urinary catheters, and all 17 staff providing on-going catheter care responded positively to the assessment. The area failing to achieve 100% compliance was in respect of staff wearing jewellery during clinical sessions (one member of staff). A planned programme for additional Training sessions on Essential Steps to Safe, Clean Care are planned to deliver to all localities before the end of the financial year.
Hand Hygiene Audits Hand hygiene audits have been undertaken with staff from the District Nurse team based at Dewsbury HC both teams working within the East and West of the patch. 12/18 staff audited scored 100% compliance. The CYH champion is continuing to audit the 6 remaining staff.
Mandatory Training for Clinical Staff Mandatory Training for non-clinical staff Corporate Induction Training
Number of Sessions
Number of Participants
Other training undertaken includes an awareness session at Dewsbury College to students undertaking a course in Health and Social Care; and GP training at Albion Mount Practice. 7
Outbreaks During quarter 2 there has been one outbreak on Maple Ward at Holme Valley Memorial Hospital. 15/09/09 Five patients had symptoms of VGE lasting for a 24hour period for each patient. The duration of the outbreak in total was two days. No causative organism was confirmed from the one specimen taken. There was a strong suspicion that the symptoms were due to other medications, for example aperients and antibiotics. Lessons to learn from this outbreak is the prompt reporting of symptomatic patients to the Infection Prevention and
Control Team, and to obtain specimens from symptomatic patients. In future, any outbreaks should be reported as an incident on KCHS system to ensure accurate follow up. 8
Management of sharps injuries A total of ten sharps injuries to KCHS staff have been reported to the Infection Prevention Team by the Risk Management Team since April this year. Analysis of the reports identified that 4 occurred as the sharps were being disposed of; 3 occurred when the patient moved unexpectedly; one occurred when a needle was being resheathed (not recommended); one occurred when the Podiatrist was removing the blade from a scalpel and no information was provided for the other injury. In all cases the injuries were recorded as being appropriately managed by the individual and their manager. Actions from the injuries include; • Ensuring sharps boxes are close to hand for immediate disposal • Not to re-sheath needles • Request help with unsteady or unpredictable patients • Provide heavy duty gloves for staff if they need to clean instruments • Ensure staff receive appropriate training • Ensure staff team receive communication regarding safe management of sharps
Policy Development / Review The following policies are currently in the review stages: • CJD • Sharps management • Hand decontamination Policies approved by the Infection Control Committee following the last meeting include • Disinfectant and antiseptic policy • Clostridium difficile policy • Aseptic technique policy
Advice on new developments / refurbishments The Infection Prevention and Control Team have provided advice regarding building works to: • Dental Practices (Fartown and Birstall) • KCHS Dental and Podiatry Services in preparation for the new CSSD service • Air sampling at Maple Ward, HVMH prior to opening • The Chestnut Centre is a LA building that is divided and managed by both Sure Start and Fresh Horizons. Both have rooms that are currently used by PCT staff- CaSH, HV’s and midwives. It is the intention of these groups of staff to convert 2 rooms to be used for clinical procedures. As such both rooms where assessed for suitability and deemed not fit for purpose. Both
rooms required waste bins, carpets removed, hand washing sinks and other minor work to be carried out. Consequently one room used by the Cash service has had the relevant alterations and followed infection control recommendations. • Thornton Lodge – Is used by the CaSH team. Following Infection Control assessment alterations and refurbishment has taken place to ensure that the clinic room meets minimum infection control standards. • Brian Jackson Centre - The CHLASP team moved from Princess Royal Community HC to basement rooms at The Brian Jackson Centre last year. The Centre is funded by a charity and Local Authority. As the Chlamydia screening Programme went under way, the team dealt with thousands of urine sample returns from the public. On arrival the sample labels are checked and sent to HRI. However there had been a number of specimens that had leaked during transportation. A further 3000 specimens would be returned over a period of 4 weeks, with a 10% positivity rate. The CHLASP team also consulted patients in a small carpeted room. The Infection Control team assessed the rooms and identified potential risks. The relevant alterations where made and infection control recommendations where implemented.
A number of new products have also been trialled to improve safe practice within the clinical field, these include – • Commode tape highlighting decontamination has occurred • Pulp disposable wash bowls
Activity for Swine Flu Demands to support activity around the swine flu agenda continues, but has reduced since the Quarter One report. Activity now includes responding to clinical enquiries from professionals through the swine flu clinical enquiry line; attending a number of meetings; maintaining information sources regarding stocks of personal protective equipment and cases of swine flu, as well as continuing to deliver training sessions, and prepare for the vaccination programme. Additional fit checking for masks training has been delivered to Independent Contractors. Only two dental practices have failed to collect their FFP3 masks. An additional 11 training sessions have been held for PCT staff (non-clinical), with 667 staff attending in this quarter. Training to 256 local authority staff included staff working in cleaning and catering; community rangers and staff working in childrens residential services. Overall this year 2019 staff have received flu training (PCT - 1348; Local Authority – 360, and Independent Contractors – 311) 12 Norovirus Workstream
The health economy HCAI meeting within Calderdale and Huddersfield have requested a workstream to review ways to improve the management of patients with viral gastroenteritis with the aim of reducing hospital admissions. A factsheet with key messages for patients, visitors/carers and professionals has been developed, as well as a risk assessment flowchart; posters; and guidance for care homes. A clinical management pathway is under development to assist staff to explore alternatives to admission to hospital. 13
Meetings Attended Team Members have attended and provided the following meetings: • Decontamination Implementation Group for KCHS Services • KCHS Operational Risk Group • Harm Reduction • Policy Development • Communicable Disease Control • Norovirus workstream and strategic meetings • HCAI Health Economy Meetings – operational and strategic (CHFT and MYHT) • Governance Committee • Pandemic Flu Committee; Command and Control; Workstream meetings for infection prevention, mass vaccination and Antiviral management • Emergency Planning Operational Group • NHS Kirklees Medicines Management Committee • Vaccination and Immunisation Group • NHS Kirklees Risk Management Overview Group • PGD Review Group • PCT / Local Medical Committee • Training and Education Group • NKFL Monitoring Meeting • E-learning training
Work with the Local Authority A self assessment audit has been facilitated within those care homes with beds commissioned by the PCT and those with which the HPA has had involvement with. The full report of the findings and actions are included on the agenda for this Infection Control Committee meeting. The three homes that failed to achieve an overall score of above 75% have been visited by the Infection Prevention and Control Nurse for that locality to understand the issues within the home, and to develop an action plan with the manager. Information from the audit has been shared with the local authority inspecting team. A further training event is planned in October to pilot a “train the trainers” session for local authority care home managers and an invitation to private care homes. It is hoped that following evaluation, this will be delivered later in the year to other care homes and home care staff.
15 Development of the Infection Prevention and Control Nurses The Team have been fortunate to attend study days/ events to ensure their knowledge remains current as expert advisers. This has included attendance at Infection Prevention Society (IPS) regional meetings, and the Conference at Harrogate. One team member has commenced the Certificate in Education course to enhance their teaching role. The Health Protection Nurse and a newly qualified Staff Nurse has also taken the opportunity to shadow the Infection Prevention Team during their working day. 16 Surveillance Activity The Team undertake enhanced surveillance of all positive isolates identified by the Acute Trusts for patients in the community with clostridium difficile and/or MRSA. This means contacting Practices and Care Homes to ascertain additional patient information, assessing appropriateness of treatments and recommending further interventions where necessary. Since April 2009, a total of 300 isolates positive for MRSA have been followed up by the Infection Prevention and Control Team. The table below provides additional information
In care homes at the time of swabbing Previous history of MRSA positive swab Had been an in-patient within previous 2 months Had been prescribed antibiotics prior to swab Number of patients screened due to attendance at hospital
Number of patients 34 55 106 17 70
26 patients in the community with c.diff toxin positive have been followed up by the Team. The table below provides additional information. Number of patients In care homes 2 Previous history of c.diff 8 Antibiotics prescribed prior to isolation of c.diff 10 Patient taking gastric suppressive agents 4 Had been in patient within previous 2 months 10 Received appropriate antibiotics when diagnosed 12 Surveillance of these isolates has identified some key learning • Repeat swabs/ specimens are often taken in Primary Care with no clinical indication • Lack of understanding of the management of patients with MRSA colonisation within Care Homes • Lack of understanding about the current MRSA screening programme within hospitals
17 Kirkwood Hospice Audit Following the Infection Control audit on Tuesday 29th September 2009 several areas of improvement had been identified.
• • • • • • • •
The Hospice has areas that are generally dirty or dusty; it is evident by the amount of dirt present on the curtain rails, patient beds, and window sills that regular effective cleaning has not been undertaken at these areas for some time. The floor in clinical areas must be impervious and not carpeted to allow cleaning. Bodily fluids are disposed of into a sluice toilet and aerosolizes. All furniture should be made of a cleanable/wipeable material. Fans are used in clinical areas. Desks and surfaces are cluttered A foot operated pedal bin is required for domestic waste ( All waste must be segregated) The upholstery requires cleaning and walls which are painted require cleaning and/ or repainting in areas where the paint is peeling. Fixed alcohol gel dispensers should be present in the clinic rooms.
18 Recommendation The Infection Control Committee is asked to read and note the contents of this report.
Sue Ross Lead Infection Prevention and Control Nurse