Infection Prevention & Control (IPC)Strategy2019-2022

!

People

Performance

Partners

Prevention

Patients

Doncaster and Bassetlaw Teaching Hospitals

NHS Foundation Trust Are your hands

CLEAN?We all have a part in protecting patients, our family and ourselves from the dangers of infection.

As a visitor, you can help in preventing infection by:

Cleaning your hands with soap and water or hand gel before and after a ward visit.Cleaning your hands with soap and water after using the toilet facilities.Please use chairs when visiting the wards to sit down, rather than on patient’s beds.Not visiting our hospital if you have an infection, for example flu. If you have had diarrhoea and vomiting, please do not visit until you have been clear of symptoms for 48 hours.

You can expect:Staff in a clinical area to be bare below the elbow.Staff to clean their hands before and after patient contact.Hand gel to be available at the patient’s bedside and at the entrance to the wards.A clean hospital.

Follow us @DBH_NHSFTVisit us at www.dbth.nhs.uk

Contents

IntroductionZero tolerance of avoidable infectionRoles & ResponsibilitiesStrategy deliveryStrategy objectivesImplementationAssurance frameworkIPC work planReferences

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3

Introduction

Organisational factors such as staff to patientratiosandtheincreaseinbedoccupancylevels.

Physical infrastructure e.g. lack of isolationfacilities.

Poorcompliancewithbestpracticee.g.failuretodecontaminatehandsbeforekeyactivities.

Thecleanlinessoftheclinicalenvironmentisvitalwhen dealingwith certainmicro-organisms suchasClostridiumDifficile.

The demographics of patient population suggestpatientsare increasinglyolderandsickertherebyincreasingtheirsusceptibility.

Global factors and travel contribute to the rapidnature of spread of infectious agents as seen innovelinfluenzastrains.

patients will experienc.

The aim of this strategy is to support the trust’s philosophy to provide the safest, most effective care possible and at the same time meet the national agenda. The strategy seeks to provide the Board of Directors with sufficient assurance that appropriate structures and processes are in place to minimise the risks of HCAI to patients, staff and visitors.

Health Care Acquired Infections (HCAIs) remainshigh on the government’s agenda and the increasein antimicrobial resistance poses dangers on thesame scale as bioterrorism (DH, 2013). Maintaininga safe care environment is reinforced by the CareQualityCommission(CQC)Outcome8CleanlinessandInfectionControlwhichrequiresallproviderstocomplywiththeHealthandSocialAct2008,CodeofPracticeforhealthandadultsocialcareonthePreventionandControlofInfectionsandrelatedguidance.

Patient safety is high on the Trust’s agenda andaspirestobeinthetop10%ofbestperformingNHSorganisations. The provision of a robust InfectionPreventionStrategyisanessentialelementinachievingthesesafetyobjectivesandinensuringcompliancetotheCodeofPracticeandtonationalandlocaltargetssuch as Meticillin Resistant Staphylococcus Aureus(MRSA) bacteraemia, surgical site infections andC.difficile infection. As the Infection Prevention andControlteamwewillbuildontheworkunderpinnedby the previous strategy and continue to activelypromote a culture of zero tolerance to avoidableHCAIs.

ThedevelopmentofHCAIscannotbeputdowntoasingle factor but several well-known factors whichinclude:

The use of invasive devices such as urinary,peripheralandcentraldeviceswhichcompromisethebody’snaturaldefencemechanisms.

Therelianceonantibioticsandtheirmisusewhichincreasestheresistancetoinfectionsovertime.

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Zero tolerance of avoidable infection

Roles and responsibilities

Patients do not expect to acquire a HCAI to beaddedtotheirexistinghealthconcerns. Inordertoaspiretoazerotoleranceofpreventable infectionsa health economy approach will be adopted, toenable lessons to be quickly learnt from infectionrelated incidents. Our aspiration to zero avoidableinfections will be underpinned by the eliminationof poor infection prevention and control practicesthroughthesystematicadoptionofevidencebasedstrategies, robust audit programme, performancemanagement, strong leadership with high profilecampaignsandprogrammes.

This infection control strategyhasbeendevelopedfor the period 2019-22. This strategy will beimplemented using an annual infection prevention& control programme to ensure compliance withTheHealthAct (2008),CQCandMonitorstandardsaswellasmeetingMRSAbacteraemiaandC.difficileinfectiontrajectories

Staff All staff are responsible to ensure they maintainand support a coordinated approach to infectionpreventionwithintheirareasofresponsibility.Allstaffhavearesponsibilityforcomplyingwithtrustpoliciesandattendmandatoryeducationrequirements.

Clinical care groupsHave a responsibility to ensure staff have the toolsandresourcestoimplementbestpracticetofacilitatea safe working environment and formulate actionplansand take remedialactionwheredeficitsexist.Any remedialactionswillbemonitoredat InfectionPrevention and Control Committee and localgovernanceforums.

IPC TeamHelptodeliverthestrategyusingexpertknowledgeandfacilitatetheOperationalGroupLeadstoembedthisintotheirdaytodaybusiness.

Doncaster and Bassetlaw Teaching Hospitals

NHS Foundation Trust

ZERO tolerance to

• All patients with a positive MRSA screen to be promptly isolated and started on decolonisation as per Trust policy.

• Any History of MRSA, consult relevant policy or consider discussion with Microbiologist for treatment of infections so antibiotics will cover MRSA.

• Poor compliance with decolonisation and the presence of devices increases the risks of BACTERAEMIA. All devices should be managed in line with Policy.

• VIP scores: Documentation for peripheral venous cannula (PVC) as well as other tunnelled lines (e.g. PICC/CVC) is vital to monitor any signs of infection.

• Daily review any invasive device to consider removal.

• It is the responsibility of all staff to check MRSA status of patients (previous admissions and present).

All wards to target 97% hand hygiene compliance

Related Trust Strategies and National Documents

•UKAntimicrobialResistanceStrategy•TrustPatientSafetyStrategy•Patientengagementandexperiencestrategy

•ClinicalGovernanceStrategy•HealthandSocialAct2008–Code ofPracticeforthePreventionandControlofHCAI–updates2015

•Strategicdirectionstrategy

5

Strategy delivery

Strategic objectives

Thestrategywillbedeliveredthrough:

Infectionpreventionandcontrolpolicies;thesearebasedonnationalbestpracticeguidanceandperformance against thepolicies ismonitoredthroughanextensiveclinicalauditprogramme.

Trust business planning processes; infectionprevention and control issues must beconsideredinbusinessplansandadvicesoughtfromtheInfectionPreventionandControlTeamifrequired.

Trainingandeducation;theInfectionPreventionandControl Teamprovide training for all newandexistingstaffviaSET&eLearning.

TrustBoardleadership;theStrategyisapprovedby the Board and the delivery is supportedand overseen by members of the InfectionPreventionandControlCommittee.

The Infection Prevention and Control Team;deliveringtheInfectionPreventionandControlAnnualProgramme.

The Trust’s care groups divisional heads ofnursing and generalmanagers are responsiblefor local performance against the preventionandcontrolofHCAI.

Local and Trust performance management;performanceagainstHCAItrajectoriesandwardaccreditation are reported through the Trustkeyperformanceindicators,clinicalgovernanceandtheIPCC.

All Trust staff have a responsibility to adhereto infection prevention and control policies inordertoreducetheoccurrenceofHCAI.

1 Minimise the risk of HCAIs to patients and aspire to prevent all avoidable infections

2 Continue to comply with statutory requirements related to the Code of Practice, Monitor, Department of Health and related bodies to maintain a safe environment.

3 Review antimicrobial stewardship arrangements within the trust and formulate or adopt national tools to enhance.

4 Explore opportunities to participate in research and quality improvement to underpin practice and improve patient experience.

5 Explore and update surveillance mechanisms and reporting to facilitate embedding of best practice.

6 Enhance patient and public involvement in infection prevention in order to improve patient experience.

7 Continue to work in a health economy approach with local providers.

8 Develop innovative methods of educating staff in the delivery of high quality infection prevention and control

9 Review the Infection Prevention and Control delivery of service to meet needs of service.

Overthenextthreeyears,actionswillfocusonthefollowingobjectives:

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Inordertodeliverourvisionandpreventavoidableinfectionswewilldothefollowing:

1 Minimise the risk of HCAIs to patients and aspire to prevent all avoidable infections

The Trust is committed to the implementationof a zero avoidable infection culture. In order toembed this approach standards of practicewill bemonitoredandwherepracticefallsbelowexpectedlevels interventionmeasures will be instigated. Allwards and large departments will be expected toparticipate in the ward accreditation programmewhich aims to embed and sustain safe levels ofpractice.

Over the next three years, we will:

Implementwhererelevantimprovementscienceand human dimensions of care to reduce poorpractice.

Continue to enhance the IPC monitoringprogramme and identify and support failingareas.

Build on existing systems to provide data in atimelymannertosatisfycareunits,Performance,Board,CCGsandIPCC.

Undertake Post Infection Review to investigateany ‘lapse in care’ associated with certainorganisms/conditionse.g.MRSA,CDI,SSI.

Exploreenhancedcleaningoptionse.g.UVC.

2 Continue to comply with statutory requirements related to the Code of Practice, Monitor, Department of Health and related bodies to maintain a safe environment.

The Trust is committed to ensuring it retains fullcompliancewithCQCOutcome8.TheTrustmonitorsgaps in compliance through the CQC assuranceframework and forum, reporting on exceptions totheIPCC,ClinicalGovernancegroupsandBoard.

Over the next three years, we will:

Wewill continue tomonitor gaps in assurancethrough exception reporting, striving toconsistentlyachievefullcompliance.

Continuetoprovideward/divisionalleveldata,identifyinganygapsincompliance.

Divisions will continue to monitor complianceand address non-compliance through theirgovernanceprocesses.

Improve cohort / ensuite / isolation facilitiesacross the trust with an aspiration of 30%isolation availability capacity within high riskunits.

WorkcloselywithEstatesandFacilitiestoensurethedeepcleanrollingprogrammecontinueswithaddedlevelsofassurance.

3 Review antimicrobial stewardship arrangements within the trust and formulate or adopt national tools to enhance.

The Trust is committed to ensure the appropriateuseofantimicrobialagents is in linewith localandnational standards. The IPC team, antimicrobialpharmacistandwardbasedpharmacistswillensuretherearesystemsinplacetomonitorprescribingisinaccordancewithpolicyandimplementmeasurestoaddressanydeviation.

Over the next three years, we will:

Buildontheantibioticpointprevalencetomakethismorefrequentandprovidetimelyfeedbacktoclinicians/prescribers.

Reviewandupdatetheantimicrobialwebsite.

Buildonthecurrentantibioticpoliciestomaintainrelevance.

Develop and provide innovative resources andeducationmaterialstostaffgroups.

4 Explore opportunities to participate in research and quality improvement to underpin practice and improve patient experience.

The IPC team are committed to leading theimplementationofresearchandqualityimprovementtofacilitateimplementationofhighqualitycareandenhancethepatientexperience.

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Over the next three years, we will:

Explore opportunities toworkwith commercialpartnerstoevaluatenewproductlines.

Build on research portfolio and promote thetrust as a leader using publication outputs andconferenceopportunities.

Maintain and improve communicationmechanisms e.g. leaflets, website, social mediae.g.twitterfeeds.

Identify,reviewandpromotequalityimprovementprogrammesthatminimiseharmfrominfection.

5 Explore and update surveillance mechanisms and reporting to facilitate embedding of best practice.

TheIPCteamandtrusthasaprocessforreviewinglearning from infection events using nationaland local tools. The surveillance of ‘alert micro-organisms’ such as mandatory reporting e.g.C.difficile, MRSA, E.Coli coli and MSSA is alreadywellestablishedusingaPIRprocess. It isenvisagedthrough multidisciplinary collaboration surveillanceofsurgicalsiteinfectionwillbefurtherexpandedtoincorporate hip and knee replacements and othercommonsourcesof infectione.g.urinarycathetersandintravasculardevices.

Over the next three years, we will:

Examine current surveillance approaches andrefinetobestmeettheneedsoftheserviceandtakeintoaccountnationalpriorities

Focus on embedding a robust surgical sitemonitoring scheme focusing on elective jointreplacementswith timely feedback to cliniciansonakeyperformanceindicators

Develop surveillance schemes to minimiseinfections from invasive devices and feedbackmechanisms to maintain practice within bestpublishedresults.

CarryoutPostInfectionReviewprocessestohelprefinecurrentapproach.

6 Enhance patient and public involvement in infection prevention in order to improve patient experience.

TheIPCteamandtrustarecommittedtoimprovinginvolvementofthepublicandpatienttobestprovideaservicethatmeetstheneedsofserviceusers.

Over the next three years, we will:

Update communicationmedia andexplorenewwaysofdisseminatinginformation

Review signage / posters with public / patientinvolvement.

7 Continue to work in a health economy approach with local providers.

The Trust is committed to working with our localhealthcareproviderstoimprovethepatientpathwayandreduceriskofsuboptimalcare.

Key partners include:PublicHealthEngland

RotherhamandDoncasterHealthServices

SheffieldTeachingHospital

SheffieldUniversity

Clinical Commissioning Groups Doncaster &Bassetlaw

Over the next three years, we will:

Maintainparticipationinmandatoryandnationalsurveillanceschemes

CollaborativeworkingwithCCGstosharelessonsandimprovepatientpathways.

Collaborateandjoinsuitablebodiestolearnfrompeersandsharebestpractice.

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8 Develop innovative methods of educating staff in the delivery of high quality infection prevention and control

The Trust is committed to ensure the workforcehave the appropriate skill sets to enable them toprovidehighqualitycare.TheIPCteamhaveasuiteofeducationalactivitiessuchashandhygiene,highimpactinterventions(AsepticNonTouchTechnique)which are monitored via the IPC accreditationprogramme.

Monitoring of training is facilitated by the trainingdepartmentandIPCgeneratedcourses.StafftrainingfigureswillbemonitoredbytheInfectionPreventionandControlCommittee.Wardpracticeismonitoredby unannounced visits from the IPC team, and IPCaccreditation.

Over the next three years, we will:

Review and update the available learningresourcesforstafftoensuremeetsneedsofstaff.

Inform CCGs of staff training compliance withregardstoIPCviatheeducationdepartment.

9 Review the Infection Prevention and Control delivery of service to meet needs of service.

The Infection Prevention and Control service isconstantlystrivingtomeettheneedsoftheserviceby adjusting its ways of delivering the service toensureitsproductiveandefficient.

Over the next three years, we will:

ContinuetoreviewthewaytheteamdeliversitsservicetomeetneedsoftheTrust.

Reviewopportunitieswhere theyarise tomakethe service even more cost effective withoutcompromisingthequalityoftheservice.

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The strategywill be implemented by the InfectionPrevention Committee, led by the Director ofInfection Prevention and Control. The InfectionPreventionCommitteewillco-ordinatedeliveryplansinordertoimplementthestrategy.MembersoftheInfectionPreventionCommitteelinktoothergroupsand committees (Clinical Governance StandingCommittee and Patient Safety Review Group) toensurethatactionstoachievethisstrategyarefullyembeddedwithintheCareGroupsdeliveryplans.

Infection Prevention and Control Committeemembers will act as a conduit for information; sothat careunitplans canbe linked via the InfectionPreventionCommitteetotheannualTrustinfectionpreventionprogramme.

TheDIPCwillcontinuetohavedirectaccesstotheMedicalDirectorand/orExecutiveLeadifmattersrequireimmediateescalationandattention.

The following key teams and committees will alsosupportimplementation:

DecontaminationGroup

AntimicrobialManagementTeam

Laboratory

Outofhours/CSMTeam

NursingandMidwiferyGroup

DivisionalGovernanceForums

TrustGovernanceGroup

TrustBoard

Estates&Facilities

ThelocalPublicHealthUnit

HealthProtectionAssuranceGroup

PatientSafetyReviewGroup

Clinical commissioning groups, Doncaster &Bassetlaw.

Staff within the Trust will contribute to theimplementationofthisstrategyandreducingHCAIsthrough:

The investigation into and learning of keyinfections.

Seeking specialist Infection Prevention andMicrobiologyadvicewhererequired.

WorkingwithClinicalSiteManagerteam,HeadsofNursing, Senior Clinical Nurses,Matrons andother clinical leaders to ensure patients withinfectionsareplacedappropriatelytomeettheircareneedsandinordertoprotectotherpatients.

Ensuring thatstaffare trained inbasic infectionpreventionandcontrol.

Working with hotel services/facilities to ensurethe clinical environment is clean and safe forpatients.

Dissemination of StrategyThestrategywillbeavailableontheTrust intranet.AwarenessofthestrategywillcirculatedviatheIPCC.

Implementation

Doncaster and Bassetlaw Teaching Hospitals

NHS Foundation Trust

www.dbth.nhs.uk Follow us @DBH_NHSFT

For more guidance please visit www.who.int and search for ‘World Antibiotic Awareness Week.’

Antibiotic resistance is a global health concern, which can affect people of any age, anywhere around the world.

Antibiotics do not work on viruses. Never share antibiotics. They must only be prescribed by a qualified practitioner.

Help reduce the spread of bacterial infections by hand washing and observing good hygiene standards.

Handle antibiotics with care.It’s in your hands.

World Antibiotic Awareness Week

12-18 November 2018

Dr Ken AgwuhConsultant Microbiologist/DIPC

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Assurance framework Trust Board The Trust Board is responsible for ensuring thatthe Trust has appropriate Infection Prevention andControlsystemsandresourcesinplacetoenabletheorganisation to deliver its objectives and statutoryrequirements. Activities to demonstrate thatinfectionpreventionand control is an integralpartofclinicalandcorporategovernanceinclude:

TheTrustBoardreceivingandformallyapprovingtheTrustInfectionPreventionandControlStrategy,theAnnualInfectionPreventionandControlProgrammeand theDIPCAnnual Report. The Strategyoutlinesobjectivesandresponsibilitiesand isarequirementof the Hygiene Code. The Annual Programme setsobjectivesfortheyear,identifiesprioritiesforaction,evidence thatpolicieshavebeen implementedandreports progress against the objectives. The DIPCAnnual Report provides performance informationfrom the preceding year and highlights anyoutstandingissuesthatneedtobeaddressedbytheAnnualProgramme.

RegularpresentationsfromtheDIPCtotheBoard;theDIPCisresponsibleforpreparingthese.Presentationandreportsincludetrendanalysisforinfectionsandcompliancewithauditprogrammes.Otherinfectionprevention and control reports are submittedquarterlyorwhenrequestedbytheexecutivelead.

Reporting monthly Trust infection prevention andcontrolkeyperformanceindicatorsreportsthroughthe Trust Governance committee to the board.Exception reports are prepared by the DIPC orsuitableotherasrequired.

Infection Prevention and Control Committee The Infection Prevention and Control Committee’spurpose is to seek assurance that the Trust hasa robust framework for infection prevention andcontrol as part of a whole health community. TheCommitteemeets six times a year. The committeewillhaverepresentativesfromeachoftheDivisionswhowillbeabletogiveanupdateonperformanceandIPCrelatedconcerns.

Aspect of strategy to be

monitoredLead Tool/Method Frequency Who will

undertakeWhere results

will be reported

Allelementsofstrategy IPCT ICCMmins Bimonthly DIPC IPCC

TrainingandEducation

Educationleads

NHS(CSTF)

CompliancechartMonthly EducationLead

Divisions governanceforum

Antimicrobialstewardship

Antimicrobialpharmacist/microbiologist

Pointprevalenceaudits/complianceaudits

MonthlyPharmacist/microbiologists/IPCnurses

IPCC

Wardenvironment/cleanliness

Hotelservicesmanager

MiC4CIPCauditsDeepcleanschedule

MonthlyandasperIPCaccreditation

Hotelservices

IPC/divisions

MonthlyHotelserviceforum.IPCC,CCGforums.

CQC compliance IPCT Spotchecks,self-

monitoringaudits Quarterly GMs/SeniorNurse

IPCC,CCGforums

Alertorganismsurveillance IPCT Dbase Monthly IPCT/DIPC IPCC,CCG

forums.

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Assurance framework Monitoringofthekeyobjectiveswillalsotakeplacethrough:

InternalCCGsperformancereviewsi.e.accountabilitymeetings

SeriousIncidents,outbreaks,neverevents

Annualprogrammereview

Infectiondataandsurveillance

Monitoringagainsttrajectories.

Key ChallengesThekeychallengestheTrustfacesandthisstrategymustovercomeare:

Levelofhospitalactivityandcapacity

Isolation/cohort/ensuitefacilities

Emerging infections and new strains i.e.pandemics

Instillingpublicconfidence

Educatingworkforce,patientsandthepublic

Transientworkforce

Ensuringacleanandappropriateenvironment

Motivatingstaffandtheengagementofstaff

Meetingnationalandlocaltargets.

Arrangements for review of the strategyThis strategy will be subject to a formal review in2022,howeveraninformalreviewwillbeundertakenon a yearly basis. The Infection Prevention workprogrammewillbereviewedonanannualbasis.

Goal

Reducehealthcareacquiredinfectionstoirreducibleminimumwithaspirationofzeroavoidableinfections.

Clinical Lead

DrKenAgwuh(DIPC)/CarolScholey(LeadNurseIPC)

Executive Lead

Richard Parker, CEO and David Purdue, Director ofNursing.

Care group lead

HeadsofNursing.

Ref

CQCOutcome8,TrustStrategicobjective–Providethesafest,mosteffectivecarepossible.

Doncaster and Bassetlaw Teaching Hospitals

NHS Foundation Trust Are your hands

CLEAN?We all have a part in protecting patients, our family and ourselves from the dangers of infection.

As a visitor, you can help in preventing infection by:

Cleaning your hands with soap and water or hand gel before and after a ward visit.Cleaning your hands with soap and water after using the toilet facilities.Please use chairs when visiting the wards to sit down, rather than on patient’s beds.Not visiting our hospital if you have an infection, for example flu. If you have had diarrhoea and vomiting, please do not visit until you have been clear of symptoms for 48 hours.

You can expect:Staff in a clinical area to be bare below the elbow.Staff to clean their hands before and after patient contact.Hand gel to be available at the patient’s bedside and at the entrance to the wards.A clean hospital.

Follow us @DBH_NHSFTVisit us at www.dbth.nhs.uk

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Action required Lead

Com

pleti

on

Date

Prog

ress

RA

G

Progress

Enhance and reformat alert organism feedback chartsUpdateMRSA,CDI,MSSAchartsusingSPCformatandbasedonper10,000beddays.ToalsoincludeEcoli, pseudomonasandklebseilla bacteraemia.

IPCT/ dataanalyst

Ongoing

UpdateHandHygienecompliance feedbackfocusingontheWHO5 moments.

IPCT/ dataanalyst

Ongoing

IPCTtocollectminimumofx20handhygieneobservationspermonthwithinhighriskunits/wardstohelpvalidatewardresults.

IPCT Ongoing

Review process for identifying areas with above expected numbers of ‘alert’ organismsEstablishrulestodeterminewhatconstitutes‘significantvariation’fromexpectedlevelofperformanceforkeyIPCcomponentse.g.CDInumbers

IPCT/ dataanalyst

Ongoing

Identifyprocessforregularreviewsforareasperformingbelowexpectedstandards.

IPCT/CCGs Ongoing

Assistcaregroupswherestandardshavedroppedbelowexpectedlevelse.g.highratesofinfection.

IPCT Ongoing

Enhance the number of single rooms / cohort and ensuite facilities within the trust to meet needs of service demandsNewschemestoincorporatea minimumof30%isolationcapacityandensuite/cohortbayswithdoors.

EstatesDirector/CCGseniornurse/manager

Ongoing

CaregroupstocompleteDatixwebreportingiflackofisolationfacilitiesorbreecheswithIPCstandards.

IPC work programme 2019-2022

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Action required Lead

Com

pleti

on

Date

Prog

ress

RA

G

Progress

Continue to provide assurances meeting requirements of Outcome 8 (CQC)UpdateIPCpoliciesinlinewithnationalguidance.

IPCT Ongoing

Ensurewardenvironmentinmedicalunitshasbeendeepcleaned/HPV atleasttwiceayearandinsurgery minimumofonce.

Facilities/Matron/Wardmanager

Ongoing

MonitormonthlyMiC4Cscoresandensurewardsscoreabove90%.

Facilities/WardManagers/ Matrons

Ongoing

Caregroupstomonitorcompliancewithintheirareasanddrive improvementswhererequired.

WardManagers/Matron

Ongoing

EnsureIPCaccreditationschemeisfullyembeddedwithinwardsandmainnonclinicalareas.

IPCT,CCGs Ongoing

Build upon the antimicrobial stewardship assurance work currently in placeMaintainantibioticpoliciesand websitesuptodateandexpandcontenttomeetusersneeds.

EstatesDirector/CCGseniornurse/manager

Ongoing

Undertakeasurveytoestablishuser satisfactionandprescribinghabits.

Microbiologists/IPCT/ antimicrobialpharmacist

Monthly

Reviewfeasibilityofundertakingthepointprevalencetrustsurveillanceon antimicrobialuseonamorefrequentbasis.

Microbiologists/IPCT/ antimicrobialpharmacist

Aug18

ProvideantimicrobialusagedatebrokendownbyCareGroups/commonagentsusingSPCformat.

Microbiologists/antimicrobialpharmacist

Aug18

Enhance research opportunities with local and national collaborativeDeveloptheIPCteamresearchcapabilities. IPCT Ongoing

opportunityCarryoutfocusedworkexploringtheroleoflinknursesandwaystoenhancetheircontribution.

IPCT Ongoing

Exploreoptionstosubmitposters/ abstractsorpublishlocalworkto promotethetrust.

IPCT/ Microbiologists

Ongoingopportunity

Undertakescopingexercisetowork collaborativelywithrelevantpartners includingcommercialorganisationsto implementnewtechnologyand developments.

IPCT Ongoingopportunity

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Action required Lead

Com

pleti

on

Date

Prog

ress

RA

G

Progress

Improve clinical areas compliance with ‘preventative’ infection prevention and control standards and practice.Reviewandupdaterelevantpolicies e.g.MRSA,C.difficile,Gramnegative multi-resistantpathogens,Respiratoryvirus.

IPCT/ Microbiologist

Ongoing

WorkwithCCGsandcommunityIPCTtoreducegramnegativebacteraemiaratesby10%

IPCT/ Microbiologist/CCGs

May18

Reviewsurgicalsitecarebundle, documentationtoensurerelevantandpertinent.

IPCT/ Microbiologist

May18

MaintainrobustorthopaedicsurgicalsitesurveillanceofhipandkneeprimaryjointreplacementsonanongoingbasisusingSSISSmethodology.

IPCT/Ward managers/ Matrons

Ongoing

Ensurewards/deptadequatelypreparedforseasonalvirusesusingspecifictoolsandeducationalsupporte.g.workshops/road-showsforNorovirus.

IPCT/ Oct18

Carryoutfocusedworkontheappropriateuseofurinarycatheters,PVCsandCVCse.g.earlyremoval,documentation, adherencewithbestpractice.

IPCT/Ward managers/ Matrons

Ongoing

Build upon the collaborative working across the two main CCGs and other local partnersWorkcollaborativelywithDoncasterandBassetlawCCGstoreducepatientharme.g.pathways,CAUTIs.

IPCT/CCGs Ongoing

ContinuetosupportthePIRandCCGICCmeetings.

IPCT/CCGs Ongoing

Review and enhance current IPC education resources on offer for staffDevelopeducationresourcestomeetstaffneeds.

IPCT DataAnalyst

Ongoing

MaintainIPCintranetsite IPCT DataAnalyst

Ongoing

IPC service deliveryReviewhowtheservicecanmeetneedsofthetrustbutmaintainefficienciese.g.6-7dayworking.

IPCT March2019

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Care Quality Commission (2016). The Essential Standards. http://www.cqc.org.uk/organisations-we-regulate/registering-first-time/essential-standards

Department of Health (2013) UK Five Year Antimicrobial Resistance Strategy 2013 to 2018https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/244058/20130902_UK_5_year_AMR_strategy.pdf

Department of Health (2015) The operating framework 2015-16: for the NHS in England https://www.gov.uk/government/uploads/system/uploads/attachmentdata/file/385749/NHSOutcomesFramework.pdf

Department of Health (2009) High Impact Actions for Nursing & Midwifery. London.http://www.institute.nhs.uk/images//stories/Building_Capability/HIA/NHSI%20High%20Impact%20Actions.pdf

Department of Health (2008). Board to ward: how to embed a culture of HCAI prevention in acute trusts. Department of Health. London.

Department of Health (2000). The management and control of hospital infection: action for the NHS for the management and control of infection in hospitals in England. London: Department of Health; 2000. (Health Service Circular: HSC (2000) 2.)

Haley RW, White JW, Culver DH, Meade Morgan W, Emori TG, Munn VP, Hooton TM (1985). The efficacy of infection surveillance and central programs in preventing nosocomial infections in US hospitals (SENIC). American Journal of Epidemiology 121: 182-205.

HPA (2011) English National Point Prevalence Survey on Healthcare-associated Infections http://www.hpa.org.uk/servlet/

Loveday H et al (2014) epic3: National Evidence-Based Guidelines for Preventing Healthcare- Associated Infections in NHS Hospitals in England http://www.sciencedirect.com/science/article/pii/S0195670113600122

NICE (2014) Infection Prevention & Control.http://www.nice.org.uk/guidance/qa61

The Health and Social Care Act (2008) Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216227/dh_123923.pdf

References & Bibliography

DocumentdesignedbytheTrust’sCommunicationsTeam©2019